Henry L. Lew

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

OBJECTIVEnTo 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.nnnDESIGNnObservational study based on chart review and Department of Veterans Affairs (VA) administrative data.nnnSETTINGnThe 4 VA polytrauma rehabilitation centers (PRCs).nnnPARTICIPANTSnService 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.nnnINTERVENTIONnMultidisciplinary comprehensive rehabilitation program.nnnMAIN OUTCOMES MEASURESnCognitive and motor FIM instrument gain scores and length of stay (LOS).nnnRESULTSnMost 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.nnnCONCLUSIONSnBlasts 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.

Auditory dysfunction in traumatic brain injury.

Effective communication is essential for successful rehabilitation, especially in patients with traumatic brain injury (TBI). The authors examined the prevalence and characteristics of auditory dysfunction in patients with TBI who were admitted to a Department of Veterans Affairs TBI inpatient unit before and after the onset of Operation Iraqi Freedom (OIF). In order to delineate the characteristics of the auditory manifestations of patients who had sustained blast-related (BR) TBI, we reviewed the medical records of 252 patients with TBI and categorized them according to admission date, either before (Group I, n = 102) or after (Group II, n = 150) the onset of OIF. We subdivided Group II into non-blast-related (NBR) and BR TBI; no subjects in Group I had BR TBI. We found that admissions for TBI have increased 47% since the onset of OIF. In Group I, 28% of patients with TBI complained of hearing loss and 11% reported tinnitus. In Group II-NBR (n = 108), 44% complained of hearing loss and 18% reported tinnitus. In Group II-BR (n = 42), 62% complained of hearing loss and 38% reported tinnitus. Sensorineural loss was the most prevalent type of hearing loss in Group II-BR patients. In light of the high prevalence of hearing loss and tinnitus in this growing population of returning soldiers, we need to develop and implement strategies for diagnosis and management of these conditions.

Prevalence of dual sensory impairment and its association with traumatic brain injury and blast exposure in OEF/OIF Veterans

Objective:To describe the prevalence of self-reported rates of auditory, visual, and dual sensory impairment (DSI) in Afghanistan and Iraq war Veterans receiving traumatic brain injury (TBI) evaluations. Design:Retrospective medical chart review. Participants:Thirty-six thousand nine hundred nineteen Veterans who received a TBI evaluation between October 2007 and June 2009. Final sample included 12,521 subjects judged to have deployment-related TBI and a comparison group of 9106 participants with no evidence of TBI. Main Outcome Measure:Self-reported auditory and visual impairment. Results:Self-reported sensory impairment rates were: 34.6% for DSI, 31.3% for auditory impairment only, 9.9% for visual impairment only, and 24.2% for none/mild sensory impairment. Those with TBI and blast exposure had highest rate of DSI. Regression analyses showed that auditory impairment was the strongest predictor of visual impairment, and vice versa, suggesting these impairments may derive from a common source. Conclusions:Veterans who self-report clinically significant hearing or vision difficulty during routine TBI evaluation should be evaluated systematically and comprehensively to determine the extent of sensory impairment. Identifying DSI could allow clinicians to collaborate and maximize rehabilitation.

Screening for mild traumatic brain injury in OEF-OIF deployed US military: An empirical assessment of VHA's experience

Background: VHA screens for traumatic brain injury (TBI) among patients formerly deployed to Afghanistan or Iraq, referring those who screen positive for a Comprehensive TBI Evaluation (CTBIE). Methods: To assess the programme, rates were calculated of positive screens for potential TBI in the population of patients screened in VHA between October 2007 through March 2009. Rates were derived of TBI confirmed by comprehensive evaluations from October 2008 through July 2009. Patient characteristics were obtained from Department of Defense and VHA administrative data. Results: In the study population, 21.6% screened positive for potential TBI and 54.6% of these had electronic records of a CTBIE. Of those with CTBIE records, evaluators confirmed TBI in 57.7%, yielding a best estimate that 6.8% of all those screened were confirmed to have TBI. Three quarters of all screened patients and virtually all those evaluated (whether TBI was confirmed or not) had VHA care the following year. Conclusions: VHAs TBI screening process is inclusive and has utility in referring patients with current symptoms to appropriate care. More than 90% of those evaluated received further VHA care and confirmatory evaluations were associated with significantly higher average utilization. Generalizability is limited to those who seek VHA healthcare.

The history and evolution of traumatic brain injury rehabilitation in military service members and veterans.

Cifu DX, Cohen SI, Lew HL, Jaffee M, Sigford B: The history and evolution of traumatic brain injury rehabilitation in military service members and veterans.The field of traumatic brain injury has evolved since the time of the Civil War in response to the needs of patients with injuries and disabilities resulting from war. The Department of Veterans Affairs and the Defense and Veterans Brain Injury Center have been in the forefront of the development of the interdisciplinary approach to the rehabilitation of soldiers with traumatic brain injury, particularly those injured from the recent conflicts in Iraq and Afghanistan. The objectives of this literature review are to examine how the casualties resulting from major wars in the past led to the establishment of the current model of evaluation and treatment of traumatic brain injury and to review how the field has expanded in response to the growing cohort of military service members and veterans with TBI.

Associations Between Traumatic Brain Injury, Suspected Psychiatric Conditions, and Unemployment in Operation Enduring Freedom/Operation Iraqi Freedom Veterans.

Objective:To examine the relations among demographic characteristics, traumatic brain injury (TBI) history, suspected psychiatric conditions, current neurobehavioral health symptoms, and employment status in Veterans evaluated for TBI in the Department of Veterans Affairs. Study Design:Retrospective cross-sectional database review of comprehensive TBI evaluations documented between October 2007 and June 2009. Participants:Operation Enduring Freedom/Operation Iraqi Freedom Veterans (n = 11 683) who completed a comprehensive TBI evaluation. Main Measures:Veterans Affairs clinicians use the comprehensive TBI evaluations to obtain information about TBI-related experiences, current neurobehavioral symptoms, and to identify suspected psychiatric conditions. Results:Approximately one-third of Veterans in this sample were unemployed, and of these, the majority were looking for work. After simultaneously adjusting for health and deployment-related variables, significant factors associated with unemployment included one or more suspected psychiatric conditions (eg, posttraumatic stress disorder, anxiety, depression), neurobehavioral symptom severity (ie, affective, cognitive, vestibular), former active duty status, injury etiology, age, lower education, and marital status. The associations of these factors with employment status varied by deployment-related TBI severity. Conclusions:Simultaneously addressing health-related, educational, and/or vocational needs may fill a critical gap for helping Veterans readjust to civilian life and achieve their academic and vocational potential.

Concordance of Clinician Judgment of Mild Traumatic Brain Injury History with a Diagnostic Standard

The concordance of Department of Veterans Affairs (VA) clinician judgment of mild traumatic brain injury (mTBI) history with American Congress of Rehabilitation Medicine (ACRM)-based criteria was examined for Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) Veterans. In order to understand inconsistencies in agreement, we also examined the associations between evaluation outcomes and conceptually relevant patient characteristics, deployment-related events, current self-reported health symptoms, and suspected psychiatric conditions. The Veteran sample comprised 14,026 OIF/OEF VA patients with deployment-related mTBI history (n = 9,858) or no history of mTBI (n = 4,168) as defined by ACRM-based criteria. In the majority of cases (76.0%), clinician judgment was in agreement with the ACRM-based criteria. The most common inconsistency was between clinician judgment (no) and ACRM-based criteria (yes) for 21.3% of the patients. Injury etiology, current self-reported health symptoms, and suspected psychiatric conditions were additional factors associated with clinician diagnosis and ACRM-based criteria disagreement. Adherence to established diagnostic guidelines is essential for accurate determination of mTBI history and for understanding the extent to which mTBI symptoms resolve or persist over time in OIF/OEF Veterans.