Christina Dillahunt-Aspillaga

Traumatic brain injury: unmet support needs of caregivers and families in Florida.

Sustaining a Traumatic Brain Injury results in familial strain due to the significant impact the injury has upon the role and function of individuals and their families at home and in the community. Using the Stress Process Model of Caregiving, a caregiver needs assessment survey was developed and conducted to better understand the needs of individuals with a Traumatic Brain Injury and their caregivers. Survey results indicate that caregivers experience many challenges including unmet needs in areas of relational supports such as maintaining relationships, long-term emotional and financial support for themselves and the survivor, and the need for a patient or caregiver advocate. Implications for future practice are presented.

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

Objectives: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. Setting:Department of Veterans Affairs Polytrauma Rehabilitation Centers (VA PRC). Participants: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. Design:Prospective observational cohort study. Main Outcome Measures: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. Results: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. Conclusions: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.

Decreased Movement Path Tortuosity Is Associated With Improved Functional Status in Patients With Traumatic Brain Injury.

Objective:To determine if movement path tortuosity in everyday ambulation decreases in Veterans being treated in a residential setting for traumatic brain injury. Elevated path tortuosity is observed in assisted living facility residents with cognitive impairment and at risk for falls, and tortuosity may decrease over the course of cognitive rehabilitation received by the Veterans. If observed, decreased tortuosity may be linked to improved clinical outcomes. Design:Longitudinal observational study without random assignment. Setting:Veterans Affairs Medical Center inpatient residential polytrauma treatment facility. Patients:Twenty-two Veterans enrolled in a postacute predischarge residential polytrauma treatment facility. Interventions:None, observation-only. Main Outcome Measure:Mayo-Portland Adaptability Index-4, and movement path tortuosity measured by Fractal Dimension (Fractal D). Fractal D was obtained continuously from an indoor movement tracking system primarily used to provide machine-generated prompts and reminders to facilitate activities of daily living. Patients were deemed “responders” (N = 10) if a significant linear decline in Fractal D occurred over the course of treatment, or nonresponders (N = 12) if no significant decline was observed. Results:Responders had lower discharge Mayo-Portland Adaptability Inventory scores (mean = 32.6, SD = 9.53) than non-responders (mean = 39.5, SD = 6.02) (F = 2.07, df = 20, P = .05). Responders and nonresponders did not differ on initial injury severity or other demographic measures. Conclusions:Fractal D, a relatively simple measure of movement path tortuosity can be linked to functional recovery from traumatic brain injury.

Integrating customized employment practices within the vocational rehabilitation system

BACKGROUND: In April 2009, the Florida Center for Inclusive Communities (FCIC) conducted a two-day training on the Discovery process for the Brevard County School System as part of the Supported, Competitive, Integrated Employment Training Teams (SCIETT) project. The Vocational Rehabilitation (VR) representatives at the training came up with a plan to integrate Discovery into the public VR system. They presented the information to the State VR office and requested support to conduct a pilot project to test the feasibility of this idea. OBJECTIVE: This article describes a systems change project initiated by the Florida Division of Vocational Rehabilitation (VR) to build the capacity of the public VR system to effectively serve individuals with complex disabilities by adding Discovery, a component of the customized employment process, as an alternative to traditional vocational evaluation. CONCLUSION: A collaborative effort between Florida VR, Marc Gold & Associates, Southeast TACE, and the University of South Florida resulted in a certification process to train community-based providers to provide Discovery as a billable service for VR customers who have not been successful in obtaining competitive, integrated employment through traditional strategies. The article includes an overview of this innovative project and lessons learned to assist other states and communities in replicating the process.

Traumatic Brain Injury Severity, Comorbidity, Social Support, Family Functioning, and Community Reintegration Among Veterans of the Afghanistan and Iraq Wars

OBJECTIVE To examine the association between traumatic brain injury (TBI) severity; social, family, and community reintegration outcomes; and return to work status among post-9/11 veterans in Department of Veterans Affairs (VA) care. DESIGN Retrospective observational cohort study. SETTING Mail/online survey fielded to a national sample of veterans. PARTICIPANTS Sample of post-9/11 veterans with at least 3 years of VA care stratified according to TBI severity and comorbidities who completed and returned surveys (N=2023). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Deployment Risk and Resilience Inventory-2 family functioning and social support subscales; Military to Civilian Questionnaire; and employment status. RESULTS Bivariate analyses revealed that veterans with every classification of TBI severity reported significantly more difficulty on social, family, and community reintegration outcomes than those with no TBI. In the fully adjusted model, veterans with unclassified and moderate/severe TBI reported significantly more difficulty with community reintegration and were less likely to be employed relative to those with no TBI; those with unclassified TBI also reported significantly more difficulty with family functioning. Veterans with mild TBI also reported significantly more difficulty with community reintegration. CONCLUSIONS This study provides insight into long-term outcomes associated with TBI in post-9/11 veterans and suggests that exposure to TBI has a negative effect on social and family functioning, community reintegration, and return to work even after controlling for comorbidity, deployment experiences, and sociodemographic characteristics. Additional research is required to explicate what appears to be complex interactions among TBI severity, psychosocial well-being, combat exposures, and socioeconomic resources in this population.

Community Reintegration, Participation, and Employment Issues in Veterans and Service Members With Traumatic Brain Injury

Traumatic brain injury (TBI) has been called the signature injury of the post-9/11 wars in Iraq, Afghanistan, and neighboring countries. Although similarities exist between veterans and service members with TBI, levels of severity and different constellations of coexisting comorbid conditions affect them differently. These conditions affect physical, cognitive, and emotional function, which in turn can complicate community reintegration (CR), or the ability to return to family, vocational, and community life. This special supplement of the Archives of Physical Medicine and Rehabilitation consists of articles written by accomplished teams from multiple disciplines, including anthropology, neuropsychology, nursing, occupational therapy, psychology, and rehabilitation sciences. Each article brings a different perspective to bear on what CR means for veterans and service members from examination of predictors and perceptions of veterans and service members and others to measurement studies. Collectively, this group of articles represents current thinking about CR and lays the groundwork for testing interventions to improve CR outcomes for veterans and service members (eg, employment, living situation, family life).

Comparison of the VA and NIDILRR TBI model system cohorts

Objective:Within the same time frame, compare the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) and VA Traumatic Brain Injury Model System (TBIMS) data sets to inform future research and generalizability of findings across cohorts. Setting:Inpatient comprehensive interdisciplinary rehabilitation facilities. Participants:Civilians, Veterans, and active duty service members in the VA (n = 550) and NIDILRR civilian settings (n = 5270) who were enrolled in TBIMS between August 2009 and July 2015. Design:Prospective, longitudinal, multisite study. Main Measures:Demographics, Injury Characteristics, Functional Independence Measures, Disability Rating Scale. Results:VA and NIDILRR TBIMS participants differed on 76% of comparisons (18 Important, 8 Minor), with unique differences shown across traumatic brain injury etiology subgroups. The VA cohort was more educated, more likely to be employed at the time of injury, utilized mental health services premorbidly, and experienced greater traumatic brain injury severity. As expected, acute and rehabilitation lengths of stay were longer in the VA with no differences in death rate found between cohorts. Conclusions:Substantial baseline differences between the NIDILRR and VA TBIMS participants warrant caution when comparing rehabilitation outcomes. A substantive number of NIDILRR enrollees had a history of military service (>13%) warranting further focused study. The TBIMS participant data collected across cohorts can be used to help evidence-informed policy for the civilian and military-related healthcare systems.

Implementation of Customized Employment Provisions of the Workforce Innovation and Opportunity Act Within Vocational Rehabilitation Systems

Effectively integrating provisions of the Workforce Innovation and Opportunity Act (WIOA) into public Vocational Rehabilitation (VR) systems will require extensive effort at both the organizational and system levels. This article presents information on WIOA provisions, enacted in July of 2014, that affect public VR systems plus rationale, strategies, and tools for implementing these provisions in a manner that promotes quality and sustainability. Both “ideal” implementation methods and “pragmatic” methods are presented based on the experience of one state’s efforts to incorporate customized employment strategies into its VR system to benefit customers who have not been successful at achieving a competitive, integrated employment outcome through traditional VR strategies.

Allostatic perspectives in women veterans with a history of childhood sexual assault

Background: Women veterans have increased reports of sexual victimization compared to women in general, including childhood sexual assault (CSA) before military service, increasing the risk of military sexual trauma. Findings from recent studies reveal negative health effects following a history of CSA. There is a strong relationship between CSA and revictimization in civilian and military life, which may contribute to allostatic load. Objectives: (1) To determine the relationship between women veterans’ CSA history and later sexual assault history and (2) to determine the relationships between women veterans’ CSA and primary mediators and secondary and tertiary outcomes of allostasis. Research design: Cross-sectional. Subjects: Women (N = 81), 18–70 years old, veterans of the U.S. Armed Services. Measures: Participants completed questionnaires and blood and hair samples were collected. Several scales were utilized: Posttraumatic Checklist–Military, Center for Epidemiological Studies–Depression Scale, Pain Outcomes Questionnaire–Short Form, Cohen’s Perceived Stress Scale (PSS), Profile of Mood States, and an investigator-developed sexual harassment/assault instrument. Results: Thirty-three percent of participants reported CSA; of these, 38.5% reported military sexual assault and 70.3% sexual assault during civilian life. Those with CSA had higher cholesterol, triglycerides, perceived stress scores, and greater pain and fatigue than those without CSA. Hair cortisol was marginally lower in women with CSA when PSS was controlled, suggesting a dampened hypothalamic–pituitary–adrenal axis. Conclusions: These data suggest that some women veterans with a history of CSA may have increased allostatic load and be at increased risk for a variety of later life illnesses.

Exploring Vocational Evaluation Practices following Traumatic Brain Injury

Background. Individuals with traumatic brain injury (TBI) face many challenges when attempting to return to work (RTW). Vocational evaluation (VE) is a systematic process that involves assessment and appraisal of an individuals current work-related characteristics and abilities. Objective. The aims of this study are to (1) examine demographic and employment characteristics of vocational rehabilitation providers (VRPs), (2) identify the specific evaluation methods that are used in the VE of individuals with TBI, and (3) examine the differences in assessment method practices based upon evaluator assessment preferences. Methods. This exploratory case study used a forty-six-item online survey which was distributed to VRPs. Results. One hundred and nine VRPs accessed the survey. Of these, 74 completed the survey. A majority of respondents were female (79.7%), Caucasian (71.6%), and holding a masters degree (74.3%), and more than half (56.8%) were employed as state vocational rehabilitation counselors (VRCs). In addition, over two-thirds (67.6%) were certified rehabilitation counselors (CRCs). Respondents reported using several specific tools and assessments during the VE process. Conclusions. Study findings reveal differences in use of and rationales for specific assessments amongst VRPs. Understanding VRP assessment practices and use of an evidence-based framework for VE following TBI may inform and improve VE practice.