Dealing with TBI

Currently, there are no approved drugs available to treat TBI. Though military researchers are conducting clinical trials on a handful of pharmaceuticals for treating acute or severe brain injury, any medications used by veterans with mTBI would treat symptoms such as headache, anxiety, or mood swings, rather than the underlying organic injury. Brain injury is so complex, with so many processes and variables involved, that it’s unlikely a magic TBI pill will be invented soon, if ever.

“There’s not one brain injury that’s the same,” said Hoffman. “One person is going to have different symptoms and conditions. Someone may have one mild TBI, and another person may have a dozen, or somebody may have moderate or severe TBI. And even among the same type of injuries – and maybe even among injuries to the same areas of the brain – there are going to be different symptoms and different rates of recovery and different long-term complications. And that’s why there is no treatment for brain injury right now.”

The current lack of treatments is why Hoffman thinks the discovery of biomarkers, measured through blood tests and brain imaging indicators, may take TBI care over the threshold. The first step toward restoring brain function, of course, is understanding and quantifying what has been lost. In the case of lower pituitary hormone levels, the treatment recommends itself; the VA is in the process of beginning a series of clinical trials evaluating the use of hormonal therapies for the treatment of mild brain injury.

VA research among animal models has established that stimulating the brain can cause it to repair itself and regain function, often by adding neural activity in some areas to compensate for a loss of function in damaged areas. Many of the rehabilitation strategies currently used by clinicians teach compensation strategies to work around deficits, and strengthen other capabilities.

When Hoffman talks about such treatments, he doesn’t talk about them as isolated approaches aimed at a TBI “cure,” but as interventions that can supplement the only proven methods for restoring neuroplasticity – rehabilitation and environmental modifications. “The problem with brain injury is not so much the injury itself,” he said. “It’s the interruption of the flow of information in the brain. If it’s not flowing properly, you’re going to have impairment.”

VA research among animal models has established that stimulating the brain can cause it to repair itself and regain function, often by adding neural activity in some areas to compensate for a loss of function in damaged areas. Many of the rehabilitation strategies currently used by clinicians teach compensation strategies to work around deficits, and strengthen other capabilities.

“I think there’s more than enough evidence that neural rehab after a brain injury does improve outcomes,” Hoffman said. “The issue is how to make rehabilitation better matched to the individual. And I think the discovery of these objective markers is exciting for two reasons: It can predict behavioral recovery, which often lags behind brain changes, and it can also allow you to tailor the rehab to make recovery faster and more efficient.”

Because of the nature of brain injury – some veterans may require some adjustment to their readjustment plans, depending on how the condition progresses over time, and most have co-occurring conditions such as posttraumatic stress disorder (PTSD) or depression – researchers in VA’s Health Services Research and Development Service (HSR&D) are looking into strategies for making adjustments to rehabilitation plans that take these variables into account. “TBI can interfere with rehabbing the mental health condition,” said Hoffman, “and the paralyzing effects of depression can interfere with a person’s motivation for rehab. So by treating these together, you can improve outcomes for both conditions. We have researchers actively involved in this right now.”

HSR&D has established a Quality Enhancement Research Initiative (QUERI) to promote the successful rehabilitation, psychological adjustment, and community reintegration of veterans who have sustained polytrauma and blast-related injuries. Because more than 60 percent of blast injuries result in TBI, VA researchers are eager to add to the evidence base for best practices in treating blast-related polytrauma relative to chronic diseases.

Since 2010, at the VA Rehabilitation Center of Excellence in Boston, Mass., researchers in the Translational Research Center for TBI and Stress Disorders (TRACTS) have been studying newly returned service members with mTBI, recording their performance on a variety of tasks in a variety of settings, to gain a better understanding of TBI and how it relates to PTSD. TRACTS researchers also evaluate the appropriateness and efficacy not only of rehabilitation services, but of the strategies clinicians use to recruit the patients these programs can benefit.

“People who have suffered repetitive mild TBI often have mental health conditions,” Hoffman said. “If you can get them into a vocational services program, they often do tremendously well in finding employment – but you’ve got to find them and get them into it and get them involved, and that in itself is a little bit difficult with someone who has issues with TBI. Sometimes, because of the nature of the injury, they have issues realizing they have problems.” The unique approach of TRACTS helps veterans with TBI and PTSD successfully integrate into society.

 

The Future: NRAP, ptsd, and tbi

Researchers will try to develop an understanding of the connection between concussions or blast-related injuries and chronic effects, comorbidities (other conditions such as depression or PTSD), and neurodegeneration. Results will help clinicians to determine risk factors for TBI, how injured service members and veterans can be better cared for, and what they and their families can expect throughout their lifetimes.

In the summer of 2013, in accordance with President Barack Obama’s executive order, “Improving Access to Mental Health Services for Veterans, Service Members, and Military Families,” issued a year earlier, the departments of Veterans Affairs, Defense, Education, and Health and Human Services released a National Research Action Plan (NRAP) aimed at improving scientific understanding, developing effective treatment, and reducing occurrences of TBI, PTSD, and other mental health conditions.

The plan builds on collaborations already in place – combining both funds and study subjects into larger pools that can offer more bankable results. VA and DoD, who have long worked together to care for service members during and after active duty, announced last fall that they would be establishing two joint research consortia, the Consortium to Alleviate PTSD (CAP) and the Chronic Effects of Neurotrauma Consortium (CENC), at a combined investment of $107 million.

CENC, whose government steering committee is co-chaired by Hoffman and Col. Dallas Hack of the U.S. Army Medical Research and Materiel Command, recently awarded funds to two new studies, led by VA scientists who each hold appointments at both the Virginia Commonwealth University Medical Center and the Richmond VA Medical Center. One study, led by Dr. David Cifu, will study what happens to service members and veterans who have suffered TBIs in prior wars, in Iraq and Afghanistan, and in accidents and falls in the United States. Researchers will try to develop an understanding of the connection between concussions or blast-related injuries and chronic effects, comorbidities (other conditions such as depression or PTSD), and neurodegeneration. Results will help clinicians to determine risk factors for TBI, how injured service members and veterans can be better cared for, and what they and their families can expect throughout their lifetimes. The $62.7 million study will involve researchers and subjects at multiple universities, military installations, and VA Medical Centers. Additional projects will be added to the CENC to address various aspects and comorbidities associated with multiple mTBIs, such as tauopathies, mental health issues, and sensory loss.

“By working with DoD,” Hoffman said, “we’ll have many more resources to recruit and to enroll patient subjects into these studies. By pooling our resources we are pushing the envelope of what we know, but we will also be much more confident in our results. Separately, we may not have been able to achieve such results – but together it’s possible.”

This article first appeared in the The Year in Veterans Affairs & Military Medicine 2013-2014 Edition