USA — Military Progresses in Identifying, Treating Brain, Mental Injuries

WASHINGTON, Sept. 22, 2010 — Nine years of con­flict has rev­o­lu­tion­ized the way the mil­i­tary treats its com­bat wound­ed, Vice Adm. Adam M. Robin­son Jr., the Navy sur­geon gen­er­al, told Amer­i­can Forces Press Ser­vice.

Dr. David Williamson, medical director for the Inpatient Psychological Heath and Traumatic Brain Injury program at the National Naval Medical Center in Bethesda, Md
Dr. David Williamson, med­ical direc­tor for the Inpa­tient Psy­cho­log­i­cal Heath and Trau­mat­ic Brain Injury pro­gram at the Nation­al Naval Med­ical Cen­ter in Bethes­da, Md., and his staff are break­ing new ground in iden­ti­fy­ing and treat­ing trau­mat­ic brain injuries and men­tal-health issues.
U.S. Navy pho­to by Sea­man Alexan­dra Snow
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The past years of con­flict have wit­nessed improved bat­tle­field care and well-oiled med­ical evac­u­a­tion and trau­ma-care net­works that are sav­ing lives that in past wars would have been lost. There’ve also been huge advances in treat­ing ampu­ta­tions and spinal-cord injuries.

Just as dra­mat­ic, Robin­son said, are the cut­ting-edge devel­op­ments in iden­ti­fy­ing and treat­ing brain injuries, includ­ing the men­tal and psy­cho­log­i­cal effects of war.

“We have final­ly, as a mil­i­tary and as a med­ical ser­vice – Army, Navy and Air Force – come to grips with the fact that war cre­ates injuries that are not seen, injuries that are just as life-chang­ing and as dev­as­tat­ing as ampu­ta­tions and oth­er phys­i­cal injuries that come back,” Robin­son said in a sun-lit con­fer­ence room here at his Navy Bureau of Med­i­cine and Surgery head­quar­ters.

“And we have done tremen­dous work in assess­ing and treat­ing and giv­ing sta­bil­i­ty and a con­text to men and women who have been injured in the war and suf­fered these unseen injuries – the ones you can’t make out, the ones the X-rays don’t show, the ones for which the blood work doesn’t show the dif­fer­ences, but that cer­tain­ly are there,” he said.

Expo­sure to road­side bombs and oth­er blasts caus­es phys­i­cal changes in the brain, and as a result, how it func­tions, Robin­son said.

“When you are in a blast, there are actu­al­ly neu­ron-cog­ni­tive changes that occur in how the brain and the synaps­es and the brain con­nec­tions – the wiring of the brain – actu­al­ly work,” he explained.

Robin­son said hor­mone and chem­i­cal lev­els fluc­tu­ate as well, often result­ing in emo­tion­al and behav­ioral changes.

“This is not just about being dis­ori­ent­ed,” he said. “You are not just dis­ori­ent­ed from the blast. You are dis­ori­ent­ed because you are in the blast, and then the blast caus­es a change in how your brain func­tions. Peo­ple have been very, very slow to come to that con­clu­sion, but it’s true.”

But except in the case of severe trau­mat­ic brain injury — defined as a pen­e­trat­ing head wound — these wounds can be dif­fi­cult to diag­nose, and symp­toms often aren’t imme­di­ate.

“When you break your arm, I can do an X-ray and can show you the break,” Robin­son said. But for troops with mod­er­ate or mild TBI, “we are find­ing that there may be changes in the neur­al psy­cho­log­i­cal and neur­al cog­ni­tive path­ways that we are just begin­ning to learn and under­stand.”

Robin­son tout­ed tremen­dous strides in address­ing severe TBIs, with life-sav­ing phys­i­o­log­i­cal, chem­i­cal and oper­a­tive advance­ments. “All of that has come togeth­er … [so that] many of the severe trau­mat­ic brain-injured patients who hereto­fore we did not think were capa­ble of sur­viv­ing have, in fact, come back and are now lead­ing pro­duc­tive lives,” he said.

Dr. David Williamson is on the front line of these advances as direc­tor of the psy­cho­log­i­cal heath and trau­mat­ic brain injury team at the Nation­al Naval Med­ical Cen­ter in Bethes­da, Md.

“This is a ded­i­cat­ed team of pro­fes­sion­als who have a mis­sion to serve just one cat­e­go­ry of med­ical dis­or­der,” he said. “Instead of break­ing the staff up by med­ical spe­cial­ties, we are a team bro­ken into the cat­e­go­ry of a clin­i­cal prob­lem: the psy­cho­log­i­cal health and brain-injury effects of com­bat.”

Oper­at­ing from with­in a wing of the Nation­al Naval Med­ical Cen­ter known as “7 East,” the team includes a com­bi­na­tion of brain spe­cial­ists: Williamson, a neu­ropsy­chi­a­trist; as well as a neu­ropsy­chol­o­gist who con­ducts high­ly detailed mem­o­ry, speech, cal­cu­la­tion, con­cen­tra­tion and oth­er cog­ni­tive tests.

Spe­cial­ists in psy­chol­o­gy and social work round out the team, which works hand-in-hand with trau­ma sur­geons to assess every sin­gle wound­ed war­rior treat­ed at the hos­pi­tal, and inter­vene imme­di­ate­ly when they diag­nose brain injuries or men­tal-health com­pli­ca­tions.

Williamson cit­ed the increase in craniec­tomies — sur­gi­cal pro­ce­dures to remove part orall of the skull to allow the brain room to swell with­out being squeezed – as one of the biggest game-chang­ers in treat­ing trau­mat­ic brain injuries.

His­tor­i­cal­ly, many peo­ple with brain injuries end­ed up dying because their brain got squeezed when it swelled, ulti­mate­ly killing the brain tis­sue, he explained. Now, for­ward-deployed sur­gi­cal ser­vices often can pre­vent this through life-sav­ing craniec­tomies.

“That means we have more severe brain injury patients that are sur­viv­ing,” Williamson said. “So the chal­lenge for us is treat­ing more severe­ly brain-injured patients through reha­bil­i­ta­tion and lat­er phas­es of care.”

As it works with the hospital’s trau­ma team to iden­ti­fy brain injuries in com­bat casu­al­ties and deter­mine their sever­i­ty, the PHTBI team increas­ing­ly relies on vestibu­lar test­ing to flag prob­lems with­in the part of the inner ear that con­trols bal­ance, Williamson said.

This semi-cir­cu­lar canal sys­tem, made of three flu­id-filled donut-shaped voids of bone, can get dam­aged by blast waves, he explained. “Noth­ing phys­i­cal­ly hits your head, but a pres­sure wave through the skull can rup­ture these flu­id-filled sacs inside bones in the skull,” he said. “It caus­es dizzi­ness, coor­di­na­tion and bal­ance prob­lems and some­times, dou­ble vision. And all that leads to headache and slows reha­bil­i­ta­tion.”

Patients diag­nosed with vestibu­lar prob­lems work close­ly with phys­i­cal ther­a­pists to “reset the equi­lib­ri­um of those sys­tems and get them work­ing prop­er­ly” through exer­cis­es focused on head move­ments, bal­ance and hand-eye coor­di­na­tion, Williamson said.

“That’s an injury that’s fre­quent­ly been missed,” he said. “This ther­a­py has proven very help­ful.”

Mean­while cog­ni­tive reha­bil­i­ta­tion is help­ing patients restore brain func­tion. “If you train brain sys­tems that are only par­tial­ly func­tion­ing, you can build up their strength and effi­cien­cy just like a weak­ened arm if you do weight train­ing on it,” Williamson explained.

Cog­ni­tive ther­a­py con­sists of a series of drills – mem­o­ry tasks, read­ing tasks, ana­lyt­i­cal rea­son­ing tasks – all focused on retrain­ing the brain, he said.

“In addi­tion, brain injury treat­ment pro­grams are using the vir­tu­al envi­ron­ment to extend what we can chal­lenge brains with,” Williamson said. Spe­cial­ized video games and oth­er com­put­er-based pro­grams pro­vide visu­al, spa­tial, lan­guage and coor­di­na­tion tasks. A dri­ving sim­u­la­tor enables them to hone their dri­ving skills under the watch­ful eyes of a trained ther­a­pist.

The PHTBI team also uses spe­cial­ized equip­ment to mon­i­tor elec­tri­cal activ­i­ty with­in the brain and iden­ti­fy a fre­quent com­pli­ca­tion of brain injuries: seizures.

“Every­one rec­og­nizes when seizures make you go uncon­scious or you are con­vuls­ing,” Williamson said. “But you can have par­tial seizures where you have changes in your abil­i­ty to think or your emo­tion­al reg­u­la­tion or your gen­er­al lev­el of alert­ness, caused by a lit­tle area of elec­tri­cal abnor­mal­i­ty.”

So the team con­ducts elec­troen­cephalog­ra­phy, con­tin­u­ous­ly over the course of five days, to test for those abnor­mal­i­ties. Patients who exhib­it them typ­i­cal­ly are treat­ed through med­ica­tion.

But the PHTBI team hasn’t lim­it­ed its efforts to drugs and con­ven­tion­al med­i­cine. “Our phys­i­cal med­i­cine reha­bil­i­ta­tion team is open to all holis­tic ther­a­pies and alter­na­tive ther­a­pies as well,” he said. “We refer peo­ple for acupunc­ture for pain man­age­ment. We do var­i­ous types of non-med­ical pain inter­ven­tions, nerve stim­u­la­tion, nerve blocks and so on.”

The biggest chal­lenge in treat­ing mod­er­ate and mild TBI, Robin­son said, is that there’s typ­i­cal­ly no out­ward sign of injury, mak­ing it dif­fi­cult to iden­ti­fy.

“With mild TBI, you know you are dif­fer­ent. You feel dif­fer­ent, but you look absolute­ly the same to those around you,” he said. “You may act dif­fer­ent­ly to those who know you real­ly well, but you can take tests and do all sorts of dif­fer­ent objec­tive instru­ments and you don’t nec­es­sar­i­ly see the dif­fer­ences.”

Often it’s a fam­i­ly mem­ber or loved one who picks up on per­son­al­i­ty or behav­ioral changes and sends up the red flag. “We’ve had spous­es come in and say, ‘The per­son I sent to Iraq or Afghanistan is not the per­son who came back,’ ” Robin­son said.

Robin­son said he believes that nobody returns home from com­bat with­out at least some degree of post-trau­mat­ic stress.

“If you are involved in com­bat and com­bat oper­a­tions, you have post-trau­mat­ic stress,” he said.

Even those not phys­i­cal­ly involved in com­bat, but oper­at­ing with­in the com­bat the­ater, are at risk, he said. “If you are exposed to the ten­sion and to the stress of a deploy­ment, you are a can­di­date to devel­op post-trau­mat­ic stress,” he said.

“I did not say you have a dis­or­der,” Robin­son empha­sized. “So when I talk about PTS, I don’t add the ‘D’ for ‘dis­or­der.’ Because we know that if we treat it and treat it effec­tive­ly, we can actu­al­ly obvi­ate the dis­or­der. If we can stave off the ‘D,’ we are ahead of the game.”

(Editor’s Note: This is the first in a series of four arti­cles about the military’s rev­o­lu­tion­ary new approach­es to treat­ing patients with trau­mat­ic brain injuries and post-trau­mat­ic stress.)

U.S. Depart­ment of Defense
Office of the Assis­tant Sec­re­tary of Defense (Pub­lic Affairs)

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