Military Traumatic Brain Injury

Military Traumatic Brain Injury - James Kelly, MD, has gone from the clinics of University of Colorado Hospital to the front lines in the fight against the signature injuries of modern American warfare.

Kelly is director of the National Intrepid Center of Excellence (NICoE) at the National Naval Medical Center in Bethesda, Md. The center brings some $65 million in infrastructure and a $30 million annual budget to help diagnose and treat soldiers returning from Iraq and Afghanistan with military traumatic brain injury and associated disorders, including post-traumatic stress disorder (PTSD).

“There’s essentially nothing equivalent to it in the country at any of the academic centers,” Kelly said.

Kelly is on a leave of absence from UCH and his position as professor of Neurosurgery and Physical Medicine and Rehabilitation at the School of Medicine. He’s a top concussion expert, a former neurologist for the NFL’s Chicago Bears and co-author of the sports concussion guidelines of the American Academy of Neurology. He was asked to lead the nascent NICoE in 2008, just after becoming the first chairman of the Defense Health Board’s Traumatic Brain Injury External Advisory Subcommittee for Military Clinical Care, Research and Education.

The patients who began arriving at the center from the front lines eight months ago face much steeper challenges than dinged linebackers do, though.

“It’s not just TBI [or traumatic brain injury]. These people come back with a combination of concussion and stress reaction, sleep disturbance, substance abuse and chronic pain,” Kelly said. “They’re coming back with problems we’ve never even seen before.”

Athletes with concussions don’t suffer from PTSD or emotional trauma, Kelly explained. They usually just want to get back on the field.

“It’s completely different when you’re blasted into a building and your buddy’s blown to pieces,” he said.

A 2008 Rand Corporation Study, “Invisible Wounds of War,” described such patients, whose lives were saved by modern armor lacking in prior wars, as “casualties of a different kind.” The study estimated that, of the 1.64 million service members deployed in Iraq or Afghanistan through October 2007, roughly 320,000 had suffered a TBI, and 300,000 were suffering from PTSD. Treating military traumatic brain injury alone was costing the military between $600 and $900 million a year, the study estimated.

Even the 400 patients NICoE will see each year – 20 at a time arrive with their families for a two- to three-week stay – represent only a tiny slice of the military traumatic brain injury population. That’s why one of the center’s primary goals is to build quickly upon military – and civilian – knowledge of TBI and the most effective ways to treat it, Kelly said.

“We’re not just a clinic. This is an institute of the Department of Defense. Our mission is to enhance the understanding of the problem and contribute a solution,” Kelly said.

In a gleaming 72,000-square-foot facility built on philanthropy from the Intrepid Fallen Heroes Fund and others, multidisciplinary teams work with patients and families of active-duty personnel from across the armed services. First-line treatments for mild to moderate military traumatic brain injury (that is, those knocked unconscious for less than 24 hours) and associated psychological conditions have failed them.

While they stay at a new Fisher House just 200 yards from NICoE, a core team that includes a neurologist, a psychiatrist, an internal medicine specialist, a neuropsychologist, a family therapist, a physical and occupational therapist and a chaplain establishes and then launches a treatment plan. At their disposal are $10 million in diagnostic and therapeutic tools.

Kelly said it’s all the product of a Congressional mandate to answer this question: “In order to have a leading-edge, state-of-the-art facility and become a world leader in this field, what do we need to build?”

The answers are impressive. For diagnosis, there’s PET, CT, MRI and magnetoencephalography scanning, all in-house. For therapy, NICoE has one of five computer-assisted rehabilitation environment systems in the world, with a motion platform, embedded treadmill and virtual environments for evaluating and rehabilitating a patient’s vision, reaction time, gait and multitasking ability.

The center also has a virtual-reality suite with vehicle and firearms simulators; a gait lab; outdoor rehabilitation space; an occupational therapy gym; vocational rehabilitation space; and onsite speech, learning and sight rehabilitation.

It’s not all about high-tech glitz, though. Patients who have been through the program more commonly mention the richness of personal care received. In their two to three weeks, Kelly said, patients have about 90 professional encounters – the equivalent of a year’s worth of care elsewhere in the military.

At most hospitals – and at UCH, in Kelly’s experience – neurological/ mental health specialists see patients in sequence, sending them from referral to referral. In contrast, NICoE starts each patient with a roughly two-hour session with the entire care team in a setting designed to feel like a living room, he said. The patient’s family is there, too. It’s not only good for the patient, he said. The providers also learn from each other, and understand the justifications for given therapies.

Specialists round together and constantly interact, “so you make great strides in moving forward and in understanding that person not only from your own perspective but from everyone else’s, in a true interdisciplinary exchange of information,” Kelly said. “That, to my knowledge, hasn’t been done in the academic environment.”

He hopes the approach catches on. Kelly said NICoE is on the cusp of creating one or more satellite clinics in military locations that borrow the collaborative approach, but not necessarily all of NICoE’s spectacular hardware. While he still treats Colorado patients on occasion, he’s planning on sticking around Bethesda.

“I’m still on faculty and have attending privileges at the hospital, but I would never jeopardize this job,” Kelly said. “I’ll do it as long as they let me.”