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Best Practices in Veteran Traumatic Brain Injury Care

Uomoto, Jay M. PhD

Journal of Head Trauma Rehabilitation: July/August 2012 - Volume 27 - Issue 4 - p 241–243
doi: 10.1097/HTR.0b013e31825ee26a

US Department of Veterans Affairs, Office of Mental Health Services, Washington, District of Columbia.

The author declares no conflicts of interest.

AT THE TIME of the writing of this preface, the United States has been engaged in Operation Enduring Freedom (OEF) in Afghanistan and associated regions for more than 11 years. In September 2010, military operations in Iraq known as Operation Iraqi Freedom (OIF) came to a close and renamed Operation New Dawn (OND) to reflect the change of mission by US forces to provide assistance and play an advisory and training role. As of May 4, 2012, the Department of Defense reported a total of 4422 deaths in OIF, 66 in OND, and 1949 in OEF,1 all of whom we deeply honor for their service and sacrifice. Although the vast majority of those who have served in these combat environments have returned without significant injury, many service members return with a wide array of injuries, not unlike that which has occurred in combat from every past conflict known to humankind. Traumatic brain injury (TBI) has been often referred to as the “signature wound” of these most recent wars, yet in reality a multitude of injuries are common among the wounded including musculoskeletal injuries with associated chronic pain, mental health conditions such as posttraumatic stress disorder (PTSD) and depression, ill-defined signs and symptoms, sensory input impairments (eg, vision and hearing deficits), and those who sustained traumatic amputations secondary to a blast exposure.2,3 The return of injured service members from the theater of war has required both the Department of Defense and the Department of Veterans Affairs (VA) to organize systems of care, develop effective and evidence-based treatments, disseminate these approaches at an enterprise level, and coordinate such efforts between the 2 departments. In those service members who separate from military service because of retirement and those whose injuries result in being medically boarded, enrollment in VA healthcare is now on the rise.

The Veterans Health Administration (VHA) organized a nationwide healthcare system to address the healthcare needs of returning service members and Veterans with complex injuries known as the Polytrauma System of Care (PSC). This system was expanded and built upon an existing network of specialty TBI programs that existed in the VA since the time of the first Gulf War. The PSC now exists as the largest single system of healthcare in the United States for those with polytrauma (ie, those with multiple and simultaneous system injuries) and TBI. Currently, the PSC is distributed across VA medical centers in the continental United States, Alaska, Hawaii, and Puerto Rico. It consists of 3 levels of care: 5 polytrauma rehabilitation centers, 23 polytrauma network sites, and 86 polytrauma support clinic teams. In addition, the PSC has 40 polytrauma points of contact in VA medical centers that do not have specialized polytrauma rehabilitation teams.4

As a sampling of the types of approaches that characterize the care of service members and Veterans, this topical section of the Journal of Head Trauma Rehabilitation focuses upon 3 best practices in the rehabilitation of those who have suffered combat injuries. Collaborative efforts between the VA and the Department of Defense (DoD) through the evidence-based practice guideline workgroup was established to advise the joint VA/DoD Health Executive Council on the application and development of clinical practice guidelines that translate empirical research to practice implementation. Several clinical practice guidelines (CPGs) have been developed to address an array of conditions seen in primary care, mental health problems, military-related disorders, pain, rehabilitation practices, and women's health issues.5 These CPGs are disseminated to the field across the VA healthcare enterprise, and themselves define best clinical practices. The 3 articles that follow augment existing CPGs and describe best practices in the delivery of comprehensive emerging consciousness rehabilitation for those with severe TBI and polytrauma, the assessment of complex co-occurring disorders in the postacute polytrauma rehabilitation setting, and best practices in the enlistment of peer support and mentorship to enhance functional recovery and quality of life in those with postdeployment conditions.

Although the number of returning military personnel from OEF/OIF/OND with severe and penetrating TBI are fewer than those with mild TBI and multiple concussions, those who have returned in a minimally conscious state and deeper levels of coma require specialized rehabilitation care, delivered at 1 of the 4 polytrauma rehabilitation centers (PRC). McNamee and his colleagues describe the VHA Polytrauma System of Care Emerging Consciousness Program that was initiated in 2007. This national 90-day program employs standardized protocols across each of the PRCs thus allowing for an aggregation of data and ability to describe patient outcomes. Not being restricted by third party payor sources as can be seen in the civilian sector, McNamee reports that patients who are admitted to this program are able to realize a trial of rehabilitation interventions that allow for tracking recovery, undergo full regimens of therapies aimed to facilitate emergence of consciousness, and provides the opportunity to develop a long-term healthcare plan. Developing a therapeutic alliance with the family and loved ones occurs in the Emerging Consciousness Program, and engagement with the VA and DoD national caregiver curriculum and training can also occur. Again, these national federal programs can be instituted in one location leading to a continuity care with the service member or Veteran's local VA Medical Center, military treatment facility, and/or other community resources.

Veterans from OEF, OIF, and OND who seek care within the VA frequently present with a complex set of conditions, diagnoses, signs, and symptoms. In the often cited study by Lew and his colleagues that describe the prevalence of problems in Veterans who had been seen at a VA Polytrauma Network Site (where postacute polytrauma rehabilitation typically occurs), 42% presented with co-occurring chronic pain, posttraumatic stress disorder, and persistent postconcussion syndrome.6 Significant challenges are presented to the clinician who upon a Veteran's first visit to the VA may need to tease out from a host of multiple postdeployment symptoms, salient conditions, and diagnoses and then develop an effective plan of care. Often this responsibility falls upon primary care physicians and recently has been seen as the responsibility of the VA Patient Aligned Care Team (PACT), which incorporates principles of the medical home. Nationally, VA medical centers are developing PACTs within primary care service lines where embedded mental health clinicians and care managers assess, develop effective treatment plans, and comanage patient care needs by coordinating with key specialized services. In the postacute setting, specialized polytrauma network sites and polytrauma support clinic teams will provide assessment of the Veteran with complex co-occurring problems. Cernich and her colleagues describe the process by which Veterans of OEF/OIF/OND are assessed with special attention given to co-occurring symptoms. In their article, these authors provide a retrospective analysis of 402 Veterans who were seen at a VA medical center for a comprehensive evaluation for TBI. In the VHA, all OEF/OIF/OND Veterans are screened for TBI and if this screen is positive triggers a referral for a comprehensive TBI evaluation unless the Veteran refuses this evaluation (which happens infrequently), or if that Veteran had been previously diagnosed with a TBI. An interdisciplinary rehabilitation plan of care is developed on each Veteran that is diagnosed with TBI, and in those that are not found to have a TBI are provided guidance and referrals for other conditions that may be prominent and in need of treatment (eg, PTSD). In their analysis of their cohort of Veterans, those who had positive screens for PTSD or depression reported more cognitive symptoms and mood problems. Thus, the clinical situation of co-occurring disorders requires significant attention to ensure that the Veteran obtains a clear and effective plan of integrated care.

The clinical presentation of co-occurring symptoms has been referred to as a “post-deployment multi-symptom disorder.”7 This syndrome refers to the conglomeration of symptoms that are developed throughout the deployment cycle of the service member, and upon separation from the military that person will present to the VA with a cumulative burden8 of symptoms and conditions as a result of injuries and exposures that were acquired during multiple deployments. A clinical situation is presented by the Veteran seeking healthcare in the VA in which the clinician must make decisions regarding the best care that will address this complex postdeployment syndrome. It is usually unsatisfactory to the Veteran and often difficult for the primary care physician to achieve optimal care of that Veteran to simply write referrals to independent and multiple specialized services within a given VA medical center (eg, to mental health, rehabilitation services, orthopedics, neurology). Such a situation, as noted earlier, has led to efforts for nationalizing the PACT model9 across all VA medical centers. There clearly is a challenge to implement such an integrated care approach across the Veterans Health Administration enterprise, and other models of care are needed to meet the needs of Veterans who present with complex clinical situations. To provide a needed remedy and to further enhance the care of Veterans, Williams and her colleagues describe the potential best practice of enlisting peer mentors and in this case, fellow Veterans, to assist in providing support, education and facilitate behavioral goals. These authors embark upon a review of the available peer mentorship literature between 1980 and 2012 and highlight the importance of enlisting current and former military service members who are able to effectively deliver support and other interventions, but with the added benefit of being delivered by those who know and live the military culture, and share unique and credible experiences that non–service members lack.

These 3 articles only begin to uncover and describe the multitude of clinical practice guidelines, clinical support toolkits, and recommendations that currently exist for active duty service members, and Veterans of all war eras. These authors all describe best practices in the Veterans healthcare system that were developed and implemented because of the humbling fact of war, with the combat- and non–combat-related injuries that our service members in uniform have sustained in the line of duty to this country.

Kurt Goldstein summarized this situation well in the preface of his book, Aftereffects of Brain Injuries in War: Their Evaluation and Treatment, published in 1948.10 His words are timeless to speak of the urgent need to develop responsive, innovative techniques, and effective treatments for those who suffered injuries from combat:

During the last war, I was faced with the responsibility of caring for a great number of soldiers suffering from brain injury. I thought myself prepared for this task through my theoretic and practical experiences as a peacetime neurologist. Very soon, however, I realized that the customary procedures were highly inadequate. Examination and treatment of soldiers with gunshot wounds of the brain required the development of new methods. It was necessary to find means of rehabilitating these men in spite of permanent defects.(p11)

Researchers and clinicians continue to develop and disseminate best clinical practices and make good on the US Department of Veterans Affairs commitment to President's Lincoln's words “To care for him who shall have borne the battle and for his widow and his orphan.”

—Jay M. Uomoto, PhD

US Department of Veterans Affairs

Office of Mental Health Services

Washington, District of Columbia

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1. US Department of Defense. News. Casualties. Accessed May 4, 2012
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9. US Department of Veterans Affairs. Patient Aligned Care Team (PACT). Accessed May 1, 2012.
10. Goldstein K. Aftereffects of Brain Injuries in War: Their Evaluation and Treatment; the Application of Psychologic Methods in the Clinic. Madison, WI: Grune and Stratton; 1948.
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