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Neurology Today:
doi: 10.1097/01.NT.0000271231.66990.d5
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Proposed Legislation to Expand Support for Gulf War Vets with TBI

Stump, Elizabeth

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Traumatic brain injury (TBI) has been deemed the “signature wound” of the Iraq War. And, until now, news accounts about care for returning veterans with TBI and other neurological problems have not been flattering — with reports of poor conditions at the Walter Reed Medical Center and problems coordinating care at local Veteran Affairs (VA) medical centers.

Figure. Sen. Clinton...
Figure. Sen. Clinton...
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But the AAN and a coalition of other groups focused on TBI joined forces on Mar. 29 to support new legislation, co-sponsored by Sen. Hillary Clinton (D-NY) and Sen. Susan Collins (R-ME), to improve services for veterans. The AAN played a pivotal role in helping to draft the language of the new bill.

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PROVISIONS OF PROPOSED BILL

The Heroes at Home Act of 2007, announced by Sen. Clinton at a Mar. 29 press conference on Capitol Hill, focuses on helping US veterans and their families adjust to home and work life after returning from deployment, as well as cope with TBI, post-traumatic stress disorder, or both.

The bill proposes, among other provisions, to improve the screening process for mild or moderate TBI with the use of an objective, computer-based assessment protocol to measure cognitive functioning before and after deployment.

“Basically the idea is to test soldiers' cognitive function before deployment, so a baseline is obtained and deficits are identified when veterans return,” Paul Rutecki, MD, chief of neurology at the Wm S. Middleton Memorial VA Hospital in Madison, WI, told Neurology Today.

Improved body armor has enabled more soldiers to survive injuries from improvised explosive devices, he explained. Those with open wounds may show obvious signs of TBI, but mild or moderate TBI is often missed in soldiers with closed-head injuries caused by the strong blast-waves. It also can be difficult to distinguish mild TBI from post-traumatic stress disorder, because both conditions share symptoms, including anxiety, irritability, and depression.

The proposed bill would also establish a training curriculum and certification program to help family caregivers of TBI patients to provide quality care at home and qualify for compensation from the VA.

To increase access to necessary medical and mental health care for service members and veterans (especially those living in rural areas), the new legislation calls for expanded use of telemedicine technologies to facilitate rehabilitation and distribute educational material.

At the press conference, Sen. Clinton also proposed new legislation that would protect financial benefits for military families (Protecting Military Family Financial Benefits Act of 2007), and ensure that wounded soldiers receive necessary disability benefits (Restoring Disability Benefits for Injured and Wounded Warriors Act of 2007).

AAN Legal Counsel Mike Amery said the new TBI legislation came about as a result of a coordinated campaign — and good timing.

At its annual Neurology on the Hill advocacy event on Mar. 14, AAN staff and 100 neurologists visited Congressional offices to advocate for improved care for returning veterans with TBI, among other neurology concerns. The New York contingent included Katherine Henry, MD, associate professor of neurology at New York University and chief of neurology at the Bellevue Hospital Center, and Bert Vargas, MD, a neurology resident at the New York University School of Medicine.

Dr. Vargas formerly served as an Air Force flight surgeon in Afghanistan and Iraq. At the news conference, both Drs. Vargas and Henry were invited to speak on behalf of the AAN in support of the proposed bill.

Dr. Henry said she “had spent a fair amount of time reviewing the legislation, learning more about deployment issues and TBI screening, and offering edits to the draft legislation.”

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NEW AAN POSITION STATEMENT

On Mar. 28, the AAN Executive Committee approved a new position statement, “Securing the Necessary Neurological Care for Combat Veterans with Traumatic Brain Injury,” which includes provisions from the Heroes at Home Act of 2007 and advocates improved coordination in transferring patient records from the Department of Defense to the VA. The statement is available online at www.aan.com.

The AAN position paper included one provision, however, that was not included in the final bill by Sen. Clinton: The Academy proposed that the VA create a national epilepsy program to evaluate and treat patients with TBI who develop post-traumatic epilepsy, and that the VA create at least six Epilepsy Centers of Excellence around the country.

Dr. Rutecki noted that “post-traumatic epilepsy may occur in more than 50 percent of those injured by penetrating high velocity injuries.” The risk is particularly high for war injuries that cause bleeding inside the brain.

“Many individuals with TBI may also have post-traumatic stress disorder, so sorting out the problem of whether or not a patient has epilepsy may be difficult,” Dr. Rutecki said.

Amery noted that the provision for the epilepsy centers is similar to the language included in legislation mandating MS and Parkinson centers of excellence, which passed last year.

The AAN is one of five organizations that endorsed the Heroes at Home Act of 2007. Others include the Wounded Warrior Project, National Military Families Association, Military Officers Association of America, and the Brain Injury Association of America.

John Booss, MD, Professor Emeritus of neurology at Yale University School of Medicine and formerly the national program director of the Neurology Service at the Department of Veterans Affairs, said he “was gratified that Sen. Clinton's staff was willing to seriously consider the issue.” The AAN will continue to work with Sen. Clinton and others to introduce legislation that will permanently authorize the epilepsy centers at the VA, he said.

Amery said the VA is likely to oppose the creation of the centers. “It would be a congressional mandate and the VA prefers as much autonomy as possible,” he said. “They probably wouldn't oppose the centers, just the mandate to create them.”

In the meantime, the AAN is asking members to write their representatives in Congress to advocate support for the legislation. The Academy is also sending informational packets on these issues to members of Congress and the Congressional Brain Injury Task Force, a bipartisan initiative established in 2001 and co-chaired by Reps. Bill Pascrell (D-NJ) and Todd Platts (R-PA).

The American Epilepsy Society (AES) is creating a task force to warn brain-injured soldiers of epilepsy risk, so that patients can recognize subtle symptoms.

“We will develop educational programs for professionals and explore clinical care options to ensure returning veterans receive optimal care,” said AES Executive Director M. Suzanne C. Berry. “We want to do this is in a collaborative way with other organizations so that all resources will be maximized for the very best possible result.”

So what will be the next steps in moving the Heroes at Home Act of 2007 forward? The bill will be referred to the Senate Armed Services Committee, Amery said, and the “most likely scenario is that it will be attached as an amendment to the National Defense Authorization bill that authorizes defense spending and programs each year.”

If this is successful, the AAN will advocate to have funding included in the FY 2008 Defense Appropriations Bill.

“The AAN position statement on TBI is critical to moving the issue forward,” said Dr. Henry. “If, as an organization, we make this a priority, we will have a strong voice in the political landscape — after all, we are over 20,000 members strong. My hope is that Sen. Clinton and others will continue to call on us as they draft new legislation.”

©2007 American Academy of Neurology

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