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Health and Fitness

Healing Invisible Wounds

NICoE Treats Traumatic Brain Injuries

Brain injuries are the signature wounds of the wars in Afghanistan and Iraq, with more than 380,000 service members experiencing them between 2001 and 2017, according to the Department of Defense. Traumatic brain injuries (TBI) can have devastating effects on those who experience them, such as vomiting, seizures, speech disorders and aggression. Long after initial impact, the resulting injuries can leave sufferers with invisible wounds that are tough to pinpoint or treat.

According to the Military Health System guidelines, a TBI is a traumatically induced structural injury or physiological disruption of brain function, the result of an external force. It's indicated by an altered mental state, such as disorientation or a decrease in cognitive functions, as well any loss of memory for events immediately before or after the injury, or the loss of or a decreased level of consciousness.

Equally challenging for medical providers is the stigma victims often feel when it comes to seeking help. But researchers say awareness and advances in the DoD's treatment and prevention strategies have changed for the better the way patients recover.

“There has been an increase of awareness about TBI, and that has made a great difference in early identification and intervention. Even in the past few years, we've seen a greater willingness to seek treatment for both TBI and psychological health concerns,” said Dr. Louis French, deputy director of operations and a clinical psychologist at the National Intrepid Center of Excellence (NICoE) located in Bethesda, Maryland.

Opened in 2010, NICoE helps active duty members, reservists, veterans, retirees and their families manage TBIs and other associated conditions while providing diagnostic evaluation, comprehensive treatment planning, outpatient clinical care, and TBI research and education.

According to French, understanding the relationship between the mind and the brain is important because psychological and emotional health can influence TBI recovery.

A TBI can impact a person's physical, cognitive, and behavioral or emotional functions. It can cause a variety of symptoms, including headache, nausea, dizziness, difficulty with concentration, memory, and language, and feelings of depression and anxiety.

“We continue to grow our understanding of the various factors that go into a person's recovery from TBI, including physical, emotional, sensory, cognitive and other aspects,” said French. “Family involvement is also now recognized as an important part of the recovery process, and for those who may have complicated recoveries.”

At the NICoE, patients and their families have access to traditional medical specialties like primary care, advanced neurology and neuropsychology, as well as complementary holistic approaches, including wellness and creative arts therapy.

One of many reasons the center was created, said Capt. Walter Greenhalgh, director of NICoE, is to provide support to patients and their families.

“NICoE treatment programs are designed to encourage family-member involvement in the patient care plan by attending appointments and participating in programs like family therapy, family education classes, and Spouse and Caregiver Support groups. Our social workers provide education and skills training for all family members and connect them with resources to help them cope as a family unit,” Greenhalgh explained.

Group therapy for those coping with similar injuries can also show patients they aren't alone and allow families the opportunity to interact with other family members.

Although TBIs are widely viewed as combat injuries, service members can still be at risk during day-to-day activities. Research conducted by the Defense and Veterans Brain Injury Center shows TBIs are more commonly the result of operational training, falls and motor vehicle accidents.

“TBI is not just a military injury. It's easy to forget that it was only 10 years ago that we wrote the first in-theater guidelines for TBI, and now we have standardized assessment and treatment protocols across the entire Defense Department,” said French.

The majority of traumatic brain injuries — 82 percent — are classified as mild TBIs or concussions. Mild TBIs:

- Can leave sufferers in a confused or disoriented state for less than 24 hours
- Can cause loss of consciousness for up to 30 minutes
- May result in memory loss lasting less than 24 hours

Moderate TBIs:

- Can create a confused or disorientated state that lasts more than 24 hours
- Can cause loss of consciousness for more than 30 minutes, but less than 24 hours
- May result in memory loss lasting more than 24 hours but less than seven days
- Can appear to be a mild TBI, but with abnormal CT scan results

Severe TBIs:

- Can create a confused or disoriented state that lasts more than 24 hours
- Can cause loss of consciousness for more than 24 hours
- May result in memory loss for more than seven days

A penetrating TBI, or an open head injury, is the most severe type of TBI:

- The scalp, skull and dura mater (the outer membrane encasing the brain and spinal cord) are penetrated by a foreign object.
- Penetrating injuries can be caused by high-velocity projectiles.
- Objects of lower velocity, such as knives or bone fragments from a skull fracture, can also be driven into the brain.

The current definition of TBI was updated in 2015 to be consistent with military and civilian guidelines, and a later review showed that many previously “unclassifiable” cases were likely moderate TBIs.

“Having standardized assessment and treatment guidelines pushed out to an entire military health system and being able to track people through an integrated medical record is amazing,” said French. “Then you have the development of places like NICoE and the Intrepid Spirit Centers that provide intensive, integrative treatment.

“The military and academia are working hand-in-hand to answer questions and improve assessment and care. There are a lot of things that have been done in support of TBI advancement — any of my civilian colleagues look at what the Defense Department achieved in this amount of time, and it's phenomenal.”

Sources: The Defense and Veterans Brain Injury Center, the Military Health System and the Armed Forces Health Surveillance Center.