Yannick: Hello everyone and welcome to the very first episode of Brightway Answers, the podcast where we ask professionals your questions about brain injury.  If you’d like your question answered by a doctor, therapist, or other professional who specializes in brain injury, submit your question by going to www.brightwayhealth.org/podcast and click Submit a Question.

I’m your host Yannick Cohen and today I’m very excited to interview Dr. Thomas Franz, a physiatrist with more than 30 years of experience who focuses on brain injury rehabilitation, spinal cord injury and spasticity control.  Dr. Franz serves as the Division Director for physical medicine and rehabilitation at Allegheny Health Network and is a member of the International Brain Injury Association.  Welcome to the show Dr. Franz!

Alright, today we’ll do the first of two interviews with you as we have a lot of excellent questions submitted by survivors, caregivers, and others in the brain injury community.  I’m just going to run down the list and we’ll get to as many as we can today, and we’ll cover the remaining questions in part two.  Ready to get started?

Dr. Franz: Yeah, let’s go.

Yannick: Alright, great!  So for our first question, I want to talk about your role as a physiatrist.  It’s a word that can easily be confused with terms like psychiatrist, psychologist, or physician, so let’s make sure we’re clear as to the difference.  Tell us a little bit about what you do as a physiatrist.

Dr. Franz: Sure, well, a physiatrist or a specialist in the field of physical medicine and rehabilitation works really to help people with conditions that can't necessarily be cured but can be treated through a combination of medications and therapies. And by therapies I mean physical therapy, occupational therapy, cognitive retraining or cognitive therapy, speech therapy, and we have a broad base of training in both musculoskeletal and neurologic conditions.

We treat both, for example, strokes, spinal cord injuries, brain injuries as well as people with trauma, somebody who had a traumatic brain injury might also have a dislocated hip or a fractured spine, and during our training we learned how to help people recover from those injuries and regain and the emphasis especially is really is on restoring function as much as possible.

So that a person can be made independent through the use of some sort of technology, then that is fine because the goal is to get them back to doing things for themselves as much as possible, and if they can be restored completely obviously that's ideal but that's not always possible right now.

Yannick: Got it.  So what are some types of interventions you do when you’re working with someone?

Dr. Franz: Well, when we're looking at acquired brain injury there's a wide range of medications and procedures, for example, that the physician might do over and above prescribing physical therapy or occupational therapy or speech therapy.

Spasticity or abnormal muscle tone, for example, is a very difficult problem after acquired brain injury for many people, and sometimes botulinum toxin or botox injections are used. It's first and foremost a muscle relaxing medication. It blocks some of the impulses where the nerve connects to the muscle. It's not a cosmetic or wrinkle treatment despite the popular press opinion to the contrary.

Peripheral nerve blocks can be used for the same purpose, serial casting can be prescribed which is usually done in conjunction with a physical therapist or some type of technician to reverse a contracture that might come as a result of spasticity. We may well prescribe medications to reduce the tone along the line of medications.

We may also help with behavior management. Not all physicians - even, for example, not most psychiatrists are not very comfortable with acquired brain injury and usually, either a neurologist or a neuropsychiatrist or a rehabilitation physician who has experience with brain injury will be the one to manage behavioral medications.

There is a role in using heat or electrical stimulation or pain medication to to manage pain. That's another role we fulfill as well.

Some patients require prescription of specialized equipment whether that be bracing or prosthetic devices or equipment to allow people to perform self-care tasks, whether it's something as simple as a reacher or a socket or something more complicated; for example, adaptive or assistive technologies that are computer-based.

And with the proliferation of tablets and phones most of the things that used to require a dedicated device for speech or other things are now just apps. So this has become an exploding field for us and frankly a lot of the smart home technologies are now being very useful for people with limited mobility or limited use of their body.

So it's quite an exciting time, really.

Yannick: Yeah, that’s fantastic.  And when should brain injury survivors see a physiatrist?

Dr. Franz: If it's a severe traumatic brain injury, I mean severe enough where somebody has an operation on the brain or where they're hospitalized for a long period or there's a prolonged period of coma or altered mental status. Most of those patients are going to need to be seen by a physiatrist in the hospital in consultation and often transferred to a rehabilitation unit or facility to complete their recovery from an acute injury. Whether that's an accident or in some cases the acquired brain injury might be due to a hemorrhage in the brain, other conditions that aren't traumatic. But regardless, if the functional result is the same, people will likely in those more severe cases require physiatry and rehabilitation both in the hospital and immediately afterwards for some weeks in some form of either a hospital-based unit or freestanding rehab hospital.

If someone has a lesser brain injury, but it's really not even a concussion, for example, a person might have a single concussion and thankfully 85 percent or so of people with concussions maybe you're seen in the emergency room, they're told some symptoms to look out for, they have a few days of problems and then they go on their way. But 15 of patients have some persistent symptoms that can be light sensitivity, dizziness, migraines, and if these things are persisting, you're really going to more likely get relief for those conditions from a physiatrist, somebody who is familiar with brain injury than from a lot of your general medical community.

Yannick: Right, yeah, I think that's something that a lot of survivors are very familiar with - those lasting symptoms. So let's transition and talk about one of those symptoms.  These next couple of questions are sleep-related.  This question was submitted by a survivor who suffered a traumatic brain injury 20 years ago.  Are sleep issues a part of my TBI recovery?

Dr. Franz: Yes, they definitely are and depending on the stage of recovery a person can have a variety of different problems with sleep. In the early phases after a brain injury, where there's been a large amount of damage the the cell membranes in the brain are very leaky, to put it in a simple term, and the chemicals that normally stimulate the brain to work are are out and floating free and they're not being released in a controlled manner.

So a person may be very restless, they may want to pace all the time, they may not sleep at all. They may almost look like they're manic, and then as those cells begin to die back and those chemicals are no longer present, the person can become very fatigued and lethargic, and then over the longer term I see patients who have sleep disorders because they have what often patients will call "racing thoughts" or can't shut their mind down. They try to go to bed and whether it's things that they're worried about or things they're trying to remember or just things that have occurred throughout the day that are coming back. They can't settle down.

There is also often damage to the pituitary which sits right at the base of the brain. This very common after head injury and so there can be hormonal problems that can cause primarily lethargy. For example, somebody has injury to the pituitary and is very hypothyroid, they may be very easily fatigued.

And finally the other thing that we see, particularly someone farther out in their recovery, is we know that a person who's had a brain injury may be able to complete a mental task but if we look at studies of the brain, at specialized scans that look at function, we call on a lot more areas of the brain to get the same task done after brain injury as compared to prior to brain injury. These patients experience then that when they're doing a cognitive task, a mental task, it might be reading, it might be taking a test but they're profoundly fatigued and most likely this is because they're activating so many different areas of the brain to get the same amount of work done. It just wears them out.

So there's a lot of reasons to have disrupted sleep after brain injury.

Yannick: Ok, next is a related question.  How can I get better sleep and deal with fatigue?

Dr. Franz: Certainly, I think that it starts with a visit to a doctor who is familiar with brain injury or or to a sleep disorder specialist, depending on what kind of problems you're encountering.

You want to start with some simple basic lab work to make sure there aren't those abnormalities for hormone levels in the blood. It may be important to do a sleep study. Sometimes the respiratory drive is off or perhaps because of physical inactivity from paralysis or in coordination after the head injury the person's put on a lot of weight and then they have obstructive sleep apnea. So assessing for those common things first, and making sure those aren't the issue are important.

And then looking at the medicines that are prescribed to see if any of the medications that are prescribed are known for causing fatigue as a side effect? Particularly people who are on seizure medication may find that fatigue is a big side effect of the medicines they're already taking, and it may be possible to change the dosing or change the medicine itself, and so there are a number of ways to address that.

If the person has more of the problems with the racing thoughts, then sometimes training the person in relaxation techniques and mindfulness techniques and meditation may help. Sometimes medications need to be prescribed if the problem is severe.

If there's some underlying issues related to anxiety and coping with the brain injury, where counseling is required, then that may need to be ordered, but starting with somebody who really understands sleep and preferably somebody else who understands brain injury is a good place to get started with those problems.

Yannick: Are there sleep doctors that are familiar with brain injury?

Dr. Franz: Well, what I would say is that you would want to look at pulmonologists as someone who would address obstructive sleep apnea. But if you have any other concerns about your sleep then seeing a neurologist or psychiatrist who operates a sleep lab would really be the the way to go.

Your physiatrist, your physical medicine rehab doctor, if you have one in your community can be a gatekeeper to getting you to those appropriate specialists.

Yannick: Yeah, that makes a lot of sense. Would it be safe to say that you serve as a kind of quarterback for many of the therapies that a brain injury survivor might get?

Dr. Franz: Yeah, that's definitely a big part of our role.

Yannick: Ok, next question - this was submitted by a caregiver.  My son was hit by a car on 4/9/2020. He is considered minimally conscious to conscious. He appears very aware with lots of tracking and some responses. Every part of his brain was injured but none were injured a lot. He can’t speak and doesn’t move much but he is not paralyzed. He turned 30 while in a coma and was in excellent health and super physically fit at the time he was hit. The doctors believed he would walk out of the hospital.  He will use yes or no buttons a little. He can point to correct objects in photos when asked.  What can I do to help my son to emerge more?

Dr. Franz: Well, this question really covers a lot of ground. The most common type of brain injury is what's called a diffuse axonal injury, and when this person describes the injury as all the parts of the brain were injured a little, but none of them a lot, they're most likely describing that diffuse axonal brain injury.

The brain can be thought of as as a biologic computer. The cells are not like your skin cells, which are kind of like bricks that just do their job because they're stacked up against each other. A cell in your frontal area might need to communicate with the other side or all the way back to your brain stem. And these long fibers that are also part of the cell are very easily damaged by the kind of forces that might occur in a fall or a motor vehicle accident, or or even being tackled or, of course, boxing and being struck or being assaulted and being struck on the head. They're also very sensitive to shock waves like explosions, so if you were in the military and somebody set off an explosion near you, the shock wave that is transmitted through the air can do the damage.

But the point is when you basically tear up the wiring to the computer, even though the individual cells may largely survive, the computer can't function very well. In milder cases like concussion, maybe the processing is slowed or more areas of the brain have to be called upon to do the work, or the areas of the brain that need to communicate really can't communicate. So unfortunately, there's probably more damage or the sum total of the damage throughout the brain - even though no one area is really badly damaged - is probably pretty significant in this person's case.

The other thing I will mention is that there are cases where the parts of the brain stem that tell you to wake up and stay alert can be damaged all by themselves. Those connections can be damaged, and then basically that wake-up call that everybody's experienced - of being sound asleep and there's a loud noise and they're immediately awake - because there's a part of your brain that's always listening, always monitoring the environment even at an unconscious level. That's also the part of the brain that tells you to wake up in the morning and when it starts to be dark out tells you to go to sleep at night. If that is disconnected in some way, if those fibers are disrupted there, those wake-up calls never get through. The rest of the brain could be relatively intact and the person will remain comatose. I don't mean to turn this into a neuroanatomy lesson, but the point is there's an awful lot going on in a case like this usually.

Now, what can be done trying to wake the person up is usually a combination of environment - trying to establish a normal day-night cycle - and also stimulation - talking to the person, giving them normal sensation as much as possible, like touch.

But it often requires medication, and stimulant medications can be used to make the person more alert.

There are even studies that have been done and are ongoing where attempts are made to use the same type of electrical stimulators that are used - for example in severe Parkinson's disease or other conditions - to go into those areas of the brain that help keep us awake and alert and and try to stimulate them to function. The ones that have really been studied the most are forms of deep brain electrical stimulation. Now, there are some interesting papers on light therapy, but I've seen those papers, that information really lends itself more to mild to moderate brain injury. If somebody's in a minimally conscious state, that by definition is a more severe brain injury and light therapy probably isn't going to be effective at least as we currently do it. But, there are always new things being developed. There may be some interesting developments there as well.

There was a period of time in the early nineties where coma stim was very popular. They would blast horns at people and put pepper on their tongue, and poke and prod and all in a hope that all that sensory input would wake them up. That really has never been shown to be very effective by itself. But establishing normal sensation, normal sleep-wake cycles, has clearly been shown to be very helpful.

So there are some things that can be done starting from the very simple things with the environment escalating the medication and then potentially, even working with a neurosurgeon on some of the latest technologies that have been developed.

Yannick: Got it, and those technologies that you mentioned, those are, are those light therapy based or it's a range of technologies?

Dr. Franz: The ones that have really been studied the most are forms of deep brain electrical stimulation. Now, there are some interesting papers on light therapy, but I've seen those papers, that information really lends itself more to mild to moderate brain injury. If somebody's in a minimally conscious state, that by definition is a more severe brain injury and light therapy probably isn't going to be effective at least as we currently do it, but there's always things coming down the pike. There may be some interesting developments there as well. There was a period of time in the early nineties where coma stim was very popular where they would blast horns at people, and put pepper on their tongue, and poke and prod all in a hope that all that sensory input would wake them up. That really has never been shown to be very effective by itself, but establishing normal sensation, normal sleep-wake cycles, has clearly been shown to be very helpful.

Yannick: Alright, let’s move to the next question.  Should I be taking supplements, such as fish oil, curcumin, etc, during the recovery process?

Dr. Franz: The research on that is limited.

We do know that one of the things that happens with brain injury is that, like a lot of conditions, an inflammatory cascade is set up. So many of those supplements, whether it's fish oils or curcumin, have some anti-inflammatory properties. I would put most of those in the category of "can't hurt, may well be beneficial".

As long as you're not being ripped off by somebody selling you their brand of supplement for fifty dollars a capsule, I think it can be a very useful thing, but just understand you're kind of out there on the edges of what scientific research is aware of. I don't see any problem with doing that, as long as you're aware that you're not going to get a double-blind controlled study with a million patients that say that this is the combination to use.

I would also say that things that tend to be hawked on TV, whether that's jellyfish extracts or things like that, that there's no clear evidence of what benefit you receive for the money you put into them. I think those are very questionable.

Yannick: How can I manage photosensitivity - or light sensitivity - and headaches? Are there treatments other than pain medications and avoiding lights?

Dr. Franz: Yes, there actually are some very good treatments. If you have a neuro-ophthalmologist or a neuro-optometrist in your area or if you can connect yourself with a rehab professional who can refer you to someone, there are for light sensitivity different monochromatic lenses or shaded lenses. The ones that adjust to the ambient light can be particularly helpful.

One of the things that the vision professionals we work with have recommended against is just wearing sunglasses all the time and it actually makes some sense. You'll see patients who do this and it kind of sets them up to have more problems. This is because it's sort of like if you're sound asleep in a dark room and somebody suddenly turns on the overhead light very brightly and how that stuns you. If you're already sensitive to light and you're taking on and off sunglasses throughout the day you're just basically doing that to yourself every time you take them off. So much better to have something that is a photo sensitive lens so that if you're in a dim room it lightens up or if you're in a very bright area it darkens up to help that. Also, some of the monochromatic where you may wear a lens of a particular color for a period of time can be helpful.

There can also be some subtle malalignment of the eyes where they are not focusing on exactly the right point in space, and eye exercises to improve what's called convergence where the two eyes focus on the exact correct point in space can be very helpful.

The other part of that is it's a vicious cycle. Different problems with vision can trigger headaches and many patients experience post-traumatic migraines and light sensitivity. They will have light sensitivity as part of the migraine, so if they are having either a migraine variant with light sensitivity or a full-blown migraine with light sensitivity, there are many very effective medication treatments now for migraine.

So I would tackle it from both ends. If it's primarily a visual problem I would talk to a vision expert like an optometrist or an ophthalmologist with neurologic experience. If it seems to be more of a migraine-related headache-related problem then I would look at some of the newer treatments for migraines, particularly the single ERP inhibitors. There are a number of them out there being advertised. I'm not going to name all the brands, but this has been a very exciting new field and the treatment of migraines has developed because we have a better understanding of the pain receptors that are involved.

Yannick: Got it, yeah it sounds like it is a good idea to approach it from both angles depending on what is the underlying cause.  Let’s move to the next question. What types of rehabilitation do you specifically recommend to help improve cognition and executive functioning?  This can be formal therapies, alternative therapies, at-home programs, online programs, or anything else.

Dr. Franz: Well, I think that you know, formal therapies particularly if a person is just starting to get a handle on their cognitive issues, whether that would be through a person who comes at it from a speech therapy background or an occupational therapist who may focus on particular tasks of daily living, they can help with cognitive tasks particularly in the initial recovery phase of a more severe brain injury or in somebody with a more severe concussion, but you can then be set up with a home program.

There is a lot of evidence that using online tasks or games that you get, you get better at what you practice. So if you play a game (there were a number of these that were popular a few years ago), the only thing they can really prove is you get better at performing the game. You don't necessarily get better, that doesn't carry over into remembering to buy the groceries you were asked to get or pay your bills or those sorts of things.

So having somebody who can work with you on setting up reminders for those tasks or having a structured system - and we, of course, are working on apps to help the people structure ways to remind a survivor to do a task whether that would be therapeutic tasks or a functional task throughout their day, but setting up something to actually remind you to do the task is probably the best way.

Now if you have a lot of anxiety that further impedes your memory, then, of course, cognitive behavioral therapy to address that can be a very useful technique as well, and certainly there's some alternative therapies such as meditation that can help with those tasks and whether you call it concentration or mindfulness, those are definitely skills that higher level, higher functioning survivors can benefit from.

Yannick: Great.  Do you have a sense (I know this is a pretty difficult question to answer) for how long TBI patients should receive rehabilitation? 

Dr. Franz: Well, that's tricky. There have been some very good studies that have shown that the Israelis, particularly, have done an awful lot of studies on their army veterans who had acquired brain injury, that show people make improvements years, decades after a brain injury. So there would be some evidence, a lot of good evidence to say that people would benefit from rehabilitation for the rest of their life if they've had a severe brain injury, or at least have the ability to gain new skills and to improve a task that they practice.

So that's obviously going to take different forms. Nobody's going to stay in a rehab hospital for 30 years. So I would say that a person getting acute inpatient rehabilitation is going to be best served, particularly if they have a lot of physical limitations from their brain injury and mobility and caring for themselves, several weeks to a couple of months to regain those skills.

If somebody has more cognitive impairments - not of the kind where they're disoriented or behaviorally aggressive - but really have trouble performing the functions of daily living like multitasking and and attending to tasks and so on, then they would be more benefited by a several week to several months program of outpatient therapies to address those skills, followed by periodic reevaluations and a guided home program from there on.

So there is potential to benefit from rehabilitation probably for the rest of your life, the rest of the person's life after a serious brain injury, and what I would say is you would need to be monitored by a physician whether that be a neurologist or a rehabilitation professional to identify when you're encountering difficulties and when a referral to a more formal therapy might periodically be indicated.

Yannick: Right, but it sounds like finding some way to keep doing some level of therapy in a sustainable way for a long time can have benefits over the course of a lifetime.

Dr. Franz: Definitely.

Yannick: All right, we’re running a little bit low on time, but I want to fit in one more question. For a 39 year old survivor who had a left side brain bleed stroke, and is not yet mobile due to left side weakness, what is the long-term mobility outlook?

Dr. Franz: Well, the mobility prognosis or outlook is better the earlier you begin to see recovery. So if we're talking about someone who had a cerebral hemorrhage, a brain bleed, a month ago and still doesn't have a lot of use of their arm or maybe they can use their arm, but their hand is lagging, they still have a pretty reasonable chance of regaining movement.

It may have always been a little bit clumsier on that side, particularly if they're tired, but if it's early in the game, and most people I think often when I see patients right after a brain bleed, if they're alert and able to understand what's going on, they often think, well, this should be some sort of musculoskeletal injury and in a few weeks I'll be just fine, and giving them perspective that you may be recovering for six months or a year is important.

So if you're saying I'm frustrated this isn't moving the way I think it is and I'm a month out, don't give up hope. There's a very strong likelihood you're going to get a whole lot better in another six months.

If this situation is, I had a brain bleed five years ago and I really don't move one side of my body very well at all, I drag my leg or I can't really use my hand, then unfortunately, although it could be looked at to see if there's spasticity, which is abnormal muscle tone, that tightness in the muscles can interfere with movement. You can look at things that might be impeding recovery, but if you don't find them at least as where we stand right now, there's not a lot of good options to help somebody recover from that if they're a long ways out more than a year, more, certainly more than two years from a brain bleed.

Yannick: Got it, got it. Would therapy help at all at that point?

Dr. Franz: It could, if the person's not really ever had therapy or had a little bit early on and then never any more, they should be re-evaluated. If they've been in a lot of therapy, if they did therapy for three months after they left the hospital and periodically ever since, it may not be as beneficial. So it really kind of depends on what they've had thus far.

And again seeing a therapist even if you don't have a good rehabilitation physician in your area, a good physical therapist would be able to say, gee I see a lot of problems here with motor planning or I see a lot of problems with muscle tone, and then could help you identify is there something here that should be treated or maybe the movements come back, but it took so long the tendons have shortened and you have a contracture and you ought to see an orthopedic surgeon. So even getting to a good physical therapist can help you begin to tease apart, is there something that could be fixed here that's holding me back because when it's been a long time and the recovery is not what you want it to be, that's our best chance at making a significant improvement. If we can say, oh yes, here's a problem that developed that can be treated.

Yannick: Right, identifying what's holding them back.

Dr. Franz: Yeah.

Yannick: Yeah, makes sense. Alright, that’s all we have time for today, but we’ll do a second conversation with Dr. Franz in the upcoming weeks to ask the remaining questions.  Dr. Franz, thank you so much for joining us today!

Dr. Franz: You’re very welcome, thank you.

Yannick: Ok, that’s it for today!  Remember to submit your questions for our upcoming episodes at www.brightwayhealth.org/podcast.  You can subscribe on YouTube or anywhere you listen to podcasts, and be sure to follow us on Instagram, Twitter, and Facebook.  And you can learn more about all the resources Brightway is creating for brain injury at www.brightwayhealth.org.

The information made available on or through this podcast is for general informational purposes only and is not, and should neither be used as, nor as a substitute for, professional medical advice, treatment, or diagnosis.

Brightway Health does not dispense medical, diagnosis, or treatment advice.  If you think you may have a medical condition or emergency, call your doctor or 911 immediately.  Do not disregard, avoid, or delay getting medical or health-related advice from your health care professional because of something you may have heard or learned from this podcast. 

I’m Yannick Cohen, thanks so much for listening to Brightway Answers.