2: Dr. Thomas Franz pt 2
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In the second episode of Brightway Answers, we continue our conversation with Dr. Thomas Franz with questions submitted by brain injury survivors and caregivers.
Dr. Franz answers questions like:
- Does TBI qualify as an increased risk for COVID-19?
- What online or other type of therapy do you recommend to stimulate memory and speech?
- What can be done to address discrimination against people with brain injuries?
Dr. Franz is a physiatrist with more than 30 years of experience who focuses on brain injury rehabilitation, spinal cord injury and spasticity control. He serves as the Division Director for physical medicine and rehabilitation at Allegheny Health Network in Pennsylvania and is a member of the International Brain Injury Association.
Full Interview Text:
Yannick: Hello everyone and welcome to episode number two 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 for this second part of our conversation! Dr. Franz is a physiatrist with more than 30 years of experience who focuses on brain injury rehabilitation, spinal cord injury and spasticity control. He 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 back, Dr. Franz!
Dr. Franz: Thank you, happy to be here.
Yannick: We have a lot of excellent questions that were submitted by survivors, caregivers, and others in the brain injury community.
Our first couple of questions were asked by caregivers and deal with a topic that’s been on all of our minds for the last year or so: COVID-19. Does TBI qualify as an increased risk for COVID-19, and therefore should TBI patients be categorized in the same group as others with underlying medical conditions in relation to vaccination priority?
Dr. Franz: It really will depend on the severity of the brain injury and the associated conditions.
Someone with a concussion that primarily has perhaps trouble focusing or chronic headaches or for balance problems would not have the type of predisposing medical condition that would make them particularly susceptible to severe forms of covid-19.
However, someone where their brain injury affected their swallowing who chronically aspirated (meaning had food and water going down into their lungs) where they're chronically compromised in terms of their respiratory status very definitely would be at higher risk.
So it would really depend on the individual but many people with this would be in a high risk category and should be in the higher categories for getting the vaccine.
Each state is handling vaccine distribution differently. Certainly, the elderly have been given the priority with good reason so I would check the resources at your state's department of health or contact your local physician who may be able to facilitate getting you access or being able to certify that you have a pulmonary condition related to a brain injury that makes you a higher risk.
Unfortunately, you know this rollout has been problematic, to say the least. Although there are many things where we do want to devolve power to the states it probably hasn't served us well in this particular instance.
Yannick: Our next few questions are about symptoms, and this next question was asked by a survivor. I’m starting to feel dizzy as I progress through the healing process. I'm not sure if this is because my psychiatrist put me on aripiprazole, so I stopped taking it. I read about a lot of bad side effects of this medication. Is my dizziness something that I won’t be able to recover from after stopping this medication?
Dr. Franz: Certainly. Aripiprazole which used to be sold under the brand name Abilify can cause some dizziness, however it's not a common side effect. There are patients who have dizziness just as a consequence of their brain injury. Either the inner ear itself, which just sits right below the brain, is damaged; or the mechanisms within the brain that coordinate all the sensory information that help us remain balanced is damaged. So it could be from the brain injury.
It could also be the medication interacting with the brain injury. I would discuss it with the physician who prescribed the medicine. If the dizziness either came on immediately after starting the medication and wasn't a problem before, or if it became worse after starting the medication I would suspect that it's at least partially to blame. There are other medications in that category that can be prescribed that may have a better side effect profile. There's no reason to think that if you have a side effect from a medication like aripiprazole that it would persist long after stopping it, so if you wean off it or stop it depending on what kind of dose you’re on there's no reason to think the side effects wouldn't go away.
There are some very rare side effects from all medicines in this class (which are called dopamine antagonists) where people get movement disorders and those can be lifelong. But dizziness itself is not something that should be a permanent condition and if eliminating the medicine doesn't get rid of the dizziness then there should be an evaluation both by a rehabilitation professional. This can be by either a physical therapist or physiatrist or even by a very specialized kind of ear doctor called a neuro-otologist, which are ear nose and throat physicians that have had additional training in neurologic disorders and understand about damage to the the inner ear, which is the portion that has to do with balance, in addition to the portion that has to do with hearing.
And again, persistent dizziness problems, particularly if they can't be attributed to a particular medication or other problem, should be further evaluated.
Yannick: That makes a lot of sense. Is that something where uh a vestibular therapist might also be able to to help out?
Dr. Franz: Yes. And depending on the severity of the symptoms, I might have you start with vestibular therapy. There will be a certain amount of evaluation that's done, but also there will be treatment to try and retrain the balance reflexes.
Now, patients do have to be cautious and understand that part of what will be done in balance therapy is they will put you in situations where you feel off balance or do exercises to challenge your sense of balance. Many patients don't expect that and then they become fearful and don't want to do the therapy but the point is to actually retrain your body to respond to that off-balance feeling and have proper reflexes to help you in a situation where the ground may not be level or it may be very challenging to balance or visual inputs may be confusing. So it's a very useful therapy but I always make sure that I explain to patients what the purpose is or they may be put off by it which is unfortunate.
Yannick: Yeah, that makes a lot of sense. Ok, now a question from a caregiver. My sister is 1yr post TBI. She speaks and is in rehab to try to walk again, but only uses one arm, has post-traumatic amnesia, and cannot stay "present." How would we determine physical & social or interactive goals for her? And who would help us determine realistic goals for her?
Dr. Franz: The rehabilitation team that she's working with now, particularly a cognitive therapist or a psychologist, can be very useful in that; sometimes even the occupational therapist or speech therapist who deals with cognitive issues. If a person is remaining in post-traumatic amnesia, then the goals are going to be more basic: interacting with people, greeting with them, perhaps doing some common tasks like sharing a meal would be all one would hope. You're not going to plan an event, for example, with someone who can't retain the information and patients you know who are in post-traumatic amnesia.
One of the hallmarks will be that they won't know that you were there yesterday. Every moment is like they just woke up, so doing a lot of complex elaborate things that really recall upon their memory will just be frustrating to the individual or to the person who's expecting perhaps a greater interaction. The rehabilitation team really ought to be able to guide you in that. If they're in a rehabilitation center, often there are activities to help with that. Now, of course, social distancing and Covid have changed the landscape of those kinds of events, unfortunately. Hopefully, we'll be getting back to that in a more realistic way soon and they may be able to help the individual interact via Zoom or some other video interface if not able to have an in-person visitation at this point.
Once they move past the post-traumatic amnesia, I think the biggest issue really depends on the person's behavioral deficits. If somebody has lost all their filters, which I think is a term most people are familiar with, they say things that pop into their head without thinking about them or they act on every impulse that occurs to them, then a lot of the interaction will be working with them in simple interactions trying to redirect them to what's appropriate and then advancing to more complex social interactions as they improve. That would be something that the family would practice with the rehabilitation team and then continue to work with the individual in that regard. For some people, it's a period of time where they're really going through a phase. For other folks, unfortunately, where the behavioral deficits are more long-term, this can be a lifelong process.
This next question comes from a survivor. I’d like advice about brain fog. My TBI is from 2011, and I’ve never been the same. I’m forcing myself to reconnect by going back to school. I struggle with motivation as well as brain fog. It seems like everything is in the way. How can I force new connections?
Dr. Franz: If you mean brain connections–learning, memorizing, reading, cognitive tasks–we know the memory works by establishing new connections and pruning others. Going back to school and going about those types of interactions are the way that you establish new connections.
As for the brain fog, that sense that one is out of it and not quite fully present, there are tasks that can be practiced to help with it. Sometimes it does require medications, we talked about those a little bit during the first interview–what's available and particularly things that increase the naturally occurring neuro-stimulants, which are things in the dopamine norepinephrine system. That can be a sign of medications needing to be reviewed. Things that might be sedating and make the person foggy should also be looked at to see if anything can be eliminated. Again, as I mentioned last time, there can be pituitary and hormonal abnormalities from brain injury and those need to be reassessed. If somebody is profoundly low cortisol or low in hormones like thyroid or testosterone because the pituitary is not signaling the body correctly and what to release, those need to be revisited. If the person's not had a good medical evaluation for the cause of their brain fog, that really should be the place to start.
As for behavioral things that this person may be able to do, it depends on the level at which they're already functioning. If they're talking about going back to school, this must be a fairly high-functioning individual. I think things that you would think are very popular right now is what is called mindfulness, but there are also other tasks that one can work on to improve attention and concentration.
There are techniques that can be taught if a person is very easily distracted: focus on a page when reading or change the computer and other devices to highlight certain areas and bring them more front and center. Also, doing simple things like using earbuds and reviewing information to strengthen those connections could be helpful. Work with a therapist to understand how you can approach written material so that you can organize it in a way that's easier. A speech therapist or again a cognitive therapist psychologist can work with an individual on these types of tasks.
Yannick: Ok, next question. Has there ever been a case where a person with post-concussion syndrome also has psychosis symptoms only after the injury?
Dr. Franz: In more severe brain injuries, features that look very much like psychiatric disorders, such as a bipolar affective disorder with manic episodes, can look like psychosis. However, not so much with post-concussion syndrome. That really is a lesser type of brain injury. It has its own sometimes very difficult functional deficits but in terms of the actual injury to the brain, it should not be severe enough to cause psychosis.
Now, if a person is developing what is called now chronic traumatic encephalopathy, which is the result of years of repetitive concussions, then yes psychotic or major depressive features, or dementia can easily be present. However, that's not a single injury with a post-concussion syndrome, that's a cumulative effect of many head injuries.
Yannick: Alright, this next question is from a caregiver. My 23-year-old son suffered a severe hypoxic brain injury just over a year ago and is gaining some movement in his arms. I am worried, however, that he is not being treated at all for drop foot. I am concerned that this will impede his chances of walking again. Why is my son's drop foot not being treated?
Dr. Franz: If the person is not up and able to walk or bear weight through the legs, it's a fairly simple thing to place splints on the person in bed and to hold the foot in a more neutral or normal position. Obviously, if you go to walk again and your Achilles tendon, which is the tendon in the back of the foot that connects your calf muscle, has become so tight and contracted that you can only stand on your tiptoes, that is going to impede the function.
Sometimes if the person is very spastic and the foot wants to forcibly push down, not just kind of flop because there's paralysis, the concern may be that splinting will cause a pressure sore that the person will push so hard against the splint that they will develop a wound. If that's the case, then there may need to be something done to reduce the tone so that the drop foot can be treated or prevented. However, if there's not spasticity and nobody is really thinking about the drop foot, then the individual asking this question would be correct. Bring it to the attention of nursing and the therapists working with their loved one to say “let's get a splint on here”.
There are probably dozens of splints available to prevent drop foot. They all have certain advantages, and some are very specifically meant to not develop pressure areas or to minimize the chance of a pressure area so that the person not only avoids the drop foot but also avoids a bedsore or a pressure sore. So yes, that should definitely be reviewed with the people caring for their loved one.
Yannick: Ok, these next questions are about therapy. What online or other type of therapy that can be done at home do you recommend to stimulate memory and speech?
Dr. Franz: I don't have a particular online therapy that I endorse or that I have worked with extensively enough to say that oh you ought to go to this website or use this app. Although I'm working with some people to develop some that may be useful in the future, I don't have a particular site that I endorse right now.
There have been a lot of these that have been developed over the years and what I would say is look at the ones that are out there. If they have you practicing real-world tasks like recalling a grocery list or taking you through some sort of simulation of a shopping trip, things you might do in your actual life, those are going to be more useful than just memorizing lists of words or playing video games. This is because what we do know is that you get better at what you practice, so if you practice memorizing and reciting lists of words that's the skill you develop. If you practice playing a video game, and unless that video game has some grounding in a real-world task, you're just getting better at playing the video game. You want something that has a connection to what you want to do in your day-to-day activities to make it translate to what we call generalized. You want to pick a task that will help you with the cognitive things you want to do in your day. Similarly, you wouldn't try to strengthen a weakened leg by working your thumb because that would be very little benefit. It might strengthen your thumb but it's not going to help you with the task at hand.
Yannick: Which type of rehab is most effective in bringing about a return to everyday activities? Particularly after the first year or once a TBI patient is released from inpatient care?
Dr. Franz: Assuming the person has already mastered what we call activities of daily living, which are washing up, dressing, the things that an occupational therapist would often work on at least initially, then it would depend on what task you're talking about. If you're talking about what we call high-level activities of daily living, such as shopping, preparing a meal, and working from a recipe, the occupational therapist may still be useful. If you're talking about developing job skills or training for a new type of position, then really a vocational therapist can be very useful in that. If it's support for return to school or return to activities and education, then a speech therapist either through the schooling or through a rehabilitation facility can be very useful. If a person is still in the public education system, then an individualized education plan that utilizes tutors and other structured learning tasks including personnel like speech therapists should be developed. It all really would depend on the age of the individual and what they're trying to return to as well as where they're at in their recovery and what comes next.
Yannick: Got it, it sounds like there's a lot of really good therapists and others that can help with that. Alright, final question. What can be done to address discrimination against people with brain injuries?
Dr. Franz: I would say the same thing that helps to address discrimination across the board, which is education and getting people out in the community and interacting with folks. What you know and what's familiar is not as scary, so I think podcasts like this, television programs, websites with information that caregivers can access, take the fear and the mystery out of it. People just need to understand that unlike other types of situations where people are discriminated against, anybody could tomorrow become a member of the brain-injured survivor class and be potentially subject to discrimination.
The other thing is being open if you don't know much about brain injury and you're dealing with somebody with one. Just ask in thoughtful, respectful way questions that you know can be helpful, and don't make assumptions. Unfortunately, I hear from patients all the time and I've witnessed myself that it's very common with people with all sorts of disabilities that when they're out in public, people don't talk to them. They talk to the person with them and they talk about them as if they're not able to process the information. It really is important to just interact and have as normal interaction as you can and I know that's a buzzword but still, I think that's probably the best way for people to understand it. Again, I would say back to the golden rule: treat people the way you would like to be treated in a similar situation. That goes a long way towards ending that kind of things. Frankly, getting the word out if you have the ability to be politically active and there are options to get information in front of legislators and agencies who provide assistance, that goes a long way too. Also, join support organizations.
Yannick: Alright, that’s all our questions! Dr. Franz, thank you so much for joining us today and for your very thoughtful responses.
Dr. Franz: You're very welcome, thank you again.
Yannick: Ok, that’s it for today, thank you for listening! 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.
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I’m Yannick Cohen, thanks so much for listening to Brightway Answers.