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Neurology Today:
doi: 10.1097/01.NT.0000297536.87655.aa
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TBI Care for America's Returning Wounded Vets is Subject of Congressional Hearings

Stump, Elizabeth

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ARTICLE IN BRIEF

✓ In a hearing before Congress, Sen. Bob Dole and former Health and Human Services Secretary Donna Shalala called for legislation to support improved care for veterans with post-traumatic stress syndrome among other legislative priorities.

Three months after the release of a report by the bipartisan President's Commission on Care for America's Returning Wounded Warriors, panel co-chairs Senator Bob Dole and former Health and Human Services Secretary Donna Shalala called on Congress on Sept. 19 to authorize legislation to support their recommendations for improving veteran care and benefits. They discussed the panel's recommendations, which included care for veterans with traumatic brain injury (TBI), in hearings before the House Committee on Veterans Affairs.

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SIX LEGISLATIVE PRIORITIES

Shalala said that, among other program priorities, legislation was needed to authorize the VA to provide lifetime treatment for veterans with post-traumatic stress disorder (PTSD); make injured service members eligible for respite care as well as medical aide and personal attendant benefits; and extend the Family and Medical Leave Act to allow relatives unpaid leave to care for injured members for up to six months without losing their jobs.

Sen. Dole asked that legislation support a complete restructuring of the disability and compensation system — so that Department of Defense (DoD) determines a member's fitness to serve, while the VA provides all disability compensation and focuses on support for injured vets. “Right now each of these departments assesses each injured service member's disability level, based on different objectives,” he said. “…The two systems often disagree, they take way too long, and the process is way too confusing.”

Figure. Dr. Rolland ...
Figure. Dr. Rolland ...
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Sen. Dole said the commission recommended legislation to support health care coverage for service members who are found unfit because of conditions acquired in combat, supporting combat, or preparing for combat.

Finally, he called upon Congress to revise the three types of payments currently provided to many veterans. “We recommend changing the existing disability compensation payments for injured service members to include three components: transition support, earnings loss, and quality of life.”

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COMMISSION FINDINGS

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Figure. Dr. Douglas ...
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The nine-member panel was established by President Bush in March 2007 to investigate treatment of wounded veterans after disclosures of problems at Walter Reed Army Medical Center. The commission sought to determine whether comparable troubles exist at other military and veterans' hospitals. Released in July, the Commission's final report, “Serve, Support, Simplify: Report of the President's Commission on Care for America's Returning Wounded Warriors,” recommended, among other action steps, that there be more aggressive prevention and improved treatment of TBI and PTSD; complete restructuring of the disability determination and compensation systems; and comprehensive recovery plans for individuals to provide accurate care and support.

On Sept. 7, Representative Jerry Moran (R-KS) and four bipartisan co-sponsors introduced the Wounded Warriors Commission Implementation Act, HR 3502, to enact the panel's recommendations requiring legislative action.

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NEED FOR BETTER TBI CARE, EXPERTS SAY

Several experts agreed that there was room for improvement in care for vets with TBI. “While the acute- and trauma care of the DoD is unparalleled, the DoD and VA systems continue to be insufficient for meeting the subsequent needs of veterans with TBI — including inpatient and outpatient neurorehabilitation and neuropsychiatric services,” Gregory J. O'Shanick, MD, told Neurology Today. Dr. O'Shanick is president and medical director of the Center for Neurorehabilitation Services in Richmond, VA, and the national medical director of the Brain Injury Association of America.

Rolland S. Parker, PhD, adjunct professor of clinical neurology at New York University School of Medicine and president of the New York Academy of Traumatic Brain Injury, a multidisciplinary professional association, noted that “in many facilities there are insufficient personnel who are highly trained in the diagnosis and treatment of TBI, PTSD, and serious somatic injuries. There is a high turnover in some treatment facilities.”

Dr. Parker emphasized that the government must support additional specialized training for TBI and PTSD. Most physicians are not trained in these specialties, he said, and even in the emergency department, if there is a somatic injury, they may not examine whether a head injury has occurred. “I have seen numerous hospital records of patients with TBI, with somatic injuries, but no record of any examination of their head!”

Dr. O'Shanick said the commission's “recovery plan” for seriously injured military personnel, where one coordinator is assigned for each patient and their family to aid in the recovery process and returning to duty or retiring from active service, is good in principle. However, he noted that recruitment and training take time and resources. “Why not “outsource” to catastrophic case managers in the civilian sector who already function in this capacity on a daily basis?” he asked.

Dr. Parker agreed that major changes in the disability system are needed since the rating schedule has not been completely revised since 1945. Diagnostic criteria are changing rapidly due to greater understanding of TBI, appreciation of the disabling impact of PTSD, and changes in the prognosis for such conditions as serious burns and amputations, he said. He disagreed, however, with the report's proposal that the evaluations to determine disability status should be performed every three years, noting that they should occur more frequently.

Dr. O'Shanick noted that the commission did not address the issue of mild TBI and blast injuries in reservists and members of the National Guard who are sent home after deployment to little or no services. “Screening programs are needed, as well as local treatment options that are a more appropriate fit regarding community re-entry and neurorehab programming,” he said.

Dr. Parker said that information about the frequency of TBI and stress in the military and civilian populations should be made more available, and “the health-care community should be re-educated concerning the actual serious consequences of the mislabeled “minor” head injury.” He told Neurology Today that he is making an effort to get professionals involved with military polytrauma to join the NY Academy of TBI.

Douglas I. Katz, MD, associate professor of neurology at the Boston University School of Medicine and the medical director of Brain Injury Programs at Braintree Rehabilitation Hospital in MA, said: “Our system of care in the US for those with TBI is fraught with difficulties in supporting their long-term needs. Perhaps, successes in revising the system for our deserving service members will lead to improvements in long-term care for persons with TBI in all health-care sectors.”

The complete testimony for the Sept. 19 hearing is available online at veterans.house.gov/hearings/hearing.aspx?NewsID=94. The commission's report is available online at: pccww.gov/docs/Kit/Main_Book_CC%5BJULY26%5D.pdf.

©2007 American Academy of Neurology

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