Dr. Allison Winters Fisher, Wellness Coordinator at the NICoE, demonstrates a yoga pose in Central Park at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland (Photo by: Liz Freeman, National Intrepid Center of Excellence).

"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."

Dr. John King, audiologist at the NICoE, demonstrates the rotary chair used to detect different vestibular diagnoses in TBI patients at the National Intrepid Center of Excellence, Walter Reed National Military Medical Center in Bethesda, Maryland (Photo by: NICoE Communications).

The Brain Fitness Center is a supplemental treatment offered at the NICoE. It's an option that uses computer-based training tools to help patients develop healthy brain habits and improve thinking skills, such as short-term memory, focus, and decision making.

Alternative Therapies

In addition to the varied clinical care specialties offered at the NICoE, there are alternative therapies, such as art or music therapy, to help patients heal. For example, music therapy is used for patients to express emotions and feelings in a way that they may not be able to through speech, said French.

"If you have a patient that has a very severe language dysfunction and can't articulate his words well, it may be that he can sing or express himself through music in a way that he can't in speaking," said French. Even though those types of cases are not common, he said.

More importantly, he highlighted, these types of therapies get people thinking about their life beyond their injury.

"We want people to start thinking about leisure activities and recreational activities and what they're going to be doing for the next 50 or 60 years of their life," said French. "These therapies help them and maybe become a hobby or an interest for them that will help get them past the period of acute rehabilitation and start to think about the rest of their life."

Engaging the Family

French emphasized the importance of family or a support network to patient recovery. He explained the therapies offered at the center's outpatient program involve the family while the patient is in care.

"We want the spouse to understand the results of the evaluation, and we can bring them into the treatment process," he said. "In some cases, there's a need for couples therapy, or ways of improving communication - and we have people to help with that.

He explained that aspects of a person's environment can make them do well or not do well - and family is a key piece of that. "Supportive family members can make a real difference in terms of recovery, particularly for people who have very difficult recoveries or are likely to have persistent problems for many years."

Research

In addition to providing clinical care, the NICoE is a research organization. French explained the center conducts very clinically oriented research and works in close partnership with other TBI experts at the Uniformed Services University of the Health Sciences, which shares NICoE's campus; the National Institutes of Health, located across the street; the other Intrepid Spirit Centers within the Defense Intrepid Network for TBI and Brain Health across the nation; and across the MHS and the Department of Veterans Affairs.

"We very much believe that conducting research is important to better understand ways of assessing and treating individuals," he said. "We strongly believe in partnership - we have some very good doctors here, but we also know that there are experts in all sorts of fields elsewhere."

To better understand how each therapy works and document findings when implementing alternative, cutting-edge therapies - such as using art or music in rehab - the NICoE conducts parallel studies, said French.

"The research studies may be about ways of finding better neuroimaging techniques, or finding better ways of treating headaches, or finding other treatment options for people," he said.

These aim to answer important questions, he noted, such as how a given therapy fixes the brain, how it helps patients make new neural connections to deal with some of the damage that's been caused by the injury, and when given therapies may be most beneficial: Is it better to do it soon after injury, once or twice a week, or much later after injury?