By Tina M. Trudel, Phd, John DaVanzo, MS, MEd, CCC-SLP, Erin O. Mattingly, MA, CCC-SLP, F. Don Nidiffer, Phd, Jeffrey T. Barth, Phd, ABPP

Traumatic Brain Injury is a major health problem in civilian and military populations, where even in peace time, injuries number in the thousands. Individuals experiencing moderate to severe brain injuries require a continuum of care involving acute hospitalization and post-acute rehabilitation, including community reintegration and hopefully a return home as a productive member of the community and family life. In the military, the goal is to help individuals with TBI return to active duty or make an optimal return to civilian life if the extent of their injuries necessitates a “medical board” discharge. Whether civilian or military, individuals with TBI who move beyond the need to live in a medical or supervised setting require supports and services in order to successfully reintegrate back into the community. This article discusses community integrated rehabilitation, and describes the Defense and Veterans Brain Injury Center at Virginia Neurocare, a program designed to provide community reintegration and rehabilitation for military personnel with TBI.

Brain injury has become a leading public health problem for civilians and the military. In the United States civilian population, 1.4 million individuals sustain traumatic brain injury (TBI) annually resulting in 235,000 hospital admissions and 50,000 deaths[1]. Economically, the total impact of direct and indirect medical and other costs in 1995 dollars is reported to exceed $56 billion[2]. The Centers for Disease Control and Prevention estimate that long-term disability as a result of brain injuries (defined as needing assistance with activities of daily living) affects 5.3 million Americans, with thousands of new individuals affected every year [3].

Brain injury is an ever present risk of military duty. The experience of brain injury in the military and the need to develop new medical, safety and rehabilitative technologies to address the efficiency of evolving warfare has been instrumental in driving research and advancement of clinical care [4]. Recognition of the unique challenges of TBI in the military and the need to provide innovative treatment approaches contributed to the development of the Defense and Veterans Brain Injury Center (DVBIC), which was established in 1991 (formerly known as the Defense and Veterans Head Injury Program) and is discussed in depth in this special issue (Zitnay, page 16). The DVBIC provides an integrated program to enhance clinical quality, research and education across the military brain injury treatment continuum, including community integrated brain injury rehabilitation through its civilian partner, Virginia NeuroCare (VANC).

The professional and public interest in military TBI has dramatically increased with the occurrence of such injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF - includes Afghanistan). With regard to OIF, the Office of the Surgeon General of the Army notes that 64% of wounded in action injuries have occurred as a result of blast from improvised explosive devices (IED), rocket propelled grenades, land mines and mortar/artillery shells [5]. Given improvements in helmet design and body armor and the resultant reductions in penetrating injuries including penetrating head trauma, blast related closed head injuries have become the signature injury of these military operations.

Many armed service members who sustain TBI are treated in theater and return to active duty, productive work, social roles, family responsibilities and their pre-morbid status. However, some military TBI survivors live with residual disability, are unable to return to active duty, have complex care needs, and/or are initially unsuccessful in re-entering home, vocational and community life. Those TBI survivors at risk for unsatisfactory outcomes or with continued rehabilitation needs are candidates for community integrated rehabilitation. Community Integrated Rehabilitation (CIR) is a broad term encompassing various approaches and contexts for treatment, with an evolving body of supporting scientific evidence. Military personnel receiving CIR services through programs such as VANC have provided, and will continue to provide, critical data for the empirical development of this level of post-acute care [6].

Approaches to Community Integrated Rehabilitation

Community integrated rehabilitation is also referred to as post-acute brain injury rehabilitation and includes diverse approaches that allow for individuals with TBI to benefit from further rehabilitation after medical stability is established and initial acute (in-hospital) rehabilitation is completed. Typically, CIR does not include sub-acute brain injury rehabilitation programs that specialize in coma management or the treatment of behaviors that actively pose a risk of serious endangerment [7]. These clinical scenarios are more often addressed in skilled nursing settings and intensive neurobehavioral programs, respectively. The most common delineation of CIR programs has followed the framework proposed by Malec and Basford (1996), including neurobehavioral programs, residential programs, comprehensive holistic (day treatment) programs and more recently, home-based programs [6, 8].

Neurobehavioral CIR programs have historically focused on treatment of mood, behavior and executive function, while ensuring supervision and safety in 24-hour, non-hospital setting. Such programs focus on psychosocial outcomes with emphasis on application of behavioral principles, development of functional skills and pharmacological management as needed. Neurobehavioral CIR programs typically have inter- or transdisciplinary treatment teams, utilize direct support personnel as therapeutic extenders, and often involve neuropsychologists, behavior analysts and/or psychiatrists [9].

Residential CIR programs were initially developed to meet the needs of individuals who required extended comprehensive TBI rehabilitation, 24-hour supervision and/or did not have access to adequate outpatient/day services. The home-like, enriched environment and staff support in such programs facilitate development of skills needed to negotiate everyday life, maximizing opportunities for practice and learning while easing generalization across community environments [9].

Comprehensive holistic day treatment CIR programs provide a milieu-oriented, multimodal approach, often with a neuropsychological focus. Interventions target awareness, cognitive functions, social skills and vocational goals through individual, group and family-mediated interventions delivered through an inter- or transdisciplinary team [11]. These programs have the greatest research foundation in the field of CIR, and while treatment guidelines are often site specific, such resources are invaluable, allowing discourse, analysis, replication, theory dvelopment and dissemination of techniques [7, 11-13].

Home-based CIR involves a highly variable array of services and supports for the individual with TBI able to reside in a home environment, and is often based on the available home service providers or professionals in a particular community. Most often, individuals receiving home-based CIR do not require 24-hour supports or supervision. Home-based CIR includes a spectrum of outpatient services commonly accessed through individual treatment providers or clinics. There is usually not an identified ‘treatment team’, although collaboration may occur across a number of health and social service systems. Behavioral approaches using self-monitoring, environmental support and cueing may be employed, as well as models wherein family members or in-home paraprofessionals serve as therapeutic agents. Additionally, some examples of home-based CIR are primarily educational, supportive and/or emphasize use of telephonic, web-based, and technological aides [6, 8].

Reviews of the effectiveness of various forms of CIR are available in the literature, with studies ranging from observational accounts to randomized control trials. While the evidence supporting the benefits of CIR has been slow to develop, recent studies demonstrate significant gains in social participation, vocational outcomes, self/family ratings of functioning, physical status, cognitive abilities and psychological well-being related to participation in CIR after TBI [14, 15, 16]. Support for the benefits of CIR exist across the continuum from mild to severe TBI [9, 17, 18] and for individuals from a year to many years post-injury [12, 19]

Implementation of a Residential Brain Injury CIR for Military Personnel

The valuable clinical research characteristics identified early in DVBIC’s history (homogeneity, available records, infrastructure, multi-site, outcomes measurement, tracking) [4] provide an optimal foundation for CIR research through the DVBIC VANC program with a long history of CIR focus and expertise. VANC’s CIR Pilot Clinical Research Project is engaged in the development, implementation and analysis of educational and treatment interventions with VANC program participants from the military who have suffered mild, moderate, and severe TBI primarily from combat IED blast forces and motor vehicle accidents. These military personnel with TBI have benefited from acute medical intervention and sub-acute rehabilitation hospitalization at other DVBIC facilities, and they have progressed to the stage where they benefit from the VANC residential and day treatment program aimed at community re-entry.

The military program participants at VANC are typically several months post injury and have made substantial recovery, yet they still suffer mild to moderate neurological and behavioral challenges, typically associated with frontal and temporal lobe dysfunction and executive dyscontrol. These service men and women are still in the active stages of recovery, but no longer require acute medical intervention. Complex brain injury sequelae may persist including balance problems, ataxia, incoordination, impaired activities of daily living, memory difficulties, attentional problems, fatigue, problematic initiation and motivation, irritability, frustration, depression, sleep disturbance, poor judgment, impulsiveness, anosognosia, organizational problems, speech difficulties, anger management and socialization skill problems, general cognitive dysfunction, and family or work stress.

There VANC program offers individualized interventions based on a common core of neurorehabilitation tools. Services provided include both individual and small group treatment, and therapeutic activities in office, home, work and community settings. Each soldier who participates in the community re-entry program at VANC stays in an eight bed residential living facility that is housed in a Victorian-style house in Charlottesville, Virginia, or as clinically indicated, in community-based apartments with support. Designed to replicate a home rather than a hospital, the residential house provides 24 hour supervision by trained staff members who administer medications, facilitate meals and activities, collect data, and provide necessary extended therapeutic support for soldiers with brain injury.

The VANC program provides an intensive rehabilitation day program, offering a unique experience of research and theoretically based therapies facilitated by occupational and physical therapists, psychologists, vocational specialists, and speech-language pathologists. The program addresses cognitive-behavioral, neuromotor, personal and community activities of daily living, and social skills in real-world settings while participating in functional, community-based activities. Military program participants work with therapists on cognitive and behavioral coping abilities, and to improve skills necessary for reintegration in the community, return to work, or return to active duty in the military.

The program features therapeutic educational modules that are being transformed into manualized treatment tools addressing: brain injury education, wellness, empowerment, time management, attention/memory, and social skills. The modules are designed to address difficulties with coping and living successfully with an acquired brain injury. Emphasis is placed on enhancing self-awareness/self-appraisal skills throughout each therapeutic endeavor. Some or all of the following skills are developed and implemented in the home and community: meal planning and preparation, grocery shopping, use of public transportation, increased volunteerism, clubhouse membership, supported work experiences, community navigation, laundry skills, social and communication skills, money management, and medication management.

If necessary, prosthetics and adaptive equipment are utilized all with the goal of developing modified independent living skills. Working toward returning to the workplace and fostering a sense of productivity, clients begin by seeking out a volunteer work experience. In conjunction with a therapist, the soldier’s volunteer experience builds confidence and demonstrates competence. A wide variety of volunteer opportunities are available, including the VANC operated used bookstore on the downtown mall of Charlottesville.

The VANC program is increasingly using advanced and everyday technology in order to maximize the potential of program participants. Current clinical projects for 2007 include use of global positioning satellite technology to facilitate orientation, community navigation skills and functional independence. Assistive technology such as personal data assistant and programmable watches are also implemented. Along with the functional implementation of technological aides, ratings are gathered regarding the person-technology interface to assess the best fit, as high acceptance of a technological aide is associated with greater likelihood of on-going use. Lastly, VANC is commencing collaboration with the University of Virginia Neurocognitive Assessment Lab to develop both assessment and rehabilitation tools utilizing a virtual reality type of driving simulator.

After demonstrating the ability to be independent with basic Activities of Daily Living (ADLs), a military program participant may be able to move into an independent living arrangement. VANC provides apartment environments dedicated to independent living. The independent living aspect of the program features modified independent living in a less intensely supervised setting. The soldier is responsible for all aspects of his/her own care from household management to bill payment. It affords service men and women the opportunity and assistance necessary to take the final step towards reintegration in the community or return to duty.

Participation in the apartment and independent living phases requires successful engagement in the intensive rehabilitation day program. Military program participants are responsible for their own community transportation, meal preparation, laundry, household management, medication management, financial management, and recreational participation. Soldiers spend the day outside the house, involved in either school, volunteer, or work activities.

Return to work is a common goal of survivors of brain injury. The vocational program has numerous work and volunteer contracts with local businesses, in order to provide situational assessment, job-site assessment, on-the-job training, work adjustment training, cognitive training and supervised work experience. Active duty military program participants often serve at the Judge Advocate General (JAG) Training School at the University of Virginia where they demonstrate their ability to maintain a competitive work situation while in a military environment. The goal is discharge to the least restrictive, most integrated environment possible, ranging from an independent to supervised living situation, or military re-entry to supported employment.

Discharge is considered when the soldier has developed and demonstrated competence in independent living, physical fitness, cognitive ability, emotional control and vocational ability. Active duty military program participants must be able to demonstrate that they are fit for duty to be able to be considered for return to duty. After completion of the program, active duty military program participants follow a set of procedures for disposition back into formal active duty. By tracking effective approaches to treating service men and women who have experienced brain injuries in the course of their duties, VANC hopes to delineate the most cost-effective strategies that can be utilized in other programs, both military and civilian. Such programs are critically needed as the number of brain injuries continue to escalate from war and non-war events.

About the Authors

Tina M. Trudel, PhD is the Principal Investigator of the Virginia NeuroCare DVBIC program, and the President/COO of Lakeview Healthcare Systems, Inc., a national provider of rehabilitation and neurobehavioral services. She is an Assistant Professor of Clinical Psychiatric Medicine in the Department of Psychiatry and Neurobehavioral Sciences at the University of Virginia School of Medicine and has published and presented extensively in the field of brain injury.

John DaVanzo, MS, MEd, CCC-SLP is the Clinical Coordinator of the DVBIC program at Laurel Highlands. He is a speech-language pathologist and the former Clinical Director of the DVBIC program at Virginia NeuroCare. He is presently completing his doctorate at the University of Virginia and is conducting research on the assessment of quality of life after brain injury.

Erin O. Mattingly, MA, CCC-SLP is the Clinical Coordinator and a speech-language pathologist for the DVBIC program at Virginia Neurocare. She is presently involved in research developing community integrated rehabilitation manualized treatment and assessment models.

F. Don Nidiffer, PhD is the Co-Principal Investigator of the Virginia NeuroCare DVBIC program and Executive Director of Lakeview Virginia NeuroCare. Dr. Nidiffer is a clinical psychologist with 23 years of experience in the University of Virginia Health System, providing rehabilitation and behavior therapy services across all ages. He completed his post-doctoral fellowship in Behavioral Pediatrics from Johns Hopkins School of Medicine.

Jeffrey T. Barth, PhD, ABPP holds the John Edward Fowler Endowed Professorship in Clinical Neuropsychology at the University of Virginia School of Medicine. He is Chief of the Neurobehavioral Study Section and Director of the UVA Brain Injury and Sports Concussion Institute. He also maintains a Senior Scientist position with Lakeview Healthcare Systems and Virginia Neurocare, and has published and presented internationally on topics including neuropsychology, brain injury and rehabilitation.

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