Woods Traumatic Brain Injury Symposium

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1 Woods Traumatic Brain Injury Symposium Veterans Health Affairs (VHA) Polytrauma/Traumatic Brain Injury (TBI) System of Care Philadelphia, PA September 28, 2013

2 VHA/Polytrauma/TBI Program: Presenters Keith M. Robinson, MD, Chief of Rehabilitation, Philadelphia VA Medical Center, and Associate Professor of PM&R, Perelman School of Medicine at Penn Paolo Nucifora, MD, PhD Neuroradiologist, PVAMC and UPHS, and Assistant Professor of Radiology, Perelman School of Medicine at Penn

3 VHA/Polytrauma/TBI Program: Presenters Elizabeth Whipple, MS, Doctoral Student, Department of Psychology, Drexel University Helene Moriarty, PhD, Research Nurse, PVAMC, and Professor, College of Nursing, Villanova University

4 The Polytrauma/TBI System of Care: Clinical Challenges/Research Questions 1. Fusing cultures of rehabilitation and behavioral health: providing rehabilitation to veterans who have concurrent major psychopathology 1. Diagnosis of TBI when there is concurrent PTSD.

5 The Polytrauma/TBI System of Care: Clinical Challenges/Research Questions 3. The cerebral neuropathology associated with blasts may be more widespread than when there are other mechanism of TBIs. 4. Including the social support system as part of treatment within a culture at the VA that has been historically disinclined to do so.

6 The Polytrauma/TBI System of Care: Clinical Challenges/Research Questions 5. Self-medication of TBI and PTSD symptoms with alcohol and drugs. 6. Increased risk of homelessness among those who have concurrent TBI and PTSD.

7 The Polytrauma/TBI System of Care: Clinical Challenges/Research Questions 7. Problematic issues during transition to civilian life: -driving behaviors; -negotiating normal younger adult growth and development after the fact of military deployments.

8 What is Polytrauma? At least 2 organ systems are impaired: -Musculoskeletal/Chronic pain -Psychological/Behavioral -Neurological (TBI) A higher level of medical complexity and a need for rehabilitation services is inferred. Signature constellation: mild TBI + PTSD + chronic pain disorders + opioid/alcohol self-medication.

9 Traumatic Brain Injury in the Military Up to 20% returning veterans from Iraq/Afghanistan combat theaters = new TBIs, that is, > 320K of almost 3 million deployed individuals; >90 % have mild severity; Blasts++ (>60%) more predominant mechanisms of injury until recently (now more non-blasts/civiliantype injuries, e.g., falls, motor vehicle collisions); Brain damage from blasts may be more widespread; airfluid interface between the environment and the brain may augment the blast wave;

10 TBI in the Military 50% of these confounded by major psychopathology: post traumatic stress disorder (PTSD), depression, anxiety; 20% of TBIs have PTSD/30% of those with PTSD had concussive symptoms; Mild TBI may increase risk of, and persistence of PTSD symptoms.

11 Polytrauma/TBI System of Care: National Perspective Congressionally mandated in 2005; Evolved since 2006; Usually situated within Rehabilitation Departments and guided by a rehabilitation philosophy, and located at every VA medical center; Top down organization: -5 Polytrauma Rehabilitation Centers: Richmond, Tampa, San Antonio, Minneapolis, Palo Alto (specialized acute inpatient to short term residential program; -23 Polytrauma Network Centers: one for each region/veterans Integrated Service Network or VISN; -87 Polytrauma Support Clinic Teams; -39 Polytrauma Points of Contact.

12 Polytrauma/TBI System of Care: Utilization During veterans treated at PRCs: 80% community discharges having FIM scores > 90/126 with average LOS of 46 days; 78,502 outpatient encounters at PNSs including 14,469 new encounters; 32,709 veterans received rehab services specifically for TBI.

13 Polytrauma/TBI System of Care: Philadelphia Philadelphia VA Medical Center serves as the Polytrauma Network Site for VISN 4: encompasses 10 medical centers across Pennsylvania, northern West Virginia, Delaware, and southern New Jersey 8 Polytrauma Clinic Teams and 1 Polytrauma Point of Contact. Since 2006, Philadelphia has received about 2000 referrals: 1000 contacts; 600 diagnosed with mild TBI; 200 actively being case-managed at any one time. Inclusive of all veterans and no longer specific to post-9/11 veterans.

14 Polytrauma/TBI System of Care: Uniform and Monitored Processes -Front line screening mechanism that triggers rehabilitation referral; -Mandate to make contact with referred veterans within 14 days, and to have comprehensive evaluation within 30 days;

15 Polytrauma/TBI System of Care: Uniform and Monitored Processes -Use of standardized tools to assess/monitor for: -Persistent post concussive symptoms: Neuropsychological Inventory (NPI); -Program outcome: Mayo-Portland Adaptability Index-4; -Weekly team meetings: articulation and follow-up of a explicit rehabilitation plan of care.

16 Polytrauma Core Rehabilitation Team in Philadelphia Physiatry/Psychiatry PT/OT/SLP/Nursing Psychology/Neuropsychology Recreation Therapy Case Management via Social Work Program Coordinator Blind Outpatient Rehabilitation Specialist

17 Polytrauma/TBI: Research Program in Philadelphia Stable and growing clinical populations that are relatively homogenous; Focused themes across the major rehabilitation levels of assessment and treatment impairment..functional integration..environment; Develop the careers of junior colleagues and faculty.

18 Polytrauma/TBI Research in Philadelphia Impairment Level: -Structural characterization of blast-induced brain injuries in those who have PTSD using MRI/diffuse tensor imaging Nucifora -Exploration of use of cognitive/motor assessment to predict later development of neurodegenerative

19 Polytrauma/TBI Research in Philadelphia Functional/Integrative Level: -Development of idiosyncratic driving questionnaire for veterans with concurrent mild TBI and PTSD Whipple/Schulteis/Drexel -Development of videogames to remediate cognitively working memory for veterans with mild TBI using a virtual reality interface Burdea/Rutgers.

20 Polytrauma/TBI Research in Philadelphia Environmental level: -TBI caregiver assessment then home occupational therapy-based psychoeducational interventions Moriarity/Winters/Piersol/Vause- Earland/Jefferson.

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