Not all combat wounds are easily seen by a soldier’s battle buddies, family members or even medical providers, according to Dr. Maria Aviles, clinical psychologist chief for Winn Army Community Hospital’s Warrior Restoration Clinic.

She said traumatic brain injuries, combat operational stress and chronic pain don’t look like other injuries, and they cannot be treated as such because they don’t heal the same way.

"We want to take care of the whole person," said Aviles, noting that many of the patients seen at the WRC for TBI have

additional injuries — including amputations — and trauma from these injuries often contributes to unseen wounds that even the soldier isn’t always aware of. "Many soldiers go through a pain/depression cycle following an injury. Chronic pain reminds them they can no longer play with their kids the way they used to or do other things they’ve always enjoyed doing. They have to learn to make adjustments in their lifestyle, and that takes time."

Aviles said most of the TBI patients seen in her clinic are there for injuries incurred in combat, usually from exposure to mortar shelling and improvised explosive devices. She emphasized that combat injuries are not like most sports injuries, nor are they treated like sports injuries. A team of doctors may work with the wounded soldier, including a neurologist, psychologist, speech therapist and ophthalmologist, she said. Through this holistic medical treatment, the WRC helps the soldier recover from his injuries and return to duty, or it prepares him to return to civilian life if the Army decides his injuries prevent continued service.

Without disclosing the soldier’s name, Aviles discussed the case of an infantryman with more than 10 years service whose vehicle was following closely behind another vehicle that hit an improvised explosive device. The blast reinjured a previous lower-back injury, and the soldier received a concussion, or mild TBI. Aviles admitted it was a battle buddy, not a medical provider, who first noticed the soldier wasn’t acting normal. He wasn’t responding to the attack the way he had been trained. He seemed disoriented and confused about what he was supposed to do.

"This soldier has a young family, and he doesn’t want to leave the Army. This was the career he chose for himself and how he wanted to support his family," she said, noting the soldier didn’t respond well to news that his back injuries were too severe to continue his military career, and his response prolonged his recovery from the mild TBI. "He became very depressed. I wanted to open a door for this person and show him there were other options for him. So, I met with his case manager, and with medications and therapy, he’s now doing a lot better at adjusting to his situation. Now he’s pending a medical review board."

In addition to treating soldiers with TBI and chronic pain, Aviles said the WRC also works with soldiers suffering from combat operational stress, which, she said, isn’t the same thing as post-traumatic stress disorder.

According the Army Behavioral Health website, www.behavioralhealth.army.mil/provider/general.html, combat operational stress is a sub-clinical diagnosis with a high recovery rate if the soldier is provided with appropriate medical care and time to recover. Post-traumatic stress disorder is an anxiety disorder associated with serious traumatic events. It included specific chronological requirements and symptom markers that can only be diagnosed by trained, credentialed health-care providers.

One of the tools Aviles said the WRC uses to treat soldiers with combat operational stress is a full-scaled humvee simulator and a 50-caliber machine gun turret, complete with virtual reality goggles that test soldiers’ cognitive reactions to real road situations that occur in combat.

"This system includes a map of Iraq that follows routes familiar to some soldiers," she explained. "The simulator allows the soldier to work through the stresses associated with combat operations without the risks."

Aviles said she believes the role of clinics like the WRC should be expanded by the Army, with more emphasis placed at the unit level to help soldiers and their leaders to identify unseen wounds. Earlier detection of these injuries will help prevent delays in a soldier’s rehabilitation, she said.