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Submission For The Record of Wounded Warrior Project

Chairwoman Buerkle, Ranking Member Michaud and members of the Subcommittee:

Wounded Warrior Project (WWP) welcomes the Subcommittee’s consideration of H.R. 1855 and is pleased to offer our views on this important bipartisan legislation. 

WWP works to help ensure that this generation of wounded warriors thrives – physically, psychologically and economically.  Our policy objectives are targeted to filling gaps in programs or policies -- and eliminating barriers -- that impede warriors from thriving.  Importantly, those objectives reflect the experiences and concerns of wounded warriors and family members whom we serve daily across the country.

H.R. 1855 addresses some of the deepest concerns we have heard from warriors’ families, and we are very pleased to be able to enthusiastically support this measure.  Its enactment would realize a key goal of our policy agenda.  Most important, it would materially change lives.

Traumatic Brain Injury Rehabilitation

Impressive military logistics and advances in military medicine have saved the lives of many combatants injured in Iraq and Afghanistan who would likely not have survived in previous conflicts.  As a result, servicemembers are returning home in unprecedented numbers with severe polytraumatic injuries.  Among the most complex are severe traumatic brain injuries.   Each case of traumatic brain injury is unique.  Depending on the injury site and other factors, individuals may experience a wide range of problems – from profound neurological and cognitive deficits manifested in difficulty with speaking, vision, eating, or incontinence to marked behavioral symptoms.  While individuals who have experienced a mild or moderate TBI may experience symptoms that are only temporary and eventually dissipate, others may experience symptoms such as headaches and difficulty concentrating for years to come.

Those with severe TBI may face such profound cognitive and neurological impairment that they require a lifetime of caretaking.  As clinicians themselves recognize, it is difficult to predict a person’s ultimate level of recovery.[1]   But to be effective in helping an individual recover from a brain injury and return to a life as independent and productive as possible, rehabilitation must be targeted to the specific needs of the individual patient.  In VA parlance, rehabilitation must be “veteran-centered.” 

While many VA facilities have dedicated rehabilitation-medicine staff, the scope of services actually provided to veterans with a severe TBI can be limited, both in duration and in the range of services VA will provide or authorize.  It is all too common for families -- reliant on VA to help a loved one recover after sustaining a severe traumatic brain injury -- to be told that VA can no longer provide a particular service because the veteran is no longer making significant progress.  Yet ongoing rehabilitation is often needed to maintain function,[2] and veterans with traumatic brain injury who are denied maintenance therapy can easily regress and lose cognitive, physical and other gains made during earlier rehabilitation. 

Some do make a good recovery after suffering a severe TBI.  But many have considerable difficulty with community integration even after undergoing rehabilitative care, and may need further services and supports.[3]    Medical literature has documented the need to use rehabilitative therapy long after acute care ends to maintain function and quality of life.[4],[5],[6] While improvement may plateau at a certain point in the recovery process, it is essential that progress is maintained through continued therapy and support. The literature is clear in demonstrating the fluctuation that severe TBI patients may experience over the course of a lifetime. One study found that even 10 to 20 years after injury individuals were still suffering from feelings of hostility, depression, anxiety, and further deficiencies in psychomotor reaction and processing speed.[7]  While some are able to maintain functional improvements gained during acute rehabilitative therapy, others continue to experience losses in independence, employability, and cognitive function with increasing intervals of time.[8]  Given such variation in individual progress, rehabilitation plans must be dynamic, innovative, and long term – involving patient-centered planning and provision of a range of individualized services.[9]

For this generation of young veterans, reintegration into their communities and pursuing life goals such as meaningful employment, marriage, and independent living may be as important as their medical recovery.  Yet studies have found that as many as 45% of individuals with a severe traumatic brain injury are poorly reintegrated into their community, and social isolation is reported as one of the most persistent issues experienced by such patients.[10]  Yet research has demonstrated that individuals with severe TBI who have individualized plans and services to foster independent living skills and social interaction are able to participate meaningfully in community settings.[11] While improving and maintaining physical and cognitive function is paramount to social functioning, many aspects of community reintegration cannot be achieved solely through medical services.  Other non-medical models of rehabilitative care -- including life-skills coaching, supported employment, and community-reintegration therapy -- have provided critical support for community integration.  But while such supports can afford TBI patients opportunities for gaining greater independence and improved quality of life, VA medical facilities too often deny requests to provide these “non-medical” supports for TBI patients.  While such services could often be provided under existing law through other VA programs[12], it is troubling that institutional barriers stand in the way of meeting veterans’ needs under a “one-VA” approach.  Instead, rigid adherence to a medical model and foreclosing social supports is, unfortunately, a formula for denying veterans with severe traumatic brain injury the promise of full recovery.  This barrier must be eliminated.

H.R. 1855

H.R. 1855 would amend current law to clarify the scope of VA’s responsibilities in providing rehabilitative care to veterans with traumatic brain injury.  While current law (codified in sections 1710C and 1710D of title 38, U.S. Code) directs VA to provide comprehensive care in accord with individualized rehabilitation plans to veterans with traumatic brain injury, in some instances warriors with severe traumatic brain injury are not receiving services they need, and in other instances, VA has cut off rehabilitative services prematurely. 

Ambiguities in current law appear to contribute to such problems.   For example, while the above-cited provisions of law do not define the term “rehabilitation,” the phrase “rehabilitative services” is defined for VA health-care purposes (in section 1701(8) of title 38) to mean “such professional, counseling, and guidance services and treatment programs as are necessary to restore, to the maximum extent possible, the physical, mental, and psychological functioning of an ill or disabled person.”  That provision could be read to limit services to restoring function, but not to maintaining gains that have been made.  (Yet limiting TBI rehabilitative care in that manner risks setting back progress that has been made.)   As defined, the term “rehabilitative services” is also limited to services to restore “physical, mental and psychological functioning.”  In our view, rehabilitation from a traumatic brain injury should be broader, to include also cognitive and vocational functioning, and, given the research cited above, should not necessarily be limited to services furnished by health professionals. 

In essence, H.R. 1855 would provide that in planning for and providing rehabilitative services to veterans with traumatic brain injuries, VA must ensure that those services --

  1. are directed not simply to “improving functioning” but to sustaining improvement and preventing loss of functional gains that have been achieved (and, as such, that rehabilitation may be continued indefinitely); and
  2. are not to be limited to services provided by health professionals but include any other services or supports that contribute to maximizing the veteran’s independence and quality of life.

WWP strongly supports this legislation.  It would eliminate barriers too many have experienced, and would offer the promise of making good on the profound obligation we owe those who struggle with complex life-changing brain injuries. 

We urge the Committee to adopt this important legislation, and would welcome the opportunity to work with you to ensure its enactment.


[1] Sharon M. Benedict, PhD, “Polytrauma Rehabilitation Family Education Manual,” Department of Veterans Affairs Polytrauma Rehabilitation Center, McGuire VA Medical Center, Richmond, Virginia; http://saa.dva.state.wi.us/Docs/TBI/Family_Ed_Manual112007.pdf (accessed April 27, 2010).

[2] Ibid.

[3] Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; “Systems of Care,” in Textbook of Traumatic Brain Injury (4th ed.), American Psychiatric Publishing (2005), 533-568.

[4] Hoofien D, Gilboa A, Vakils E, et al. “Traumatic brain injury (TBI) 10-20 years later: a comprehensive outcome study of psychiatric symptomatology, cognitive abilities and psychosocial functioning.” Brain Injury 15.3(2001):189-209.

[5] Sander A, Roebuck T, Struchen M, et al. “Long-term maintenance of gains obtained in postacute rehabilitation by persons with traumatic brain injury.” Journal of Head Trauma Rehabilitation 16.4(2001): 356 – 373.

[6] Sloan S, Winkler D, Callaway L. “Community Integration Following Severe Traumatic Brain Injury: Outcomes and Best Practice.” Brain Impairment 5.1(May 2004): 12 – 29.

[7] Hoofien, et al. 201

[8] Sander, et al. 370

[9] Sloan, et al. 22

[10] Sloan, et al. 12

[11] Nathan D. Cope, M.D., and William E. Reynolds, DDS, MPH; “Systems of Care,” 533-568.

[12] See VA’s program of independent living services (administered by the Veterans Benefits Administration) under 38 U.S.C. sec. 3120, and VA’s authority under 38 U.S.C. sec. 1718(d)(2) to furnish supported employment services as part of the rehabilitative services provided under the compensated work therapy program (administered by the Veterans Health Administration).