April 2018

“Something’s Not Right”

Marine Corps, DOD Confront Signature Wound Of Modern-Day Combat, Part II
Volume 101, Issue 4

Patricia Everett

While attached to a safety harness, a servicemember with TBI walks on a treadmill through a virtual reality scenario at the NICoE in Bethesda, Md., March 20, 2017. Motion capture cameras track the patient’s movements via reflective markers that are applied to the patient and provide data on physical deficits.
J.M. Eddins Jr.

This is the second installment in a two-part series, the first of which appeared in the March issue of  Leatherneck in recognition of Brain Injury Awareness Month. The series was made possible through the assistance of the Defense and Veterans Brain Injury Center (DVBIC), Naval Medical Center Camp Lejeune, N.C., the Intrepid Spirit Center at Camp Lejeune and Wounded Warrior Battalion–East.

Return to Forces

“When you’ve seen one TBI, you’ve seen one TBI,” is a saying commonly heard among the doctors and staff at Defense and Veterans Brain Injury Center (DVBIC). It’s a simplified way of explaining that despite numerous advances in the field of TBI research and care, there will never be a solitary “cure.” The complexity of the human brain is such that individualized treatment is key to recovery and successful reintegration. What works for one servicemember with TBI may not work for another, but the end goal is the same: to put them in control of their symptoms rather than allowing their symptoms to control them.

Leading experts in the field of military TBI, like Navy Captain Thomas Johnson, a neurologist and the director of the Intrepid Spirit Center (ISC) at Marine Corps Base Camp Lejeune, N.C., believe that retraining the brain can restore servicemembers to the highest possible level of function, whether they suffer from the effects of mild TBI, commonly known as concussion, or a more serious TBI, which can be classified as either moderate, severe or penetrating. For between 85 and 95 percent of the individuals who are part of the brain recovery program at the state-of-the-art facility, treatment ultimately leads to their return to the force.

It’s an impressive statistic, and evidence that the DOD is on the right track in its approach to caring for those Marines and other servicemembers who are quietly fighting their own battle against the effects of invisible wounds.

“Instead of trying to cover up the symptoms, we try and take advantage of this phenomena of neuroplasticity to sort of re-train the brain—whether that’s retraining their balance capabilities or retraining them so that their sleep hygiene improves, or other non-narcotic tools to give them mastery over their symptoms like headache, pain, sleep disturbance,” said Johnson, referring to the brain’s ability to change, modify its connections and, in a sense, “re-wire” itself.

In an effort to expand the reach of the model of care first implemented at the National Intrepid Center of Excellence (NICoE) in Bethesda, Md., and the Center for the Intrepid in San Antonio, the Intrepid Fallen Heroes Fund, founded by the philanthropic Fisher family, offered to build nine satellites—Intrepid Spirit Centers—across the nation. Among its locations are Camp Lejeune, which opened in 2013, and Camp Pendleton, Calif., which is still under construction and expected to open its doors this year.

These facilities are part of what Johnson describes as a network or “web” of providers and institutions such as DVBIC, VA Polytrauma Centers and military treatment facilities. It’s less hierarchical than most areas within the DOD, Johnson said, which allows for more rapid sharing of ideas and innovations among the different entities dealing with military TBI.

The holistic, integrated, interdisciplinary model used at the Intrepid Spirit Centers represents the shift in mentality over the last decade regarding brain injuries, whether they were sustained in combat or in garrison. The stigma surrounding TBI has been greatly reduced, seeking help is no longer widely perceived as a sign of weakness, and the treatment options available are based on cutting-edge research and a focus on the whole person.

“Holistic means you’re looking at someone from 360 degrees—so mental, physical, emotional, spiritual,” explained Johnson. “Integrative means you have different disciplines working together, and then interdisciplinary means that the different health professionals—the providers who see them—work with the servicemember in a way to develop a treatment plan in partnership with each other.”

Each servicemember who comes into the ISC receives a standard evaluation, which includes lab work and a meeting with a team of specialists: a physician, physical therapist, occupational therapist, speech and language therapist, and behavioral health provider. With all of these individuals in the same room together, the servicemember is given the opportunity to tell their story.

“What this is, is an effort so that the servicemember doesn’t have to tell their potentially traumatic experience over and over again,” said Johnson, adding that the three questions the group of providers will ask the Marine are: “What happened to you? What’s bothering you? What can we do to help you?”

Following the standard evaluation, the servicemember’s perspective and the medical team’s assessment are combined and an individualized treatment plan is developed. And while the program is generally referred to as a 16-week process, Johnson said, as long as the servicemember is benefiting, they will continue to receive care. In keeping with the “warrior-athlete” paradigm with an expectation of recovery, said Johnson, most Marines remain a part of their parent unit the entire time and receive treatments as needed.

These treatments range from traditional therapies like physical, speech and occupational to less traditional, such as acupuncture, yoga and art. The servicemembers Johnson has worked with have been overwhelmingly receptive to the non-traditional “complementary” therapies, and he’s observed that most have a real hesitancy about taking pills, particularly narcotics, and want to find ways to truly get to the root of their symptoms rather than simply mask them.

It’s a matter of trying different therapies and figuring out what combination works best for the individual. Captain Andrew Yeary’s headaches are best controlled by Botox injections; for Major Joshua Ellsworth, acupuncture is effective. Both Marines believe that the DOD and the Marine Corps have offered them access to the best and the brightest clinicians in the field.

“They went out and got some rock star long-ball hitters when it comes to understanding what’s going on and trying to help the Marines and the family,” said Yeary, who reinforced his belief that even with the availability of the best specialists, the Marine has to fully “buy in” to the treatment in order for it to be successful.

The referral process to Intrepid Spirit has what Johnson characterizes as a “wide aperture.” Most receive referrals from their medical officer, but specialists in mental health or sports medicine can also refer them. Servicemembers may also self-refer.

“We’d rather see too many people and have some of them not have a brain injury rather than miss some of the people,” Johnson.

The center is designed to meet the needs of servicemembers who have sustained a brain injury and require more support than the traditional clinic setting can provide. According to Johnson, patients with evidence of a brain injury and certain symptoms are selected based on their willingness, commitment, time and command support to participate in the program.

“You think of your brain kind of like a computer if you have too many windows open,” said Johnson. “If you have insomnia, chronic back pain, headache, concerns about performance at the workplace and stress at home, it’s just too much. But in our program if we’re able to get control of pain and sleep … all of a sudden that allows them to focus on other issues, like trying to express things that have been stressful or experiences that were traumatic for them,” he added.

Early Detection and Treatment

One of the benefits to a close alignment among NICoE, the network of ISC sites and DVBIC is the standardization of data collection and development of “best practices” in TBI care. It’s central to what DVBIC’s acting director Kathy Helmick says is an ongoing effort to establish TBI “pathways of care” within the Defense Health Agency. This involves matching patient requirements with the capabilities of the military health system and delivering the latest research and education findings to military healthcare providers, ensuring continuity and standardization of care throughout the entire DOD and, when applicable, in the transition to care through the VA.

For approximately 85 percent of servicemembers who sustain a concussion, a period of rest followed by a progressive return to activity—the current clinical recommendation—enables their recovery within seven days with no need for ongoing care, said Dr. Katharine Stout, a physical therapist and board certified neurological specialist who is the chief of the clinical affairs section at DVBIC.

“The sooner somebody is treated … their symptoms will more typically resolve early and not be lingering or lifelong challenges,” said Stout. “The longer somebody waits to report, the more challenging it becomes to treat.”

In some cases, subsequent concussions after the initial injury can compound the symptoms, and it can be virtually impossible to distinguish which incident caused which symptom. Another challenge in treatment is an overlap of symptoms with post-traumatic stress disorder (PTSD) or anxiety.

“We’ll have people come in and say that they can’t remember—that they’re forgetting stuff. Well, if you’re tired, you’re not going to remember. So is it a cognitive deficit or a sleep deficit?” said Stout. “There’s this interplay between all the symptoms, so it’s trying to figure out what … are the primary symptoms and which are the secondary impact of those symptoms.”

This complexity of symptoms is one of the reasons that the interdisciplinary model, with specialists from multiple areas as part of the team, has been so successful.

Stout and the rest of DVBIC’s clinical affairs staff focus their efforts on developing clinical recommendations on how to manage best practices for TBI care in the military; providing recovery support networks for servicemembers transitioning out of TBI programs; measuring long-term outcomes of servicemembers with TBI; and surveying the impact of TBI and the needs of the clinics across the DOD.

The presence of DVBIC staff at its 22 network sites aids in the efficacy of developing recommendations for clinicians within the military health system in regard to how to deal with patients who have or are suspected of having TBI. Ultimately, the goal is to promote state-of-the-science care for all servicemembers and veterans whether they’re treated at clinics, emergency departments, outpatient or inpatient facilities, Intrepid Spirit Centers or other TBI programs.

In developing clinical recommendations for military health providers, DVBIC has collaborated with clinicians and research experts from the civilian sector, particularly from Johns Hopkins Medicine, the Cleveland Clinic and the University of Pittsburgh, as well as from the sports community—namely the NFL and NCAA.

DVBIC’s primary focus group, according to Helmick, is providers, with the goal of educating clinicians to recognize the signs and symptoms of TBI and treat them in a timely and appropriate manner. Beyond that, it is imperative that unit leaders and primary care managers emphasize to servicemembers and their families how important it is to seek medical attention following any impact to the head that’s accompanied by an alteration of consciousness—not only in combat, but also in garrison. Whether it’s a sports injury, vehicle crash, or proximity to an IED blast, it’s vital to be seen by a provider as soon as possible to minimize long-term effects.

“We know that if we can treat your symptoms and we can progressively return you back to your pre-injury activity level, you have the best outcomes,” said Helmick, adding that the vast majority of early-detected TBI patients are “scooting back out into the fight.”

The challenge, said Helmick, is that in the case of concussion, these early detections currently are not based on objective data. There is not yet an MRI or CT scan that can see a concussion; nor is there a known biomarker in the blood that conclusively indicates one. While the last decade has seen great improvements in recognizing signs and symptoms of mild TBI among servicemembers, diagnosis remains entirely event-based with symptoms. Helmick and her staff won’t rest until there’s an objective way to determine whether someone has a concussion.

“Right now the clinical scenario is you tell me your story, I ask what your symptoms are, and I try to treat your symptoms,” said Helmick. While it frustrates her that there’s a lack of assessment data and no way to truly confirm a diagnosis of concussion, she’s also hopeful that technological advancements that currently are being worked on diligently will be ready to push out to the field in the next year to two years.

“We’re working these things very feverishly,” Helmick said, adding, “We’re not where we need to be.”

Filling the Gaps

“What do we still not know?” It’s a question that Stout says drives DVBIC’s progress in the fight against TBI.

In her work with clinicians to develop best practices for TBI care, she hears their questions and concerns, which she then feeds to the DVBIC research team so that they can better design research studies to find the answers to those questions.

Currently overseeing DVBIC’s open research studies—which totaled 71 as of Jan. 3—is Dr. Saafan Malik, neurosurgeon and DVBIC research section chief.

The studies are all put through a rigorous approval process prior to receiving funding and must focus on filling the current gaps in TBI research.

Most notably are three different longitudinal 15-year studies looking at the long-term effects of TBI on Operation Iraqi Freedom and Operation Enduring Freedom veterans, including the effects on their caregivers.

Researchers also are studying the impact of servicemembers’ exposure to repetitive low-level blasts in training environments. “How much is too much? When do you start to have cognitive changes?” said Helmick. “You haven’t been injured yet, you haven’t lost consciousness, you haven’t had any alteration of your consciousness but you keep firing off weapons and it’s causing blast problems.”

Both Camp Pendleton and Camp Lejeune are key DVBIC sites in studies designed to measure the effects on the brain of repetitive firing of shoulder-mounted munitions. Marines will come off the range and go through blood draws, ear testing, balance testing and more to compile data that, if conclusive, may eventually effect policy change within the DOD regarding striation of training.

“Marines like to know, ‘OK, when I’m going out there every day and I’m getting kind of ‘blown up’ or I’m practicing in breacher scenarios, how do I know that this isn’t going to do long-term damage to me?’ ” said Helmick.

While exposure to and firing of high-velocity weapons may not lead to TBI, said Malik, the cumulative exposure may give some servicemembers symptoms that are closely affiliated with the symptoms of concussion. It’s something they don’t yet know enough about and a gap they hope to fill in the coming years.

Another area of interest is chronic traumatic encephalopathy (CTE), caused by subconcussive blows—repetitive trauma to the brain. Postmortem diagnosis of CTE among several well-known football players in recent years has raised awareness of the degenerative brain disease and has researchers looking for answers on how to avoid or prevent such injuries.

“Necessity is the mother of invention, and if you need something, you go for it and find a solution for it,” said Malik.

Malik oversees DVBIC’s entire research portfolio, and his staff at DVBIC headquarters in Silver Spring, Md., tracks and monitors all 71 studies—several of which are congressionally mandated—across the 22 network sites. Other pockets of TBI research are conducted throughout the DOD through Uniformed Services University of the Health Sciences and the U.S. Army Medical Research and Materiel Command (MRMC).

The sustained efforts of DVBIC—formerly known as the Defense and Veterans Head Injury Program—have led to the production of more than 400 publications that Malik says have a high impact on the body of TBI research to date. The military’s research on TBI began with the Vietnam Head Injury Study, which tracked for more than 40 years a cohort of Vietnam veterans who sustained penetrating TBIs in combat. Today, the majority of the research is focused on concussion—“the one that we didn’t know anything about,” said Helmick.

“We are really stepping up and pushing ourselves to get anything we can get our hands on and push our limits to have things available for our servicemembers,” said Malik.

A handheld diagnostic device—the Infrascanner—was tested by Marines and subsequently fielded throughout the Corps in 2015. It uses near-infrared light to check for intracranial hematomas—clots or accumulations of blood between the brain and the skull—allowing corpsmen to assess brain injuries on the battlefield. Another new device, BrainScope, records the electrical activity of the brain and can detect abnormalities consistent with TBI.

There’s also currently a study testing three different eye-tracking devices to determine which one should be used by the DOD for TBI diagnostics. It involves a partnership with Walter Reed National Military Medical Center and is funded through NRMC—making it what Malik calls a “group effort” within the DOD.

“Our research is requirements-driven, gaps-oriented, for the servicemember,” said Malik, pointing out the difference between research conducted by DVBIC and studies by civilian healthcare chains, which are profit-driven. “For us, the profit is to serve the servicemembers,” he added.

A Head for the Future

Dr. Scott Livingston spent two years at Camp Lejeune as the manager of the Warrior Adaptive Reconditioning program at Wounded Warrior Battalion–East before becoming the chief of DVBIC’s education section.

“In the period of time that I was there, from 2013 to 2015, the percentage of Marines and Sailors with musculoskeletal type injuries, amputations or blast-type injuries went way down and we were seeing much more invisible wounds—TBI, post-traumatic stress, chronic pain,” he said.

The experience provided invaluable insight into his current role, which involves overseeing DVBIC’s educational initiatives geared towards three primary audiences—servicemembers; medical professionals and clinicians; and caregivers. The most recognizable of these initiatives is the “A Head for the Future” campaign, which promotes awareness about TBI and provides resources to aid the military community in prevention, recognition and recovery.

From materials about safe helmet use, preventing falls and wearing seatbelts to video testimonials from “TBI champions”—active-duty servicemembers and veterans sharing their stories of recovery and hope—“A Head for the Future” aims to dispel myths about TBI and get the facts straight.

Regional education coordinators at DVBIC’s 22 network sites disseminate fact sheets and materials and conduct a variety of classes and training opportunities. For servicemembers and their families, they educate about helmet safety and how to recognize the symptoms of concussion. For clinicians, they distribute clinical recommendations on topics like management of sleep disturbances or progressive return to activity after TBI—and provide accompanying face-to-face training.

Recently DVBIC’s education section has developed an interactive decision-making and assessment tool that clinicians can access online or download to their iPhone or Android devices.

“[It] guides them through a focused headache history, exam, everything they should include when they evaluate a patient,” said Livingston. “It’s just a nice interactive tool to help them guide their assessment, guide their evaluation and make the best decisions on how to treat those patients in a format that’s more user-friendly.”

For family members who are caregivers for servicemembers with TBI, DVBIC, in conjunction with DOD and VA, produced a congressionally mandated caregiver education curriculum in 2010.

“Caregivers like having access to current, relevant information, but they most want training on how to be a caregiver. What does it mean to be a caregiver and how do I navigate through the caregiving process over the long term?” said Livingston.

The caregiver curriculum is currently under revision, and a new effort to broaden its reach has come in the form of a Podcast called “The TBI Family.”

“The Podcast was kind of a better way to get that information across in smaller, easier to consume bits,” said Livingston. “A lot of what we’ve learned from our caregivers … is that they want that information in an one-on-one dialogue. They want to hear it from other caregivers, they don’t want to just read it … so we took the physical product and really expanded it.”

The overarching goal of all of these educational initiatives is to continue to reduce the stigma of TBI in the military and ensure that those servicemembers who sustain them are given the treatment they need in order to return to duty.

The resources are there—and it’s up to servicemembers and veterans to take advantage of them.

“People should seek medical care for evaluation and treatment if they think they have had a head injury. They should also never give up hope, no matter how severe the injury may be,” said CAPT Johnson, who quoted Hippocrates: “There is no head injury so trivial that it should be despised, or so serious that it should be despaired of.”

Author’s note: If you’re a servicemember or veteran who knows or believes you have sustained a TBI—even if the injury occurred years ago—DVBIC’s TBI Recovery Support Program is available to you. Visit www.dvbic.dcoe.mil/service-members-veterans for more information.