Using Telehealth to Treat Combat-Related Traumatic Brain Injury

It has been nearly seven years since speech-language pathologists (SLPs) at Walter Reed Army Medical Center introduced us to types of injuries sustained by military service members returning from the Global War on Terrorism (Newman, Battiata, Gurevich, Powell, & Walsh, 2003). These injuries differed from those of previous conflicts because of technological advances in weaponry, protective gear, and medical care. In describing the SLP's role in treating military casualties, these authors noted that soldiers and civilians with severe injuries were surviving as a result of technological and medical changes, and that the wounded were receiving speech-language services more quickly after injury than in any previous war.

An SLP at Tripler Army Medical Center in Hawaii prepares for a treatment session with a patient by consulting with the TBI telehealth program coordinator and facilitator in American Samoa.

In her 2006 "Blast Injury" primer in The ASHA Leader, Gloriajean Wallace challenged medical SLPs to explore the emerging landscape of blast injuries and define their role in "facilitating restoration and wholeness" to returning military service members with communication and swallowing impairments. SLPs are playing a critical role in the recovery and rehabilitation of wounded soldiers and using technological advancements to enhance access to the specialty care we provide. In fact, just as technological advances have changed the nature of warfare and injuries sustained in combat, the armamentarium of telehealth and advanced technologies are being used to improve access to and the quality of rehabilitative care for military service members and veterans in environments that lack the presence of SLPs.

"Blast injury" results primarily from barotraumas generated from explosive munitions such as rocket-propelled grenades, improvised explosive devices, projectiles, and land mines. Casualties also may be sustained from the impact of blast-energized debris (penetrating and non-penetrating) such as bomb fragments and related structural collapse, or from an individual's bodily displacement caused by the blast wind (Belanger, Uomoto, & Vanderlploeg, 2009; Wallace, 2006). Traumatic brain injury (TBI) is common following blast. In one report, clinician-confirmed TBI history was identified in 22.8% of 3,973 soldiers screened for history of TBI following deployment to Iraq in a U.S. Army Brigade Combat Team (Terrio et al., 2009).

The precise incidence of mild TBI (mTBI) in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) is difficult to determine as many service members with mTBI have unrecognized or unrecorded injuries because they do not seek medical care; others are identified through unwitnessed and unverified self-report with questionnaires administered months following the suspected injury (Helmick, 2010). Despite problems with identification and diagnostic precision, it is clear that mTBI is one of the most common forms of combat-related injury and has been referred to as the signature injury of OEF/OIF. As a result, rehabilitation specialists are striving to develop military-based research and clinical programs that represent best practice (Belanger et al., 2009; Helmick, 2010). The literature (e.g., Belanger et al., 2009; Lew et al., 2009; Tanielian & Jaycox, 2008; Vanderploeg, Belanger, & Curtiss, 2009) identifies many challenges, including:

• Evidence addressing the effectiveness of cognitive rehabilitation for the mTBI population is sparse.
• The literature on combat-related mTBI is in the emergent stage.
• The recovery trajectory from combat-related mTBI is complicated by factors such as:
  • The physically and emotionally traumatic circumstances and extreme environments in which many injuries are sustained.
  • Multiple co-morbidities (e.g., concomitant physical injuries to other parts of the body, post-traumatic stress, pain, headaches, acoustic trauma, sensory impairments, depression, substance abuse).
  • The potentially repetitive and cumulative nature of concussions sustained during combat duty.
  • Difficulty in complying with recommendations for optimal post-concussion recovery in deployed settings.

The Role of SLPs 

SLPs are exceptionally qualified to provide rehabilitation services for individuals with cognitive-communication disorders resulting from TBI. Cherney and colleagues (2010) affirm that "SLPs and audiologists have the knowledge and skills to evaluate, treat, and research swallowing, speech, hearing, and cognitive-communication functions, and they should have a primary role in determining the clinical management of, research agenda for, and public health policies regarding individuals with blast-related head injuries from the time of injury to their return to maximized life participation and quality of life."

In 2009, a working group of 10 SLPs from Department of Defense (DoD) and Veterans Administration (VA) Medical Centers and academia formulated clinical practice guidance (CPG) for cognitive-communication interventions for active duty service members and veterans with chronic symptomatic concussion/mTBI. The CPG is designed to provide SLPs with guidance for clinical decision-making and is based upon reviews of research literature, existing guidelines, preferred-practice documents, consensus recommendations of experts with clinical experience, and feedback from patients who participated in cognitive-communication rehabilitation. The working group invited a panel of five subject-matter experts to review the CPG. The final document was submitted to the Proponency Office for Rehabilitation and Reintegration, Health Policy and Services, Office of The Surgeon General, in November 2009 and is pending approval for implementation and dissemination.

Use of Technology to Provide TBI Care 

Advances in technology have transformed the provision of medical care in military settings and within the VA. Telehealth capabilities are supporting the care of service members and veterans with TBI, including the application of new technologies to enhance the identification of TBI, manage symptoms in deployment settings, and improve care coordination throughout military and VA systems (Girard, 2007).

The Defense and Veterans Brain Injury Center Tele-TBI Clinic and Remote Assessment Center provides TBI screening, assessment, consultation, and care to patients at remote military medical centers and troop-intensive sites where demand for specialized care fluctuates with mass mobilizations. The Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network to provide patients with timely and convenient access to specialist rehabilitative care and enable their return to their local communities (Cornis-Pop, 2006; Darkins, Cruise, Armstrong, Peters, & Finn, 2008). Because of the complex nature of combat-related mTBI, including common co-morbidities, an interdisciplinary team approach strengthens the rehabilitative framework. Video teleconferencing (VTC) capabilities enhance communication and collaboration among team members who are not co-located and support seamless transition and continuity of care.

In September 2009, the U.S. Army Medical Research and Materiel Command, the Telemedicine and Advanced Technology Research Center, and the American Telemedicine Association assembled a group of experts from government, military, academia, and industry. The symposium was convened to share knowledge, challenges, and ideas on existing and potential applications of telemedicine and innovative technologies to:

• Connect patients remotely with providers and specialists.
• Identify concussion and mTBI using electronic cognitive assessment systems.
• Provide real-time video visits with family members.
• Share information that enables clinical teams to collaborate on TBI care.
• Manage medication.
• Provide interactive video programs and web-based courses to train medics, physician assistants, nurses, and other providers in civilian and military settings (Doarn, 2009).

The U.S. Army Medical Information Technology Center is supporting tele-TBI and tele-psychological health initiatives by providing the infrastructure to connect soldiers and health care providers via VTC to medical facilities and specialists. The network also is being used for professional education with monthly multidisciplinary TBI grand rounds broadcasts from Brooke Army Medical Center (BAMC). These broadcasts have included outstanding presentations by SLPs on psychogenic versus neurogenic stuttering (Joseph Duffy, professor of speech pathology at the Mayo Clinic) and assessing and treating attentional processes (McKay Sohlberg, professor in communication disorders and sciences at the University of Oregon). Kevin Manning (Traumatic Brain Injury Service at Brooke Army Medical Center in Fort Sam Houston, Texas) and his colleagues are using the network to provide speech-language services remotely via VTC.

Cognitive-Communication Rehabilitation 

Speech-language pathology clinicians and researchers are committed to advancing the science of cognitive-communication interventions to fulfill our critical role in rehabilitating service members and veterans with TBI, and are partnering with colleagues across disciplines as well as across DoD, VA, civilian, and academic sectors to develop innovative technological solutions. For example, Sohlberg and Steve Fickas (professor in computer sciences) at the University of Oregon are beginning a five-year project funded by the National Science Foundation that focuses on compensatory reading comprehension strategies for students in post-secondary courses. In the first four years of their CampusReader project, they will work closely with active-duty service members and veterans with mTBI who intend to enroll in specialized training programs or return to university or community college campuses. They also are incorporating technology-assisted prompting (TAP) in administering the evidence-based Attention Process Training (APT)-II (Sohlberg et al., 2001) program to address attentional deficits for patients with mild cognitive dysfunction (personal communication, Sept. 12, 2010).

Research in mTBI has been unparalleled over the past five years because of the nation's need to care for fighters returning from OEF and OIF. The telehealth service delivery model should be included in research initiatives for cognitive-communication interventions for this patient population. The service delivery model is being used and tested in the civilian population as well. Lyn Turkstra, professor in the Department of Communicative Disorders at the University of Wisconsin just completed a study with Maura Quinn-Padron, speech-language pathologist at the Marshfield Clinic, in which they compared telehealth to in-person assessment of cognitive-communication functions in 20 adults with chronic TBI (personal communication, Sept. 10, 2010). Results support the use of telehealth for the assessment of cognitive-communication functions in adults with TBI who have sufficient cognitive skills to follow telehealth procedures. They concluded that telehealth has particular appeal for management of post-TBI cognitive-communication disorders because communication problems often become more apparent in the chronic stage post-injury after acute rehabilitation has ended, when the individual returns home and attempts to re-enter community life. A comparable study with veterans would have high relevance, as access to speech-language services in their local communities after discharge from acute care or rehabilitation facilities would be a significant advantage.

TBI Rehabilitation 

Tripler Army Medical Center (TAMC) in Hawaii is the only federal tertiary care hospital in the Pacific Basin. Over the past 10 years, telehealth has been an important initiative for otolaryngology, audiology, and speech-language pathology because of the vast geographic span of our catchment area (Burgess et al., 1999; Mashima et al., 2003; Mashima & Holtel, 2005). Organizational support has been vital to the success of our cognitive-communication rehabilitation program, including the telehealth component. Telehealth was incorporated in TAMC’s multidisciplinary TBI team's strategic plan; resources allocated for telehealth include upgrading VTC equipment and providing administrative and technical personnel support for implementation and maintenance onsite and at the remote site.

In speech-language pathology, we have used interactive VTC for consultations with patients, group and individual treatment, patient and family education, and clinician mentoring. In addition, multiuse of the VTC system supports care coordination and professional education. The multidisciplinary TBI team at Tripler collaborates with the TBI team at the Schofield Barracks Health Clinic (SBHC), which is part of the Pacific Regional Medical Command, for weekly case discussions and program planning; for example, the SLP at the SBHC participates in program development meetings and TBI journal groups at Tripler.

As with any clinical endeavor, we gained the necessary technical and clinical skills to provide competent, ethical, and secure services for the benefit of patients and their families before providing TBI services via telehealth (ASHA, 2010). Administrative considerations included proper credentialing, criteria and procedures for referring and scheduling patients, and appropriate coding with modifiers for telehealth visits. In May 2010, we initiated cognitive-communication rehabilitation services via VTC to patients in American Samoa (AS) because Army reservists and veterans who returned to their homes in AS after serving in OEF/OIF did not have local access to SLPs. In preparation for our VTC clinical encounters, we received training from a military service member native to AS to increase our understanding of and sensitivity to the local culture with respect to beliefs, customs, practices, pragmatic communication, and social behaviors. Our telehealth program eliminates the need for patients to travel approximately 2,500 miles from AS to Hawaii and provides services on a more timely and regular schedule.

The benefits of telehealth for our patient population include improving access to care, not only for patients in remote geographic areas, but for those who now may receive care on their military base in rural Oahu rather than drive to TAMC, thus eliminating the frustration and fatigue of heavy traffic—often in the direction of bright sunlight, which can trigger headaches. We anticipate that in addition to improving access to care, the appeal of technological innovation may increase motivation for and compliance with treatment for a "tech-savvy" generation of young military service members and veterans.

Moving Forward 

We consider it a distinct honor and privilege to participate in the rehabilitation of our military service members and veterans to enable their return to active duty, or reintegration into civilian lives and careers. SLPs are fulfilling this vital role by forming collaborative partnerships across military, civilian, and academic sectors to advance our knowledge of TBI and improve outcomes. The resilience and triumphs of our patients and their families serve as our inspiration. Just as military medicine has advanced the science of health care throughout our nation's history, future patients with TBI will benefit from the new knowledge discovered in the process of caring for those with the signature injury of this war.

References

American Speech-Language-Hearing Association (2010). Professional Issues in Telepractice for Speech-Language Pathologists [Professional Issues Statement]. Available from www.asha.org/policy.

Belanger, H. G., Uomoto, J. M., & Vanderploeg, R. D. (2009). The Veterans Health Administration system of care for mild traumatic brain injury: Costs, benefits, and controversies. Journal of Head Trauma Rehabilitation, 24(1), 4–13.

Burgess, L. P. A., Holtel, M. R., Syms, M. J., Birkmire-Peters, D. P., Peters, L. J., & Mashima, P. A. (1999). Overview of telemedicine applications for otolaryngology. Laryngoscope, 109, 1433–1437.

Cherney, L. R., Gardner, P., Logemann, J. A., Newman, L. A., O-Neil-Pirozzi, T., Roth, C. R., & Solomon, N. P. (2010). The role of speech-language pathology and audiology in the optimal management of the Service Member returning from Iraq or Afghanistan with a blast-related head injury: Position of the communication sciences and disorders clinical trials research group. Journal of Head Trauma Rehabilitation, 25(3), 219–224.

Cornis-Pop, M. (2006, July 11). A new kind of patient for speech-language pathologists. The ASHA Leader.

Darkins, A., Cruise, C., Armstrong, M., Peters, J., & Finn, M. (2008). Enhancing access of combat-wounded veterans to specialist rehabilitation services: The VA polytrauma telehealth network. Archives of Physical Medicine and Rehabilitation, 89, 182–187.

Doarn, C. R. (2009, September). Symposium Report of Innovative New Technologies to Identify and Treat Traumatic Brain Injuries: Crossover Technologies and Approaches between Military and Civilian Applications. Symposium sponsored by U.S. Army Medical Research & Materiel Command and Telemedicine and Advanced Technology Research Center, hosted by the American Telemedicine Association, Indian Wells, CA.

Georgeadis, A. C., & Brennan, D. M. (2003). Telepractice research: Learning more about remote speech-language and cognitive-communication services. The ASHA Leader, 8, 16

Girard, P. (2007). Military and VA telemedicine systems for patients with traumatic brain injury. Journal of Rehabilitation Research & Development, 44(7), 1017–1026.

Helmick, K. and members of Consensus Conference (2010). Cognitive rehabilitation for military personnel with mild traumatic brain injury and chronic post-concussional disorder: Results of April 2009 consensus conference. NeuroRehabilitation, 26, 239–255.

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Sohlberg, M. M., Johnson, L., Paule, L., Raskin, S. A., & Mateer, C. A. (2001). Attention Process Training-II: A program to address attentional deficits for persons with mild cognitive dysfunction (an upper extension of the APT-I). Wake Forest: Lash & Associates Publishing/Training Inc.

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Terrio, H., Brenner, L. A., Ivins, B. J., Cho, J. M., Helmick, K., Schwab, K., ... Warden, D. (2009). Traumatic brain injury screening: Preliminary findings in a US Army Brigade Combat Team. Journal of Head Trauma Rehabilitation, 24(1), 14–23.

Vanderploeg, R. D., Belanger, H. G., & Curtiss, G. (2009). Mild traumatic brain injury and posttraumatic stress disorder and their associations with health symptoms. Archives of Physical Medicine and Rehabilitation, 90, 1084–1093.

Wallace, G. L. (2006, July 11). Blast injury basics: A primer for the medical speech-language pathologist. The ASHA Leader.