Dr. Steven DeKosky: CTE History, Questions and Future Directions, Part 2

Catherine Parkin serves as Clinical Assistant Professor, Department of Rehabilitation Medicine at NYU Grossman School of Medicine, She co-authored the book, Medical aspects of disability for the rehabilitation professionals in 2017 by the Springer Publishing Company. Mary Regina Reilly has served as the Clinical Director of Speech Language Pathology at Rusk Rehabilitation, NYU Langue Health for the last ten years.  Her Master’s Degree is from Columbia University and she did her fellowship at Montefiore Medical Center in the Bronx, New York.  Clinical concentration has focused on pediatric dysphagia with medically complex infants with additional efforts in developing specialty programs for adults with acquired neurogenic disorders. She was instrumental in assisting in the development of the Masters of Science Program in Communication Sciences at Yeshiva University and has served as an adjunct professor at both Mercy College and NYU Steinhardt. Dr. Angela Stolfi is the Director of Physical Therapy, Director of Therapy Services at Rusk Ambulatory Satellite Locations, Site Coordinator of PT Clinical Education, and Director of PT Residency and Fellowship Programs at Rusk Rehabilitation, NYU Langone Health.  Dr. Stolfi holds a faculty appointment in the Department of Rehabilitation at NYU School of Medicine and regularly lectures in the physical therapy programs at both NYU and the University of Scranton. The focus of much of her current and recent research relates to mentoring and education of student physical therapists.  She is also an Associate Editor of the Journal of Clinical Education in Physical Therapy (JCEPT). Maria Cristina Tafurt is the Site Director at the Rusk Institute NYU Langone Medical Center, Hospital for Joint Diseases.  She has been a licensed occupational therapist for over 30 years receiving her Bachelor’s degree from the University of Rosario in Bogata Colombia, and her Advance Master’s degree from NYU University.  Her clinical experience has varied with an emphasis on brain injury rehabilitation, pain management, hand therapy, and orthopedics. She holds a faculty appointment in the Department of Rehabilitation Medicine as a Clinical Instructor and has authored or co-authored sixteen articles, abstracts and international presentations in her field. The discussion in Part Two covered the following topics: types of patients treated, impact of health care disparities, and patient cooperation in health care interventions by providers.

Catherine Parkin serves as Clinical Assistant Professor, Department of Rehabilitation Medicine at NYU Grossman School of Medicine, She co-authored the book, Medical aspects of disability for the rehabilitation professionals in 2017 by the Springer Publishing Company. Mary Regina Reilly has served as the Clinical Director of Speech Language Pathology at Rusk Rehabilitation, NYU Langue Health for the last ten years.  Her Master’s Degree is from Columbia University and she did her fellowship at Montefiore Medical Center in the Bronx, New York.  Clinical concentration has focused on pediatric dysphagia with medically complex infants with additional efforts in developing specialty programs for adults with acquired neurogenic disorders. She was instrumental in assisting in the development of the Masters of Science Program in Communication Sciences at Yeshiva University and has served as an adjunct professor at both Mercy College and NYU Steinhardt. Dr. Angela Stolfi is the Director of Physical Therapy, Director of Therapy Services at Rusk Ambulatory Satellite Locations, Site Coordinator of PT Clinical Education, and Director of PT Residency and Fellowship Programs at Rusk Rehabilitation, NYU Langone Health.  Dr. Stolfi holds a faculty appointment in the Department of Rehabilitation at NYU School of Medicine and regularly lectures in the physical therapy programs at both NYU and the University of Scranton. The focus of much of her current and recent research relates to mentoring and education of student physical therapists.  She is also an Associate Editor of the Journal of Clinical Education in Physical Therapy (JCEPT). Maria Cristina Tafurt is the Site Director at the Rusk Institute NYU Langone Medical Center, Hospital for Joint Diseases.  She has been a licensed occupational therapist for over 30 years receiving her Bachelor’s degree from the University of Rosario in Bogata Colombia, and her Advance Master’s degree from NYU University.  Her clinical experience has varied with an emphasis on brain injury rehabilitation, pain management, hand therapy, and orthopedics. She holds a faculty appointment in the Department of Rehabilitation Medicine as a Clinical Instructor and has authored or co-authored sixteen articles, abstracts and international presentations in her field. The discussion covered the following topics in Part One: a description of each of the three professions, educational requirements to become practitioners, and recruitment and retention of clinicians. 

Dr. Heidi Fusco is an assistant professor of Rehabilitation Medicine at NYU LANGONE Health and the Rusk Rehabilitation hospital. She is the Assistant Director of the Traumatic Brain Injury Program at Rusk and the Medical Director of the Brain Injury Unit at Queens Nassau Nursing and Rehabilitation. She completed a fellowship in Brain injury Rehab in 2013 at the Rusk Institute and is board certified in Brain Injury medicine and Physical Medicine and Rehabilitation. Alaina B. Hammond is a board certified rehabilitation psychologist and currently serves as Clinical Assistant Professor and Staff Psychologist in the NYU Langone Rusk Adult Inpatient - Brain Injury Rehabilitation Program.  She provides psychological and neuropsychological intervention and assessment to patients and families with acquired brain injury, stroke, spinal cord injury and other illness/injuries. In addition, she supervises psychology interns and enjoys researching family/caregiver adjustment to medical illness.  Dr. Jessica Rivetz is the current Brain Injury Medicine Fellow at NYU Rusk Rehabilitation. She recently completed her residency in physical medicine and rehabilitation at NYU Rusk. She received her MD degree at Albany Medical College, and also has a Master's of Science in health care management. Extracurricular activities include serving as co-chairperson of the NYU GME House Staff Patient Safety Council. Within brain injury medicine, she has a special interest managing patients with moderate to severe traumatic brain injury and helping them and their caregivers navigate life after brain injury and achieve their functional and quality of life goals. Part 3 The discussion covered the following topics: phases of treatment when mindfulness and self-compassion can be introduced to achieve optimal effectiveness; the role of telehealth; extent to which a group-based approach is used; availability of commercialized digital resources on the Internet, such as apps; use of wearable devices by patients; and the impact of artificial intelligence on patient care.  

Dr. Heidi Fusco is an assistant professor of Rehabilitation Medicine at NYU LANGONE Health and the Rusk Rehabilitation hospital. She is the Assistant Director of the Traumatic Brain Injury Program at Rusk and the Medical Director of the Brain Injury Unit at Queens Nassau Nursing and Rehabilitation. She completed a fellowship in Brain injury Rehab in 2013 at the Rusk Institute and is board certified in Brain Injury medicine and Physical Medicine and Rehabilitation. Alaina B. Hammond is a board certified rehabilitation psychologist and currently serves as Clinical Assistant Professor and Staff Psychologist in the NYU Langone Rusk Adult Inpatient - Brain Injury Rehabilitation Program.  She provides psychological and neuropsychological intervention and assessment to patients and families with acquired brain injury, stroke, spinal cord injury and other illness/injuries. In addition, she supervises psychology interns and enjoys researching family/caregiver adjustment to medical illness.  Dr. Jessica Rivetz is the current Brain Injury Medicine Fellow at NYU Rusk Rehabilitation. She recently completed her residency in physical medicine and rehabilitation at NYU Rusk. She received her MD degree at Albany Medical College, and also has a Master's of Science in health care management. Extracurricular activities include serving as co-chairperson of the NYU GME House Staff Patient Safety Council. Within brain injury medicine, she has a special interest managing patients with moderate to severe traumatic brain injury and helping them and their caregivers navigate life after brain injury and achieve their functional and quality of life goals. Part 2 The discussion covered the following topics: persistence of sleep disorders and the role of physical exercise in treating them; definition of mindfulness; kinds of interventions included under the heading of mindfulness; examples of how it aims to address the severity of various TBI-related health problems; duration of mindfulness treatment; and self-compassion as another type of non-pharmacological intervention.

Dr. Heidi Fusco is an assistant professor of Rehabilitation Medicine at NYU LANGONE Health and the Rusk Rehabilitation hospital. She is the Assistant Director of the Traumatic Brain Injury Program at Rusk and the Medical Director of the Brain Injury Unit at Queens Nassau Nursing and Rehabilitation. She completed a fellowship in Brain injury Rehab in 2013 at the Rusk Institute and is board certified in Brain Injury medicine and Physical Medicine and Rehabilitation. Alaina B. Hammond is a board certified rehabilitation psychologist and currently serves as Clinical Assistant Professor and Staff Psychologist in the NYU Langone Rusk Adult Inpatient - Brain Injury Rehabilitation Program.  She provides psychological and neuropsychological intervention and assessment to patients and families with acquired brain injury, stroke, spinal cord injury and other illness/injuries. In addition, she supervises psychology interns and enjoys researching family/caregiver adjustment to medical illness.  Dr. Jessica Rivetz is the current Brain Injury Medicine Fellow at NYU Rusk Rehabilitation. She recently completed her residency in physical medicine and rehabilitation at NYU Rusk. She received her MD degree at Albany Medical College, and also has a Master's of Science in health care management. Extracurricular activities include serving as co-chairperson of the NYU GME House Staff Patient Safety Council. Within brain injury medicine, she has a special interest managing patients with moderate to severe traumatic brain injury and helping them and their caregivers navigate life after brain injury and achieve their functional and quality of life goals. Part 1 The discussion covered the following topics: concussions and TBIs; pediatric care; use of biomarkers; common causes of a TBI; common symptoms and their length of duration; involvement of informal caregivers; and occurrence of sleep disorders.

Dr. Steven DeKosky is professor of Alzheimer’s research at the University of Florida College of Medicine and Deputy Director of the McKnight Brain Institute at that institution. He also is a professor of neurology and neuroscience there. Previously, he served as vice president and dean of the University of Virginia School of Medicine and was chairperson of the department of neurology at the University of Pittsburgh. Part 2 For the short-term, with mild to moderate traumatic injury you can have altered synaptic structure and function. For the longer term, chronic inflammation and chronic oxidative stress can lead to subsequent degeneration and also some chronic microglial activation, which may turn on mechanisms that you do not necessarily want, including cleaning up partially injured neurons that may recover. Especially in patients who get the disease in an older age, there is other pathology in the CTE. There are nerve fibrillary tangle and Lewy body.  Amyloid beta can be elevated in both white matter and grey matter and might add to the cascade that is thought amyloid leads to, which leads to degeneration especially Alzheimer’s disease, but cannot prove it. Participants in contact sports all are at significant risk. APOE 4 increases the risk of Alzheimer’s disease and the risk of tau deposition. Currently, when patients arrive for rehabilitation, they are going to have things a lot better described than was the case previously.  We can look at disruption of structures, see hemorrhage and inflammation. We know that CTE is not a new disease, but we do see the pathology in other contact sports and we do not view it in autopsy series unless the individual had a history or repetitive head injury. A Question & Answer period followed.

Dr. Steven DeKosky is professor of Alzheimer’s research at the University of Florida College of Medicine and Deputy Director of the McKnight Brain Institute at that institution. He also is a professor of neurology and neuroscience there. Previously, he served as vice president and dean of the University of Virginia School of Medicine and was chairperson of the department of neurology at the University of Pittsburgh. Part 1 Dr. DeKosky described how CTE has a fascinating history, There still are questions about it. Some questions are old while some are new, but they all are interesting with respect to injury to the brain and how you try to repair it. Future directions also will be covered because the data arrive quickly. Mild traumatic brain injury usually means at least being knocked unconscious. It is not clear whether there is short-term pathology that lasts. Recovery usually is good. It is not clear exactly how much of an increased risk of Alzheimer’s disease there is with a single severe TBI while more is being learned about the long-term effects. Only recently has CTE been defined clearly. Boxing is where CTE came from initially. He indicated that football helmets first were used at the U.S. Naval Academy in 1894 because one player needed protection against experiencing another head injury. He mentioned that the NCAA owes its origins to efforts to reduce brutal injuries sustained by football players. President Theodore Roosevelt led governmental efforts to prevent such injuries. Several examples were provided of developments that occurred over the decades to obtain a greater understanding of the prevention and treatment of brain damage. Apart from head injuries in sports, an uptick in interest in such uncommon disorders resulted from modern day wars in the middle east involving blast injuries from IEDs and the discovery that playing football and other sports led to many injuries viewed as being more common.

The introduction is done by Dr. Steven Flanagan, Chairperson of the Department of Rehabilitation at NYU Langone Health. His remarks ended at the 2 minute: 24 second mark. Dr. Darryl Kaelin is the Endowed Chair of Stroke and Brain Injury Rehabilitation at the University of Louisville. In this Grand Rounds session, he speaks about Traumatic Brain Injury and its Association with Neurodegenerative Disorders. Part 2 Repetitive mild brain injuries also can result in the same kinds of findings. So, it is not just moderate to severe, but repetitive mild injuries that increase the risk. Although there may not be a direct causal relationship, certainly having a brain injury, multiple mild brain injuries or a moderate to severe brain injury increases the risk of developing neurodegenerative processes like Alzheimer’s and Parkinson’s.  He tells his patients that the likelihood of developing a neurodegenerative process may be there, but in each individual it can be different. We don’t know specifically what it might mean for you. On average the risk may go up, but it still is very small. He talked about some potential neuro-protective treatments that might exist out there or are in the process of being looked at. He stated that this patient population is heavily heterogeneous, especially in how it presents and responds to trauma. Additionally, patients in the U.S. don’t all receive exactly the same treatment after their trauma, which is a confounding variable that results in a very different outcome for each of those kinds of patients. Nutrition is a highly important factor when it comes to recovery and outcomes.  Parenteral nutrition goes a long way in helping their outcomes. It also is important to keep an eye on vitamin and mineral levels.  Zinc is a key supplement for many patients and magnesium can help in recovery. He closed by describing a disorders of consciousness program at his institution called the Emerge Program. A Question &Answer period followed.  

The introduction is done by Dr. Steven Flanagan, Chairperson of the Department of Rehabilitation at NYU Langone Health.  Dr. Darryl Kaelin is the Endowed Chair of Stroke and Brain Injury Rehabilitation at the University of Louisville. In this Grand Rounds session, he speaks about Traumatic Brain Injury and its Association with Neurodegenerative Disorders. Part 1 Dr. Kaelin described the interesting relationship between the University of Louisville Frazier Rehabilitation Institute and NYU Rusk in New York. The Institute has its origins at NYU. His presentation had a focus on cellular level and pathophysiology that contribute to complications of brain injury, Alzheimer’s type dementia, Parkinson’s Disease and some similarities that exist. He began a literature review one-year ago on this topic, which has led to today’s discussion. It is important to start by talking a little about the pathophysiology TBI and cerebral insults. It can have some correlation to stroke and other insults to the brain and central nervous system. He also talked a little bit about things that we don’t think about much as physiatrists –astrocytes and microglia and what their roles are in the brain and in brain trauma. He indicated that astrocytes are the scaffolding or the structure upon which neurons and other cells hold themselves to and create the structure and shape of the brain. Microglial cells help in brain infection and brain inflammation. In a resting, healthy brain they are highly mobile and will undergo morphological changes following a brain trauma. He indicated that synapses between neurons are significantly affected both mechanically and in becoming lost in severe brain injury. He discussed the importance of sleep for patients with a brain injury.  

Dr. Julie Silver is an associate professor and associate chairperson in the department of physical medicine and rehabilitation at Harvard Medical School PART 2 In Part 2, Dr. Silver began by indicating that thinking about belonging and social integration are super important. There are two bodies of literature--a retention literature and a belonging literature. Very few studies have looked at them together. One investigation that did so found that women who have fewer belonging components are more likely to leave their workplace and more likely to stay if they have more of these components. What can be done right now to improve the situation? Her answer is that individuals should be told that they belong. Inclusion is not a synonym of belonging. She provided examples of constructive steps that have been implemented at other academic institutions. Mentoring is a critically important model. She described how she works with individuals in helping them to feel that they belong and indicated five strategies that leaders can implement. Let’s not assume that progress happens. Instead, let’s believe the science and follow the data. When looking at the proportion of women on specialty boards, they found in a comparison study that six boards decreased and that two stayed the same. Progress does not just happen on its own. In PM&R, there was an increase, but it still is not really at the equitable level.  We must continue to focus on it. The same holds true when looking at race and ethnicity.