Repairing the Injured Brain

An interview with Dr. Theresa Pape

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Dr. Theresa Pape is a clinical neuroscientist at the Edward Hines Jr. VA Hospital and research associate professor at Northwestern University. She earned a master's of arts degree in speech-language pathology from Western Michigan University and a doctorate of public health from the University of Illinois at Chicago.

Dr. Pape's research career objective is to conceptualize and develop rehabilitation interventions to ultimately lead to functional recovery after severe traumatic brain injury.

Science in Society spoke with Dr. Pape to learn more about her innovative work.

Tell me about your research.

My research is on neural plasticity and neural rehabilitation of traumatic brain injury (TBI). When I retire someday I would love to be able to say that we know how to make the neural environment [in the brain] more conducive to repair after traumatic brain injury. I would also love to be able to say: now that we can create a supportive healthy environment we also have a treatment to facilitate that repair, whether it be by facilitating neural activity or inhibiting neural activity. Finally, I would also like to be able to say that we can also shape that modulated activity so that it becomes a functional skill.

What happens to the brain in a traumatic brain injury (TBI)?

Brains are heterogeneous, so each TBI will, therefore, be unique. There will, however, be certain common injuries with severe traumatic brain injury. You have the unique lesions that occur at time of injury and these will depend on the force that actually impacts  the head. The common lesions, for the majority of severe TBIs, are diffuse axonal injuries (DAIs) as well as contusions or bruises and hematomas (which is just blood collection).

Then you have secondary injury to the brain caused by the initial injuries to the brain. Initial injuries with severe TBI often cause, for example, pressure on the brain, neurochemical changes within the brain and disruptions to the circulation of cerebral spinal fluid.

Since the brain is encapsulated in a hard bony skull, swelling on the brain means that the brain has nowhere to go and this abnormal pressure will cause further brain damage.

Disruptions of normal biochemical processes through the brain can include proliferation of proteins, for example. Some of these proteins are produced so prolifically that they actually create barriers to neural repair after injury. A disruption of the circulation of the cerebral spinal fluid through the central nervous system is another common secondary injury and this can cause hydrocephalus (i.e., fluid on the brain that does not belong there because it did not drain as it would normally).

So, you have the primary insult injuries and then you have secondary. Ultimately this will all present behaviorally, which is observable at the bedside.  That is, it will all present as cognitive and physical impairments. A person with a severe TBI is going to be in a coma or a vegetative state or a minimally conscious state, and currently we do not have the evidence to inform us unequivocally about when they’re going to wake up.

What are some of the most common ways that people get TBIs?

I work with civilians, veterans and active duty military. In the civilian sector, the most common cause of a traumatic brain injury is motor vehicle accidents, falls and child abuse. With the younger population it’s the motor vehicle accidents. Anyone from 16-24 is at high risk for traumatic brain injury from a motor vehicle crash. The older population is at highest risk for a traumatic brain injury largely from falls. Then our children are at high risk because of child abuse – shaken baby syndrome.

In the veteran population it really just depends. Our veterans, like our Korean war-era vets, are at risk because of falls just like the civilians. But, our younger vets returning from Afghanistan and Iraq are at risk because of the roadside bombs – the improvised explosives devices, which are commonly referred to as IEDs. While defending our freedom during combat they are exposed to bombs, grenades and other explosive devices as well as gunshot wounds. And, they’re also at risk for everything that civilians are at risk for.

Let's talk about ways to mend the brain. How can a familiar story told by a familiar voice help with healing?

I created the familiar voice intervention for multiple reasons. One was that families need something now, not in five years. The families also feel engaged. Here they’ve had so much control taken away from them, and they’re feeling totally out of control. Nothing is normal anymore. And here is something that they can latch onto and actually contribute to for their loved one’s rehab and therapy. The other advantage of that particular intervention is that it’s cheap and easy for families to administer, once the therapists help create the stories.

My theory is that the familiar voice intervention is creating a healthier neural environment, which will support other treatments inducing neural activity. So, think of something like a Twizzler. When they’re fresh they’re very flexible and when they get stale they’re very hard. If we don’t eat it right away when it’s fresh it doesn’t taste as good. If we do not keep our brain healthy after injury, then brain repair or mending will not be optimal.

The idea with the familiar voice intervention is to exercise our brains neural networks because if we don’t they will just become non-responsive, and basically non-functional over time. So, the idea or theory behind the familiar voice intervention is that we’re keeping the neural environment healthy by referencing and engaging (exercising) these networks. That way they’re exercising a little bit and they’re staying flexible. So that way, when I come in with an intervention such as transcranial magnetic stimulation (TMS), I have a neural environment that will support inducing neural activity or, in other words, a healthier neural environment to work with.

How does transcranial magnetic stimulation (TMS) work?

With the TMS treatment I’m theorizing (keep in mind that this is theory) that I’m inducing neural activity or increasing activity in the injured brain in a safe way. The very injured brain is at high risk for seizures, so I can’t be too aggressive, but yet they need some major induction of activity. So, what I adapted was essentially a protocol that I think optimizes safety and yet maximizes potentially efficacy.

Do you have a picture in your mind of a generator? A generator puts out a pulse and it goes through a coil. Think of a figure-of-eight coil. A pulse is literally circulating around this figure-of-eight and it’s that circulating around that figure-of-eight that actually creates a magnetic field.

Put the coil on the scalp and this pulse will transcend the scalp beneath the brain tissue. The nature of our neural tissue is such that it will actually reverse the direction of this circulating pulse. So the pulse circulates around and the minute it transcends the scalp it’s actually going to reverse direction, and that’s what creates a magnetic field. Sort of like an MRI. The magnetic field is alternating the structure of the brain, essentially, at the proton level.

So, when it reverses the direction and creates this magnetic field it’s creating neural activity by altering the action potential of the neurons and making them fire. When one neuron fires it has to connect to another neuron. So, that’s the challenge. I have to find a neuron in a very injured brain and I have to find a neuron that can connect with another neuron. That is a simplistic description of what I think the TMS is doing over time.

If I give them enough treatments (they get 30 treatments from me over the course of three weeks) we’ll, in theory, be exercising the neurons connectivity into areas that are remote from the site of stimulation. So, can we go from the front of the brain to the brain stem with this neural connectivity?  That is what I am investigating and I certainly think so, but my current research will answer that question.

Do you think we will eventually have an immediate treatment for someone who has had a TBI?

By the time I retire, yes, that’s my plan. That’s the end game.

What career advice do you have for someone who would like to work in your field?

There’s the traditional path, and then there’s the path I took.

If you want to do clinical research that involves high-risk interventions to the brain, normally you would probably go to an MD/PhD program. And, then apply and compete for federally funded career development awards to develop your own research track using that protected time. That is the traditional pathway to independent funding.

I’m not the only nontraditional pathway out there. Not everybody does an MD/PhD program. Clinically I’m a speech pathologist. I obtained my master's in speech pathology first, and worked at the Rehabilitation Institute of Chicago for a long time on their traumatic brain injury in-patient program. And then, while I was doing that I went to school for my doctorate.

My doctorate is in public health. And, so, what that gives me is a very strong methods background. So, in other words, I’ve expertise in bio statistics and epidemiology (studying diseases in populations).

And then I did a postdoc fellowship at Northwestern in rehabilitation measurement, which is another body of methods expertise. Then I applied for and was awarded three career developments awards. I had nine years of protected time to then really build my knowledge sets and expertise in neurosciences. I had some very strong mentoring during those nine years. Now my job is to do that which I’ve prepared for.

Is there anything else you think is important to mention?

As scientists it’s important to remember who we serve in academic sciences. I serve those people who can’t speak for themselves. I serve those who are most vulnerable. 

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Comments

Best of luck with your study!

Best of luck with your study! We, too, are embarking on several studies centered around measuring both subjective and objective measures of improvement in TBI with our HPN (High-Performance Neurofeedback) technology. Rather than generating relatively low frequency component magnetic fields externally, we send very tiny, extremely brief currents, originating from four scalp locations, converging internally, which naturally establish high gradient rates of change in the magnetic flux. This is accomplished with just a few picowatts of power, well below conscious perception. We are hoping to formally confirm the early positive subjective clinical observations. We will be working with two groups from our armed forces, and one from professional sports. These are exciting times!

My Son Suffered a level 3

My Son Suffered a level 3 diffused axonal injury 1/28/13 resulting from a car accident. My son is alert and oriented times 4, he is fully cognitive and aware and able to communicate verbally. He is spastic quad and is very frustrated as his body needs to catch up with his brain. We are looking into alternative medicines to help him attain and achieve his desired rehabilitation. Conventional therapies are important but we believe and so does he that the out of the box treatments which have not been adopted by the medical community need to be used and tried early after the injury occurs. I would love to speak with anyone who would have anything that could help us help him.

Hi Jeannie, I'm sorry to hear

Hi Jeannie, I'm sorry to hear about your son's accident. Here is the website for the Rehabilitation Institute of Chicago: http://www.ric.org/. They might be able to provide guidance as to next treatment steps. Bethany Hubbard (Editor-in-editor Chief of HELIX)

Jeannie, I'm sorry to hear

<p><span style="font-family: Roboto, LucidaSan-Rom, 'Trebuchet MS', 'Helvetica Neue', Arial, Helvetica, sans-serif; font-size: 14px; line-height: 21px;">Jeannie, I'm sorry to hear about your son's accident.&nbsp;</span><span style="font-family: Roboto, LucidaSan-Rom, 'Trebuchet MS', 'Helvetica Neue', Arial, Helvetica, sans-serif; font-size: 14px; line-height: 21px;">Best of luck</span></p><p><span face="Roboto, LucidaSan-Rom, Trebuchet MS, Helvetica Neue, Arial, Helvetica, sans-serif" style="font-family: Roboto, LucidaSan-Rom, 'Trebuchet MS', 'Helvetica Neue', Arial, Helvetica, sans-serif;"><span style="font-size: 14px; line-height: 21px;">Regards</span></span></p>

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