Mild traumatic brain injury can be a difficult diagnosis to make, with symptoms including headache, dizziness, excessive fatigue, inability to concentrate, irritability, vision change and sleep disturbance. In soldiers returning from war, diagnosis can be complicated by post-traumatic stress disorder, which presents similarly. When a veteran lives in a rural area, far from a treatment facility, the difficulty in treating TBI can be compounded further.

To better meet the needs of returning soldiers, some facilities are enabling occupational therapists to provide care through telerehabilitation programs, in which treatment is provided remotely.

“The diagnosis in combat veterans is a different animal than in the civilian world, where typically people have a major incident that happens once,” says Charles Levy, MD, chief of physical medicine and rehabilitation services at the North Florida/South Georgia Veterans Health System and an adjunct associate professor in the University of Florida’s occupational therapy department. “The story is much more complex in soldiers. These are people who have been deployed multiple times, may have had injuries prior to battle, and we’re not necessarily seeing them the day they come home. Six months may have passed.”

Leonard Trujillo, OTR/L, PhD, FAOTA, chairman of East Carolina University’s occupational therapy department, refers to soldiers returning from battle with mild TBI as the “walking wounded.” The U.S. Army estimates that 20% of soldiers returning from battle have some form of TBI.

“You can injure the brain and it recovers, it returns to normal and major problems start to resolve themselves,” Trujillo says. “But the person may still have a residual problem tying their shoes, or determining left from right, or making the choice of what socks to wear.”

Delivering Care Remotely

The Department of Veterans Affairs has set a goal for facility directors to increase their telehealth presence by 50% each year for the next three years, Levy says. Veterans are being monitored remotely for wound care and some spinal cord injuries. “The common model is to have a medical or therapy expert be at the medical center and for the patient to receive care in the city they’re in,” Levy says. But that’s not always possible for a patient who needs long-term, ongoing care on a weekly basis and who lives in a rural area where a medical center is not easily accessible.

The Rural Veterans Telerehabilitation Initiative, implemented in the summer of 2009, provides veterans with Tandberg videoconferencing phones, which look similar to small computer monitors with a few buttons. “We arrange to get them help they might not have otherwise received, and people are pretty appreciative to be part of the program,” Levy says.

“We try to attack their difficulties from as many dimensions as possible,” Levy says. These include occupational, physical and recreational therapy; neurology; and psychology. After an initial in-person assessment, the patient uses the Tandberg device to call in to a scheduled appointment with a therapist to engage in weekly sessions where both the therapist and patient can see each other.

“We can provide cognitive therapy at a distance or therapy directed at range of motion for a particular limb, for example,” Levy says. He describes one veteran he treats who works in construction. “He takes his Tandberg unit with him, and I can keep visual contact with him at the job site,” Levy says.

Preparing to Go Back to Battle

While Levy’s program prepares veterans to return to society, Trujillo’s program, Operation Re-Entry North Carolina, prepares servicemen and women with mild TBI to return to combat. The residual effects of mild TBI tend to surface more quickly in a soldier who is returned to active duty because of the rigid schedules and organization in the military. “In the military, if you’re not able to respond, it gets picked up very quickly,” Trujillo says. “Everyone is depending on you and expects you to do what you’re supposed to do. Everything seems fine until you’re placed in a situation of demand.”

Trujillo’s work focuses on using the Interactive Metronome combined with rhythmic exercise. The IM is a computer program that works like a regular metronome. “Our systems employ a rhythmic pattern,” Trujillo says, and in mild TBI, that rhythm has been disturbed, which makes a patient feel “off.” The IM provides a timing pattern and then challenges the person to press a button at the same time as the sound. It can determine how many milliseconds a person is from hitting the button, and it helps the patient to move closer to hitting the button at exactly the right moment.

“It gives the patient a centered balance; there’s a true internal rhythmic pattern,” Trujillo says. “We have found that it improves memory, attention, processing and sequencing. When you put those things together, you end up with better language processing, better fine motor skills and you have an overall return to coordination.”

Patients can use the IM at home after evaluation and training, and the results are transmitted to Trujillo. “We can suggest changes to make improvements,” he says. “But we would not abandon the individual who is struggling. If they cannot do it, we would be here to provide direct care.”

Recent Creighton University graduate Nina Jensen, OTD, conducted a critically appraised topic paper on the effectiveness of telerehabilitation programs in treating those with TBI. “There’s not enough evidence out there,” she says. “Evidence-based practice is the push for the future of the field, and this is a good example that needs more evidence and more documentation. If OTs are doing it, they need to do research and put it on paper to prove that it actually works.”•

Meghan Gourley is a freelance writer.