Community-Integrated Brain Injury Rehabilitation: Treatment Models and Challenges for Civilian, Military, and Veteran Populations

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INTRODUCTION

Traumatic brain injury (TBI) has become a leading public health problem for civilians and the military. In the U.S. civilian population, 1.4 million individuals sustain 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 (necessitating assistance with activities of daily living) affects 5.3 million Americans, with thousands more affected every year [3].

Brain injury has always been a possible consequence of military duty. The frequency of TBI in the military and the need to develop new medical technologies to address the efficiency of evolving warfare have been instrumental in encouraging research and advancement of clinical care for TBI [4]. Recognition of the unique challenges of TBI in the military and the need to provide effective treatment approaches contributed to the development of the Defense and Veterans Brain Injury Center (DVBIC), established in 1992 (formerly known as the Defense and Veterans Head Injury Program). The DVBIC provides an integrated program to enhance clinical quality, research, and education across the military and veteran TBI treatment continuum, including community-integrated brain injury rehabilitation through its civilian partner, Virginia NeuroCare (VANC).

The professional and public focus on TBI in the military has dramatically increased with the rise of brain injuries in Operation Iraqi Freedom (OIF) and Operation Enduring Freedom in Afghanistan. With regard to OIF, the Office of the Surgeon General of the Army notes that 64 percent of wounded-in-action injuries are the result of blasts from improvised explosive devices (IEDs), rocket-propelled grenades, land mines, or mortar/artillery shells [5]. Given the improvements in protective helmets and the resultant reductions in penetrating head trauma, closed-head blast injuries have become the signature injury of these military operations [5].

Many individuals who sustain TBI in military and civilian settings are treated and return to active duty, productive work and social roles, family responsibilities, and their premorbid lifestyle. However, some TBI survivors live with residual disability, have unmet care needs, or are initially unsuccessful in reentering home, military, vocational, and community life. Those TBI survivors at risk for unsatisfactory outcomes or with continued rehabilitation needs are candidates for community-integrated rehabilitation (CIR).

CIR is a broad term that encompasses various approaches and contexts (hospital, neurobehavioral facility, residential setting, home, and day programs) for treatment, supported by a gradually evolving body of observational and scientific evidence. Military personnel and veterans receiving CIR services through DVBIC and programs such as VANC will provide us with practical data for the continued development of a variety of postacute rehabilitation services [6].

APPROACHES TO COMMUNITY-INTEGRATED REHABILITATION

CIR is one facet of postacute brain injury rehabilitation and generally includes a number of approaches that allow 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 subacute brain injury rehabilitation programs that specialize in coma management or the treatment of behaviors that actively pose a risk of serious endangerment [7]. The most common delineation of CIR programs has followed the framework proposed by Malec and Basford [7], including neurobehavioral programs, residential programs, comprehensive holistic (day treatment) programs, and home-based programs [6-9] (Table).

Neurobehavioral CIR programs have historically focused on treatment of mood, behavior, and executive function disorders, while ensuring supervision and safety in a residential, nonhospital setting. …