Traumatic brain injury (TBI) is a complex disease process and the signature injury of current military conflicts, affecting 10-20% of those wounded during service in Operation Iraqi Freedom and Operation Enduring Freedom. Recent Institute of Medicine reports have recommended the Veterans Administration (VA) conduct research to develop protocols to improve management of symptoms and improve health and well-being of service members with TBI. There is a growing literature on the efficacy of self-management support (SMS) programs designed to support patients with chronic diseases such as chronic obstructive pulmonary disease, arthritis, and diabetes;collectively, the results suggest that SMS is a key component to realizing optimized outcomes for individuals with chronic conditions. The VA commitment to telehealth is unrivaled, and though comprehensive SMS programs for mild TBI (mTBI) have not been studied, preliminary evidence from skill-specific training programs for TBI suggests that a comprehensive SMS telehealth program for mTBI could be beneficial. The proposed project is designed to advance clinical telehealth practice for mTBI by completing the preliminary steps toward the development of a measure to assess self- management knowledge, skills and beliefs of veterans with mTBI, pairing it with new """"""""gold standard"""""""" symptom and quality-of-life assessment tools, and linking both components to evidence-based intervention options. The mixed-method research approach was modeled after the comprehensive measurement development activities developed by the PROMIS network, a 100 million dollar NIH Roadmap effort, which is developing a new and comprehensive system of patient self-report symptom and quality of life measures. This approach incorporates expert panel and veteran focus group review of patient self-management information domains compiled through comprehensive search strategies. The conceptual model produced through qualitative review will be actualized through the creation of item pools for the subdomains of patient activation. The dimensionality of the construct and psychometric properties of the item pool will be evaluated using both multivariate statistical and modern measurement models (i.e., Item Response Theory). Finally, the scope and strategies of a measurement-based telehealth intervention will be defined and introduced to implementers. Achieving the aims outlined in this protocol will immediately increase the functionality of the VA telehealth program. By leveraging and aligning with ongoing research efforts, the current project (1) transforms VA telehealth text messaging devices into precision assessment instruments while decreasing the response burden for patients, and (2) allows comparison of disease burden across different VA patient populations and between civilian and veteran patient populations, allowing the VA to prioritize clinical and research resources most efficiently. This application is significant because of the large number of veterans with mTBI that will require clinical care in the coming decades. The application is also innovative because of its development and validation of psychometrically sophisticated yet pragmatic measures to assess and monitor mTBI coupled with a strategy to create effective self-management strategies as step 1 care for delivery in telehealth programs.

Public Health Relevance

Mild traumatic brain injury (mTBI) has affected thousands of veterans involved in recent military conflicts. Persistent symptoms occur in 10-20% of patients with mTBI. This project is designed to develop an assessment tool to measure the self-management knowledge, skills and beliefs of veterans with mTBI that would be paired with symptom assessment tools and linked to evidence-based rehabilitation approaches. This comprehensive assessment system would be delivered using existing telehealth infrastructure, significantly extending the ability of care managers to monitor veterans with mild traumatic brain injury and reduce the long-term psychosocial and medical needs from both persistent deficits and problems that develop in later life, including increased risk of suicide, homelessness, unemployment, marital discord, neurodegenerative diseases, and reduced community participation.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (IK2)
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Rlr VA Medical Center
United States
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