By Barbara Yaffe
Good-news stories are not often associated with Traumatic Brain Injury, or TBI. So, a University of British Columbia study that points to a potentially positive prognosis for brain trauma sufferers is worth highlighting.
The 2017 research strongly suggests there is some light at the end of the tunnel for brain-injured people who undergo cognitive training following their trauma. Moreover, findings point to the notion that cognitive gains can be achieved well after a two-year period that formerly was thought to be the end-time for any such improvements.
The study’s abstract, titled “Changes in brain-behaviour relationship following a 3-month pilot cognitive intervention program for adults with traumatic brain injury,” summarizes work carried out by a team of six researchers led by Dr. Naznin Virji-Babul, a director in the Department of Physical Therapy and associate professor in UBC’s Faculty of Medicine.
Virji-Babul confirms: “We were able to document changes in both the brain and in behaviour – in cognitive function. In this study we saw changes that were directly correlated with changes in cognition that were likely associated with taking part in the intervention program.”
Funding was provided by the Mitacs-Accelerate Graduate Research Internship Program along with the Eaton Education Group, which operates schools focusing on cognitive rehabilitation using the BrainEx cognitive exercises, which are part of the Arrowsmith Program. The research project began in 2015 and culminated in findings published in July 2017.
The topic tackled is a particularly pressing one. Traumatic brain injury impacts about 200 of every 100,000 people, and results in death in 11 per cent of cases, according to the Neurologic Rehabilitation Institute of Ontario. Fully 15 per cent of all brain injuries are classed as “severe,” as opposed to mild or moderate.
South of the border, 1.6 million TBIs are reported annually. About 2 per cent of Americans live with permanent disability related to TBI, costing the U.S. economy about $60 billion.
According to Ottawa’s Canadian Institute of Health Research, TBI is a key cause of disability in individuals under the age of 45, constituting “an important global health burden that has until now defied conventional approaches to diagnosis and therapy development because of its heterogeneity and complexity.”
Strategies to improve outcomes for TBI sufferers are clearly needed and, it was with this in mind, that the UBC researchers set out to test the usefulness of cognitive rehabilitation programs for those who have sustained brain injury.
Some background on these sorts of injuries: They generally are caused by a trauma to the brain and result in physiological changes that occur, for example, when brain tissue hits the inside of the skull; a penetrating injury such as a gunshot enters the brain; a lack of oxygen causes brain cells to die; or toxic chemical agents damage or kill brain cells.
The Neurologic Institute in Ontario reports that 60 per cent of acquired brain injuries are the result of motor vehicle mishaps; 15 per cent derive from work-related accidents; 15 per cent are sports-related (football, baseball and cycling are deemed the most dangerous in this regard); and 10 per cent are inflicted by physical assault.
In recent years the public has been learning just how serious brain injury can be for athletes. Chronic Traumatic Encephalopathy
has been identified as a progressive degenerative disease afflicting those who have suffered repeated concussions. The brains of CTE sufferers gradually deteriorate and are liable to atrophy.
Worryingly, the National Institute of Health Research says, “acute and long-term risk factors associated with youth and sports concussions are a major concern, and there is increasing evidence that multiple mild TBIs may pre-dispose to early onset dementia, later substance-use disorders and mental illness.”
Mercifully, instances of brain trauma are becoming less, rather than more, common. This is thanks to medical advances and public safety innovations like airbags for cars. Also effective have been public campaigns encouraging people not to drink and drive or speed and to wear seatbelts, bicycle helmets and other protective gear. That said, the increased survivorship translates into a greater number of people who are surviving with severe brain injuries, and who obviously would be keen to benefit from any available useful treatment.
The brain is a remarkable asset, about the size of a small head of cauliflower. It bestows an unbelievable cornucopia of capabilities. Consider, the brain controls body temperature, blood pressure, heart rate and breathing. It is responsible for allowing a person to experience the various senses – hearing, seeing, smelling, tasting and touching. It presides over physical movements and allows human beings to think, dream, reason and feel emotion.
Super complex, the brain physically comprises an assemblage of hemispheres and lobes, grey and white matter. Within the brain, nerve cells, also known as neurons, interconnect by way of electrical impulses that travel at lightening speed along highways that crisscross the brain. Specifically, these nerve cells receive messages from their tentacle-like dendrites and send them out on their extending axons.
But you don’t have to be able to distinguish a Hypothalamus from a Cerebellum to know that when there is trauma to the brain, it truly is traumatic. Brain cells do not regenerate. You cannot transplant the brain like a kidney or replace it like a hip or put it in a cast like a broken bone.
Injuries to the brain, the UBC researchers note, can result in “unique and dramatic changes in brain structure and brain function at many levels, ranging from microscopic tears in white matter to global changes in functional brain networks.”
What follows for the individual can range from headaches to dizziness, sleep disturbances to fatigue, loss of memory to an inability to pay attention. Ordinary physical functions can be affected, such as standing or walking or hand-eye coordination. Personality traits can change. People may lose their inhibitions and ability to control behaviours. In short, brain injuries can impact all areas of a person’s life and lead to prolonged or even lifelong disability and dependence on the health care system.
But increasingly there is optimism around being able to mitigate or remediate these disabilities through cognitive intervention programs. The trick, of course, is figuring out ways to measure the impact of such programs on the brain to in order to substantiate and gauge their efficacy.
The UBC Study – Findings
That’s where the UBC study comes in. The researchers observed the brain’s neuroplasticity — both before and after cognitive-strengthening intervention. By examining the precise ways in which the neurons functioned, both within specific areas of the brain, and across different regions of the brain, they could objectively measure shifts that were associated with improvements in the function of people with brain injury.
Specifically, the UBC team recruited a group of 10 people with chronic TBI, as well as a control group of 11 who were age- and gender-matched to the 10, and proceeded to assess the impact of an intensive three-month cognitive intervention program. The goal: to determine if and how the program affected brain behaviour relationships in the brain-injured cohort.
The researchers conducted brain-imaging tests or EEGs on both groups and also deployed a specific mathematical approach, known as graph therapy, to analyze the change in brain networks.
The baseline data, as expected, showed the TBI group’s performance lagged behind that of the control group. The researchers tested the group of 10 people with TBI a second time, following the three-month intervention program. Test results this time showed the TBI group had not been able to entirely catch up to the control group but had, nonetheless, significantly improved.
The researchers observed changes in neuron connectivity in the right and left frontal gyrus areas — gyruses being the folds that characterize the brain — “that suggest the brain reorganized after the intervention. This, combined with trends showing improvements in cognitive function, indicate that there were positive neuroplastic changes” that occurred, reports Virji-Babul.
She adds: “having evidence of reorganization, combined with the changes in cognition, suggests there is a huge potential for the brain to change even many years after an initial injury. This reorganization is associated with improvements in cognitive function such as verbal learning and memory, attention and verbal fluency. This finding does provide hope for people with chronic TBI.” Dr. Naznin Virji-Babul, director in the Department of Physical Therapy and associate professor in UBC’s Faculty of Medicine.
Needless to say, all of this was good news — especially in that some of the individuals with TBI had sustained their brain injuries decades prior to their testing. Specifically, three in the group had suffered their injuries more than 20 years earlier, which suggests again that individuals are able to benefit from cognitive intervention programs well after the two-year mark.
In the past, many experts and insurance companies have held to the view that two years post-injury marks the maximum recovery that can be expected, or at least that any improvements slowed substantially after that point. This belief provided insurers with a financial justification after two years to curtail benefits supporting continued rehabilitation for TBI patients, and certainly was deeply discouraging for brain trauma patients.
Here is a bit more detail on the UBC study: twenty-one participants were recruited from Greater Vancouver. The mean age of the TBI group was just under 40, half were male and the participants had sustained their injury an average of 11.7 years beforehand. The control group was similar, though three quarters were male.
All underwent resting-state EEG testing at UBC, as well as testing to assess processing speed, memory and executive function (managing time and paying attention), recall and verbal fluency. These latter tests took between an hour and a half and two hours. Testing of the TBI group was repeated after the three-month intervention program.
The three-month intervention consisted of a series of cognitive exercises aimed at improving brain functioning as it relates to memory, reasoning and executive functions. These BrainEx exercises, the same ones used in the Arrowsmith Program consisted of written, visual, auditory and computer exercises, personalized to address a TBI individual’s areas of particular difficulty. The program, applied over the three-month period, featured graduated levels of complexity and was administered four days a week, for four to five hours daily.
The Arrowsmith Program
For those unfamiliar, Arrowsmith has been around since 1978 and is offered at a number of public and private schools in Canada, the U.S., Australia, New Zealand, Thailand, South Korea, Malaysia and Spain. The philosophy of Arrowsmith, which uses the BrainEx cognitive exercises, holds that learning difficulties can be overcome by identifying and strengthening a person’s specific weak capacities, which are rigorously assessed prior to the program’s application.
The program aims to strengthen a student’s learning capacity rather than following the usual game plan of having students develop compensatory strategies to work around their problems.
A compensatory approach, for instance, might have someone with poor memory capacity, making audio recordings of his lectures so that he subsequently could review material he was unable to retain in his memory. The difficulty with the compensatory approach is that it seldom is completely effective and takes considerable energy to implement.
The Arrowsmith program focuses on strengthening actual learning capacity by utilizing the brain’s neuroplasticity, or ability to change its physical structure and organization in response to cognitive exercises. Physiologically, this might involve growing new dendrites on neurons, the branches that receive signals from other neurons, or strengthening neuron connections or stimulating the growth of new neurons.
Mark Watson, co-director of the Watson Centre Society for Brain Health, who received a dyslexia diagnosis when he was in grade school, says that through the teaching process, he personally has experienced the benefits of cognitive programs.
Watson, who has a Master’s degree in Educational Leadership and founded the Watson Centre in 2014 with his fellow co-director Howard Eaton, adds: “I have seen firsthand the overwhelmingly positive impact that strengthening specific neurological capabilities can have in all aspects of a student’s life.”
The Burnaby, B.C.-based Watson Centre, a non-profit society, aims to make life better for brain injury sufferers. Its educators design and deliver customized treatment plans directed to improving specific cognitive deficits caused by brain injury.
The UBC study is significant and exciting, in that it points to real shifts in brain functioning following cognitive intervention.
Science Direct, considered one of the world’s leading sources on peer-reviewed scientific, technical and medical research, recently included the UBC study’s abstract in the roster of online material it has been showcasing for the past 20 years.
The real value of the UBC study, says Watson, will be to “help provide a real reason for hope for people with long-term cognitive impairment due to brain injury.”
He noted that, the UBC study is the first peer-reviewed published paper that points to a real shift in braining functioning following the implementation of the Arrowsmith Program/BrainEx over a period of three months. “The brain can change. And such neuroplasticity is possible throughout a person’s lifetime.” Mark Watson, co-director of the Watson Centre Society for Brain Health.
The UBC researchers caution that their study had a small sample size and lacked a TBI control group that did not receive the cognitive intervention (which would have been needed to rule out practice effects for cognitive improvements).
The UBC data, says the study, “suggests that brain network organization is capable of reorganization, even in chronic patients with intense intervention.”
That said, the abstract cautions: “further work with a larger sample is clearly needed to understand the nuances of how brain organization impacts on cognitive ability and performance.”
Adds Virji-Babul: “We need to repeat this study with a much larger group of people and include a group who does not get the same intervention. It is very important to include a group that either has no intervention or has a different kind of cognitive intervention so that we can better understand the type of intervention that can optimize the changes in both the brain and in cognition.”
And “Another very important question is how long will these effects last? We know that doing the same activity every day, for example, crossword puzzles and the like, does not lead to improvements in cognition. The brain must be stimulated with new information and we need to do activities that are interesting, engaging and stimulating to maintain the changes. How to best optimize the intervention to continue to make gains is another big question that has come out of this study.”
Those who carried out the study, in addition to Dr. Virji-Babul, were Shaun Porter; Ivan Torres; William Panenka; Zahra Rajwani; Delrae Fawcett and Amna Hyder.