In her interview, Dr. Therrien talks about some of her favorite pastimes, including running, knitting, gardening, and cooking. She walks listeners through her career path and shares what it has been like launching her new research laboratory over the past year.
The interview also covers some of Amanda’s new and ongoing research projects. In one of her research lines, Dr. Therrien is working to optimize therapeutic interventions for ataxia, a disorder caused by damage to the cerebellum that results in impaired movement coordination. The goal of these interventions is to teach people with ataxia how to achieve movement outcomes (e.g. reaching to a target in a coordinated way) by leveraging a training mechanism that is less dependent on the cerebellum. Dr. Therrien also describes a new collaborative research study that will elucidate the sensorimotor processing involved in dynamic proprioception. Dynamic proprioception refers to our sense of where our limbs are in space while they are moving, and it is important for motor learning.
In America alone, nearly 125,000 people experience a traumatic brain injury (TBI) each year. Beyond the need for rehabilitation to address impairments in function, there is a critical need to help patients combat the depression and loss of motivation which commonly occur after injury. In fact, people with traumatic brain injury are eight times more likely to be diagnosed with depression compared to those without brain injury. Amanda Rabinowitz, PhD, is director of the Brain Injury Neuropsychology Lab at MRRI, and she has been working with colleagues to develop a chatbot to help people with TBI continue to stay focused and connected between clinical care visits.
Philadelphia Public station WHYY recently featured Dr. Rabinowitz and the RehaBot chatbot she has been studying.
“It extends the reach of the therapy by providing an always-available companion that can help somebody between sessions be more successful in fulfilling their goals and doing more of the activities that we know lead to a sense of accomplishment and pleasure that can lift somebody out of a depression,” Dr. Rabinowitz explained in the interview.
This chatbot operates via text message, and it uses elements specifically targeted to engage users and facilitate behavior change.
At MRRI, researchers are dedicated to conducting theory-driven research to improve the lives of people with neurological disabilities. RehaBot is currently being evaluated in focus groups, and it may ultimately become an important resource for people with traumatic brain injury.
Areas of interest within the Cognitive Neuroscience and Cognitive Rehabilitation focus area at Moss Rehabilitation Research Institute (MRRI) include investigating the neural underpinnings of language processing and expression, as well as understanding how language can be impacted by brain injury or disease. MRRI is dedicated to engaging with other leaders in the field to exchange ideas and continue important discussions in these research areas. Over the past three months, MRRI hosted a series of virtual presentations from leading experts in our Visiting Scholars Language Mini-Series. Each presentation is available on our YouTube channel for anyone interested in learning more.
Professor in the Departments of Cognitive Science and Neuroscience at Johns Hopkins University
View Dr. Rapp’s presentation titled “From voxels to hemispheres: Understanding language recovery at multiple network scales” recorded on January 27, 2021.
Network science provides a promising approach to understanding post-stroke recovery in aphasia. One challenge, however, is the fact that brain networks occur at multiple scales, from micro to macro. In terms of the functional networks that can be evaluated with fMRI, these may range from networks of clustered voxels, functional connectivity within processing components, connectivity between components as well as inter-hemispheric connectivity. We don’t yet know if any or if all of these levels will be relevant for understanding the brain changes that support recovery of function in post-stroke language disorders. In this talk, Dr. Rapp discusses data analyses and findings that identify changes that occur at these multiple levels and which are linked with behavioral changes resulting from language treatment. She proposes that these findings provide a basis for beginning to understand and ask motivated questions about the complex, multi-level network processes involved in recovery of function in the damaged brain.
Associate Professor of Neurology and Rehabilitation Medicine at Georgetown University Medical Center
View Dr. Turkeltaub’s presentation titled “Inner Speech in Aphasia” recorded on February 24, 2021.
Many people with aphasia report that they can say words in their heads that they can’t say aloud. Understanding more about these subjective reports could have implications for our understanding of the nature of inner speech and self-awareness and could have clinical implications for how we diagnose and treat anomia. Dr. Turkeltaub discusses a series of studies assessing how these subjective reports relate to objective measures of word retrieval and production. He also shares recent related work on overall awareness of anomia and error awareness in aphasia.
Professor in the Department of Psychology, Department of Kinesiology, Program in Neuroscience, and the Beckman Institute for Advanced Science and Technology at the University of Illinois.
View Dr. Federmeier’s presentation titled “Finding meaning in time: What electrophysiology reveals about how the brain makes sense of the world” recorded on March 24, 2021.
A lynchpin of human cognition is the ability to rapidly and effectively link incoming sensory information to knowledge stored in long-term memory. Work in Dr. Federmeier’s laboratory, focusing on the cognitive and neural mechanisms that make this possible, has revealed the critical import of time and context for meaning processing. Comprehension is sub served by a set of core mechanisms that use time to create links between sensory stimuli and stored semantic knowledge, affording the continuous infusion of meaning into human perception. In addition, compelling evidence shows that language processing can be facilitated by active, context-based expectations for semantic, lexical, and sensory features of likely upcoming words. In this presentation, Dr. Federmeier reviews the neural and cognitive bases for expectation-based processing. She describes emerging evidence showing that multiple language comprehension mechanisms are implemented in parallel and that the brain dynamically adapts its use of these mechanisms, both over the long-term in response to changing neural and cognitive abilities with age, and over the short-term in response to situational and task demands. Collectively, these findings reveal the complex relations among sensory processing, attention, memory, and control systems that allow people to rapidly and fluidly understand one another across the lifespan.
Laurel Buxbaum, PsyD, associate director of MRRI, director of the MRRI Cognition and Action Lab, and research professor of Rehabilitation Medicine at Jefferson University has been appointed to the Board of Directors of the American Society of Neurorehabilitation (ASNR).
Dr. Buxbaum will share with ASNR her expertise in the interface between cognition and motor control, patient-based cognitive neuroscience, and neurorehabilitation assessment and treatment. Her research has been funded by the National Institutes of Health, the James S. McDonnell Foundation, and the National Institute for Disability and Rehabilitation Research.
ASNR was founded in 1990 to advance clinical care as well as basic and clinical research of patients with chronic neurological disabilities. “I’m looking forward to supporting the outstanding mission of ASNR,” Buxbaum said. “ASNR’s meetings, mentorship, and high-quality scientific journal (Neurorehabilitation and Neural Repair) all facilitate rigorous basic and clinical research, so the values of the organization align very closely with the mission of MRRI and MossRehab.”
Dr. Buxbaum’s three-year term begins immediately.
Learn more about Dr. Buxbaum and her work in neurorehabilitation.
We are pleased to announce that Marja-Liisa Mailend, PhD, has recently joined our team of Institute Scientists at MRRI. Dr. Mailend’s academic training began with a clinical focus at the University of Tartu in Estonia where she received her master’s degree in speech-language pathology. During her early scientific training, she realized the critical need for further development of a solid evidence base for clinical care. This, combined with her passion for research and scientific thinking, drove her to pursue a doctoral degree. Dr. Mailend was awarded her Ph.D. in Speech, Language, and Hearing Sciences from the University of Arizona where she had an opportunity to work with several exceptional researchers. In 2017, Dr. Mailend came to MRRI where she trained as a postdoctoral fellow under the mentorship of Erica Middleton, PhD, and Laurel Buxbaum, PsyD.
Research in Dr. Mailend’s new laboratory focuses on improving our understanding of impairments of phonological encoding and motor planning for speech. She applies theoretical models of typical speech production to elucidate the underlying impairments in apraxia of speech (a motor speech disorder that makes it difficult to speak) and aphasia (an acquired language impairment that impairs one’s ability to express and understand language). The ultimate goal of Dr. Mailend’s research program is to develop theory-driven assessments and treatments to help people with speech and language impairments lead independent and fulfilling lives.
Dr. Mailend’s work complements ongoing research at the Institute in the area of cognitive neuroscience and cognitive rehabilitation, and she looks forward to continuing to build collaborations with other world-class researchers both within and outside of MRRI.
MRRI Institute Scientist Amanda Rabinowitz, PhD, was recently featured on KYW Newsradio. During her interview, Dr. Rabinowitz discussed her recent work developing a chatbot to help people with traumatic brain injury. After a brain injury, many people experience depression and loss of motivation. This can have a tremendous impact on their quality of life as well as the course of their rehabilitation. In developing the chatbot, Dr. Rabinowitz and her colleagues incorporated evidence-based principles that promote engagement and behavior change. The chatbot (called RehaBot) operates via text message and could be a key resource for patients between their therapy sessions.
“We think that this is going to be a really effective way to keep people focused on maintaining their progress and give them that sense of joy and accomplishment and pull them out of the depression,” Dr. Rabinowitz noted.
This study is one of many innovative research projects at MRRI that are incorporating rigorous, theory-driven approaches to contribute to the development of novel clinical treatments in neurorehabilitation.
Women have been integral to the evolution of MRRI from its inception, from co-founder, visionary, and scientist Myrna Schwartz, PhD, to the present day, where eleven of sixteen senior scientific staff and affiliates and two thirds of the entire Institute are women. Their positions span the spectrum of roles at MRRI, including critical daily research activities, senior leadership, administrative support, and scientist training. Our women scientists conduct theoretical, practical, prospective, and retrospective studies to advance our mission.
Having grown up in a family of progressive women in the arts and medicine and graduated from Edith Cowan University, the only Australian University named after a woman, the breadth and impact of women at MRRI is a source of pride for me. The women at MRRI make important contributions not only through brilliant thinking, efficiency, and attention to detail, but more broadly in the adaptability and interpersonal relationships that make our Institute a dynamic and collaborative environment.
During Women’s History Month and beyond, we should pause to consider the imbalance of opportunities and the challenges faced by women historically and in the present. It is important to appreciate women’s scientific, cultural, political, economic, and social achievements to date, and to recognize those who are presently blazing trails for future women.
While gender equality is improving, we should all be attentive to ensuring that women receive the opportunities in science that are experienced by men. This includes outcomes in grant and manuscript submissions that are equivalent across gender, and equal proportions of women invited as conference speakers, prestigious scientific board members, and leaders in professional organizations. I encourage you to visit mrri.org/who-we-are to learn more about the history, current innovations, and significant scientific progress being made by the women at our Institute.
The critical need for options to deliver healthcare treatments remotely has been brought into the spotlight during the COVID-19 pandemic. COVID-19 has placed limitations and restrictions on the delivery of healthcare, making traditional in-person office visits more of a challenge. Even prior to the pandemic, brain injury rehabilitation providers had noted that transportation and financial barriers limit access to in-person treatment.
MossRehab has partnered with the Brain Injury Association of Pennsylvania (BIAPA) and other local rehabilitation providers to conduct a pilot demonstration study of remote delivery of cognitive rehabilitation for persons with traumatic brain injury (TBI), funded by the Pennsylvania Department of Health. Telehealth solutions for cognitive rehabilitation (telerehab) may be more effective and efficient than in-person services alone. The ability to deliver treatment to individuals in their homes could reduce missed appointments, while increasing access to services and allowing therapists to work with patients in their home environments.
After a moderate to severe TBI, many people have difficulties with everyday thinking skills. Cognitive Rehabilitation therapy is a broad term describing treatments that address these issues. Therapists must take into account each patients’ unique situation—their cognitive strengths and difficulties, the demands of their every-day lives, and the resources and supports available to them in their home environments. Given the wide range of problems and needs of individuals with brain injury, therapy varies from person to person. Although cognitive rehabilitation may include elements that target restoration of cognitive skills, for patients with brain injury, treatments that focus on compensating for cognitive deficits have a greater positive impact on real world functioning. Compensatory therapies focus on training strategies to overcome specific problem areas, often using external aides like smart phone applications, memory notebooks, and family calendars.
There are a number of challenges to providing cognitive rehabilitation via telehealth. Not all patients have access to high-speed internet and adequate hardware, that is, a computer or tablet with video capability. In the pilot demonstration project, a program evaluation team is tracking what patients already have access to and providing hardware and internet to those who need it. They are also providing staff and patients with an initial training session and ongoing technical support. Estimating the time and effort required for training and support will be important for evaluating the feasibility and sustainability of offering telerehab services beyond the scope of the current program.
This demonstration study is enrolling patients who are receiving cognitive rehabilitation and brain injury counseling supported by the Pennsylvania Department of Health’s Head Injury Program (HIP). Just as they do in usual practice, therapists work with individual patients to develop treatment plans around their goals. For the duration of their participation, patients are provided with iPads and high-speed internet to take part in HIPPA-compliant video conferencing. Patients enrolled in the program participate for at least six months, and as long as the remaining duration of their HIP-supported benefit for cognitive rehabilitation and brain injury counseling.
The therapists participating in the program have been holding video conference sessions with patients since March of 2020 and have noted many benefits of telerehab. Amanda Johnson is a therapist at MossRehab’s Drucker Brain Injury Center at Elkins Park. She described how video conferencing has allowed her to help patients improve their organization skills within their home environments, adding that some patients are more comfortable with video conferencing than home visits. Being able to view the patient’s home environment unlocks new opportunities for treatment. For example, Ms. Johnson was able to see the ingredients and kitchen equipment in a patient’s kitchen, which was useful in coaching them through meal planning and preparation. An added benefit that Ms. Johnson has noticed is that patients’ experiences with the iPad and video conferencing software have helped some become more comfortable with technology.
Amanda Rabinowitz, PhD, institute scientist at Moss Rehabilitation Research Institute (MRRI) and director of the Brain Injury Neuropsychology Laboratory, is leading the program evaluation team, which will evaluate feasibility and user-satisfaction with services delivered over the telehealth platform. The team is looking at several different factors related to how practical and desirable telerehab may be for patients with brain injury. One of these factors is the financial cost and technological support needed to get patients set up to use the video conferencing. Treatment providers are monitoring attendance at appointments throughout the duration of treatment, keeping track of any barriers to treatment encountered along the way. At the conclusion of the study, both patients and therapists will report on the usability of the video conference platform and their satisfaction with the experience. Both patients and providers are surveyed on the potential benefits and any potential disadvantages of holding cognitive rehabilitation visits remotely through video conference.
Eliminating the logistical challenges of transportation to and from the clinic could improve attendance. The team is interested in learning whether telerehab sessions are better attended and more easily rescheduled than in-person sessions. The team will also be investigating how clinicians make use of the opportunity to provide therapy for patients within their home environment. Do therapists involve family members, calendars, and other elements of the home environment to do real-time strategy development, for example, for the management of mail or the payment of bills?
Researchers and clinicians involved in this demonstration study were pleased to discover that patients were highly interested in participating. The team closed enrollment in January 2021 with 28 active participants, and this was considerably more than their target enrollment of 20 participants. The study will conclude at the end of May 2021, and we look forward to using these results to help us continue to develop new and innovative treatments at MossRehab.
Rehabilitation scientists and care providers have come to understand that traumatic brain injury (TBI) is a dynamic condition that often leads to health issues persisting for many years after the event. For a subset of those living with TBI, decline occurs over time and is likely due to a myriad of causes including progressive neurodegenerative processes, comorbid conditions, aging, behavioral choices, and psychosocial factors. Deterioration, whether directly or indirectly associated with the original brain injury, must be proactively managed to maximize health, independent function, and participation in society.
Management of chronic diseases, such as diabetes and heart disease, differs from medical management of acute conditions. Care of individuals with chronic conditions must be coordinated across primary and specialty care providers. Patients themselves must take an active role in day-to-day decisions about the management of their illness. Effective chronic care management relies on the partnership between patients and health care professionals. When patients are more informed, involved, and empowered, they interact more effectively with the healthcare system and make lifestyle choices to promote better health.
Drs. Hammond, Watanabe, Rabinowitz, and their colleagues want to extend this chronic disease approach to people living with TBI. The model they are developing is called “BeHEALTHY,” and it aims to transform treatment of chronic TBI by optimizing diagnosis, evaluation, and management of patients with TBI. This approach is designed as a cooperative model, encompassing primary and specialty care providers, patients, and their caregivers, as well as modifications to the health care system.
This comprehensive approach will involve broad efforts spanning professional education, development of tailored self-management approaches, and structural changes to healthcare systems. For example, clinicians who are not brain injury specialists will require training in methods for identifying TBI in their patients, as well as education on common medical comorbidities and best practices for treating these conditions in the context of TBI. To develop tailored self-management approaches for improving physical and mental health in people with TBI and their caregivers special attention must be given to common cognitive and physical limitations of TBI. These self-management programs may include community resources and peer support groups, as well mobile apps to assist with self-monitoring. In order to ensure that clinical and self-management programs are feasible and sustainable, the group will also design modifications to the health care system to support these efforts. For example, changes to the medical record and billing/funding practices would facilitate communication across care providers and ensure broad access to care. In developing this comprehensive approach, the team is drawing from models of care shown to be effective for other chronic conditions.
Since the project began at the end of last year, the research team has been reviewing the medical literature to inform the development of the BeHEALTHY model. Once developed, the model will be refined using input from people living with brain injury and their caregivers. Over the final two years of the project, the research team will conduct clinical trials to test the components of BeHEALTHY for feasibility, and they will begin disseminating the program to healthcare systems across the country. “The goal is to transform care, so that people with TBI can live longer, healthier, happier, and more productive lives,” notes Dr. Rabinowitz. MossRehab is proud to be one of the TBI Model Systems sites that is participating in this important project. Dr. Watanabe lends his expertise on clinical management as part of the work group that is developing guidelines for clinical care. Dr. Rabinowitz is overseeing all project-related research activities at Moss and contributing to the effort to develop self-management approaches.
Umi Venkatesan, PhD, who directs the Brain Trauma and Behavior (BraTBehavior) Laboratory, recently launched a project examining social factors that may affect the recovery of adults with traumatic brain injury (TBI). This exciting work is funded by the Albert Einstein Society, and it focuses on pre-injury, early life experiences that may shape how individuals recover from TBI sustained in adulthood.
Why do pre-injury experiences matter? Oftentimes what we think of as “brain injury outcomes” are in fact much more than that. When we ask someone how they are doing emotionally or about their social relationships, we are not just capturing their life now (since their injury) but the effects of all their life experiences (before and after injury) combined. For example, it is well documented that TBI can negatively affect mental health, but a person’s emotional functioning is also influenced by whether they may have struggled with psychological problems in the past. As one might expect, problems present before injury do not stop being relevant after injury; in fact, they are at risk of worsening. In other words, TBI changes someone’s life, but it does not erase who they were before their brain injury.
Previous research has centered mostly on demographic factors that influence TBI outcomes, such as sex, race, and socioeconomic status, but these do not tell us much about a person’s “lived experience” before injury. We know that social experiences earlier in life can have significant impacts on how people approach daily life activities and, importantly, how they cope with stress. Indeed, recovering from TBI can be a major source of stress!
In his current work, Dr. Venkatesan is asking survivors of TBI about negative childhood family and social experiences that may ultimately affect how well they recover from TBI. In the general population, these experiences have been shown to have a number of negative health effects later in life, including increasing the risk for sustaining a TBI. Dr. Venkatesan’s lab is examining whether these kinds of experiences may have similar effects on outcomes after TBI. The long-range goal is to bring us closer to a more holistic understanding of each patient, which would allow clinicians to better personalize treatment to reflect the life perspectives of each individual. Dr. Venkatesan argues that while demographic factors and the effects of injury on the brain are not easily changed, we can better understand and modify attitudes and behaviors that could interfere with recovery potential. This approach may prove fruitful in improving the quality of life of those impacted by TBI.
Recruitment for this study is underway, and several participants have already been enrolled. The project will run through 2021, and Dr. Venkatesan expects to collect data on 80-90 individuals living with TBI in the Philadelphia region. The study is believed to be the first of its kind, and it has already led to collaborations with other TBI investigators across the country. With these scientists, Dr. Venkatesan recently founded a research workgroup devoted to characterizing pre-injury functioning in individuals with TBI. This initiative, known as Lives Before Brain Injury (LiBBI), meets monthly to discuss methodological and conceptual issues, share current research projects of its members, and identify collaborative opportunities.
Dr. Venkatesan’s research program at MRRI hopes to address a critical gap in the literature regarding individual life trajectories and how they may be modified by TBI. The BraTBehavior Laboratory is fortunate to be able to conduct this work within the diverse population of the Delaware Valley and looks forward to expanding its scientific mission with future research partnerships.