Since the Vietnam War, doctors have seen an increase in service members returning from combat with traumatic brain injuries from blasts. At the National Intrepid Center of Excellence, a directorate of Walter Reed National Military Medical Center in Bethesda, Maryland, doctors and therapists use research and technology to help service members with TBI in their recovery.
Dr. Louis French, the center’s deputy director, said NICoE uses this research and technology to study the structure and metabolic activity in the brain, how it metabolizes glucose, where the blood flow is, and the electrical activity in the brain.
“All of those things we want to know go into this idea of function, and we want to visualize those better,” he said. “And the techniques we have developed, there are ways of better visualizing abnormalities in the brain. Once we gain better insight into what these abnormalities are, then we can find ways of targeting treatments better.”
NICoE is the only clinic in the nation to have a magnetoencephalography scanner, or MEG, dedicated to the treatment of TBI, said Dr. John Hughes, a neurologist and the director of the MEG lab. “It’s really unprecedented that an institution can have this dedicated to one disorder,” he added.
The MEG is a technique used to measure and record the brain’s magnetic fields during its normal activity and provide insight into how the brain is functioning, Hughes said. NICoE uses it to study the electrical oscillations in a mildly traumatic brain as well as the physiology of the cortex of the brain and the psychological issues related to it, he said, noting that there are only 40 MEG labs in the country.
“The fact we have an MEG lab that’s really dedicated to understanding traumatic brain injury is a wonderful opportunity for all of our active-duty members and veterans to help us understand these disorders,” he said. “This is a pretty unique situation. It’s very sophisticated instrumentation.”
The MEG requires liquid helium that goes over more than 300 sensors placed just above the scalp to keep the sensors very cold.
“I’m thrilled to be able to apply this technology to this specific problem,” Hughes said. He said the MEG is similar to the electroencephalography, or EEG, used to record the electrical component of brainwaves, but the magnetic fields require the more sophisticated instrumentation.
“If we continue to study traumatic brain injury with MEG, we can’t fail to make significant insights into understanding the physiological basis of symptoms of TBI, and we’ll reap huge benefits in terms of developing therapies specific to those physiological issues we can discover with MEG,” he added.
Another device NICoE uses is the ActiGraph watch, used to record sleep patterns. Similar to a fitness tracker, patients can wear it instead of needing the sensors used in a traditional sleep study to be attached to their heads, said Dr. Tony Panettiere, a neurology sleep medicine physician.
“Most people who’ve had traumatic brain injury who we see often have neurological complaints such as headaches, memory dysfunction, irritability, focus attention issues and sleep issues,” Panettiere said. During a sleep study, he said, the device measures brainwaves, muscle relaxation, how a patient is breathing and heart rhythm. Technicians can tell if a person has sleep apnea or a limb movement disorder.
Panettiere said the advantage of the ActiGraph is that the results are less artificial than they’d be if the patient had to sleep with all of the wires attached as they do in a traditional sleep study. “They’re back in their own bed, and we even do it a couple weeks with them wearing the watch if there’s any information that’s contrary to what we’ve found in the lab,” he said.
Research, imaging devices
French said the research goes primarily in two directions. The first is in the characterization of patients — understanding the symptoms they have after they’ve been injured through advanced neuroimaging.
NICoE also has PET CT, CT, 3 Tesla MRI, a magnetic resonance spectroscopy and a number of other dedicated imaging devices for traumatic brain injury patients, said Navy Cmdr. (Dr.) Grant Bonavia, interim chief of the research department and chief of neuroimaging and measurement devices.
“We have a group of researchers who are looking at techniques and modalities that are not necessarily well described yet, but there’s hope that using these advanced technologies that one could find abnormalities that may be there just below the threshold of standard neuroimaging that would be done at outside institutions,” he said. “So we’ve looked into functional MRI and diffusion tensor imaging, which are advanced techniques. We also have PET data from a large number of patients that we’re analyzing. And the MEG, which is also a very advanced device, has a lot of potential to assist in diagnosis in following the patient’s response to therapies.”
French said he’s the principal investigator on a congressionally mandated 15-year mandated longitudinal study, which will study the effects of TBI and the expression of symptoms over time. “Our goal is to follow people for 15 years and find out how their symptoms change over time, how they do after having had a brain injury in a military situation, and understand how the brain injury recovery may intersect with the aging process,” he said.
French said NICoE is working in partnership with the National Institutes of Health, which is giving the center access to some specialized researchers and techniques with these characterization studies.
NICoE also is exploring new treatment options, French said. Currently, he noted, NICoE offers animal-assisted therapy, assistive technology, audiology and vestibular services, a brain fitness center, driving assessment and rehabilitation, a computer-assisted rehabilitation environment, family education and art therapy.
“We have treatments we provide for people here, and we see those techniques work for people, but we don’t always completely understand them,” French said. “So we want to know a little bit more about. Why do they work for some people and not as well for other people? Is there an optimal time that you should start these treatments? Is there an optimal intensity or dosage that we do for these kinds of things?
“Those are fundamental questions that have not always been asked,” the doctor continued, “and we want to understand more about what we’re doing. We want to make sure there’s a firm scientific foundation for all the clinical work we do so we can conduct studies in that regard.”
Some of the treatments NICoE uses are complementary and alternative therapies, such as acupuncture and art therapy.
“We use a lot of (those) therapies here at NICoE that have evidence-base that also help these service members improve,” said Dr. Gene Casagrande, team coordinator and primary care physician. “To watch a headache improve without narcotics and to watch patients relax and sleep better with just breathing, to me, that’s very important. We’re doing a lot of different things here at NICoE that haven’t been introduced in the past at their home station.”
Sleep and nutritional education play important roles in some of his patients’ lives, he added.
System of care
French, who’s been working with TBI care for 16 years, said the military went from being behind the curve to establishing a care system at every major troop center at every major military treatment facility today. He said Intrepid Spirit Centers are being built around the country and will share lessons learned with NICoE.
“We’re trying to develop a national care system that’s all linked together so we can communicate about best practices,” he said.
Inpatient screening and consultation services are available at Walter Reed, French said.
“We continue to provide and have assets related to the long-term care of people,” he said. “We have some of our services over in the hospital. We have our brain fitness center, which is our computerized cognitive remediation program, which is a program that works in conjunction with the speech pathologists and the occupational therapists and the neuropsychologists to focus on trying to improve cognitive dysfunction, memory intention, language and problem solving.”
French said NICoE wants to ensure patients have access to all aspects of the health care system.
“NICoE is the centerpiece of our care system for traumatic brain injury,” he said. “But think about NICoE as a concept and a system, rather than just this building. It’s way more than just this building.”
Bonavia said the research and technology at NICoE is vital.
“It’s a clinical institute that allows clinicians as well as researchers to be under the same roof to collaborate and to take care of patients and to discuss findings,” he said. “We can talk about modalities that may be more effective than others for therapy and talk about the future for TBI and psychological health care going forward at one site.”
The center’s location on the Walter Reed campus allows access to a number of different resources, he said, and being across the street from the National Institutes of Health provides easy access to a significant presence in researching and taking care of patients with TBI and psychologic health problems.
“What we’re doing for the patients we’re putting into the research side of things so we’re able to analyze what’s working and what’s not and bring that to the next person who comes a week later, a month later, a year later,” Panettiere said. “So we’re better now than we were even five years ago when I started here.”