Project Victory – A Brief, Intensive, Residential Treatment
Program for Mild Traumatic Brain Injury from Combat-Related
Blast Exposure
A Description and Preliminary Data Analysis
INTRODUCTION
•
Traumatic Brain Injury (TBI) is the signature injury of
Operation Enduring Freedom (OEF) and Operation Iraqi
Freedom (OIF)
•
A RAND report (2008) estimated 320,000 troops sustained
multiple concussions or mild TBI during OEF/OIF
deployments between 2001 and 2008.
•
A
significant
number of Veterans of OEF/OIF that accessed
services from Veterans Administration (VA) hospitals showed
symptoms of mild TBI or post concussion syndrome
(Couch & Cohen, 2012).INTRODUCTION
•
Commonly reported symptoms, up to 8 years post deployment:
–
headache
–
dizziness
–
balance problems
–
poor coordination
–
poor memory and
–
difficulty making decisions
•
A significant number reporting mTBI or post concussive
symptoms also report
one or more psychiatric disturbances:
–
post traumatic stress disorder (PTSD) or
–
depression, anxiety
INTRODUCTION
•
If still on active duty status
–
receive case management services and
–
have access to therapy services provided by poly trauma units or
Wounded Warrior regiments
•
If leave active duty status
–
may not have access to the same services or
–
service delivery may be fragmented.
•
Recent studies recommend the use of interdisciplinary
INTRODUCTION
Project Victory was developed
for active duty and
veteran military personnel who sustained mild TBI or
multiple concussions due to blast exposure while
serving in OEF/OIF theatres of combat. It was designed
to provide:
–
evidenced-based
–
interdisciplinary
–
residential
–
post acute
–
rehabilitation services
METHODS
Approach and Data Collection
The Project Victory program encouraged:
•
development of skills and compensatory strategies
For safe and independent performance of advanced activities of daily living (ADL’s) using
community skills training techniques (Cullity, Jackson & Shaw, 1991)
•
use of external aids (including smart phone, IPad technologies)
For memory compensation, (Cicerone, 2005; Gordon, 2006)
•
use of individual and group cognitive-behavioral psychotherapies
For treatment of anxiety and depression, (Beck; Michenbaum)
•
use of Motivational Interviewing and Stage Change techniques
For treatment of substance use/abuse, (Miller &Rollnick, 2002; Diclemente, 2003)
•
use of the Shut-I protocol
For sleep disorders
•
use of community exposure (i.e., structured generalization)
METHODS
Approach and Data Collection
Therapeutic Environment:
•
All therapies were provided in modules of about one (1) hour duration;
•
5-6 hours of skilled therapy were delivered each week day;
Inclusion Criteria
Military personnel who sustained
combat-related TBI or multiple
concussions while serving in
OEF/OIF theatres were eligible to
participate in Project Victory.
Methods
Variable
Mean Range
Age (years)
35
22-50
Length of Stay
(days)
54
1-92
Time since
injury (years)
4.5
<1-9
Demographics and Injury
Characteristics of Project
Victory Participants (N=40)
Population
I
Methods
Additional Inclusion Criteria
Other inclusion criteria
included
:
• medical stability (participant
did not require 24-hour
nursing care);
• self-preserving (participant
was not a danger to self or
others),
• and sobriety (participant was
not chemically dependent) at
the time of admission.
Variable
N
Percentage
Gender
Male
Female
38
2
94%
6%
Service Branch
Army
Navy
Marines
28
3
9
70%
7%
23%
Cause of Injury
Blast
Fall
Blow/head
GSW
28
1
10
1
70%
3%
25%
3%
Co-Morbidities
PTSD
Depression
Sub Abuse
Sleep Prob
Cog Prob
Anger
Pain
33
20
17
28
40
17
23
83%
50%
43%
70%
100%
43%
58%
Status
Active Duty
Veteran
15
25
38%
62%
Referral Source
Fort/base
VAMC
Other
10
28
3
25%
70%
5%
Outcome Measures
Objective measures collected within 24 hours of admission and
again within 24 hours of discharge:
•
Participation in activities of daily living
the Mayo-Portland
Adaptability Inventory – 4
(Malec, 2005).
•
Alcohol Dependency
the Alcohol Use and Dependence
Identification Test (AUDIT)
(Saunders, et al., 1993).
•
Depression
the Centers for Epidemiologic Studies Depression
Scale
(Ratliff, 1977).
•
Positive Emotion
the 4 positive affect items from the CESD
•
Life Satisfaction
the Satisfaction with Life Scale
(Diener, et al., 1985).
Outcome Measures
Self-report measures collected during treatment:
•
Quality and duration of sleep
participants asked to
record the hours of sleep and self-report on the quality of
sleep.
•
Anxiety in community-based settings
participants
self-rated on a 1 to 10 scale with 1 indicating no anxiety and
10 indicating extreme anxiety.
At discharge, a satisfaction survey was competed:
•
Participant satisfaction
a TLC Patient Satisfaction
Survey developed by the facility to assess consumer
satisfaction.
RESULTS
•
Thirty-three participants (83%) completed Project Victory and graduated;
seven participants did not complete the program (2 discharged – medical
reasons; 5 AMA).
At discharge
:
•
Participants demonstrated significant improvement in function as measured
by the Mayo-Portland Adaptability Inventory – 4 (
p
< .001). The greatest
improvement was noted in the Ability subscale which measured activities
of daily living and cognition.
•
Of participants reporting substance use/abuse prior to admission, 73%
maintained sobriety during treatment; 27% continued to engage in alcohol
consumption.
•
65% reported fewer depressive symptoms as measured by the CESD
•
Participants reported a significant increase in positive emotion (
p
=. 004).
•
Participants reported significant increase in life satisfaction as measured by
the SWLS (
p
= .002).
RESULTS
• Seventy (70%) of participants reported sleep
difficulty at admission (i.e., difficulty going to
sleep, difficulty staying asleep, nightmares,
etc.); no significant change was reported at
discharge
•
No statistically significant reduction in
self-reported anxiety in community settings was
noted at discharge.
In terms of participant satisfaction:
•
80% - 100% received needed clinical services
•
Clinical and Residential services received highest ratings (90% -
100%) for knowledge/experience, professionalism, caring,
helpfulness and quality of services.
•
Physical plant received high ratings (90% - 100%) for accessibility,
cleanliness, furnishings, and comfort.
•
Consumer satisfaction issues ranked 100% for: respect for
rights/dignity; taking seriously & handling questions/concerns;
opinions listened to/input solicited.
DISCUSSION
Consistent with reports in the current literature:
•
Large % sustained mild TBI or multiple concussions from blast exposure.
•
All participants reported cognitive deficits stemming from injury
•
Large % reported psychiatric disturbance (i.e., anxiety, depression, etc.).
•
Cognitive deficits and psychiatric disturbances continued for up to nine years post
deployment for some participants.
Using an interdisciplinary approach and evidenced-based techniques:
•
Significant improvement was noted in safe and independent performance of advanced ADL’s,
and cognitive function; use of external compensatory strategies for memory deficits; reported
level of positive emotion; and life satisfaction. A large percentage maintained sobriety while
in the program
Significant change not noted in:
•
Self-reported depressive symptoms, sleep quality or duration, or anxiety in community
settings.
(brief length of stay (i.e., average length of stay of 54 days), and non-compliance with some
aspects of treatment may account for these results)
Limitations:
While the preliminary analysis of Project Victory
appears promising, a number of limitations exist:
–
small sample size
–
non-random assignment of participants to
treatment
–
a significant number of participants were lost
CONCLUSIONS
•
Project Victory approach may be an effective post acute
rehabilitation model for mTBI due to combat-related blast
exposure.
•
Established private sector post acute rehabilitation programs
can extend military continuum of care to the large number
of soldiers returning from deployment with mTBI.
•
Allocate resources for follow-up/maintenance as TBI is now
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