Hopes to Focus on the Science of Diagnosis and Assessment
By Peggy Eastman
BETHESDA, MD—A cutting-edge new center for traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) aims not only to help wounded servicemen and women recover, but also to advance the science underlying diagnosis, comprehensive assessment, and effective treatment.
The $65 million National Intrepid Center of Excellence (NICoE) is a 72,000 square-foot, state-of-the-art facility on the grounds of the National Naval Medical Center in Bethesda, MD, across the street from the NIH. One day before the official June 24 dedication, the center, funded by private donations spearheaded by the Intrepid Fallen Heroes Fund, was opened here for a special tour and briefing for news organizations, including Neurology Now. The first patients are expected in the fall of 2010.
NICoE Deputy Director Thomas DeGraba, MD, called the center “an outstanding gift for our warriors from the American people.” Dr. DeGraba, who established the first intramural clinical stroke program at NIH, added: “From a clinical standpoint, this is the next generation of medical care.”
He said the center will not only provide state-of-the-art clinical diagnosis, multidisciplinary assessment and care, but will also be a center of research and education. It will be a place, he said, “where the military and civilians can come together to share cutting-edge knowledge.”
NICoE will provide an information technology infrastructure for data sharing between the Department of Defense (DoD) and the Department of Veterans Affairs (VA), said Dr. DeGraba.
Dr. DeGraba explained that active-duty patients who are not recovering with current therapies — most of whom will have mild TBI or psychological problems, or both — will be referred to the center from other military facilities, and will come with their families to live at the center for a two-week period. After two weeks of comprehensive multidisciplinary assessment and care, the patients will return to their homes and their referring facilities with a treatment plan, with an ultimate goal of returning to active duty. The NICoE patients will continue to be followed by the center.
“We are still dealing with a new injury — it is not quite what you see in sports,” said Dr. DeGraba of blast-injury TBI caused by improvised explosive devices (IEDs) and TBI caused by blunt force trauma from vehicle rollovers. In addition to adding to knowledge on TBI, he said, the center will also investigate what happens to the brain during the chronic stress of combat.
“We know that exposure to chronic stress affects the brain; nerve cells begin to shrink and their connections to each other become incompetent,” he noted. Asked by Neurology Now if there could be repeat TBI or PTSD patients referred to the center, since multiple deployments to combat zones are common today, Dr. DeGraba said that is possible if they experience multiple IED blasts.
A keystone of NICoE is a multimillion-dollar advanced neuroimaging area equipped for scanning with the most up-to-date PET, MRI, CT, and MEG. Multiple digital images of a patient’s brain can be projected in 3D on a large curved screen for staff consultation and discussion. Up until now, there have been limited neuroimaging findings for patients with mild head injury, said Dr. DeGraba, so it is important to try to capture what actually happens in the brain with TBI.
“We know patients have persistent symptoms in their daily lives,” said Gerard Riedy, MD, PhD, NICoE chief of neuroimaging. What is important, said Dr. Riedy, is using neuroimaging to pinpoint the specific brain lesion caused by TBI. “It’s an objective measure,” he said of a neuroimaging finding. “We’ve got no other objective measures.”
Having located a TBI patient’s specific brain lesion on neuroimaging, “You can make a diagnosis and correlate that with symptoms,” he said. “Then you can put patients in a treatment group properly.”
The military can use the objective data generated by neuroimaging to determine whether and when the patient can return to active duty, he noted.
In addition to providing neuroimaging evaluations for patients who come through NICoE, Dr. Riedy said neuroimaging scans can be sent to him electronically from other military bases for evaluation. He also hopes the advanced neuroimaging technology he is using will find its way onto other military bases. “In the future we hope to take this technology and export it to other military facilities,” he said.
NICoE also includes a computer-assisted rehabilitation environment (CAREN), a system with a motion platform, treadmill, and virtual environments for evaluating and rehabilitating a TBI or PTSD patient’s visual acuity, gait, reaction time, and ability to do dual tasks. Virtual reality suites, which simulate combat scenarios, including a firearms training simulator, will also be used for patient evaluation and rehabilitation.
“We can simulate experiences to better assess patients and help them return to duty,” said Melissa Hunfalvay, PhD, NICoE virtual reality consultant. For example, she said, “We can simulate a virtual Iraq and a virtual Afghanistan.”
Patients coming to NICoE will also have access to comprehensive physical and occupational therapy — including auto driving rehabilitation — as well as access to “Central
Park,” a restful, naturalistic center with plants, simulated bird calls, different surfaces to walk on for different sensory experiences (stones, artificial turf, carpet) and a labyrinth for meditative walking.
“Understanding TBI is not all that easy, and rehabilitation for TBI is not all that easy either,” said NICoE occupational therapist Lt. Col. Matthew St. Laurent, OTR/L.
“In the civilian world, TBI comes [primarily] from sports injuries. This is a whole new cohort of patients. We look at the behavior that results from the TBI, the cognitive deficits that can affect activities of daily living.” Col. St. Laurent added: “A lot of times our patients need to understand that they’re not crazy. There’s something wrong with their brain tissue.”
While NICoE is a place of science, it is also a place where human warmth can help heal, said Col. George Nussbaum, PhD, NICoE deputy director for clinical and research support. “We are being given an opportunity to reinvent hospitality for our patients,” said Col. Nussbaum.
“NICoE is a family-focused and hospitable environment.” He explained that “family agenda coordinators” will work closely with the patients and their families: “they are the eyes and ears of the clinical team.” These family coordinators will ensure that the individual needs of NICoE patients and their families are being met, he said.
Photographs of the NICoE are courtesy of the Navy Medicine Support Command