Ep. 225: Cognitive Rehabilitation After Traumatic Brain Injury

00:00:00: Welcome to EANcast, your weekly source for education research and updates from the European Academy of

00:00:18: Neurology.

00:00:37: and what can we actually do to improve it?

00:00:41: I'm very pleased to welcome Professor Arseny Sokolov.

00:00:46: Professor Sokolove is a Cognitive Neurologist, Chair of Neurabilitation at Luzan University Hospital and the leading expert in cognitive neurabilitation.

00:00:56: He's also member of the Lancet Commission on Neuribilitation.

00:01:00: His work has a particular focus on social cognition brain connectivity serious gaming and virtual reality.

00:01:08: Arsene, thank you very much for joining us today.

00:01:11: Thank you Luca it's a great pleasure!

00:01:14: So let's start from the clinical side.

00:01:17: which cognitive problems after TBI affect everyday life most?

00:01:24: Yeah I think this is a very important question and especially in TBI we do see that its mainly process of attention working memory executive function.

00:01:37: They will also affect the return to work.

00:01:39: It'll effect driving capacity in patients and, In the end this is the problems that we see that also persisted.

00:01:45: long-term necessitates rehabilitation

00:01:48: Yes but patient can be very different.

00:01:52: How do you decide what to target in cognitive rehabilitation for an individual patient?

00:01:58: Yeah I think one of the biggest principles That's we apply in Lausanne And i think they should be applied in every TBI Rehabilitation Clinic and also for other neurological conditions is to conduct a precise neuropsychological assessment.

00:02:12: And that neuropsycological assessments should be as close every day function as possible, so I have the greatest psychological validity possible.

00:02:20: Then with this precise assessment which goes into subdomains of processes such working memory where we don't only look at mental load but when you're looking up dating or interference management you can have much more detailed assessments of the patient's individual capacities, their deficits also resources.

00:02:44: And then based on this we design specific target distribution plans that really go into those specific functions.

00:02:51: and ideally This is not yet implemented.

00:02:53: but something should be also on agenda for future to try and titrate amount of specific functional rehabilitation depending on severity deficit in each subdomain.

00:03:04: So sticking with the example of working memory saying that, you know if there is for example bigger problems With interference management then that's also something we will look into more More intensely than in the other subdomains of working-memory.

00:03:18: or Also seeing how to best combine and maybe also take some inferences That actually Processes like divided attention and multitasking may also be affected.

00:03:29: And so this Probably the best way to design at the interventions is make them multi-domain, multimodal but rely on very precise neuropsychological assessments from beginning and outside.

00:03:40: And also continue monitoring how patients progress over course of rehabilitation.

00:03:45: after several weeks try to adapt their paradigms as much possible.

00:03:50: Interesting!

00:03:51: A quick question for neurologist or patient... How can we predict about cognitive recovery?

00:04:00: Yeah, so TBI is a very heterogeneous condition.

00:04:04: Obviously the current classification of mild moderate and severe TBI has some prognostic value.

00:04:10: obviously this is also how that classifications were done but it remains very abstract then very rough And not sufficiently fine-grained for individual prognostics.

00:04:21: We know even patients with so called mild TBI will have issues with cognitive problems returning to work for about fifteen to twenty percent of the patients with persistent post TBI cognitive impairment.

00:04:34: And what we do see, there are a few recent studies that have looked into return-to-work in patients with mild TBI and they're... We see about similar rates that fifteen to eighteen percent of patients Are not able To resume their work at all or to resume At the previous level of employment?

00:04:53: What would you say as main predictors for example at twelve months are actually the overall traumatic severity and also the presence of post-concussive symptoms at two months after the TBI.

00:05:03: So this is very important to look into complaints from patients in their first weeks or months already, trying document them as well because it can be a good predictor afterwards for what needs to be done with rehabilitation and reintegration and potential symptomatic treatment.

00:05:20: but on the other hand precise prognosis with respect to cognitive domains it's not yet clearly available, so the evidence is very low for this.

00:05:30: And there was also a conceptual question from what we see in clinical practice that basically depending on the profile of patients... We do not really see specific cognitive functions.

00:05:43: you would have more difficulties to recover than others and often its general cognitive impairment or improvement needed afterwards.

00:05:54: And what about imaging?

00:05:56: Are there findings that you can already consider useful in clinical practice.

00:06:03: Yes, so imaging remains an interesting approach and also remains an approach with limitations.

00:06:11: This is something we specifically see with less experienced colleagues or with insurance medicine That actually until now even if There was a MRI done in the time frame that should be performed for tbi which means between three days and three weeks after the injury.

00:06:28: so we should not be too early.

00:06:30: And not be to late especially to pick up the shearing injuries the external injuries, the micro bleeds with iron sequences then still have.

00:06:41: many patients will show any lesions but was still exhibit functional impairment cognitive impairment maybe also psychiatric comorbidity insurance medicine and also less experienced colleagues would say, well there is no sequelae of the TBI or at the symptoms that you present are actually more related to psychiatric distress.

00:07:05: Or maybe other comorbidity may even be psychosomatic?

00:07:08: And this is a huge problem because many of the colleagues will not realize as with every technique we deal resolution issues when talking about MRI techniques like that.

00:07:19: so they're still micro damage in patients who present with persistent impairment, but we are just not able to pick that up for the three Tesla MRI even if it's state-of-the art imaging.

00:07:30: And so there is an absolute need to further develop our imaging approaches and documentation approaches.

00:07:37: obviously one documentation approach as just a go through behavior into have very precise very clearly documented protocols or evaluation also convince insurers.

00:07:47: And on the other hand, in terms of imaging I would say that most promising study over the last five years was published.

00:07:54: In brain two thousand twenty one.

00:07:56: i think it's colleagues from UK who actually tried to standardize the assessment off structural white matter integrity in tbi and so they were looking into the diffusion tensor imaging parameters such as mid diffusivity inflection anisotropy in the wide matter of post-TBI patients, and they were comparing them to age meshed and gender matched controls.

00:08:18: And they found consistent differences.

00:08:21: This is a rather spectacular finding given that diffusion tensor imaging exhibits such high interindividual variability.

00:08:29: so this also shows we can look at level where it's more fine grained than what you can right now afford with clinical imaging but need research efforts.

00:08:41: Yeah, it's very interesting.

00:08:43: Let me move to something even

00:08:45: more

00:08:46: interesting.

00:08:47: how important is social cognition after TBI and how do we still underestimate

00:08:53: that?

00:08:54: I believe in general, in neurological conditions apart from frontotemporal dementia, social cognition generally underestimates what happens on the radar.

00:09:07: Maybe one could say that in TBI over the last years there is more and more Consciousness about about that a particular aspect of neurological function.

00:09:16: also because of their behavioral deficits disexecutive deficits That's tbi patients often present.

00:09:21: Also related to the lesion pattern, but would often concern the medial prefrontal lobe.

00:09:27: But in general it is still underestimated And they were still very limited approaches on how to diagnose them especially also treated.

00:09:34: current estimations Go as far is to say that about thirty, thirty five percent of patients with TBI will have deficits in social cognition.

00:09:42: There again from the clinical point-of view I think we need to be very balanced and very clear That not every deficit that we pick up on one neuropsychological test off Social Cognition Will Be Meaningful In Terms Of Everyday Life.

00:09:57: Social Cignition Because there Are Also Ways To Compensate.

00:09:59: And Also Because Every Day Social Cagnition Is Multi-Modeling Does Not Relay On One Single Modality.

00:10:05: So probably the thirty-five percent of deficit prevalence is slightly overestimated from a clinical perspective and we need more research to really look into which proportionate patients are affected on their everyday life.

00:10:20: It's also very important to develop approaches for assessing every day social cognition, not just small or several sub aspects of social cognition.

00:10:31: In our team, we just validated the movie for the assessment of social cognition which comes originally from Germany and research on autism spectrum disorder.

00:10:41: There's also efforts in France that are ongoing to try to standardize this approach And there is actually a movie sequence of clips where you see with story And that is interrupted with multiple choice questions to try to infer the mental states means emotions, intentions of actors.

00:11:02: This shows a very promising approach and very promising results.

00:11:06: in order go ahead evaluate patients every day condition.

00:11:12: What we do see are outcomes on this mask performance correlated with questionnaires for social behavior everyday life.

00:11:21: so there's an ecological value that is quite prominent and this is the direction we should be taking in terms of social commission detection.

00:11:30: And assessment, then thinking about rehabilitation there are a few concepts emerging also in Australia France from neuropsychologists.

00:11:39: think about group based therapy to think about therapies will look into different sub-components for social commission and social attribution This certainly very important aspect.

00:11:50: going back to prevalence I think Even if we have only fifteen or twenty percent of patients who show subtle social condition deficits, very often this is going to be the most relevant determinant of successful professional life.

00:12:02: Of also maintenance of a couple.

00:12:04: live for family life and so we should really consider this aspect than actually not only in traumatic brain injury but also stroke and multiple sclerosis where those issues are pretty much prevalent as well?

00:12:17: And it's a very modern way to investigate CBI patients.

00:12:23: How should we treat this problem?

00:12:26: When should we try to restore an impaired function and when it's better to focus on compensatory strategies.

00:12:32: So, there is also a very important point Luca that goes through the core of new rehabilitation in general... ...is thinking whether do we restore functions or compensate for functions.

00:12:43: The question isn't yet ultimately clarified because there was lack of evidence on those kind of trajectory approaches saying component A first, B then or do we combine them?

00:12:55: The best guess that I can give is coming also from literature and other fields of rehabilitation, including actually people with progressive cognitive decline due to neurogenerative disease.

00:13:06: Also for multiple sclerosis.

00:13:07: We see the more comprehensive we address patients, the better it is in terms of outcomes.

00:13:17: In neuro rehabilitation, also in neuropsychology there is this paradigm that one should think of restoration and off-compensation as quite separate processes.

00:13:27: Approaches and processes are also in terms functional consequences.

00:13:30: while it may be true for motor rehabilitation where we tend to focus on restoration first then go into compensation not interfere with restoration but provide everyday life recovery function for patients In cognition, it seems slightly different.

00:13:48: What we do see in some published studies and also data that is about to be accumulated on our own center... ...is actually when you go into compensator rehabilitation of patients where your work specifically with internal strategies such as visual imagery or other techniques to promote working memory and other executive functions then actually you'll also do see improvement in the function itself.

00:14:13: So the border between restoration and compensation is probably quite fluid.

00:14:17: And it means that also when we work on compensation, potentially even with external strategies which may be less helpful We would actually influence the function itself as a potential of the function to be restored after deletion.

00:14:33: so short answer or longer answer for this question.

00:14:39: I think by providing integrates approaches, we should certainly push restoration to its limits and this is not what we are doing right now.

00:14:49: We're certainly underdosing the cognitive rehabilitation.

00:14:52: for many patients it's not even available And those where it was available provide two little sessions per week in total.

00:15:00: But on other hand also think about integrating a compensatory and meta-cognitive component because that has been shown to be promising.

00:15:08: This is also were most of evidences.

00:15:13: So, it means develop restorative rehabilitation but also consider that its not only about restoration even if we can push with technology.

00:15:22: But we need to integrate the compensatory components quite soon.

00:15:26: Very interesting and another issue is how a measure recovery?

00:15:30: what should be considered meaningful outcome or meaningful recovery?

00:15:36: Yeah, this is a very important question.

00:15:37: Luca we are about to publish consensus paper with experts in neuropsychology and cognitive neuro rehabilitation from France Belgium In Switzerland.

00:15:46: it will come up in current opinion neurology in the December issue I believe and trauma and rehabilitation issue.

00:15:52: And so this precisely the questions that we discuss.

00:15:54: also on the outcome measures because obviously if you only look into your psychological outcomes measures We may fall short of capturing all the everyday relevant improvements and also effects, but also persistent deficits that may be after rehabilitation.

00:16:11: On the other hand going back to the Everyday Relevant Ecological Neuropsychological Assessment we do see.

00:16:18: there are measures in neuropsychology which really nicely predicts how patients will function.

00:16:28: But still what appears essential in measuring outcomes and to make them as meaningful is possible, it's looking into the self-reported and informant reported cognition.

00:16:38: That means using patients' reported outcome measures prompts on everyday cognitive function and also quality of life with obviously the downside that the cognitive outcome measures are often correlated with moods factor.

00:16:54: that is actually biasing and influencing what's happening in those outcome measures.

00:16:59: And quality of life can also be influenced by moods, then the quality-of-life has a very general concept which may influence many other factors not just the rehabilitation itself but still to provide a clear image on how it affects patients' everyday lives Especially when we know that in the literature and evidence so far most studies focus only on neuropsychological cognitive outcome measures, only objective ones.

00:17:29: And there is very little impact seen on subjective cognitive reports or quality of life which obviously constrains also perceived relevance for rehabilitation.

00:17:43: So I think we really need to move into that direction and then try to construct progressively objective measures of participation in cognitive rehabilitation, which is not easy.

00:17:53: But for example one candidate could be returned to work where we can look at the trajectory of return-to-work to see how quickly... ...how high patients are able to return to work in terms of percentage?

00:18:08: And to see whether rehabilitation can play a role.

00:18:10: there's few studies That I've looked into that as well, but the domain still remains very limited.

00:18:16: And this is one of the candidates even though it's only limited to one of portions of the population on either working age people.

00:18:24: But that something we can try look at and really measure participation more.

00:18:29: Let us move onto new technologies in another field where you are a pioneer.

00:18:34: What can serious gaming offer to cognitive rehabilitation?

00:18:39: how good is the evidence?

00:18:41: and where do you see the role of virtual reality.

00:18:44: And artificial intelligence,

00:18:46: thank you a lot.

00:18:46: look at that's uh... That's complex issue as i said before um.. I believe technology going to be indispensable too will deliver adequate doses of rehabilitation for patients.

00:18:57: this in general an important aspect of your rotation today off contemporary notation it's to think about uh... reloadation therapy terms of parameters in terms of dosage in terms frequency and really to make it a prescription, such as we would do with a drug.

00:19:13: And not just say that you need physical therapy or neuropsychology... As neurologists and specialists in rehabilitation don't really care about how this is actually performed but also how it needs to be adapted.

00:19:24: So today at our center I'm prompting the junior fellows and the junior doctors To consider how much rehabilitation patients will need when they move for example from hospital phase to outpatient phase.

00:19:38: And our problem, I think as everywhere even though we are certainly privileged in Switzerland is that... ...we don't have all the resources.

00:19:46: The manpower and the finances to provide the rebuttation doses that you need.

00:19:51: This especially true for restorative rehabilitation which relies on repetitive exercise Which appears very important for recovery of brain.

00:20:00: but Even in the evidence that we have, most of their approaches are underdosed.

00:20:05: So if say for example restorative rehabilitation fails in restoring executable functions then very likely this is true especially because we're not providing significant or satisfying doses and maybe also not the right approaches.

00:20:24: And so when we work on technology be it serious video games immersive non-immersive or other approaches that are technology related, then we try to think in a multi-domain manner as well.

00:20:35: So we tried to tackle several cognitive functions at the time not just one specific cognitive process that will maybe have less carry over... ...to other functions and everyday life.

00:20:47: The huge promise of serious video games and virtual reality is also the motivation component that we can not only deliver those without the need for additional personal, but actually also to deliver it in a way that is enjoyable by the patients.

00:21:00: I believe everybody has already done some kind of rehabilitation maybe even for an ankle or for hip physical therapy.

00:21:07: It's a bit monotonous Even though we have may be the most skilled talented and fun therapists who are providing it.

00:21:13: And so here there is potential to engage the patient more.

00:21:16: We do know motivation closely related with outcomes.

00:21:21: So this is a way to boost the outcomes for patients.

00:21:24: We are also following serious video game approaches, that's called cognitive exergaming and it means those of you games combining physical exercise with hope that combined exercise will have synergistic effects both for cognition but motor functions as well as physical function.

00:21:43: And what we see in pilot randomized controlled trials here at Lausanne is that those kind of approaches actually can deliver.

00:21:52: effects are about two and a half, three times higher than what we see with conventional computerized cognitive training.

00:21:59: And those are the facts observed on quality-of life or self reported everyday cognition.

00:22:05: so exactly functions and outcome measures which should be looking for meaningful change.

00:22:10: Finally you were asking virtual reality.

00:22:14: I think here it is important to underline that when we're talking about virtual reality, we should ideally be only talking about immersive virtual reality.

00:22:21: So really focus on the immersive components and hear We hope there's an embodiment of being transported into another environment That can help people better improve and participate in certain activities And also provide activities meaningful and engaging for patients.

00:22:42: And when we look into the evidence, especially on traumatic brain injury stroke that are also closely related.

00:22:50: For now there is very little evidence saying that immersive approaches are much better than non-immersive and so I think we really need to think where those approaches can play their biggest role?

00:23:05: And when we probably can use virtual reality to transport them out of the hospital and give them an environment that is really engaging, but makes them forget about the hospital setting.

00:23:20: About a severity of disease and potentially gave him some other idea about their current situation and also enable them and empower them to perform it better and improve every day.

00:23:35: And the other point is on the other extreme of continuum when we have patients who are already out-of-the hospital, who did not have access or were already done with outpatient rehabilitation in a structured manner.

00:23:48: That will be then at home needing tele-rehabilitation and there was actually just a tele-rehabilitation study using ImmersiveVR in TBI that came up from Norway in the beginning of twenty twenty six to use commercial virtual reality video game which showed improvements in attention and also modest improvements in everyday cognition, quality of life.

00:24:08: So I think this is a first step forward to look into how immersive virtual reality could change the landscape... ...and improve accessibility of rehabilitation for patients.

00:24:20: But obviously what we need always consider are costs that come from technology And despite the fact it can help us be more efficient with resources We always need to make this comparison and see, is it superior or at least non-inferior to other approaches in other technologies?

00:24:35: And also what's the cost benefit for those kind of technologies.

00:24:41: Is that something really worth it?

00:24:44: There are a lot of researches still needs to be done... ...to make this way into market and standard clinical care.

00:24:52: but there was clear potential especially integration of physical and cognitive exercise be it immersive, or non-immersive.

00:24:59: Maybe also with the advent of management reality that can be something really helpful especially for home setting?

00:25:06: That is probably very interesting in terms of future of this field.

00:25:12: but we cannot forget something more old about drugs which post TBI symptoms.

00:25:20: can we treat pharmacologically and where do you think the evidence is strongest?

00:25:26: Yeah, I think this is also a very important question and what directly concerns neurologists even those who are not specialized in rehabilitation.

00:25:34: Whenever there are TBI patients... And actually these can apply to stroke patient's in the long run when they present with symptoms for example as headache or fatigue sleep disorders anxiety etc.

00:25:47: This where we should always consider our role of prescribing useful medication.

00:25:52: In terms of evidence, the strongest evidence is there for methylphenidate even in improving some cognitive functions such as attention and processing speed.

00:26:02: So this can be useful.

00:26:03: Methylphenidated can also be used to increase the cognitive endurance.

00:26:07: that means try to balance out the cognitive fatigue many patients will present with And it's really a big topic considering future in order to really serve the patients as good as possible.

00:26:21: And there, the evidence is more limited for metilfinidate but also other drugs.

00:26:26: In our practice in Lausanne we use vanilla vaccine retards quite a bit in the morning To try and enhance cognitive endurance.

00:26:35: There's literally very limited data on this maybe only from animal studies does seem to work in several patients, and so we are about to see what the exact effect can be.

00:26:48: In a first preliminary study that we're running here.

00:26:51: then for headache where we have good experience there is also evidence with amitriptidine.

00:26:58: Then it's best go lower doses at night time To avoid carryover fatigue, drowsiness but also to avoid any impact on cognitive functions And this seems to work quite well, also according to studies.

00:27:13: What we see in the clinical practice is that patients can after a few weeks already report significant improvement or even complete resolution of headaches and so it's something which we use quite often.

00:27:29: There was one study looking into treating patients in a prophylactic manner with amitriptyline.

00:27:35: So all TBI patients who came here And they didn't find effects, but I also think it's not reasonable.

00:27:40: It should really go targeting the symptoms of the patients and... ...it is important to note that we should treat as early as possible in order prevent there was a chronification or medication overuse for headaches etc.

00:27:56: So maybe the last point i would make is also about sleep disturbances especially people who have difficulties falling asleep who wake up very frequently because they are anxious, maybe have a bit of an adaptation disorder related to the accident or trauma and change in life.

00:28:15: So here we had quite good experience with trusodone.

00:28:19: there is also some evidence for melatonin.

00:28:20: I think this study right now on going that checking combination of both And so I think those are the key aspects that we should keep in mind and consider.

00:28:35: This also gives us as neurologists, even if we're not providing rehabilitation a possibility to intervene or respond to needs of patients without just noting them then saying they aren't really sure how to treat

00:28:48: it?

00:28:48: We always do personalize drug therapy on our field...I agree!

00:28:54: Then perhaps we can finish with clinical examples.

00:28:58: Could you tell us about one or two patients whose recovery taught you something important, about cognitive rehabilitation at the TBI?

00:29:06: Yeah absolutely Luca.

00:29:08: So I would say that in some of the most impressive cases of TBI followed was an older gentleman maybe sixty-two who had a very high position on international organizations and he suffered from TBI then had a neuropsychological assessment and came to my consultation, didn't really have many objective deficits.

00:29:31: that remains.

00:29:32: There was obviously the strong fatigue And so for one-and-a-half years we tried with different drug options.

00:29:39: I just mentioned other approaches also energy management approaches provided by neuropsychologists and occupational therapists To improve his work capacity.

00:29:48: We were always stuck about thirty or forty percent also with somebody who never respected the limits, always overworked or accumulated more and more fatigue.

00:29:58: And in the end we had to realize that there was actually very likely personality disorder at first place... ...and it's an ADHD.

00:30:08: The main thing I want to underline is that we need to consider the role of psychiatric comorbidities.. ..and also ADHD in neurological patients not only in TBI patients because they can interfere with the recovery and it's important to detect them as soon as possible because otherwise we will have unexpected trajectories in patients who would be stuck.

00:30:28: In their recovery process, then we'll be unable really do what is needed.

00:30:34: And The other case Is also a gentleman Who was followed by one of my fellows I think for two years and was recovering very slowly.

00:30:45: that was a patient with very few lesions and also very few residual deficits after the cognitive rehabilitation.

00:30:53: But there were still important issues of going back to work, of supporting accumulations of people or supporting sounds being able manage priorities interferences.

00:31:06: And what we realized when I supervised the case and looked into all of history is that actually no one ever screened for sleep apnea disorders.

00:31:17: We sent a patient for polysomnography, he was diagnosed with sleep apnea disorder... ...and received also the CPAP treatment.. ..and then saw quite significant improvement in his functional capacities and fatigue in his work capacity, I think that allowed us to probably gain another forty-fifty percent of word capacity only due this.

00:31:41: And so given the very strong association between stroke and sleep apnea... ...and also the prevalence of sleep apnea in people with TBI….

00:31:52: …I think it's important for screen for that!

00:31:54: In general we should think about sleep as one our greatest allies in terms of rehabilitation because it also helps the recovery and can pose significant barriers on recovery if something is going wrong.

00:32:06: Yeah, Arsene thank you very much for this nice contribution today.

00:32:11: I think you have illustrated how much these fields can be complex but fascinating And really meaningful to recover the quality of life Of our patients.

00:32:23: so Thank You again For joining us Today on EANcast.

00:32:29: Thank you to everyone

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