Navy Lt. Cdr. Jena McLellan, a clinical trials coordinator with the National Intrepid Center of Excellence, demonstrates the center's Computer-Assisted Rehabilitation Environment virtual reality system to assess wounded warriors with traumatic brain injury or post-traumatic stress, at the National Intrepid Center of Excellence in Bethesda, Md., June 23, 2010. NICoE photo by Linsey Pizzulo

When the National Intrepid Center of Excellence opened its doors here last week, the sense of hope in reversing the rising tide of brain injuries and psychological illness in service members was palpable.

From its warm design and family-friendly amenities to its best-in-the-world diagnostic and assessment equipment, the center boasts the convergence of art and science that officials hope will become the new normal in researching, diagnosing and treating traumatic brain injuries and post-traumatic stress disorder.

As Deputy Defense Secretary William J. Lynn III said at the center’s June 24 dedication ceremony, the need for such a center could not be more pressing. Hundreds of thousands of servicemembers are believed to have suffered TBIs and PTSD during their service in Afghanistan and Iraq, and many go undiagnosed, suffering the “invisible wounds” of war without explanation.

Gen. Peter Chiarelli, Army vice chief of staff, was asked during testimony before a U.S. Senate committee last week why the military cannot better diagnose brain injuries and PTSD. “I promise you it is not from lack of trying,” he said. “We are doing everything we can.”

That’s where the Intrepid Center comes in. Not a clinical care hospital, the center instead is designed to accept on referral those military members whom the services struggle to help, those whose injuries are so elusive to not be detected, or that are unresponsive to treatment developed at base hospitals, which are lacking in proper equipment, staffing and expertise, officials said during a June 23 media event.

The Intrepid Center holds the promise of proper diagnosis and treatment plans for those toughest cases. The $65 million center on the grounds of the National Naval Medical Center houses $10 million in equipment, much of it unique to the center and a handful of academic research institutes.

It includes brain imaging equipment that produces up to 6,000 images per brain scan, Dr. Gerard Riedy, the center’s chief of neurology, said. While standard magnetic resonance imaging equipment allows for about 750 images mostly showing the outside structure of the brain, Riedy said, the center’s three-dimensional imaging equipment shows everything from lesions of mild TBI on the brain’s surface to internal brain functions, seen in real time.

“It’s all non-invasive,” Riedy explained from the center’s “visualization” room, surrounded by a large, 3-dimensional screen and multiple smaller screens showing brain images. While a patient undergoes what seems like a standard MRI or positron emission tomography or computed tomography scans in another room, Riedy and his staff of six assess color-coded images of the brain’s magnetic fields, wiring, and the like. One screen displays the brain activity when the patient is asked to do certain tasks, allowing doctors to assess proper functioning, including psychological stress.

Riedy said his staff with be interoperable, meaning they will process scans from military facilities and share their discoveries and observations. “This stuff is not easy to do,” he noted, “and I have six people working for me.”

Down the hall from the brain imaging room, patients may enter virtual reality suites where they can be assessed on their reaction to being fully immersed -– smells of burning rubber or dead bodies included — in recreated scenes from Iraq or Afghanistan. Or researchers or clinicians may test their driving or shooting ability in simulators for their possible return to duty.

In another room, a patient may walk or run on a treadmill suspended on a moving platform surrounded by any number of scenes that staffers create, from a street scene in Baghdad to a fishing pond in Idaho. The patient’s reactions to given tasks allows staff to assess functions such as balance, coordination, multitasking, reaction times and visual acuity, said Johanna Bell, an operator of the Computer-Assisted Rehabilitation Environment, or CAREN, machine.

Such equipment may provide the missing link in proper diagnosis and treatment.

“We’ve got no other objective measures of TBI right now,” Riedy said. Service members take written tests when returning from deployment, but those aren’t conclusive in the ways of brain scans and virtual reality equipment.

Still, expensive equipment alone won’t solve the problem of TBI and psychological illness in servicemembers. The center’s staff also offers hope of improved care, not only with their understanding of the science and equipment, but also in the art of working with and understanding patients.

“A lot of these patients just need an understanding that they are not crazy,” said Army Lt. Col. Matthew St. Laurent, assistant chief of occupational therapy at Walter Reed Army Medical Center in Washington, D.C. “There’s something wrong in their brain tissue.”

St. Laurent said he is honored to be associated with the center, which he called “a place for us to come and learn” about the nascent science of combat-related TBI.

In a second-floor open area surrounded by windows and flooded with natural light, St. Laurent and others can assess patients on various types of exercise equipment to measure their ability to push, pull, carry, lift and perform other basic functions.

A few steps away, patients can open a door into the center’s “Central Park,” a circular refuge of tranquility with skylights, green plants and park benches. Displaying the center’s openness for alternative therapies – in this case, ambient therapy — the room’s floor is a labyrinth of two-toned, polished wood, inviting its guests to relax or confront their troubles on its winding paths.

From the best diagnostic and imaging equipment to the desire to make military families comfortable and engaged, staff members are clear about their goals.

“Our ultimate goal is to get our military men and women back to duty,” St. Laurent said.

DVIDS
Story by Lisa Daniel

National Intrepid Center of Excellence (NICoE) Facebook Page

Maj. Larissa G. Coon developed several stress coping programs as the occupational therapist officer at the Patriot Clinic on Joint Base Balad, Iraq. Photo by Spc. Brian Barbour

In order to be successful in their missions, Soldiers deployed throughout Iraq deal with combat stress daily whether they perform their duties inside or outside the wire.

The 1835th Medical Detachment (Combat Stress Control) helps Soldiers find positive ways to cope with that combat stress and reduce incidence of suicide through their work at the Patriot Clinic here.

Maj. Larissa G. Coon, Patriot Clinic occupational therapist officer describes combat stress as “dealing with one of the top life stressors while in a combat or deployed environment.”

“This combat stress can be identified through dramatic changes in habits or routines,” Coon said.

Coon, a resident of Goodland, Kan., designed and implemented many of the stress coping programs available here.

She said some of the top stressors that people deal with in their lives are: a job change, a divorce or marriage, the birth or adoption of a child, the death of a family member or close friend, or major purchases like a house or a car.

Coon said these stressors are challenging for anyone to cope with, but when the stressor is combined with a deployment, the stressor for a Soldier is magnified many times over.

When these triggers occur, the affects on a Soldier can be seen in several areas. Soldiers may become angry at everything, have a change in sleeping habits or become withdrawn from contact with family, friends, or coworkers, Coon said.

The combat-stressed Soldier may have a change in eating habits, or may no longer be interested in activities that once brought them pleasure, she said.

Coon said battle buddies and unit leaders need to watch for any dramatic and significant changes in a Soldier’s behavior; it could indicate the need for a “buddy check.”

“Change is the main clue – the key,” she said.

Coon explained that combat stress should not be mischaracterized as Post-Traumatic Stress Disorder. PTSD is a long-term mental health diagnosis where dramatic changes in a person’s habits or routines continue for six months or longer.

A 2003 Army Medical Command report on mental health indicated that forward deployed behavioral health units experienced more than a 95% rate of return to duty status for Soldiers who sought combat stress treatment. The report indicated that almost half of the Soldiers surveyed reported not knowing how to obtain their mental health unit’s services.

The presence of combat stress control units here in Iraq now reflects the efforts the Army has taken to make these services readily available to service members.

There are currently five clinics that offer stress coping programs to service members needing them. These clinics in Iraq are located at Joint Base Balad, Contingency Operating Base Speicher, Camp Liberty, Camp Taji and Forward Operating Base Diamondback.

There are behavioral health assets dispersed across Iraq in more than 25 locations.

Coon said an overwhelming majority of the service members visiting the clinic come voluntarily with only 1 percent of Soldiers being command referred.

When a battle buddy accompanies a fellow Soldier to the Patriot Clinic for assistance, the clinic has no obligation to report the visit to the Soldiers command. The only time this happens is when there is a fear for the immediate safety of the Soldier.

Coon said that Soldiers exhibiting combat stress do not all need to be treated as being a risk of suicide.

“Sometimes they just need someone, like their battle buddy, to offer some help,” she said. Coon said the help a Soldier needs might not be anything more than hearing a buddy’s offer of advice or guidance to some of the resources to help them handle an issue.

The Soldier talking about the stressors they are experiencing can do a lot to relieve some of the pressure they are dealing with alone, Coon said.

If a Soldier needs additional help, Coon listed some other resources besides the clinic where Soldiers can turn to. Such resources are the Judge

Advocate General’s office for legal issues; the finance office for pay issues; the chaplain for spiritual guidance; the Army Emergency Relief fund for unexpected financial shortfalls; the Veterans of Foreign Wars or American Legion for support to loved ones back home; and Military OneSource as a gateway to numerous other agencies and organizations who provide military support, counseling, and assistance in the states.

Coon said: “I have the best job in the Army as I get to supply the activities to make people forget about their stress!”

The 1835th Med. Det. is an Army Reserve unit from Aurora, Colo. The fifty Soldiers of this unit will return to the Fitzsimmons Reserve Center in the spring of 2009 at the end of their deployment.

DVIDS
Story by Maj. Christopher Emmons

After being medically retired from the Army last year as a result of mental wounds he suffered in Iraq, Michael Bradley faced a daunting challenge that would later prove pivotal in his recovery: holding down a job in the civilian world.

But a new education campaign, America’s Heroes at Work, aims to make employment a less intimidating transition by teaching bosses and managers how to accommodate workers like Bradley — a pool of productive, capable employees who are afflicted with post-traumatic stress disorder or traumatic brain injury.

Bradley, who today joined officials from the departments of Labor and Defense and industry representatives at a news conference to kick off the new program, shared his story with American Forces Press Service.

With six years under his belt as an active-duty medic, Bradley’s move back to civilian life was precipitated by a roadside bomb in Baqouba, Iraq, that detonated under his vehicle.

“I was driving a high-profile individual,” recalled Bradley, a former staff sergeant with the Army’s 4th Infantry Division. “All I remember is that I saw the flash, and I pulled him to get him out of the way of the blast. That’s all I remember.”

Moments later, a 155 mm mortar struck the driver’s seat. “A piece of shrapnel had taken out my seat where I was sitting; it probably would have killed me,” he said. But the preceding blast that knocked him unconscious had caused him to slump over and out of the way.

Though he escaped the horrific scene without serious physical wounds, the scar tissue on the former staff sergeant’s mind is still fresh. His memories are so raw that the sound of a slammed door makes him edgy and on guard.

“I went to Disneyland, and the cannons starting firing off the ship,” Bradley recalled. “And here I am low-crawling across the ground, knowing full well that I’m in Disneyland, but my body’s reacting.

“My mind is saying, ‘Get up you fool.’ But my body’s saying, ‘No. I’m not going to do it,’” he said.

Intense physiological responses to harmless stimuli often are a hallmark of post-traumatic stress disorder and traumatic brain injury — known as PTSD and TBI — afflictions that affect Bradley and an estimated 20 percent of U.S. veterans of the wars in Iraq and Afghanistan, according to a report by the Rand Corporation.

But Bradley, who was hired as an analyst with Halfacre & Associates in February, has found that, in addition to dispelling his fears that the skills he learned in the Army wouldn’t translate into a civilian job, his employment also has helped on the road to recovery.

“To get back into the work force and be able to see that I can succeed [and that] what I wrote down on my resume is true, and that I can do it, and I have a lot to offer … has really decreased stress,” he said. “To overcome those obstacles, and being able to be out in the work force, has really helped emphasize that I can do it and I can succeed.”

Bradley, 27, credits his patient boss for exercising understanding when Bradley takes occasional brief breaks from work to mitigate problems stemming from his ailments. Common symptoms can include dizziness, headaches and anxiety, according to the Department of Labor.

But in most cases, employers need only make modest and inexpensive changes — most totaling under $500 — to adapt a workplace to fit the needs of an employee with similar mental afflictions, said Neil Romano, assistant secretary of labor for disability employment policy.

The mitigation of minor symptoms, which in some instances can take the form of basic accommodations like providing better-lit office space or a quieter work area, can pay huge dividends, Romano said. Eighty percent of the time, he added, effects of mild TBI cases disappear in about a year.

“We can’t lose their productivity; we can’t lose their skills; we can’t lose their value to society,” Romano said last week. “These are human beings that deserve the opportunity to continue doing what it is they want to do, which is to continue to be productive in society.”

Romano noted that while the America’s Heroes at Work initiative applies to a wide range of Americans suffering from PTSD and TBI, the nation has a special obligation to its returning veterans.

“An initiative like this is terribly important, because if you’re going to have one in five veterans coming home with this, they’re just not people we can afford to forget or lose,” he said. “They didn’t forget us, they did their job. And we can’t [forget them].”

The Labor Department spent almost a half-million dollars developing the program’s Web site, americasheroesatwork.gov, Romano said, adding that additional contributions have come from interagency and business partners.

David S. C. Chu, undersecretary of defense for personnel and readiness, said the Labor Department-led effort is to create the kind of environment that “promotes resiliency.”

“What Labor is trying is to do, in my judgment, is help employers understand [that] if you support [the employee], he’ll perk back up again,” Chu said. “It’s a bit like being on team with a good coach. You’ve got a good coach, that performer somehow finds an extra amount of energy, an extra effort.

“What we’re hoping to do is to give each one of these veterans a little bit of extra coaching, a little bit of extra help that will get them to the finish line,” he said.

DoD
By John J. Kruzel
American Forces Press Service

With growing recognition of the toll post-traumatic stress disorder has taken on U.S. forces, Defense Secretary Robert M. Gates said the Defense Department may consider awarding Purple Heart medals to combat veterans afflicted with it.
“It’s an interesting idea,” Gates said when asked about the concept during a May 2 media availability at Red River Army Depot, Texas. “I think it is clearly something that needs to be looked at.”

Gates’ comment followed his visit the previous day to Fort Bliss, Texas, where he toured the post’s Recovery and Resilience Center, which is using a holistic approach to treating troops with PTSD.

John E. Fortunato, who conceived of and runs the center, told reporters that awarding the Purple Heart to PTSD sufferers would go a long way toward chipping away at prejudices surrounding the disease. Because PTSD affects structures in the brain, it’s a physical disorder, “no different from shrapnel,” Fortunato said. “This is an injury.”

The Army classifies PTSD as an illness, not an injury, so troops with PTSD don’t qualify for the Purple Heart. That distinction is limited to troops killed or wounded in a conflict.

“I would love to see that changed, because these guys have paid at least as high a price, some of them, as anybody with a traumatic brain injury, as anybody with a shrapnel wound,” Fortunato said.

Not recognizing those with PTSD with a Purple Heart “says that this is the wound that isn’t worthy,” Fortunato said. “And it is.”

Fortunato said he’d also like to see a regulation prohibiting harassment of troops with PTSD, similar to regulations banning racial or sexual harassment. “Until there are sanctions that make a superior pay a price for harassing a soldier with mental health problems, I don’t know that it will change that much.”

Soldiers still get laughed at for seeking mental-health services or told that it will ruin their careers, he said. Some in the force view people with PTSD as weak, believing that if those with the disease “just sucked it up and soldiered on, [they would] could get over this,” Fortunato said.

“The Army is making a lot of strides toward changing that, but it’s a slow go, because it has to happen at the grassroots level,” he said. “Like any other prejudice, it’s hard to die.”

During his visit to Fort Bliss, Gates announced a new policy in which combat veterans no longer have to acknowledge on their federal security clearance forms that they have received mental health care for combat stress. Gates said he hoped the policy would eliminate troops’ concerns that seeking mentalhealth care can cause them to be denied a security clearance and threaten their careers. He also expressed hope it would take the stigma away from seeking treatment.

Gates called on senior noncommissioned officers to encourage their soldiers who need it to get care, and to let them know that doing so is a sign of strength, not weakness.

“All of you have a special role in encouraging troops to seek help for the unseen scars of war — to let them know that doing so is a sign of strength and maturity,” Gates told soldiers attending the Army Sergeants Major Academy, at Fort Bliss. “I urge you all to talk with those below you to find out where we can continue to improve.

“Those who have sacrificed for our nation deserve the best care they can get,” he continued. “As I have said before, there is no higher priority for the Department of Defense, after the war itself, than caring for our wounded warriors.”

DoD
By Donna Miles
American Forces Press Service

CJTF-82
Written by Army Pfc. Daniel M. Rangel 22nd Mobile Public Affairs Detachment

BAGRAM AIRFIELD, Afghanistan – Thousands of Servicemembers are returning home this spring. As they return to their regular lives, reintegration with their friends and loved ones can be a challenge; especially for those suffering from symptoms of Post Traumatic Stress Disorder.

“PTSD can occur after any kind of trauma,” said Air Force Dr. (Maj.) Kellie Griffith, Task Force MED psychiatrist at the Combat and Operational Stress Control Clinic here.
The three primary symptoms of PTSD are: re-experiencing, where one relives a traumatic event through nightmares, flashbacks or intrusive images; hyper-vigilance, which includes irritability and jumpiness; and avoidance, not wanting to think about the trauma again and doing anything to avoid it, Griffith said.

Another common symptom is what’s called sense of a foreshortened future. It’s the belief that the future is not going to work out, like somehow it’s going to be cut short.

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