CDMRP Investigator Vignette

Title: Tele-Rehabilitation for OIF/OEF Returnees with Combat-Related Traumatic Brain Injury

Investigators: Kris Siddharthan, PhD and Steven Scott, DO; James A. Haley VA Medical Center

Siddharthan: My initial interest in traumatic brain injury started with a grant that I received from the Veterans' Administration to study blast-related explosions and its sequelae with troops coming back from combat theaters in Afghanistan. And we noticed that one of the signature wounds of this war is going to be traumatic brain injury, and that's what got me interested in epistemology and the etiology of traumatic brain injury among returning Veterans.

The challenges facing our soldiers are manifold. One of the problems we have is when they are wounded they have to be evaluated quickly as to whether they go back to combat or are in fact sent back to the United States for treatment. This could be a difficult problem because detecting traumatic brain injury is very difficult, and frequently soldiers live with the burden of both the disease and its consequences such as PTSD. And they have to finish their tours, and only when they come back to the United States do they realize that there's something wrong with them and seek help.

Scott: One of the functions of the VA is that we take care of everyone from, they say, when they enlist to the grave. Our mission is to take those who are disabled and have tremendous impairment, and give them back their independence, give them back their freedom. That's what we're here for, to give them the support mechanisms, give them the tools and the rehabilitation in aspects so that they can go on and live their lives as full as they can.

Siddharthan: I've had two grants with CDMRP. The first one was to follow here at the James A. Haley, which is one of the polytrauma centers in the country, a cohort of approximately 60 wounded Veterans who have mild or moderate traumatic brain injury and see if care coordination can improve the quality of care that they receive here.

And the second grant is using two sides, that's both Miami as well as the Tampa VA, to study an even larger cohort of approximately a hundred Veterans equally divided between a group that receives the intervention and a control group that receives the usual care from the VA.

Scott: When you rehabilitate people in a hospital setting or a rehabilitation setting, they're in a very structured environment. And when people have head injuries in a structured environment, it's fairly simple to keep following the numbers; you know one, two, three, four... When they leave that structured environment and go into the home setting, when they leave that structured environment and go out into the community, it's nonstructured. And with that, head injuries have their major problems. Their lives are disorganized. That's when the difficulties and the disabilities start to appear. So if you could imagine yourself with a head injury, and the kids are yelling the TV's on, the phone rings, someone's running down, and how do you manage all that? You know. And how do you manage the problems with that? How do you manage if you haven't slept the last three nights because you didn't have the right medication? How do you manage that you suddenly have a severe headache? And all these things are hitting your mind at the same time and you can't process it. That's where the issues come up. And that's why a program where we can then continue to manage and care and rehabilitate them in a different environment, you know, with this system, and try to monitor and change that, is what the strength of the study is.

Siddharthan: Basically what the Veterans do is report their symptoms and report all their conditions through the nurse practitioner who then provides the care coordination. On a number of occasions we found out that Veterans have ailments that are not contained in their medical charts. In other words, they were not reported. We have one Veteran, for example, who suffers from epileptic disorders, and it was only by chance that he mentioned that he had a seizure and this caused the nurse to go into his chart and find out that he didn't, in fact, report it. And we treated him for the same. So, uncovering missed diagnoses and so on has been a priority for us.

We use a number of instruments that we post online that they have to fill in. They also use secure messaging by our VA main system to communicate frequently with our care providers, who then decide what the best course of action is with respect to treating them.

Scott: Head injuries are different too; they always say it's like a snowflake. Everyone's a little different, because everyone's a little different in our personalities and behavior. And therefore, you can't just go by a textbook. You can't just go by a clinical pathway, you know, and say well if you have this, this, this...you can do that a little bit...but you have to have that experienced person at the other end that knows the individual, knows the family, and can redirect them in that too. So you can see to have that ability to cause is a safety, it gives you confidence, it also helps you redirect your day in that course, you can get immediate attention either at home or you can bring him back in, which is not uncommon. But more importantly, it can also be to reassure their positive behaviors that day, and positive things.

Siddharthan: What we have noticed is something very interesting. We have noticed that those people who have TBI alone without a comorbid condition of PTSD do very well. However, those who have traumatic stress disorders resulting from the injury, resulting from their actions in war, find it much more difficult with respect to their cognition, with respect to integrating in society, holding employment, and so on. That's our biggest challenge in treating them because we find that the cohort with TBI after some time stabilize with their symptoms; however, the ones with PTSD appear to be behind the curve in rehabilitation.

Those who have a comorbid condition of PTSD tend to follow two categories. Ones who can be rehabilitated over time, but a very small group who needs immediate and urgent care because these people have suicidal tendencies, have anxiety problems, and major issues with anger management. And unless and until we provide them intensive and timely care, they are liable to hurt themselves or others in society.

At least on one occasion, our care coordinator here was able to intervene in a timely manner and possibly prevent one of our Veterans from taking his own life due to timely action.

Scott: We think this is the direction to go, you know. And the direction of care, the direction of improving people's lives, the direction and mechanism we should put as part of the pathway and the continuum that we see. You know we concentrate a lot on the trauma component of the war, how to get people off the battlefield, how to control their bleeding, how to control and keep them alive. What about the other end? What do you do when you keep them alive? You know, and this is just another step in the puzzle here. It's a big step, because it's back in the home and in the community.