Using International Classification of Functioning, Disability and Health to understand challenges in community reintegration of injured veterans

This pilot study used the framework of the World Health Organization's International Classification of Functioning, Disability and Health (ICF) to understand the challenges faced by Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) veterans as they reintegrate into the community. We conducted semistructured interviews with 14 injured veterans, 12 caregivers, and 14 clinicians. We used ICF taxonomy to code data and identify issues. We identified challenges in the following ICF domains: learning and applying knowledge; general tasks and demands; communication; mobility; self-care; domestic life; interpersonal interactions, major life areas; and community, social, and civic life. We found many similarities between the challenges faced by veterans with and without polytraumatic injuries, although veterans with polytraumatic injuries faced challenges of greater magnitude. Identifying community reintegration challenges early and promoting reintegration are important mandates for the Department of Veterans Affairs. The findings of this study are useful in understanding the needs of OEF/OIF veterans.     

Preliminary analysis of posttraumatic stress disorder screening within specialty clinic setting for OIF/OEF veterans seeking care for neck or back pain

Escalating prevalence estimates of posttraumatic stress disorder (PTSD) among recently returning Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans highlight the need for early detection and management for reducing chronic mental illness and disability. Because PTSD and chronic pain are common comorbid conditions among veterans, PTSD screening within specialty clinic settings addressing musculoskeletal pain may be of value. This retrospective study evaluated measures of diagnostic value for the PTSD Checklist (PCL) for a sample (n = 79) of OIF/OEF veterans seeking care for neck or back pain within a Department of Veterans Affairs specialty clinic. Because published accounts of optimal PCL cutoff scores vary considerably, we used receiver operating characteristic curves to identify whether the optimal PCL cutoff score for the sample differed from a conventional cutoff score of 50. A clinical psychologist experienced in diagnosing and managing PTSD confirmed the diagnosis of PTSD for 37 veterans through a review of clinical records. The prevalence of diagnosed PTSD was 46.8%, with an optimal PCL cutoff score of 44. These findings may guide future research and influence clinical practice regarding PTSD screening for recently returning veterans with chronic pain.     

Factors Associated With Posttraumatic Stress Disorder Among Veterans of Recent Wars Receiving Veterans Affairs Chiropractic Care

ObjectivesPost-traumatic stress disorder (PTSD) is thought to complicate pain management outcomes, which is consistent with the impact of other psychosocial factors in the biopsychosocial model of pain. This study aimed to identify patient sociodemographic and clinical characteristics associated with PTSD prevalence among veterans of Operations Enduring Freedom/Iraqi Freedom/New Dawn (OEF/OIF/OND) who received Veterans Affairs (VA) chiropractic care.MethodsA cross-sectional analysis of electronic health record data from a national cohort study of OEF/OIF/OND veterans with at least 1 visit to a VA chiropractic clinic from 2001 to 2014 was performed. The primary outcome measure was a prior PTSD diagnosis. Variables including sex, race, age, body mass index, pain intensity, alcohol and substance use disorders, and smoking status were examined in association with PTSD diagnosis using logistic regression.ResultsWe identified 14,025 OEF/OIF/OND veterans with at least 1 VA chiropractic visit, with a mean age of 38 years and 54.2% having a diagnosis of PTSD. Male sex (adjusted odds ratio [OR] = 1.23, 95% CI = 1.11-1.37), younger age (OR = 0.99, CI = 0.98-0.99), moderate-to-severe pain intensity (numerical rating scale ≥ 4) (OR = 1.72, CI = 1.59-1.87), body mass index ≥ 30 (OR = 1.34, CI = 1.24-1.45), current smoking (OR = 1.32, CI = 1.20-1.44), and having an alcohol or substance use disorder (OR = 4.51, CI = 4.01-5.08) were significantly associated with a higher likelihood of PTSD diagnosis.ConclusionPost-traumatic stress disorder is a common comorbidity among OEF/OIF/OND veterans receiving VA chiropractic care and is significantly associated with several patient characteristics. Recognition of these factors is important for the appropriate diagnosis and management of veterans with PTSD seeking chiropractic treatment for pain conditions.     

Prevalence and characteristics of driving difficulties in Operation Iraqi Freedom/Operation Enduring Freedom combat returnees

We studied the prevalence and characteristics of self-reported driving difficulties and examined their association with traumatic brain injury (TBI) and/or posttraumatic stress disorder (PTSD) in Operation Iraqi Freedom/Operation Enduring Freedom (OIF/OEF) veterans who were seen at a Department of Veterans Affairs outpatient polytrauma clinic. In this study, we used a brief driving questionnaire and chart reviews to assess the prevalence and characteristics of driving difficulties in the following four groups of patients: TBI only, PTSD only, TBI + PTSD, and Neither (neither TBI nor PTSD). Compared with before deployment, 93% of OIF/OEF veterans seen in the polytrauma clinic reported more difficulties with driving in at least one domain, with the most common areas of difficulty being (1) problems with anger or impatience (82%), (2) general driving difficulties (65%), and (3) experiences with near misses (57%). Patients with PTSD (with or without TBI) reported the most significant driving impairments, whereas respondents with a history of only TBI endorsed driving difficulties similar to veterans without either diagnosis. Qualitative analysis of veterans' comments also revealed similar patterns. Self-reported driving problems were common among OIF/OEF returnees. Respondents who had a diagnosis of PTSD (with or without TBI) reported the most severe driving difficulties since returning from deployment. The association between PTSD and driving problems warrants further investigation.     

Identification of domains and measures for assessment battery to examine well-being of spouses of OIF/OEF veterans with PTSD

Family members play an important role in the physical and mental recovery of soldiers returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF). Posttraumatic stress disorder (PTSD) has been associated with strained marital and family relations and parenting difficulties, and many veterans with PTSD experience difficulty finding and maintaining employment. Family members who assist with the veteran's recovery also experience significant strain and may have to leave employment to care for the veteran. Our objective was to identify appropriate assessment measures for examining the well-being of spouses assisting with veterans' recovery and to identify opportunities for supporting veterans' spouses. We used a combination of expert panel input and qualitative methods (focus group interviews) to develop a battery of instruments for use in future research with OIF/OEF family members to examine well-being. Research is needed to elucidate and refine the special needs and issues surrounding PTSD in current and future OIF/OEF veterans and their families. This study provides a first step toward understanding appropriate measures. Expert panel methods and focus group interviews yielded valuable input on the domains and measures that should be included in the assessment battery as well as opportunities for assisting spouses.     

Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in a growing number of seriously injured soldiers who are evacuated to the United States for comprehensive medical care. Trauma-related pain is an almost universal problem among these war-injured soldiers, and several military and Department of Veterans Affairs initiatives have been implemented to enhance pain care across the continuum of medical services. This article describes several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation and presents summary data characterizing the soldiers, pain management services provided, and associated outcomes. We also identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and provide recommendations for future research and practice priorities.     

Development of an integrated stroke outcomes database within Veterans Health Administration

A fundamental goal of the Rehabilitation Outcomes Research Center of Excellence is to improve care and outcomes for veterans with rehabilitation needs. To achieve this goal, the Center's primary objective is increasing research capacity. The Integrated Stroke Outcomes Database is a collection of Veterans Health Administration (VHA) clinical and administrative data containing patient information on a cohort of stroke patients found in the Functional Status Outcomes Database (FSOD), National Patient Care Database (NPCD), and other VHA sources. Clinical and administrative data were abstracted from several VHA data sources and linked to form an integrated outcomes database. A primary cohort of stroke patients treated during fiscal year (FY) 2001 was identified from the FSOD. Matching data from the NPCD, Decision Support System, Health Economics Resource Center, and the National Veterans Survey were obtained, merged, and reported in brief. This integrated database structure will provide valuable support to enhance the VHA capacity to perform stroke rehabilitation research.     

"There's more to this pain than just pain": how patients' understanding of pain evolved during a randomized controlled trial for chronic pain

Chronic pain is prevalent, is costly, and exerts an emotional toll on patients and providers. Little is known about chronic pain in veterans of the recent military conflicts in Afghanistan and Iraq (OEF/OIF/OND [Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn] veterans). This study's objective was to ascertain veterans' perceptions of a multicomponent intervention tested in a randomized controlled trial for OEF/OIF/OND veterans with chronic musculoskeletal pain (ESCAPE: Evaluation of Stepped Care for Chronic Pain). Qualitative interviews were conducted with patients in the intervention arm of ESCAPE. Questions related to veterans' experiences with trial components, overall perceptions of the intervention, strengths, and suggestions for improvement. Twenty-six veterans (21% of total intervention patients) participated. Patients were purposefully sampled to include treatment responders (defined as ≥30% reduction in pain-related disability or pain severity) and non-responders. Non-completers (completed <50% of the trial) were also sampled. Qualitative analysis was guided by grounded theory, using constant comparative methodology. Both responders and non-responders spoke about their evolving understanding of their pain experience during the trial, and how this new understanding helped them to manage their pain more effectively. This evolution is reported under 2 themes: 1) learning to recognize physical and psychosocial factors related to pain; and 2) learning to manage pain through actions and thoughts. PERSPECTIVE: Responders and non-responders both described making connections between their pain and other factors in their lives, and how these connections positively influenced how they managed their pain. Traditional quantitative measures of response to pain interventions may not capture the full benefits that patients report experiencing.     

Creating a sampling frame for population-based veteran research: representativeness and overlap of VA and Department of Defense databases

Most veteran research is conducted in Department of Veterans Affairs (VA) healthcare settings, although most veterans obtain healthcare outside the VA. Our objective was to determine the adequacy and relative contributions of Veterans Health Administration (VHA), Veterans Benefits Administration (VBA), and Department of Defense (DOD) administrative databases for representing the U.S. veteran population, using as an example the creation of a sampling frame for the National Survey of Women Veterans. In 2008, we merged the VHA, VBA, and DOD databases. We identified the number of unique records both overall and from each database. The combined databases yielded 925,946 unique records, representing 51% of the 1,802,000 U.S. women veteran population. The DOD database included 30% of the population (with 8% overlap with other databases). The VHA enrollment database contributed an additional 20% unique women veterans (with 6% overlap with VBA databases). VBA databases contributed an additional 2% unique women veterans (beyond 10% overlap with other databases). Use of VBA and DOD databases substantially expands access to the population of veterans beyond those in VHA databases, regardless of VA use. Adoption of these additional databases would enhance the value and generalizability of a wide range of studies of both male and female veterans.     

Nursing Leadership Collaboration for Rehabilitation of Polytrauma Patients

This article describes a variety of nursing issues that emerged over a 3‐year period on polytrauma rehabilitation nursing units and the leadership roles and strategies that were used to meet the rehabilitation needs of newly injured servicemembers who served in Operation Enduring Freedom (OEF) in Afghanistan and Operation Iraqi Freedom (OIF). Nursing's leadership responsibilities focus on three primary areas: patient advocacy, family centeredness, and advocacy for staff. Collaboration among the four national polytrauma rehabilitation centers (PRCs) run by the U.S. Department of Veterans Affairs has enhanced the skill set for nursing staff members. These rehabilitation nurses possess the strong skills necessary to assess complex patient cases involving blast injuries, as well as strengthened interpersonal competencies in family dynamics, family education, and team function.     

Initial developmental process of a VA semistructured clinical interview for TBI identification

Identification of a remote traumatic brain injury (TBI), particularly mild TBI, is a challenge. The acknowledged standard for determining a history of prior TBI is self-report elicited through a structured or in-depth clinical interview. In April 2007, the Veterans Health Administration (VHA) mandated that the four-section TBI Clinical Reminder screening instrument be completed on all individuals returning from deployment in the Operation Iraqi Freedom/Operation Enduring Freedom theaters of operation (VHA Directive 2007-013). If positive, a follow-up Second Level TBI Evaluation is to be completed. For validation studies of the TBI Clinical Reminder screening process and with the long-term goal of providing a structured methodology to complete the TBI history portion of the Second Level TBI Evaluation, we sought to develop a "criterion standard" semistructured clinical TBI identification interview. This tool was developed through consultation with TBI subject matter experts and built on the strengths of existing tools in the literature. This article describes the six-step developmental methodology and presents the resulting semistructured interview and accompanying manual.     

A multimodal imaging study in U.S. veterans of Operations Iraqi and Enduring Freedom with and without major depression after blast-related concussion

Although the exact number of affected individuals is unknown, it has been estimated that approximately 20% of U.S. veterans of Operations Enduring Freedom (OEF) and Iraqi Freedom (OIF) have experienced mild traumatic brain injury (mTBI) (i.e., concussion), which is defined as a brief loss or alteration of consciousness from a blow or jolt to the head. Blast exposure is among the most common causes of concussion in OEF–OIF warriors. Although the mechanism is unknown, major depressive disorder (MDD) after head injury is common. The purpose of this study was to use diffusion tensor imaging (DTI) and functional magnetic resonance imaging (fMRI) to examine the structural and functional neural correlates of MDD in OEF–OIF combat veterans with a self-reported history of blast-related concussion. We hypothesized that subjects in the MDD group (i.e., individuals with a history of blast-related concussion who were experiencing current MDD) relative to individuals in the non-MDD group (i.e., individuals with a history of blast-related concussion but no current or lifetime history of MDD) would show amygdala hyperactivity and disruption of white matter tracts connecting prefrontal and limbic brain regions. To test these hypotheses, 11 MDD and 11 non-MDD individuals underwent DTI and performed a validated emotional face matching task during fMRI. MDD relative to non-MDD individuals showed greater activity during fear matching trials in the amygdala and other emotion processing structures, lower activity during fear matching trials in emotional control structures such as the dorsolateral prefrontal cortex and lower fractional anisotropy (FA) in several white matter tracts including the superior longitudinal fasciculus (SLF). Greater depressive symptom severity correlated negatively with FA in the SLF. These results suggest a biological basis of MDD in OEF–OIF veterans who have experienced blast-related concussion, and may contribute to the development of treatments aimed at improving the clinical care of this unique population of wounded warriors.     

The reality of virtual learning for nurses in the largest integrated health care system in the nation

The health care network and hospital system within the Department of Veterans Affairs (VA), the Veterans Health Administration (VHA), provides employment to more than 56,000 nursing personnel and serves as clinical education site to countless other nursing and health professional students. Nurse administrators and educators are posed with the challenge of providing an environment in which each nurse is able to gain needed knowledge, learn new skills, and share and communicate this knowledge with other colleagues. The education of nurses improves the health status of veterans while also realizing individual professional enhancement. Regional and cultural diversity of the system present challenges to education, in both delivery and content. VHA's learning organizations, the Employee Education System and the Office of Special Projects, have maximized new technologies and information systems to provide innovative, virtual education opportunities, capitalizing on the benefits of informal and formal learning, thus moving VHA to the forefront in knowledge sharing and dissemination. The Virtual Learning Center, VA Knowledge Network, Learning Catalog, and VA Learning Online provide VHA's nurses with interactive, desktop virtual learning opportunities.     

Using VA data for research in persons with spinal cord injuries and disorders: lessons from SCI QUERI

The Department of Veterans Affairs (VA) provides integrated services to more than 25,000 veterans with spinal cord injuries and disorders (SCI/D). VA data offer great potential for providing insights into healthcare utilization and morbidity, and these capabilities are central to efforts to improve healthcare for veterans with SCI/D. The objective of this article is to introduce researchers to the use of VA data to examine questions related to SCI/D using examples from Spinal Cord Injury (SCI) Quality Enhancement Research Initiative studies. Sources of VA data available to investigators interested in SCI/D-related research include national-level VA administrative and clinical databases and primary data (medical record review, patient surveys). Methods used to identify veterans with SCI/D include the Allocation Resource Center cohort, the Spinal Cord Dysfunction (SCD) Registry, and the VA inpatient SCI flag; only 33% of veterans were included in all three groups (n = 12,306). While neurological level of SCI was unknown for approximately a third of veterans (from SCD Registry data alone), the percent decreased to 13% when augmented with diagnostic codes. Primary data can be used to augment other missing SCI data and to provide more detailed information about complications commonly associated with SCI/D.     

Psychological Stress–Induced Immune Response and Risk of Alzheimer's Disease in Veterans from Operation Enduring Freedom and Operation Iraqi Freedom

PurposePsychological stress is a significant health problem in veterans and their family members. Traumatic brain injury (TBI) and stress lead to the onset, progression, and worsening of several inflammatory and neurodegenerative diseases in veterans and civilians. Alzheimer's disease (AD) is a progressive, irreversible neuroinflammatory disease that causes problems with memory, thinking, and behavior. TBIs and chronic psychological stress cause and accelerate the pathology of neuroinflammatory diseases such as AD. However, the precise molecular and cellular mechanisms governing neuroinflammation and neurodegeneration are currently unknown, especially in veterans. The purpose of this review article was to advance the hypothesis that stress and TBI-mediated immune response substantially contribute and accelerate the pathogenesis of AD in veterans and their close family members and civilians.MethodsThe information in this article was collected and interpreted from published articles in PubMed between 1985 and 2020 using the key words stress, psychological stress, Afghanistan war, Operation Enduring Freedom (OEF), Iraq War, Operation Iraqi Freedom (OIF), Operation New Dawn (OND), traumatic brain injury, mast cell and stress, stress and neuroimmune response, stress and Alzheimer's disease, traumatic brain injury, and Alzheimer's disease.FindingsChronic psychological stress and brain injury induce the generation and accumulation of beta-amyloid peptide, amyloid plaques, neurofibrillary tangles, and phosphorylation of tau in the brain, thereby contributing to AD pathogenesis. Active military personnel and veterans are under enormous psychological stress due to various war-related activities, including TBIs, disabilities, fear, new environmental conditions, lack of normal life activities, insufficient communications, explosions, military-related noise, and health hazards. Brain injury, stress, mast cell, and other immune cell activation can induce headache, migraine, dementia, and upregulate neuroinflammation and neurodegeneration in veterans of Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn. TBIs, posttraumatic stress disorder, psychological stress, pain, glial activation, and dementia in active military personnel, veterans, or their family members can cause AD several years later in their lives. We suggest that there are increasing numbers of veterans with TBIs and stress and that these veterans may develop AD late in life if no appropriate therapeutic intervention is available.ImplicationsPer these published reports, the fact that TBIs and psychological stress can accelerate the pathogenesis of AD should be recognized. Active military personnel, veterans, and their close family members should be evaluated regularly for stress symptoms to prevent the pathogenesis of neurodegenerative diseases, including AD.     

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) military mental health issues. Information on the wars' signature wounds: posttraumatic stress disorder and traumatic brain injury

This topic can be related to the nursing profession and the need to be better educated on military mental health. Since mood disorder, suicide, alcohol abuse, PTSD and TBI are evident in actively serving and returning service members, it is imperative to educate nurses and healthcare providers about these conditions, the available evidence-based treatments and referrals to programs for these signature OEF/OIF wounds. The authors encourage nurse educators to consider ways to include military mental health and other service-related health issues into nursing curricula and to use Veterans Administration and veterans-related healthcare facilities for clinical courses. As the wars in Afghanistan and Iraq continue into the foreseeable future, many veterans will be seen not only in VA facilities, but they will self-refer to academic and community hospitals, and psychiatric and rehabilitation centers. It is important for all nurses to be aware of the effects of PTSD, depression, suicide, substance abuse and TBI on our patients and to be effective advocates for quality care of veterans in all settings. Nurses need to advocate for screening and provision of mental health services in primary care settings. When such services are offered in primary care settings, it normalizes the care and the service member will more likely allow themselves to receive the care (Jones, 2004). All nurses must understand the price of war experienced by U.S. service members and their families, and in particular, the invisible wounds of war.     

Racial disparities in VA service connection for posttraumatic stress disorder disability

BACKGROUND: "Service connected" veterans are those with documented, compensative conditions related to or aggravated by military service, and they receive priority for enrollment into the Veterans Affairs (VA) health care system. For some veterans, service connection represents the difference between access to VA health care facilities and no access. OBJECTIVES: To determine whether there are racial discrepancies in the granting of service connection for posttraumatic stress disorder (PTSD) by the Department of Veterans Affairs and, if so, to determine whether these discrepancies could be attributed to appropriate subject characteristics, such as differences in PTSD symptom severity or functional status. RESEARCH DESIGN: Mailed survey linked to administrative data. Claims audits were conducted on 11% of the sample. SETTING AND SUBJECTS: The study comprised 2700 men and 2700 women randomly selected from all veterans filing PTSD disability claims between January 1, 1994 and December 31, 1998. RESULTS: A total of 3337 veterans returned usable surveys, of which 17% were black. Only 16% of respondents carried private health insurance, and 44% reported incomes of 20,000 US dollars or less. After adjusting for respondents' sociodemographic characteristics, symptom severity, functional status, and trauma histories, black persons' rate of service connection for PTSD was 43% compared with 56% for other respondents (P = 0.003). CONCLUSION: Black persons' rates of service connection for PTSD were substantially lower than other veterans even after adjusting for differences in PTSD severity and functional status.     

Mental health diagnosis and occupational functioning in National Guard/Reserve veterans returning from Iraq

Occupational functioning represents both an important outcome for military service members returning from Operation Iraqi Freedom (OIF) and Operation Enduring Freedom and a predictor for long-term mental health functioning. We investigated the role of mental health diagnoses, determined by structured clinical interviews, on occupational functioning in a group of 262 National Guard/Reserve service members within 1 year of returning from a 16-month OIF combat deployment. We assessed occupational functioning at the time of diagnostic interviews and 1 year later. We hypothesized that service members with diagnoses of posttraumatic stress disorder (PTSD), depression, and/or alcohol abuse or dependence would exhibit lower rates of employment at both time points and lower rates of reported work and/or school role functioning. Service members with a diagnosis of PTSD (5%, n = 13), subthreshold PTSD (6%, n = 15), a major depressive disorder (11%, n = 29), or alcohol abuse or dependence (11%, n = 28) did not differ on employment status from service members without a diagnosis at either time point. However, those with a diagnosis of PTSD, depression, and/or alcohol abuse or dependence reported lower levels of work role functioning. In addition, service members with a diagnosis of PTSD reported greater rates of deterioration in work role functioning over time.     

Identifying veterans with acute strokes with high-specificity ICD-9 algorithm with VA automated records and Medicare claims data: a more complete picture

Medicare claims data are available to Department of Veterans Affairs (VA) researchers to identify veterans with acute stroke. Our study sought to (1) ascertain whether additional acute stroke cases are identified with Medicare data and (2) assess the use of VA and Medicare inpatient automated data for assigning the stroke date. The study population was veterans living in Veterans Integrated Service Network 8 with an acute stroke diagnosis during fiscal year 2001. High-sensitivity and high-specificity algorithms were applied to VA data sets and matched with Medicare files. We confirmed acute stroke cases and index dates using the VA Computerized Patient Record System (CPRS). VA data identified 582 veterans with acute stroke, but Medicare claims data identified 201 more such veterans. CPRS confirmed 94% of the VA and 77% of the Medicare cases. The median difference between CPRS and automated index dates was 11 days for VA and 4 days for Medicare data. Use of both VA and Medicare data provides a more complete sample of veterans with acute stroke.