Polytrauma Support

Clinic Team

Polytrauma and Traumatic Brain Injuries

Zablocki VA Medical Center

Milwaukee, Wisconsin

August 19, 2010

Objectives

• To introduce the VHA Polytrauma System of

Care

• To learn about combat related Polytrauma and

Traumatic Brain Injury conditions

• To appreciate the complexities of diagnosis

and management of post deployment health

and reintegration issues facing returning

soldiers and families

Polytrauma Injuries and TBI

Evaluation: Milwaukee

Polytrauma Support Clinic Team

Judith B. Kosasih, M.D.

Director, Polytrauma Support Clinic Team,

Zablocki VAMC

Associate Professor, PM&R,

Medical College of Wisconsin

“To Care For Him Who Shall Have

Borne the Battle, And For His Widow

and Orphan”

- Abraham Lincoln

How close does a soldier have to be to

a blast to cause an injury?

The answer is that we don’t know……

Background • New war, new injuries, new generation of veterans, new

system of care

• 90% of soldiers injured in combat are surviving

• Blast exposure has become the most frequent cause of combat related injury

• TBI is often referred to as the ―signature injury of the war‖

• Many of those returning from current combats had IED/blasts events, that put them AT RISK for TBI

• Symptoms of mild TBI may be difficult to recognize, or confused with other overlapping conditions

Implementation of the VA

Polytrauma System of Care

February 05: Four Polytrauma Rehabilitation Centers

December 05: 22 Polytrauma Network Sites

March 07:

80 Polytrauma Support Clinic Teams,

50 Polytrauma Points of Contact

1992: VHA TBI Lead Centers Selected

July 06: Polytrauma Telehealth Network

April 07: TBI Screening

http://www.va.gov/

VISN 12 Polytrauma System of Care

• Regional Polytrauma Rehabilitation Center – Minneapolis VAMC (Component I)

• VISN 12 Polytrauma Network Site (PNS) – Hines VAH (Component II)

• VISN 12 Polytrauma Support Clinic (Component III)

– Milwaukee VAMC

– Madison VAH

– Jesse Brown VAMC

– North Chicago VAMC

– Tomah VAMC

• VISN 12 Polytrauma Point of Contact – Iron Mountain VAMC (Component IV)

Polytrauma Support Clinic Team

VISN 12: Zablocki VA Medical Center

• Director: Judith Kosasih, MD, Physiatrist

• Neuropsychologist: Thomas Hammeke, Ph.D.

• Point of Contact: Jennifer Kiefer, MSW

• Nurse Practitioner: Susan Giulianetti, APN, BC

• Physiatrist: Merle Orr, MD

• Psychologist: Peter Graskamp, PhD

• Speech Pathologist: Terilynn Nitschke, MS-CCC

• Physical Therapist: Jennifer Batie Mueller, P.T.

• Occupational Therapist: Mary Van Derven, OTR

TBI initiatives • VHA Directive 2007-013

• Policy and procedure for screening and evaluation of possible Traumatic Brain Injury in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans

• TBI Screening Clinical Reminder • Activated April 2, 2007

• TBI Performance Measures • To ensure that all returning soldiers presenting for

care at a VA facility are screened and evaluated for possible TBI

• TBI National Database/Tracking System • Activated June 2008

426,413 Total OEF/OIF Veterans Screened

79,754

21,292

Veterans Consenting to Further Evaluation (94.9%)

Mandatory TBI Screening Results

14 April 2007 – 31 May 2010

84,008

12,583

Veterans Requiring Further Evaluation (19.7%)

Veterans with Self Reported Prior TBI (3.0%)

TBI Confirmed (54.7%)

TBI Ruled Out Diagnosis Pending

58,781 Veterans Completed Comprehensive Evaluation (73.7%)

32,148

26,391

242

Sources of TBI During Combat

• Blast Injuries—Limited or no physical signs

– Improvised Explosive Devices (IED), Rocket

Propelled Grenades (RPG) , Mortars

• Impact Injuries-Physical injuries noted

– MVC, Bullets, Falls/Accidents

• Each incident can potentially cause multiple

system injuries.

POLYTRAUMA

• Defined as:

– ―two or more injuries to physical regions or

organ systems, one of which may be life

threatening, resulting in physical, cognitive,

psychological, or psychosocial impairments

and functional disability.‖

• Blast injuries are often polytraumatic,

given the various mechanism of injury

POLYTRAUMA

• Multi-Dimensional injuries, unique in this population.

• TBI frequently occurs in polytrauma combat injuries in combination with other disabling conditions such as: – Amputation

– Auditory and visual impairments

– Nerve injuries, burns, musculoskeletal, complex fractures

– Chronic pain

– Spinal Cord Injury

– PTSD (Post Traumatic Stress Disorder) and other mental health conditions.

Post-Deployment Syndrome

• 5-20% OEF-OIF Service members are returning with

persistent physical and psychological symptoms after

combat exposure.

• Controversies concerning etiology of symptoms

– Blast exposure

– Post-concussive syndrome

– Post-traumatic stress disorder

– Depression

– P3+ (PTSD, Polytrauma, Polysubstance Use, Pain)

– Environmental factors

– Impact of multiple exposures (blast, trauma)

POLYTRAUMA CLINIC

• The setting for comprehensive TBI evaluation and other polytrauma issues.

• Team approach, directed by PM&R physicians.

• Interdisciplinary PSCT team: Physiatrist, Neuropsychologist, Social Worker, Nurse Practitioner, Psychologist, Physical Therapist, Occupational Therapist, Speech and Language Pathologist.

TBI/Polytrauma Evaluation • DIAGNOSIS: mild TBI = Concussion

– Determine if TBI occurred

– Evaluate symptoms and determine, if possible, the etiology of residual symptoms (TBI, mental health, or combination)

– Describe the functional impairments

• Evaluate other Polytrauma injuries

• Specialty Consults: Mental Health, Neurology, Eye/Optometry, Audiology, Visual Impaired Service, Electrodiagnosis, ENT, Orthopedic, Plastic, etc.

• Integration and coordination of treatments and resources.

Comprehensive Evaluation

• Physical problems

• Cognitive deficits

• Emotional/behavioral issues

• Community reintegration • Money management

• Employment

• School/Academic

• Recreational activities

• Family/Significant Other

• Social interaction

• Psychosocial complexity

Diagnostic Challenges

• Reliance on self-report history; limited supporting documentation and baseline clinical information

• Non-specific diagnostic criteria, normal imaging, normal neurological exam

• Often difficult to confirm/make a mTBI diagnosis

What causes the prolonged symptoms

reported by many soldiers

– Overlapping symptoms: symptoms may

be due to multiple sources

• Due to mTBI only

• Due to mTBI and adjustment stress

• Due to mTBI and PTSD or depression

• Due to premorbid difficulities

–Started prior to military; possibly

exacerbated by the combat duty

Sources of Sustained Residuals • Severity, multiple incidence, and mechanism of

TBI

• PTSD

• Prior history of psychiatric distress (depression/anxiety)

• Military onset of psychiatric distress

• Drug use (especially cocaine and marijuana)

• Alcohol abuse

• Previous brain/head injury

• Previous childhood learning conditions (LD, AD/HD)

• Chronic and/or acute pain

Potential Clinical Presentation

Attentional

problems

Depression

Flashbacks

Nightmares

Anxiety

PTSD

Dizziness

TBI

Headaches

Irritability

Insomnia

PTSD

N=232

68.2% 2.9%

16.5%

42.1%

6.8%

5.3%

10.3%

12.6%

TBI

N=227

66.8%

Chronic

Pain

N=277

81.5%

Prevalence of Chronic Pain, PTSD and TBI

in a PNS clinic sample

Lew et al., (2009). Prevalence of Chronic Pain, Posttraumatic Stress Disorder and Post-

concussive Symptoms in OEF/OIF Veterans: The Polytrauma Clinical Triad. Journal of

Rehabilitation Research and Development, 46, 697-702.

N = 340

PTSD Re-experiencing

Avoidance

Social withdrawal

Memory gaps

Apathy

Mild TBI Residua

Difficulty with decisions

Mental slowness

Concentration

Headaches

Dizzy

Appetite changes

Fatigue

Sadness

Suicidality

Altered Arousal

Sensitive to noise

Concentration

Insomnia

Irritability

Depression

Substance

Use (Poly)

Pain

Medication effects

Pain

PTSD

Mild TBI

Depression

Anxiety

Pain

Substance Use Disorder

Physical Injuries

Deployment Stress &

Post-Deployment

Re-Adjustment

Who are the OEF/OIF patients?

29

Blast Exposure

TBI

Depression

PTSD

Marital Stress

Medical Diagnosis Impairment in Function and

Social Reintegration

Musculoskeletal

Pain

Deficits in

Social Role

Functioning

Vocational

Challenges Financial

Stress

So what can be done to ameliorate symptoms

and encourage successful reintegration in

soldiers

Early Identification & Intervention Education of Expected Recovery Proactive Reintegration Efforts

Early Identification

• DOD – Field evaluations

– Military Treatment Facilities

• DOD and VA Liaisons

• VA

– TBI screening

– Polytrauma/TBI system of care

• Private Sector collaboration

Early Intervention

• Value of Early Intervention

– Improves short and long term outcomes

– Education/positive reassurance

– Symptoms treatment: analgesics, antidepressants, sleeping aid/sleep hygiene, psychological intervention

– Cognitive remediation/compensatory strategies

– Care coordination/Case management

– Close follow-up/monitor progress: symptoms, life/job performance

Education of Expected Recovery

• Post Traumatic Growth:

– ―… emphasizing the potential for FULL RECOVERY

may minimize the unnecessary attribution of common

stress reactions to pathology and facilitate resilience

after mild TBI.‖

– Richard A. Bryant, PhD

PTSD specialist, University of New South Wales,

Australia

---Tom Valeo, Neurology Today, March 20, 2008

Proactive Reintegration Efforts

• Community Reintegration: • Vocational Rehabilitation

• Work Hardening program

• Recreation/Exercise, Recreation Therapist

• Psychosocial/Family support and resources

• Adaptive equipments: PDAs, recorders, etc.

• Active duty/reserve: • Redeployment/return to combat

Resources • Women’s Health Clinic: female focused

treatment in women’s clinic – Wellness Fair for women’s veterans

• OEF/OIF Connection Team (Outreach)

• Homeless Veteran program – HUD/VASH: Housing & Urban Development/VA

Supportive Housing Program

• Caregiver Support Program

Initiatives/Resources

• VA initiatives: – Staff Education and Communication

• Conferences, Teleconference calls, Live meetings

• VHI: TBI Independent Study Course: April 2010

– Patient Education • Study skills group, Sleep education group,

Pain school

• Family support: children/spouse education materials

– Innovative treatments • Heart Math biofeedback

• Battle –body retraining: relaxation training (Yoga)

• Wii games

– Telehealth rehabilitation

37

RECOVERY CONTINUUM

RESILIENCE CONTINUUM

Medical

Physical

Social

Mental

Occupational

Cognitive

Rehabilitation

Future Directions • Research opportunities:

– Blast related conditions: diagnostic imaging, pathophysiology, etc.

– Polytrauma Pain

– Post traumatic headaches

– Sensory: Visual and hearing issues

– Advances in prosthetic devices

– Telehealth Rehabilitation initiatives

• Local:

– Zablocki VAMC Advanced Low Vision Outpatient Clinic

• National:

– New: VHA Interprofessional Polytrauma/TBI Rehabilitation Clinical Fellowship

– New: VHA Amputation System of Care

– VHA PM&R Transitional Rehabilitation (PMRTR) program

– VHA TBI Specific Ocular Health and Visual Functioning Examinations for Polytrauma Rehabilitation Center Patients

– Post Deployment Care Initiatives

Website resources

• vaww1.va.gov/rehab4veterans (VA PM&RS)

• www.biaw.org (Brain Injury Assoc. of Wisconsin)

• www.neuro.pmr.vcu.edu (National resource

Center for Traumatic Brain Injury)

• www.pdhealth.mil/TBI.asp (Deployment Health

Clinical Center (TBI)

• www.va.gov/health_benefits (VA Benefits)

• www.vetsuccess.gov (Voc Rehab and

Independent Living Services)