Brian Conroy spent several weeks in the hospital after an ATV accident left him in a 5-day coma. The 17-year-old awoke with a traumatic brain injury.
Those early days in April 2004 were difficult. He was confused, once thinking George Washington was the current president. He experienced headaches, balance problems and mood swings. He was so fatigued that he slept much of the day.
That summer, he began intensive rehabilitation therapy: physical, cognitive, learning and speech. His doctors told him he’d make the biggest strides toward recovery in the first three months. Then six months. Then a year. Then two years.
“After two years, your brain is kinda what it's going to be,” Brian recalled his doctors telling him. “And that was frustrating to hear. I didn't want to be 19 and say, OK, well I guess this is it.” For a long time, this was what doctors told the 1.7 million Americans who suffer a traumatic brain injury, or TBI, each year.
But the tide is shifting toward proactive approaches, even after patients pass the two-year mark. Researchers at the University of Texas at Dallas Center for BrainHealth are discovering that targeted training can improve both cognitive functioning and alleviate depressive symptoms in TBI patients.
The researchers linked these improvements to changes in both the structure and communication pathways of the brain, a first for TBI studies.
The training program, called SMART™, stands for Strategic Memory Advanced Reasoning Tactics. Sandra Chapman, the director of the center, developed the program about 20 years ago and adapted it for TBI. Brian was one of the first TBI patients to complete SMART in 2013.
While every brain injury is different, many result in impaired executive thinking. A person with a brain injury can struggle to make plans, decide what brand of cereal to buy, or learn and retain new information.
Brian experienced many of these problems as he worked through his senior year in high school and then at Wake Forest University. He especially struggled with short-term memory. He would practice with memory cards with his mom. But initially “he just could not do it, and got so frustrated,” said his identical twin, Andrew.
Brian processed things more slowly, and would often have trouble expressing his thoughts coherently. His brother described Brian as having “no filter,” a consequence of impaired executive functioning that normally inhibits impulsivity.
SMART seeks to address these deficiencies through a progressive, eight-week group program designed to strengthen top-down cognitive control. Molly Keebler, head of community programs at the center, says SMART differs from computer-based brain games “by targeting complex functional skills and having patients practice them in the real world.”
SMART starts with building selective attention skills, a common deficit in TBI. Next, participants practice integrative reasoning. In groups, they extract the bigger picture from photos and articles, and talk through their reasoning. Finally, the training develops “innovative reasoning.” Keebler says this final stage helps participants think more flexibly about complex ideas and situations.
Brian says SMART was more practical than his earlier rehab. “Prior to [SMART], I just got caught up in the day to day, didn't really think strategically,” he said. “The training gave me a framework to think about things and why I'm doing them.”
Tracking the changes in the brain
But is SMART measurably changing the brain? To find out, Kihwan Han and Daniel Krawczyk, researchers at the Center for BrainHealth, recruited 60 participants who had been living with TBI for, on average, eight years. The researchers assigned them to complete either the SMART program or be part of a control group.
The control group spent as much time in training as the SMART group, but instead of learning new ways of thinking, they learned facts about brain health. This comparison allowed the researchers to isolate changes specific to the strategic learning.
Our brains contain more neurons than stars in the Milky Way, making any detailed measurement challenging. Han and Krawczyk settled on two separate measurements — changes in the thickness of brain tissue, and visualizing changes in the communication pathways among brain regions.
Increased thickness in one area suggested that area was activated by the training. But this measure alone is incomplete.
Our thoughts, feelings, and behaviors don't just spring from specific brain regions. They emerge from the communication among many regions. The researchers traced these connections using MRI, giving clues as to how the brain is organized, where information is stored, and how that information travels, all of which can be disrupted by brain injury.
The researchers scanned participants' brains before training, after, and again three months later. Additionally, patients took standard cognitive tests and completed depressive symptom surveys.
SMART boosted scores on standard neuropsychological tests, indicating improved cognition. In the brain, Han found that after training the SMART group saw many brain regions thicken, while the control group actually had thinning, suggesting strategic learning caused positive change.
Many of these thickened regions also saw increased connectivity. In other words, the brain regions involved in strategic behaviors got better at working together.
However, three months after training the researchers found that while the changes in connectivity persisted, cortical thickness returned to baseline. If the researchers had only measured thickness, they would have missed the lasting effects of training, underscoring the need to look at changes in brain structure and connectivity.
SMART and depression
Depression is a common and devastating consequence of TBI. Brian grieved over the loss of his old self, especially when he looked to his twin brother, who represented “what he could have been, should have been, used to be.”
“There is a grieving period. You have to accept you're not the same person,” said Brian. “Emotionally that can be hard.” Brian gained traction when he accepted he was different, but also believed he could improve. This attitude drove his commitment to better himself through programs like SMART.
When the researchers investigated the effect of SMART on depressive symptoms, they were surprised to find that, despite not directly targeting psychological factors, SMART training eased depressive symptoms in participants.
In the brain, the researchers found thickening in areas involved in emotional control, and decreased connections to areas known to be hyperactive in depressed patients.
The ultimate goal of this research is to give clinicians tools to pinpoint the cause of TBI symptoms, and test which treatments work.
Tom Talavage, professor and co-director of the Purdue MRI facilities, was not involved in these studies. He thinks it will be some time before such approaches are commonplace. “But this is exactly the type of work that has the potential to make that happen,” said Talavage.
Brian, currently 32, lives in Dallas with his wife and three daughters and is a senior product manager for a medical device company. He credits where he is now to the tremendous support of his family. He sees his progress as a testament to the resilience of our brains, although he still acknowledges his limits.
“There are times where I get frustrated, because there's not much more I can do to change,” Brian said. “That is challenging for me, but then I end up thinking, well, you can sit here and dwell on the loss, or you can keep on keeping on.”