Rethinking patient care, recovery for brain injury
As a physician-scientist, I have stood at the bedside of a man as an electrical current was passed through central structures of his severely injured brain and heard him utter words for the first time in more than six years. Though it was more than a decade ago, I remember my thoughts vividly. In that moment, I knew with great certainty that the brain’s plasticity — its ability to heal and change — could be harnessed for far greater recovery after a major trauma than we had ever imagined.
Since then, multiple studies have shown the brain’s ability to change even after severe injury. In some cases, late improvement has come with physical therapy; in others, simply with the passage of time. It has been surprising and illuminating to see the continuing advance of the science of recovery after brain injury. And yet, the pace at which these discoveries have translated into even basic applications in patient care has been haltingly slow.
Recently, my colleagues and I published a paper in Science Translational Medicine using imaging techniques that revealed progressive rewiring of the spoken language area in the brain of a severely injured woman. Two years after her injury, we discovered that she could move one eye by request, an observation that required only a careful bedside exam. With this discovery, she was able to communicate using yes-no questions and an eye-tracking device. She had the constant engagement of her mother and other caregivers.
Slowly, over the course of three years and as the woman’s ability to communicate via eye movement improved, we began to see that wide areas of her brain had begun to function together in response to language. In this instance, harnessing her brain plasticity did not require expensive devices, just careful assessments, patience and an enduring commitment to rehabilitation.
Multiple studies in medical settings around the world and undertaking a variety of approaches show this capacity for connections in the brain to reorganize themselves in patients with traumatic head injury.
But how should these scientific observations change the way we try to rehabilitate these severely injured patients? And how close are we to using our evolving understanding to help such persons?
First, we need to appreciate that recovery can happen even when rehabilitation does not begin immediately following injury and that healing will always take time. Second, we need to anticipate that the capacity for return of a patient’s brain function can be greater than may have been predicted at the time of injury. As a result, we must realize that a patient may benefit not only from rehabilitation that begins long after the initial injury, but that the brain might, in fact, be recovering on its own — even though caregivers may not notice progress.
These realizations will require a broad rethinking of each severely braininjured person’s potential for recovery. It will mean bringing together neuroscientists, physicians and the health-care delivery system, including hospitals and health insurance providers, to find new ways to organize care and develop innovative treatments for the best possible outcomes.
While there is much we don’t know, what is clear is that the majority of patients who survive an initial severe brain trauma will never receive any sort of rehabilition at all. What’s worse is that most patients won’t even be properly evaluated for their potential to benefit from such therapies. The first step to improving this bleak outlook is understanding that the severely injured brain possesses a remarkable capacity for recovery, a self-healing power doctors are only beginning to understand how to tap.
Having worked for decades on this problem, I have seen great advances in what we know about recovery of consciousness in the human brain. We now know that the brain can continue to heal without any outward sign. And that these patients, because they have limited options for connecting to the outside world, are highly vulnerable to isolation and neglect. These facts alone, now wellestablished in the medical literature, should prompt a broad effort to carefully evaluate all severely brain-injured patients and to offer all appropriate efforts to advance care.
Similarly, all such patients and their families should benefit from our evolving scientific knowledge of brain plasticity.
We must begin creating bridges from research to innovative clinical care tailored to understanding the potential for recovery in each person with severe brain injury, and, where possible, giving them access to potentially life-restoring rehabilitation therapies.
The brain will do its part if we do ours.
Schiff is Jerold B. Katz professor of neurology and neuroscience at Weill Cornell Medicine.