An interview with John D. Corrigan, PhD, about how Cognitive Rehabilitation fits with brain injury as a chronic health condition.

Dr. Corrigan is a Professor in the Department of Physical Medicine and Rehabilitation at Ohio State University and Editor-in-Chief of the Journal of Head Trauma Rehabilitation. He is Director of the Ohio Valley Center for Brain Injury Prevention and Rehabilitation and has been the PI and co-PI of the Ohio Regional Traumatic Brain Injury Model System since 1997. He also directs the Ohio Brain Injury Program, which is the designated lead agency in the state of Ohio for policy and planning related to living with brain injury. Dr. Corrigan is a member of the Board of Directors of the Brain Injury Association of America and has previously served national organizations, including CARF, the Injury Control Center at CDC, the Veterans Administration and the U.S. Department of Defense, Defense Health Board.

Why did we start thinking about brain injury as a chronic health condition?

Most traumatic brain injuries (TBI) are mild and cause temporary neurological impairments. While some mild TBIs, and many severe injuries, cause permanent changes, the clinical precept in the past was that residual impairments due to TBI are static once an initial recovery phase has plateaued. This assumption––that the effects of TBI do not change over the remainder of a person’s life––has been drawn into question by several independent bodies of research. The emerging picture is that for more severe injuries, as well as some less severe, the long-term course of TBI is better characterized as dynamic, not static.

A broad group of stakeholders in the brain injury field met at the Galveston Brain Injury Conferences and arrived at the following consensus statement: “Injury to the brain can evolve into a lifelong health condition termed chronic brain injury. Chronic brain injury impairs the brain and other organ systems and may persist or progress over an individual’s life span. Chronic brain injury must be identified and proactively managed as a lifelong condition to improve health, independent function and participation in society.” We have been working since to conduct the research and develop the clinical protocols that will turn this recognition into real advancements for people living with brain injury.

What is a “disease management" model?

As noted in the aforementioned Galveston Brain Injury Conferences consensus statement, as a chronic condition living with brain injury needs to be approached proactively. This is common in other chronic health conditions like diabetes and heart disease—the individual, family and healthcare professionals all have roles intended to optimize a person’s health. Chronic disease management entails:

• on-going surveillance and screening for early detection and intervention of new health conditions that might emerge; • prevention efforts targeting high incidence and/or high-risk complications; • person and caregiver engagement in self-management skills to improve health and well-being; • access to specialized medical and rehabilitation services to keep health and functioning optimal. I am pleased to add that a grant award recently announced by the National Institute on Disability Independent Living and Rehabilitation Research will provide resources to develop a “Chronic Disease Management” model specific for living with brain injury. Flora Hammond from Indiana University will be leading that effort and I will be serving as the Co-PI. We will be engaging all the resources of the civilian and VA TBI Model Systems in the development of the “BeHealthy” model.

How does Cognitive Rehabilitation (CR) fit into a disease management model”?

CR is both a direct intervention to improve function and a “gateway” to multiple other ways to improve health. Many years of research support the specific ways in which CR can improve function after brain injury. But we sometimes ignore that the improvements accomplished via CR allow a person to more effectively take advantage of other services and supports. That is what I mean by being a “gateway”. Compensatory skills I’ve learned for maximizing my attention will improve my ability to participate in education or treatment for an addiction, if that was something I needed. Being better organized will allow me to be more consistent with goals I have set for exercising or better nutrition. Compensatory strategies for memory will allow me to be more effective in my selfmanagement of any medical conditions I may have. Thus, in addition to the direct positive effect on functional independence, CR also has a very important role in maximizing other aspects of life, including a disease management approach.

Another important aspect of a disease management model is that services should be available throughout one’s lifetime. This includes therapies like Physical, Occupational and Speech therapies, and it definitely includes CR. While the initial phase of recovery right after the injury is really important, we need to also recognize that services should be available over the years following injury. There is a tendency for skill levels we attain to diminish over time, either because we don’t use the skill enough, we develop some other condition that affects our abilities, or we simply experience aging-related changes. There are numerous studies supporting the effectiveness of CR long after the initial injury. We need to be able to access CR professionals periodically throughout life in order to keep our cognitive skills at their optimum levels.

What do you think is the biggest barrier to making CR available across a person’s lifespan?

Unfortunately, currently there are multiple barriers to being able to access CR services across the lifespan. First and foremost is that healthcare professionals have not embraced chronic disease management approaches for brain injury and thus don’t recognize the importance of sustaining skills and abilities over one’s lifetime. If a professional does recognize the need for CR, a second barrier is the lack of, or limited, health insurance coverage. CR needs to be a standard part of the therapies covered by insurance, and that coverage should be adequate to allow any therapies to be accessed to re-optimize abilities. A big step forward for those with the most severe disabilities would be to include CR among allowable services in Medicaid-funded Home and Community Based Service Waivers.

Finally, we need to make sure we have a workforce of trained professionals who know how to do evidence-based CR. Speech Pathologists, Occupational Therapists and Psychologists all include practitioners with the needed competency, but instruction in CR needs to become more integrated into training programs so that a larger number of professionals, geographically dispersed, are available to people with brain injuries. Along these lines, I am optimistic about what I am seeing in training programs for Occupational Therapists.

Any final thoughts?

Thank you for the opportunity to share a few ideas. I see the field of brain injury rehabilitation making some important changes in how we think about brain injury. Most encouraging, I see significant increases in the attention given to living one’s life with a brain injury. This awareness and attention in both research and services will result in much better lives for persons living with the effects of brain injury and their families.

Dr. Yelena Goldin is a board-certified senior neuropsychologist at the JFKJohnson Rehabilitation Institute, Clinical Assistant Professor of Physical Medicine and Rehabilitation at Rutgers-Robert Wood Johnson Medical School, Project Director of the JFK-Johnson TBI Model Systems, and Training Director of the JFK-Johnson neuropsychology residency program. She is the co-chair of the ACRM BI-ISIG Cognitive Rehabilitation Task Force, where she is currently leading the next update to the evidence-based systematic review on cognitive rehabilitation in TBI and stroke, as well as the co-chair of the Girls and Women’s with ABI Task Force. She earned several awards for her work in brain injury rehabilitation.

NEUROREHABILITATION & RESEARCH HOSPITAL

Madison Schwartz, Stanford Law, Randall H. Scarlett, Randall A. Scarlett, Ronnie Pang, Olga Rios, Mary Anne Scarlett, and Brendan D. Nay.

Scarlett Law Group is a premier California personal injury law firm that in two decades has become one of the state’s go-to practices for large-scale personal injury and wrongful death cases, particularly those involving traumatic brain injuries.

With his experienced team of attorneys and support staff, founder Randall Scarlett has built a highly selective plaintiffs’ firm that is dedicated to improving the quality of life of its injured clients. “I live to assist people who have sustained traumatic brain injury or other catastrophic harms,” Scarlett says. “There is simply no greater calling than being able to work in a field where you can help people obtain the treatment they so desperately need.”

To that end, Scarlett and his firm strive to achieve maximum recovery for their clients, while also providing them with the best medical experts available. “As a firm, we ensure that our clients receive both the litigation support they need and the cutting-edge medical treatments that can help them regain independence,” Scarlett notes.

Scarlett’s record-setting verdicts for clients with traumatic brain injuries include $10.6 million for a 31-year-old man, $49 million for a 23-year-old man, $26 million for a 7-year-old, and $22.8 million for a 52-year-old woman. In addition, his firm regularly obtains eight-figure verdicts for clients who have endured spinal cord injuries, automobile accidents, big rig trucking accidents, birth injuries, and wrongful death.

Most recently, Scarlett secured an $18.6 million consolidated case jury verdict in February 2014 on behalf of the family of a woman who died as a result of the negligence of a trucking company and the dangerous condition of a roadway in Monterey, Calif. The jury awarded $9.4 million to Scarlett’s clients, which ranks as one of the highest wrongful death verdicts rendered in recent years in the Monterey County Superior Court.

“Having successfully tried and resolved cases for decades, we’re prepared and willing to take cases to trial when offers of settlement are inadequate, and I think that’s ultimately what sets us apart from many other personal injury law firms,” observes Scarlett, who is a Diplomate of the American Board of Professional Liability Attorneys.

In 2015, Mr. Scarlett obtained a $13 million jury verdict for the family of a one year old baby who suffered permanent injuries when a North Carolina Hospital failed to diagnose and properly treat bacterial meningitis that left the child with severe neurological damage. Then, just a month later, Scarlett secured an $11 million settlement for a 28-year-old Iraq War veteran who was struck by a vehicle in a crosswalk, rendering her brain damaged.