nancy d. chiaravalloti, ph.d. - kessler foundation update...tbi research at kessler foundation nancy...
TRANSCRIPT
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TBI Research at Kessler Foundation
Nancy D. Chiaravalloti, Ph.D.
Director of the Centers for Neuroscience, Neuropsychology and Traumatic Brain Injury Research
Kessler Foundation
Research Professor of Physical Medicine and RehabilitationRutgers, New Jersey Medical School
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Overview of TBI Research
• TBI Model System
• Areas of Specific Research– Functional Status– Rehabilitation – Imaging– Caregiver Health– Cross Cultural Influences
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Overview of TBI Research
• TBI Model System
• Areas of Specific Research– Functional Status– Rehabilitation – Imaging– Caregiver Health– Cross Cultural Influences
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TBIMS: Purpose• Study the clinical course of individuals with
TBI from time of injury through rehabilitation care
• Evaluate the recovery and long-term outcome of individuals with TBI
• Contribute data to a National TBI Database– Currently over 20,000 cases
• 16 centers nationwide
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5 Components of any TBIMSI. Exceptional Clinical Care throughout the
continuumII. National Data CollectionIII. Site Specific Research ProjectIV. Modular Participation
– Collaborative Effort: at least 4 centersV. Dissemination
– Consumer– Professional
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I. Clinical Care• Kessler Institute for Rehabilitation
• 4 Acute Care Facilities– Morristown Medical Center– University Hospital– Hackensack University Medical Center– St. Joe’s Regional Medical Center
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II. National Data Collection
• Data collected at several time points:– time of injury (during inpatient rehabilitation) – 1 year post injury– 2 years post injury – 5 years post injury – every 5 years thereafter
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III. Site Specific Project• Each center works independently
• Recruitment done at the center, so enrollment is only open to patients we see
• Cognitive Rehabilitation
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IV. Modular Participation• Every center must participate in at least one
module– 10 ongoing modules around the country– Select modules based on interests and resources
• Topics– Menopause following TBI– Cognitive trajectories following TBI– Caregiver resilience– Health Literacy– Problem Solving Training for caregivers
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V. Dissemination• Professional
– National and International Conferences– Local Presentations– Peer-reviewed publications– Pod-casts– Webinars
• Consumer– Newsletter– Conferences
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Overview of TBI Research
• TBI Model System
• Areas of Specific Research– Functional Status– Rehabilitation – Imaging– Caregiver Health– Cross Cultural Influences
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I. Functional Status
• Daily life• Cognitive deficits• Employment• Aging
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II. Rehabilitation
• Ties into Functional status• Treating Emotional Processing Deficits• Treating Sleep Disturbance • Cognitive Rehabilitation
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III. Imaging• 3 Tesla GE Scanner• Fatigue• Cognition• Emotional Functioning• Biomarkers• Treatment Efficacy
– Cognition– Emotional function– Fatigue
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IV. Caregiver HealthOngoing studies
• Resilience– Chronic TBI
• Problem Solving Training– Inpatient, preparing for transition home
• Novel ways of working through the transition to caregiver– Tele-rehabilitation
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IV. Caregiver HealthRecent Findings
• Helpful resources differ by caregiver relationship– Child caregiver– Parent caregiver– Spouse caregiver
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Caregiver Health
Imaging
Cross Cultural
Influences
Functional Status
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Study Examples:
Impacting Outcome at all Stages
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In the Trauma Center…
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Trauma Center• Purpose:
– Not all acute care hospitals have a physiatrist on their trauma team, One of our acute care hospital does. Does this impact outcomes?
• Why is this important?– If we can identify the contributions of a
physiatrist in the trauma center as beneficial to overall outcomes, other hospitals may consider adding this to their team and maximize outcome
Greiss, C., Yonclas, P. P., Jasey, N., Lequerica, A., Ward, I., Chiaravalloti, N., ... & Livingston, D. H. (2016). Presence of a dedicated trauma center physiatrist improves functional outcomes following traumatic brain injury. Journal of Trauma and Acute Care Surgery, 80(1), 70-75.
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Trauma Center
Jasey N, Ward I, Lequerica A, Chiaravalloti ND. (2018). The therapeutic value of cranioplasty in individuals with brain injury. Brain Injury 32(3):318-324.
*Medication management differs with a physiatrist in the acute care setting (Neurostimulants and sleep meds)
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During Inpatient Rehabilitation…
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Acute Rehabilitation:Immediate and Delayed Outcomes
and Brain Activation
• Striatum:– Immediate outcomes
• Lentiform nucleus– Delayed outcomes
Striatum
Lentiform nucleus
p <0.05, corrected
Dobryakova & Tricomi, 2013 25
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Acute Rehabilitation• Context of outcome presentation influences
brain mechanisms
26
Striatum
Lentiform nucleus
Immediate outcomes: Striatum
Delayed outcomes: Lentiform nucleus
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Acute Rehabilitation?• Circumvent inability to learn from
immediate outcomes by altering outcome timing– Presenting outcomes after a delay
• Activating a different network– Switch from the striatum to lentiform
nucleus by changing the way we. Provide feedback
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Living Following TBI…
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Chronic Stages: 1. Impacting Employment
• Purpose – Identify modifiable differences between
individuals with TBI that are employed or unemployed
• Why is this important?– If we can improve a characteristic of
individuals with TBI that are unemployed we may be able to improve unemployment rates in persons with TBI
Weber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
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Chronic StagesEmployed vs Unemployed
Weber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
0
10
20
30
40
50
60
70
80
90
Apathy Disinhibition Executive Dysfunction Apathy Disinhibition Executive Dysfunction
Self Family
Employed Unemployed
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Chronic Stages
• Why is this important?– Identified a potentially modifiable factor
• Next step:– Identify and effective means of treating
neurobehavioral symptoms
• End game:– Improve employment rates following TBI
Weber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
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Chronic Stages (Impacting Daily Life):2. Prospective Memory
• Remember to remember
• Why is this important?– PM has a substantial impact on daily life
functioning– We need to understand it
Weber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
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Chronic Stages(Impacting Daily Life):Time-based versus Event-based Prospective
Memory
Weber, E., Chiaravalloti, N. D., DeLuca, J., & Goverover, Y. (in press). Time-based prospective memory is associated with functional performance in persons with MS. Journal of the International Neuropsychological Society.
0
1
2
3
4
5
6
7
8
MIST TB MIST EB
MS HC
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Monitoring model: “baking cookies”
TESTare the cookies baked?
WAITclose oven – resume activities
EXITtake cookies out of oven
YES
NO
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Time Monitoring in TBI
• Flattened monitoring curve• Independent of time estimation and production• Related to cognitive abilities
Carlesimo et al., 2004
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Chronic Stages
• Why is this important?– PM has a substantial impact on daily life
functioning– Identified a potentially modifiable factor
• Next step:– Identify and effective means of treating TB
prospective memory• End game:
– Improve daily life functioning following TBIWeber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
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Chronic Stages
• Why is this important?– PM has a substantial impact on daily life
functioning– Identified a potentially modifiable factor
• Next step:– Identify and effective means of treating TB
prospective memory• End game:
– Improve daily life functioning following TBIWeber, E., Spirou, A., Chiaravalloti, N. D., & Lengenfelder, J. (2018) Impact of frontal neurobehavioral symptoms on employment in individuals with TBI. Rehabilitation Psychology. Aug;63(3):383-391.
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Funding Sources
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• John DeLuca, PhD• Ekaterina Dobryakova, PhD• Denise Krch, PhD• N. Erkut Kucukboyaci, PhD• Jean Lengenfelder, PhD• Anthony Lequerica, PhD• Nancy Moore, MA• Angela Smith• Erica Weber, PhD• Glenn Wylie, D.Phil.