Developing a Novel Clinical Program for People with Primary Progressive Aphasia

Primary progressive aphasia (PPA) is a cluster of neurodegenerative disorders characterized by insidious loss of speech and language, which over time severely impairs the ability to articulate, remember words, understand others, and in some cases even comprehend the use for common objects, like a spoon or a key. There are several variants of PPA, which are associated either with Frontotemporal Degeneration, the most common form of dementia for people under the age of 60 (theaftd.org), or, in some cases, Alzheimer’s Disease pathology. While knowledge of PPA has begun to increase in the healthcare community, it can still take more than three years for families to receive an accurate diagnosis, delaying access to treatment. Due to the young-onset of PPA, difficulty accessing resources is further exacerbated by the fact that many caregivers are still working full time to support families that may include young children.

To assist in bridging this critical gap in services within the greater Philadelphia community and beyond, the MossRehab Aphasia Center developed a program called the Strategy Training and Education Program for People Living with Primary Progressive Aphasia (STEP-LPPA). This pilot program, funded by the Albert Einstein Society, provides communication, psychosocial, and educational support to individuals with PPA and their primary care/communication partners. Participants receive individualized training and information regarding support services in a service-delivery model designed to maximize building friendships and a community for long-term support. Direct programming occurred over the course of approximately one month in the late spring of 2022, with follow-up support sessions planned through November 2022.  Participants with a diagnosis of PPA and their communication partners provided feedback throughout the course of the month-long program and will continue to have the opportunity to share their thoughts and advice.

People with PPA

“I think this is what we have to have. When we started, it [PPA] was weird, now it is not.”

“I have taken so much. I didn’t know what it [PPA] was, but now … It is very comforting.”

Communication Partners

“I feel like I’ve become a better caregiver”

“There are things I have never said to anyone else that I have said in this group.”

“We’re so grateful to each of the pilot participants for their dedication to the program and their willingness to provide us with such informative feedback. It was a true pleasure getting to know each of them.” says Sharon M. Antonucci, PhD, CCC-SLP, Director of the MossRehab Aphasia Center.

This article was adapted from an article originally published in the 2022 MRRI Letters annual newsletter.


Dr. Sharon Antonucci Featured by the National Aphasia Association

MossRehab Aphasia Center Director Sharon M. Antonucci, PhD, CCC-SLP, was recently invited by the National Aphasia Association to present as part of their “Ask the Expert” webinar series. This series uses an interactive format to connect people with aphasia with experts in a variety of aphasia-related clinical and research fields. In her presentation, Dr. Antonucci discussed animal-assisted therapy, historical evidence supporting this form of therapy, and her current research on aphasia rehabilitation using animal-assisted therapy.

You can watch the full webinar on the National Aphasia Association’s YouTube Channel.


The Sensorimotor Learning Lab Receives New Grant to Study Primary Motor Cortex Changes in People with Degenerative Cerebellar Ataxia

 

A lab assistant tests hold an electromagnetic to a patients head.

A person’s ability to properly coordinate their movements as they go through their daily life relies on a part of the brain called the cerebellum. Cerebellar ataxia is a movement disorder that results when the cerebellum is damaged. People with cerebellar ataxia have difficulty controlling their balance, and their walking can have a “drunken” appearance. Damage to the cerebellum also impairs the control of reaching movements, eye movements, and speech.

There are a host of genetic conditions that can cause a progressive degeneration of the cerebellum, and these conditions affect many people around the world. In the United States alone, it is estimated that between 15-20,000 people have autosomal dominant spinocerebellar ataxias, and tens of thousands more are affected by autosomal recessive and sporadic ataxias.

Currently, there are no medications that are effective in treating the broad movement incoordination associated with cerebellar ataxia. This leaves physical and occupational therapy as the main options for managing the condition. However, current therapy interventions often show limited success.

Rehabilitation for cerebellar ataxia is challenging because cerebellar damage impairs an important mechanism for learning to alter movement patterns, called adaptation. For the past few years, Amanda Therrien, PhD, Director of the Sensorimotor Learning Laboratory at Moss Rehabilitation Research Institute (MRRI), has been studying whether people with cerebellar degeneration can leverage a different mechanism, called reinforcement learning, to change their movement. This work has shown that reinforcement learning is less dependent on cerebellar integrity than adaptation and that people with cerebellar degeneration can use reinforcement learning to change their movement patterns.

Despite showing promise for most people with cerebellar degeneration, Dr. Therrien’s research has revealed some variability in the responses to reinforcement learning interventions. That is, some people with cerebellar ataxia learn more with this training than others. The ability to predict which people are likely to benefit most from reinforcement learning is a critical step in translating this kind of training to interventions that could be useful in clinical settings.

Reinforcement learning depends on excitatory plasticity in a region of the brain called the primary motor cortex. The cerebellum is highly connected with the primary motor cortex, and cerebellar damage can alter primary motor cortex activity in a way that may hinder the plasticity needed to leverage reinforcement learning. Dr. Therrien recently received a grant from the National Center for Neuromodulation for Rehabilitation to use non-invasive brain stimulation to study changes in primary motor cortex activity in people with degenerative cerebellar ataxia. MRRI Institute Scientist Shailesh Kantak, PT, PhD, is a co-investigator on the grant, and MRRI Director Dylan Edwards, PhD, will serve as a consultant on the project. The project will determine whether these changes can predict responsiveness to a reinforcement learning intervention.


Researchers and Clinicians Collaborate on Multi-center Study of Inpatient Rehab for TBI

Moderate to severe traumatic brain injury (TBI) results in difficulties in thinking, behaving, feeling, moving, and sensing that can have a devastating impact on an individual’s ability to function independently at home and in the community. Comprehensive interdisciplinary inpatient rehabilitation can maximize function and reduce complications. Currently, a wide range of rehabilitation interventions are used, however, clinicians still struggle with answering the question: “Which intervention approach is best for my patient?”

Funded through the National Institutes of Health, National Institute of Neurological Disorders and Stroke, the Comparing Treatment Approaches to Promote Inpatient Rehabilitation Effectiveness for Traumatic Brain Injury (CARE4TBI) Study, aims to close this evidence gap by leveraging the infrastructure of the National Institute on Disability, Independent Living and Rehabilitation Research’s TBI Model Systems, as well as recent advances in data capture through electronic medical records (EMR), and in advanced statistical methods to study rehabilitation strategies. Jennifer Bogner, PhD, and Cynthia Beaulieu, PhD, at Ohio State University Wexner Medical Center and Erinn Hade, PhD, at New York University Langone Health are co-leading this pragmatic observational study of nearly 1,600 participants to be recruited through 15 TBI Model Systems sites, located across the United States in varied health systems and communities.

Andrew Packel, PT, NCS, is making an important contribution to this project by representing Moss to the multicenter, multidisciplinary team responsible for identifying and designing new data forms and response sets to be added to the standardized EMR. The aim is to capture data chronicling treatment and recovery during the natural course of a patient’s hospitalization.

Using the standardized data captured during inpatient stays, the impact of different approaches to rehabilitation therapy on patient outcomes will be evaluated relative to their effectiveness in improving the person’s ability to care for themselves and to function at home, at work/school, and in the community by 1 year post-injury. Mr. Packel, working with the clinical frontline staff on Moss’ inpatient TBI unit, will provide input to the project regarding suggested EMR changes to capture this important clinical information accurately and efficiently. At the same time, they will work to make sure that the recommended changes integrate well into Moss’ current EMR to enhance daily documentation of care by the numerous therapists on the unit.

Mr. Packel is joined in this project by Amanda Rabinowitz, PhD, and Mary Ferraro, PhD, OTR/L, as well as bioinformaticist Lisa Peck who make up the team responsible for conduct of the project at Moss. Dr. Ferraro is the lead Occupational Therapist and a member of the Executive Committee that oversees the project design and implementation. The varied rehabilitation disciplines (physical therapy, speech therapy, therapeutic recreation) are represented in all the working groups of the project.

This research project has the potential have a major impact on clinical care for TBI. As Dr. Ferraro notes, “this project has engaged clinicians and EMR developers to standardize elements of clinical documentation. This observational study will be a huge advance for broader data collection and analysis of TBI inpatient rehab practices.”

This article was adapted from an article originally published in The MossRehab Traumatic Brain Injury Model System’s Spring 2022 Edition of Brain E-News.


MRRI Scientists Featured by THERA-Trainer in THERAPY Specialist Magazine

Research at MRRI spans the translational pipeline from basic research to studies in clinical neuroscience and neurorehabilitation. Through their innovative research, scientists at MRRI are advancing the field of neurorehabilitation and bringing novel treatment approaches closer to important applications in the clinic to improve outcomes for patients with stroke, brain injury, and other neurological conditions. In particular, MRRI researchers and MossRehab clinicians are at the forefront of applying technology to enhance rehabilitation.

MRRI Director Dylan Edwards, PhD, MRRI Associate Director Laurel Buxbaum, PsyD, and MRRI Institute Scientist Amanda Rabinowitz, PhD, were recently featured by the German rehabilitation device company THERA-Trainer in their THERAPY Specialist Magazine. This article discusses the researchers’ respective contributions to cutting-edge work on digital gaming, virtual reality, and home-based approaches for rehabilitation after stroke or brain injury.

You can read the full article here.

 


Amanda Rabinowitz, PhD, was a Guest Editor and Article Co-Author in Recent Journal Issue

Mobile health (mHealth) has tremendous potential to change the nature of health care worldwide, and different mHealth approaches are being explored for a wide variety of health conditions. Amanda Rabinowitz, PhD, is Director of the Brain Injury Neuropsychology Laboratory at Moss Rehabilitation Research Institute (MRRI), and her work has been examining how mHealth technology can be used to improve outcomes for people following traumatic brain injury (TBI). Dr. Rabinowitz served as a guest editor for the latest issue of The Journal of Head Trauma Rehabilitation, a leading peer-reviewed journal focused on the clinical management and rehabilitation of people with TBI. The Journal of Head Trauma Rehabilitation is the official academic journal of the Brain Injury Association of America.

As guest editor of this issue, Dr. Rabinowitz and Shannon Juengst, PhD, of UT Southwestern Medical Center worked to assemble a collection of articles from top scientists examining important areas of research related to the use of mHealth for TBI rehabilitation. Dr. Rabinowitz is lead author on one of the featured articles in this issue, and she is a co-author on another article. In the first article, Dr. Rabinowitz and colleagues describe their work developing and testing a chatbot (called RehaBot) that can communicate with users with TBI to provide reminders, encouragement, and supportive feedback. RehaBot is being designed to augment face-to-face therapy to reduce depression and increase participation in people with moderate-to-severe TBI.

In the second article, Dr. Rabinowitz and colleagues investigated the feasibility of remote collection of data on neurobehavioral symptoms and heart rate variability via a commercially available wearable device. Their work suggests this method of data collection is feasible, and heart rate variability has potential to be used as a physiological biomarker or neurobehavioral symptoms.

Through opportunities such as serving as guest editors for academic journals, MRRI scientists are continuing to lead and guide research in their respective fields with the ultimate goal of advancing neurorehabilitation treatments to improve the lives of patients.


New Edition of the MossRehab TBI Model System’s Brain E-News Released

The scientists, clinicians, and staff within The MossRehab Traumatic Brain Injury (TBI) Model System are excited to share news and updates in the Spring 2022 Edition of Brain E-News. This edition of the newsletter features an article about the ongoing Comparing Treatment Approaches to Promote Inpatient Rehabilitation Effectiveness for Traumatic Brain Injury (CARE4TBI) Study which is comparing different intervention approaches to help optimize care and outcomes for people with TBI. Also in this edition, the team shares the story of a MossRehab TBI Model System Member, provides information on a new Empowerment Group for people with TBI, features work being done as part of the Curing Coma Campaign, and gives an update on the Brain Injury Association of Pennsylvania’s Annual Conference coming up June 26 – 28, 2022.

Click here to read the full Spring 2022 Edition of Brain E-News.


Pioneering Research Led by Dr. Laurel Buxbaum Has Informed Knowledge of Tool Actions

Over the course of her career, Laurel Buxbaum, PsyD, has worked with collaborators and trainees to make substantial advances in our understanding of how the human brain allows us to successfully use tools and how these processes can become disrupted following stroke. Dr. Buxbaum is Associate Director of Moss Rehabilitation Research Institute (MRRI) and Director of the Cognition and Action Laboratory at MRRI. Research in Dr. Buxbaum’s lab has focused on how (and in which brain regions) tool-use information is learned, organized, activated, and selected.

Deficits in the ability to pantomime, imitate, and recognize tool actions occur in a neurological disorder known as limb apraxia. Apraxia may be present in people with a variety of neurological disorders, and it is most commonly studied in individuals who have experienced a stroke in the brain’s left hemisphere.

In 19821, Ungerlieder and Mishkin proposed that different kinds of visual information may be processed in two different pathways in the brain. This idea was further explored and refined over the years by Goodale and Milner2. The dorsal stream was observed to be relevant for visual information required for executing actions, such as reaching, grasping, and eye movements to visual targets. In contrast, the ventral stream was found to be important for visual information necessary for perception such as object recognition and semantic knowledge.

This initial model accounted for some of the symptoms and patterns observed in patients with apraxia post-stroke, but Dr. Buxbaum and others in the field found that this model wasn’t sufficient to describe the complexity of the behaviors observed in these patients.

Developing New Models to Account for Tool Use Deficits

In 20013, Dr. Buxbaum proposed a new functional neuroanatomic model that includes two action systems that are specialized for distinct aspects of tool actions: a bilateral dorso-dorsal network relevant for moving tools (the “Move Network”) and a left hemisphere ventro-dorsal network critical for tool use (the “Use Network”). The Move Network is specialized for actions to currently-viewed objects.  The information is short-lasting, and the network is responsible for processing information related to tool structure (size, shape, and orientation). In contrast, the Use Network is responsible for the representation of remembered trajectories and body postures necessary for learning the skilled use of tools and other manipulable objects.

Subsequent work in the Cognition and Action Laboratory has successfully tested and validated this proposed Two Action Systems model. Dr. Buxbaum and colleagues have demonstrated that tool use depends on the ventro-dorsal stream, and they have further identified that the posterior temporal lobe is an important repository for tool use knowledge and tool action semantics. In contrast, the inferior parietal lobe may be important for knowing how tool use actions are supposed to feel and for buffering the representations that are candidates for tool use actions prior to selection.

In individuals with apraxia, Dr. Buxbaum and colleagues have demonstrated that there is slower and weaker activation of took knowledge. This results in deficits in prediction and a dependence on visual feedback to complete tasks, such as imitating tool use. The impairments in activation of tool knowledge also lead to deficits in selecting task-relevant tool actions and resolving competition between tools with similar actions.

Dr. Buxbaum has also worked with collaborators to expand our understanding of the neural nodes and connections of the tool use network. Based on their data from neuroimaging studies, their Two Action Systems model was expanded to include two additional areas relevant for action selection4. This Two Action Systems Plus model further clarifies the brain regions that are likely involved in accumulating potential actions that could be executed and providing goal-relevant signals that may inform action selection.

Subtypes of Apraxia and Relevance for Rehabilitation

Different subtypes of apraxia have been identified based on lesion location and the impairments that result, and Dr. Buxbaum refers to these according to the underlying mechanisms that may be impacted. While individuals may demonstrate impairments that are considered hallmarks of more than one apraxia subtype, identifying underlying causes of different presentations of apraxia can aid in the identification of targeted rehabilitation approaches.

Preliminary work5 from the Cognition and Action Laboratory suggests that certain individuals may benefit from a treatment program that focuses on strengthening semantic associations between tool actions and other types of tool knowledge, while others may benefit from treatment programs that involve gesture training with repeated practice of actions. Dr. Buxbaum hopes to continue this line of research to improve treatment options for people with limb apraxia after left hemisphere stroke.


Funding Renewed for the Klein Family Parkinson’s Rehabilitation Center at MossRehab

Members of the Family Parkinson's Rehabilitation Center standing in front of the donor wall at MossRehab.

In 2019, the Klein Family Parkinson’s Rehabilitation Center at MossRehab was founded to support and enhance the lives of people living with Parkinson’s disease through innovative research combined with clinical care to advance and improve rehabilitative therapies. MRRI Institute Scientist Aaron Wong, PhD, and MossRehab physician Tariq Rajnarine, MD, serve as the scientific and clinical directors, respectively. This rehabilitation program seeks to drive progress by bridging the traditional silos of research and clinical care through real-time collaboration between clinicians, therapists, and researchers and by developing and supporting joint clinical-research programs. The Klein Parkinson’s Rehabilitation Center was made possible by generous support from the Klein Family, whose members have contributed to advances in research and innovation across Einstein Healthcare Network for five generations.

MRRI is pleased to announce that the Klein Family has recently agreed to renew funding for this innovative program for an additional five years. Since its inception, the Klein Parkinson’s Rehabilitation Center has developed a new database for patient volunteers interested in participating in research, providing opportunities for individuals with Parkinson’s disease to get involved with the cutting-edge research led by investigators at MRRI. This in turn has spurred increased research activity in the area of Parkinson’s Disease at MRRI. More recently, the Klein Parkinson’s Rehabilitation Center has become a resource for people with Parkinson’s disease by introducing a multidisciplinary clinic at MossRehab to provide holistic assessments and rehabilitation plans. Expanded clinical, research, and community outreach programs are actively being developed as part of this next funding cycle.

The researchers and clinicians at MRRI and MossRehab are thankful for the Klein Family’s continued support, and they look forward to further integrating pioneering research from MRRI with the exceptional rehabilitation services delivered by MossRehab to improve the lives of people with Parkinson’s disease.


Catching Up with Former MRRI Research Assistant Julie Wilson

Julie Wilson worked as a Research Assistant at the Brain Injury Neuropsychology Laboratory at Moss Rehabilitation Research Institute (MRRI) until 2021 when she enrolled in graduate school. During her time at MRRI, she worked under the mentorship of lab director Amanda Rabinowitz, PhD, and it was a pleasure to catch up with Julie to hear more about what she is doing now.

1) Can you tell us what you are doing now?

I am currently in the doctoral program in the Psychology Department at Lehigh University, with a focus on cognitive psychology.

2) Why did you choose this particular program?

I chose this program for a couple reasons. First, my research interests are closely aligned with those of Dr. Jessecae Marsh, my current advisor at Lehigh University. Dr. Marsh’s lab focuses on beliefs in relation to causal connections, and how those beliefs affect our categorization decisions. Here is a link to the lab webpage for more information: https://wordpress.lehigh.edu/ccrlab/. In addition, I had multiple interviews with Dr. Marsh before deciding to attend Lehigh University, and each of our interactions strongly suggested to me that we would work well together. Lastly, I had a location restriction since I own my home near Philadelphia, PA. I chose to look at schools that were up to a 2.5-hour drive away from home, and Lehigh University was a great fit for all of my needs.

3) What are your current research interests?

I am currently interested in the interrelationships between perception, belief, and decision-making. My first-year project involves evaluating peoples’ perceptions of their own knowledge about certain everyday devices (i.e., a toaster, can opener, etc.) before and after asking them to explain how the device works. Previous research has shown that people tend to initially overestimate their knowledge about certain causal mechanisms of these devices and that the act of physically attempting to explain how the device works causes most people to realize their intellectual miscalibration. In my study, my research aims to determine what elements within these freely-written explanations lead someone to reassess their knowledge. Specifically, what is it about someone’s explanation that either allows them to recognize their ignorance or to continue to maintain their false perception of understanding?

4) Why did you choose to work as a Research Assistant at MRRI?

I chose to work as a Research Assistant and MRRI because I was interested in both psychology and neuroscience, and I knew I wanted to work with people. I believed working at MRRI would allow me to gain the experience I needed before advancing my education in either psychology of neuroscience.

5) What was it like working in the Brain Injury Neuropsychology Laboratory at MRRI?

It was an honor and a pleasure to work in the Brain Injury Neuropsychology Lab at MRRI. It was easy to become friends with each of my colleagues and my mentors treated me with respect while pushing me to do my best. I loved working with our study participants and was so grateful to have made connections with patients and their families.

6) Is there something you learned at MRRI that has helped you in your current endeavors?

Working at MRRI taught me how to efficiently manage my time since I was often part of multiple research projects at once. I also helped to write and publish two peer-reviewed journal articles during my time at MRRI, and these experiences will definitely help me now that I am in graduate school and am beginning to lead my own research projects. Most importantly, I further developed my compassion for people in all walks of life and my ability to listen to someone’s story without judgment.

7) What is one of your favorite memories from your time working at MRRI?

I have many wonderful memories from working at MRRI! I loved the time spent talking with and getting to know my co-workers, both at MRRI and in the Brain Injury Unit. We even got to play with the therapy dog, Pender, once each month! However, my favorite aspect of my job at MRRI was spending time with our study participants. I really enjoyed listening to each of their unique stories and how their brain injury had changed their perspective on life. I was very lucky to have met each and every one of them.

8) What is something that you are really excited about or looking forward to in your current role?

In my current role as a graduate student, I am really excited to be able to answer my own scientific questions. As a Research Assistant, you perform the tasks necessary to successfully complete research projects designed by other people. Now, I finally get to learn how to develop my own research studies to find answers to questions that I find interesting or believe need to be solved.

9) Can you tell us more about your long-term career plans or goals?

After I graduate, I would ideally like to work at an academic institution doing about 60% research and 40% teaching. I enjoy teaching and tend to find myself learning just as much from the ideas and perspectives of the students as what I hope they learn from me. However, my constant curiosity and passion for problem-solving lead me to believe that research is where I want to spend the majority of my time during my career.

10) What are some of your personal interests or hobbies?

In my spare time, I volunteer at an animal shelter in Media, PA. I spend my time there walking dogs, cleaning kennels, and even helping at outside events. I also enjoy hiking and the outdoors, as well as learning new types of crafting. Free time in graduate school can be hard to come by, but I still try to make it to the animal shelter at least once per week.