Leading TBI treatment into the future

Ohio State researchers are changing how clinicians think about brain injuries — and giving hope to those with traumatic brain injury and their families.

In the early 1990s, when Jennifer Bogner ’89 PhD, ABPP, FACRM, first began working with traumatic brain injury (TBI) survivors, clinicians treating TBI thought their patients’ potential for recovery maxed out at two years.

Today, 2.8 million Americans are treated every year for TBI. In Ohio, about one in four people has had a TBI. Car crashes, falls, physical violence, sports, military service — all are common causes. Some brain injuries have mild effects that let a person go back to work or school after a few days of rest and pain relievers. Others lead to permanent cognitive problems, physical disabilities and even death.

“Back then, we didn’t have that much data about what was happening with [injured individuals] long term,” says Bogner, a psychologist and the Bert C. Wiley Professor of Physical Medicine and Rehabilitation in the Department of Physical Medicine and Rehabilitation at The Ohio State University College of Medicine. “What we thought was that individuals who experience a moderate or severe TBI, once they hit the two-year mark, are going to hit a plateau and that’s the way they’re going to be for the rest of their life.”

Thankfully, that belief has completely changed. Decades worth of data gathered through the TBI Model Systems program, a network of 16 brain injury care centers across the country, reveals hopeful news for patients — and Ohio State is leading the way.

Gathering data

The TBI Model Systems program was established in 1987 with funding from the National Institute on Disability, Independent Living, and Rehabilitation Research. Ohio State’s Department of Physical Medicine and Rehabilitation has been home to the Ohio Regional TBI Model System (ORTBIMS) since 1997. Bogner and John Corrigan ’81 PhD, ABPP, a professor emeritus in the Department of Physical Medicine and Rehabilitation and director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation, serve as co-principal investigators, directing ORTBIMS research.

Each injury care center in the system contacts its patients at one, two and five years, and thereafter every five years after their injury to learn about the long-term effects of moderate and severe TBIs. These surveys contribute to the trove of longitudinal data at the Traumatic Brain Injury Model Systems National Data and Statistical Center at Craig Hospital in Englewood, Colorado.

“The TBI Model Systems is now following folks 35 years post-injury,” Bogner says. “What we now know is that folks [with a history of TBI] continue to change throughout their lifetime. Some people will continue to improve well past the two-year mark. Some people will go up and down and other people will decline.”

Corrigan offers the comparison of a broken leg — i.e., once your leg heals, it’s stable and your doctor no longer keeps track of it. “But now we’re recognizing brain injury is more like a chronic condition — like low back pain, not a broken leg,” he says. “It’s going to be either constant or recurring or have late-late-emerging effects.”

And those effects can include cognitive and mood changes that impact how well patients understand their other health conditions, remember to take their medicine and follow their doctors’ instructions.

Although having a chronic condition doesn’t sound like a good thing, thinking of TBIs this way can be positive. Hopeful, even. “The message about being a chronic condition is that it’s dynamic,” Corrigan says. “And if it’s dynamic, then you can do something about it.”

Assessing for TBI

But doctors — and even patients themselves — are often unaware a TBI has occurred because screening isn’t common. In the early 2000s, a growing understanding of the prevalence of TBI led Bogner and Corrigan to develop the Ohio State TBI-ID assessment. It’s now considered a gold standard method to uncover a person’s lifetime exposure to TBI.

“We knew that there were many individuals out in the community who had a history of exposure to TBI, but there were people providing care for them — such as behavioral management specialists — without the knowledge that these people had a history of TBI,” Bogner says. “And if you had told them that a patient had a history of TBI, they would say they shouldn’t be treating them, because they thought that wasn’t within their realm of expertise.”

Behavioral health treatment addresses issues like substance use disorder, mental health conditions and stress-related physical symptoms. These patients have often experienced situations that put them at high risk for TBI, such as incarceration, domestic violence and homelessness.

But just asking someone if they’ve had a TBI doesn’t work, Bogner says. Most people don’t know exactly what a TBI is or if they’ve had one.

“The method we developed is a brief but comprehensive way of walking people back through their lifetime to look at events that could have been a TBI, and then narrowing it down to determine which ones were likely traumatic brain injuries.” It’s effective at revealing not just obvious TBIs that resulted in ambulance trips and hospital stays, but also more subtle injuries that went untreated.

“What we came to find out after using the Ohio State TBI-ID is that 50–80% of behavioral health clientele actually have a history of multiple TBIs,” Bogner says.

The finding casts a new light on patients who might appear uncooperative. For example, someone with TBI who is inattentive during a two-hour group therapy session may not be able to maintain focus for that long and may need adjustments to be able to fully engage in their treatment.

Neurologic-informed care

A health care approach that takes into account the effects of TBI is what Corrigan calls “neurologic-informed care.” He and other TBI experts defined the term last year in The ASAM Criteria, 4th ed., the American Society of Addiction Medicine’s substance use disorder treatment guidelines.

“We were asked to write a chapter about cognitive impairment,” he says. “In writing that, we introduced this concept of neurologic-informed care. Basically, it says that substance use disorder treatment providers need to be aware that not everybody has the same cognitive abilities, and that’s because of differences in injury or other abilities.”

Establishing neurologic-informed care as the standard means that clinicians need to find out if their patients have TBI.

“I take the approach that everybody should be screened, because you’re not going to know whether your client has a brain injury,” says implementation scientist Kathryn Hyzak ’23 PhD, a faculty affiliate in Ohio State’s Chronic Brain Injury program in the Department of Physical Medicine and Rehabilitation.

Her research focuses on developing and testing the most effective ways to help health care organizations and professionals incorporate neurologic- informed care into routine practice.

“What we’re trying to do is integrate a combination of screening for a history of brain injury, so providers can, first, know if this client has a history of brain injury, what their symptoms are and how the effects of the brain injury might be manifesting,” she says.

“We can then direct our course of treatment differently to help improve the quality of care.”

Using evidence-based treatment

Central to Ohio State’s TBI Model Systems research is Care4TBI, a seven-year-long observational study involving approximately 1,600 patients at 14 model systems. The ORTBIMS is leading this exploration of using standardized electronic medical records (EMR) to document daily inpatient rehabilitation therapy, and investigating how effectively different treatment approaches help patients to become independent and participate in their communities.

“The entire first two years was devoted to figuring out not only what our primary rehab therapists — physical, occupational and speech — do on a day-to-day basis, but also how to capture that without putting undue burden on them,” says Cynthia Beaulieu ’88 PhD, a neuropsychologist and clinical associate professor of Physical Medicine and Rehabilitation.

Ohio State researchers then helped design EMRs with dropdown menus where rehabilitation therapists can easily record their interactions with TBI patients. This turns narrative information into numerical data that can be analyzed.

“Every one of those encounters, they do things with the patients to promote their recovery, to promote their skill level, and so we are collecting all of that information that has been identified as critical, to analyze it and look at what’s the most effective to produce better outcomes,” Beaulieu says. “It allows us to also develop formulas to then help guide what’s going on in this setting.”

Eventually, Bogner says, therapists will be able to analyze individual patient data and quickly adjust care as needed. She’s excited about the potential of Care4TBI and other TBI Model Systems research to create learning health care systems — research-partnered care networks that arm clinicians with data they can use to continuously improve treatment for TBI patients.

“It’s really getting us to the point where we’re using the information that we’re learning from patients every day to improve their outcomes — and future patients’ outcomes.”

Getting best practices into practices

Just because researchers discover anew best practice doesn’t mean that clinicians will immediately begin to use it. That’s where implementation scientists come in.

“Implementation science as a field seeks to expedite the pace at which innovations are used in direct practice,” says Kathryn Hyzak ’23 PhD, an implementation scientist in the Department of Physical Medicine and Rehabilitation and a participant in the Provost’s Tenure-Track Fellow to Faculty Program. Those innovations might be policies, guidelines, interventions, medical devices or medications.

Hyzak is a faculty affiliate in Ohio State’s Chronic Brain Injury Program and in the Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research (CATALYST), a program that comprises 60 faculty members across five colleges at Ohio State.

Implementation science studies the methods that promote the use of evidence-based practices, treatments and policies into routine health care to improve public health. “We’re always working with two different things in implementation science,” Hyzak explains. “We have the clinical intervention that we’re trying to get implemented, and we have the ‘how’ we get that implemented — the implementation strategy.”

One example of an implementation strategy is when an organization (e.g., a community-based mental health clinic) uses a researcher, occupational therapist or other professional trained in external facilitation who can help the organization with its challenges and deliver a recommended intervention (e.g., TBI screening and accommodation), which the organization can adopt, use and ultimately sustain on its own.

Another example is an implementation blueprint, which is a comprehensive plan that identifies specific goals, actionable steps to achieve those goals, key personnel responsible for each step and completion timelines. Blueprints are a strong tool for engaging leaders, front- line providers and clients to ensure that implementing the intervention is feasible, effective at producing change and useful for carrying out across similar settings.

For Hyzak and other implementation scientists who study these efforts, the goal is not to test the effectiveness of the clinical intervention, but rather to test whether the implementation strategy (e.g., the use of the trained support person) has been successful in promoting and sustaining the organization’s intervention.

“Your implementation strategy should be working as hard as — if not harder than — your clinical intervention,” she says.

In 2022, Hyzak, then a PhD student at Ohio State, secured one of the first implementation science grants ever funded by the National Institute of Neurological Disorders and Stroke, to study factors leading to the adoption of TBI screening in behavioral health care.

She’s also researching an assessment that an organization can use to determine its readiness to implement neurologic-informed care, with a goal of getting organizations to discuss and figure out how to change their practices related to brain injury.

Story is from Ohio State Medicine Alumni magazine, Summer 2024