Congresswoman Gabrielle Giffords recovers from attack

Stories about brain injuries are receiving more media attention than ever. Updates are issued daily on Congresswoman Gabrielle Giffords’s recovery from a gunshot wound, and the media has been exploring the challenges faced by soldiers who return to the States with traumatic brain injuries. On a related topic, the Academy Award-nominated film The King’s Speech has shone a spotlight on the topic of stuttering.

The Office of Communications and Marketing recently spoke about these topics with Emerson College’s resident expert on communication disorders and speech pathology, Daniel Kempler, department chair and professor of Communication Sciences and Disorders. Kempler is a specialist in acquired neurologically based communicative disorders in adults. He has written extensively on the topics of dementia, Parkinson’s disease, and aging, and has presented his research at dozens of national and international conferences.

Q: With brain injury, what are some of the key factors that determine a patient’s recovery?

A: Severity of the impairment and size and location of the brain injury play a role in how quickly and fully a patient recovers. For instance, a person may have a small stroke in one area of the brain and have momentary speech, balance, or movement difficulty, but recover quickly and completely. On the other hand, even a relatively small brain injury in an area near the base of the brain can have a severe lasting impact, as structures in this area regulate some essential functions.

Other determining factors in recovery are age—younger people tend to recover more quickly and more fully. Other existing health conditions such as overall conditioning, diabetes, or respiratory difficulties can complicate and slow recovery.

There are also many things we still don’t understand about the brain, brain injuries, and recovery. Statistically, we know certain factors are important, but every individual is unique. Brain organization and resilience differ from patient to patient, making it difficult to predict precise patterns and degrees of recovery. Every clinician has had clients who surprised them by the timing and extent of their recovery. We see clients in Emerson College’s Robbins Speech, Language and Hearing Center who are many years post-stroke and/or brain injury and are still making small but noticeable improvement.

“Given the number of children diagnosed with developmental disorders such as autism and the growing need for rehabilitation in medical contexts, I anticipate even greater demands for our services in the future.”

–Daniel Kempler, department chair and professor of Communication Sciences and Disorders

Q: What kinds of rehabilitation treatments are typical for brain injury patients?

A: Rehabilitation following brain injury most typically involves speech-language, physical, and occupational therapies. Rehabilitation approaches can be very broadly categorized into those that work to restore lost functions and those that help the client develop ways to compensate for lost functions.

To restore impaired or lost abilities, patients often engage in repetitive drills. For example, those with impaired speech articulation may be asked to repeat and read lists of words; those with impaired ability to retrieve object names may spend time naming objects in pictures, completing sentences, using gestures to cue themselves when having trouble retrieving a word, and drawing networks of related words to strengthen meaning associations between concepts and words.

Constraint-induced therapy is another approach. During recovery, patients tend to naturally and spontaneously compensate when they have an injury, but it’s often less effective in the long run. Constraint-induced therapy tries to prevent these habits right from the start. This approach has had great success with restoring function to paralyzed limbs in physical therapy. For example, a physical therapist would immobilize a patient’s “good” (i.e., unimpaired) arm, forcing the use of the weak or paralyzed arm. The idea is that a patient will therefore recover his or her original function rather than have a different part of the brain take over in a less effective way.

With communication impairments, when clients have trouble using verbal expression, they often spontaneously use gesture or writing in order to communicate, despite the fact that gesturing and writing tend to be slower and less effective than speaking. Such spontaneous compensations can set up long-term habits that may interfere with relearning or restoring lost functions (in this case, speaking). Work done at Emerson and at other aphasia centers has demonstrated initial success with a constraint-induced approach.

Some brain injuries are so severe that original functions cannot be restored. Therefore, compensatory approaches are also used. These approaches help patients and their families use alternate means to regain function. Many patients are treated with a hybrid of these different types of therapies. Each patient and each injury is unique. At most rehabilitation facilities, including the Robbins Speech, Language and Hearing Center at Emerson, treatment strategies and goals for each patient are determined through collaboration between the client, caregivers, significant others, and the clinician.

Q: What treatments for brain injury patients are new in the last 10 years—in surgery or rehabilitation?

Great progress in neuroimaging allows us to obtain clear images of the brain. These tools allow us to see brain structure and structural damage as well as brain function in both damaged and preserved brain regions. Although I am not a physician, I have been impressed with how these technologies can be helpful in everything from diagnosis of brain injury to guidance in delicate neurosurgical procedures.

There have also been advances in medication, including clot-busting drugs, which if given quickly after a stroke, can reduce the extent of brain injury.

In terms of rehabilitation therapy, I have been struck by how augmentative communication devices have recently evolved. It used to be that severely impaired and nonverbal patients had relatively few alternatives, and most were expensive, inflexible, or both. Now, alternative communication devices are easily tailored for individuals, can be very effective for communication, and are as accessible as an iPod or iPhone app. Moreover, many of these same technologies are widely used, which helps de-stigmatize the impairments and non-standard communication.

Q: Based on what has been reported on Congresswoman Giffords, how has her recovery been different or similar to others who have suffered similar brain injuries?

Much of what has been reported in terms of the difficulty of predicting outcomes as well as the positive early indicators is consonant with the research and my own clinical experiences. I have heard much about her apparent early and rapid steps toward recovery. This is generally a very positive sign. Often the greatest gains are made in the first six to 12 months following an injury. But when I talk to clients, family members, or students about this rule of thumb, I also always mention exceptions to the rule.

Q: Brain injuries and rehabilitation therapies seem to be in the news a lot lately—e.g., reports of soldiers returning from combat with brain injuries and young people with sports-related head injuries. Is there an increased need for professionals in fields related to brain injury and recovery?

Communication disorders and speech pathology services in particular are historically understaffed. A great percentage of our master’s students have excellent job offers before they graduate. Our recent alumni surveys show that all have jobs within three months of looking.

Given the number of children diagnosed with developmental disorders such as autism and the growing need for rehabilitation in medical contexts, I anticipate even greater demands for our services in the future. Every war seems to increase the demand for professionals in certain medical and rehabilitation fields. We saw this after WWII as well as following the Vietnam War, when I entered the field. The conflicts we’re engaged in now are no different; they have amplified the need for care in a variety of fields, from trauma prevention and brain injury rehabilitation to counseling.

Q: The King’s Speech has been nominated for several Academy Awards, and this has spurred a focus on stuttering. What causes stuttering?

We don’t know what causes stuttering. Some individuals may have an underlying biological susceptibility, although this factor clearly interacts with the speakers’ own experiences, including their emotional responses to their own stuttering and listeners’ reactions to them. Speech pathologists in our department and at the Robbins Speech, Language and Hearing Center are actively engaged in trying to sort out how various parameters affect fluency and the best treatments for reducing the behaviors and the anxiety that they can elicit. I hope the movie helps to introduce the public to some of these issues. They are complex and endlessly fascinating.

Photo credit: Aja Neahring ‘13