Polytrauma Rehabilitation Centers Research Articles

Nutrition and Food Security Among Veterans: Operationalizing Nutritional Functioning

ObjectiveTo assess injured military veterans’ experiences, beliefs, and daily physical and psychosocial functioning in relation to food and nutrition. DesignWe used a convergent mixed-methods study design and the International Classification of Functioning, Disability, and Health to operationalize the core constructs and influencing factors related to physical and psychosocial functioning, food, and nutrition. SettingThree Veterans Affairs polytrauma rehabilitation centers. ParticipantsVeterans who served in the United States military on or after September 11, 2001, and whose medical diagnoses met the criteria for polytrauma; at least 1 mild traumatic brain injury and at least 1 associated comorbidity (eg, posttraumatic stress disorder, chronic musculoskeletal pain, vestibular disturbances), for a total N of 43. InterventionsNone. Main Outcome MeasuresThemes from survey responses and semistructured interview data were pooled into core constructs and influencing factors. ResultsThirty-seven veterans completed all surveys and participated in recorded interviews. Based on qualitative and quantitative data, veterans’ relation to food and nutrition (ie, nutritional functioning) was found to be characterized by 5 core constructs, including food background, nutrition knowledge, meal aptitude, resource navigation, and navigation to/of food spaces. Nutritional functioning was found to be shaped by 5 influencing factors, including injuries and health conditions, ideological and cultural exposures, relations, current beliefs, and current behaviors. ConclusionsNutritional functioning (food background, nutrition knowledge, meal aptitude, resource navigation, navigation to/of food spaces) among injured veterans is complex and shaped by multiple physical, psychosocial, economic, and cultural factors.

23 Cross-Sectional Analysis of Rehospitalization Following Discharge from Inpatient Rehabilitation in Veterans with Traumatic Brain Injury Up to 10 Years Postinjury

Objective:To characterize reasons for rehospitalization of Veterans and Service Members with mild, moderate, and severe traumatic brain injury (TBI) who received inpatient rehabilitation at a Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC) up to 10 years postinjury. TBI is a chronic condition, and a subset of TBI survivors experience rehospitalization after discharge from inpatient rehabilitation. Extant literature focuses primarily on persons with moderate-to-severe TBI and utilizes broad categories when determining readmission reasons. The present study aimed to delineate with greater specificity the reasons for rehospitalization up to 10 years postinjury across the TBI severity spectrum.Participants and Methods:Participants were drawn from the VA TBI Model Systems multicenter longitudinal study for a cross-sectional analysis. Eligibility criteria included TBI diagnosis per case definition; age > 16 years at TBI; admitted for inpatient rehabilitation at one of the five VA PRCs; and informed consent by the participant or legally authorized representative. At follow up interviews 1, 2, 5, and 10 years post-TBI, participants were asked whether they were rehospitalized within the past year (up to five admissions). Rehospitalizations were classified according to the Agency for Healthcare Research and Quality’s Healthcare Cost and Utilization Project classification (18 categories). In the present analyses, TBI severity was classified by duration of posttraumatic amnesia (PTA; 0-1 days=mild, 2+ days=moderate-severe). Statistical analyses were conducted in SPSS.Results:Participants (N=1101; n=338 0-1 days PTA, n=513 2+ days PTA, n=250 no PTA data) ranged in age from 17 years to 91 years at the time of interview. Participants across all follow up timepoints reported 317 rehospitalizations in the past year. 19.45% of Year 1 participants, 24.37% of Year 2 participants, 16.19% of Year 5 participants, and 16.25% of Year 10 participants reported 1+ rehospitalizations in the past year. When controlling for age, participants with at least 2 days of PTA were more likely to be rehospitalized at least once compared to those with 0-1 days of PTA at Year 2 (OR=4.05, p<0.001) and Year 5 (OR=2.39, p=0.03) post-TBI. The three most common reasons for rehospitalization across all timepoints were injury and poisoning (17.3%), mental illness (16.7%), and diseases of the nervous system and sense organs (9.1%). Mental illness was the modal reason for rehospitalization at Years 2, 5, and 10, frequently due to substance- or alcohol-related disorders and suicide/intentional self-inflicted injury.Conclusions:Compared to prior research, rates of rehospitalization were lower in this sample across follow-up time points. The inclusion of mild TBI in this analysis may partially explain the discrepancy. Importantly, two of the top three rehospitalization reasons are potentially preventable, and strategies to reduce risk of re-injury and minimize escalation of psychiatric distress should therefore be explored. Psychoeducation, supervision, and mental health support during the transition from hospital to community should be considered in order mitigate preventable causes of rehospitalization among long-term TBI survivors.

Retrospective Analysis of Vision Rehabilitation for Veterans With Traumatic Brain Injury-Related Vision Dysfunction.

Traumatic brain injury (TBI) can trigger vision-based sequelae such as oculomotor and accommodative abnormalities, visual-vestibular integrative dysfunction, visual field loss, and photosensitivity. The need for diagnosis and management of TBI-related vision impairment has increased because of the increasing frequencies of combat warfighters returning from Iraq and Afghanistan with TBIs. The purpose of this research was to learn the sequelae of rehabilitation service delivery to veterans with TBI-related visual dysfunction after they are diagnosed. To accomplish this, we investigated vision rehabilitation assessments and interventions provided to veterans with TBI-related visual dysfunction at the Department of Veterans Affairs (VA) specialty polytrauma facilities for the 2 years following their injury. The research questions asked what assessments, interventions, and prescribed assistive devices were provided by VA specialty clinics (e.g., occupational therapy, polytrauma, and blind rehabilitation) and how service delivery was affected by demographic and clinical variables. A retrospective design was used to analyze VA data using natural language processing of unstructured clinician notes and logistic regression of structured data. Participants included 350 veterans with TBI who received rehabilitation at one of the five VA Polytrauma Rehabilitation Centers (Tampa, FL; Richmond, VA; Minneapolis, MN; San Antonio, TX; and Palo Alto, CA) between 2008 and 2017 and who were administered the 2008 congressionally mandated "Traumatic Brain Injury Specific Ocular Health and Visual Functioning Exam." The outcome variables were vision assessments, interventions, and prescribed assistive technology discovered via natural language processing of clinician notes as well as the vision rehabilitation specialty clinics providing the clinical care (polytrauma, occupational therapy, outpatient blind rehabilitation, inpatient blind rehabilitation, optometry, and low vision) extracted from VA structured administrative data. Veterans receiving rehabilitation for TBI-related vision dysfunction were most frequently assessed for saccades, accommodation, visual field, and convergence. Intervention was provided most frequently for eye-hand coordination, saccades, accommodation, vergence, and binocular dysfunction. Technology provided included eyeglasses, wheelchair/scooter, walker/cane, aids for the blind, and computer. There was an overlap in the services provided by specialty clinics. Services available and delivered were significantly associated with the comorbidities of each patient and the specialty clinics available at each VA Polytrauma Rehabilitation Center. The delivery of patient services should be driven by the needs of veterans and not by system-level factors such as the availability of specific vision rehabilitation services at specific locations. Traditional low vision and blind rehabilitation programs were not designed to treat the comorbidities and symptoms associated with TBI. To address this challenge, blind rehabilitation and neurologic recovery cross training is needed. Our findings document how five VA Polytrauma Rehabilitation Centers implemented this training in 2008. The next step is to extend and standardize this new paradigm to community care, where these post-deployment patients now reside.

Effect of Post-traumatic Amnesia Duration on Traumatic Brain Injury (TBI) First Year Hospital Costs: A Veterans Affairs Traumatic Brain Injury Model Systems Study

ObjectiveTo examine the association between severity of traumatic brain injury (TBI) as measured by duration of post-traumatic amnesia (PTA) and first year hospitalization costs for service members and veterans (SMVs) treated for TBI at Polytrauma Rehabilitation Centers (PRCs) within the Veterans Health Administration (VHA). DesignMultivariable models of merged datasets from the VA TBI Model Systems (VA TBIMS) national database containing TBI clinical characterization including PTA with VHA hospital cost data. SettingFive VA PRCs. ParticipantsVA TBIMS participants with known PTA who received inpatient rehabilitation within 1 year of their TBI at any of 5 PRCs between 2010 and 2020 (N=717). InterventionsN/A. Main Outcome MeasuresTotal, acute care, rehabilitation, intensive care unit (ICU), and surgery costs across all VA hospitals. ResultsA total of 717 SMVs (mean age 36.9 years, 94.1% men, 76.8% non-Hispanic White, 7.8% active duty) met inclusion criteria for the unadjusted analyses. Unadjusted mean total hospital costs in the first-year post TBI were approximately $201,214 higher for those with PTA duration ≥24 hours ($351,157) than PTA <24 hours ($149,943). In adjusted models (n=583), each additional day of PTA duration incrementally increased total ($1453), rehabilitation ($1324), ICU ($78), and surgery ($39) costs. Other significant covariates included age, acute care length of stay, Disability Rating Scale on rehabilitation admission, penetrating violent cause of injury, and drug abuse. ConclusionsThis study demonstrates that PTA as a quantitative measure of TBI severity significantly affects first-year hospitalization costs of SMVs treated at PRCs. Each additional day of PTA was associated with higher total, rehabilitation, ICU, and surgery costs. Mean first year hospital costs were also found to exceed the highest budget allocation to VHA facilities for a veteran treated at a PRC. These findings have possible implications for hospital care provision for those receiving inpatient rehabilitation in VHA settings.

Exploring racial/ethnic disparities in rehabilitation outcomes after TBI: A Veterans Affairs Model Systems study.

Almost one-third of the U.S. military population is comprised of service members and veterans (SMVs) of color. Research suggests poorer functional and psychosocial outcomes among Black and Hispanic/Latine vs. White civilians following traumatic brain injury (TBI). This study examined racial/ethnic differences in 5-year functional independence and life satisfaction trajectories among SMVs who had undergone acute rehabilitation at one of five Veterans Affairs (VA) TBI Model Systems (TBIMS) Polytrauma Rehabilitation Centers (PRCs). Differences in demographic and injury-related factors were assessed during acute rehabilitation among White (n = 663), Black (n = 89), and Hispanic/Latine (n = 124) groups. Functional Independence Measure (FIM) Motor, FIM Cognitive, and Satisfaction with Life Scale (SWLS) scores were collected at 1, 2, and 5 years after injury. Racial/ethnic comparisons in these outcome trajectories were made using hierarchical linear modeling. Black SMVs were less likely than White and Hispanic/Latine SMVs to have been deployed to a combat zone; there were no other racial/ethnic differences in any demographic or injury-related variable assessed. In terms of outcomes, no racial/ethnic differences emerged in FIM Motor, FIM cognitive, or SWLS trajectories. The absence of observable racial/ethnic differences in 5-year outcome trajectories after TBI among SMVs from VA TBIMS PRCs contrasts sharply with previous research identifying disparities in these same outcomes and throughout the larger VA health care system. Individuals enrolled in VA PRCs are likely homogenized on key social determinants of health that would otherwise contribute to racial/ethnic disparities in outcome trajectories.

Examining the Relationship Between Sleep Apnea Diagnosis and Suicide Risk in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

Obstructive sleep apnea (OSA) is a common sleep disorder in people with traumatic brain injury (TBI). Although sleep disturbances have been associated with an increased risk of suicide compared with the general population, the relationship between OSA and suicide risk after TBI is not well documented. In this study, we hypothesized that OSA diagnosis would predict suicide risk in veterans with TBI. Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. Participants were drawn from the VA TBI Model Systems study, with follow-up interviews at year 1 ( n = 392), year 2 ( n = 444), year 5 ( n = 498), or year 10 ( n = 252) post-TBI (7.8%-14.5% follow-up attrition). This was a retrospective analysis from observational data using logistic regression with repeated measurements. Suicide ideation and suicide attempts were examined as outcomes at each follow-up to evaluate the relationship between OSA and suicide risk after adjusting for other risk factors determined a priori via literature review. Suicidal ideation (Patient Health Questionnaire-9 item 9), suicide attempt during the past year (self-reported), and OSA diagnosis (self-reported). Contrary to study hypotheses, OSA diagnosis had no statistically significant association with suicide ideation or attempt after accounting for known predictors. However, greater depression symptoms, headache severity, and pre-TBI suicidal ideation and attempts predicted suicide risk at follow-up after accounting for other predictors. Results of this study did not support a relationship between OSA and suicide risk, possibly due to methodological limitations of OSA measurement. Future research on this topic should include objective measures of OSA severity and OSA treatment including adherence. Although suicide is a low base rate occurrence, the impact is disastrous and further research is needed to mitigate suicide risk.

Causes of Mortality Among Veterans Previously Hospitalized After Traumatic Brain Injury

<h3>Research Objectives</h3> To examine mortality rates and causes among Veterans with traumatic brain injury (TBI) following discharge from inpatient rehabilitation. <h3>Design</h3> Secondary analysis; Cohort study. <h3>Setting</h3> Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. <h3>Participants</h3> Persons enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) who were admitted to rehabilitation within one year of TBI and discharged (alive) from rehabilitation between 01/01/2009 and 03/31/2020, and who died after rehabilitation discharge (N=82). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Mortality. <h3>Results</h3> The mortality rate was 8.3% for participants within this study's time frame. Most deaths (46.9%) occurred between 2 and 5 years from discharge. Reasons for death (among the known causes: 67.1%) were as follows: external causes of injury (29%), circulatory (22%), respiratory (18%), digestive (13%), neoplasm (9%), nervous system (7%), and infectious disease (2%). <h3>Conclusions</h3> Overall mortality rate was comparable to research in the civilian TBIMS (9-10%). Prior research implicated circulatory conditions as the most common cause of death, but in this study, the primary reasons were external causes (e.g., late effects of intracranial trauma; suicide). Digestive conditions (e.g., alcoholic liver disease) were the fourth most common cause of death yet a negligible cause in the general TBI population. Implications of the current findings include targeted clinical interventions for prevention or treatment of causes of mortality among veterans following discharge. <h3>Author(s) Disclosures</h3> Supported in part by NIDILRR [grant #90DPTB0002] (Hammond). Conducted with resources and use of facilities at the following: Hunter Holmes McGuire VA, Richmond, VA; James A. Haley VA, Tampa, FL; Minneapolis VA, Palo Alto VA, and South Texas VA. The authors declare no conflicts of interest. The views expressed here are the authors' and do not necessarily represent official policy/position of any federal government agency. This work was prepared under Contract HT0014-21-C-0012 [DHA Contracting Office (CO-NCR) HT0014] and defined as U.S. Government work under Title 17 U.S.C.§101. Per Title 17 U.S.C.§105, copyright protection is not available. For more information, contact TBICOEinfo@mail.mil. UNCLASSIFIED

Principal Component Analysis of the Traumatic Brain Injury Rehabilitation Needs Survey: Comparison of Three Models

<h3>Research Objectives</h3> To examine the higher-order structure of the Rehabilitation Needs Survey (RNS) and explore the internal consistency of the identified components. <h3>Design</h3> Principal Components Analysis; Cohort study. <h3>Setting</h3> Five Veterans Affairs (VA) Polytrauma Rehabilitation Centers. <h3>Participants</h3> Persons enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) who completed a five-year post-TBI follow-up interview (N=378; 96% male, age M=34.8; SD=14.0). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> RNS. <h3>Results</h3> The Kaiser Criterion resulted in a four-component solution with only three components containing ≥ 3 items (Cronbach alphas 0.837 to 0.900). The scree plot method resulted in a two-component solution with both containing ≥ 3 items (Cronbach alphas 0.826 to 0.901). Parallel analysis resulted in a three-component solution, all containing ≥ 3 items (Cronbach alphas 0.608 to 0.901). Twenty of the 21 items had acceptable corrected item-total correlations. The average corrected item-total correlations were 0.589 (range 0.224 to 0.715), 0.593 (range 0.434 to 0.712), and 0.602 (range 0.378 to 0.573) across the 4-, 2-, and 3-component solutions, respectively. There were between 7-9 cross-loading items depending on the model. Overall, items loaded on to components representing Activities/Participation and Body Functioning domains consistently and Vocation/Productivity inconsistently. <h3>Conclusions</h3> The three-component solution of the RNS appeared to be the clinically useful model that accounted for all 21 items with at least three items and minimally acceptable internal consistency. Although there were several cross-loading items, they refer to complex rehabilitation needs that are influenced by multiple factors. Alternatively, there are items that may require alteration and redundant items that should be considered for elimination. <h3>Author(s) Disclosures</h3> Funding: GDIT subcontract from DHA (Richardson [HT0014-21-C-0012]) and NIDILRR (O'Neil-Pirozzi, [#90DPTB0011], Walker, [#90DP0033]). This research was conducted with James A. Haley Veterans' Hospital resources and use of facilities. The views and/or findings are those of the authors and not official policy of the U.S. Departments of Defense, Veterans Affairs, Defense Health Agency, or any other federal agency. No official endorsement should be inferred.

Post-traumatic Headaches after Traumatic Brain Injury in a Military and Veteran Cohort

<h3>Research Objectives</h3> To examine post-traumatic headaches (PTH) characteristics in subjects with post-TBI. <h3>Design</h3> Cohort analysis of TBI patients participating in a prospective longitudinal study to examine TBI outcomes. Descriptive statistics used to describe the headache characteristics of the participants. <h3>Setting</h3> VA Palo Alto Polytrauma Rehabilitation Center. <h3>Participants</h3> 224 U.S Military Service Members and Veterans diagnosed with mild-severe TBI, seen for rehabilitation/treatment and followed at Years: 1, 2, and 5 post-injury. <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Patterns and trajectory of PTHs. <h3>Results</h3> 39% of the injuries were Blast-related, following 22% motor vehicular accidents. Most participants reported having headaches at the time of rehabilitation and treatment (61%). Among those with mild TBI 75% reported experiencing headaches post-TBI. The percentage of participants that reported experiencing 15 or more headache episodes per month, was 48% of those with mild-TBI. The majority of the severe TBI 49%, and mild-TBI 35% participants reported an episodic pattern of headaches, lasting between 4 hrs to 24 hrs, untreated headaches during the first year. Unilateral headache episodes among the mild TBI were reported with some headaches, 35%, and among severe TBI with every headache, 34%. In describing the level of headache pain, 37% of mild TBI participants reported feeling throbbing or pulsating sensation when it is at its worst, and 33% of the severe TBI participants reported feeling pressure or "vise-like' headache sensation. <h3>Conclusions</h3> Post-traumatic headaches are a common sequelae post-injury, and are often a difficult post-concussive symptom for patients to manage. This analysis serves as a foundation for understanding PTHs and for informing advances in treatment. <h3>Author(s) Disclosures</h3> I have no financial interests or relationships to disclose.

Quetiapine as an adjunct to enhance engagement in prolonged exposure therapy for PTSD in veterans: A randomized, pilot trial

Despite established efficacy, there is low engagement in prolonged exposure (PE) therapy for PTSD among combat veterans. In preparation for a full-scale randomized trial, we sought to evaluate the feasibility, safety, and preliminary efficacy of quetiapine to enhance patient engagement in PE therapy. Open-label, randomized pilot trial of quetiapine monotherapy vs. Treatment as Usual (TAU) medications in 20 military veterans with combat related PTSD who were seeking care from the San Antonio Polytrauma Rehabilitation Center at the South Texas Veterans Healthcare System (STVHCS). Participants were randomized to receive either Quetiapine ( n = 10) monotherapy or pharmacological TAU ( n = 10) in patients who were receiving PE as a standard of care therapy. We collected information on (1) the number of potentially eligible veterans approached, the number screened, and the number randomized, (2) adverse events reported, (3) number of participants continuing PE treatment at least until session #4 (i.e., after first exposure session) and the total number of sessions of PE completed by the participants, and (4) change in PTSD severity and sleep quality measured by the PTSD Checklist for DSM-5 (PCL-5) and Pittsburgh Sleep Quality Index (PSQI). Data were analyzed for 18 intent-to-treat participants with mean (SD) age, 53.5 (13.4) years; and baseline PCL-5 score, 57.6 (7.6). More veterans in the quetiapine group ( n = 9; 100%) received at least the first exposure session of PE therapy compared to TAU (( n = 3; (37.5%), p = .006] and completed PE therapy ( n = 8; (88.9%) vs ( n = 3; (37.5%), p = .03). Both PCL-5 ( p = .03) and PSQI ( p = .02) scores decreased significantly more for participants in the quetiapine than the TAU group. Preliminary findings support the feasibility, safety, and possible efficacy of quetiapine as an adjunct to enhancing engagement in PE therapy. A full-scale randomized trial is required to determine the true efficacy of quetiapine to enhance engagement in PE treatment.

A Network Analysis of the PART-O at 1 and 2 Years After TBI: A Veterans Affairs Model Systems Study.

The construct of participation after traumatic brain injury (TBI) can be difficult to operationalize. Psychometric network analysis offers an empirical approach to visualizing and quantifying the associations between activities that comprise participation, elucidating the relations among the construct's components without assuming the presence of a latent common cause and generating a model to inform future measurement methods. The current research applied psychometric network analysis to the Participation Assessment with Recombined Tools-Objective (PART-O) within a sample of service members and veterans (SM/Vs) with a history of TBI at 1 and 2 years ( T1 and T2 ) postinjury. Participants ( N = 663) were SM/Vs with a history of TBI who completed comprehensive inpatient rehabilitation services at a Department of Veterans Affairs (VA) Polytrauma Rehabilitation Center (PRC). Five VA PRCs. Cross-sectional, retrospective analysis of data from the VA TBI Model Systems study. PART-O. Network analysis demonstrated that the PART-O structure was generally consistent over time, but some differences emerged. The greatest difference observed was the association between "spending time with friends" and "giving emotional support" to others. This association was more than twice as strong at T2 as at T1 . The "out of the house" item was most central, as demonstrated by dense connections within its own subscale (Out and About) and items in other subscales (ie, Social Relations and Productivity). When examining items connecting the 3 subscales, the items related to giving emotional support, internet use, and getting out of the house emerged as the strongest connectors at T1 , and the internet was the strongest connector at T2 . Providing emotional support to others is associated with greater participation across multiple domains and is an important indicator of recovery. Being out and about, internet use, and engagement in productive activities such as school and work shared strong associations with Social Relations. Network analysis permits visual conceptualization of the dynamic constructs that comprise participation and has the potential to inform approaches to measurement and treatment.

Barriers and Facilitators to Accessing Rehabilitation Health Care: A Veterans Affairs Traumatic Brain Injury Model Systems Qualitative Study

ObjectiveTo compare barriers and facilitators to accessing health care services among service members and veterans (SMVs) by traumatic brain injury (TBI) severity groups. DesignQualitative descriptive study guided by an access to health care services conceptual framework. SettingFive Veterans Affairs (VA) polytrauma rehabilitation centers. ParticipantsSMVs (N=55, including 10 caregivers as proxies) ≥2 years post-TBI recruited from the VA TBI Model Systems and grouped by TBI severity (mild/moderate, severe). Main Outcome MeasuresBarriers and facilitators accessing care. ResultsThe main facilitators included ease of communicating with providers to help SMVs identify and utilize appropriate health care, family advocates who promoted engagement in health care, ability to use government and community facilities, and online resources or equipment. Distance to services was uniformly identified as a main barrier for both patient groups. However, facilitators and barriers to health care access differed by TBI severity. SMVs with severe TBI highlighted the role of nonprofit organizations in promoting health care engagement and the availability of VA specialty residential programs in meeting health care needs. Having unrecognized health care needs in chronic stages and communication difficulties with providers were more commonplace for those with greater TBI severity and affected quality of care. Those with mild/moderate TBI highlighted challenges associated with paying for services in the community and scheduling of services. ConclusionsBarriers and facilitators exist across multiple dimensions of a health care access framework and vary by TBI severity. Results suggest possible mechanistic links between health care access and SMV health outcomes. Findings support current policy and practice efforts to facilitate health care access for SMVs with TBI but highlight the need for tailored approaches for those with greater disability.

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

Acute Cognitive Dysfunction in a Patient With Traumatic Brain Injury: A Clinical Vignette.

Factors Influencing the Implementation of Guideline-Recommended Practices for Postconcussive Sleep Disturbance and Headache in the Veterans Health Administration: A Mixed Methods Study

ObjectiveUnderstand barriers and facilitators of implementing recommended practices for postconcussive sleep disturbance and headache, as outlined in the Veterans Administration/Department of Defense 2016 Clinical Practice Guideline (CPG) for mild traumatic brain injury (mTBI). DesignConvergent parallel mixed methods. SettingTen national Veterans Health Administration (VHA) facilities. ParticipantsTwenty VHA stakeholders (14 clinicians; 4 researchers; 2 policymakers), 55% of whom were affiliated with a VHA polytrauma rehabilitation center (N=20). InterventionsNone. Main Outcome MeasuresStakeholders rated the quality of recommendations for sleep disturbance and headache using the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence instrument. A descriptive analysis of item scores was performed to understand the following features of the recommendations: (1) clinical credibility (eg, evidence quality), (2) alignment with stakeholder values, and (3) implementability. We conducted semistructured interviews with stakeholders and used descriptive and interpretive analyses to reveal emergent themes. After analyzing the Appraisal of Guidelines Research and Evaluation-Recommendations Excellence and qualitative interview data, we synthesized the results into coherent conclusions (ie, meta-inferences) by comparing and contrasting respective findings. ResultsStakeholders highlighted that the mTBI CPG includes features that reflect clinical priorities (eg, alignment with veteran preferences), making it an appropriate standard of care and facilitating its implementation. However, stakeholders also identified that the design of the mTBI CPG, along with provider-level (eg, knowledge) and facility-level (eg, resources) factors, may create barriers for implementation. In addition to these potential barriers, stakeholders noted a lack of comprehensive and systematic efforts designed to promote the uptake of these recommendations. Findings also revealed stakeholder recommendations for addressing potential barriers (eg, decision support). ConclusionsWith the recent release of the 2021 mTBI CPG, decision makers are encouraged to incorporate information gathered from previous implementation efforts to promote adherence to updated recommendations. Study findings, including recommended changes suggested by stakeholders, offer information that can be leveraged to design such efforts and promote care quality and associated outcomes for veterans with mTBI.

Longitudinal Patterns of Alcohol Use Following Traumatic Brain Injury in an Active Duty and Young Veteran Military Sample: A VA TBI Model Systems Study.

To describe alcohol use among younger military active duty service members and veterans (SMVs) in the first 5 years after traumatic brain injury (TBI) and examine whether differential alcohol use patterns emerge as a function of brain injury severity and active duty service at time of injury. Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). In total, 265 SMVs enrolled in the VA Traumatic Brain Injury Model Systems (TBIMS) PRC national database. Participants sustained a TBI of any severity level; received inpatient care at a PRC within 1 year of injury; were younger than 40 years; and completed survey interviews or questionnaires regarding their pre- and postinjury alcohol use for at least 3 of 4 time points (preinjury, postinjury years 1, 2, and 5). Self-reported alcohol use, defined as amount of weekly consumption and endorsement of binge drinking. Participant information related to demographics, injury, TBI severity, active duty status, mental health treatment, and FIM (Functional Independence Measure) total scores was also obtained to examine impact of these as covariates in the analyses. Alcohol use generally increased following an initial period of reduced consumption for SVMs with moderate-to-severe TBI. Individuals with mild TBI showed an opposite trend, with an initial period of increased use, followed by a decline and return to baseline levels in the long term. However, alcohol use did not significantly differ over time within this subsample after adjusting for covariates. The current study identified longitudinal alcohol use among a young, military/veteran cohort with a history of TBI, an at-risk population for problematic alcohol use. Patterns of self-reported alcohol consumption suggest the time frame of 2 to 5 years postinjury may be a critical window of opportunity for further intervention to maintain lowered levels of alcohol use, particularly among SVMs with moderate-to-severe TBI.

Development and Evolution of a Comprehensive Mild Traumatic Brain Injury Inpatient Rehabilitation Program: A Nursing Perspective.

The James A. Haley Veterans' Hospital in Tampa, Florida has developed an innovative approach to the unique rehabilitation needs of active duty Special Operations Forces (SOF) and veterans with chronic conditions related to their military service. Tampa's program, the Post-Deployment Rehabilitation and Evaluation Program (PREP), was established in 2008. The interdisciplinary team includes one nurse practitioner and eight staff registered nurses. The Veterans Health Administration (VHA) is using Tampa's established and successful PREP as a model to actively expand the program to other Veterans Administration (VA) Polytrauma Rehabilitation Centers over the next several years. There are several important nursing and rehabilitation team considerations for the successful development of these mild traumatic brain injury (mTBI) inpatient rehabilitation programs.

Veterans with Traumatic Brain Injury-related Ocular Injury and Vision Dysfunction: Vision Rehabilitation Utilization.

Visual dysfunction is frequently associated with traumatic brain injury (TBI). Although evidence regarding the prevalence of symptoms of this population has been published, little is known about health care utilization. A retrospective review of the data derived from the Department of Veterans Affairs (VA)-mandated "Traumatic Brain Injury Specific Ocular Health and Visual Functioning Examination for Polytrauma Rehabilitation Center Patients" provided a unique opportunity to investigate vision rehabilitation utilization. The purpose of this study was to understand (a) the frequency of vision rehabilitation follow-up visits at 6, 12, and 24 months; (b) the association between follow-up and demographic, comorbidity, and severity of TBI covariates as well as ocular and visual symptoms, geographic access, and evaluating facility; and (c) why some veterans did not follow up with recommendations. Retrospective and survey designs were used. The sample included 2458 veterans who served in the Operation Enduring Freedom/Operation Iraqi Freedom conflicts and received care at one of the five VA Polytrauma Rehabilitation Centers between January 1, 2008, and December 31, 2017. Quantitative and qualitative descriptive analyses and stepwise logistic regression were performed. About 60% of veterans followed up with recommended vision rehabilitation with visits equally split between VA Polytrauma Rehabilitation Centers and community VA facilities. For each 10-year increase in age, there was a corresponding reduction of 12% in the odds of follow-up. Veterans with decreased visual field had 50% greater odds of follow-up than those who did not. Veterans with difficulty reading had 59% greater odds of follow-up than those who did not. Those who had a double vision had 45% greater odds of follow-up than those who did not. Our findings suggest that the need for vision rehabilitation may extend as long as 2 years after TBI. Access to vision rehabilitation is complicated by the paucity of available neuro-optometric services.

Health Conditions Among Special Operations Forces Versus Conventional Military Service Members: A VA TBI Model Systems Study.

To examine traumatic brain injury (TBI) characteristics and comorbid medical profiles of Special Operations Forces (SOF) Active Duty Service Member/Veterans (ADSM/Vs) and contrast them with conventional military personnel. The 5 Veterans Affairs (VA) Polytrauma Rehabilitation Centers. A subset of participants in the VA TBI Model Systems multicenter longitudinal study with known SOF status. These included 157 participants who identified as SOF personnel (average age = 41.8 years; 96% male, 81% active duty), and 365 who identified as Conventional Forces personnel (average age = 37.4 years; 92% male, 30% active duty). Retrospective analysis of prospective cohort, cross-sectional. The Health Comorbidities Interview. SOF personnel were more likely to have deployed to a combat zone, had more years of active duty service, and were more likely active duty at time of TBI. SOF personnel were more likely to have had mild TBI (vs moderate/severe) and their TBI caused by violent mechanism. SOF personnel had a higher number of comorbidities, with more diagnoses of chronic pain, osteoarthritis, hyperlipidemia, hip fractures, and obstructive sleep apnea. SOF personnel are at a higher risk for multimorbidity after TBI. Current rehabilitation practices should incorporate early screening and treatment of common conditions in this population, while future practices may benefit from a focus on prevention.

Facilitators and Barriers to Non-Pharmacologic Chronic Pain Treatment for Service Members and Veterans with Traumatic Brain Injury

<h3>Research Objectives</h3> To identify treatments utilized by Service Members and Veterans (SMVs) with TBI and chronic pain and characterize access barriers and facilitators to non-pharmacologic treatments. <h3>Design</h3> A secondary data analysis of SMV with TBI interview data guided by a biopsychosocial model of pain management1-3 and framework for accessing healthcare services4. <h3>Setting</h3> Five geographically diverse VA Polytrauma Rehabilitation Centers (PRC) within the Department of Veterans Affairs. <h3>Participants</h3> The secondary data analysis includes a sample of 55 SMVs with chronic TBI (>2 years) who were enrolled in VA TBI Model Systems. Half the sample had severe TBI (56%) with a mean age of 43 at time of injury, were male (93%), and married (51%). <h3>Interventions</h3> N/A. <h3>Main Outcome Measures</h3> Facilitators and barriers to accessing non-pharmacologic chronic pain treatment. <h3>Results</h3> Thematic analysis revealed that chronic pain and/or headache was a common rehabilitation need. The use of polypharmacy (including opioid use) was a common theme for those reporting chronic pain concerns. Facilitators to accessing treatment (including non-pharmacological treatments) for chronic pain included the ability to use the VA Choice Program to access community care and family or other social support to advocate for treatment. The primary barriers to accessing care for chronic pain included having insufficient information about alternative treatment options. <h3>Conclusions</h3> Despite VA/DoD clinical practice guidelines advising against using opioids in persons with documented TBI, polypharmacy emerged as a theme in this study cohort. Findings highlight facilitators and barriers to alternative evidence-based treatments with implications for practice and policy. <h3>Author(s) Disclosures</h3> None.

Outcomes of the Suicidal Ideation Assessment Protocol Decision Tree Responses from the Tampa VA TBI Model Systems Research Study

<h3>Research Objectives</h3> To describe participant outcomes from implementation of the Suicidal Ideation Assessment Protocol (SIAP) as a tool for non-clinical research staff to appropriately assess and respond to suicide risk. <h3>Design</h3> Descriptive. <h3>Setting</h3> James A. Haley Veterans Affairs Polytrauma Rehabilitation Center. <h3>Participants</h3> N=155 participant follow-up interviews. <h3>Interventions</h3> Tampa VA TBIMS data collectors implemented the SIAP decision tree in response to participant endorsements of SI on the Patient Health Questionnaire (PHQ-9), a brief self-report rating scale to screen for depression (e.g. "thoughts that you would be better off dead or hurting yourself in some way"), on the Pain Catastrophizing Scale (PCS), a self-report scale that measures trait pain catastrophizing (e.g. "I feel my life isn't worth living"), or through sporadic comments about death or suicide during remote follow-up telephone interviews. <h3>Main Outcome Measures</h3> SIAP as a tool for non-clinical research staff, percentage of participants who endorsed SI during follow-up interviews, and percentage of participants who accepted VCL resources or declined VCL resources because they already had, or did not want them. <h3>Results</h3> Data collectors conducted 155 interviews. 27 participants (17.42%) endorsed SI and were offered the VCL call and text numbers. 10 participants (37.04%) accepted VCL resources, 17 participants (62.96%) declined VCL resources, and 1 participant was transferred to the VCL. The PCS alone had the highest number of SI endorsements (n=8), followed by the PHQ-9 alone (n=7), and both the PCS and PHQ-9 (n=7). <h3>Conclusions</h3> Implementation of the SIAP and referral to VCL resources demonstrates the feasibility and importance of the decision tree for data collectors involved in research with high risk populations. <h3>Author(s) Disclosures</h3> Financial Disclosures: None. This material is the result of work supported with resources and the use of facilities at the James A. Haley Veterans' Hospital. Disclaimer: The views expressed in this abstract are those of the authors and do not necessarily represent the official policy or position of the Defense Health Agency, Department of Defense, or any other U.S. government agency. For more information, please contact dha.TBICOEinfo@mail.mil.