Yevgeny Zadov, D.O., Blessen Eapen, M.D., David X. Cifu, M.D.
The United States began combat operations in 2001 in Afghanistan, referred to as Operation Enduring Freedom (OEF) and, in March 2003, the U.S. expanded military operations to Iraq, referred to as Operation Iraqi Freedom (OIF) and later Operation New Dawn (OND). These wars now account for the longest military campaign in U.S. history with 2.3 milliontroop deployments. These conflicts have resulted in 233,425 documented traumatic brain injuries (TBI) in U.S. troops.  Advances in battlefield medicine and protective armor have led to a higher percentage of soldiers surviving physical injuries that likely would have been fatal in prior combat operations. Many of the injuries sustained during the current combat operations have been described as Polytrauma, which is defined as “two or more injuries to physical regions or organ systems, one of which may be life threatening, resulting in physical, cognitive, psychological, or psycho-social impairments and functional disability.” [4,5]
In response to a growing need, the Veterans Health Administration (VHA) created the Polytrauma System of Care (PSC) in 2004. The PSC includes Polytrauma Rehabilitation Centers (PRC), Polytrauma Transitional Rehabilitation Programs (PTRP) and Polytrauma Network Site Clinics (PNS).[4,5,6] The PRCs, located at the VHA medical centers in Minneapolis, MN; Palo Alto, CA; Richmond, VA, Tampa, FL, and San Antonio, TX. , serve as regional referral centers for acute medical and rehabilitation care and as hubs for research and education related to Polytrauma and TBI. They provide a continuum of rehabilitation services including specialized “emerging consciousness” programs, comprehensive acute rehabilitation care for complex and severe polytraumatic injuries, outpatient programs, and residential transitional rehabilitation programs (PTRP).[4,7] The VHA PSC provides comprehensive, high-quality, and inter-disciplinary care to patients. Teams of providers from all relevant fields plan and administer an individually tailored rehabilitation plan. 
Identifying the Needs of Returning Heroes
The Polytrauma Transitional Rehabilitation Program is for veterans and active duty service members with polytrauma and/or TBI who have physical, cognitive, or behavioral impairments that may hinder their effective reintegration into the community or return to active duty. Developed through an extensive review of research on the effective components of existing transitional rehabilitation models, transitional rehabilitation offers a progressive return to independent living through a milieu-based, structured program, focused on restoring home, community, leisure, psychosocial, and vocational skills in a controlled, therapeutic setting. Services provided typically include group therapies, individual therapies, case management, care coordination, medical care, vocational and educational rehabilitation services. 
The PTRP has the potential to allay some of the costs associated with brain injury both in terms of productivity and lost wages. Currently, the cost associated with lost productivity and wages along with acute care for rehabilitation of acute traumatic brain injuries is estimated at $22 billion annually.  The transition from the rehabilitation setting to home and community is fraught with challenges for brain-injured patients and their caregivers. The prolonged hospital course and ongoing support after discharge that are often required after moderate to severe acquired brain injury (ABI,)and the impact of persistent emotional and psychosocial factors make this population particularly susceptible to difficulties after discharge.  The coordination and planning involved in transitioning from hospital to community has been identified as a crucial part of the overall rehabilitation process and assistance with return to work is an integral part of that process for both the patient with ABI, family and caregivers. 
While the return to work (RTW) rates for TBI patients are relatively low, usually around 30 percent, recent literature supports the efficacy of vocational rehabilitation programs in increasing that rate.  Kendall and colleagues showed that people who received a vocational intervention had a quicker RTW than those who did not. They also concluded that the RTW rate for persons who received intervention remains above the “natural course” RTW rate over any time period.  Which approach to vocational rehabilitation is most effective, however, is still being answered. There are three broad categories of vocational rehabilitation programs. Program based, individual placement and case coordination have been well described in the literature. In the Veterans Health Administration (VHA), ABI care is provided through the Polytrauma System of Care. One of the unique features of the PSC is a specialized residential approach to vocational rehabilitation for individuals who are unable to maximally benefit from more traditional outpatient programs.
A Review of Return to Work after Brain Injury
A key factor in the process of RTW after ABI is a return to the community and integration into the society. There are several factors that have been shown to influence the social integration of individuals, including the impact of impairments such as personality change, memory impairment and dysarthria; societal attitudes; public preconceptions; natural changes in the social environment; and relationships within the family. As one would expect, these elements are also important in RTW outcomes. [10,12] Other factors, such as age and the level of premorbid education have also been shown to influence RTW. Younger individuals with a higher level of education are more likely to find sustained employment after an ABI. Furthermore, work by Kendall and colleagues suggests that people who have had vocational intervention showed a faster RTW rate than those who did not. 
The ability to return to work is a recognized goal of most patients and families who enter acute rehabilitation programs after ABI. Identifying realistic vocational goals and initiating a set of milestones to attain that goal early in a rehabilitation program will enhance the hope of both the patient and team members. Simply entertaining the possibility of RTW as a goal may positively influence the treating team's willingness to prognosticate RTW as an achievable outcome.[12,13,15] Functional and socialization improvements that allow for a return to competitive work not only bring tangible returns on the cost of acute medical and rehabilitation care, they also help the individual to maintain a sense of self. This enhanced sense of self and clarity of role will also typically benefit the overall social support structure for that individual. This reintegration into societal roles, particularly when accompanied by a successful RTW, helps to decrease the concerns regarding an individual’s capacity to return to work after ABI.
The Polytrauma Transitional Rehabilitation Program
An innovative community reintegration and RTW program has been instituted across the VHAPSC. The PTRP at each PRC is dedicated to comprehensive, CARF-accredited rehabilitation for active duty service members and Veterans with brain injury and associated co-morbidities (e.g., fracture, amputation, burns, spinal cord injury, psychological disorders.)Each PTRP has established integrated holistic approaches for the treatment of brain injury and its many sequelae, including issues related to returning to the community and work. The PTRP utilizes the interdisciplinary, integrated team approach involving all rehabilitation disciplines, as well as blind rehabilitation services (BROS), cognitive rehabilitation, case management, community-based agencies for rehabilitation and vocational evaluation, and local and regional employers that can provide real world scenarios tailored to the individual. [4,15]
In the Richmond PTRP, vocational rehabilitation starts with an interdisciplinary approach to the evaluation of a patient who no longer requires inpatient medical care, but is likely to have many of the cognitive and behavioral sequelae of brain injury. The process starts with evaluations by the therapy disciples (speech and language pathology, physical, occupational, recreational, vocational, and blind rehabilitation therapies, psychiatry, psychology, and physiatry to evaluate an individual’s readiness to begin task specific vocational rehabilitation. Weekly interdisciplinary team conferences, which include patient and family input are a vital aspect of the program. The rehabilitation process starts with the basic goals of returning and re-acquiring the cognitive skills needed for routine household tasks and personal finance. These goals help the patient establish routines and coping strategies for cognitive deficits, which will subsequently be applied to specific RTW issues.
Various memory aids, including written reminders, smart phones, and more high-technology assistive devices are used to help those with cognitive difficulties return to providing self-care activities required in the home and community. Weekend passes for return to home with loved ones or for community activities with therapists are instituted as soon as the patient is safe to do so. This allows the patient, caregivers, and therapists to utilize learned strategies and report to the treatment team regarding both successful and less than successful experiences, while not necessarily under direct therapist supervision or under the constraints of the facility. This type of feedback is essential for re-evaluation of team and patient goals and strategies within the scope of the PTRP program. When a patient is deemed ready for the initiation of a specific return to work goal, the treatment team (including the patient) evaluates the specific job or job types that may be available and appropriate given the patient's cognitive and behavioral status, previous education, interests, and availability of particular services in the immediate area.
When vacancies for a particular job are not readily available locally or the skills required are above the patient's existing abilities, a program of vocational training or retraining is created. A key element of the PTRP's approach is to involve partners, including Veteran Service Organizations (SVOs), individual Veteran business leaders, and businesses who have established programs for hiring veterans. One of the major contributors for vocational training, serving as both a training site and an eventual hiring entity, is the local site of the Defense Logistics Agency (DLA)The agency employs civilians in various positions, such as information technology, human resources, accounting, and various supply management, environmental protection and property disposal positions. This site has often hosted on-site job evaluations, allowed patients to explore new vocational interests and abilities, and has been a hiring resource for Veterans who have completed the vocational rehabilitation program at the PTRP.
One of the key factors for success of the Richmond PTRP has been its integration within the larger VHA PSC, and specifically the full continuum of services offered at the Richmond Veterans Medical Center (VAMC). The polytrauma services at the Richmond VAMC include the PRC, a 12-bed acute brain injury unit, the PTRP, and the Polytrauma Network Site (PNS) program. The PNS program provides a full range of outpatient evaluation and rehabilitation services for Veterans and active duty service members with impairments and disability related to the OEF/OIF wars. Particular emphasis in this clinic is placed on difficulties related to brain injury. These services are also available to Veterans who have disability resulting from brain injury from other causes, including non-traumatic acquired brain injuries from cerebrovascular, neoplastic, and infectious etiologies. 
These programs should be viewed as an overlapping continuum of care for the brain injured patient. Each of these programs frequently refers patients to each other based on the evaluation of the program treatment teams. For instance, it is common for an injured Veteran or service member to be referred to the PTRP after they have successfully completed a course of brain injury rehabilitation in the inpatient PRC setting. At discharge from the PTRP, a patient will be followed by either the Richmond PNS program if they live locally, or at any of the 108 polytrauma outpatient sites across the United States. These three programs are clinically integrated and are in close physical proximity with treatment teams that work closely to coordinate the most appropriate care for each individual patient. Importantly, vocational rehabilitation, community reintegration, and symptom-focused individual and group therapy programs are all integrated within the PTRP program. The parallel delivery of care at all levels allows for real world, hands-on application of lessons learned.
Recent review of the data regarding RTW for the 2011 financial year showed that the majority of patients returned to a Warrior Transition Unit within the military. Of the other patients, 22 percent were either employed or volunteering, and only 11 percent were retired because of disability. The return to a Warrior Unit designation is unique to the PTRP / DOD affiliated programs. These individuals are on varied paths within the RTW spectrum. Some are remaining employed within the military, while others are in the process of a medical discharge because of injuries. Many of the patients being discharged from military service will be retraining for civilian employment, enrolling in vocational training at colleges or pursuing higher education at the university level.
As part of the comprehensive continuum of care available in the Polytrauma System of Care, the VHA’s Polytrauma Transitional Rehabilitation Programs offer community reintegration and vocational rehabilitation services in a unique, residential setting to America’s servicemembers and Veterans with many of the complex disabilities that result from polytrauma. These programs provide a much-needed service for individuals who have regained a high level of physical, cognitive and behavioral independence but continue to need rehabilitation to promote community integration and productivity.
- Belasco, A. Troop Levels in the Afghan and Iraq Wars, FY2001-FY2012: Cost and Other Potential Issues. July 2, 2009 available at http://www.fas.org/sgp/crs/natsec/R40682.pdf last accessed on 5/4/12
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Yevgeny Zadov, D.O.
Polytrauma Fellow, Hunter Holmes McGuire VAMC
Department of PM&R, Virginia Commonwealth University
Blessen Eapen, M.D.
Attending Physician, Audie L. Murphy Memorial VAMC
Department of PM&R, University of Texas Health Science Center- San Antonio
San Antonio, Texas
David X. Cifu, M.D.
National Director for PM&R Program Office
Department of Veterans Affairs
Chairman and Herman J. Flax, M.D. Professor
Department of PM&R, Virginia Commonwealth University