Telerehabilitation for OIF/OEF Returnees With Combat-Related Traumatic Brain Injury

Rational: TBI can cause life-long impairments in physical, cognitive, behavioral and social
function that are usually more disabling than the residual physical deficits. Recovery can
continue many years after initial trauma. Little is known about optimal methodologies to
treat the vast and complicated secondary manifestations of combat related TBI.
Applicability: The goal of this rehabilitation program is eventually to optimally define
telerehabilitation services for all Veterans with polytrauma, including accurate and
efficient screening instruments, educational material for patients and families, family
support, and family counseling to enhance care coordination and to maximize functional
outcomes and quality of life.

Patient population: The program will help wounded Veterans with a diagnosis of TBI from
combat operations in Iraq and Afghanistan. Many Veterans reside in rural and underserved
areas. Although access to health care for rural patients remains a critical challenge,
telerehabilitation may represent a viable means for the delivery of therapeutic services to
such patients, particularly those served by the VA. The program has implications for
civilian populations as well including those injured in automobile or industrial accidents
and similar in illness to the cohort of Veterans the investigators intend to follow.

Clinical applications, benefits and risks: The goals of the rehabilitation project will be
to enhance the wounded Veteran's capacity to process and interpret information and to
improve his ability to function in all aspects of family and community life. It will involve
a combination of restorative training which focuses on improving a specific cognitive
function and compensatory training which educates Veterans on adapting to the presence of a
cognitive deficit that may or may not be curable using singular one to one interventions as
well as integrated interdisciplinary approaches to target multiple conditions. The
investigators see no risks involved in this clinical intervention.

Projected time to achieve a consumer-related outcome: The results of the telerehabilitation
project should immediately be available for dissemination throughout the VA. The VA has
already committed itself to a nationwide rollout of similar telerehabilitation projects for
wounded Veterans. Hence, the findings should have immediate application in VA care for
returnees from combat.

The investigators recently added MyHealtheVet to the TeleRehab I care coordination for
existing TeleRehab I subjects. MyHealtheVet is the VA's Personal Health Record and offers
Veterans an additional way for Veterans to partner with the health care team in making
informed decisions. MyHealtheVet is an existing, innovative program available to Veterans
throughout the VA. (see https://www.myhealth.va.gov/index.html for additional information)
Most of the remaining TeleRehabilitation Veterans are already enrolled in the MyHealtheVet
program. Besides giving patients access to their health records and online prescription
ordering, there is a secure messaging system with VA providers, who can save the secure
message into the patient's electronic medical record (CPRS) with a single click.

A total of 75 of the 85 IRB-approved subjects were initially enrolled. The investigators
wanted to enroll up to 10 new subjects, and the existing TeleRehab I subjects were all be
asked to sign a revised ICF that adds MyHealtheVet to the study, and makes other changes to
the ICF required by Tampa VA R&D. If the subjects consent they will be required to register
and be authenticated to use MyHealtheVet in order to participate or continue to participate
in the study. An additional 6 subjects were enrolled for a total of 81 subjects on whom
demographic data was collected. Sufficient data was collected on 75 subject for analyses of
their responses to surveys.

MyHealtheVet enrollment and secure messaging authentication is required to continue in the
study, and changes to the protocol will reflect this additional eligibility criterion. All
other methods of communication with subjects and existing surveys will continue. Eventually
MyHealtheVet will replace the LAMP for secure communications with the Care Coordinator.

Inclusion Criteria:

- Veterans or active duty military personnel discharged from the James A. Haley
Veterans' Hospital in Tampa, FL or in rehabilitation there

- ages 18 and older

- have sustained a TBI as evidenced by primary or secondary diagnosis on initial
admission, with or without comorbid Post-traumatic Stress Disorder (PTSD)

- enrolled and receiving medical services through the Tampa VA and medically stable as
clinically determined by the patient's physician.

In order to add MyHealtheVet to the study as a method of care coordination, MyHealtheVet
enrollment and secure messaging authentication is required to continue in the study. All
other methods of communication with subjects and existing surveys will continue.
Eventually MyHealtheVet will replace the LAMP for secure communications with the Care
Coordinator.

Exclusion Criteria:

- Telerehab services will be offered only to those patients with low ADLs who require
additional care and who stand to benefit from the care coordination program.

- The investigators will also exclude those who are severely injured or
institutionalized. This includes patients with a severe psychopathology.

- Refusal to enroll in MyHealtheVet with Secure Messaging will eventually lead to
subjects being dropped from the study.