DURING the most recent State of the Art (SOTA) conference sponsored by the Department of Veterans Affairs (VA) Office of Research and Development, VA was noted to be at an advantage to facilitate research in traumatic brain injury (TBI) and understanding lifetime needs. This special issue highlights the use of the VA TBI Model System (TBIMS) program of research in addressing some of the key focus areas discussed at the SOTA meeting. The TBIMS of research is a longitudinal multicenter study that examines the course of recovery and outcomes following inpatient rehabilitation for TBI within the 5 VA Polytrauma Rehabilitation Centers located in Minneapolis, Minnesota, Palo Alto, California, Richmond, Virginia, San Antonio, Texas, and Tampa, Florida.1 This lifetime study conducts follow-up at years 1, 2, 5, 10, 15, and every subsequent 5 years postinjury.2,3
The VA TBIMS parallels the legacy civilian hospital–based TBIMS funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), now housed in the Department of Health and Human Services. Since inception, the 16 currently funded civilian sites (since 1987) and 5 VA Polytrauma Rehabilitation Centers have conducted more than 50 000 follow-up interviews on more than 16 000 participants. At the time of this submission, the VA TBIMS had enrolled more than 1000 of those participants, all since 2010. The TBIMS infrastructure includes funding for a Model Systems Knowledge Translation Center that helps translate TBIMS science to products relevant for stakeholders including patients, caregivers, policy makers, and other scientists that are available online.4 Another measure of success includes the online registry of the more than 830 peer-reviewed publications generated from TBIMS database studies.4
Historically, special issues in scientific journals have often been used to highlight special focus areas leveraging the TBIMS longitudinal study. This is the first special issue exclusively featuring articles using the VA TBIMS database. Following a prolonged period of war, Congress has mandated longitudinal studies to examine the long-term rehabilitation needs following TBI. The VA TBIMS is uniquely positioned to inform policy about the health, mental health, socioeconomic, rehabilitation, and caregiver needs following TBI.5 Funding for this special issue would not be possible without the support of the Defense and Veterans Brain Injury Center within the Defense Health Agency. In the true spirit of federal interagency collaboration, scientists from VA, Department of Defense (DoD), and academia partnered to generate the articles highlighted.
The first article (Nakase-Richardson et al) in this issue is the first comparison of TBI participants enrolled in the VA Polytrauma Rehabilitation Centers with those enrolled in the civilian-based TBIMS settings across a similar time frame (2009-2015) and on baseline enrollment variables (eg, premorbid history, injury characterization, acute rehabilitation outcome).6 Although inclusion and exclusion criteria differ across the 2 data sets, the authors constrained the VA sample to increase comparability on key variables. While both data sets had large proportions with motor vehicle–related crashes, the VA cohort had more violence-related TBIs and the civilian TBIMS had a greater proportion of those with fall-related TBIs. As such, comparisons were made within similar mechanisms of injury.6 Overall and within subgroups, bidirectional differences emerged across demographic, injury characterization, and outcomes during acute inpatient rehabilitation.6 A surprising finding was that 13% of the civilian cohort had a military history.6 However, years of duty and combat exposure were significantly less than the cohort enrolled in the VA TBIMS database. This is consistent with literature highlighting that service members in recent conflicts have had multiple and prolonged deployments relative to their predecessors and likely comprise a greater proportion of the military database.7 Further exploration of the civilian cohort with military history may help provide a larger or complementary sample of Veterans/service members with TBI who primarily use civilian healthcare. This study along with other articles in this issue suggests that military healthcare needs may not be fully informed by civilian-based studies. In combination with the Veteran cohort enrolled in the civilian TBIMS, joint analyses of both databases will help inform policy regarding the lifetime care needs of Veterans with TBI across healthcare settings for which VA is tasked.
Another key area of focus at the recent TBI SOTA meeting included addressing the needs of caregivers. The VA has created significant programming for caregivers, with a paucity of research to guide adaptation for military TBI.8 Two studies from the VA TBIMS database demonstrate the impact of military TBI on caregivers in the initial years following TBI.9,10 Bailey and colleagues9 were the first to highlight that 35% of Veterans and service members with moderate to severe TBI continue to require supervision (eg, monitoring for safety due to TBI sequelae) at 1 year postinjury, with 28% living in alternative settings (eg, institution, hospital setting). Service members and Veterans who were at greater risk for needing supervision were older (mean age = 35 years) and were among the more severely injured (longer posttraumatic amnesia duration, mean = 153 days).10 As the first article to address this specific rehabilitation outcome in a military sample, findings have implications for VA and DoD policies regarding provision of long-term care services and should inform the evolution of interventions needed to alleviate caregiver burden described by military families.11,12 The second article by Stevens and colleagues10 highlights that relationship status is primarily stable in the first 2 years postinjury. However, changes occurred in both positive (formation of new relationships) and negative directions (removal of a relationship) with novel associations. Thirteen percent experienced a positive change (ie, changed from single to married), with combat-related TBI being a significant predictor of this change. Furthermore, 22% experienced a negative change in status (eg, changed from married to single, divorced, or separated). Risk factors for negative changes or instability include younger age, lower education levels, and preinjury mental health utilization. With implementation of family support personnel (ie, family therapists) within VA settings, these findings may help stratify those in greater need of services within VA caregiver programming. Furthermore, the TBIMS database is replete with in-depth measures that may inform outcomes from VA caregiver programming. This is one illustration of the advantages of merging the VA TBIMS database with VA and/or DOD administrative data sets to evaluate TBI-specific programming in future research endeavors.
Enhancing lifetime care needs was a key theme across several tracks at the TBI SOTA conference. Three studies in this issue advance our understanding of care needs to promote health, quality of life, and community reintegration for Veterans and service members.13–15 Indeed, Tran and colleagues13 were the first to highlight the prevalence of rehospitalizations in the first year post–military TBI and how the nature of those readmissions varied from causes identified in the civilian literature. Rehabilitation readmission and causes not currently classified were the most common reasons for rehospitalization in the military cohort.13 Those injured during deployment and those with greater severity of TBI were more likely to be rehospitalized and have more frequent hospitalizations in the first year post-TBI. This finding underscores the importance of VA and DoD coordination of care in the first year following injury.13 Greater understanding of the specific military and Veteran medical and mental health needs requiring rehospitalization is needed. Next, Gause and colleagues14 cite unique predictors of quality of life in military service members that may help inform discharge planning and rehabilitation foci. Overall, preinjury mental health utilization is more prevalent in the VA TBIMS cohort,6 and this was associated with overall lower quality of life at 1 year post-TBI, along with older age and preinjury employment.14 Protective factors associated with higher quality of life included being active duty and married at the time of injury.14 Finally, Dillahunt-Aspillaga and colleagues15 reported approximately 20% returned to competitive employment in the first year post-TBI. Those vulnerable to poor outcomes included minorities and those with more severe injury requiring sustained focus on community reintegration.15 Collectively, these studies support ongoing investigation of the unique military healthcare and caregiver needs following TBI.
The VA TBIMS infrastructure is a resource for expanding research collaboration across the VA Polytrauma Rehabilitation Centers, DoD, and academia. The inclusion of TBI Common Data Elements across the injury severity spectrum is a resource for investigator-initiated research in studies examining areas relevant to military health. Indeed, several investigator-initiated studies have been funded using this infrastructure.16–19 In collaboration with Veterans and service members enrolled in the NIDILRR TBIMS database, many high priority research topics can be pursued across military, VA, and civilian settings. The articles in this issue along with past VA TBIMS articles highlight some important directions for research including:
- Novel treatments that target TBI sequelae resulting in ongoing supervision needs and high cost of institutionalization and exacerbation of caregiver burden.
- Earlier recognition of TBI comorbidities and lifestyle factors (eg, substance use, sleep disorders, tobacco use, obesity) that worsen outcome and increase cost of lifetime care.
- Emerging health and rehabilitation needs and their impact on outcome (eg, quality of life, functioning, community reintegration) in the years following TBI.
- The interaction of mental health (eg, posttraumatic stress disorder, depression, suicide, generalized anxiety) with TBI severity on outcomes including employment and family relationships.
- The understanding of long-term outcomes from deployment-related TBI and blast injury mechanisms.
These initial studies leveraging the VA TBIMS can help inform the next evolution to the Polytrauma System of Care created during this current global conflict. Commentary provided by Joel Scholten, MD, National Director of the Physical Medicine and Rehabilitation within VA, is evidence of promoting knowledge translation to improve Veteran and service member healthcare.20 Informing stakeholders of the value and findings of the VA TBIMS database is another step toward improving VA's healthcare for our nation's heroes with TBI.
1. Sigford BJ. “To care for him who shall have borne the battle and for his widow and his orphan” (Abraham Lincoln): the Department of Veterans Affairs Polytrauma System of Care. Arch Phys Med Rehabil. 2008;89:160–162.
2. Lamberty GJ, Nakase-Richardson R, Farrell-Carnahan L, et al Development of a TBI Model Systems within the VA Polytrauma System of Care. J Head Trauma Rehabil. 2014;29(3):E1–E7.
3. Dijkers MP, Harrison-Felix C, Marwitz JH. The traumatic brain injury model systems: history and contributions to clinical service and research. J Head Trauma Rehabil. 2010;25(2):81–91.
4. Publication Database of the TBI Model System National Dataset on the Model Systems Knowledge Translation Center Website. TBI Model Systems Publications. http://http://www.msktc.org
/publications?sys=T. Accessed April 14, 2017.
5. The John Warner National Defense Authorization Act (NDAA) for Fiscal Year 2007 (Pub Law No. 109-364).
6. Nakase-Richardson R, Stevens LF, Tang X, et al Comparison of the VA and NIDILRR TBI Model System cohorts. J Head Trauma Rehabil. 2017;32:221–233.
7. Institute of Medicine, Board on the Health of Select Populations, Committee on the Initial Assessment of Readjustment Needs of Military Personnel, Veterans, and Their Families. Returning Home From Iraq and Afghanistan: Preliminary Assessment of Readjustment Needs of Veterans, Service Members, and Their Families. Washington, DC: National Academies Press; 2010. Ebook 978-0-309-15285-3. https://doi.org/10.17226/12812.
8. Department of Veterans Affairs. VA caregiver support. https://http://www.caregiver.va.gov
/support/support_services. Updated February 10, 2017. Accessed April 26, 2017.
9. Bailey EK, Nakase-Richardson R, Patel N, et al Supervision needs following Veteran and service member moderate to severe traumatic brain injury: a VA TBI Model System study. J Head Trauma Rehabil. 2017;32:245–254.
10. Stevens LF, Lapis Y, Tang X, et al Relationship stability after traumatic brain injury among Veterans and service members: a VA TBI Model System study. J Head Trauma Rehabil. 2017;32:234–244.
11. Griffin JM, Friedemann-Sanchez G, Jensen AC, et al The invisible side of war: families caring for U.S. service members with traumatic brain injuries and polytrauma. J Head Trauma Rehabil. 2012;27:3–13.
12. Department of Veterans Affairs. Caregivers program. Final rule. Fed Regist. 2015;9:1357–1378.
13. Tran J, Hammond F, Dams-O'Connor K, et al Rehospitalization in the first year following Veteran and service member TBI: a VA TBI Model System study [published online ahead of print February 10, 2017]. J Head Trauma Rehabil. doi:10.1097/HTR.0000000000000296.
14. Gause LR, Finn JA, Lamberty GJ, et al Predictors of satisfaction with life in Veterans with traumatic brain injury: a VA TBI Model system study. J Head Trauma Rehabil. 2017;32:255–263.
15. Dillahunt-Aspillaga C, Nakase-Richardson R, Hart T, et al Predictors of employment outcomes in Veterans with traumatic brain injury: a VA TBI Model system study [published online ahead of print January 5, 2017]. J Head Trauma Rehabil. doi:10.1097/HTR.0000000000000275.
16. Patient Centered Outcomes Research Institute. Comparison of sleep apnea assessment strategies to maximize TBI rehabilitation participation and outcome. PCORI R-1511-33005. http://http://www.pcori.org
/research-results/2016/comparison-sleep-apnea-assessment-strategies-maximize-tbi-rehabilitation. Accessed May 7, 2017.
17. Veterans with mTBI: barriers to community reintegration. HSR&D SDR 13-228. https://http://www.cindrr.research.va.gov
/CINDRRRESEARCH/about/focus_areas.asp. Accessed June 15, 2017.
18. Improved Understanding of Medical and Psychological Needs (I-MAP) in Veterans and service members with chronic TBI. http://dvbic.dcoe.mil/research/improved-understanding-medical-and-psychological-needs-i-map-veterans-and-service-members. Accessed May 7, 2017.
19. Sleep-EEG Predictors of Functional Outcome After TBI. Washington, DC: VA RR&D 1 I21 RX001923-01A1. RR&D Brain Rehabilitation Research Center (BRRC). https://http://www.brrc.research.va.gov
/index.asp. Updated March 30, 2017. Accessed May 7, 2017.
20. Scholten J. Department of Veterans Affairs collaboration with Traumatic Brain Injury Model Systems program. J Head Trauma Rehabil. 2017;32:219–220.