Brain Injury Research. State of the Art.

Thomas Felicetti, PhD

The following is an informal and obviously not exhaustive summary of some aspects of the state of the art in brain injury research. This summary is divided into three areas:

1. Research on aging with brain injury.
2. Research on falling and brain injury.
3. Research on optimal cognitive interventions in brain injury.

This data will be used in the following ways:

a.) To be shared with residents of Whitemarsh House via a special instructional unit on brain injury. In language accessible to these consumers.

b.) To be shared with Whitemarsh families, stakeholders and the general public via the web site.

c.) To be shared with Whitemarsh staff via targeted in-services and trainings in brain injury.

Aging with Brain Injury

This section draws from the following articles of Felicetti, Trudel, Purdum and Mozzoni:

Felicetti, Thomas PhD “Preface: The Graying of Brain Injury” The Journal of Head Trauma Rehabilitation Volume 23 #3 May-June 2008.

Felicetti, Thomas, PhD “An Update on Activities of the Long-Term Issues Task Force.” IBID

Felicetti, Thomas, PhD, Trudel, Tina, PhD and Purdum, Christina, MA. “Obesity, Overweight and Hypertension in Brain Injury”. Rehab Pro Vol 15, #1 February-March 2007.

Trudel, Tina PhD, Felicetti, Thomas PhD and Mozzoni, Michael PhD “The Graying of Brain Injury; an Overview” Brain Injury Professional Vol 2 #2.

Felicetti, Thomas PhD, Trudel, Tina PhD and Mozzoni Michael PhD “Health, Aging and Brain Injury” Lippincott’s Case Management Vol 10 #5

Please note: These articles, among the early systematic investigations of state of the art in aging and long-term issues in brain injury, were written under the auspices of the long term issues task force of the brain injury division (BI-ISIG) of the American Congress of Rehabilitation Medicine. That work goes on today and is updated by new Chair of the task force Dr. Flora Hammond et al. Dr. Hammond is Medical Director of the Rehabilitation Hospital of Indiana, so please refer to the published works of Dr. Hammond and her colleagues for updated and current state of the art information. Furthermore, please refer to the 2009 fact sheet by Marilyn Lash, MSW Associates on this topic. Also rather current information on the topic can be obtained in the publications of Hibbard, Mary PhD and Gordon Wayne, PhD (Mount Sinai Rehab). Finally, a fact sheet developed by David Krych et al (Remed Recovery Services) is most helpful on this topic and was developed subsequently to the articles by Felicetti, Trudel and Mozzoni. As I summarize the various findings on aging with brain injury, I am drawing freely on the published work of Hammond, Lash, Hibbard, Gordon, Krych et al. Again, this is an informal teaching tool for clients, families, stakeholders and staff of Whitemarsh House and is not intended as a free-standing research paper.

Some Basic Concepts on Aging with Brain Injury

When we present our papers at conferences on this topic to caregivers and families and to individuals with brain injury, we advise at the outset that the challenges of aging with brain injury can seem extremely daunting. But we urge that the consumers not fall into undue pessimism or depression over possible sequelae. To begin with, these are clusters of outcomes post-brain injury that affect sub-groups of individuals. And some people fully recover without the problems addressed here. Virtually no-one exhibits all of these symptoms. Secondly, while the statistical data are valid in the overall brain injury population, facing the potential problems squarely can help prevent more serious issues. Many of the consequences we studied are medical in nature, as that was the essential focus of our research, but our various surveys did tease out some non-medical outcomes as well.

What follows is a partial basic list of consequences for some individuals as they age with brain injury:

1. Obesity, Overweight and Hypertension.
2. Addiction (alcohol and drug seeking) ( May also have pre-morbid roots).
3. Increased falling (please see next section).
4. Increased tendency to early dementias.
5. Seizures.
6. Loneliness and social isolation (Lack of companionship of significant other and of peer groups). (Sometimes termed as poor social capital).
7. Headaches.
8. Lower vocational opportunities.
9. Dizziness.
10. Tendency to avoid important medical screenings and diagnostic tests (unless individual lives in a rehab or personal care facility or nursing home).
11. Depression and Anxiety.
12. Memory Loss (especially short term memory but may also involve pre-accident amnesia as well as immediate post-trauma) (see section 3).
13. Judgement issues
14. Overall planning issues, concrete thinking, word-finding, speech impairments, difficulties with recognizing body language of others etc. (Again see section 3).
15. Potential suicidal thoughts or gestures.
16. Less engagement in leisure activities.
17. Repeat head injuries.
18. Fewer opportunities for safe driving or increased traffic accidents while driving (Often related to difficulty in planning ahead…seeing potential hazards in streets ahead of the vehicle).
19. Increased irritability and anger (Again also related to driving behavior).
20. Emotional lability in the form of bouts of uncontrolled laughing or crying.

Some Causes Of Falling With Brain Injury

We draw this partial summary primarily from the following articles, papers and publications:

Felicetti, Thomas PhD “Falls Prevention at Beechwood” Beechwords Fall, 2009.

Felicetti, Thomas PhD “”Falling in an Aging Brain Injury Population…” Professional Case Management Vol 14 #3 May-June 2009.

I again rely somewhat on my own research for this section because I can obviously speak most accurately to these concepts. However, once again I urge the reader to pursue other and quite current sources as discussed in section 1. Furthermore, the fact sheet developed by Krych and his colleagues is also indispensable here and the fact sheet on falling developed by the American Physical Therapy Association is considered an authoritative classic in the field. These concepts on causation draw from all of these sources, not simply from my own data.

Some Basic Falls Causation with Implications for Falls Prevention:

1. Fear of falling.
2. Inattention or hyper-attention to walking or navigating in the environment (Hyper-attention in some cases is related to fear of falling).
3. Environmental clutter, especially around doorways and egress points. (Especially important for caregivers and consumers to do an environmental “environmental survey” of rooms frequently to check for loose carpets, wires, objects blocking passage-ways etc.).
4. Slippery surfaces. (Especially important to be vigilant in using bathroom after roommates etc. have showered or bathed).
5. Falls during aggressive outbursts or when victim of aggression.
6. Improper use of wheelchair equipment such as seat belts.
7. Improper use of adaptive equipment such as canes, crutches etc. (Special vigilance to actually using canes instead of swinging them above hazard or above walking surface).
8. Refusal or unwillingness or impatience with waiting for assistance from caregiver.
9. Impulsivity is related to cause #8.
10. Improperly working van or vehicle equipment such as poorly working lifts or defective entryways and exits of vehicle.
11. Refusal or unwillingness or inability of consumer to follow prescribed safety procedures. (May also be due to memory lapses rather than intentional obstinacy).
12. Dizziness.
13. Vertigo may be related to medication and medication changes. (Special caution urged when medication is changed).
14. #13 May also be related to drug interactions or alcohol or drug use. (Wariness is urged when using Narcotics to relieve pain or for recreation).
15. #13 May also be related to other medical conditions (Be wary of low blood pressure etc.).
16. Deteriorating muscular or orthopedic ability. (Physical therapy may be indicated here or medication for osteoporosis, diabetes, etc.).
17. Poor lifestyle factors such as smoking, lack of exercise, lack of stretching, lack of strengthening activities, lack of weight bearing activities etc. (Here Yoga and Tai Chi are sometimes used as adjuncts to other medical treatments.) Consult physicians.
18. Confusion.
19. Some frequency in second falls or repeat falls causing second brain injury.
20. Excessive noise or commotion in Milieu. (Sound sensitivity not uncommon in brain injury. Headphones sometimes used by consumer to create “white noise” effect in loud environments. Care-givers must also practice calm quiet behavior in these circumstances.

Optimal Cognitive Interventions in Brain Injury

This summary is drawn largely from:

Cicerone, Keith D, PhD, Langenbahn, Donna M PhD, Braden Cynthia, MA, Malec, James F. PhD, Kalmar Kathleen, PhD, Fraas, Michael PhD, Felicetti, Thomas PhD, Laatsch, Linda PhD, Harley, Preston J, PhD, Berquist, Thomas, PhD, Azulay, Joanne PhD, Cantor, Joshua, PhD, Ashman, Teresa, PhD. “Evidence-Based Cognitive Rehabilitation: Updated Review of the Literature From 2003-2008.” Archives of Physical Medicine and Rehabilitation Vol 92 #4 April 2011.

It was a privilege to be a very small part of the research team on these data generated by Dr. Cicerone et al. The series of updates on the state of the art in Cognitive Therapy were conducted under the auspices of the Cognitive Task Force of the Brain Injury Division (BI-ISIG) of the American Congress of Rehabilitation Medicine. (ACRM). With the Cognitive Task Force still in operation under the guidance of Dr. Cicerone since my retirement from ACRM activities, there may well be an even more current published update or one may be coming soon.

The research methodology for determining the top classes of studies underpinning state of the art Cognitive interventions, was quite sophisticated and need not be elaborated upon in this summary which only seeks to serve as an accessible teaching tool for Whitemarsh residents, staff, stakeholders and families.

Let it suffice to say that for a then Executive Director of a Post-Acute Rehab Facility like me, without the kind of research staff that is available to those serving in large Rehabilitation Hospitals, this was a great opportunity to work with and learn from, some of the leading brain injury experts and researchers in the field.

In summary, this large meta-analysis found substantial evidence to support interventions for attention, memory, social communication skills, executive functioning, problem-solving and awareness and comprehensive-holistic neuropsychological rehabilitation after Traumatic Brain Injury (TBI). Evidence also supports visuospatial rehab after right hemisphere stroke and interventions for aphasia after left hemisphere stroke.

It is important to consider this data in relation to section 1 and section 2 of this teaching tool. So many of the apparently “dismal” prospects of aging with brain injury and falling with brain injury are cognitive in nature.

For example, the profound loneliness or lack of social capital experienced by some such individuals as they age can be tied to speech impairments and poor communication skills. There is now solid evidence that these are skills that can be re-learned or at least ameliorated to some extent. The same is true for the many implications of memory loss in the graying of brain injury, for judgment issues and for overall planning (Executive Functioning).

And in the propensity for falling with brain injury, we again now have strong evidence for the efficacy of interventions for inattention, hyper-attention, memory (still again), planning ahead, and confusion.

So given this research as a whole, we can see that so many individuals with brain trauma and stroke long after the initial trauma can have increased quality of life and safety, given adequate cognitive therapy by trained professionals.

As said in the previous paragraph, it cannot be repeated enough that this is nothing short of a call for reversal of our thinking on allocation of Government and private rehab dollars. Individuals well post-trauma can benefit from such intervention.

This is a call for extreme public advocacy in the political and social arena.

January 4, 2018