Venerable TBI program continues innovations

Facility renowned for Return to Driving program

[Editor’s note: This is the second in a two-part series about traumatic brain injury (TBI) treatment and advances in understanding and services among rehab facilities and providers. In last month’s issue, there were articles about a rehab facility that treats TBI patients holistically and another TBI program that trains staff on behavioral management skills. This month we will discuss one facility’s multi-tiered approach to treatment, which includes involvement of a neuro-optometrist.]

Treating traumatic brain injury (TBI) patients poses a wide variety of challenges that require continual collaboration between physicians, therapists, psychologists, and other clinicians.

Making this continuum of care work efficiently also may require rehab staff to think and work together in a multi-tiered approach that addresses behavior, mood, and cognition, as well as physical difficulties, says Jonathan Fellus, MD, neurologist and director of Brain Injury Services for Kessler Institute for Rehabilitation in West Orange, NJ. Fellus also is a clinical assistant professor at New Jersey Medical School in Newark.

"We approach TBI treatment from the angle of cognitive therapy, medication, behavioral management, counseling to help people comes to terms with their disability, and a lot of education to help patients gain insight," Fellus says.

Kessler Institute first formalized its TBI rehab around 1980, making it one of the first rehab facilities in the United States to have a dedicated TBI unit. The institute has a 36-bed TBI unit and a 16-bed satellite, as well as a subacute brain injury unit, an extensive outpatient program, a formal cognitive remediation program, and a renowned Return to Driving project. For the past five years, the institute has been recognized by the state of New Jersey as a "Model System of Care."

"We do a great deal of research and have products focused on developing better and more efficient ways of delivering care, including programs such as going to patients’ homes and identifying social and interpersonal barriers or hurdles that make it difficult for patients to interact with family or community," Fellus says.

The TBI staff include cognitive therapists, neuropsychologists, a neurologist, a physiatrist, neuropsychiatry, neuro-optometry, therapists, a dietitian, and nurses. There also are therapists specializing in spasticity management. 

Each person’s role is important to helping patients understand their limitations and improve, Fellus says. For example, the dietitian’s role is crucial because post-traumatic weight gain is a hormonal problem that often occurs in brain injury patients, Fellus says.

Likewise, each member of the staff and each separate program contributes to the patient’s recovery and acceptance. Fellus outlines several parts of the program’s multi-tiered approach to treatment:

Return to Driving project.

This two-stepped program provides an analysis of skills, such as the patient’s reaction time, information processing, and perception, and it has a behind-the-wheel test in which a patient’s skills are observed on the road.

Soon it may be possible to have the behind-the-wheel test without therapists having to take a patient on the actual road, Fellus says.

"We’re moving ahead technologically and are looking at virtual reality simulators that are cutting-edge," Fellus explains. "We’re testing how accurately a virtual reality machine is at predicting a safe return to driving. This may be able to eliminate the need for actual road testing."

New drug improves cognitive efficiency

Helping patients cope with fatigue.

Depending on whether patients suffer from a traumatic brain injury or from another type of brain injury, such as stroke, aneurysm, toxic exposure, or anoxia-ischemia from cardiac arrest, the pattern of each patient’s recovery varies.

"But they share behavioral features like agitation and depression, and certainly short-term memory is almost always affected," Fellus says. "Fatigue is one of the least studied but most common symptoms."

The standard therapeutic approach is to teach patients how to rest and conserve energy, and physicians may prescribe the classic stimulants, Fellus says.

Through some new research, the institute has found that a new agent called Modafinil has a unique mechanism of action that appears to improve cognitive efficiency, Fellus says.

"So it helps with fatigue in a direct sense, but it may have an indirect benefit to fatigue by making it so that our brains require less work to accomplish the same tasks," Fellus says.

Patients taking Modafinil have been shown on a functional MRI to use less brain energy when accomplishing tasks, resulting in an efficiency that reduces fatigue.

Working collaboratively with physicians on treatment of comorbidities.

Fellus’ review of medications frequently reveals that brain injury patients are being treated with medications that will hinder their brain recovery process.

"For instance, all too often people are left on seizure medications because of the fear they are still at risk," Fellus says. "This is even when they may never have had a seizure, or they had one in the first few days when they were medically unstable."

Although it’s true there might be some increased risk for a seizure, it’s also true that the risk usually does not warrant the cost of keeping patients on these medications, Fellus says.

"These medications work by suppressing brain activity in a nonspecific way," Fellus explains. "The American Academy of Physical Medicine and Rehabilitation and the American Academy
of Neurosurgery recommend that patients be on seizure medications for one week after a brain trauma, and then they should be discontinued."

Also, there are certain psychiatric medications that will suppress brain activity, as do some blood pressure medications. The older antidepressants also have the side effect of reducing the chemical in the brain that’s important for memory, although the newer antidepressants do not have this drawback, Fellus says.

"These are a few examples of medications that have been associated with slowed recovery or reduced outcomes," Fellus says. "So you first want to do a good analysis of the medications a brain injury patient is on and then take the patient off the offending medications."

However, this is not always easy to achieve. Rehab physicians will need to communicate with a patient’s other doctors and offer suggestions for medication substitutes because physicians, including psychiatrists, often do not know how the medications they prescribe impact brain function, Fellus says.

"They don’t really have the training, and this is why you need a neuropsychiatrist or neuropsychologist or dedicated rehab physician to help protect the patient from the more invasive or aggressive treatments," Fellus adds.

"We really don’t have a lot of tricks in our bag that we can use to speed recovery from brain injury," Fellus explains. "So whenever possible, the least we can do is remove the offending agents and give the brain the best chance possible to recover on its own."

Addressing a patient’s substance abuse.

It’s well-documented that among TBI patients, 50% or more often have problems with alcohol or drug use, Fellus says.

This is why it’s important for rehab clinicians to refer patients who have a history of substance abuse to addiction counselors, psychiatrists, or support groups to help prevent the patient from having a second brain injury.

"Statistically, once you’ve had one brain injury, you’re at a much greater risk for a second one, and once you’ve had two, you have exponential risk," Fellus says. "Brain injury patients are at risk for many reasons and engage in risky behaviors statistically, such as driving fast, taking drugs, getting into arguments and fights in bars."

This impulsivity, added to a brain injury patient’s poor judgment, slow reflexes, and tardy reaction time, all conspire to place the patient at greater risk for a second brain injury, Fellus says.

Educating patients about how continued substance use might contribute to their having a second brain injury is one of the greatest services a rehab team can provide, he adds.