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NICoE at forefront of traumatic brain injury research and treatment

Picture of a mask with the American flag on one side and camo on the other side Display poster and NICoE patient’s art therapy mask at the “Visual Voices of the Invisible Wounds of War” event at the Medical Museum Science Café in the National Museum of Health and Medicine in Silver Spring, Maryland (Photo By: NICoE Communications).

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The National Intrepid Center of Excellence  at Walter Reed National Military Medical Center is dedicated to treating the invisible wounds of traumatic brain injury.

Through its mission to provide cutting-edge and excellent clinical care diagnoses, research, and education around TBI and associated health conditions, the NICoE aims to bring hope, healing, discovery, and learning to patients and their families, medical providers, and the research community.

TBI is significant among U.S. service members and veterans and occurs when an external force causes damage to the brain and a disruption in its normal function. TBI occurs on a spectrum, from mild - or mTBI, also known as concussion, - to severe, with mTBI considered the most common TBI affecting military service members. Those who experienced an mTBI usually recover completely.

The Defense Medical Surveillance System reported that between 2000 and the third quarter of 2020, over 430,000 U.S. service members suffered TBIs, of which 82.4% were mild. However, unlike visible physical injuries, such as cuts, gunshots, broken limbs, or others, TBIs often can't be recognized with the naked eye, said Dr. Louis M. French, neuropsychologist and deputy director of the NICoE.

"For those people that are at the milder end of the TBI spectrum, and for some people with more severe TBI, often there are no external physical signs that you would notice about someone in casual conversation," said French. "You might not see that they're impaired when the brain has been affected."

When the brain doesn’t work in the way that it normally would or should, this can create a very frustrating situation for patients, French noted, saying, "they have these very significant concerns they're dealing with, and other people may not see that they really have been affected."

Additionally, post-traumatic stress symptoms and post-traumatic stress disorder often occur in parallel to TBI, and each case presents unique symptoms, noted French.

"If you've been injured in a combat situation, it increases your risk of having PTS symptoms," he said. "The things that wound you physically can also wound you mentally."

And since we're all different, "we come into these situations with different bodies, different experiences, different ages - there are all sorts of factors that go into how one is affected by a situation," he explained. Likewise, "there are a lot of factors that affect whether someone is injured and the outcome that they have after that."

Assessment Tools and Guidelines

Due to the number of TBIs U.S. service members have suffered over the last decade or more, the Military Health System has developed several tools to quickly diagnose and assess people with a potential TBI or concussion, explained French.

"There are guidelines that the military has put out both for in-theater and in-garrison regulations around the assessment and treatment of TBI, as well as about the return to activity and return to duty," he said. "These are standardized instruments that the military uses acutely to do these kinds of assessments to identify service members who may be affected either in peace time or in war time."

French explained how most TBI patients will be able to return to duty after a period of recovery. The therapy offered at the NICoE is designed to get each individual back to their maximum level of function, whatever that is.

"Most of those people go on to have quite uneventful recoveries - they may be symptomatic for a while, but they do well ultimately," he said.

Still, there's a small percentage of people who, for various reasons, may have persistent symptoms.

Military personnel demonstrating a yoga pose
Dr. Allison Winters Fisher, Wellness Coordinator at the NICoE, demonstrates a yoga pose in Central Park at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland (Photo by: Liz Freeman, National Intrepid Center of Excellence).

"Those with mild TBI that have persistent symptoms need further assessment and treatment," said French. "The people at the more severe end of the spectrum typically have more severe symptoms early on and may have more chronic issues over time, and they too need accurate diagnoses and assessment."

Types of Treatment

Depending on the severity of the injury, the NICoE offers various treatments to help patients rehabilitate physically as well as psychologically.

"For some people with very severe injuries, there is a component of physical rehabilitation to help them with all those activities of daily life," said French. "Thankfully, since our combat casualties have diminished, we have fewer of those kinds of cases than we did before, so we're treating all the elements that affect functioning"

For example, he noted, some people have cognitive dysfunction. "We work on cognitive rehabilitation with them so that their memory, concentration, and attention are better."

In other cases, pain is a big issue - specifically, headache is very common after brain injury, he said, "so, if we can fix some of their pain, we can get them functioning better."

Also, "people often have sleep abnormalities, so we conduct sleep studies and treatments to improve their sleep," he said.

Treatment Programs

French explained that the NICoE was designed for a specific type of population. Since it's located in a dedicated building in Bethesda, Maryland, with health care experts in more than 18 different specialties as well as various high-tech diagnostic machines, patients can benefit from the NICoE as a one-stop shop for TBI care.

"We have an intensive outpatient program, which was designed to treat those people that may have failed other more traditional treatment interventions," he said. "Our goal for that population is really to carefully assess and treat and get those individuals back to their maximum level of functioning and hopefully get them back to duty.

"Our other treatment track is a regular outpatient program that treats people across the spectrum of TBI severity, and they may be people who were injured locally, like in a car accident or a fall during training. It could be anything, and we work to assess and treat them here.

The NICoE's intensive outpatient program lasts four weeks. Each week, a group of TBI patients are admitted to the center for that period, during which they are intensely evaluated daily, combining elements of treatment and assessment from morning to afternoon, said French.

"By the time they leave here after four weeks, they will have had well over 100 appointments with providers from 18 different clinical specialties combined with advanced neuroimaging and other diagnostic techniques that we can bring to bear to make sure we really understand where the difficulties are with that particular person," explained French. "Then, we try to design interventions and treatment plans that will potentially be the most useful for that person and send them back to their local care providers to implement that care plan."

The regular outpatient program is more traditional. Patients visit the clinic for initial assessment and are referred to NICoE providers who can address their needs.

"Those treatments may take place over a course of weeks or sometimes months or years, depending on what the needs of the person are," said French. "For example, we have specialists in headache treatment, sleep problems, musculoskeletal pain, cognitive dysfunction, who can assess and treat any of those kinds of conditions."

Picture of military personnel using a rotary chair used to detect different vestibular diagnoses in TBI patients
Dr. John King, audiologist at the NICoE, demonstrates the rotary chair used to detect different vestibular diagnoses in TBI patients at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland (Photo by: NICoE Communications).

The Brain Fitness Center is a supplemental treatment offered at the NICoE. It's an option that uses computer-based training tools to help patients develop healthy brain habits and improve thinking skills, such as short-term memory, focus, and decision making.

Alternative Therapies

In addition to the varied clinical care specialties offered at the NICoE, there are alternative therapies, such as art or music therapy, to help patients heal. For example, music therapy is used for patients to express emotions and feelings in a way that they may not be able to through speech, said French.

"If you have a patient that has a very severe language dysfunction and can't articulate his words well, it may be that he can sing or express himself through music in a way that he can't in speaking," said French. Even though those types of cases are not common, he said.

More importantly, he highlighted, these types of therapies get people thinking about their life beyond their injury.

"We want people to start thinking about leisure activities and recreational activities and what they're going to be doing for the next 50 or 60 years of their life," said French. "These therapies help them and maybe become a hobby or an interest for them that will help get them past the period of acute rehabilitation and start to think about the rest of their life."

Engaging the Family

French emphasized the importance of family or a support network to patient recovery. He explained the therapies offered at the center's outpatient program involve the family while the patient is in care.

"We want the spouse to understand the results of the evaluation, and we can bring them into the treatment process," he said. "In some cases, there's a need for couples therapy, or ways of improving communication - and we have people to help with that.

He explained that aspects of a person's environment can make them do well or not do well - and family is a key piece of that. "Supportive family members can make a real difference in terms of recovery, particularly for people who have very difficult recoveries or are likely to have persistent problems for many years."

Research

In addition to providing clinical care, the NICoE is a research organization. French explained the center conducts very clinically oriented research and works in close partnership with other TBI experts at the Uniformed Services University of the Health Sciences, which shares NICoE's campus; the National Institutes of Health, located across the street; the other Intrepid Spirit Centers within the Defense Intrepid Network for TBI and Brain Health across the nation; and across the MHS and the Department of Veterans Affairs.

"We very much believe that conducting research is important to better understand ways of assessing and treating individuals," he said. "We strongly believe in partnership - we have some very good doctors here, but we also know that there are experts in all sorts of fields elsewhere."

To better understand how each therapy works and document findings when implementing alternative, cutting-edge therapies - such as using art or music in rehab - the NICoE conducts parallel studies, said French.

"The research studies may be about ways of finding better neuroimaging techniques, or finding better ways of treating headaches, or finding other treatment options for people," he said.

These aim to answer important questions, he noted, such as how a given therapy fixes the brain, how it helps patients make new neural connections to deal with some of the damage that's been caused by the injury, and when given therapies may be most beneficial: Is it better to do it soon after injury, once or twice a week, or much later after injury?

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