- [Announcer] Live from your public media studios, WVIA presents "Keystone Edition: Health," a public affairs program that goes beyond the headlines to address issues in Northeastern and Central Pennsylvania.

This is "Keystone Edition: Health."

And now, Moderator Tonyehn Verkitus.

- Good evening and welcome to "Keystone Edition: Health."

I'm Tonyehn Verkitus.

Thank you for joining us tonight.

A serious and often invisible condition that can affect anyone, from athletes and accident survivors to children and older adults, are brain injuries Whether it's a mild concussion on the field or a severe trauma from an accident, brain injuries can change everything in an instant.

But with growing awareness, cutting-edge treatment, and powerful stories of recovery, there's hope and progress like never before.

But first, WVIA's Lydia McFarland has more.

(logo whooshes) - [Lydia] Brain injuries are any damage to the brain that affects its normal function.

They can result from an external force, such as a blow to the head, or internal factors, like a stroke or lack of oxygen.

Brain injuries are classified into two main types, traumatic brain injury, or TBI, which is caused by external mechanical force.

Examples include concussions, contusions, or penetrating injuries.

Acquired brain injury, or ABI, occurs after birth and is not due to trauma.

Common causes include stroke, infections, tumors, or oxygen deprivation.

These injuries can range from mild to severe and may lead to temporary or permanent changes in cognition, physical ability, behavior, and emotion.

According to an article from Penn Medicine News, overall, 9.5% of all dementia cases in the study population could be attributed to at least one prior head injury.

A wide range of efforts are underway to improve the prevention, diagnosis, treatment, and rehabilitation of brain injuries.

For WVIA News, I'm Lydia McFarland.

- Joining us tonight, we have Jennifer Hoats, a speech therapist with Lehigh Valley Health Network, part of Jefferson Health, Kristin Walsh, an occupational therapist with Allied Services, and Dr. Paul Horchos, physician partner and director of Concussion Care Clinic at Northeast Rehab.

Thank you all for joining us.

- Thank you.

- Thanks for having me.

- Yeah.

I'd like to start with you, Paul, actually.

They talked about the different types of traumatic brain injuries that exist in ABI as well, but how is a traumatic brain injury different from a concussion?

- Well, a traumatic brain injury follows a very varied recovery course.

That's the most important thing.

So, a lot of times people try to apply things that they know about maybe having had a stroke or maybe a person who's had cerebral palsy to the recovery for a concussion or traumatic brain injury, but really, it's following its own trajectory.

And so you always have to be open-minded to the fact that the patient can still improve.

- So, are you saying that the brain can possibly rewire itself?

- Oh, absolutely.

It has great capacity to improve itself, especially if you challenge it in the right ways.

- And when someone comes to Allied and they've had some sort of injury, are they normally coming to you from a hospital setting or are people coming from home per chance?

- Generally, from the hospital setting, but we do occasionally have people who come back from home if they're having issues to try and work on, you know, their speech, their function, whenever they need to work on.

But generally from the hospital.

- And you're normally working with speech, and are you seeing people from all different age ranges?

And also, just outta curiosity, is brain injury the only thing that you're working on?

- I see patients for a variety of diagnoses.

My particular position, I do see the vast majority of my caseload are acquired brain injuries and traumatic brain injuries, and I see that across the lifespan.

So, you know, brain injuries aren't something that just affects adults.

You know, I have had children as young as eight years old who've had strokes, and I've had four and five year olds who have fallen and hit their head.

So, you know, it impacts all ages and everybody a little differently.

- So, when you're thinking about treatment, what exactly are you looking for to come up with a protocol?

- So, kinda like Dr. Horchos said about, you know, every patient is a little different.

So, what we're looking at, primarily, what are the areas of deficit.

You know, is that individual having difficulty with their language skills?

Is it with their swallowing?

Is it with, you know, their memory, their concentration, their reasoning skills.

And then we tailor a program that involves, you know, activities and things that are salient to the patient, things that they enjoy doing, things that are important to them in their daily routine, and then we're gearing the treatment to that.

- And Paul, when someone becomes your patient, they've had this injury, they may have spent some time in the hospital.

What is happening during your diagnosis before they're ending up with speech pathology?

- Well, right, I mean, that's super important, medical care.

Sometimes, patients go to the emergency room and are seen after a traumatic brain injury or after a cerebral concussion, and they'll complain that not much was done.

But what the emergency room may have done is it may have confirmed that there is no life-threatening injury, and that's super important.

But that doesn't mean that that's where the end of the medical care stops, that's actually where the medical care starts.

And that's where we start to, just like we said, we're trying to define where we're moving forwards, what kind of deficits, and what kind of complaints and problems the patient has.

And sometimes, it's also important to get the input of other individuals who are living with that person.

So, sometimes, patients will come in and say, "I have no problems."

And then you'll turn to their husband or wife and they'll say, "Oh, he's got lots of problems."

- [Kristin] Yes, yes.

(everyone laughs) - Yeah, that happens a lot.

- And when they're going through therapy with you, obviously, there's cognitive and physical therapy.

Can you tell us a little bit about what you're doing with physical therapy to start?

- Well, in occupational therapy, we usually work on more of the functional activities, like being able to get dressed, you know, getting in and outta bed, in and out of the bathroom, in and out of the car.

And depending, again, on what their deficits are, we might need to work on their arm, their leg, their walking, their balance besides the cognition.

You know, we also can work on cooking activities to help with direction following, safety, medication management, and different things like that.

- And when you see patients, obviously, you said different age ranges, do you find, and this might be a question for you as well, Paul, that certain age groups are coming in with a particular type of injury?

For instance, I would think that maybe seniors are having falls more often than car accidents, for instance.

I don't know.

- Yep, absolutely.

(laughs) You know, obviously, the main types of injuries are what you would expect for each age group.

You know, high school students, most of the time, they're coming in because they've had a sports injury.

Geriatrics most of the time are coming in because they've had a fall.

Young children, it could be, you know, any number of things.

They might be in an abusive home situation where they've suffered a traumatic brain injury because of something an adult has done to them, or maybe they've had a fall or some type of accident.

- Right, the other thing that's important there too is, older people have a tendency to be on medications that can complicate their injury.

So, a regular fall that a young person might be able to tolerate without too much issue, maybe just a small concussion, in an older person, that can cause a subdural hematoma or a bleed inside of their brain, which, if it's not identified, could really complicate things.

And even if it is identified, the recovery is still going to be more complicated.

- And I never really thought about that.

So, when I'm thinking treatment, I'm just thinking about the actual brain injury.

But you're saying there could be changes in medication required as well?

- Well, older people tend- - Potentially?

- To be on blood thinners.

So, blood thinners change the game.

So, when you hit your head and you're on blood thinners, your risk of having a bleed inside of your brain goes up significantly, so you have to be aware of that possibility.

And sometimes, after a traumatic brain injury, you might have to be on different medications as well, like anti-seizure medications, okay?

And that can also change things.

- And in terms of occupational therapy, how do you think it's changed since the past?

Do you think people are going through therapy quicker?

Are there tools that make it easier?

- Well, I think definitely patients have not been as severe as they have been in the past, and I think that's because of the increase in the medical care and definitely length of stay has shortened.

In the past, a brain injury would stay for months.

Now, the length of stay is about two weeks, depending on their status and how they're functioning.

- And Paul, can you tell us a little bit about the difference between TBI and ABI?

I know they addressed it in the intro, but in terms of care?

- Right, so, a traumatic brain injury would be associated with a motor vehicle accident or a fall or a sports-related injury, something like that.

And an acquired brain injury would be something that we might see with people who suffer from a drug overdose.

If you inject and then, you know, the problem with injecting medication is that you stop breathing.

So, when you stop breathing, then you suffer from an anoxic injury to the brain.

You can also see that kind of injury with a cardiac arrest.

So, sometimes, patients will have a cardiac arrest and they can be recovered, but then their brain has been starved of oxygen.

So, usually, acquired brain injuries usually are representative more of a problem with regards to either blood flow or oxygen flow.

- So, is the therapy then different?

- Well, it is, because an acquired brain injury from anoxia or loss of oxygen to the brain is more global.

So, global means that it affects the entire brain, so you tend to get more requirements for everybody else to be participating in the recovery.

Whereas if you have just a focal injury to the brain, then they might have a problem with one part of their function, and so you kind of focus in a little bit more on that.

- So, for you for instance, if we're looking at a global injury, then I assume in terms of the skills you're working on, that would be different, and how does that change things for you?

- Yeah, if I get a patient who has, you know, for example, anoxic brain injury that was mentioned, a lot of times, oxygen is deprived from the entire brain.

So, you have a patient that's coming in that probably has, you know, memory and cognitive problems in addition to the fact that they're having trouble with word finding, they're having a difficult time putting sentences together.

Their speech might be changed in terms of being slurred or hard to understand.

So there's a whole lot more that's going on with that patient that needs to be addressed than just, you know, maybe a cognitive problem or a language problem.

- And I hadn't really thought about this, but I would assume if someone's dealing with this sort of injury, there's probably a lot of mental and emotional things that are happening as well.

- Absolutely.

- How do you deal with those?

And anyone can answer that.

- Usually, I know with me, people are very frustrated, especially when they can't get their words out, they can't speak, or if they're trying to do an activity in OT and they just get extremely frustrated if they can't use their hand, you know, if they can't stand and do things.

So, usually, just calm voice, you know, just talking them through it, you know, going through saying that, "You know, this happens very quickly, but it takes time to recover and you have to give your body a chance to heal for things to get better."

- Yeah, sometimes patients get concerned because they will refer to themselves as, "Is this the new me?"

And the new me though, it might be a different kind of person, but the new me is still somebody who can be very functional and do all of the things that they used to love to do, but they might just have to do it a little bit of a different way.

And helping them to understand that these injuries have a recoverable component, meaning that they can get better, is essential to recovery from TBI.

- How do you... Oh, go ahead.

- So sorry.

- No, please state, go ahead.

- I think education is, you know, a huge part of what we do at every phase.

You know, I know at our facility, all of the therapists do a lot of education with the patients, because when they know what they can expect, it helps them to kinda understand where they're at in that recovery process and see that they are making progress, they are making gains.

It just kinda helps to ease that, you know, discomfort that like, "I'm still not the person I was before."

You know, they wanna be better five days ago.

But when they can see that they're making progress, and we do a lot of education about, you know, a typical course of treatment and, you know, "You're at this point.

You can expect to be further next week.

Look at how much further you are than last week."

- Right, and I think one of the things that can sometimes be a little confusing for patients is they see professional athletes.

Professional athletes getting a cerebral concussion and then next week, they're back on the field.

But those individuals are very unique and they're very special and they have a whole system behind them that helps to support them.

So I'm always telling patients that, "You're not a professional athlete, so you have to give yourself a little bit more time to recover."

- Yeah, I was actually gonna touch on that a little.

- Right.

- Because you talked about the new me.

So, I'm kind of wondering how you help people get past that hurdle, but I'd also think there's people who maybe over-therapy themselves?

Does that make sense?

Because they wanna move forward so quickly, they go home and they're doing the exercise 10 hours a day.

Do you see that?

(laughs) - We see the extremes sometimes, yeah.

- Yeah.

I would imagine.

Also, what do you do to help the family in order to support these people as they're going through therapy?

I don't know if you wanna touch on that, especially since you were talking about some of the physical aspects.

- Education is very important.

And we have the families come in and actually see the fam or the patient going through therapy.

They go through physical therapy, occupational therapy, speech therapy to see what they're doing and see how they're progressing.

And if we have someone who comes in who is low level, they're having a lot of difficulties, we might have them come in a few different times, you know, to see, and then they can actually see the progress.

- And when they go home, because I would think some people don't have someone at home, how does that work?

Do they just stay in therapy longer?

Do they get care from outside?

- It depends.

If they don't have anybody at home, sometimes they might need to go to another facility for more therapy till they could be independent.

And sometimes, people will hire assistance.

So, it all depends on the situation.

But sometimes, they need continued care.

- And sometimes it can be complicated too, because sometimes the patient doesn't want to give up their independence.

- Yes.

- And sometimes, they're not willing to acknowledge that they might not be safe.

So, sometimes, it does get to be complicated in that regards where the patient wants to go into an environment that's quite frankly not safe.

So then you have to help the family understand that it's not a good place for them to be.

- Were you gonna add something?

- Oh, yeah, I think it's really good to incorporate family members.

You know, by the time patients are getting to me, they've already been through that acute phase of rehab, they're back at home and, you know, like the family is adjusting to that new dynamic.

You know, maybe the person who had the injury was, like, the primary caretaker for everyone, and now they need the care-taking.

So, I encourage family members to come in and attend sessions.

And whenever it's appropriate, you know, if they're going to need assistance with something at home, I encourage the family members to participate in the session and actually get practice with that.

You can give them some tips and some education on how they can change their interaction style, change how they're saying things just so that it's a smoother transition.

- We talked about TBI and ABI, but I'd like to talk about concussions, because I know that's something we see in young people quite a bit, especially athletes.

Are you seeing a lot of kids coming in with concussions still?

And are there concussions that are maybe hidden and go untreated?

And what can occur if that happens?

- Oh yeah, concussions, we see them every day.

All sports, I mean, boys football, girls soccer, very popular sports, and there's a lot of concussions in those areas there.

But really, it's the community.

The community has been educated over the last few years by people like us to take these things seriously, right?

We used to call it, you know, getting a ding to the head or something like that.

Now, the coaches, the teachers, the athletic directors at these schools, everybody is on board with this.

And so, actually, I think that treating high school and college concussions is actually easy, because they have a full system that is very supportive of it.

Where it gets to be difficult is when you have people who have a job that they have to go to, they have a family that they have to take care of, and now their capacities are somehow reduced, right?

So, you know, when you come home from work, you start all the other work that you do at home, right?

And so, if you have a cerebral concussion, you come home and then you're exhausted and you can't get this stuff done and you get behind, it's really hard to find the support for that.

But I do think that the communities at large have really become very supportive of the care and the recovery of cerebral concussions.

And they've realized that if you identify a concussion, that concussion gets treated appropriately and that player comes back.

So, it's not like they're being, you know, removed from play.

- Right.

And so, if it goes untreated, what sort of complications can occur?

- Well, I've had patients who their parents tell me that, "Oh, you know, so and so used to love to read.

They used to read all the time."

And and then I see them and maybe they've had three concussions or something like that.

And I ask whether they read anymore and they tell me, "No, they don't read anymore."

And then we investigate their eye movements and the way that they can actually look at a page, and we realize that their eyes are not moving appropriately.

So, that's something where the student might not acknowledge that they're having a problem and it's only because we identify it that we can then enroll them into appropriate programs that can help to correct these things.

- Yeah, and I guess that's where the family comes into play again, so that part's important.

I'm wondering if you could touch on, let's just carry this story along, if someone's having these visual issues, what types of therapy do you actually do for them to help improve that?

- We have, it's called the BITS.

There's all visual programs on there, scanning different, excuse me, (clears throat) to check for visual field cuts, all different kinds of things.

And we do recommend that they see the eye doctor too.

'Cause occasionally, if their eyes aren't working together, sometimes they can also use prisms in the glasses to help the eyes work better together.

- And can we cause speech problems from concussions as well?

Would that be something- - Yeah, stuttering, you know, difficulty identifying the right word.

Like they're calling this a... You know, they're trying to find the right word, but what they should be saying is glass of water, but they can't say that, so they use different words to describe it.

And also, they sometimes have difficulty hearing.

And when I say hearing, I don't mean hearing, but rather perceiving what's being said.

And it becomes very difficult, especially when they're in a crowded environment.

Like it's very quiet here.

But imagine, like, being in a restaurant where lots of people are talking and it's hard to of separate out the different kinds of voices that are coming.

And so, what they do is stop going out to restaurants and they change their lifestyle.

- And you're nodding, so I'm assuming you've seen this.

And how do we deal with this?

- Yes.

Yeah, I mean, concussion is a very large part of my caseload.

And, you know, one of the hallmark features of 99% of the individuals who have a concussion is there's some impairment in the attention.

And attention is so important from so many things.

You know, if you can't attend or focus on something, you're not getting the information to remember it later.

If we're having a conversation and I'm not paying attention while you're talking to me, then I'm going, "Huh?

What?

What did you ask me?"

You're lost.

And communication is such a fundamental part of what we do as people.

You know, we talk to other people, we communicate our wants, our needs, our ideas.

And all of that is impacted when, you know, something is simple as your ability to focus on what's going on around you is impacted.

- I wonder if that's ever misdiagnosed as ADHD or something.

You know, someone doesn't know that that injury was there.

- Well, it is, but also, it is important to remember that medications can be utilized in this environment as well.

So, along with all of the physical therapy, the occupational therapy, the speech therapy, sometimes, medications can offer just that little, little bit of extra attention.

And I often tell patients, "It's a lot like, you know, putting high-test gas in your car.

The car hasn't changed, but theoretically, you're getting a little bit more horsepower out of the motor."

- What type of medications are you referring to and how exactly do they impact the functioning?

- Well, there's a host of different medications that can improve neurotransmitters in the brain.

So, what patients maybe don't know is that we have about 200 billion nerve cells in our brain, and those nerve cells run on electricity.

But in order to be able to communicate, those nerve cells have to send a chemical message to each other.

And sometimes, those chemicals get disrupted.

And so, using medications that can help to increase certain nerve chemicals can help these brain cells to communicate, and that can help improve their function.

- That's amazing.

I never really thought about the fact that you could use a little medication to kind of help improve the outcomes- - Right.

- Especially if they're struggling with that kind of attention to detail or just too much noise, for instance.

I'd like to talk a little bit more about speech pathology in particular, since that's what you do.

How are you working with people to improve their language skills?

And does it go back to, 'cause we were talking about the eyesight and the reading and the hearing, I'm assuming it's all tied together?

- Yeah, I mean, everything our brain does is interconnected, so there is a lot of overlap between, you know, what all of the therapies are doing in terms of each discipline.

But really, like in terms of a brain injury, we're focusing in on whatever the specific areas of deficit are.

I always tell patients, "Speech therapy is probably not what you expected it to be."

'Cause people will come in and they'll be like, "I talk fine.

I don't need this."

So, you know, speech covers speech and cognition and language and swallowing and voice, and the list goes on.

But pretty much anything that can impact your thinking or your speaking or your swallowing, we're addressing in the speech therapy session.

- So, if you all were to give one piece advice to someone who may be out there right now thinking, "I'm not going to get better."

What would you say?

And I'll leave that open to... - I would say, you know, the brain is an amazing organ in our body.

We have neuroplasticity, which means any neuron in your brain can learn to do any new function that a damaged neuron was doing.

So, sometimes that takes time.

It's like a roadblock that your brain has to learn how to get around.

But give it the time and it will get better.

- And, well, I'll let you speak in a second, but you saying that makes me feel like a brain injury might almost be better than a broken leg or something, or a shoulder replacement, (everyone laughs) because there's new pathways you can build.

Sorry, go ahead.

- No, that's okay.

Definitely, time is a factor.

And the more that they continue to try and get better, the repetition of, you know, doing the different things that they need to and incorporating it into their activities of daily living, the better they're gonna get.

They just have to keep trying and keep at it.

- Patience.

- Yes.

- Okay.

- Yeah, I mean, basically, the brain is just incredibly adaptable and, you know, sometimes they need a coach.

And the coach, just like a coach on a team, sometimes the coach tells you to do things that are painful and you don't really want to do them, but when you do them, you get better and you get faster and you get stronger.

So, that's our job, is to try to find out how we can coach our patients to get better.

And sometimes, it's a little bit uncomfortable for them.

But usually, after a period of frustration, they're ready to do whatever it takes.

- Yeah, I would think they'd like their normal life back.

Thank you so much.

I'd like to thank all of our guests for their insights and like to thank you for joining us of course.

This and every episode of "Keystone Edition" is available on demand on our YouTube channel, and now is a special audio podcast, so you'll never miss an episode.

Visit wvia.org/keystoneeditionhealth to stream episodes or subscribe to the podcast.

For "Keystone Edition: Health," I'm Tonyehn Verkitus.

Have a good evening.

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