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Writer, journalist, U.S. Air Force Veteran, and traumatic brain injury survivor, Christina Brown Fisher speaks with Dr. Russell Gore who is the chief medical officer of the Avalon Action Alliance (www.avalonactionalliance.org). The Avalon Action Alliance is a national network of programs treating mild and complex traumatic brain injury, for first responders, active duty military servicemembers, and veterans.
Dr. Gore is a neurologist and biomedical engineer, who also spent several years in the U.S. Air Force, as a flight surgeon. He is the director of the Complex Concussion Clinic, and medical director of the SHARE Military Initiative at the Shepherd Center, in Atlanta, Georgia.
This discussion is for informational purposes only and does not serve as medical advice. Please speak with your medical professional before seeking treatment.
Dr. Gore is a neurologist and biomedical engineer, who also spent several years in the U.S. Air Force, as a flight surgeon. He is the director of the Complex Concussion Clinic, and medical director of the SHARE Military Initiative at the Shepherd Center, in Atlanta, Georgia.
This discussion is for informational purposes only and does not serve as medical advice. Please speak with your medical professional before seeking treatment.
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What is Me, Myself & TBI: Facing Traumatic Brain Injury Head On ?
Me, Myself & TBI: Facing Traumatic Brain Injury Head On provides information and inspiration for people affected by brain injury. Each episode, journalist and TBI survivor Christina Brown Fisher speaks with people affected by brain injury. Listen to dive deep into their stories and lessons learned.
Christina Brown Fisher
Hello, welcome to “Me Myself and TBI: Facing Traumatic Brain Injury Head On.”
This program is for informational purposes only and does not serve as medical advice. Please speak with your medical professional before seeking treatment.
I'm Christina Brown Fisher and I am a writer and journalist, and traumatic brain injury survivor in 2014, I was hit by a tow truck. One moment I was riding in a car, the next I was waking up in an emergency room, unable to remember my name. I suffered a traumatic brain injury, as well as several other injuries. Life as I knew it was turned upside down. I spent a week in the hospital and a year in neurorehabilitaion, at a Department of Veterans Affairs medical center. I am also an Air Force veteran.
My guest today is an Air Force veteran, whoorah! Dr. Russell Gore is the chief medical officer for the Avalon Action Alliance. The Avalon Action Alliance is a national network of programs treating complex and mild traumatic brain injury, for first responders, active duty military servicemembers as well as veterans.
According to the Department of Defense, from 2000-2017, more than 375,000 military members have been diagnosed with traumatic brain injury. And many TBIs among veterans are connected to combat, but also proximity to explosions, blasts whether in battle or from training.
My guest, Dr. Gore is the founding director of the Complex Concussion Clinic at the Shepherd Center, in Georgia, and serves as medical director for Shepherd's SHARE Military Initiative which provides medical treatment, research and rehabilitation for the men and woman who’ve served and suffered spinal cord injury, brain injury, and other neuromuscular conditions.
Clinically Dr. Gore is a neurologist who specializes in sports and performance neurology, managing athletes and veterans with brain injury. But before he began his career in neurology, Dr. Gore was a military flight surgeon in the U.S. Air Force. He took care of troops at home and overseas and witnessed the impact of combat injuries. He leads an interdisciplinary research team developing methods to assess, quantify, and treat brain injury for military and sports applications.
Dr. Gore is also a concussion advisor for several national athletics organizations, college and professional sports teams, the U.S. Department of Veterans Affairs, and the Department of Defense. Doctor Gore joins me from his, your home, or your office in Georgia?
Dr. Russell Gore
Yes. That's correct.
Christina Brown Fisher
Your home office? Your home office in Georgia?
Dr. Russell Gore
Yep, my home office. How about that?
Christina Brown Fisher
Thank you so much for joining me today. What an amazing, background and bio, the work that you are doing and have been doing. In many ways, I don't know where to begin, but let's try to start from the beginning. I want to talk a little bit about your Air Force career. And what led you to specialize, in that particular, area?
Dr. Russell Gore
So, I started out in the Air Force. Actually, prior to entering the Air Force, I was a ROTC guy. So, I knew that I was going to serve. And then I, made the decision late in college to attend medical school. And when I was in medical school, I was looking at all the possibilities in terms of what to specialize in, and I was really drawn towards aviation medicine. My, my father, was one of the original, folks to fly the F-15 back, at the dawn of that, airframe, time and, and he flew at F-4’s at the end of Vietnam. And so I grew up, you know, around, Air Force and the son of a fighter pilot. And, and so while I was in med school, I thought, “you know, I really, I'm going to be serving in the Air Force. I think I want to do something operational.” And I made the decision, as an intern, that I was actually planning to pursue, aviation medicine. And that same year, in September, of course, September 11th, the attacks occurred. So, that really changed my calculations.
Christina Brown Fisher
So this is 2001.
Dr. Russell Gore
Yeah, it was in 2001, you know, when I was an intern. Yeah, it was in 2001, you know, when I was an intern. Yeah. So, so I, you know, went straight into the military that summer, and it was a bit of a whirlwind of, training, and that was, right at the beginning of, of the war. So, so, so I really decided that I wanted to be operational, and that's what led me into aviation medicine. But, through that experience, I really actually was most interested in, pilot performance issues. And one of the, the, the areas that interested me the most was the kind of interface between how you performed in the jet and the environment that you were trying to perform in, and in the dynamic movement environment, that dynamic motion environment. It's the fighter community really interested me with, you know, lots of, rolling and, and, and, and advanced maneuvering at the same time trying to monitor and use advanced aviation systems. And of course, that all involves the brain and involves the, dizzy systems within the inner ear and how you perceive, where you are in space. And that really, was something that captured my interest and attention. And I started to recognize that it was a big deal. It wasn't, you know, there were there were issues that we were managing, when I was active duty, related to pilots getting disoriented in combat scenarios because, of sensor disorientation or because of movement based disorientation and, and it, it at times had, life and death implications. And I was, you know, really drawn to that kind of work and, that's where, how I landed at the Air Force research labs because of my interest in that, that area. And later, when I was trying to think about what I was going to be when I actually grew up and got out of the military, it was sort of a natural fit that I would, pursue, neurology and neuroscience, because that's where all of those different systems converge.
Christina Brown Fisher
When you talk about your time in service, in active duty, particularly in the aftermath of 9/11, can you talk a little bit about where you were, where were you stationed? Were you in Iraq, were you in Afghanistan, or were you in some of the supporting areas?
Dr. Russell Gore
You know, I really was in all of the above. So, all of my deployment experience was either as a physician. So, I spent time in, Bagram, in Balad doing, a lot of, the duster mission work where we would be in helicopters, or in C-17s or C-130s when they needed, physician level support, for transporting casualties between different echelons of care is what we call it, sort of the forward positions back to, Balad and then to Germany.
Christina Brown Fisher
You’re at Ramstein, you're at Ramstein Air Base in Germany?
Dr. Russell Gore
Yep, so Rams, so Ramstein Air Base is where we would you know, kind of where we would take patients. You know, if they were, if we were leaving Balad within in, in the, in the Iraqi theater, we would end up, in, in Balad because they had a fantastic, forward hospital that could manage, very complex, injuries. And then I was also deployed with, two seat F-15 squadrons, so the Strike Eagle. And my role in that context was as the performance doctor, right? So, I was taking care of everything from toenail fungus to folks trying to manage crazy sleep schedules and, 14-plus hour missions and needing stimulants, or sleep aids in order to manage the operational tempo and, and then at the same time being assigned to, to, air evacuation missions. So, it was very dynamic, you know, work when I was downrange. And then when I was at home, I was a wonderfully glorified family practice doctor. I got to take care of, the pilots and their families and their kids and, really build personal relationships with my patients, and, and loved that kind of work. It was, you know, one of the few places in the world, I think, these days, where we can practice medicine, kind of like it was in the old days in a small town, you know, so sort of small-town medicine because you really get to know everyone. So, when I was at home, I was doing that. But when I would deploy, of course, it was a very different job.
Christina Brown Fisher
Brain damage among servicemembers returning home from Iraq and Afghanistan was so commonplace it resulted in medical experts calling traumatic brain injury the signature wound of the war. Dr. Gore, do you recall when serving as an Air Force flight surgeon how long did it take for you to start putting the pieces together and seeing the impact of TBI?
Dr. Russell Gore
You know, I think I was similar to a lot of, the community in terms of military physicians where I didn't take mild injuries very seriously.
Christina Brown Fisher
What do you mean by mild injuries?
Dr. Russell Gore
I mean, you know, blast exposures, concussions with a brief loss of consciousness. We were generally managing poly trauma. So, these are service members with broken bones or, penetrating traumas to their arms and legs and torso. And, and those injuries that were the blast related injuries not causing severe injury to the brain were less of a focus. We were much more focused, which is similar to if you go to the emergency room after a car crash these days, they're going to really focus on the life-threatening injuries to the limb threatening injuries first, as they should. And then, and then often folks end up at home saying, "I've got these symptoms, they're not going away. I'm feeling really bad." And, and there wasn't a formal diagnosis of a mild brain injury or a concussion, through the emergency room because it wasn't life threatening, and their job is really to keep you alive and then get you on into the system so that you can be diagnosed, down the line, and, and the military was no different. So, that emphasis really wasn't there when I was, on active duty. What I, where I first became really interested is as a trainee in neurology, I started, I became the person who was interested in taking care of athletes and, and service members, as opposed to epilepsies and strokes and the kind of more traditional neurology areas. And what I saw was that there were very few of us that, a lot of, patients were being turned away when they would call because an accident was involved. And there's, somewhat of a fear of litigation or being involved with litigation because it's very, time consuming, for a medical practice. So, patients were being discharged from hospitals being told you should see a neurologist, and they would then be turned away by most of the neurologists they would call. And, and I actually had I had an interest in that. So, I started to, to become "Mikey likes it." You know, I would say, "no, no, no, that's something I want to see." And as a result, I suddenly was seeing a large volume of these, mild injuries that hadn't often been diagnosed at the point of emergency care and and became very interested in how do we help to manage, this condition that's essentially invisible. Right? That's the hard part is, you know, 95-plus percent of the time, imaging is going to be normal, even when we are certain that someone meets the diagnostic criteria for a mild brain injury. And, and because there's nothing on imaging and, and because, at the time, there weren't a lot of resources, to look at other objective markers. There was a primarily a focus on cognitive functioning there. There were limited tools to look at, balance functioning and, eye movements and other areas that can be involved. There really were very few objective…
Christina Brown Fisher
And is it fair to say that it was, was driven by self-reporting as well, people coming in telling you this, and if they don't tell you, then you don't know?
Dr. Russell Gore
Absolutely, so self-report is and that's still a challenge for all of us in the field, is that, folks are describing symptoms which overlap with a lot of other conditions. You can have a sleep disorder, you can have depression, you can have anxiety. You can have another; a different form of cognitive impairment and you will present with exactly the same symptoms. Now we see constellations of symptoms that are much more common after mild brain injuries, and we and we also see that mild brain injury increases the risk of those other problems. So, you're much more likely to develop depression. You're more likely, to develop, a sleep problem, but we see because of that overlap, then we're very dependent on symptoms, and as a result, there's a general feeling in the community that there aren't objective ways to diagnose this problem. And as a result, patients often don't get the care that they need.
Christina Brown Fisher
I appreciate that you said “there's a general feeling,” Dr. Gore, because, of course, feelings are not facts, and you're a researcher, so, can you, can you explain the disconnect about the prevailing thoughts, wisdom about diagnosis and, and what really is available and out there?
Dr. Russell Gore
Yeah, so that's a that's a fantastic question. So, you know, the prevailing wisdom has shifted dramatically in the past 20 years in terms of these issues, in terms of mild brain injury, or concussion. And I use those term synonymously. Right? So a mild brain injury and a concussion are really the same thing. You know, some folks will say that a mild brain injury is the injury itself, a mild TBI, and a concussion is the syndrome that comes along with it. But but I use those terms, interchangeably. So, you know, the prevailing wisdom for many years was that concussions always resolved that, that if you were complaining of symptoms beyond six months, that it couldn't be from a mild brain injury because it was just a mild injury. And what we now know is that actually, quite a large proportion of folks, at least 20% and in some studies looking at emergency of patients that present to emergency rooms, they, it can be as high as 50% are still reporting and, and still testing with abnormalities objectively. Even six months post injury and and so 20 to 50% of these injuries can have protracted recovery essentially. And as we start to look more critically at our own, research, what we see is that I think we were grossly underestimating in the, in the past, the effect of these injuries. And there's a few reasons for that. I mean, one, we really lack, diagnostic tests for this injury. Now we can, we're a, I work at a rehabilitation hospital, so we have a team of therapists who can look objectively at visual function, balance function, cognitive function. And we absolutely document objectively brain injury related deficits.
Christina Brown Fisher
But there's no blood test and there's no imaging?
Dr. Russell Gore
Correct exactly, so, you know, there isn't an imaging test that's going to give us the answer. There isn't a blood test that’s going to give us the answer, so it doesn't fit nicely into sort of our medical systems expectation that most diagnosis are going to be based on, as you indicate, a blood test or an imaging method. So, we, we absolutely, though can objectively assess these injuries, and we see even though there are overlaps with other diagnoses in terms of just the symptom reports, we are constantly finding objective, evidence of brain injury that we've got very high performing patients that tell us, "gosh, you know, we, I, I've been complaining about this for five years, and no one has really ever been able to show me the data that tells me that, that I have this problem." And that's often because our approach is very hands on and it's very objective focus because it's rehabilitation. You know, a therapist is very skilled at, looking to see how you're functioning. So we do lots of functional tests, and those tests will show patterns of impairment that are consistent with brain injury.
Christina Brown Fisher
In your work with professional athletes, active-duty service members, but also within the veteran communities, where do you see overlap, similarities in their approach to recognizing there’s a problem and seeking help?
Dr. Russell Gore
That's, that's a great question. So, you know, I really, I really think it starts with sort of self-selection if that makes sense. So folks that grav, so folks at a young age that gravitate towards participation in activities that require a, a high level of performance. And I would put, I would put athletes obviously into that group. And that's the you know, that's a lot of the focus, and that's something that universally folks understand. But, you know, I've cared for Broadway level performers who have had injuries, you know, related to that, I've, I've cared for musicians who've had injuries and, and they think the same way. So, they're very, purpose driven, they're very high performing. If you look at the average person who becomes a service member, who makes the decision to, enlist in the military, it is a very similar group. Right? These are these are folks that see themselves as individually contributing to something that's bigger than just, you know, them and them, themselves. And they're very driven physically and mentally to succeed, and they're, they're generally very capable of working within a team environment, and they're very outcomes driven. So they really, you know, they want to win. They want, to see that, that they are contributing to, to a winning team.
Christina Brown Fisher
I see.
Dr. Russell Gore
And, and you can't take that away from someone. So, we see that those similarities, I take care of a lot of Special Forces, a lot of the Special Forces community often…
Christina Brown Fisher
And when you say Special Forces, Special Forces are for the Navy, that would be the SEALS. The Army would be the Rangers.
Dr. Russell Gore
Yep, Delta Force, Rangers, Green Berets within the Army.
Christina Brown Fisher
Right, Air Force would be the Pararescuemen, and the Marines would just be the Marines.
Dr. Russell Gore
For the Marines, it would be the Marines, yep, so, and, and then and then there, you know, there are ordnance disposal folks, you know, and there are, you know…
Christina Brown Fisher
But they're distinguished within the military when you talk about Special forces.
Dr. Russell Gore
Absolutely, so you know, these are, these are kind of the, the most physically demanding and selective and in many cases most physically demanding and selective subgroups within the military that are often the most operationally active and exposed the most to blasts and booms and bangs and, and that they're, they're often exposed to the most injury potential. And I think it's important, though, to recognize that, you know, this group only accounts for a small percentage of military service members, and especially the way that our, the way that we've been waging war for the past 20 plus years. There are lots of military members who are exposed to all of those things who aren't in the Special Forces, and we can't forget that, that those individuals’ service and their lives are just as important. Right? You know, they're you know, if you're the driver in a convoy that's hit by a, an improvised explosive device, it has a devastating effect on your, on your life, potentially long term. And we need to make sure that that everyone gets access to care. But when we talk about performance, you know, the Special Forces within the military are sort of like the pro athletes. If we compare a division, you know, a college athlete to a pro athlete in the, in the civilian community, that would be, you know, kind of a similar comparison between a military member and someone who's a member of the Special Forces, and, and caring for those, these populations. What we'll often see among all military members early on is a desire to continue to do what they do. When I was flying, you know, when I was in a fighter squadron, I was a back seater in the two seat F-15, and the worst possible outcome of any day would be to end the day not on flying status anymore. And so nobody wanted to come to the flight surgeon. Nobody. I did most of my medicine, in the briefing room before I was going to go fly. People would pull me aside and tell me what was bothering them. They would not show up in the clinic because if they showed up in the clinic, you know, there was a decent chance it would end up off of flying status.
Christina Brown Fisher
Then it gets documented?
Dr. Russell Gore
And that was the worst possible thing that could happen. And so, you know, there's a lot of, of underreporting of symptoms. And so if an injury occurs, you also don't have the luxury of saying, I'm symptomatic. You, you know, I just need to be evacuated. I mean, you're in a life and death situation. Your contribution sending, you know, rounds downrange can make a difference between your team surviving or not. And so, you have to keep playing the game. It's not as simple as the NFL, where you can be pulled off onto the sideline and go into a tent, you know, so a lot of, there's a lot of denial of injury because it's necessity. But that also leads to not wanting to let your, teammates down and not wanting to end up on the injured roster. And so, a lot of denial of symptoms…
Christina Brown Fisher
And it would just also complicate any ability to recover as well if you're not admitting to it.
Dr. Russell Gore
Yep, oh, absolutely, oh, if you're not admitting, and so we see cumulative injuries a lot of underreporting where folks don't want to kind of acknowledge that that they have day to day symptoms because there's an attitude. You know, when I was in a fighter squadron and I my understanding, you know, I was just taking care of a Navy SEAL a few weeks ago and this came up and he said, "oh, yeah, it's the same thing in our offices." He's, you know, out in San Diego. You know, they have the "no whining signs." So, you know, everyone has it on their desk, you know. You know, don't, don't complain. Just get the job done, which I think is amazing. But that ethos, that sort of silent service, which I value so much in, in service members, leads to underreporting of these injuries and a lack of recognition that there's injury and the care isn't provided. And we see the same thing across military members and athletes when they are still actively engaged. And then later in, in the kind of injury journey or later in our lifespan when we're older, like I am now, you know, a veteran and I'm not still doing these high speed…
Christina Brown Fisher
So, it's really when they leave service that the transparency and honesty comes out?
Dr. Russell Gore
Yeah, when they leave service, then the transparency. Absolutely, but but, but, but you never stop thinking like a high performer. I mean, when I, when I'm working with folks with lots of impairments that are struggling to even get out of their basement, struggling with basic relationships within their family, unable to work. They these, these individuals don't think suddenly like, a disabled individual or they don't. Their ethos is still a high performing ethos that they see themselves differently.
Christina Brown Fisher
I'm not sure if I understand. How does that show up? When you are, using your example, you are struggling to get out of your basement, how does the high performing mindset inform your ability to rehabilitate? Seek help or not, maybe?
Dr. Russell Gore
Well, a lot of times that, leads to not seeking help. A feeling of "I have always been able to be resilient and push through, problems, and so I'm not going to self-identify, even though it's clear that I desperately need help to everyone around me. I don't want to admit that. I don't want to; I don't want to ask for help." And then and we see this in frustrations with some of the, the health care systems that are, that are available to veterans like the Veterans Administration. You know, it's very focused on, disability and benefits and, and, you know, the more unwell that you are, the more benefits that you qualify for, which makes sense. But it's it, disincentivizes wellness, and so then there's this feeling of, of sort of loss of, performance, loss of support. It's like when I work with athletes that are having to retire from their sport because they've had a number of injuries and they have impairments, whether those are neurologic or orthopedic, whatever they may be. There's this loss of identity that comes with that. And we see this often in veterans that are struggling to ask for help. They are ashamed because of this loss of identity, because they they feel like a high performer, but they can't perform at that level currently. And, and that results in, in many cases in a bit of a, of a spiral. And, and we really, you know, what we're really focused on is trying to, to break that cycle and, and harness that innate high performing mindset to start to take the first step towards getting back to that level of performance. That might be your goal, you know?
Christina Brown Fisher
I know the suggestion isn’t that people who utilize VA health care, I’ve utilized VA health care, are not incentivized to rehabilitate because they have a disability rating. I know that that's not what you're saying. What’s really being addressed here is health care infrastructure, that may or may not necessarily be beneficial for some individuals who are recovering from, mild to moderate TBI. Is that fair?
Dr. Russell Gore
I appreciate your clarification on, on what we've been discussing in terms of the VA. The VA does a phenomenal job in so many areas, managing, a very large population of, of, of service members and of, of veterans with, with a lot of needs. Right?. It's, you know, they're, they are, when I was a primary care doctor in the Air Force, I knew what it's like to be sort of the jack of all trades. And you really it was an overwhelming, challenge to need to be amazing in so many different areas. Right? And so I now have the luxury of being a specialist in just one organ. You know, it is a complicated organ, the brain. But it you know, I get to focus on, on one, one organ system. So the VA does a great job in terms of the overall net, and as we're capturing, the needs of this large population of veterans with very, diverse needs. One of the biggest challenges in brain injury care, though, is there isn't currently a standard of care. So, you know, when we talk about who's getting the care that they need, there isn't a lot of agreement between the whole community about, how to diagnose these injuries and then how to treat them. And, and so I see our role in the context of the VA's care as kind of I use the analogy of, of going through a drive through, to get to get a lunch, you know, you pull up to the, to the menu and you're perusing the menu and talking to the person over the speaker. And, you know, as a clinician, the worst feeling I have as a, as a, as a physician in my whole career is when you're in the room with someone and you don't feel like there's anything on the menu that's going to help, that they can help that patient.
Christina Brown Fisher
I see. How do programs like the SHARE Initiative and the network that’s part of the Avalon Action Alliance fill in these healthcare gaps?
Dr. Russell Gore
So I see what we provide as a very important part of the menu. But there are other treatments that can be very beneficial that the VA does provide that are within the menu. And interestingly, the VA now provides care that's similar to SHARE and the Avalon network at its poly trauma site. It's called the IETP program.
Christina Brown Fisher
And I.E.T.P. stands for Intensive Evaluation and Treatment Program. Traumatic brain injury I.E.T.P. typically delivers evidence-based care but in a compressed timeline.
Dr. Russell Gore
And we've been talking with the VA about the care we've been providing since 2007. And, and actually, the VA is now opened centers that are focused on, providing similar care. So interdisciplinary, meaning multiple therapists all working together; care that's all co-located. So, you go to a program, and you get an intensive course of therapy. That is the that's the magic for all of our programs. And now the VA has a handful of programs that are providing similar care that just opened. So we really, you know, are excited to see that that is now on the menu within the VA. But the need is huge. And there are there are far more veterans and service members and individuals in the community. You know, our organization is focused currently on veterans, servicemember care, and first responders. But we recognize that this need extends into the whole community. You know, there are millions of concussions every year, and we know that 20-plus percent of them have protracted recovery. And we know that rehabilitation is the current standard of care. But defining what that means and and how exactly to do it, where we want to be a part of, of, of defining that. But those needs are absolutely not being met across multiple populations. But the VA is, is, you know, really partnered with us in the sense that, through a number of different organizations, we're working with the VA, we have, VA case managers that are assigned to our programs that are actually, paid for by the VA that help us with managing records as we're bringing in new clients in order to assess their need for treatment, in order to make sure that our clinicians are aware of their needs and when they come in for assessment and treatment. So, we're partnered with the VA in that regard.
Christina Brown Fisher
It seems like also what you're saying Dr. Gore is that because of the culture and climate of, active duty, which essentially, fosters a mentality where, you don't you're less inclined to report your symptoms. It seems like what you're saying you're far more likely to see someone after their service. So, when they are a veteran, that's when they're engaging with you. That's when they're engaging with the need to rehabilitate. So, what does that mean for their care? Because now correct me if I'm wrong, if you, if it's a veteran who's coming to you, we are, what, months, years out from the injury? What kind of impact does that play on the rehabilitation process?
Dr. Russell Gore
That's a great question. So, one of the most common big picture observations that, that, that I've made in my career, observing brain injured individuals and how they're managing their lives is that because we don't come with a user manual, you know, there isn't a user manual we can flip to, you know, the, the light that came on in the car and say, okay, "what does that light mean? And what is how do we troubleshoot this?" We're sort of making it up as we go if, if you're not seeking help, and there are a number of strategies that individuals develop that are helping them in the moment. So maybe they have sensory sensitivity if they're in, if they go to busy places because of their, because of their, their head injuries. Well, one strategy may be to avoid busy places. Right? So, so they may only go to the grocery store if it's past midnight and it's going to be really quiet or, or they may start, ordering their groceries online, you know, which is available these days, or they may no longer go to church services. They, they perhaps are disengaging from their faith community because, because that environment makes them feel symptomatic. So those are strategies that in the short term seem very logical. It makes perfect sense. But they're maladaptive, right? So, when you do that, you now become isolated. If you are not exposed to those sensory environments, when you then are forced to be, so you have to go to the grocery store because you suddenly have to go get milk.
Christina Brown Fisher
You have to go to your kid's school. There's certain things you have to do.
Dr. Russell Gore
You have to go to your kid's school, then you're going to feel a lot more symptomatic because you've been avoiding for so long. Now you're going to feel a lot more symptomatic, which reinforces this idea that you've got to self-isolate. And so, we head down, the further we are from injury and these things aren't being addressed, we head down this path of maladaptive strategies that are perfectly logical and intelligent. I often tell my patients, if you touch an electric fence and then you touch it again, you know, you you probably aren't, an Air Force veteran doing podcasting for a living. Does that make sense? You know, like, that's not a smart, smart thing. And so, it's normal to develop avoidance behaviors, but they can be very maladaptive to your life. And so, the further you are from injury, often the more of those maladaptive behaviors that have to be addressed and, and interdisciplinary rehabilitation when we're, attacking the problem from so many different specialized angles. So physical therapists, therapists that specialize in vision, therapists that specialize in cognitive function, integrating the emotional health component, integrating peer support, integrating vocational support. When those types of specialists are all around you, we really wrap our arms around you. Then we can help you to identify those maladaptive strategies that you've sometimes been using for years.
Christina Brown Fisher
And you may not necessarily realize that it's because of that?
Dr. Russell Gore
Yes, often it's it, folks are unaware that that they've developed strategies that are maladaptive. And so the therapists identify those, and then we help you take that first baby step towards getting back out into the community. And, and we try to identify barriers, you know, that they may be medically treated. You know, if you're depressed, it's going to make cognition worse. For example, well, let's treat the depression at the same time that we're trying to help you with your cognitive problem. And if we do that in an interdisciplinary and intensive way, we often are able to turn the tide so that, now we have adaptive strategies. So now your your strategies are more informed and, and often your symptoms are less and you're more integrated into the community. So that really is the big picture focus for what our organization does?
Christina Brown Fisher
Is this when Avalon Action Alliance steps in? How does it prove itself to be so critical in this type of recovery process?
Dr. Russell Gore
So the Avalon Action Alliance is a clinical group of programs that are focused on brain injury and co-occurring disorders. So, disorders or issues that commonly come along with traumatic brain injuries.
Christina Brown Fisher
Like what?
Dr. Russell Gore
Things like post-traumatic stress, depression, substance use, behaviors that are, that are, destructive for your life, whether they're abuse or misuse. And these often come in a constellation is very overwhelming for not only the individual suffering from these issues, but their but their doctors. Right? If you when you go to your primary care doctor and you've got a problem in multiple areas and they're all working against you in some way, it's, it's, it's very difficult not to untie. Right? And so that's that, so we have currently seven national programs, the SHARE Military Initiative at the Shepherd center, which is, is my local program that that's that's one of seven national programs.
Christina Brown Fisher
That's in Georgia.
Dr. Russell Gore
That's correct, and so we have programs in, Florida, Philadelphia. Wisconsin is the most recent program that opened, New Orleans and Louisiana at Tulane. And in Colorado, and actually North Carolina. So, we have a program at UNC. So seven national programs that are, focused on TBI and these co-occurring disorders, and these are all intensive treatment programs with interdisciplinary rehabilitation. Our organization also has a non-clinical arm. So, Boulder Crest and the Warrior Path program are the non-clinical arm of the of the Avalon Action Alliance. And so, this is an organization that is addressing, post-traumatic stress and, mostly the behavioral health symptoms, but in a non-clinical treatment methodology.
Christina Brown Fisher
So, this would be peer to peer support?
Dr. Russell Gore
Yes, so the seven national programs that are clinical, but we also have a network of national programs that are non-clinical through the Boulder Crest Foundation's Warrior Path program. And this is a peer to peer focused, treatment program or peer to peer focused, traumatic growth program that really helps for veterans and first responders to leverage their experiences that include these traumas and to grow from those experiences in order to move forward. And their their outcomes are fantastic, but this is their treatment programs or their programs aren't actually clinical programs. These are peer to peer driven. So, our overarching organization includes the clinical programing as well as the non-clinical programing. And we're collaborating very closely because the needs often overlap. A lot of those who seek the experience of Warrior Path, who also have a traumatic brain injury that hasn't been treated. And and we often see, clients within our traumatic brain injury programs that benefit from attending Warrior Path programing. So, we were working closely together with the common goal, really, what we want is for veterans, first responders, service members to live their best lives and to address these issues that have often been neglected or or really, over treated in some cases. You know, we I think if we diagnose folks with a problem and we start to add medications and they're not responding, we have to look for other solutions. And for, a vast group of veterans and service members and first responders, these issues have either been unreported or neglected, or when they're treated, they're treated in, in, in an overly pharmacologic focused, treatment setting. I mean, that our entire health care system is, in my view, overly focused on, on, on pharmacologic intervention. And it's certainly a part of the treatment that's necessary for a lot of veterans and service members. But we can't neglect that peer to peer interaction and its value. We can't neglect the value of a rehabilitation intervention, because the combination is most valuable.
Christina Brown Fisher
I saw in an interview in talking about this program, you talked about you said “it's medication versus tools,” and your program is heavy on providing tools. Explain that to me. What do you mean by that? Because medication plays a role too.
Dr. Russell Gore
So, medications absolutely play a role in the care of many of our clients. You know what we need to make sure that we're not doing, though, is assuming that that pharma is going to be the solution for everyone. And it's not often a solution in isolation. It's very rare that I see a patient that benefits from just starting a drug. When we're dealing with such a complex system as the brain, and when we're dealing with trying to get individuals back to their lives. You know, if we start a medication, in some cases, we'll see the depression improves and, and, and folks get back to their lives. In many cases, they need tools in order to navigate symptoms which are not going to just go away because you've started a drug. The drug may improve the symptoms, but what we want, when I talk about giving an individual tools, I use the term tools and strategies interchangeably. But we want you to have a, a toolbox to deal with the good days and to deal with the bad days. So, if you have sensory sensitivity and you wake up one morning and today, often, an individual can tell me, "you know, it's going to be a day where I'm going to have some headache, I'm probably going to be more sensitive to my environment today." Okay, well, "what tools do you have to get through your day?" Just like if anyone anyone who's had young children who decide to to, you know, have a cold and they don't sleep all night. You wake up in the morning exhausted, but you've got to move on with your day. So, you develop strategies for that. You know, I saw an article in the newspaper actually this morning that said, well, what are the most effective ways to handle a bad night's sleep? You know as you get through the day. So those are tools, and how to manage a bad day. And then you want to figure out, well, how do you leverage the good days? And, and so rehabilitation is really effective at giving you tools. Again, we didn't come with a, a user manual. So if you work with someone who's, has a lot of experience with mild brain injury, in the case of our programs and getting individuals back into their community and back into their lives, back to work, back to recreation, back to doing the things that we all love, they can often give you suggestions and tools and strategies that are effective that you may not have thought about and, and, and help you to manage those days where the symptoms might be higher than others. And what we often see is that staying engaged with the community, continuing to exercise. These are all treatments for a variety of brain related conditions. You know, being active during the day is a treatment for insomnia. You know, you're you're more likely to sleep better the next day. Activity is a treatment for depression. Activity is a treatment, is a preventative for headaches. So, so we want to keep the activity up. And that and these tools allow you to manage kind of the roller coaster of life right when you have a good day versus a bad day. What what's your plan?
Christina Brown Fisher
You said that the people who can currently access the program are first responders, service members, active-duty service members, and veterans. Is that right?
Dr. Russell Gore
That's correct. So, the focus of the program is veterans, service members and first responders. All of the programs treat veterans and first responders, and we have a handful of programs, and we will likely be expanding to treat more service members. What we find is that, you know, we had mentioned before, kind of throughout the career span within the military, as you're starting to approach separation, whether that's because of medical issues or you're retiring, because you're completing your military service. Those of us that have served, you know, we're very familiar with sort of the cliff that you fall off, you know, being within military service, regardless of your health status, provides a lot of support, both social support and and work-related support and camaraderie and identity, and, and community. And so, everyone, when they separate, regardless of the circumstances, sort of falls off that cliff where they now have to try to navigate this external to the military. And what we find for service members is often there are injuries where the goal is to get back to service, and we manage that. And if that's the goal, we're going to absolutely support, trying to make that a reality. Many of the clients that I've cared for that I feel like I make the biggest impact, when they're still active duty, when they're still service members is during that transition phase. So, when, when they're approaching the end of their military service, we're identifying that these injuries and, and co-occurring disorders are present. And we get actually given an opportunity to to treat them. We see improvements. They leave with a toolbox. And then they're often setting goals that aren't military related. They're looking past the horizon of the military into their life beyond. And that's where their goals maybe they have educational goals, work related goals. We're helping them to achieve those.
Christina Brown Fisher
Yeah, but how do they come to you? I guess the question that I'm really getting at is, particularly for someone who may be months or years out from whatever the original event is that's behind the TBI, and are we talking just mild TBI or also moderate TBI for your program?
Dr. Russell Gore
So mild to moderate TBI for all of, our all of our programs, yes.
Christina Brown Fisher
How do you evaluate, quantify, determine whether or not this person is, one eligible for the program? And then kind of a natural follow up, or part of that, is and I bring this up because you had mentioned blast exposure. There's a significant segment of the military and veteran population who may have been exposed, to blasts, but it didn't necessarily mean that it was documented medically, that there was an injury associated because of their exposure to a blast. How do you determine whether or not, “okay, yes, there is a medical history that clearly points to, a mild or moderate TBI,” particularly among the veteran population who, you know, may have been exposed to blasts?
Dr. Russell Gore
So access is simple. If, if you go to the Avalon Action Alliance website or any of the associated programs. So, here in Georgia, for example, the SHARE Military Initiative through the Shepherd Center. Then there is an outreach number, and we actually have an online form that you can complete that where you give us just basic information about, the individual, some of the information about their service history and some information about injury history.
Christina Brown Fisher
But what if I don't know that I've had a mild TBI or a moderate TBI?
Dr. Russell Gore
In many cases, folks aren't sure. And they they complete the form and they say, yeah, "they say, I'm not sure if I've ever had a mild brain injury. That's why I'm reaching out." So we have outreach specialists that will, get in touch and we collect a little bit of additional information in order to figure out eligibility to come into the, into the programs. And that's really more focused on, you know, was there a history of repetitive blast exposure, which is what you mentioned previously. Sometimes a formal diagnosis of mild or moderate traumatic brain injury was never made because there was never that sort of moment of concussion where, you know, in sports where the crowd might say, "ooh," you know, there was a moment when a big hit occurred. It's, it's that repeat exposure to head injury that can accumulate over time, and individuals will start to exhibit those symptoms. So, if you have a history of a repeat exposure or if you have examples of those service-related or even not service-related head injuries, many of the veterans that we treat may have had a car accident after their military service that has that that meets criteria for mild brain injury, and they would absolutely be eligible to come in for treatment. And so, so our outreach folks will gather a little bit of additional information. And then all of our programs have an intensive assessment is the first step. So, you come to the program, and it ranges anywhere from three days to about two weeks, just depending on how much time you have and depending on the program where you come to us. And our entire assessment team does that wraparound approach. But from a diagnostic standpoint, what we want to figure out is where is there evidence that you had a brain injury. We want to figure out what are the co-occurring and complicating issues that might be, increasing or worsening your symptoms or contributing to your symptoms. And we also want to establish what your goals are in treatment and and to all of that occurs on site during an intensive assessment period. Once you complete that assessment period, we sit down with you and your loved ones, and we let you know what we found and what we think and what we would recommend in terms of a treatment plan. And so, for, for a group of those individuals, what we find is that we don't think you have a brain injury, which is great news. For a majority of the folks that come to us because of our screening program, then we establish that you do have a history of a brain injury, and we talk about having you come back for treatment.
Christina Brown Fisher
I just want to kind of make it clear that first responder, active-duty service member, and veteran, are the people who you're currently engaged with right now. But the other thing that I think is a really important point is that you don't necessarily need to know that you have had a brain injury or that you've been diagnosed with brain injury. So, I guess let me just ask it this way or I'll frame it another way, if I am someone who is experiencing “fill in the blank” symptoms, who is the person who should be reaching out to you and to your organization? What kind of symptoms, what kind of experiences are impacting, their daily life in which the intervention that you provide is what's necessary?
Dr. Russell Gore
That's a great question. So, the types of symptoms that we might expect to be secondary to a history of brain injuries or repetitive exposure to head impacts, or head or repetitive exposure to blast are cognitive symptoms. So, feeling slow processing problems with memory, problems with concentration that may either be stable since a certain point in time that might have been an injury or are progressively worsening. And it's very common for me to meet veterans where these kinds of symptoms seem to be minimal. And they were compensating well during their military service. And now they're five years post military service. Maybe they had another injury of some sort, or maybe not, but they suddenly notice a decline. So cognitive symptoms are a common complaint. Problems with dizziness and imbalance. So, feeling dizzy with posture changes, feeling imbalanced, you know, resulting in a decrease in physical activity or falls, problems with sensory functioning. So that can be, feeling overwhelmed and, in environments where there may be a lot going on, like, we mentioned avoidance behaviors from grocery stores in church, and, and your, your children's school, if those kinds of environments are increasing your symptoms or causing, you to avoid those sorts of environments that would be, potentially a brain injury symptom. Visual functioning folks have changes in vision function. And then there's a big there's an increased risk of emotional dysfunction after having had brain injury. We know that the co-occurring brain injury associated with post-traumatic stress disorder, for example, is at least 50%. And, and that's really based on data where they're only taking into account, in most cases, those individual moments where someone feels they had a concussive event. There's very little literature looking at repetitive blast exposure and how it may be influencing or co-occurring with post-traumatic stress disorder. So, there are folks out there with PTSD diagnoses that have been in treatment. And, and they feel that the treatment has not been able to get them to where they want to go in terms of their functioning. And, they would they then tell us, well, I also have these cognitive symptoms where I feel like I can't keep up with, with my peers at work, or I'm having to do twice as much effort and make long lists, and I'm getting confused when I'm trying to, to function.
Christina Brown Fisher
I know about that, yeah.
Dr. Russell Gore
And that can be secondary to anxiety or post-traumatic stress, but it also can be secondary to brain injury. So those sorts of symptoms are examples that would then what we would, we would be asking about the potential exposures. And again, that can be moments of injury service related or not, you know, big booms in the military where somebody lost consciousness, but they can also be, repeat exposure, things like lots of breech exposures, lots of larger artillery, exposures. And it can be, I take care of folks where they played, college football, and they had lots of head injury exposures before their military service. And they’re, they they're having worries about those sorts of symptoms as a veteran. And we'll find that the brain injury from their their football days, is what is influencing them now. And that those are those are all very, appropriate calls for us to take a look. So we really what we would like is for, for individuals in the community with these kinds of symptoms, to have a low bar for reaching out, because we are we're set up to do this assessment and to do some screening. And and in some cases, we're providing reassurance that, we don't think a brain injury is, is is the primary issue here. And we want to provide support, to address anything we find it that they're the primary issues. In many cases, we're taking care of folks where we absolutely find that a brain injury is, is a big piece of the puzzle. And in in it is not unusual for those individuals to not have a brain injury that's recognized by the D.O.D. or the V.A. just because they haven't been through the process of, of having a full assessment.
Christina Brown Fisher
And what is the out-of-pocket cost, to the first responder or veteran should they decide to utilize Avalon Action Alliance services?
Dr. Russell Gore
So, there is no out of pocket cost at all.
Christina Brown Fisher
I feel like I didn't hear that properly. Are you serious?
Dr. Russell Gore
We’re a donor funded, donor, donor funded programs.
Christina Brown Fisher
You’re going to have people flooding, you're flooding your gates after this.
Dr. Russell Gore
There's no out of pocket cost. We provide, housing on site, we provide transportation, we provide meals. We, and there's no there's no fees for treatment.
Christina Brown Fisher
How critical is all of that? Because what you're talking about is essentially creating an environment in which the only thing, a person is focused on is really rehabilitating. Because all of those things housing, food, insurance bills, medical bills, all of that weighs on someone when they're trying to rehabilitate. And you've basically kind of taken that all off the table.
Dr. Russell Gore
And we were so fortunate to have, donors who believe in this mission, who want for there to be zero financial barriers to, to, to receiving this, this sort of assessment and care. And, and I find that that's often a barrier we even within the V.A. system because of potential travel costs, and they do a great job with, with offsetting those sorts of costs as well. There are a group of veterans who have less than honorable discharge status, for example, who don't have access to V.A. care. And that is and we, we will absolutely assess anyone that calls us if they're, active duty, veteran or a first responder. And so, we don't have that barrier, and which is, which is a, a benefit, obviously, for individuals that don't have V.A. care. And, and so, yeah, we want to take down any, all, any and all of those barriers so that we can help, the most and the help, help individuals with these needs.
Christina Brown Fisher
I want to talk a little bit about the research. First I want to talk about, kind of where we are, technology wise, how, obviously, I can't exactly expect you to pull out your, crystal ball and wave a magic wand and tell us how far away are we from blood tests, from biomarkers, but where is the science and research, leading us? What are the appropriate expectations about what we should be hoping doctors can tell us about what's going on with brain injury?
Dr. Russell Gore
So right now, I would say if we separate research and the needs here into three kind of large categories. So, one would be prevention. You know, how do we prevent these injuries from occurring in the first place or prevent prevent the long term. You know, minimize the number of folks with a protracted recovery. So, you know, a majority of folks with these mild brain injuries, if it's a single injury, will recover within a month of injury and may have no long-term effects.
Christina Brown Fisher
But that's provided that they're diagnosed and treated right away?
Dr. Russell Gore
Correct, correct, well, a lot of folks will spontaneously recover. So we know that only, only you know is a relative term, but 20 to 50% are going to have more long term symptoms. So that means 50 to 80% are having spontaneous recovery. And so that's wonderful if you're in that group, if you're in the 20 to 50% that that have a protracted recovery, you know, then you're you're going to be asking about, well, how could we have prevented the injury in the first place? Or, you know, the next phase is, well, what are we doing to diagnose these injuries, right? So we want to focus research dollars on prevention would be ideal. We also have a problem where we don't have reliable diagnostics that that help us to determine who has an injury and who doesn't. What's the severity of the injury? So diagnosis and then treatment. So so if we think of those as big categories, a lot of the current work that has that in advance is in terms of traumatic brain injury, especially in the mild to moderate range and in the diagnostic space. And that's where we're talking about blood tests, blood biomarkers, imaging methodologies that aren't conventional, normal. You know, MRIs is that you might get more advanced imaging methods, objective assessments of things like balance or eye movements or cognitive testing, for example, anyone you know that has kids playing sports will be familiar with the computerized cognitive testing, like, the impact test. You know, that is, that is a cognitive measure that that can help diagnose, concussion. And, so a lot of the effort has gone into those diagnostics. We're inching towards a solution. The problem is that the brain functions as a group of networks, and those networks all subserve different functions that for you when you're, you know, out in the community. So cognitive function is a network actually emotional function and emotional regulation is a network. It's called the limbic system. Balance function is a network. And eye move, eye movements and eye tracking and occ, and vision function is a is a group of networks. These networks are all overlapping within the brain. And every injury affects the networks in different ways. Right? So we see across those domains deficits. The problem is if if you develop a device, for example, that tracks eye movements, and then you do testing to see if it's a good diagnostic, what we continue to find is, is is disappointing results. And, and I believe that that's because we're only looking at a single network. So we're if we focus a test on just eye movements or, you know, pupil response to light, for example, you know, we're trying to simplify this incredibly complicated organ that has all these overlapping networks for all of these important functions that we benefit from every day down to just pupil response. And so what we find is that as a diagnostic pupil response alone doesn't do, you know, isn't a great diagnostic. We're going to miss folks.
Christina Brown Fisher
It's not telling you everything.
Dr. Russell Gore
It's not telling us everything. And so what we what we've got to have is more multimodal testing, multimodal assessments. And the data really supports this. If we look at cognitive functioning and balanced functioning and visual functioning, then we're much more accurate in our diagnostics. And so again going back to this concept of an interdisciplinary or rehabilitation assessment, you know, you're being evaluated by a therapist that specializes in balance, a therapist that specializes in vision function, a therapist who specializes in cognitive function. And we're putting all that data together to try to build a picture of of your of your brain and your injury. And and so we're doing multimodal assessment, the technology that's out there, partly because of the way that we get FDA approvals and the way that technology and startup businesses work. You know, everyone comes up with an idea that's often single modal, you know, like pupil response, you know, and then they say, “well, we've got to commercialize it and we've got to tell everybody it's this great diagnostic.” And in reality it's it's just one it's only testing one thing. And the brain is much more complicated than that.
Christina Brown Fisher
And it's not there yet.
Dr. Russell Gore
So we're getting there. I would argue the same thing with blood testing. You know, we're seeing some biomarkers are effective for more severe injuries, but they're not great predictors of less severe injury. And so that's a big challenge. And so right now there is not an effective diagnostic that is a blood test. And yet there are a couple of products that are actually FDA approved that are on the market. They're just not useful. And, and so we're inching our way towards diagnostic tests, which will be tremendously valuable because not only can we diagnose from these, especially if they're looking at different brain networks, if we not only can say, “yes, you have a brain injury or no, you don't.” If we have information about each of these networks, that helps to guide a treatment plan, right? So, if you don't have a lot of cognitive issues, but your primary issues are balance and, and, and dizziness issues, then we can put you down a certain path from a treatment standpoint compared with someone who has predominantly a cognitive presentation for example. So, it not only lets us know do you have a brain injury? Those tests would also help us in the assessments that we do help us with where are the bullseyes? Where can we really focus? Which networks are the most involved so that we can, prioritize treatment to, to get the biggest bang from the treatment effort.
Christina Brown Fisher
And again, you're saying, it doesn't necessarily, I don't want to say that it doesn't matter, but, the time from the injury is not, and again, I don't want to say it's not relevant. But in other words, I don't want someone to think, “you know, my injury was ten years ago. What can they possibly do for me now?” Right?
Dr. Russell Gore
Yeah, yeah, that's and that's a really, really good question to ask. What we see in our veteran, servicemember, and first responder program is a vast majority of the individuals we're treating are, far from injury. Our average in the series that we published that I shared with you was seven plus years post that, what what an individual identified as their sentinel injury. So they may have had injuries that were more recent. But we ask was there an injury that for you you perceive as being the most severe where maybe things changed, you started to notice that, these issues emerge that weren't present prior to that injury. So, we call that the sentinel injury. And on average, it's seven plus years after the sentinel injury is what we're treating. What we know within the rehabilitation community and treatment of, of concussions is that the earlier we treat, the more, the less likely it is that you'll have long term symptoms. So, there is a place for seeking care when you have an injury that is four, six weeks and you're not recovering spontaneously, that's critical. And we provide that sort of treatment at a number of the treatment programs. And those individuals need an assessment with a clinician that can help to guide, you know, where the bull's eyes, how can we how can we treat you. And that treatment is generally rehabilitation, that it is what's validated. And then but when we get to the chronic phase, that's a that is a vast majority of the veterans and first responders that we're treating are folks in that chronic phase. And we absolutely see response to treatment. It is not too late again, because folks develop maladaptive strategies for getting on with their lives, those maladaptive strategies are a constant problem. Now it's you know, that's why we call them maladaptive. They're struggling partially because the way that they're handling their injury related symptoms is maladaptive. It's not working. So, we can help change that.
Christina Brown Fisher
Yeah, I know for me, I know for me, I for because I had light sensitivity for a good long while after my TBI, and I just wore ball caps or dark lenses. Actually, I wore amber colored lenses, even at nighttime. Because I was just so sensitive to the light. And it worked, right? I mean, what's what's wrong with wearing a ball cap or what's wrong with wearing these glasses? But of course, at some point you got to, engage in the appropriate therapy, to move you past, to move you past that, which kind of gets back to, something that you said earlier in our discussion, which is there is kind of a type, right? A personality type that is, willing, able to kind of engage in doing, the hard work, if you will. Approximately how long, are most of your, your patients or clients typically having to take part in this particular type of rehabilitative program? Is it weeks, months, year? You know, how do you, how do you prepare someone for the amount of work that they they too will have to put in?
Dr. Russell Gore
So our treatment programs generally range where I mentioned that there's an assessment that's roughly a week, and treatment programs can range within our network to, from three weeks out to 12-weeks of treatment. Now not everyone can take 12-weeks off to come and get treated, right? And so our programs are really designed to be flexible in terms of meeting your needs, with intensive treatment that's on site. And then many of our programs also have the ability to continue certain treatments when you go home and completing a treatment program that's virtual. So, we have clients, we meet you where you're at. We have clients. Well, we'll recommend an eight-week plan of care, but they're not able to stay on site for eight weeks. So, we have them coming for blocks of intensive treatment, and then they go home to meet their responsibilities at home in between. So maybe we spread that eight weeks turns into only four weeks where they're on site, and the rest they're getting support when they're at home virtually. So there are a lot of ways to, you know, what we do is do an assessment, propose based on what we know about your, availability for treatment, like in order to reach your goals, we think this is what it's going to take. And then but then we have that conversation about, well, what's feasible. But as short as a three-week treatment program, we have very strong data that shows that there's, that there's a response to treatment that's very impressive. And, and again, that wraparound approach during that, for example, three weeks, you're receiving as much treatment as you would in the community or in the V.A system. For example, if you're not in an intensive program, you're receiving the equivalent of a 12-week treatment program, crammed into, you know, in an intensive three week block. And that's because all of the therapists are under the same roof communicating with one another. You're getting, therapy continuously for that three weeks, and, and intensive programs are very effective. There are intensive models that have been shown to be very effective for post-traumatic stress disorder, for substance use treatment, for depression. And, and we are, showing that intensive models work well for traumatic brain injury, with those other co-occurring issues.
Christina Brown Fisher
Acting as a cynic here, so can you just kind of help reconcile how, "I've been struggling with x, y, z, TBI symptoms for, let's say, 12 years," explain to me how in three weeks they can be corrected. Can you kind of just give me example of, you know, someone came in like this? Here is the treatment plan that was developed for this individual, and here's how and why it worked.
Dr. Russell Gore
So, you come to our program, you've had 12 years of often, often not 12 years of no treatment, right? Maybe you've been to a few different programs. You've had folks that did something like, you know, treatments that aren't actually that have been invalidated based on most of the research things like, hyperbaric or you've done a little bit of therapy here and there. But essentially you haven't had the benefit of an intensive program. So, you come to us, it's 12 years later. So, when we do an assessment, (a) we're going to identify the primary areas that you have the most need. So let me use, chronic pain as an example. So, folks will come to us and they what, we’ll identify is that the, the, the barrier for their, for their recovery after their mild brain injuries or repetitive exposure to blast whatever led them to this point. Is that they also have chronic pain. They have, back pain, or I just had a gentleman with, significant hip pain related to his sentinel injury. That was a big blast exposure. So, he had head injury related injuries, but he had his ongoing hip pain. That hip pain was leading to, a variety of different maladaptive issues. So, one was a decrease overall in physical activity. So, there were there was weight gain. There was not a lot of physical activity happening because of, struggling, because of limitations from pain. And of course, not a lot of physical activity, you know, leads to an increase in brain injury related symptoms. So, headaches were more common because of a lack of physical activity. There also, you know, you get endorphins from physical activity that help with mood. Then the treatment for the pain was focused on sedative medication treatment, right? So, taking narcotic medications, which are, C.N.S. central nervous system depressants, right? So someone who's on chronic pain medication is going to feel down because they're they're taking a depressant and they're also going to feel cognitively slowed. And those lead to, you know, so those are leading to problems with cognition, work interactions, maybe even the inability to work. Those are going to influence family dynamics and family activities. And so when that individual comes into an assessment plan, the assessment, period, (a) we identify brain injury related issues, but we identify barriers. And so, identifying that the strategies being used to manage the pain are a big contributor to the brain injury symptoms being worsened. And, and, and this individual's inability to move beyond the brain injury symptoms. So, so then part of their treatment plan during that three weeks is to, have a pain assessment with, with a different pain provider that can help with how do we move you away from C.N.S. depressant pain medications, you know, how do we give you strategies? Having intensive physical therapy that's focused on not how do we just decrease your pain, but how do we increase your activity? You know, how do we shift the conversation away from the goal isn't for your necessarily for your pain to go away? Maybe that's not realistic, but we need to figure out how to increase physical activity despite your left hip pain so that we can improve you, improve how clear you feel and give you that, the benefits of physical activity. So that's just one example. Others would be sleep related issues. Others would be headaches that are, post traumatic related, but now they're also migraine, right? And often we're dealing with a little bit of all the above. So that wraparound approach gives us an opportunity to identify, which of those barriers are the biggest bull's eyes. And in a very short period of time, we can get the ball rolling towards addressing those bull's eyes. The other piece that that that can't be neglected is that during these treatment periods, we're also coming up with what we call a wellness plan. And that is, you know, who needs to be on your team and what should your plan be when you leave treatment in order to continue your progress? And what we've shown and the some of the literature that I, that I, shared with you from our lab showed that clients meeting their goals at graduation from our program were significantly better than when they entered. We also followed them for a year after their injury, after graduation from our treatment program. And what we showed was that their they were statistically even better 12 months post-treatment, right? So that journey is the treatment. The intensive treatment is just the start. So, the idea is that then we help develop a wellness plan where we help with we've got to find a pain provider, that's going to give you access to interventions that aren't narcotic medication, for example. We've got, we've got often we're getting folks off of medicines. There's a huge amount of sort of polypharmacy and overtreatment in individuals with these challenges because …
Christina Brown Fisher
And getting off the medicines is improving the brain injury symptoms?
Dr. Russell Gore
Yeah, it, it is, in and in, but we have an opportunity. You want to do that with, with medical supervision. And we have an opportunity because we're with the individual for a number of weeks to be able to target. Let's okay. Let's start with this medicine and let's wean it. Let's, let's look to see where we have where we can take medicines away to really focus the medicine treatment on the, on the medicines that are, that are the bull's eyes. And so, in some cases we're starting a medicine that's, that is, a critical, you know, performance improving. You know, depression is one of your biggest barriers. “Gosh, let's see if we can really hold your hand and get you through that first few weeks,” where people tend to notice the most side effects. And if we can get beyond that and improve your depression with this level of support, then here you are now you're tolerating and benefiting from a single medicine, let's say. Or sometimes folks come to us and they're on 12 medicines that are affecting their brain. And we set up a plan not just for the treatment program, but for that year, for how do we slowly try to decrease the medicines that you're on, because in many cases, they can be contributing to the problems. And again, without a wraparound approach, these are big challenges for an individual clinician. You got to realize when you see the physician, whether it's a specialist or a primary care physician, in any setting, you know, they in general are having 15 to 30 minutes of time to think about what they need to do with you.
Christina Brown Fisher
If that, if you even get a half hour.
Dr. Russell Gore
And yeah, and that's, that's a that yeah, that would be generous to have a full 30 minutes. When I'm seeing, clients through this program, I've got a team of clinicians that have spent days with the client during an assessment, and then myself and my medical staff, my nursing and, and, and medical support staff, you know, we're digging into records like we're really able to, to digest because we have the luxury of an entire team that's systems focused, looking at these different systems. And then we've got all the records right there. We're able to really sit down and help with, where are the bull's eyes? What can we do to start taking away barriers? And that isn't just for the intensive treatment component. That's also developing a plan for what things should look like for that 12-months. And that's where we see the biggest gains.
Christina Brown Fisher
I just want to very quickly kind of dig in a little bit more on the research that you shared with me and specifically, I want to talk about, the patterns that emerged in terms of, successful outcomes.
Dr. Russell Gore
Well, folks that came to us more separate from the world. So, they were the more isolated folks, they were more depressed. They tended to be, more likely to be in their basement, you know, as a, as an analogy. But of course, not everyone at all is in their basement, but they feel like they want to be right, you know, or, you know, struggling in terms of those avoidance behaviors, those individuals. That was one of the predictors for the best response because our program is giving you tools, you know, you are, around your peers. There's peer support folks that are within the program that really get you as, as our one of our peer support guys likes to say, you know, he, speaks infantry, right? And so, you know, you know, it's a very unique clinical setting to have that level of support, along with all the clinicians, many of which have a connection with, service members and veterans within their family or their veterans themselves. And so being in that supportive environment but helps you to get to get back into the community. So what we found was, as we would expect, given the structure of our programing, community reintegration was an area we were succeeding in spades.
Christina Brown Fisher
The study you shared with me was 91% men, in terms of the predictors of goal attainment at discharge they tended to be men. They tended to have higher cognitive and physical abilities. Were there any other factors that you were able to take note in terms of what was also informing, how well someone did coming through this program?
Dr. Russell Gore
Areas where we need to do better, as you indicated, a smaller percentage of our clients are women. And, and men, male sex tended to be a predictor of success in the program, suggesting that that our females weren't as responsive to treatment. Now, part of that may have been, partially secondary to the fact that the program is, is a lot of males, right? And so, you know, opening up and having conversations about what your needs are and about your traumas and those sorts of things and some of the group settings and the, the group component of our treatment, which everyone isn't involved with, it depends on your needs. But, you know, that maybe wouldn't lend itself as well if you were, not represented in the group. If you're, let's say, the only female in treatment at that point. But there are a lot of unique needs among women veterans that that we realized that we need to dig deeper into and learn how to, to cater our treatment as individually as possible to those needs. So that was an area that we really identified that we needed to do better. So, you know, I would say on the whole, what we found, you know, were some logical findings. One was the longer that you were in treatment, the better your outcomes. You know, treatment, you know, which which makes sense. If you get a higher dose, well, it would be logical if the treatment works and you get a bigger dose than, well, you probably would have a bigger response. And so that was a logical result of that effort. But it validated, you know, that we have a very we have a flexible length of stay. So, if you need to be there longer in order to meet your goals, depending on, on what you’re, what we're addressing then, then we want to provide that extra treatment. And, and so there were a number of, there are a number of areas that we've learned in terms of strengths and relative weaknesses in, in this approach. And so, it's definitely not for everyone. But what's nice about our approach is that we do a comprehensive assessment, so we get a chance to sit down with you and talk about these things because it's so individualized and that's unique. You know, you don't I we've all had the opportunity and health care to kind of have that, there's that experience of you show up and it's “well this is what we do.” You know, first you do, you know, it's, it's A,B,C. Everyone does A,B,C well that, you know, there's a lot of, discussion these days about individualized care and, and patient centered care. And, and by definition, if you show up and you're told, well, the treatment for this is A,B,C for everyone, well, that's not very individualized. And I think, what we found was that trying to, to cater our treatments to the needs of the individual, individual, veteran or service member as well as their individual goals has really, helped us to become more client centered or our patients centered. And, but that's hard to do. You know, it's it's not an easy treatment for other people to emulate. Just because of the resources required. You've got to have, you know, not it's hard to come across therapists that are specialists in, in, in neuro rehabilitation…
Christina Brown Fisher
And even harder, getting an appointment with them, too, for the few that are out there.
Dr. Russell Gore
Yeah it is. And so, you know and so we want to figure out we're working on how this can be a hub and spoke model. You know. But because we want to get folks in for assessment, not everybody needs the intensive program. And then we set you up for success when you leave, if you don't. But if you need the intensive program, the assessment is going to go going to tell you that. And, and then and then give you a very clear, as you indicated earlier, expectation for, you know, if I invest this much time, this is what our team feels like your outcome will be. And and then you can make that value decision, right? It's up to you.
Christina Brown Fisher
My guest has been neurologist, researcher and scientist, Dr. Russell Gore who is the founding director of the Complex Concussion Clinic at the Shepherd Center, in Georgia, and serves as Medical Director for Shepherd's SHARE Military Initiative which provides medical treatment, research and rehabilitation for service members.
Dr. Gore is the Chief Medical Officer for the Avalon Action Alliance. The Avalon Action Alliance is a national network of programs treating complex and mild traumatic brain injury for first responders, active duty military servicemembers as well as veterans. Details about how to connect with the Avalon Action Alliance are provided within the show notes.
This program is for informational purposes only and does not serve as medical advice. Please speak with your medical professional before seeking treatment.
Thank you for joining me, I’m Christina Brown Fisher, and again, I can’t say it enough, thank you, thank you, thank you, for your continued support of Me, Myself and TBI.