Umi Venkatesan, PhD, who directs the Brain Trauma and Behavior Laboratory at Moss Rehabilitation Research Institute (MRRI), is Site Principal Investigator of a new study that will examine learning and memory in individuals living with traumatic brain injury (TBI) and depression. Amanda Rabinowitz, PhD, Director of MRRI’s Brain Injury Neuropsychology Laboratory, will also contribute to this effort. The project represents a collaboration between scientists at Kessler Foundation (lead site; East Hanover, NJ), Montclair State University (Montclair, NJ), the University of Pennsylvania, and MRRI. The work is funded by the National Institute of Neurologic Disorders and Stroke, National Institutes of Health.
Symptoms of depression are commonly experienced by individuals with TBI and can present significant functional challenges beyond cognitive or mobility impairment. However, many research studies on cognition after TBI do not examine depression symptoms, or exclude individuals with depression, rather than understanding the impact of depression on cognitive outcomes. This new study aims to fill that gap by examining how individuals learn and remember information when they are living with either TBI or clinical depression, and also how having both conditions at the same time impacts memory. It will incorporate both paper-and-pencil testing of cognitive abilities as well as advanced, non-invasive neuroimaging (MRI) methods. Using specialized tasks, the research team hopes to study new ways in which we can improve memory performance when people are simultaneously experiencing the effects of TBI and depression. Ultimately, the goal is to find support for new memory treatments that could positively impact patients’ quality of life.
Study planning is well underway, and recruitment at MRRI will begin within the next month. Research participation consists of an MRI scan and computerized testing at the University of Pennsylvania, followed by a research visit at MRRI for further assessment of cognitive abilities and psychological functioning. The study will run through Spring 2026, and findings will provide important insights into the mechanisms underlying memory impairment in TBI. A better understanding of these mechanisms will inform development of future treatments, particularly in individuals living with both TBI and depression. This study is just the latest in MRRI’s long history of productive scientific collaboration and commitment to work that matters to patients, families, and healthcare providers.
The National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) awards Traumatic Brain Injury (TBI) Model Systems grants to institutions that are national leaders in medical research and patient care. Launched in 1997, the Moss TBI Model System is a world class center of excellence providing state-of-the-art research, innovative treatment, and valuable programs for people with Traumatic Brain Injury. Each TBI Model System contributes to the Traumatic Brain Injury Model Systems National Data and Statistical Center, participates in independent and collaborative research, and provides information and resources to individuals with TBI; their families, caregivers, and friends; health care professionals; and the general public.
Moss and MRRI are very proud to be recognized as a TBI Model System. This prestigious designation was recently added as an element of the US News and World Report ranking methodology for Best Hospitals for Rehabilitation, and it contributed to Moss’s Top 10 ranking in 2021. In this new data-driven ranking system, rehabilitation facilities receive points for measures of resources related to patient care (structure), clinicians’ decisions and actions toward patients (process), and patient outcomes (outcomes). Facilities receive credit in the structure category if they have one or more model systems designations awarded by NIDILRR (designations are available in the areas of Spinal Cord Injury, Burn, and Traumatic Brain Injury), and the model systems designation accounts for 2% of the overall ranking.
Over the past 24 years, the Moss TBI Model System has followed 1,390 participants and conducted over 4,500 interviews out to 20 years post-injury. Our efforts and collaborations have resulted in 112 peer-reviewed research publications and 16 research grants, as well as the development of novel clinical programs and products. Moss clinicians and researchers look forward to continuing to serve as leaders in the field of rehabilitation for people with traumatic brain injury as they work to advance innovative research projects and deliver exceptional clinical care through the Moss TBI Model System.
Clinical/research integration (CRI), like democracy, is a promising ideal that is an ongoing challenge to achieve. It has been part of the vision of Moss Rehabilitation Research Institute (MRRI) since its inception, but what does that vision entail, and what are the key elements required to make some progress toward the vision? “I believe that efforts toward CRI are essential for the success of a translational research enterprise and for a clinical enterprise that seeks to be on the leading edge of practice. We know how hard it is for evidence to make inroads into clinical practice, and it will take efforts on the part of both researchers and clinicians, to bridge this gap,” states MRRI Founding Director and Institute Scientist Emeritus John Whyte, MD, PhD.
CRI is, most importantly, a two-way street – an ongoing process of interaction and dialog among clinicians and researchers. Researchers, by nature, tend to simplify and isolate the problem they study. Clinicians, by nature, must address any problem in the context of the patient’s array of problems and strengths. Consequently, effective translational researchers need a rich understanding of the clinical context of their area of study. This ranges from the very practical (How long will most patients be available in the hospital for study? How busy is their schedule?) to the more scientific (How “important” and how “isolate-able” is this problem in the lives of the patients who have the problem, given the array of other problems they may also face?). On the other hand, researchers can contribute greatly to the clinical environment in both general and specific ways. “I have found that my training often allows me to plan ways of analyzing information for clinical problem solving even outside of my main areas of content knowledge. Just the mere tendency to think in terms of patterns of data and variability in those patterns can strengthen clinical problem solving,” remarks Dr. Whyte. Translational researchers also can synthesize emerging evidence in their area of content expertise and contribute it to discussions of care processes and quality improvement in those areas.
If that two-way vision is convincing, then why is it so challenging to achieve? Dr. Whyte summarizes below some of the barriers that he has encountered.
Attitudes and Leadership
Time and motivation are needed to undertake the communication envisioned by CRI. Ultimately, that means that clinical leaders as well as research leaders need to appreciate the value and support it. Articulating that value is challenging, since most of the assumed benefits are broad and long-term. Although leadership support is necessary, it isn’t sufficient. Front-line clinicians need to have an attitude of questioning their own practice to choose to engage with researchers. Researchers must similarly think they have something to learn from clinicians. Leadership attitudes may be the most useful place to start to build CRI – if not overall leaders, at least “local” leaders who can support small concrete efforts to toward it and who can help advocate for resources. And leaders can help select staff with the needed perspective and groom that perspective among those present.
Time and Money
Even with the most supportive leadership attitudes, it takes time to communicate beyond what’s absolutely necessary for patient care or research progress. But the process of CRI is, to varying extents, an exploratory process. It can be expected to deliver benefits periodically, and to spin off important practical projects, but it cannot be expected to deliver benefits hour-by-hour. One of the biggest challenges is the clinician’s typical productivity requirements and the money required to offset those requirements for “non-productive activity”. Although researchers tend to be more flexible hour-by-hour, if they are largely extramurally funded, they, too, must be quite narrowly focused on their research to succeed, not to mention that it’s not legal to conduct a clinical improvement project on grant-funded time. Ultimately, the process of CRI does require money, and those seeking to advance it would do well to consider philanthropic support, program demonstration grants, and institutional “R&D” investment as sources of funding.
Structures and Processes
The needs of clinicians and researchers for various kinds of infrastructure vary. “Over the years I have seen this in systems ranging from finance to electronic data systems,” Dr. Whyte explains. For CRI, one ultimately needs systems that meet both sets of needs. For example, clinical purchasing systems expect to order large amounts of materials from a stable set of suppliers; research purchasing systems need to provide payments to a variety of vendors, many of which are project-specific or short-term; a payroll system may not flexibly handle an employee whose salary comes partly from research and partly from clinical sources, particularly if that mix changes periodically. In terms of clinical data, researchers benefit from having every variable coded as present/absent or unknown, whereas clinicians prefer to be able to select problems that apply (and may not always exclude those that don’t). Systems for extracting EMR data may be well-suited to producing standard daily or monthly reports and ill-suited to designing and quickly revising one-time complex queries. Both clinical and research perspectives need to be represented when such systems are selected and designed.
Ethics and Communication
Sometimes concern about the ethical boundary between research and clinical care can be an obstacle to CRI. Clinicians should not be pressured to collect patient data for research purposes. But may researchers advocate for the clinical usefulness of data elements that would benefit them and seek their clinical adoption? How much information should a clinician provide to a researcher about a patient’s family situation or behavioral characteristics, to facilitate research recruitment? May clinicians adopt methods such as randomization and blinded treatment conditions in order to validate their clinical conclusions? How familiar should clinicians be with the principles of human subjects research ethics in order to practice in an environment that is rich in CRI? “While I believe that there are risks inherent in CRI of crossing an ethical boundary, and even current human subjects review criteria are rapidly evolving to address ‘learning healthcare systems,’ I don’t believe that building a wall between research and practice is the solution,” says Dr. Whyte. Rather, both sides of the dialog need to understand the possible benefits of CRI as well as the potential risks, and actively discuss the many ethical ambiguities that may be encountered. The challenges associated with CRI as well as the benefits to be achieved will continue to evolve. Small and concrete efforts at CRI (e.g., a joint journal club for clinicians and researchers; a jointly run lunchtime seminar; hiring clinicians as consultants on research grants) can begin to build support for expanding efforts. Designing the process and monitoring its implementation and impact are ongoing processes in a changing landscape. Scientists and clinicians at MRRI and MossRehab are dedicated to working towards better integrating efforts and systems between research and clinical care to continue to advance our understanding of recovery following neurological injury or disease and to provide the best treatments possible for patients with these conditions.
Designation as a Model System highlights Moss’s excellence in treatment and research related to traumatic brain injury (TBI). The Moss TBI Model System has been continuously funded since 1997. Over more than two decades, Moss Rehabilitation Research Institute (MRRI) scientists and MossRehab clinicians have led numerous studies and participated in many research projects in collaboration with investigators from other TBI Model Systems.
This “CARE 4 TBI” study will compare the effectiveness of different inpatient rehabilitation approaches for people with moderate-severe TBI in order to optimize functional outcomes and community participation. Moderate-severe TBI results in physical, behavioral, and cognitive impairments that can have devastating effects on functioning in the community. Considering the growing strain on healthcare resources and reductions in inpatient lengths of stay, there is a critical and urgent need to identify the specific rehabilitation approaches that can optimize outcomes for people with TBI.
To address issues related to the complexity of rehabilitation and the heterogeneity of patients with TBI, scientists will conduct a prospective observational study using data from standardized electronic medical records from a total of 15 TBI Model System sites. Results from this study may potentially advance standards of practice in rehabilitation for people with TBI and provide clinicians and healthcare administrators with evidence-based guidance on the most effective practices in TBI rehabilitation.
The MossRehab Aphasia Center Advanced Clinical Therapy (ACT) Program is a unique-to-the-region collaboration among MossRehab Hospital, Moss Rehabilitation Research Institute (MRRI), and the MossRehab Aphasia Center bringing ‘up-to-the-minute’ aphasia rehabilitation research directly into the clinical setting.
At the time of the inception of the ACT program, treatment was less commonly available for those with chronic aphasia due to the prevailing ‘myth of the plateau’, which suggested that continued improvement was not possible after more than a few months post-stroke. However, a core group of researchers around the world, including scientists at MRRI, were studying new treatments and documenting improvement in people with chronic aphasia. This work was creating a stronger evidence base showing that individuals with aphasia were responsive to treatment even years after their stroke. ACT speech-language pathologist emerita Paula Sobel, MA, CCC-SLP, recently recounted her experience working in the 1990s as a research speech-language pathologist evaluating connected speech samples as part of a project being led by MRRI co-founder Myrna Schwartz, PhD. Although blinded to what was happening during the sessions in the study, it was clear to Ms. Sobel that participants’ language was improving. The treatment those participants received, published under the name Mapping Therapy, has since been cited in more than 200 scientific journal articles, and it continues to be utilized to treat grammatical impairments for those with aphasia.
In addition to Mapping Therapy, MRRI scientists have contributed to the development of the Philadelphia Naming Test, an image-based naming test developed to explore lexical access in people with and without aphasia. This test is used within MossRehab and the ACT program, as well as around the world. In addition, researchers at MRRI worked to develop MossTalk Words and the subsequent MossTalk Words 2. These are evidence-based, computer-assisted treatment programs designed specifically to optimize word comprehension and production in people with aphasia. Once developed, this technology was incorporated into treatment plans to enhance rehabilitation in people with aphasia.
The ACT program was developed to bridge this type of cutting edge research with speech-language pathologists’ clinical expertise for the benefit of individuals with aphasia. Through this program, the MossRehab Aphasia Center became a leader in implementing aphasia rehabilitation approaches based on models of how language is processed in the brain, combined with a functional, person-centered approach to developing direct treatment and home practice programs. Informed by ‘hot-off-the-press’ research findings, speech-language pathologists who understood the methods for taking a theoretically-motivated case-report approach to their practice began to work with individuals with chronic aphasia.
Today, the speech-language pathologists within the ACT program continue to communicate directly with MRRI researchers, staying apprised of the latest aphasia rehabilitation research for those with chronic aphasia, as well as primary progressive aphasia. Their work incorporates a wide variety of evidence-based assessment and treatment protocols individualized to each patient and grounded in the Life Participation Approach to Aphasia. The Life Participation Approach to Aphasia prioritizes collaborating with each individual to develop and progress toward the goals they have for themselves.
