General Brain Injury Research Not Always Useful for Veterans
By Annette M. Boyle
TAMPA, FL—Traumatic brain injury (TBI) has been called the signature wound of recent U.S. conflicts. These injuries have driven the DoD and VA to closely examine the causes, consequences and therapies for TBI and to pioneer strategies to help servicemembers and veterans who require continuing care as a result.
Recent research validates these efforts, underscoring that veterans with TBI differ from their civilian counterparts in significant ways that could affect their long-term care.
While many servicemembers sustain TBIs during military training and deployment, significantly more sustain these injuries as a result of motor vehicle accidents, which are also the most common cause of TBIs among civilians.
“As of February 2017, the Defense and Veterans Brain Injury Center (DVBIC) reported a total of 361,092 first-time TBIs sustained by active duty servicemembers worldwide,” according to the VHA physical medicine and rehabilitation program office. Not all of those servicemembers will need ongoing care, as more than 80% of the TBIs were classified as mild injury or concussions.
The VA treats about 87,000 unique veterans for TBI annually. Of those, 3.8%, or 2,897, required care in a long-term care facility in 2016, the VA reported.
In a study published in the Journal of Head Trauma Rehabilitation, VA researchers compared data on the course of recovery and outcomes of 5,270 patients from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) to those of 550 patients in the VA TBI Model System. The NIDILRR aggregated data from 16 civilian hospitals on more than 16,000 TBI patients who received inpatient rehabilitative care. The VA TBI Model tracks the results of military TBIs and currently includes information on 1000 patients who have been treated as inpatients at five regional VA polytrauma rehabilitation centers (PRC).1
For both veterans and servicemembers with TBI, “inpatient rehabilitation is usually for those with greater severity of TBI who require treatment from multiple rehabilitation disciplines. Those with a single mild TBI typically do not require inpatient rehabilitation admission,” explained lead author Risa Nakase-Richardson, PhD, of the James A. Haley Veterans’ Hospital in Tampa, FL.
The study identified significant differences between the types of brain injuries experienced by the two groups, which highlight the challenges of extrapolating from civilian results when treating veterans. While just 4% of patients in the VA TBI system were female, 27% of the civilian data base was female. The small numbers in the VA system limit “our ability to understand how gender may influence outcomes, leaving us to largely depend on civilian-based samples of female TBI,” explained study co-author Lillian Stevens, PhD, of the Hunter Holmes McGuire VAMC in Richmond, VA.
Violent injuries, primarily from blast exposure, were the second most common injury in the VA group, but the least common among civilians. Because previous research by this author group showed “the most severely injured cohort with blast-related TBI (disorder of consciousness) treated at the polytrauma rehabilitation inpatient centers showed a less favorable prognosis in the short term,”2 the current study analyzed subtypes of TBIs to get a better understanding of outcomes, Stevens told U.S. Medicine.
“We compared motor vehicle accidents to motor vehicle accidents, falls to falls, and decided to compare violent brain etiology (regardless of mechanism given the lack of blast TBI in the civilian database) to each other,” she said.
Despite comparing similar injuries, the prognostic factors varied between the groups. Veterans and servicemembers were typically younger in the fall- and violent-injury groups and were more educated overall, both factors considered generally favorable. Patients in the VA cohort also had longer acute-care hospital stays before their inpatient rehabilitation, which generally meant that the data for them was captured later or further along in the recovery process than for civilians, according to the authors.
Still, the VA patients had sustained more severe traumatic brain injury on average and experienced longer stays in both acute and rehabilitative hospital settings. There was no difference in mortality rates between the two groups.
External factors, notably insurance coverage, account for much of the difference in treatment decision-making, Nakase-Richardson told U.S. Medicine. “The VA TBI Model System cohort have double the length of stay in rehabilitation, a mean of 67 days, compared to the civilian-based sample, which had a mean of 25 days,” Nakase-Richardson pointed out. “As a former civilian-based TBI rehabilitation provider, the shorter acute rehabilitation lengths of stay in civilian settings, largely influenced by insurance companies, is not enough time to treat and prepare family to bring home a severe TBI.” In contrast, the inpatient rehabilitation treatment program allows clinicians in the VA to provide treatment based on what patients need, she noted.
In addition to the longer stay, patients benefit from the specialized programs at the polytrauma rehabilitation centers. These include rehabilitation for patients with prolonged disorders of consciousness; programs that address common comorbid conditions such as PTSD, sleep disorders and pain; assistive technology labs; and inpatient polytrauma transitional rehabilitation programs that help veterans and servicemembers reintegrate into their communities and return to school or work, according to the VHA physical medicine and rehabilitation program office.
The VA and DoD also have several programs to support and educate family members of veterans or servicemembers who have sustained serious TBIs, including Fisher Houses at the polytrauma rehabilitation centers and major military treatment facilities that allow family members to stay nearby during rehabilitation. The programs provide extensive education, training and support for patients, family members and caretakers prior to program discharge.
Nasake-Richardson and Stevens urge clinicians, particularly those outside of the federal medicine system, who work with veterans or servicemembers who have sustained TBIs to consider the unique stressors associated with military service and deployment. “Mental health treatment for the veteran and family should be in the treatment equation,” they said. While the VA commonly screens patients for a variety of mental health conditions including depression, post-traumatic stress disorder and substance abuse, civilian hospitals often do not.
In addition, when evidence-based therapies for PTSD, depression, insomnia and other conditions are not available or not covered for veterans who have experienced TBIs and are receiving care outside the VA system, they encourage civilian providers to consider referring these patients to the VA.
- Nakase-Richardson R, Stevens LF, Tang X, Lamberty GJ, Sherer M, Walker WC, Pugh MJ, Eapen BC, Finn JA, Saylors M, Dillahunt-Aspillaga C, Adams RS, Garofano JS. Comparison of the VA and NIDILRR TBI Model System Cohorts. J Head Trauma Rehabil. 2017 Jul/Aug;32(4):221-233.
- Nakase-Richardson R, McNamee S, Howe LLS, Massengale J, Peterson M, Barnett SD, Harris O, McCarthy M, Tran J, Scott S, Cifu DX. Descriptive characteristics and rehabilitation outcomes in active duty military personal and veterans with disorders of consciousness with combat and non-combat-related brain injury. Arch of Phys Med Rehab. 2013;94(10):1861-1869.