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Traumatic Brain Injury within the VHA and DoD Systems of Health Care Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April.

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Presentation on theme: "Traumatic Brain Injury within the VHA and DoD Systems of Health Care Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April."— Presentation transcript:

1 Traumatic Brain Injury within the VHA and DoD Systems of Health Care Rodney D. Vanderploeg, Ph.D. Tampa VAMC VA Psychology Leadership Conference/APA April 2006

2 Objectives  Describe the DoD/VHA system of specialized TBI care for active duty and veterans  Briefly describe TBI, and its incidence, severity, time course of recovery, and treatment stages  Describe the role of psychology and neuropsychology in TBI evaluation and care

3 Defense & Veterans Brain Injury Center Defense & Veterans Brain Injury Center Education Clinical Care Research Prevention Established in 1992

4 Defense & Veterans Brain Injury Center  Multi-site Center  Collaboration of Department of Defense & Department of Veterans Affairs  Established in 1992  Congressionally funded  Mission: Clinical Care, Clinical Research, and Education

5 Director Deputy Dir Center HQ SupportAdvisorsResearchClinical CareEducation DoD VA VaNC Provider Consumer Doctor/ Therapist Medic Family/ Caregiver Patient Registry Rehabilitation Pharm/Neurobehavior Concussion Defense & Veterans Brain Injury Center (DVBIC)

6 Defense & Veterans Brain Injury Center  3 Military Sites  4 VA Sites  1 Civilian Partner Program

7 Defense & Veterans Brain Injury Center  Military Sites Walter Reed Army Medical Center (Head Quarters) Walter Reed Army Medical Center (Head Quarters) Naval Medical Center, San Diego Naval Medical Center, San Diego Wilford Hall US Air Force Med Ctr Wilford Hall US Air Force Med Ctr

8 Defense & Veterans Brain Injury Center  VA Sites Minneapolis VA Medical Center Minneapolis VA Medical Center Palo Alto Health Care System Palo Alto Health Care System Richmond VA Medical Center Richmond VA Medical Center Tampa VA Medical Center Tampa VA Medical Center  Civilian Partner Program Virginia NeuroCare, Charlottesville Virginia NeuroCare, Charlottesville

9 VHA TBI Network of Care  4 Lead TBI Centers  16 Network Sites  7 Associate Network Sites

10 * * * * Minneapolis Tampa Richmond Palo Alto VHA TBI Network of Care: Four Lead TBI Rehabilitation Sites

11 Interdisciplinary Team and Interdisciplinary Rehab Approach  Rehab Medicine physician  Rehab nurses (primary nurse model)  Physical, Occupational, Recreational, and Vocational Therapists  Speech Therapists  Social Workers  Case Managers (including long-term)  Rehab or Counseling Psychologists  Neuropsychologists

12 Inpatient Acute Rehabilitation  3-5 hours of therapies per day (OT, PT, SP, Recreational, Psychology)  Average length of stay 1-3 months  Therapies include community outings planned and organized by the TBI patients together with the therapists  Case management begins before patients arrive and includes contacting families  Case management continues following discharge, may last for years

13 Other Lead TBI Center Programs  Low level or coma program: Only for those with acute coma, NOT long-term coma or vegetative state care  Short-stay admissions for: Evaluation and treatment planning Evaluation and treatment planning Treatment trials Treatment trials Re-evaluation Re-evaluation Vocational evaluations Vocational evaluations  Respite Care upon occasion

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15 Traumatic Brain Injury  Insult to the brain caused by an external physical force  Produces a diminished or altered state of consciousness  Results in impairments in physical, cognitive, behavioral, and/or emotional functioning

16 Glasgow Coma Scale Motor Response Obeys commands Localizing responses to pain Generalized withdrawal to pain Flexor posturing to pain Extensor posturing to pain Extensor posturing to pain No motor response to pain No motor response to pain654321 Verbal Response Oriented Confused conversation Inappropriate speech Incomprehensible speech No speech 54321 Eye Opening Response Spontaneous eye opening Eye opening to speech Eye opening to pain No eye opening 4321 Coma52 __1_ < 8 GCS Mild TBI = 13 - 15 Moderate TBI = 9 – 12 = 9 – 12 Severe TBI = 3 - 8

17 Post-traumatic Amnesia  The time interval from when the person regains consciousness until he or she is able to form memories for ongoing events  The individual is not fully oriented, typically confused, and unable to remember information after a period of distraction

18 Criteria for Severity of TBI MildModerateSevere LOC < 30 min with normal CT &/or MRI LOC < 6 hours with abnormal CT &/or MRI LOC > 6 hours with abnormal CT &/or MRI GCS 13-15 GCS 9-12 GCS 3-8 PTA < 24hr PTA < 7days PTA > 7days

19 3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems

20 Traumatic Brain Injury  Types of TBI Open vs. Closed Open vs. Closed  Etiology Motor vehicle accidents Motor vehicle accidents Falls, assaults, gun shots to the head Falls, assaults, gun shots to the head Explosive Blasts (Iraqi conflict) Explosive Blasts (Iraqi conflict)  Demographics Males > Females Males > Females Peak ages of incidence: Peak ages of incidence: 1-5 yrs; 15-24 yrs; >75 yrs

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22 Civilian Incidence of TBI  General Population 1.5 Million Americans per year 1.5 Million Americans per year 91 per 100,000 91 per 100,000 > Stroke, Spinal Cord Injury, MS > Stroke, Spinal Cord Injury, MS Prevalence: 5.3 million with TBI disability Prevalence: 5.3 million with TBI disability

23 Military Incidence of TBI  Military and Veterans 7,000 peacetime admissions annually 7,000 peacetime admissions annually Active Duty males: 225 per 100,000 Active Duty males: 225 per 100,000 Active Duty females: 150 per 100,000 Active Duty females: 150 per 100,000

24 Blast Induced Brain Injury  Rats exposed to whole body blasts (overpressurization waves) & to focal blasts to torso while head protected had cognitive dysfunction (Cer nak et al. 2001)  Clinical characteristics of blast TBI in humans not well described in literature

25 War Injuries: Explosive Blasts  Most common cause of injury  64% of war injuries caused by blasts  41% of blast injured at WRAMC had TBI ( 01/05 - 02/06 )  85% closed head injury

26 Key Iraq wound: Brain trauma By Gregg Zoroya, USA TODAY “A growing number of U.S. troops whose body armor helped them survive bomb and rocket attacks are suffering brain damage as a result of the blasts. It's a type of injury some military doctors say has become the signature wound of the Iraq war.” Shaun Radhay, a Marine, suffered brain damage and other injuries in a mortar blast. By H. Darr Beiser, USA TODAY

27 Consequences of TBI  Cognitive Attention Attention Information processing (speed & efficiency) Information processing (speed & efficiency) Memory and Learning Memory and Learning Abstract Reasoning Abstract Reasoning Executive Functions Executive Functions Problem solving, planning, insight/awareness, set shifting, sequencingProblem solving, planning, insight/awareness, set shifting, sequencing

28 Consequences of TBI  Behavioral-emotional Irritability Irritability Impulsivity Impulsivity Affect Regulation: apathy, agitation, aggression Affect Regulation: apathy, agitation, aggression Depression, Anxiety Depression, Anxiety Social Pragmatics Social Pragmatics Cognitive and behavioral impairments are the most disabling long-term, more so than physical injuries

29 Psychology-Related Assessment Issues  Determining original severity of injury  Identifying past and present treatment, and the success or lack thereof  Neuropsychological evaluation of current functioning  Psychological functioning: Axis I & II, and coping resources  Identifying and assessing family and systems issues

30 Neuropsychological Assessment  Focus on Memory and Executive problems  Core (Brief) DVBIC Battery WTAR (Wechsler Test of Adult Reading) WTAR (Wechsler Test of Adult Reading) CVLT-II CVLT-II Brief Visuospatial Learning Test – Revised Brief Visuospatial Learning Test – Revised Letter-Number Sequencing (working memory) Letter-Number Sequencing (working memory) D-KEFS Verbal Fluency (letters and semantic) D-KEFS Verbal Fluency (letters and semantic) Design Fluency Design Fluency Trails A and B Trails A and B WCST-64 WCST-64 Grooved Pegboard Test Grooved Pegboard Test

31 Treatment Considerations  Treatment varies based upon: Severity of injury Severity of injury Time since injury Time since injury Constellation of impairments Constellation of impairments

32 Mild TBI: Overlapping Symptoms across Conditions  Postconcussion Syndrome (PCS) Insomnia Insomnia Impaired memory Impaired memory Poor concentration Poor concentration Depression Depression Anxiety Anxiety Irritability Irritability Headache Headache Dizziness Dizziness Fatigue Fatigue Noise/light intolerance Noise/light intolerance  PTSD Insomnia Insomnia Memory problems Memory problems Poor concentration Poor concentration Depression Depression Anxiety Anxiety Irritability Irritability Stress symptoms Stress symptoms Emotional numbing Emotional numbing Avoidance Avoidance

33 Predisposing FactorsCausative FactorsPerpetuating and Mitigating Factors Self- Expectation mTBI Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Demographic Characteristics Medical Iatrogenesis Litigation Iatrogenesis Acute Symptoms Chronic Symptoms Psychiatric Conditions Personality Traits Medical Conditions Intelligence Level Coping Abilities Social Support Coping Abilities

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36 3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems Mild TBI Interventions Psychological Support, Psychotherapy, Existential Issues, Family Issues

37 3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems Acute Specialized Brain Injury Rehabilitation Psychological Support, Psychotherapy, Existential Issues, Family Issues For those with Moderate to Severe Injuries

38 3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems Subacute Rehab, Outpatient Therapies, Day Treatment, or Community Re-Entry Programs Psychological Support, Psychotherapy, Existential Issues, Family Issues

39 3 Cognitive LevelCognitive Level Preinjury Functioning PTA Coma INJURYINJURY Retro- Grade Amnesia Months 6 9 12 Mild TBI Moderate TBI Severe TBI Ongoing Cognitive Problems Brief PTA PTA Ongoing Cognitive Problems Vocational Rehabilitation and/or Ongoing Case Management Psychological Support, Psychotherapy, Existential Issues, Family Issues


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