The ANA Q&A: Traumatic Brain Injury

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"There are a lot of areas in neurology that are pretty stable and very important, still, but traumatic brain injury in neurology is an area of growth and a lot of young neurologists are quite interested in this area. There’s a lot of opportunity; there’s still a huge unmet need."

~David Brody, M.D., Ph.D, Professor of Neurology

In recognition of Brain Injury Awareness Month (March), we spoke with ANA member and Professor of Neurology David Brody, M.D., Ph.D. Dr. Brody is a board-certified neurologist with both a research and a clinical specialization in traumatic brain injury (TBI) and neurodegenerative diseases.

What does the public need to understand about traumatic brain injury that it often doesn’t?

The public needs to understand that traumatic brain injury is one of the most important causes of death and permanent disability, especially in young people—defined as under age 45—but also increasingly important in older individuals who are having higher and higher rates of traumatic brain injury from falls. As people get more active in their lives, their risk of falls and subsequent traumatic brain injury goes up and so there’s a lot that people can do to help mitigate their risk of traumatic brain injury and also to help recover from traumatic brain injury. So, people can be proactive at improving their health in this direction. Another thing people need to know about traumatic brain injury is that it dramatically affects people in the developing world where people don’t have access to cars that are as safe as ours or roads that are as safe as ours and are increasingly at risk of violence. There’s a huge burden of injury-causing cognitive impairment and emotional dysregulation and chronic pain in the developing world. So, all of us that are interested in equity around the world should be focused on this issue of traumatic brain injury in the developing world.

Can you provide any examples of things people can do to mitigate their risk of traumatic brain injury?

Sure. Some examples of things people can do to mitigate their risk of traumatic brain injury include using the safest car or transportation method that they can. That means things like airbags, antilock brakes, traction control, high-quality seatbelts and, importantly, not driving while distracted. Cell phones and text messaging are very distracting and a common cause of crashes related to traumatic brain injury. In the United States, still motor vehicle crashes and transportation are the most common cause of traumatic brain injury. But a close second is falls. And in terms of mitigating falls, things people can do are to do balance training (things like yoga and tai chi and martial arts and dance and other balance exercises to improve balance to reduce their risk of falls), to make sure they’re using good footwear to reduce the risk of a fall, and to make sure their homes, especially stairways, are safe. One of the most common causes of falls causing traumatic brain injuries in the elderly is slipping and falling on stairways. We can do a lot to make our stairways safer.

How are treatment options for TBI different today from 10 years ago?

Treatment options for traumatic brain injury are dramatically improved now compared with the way they were 10 years ago. We still don’t have as big an evidence base as we would like and there’s still a lot of room for randomized and controlled trials of treatment interventions that have potential for benefit. So, I would not in any way say that we are where we need to be in terms of TBI treatment. But, nonetheless, we understand a lot more now than we did 10 years ago about treatment in several important domains. And those domains include post-traumatic headache, which is the most common persistent complaint after a traumatic brain injury, post-traumatic mood dysregulation—depression, anxiety, and other mood disorders—are not something we were focusing on as much 10 years ago as we are now, and post-traumatic sleep dysregulation, especially insomnia and increased risk of obstructive sleep apnea. Those are all things that are treatable. In regard to headaches, we have good migraine-based treatments that we think are effective for traumatic brain injury-related headaches, but we don’t have a solid evidence base. We use them clinically and we think they’re effective, but we’re in the process of doing randomized control trials to really understand how effective they will be. Plus, treatments like botulinum toxin, occipital nerve blocks, light cell modification for post-traumatic headache, are all areas that we’re doing a lot of in our practice. In the domain of post-traumatic mood dysregulation, we’re using medications, cognitive behavioral therapy, intervention, lifestyle modifications like exercise and alcohol cessation and excitingly, a new incarnation of transcranial magnetic stimulation for depressive symptoms following traumatic brain injury. So far in our preliminary data it’s working very well. We’re in the middle of randomized controlled trials to determine how effective it will really be in a more generalized population. And in the domain of sleep, the recommendations for cognitive behavioral therapy for insomnia are now pretty solid and in our experience it’s been working very well for people with traumatic brain injury-related insomnia. Plus, so many more traumatic brain injury patients are getting assessed and treated for obstructive sleep apnea than they were 10 years ago, we really weren’t thinking about that 10 years ago.

What work is your research group undertaking to move understanding or treatment for traumatic brain injury forward?

We’ve now recognized that it is time to start engaging in a serious program of randomized controlled trials for the late-phase, so acute to chronic sequelae of traumatic brain injury. In the past, we were primarily focused on randomized controlled trials in the very earliest phase from acute severe traumatic brain injury looking for neuroprotectives. That line of inquiry was not especially successful and now we’re shifting our focus toward treatment of the more chronic phases using randomized controlled trials. So, for example, we’re doing a randomized controlled trial of resting state MRI-guided transcranial magnetic stimulation for depressive symptoms after traumatic brain injury. We’re gearing up for a trial of internet-based cognitive behavioral therapy for insomnia in traumatic brain injury patients. And we’re gearing up for a trial of a calcitonin gene-related peptide monoclonal antibody in post-traumatic headache patients. Those are just a few of the examples, but the big picture can be seen in an editorial I wrote that was published in the Annals of Neurology last June called “How You Treat Traumatic Brain Injury: One Symptom at a Time.” The article begins “When General Creighton Adams was asked how to tackle a difficult problem, he reputedly answered, ‘When eating an elephant, take one bite at a time.’ In our view, the problem of treating traumatic brain injury (TBI) should be addressed the same way, one symptom or subdomain at a time.” 

What promising research is poised to change the standard of treatment for TBI?

The three studies I mentioned are things that our research group, specifically, is doing. There are a lot of other exciting trials that are going on right now including case management for post-concussive symptoms in sports-related concussions. There’s some very exciting work involving sub-symptom exercise treatment for recovery from sports concussions. There’s a lot of movement toward understanding best practices in comparative efficacy studies from centers all around the world where people are treated differently for traumatic brain injury and by assessing how people do relative to the differences in practices, different centers will begin to understand what practices may be most effective. And then there’s just a lot of consolidating into large, multi-center research groups, which I think is very helpful for the power to perform larger randomized control trials to develop an evidence base for treatment. Furthermore, there’s a substantial number of companies that are getting into the business of traumatic brain injury treatment. We are tracking these companies that are engaged in traumatic brain injury treatment research and we are tracking 41 companies that are active in the traumatic brain injury research space focusing on drugs, devices, medical foods and dietary supplements, biological treatments, etc.

How has the ANA supported your career and/or work in this area? 

The ANA has been very helpful for me. As a young investigator, when I was a fellow in David Holtzman’s lab at Washington University, the ANA had a Career Guidance Symposium for new K08 and K23 awardees from the NIH and getting together with all of us that were all about the same stage in the career was really helpful for me because I made a lot of friends and met a lot of colleagues and we’ve had a good collegial group over the years. And people who are working in other fields have been inspiring to me. That started early on in my career, that Career Symposium was probably in 2005. Another thing the ANA has been doing which I’ve been very happy about is the interest group meeting at the ANA Annual Meeting in traumatic brain injury. We’ve been meeting for several years in a row and every year it seems like there are about twice as many people attending and participating as the year before. So it is clearly a growth area for neurologists. There are a lot of areas in neurology that are pretty stable and very important, still, but traumatic brain injury in neurology is an area of growth and a lot of young neurologists are quite interested in this area. There’s a lot of opportunity. There’s still a huge unmet need. There are still a lot of people who have the disease and not that many really well-qualified neurologists who are expert in it. So, there’s a big need for highly qualified neurologists. Clearly, traumatic brain injury is an important neurological concern for the U.S. military. So, I hope the ANA will reach out more to the U.S. military neurology community. I’m certainly trying to do that myself so that we can care for service members and veterans who’ve had traumatic brain injuries through the wars in Iraq and Afghanistan, other conflicts around the world, and in just the very aggressive training that these individuals undergo.

Is there anything else you’d like to add?

One thing I would like to add is that although the public is focused a lot on sports-related concussions, sports-related concussions are just the tip of an iceberg for traumatic brain injury. Most traumatic brain injuries are not due to sports, most of them are due to motor vehicle accidents or falls. And most traumatic brain injuries do not occur in very healthy, physically fit young athletes. Most of them occur in regular people who may have comorbidities and may not be quite as resilient as our athletes that we’re studying. So, the information that we’ve learned about sports-related concussions, while very important, is not necessarily 100% applicable to traumatic brain injuries in other populations. As I mentioned, traumatic brain injury in the elderly, military service members, and just in regular folks, is an area of really important concern. Another thing I’d like to point out is there are an increasing number of traumatic brain injury specialists among neurologists, psychiatrists, physical rehabilitation doctors, family practice doctors, and sports medicine doctors. So, a lot of times even when people have sought care with a provider and have not necessarily benefited from that treatment, it may be worth it to go back and ask for another opinion because there’s a lot of new expertise in the field. And as a final thing, I’d like to mention I’ve tried to summarize some of my clinic’s practices in the field of traumatic brain injury in the “Concussion Care Manual” that was published by Oxford University Press; the second edition came out last year. I think it’s worth looking at for neurologists who are getting interested in traumatic brain injury care.