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Understanding the Injured Brain

Dr. Jonathan French, conducting a patient evaluation, developed an interest in the brain as an undergraduate psychology major at Widener.

By Jennifer Kitchen '11

Ryan Raiker remembers getting in his friend’s Pontiac Grand Am on a rainy, winter night to go to ice hockey practice, but he doesn’t remember his head hitting the roof of the car after it crashed. “I know I was taken to the hospital, and they kept me over night,” he said. “My mother came the next day, and I didn’t know who she was. It was scary for both of us.”

Raiker, a senior business informatics major at Widener University, experienced memory loss and language impairment immediately after the collision his freshman year. The injury to his left frontal cerebral cortex produced common signs of a traumatic brain injury (TBI) and the risk of further injury forced an end to Raiker’s college hockey career. The Northeast Philadelphia native who started ice-skating when he was a year and a half old had been a starter for the Widener Ice Hockey club team.

After his diagnosis, Raiker’s memory returned and he began speech therapy to improve his language skills, but he easily forgot things like why he went to the market or the color of his favorite coffee cup, so he started cognitive therapy. “Everything changed,” he said. “It was frustrating to look into the mirror and not see anything wrong, but feel completely unbalanced. It is easy for many to see a smile, but internally there was a great struggle trying to understand what was wrong with my head.”

Understanding what is going on in a patient’s head when diagnosing a concussion can be hard, even for doctors. “There is no agreed upon definition of what a concussion is,” said Dr. Jonathan French, a neuropsychologist and assistant professor at the influential University of Pittsburgh Medical Center (UPMC) Sports Medicine Concussion Program who earned both his undergraduate and doctoral degrees from Widener. “It’s a complex pathophysiological process affecting the brain when direct or indirect forces cause the brain to move inside the skull. Most symptoms are immediate; however, there can be a delay in their presentation. Until recently, it was thought that all concussions resolve relatively quickly, but we are beginning to understand there can be significant, long-term consequences, if not treated appropriately. We no longer grade the severity of concussions, because the ones that appear more severe can be mild, while the mild ones can turn more severe.”

Regardless of how it’s defined, experts say a concussion or any traumatic brain injury should be taken extremely seriously because what is happening inside the skull can be difficult to detect. A mild TBI, such as a concussion, can be misdiagnosed or undetected, and that’s where a lack of appropriate treatment can cause long term difficulty. “If you take an egg and shake it, what happens to the yolk?” French asked. “The egg shell is fine, there is no damage, but the biomechanical forces affect the egg yolk. This is similar to how our brain reacts in a mild traumatic brain injury.”

Dr. Jonathan FrenchAwareness of traumatic brain injuries is on the rise. As many as 3.8 million sports and recreation-related concussions occur each year in the United States, according to the Center for Disease Control (CDC), with children and teens at the highest risk. From 2001 to 2010, the CDC reported that the number of TBI-related emergency room visits increased by 70 percent.

Brain injuries aren’t simply limited to sports and can happen in our everyday life. Traumatic Brain Injuries are a major cause of death and disability in the United States, contributing to about 30 percent of all injury deaths, according to the CDC. Every day, 138 people in the nation die from injuries that include TBI.

This increased attention on brain injuries has been central to promoting further research and study in Widener’s Institute for Graduate Clinical Psychology (IGCP). “At the time I started pursuing my PsyD, there were only a few programs examining the injury, but during my time at Widener, there was a stronger push on evaluating sports-related brain injuries,” French said. “There was a greater need for better assessment and treatment techniques, as more and more people were experiencing such injuries.”

That awareness of brain injuries continues to expand, both across Widener’s campus and with alumni who have gone into the field. The university’s varied programs are playing a key role in the research and treatment of brain injuries at a number of different levels and through a variety of assessments and interventions.

Widener Alumni Prominent at Leading Concussion Center

The program in Pittsburgh where French has been on staff since earning his PsyD from Widener in 2010 is a pinnacle of sports concussion research. The first of its kind when it opened its doors in 2000, the UPMC Sports Medicine Concussion Program has been a global leader in the testing, treatment, and research of sports-related concussions. Staff members see more than 17,000 patients each year including high school, college, and pro athletes from all of the major leagues.

French, a native of Jonestown, Pennsylvania, earned a 2003 undergraduate psychology degree from Widener. He was always fascinated by the brain and how it works, so pursing the neuropsychology concentration in the university’s doctoral program was a natural step. A former Widener baseball player and member of the golf team, French quickly became interested in sports concussions. After completing his PsyD, he landed a post-doctoral fellowship with the UPMC Sports Medicine Concussion Program, the largest concussion program in the country, where he ultimately was hired full time as faculty.

In his role at UPMC, French practices in the clinic, lectures, and conducts research. He provides expertise in neurocognitive assessment and treatment of sports-related concussions of all ages, from amateur to professional athletes. “I couldn’t imagine doing anything else,” he said. “I enjoy going to work every day because I have been able to combine my interest of sports with the brain. I get to work with athletes of all ages and skill levels from initial assessment to return to play. It is always gratifying when helping patients get back to their normal selves and helping athletes safely return to play.”

The UPMC Sports Medicine Concussion Program currently has a grant from the National Football League to research a more systematic display on diagnosis. There is currently not a diagnostic tool available to medical professionals; it remains a clinician-driven diagnosis. The only way to study the effects of a concussion is through signs and symptoms such as dizziness and headaches, cognitive testing, and vesibular-occular testing. The understanding of such brain-behavior relationships is the foundation for neuropsychology.

Everyone’s brain is different, and therefore every concussion is different. No one can be treated the same; every injury requires an individualized approach. “We are beginning to identify different clinical trajectories that concussions can take and creating treatment protocols for each pathway,” French said. “There are many variables involved in identifying how the brain functions. There is no single diagnostic test available to confirm concussion, and it cannot be seen on a CT scan. But just because you can’t see it doesn’t mean that patients don’t suffer or experience symptoms.”

French is not the only Widener alumnus with ties to UPMC. Last year, Christina Kunec ‘12, PsyD, completed a post-doctoral fellowship there, and recent graduate Jill Fleischer ’15, PsyD, started her post-doctoral appointment there this fall.

Choosing a program like the one at UPMC is a nontraditional path for a clinical psychologist, but that is what Fleischer is looking forward to the most in her fellowship. “I strongly believe in the educational component that this fellowship offers,” Fleischer said. “While I’m clinically focused, I’ll have the resources to research as well.”

Fifth-year doctoral student Natalie Sandel had the opportunity to shadow staff at the UPMC as an undergraduate student, which triggered her to switch her focus from biomed to neuropsychology. “It’s the cutting edge of the field,” Sandel said of the research in sports concussions. “There are a number of innovative practices on the best diagnostic and treatment approaches and I wanted to be a part of that.”

Sandel’s dissertation focuses on concussions among male and female lacrosse players. “As other sports such as lacrosse grow in popularity, so does the number of brain injuries,” she said. Sandel has co-authored four research articles on sports-related concussions while at Widener.

Alumnus a Leader in Pediatric Neuropsychology

Unlike Sandel, Dr. Jonathan Lichtenstein ’12, PsyD, MBA, came to Widener’s grad program with the intent of studying psychotherapy. As a third year student, he took Dr. Ken Goldberg’s introduction to neuropsychology course and something clicked for him. “Everything I was interested in blended together,” he said.

Now the interim director of pediatric neuropsychological services at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, New Hampshire, Lichtenstein manages inpatient and outpatient services for children with a wide array of developmental and medical presentations including epilepsy, TBI and post-concussive syndrome, cancer, autism spectrum disorders, genetic syndromes, psychiatric disorders, ADHD, and learning disabilities. As DHMC’s only pediatric neuropsychologist, Lichtenstein also works on several multi-disciplinary teams, providing assessment for medically complex cases in collaboration with neurologists, developmental pediatricians, and pediatric psychiatrists.

Lichtenstein also consults with high schools and colleges in the area, providing expertise on concussion management and neuropsychological assessment. According to a CDC study, an estimated 248,418 children and teens 19 or younger were treated in emergency rooms for sports and recreation-related injuries that included a diagnosis of concussion or TBI in 2009. In response to these alarming statistics, the CDC developed “Heads Up to Concussions,” a series of educational initiatives for children, teens, parents, and coaches that have a common theme of spreading awareness and protecting children from brain injuries in 2011. There has also been a push under the Obama administration for the fiscal year 2016 budget to include an increase of $5 million for the CDC to improve estimates of sports and recreation-related concussions experienced by youth.

“The science around brain injuries is improving,” Lichtenstein said. “Before, people ignored these injuries because they weren’t aware. The tests are relatively new, but there is a proven difference and more people are becoming interested. It’s become a public health issue as the amount of head injuries in athletics increases.”

Lichtenstein’s research has followed the increased interest and need for improved services around concussion. While he initially focused on issues related to test administration in computerized testing for concussion, he is currently the co-primary investigator on a federally-funded pilot program to implement behavioral management and improve return-to-learn programming in New Hampshire high schools. He has also studied the impact of behavioral interventions, such as programmatic physical activity and yoga and mindfulness on recovery post-concussion. As Dartmouth’s representative to the Big Ten-Ivy League TBI Research Collaboration, Lichtenstein is working with leading researchers at multiple educational institutions to better understand the underlying mechanisms in mild TBI. “To be honest,” Lichtenstein said, “my spark and drive towards investigating concussions started at Widener. I owe a lot to Dr. Ken Goldberg and Dr. Mary Lazar for fostering that interest.”

Neuropsychology Assessment and Intervention on Campus

More and more Widener students are becoming interested in the field. A sports concussion group that meets two-to-three times a semester was formed to discuss the latest research trends and case studies with Goldberg, a 1996 Widener PsyD graduate who has been director of the neuropsychology program for 18 years.

The 2013 recipient of Widener’s Outstanding Researcher Award, which recognizes a faculty member who is acknowledged nationally for research and scholarship, Goldberg gave the university’s President’s Lecture on sports concussion research. He specifically discussed the behavioral areas that concussions permanently damage and how students in the program applied this research to dissertations.

Goldberg’s research focuses on evaluation and rehabilitation of patients with traumatic brain injury, learning disabilities, and differential diagnosis of dementia. He has contributed to the research community by developing a neuropsychology database of more than 2,000 patients that has been used extensively in nearly 100 graduate students’ research.

In addition to his faculty responsibilities, Goldberg is a clinical consultant in Widener’s Neuropsychology Assessment Center (NAC), which opened in 2004.

A division of the Institute for Graduate Clinical Psychology at Widener, the center specializes in the assessment of children and adults with learning disabilities, attention deficit/hyperactivy disorder, autism, and other developmental disorders. They also evaluate individuals with brain injuries, epilepsy, stroke, and dementia. “Neuropsychological assessment is unique because it is a one-on-one assessment that looks at IQ, memory, language, and emotional function,” said Dr. Mary Lazar, director of the center. “We focus on understanding the whole person and providing an evaluation that not only helps with diagnosis, but leads to a better understanding of that person’s unique difficulties. This allows us to develop an individualized action plan for treatment.”

An evaluation at the center can also help determine the functional impact of a brain injury. “In addition to problems with attention, concentration, and memory, the individual might also experience associated symptoms of anxiety or depression,” Lazar said. “This is why it is important not only to assess cognitive functioning, but also undertake a thorough evaluation of emotional functioning. This is especially valuable in mild traumatic brain injury when the person has not recovered in the expected time frame, and academic and/or social functioning is starting to get worse rather than improve. For Widener students who sustain a TBI and are referred to the Neuropsychology Assessment Center, this assessment helps guide treatment planning as well as allows us to interface effectively with Widener’s TBI treatment team.”

The center on the edge of Widener’s campus conducts more than one hundred mental health evaluations of individuals from all over the Delaware Valley who are referred by physicians, therapists, schools, parents, as well as the Widener community. It is one of very few university-based neuropsychology clinics that focus solely on testing. “Most clinics are affiliated with university hospitals,” Lazar said.

The center has a three-fold mission: clinical treatment, training, and research. It provides high quality assessment and treatment services at an affordable rate to individuals ranging from children to adults. The center is a non-profit organization that was created to make services more accessible to those who might not otherwise afford testing due to the high cost. Fees are based on a sliding scale.

It serves as a training “arm” of the neuropsychology program at Widener; assessments are performed by doctoral students under the direct supervision of licensed psychologists. “Interning at the Neuropsychology Assessment Center was an absolute asset for me in getting my career started,” said Meghan Jorgenson, a 2015 PsyD graduate who has a post-doctoral appointment at the New York University’s Child Study Center. “It’s a valuable placement for students, as there is a strong focus on training and students are involved in the entire process of each case, from the clinical interview to providing feedback. You get the full experience.”

Traumatic brain injuries can adversely affect a person’s quality of life in numerous ways, including cognitive, behavioral, emotional, and physical effects that affect interpersonal, social, and occupational functioning, according to the CDC. These dramatic neurological effects make a case for the importance of assessment and intervention. Out of the number of different treatments that patients can receive post-TBI, neurofeedback is often recommended, but it can be intensive.

The biofeedback clinic at Widener offers treatment for TBIs, however, neurofeedback services are more rigorous and require constant therapies. Dr. Pam Calvert-Hirt, director of the Biofeedback Clinic, and Dr. Bret Boyer, professor of clinical psychology, conducted a pilot study in the spring of 2015 on EEG software that can be used at home, and will therefore be more accessible to clients. “It is the first step at incorporating training into daily life,” Calvert-Hirt said.

She worked with a group of students who studied the software with the home trainers. Calvert-Hirt and Boyer are currently reviewing the data and are excited for the potential this will allow patients. “This training is a very helpful tool for number of different neurological disorders,” she said. “It helps patients enter a more mindful state of being. Improving this state of being will allow for patients to pay attention better, and overall, improve function of the brain.”

Prevention and Awareness Among Students

With the country taking a more proactive approach in monitoring of TBIs, Widener University has been ahead of the curve with baseline testing for its Division III and club sport athletes as well as purposeful education and awareness programming for students.

Over the last ten years, Lynn Nelson-Russom, director of health services, realized that a number of university units had been working on similar issues around TBIs, so a TBI Treatment team was formed in 2014 to better provide a holistic approach across interdisciplinary units at Widener. “Our team meets monthly to review case studies and best practices,” Nelson-Russom said. “We want to be sure we are providing evidence-based quality healthcare and that we are all up to date with the most current research.”

The team provides a value-added approach to offering the best care to students at Widener. “We consider the cognitive, emotional, and physical aspects of the injury,” she said. “We evaluate, treat and provide continued, integrated follow-up to students here on campus, and refer them externally when needed, so students have an outside provider for ongoing care if required.”

At Widener, the focus is not just on athletes, but the entire student population. Starting with freshman seminars, students are educated on awareness of TBIs and the importance of seeking treatment.

“Not all students may have a concussion, but it’s important they are educated on ways that you can sustain a TBI as well as possible symptoms,” Nelson-Russom said. “Students need to have the knowledge should anything happen to them, so they can be prepared to seek the appropriate care, treatment, and support to assist them to successfully persist in the classroom and life while recovering.”