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VA PREPARES FOR YOUNGER POPULATION WITH
TRAUMATIC BRAIN INJURIES -- Vision problems are
just one of the constellation of often lifelong
impairment
resulting from a traumatic brain injury.
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VA Prepares For Younger Population With
Traumatic Brain Injuries
By Judy Benson
The typical veteran who comes to the six-week blind rehabilitation
program at the VA hospital in West Haven is in his late 60s, 70s or 80s,
with memories of World War II to swap with the others there who've also
lost their sight with age.
As the U.S. population ages, and with it, the prevalence of vision loss
from macular degeneration, glaucoma and diabetes, the Veterans' Affairs
program will be in even greater demand by the nation's older veterans.
But at the same time, a new and different group of veterans will soon be
heading into the VA medical care system seeking help in dealing with
diminished vision. For them, vision problems are just one of the
constellation of often lifelong impairments resulting from a traumatic
brain injury suffered in Iraq or Afghanistan.
Head trauma injuries, mainly the result of roadside bombings, are
considered the signature wound of these wars, afflicting 2,130 soldiers
as of early June, according to Chuck Dasey, public affairs officer for
the Army Medical Research and Material Command. About 30 percent are
considered severe to moderate injuries, but vision problems are seen in
those with even mild head injuries.
Most of the soldiers with traumatic brain injury, said Penny Schuckers,
chief of blind rehabilitation services at the hospital, are in one of
the VA's four special polytrauma treatment centers. Others are still in
hospitals run by the Department of Defense's separate medical care
system.
Once the acute phase of their care is complete and they are considered
“medically stable,” she said, they will return home and begin tapping
into the medical services at the VA hospitals in their home states.
Those with vision problems will also be in need of the intensive
rehabilitation services offered in VA centers in West Haven and nine
other VA hospitals nationwide.
“We are doing a lot to prepare for those patients,” she said.
The anticipated influx of traumatic brain injury victims is bringing
changes and new challenges throughout the VA medical system.
“We will get these patients, but we'll get them farther along, and right
now, we are not perfectly set up and ready to do that,” said Dr. Kara
Gagnon, director of low vision optometry at the West Haven hospital.
At present, the blind center and many other areas of the VA system are
geared for an older population, which for years has made up the majority
of its patients. It's basically geriatric medicine and rehabilitation,
and bringing a wounded veteran in his 20s into that setting can be a bad
fit, Gagnon said. Thus far, only five soldiers from Iraq or Afghanistan
have come through the West Haven blind center, and none of their eye
injuries were from roadside bombings. But the staff there has learned
from those soldiers about the needs of this group.
“They do better in a group of other young men and women,” she said.
“They don't want to be in a geriatric population.”
In 2004, the VA took an initial step toward preparing its staff for this
population, when it distributed an independent study manual on traumatic
brain injury and its visual consequences.
“Visual impairments frequently go undetected following brain injury,” it
reads, “in part because of the patient's unawareness of visual changes
or inability to communicate their altered experience.”
Two-thirds of brain trauma victims lose the ability to focus
automatically, it states. This can interfere with reading, computer use,
driving and working. About half of these patients also have problems
controlling eye muscles, leading to problems scanning, tracking text
while reading, moving the eyes quickly from one spot to another,
dizziness, nausea and eyestrain. More than half, according to the
report, also have trouble getting both eyes to work together, leading to
double vision.
“The visual consequences of traumatic brain injury can be very obvious
or very subtle,” said Gagnon. “One vet said he could only read 16 words
an hour. And what about those patients (who) can't explain it?”
Recently, vision therapists have been added to the teams caring for
patients at the VA's four polytrauma centers, Schuckers said, to begin
working with them on eye exercises to retrain eye muscles.
“What we're finding,” she said, “is that the earlier we can do some
vision rehabilitation, the better they're able to tolerate
rehabilitation intervention later.”
Oftentimes, the vision problems are not the result of a direct assault
on the eye from a projectile or piece of shrapnel. Helmets and goggles
protect from that. Instead, injuries occur from the shock waves of the
blast coursing the brain, and repeated banging of the brain against the
skull when the soldier is thrown by the force. The occipital lobes of
the brain, where visual information is received and processed, as well
as the optic nerves and blood vessels, can be damaged when the brain
endures this onslaught. There may be no visible piercing of the skull at
all, but the so-called “closed head” trauma that can be just as
debilitating as visible injury.
Some of the effects may be temporary, the report states, and others not.
Vision therapy can help reduce or in some cases undo the effects, and
there is a growing appreciation in the medical world for the brain's
capacity to at least partially rewire itself after an injury — an
ability that can be greatly enhanced by training it with the right
therapies.
“Early intervention is definitely critical, because of the plasticity of
the brain,” said Gagnon.
She said the VA blind centers need more neuro-optometrists who can
accurately diagnose the visual effects of brain injury and use that
information to design specific therapies. Vision therapists may need to
hone specific skills for these patients.
The VA, she said, also needs to take a multi-disciplinary approach to
therapy for brain trauma victims, so that they could come for extended
sessions of vision therapy in combination with physical, cognitive and
occupational therapy.
“Traumatic brain injury is a very complex neurological situation,” she
said, “and neuro-optometry is a large component.”
Gagnon has made it part of her personal mission at the VA to bring
attention to the sight problems that go with brain injury, and to
increase knowledge throughout the VA system of the best treatments and
therapies. As part of that effort, she is organizing a major conference
on the subject in December in San Antonio, Texas. It will bring together
leading experts in the fields of neuro-psychology, neuro-optometry and
related specialties to share and disseminate the latest information.
“I am so concerned about this population,” she said. “This is a kind of
passion.”
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Larry Scott --
