Veterans Affairs Polytrauma Rehabilitation Centers Research Articles

Predictors of Psychiatric Hospitalization After Discharge From Inpatient Neurorehabilitation for Traumatic Brain Injury.

To examine, among persons discharged from inpatient rehabilitation for traumatic brain injury (TBI), the degree to which pre-TBI factors were associated with post-TBI hospitalization for psychiatric reasons. The authors hypothesized that pre-TBI psychiatric hospitalization and other pre-TBI mental health treatment would predict post-TBI psychiatric hospitalization following rehabilitation discharge, up to 5years post-TBI. Five Veterans Affairs Polytrauma Rehabilitation Centers. Participants with nonmissing rehospitalization status and reason, who were followed at 1 year (N=1006), 2years (N =985), and 5years (N =772) post-TBI. A secondary analysis of the Veterans Affairs TBI Model Systems, a multicenter, longitudinal study of veterans and active-duty service members with a history of mild, moderate, or severe TBI previously admitted to comprehensive inpatient medical rehabilitation. This study examined participants cross-sectionally at 3 follow-up timepoints. Psychiatric Rehospitalization was classified according to Healthcare Cost and Utilization Project multilevel Clinical Classifications diagnosis terminology (Category 5). Rates of post-TBI psychiatric hospitalization at years 1, 2, and 5 were 4.3%, 4.7%, and 4.1%, respectively. While bivariate comparisons identified pre-TBI psychiatric hospitalization and pre-TBI mental health treatment as factors associated with psychiatric rehospitalization after TBI across all postinjury timepoints, these factors were statistically nonsignificant when examined in a multivariate model across all timepoints. In the multivariable analysis, pre-TBI psychiatric hospitalization was significantly associated with increased odds of post-TBI psychiatric hospitalization only at 1-year post-TBI (adjusted odds ratio=2.65; 95% confidence interval, 1.07-6.55, P =.04). Posttraumatic amnesia duration was unrelated to psychiatric rehospitalization. Study findings suggest the limited utility of age, education, and pre-TBI substance use and mental health utilization in predicting post-TBI psychiatric hospitalization. Temporally closer social and behavior factors, particularly those that are potentially modifiable, should be considered in future research.

Psychometric network analysis in rehabilitation research: A methodological demonstration in depression symptoms of veterans and service members at 1 and 2 years after traumatic brain injury.

Psychometric network analysis (PNA) is an application of dynamic systems theory that can inform measurement of complex rehabilitation phenomena such as depressive symptom patterns in veterans and service members (V/SMs) after traumatic brain injury (TBI). This study applied PNA to the Patient Health Questionnaire-9 (PHQ-9), a common measure of depressive symptoms, in a sample of V/SMs with TBI at Years 1 and 2 (Y1-2) postinjury. A sample of 808 V/SMs with TBI participated, 594 contributing PHQ-9 data at Y1 and 585 at Y2. Participants were recruited while or after receiving inpatient postacute rehabilitation from one of five Veterans Affairs Polytrauma Rehabilitation Centers. The networks were stable and invariant over time. At both times, network structure revealed the cardinal depressive symptom "feeling down, depressed, or hopeless," as evidenced by its strength centrality. In the Y1 network, the suicidal ideation node was connected exclusively to the network through the guilt node, and in the Y2 network, the suicidal ideation node formed a second connection through the low mood node. The guilt node was the second most influential node at Y1 but was replaced by anhedonia node at Y2. This study demonstrated the potential of PNA in rehabilitation research and identified the primacy of feeling down, depressed, and hopeless after TBI at both Y1 and Y2, with guilt being the second most influential symptom at Y1, but replaced by anhedonia at Y2, providing supportive evidence that the relationships among depressive symptoms after TBI are dynamic over time. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

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.

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.

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.

Neurobehavioral Symptoms in U.S. Special Operations Forces in Rehabilitation After Traumatic Brain Injury: A TBI Model Systems Study.

Special Operations Forces (SOF) personnel are at increased risk for traumatic brain injury (TBI), when compared with conventional forces (CF). Prior studies of TBI in military samples have not typically investigated SOF vs. CF as specific subgroups, despite documented differences in premorbid resilience and post-injury comorbidity burden. The aim of the current study was to compare SOF vs. CF on the presence of neurobehavioral symptoms after TBI, as well as factors influencing perception of symptom intensity. This study conducted an analysis of the prospective veterans affairs (VA) TBI Model Systems Cohort, which includes service members and veterans (SM/V) who received inpatient rehabilitation for TBI at one of the five VA Polytrauma Rehabilitation Centers. Of those with known SOF status (N = 342), 129 participants identified as SOF (average age = 43 years, 98% male) and 213 identified as CF (average age=38.7 years, 91% male). SOF vs. CF were compared on demographics, injury characteristics, and psychological and behavioral health symptoms. These variables were then used to predict neurobehavioral symptom severity in univariable and multivariable analyses. SOF personnel reported significantly greater posttraumatic stress disorder (PTSD) symptoms but less alcohol and drug use than the CF. SOF also reported greater neurobehavioral symptoms. When examining those with TBIs of all severities, SOF status was not associated with neurobehavioral symptom severity, while race, mechanism of TBI, and PTSD symptoms were. When examining only those with mTBI, SOF status was associated with lower neurobehavioral symptoms, while PTSD severity, white race, and certain mechanisms of injury were associated with greater neurobehavioral symptoms. Among those receiving inpatient treatment for TBI, SOF SM/V reported higher neurobehavioral and symptom severity. PTSD was the strongest predictor of neurobehavioral symptoms and should be considered an important treatment target in both SOF and CF with co-morbid PTSD/TBI. A proactive human performance approach towards identification and treatment of psychological and neurobehavioral symptoms is recommended for SOF.

Predictors of Driving Status in Service Members and Veterans at 1 Year Posttraumatic Brain Injury: A VA TBI Model Systems Study.

To identify predictors of driving status in service members and veterans 1 year following a traumatic brain injury (TBI). The 5 Department of Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRCs). A total of 471 service members and veterans (128 with mild/complicated mild TBI and 343 with moderate/severe TBI) who received TBI-focused inpatient rehabilitation at one of the VA PRCs and who participated in a 1-year postinjury follow-up assessment. Secondary analysis from the Department of Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems (VA PRC TBIMS) national database. Primary outcome was a single item that assessed driving status at 1 year postinjury. Predictor variables included demographics; sensory impairment, substance use, and employment status at time of injury; PTSD symptoms reported at study enrollment; and functional impairment rated at rehabilitation discharge. In unadjusted bivariate analyses, among those with a mild/complicated mild TBI, older age and greater functional impairment were associated with lower likelihood of driving. Among those with a moderate/severe TBI, discharge to a nonprivate residence, greater functional impairment, and higher PTSD symptoms were linked to lower likelihood of driving. Adjusted multivariate analyses indicated that functional impairment was uniquely associated with driving status in both TBI severity groups. After controlling for other predictors, self-reported PTSD symptoms, particularly dysphoria symptoms, were associated with lower likelihood of driving in both severity groups. Given the significance of clinician-rated functional impairment and self-reported PTSD symptoms to the prediction of driving status 1 year post-TBI among service members and veterans, rehabilitation efforts to improve functioning and reduce negative affect may have a positive impact on driving and community integration.

Posttraumatic Stress Disorder Symptoms Contribute to Staff Perceived Irritability, Anger, and Aggression After TBI in a Longitudinal Veteran Cohort: A VA TBI Model Systems Study

ObjectiveTo examine the relationship between staff perceived irritability, anger, and aggression and posttraumatic stress disorder (PTSD) in veterans with traumatic brain injury (TBI) of all severity levels. DesignLongitudinal cohort design. SettingVeterans Affairs Polytrauma Transitional Rehabilitation Programs. ParticipantsVeterans and service members with TBI of all severity levels enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers’ Traumatic Brain Injury Model System national database (N=240). InterventionsNot applicable. Main Outcome MeasureUnivariable and multivariable logistic regression modeling was used to examine the association between irritability, anger, and aggression and potential risk factors, including PTSD symptoms. Irritability, anger, and aggression was measured as a single construct using an item from the Mayo-Portland Adaptability Inventory-4 that was rated by program staff at admission and discharge from the inpatient rehabilitation program. PTSD symptoms were assessed using the PTSD Checklist–Civilian Version. ResultsPTSD symptoms uniquely predicted program staff-rated irritability, anger, and aggression at discharge even after controlling for severity of TBI, age, male sex, education, and annual earnings. The model explained 19% of the variance in irritability, anger, and aggression. ConclusionsWhen TBI severity and PTSD symptoms were considered simultaneously in a sample of veterans, only PTSD symptoms predicted staff-rated irritability, anger, and aggression. Given the negative outcomes linked with irritability, anger, and aggression, veterans may benefit from assessment and treatment of PTSD symptoms within rehabilitation settings.

Postrehabilitation Mental Health Treatment Utilization in Veterans With Traumatic Brain Injury: A VA TBI Model Systems Study.

To identify preinjury variables related to mental health treatment utilization at 2 years post-traumatic brain injury (TBI). Veterans Affairs (VA) TBI Model Systems includes 5 VA Polytrauma Rehabilitation Centers. Veterans and service members enrolled in TBI Model Systems who completed the year 2 follow-up assessment and provided mental health information. Sample was largely male (97%) and White (72%), with median age of 30 years. Participants with elevated mental health symptoms were identified by measures of depression, anxiety, and posttraumatic distress; suicide attempt in the past year; or problematic substance use in the past year. Forty-seven percent of participants had elevated mental health symptoms at 2 years postinjury. Among those with elevated symptoms, comparisons were made between those who sought mental health treatment in past year and those who did not. Demographic, historic, environmental, psychological/mental health, and injury/rehabilitation variables. Within the sample, 23% denied utilizing mental health services. Nonutilizers were more likely to deny a preinjury mental health treatment history, to report problematic substance use at year 2, and to report lower levels of internalizing symptoms than the treatment utilizers. Veterans and service members with elevated mental health symptoms may require tailored tactics to promote treatment utilization post-TBI.

The Impact of Stigma on Community Reintegration of Veterans With Traumatic Brain Injury and the Well-Being of Their Caregivers

ObjectiveTo assess the association between perceived stigma and discrimination and caregiver strain, caregiver well-being, and patient community reintegration. DesignA cross-sectional survey study of 564 informal caregivers of U.S. military service veterans of wars in Iraq and Afghanistan who experienced traumatic brain injuries or polytrauma (TBI/PT). SettingCare settings of community-dwelling former inpatients of U.S. Department of Veterans Affairs Polytrauma Rehabilitation Centers. ParticipantsCaregivers of former inpatients (N=564), identified through next-of-kin records and subsequent nominations. InterventionsNot applicable. Main Outcome MeasuresCaregiver strain, depression, anxiety, loneliness, and self-esteem; as well as care recipient community reintegration, a key aspect of TBI/PT rehabilitation. ResultsFamily stigma was associated with strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration. Caregiver stigma-by-association was associated with strain, depression, anxiety, loneliness, and lower self-esteem. Care recipient stigma was associated with caregiver strain, depression, anxiety, loneliness, lower self-esteem, and less community reintegration. ConclusionsPerceived stigma may be a substantial source of stress for caregivers of U.S. military veterans with TBI/PT, and may contribute to poor outcomes for the health of caregivers and for the community reintegration of the veterans for whom they provide care.

Descriptive Findings of the VA Polytrauma Rehabilitation Centers TBI Model Systems National Database

ObjectivesTo present initial descriptive findings from the Veterans Affairs (VA) Polytrauma Rehabilitation Centers (PRC) Traumatic Brain Injury (TBI) Model Systems (MS) National Database. DesignProspective cohort study. SettingVA PRC TBIMS National Database. Participants712 service members and veterans with TBI who consented to participate between January 2010 and June 2015. InterventionsNot applicable. Main Outcome MeasuresDemographics, preinjury characteristics, injury characteristics, rehabilitation course, functional outcomes, and discharge disposition by TBI severity level. ResultsThe study cohort was predominantly male with moderate to severe TBI secondary to vehicular accident or blast injury. Sixty-five percent were active duty service members; one-third had been injured during deployment. One-third reported mental health treatment and/or alcohol use problems in the year predating the index TBI. The median number of days between injury and PRC admission was 42.5. Nearly 25% reported clinical levels of posttraumatic stress disorder; 75% reported mild to moderate neurobehavioral symptomatology. The median length of stay in the PRC was 36 days; those with severe TBI had the longest lengths of stay. Functional independence ratings improved from admission to discharge across all TBI severity levels. A majority were discharged to urban areas to reside with spouses or other residents in private residences or adult homes, with some variability by injury severity. ConclusionsThe VA PRC TBIMS national database is a rich source of information on a unique group of individuals with TBI and promises to complement existing knowledge on TBI in the civilian population.

Relationship Stability After Traumatic Brain Injury Among Veterans and Service Members: A VA TBI Model Systems Study.

To explore stability of relationships and predictors of change in relationship status 2 years following TBI/polytrauma. Five Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRCs). A total of 357 active duty service members and Veterans enrolled in the Veterans Affairs Polytrauma Rehabilitation Centers Traumatic Brain Injury Model Systems database with complete marital status information at 2 years postinjury. Prospective, longitudinal, multisite. Relationship status change was defined as change in marital status (single/never married; married; divorced/separated) at 2-year follow-up, compared with status at enrollment. At the time of enrollment, 134 participants (38%) were single/never married; 151 (42%) were married, and 72 (20%) were divorced/separated. Of those married at enrollment, 78% remained married at year 2 while 22% underwent negative change. Multivariable analyses revealed that age and education at the time of injury and mental health utilization prior to injury were significant predictors of relationship change. Among those who were single/divorced/separated at the time of enrollment, 87% remained so at year 2 while 13% underwent positive change. Injury during deployment significantly predicted positive relationship change. The unmalleable, preinjury characteristics identified may be used as potential triggers for education, prevention, surveillance, and couples therapy, if needed.

Predictors of Employment Outcomes in Veterans With Traumatic Brain Injury: A VA Traumatic Brain Injury Model Systems Study.

To examine the length of time to return to work (RTW) among service members and veterans (SM/V) with traumatic brain injury (TBI) and to identify variables predictive of RTW. Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRC). SM/V enrolled in the VA PRC Traumatic Brain Injury Model Systems database who were of 18 to 60 years of age and admitted with the diagnosis of TBI. Prospective observational cohort study. Employment status at 1-year postinjury follow-up; Time to Employment (ie, number of days it took to RTW) as documented during 1-year postinjury follow-up. The final sample (n = 293) included male (96%) SM/V with severe TBI (69%). Approximately 21% of the sample participants were employed at 1 year postinjury. Younger individuals who self-identified as nonminority returned to work sooner. Significant associations were observed for time to employment for cause of injury and injury severity. Few SM/V with moderate to severe TBI returned to work at 1 year postinjury. Predictors such as younger age at the time of injury, minority status, and severity of TBI affected time to and probability of RTW. Findings from this study have important implications for rehabilitation planning and service delivery across the continuum of recovery.

Employment Stability in Veterans and Service Members With Traumatic Brain Injury: A Veterans Administration Traumatic Brain Injury Model Systems Study

ObjectiveTo examine incidence and predictors of employment stability in veterans and military service members with traumatic brain injury (TBI) who return to work. DesignProspective observational cohort study. SettingFour rehabilitation centers. ParticipantsVeterans and military service members (N=110) with mild (26%), moderate (22%), or severe (52%) TBI enrolled in the Department of Veterans Affairs Polytrauma Rehabilitation Centers TBI Model Systems database within 2 years of injury who were discharged between January 2009 and June 2015. InterventionsNot applicable. Main Outcome MeasureEmployment stability as reflected by competitive employment at 1- and/or 2-year follow-up. ResultsOver half (n=61, 55%) of the participants had stable employment at the time the first competitive employment date was recorded. Individuals with stable employment were more likely to be white (79%) and to have slightly higher cognitive and motor discharge scores on the FIM. Based on univariate analysis, more severe TBI and higher FIM motor scores at discharge were significantly associated with employment stability. At follow-up, compared with veterans and military service members who had unstable employment, those with stable employment had higher scores on motor and cognitive FIM and lower scores of self-report symptoms on the Neurobehavioral Symptom Inventory, the 9-item Patient Health Questionnaire-Depression, the 7-item Generalized Anxiety Disorder Questionnaire, and the PTSD Checklist-Civilian version. ConclusionsA number of unique factors affect employment stability in veterans and military service members with TBI. Study findings identify veterans and military service members who have stable employment and predictors of employment stability.

Development of a Traumatic Brain Injury Model System Within the Department of Veterans Affairs Polytrauma System of Care

In 2008, the Department of Veterans Affairs Polytrauma Rehabilitation Centers partnered with the National Institute on Disability and Rehabilitation Research to establish a Model Systems program of research that would closely emulate the civilian Traumatic Brain Injury (TBI) Model Systems Centers Program established in 1987. To describe the development of a TBI Model Systems program within the Department of Veterans Affairs Polytrauma System of Care. Enrollment criteria and data collection/data quality efforts for the newly established Department of Veterans Affairs sites are reviewed. Significant progress has been made in the establishment of a Model Systems program for the Polytrauma System of Care. Data collection has moved forward and program-specific modifications have been implemented. The Veterans Affairs TBI Model System program is established and growing, with many projects underway and a strong working relationship with the civilian TBI Model System programs.

Family care map: Sustaining family-centered care in Polytrauma Rehabilitation Centers

The study assessed sustainability of the Family Care Map, a family-centered approach to providing care for Veterans with polytrauma-related injuries, in four Department of Veterans Affairs Polytrauma Rehabilitation Centers. We applied a mixed-methods approach. Staff surveys used standardized measures of sustainability, commitment to change, information, and participation during implementation. Qualitative inquiry assessed Family Care Map implementation and facilitators and barriers to sustainability. Staff sustainability perceptions had a significant positive correlation with affective commitment to change, participation, and information received about the change process. Family Care Map integration into standard practices and use of its concepts with patients and families related to staff perceptions about sustainability. The degree of use and integration of the Family Care Map in traumatic brain injury/polytrauma care varied among the Polytrauma Rehabilitation Centers. Some successful sustainability strategies included integration into daily workflow and organizational culture. Examples of sustainability barriers included staff awareness and use and outdated information. Some practices, such as measuring and documenting the use of the Family Care Map in treatment plans, may not routinely occur. The focus on family-centered care will require further evaluation of organization-, staff-, and innovation-level attributes that influence sustainability of changes designed to improve family-centered care.

Provider Perspectives on Rehabilitation of Patients With Polytrauma

Friedemann-Sánchez G, Sayer NA, Pickett T. Provider perspectives on rehabilitation of patients with polytrauma. ObjectivesTo describe, from the perspective of U.S. Department of Veterans Affairs (VA) polytrauma rehabilitation providers, (1) patients with combat-related polytrauma and their rehabilitation, (2) polytrauma patient family member involvement in rehabilitation, and (3) the impact on providers of providing polytrauma rehabilitation. DesignQualitative study based on rapid assessment process methodology, which included semistructured interviews, observation, and use of a field liaison. SettingThe 4 VA polytrauma rehabilitation centers (PRCs). ParticipantsFifty-six purposefully selected PRC providers and providers from consulting services. InterventionsNot applicable. Main Outcomes MeasuresProvider self-report of polytrauma patient characteristics, polytrauma patient family member involvement in rehabilitation, and the impact of polytrauma rehabilitation on providers themselves. ResultsAccording to PRC providers, polytrauma patients are younger than VA rehabilitation patients. Strong military identities affect rehabilitation needs and reactions to severe injury. The public and the media have particular interest in war-injured patients. Patients with blast-related polytrauma have unique constellations of visible (including amputations, craniectomies, and burns) and invisible (including traumatic brain injury, pain, and posttraumatic stress disorder) injuries. Providers have adjusted treatment strategies and involved services outside of rehabilitation because of this clinical complexity. Family members are intensely involved in rehabilitation and have service needs that may surpass those of families of rehabilitation patients without polytrauma. Sources of provider stress include new responsibilities, media attention, increased oversight, and emotional costs associated with treating severely injured young patients and their families. Providers also described the work as deeply rewarding. ConclusionsThe VA should prioritize the identification or development and implementation of strategies to address family member needs and to monitor and ensure that PRC providers have access to appropriate resources. Future research should determine whether findings generalize to patients injured in other wars and to people who sustain polytraumatic injuries outside of a war zone, including victims of terrorist attacks.

Characteristics and Rehabilitation Outcomes Among Patients With Blast and Other Injuries Sustained During the Global War on Terror

Sayer NA, Chiros CE, Sigford B, Scott S, Clothier B, Pickett T, Lew HL. Characteristics and rehabilitation outcomes among patients with blast and other injuries sustained during the Global War on Terror. ObjectiveTo describe characteristics and rehabilitation outcomes among patients who received inpatient rehabilitation for blast and other injuries sustained in Iraq and Afghanistan during the Global War on Terror. DesignObservational study based on chart review and Department of Veterans Affairs (VA) administrative data. SettingThe 4 VA polytrauma rehabilitation centers (PRCs). ParticipantsService members (N=188) admitted to a PRC during the first 4 years of the Global War on Terror for injuries sustained during Operation Iraqi Freedom or Operation Enduring Freedom. InterventionMultidisciplinary comprehensive rehabilitation program. Main Outcomes MeasuresCognitive and motor FIM instrument gain scores and length of stay (LOS). ResultsMost war-injured patients had traumatic brain injury, injuries to several other body systems and organs, and associated pain. Fifty-six percent had blast-related injuries, and the pattern of injuries was unique among those with injuries secondary to blasts. Soft tissue, eye, oral and maxillofacial, otologic, penetrating brain injuries, symptoms of post-traumatic stress disorder, and auditory impairments were more common in blast-injured patients than in those with war injuries of other etiologies. The mechanism of the injury did not predict functional outcomes. LOS was variable, particularly for those with blast injuries. Patients with low levels of independence at admissions made the most progress but remained more dependent at discharge compared with other PRC patients. The rate of gain was slower in this low-functioning group. ConclusionsBlasts produce a unique constellation of injuries but do not make a unique contribution to functional gain scores. Findings underscore the need for assessment and treatment of pain and mental health problems among patients with polytrauma and blast-related injuries. Patients with polytrauma have lifelong needs, and future research should examine needs over time after community re-entry.