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CCN 06-164 – HSR&D Study

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CCN 06-164
Blast-Related Health Problem Identification and Polytrauma Taxonomy
Steven G. Scott DO MS BS
James A. Haley Veterans' Hospital, Tampa, FL
Tampa, FL
Funding Period: January 2008 - June 2011

BACKGROUND/RATIONALE:
Operations Iraqi and Enduring Freedom (OIF/OEF) are presenting new challenges for the VA health care delivery system. Despite improvements in body armor and surgical stabilization at the front-line of combat, returning service members are presenting with complex, multiple injuries in unpredictable patterns, known as Polytrauma/Blast-Related Injury (PT/BRI). PT/BRI is a new phenomenon and the epidemiology is not well defined, particularly for the "less visible" physical and psychological sequelae. Characterizing PT/BRI is challenging because the medical and psychiatric sequelae, such as ear trauma and resultant hearing loss, concussion and resultant cognitive and vestibular deficits, and posttraumatic stress disorder (PTSD) may be missed when attention is focused on more "visible" injuries, such as amputations or burns.

OBJECTIVE(S):
The purpose of this project was to further define the epidemiology of exposure to war-related explosions (PT/BRI) with an emphasis on the identified gaps in knowledge (i.e., less visible sequelae) so that we may be able to modify the natural history of these blast-related injuries, minimizing the adverse sequelae and maximizing recovery. Specific objectives included: 1) Describe the prevalence of physical and psychological symptoms associated with blast events; 2) Create a set of symptom profiles that will allow us to begin development of a taxonomy of PT/BRI with specific attention to the mechanism of explosion, time since exposure, nature of immediate injury of any blast exposure, severity of initial injury, and persistent symptoms; 3) Using grounded theory methodology, develop a substantive theory describing how persons exposed to war-related blasts understand their healthcare experiences.

METHODS:
This population-based study of the OEF/OIF experiences with PT/BRI among the 10,000 members of the Florida National Guard was designed to use a mixed methods approach. Quantitative methods to obtain information on exposure to, and sequelae of, blast exposures, with qualitative methods to give the personalized experience of blast exposure in the subset so exposed. The self-administered online survey collected data from the soldiers on demographics, current physical injuries or problems and psychological health, current co-morbidities, and current health-related quality of life. We asked questions about pre-deployment trauma and health status. For those exposed to blasts in OEF/OIF, blast exposure history, body region(s) injured by the blast, and injury severity. We asked for volunteers to complete physical and neuropsychological exams on a subset of 30 respondents to validate self-reported injuries and conditions. The quantitative component includes three groups from the Florida National Guard (FNG): 1) respondents who were deployed and exposed to one or more blasts and 2) respondents who were deployed and not exposed to blasts; and 3) respondents who were not deployed. For the qualitative component, we asked for volunteers for a convenience sample of 30 who were exposed to blasts in combat to be interviewed regarding their lived experience of blast exposure.

FINDINGS/RESULTS:
The major portion of this study was an anonymous, online survey, which the subjects did not have to take or complete. Preliminary data analyses have been done on a subset of the surveys. These preliminary analyses were restricted to the subset of surveys that were 1) complete, AND 2) not duplicates (i.e., some people took the survey multiple times-we have not yet analyzed this group or incomplete surveys). The preliminary analyses are based upon this subset (3211) of the total responses (4005).
Analyses were done for: deployed vs. never-deployed. For the 4 blast-related groups: non-deployed; deployed and primary blast; deployed and non-primary blast; and deployed and no blast. The groups were compared for the respondents: by gender, by race/ethnicity, by marital status, by education, by multiple deployments vs. single deployment, by pre-deployment psychological trauma, by deployment-related trauma, by pre-deployment TBI. Additional analyses were done to compare the 3 deployed and blast exposure groups by direct combat-related actions (did not hurt or kill vs. did not know vs. hurt or killed), by deployment-concomitant loss of social support, by significant physical injury/loss.
Additional preliminary analyses have been done to examine psychological health outcomes by demographics, deployment stress, physical injuries, blast exposure, mild TBI, and post-deployment social support. Pre-deployment TBI history responses, as well as deployment-related TBI history, depression, etc. were also examined. Major depression (12.8%), anxiety syndrome (21.0%), PTSD (7.4%) were reported most frequently in the respondents who had a primary blast exposure during deployment. Strong, statistically significant associations were found between military deployment-related factors and current adverse health status.
Physical health outcomes were also examined. More respondents in the primary blast group reported their health got worse. The reported current major health problems also varied by blast exposure, with the blast-exposed group reporting more memory problems, anxiety problems, and depression than the other two groups (no blast and not deployed). This group also reported higher rates of many physical symptoms (e.g., back pain, ringing of the ears, swollen joints, headaches, muscle aches, etc.).
Preliminary conclusions: 1) Deployment-related physical trauma, TBI and blast are predictors of both psychological and physical outcomes; 2) Deployment-related psychological trauma is not a potent predictor; 3) Demographic characteristics are predictors of sick call and alcohol abuse/dependency; and 4) Pre-Deployment psychological trauma is a predictor of some psychological outcomes, body pains, and "Light Duty", more so than deployment psychological trauma. The results were complex and analyses continue.
The two additional portions of the study (Qualitative Telephone interviews, Physical & Neuropsychological Exam) required potential subjects (maximum 30 subjects for each portion) to contact us and volunteer to participate. Incentives were offered. Informed consent would have been obtained from volunteers in the Exam portion of the study. Only one potential subject ever contacted us, but then did not respond to attempts to contact him. So no subjects were enrolled in those portions of this study.

IMPACT:
Better understanding of the complex relationships between multiple deployment-related factors and numerous overlapping and co-occurring current adverse physical and psychological health outcomes can help design an integrated healthcare approach beneficial to post-deployment care for veterans.

PUBLICATIONS:

Journal Articles

  1. Toyinbo PA, Vanderploeg RD, Belanger HG, Spehar AM, Lapcevic WA, Scott SG. A Systems Science Approach to Understanding Polytrauma and Blast-Related Injury: Bayesian Network Model of Data From a Survey of the Florida National Guard. American journal of epidemiology. 2017 Jan 15; 185(2):135-146.
  2. Guihan M, Sohn MW, Bauman WA, Spungen AM, Powell-Cope GM, Thomason SS, Collins JF, Bates-Jensen BM. Difficulty in Identifying Factors Responsible for Pressure Ulcer Healing in Veterans With Spinal Cord Injury. Archives of physical medicine and rehabilitation. 2016 Dec 1; 97(12):2085-2094.e1.
  3. Cotner BA, Njoh EN, Trainor JK, O'Connor DR, Barnett SD, Ottomanelli L. Facilitators and barriers to employment among veterans with spinal cord injury receiving 12 months of evidence-based supported employment services. Topics in spinal cord injury rehabilitation. 2015 Jan 1; 21(1):20-30.
  4. Vanderploeg RD, Silva MA, Soble JR, Curtiss G, Belanger HG, Donnell AJ, Scott SG. The structure of postconcussion symptoms on the Neurobehavioral Symptom Inventory: a comparison of alternative models. The Journal of head trauma rehabilitation. 2015 Jan 1; 30(1):1-11.
  5. Fadul RM, Brown LM, Powell-Cope G. Improving transfer task practices used with air travelers with mobility impairments: a systematic literature review. Journal of Public Health Policy. 2014 Feb 1; 35(1):26-42.
  6. Vanderploeg RD, Cooper DB, Belanger HG, Donnell AJ, Kennedy JE, Hopewell CA, Scott SG. Screening for postdeployment conditions: development and cross-validation of an embedded validity scale in the neurobehavioral symptom inventory. The Journal of head trauma rehabilitation. 2014 Jan 1; 29(1):1-10.
  7. Vanderploeg RD, Donnell AJ, Belanger HG, Curtiss G. Consolidation deficits in traumatic brain injury: the core and residual verbal memory defect. Journal of clinical and experimental neuropsychology. 2013 Dec 4; 36(1):58-73.
  8. Besterman-Dahan K, Lind JD, Crocker T. You never heard Jesus say to make sure you take time out for yourself: military chaplains and the stigma of mental illness. Annals of anthropological practice. 2013 Nov 1; 37(2):108-129.
  9. Soble JR, Donnell AJ, Belanger HG. TBI and Nonverbal Executive Functioning: Examination of a Modified Design Fluency Test's Psychometric Properties and Sensitivity to Focal Frontal Injury. Applied neuropsychology. Adult. 2013 Oct 1; 20(4):257-262.
  10. Vanderploeg RD, Belanger HG, Horner RD, Spehar AM, Powell-Cope G, Luther SL, Scott SG. Health outcomes associated with military deployment: mild traumatic brain injury, blast, trauma, and combat associations in the Florida National Guard. Archives of physical medicine and rehabilitation. 2012 Nov 1; 93(11):1887-95.
Journal Other

  1. Crocker T, Powell-Cope G, Brown LM, Besterman-Dahan K. Toward a veteran-centric view on community (re)integration. [Editorial]. Journal of rehabilitation research and development. 2014 Jun 1; 51(3):xi-xvii.
Conference Presentations

  1. Scott SG, Vanderploeg RD, Belanger HG. Sorting Through the Contributions to Health Outcomes from the Florida National Guard Survey Study: Blast and TBI Effects. Presented at: Federal Interagency Conference on Traumatic Brain Injury; 2011 Jun 15; Washington, DC.


DRA: Acute and Combat-Related Injury, Brain and Spinal Cord Injuries and Disorders, Military and Environmental Exposures
DRE: Epidemiology, Diagnosis
Keywords: Clinical Diagnosis and Screening, Deployment Related, Operation Enduring Freedom, Operation Iraqi Freedom, Outcomes - Patient, Quality of Care, TBI
MeSH Terms: none

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