BETHESDA, Md.  –   When service members suffer a traumatic brain injury (TBI) or from post-traumatic stress, called the “invisible wounds of war,” many may think there’s no road to recovery. But the National Intrepid Center of Excellence (NICoE) at Walter Reed is there to make the road to recovery smoother for these service members and other Military Health System (MHS) beneficiaries through cutting-edge, holistic care and research to treat those invisible wounds.

NICoE is the Department of War’s Center of Excellence for TBI and related psychological health clinic care, research and education, bringing together expert providers under one roof to create care plans for each “brain warrior.” Providers and specialists at NICoE focus on an array of modalities, including brain fitness, restorative sleep, stress management, art therapies, social engagement, physical activity and nutrition to help battle TBI and mental health challenges.

“Beneficiaries are eligible for [care at] NICoE if they have suffered a TBI and have ongoing sequelae, especially if they require concomitant mental health care and/or rehab,” explained Army Col. (Dr.) Shannon Ford, NICoE’s director.

“We have 20 specialties under one roof to contribute to the interdisciplinary model that has been replicated across multiple civilian programs, and we are the lead and largest within the Defense Intrepid Network (DIN),” added Ford, a psychiatrist and a diplomate in psychiatry, consultation-liaison psychiatry, and geriatric psychiatry.

In 2008, the National Defense Authorization Act directed the Department of Defense (DOD) to establish a comprehensive plan for programs to prevent, diagnose, treat, and rehabilitate service members with TBI, PTSD, and other mental health conditions. Congress further instructed DOD to conduct research to better understand TBI interventions and new therapies, and mandated dissemination of these practices. This came in the wake of 9/11 and the Global War on Terrorism when TBIs became the defining injury of the war.

With care from NICoE, which opened its doors on June 24, 2010, many service members who suffered a TBI are able to return to duty. NICoE now serves as the "hub" of the Intrepid Spirit Centers, located throughout the continental United States, and Overseas TBI and Brain Health Clinics at Joint Base Elmendorf-Richardson, Alaska, and Landstuhl Regional Medical Center in Germany. The centers make up the DIN.

Ford explained that unique components of the NICoE at Walter Reed include the Brain Fitness Center (BFC) and Arts in Health.

“The Brain Fitness Center is accessible to patients across the hospital, often used by oncology patients with cognitive concerns in addition to those who have experienced a TBI/concussion,” she shared. The BFC uses computer-based brain training, heart rate variability biofeedback, and mind-body techniques to improve memory, attention, and processing speed. Since it opened in 2009, more than 3,000 service members and beneficiaries have participated in the BFC program.

“Arts in Health has a monthly Cognitive Creations Art Therapy group at the BFC, in addition to weekly groups about communication, memory strategies, and nutrition for brain health,” Ford added.

The Arts in Health program at NICoE began in 2011 when NICoE partnered with the National Endowment of the Arts (NEA) to develop a creative arts therapy program. The collaboration has resulted in therapies and programs supported by visual art, music, dance, yoga and writing. Since the program began, nearly 4,000 service members and beneficiaries have been reached through the program.

A key component of the art therapy program is mask-making and other creative acts, allowing service members to visualize and process complex emotions to help tackle the challenges of invisible wounds. NICoE also has an Intensive Outpatient Program (IOP), a multi-week initiative for TBI patients that’s tailored treatment plans focus on the mind, body and spirit. Other programs include the Acute Concussion Clinic, Sleep Clinic, Pain Clinic, and Mind-Body Wellness Program.

Ford also discussed some of the recent research efforts of her NICoE team.

NICoE’s Dr. Treven Pickett is currently a research leader in a study using teletherapy to improve emotional health after brain injury. The study is investigating how to strengthen emotional health and resiliency in people with mild TBI who experience alexithymia, a condition marked by difficulty recognizing and expressing emotions. The goal is to also lessen the challenges of post-traumatic stress, anxiety, depression, and anger.

NICoE researchers are also looking into providing increased access to evidence-based moral injury treatment throughout DIN with train-the-trainer methodology and a goal of intervention delivered largely via telehealth.

Moral injury can happen when a person “perpetrates, fails to prevent, or witnesses acts that violate their personal ethics, often causing intense feelings of guilt, shame, anger, and betrayal.” In the military, moral injury is defined as “the deep psychological, ethical, and spiritual harm resulting from actions — or inactions — that violate deeply held moral beliefs during combat,” according to the National Center for PTSD. “Common in veterans, moral injury causes profound shame, guilt, and mistrust, distinct from the fear-based symptoms of PTSD. It often stems from killing, witnessing suffering, or following orders that conflict with personal ethics.”

“NICoE continues to excel in the delivery of patient-centered, interdisciplinary care to service members and veterans with TBI. Our efforts have been recognized across multiple fronts, most notably by our patients, who regularly share testimonials that our compassionate holistic approach heals warfighters and helps them overcome stigma and the challenges of moral injury,” Ford stated.