On the Front Lines

Dr. Carlos Jaramillo and fellow researchers at UT Health San Antonio take a holistic approach to treating returning veterans who have suffered traumatic brain injuries

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By Ivy Ashe
Population Health Scholar
University of Texas System
PhD Student in Journalism
UT Austin Moody College of Communication


Since 2001, about 2.5 million service members have deployed to war zones in Afghanistan and Iraq.

Between 15 and 22 percent returned home having suffered some form of traumatic brain injury, typically a mild TBI (concussion).

A traumatic brain injury isn’t a war-specific condition. Veterans are subject to getting TBIs in the same ways civilians are, such as car accidents and falls. But exposure to improvised explosive device (IED) blasts leads to traumatic brain injuries with such frequency that the TBI is considered the signature injury of modern warfare, according to one Department of Defense-commissioned study by the RAND Corporation.

The signature injury is also a largely unseen one.

“It’s not obvious from the outside that people are suffering from issues such as traumatic brain injury or post-traumatic stress disorder (PTSD),” said Dr. Carlos Jaramillo, assistant professor in the University of Texas Health Science Center at San Antonio’s Department of Rehabilitation Medicine. “They might not always have overt scars.”  

Jaramillo works in the Polytrauma Rehabilitation Center at UT Health San Antonio, a facility dedicated to care of Iraq and Afghanistan veterans (polytrauma refers to a veteran having suffered multiple life-threatening injuries). Built in 2011, San Antonio’s PRC is one of five across the country. Jaramillo joined its staff in 2012, fresh out of his UT Health San Antonio residency. His research, primarily funded by the DOD, the U.S. Department of Veterans Affairs, and the National Institute of Health, focuses on the long-term effects of injuries like TBI. That means investigating not only the TBIs themselves, but their multiple co-occurring conditions.

“We’re treating a lot of symptoms that can be assigned to TBI, but they can also be associated with depression and PTSD, as well as chronic pain,” Dr. Jaramillo said. “What we’ve learned clinically is that you can’t easily assign these symptom to one of these diagnoses. You can’t always say this is just PTSD or TBI. If you treat one, some of the symptoms don’t resolve, and vice versa.”

This phenomenon is in part because typical TBI treatment tackles one symptom at a time. Medication for one symptom, however, can have side effects that resemble other TBI-related conditions. For example, headaches, dizziness, insomnia, difficulty concentrating, and irritability are all signs of a mild TBI (concussion). They’re also all side effects of medications that work on the central nervous system, Jaramillo said. Treating for a headache can lead to dizziness and vice versa, which further obscures the underlying problem.

Understanding the links between symptom and medication, the overlaps between TBI comorbidities, and the ways one condition can amplify--or mask--another medical issue is tricky enough when working with civilian patients. For military members, the problems become more complex.

“What we’re challenged with is teasing apart all the other effects from their deployment,” Dr. Jaramillo said. “Sleep deprivation, the stress of life-threatening work, being in combat and the first-hand witness and experience of trauma--and then coming back and not having that same sense of purpose and drive after deployment. It puts someone in a completely different state.”

“In a lot of cases they’re needing to heal both physically and emotionally.”

UT Health San Antonio is part of two nationwide efforts aimed specifically at addressing these dual wounds. Together, the Consortium to Alleviate PTSD and the Chronic Effects of Neuroscience Consortium have received more than $100 million in funding from the VA and DOD. San Antonio is one of the lead sites for CAP’s work, which focuses on developing ways to treat PTSD to a point of remission.

The CENC project emphasizes study of long-term concussion effects and includes key players like Dr. Ann McKee, best known for her work on chronic traumatic encephalopathy in professional football players. Epidemiologist Mary Jo Pugh, who frequently collaborates with Jaramillo as well as fellow rehab medicine colleague Blessen Eapen, leads the UT Health San Antonio team. A current project examines the role of cognitive behavioral therapy in treating headaches experienced after TBIs, while another just-funded DOD study will attempt to determine how much cognitive rehabilitation is ideal for treatment.

TBI research over the past decade has increasingly moved toward treatment via the holistic approach. Identifying non-pharmacological means of intervention is considered a primary need for physicians.

“We have to work in interdisciplinary teams that have expertise in different areas,” Jaramillo said. In this way, the partners on a treatment team are similar to those of the research teams working in CNEC: Jaramillo, Eapen and Pugh also work with UT Health San Antoniopsychologists Cindy McGeary and Donald McGeary.

“The biggest thing is that people want their lives back, and they don’t want a lot of medication,” Jaramillo said. “We have to get really creative in how we do that. It’s forced us out of the typical doctor mindset of ‘There’s a disease and there’s a medication that cures that.’”

Better understanding of ways to treat veterans can also lead to improved treatment for civilian populations.

“People have multiple comorbidities now, and there are a lot of people who have more than one condition,” Jaramillo said. “We want to be able to contribute to what the rest of society is struggling with as well.”