Rehabilitation needs of combat-injured service members admitted to the VA Polytrauma Rehabilitation Centers: the role of PM&R in the care of wounded warriors.

OBJECTIVE: To describe the rehabilitation course of combat-injured service members who sustained polytraumatic injuries during the current wars in and around Iraq and Afghanistan. DESIGN: Retrospective descriptive analysis. SETTING: Department of Veterans Administration Polytrauma Rehabilitation Centers (PRCs). PARTICIPANTS: One hundred eighty-eight consecutive, acutely combat-injured service members suffering polytraumatic injuries requiring inpatient rehabilitation and being treated at PRCs between October 2001 and January 2006. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Medications prescribed, devices used, injuries and impairment information, and consultative services. RESULTS: Ninety-three percent of the patients had sustained a traumatic brain injury (TBI) and more than half of these were incurred secondary to blast explosions. Over half of the patients had infections or surgeries prior to PRC admission that required continued medical attention during their stay. Pain and mental health issues were present in 100% and 39%, respectively, of all patients admitted and added complexity to the brain injury rehabilitation process. Common treatment needs included cognitive-behavioral interventions, pain care, assistive devices, mental health interventions for both patients and their families, and specialty consultations, in particular to ophthalmology, otolaryngology, and neurology. CONCLUSIONS: Combat-injured polytrauma patients have complex rehabilitation needs that require a high level of specialized training and skill. Physical medicine and rehabilitation specialists treating war injured service members need a high level of expertise in assessment and treatment of co-occurring pain, TBI, and stress disorders. Physiatrists are playing an important role in providing and coordinating the rehabilitation care for individuals with significant polytraumatic war injuries from the Operation Enduring Freedom/Operation Iraqi Freedom (OEF/OIF) conflicts.

Veterans with history of mild traumatic brain injury and posttraumatic stress disorder: challenges from provider perspective.

The Department of Veterans Affairs (VA) has separate clinical structures and care processes for traumatic brain injury (TBI) and posttraumatic stress disorder (PTSD). However, because veterans are returning from the wars in Iraq and Afghanistan with TBI (most frequently mild TBI [mTBI]) and PTSD, the VA needs to evaluate current service delivery systems. We conducted key informant interviews with 40 providers from across the United States who represented separate clinical teams providing specialized TBI or PTSD services. We identified challenges providers perceive in scheduling and engaging patients with co-occurring mTBI and PTSD (mTBI/PTSD) in treatment, determining the etiology of patients' presenting problems, coordinating services, and knowing whether or how to alter standard treatments. We found consensus that patients with mTBI/PTSD often have other morbidities requiring specialized treatment, including pain and sleep disturbance. Another important theme we found was the need for patient and family educational material on mTBI/PTSD or pain and mTBI/PTSD and provider education tailored to provider specialty. Together, findings point to the need for guidance for providers on best practices to assess and treat mTBI/PTSD given available information, a systematic approach toward patient and provider education, and research to build the evidence base for practice.

Rehabilitation of traumatic brain injury in active duty military personnel and veterans: Defense and Veterans Brain Injury Center randomized controlled trial of two rehabilitation approaches.

OBJECTIVES: To determine the relative efficacy of 2 different acute traumatic brain injury (TBI) rehabilitation approaches: cognitive didactic versus functional-experiential, and secondarily to determine relative efficacy for different patient subpopulations. DESIGN: Randomized, controlled, intent-to-treat trial comparing 2 alternative TBI treatment approaches. SETTING: Four Veterans Administration acute inpatient TBI rehabilitation programs. PARTICIPANTS: Adult veterans or active duty military service members (N=360) with moderate to severe TBI. INTERVENTIONS: One and a half to 2.5 hours of protocol-specific cognitive-didactic versus functional-experiential rehabilitation therapy integrated into interdisciplinary acute Commission for Accreditation of Rehabilitation Facilities-accredited inpatient TBI rehabilitation programs with another 2 to 2.5 hours daily of occupational and physical therapy. Duration of protocol treatment varied from 20 to 60 days depending on the clinical needs and progress of each participant. MAIN OUTCOME MEASURES: The 2 primary outcome measures were functional independence in living and return to work and/or school assessed by independent evaluators at 1-year follow-up. Secondary outcome measures consisted of the FIM, Disability Rating Scale score, and items from the Present State Exam, Apathy Evaluation Scale, and Neurobehavioral Rating Scale. RESULTS: The cognitive-didactic and functional-experiential treatments did not result in overall group differences in the broad 1-year primary outcomes. However, analysis of secondary outcomes found differentially better immediate posttreatment cognitive function (mean+/-SD cognitive FIM) in participants randomized to cognitive-didactic treatment (27.3+/-6.2) than to functional treatment (25.6+/-6.0, t332=2.56, P=.01). Exploratory subgroup analyses found that younger participants in the cognitive arm had a higher rate of returning to work or school than younger patients in the functional arm, whereas participants older than 30 years and those with more years of education in the functional arm had higher rates of independent living status at 1 year posttreatment than similar patients in the cognitive arm. CONCLUSIONS: Results from this large multicenter randomized controlled trial comparing cognitive-didactic and functional-experiential approaches to brain injury rehabilitation indicated improved but similar long-term global functional outcome. Participants in the cognitive treatment arm achieved better short-term functional cognitive performance than patients in the functional treatment arm. The current increase in war-related brain injuries provides added urgency for rigorous study of rehabilitation treatments. (http://ClinicalTrials.gov ID# NCT00540020.).

"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.

The initiation of combat in Iraq and Afghanistan has resulted in a new cohort of active-duty service members and veterans seeking rehabilitation care through the U.S. Department of Veterans Affairs (VA). Service members injured in combat most often sustain multiple injuries (polytrauma) and require a unique service delivery model to meet their needs. The VA recognized this need and responded with the development of the Polytrauma System of Care (PSC). This national system of care balances access and expertise to provide specialized life-long care to the combat injured. The PSC is comprised of: 4 specialized regional rehabilitation centers that are accredited in brain injury by the Commission on Accreditation of Rehabilitation Facilities; 21 specialized outpatient and subacute rehabilitation programs; designated polytrauma teams at smaller, more remote VA facilities; and a point of contact at all other VA facilities. In addition, the PSC has developed a proactive case-management model, a specialized telehealth network, guidelines for long-term follow-up, and services for those individuals who are unable to return home. The following commentary and articles provide additional detail on this new and unique system of care.