BACKGROUND/RATIONALE:
As of June 2009 over 4,300 U.S. military personnel have died and more than 37,000 have been wounded in combat in Operations Iraqi and Enduring Freedom (OIF/OEF). TBI related to combat and accidents in combat theatres can cause life-long impairments in physical, cognitive, behavioral and social function that are usually more disabling concerning activities of daily living than the residual physical and deficits. Telerehabilitation: The current telerehabilitation study at the James Haley VAMC at Tampa, Fl (Tampa VA) expanded the existing rehabilitation program in place for veterans discharged from the Level 1 Polytrauma/Blast Related (PT/BRI) Center at the Tampa VA with a diagnosis of mild and moderate TBI incurred in combat theatres. It promoted independence at home for veterans experiencing difficulties with activities of daily living with the aid of services rendered with assistive technology and home environmental modifications together with providing needed medical care via telehealth.

OBJECTIVE(S):
The goal of this proposed continuation of care program was to meet the rehabilitation needs of veterans with combat related TBI and evaluate the impact of the program on patient and caregiver outcomes. The primary objectives of this 36 month quasi-experimental studies were to 1) Provide care coordination to meet the needs of OEF/OIF veterans with mild to moderate TBI. 2) Determine the immediate and sustained effects of telerehabilitation on patient outcomes including function and community participation 3) Examine the perceived benefits and limitations of the telerehabilitation from the veteran and caregiver perspectives and 4) Evaluate the impact of telerehabilition on resource utilization (e.g., clinic visits, hospital bed days of care).

METHODS:
Study design: This 36 month study used a quasi-experimental design to evaluate TBI LAMP care provided to a sample of 75 OIF/OEF veterans discharged from the James A. Haley Veterans Hospital in Tampa, FL with a diagnosis of mild/moderate TBI with or without comorbid PTSD. We utilized quantitative analysis for evaluating changes in functional status, community participation, VA healthcare utilization, and veteran/family perceptions of telerehab.
Inclusion characteristics: Veterans or active duty military personnel diagnosed with combat related TBI treated and discharged from the Tampa VA and residing within a two hour drive from the Tampa VA who were willing to accept technology in their homes for monitoring purposes and signed a consent form. Telerhabilitation services were offered only to those patients who required additional care and stood to benefit from the program. Due to disenrollment and other issues we expected to follow a cohort of at least 60 veterans for at least a one year time period needed to assess the effectiveness of the program. We requested an increase in enrollment to 85, and ultimately enrolled 81 veterans into the study.

FINDINGS/RESULTS:
The major findings our research suggest:
1) Functional capabilities measured by locomotion and mobility appear to have stabilized among our cohort of veterans while deficiencies in cognition (memory, problem solving), psychosocial adjustment (anger, emotional status) and problems in integrating into society pose challenges.
2) Headaches, depression and other Post Traumatic Stress disorders appear to afflict a majority of patients.
3) Individualized treatment pathways are needed for rehabilitation and ultimate integration into society.
4) Those with comorbid PTSD exibit erratic rehabilitation trajectories as compared to those with mTBI only.
5) Veterans have expressed appreciation for the program and for the care coordination provided.
The addition of MyHealtheVet as a method of communication with Veterans for the purposes of care coordination has been well-received by the Veterans.

IMPACT:
The impact of our study has been manifold. DOD had provided us additional monies to conduct a separate, randomized control trial of our telerehabilitation with the Miami VA as a control site. Additional Veterans with combat related trauma equally divided between the intervention (telerehabilitation) group and the control group (usual care) were consented in Miami.
Our findings have been widely disseminated at VA Telehealth and Mental Health conferences and DOD forums including a selective invitation to present at the NATO Symposium on Mental Health and Well Being at Bergen, Norway in April, 2011. Our findings were presented at other DoD meetings. We are preparing additional manuscripts.
Our findings have impacted our care coordination especially in mental health with veterans diagnosed with PTSD. We continued refining our care coordination to have maximal impact on the well beong of our veteran cohort during the study. As the VA enhances its MyHealthvet program to include two way communication between providers and patients our findings should be valuable to the VA in structuring telehealth for combat wounded veterans nationwide.
Our evaluation of the impact of our intervention on our veteran subjects suggests that it was valuable to the veterans, and provided them a means of better communication with their healthcare providers. The impact of the addition of MyHealtheVet with secure messaging as a method of communication with Veterans for the purposes of care coordination is relatively recent but seems to be valuable and appreciated by the veterans.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Chapman PL, Elnitsky CA, Thurman R, Spehar AM, Siddharthan K. Exploring combat-related loss and behavioral health among OIF/OIF Veterans with chronic PTSD. Traumatology. 2013 Jun 1; 19(2):154-157. [view]
2. Siddharthan K. The effect of post traumatic stress disorders on rehabilitation among combat-wounded veterans. Studies in health technology and informatics. 2012 Jan 1; 182:114-24. [view]

Conference Presentations

1. Siddharthan K. Effect of care coordination on health resilience among OEF/OIF female combat wounded veterans. Paper presented at: Women's Health Annual Congress; 2014 Jul 11; Washington, DC. [view]
2. Siddharthan K, Spehar AM, Brock S, Lapcevic WA. Redesigning care coordination for combat-wounded veterans via telerehabilitation. Paper presented at: VA VHA System's Redesign Improvement Annual Forum; 2011 Sep 20; Las Vegas, NV. [view]
3. Siddharthan K. Rehabilitation at a distance for combat wounded veterans. Paper presented at: VA Patient Centered Medical Home Summit; 2010 Apr 13; Las Vegas, NV. [view]
4. Siddharthan K. Telerehabilitation for combat wounded with Traumatic Brain Injury (TBI) and Post Traumatic Stress Disorder (PTSD). Paper presented at: Military Health Research Forum; 2009 Aug 31; Washington, DC. [view]
5. Siddharthan K. Telerehabilitation for combat wounded with traumatic brain injury and post traumatic stress disorders. Paper presented at: Trauma Spectrum Disorders Annual Conference; 2010 Dec 7; Bethesda, MD. [view]
6. Siddharthan K. Telerehabilitation for OIF/OEF returnees with combat-related traumatic brain injury. Paper presented at: Department of Defense Health Annual Forum; 2011 Jul 1; Fairfield, VA. [view]
7. Siddharthan K. Telerehabilitation for Veterans with combat related TBI/PTSD. Paper presented at: North Atlantic Treaty Organization Research and Technology Organization Human Factors and Medicine Panel Annual Symposium; 2011 Apr 1; Bergen, Norway. [view]
8. Siddharthan K. The effect of post-traumatic stress disorders on integration into society for combat wounded veterans. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 27; Little Rock, AR. [view]

DRA: Military and Environmental Exposures, Health Systems, Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Prognosis
Keywords: Operation Enduring Freedom, Operation Iraqi Freedom, Traumatic Brain Injury
MeSH Terms: none