TBI & Polytrauma Care

A traumatic brain injury (TBI) is a disruption of normal brain function caused by an external force — a blast, blow, jolt to the head, or a penetrating head injury. TBI is one of the most common injuries among veterans, particularly those who served in Iraq and Afghanistan.

TBI is classified by severity:

• Mild TBI (concussion): Brief change in mental status or consciousness. This is the most common form among veterans. Symptoms may include headaches, dizziness, memory problems, and difficulty concentrating.
• Moderate TBI: Loss of consciousness lasting from a few minutes to a few hours, confusion lasting days to weeks, and physical, cognitive, or behavioral impairments that may last months or be permanent.
• Severe TBI: Extended period of unconsciousness or amnesia. Can result in long-term complications affecting cognition, motor function, sensation, and emotion.

Polytrauma means two or more injuries sustained in the same event, at least one of which is life-threatening. TBI is commonly a component of polytrauma, especially from blast injuries. VA treats TBI and polytrauma together because they frequently overlap and require coordinated, interdisciplinary care.

According to VA Research:

• 414,000 TBIs among U.S. service members worldwide between 2000 and late 2019. The majority were classified as mild.
• 185,000+ veterans diagnosed with at least one TBI use VA healthcare.
• Dementia risk: 6.1% of veterans with TBI developed dementia compared to 2.6% without TBI (2001–2014) — more than a twofold increase.
• Suicide risk: Veterans with moderate or severe TBI were 2.45 times more likely to die by suicide compared to those without TBI.
• Post-concussive symptoms: Nearly 50% of soldiers with mild TBI from Afghanistan/Iraq had post-concussive symptoms three months after deployment.
• Employment: 85% of veterans with severe TBI were unemployed one year post-injury; 63% with moderate TBI were unemployed.
• Epilepsy: Iraq/Afghanistan veterans with mild TBI were about 28% more likely to develop epilepsy than those without TBI.

The VA Polytrauma/TBI System of Care is an integrated network of specialized rehabilitation programs serving veterans and service members with both combat and civilian-related TBI and polytrauma. It provides a continuum of care across four facility levels:

Level 1 — Polytrauma Rehabilitation Centers (PRCs): 5 Locations

These serve as regional referral centers for acute medical and rehabilitation care, and as hubs for research and education. Each PRC has a full interdisciplinary team including physiatrists, physical and occupational therapists, speech-language pathologists, neuropsychologists, social workers, vocational counselors, blind rehabilitation specialists, and more.

Level 2 — Polytrauma Network Sites (PNS): 23 Facilities

One per VISN (Veterans Integrated Service Network), these provide post-acute rehabilitation including inpatient rehab, comprehensive outpatient TBI evaluations, therapy services, and durable medical equipment evaluation.

Level 3 — Polytrauma Support Clinic Teams (PSCT): 86 Teams

Provide interdisciplinary outpatient rehabilitation services for mild or stable cases, including TBI evaluations, outpatient therapy, and case management.

Level 4 — Polytrauma Points of Contact (PPOC): 39 Facilities

Located at VA Medical Centers without specialized teams, these coordinate referrals and case management within their VISN.

You can find your nearest polytrauma facility through the VA Polytrauma Facility Locator.

Since 2007, VA has required TBI screening for all veterans who served in combat operations and separated from active duty after September 11, 2001. The screening happens when you access VA care.

How the screening works:

• A four-question screen identifies veterans who were exposed to events that increase TBI risk and who experience symptoms that may be related to those events.
• A positive screen does not diagnose TBI. It only indicates the need for further evaluation.
• Veterans who screen positive are offered a Comprehensive TBI Evaluation (CTBIE) with a specialty provider.

If you did not serve in post-9/11 combat operations but believe you may have a TBI, you can ask your VA primary care provider for a TBI evaluation referral at any time.

Veterans who screen positive are offered a Comprehensive TBI Evaluation with a specialty provider who can determine whether the veteran has sustained a TBI. Depending on the veteran's needs, the evaluation may involve multiple specialists:

• Social workers
• Physical and occupational therapists
• Speech-language pathologists
• Psychologists and neuropsychologists

After the evaluation, results are discussed with the veteran and recommendations made for follow-on care with primary care and other specialty providers.

Plan of Care: If rehabilitation treatment is indicated, the veteran collaborates with the rehabilitation team to develop a Plan of Care that addresses their recovery goals. The plan includes the types of treatment recommended, how often they occur, and a timeline for when goals are expected to be achieved.

Treatment through the Polytrauma/TBI System of Care includes:

• Interdisciplinary evaluation and treatment
• Development of a comprehensive plan of care
• Case management
• Patient and family education and training
• Psychosocial support
• Advanced rehabilitation treatments and prosthetic technologies
• Virtual and telehealth services
• Assistive technology services

Treatment team disciplines may include:

• Physiatry (rehabilitation medicine)
• Physical therapy and occupational therapy
• Speech-language pathology
• Neuropsychology and psychology
• Rehabilitation nursing
• Social work
• Recreation therapy
• Vocational counseling
• Blind rehabilitation
• Prosthetics and orthotics
• Dietetics and pharmacology
• Chaplain services
• Assistive technology

Polytrauma Transitional Rehabilitation Program (PTRP)

The PTRP is a structured residential program in a therapeutic, "real-world" setting. It is co-located at each of the five PRC sites. The program includes the Service Member Transitional Advanced Rehabilitation (STAR) program, which focuses on intensive evaluation and treatment.

Emerging Consciousness (EC) Program

The EC Program is embedded in each of the five PRCs and focuses on assessment, treatment, and care of individuals who have sustained the most severe traumatic brain injuries.

Admission criteria:

• Functioning in a coma, vegetative, or minimally conscious state
• Within two years of the injury (those outside the two-year timeframe will still be offered appropriate services but do not qualify for the comprehensive inpatient EC Program)
• Medically stable

Program goals:

• Progressively improve arousal (awakening) level
• Increase responsiveness and interaction within the environment
• Work toward establishing effective communication, beginning with a yes/no response
• Educate and support caregivers

The standard inpatient stay is 90 days. If the individual does not demonstrate signs of progression toward emergence by the end of 90 days, a coordinated discharge to the most appropriate supportive setting is arranged. The stay may be extended when patients show emerging consciousness.

VA provides multiple levels of support for families and caregivers of veterans with TBI and polytrauma:

• Dedicated case managers assigned to each patient and family at PRCs, with workloads of approximately six patients each
• Access to psychologists, social workers, family therapists, chaplain services, and military liaisons
• Home modification and equipment information
• In-home care options

Program of Comprehensive Assistance for Family Caregivers (PCAFC):

• Education and training
• Health insurance (if the caregiver is otherwise uninsured)
• Mental health counseling
• Monthly financial stipend
• Respite care and other services

Caregiver Support Line: 1-855-260-3274 — Learn more at caregiver.va.gov.

Post-9/11 Combat Veterans

TBI screening is automatic for all veterans who served in combat operations and separated from active duty after September 11, 2001, when they access VA care. A positive screen triggers a Comprehensive TBI Evaluation.

All Veterans

• Enroll in VA health care at va.gov/health-care/how-to-apply
• Contact VA health care enrollment: 1-877-222-8387
• Ask your VA primary care provider for a TBI evaluation referral
• Contact your local VA's Polytrauma Point of Contact
• Find your nearest polytrauma facility: VA Polytrauma Facility Locator

• VA Polytrauma/TBI System of Care — Overview of the program, facility levels, and services
• Polytrauma Facility Locator — Find your nearest polytrauma care facility
• VA TBI Screening Information — Details on TBI screening and the Comprehensive TBI Evaluation
• Emerging Consciousness Program — Information for families of veterans with severe TBI
• VA Research on TBI — Current research findings and statistics
• VA Caregiver Support — Programs and resources for caregivers
• VA Health Care Enrollment: 1-877-222-8387
• Caregiver Support Line: 1-855-260-3274