NICoE at forefront of Traumatic Brain Injury research and treatment

Story by Claudia Sanchez-Bustamante for Military Health System

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.

“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.”

Posted on May 3 2021 in News

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