Traumatic brain injured individuals do have hope at recovery, as new research shows that people continue to recover, sometimes for a lifetime, as long as they are actively in treatment or utilizing tools that they learned, according to neuropsychologist Dr. Zonya Mitchell.
While the greatest visible progress in recovery happens in the first six months for the brain-injured patient, after that timeframe, she said there are still improvements, but they may not be as obvious; and that after a year, professionals can reasonably predict how much recovery a person's going to make, even though it may not have happened yet.
"People continue to improve for many years after a brain injury and this is pretty new to the medical world's thinking, because just maybe a year or two ago, it was felt that after the first year or two, there is going to be very minimal, if any, recovery, but new research shows that people continue to recover sometimes for a lifetime as long as they are actively in treatment or utilizing some of the tools that they learned before," said Dr. Mitchell, who spoke via live video on the role of neuropsychological testing and neurorehabilitation at the most recent Doctors Hospital Distinguished Lecture Series.
According to the neuropsychologist, all brain injuries, whether severe or mild, should be subjected to neuro-psych testing, because the effects of mild brain injury can't be determined by just an examination.
Neuro-psych testing typically begins with an important clinical interview to understand how a person functioned before the brain injury, to gathering information from family members and the individual themselves about symptoms and how things changed.
"Brain injury refers to the occurrence of an insult to the brain that causes damage. It is typically divided into two categories -- traumatic brain injury (TBI) is defined as a blow or jolt to the head (car accident, punch or fall), or a penetrating head injury (stab wound or bullet to the brain) that disrupts any of the brain's function. And it is important to determine functioning and treatment needs after the brain has been compromised and for children suspected of developmental disabilities," said the clinical lifespan neuropsychologist, who specializes in neuropsychology and neurorehabilitation psychology.
Dr. Mitchell said acquired brain injuries are usually caused by some medical conditions, including strokes, pneumonia, brain tumors, diabetes, encephalitis, aneurysms, anoxia (lack of oxygen during surgery, drug overdose, or near drowning), metabolic disorders, meningitis or brain tumors.
"Neuropsychological evaluation is an assessment of how one's brain functions. The point is to tell us what's happening in the brain -- both where the damage has occurred, and how that's affecting a person's ability to function in real life. It provides a lot of useful information about what a person can and can't do that may not be able to be seen otherwise," said the Bahamian doctor who is based in New York.
Coming out of brain injury awareness month, which was recognized in March to raise awareness, Dr. Mitchell said neuropsychological assessment provides useful information about a patient's cognitive functioning, something that may not be easy to obtain otherwise. And that neuropsychological tests evaluate functioning in a number of areas, including intelligence, executive functions (such as planning, abstraction, conceptualization), attention, memory, language, perception, sensorimotor functions, motivation, mood state and emotions, quality of life and personality changes.
Dr. Mitchell who is employed at an affiliate clinic of the North Shore-Long Island Jewish Hospital System, and is a consultant neuropsychologist at Doctors Hospital and director of the Mind Institute in New Providence, said when cognitive complaints are reported or persist following a mild traumatic brain injury in adults, neuropsychological testing can assist with diagnostic issues as well as with treatment and rehabilitation planning.
Value of neuro-psych testing
"The point is to understand the nature, the severity of the complaints that an individual is basically trying to convey to either their doctor, family member or neuropsychologist. So while an MRI (magnetic resonance imaging) can show you which part of the brain may be injured, it cannot really give you information about how that injury is affecting the person. It can't tell us if a person has a verbal memory problem ... how that presents itself by either problems retrieving information but not encoding it into memory. It really just says here is a blip on the brain in the temporal lobe or frontal lobe; the neuro-psych testing allows us to find out how that blip is affecting a person's behavior, and their ability to go back to work, school, or survive at home."
Dr. Mitchell, who is also a trustee on the board of the Mitchell Ekedede Brain Injury Foundation, for which one of the missions is to bring about more brain awareness to the Bahamian community as well as education, said along with assisting with diagnostic issues, neuro-psych testing is used for deciding the kind of treatment necessary to plan a person's rehabilitation.
Test administration
The cognitive and emotional domains that are typically assessed in a comprehensive neuropsychological assessment are intellect, higher cognitive abilities (executive functioning), attention, memory, visual-spatial abilities, motor and sensory abilities and emotional status.
How quickly a person processes information, their working memory as far as holding information like a telephone number they need to hold onto for a few minutes until they can dial it or write it down, as well as their ability to plan, organize, reason and judge, mental flexibility and abstract thinking are taken into account during the test.
"We also look at attention because it's important to not only investigate whether someone is still able to focus, but also if they're able to use joint attention -- if they can listen to someone speaking to them while there's noise on the other side of the room or if TV is playing, they can both hear the TV and the phone ringing and pay attention to both."
Verbal, visual, short-term memory or long-term memory loss may be experienced by the brain injured person. Investigation of visual-spatial abilities, which tells them if a person is able to drive or would get lost if they go out, also has to be determined. They also look at the patient's motor and sensory abilities -- whether they can button a button or zip a zipper.
She said it all must be taken into account in understanding how much care the brain injured person may need once they leave the hospital. Dr. Mitchell said a patient's emotional status is always evaluated.
Neuro-psych testing, she said, helps doctors plan treatment to set goals to see the next level of functioning they can try to reach with a patient, such as life planning or whether the person will need a guardian to take over their affairs. It is also used to evaluate the effectiveness of a rehab program.
"If something is put in place and everybody is working hard trying to rehabilitate the brain injured individual, we have no way of knowing if it's working without being able to continuously evaluate along the way. It's important if something isn't working to re-plan. We also use neuro-psych testing to give more information about what skills a person has, such as being able to live alone, return to school or study, drive a car, or manage their finances, preparing for a significant change such as leaving hospital or changing accommodation. And to establish the existence of a brain injury, the extent of that brain injury, and the disability that person suffers, so that we can quantify it if someone is seeking compensation because the brain injury is not their fault, and they can put the onus on a company or person, and/or their insurance company to pay."
Unlike a broken bone for which healing can be measured in weeks to a few months, Dr. Mitchell said brain injuries do not heal easily. She said recovery from a concussion or a mild brain injury can also be short, but when you have a substantial brain injury, recovery can take months to years, or even be lifelong.
Neurorehab she said tries to focus on a person's whole well-being and offers a series of therapies from different modalities. The most important therapies, she said, are those that help people live their everyday lives. They include physiotherapy, occupational therapy, psychological therapy, cognitive rehabilitation therapy, speech and language therapy, vision therapy, and therapies focused on daily function and community reintegration.
Neurocognitive rehabilitation therapy
"Neurocognitive rehabilitation program will focus on one or several of the following areas, depending on the brain injured person's needs -- neurocognitive rehabilitation (learning, memory and executive functioning skills); cognitive behavioral therapy (anxiety, depression, anger management, affect regulation and social adjustment); assistance with family stressors related to the injury/illness and/or disability; cognitive behavioral therapy for pain management and back to school transitions (letting teachers know how to best assist an individual in the classroom)."
The neuropsychologist said key points of successful rehabilitation and making sure that progress happens as quickly as possible, is understanding the severity and location of a brain injury. She said it really affects rehab and how much skills a person can gain.
"How quickly you start rehabilitation is very important, and can start while the person's still in a coma by stimulating the brain until the person wakes up. Once they're no longer acute and start to recover, rehabilitation should start."
A person's attitude -- whether they're positive, have hope and faith and believe they will get better -- she said, also factors into the healing process.
The rehab team and their experience, as well as family cooperation is also important in recovery, according to the doctor. She said if the brain injured patient does not have a team of people that are working together and experienced in neuro-rehab, that obviously can affect progress.
Cognitive rehabilitation
Cognitive rehabilitation really aims to be holistic, patient-focused, inclusive, participatory, sparing, lifelong, resolving and community-focused. And the four components of CRT include education, process training, strategy training and functional activities.
Education, she said, is about cognitive weaknesses and strengths, with the focus on developing awareness of the problem. Understanding and developing an awareness of the actual problem, she said, is important in recovery, and that knowing your own weaknesses and strengths can help you understand why its necessary to participate in a rehab program and help you focus on what you need to do.
Process training, she said, in reference to the development of skills through direct retraining or practicing the underlying cognitive skills, focuses on resolving the problem. If you spend any time in the hospital that's significant. She said a patient has to learn how to walk again because they forget.
Strategy training, involving the use of environmental, internal and external strategies, is where the focus is on compensating rather than resolving the problem. When you come in the door to your apartment everyday, you hang your keys in the same place and they're always there, even if you don't know how they got there, because they're always there, because it becomes an automatic process.
Functional activities and training involve the application of the other three components in everyday life, with the focus on real life improvements. She said training takes all of the other components and looks at how it works in everyday life.
Restorative and compensatory treatment and outcomes
"We kind of decide by the severity of the impairment whether we're going to use restorative methods of rehab or compensatory methods, which is trying to use strategies to get around having to use your brain, or are we going to use both. Once decided, we look at the potential mediators and moderators, because things can get in the way of progress and can affect it."
Restorative treatment is aimed at improving, strengthening or normalizing specific impaired cognitive functions.
Compensatory treatment seeks to provide alternative strategies for carrying out important activities of daily living, despite residual cognitive treatment.
When looking at outcomes, the neuropsychologist said they're looking at the brain-injured patient's participation in society, and regaining a certain quality of life which they measure by the person's employment status, role in the home, educational attainment, community participation, quality of life and family/caregiver health.
Computer-assisted cognitive retraining
"As technology advances, we have more computerized ways of helping to retrain the brain. Right now, more than 73 percent of the neurorehab centers in the United States use some kind of computer-assisted cognitive retraining software. However, these programs still use the principles of cognitive rehabilitation, they still have to be individualized and still work on restoring cognitive function. Right now, the most successful programs have made a lot of inroads improving attention, visual processing and reasoning and problem-solving. But you still have to have a skilled clinician -- they have to understand what programs to use, how to analyze data, why they're using it, and how it fits into the person's current overall treatment."
Despite this, Dr. Mitchell said that rehabilitation after brain injury is largely unpredictable as every injury is unique.
"Unlike most other cells in the body, brain cells do not regenerate when they are destroyed. However, the brain is somewhat flexible and is sometimes able to reorganize itself, and use whatever other functioning parts of the brain to regain lost function. Rehabilitation aims to help the brain learn alternative ways of working in order to minimize the long-term impact of the brain injury. Rehabilitation also helps the survivor and the family to cope successfully with any remaining disabilities."
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