Traumatic brain injuries

Oct 04, 2010

Dr. David Williamson, medical director of the inpatient Traumatic Brain Injury Unit at the National Naval Medical Center in Bethesda, Md., will be online Monday, Oct. 4, at Noon ET to discuss brain injuries and treatment for the combat wounded coming out of Afghanistan and Iraq.

The Cost of War: Traumatic Brain Injury

Photo Gallery: Coming home a different person

This is Dr. David Williamson. I am the director of the Inpatient Traumatic Brain Injury unit at National Naval Medical Center,  Bethesda. I work with a team of specialists who assess and treat our wounded warriors with Brain Injury. I look forward to your questions.

It is my understanding that some of these bombs rattle the brain and that it may take some time to diagnose brain injuries. Is this correct? What are some of the ways one can tell if they are suffering from such injuries?

Sometimes it is unclear early after a blast exposure whether there will be any permanent effects, or just a transient disturbance of brain functioning - what some people call a concussion

We can tell if there is injury to the brain from brain imaging such as CT scans or from bedside examination of the nervous system

PT is different depending on who provides the care. What else can be done for patients who are arrive at a center weeks after injury?

The first thing is to accurately assess brain function to see what is affected. Treatment almost always involves a team of specialists. So physical therapists help with recovery of motor skills and balance, Occupational therapists with daily living skills, speech pathologists help with speech and language disorders, Neuropsychologists with disturbance of memory

Can the brain repair itself? Can the patient eventually get some or all movement back , for example, when it was lost in an injury? Are there foods or vitamins that help stimulate brain function or growth?

The brain has limited capacity to repair connections in humans. However many effects from TBI are caused by bleeding or swelling compressing brain tissue and those processes resolve and function can return. Additionally despite TBI we can still learn and there is some evidence that complex functions can be partially taken over by other areas of brain. Improvement can occur for many months after TBI

I was under the impression that TBI and PTSD are two entirely different type of injuries. If that is so why do many medical professionals use the terms interchangeably? Not to dimension either of the injuries it would seem that TBI is by far a more serious injury and the treatment would be far more complex.

You are correct. PTSD and TBI are different disorders. The overlap occurs because many wounded sustain both a TBI and develop symptoms of PTSD. They are very different conditions however.

In many cases, the real neuro behavioral issues due to MTBI may not be apparent until soldiers try to integrate back into the community. What are you doing to track this issue?

You are correct. We screen all our incoming casualties at Bethesda for the presence of TBI. If we identif TBI an important part of what we do is educate Warriors and their families that real life is more complex and challenging than time in the hospital and that problems may emerge after discharge. We arrange surveillance follow up with brain specialists after return home to capture any late problems.

How do you differentiate premorbid issues such as ADD or ADHD from the findings post trauma?

ADHD and learning disorders can cause patients to look like they have symptoms of TBI on testing. What we do is try to obtain records from the school psychologists if testing was done before injury and we arm our Neuropsychologists with the information - they are very good at including pre-morbid issues in their analysis. Sometimes those issues make it difficult in subtle injuries to tell what is new and what is old.

How does a veteran get a referral to you or the program you offer?

The Veteran's case manager or treating Doctor can make the referral as they would for other hospital specialist programs.

Are there any new promising drugs to treat the short term memory deficits as a result of traumatic brain injury?

We do not find great success with memory enhancing drugs in TBI. In fact many patients have adverse effects from being on too many medications and we often reduce the number of medications - especially pain medications and sleeping medications - when they are causing memory problems

Hello sir, hope you are doing well. I am a Canadian, but having had a brain injury myself, I was really touched by what I read; as well, I am wishing to know if I can help out in any way. I really think what you are doing is admirable! Aside from financial contributions, can I do anything else? Like volunteer?

Anybody who is interested in helping TBI survivors, or learning more about what they can do, or the condition, could start with the Brain Injury Association of America, they have a National website with local affiliate chapters that do all kinds of things to support TBI patients and their families


Does a person who has suffered TBI eventually regain over time, the same level of cognitive reasoning as before the injury?

Outcome after TBI is very variable. In general mild injuries are followed by good recovery, with some exceptions. Moderate and severe injuries are less likely to be followed by a complete functional recovery but we see many remarkable recoveries over time. Cognitive reasoning is the most advanced of brain functions, and one of the most sensitive to injury. We use Neuropsychological testing to measure recovery of cognitive functions and the more severe the injury, the more likely there will be some permanent effects. It also depends on the type/cause of injury.

Does TBI have the same penumbra generation as a stroke? Are there separate therapy protocols for penumbra recovery vs. dead brain recovery?

To generalize, TBI is anatomically a lot more complicated than a stroke in that we often have multiple mechanisms and areas of injury at once. However similar principles apply. In stroke a single artery may become blocked and an area of brain tissue loses blood supply for a time and the penumbra issue has to do with rescuing or protecting tissue at the margin of the damaged tissue where there may still be some blood flow. In TBI there are a number of things the Neurosurgeons and ICU physicians do to protect and rescue "at-risk" brain tissue including cooling body temperature to slow metabolism, shrinking the brain by controlling blood chemistry to reduce the effects of brain swelling, and most importantly removing part of the skull to allow the brain to decompress. These are analagous to penumbra rescue.

I had a really bad concussion from falling on pavement at a high speed. The injury was in the top/back portion of the brain. I never really lost consciousness, but I was unaware of who I was or where I was or what had happened for several hours. The doctor stiched me up and sent me home where I puked all night. I had impaired vision for about two weeks afterwards, lost my sense of smell. What I'm wondering is, could this injury when I was 30 start exhibiting mental effects when I'm 50? I have a hard time recalling words (especially nouns) and it affects my ability to speak and communicate fluently. I also have a hard time holding a thought in my head and following through on a sequence of tasks. Is there any way to test and see if the original injury caused some brain damage?

You should consider seeking out a Neuropsychiatry Clinic and having an evaluation.

Many of the caregivers in the article made the statement that your program is the only one they have been able to find that has been able to address the numerous complex issues that their loved one is dealing with (TBI, PTSD, substance abuse, behavior issues, other physical injuries). This seems to be an on-going issue with service members and veterans nationwide. How does a service member, veteran or their caregiver learn more about possibly entering your program?

Service members and their families interested in the Bethesda Program should work through their case managers or their treating physician to make a referral.

Do you have any data on Dystonia in veterans as a result of TBI?

I am not aware of data on dystonia in veterans with TBI but most doctors would agree that side effects of medication that causes dystonia is more common after TBI.

My husband has TBI like injuries from a stroke he had at 33. He is now having trouble with empathy and relating emotionally to people. Can this improve?

He needs a sophisticated evaluation to determine what the cause of his symptoms is. You should consider seeking out a Neuropsychiatry Clinic at an Academic teaching hospital where they can provide all the necessary elements of assessment.

What efforts are being made to assimilate TBI survivors back to a productive fulfilling life taking into consideration a certain level of handicap?

There are many initiatives to assist, more are needed. For veterans the Veterans Administration has vocational rehab specialists and a variety of programs to support transition to the community. Private employers also help - one example as a model for employers would be something like Northrop Grumman's Operation Impact, which is a program designed to place and support wounded warriors in the workforce.

It was entriguing to see John Barnes living at home and working with a life coach to assist in behavior modification techniques. It seems that there are so many TBI survivors who would benefit from this type of assistance, and take the pressure off of the caregiver as well. Is this type of "prosthetic device" something that you and other physicians are advocating the VA to have as an available option for continued rehabilitation?

The Cost of War


My husband has a mTBI from Iraq and his injury was 4 years ago. He still suffers from mild aphasia, headaches, confusion, clumsiness, anger. His secondary set of Neuropsych testing was done to figure out the most damaged areas of his brain. His prefrontal cortex is severely damaged, with mild impairment everywhere else. My question is, is it possible for him to actually get worse instead of better? He seems to be much more angry/irritable than in the earlier years of his injury. Also, what kind of medicines would you suggest for the really bad headaches? A NP put him on an antidepressant saying it would help his headaches, and in reality it made him even less functional than he already was. I am so tired of the lack of good TBI care out there. Thanks for your time and I appreciate all that you do for our veterans.

I would suggest a referral to a TBI specialty clinic for an evaluation. I can't speak to his case but in general deterioration late after TBI is potentially treatable and could be due to medication side effects, treatable complications such as depression, seizure activity, poor sleep regulation any many more - seek out a TBI specialty clinic at a center of excellence

What are some of the methods that you are using to treat PTSD?

Various types of structured psychotherapies, both group and individual, medications, a number of alternative therapies, avoid self medication, exercise and diet regulation, good sleep hygiene

I've read that the brain is more flexible than once thought and that when one region is injured, sometimes other regions can be rewired to perform the injured area's tasks. How true is this and what regions are most likely to have a "backup" region?

Mapping of functions within the brain is dynamic, it is continually modified by electrical activity of brain cells, much like muscle mass responds to execrising muscles. The brain doesnt grossly remap or create completely new wiring patterns but existing circuits are enhanced by activity and over time areas of brain mapped to certain functions can enlarge.

Earlier a questioner asked if diet or vitamins can help with brain recovery, but you did not address this part of the question. Do you have any insights on this?

Healthy diet and lifestyle is important in TBI recovery. We work with nutritionists to prescibe the right diet. There is no single vitamin that we prescribe to promote brain recovery except in special vitamin deficiency disorders.

It seems from the article and videos that many who have suffered a brain injury don't notice the mental health or behavioral chances until years after their injury. Is there a way to predict these changes or difficulties earlier on? And more importantly how can an individual be prepared to reduce the changes or difficulties, before they become a real problem?

That is the goal of our program.

It was quite disturbing to read the small number of beds that are available on your unit, compared with the high numbers of service members that are now living with TBI. Is there discussion to expand your unit so that a higher number can be served, or are you working with other physicians in your area of expertise that are practicing within the DoD/VA to treat TBI with the methods that you have been utilizing?

Our program at Bethesda is anew model of care in that trauma surgeons and intensivists are bringing behavioral health and rehab specialists into the management of TBI patients very early after injury. The goal is to identify and treat all the complications of TBI as early as possible and avoid behavioral and cognitive problems emerging later that families and patients are not prepared for. We are in constant discussion with our colleagues in the VA system and other physicians and leaders in the military sharing our wisdom and helping develop new models of care with other TBI providers.

I have both a brother (assault) and sister (car accident) who suffered TBI. My brother's incident is most recent and he's still hospitalized in a coma. From my sister's experience, I cannot help but feel like many of her doctors are quick to prescribe a variety of medications to treat her TBI symptoms as a "cover-up" to the problem and that she's not getting the help or therapy to work on the problems for the long-term. Also cannot help but feel this is tied into the cycle of drug companies making more and more money off that prescribing. Can you make some comment on your experience and observation in the overall use of anti-depressants and other behavior regulating drugs for TBI?

medications can be very helpful for some complications of TBI or co-occurring disorders. However TBI renders the brain sensitive to medication side effects and they can do more harm than good in some patients. The key is to find healthcare providers that work with TBI and understand the special nature of the condition and will use medications sparingly and with awareness of adverse effects.

I have an adopted son who was abused as an infant, resulting in multiple TBIs. How will some of the research and treatments being developed help him? He has frontal lobe damage, Brocas, temporal lobe damage, and a very thin corpus collustrum.

TBI in  children is different because their brains are still growing, they are more plastic and resilient than older patients. The important thing is to keep contact with a teaching hospital clinic that has experts in childhood TBI to make sure you get all the support and evaluations you need for help with education.

Thanks for all of your questions and interest in TBI. If you are looking for more information on TBI there are weblinks under the multimedia section of Mr. Davenport's article that are a good starting point.
Thanks for participating,
David Williamson

In This Chat
Dr. David Williamson
Dr. David Williamson is the director of the inpatient Traumatic Brain Injury Unit at the National Navel Medical Center in Bethesda, Md. He received his board certification in psychiatry and is a member of the American Psychiatric Association, the American Neuropsychiatric Association and the Johns Hopkins Medical and Surgical Association.
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