Telerehab for TBI Shows Promise, Comorbid PTSD Remains Problematic

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BETHESDA, MD—There is a pressing need to understand what the rehabilitation trajectories are going to be for those servicemembers returning with mild and moderate TBI, according to Kris Siddharthan, PhD, a health services researcher at the James A Haley Veterans’ Hospital in Tampa, FL. In a presentation at the 3rd Annual Trauma SpectrumConference last month, Siddharthan cited that “When the war first started, we misunderstood very much what the complications were going to be for this group.”

VA is discovering that, while most mild and moderate TBI symptoms are acute, there are some patients who continue to have persistent symptoms, for which they need life-long monitoring and therapy. Further complicating treatment is the fact that frequent treks to the nearest VA medical center can be a considerable burden for most veterans.

In 2008, Siddharthan and his fellow researchers began recruiting 75 OEF/OIF veterans with mild to moderate TBI to test out a telerehabilitative intervention for TBI. The intervention emphasizes care coordination, with a group of physicians, including a primary care physician, psychiatrist, psychologist, and rehab specialists, working together to determine the patient’s course of treatment.

Patients have to communicate at least once weekly with a full-time interventionist—an advanced registered nurse practitioner (ARNP)—over the Internet. “We did not come up with [pre-planned] dialogues,” Siddharthan explained. “This is a very complex group of people. When we started this intervention, we had no idea what type of dialogue to use. We decided to go free format. This has worked very well. There are as many dialogues as there are veterans to follow. Each veteran is unique.”

The interventionist, backed by the care team, coordinates the patient’s therapy, including scheduling appointments, pain management, drug therapy, substance abuse treatment, and behavioral modification. The group also started a drug-tapering program, since patients going from acute care to home care frequently have problems due to addiction to long-term pain killer use.

The group also keeps a regular account of the veteran’s health status over time.

Those directing the intervention have found that veterans end up, either because of the regular contact or the informal nature of the contact, telling the ARNP things they never told their primary care provider. “One veteran told the ARNP that he [couldn’t reply] to her chat because he had a seizure,” Siddharthan said. “It was a symptomatology that was not listed in his health record.”

Siddharthan and his team are conducting a longitudinal study as part of the overall study, looking at changes in patients’ ability to self-care, as well as their mobility, locomotion, communication skills, adjustment, and cognitive function. Early results show that patients with just TBI show a fairly stable course from baseline out to 18 months. However, those with comorbid PTSD show a more erratic course. “They go way up and are stable for a long time, then come crashing down,” Siddharthan said. “How do we deal with this? There are no models for this.”

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