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Traumatic brain injury (TBI) has become an increasing concern among military members and their families since the start of the war, a decade ago. To further understand and enhance treatment, Walter Reed Bethesda continues making strides in research while educating patients, families and providers.

A TBI can occur when an external force on the body causes some structure or physiologic change to the brain, according to Louis French, chief of Traumatic Brain Injury Service, Department of Rehabilitation, at Walter Reed National Military Medical Center (WRNMMC).

“The way we typically see that, is through some change in level of alertness or consciousness,” French said.

At WRNMMC, service members with mild brain injuries are often seen in the context of other injuries they may have endured on the battlefield, he explained, adding that explosions are the most common cause of brain injury in the population served at WRNMMC.  

“We worry about identifying and treating the brain injury that occurs with those other [injuries] because it may have an impact on their rehabilitation,” he said. If a patient has memory problems because of a TBI, they may not remember their appointments, wound care or medications, he continued; therefore, upon arriving at WRNMMC from combat, each patient is screened for TBI, he said. 

“We’ve been doing that for many years,” he said. “We also have a system of care now that is assessing people in theater, [and] assessing in Germany as they go through the evacuation process. There are lots of opportunities to capture those [injuries].”

Providers evaluate loss of consciousness after the traumatic injury, to determine the level of severity.  Loss of consciousness for less than an hour is generally considered a mild TBI, while loss of consciousness for a week is severe, and anywhere in between may be diagnosed as a moderate TBI, French explained.

“In general, the more severe the brain injury, the longer we can expect symptoms to last, and the more significant the impairments of functioning,” he continued. “We see the full range of severities here.”

In addition to measuring consciousness, a TBI can be identified by a number of symptoms, such as headaches, memory loss, dizziness, nausea, blurred vision, light sensitivity and seizures. In urgent conditions, an individual may not be able to recognize people, or have weakness in their limbs, slurred speech, double vision, or have a declining neurological exam.

Regardless of severity, French went on to explain that care encompasses a wide variety of services, and treatment is based on an individual’s needs.

“Not everybody has all the symptoms, and some people don’t have any of the symptoms,” he said.

Generally, symptoms are viewed in three areas: cognitive, physical and behavioral/emotional. Cognitive symptoms may include disruptions to memory, problem solving and language. Treatments targeted towards recovering cognitive function, may include working with occupational therapists (OTs), speech pathologists and neuropsychologists, he explained.

Physical symptoms may involve changes in motor function, vision, balance, vision and sleep, as well as the most common, headaches. For headaches in particular, there are physicians available, who are experts in pharmacology, French said.  Physical therapists, as well as physical medicine and rehabilitation doctors work with patients suffering physical impairments from a TBI, while OTs may teach how to work around these physical limitations.  

Behavioral/emotional symptoms may be more complicated, as it may be difficult to disentangle from other circumstances the patient often encounters during treatment, French explained. Often, these individuals are young and healthy, and being in the hospital can make them irritable, frustrated and sad, he said. It can be a challenge to differentiate these symptoms from those actually related to the brain. Emotional symptoms, though rare, may include depression, anxiety, agitation, irritability and impulsivity, he said. Providers offer a number of methods to help patients cope, such as relaxation and techniques, acupuncture and biofeedback, using one’s thoughts to control their body.

Treatments must be thorough, addressing the wide range of symptoms, and WRNMMC’s multidisciplinary TBI team provides several layers of treatment, French said. Not every method of treatment works for the same people at the same time.

“We have to address the problems people are having from head to toe,” French said. “We have to deal with the whole range, and if we’re not successful in addressing all [problems], people just don’t get better the way we would like.”
Keeping Patients, Families Informed

An essential component in a patient’s TBI treatment at Walter Reed Bethesda is education, French said, and that’s where the Defense and Veterans Brain Injury Center (DVBIC) comes in. Part of the U.S. military health system, DVBIC is the TBI operational component of the Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE), explained French, who is also director of the DVBIC site at WRNMMC. 

DVBIC has sites at military medical centers across the globe, with the one at Walter Reed Bethesda being the largest in the U.S. and Germany, according to DVBIC’s website. 

“Since there are similar DVBIC sites at Landshtul and across the U.S., care is continuous and education is standardized for service members from the point of injury overseas, and throughout their recovery,” said Laura Wolf, a DVBIC regional education coordinator at WRNMMC.

DVBIC educators meet with each patient after they arrive off the medevac, and they continue to offer support over the course of each patient’s recovery, Wolf explained.

“We’ll go through the different steps, what a TBI evaluation is, and then after that, we’ll discuss the diagnosis, treatment, the process,” she said.

In addition to the bedside education for TBI inpatients, and their families, DVBIC educators offer educational classes for outpatients and families, Wolf said. Throughout the year, they’re also committed to organizing outreach events at both the medical center and out in the community, she added.
Advancements in Research

Furthering research is an important aspect of care, and providers at WRNMMC are working diligently to do just that, he explained. Providers have been able to document what they’ve seen, ensuring future care givers benefit from what they have learned. At WRNMMC, providers and researchers have been able to capture and use clinical data for research, gathering information on thousands of individuals, French said.

To understand what factors predict a good outcome, a 15-year natural history study has been ongoing for about a year, he said. The study will involve following patients over a long period of time, bringing them back for comprehensive evaluations.  The Brain Fitness Center at WRNMMC is also conducting research using computer-based brain training programs to exercise the brain in a game-like format, French added. To improve understanding of computer-based cognitive rehabilitation outcomes, the center is open to any service member struggling with their thinking skills, and is located in the Amputee Center in the America Building.

“We’re constantly enrolling people in those studies,” he said.

Finding the best forms of treatment, WRNMMC is also partnered with a number of agencies in research, such as the National Institutes of Health, Uniformed Services University of the Health Sciences, and the National Intrepid Center of Excellence (NICoE), French said.

The NICoE, an extension of WRNMMC located onboard Naval Support Activity Bethesda, is dedicated to treatment, research and education for service members with complex forms of mild traumatic brain injury and psychological health conditions.  Director Dr. James Kelly noted one of their significant findings related to TBI, of late, has been sleep disturbance.  Each patient treated at NICoE, undergoes an overnight sleep study in one the center’s two sleep labs, set up similar to a hospital room, he said.

“The majority of our patients have some version of a sleep disturbance, some of which is neurological or pulmonary, [such as] obstructive sleep apnea. Some of it is just poorly regulated sleep,” Kelly explained. “In order to heal, we know you need restorative deep sleep, and people who don’t get that have persistent symptoms from concussion or PTSD (post traumatic stress disorder).”

With these findings, providers are better able to target an individual’s sleep problem, in order to treat it, and ensure a better overall recovery.

“That’s made a huge difference,” the neurologist said. “If you don’t start with those simple, bodily, physiological things, you get nowhere.”

At the NICoE and WRNMMC, providers are using state-of-the-art equipment, such as the Computer Assisted Rehabilitation Environment (CAREN), which uses a motion platform with an embedded treadmill, 180-degree projection screen and customized virtual environments, used to improve a patient’s balance and multi-tasking in the real world.

Kelly also noted the success at the center of excellence has led to nine satellite NICoEs being built around the country. This summer, two are expected to open: one at Fort Belvoir, Va., and another at Camp Lejeune, N.C.  These satellites will be on a smaller scale of the NICoE – about a third of the size, Kelly said. They will extend the care currently provided at the NICoE, and treatment from these centers will be transmitted back to the NICoE, aiding its ongoing research efforts, thus improving diagnosis and treatment.

While Kelly believes patients will succeed in their treatment at the satellite level, they may continue to be referred to the NICoE in Bethesda, when necessary.

“We’ll make sure everyone gets assessed carefully and pointed in the right direction,” added French.  He wants people to know, a TBI doesn’t have to mean a lifelong concern. “We have a lot we’re doing. It’s exciting. We’re very fortunate we have a lot of resources here.”