Battling Traumatic Brain Injury
words by Maryann Brinley
Start by envisioning a bowl of jello. Tap it on one side and watch how it wiggles all the way over to the other. This mundane image actually demonstrates the force of a blast wave — from a bomb, an improvised explosive device (IED), a mine, grenade or mortar shell — traveling through brain matter, disrupting pathways and unleashing a chemical soup on its victim, according to Jonathan Fellus, MD, UMDNJ- New Jersey Medical School assistant professor and Director of Brain Injury Services at Kessler Institute of Rehabilitation.
ust the first of several possible onslaughts to a soldier’s body in battle, sometimes the blast wave leaves no outward physical manifestation of the devastation within. Traumatic brain injury (TBI) has been called the “signature wound” of the Iraqi and Afghanistan conflicts, probably because it accounts for a larger proportion of troop casualties than in previous American wars. What’s frightening is that, according to the United States military’s own statistics, 20 percent of all returning veterans may have some degree of brain injury.
Fellus has seen the results up close and personally in his patients, learning from them and for them. “Unfortunately, because of the war, we are riding a tremendous wave of knowledge in this field. I like to think of myself as a bit of a mad scientist, who tinkers and experiments. But if you aren’t creative and gutsy, then you don’t belong in brain injury rehabilitation.”
A passionate neurologist with an incisive understanding of pharmacology, he is charged with the hands-on care of brain injured soldiers who manage to negotiate their way out of the military’s medical system and into Kessler. After only a few minutes spent in non-stop conversation with this renegade in a small patient examining room in West Orange, it’s abundantly clear that soldiers like Army Sergeant Daniel Tallouzi — just one of the most recent military patients under his care — are lucky to have this brain doc on their therapeutic side. All the “mean, nasty, horrible, terrible things that happen to the brain” end up in a unit just like Fellus’ but he’s the kind of guy who won’t give up easily and loves using every possible trick and technique navigating through the fog in what he describes as “the great black box of medicine, the infinite capacity of the mind.”
For the past 11 years, Fellus, a UMDNJ-Robert Wood Johnson Medical School grad ’92, has been strategizing, brainstorming and practicing at Kessler, recognized as one of the best in the nation for rehabilitation and one of only 14 model systems nationwide that were mandated by Congress for comprehensive clinical care for traumatic brain injury and spinal cord injury. “There isn’t another facility in the country with more depth in training and sheer number of subspecialty physicians.”
Determining exactly what happened from the time of actual injury until these soldiers reach Kessler is not just an agonizing exercise for Fellus or his patients. In fact, knowing what he calls the “mechanism of injury” will shed light on the wounds within. That powerful first blast wave or primary injury, he explains, will blow out eardrums and can wreak havoc in the brain without breaking the skin or spilling a drop of blood. But, there are at least four mechanisms for brain injury in military settings.
A second way to be injured from a blast is when the force throws materials into the brain, penetrating the skull, depressing brain matter, and leaving behind fragments of bone, shells, shrapnel, or even pieces of rusty nails from the home-made IEDs. “The soldier upstairs right now had pieces of metal propelled into his brain. Interestingly, he was speaking on the scene of the accident but that was before brain swelling took over and caused multiple areas of secondary damage.”
Make a note here that the younger the brain, the more prone it is to swelling and damage. As compared to older brains, young soldiers’ gray matter is plumper so it has less room to swell before it compresses internally against the inside of the skull. “This is why we are seeing massive craniectomies,” Fellus says. A craniectomy is a procedure during which a surgeon removes part of the skull to make room for the brain to swell. “I have another young man upstairs whose cranial bone flap has been tucked under his abdominal wall to keep it viable until it can be replaced.”
The third way to suffer a brain injury in war is body displacement — when a person is physically thrown some distance as a result of the blast. “Let’s say a soldier is sent crashing into a wall or a vehicle, or debris,” he suggests. Those contusive forces will result in more damage. And, the fourth mechanism causing brain injury, as well as all the other poly-traumatic, “dirty” wounds, comes from the falling debris. Troops end up with burns, fractures, and crushed limbs, all of which may trigger systemic effects. Explosion related side effects include everything from the TBI Fellus treats to amputation, fractures, lacerations, psychological disturbances (PTSD), crush injuries, impaired hearing and balance, blindness, impaired speech, renal damage, pulmonary damage, cardiovascular complications (shock), other organ damage, pain and neuropathies.
Meanwhile, clinicians who work at the Department of Defense (DOD) and the Veterans’ Affairs (VA) Administration have presented formally at scientific meetings that these war injuries may be unprecedented. As David Tulsky, PhD, NJMS associate professor, Vice President of Outcomes Assessment Research and the Director of Spinal Cord Injury at the Kessler Medical Rehabilitation Research and Education Center (KMRREC), admits, “I’ve heard people within the VA system ask, ‘Could these be totally new injuries?’ They certainly aren’t the same as what clinicians like Dr. Fellus treats as a result of car or motor vehicle accidents. I suspect that the VA and DOD have never had so many injured so quickly and so severely with amputations, spinal cord trauma and brain injury.”
Not a neurosurgeon, Fellus likes to think of himself as performing surgery with his own brain using his ability to envision the neuro-chemical, psychological and pharmacological scene inside a soldier’s head. “This is the most rewarding thing that I could be doing,” he insists. But it takes willingness to go through a lot of trial and error. “I come to work believing that I am going to hit a home run every single day. There is no brain injury that looks exactly like the next one. Every one is new and different,” which may be why the uncharted territory of the neuro-psychopharmacology of the brain was an area that chose him. “I would hate having to follow a formulaic cookbook approach to an injury.” He prefers practicing medicine in a miasma of symptoms. “For better or for worse, my career, particular interests and talents are perfectly timed to this wave of war-related brain injuries.”
|Jonathan Fellus, MD, assistant professor, UMDNJ-New Jersey Medical School director of brain injury services at Kessler Institute of Rehabilitation|
Fellus believes that clinicians can’t afford to wait until every medication or therapy has been vetted in clinical trials. Nor can they opt for prescribing just one or two drugs. That conservative approach can lose a patient a slim window of opportunity for healing in the brain, closed too often when soldiers are simply left in bed without adequate physical therapy and overmedicated on muscle relaxants and anti-seizure medications which actually slow down brain functions. “Time is a cruel mistress,” Fellus admits.
Here’s one of the first dramatically simple things he does for the injured soldiers who are arriving more and more often at Kessler:
“I wake them up during the day and put them to sleep at night,” he says.
Seriously, for patients like Sergeant Tallouzi, “the goal was to take away the medications that were getting in the way of brain function and blocking certain chemical systems, suppressing activity.” Two common anti-seizure medicines are routinely used in care elsewhere but they inhibit recovery, slow cognition, impair balance and have long-term side effects, according to Fellus. To stimulate these injured brains, “I beg, borrow and steal from medicines and knowledge in other neurological disorders, including Alzheimer’s and Parkinson’s.”
In his weaponry for this battle against brain injury, you’ll find a wide range of treatment options, from a pump to infuse muscle relaxants into the body without affecting brain activity, to median nerve stimulators for opening up the language area in the left hemisphere. “It’s my job to know everything, especially about medications, which ones are in the pipeline, how to use them creatively, and how to use their side effects to the patient’s advantage.” He is also constantly prowling the literature for “even an inkling of what might help.” Medications to stimulate the neurotransmitters in the brain are high on his list and Fellus relies on “meds like dopamine, acetylcholine, neuroadrenalin, and glutamate” for these patients.
Perhaps the most dramatic aspect of the Fellus approach to care is that patients are typically given not one or two clinically-trial tested, approved medications, but up to eight or ten pharmaceuticals at one time.
Ten drugs at one time?
“Well, yes…I throw everything I’ve got at them at first until I get consistent results.” But he takes a rational, cautious tack, watching closely for reactions, refining his approach and monitoring the responses as each medication takes effect. Using quantitative EEGs, which can measure and record electrical activity in the brain, he checks inside these injured brains regularly for changes and activity. “We can’t use functional MRI (fMRI) equipment because of the risk of embedded shrapnel or metal.” But portable EEGs used at bedside can provide an objective, neuro-physiological measure so we can track the brain waves moving from slow frequency toward normalization. This helps guide the pharmacological and clinical interventions. “Sometimes I’ll pull back on a drug that is turning out to be too much of a good thing in terms of over-stimulation.”
Along with these mixed drug cocktails, sound sleep at night, and long hours of intense daytime physical, speech and occupational therapy, hormones are high on his list.
“The disruption of the hormone systems in the brain is a hugely underappreciated area.” It’s well known that after a TBI, some people develop acne, some women stop menstruating and some patients feel unnaturally cold, all signals of hormonal dysfunction. The regulation by the pituitary gland has been damaged. Testosterone, for instance, is so important for mood, energy, musculoskeletal health and obviously sexual function and Fellus has picked up on low levels of this essential human ingredient in veterans there at Kessler. He measures and supplements when possible. Progesterone, he reports, has been shown conclusively to limit the trauma in animal models of TBI.
Elie Elovic, MD, Director of Traumatic Brain Injury Research at KMRREC, agrees. “Hormones are chemical neurotransmitters, active ingredients that affect a body’s function level. Too often, people pooh-pooh this relationship between hormones and quality of life.” Elovic’s research team has already shown how a drop in insulin growth factor, a hormone they evaluated, is related to fatigue, less community integration and more depression. “Theoretically, we know we can intervene now and make a difference.” The Kessler team believes strongly that victims of TBI should always be evaluated for endocrine dysfunction as a potential treatment that can otherwise be missed.
One component of what Fellus calls his “advanced treatment protocol” was developed in coordination with Phil DeFina, PhD, chief executive officer as well as chief scientific officer at the International Brain Research Foundation. This involves nutriceuticals, or nutrients, to support brain health. Mega-doses of Omega 3 fatty acid fish oil, curcumin or turmeric extract (the ingredient in curry which is being studied for Alzheimer’s), gingko biloba, B vitamins, and other elements are added to a therapeutic dietary regimen. “We know that part of the cascade of symptoms in the brain is caused by the inflammatory process so we need to modulate this.”
Eyebrows raise and more conservative physicians sometimes question Fellus’ aggressive tactics. But he’s lectured to audiences of military medical personnel who recognize the value of this approach. Jokingly, he calls critics “nattering nabobs of negativism or therapeutic nihilists.” At the end of the day, he wants his patients’ loved ones to say thank you for an accurate diagnosis and for “unleashing the best pharmacology, techniques and modes of stimulation known to medicine.” He admits, “Brain injury is a crapshoot. Guess what? Sometimes you have to pull out all the stops. These patients may have only one shot at rehabilitation. If I don’t use everything in my power that is rational, or may help based on my understanding of the mechanism of the injury and the clinical situation lying right before me, then I’d better step out of the way.” And spoken like a general determined to win victory, he says, “The key to TBI is a kaleidoscope of interventions to assault the injury from all sides. Look, some of the greatest breakthroughs in medicine have come from people who stumbled upon something luckily. How are you going to stumble on that something unless you try, observe and keep your mind open?”
Daniel Tallouzi, an injured helicopter electronics technician, has spent months at Kessler away from his home in New Mexico. He is certainly not the same young man who was wounded in Iraq, but his mother Mary applauds this open-minded approach to brain rehabilitation and can say with an easy heart, “No matter what happens, all you know is that you did your best.”