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Neuro Landscape Blog - A Brain Injury Blog by Dr. Mark J. Ashley, CEO, Centre for Neuro Skills
Neuro Landscape
A Brain Injury Blog by Dr. Mark J. Ashley, CEO
Centre for Neuro Skills

Neuro Landscape Blog

How COVID-19 Can Affect and Damage the Brain

Friday, January 15th

On December 1, 2020, the number of COVID-19 cases worldwide totaled over 63.6 million, with 13.6 million cases within the United States. Of this total, nearly 1.5 million deaths were attributed to COVID-19, with over 269,000 of the deaths occurring in the U.S.1

COVID-19 had primarily been thought to be a respiratory disease. In recent months, however, growing evidence shows that the disease may likely be a disease of the epithelium of the lungs, or the lining of the respiratory tract, and the endothelium, the lining of arteries and veins throughout the body.2

Because of this, complications of COVID-19 tend to strike some organ systems more frequently than others.  Respiratory, cardiovascular, renal, gastrointestinal, and neurological systems appear to be the most commonly impacted. Infection can present a loss of the sense of smell (anosmia) or taste (ageusia), Guillain-Barre syndrome, encephalopathy, encephalitis, and acute cerebrovascular disease.3,4

While extensive longstanding research has not been conducted due to relative inexperience with the virus, information is emerging that strongly suggests the risk of neurologic damage. One study compared the rate of acute ischemic stroke in individuals with COVID-19 to a group of people with influenza, a known stroke trigger. The research found the likelihood of stroke with COVID-19 infection (1.6% of people) to be substantially higher than for influenza (0.2%). 3

Another study examined the risk of developing cerebrovascular disease with COVID-19 infection, which refers to disorders that affect the blood vessels and blood supply to the brain. The categories of cerebrovascular disease examined included cerebral ischemia, intracerebral hemorrhage, and leukoencephalopathy of the posterior reversible encephalopathy type. In total, 1.4% of 1,683 cases developed neurological complications over 50 days.2 Neurological injuries included arterial dissections, subarachnoid hemorrhage, microbleeds, and single or multiple hematomas -severe injuries that resulted in high rates of death or significant disability.

The study found that the injuries tended to occur in the vascular areas that serve the brainstem and posterior (back) portions of the brain. Blood clotting in these areas can be exceedingly significant and impact the arteries feeding blood to the brain.5

There is also emerging evidence that individuals with pre-existing neurological injury are at greater risk for developing neurological complications in the event of COVID-19 infection. A case report of post-COVID-19 autoimmune encephalitis, an inflammation of the brain and spinal cord, found potentially significant long-term neurological symptoms and consequences if undiagnosed or improperly treated. These included non-fluent aphasia, oculomotor dysfunction, myoclonus of the tongue and limbs, echolalia, perseveration, and hallucinations.6

Recovery patterns post-COVID-19 show symptoms persistence at the time of follow-up visit to range from 5% to more than 50% for neurological symptoms ranging from myalgia, vertigo, lack of appetite, headache, loss of taste, loss of smell, and fatigue.7

For the time being, it is reasonable to exercise caution in prediction about recovery from neurological deficits that accompany COVID-19 infection. There is evidence of recovery in some symptoms, such as the loss of taste or smell and significant long-term deficits associated with other complications such as stroke. However, we remain in the earliest stages in regards to understanding the near- and longer-term neurological consequences of COVID-19 infection.  Recovery and symptom severity in the presence of newer interventions that impact viral replication rates and address inflammatory processes may be different, and hopefully better, than the currently available data.



  1. Coronavirus Resource Center. 2020. (
  2. Hernández-Fernández F, Sandoval Valencia H, Barbella-Aponte RA, et al. Cerebrovascular disease in patients with COVID-19: neuroimaging, histological and clinical description. Brain 2020;143:3089-103.
  3. Merkler AE, Parikh NS, Mir S, et al. Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza. JAMA Neurol 2020;77:1-7.
  4. Ellul MA, Benjamin L, Singh B, et al. Neurological associations of COVID-19. Lancet Neurol 2020;19:767-83.
  5. Matschke J, Lütgehetmann M, Hagel C, et al. Neuropathology of patients with COVID-19 in Germany: a post-mortem case series. Lancet Neurol 2020;19:919-29.
  6. Khoo A, McLoughlin B, Cheema S, et al. Postinfectious brainstem encephalitis associated with SARS-CoV-2. J Neurol Neurosurg Psychiatry 2020;91:1013-4.
  7. Carfì A, Bernabei R, Landi F. Persistent Symptoms in Patients After Acute COVID-19. Jama 2020;324:603-5.

Concerns Surrounding Stroke Treatment in the Era of COVID-19

Monday, November 30th

Stroke is an acquired brain injury and is a leading cause of long-term disability in the United States. Almost 800,000 people in America will experience a new onset or recurrent stroke each year. Worldwide, stroke is the second leading cause of death and disability.

Stroke is often thought of as a disease that occurs in older people. While this is often the case, the incidence of ischemic stroke in people aged 20-54 has increased.

Slightly over one-third of people who experience a stroke are functionally dependent or die by three months post-discharge. Recovery after stroke can require the care of a team of individuals, including physicians, nurses, physical and occupational therapists, speech-language pathologists, recreational therapists, psychologists, nutritionists, social workers, and others.

Stroke rehabilitation in the era of COVID-19

As we consider the impact of the recent COVID-19 pandemic, a number of concerns arise regarding the rehabilitation dosing afforded to individuals who sustain a stroke.

Hospitals have, necessarily, reduced lengths of stay for non-COVID-19 diagnoses as they attempt to free up bed space for COVID-19 cases. As a consequence, rehabilitation therapies have become shortened or non-existent. Further, outpatient rehabilitation services have been suspended in many locations, leaving one to wonder how people who suffer from stroke will receive crucial treatment.

Factors impacting stroke recovery

We know that many factors impact a person’s functional outcome after a stroke. These include age, where a younger age is associated with a better outcome, and the timing of therapy, which is essential because therapy that is provided too early can be detrimental, and therapy that is delayed can negatively affect the outcome. The exact window of opportunity is not clear and most likely varies with several patient-specific factors.

We also know that the degree of the expertise of rehabilitation treatment impacts outcome; with more expertise comes better outcomes. And we know that both the frequency and intensity of therapy affect the degree of recovery of function a person will achieve and reduce the likelihood of hospital readmission. Simply put, more therapy is associated with better outcomes. Furthermore, higher intensity therapy is associated with more recovery.

Several factors seem to merge around interfering with a person’s ability to recover to their fullest potential. One factor is bundling payments, wherein a hospital is incentivized to discharge a person quickly and to attempt to reduce re-hospitalization. It has been demonstrated that bundled payment arrangements result in less use of tertiary care settings, such as rehabilitation. As well, payers have become accustomed to very short inpatient rehabilitation stays, followed by simple outpatient rehabilitation services.

It is clear that more attention must be paid to scientific evidence that strongly links better outcomes with more frequent therapy, therapy of higher intensity, therapy that is properly timed and of sufficient duration, and therapy that is provided by properly trained specialists in neurorehabilitation.

Finally, great care in payment structuring should be taken to avoid skimping on care for this vulnerable population.

COVID-19 Risk Factors for Traumatic Brain Injury

Wednesday, April 29th

As the COVID-19 crisis has enveloped the world, the risk to individuals living with a brain injury has yet to be fully appreciated. The risk of contracting the virus is likely elevated for individuals with brain injury.

People with a relatively recent injury, and people who have been living with injury may not have normally functioning immune systems and may have more co-morbid health conditions. As a result, they may be at higher risk for severe complications if they contract the COVID-19 virus.

As well, people without brain injury who experience a COVID-19 infection may emerge with damage to the brain.

We do not know whether neurologic symptoms that develop with infection from the virus will be permanent. These symptoms can include changes in a person’s sense of smell or taste, extreme fatigue, headache, or disorders of consciousness and may also include muscle damage. Some patients are emerging with symptoms similar to Guillain-Barre syndrome. People may additionally require prolonged treatment on ventilators. And these people will not only be physically debilitated, requiring rehabilitation, they may also have lung damage, heart damage, renal damage, and could add injury to the brain as well. Further, there are reports of a high prevalence of coagulopathies resulting in deep-vein thromboses, myocardial infarcts, and strokes. However, the prevalence cannot be fully distinguished from the increased risk seen in critically ill patients in general.

Unfortunately, there is very little research available at this point in time. What is available, however, speculates that, perhaps, the epithelial lining of capillaries in the brain may be damaged by viral budding within the capillaries, thereby potentially enabling the virus to invade the brain. A second mechanism postulates the entry of the virus via the cribriform plate near the olfactory bulb of the brain. And a third mechanism suggests the potential for easier entry via leaky blood-brain barrier function after brain injury.

For now, we can only hope that the neurologic symptoms are temporary. Further, we can only speculate on the course of the disease and how it will affect people living with brain injury. And we cannot know whether there will be only near-term consequences of viral infection or unknown, as of yet, long-term consequences.

If there is a heightened element of risk to a person living with brain injury for a more severe manifestation of the disease, it is all the more critical that they, and the people who love them, take every available precaution to prevent exposure.

Neurobehavioral Challenges After Brain Injury

Friday, September 27th

(Note:  In this guest blog from Chris Persel, Regional Director of Clinical Services and Director of Behavior Programming for CNS, he explains behavioral changes following brain injury and the value of behavior analysis).

The effects of neurological damage from events like trauma and stroke can be devastating to the individual and those close to them. Brain injury can result in lifelong physical, cognitive, and behavioral changes. The impact of behavior changes can profoundly alter how the injured person functions day to day, even impeding rehabilitative goals and impacting the ability to live independently. Changes in personality and behavior following traumatic brain injury (TBI) often represent the most significant barrier to a successful outcome including reintegration into the community whether for basic daily tasks, work or recreational/social activities.

Common behavior issues following brain injury include behavioral excesses (occurring too much) such as irritability (e.g., poor tolerance, short temper) and aggression (e.g., hitting, grabbing, kicking), property destruction (e.g., striking furniture, throwing items) and inappropriate vocalizations (e.g., cursing, yelling, threats). Also presenting a concern are behavior deficits (do not occur enough) such as compliance with tasks (e.g., cooperation with requests), social skills (e.g., overfamiliar discussions, uncharacteristically rude remarks), initiation (e.g., knowing when to begin tasks) and the academic and return to work skills (e.g., being on time, following directions) to be successful. Some of the most difficult behaviors can be dangerous to the patient and others around them. Treating these dangerous and challenging behaviors, which may include physical aggression toward others, self-injurious behavior, sexual disinhibition, and escape or elopement, requires a treatment commitment across the continuum of care.

In the early, acute stages of recovery from brain injury, many of the behavioral complications demonstrated are considered to be a normal phase of recovery. When these behaviors continue beyond those early phases, however, and form on-going negative patterns of interaction with others, very specialized treatment is required.  These behaviors can be disturbing to families and staff, disruptive to therapy, and jeopardize patient safety. The future quality of life for the patient and their family depends on effective interventions, provided with a great deal of consistency and structure. Behavior analysts (professionals in Applied Behavior Analysis) add value to interdisciplinary rehabilitation teams by helping to develop both skill acquisition and behavior reduction programs throughout the patient’s recovery (i.e., acute, post-acute, long term care). Behavior analysts spend a great deal of time directly observing interactions, determining what may be motivating the difficult behaviors, and what responses may need to be strengthened and reinforced. The behavior analyst must then provide training to all those who may interact with the patient, including most importantly, the family. This skilled, specialized intervention establishes more effective and acceptable response patterns that allow the patient to have their needs met and be better understood without displaying problem behavior. The structured behavior plan can also help the patient develop positive, prosocial responses, and more efficient functional skills.

The effects of brain injury are highly individual, which then challenges the behavior analysts, family and others on the treatment team to continually evaluate the responses, goals, and outcomes throughout recovery (e.g., monitoring response to new medications).

Considering the risk to patients and families, the rising healthcare cost and the possibility of reduced services being available, a focus on efficient and effective interventions such as behavior analysis seems essential to a well-integrated, interdisciplinary rehabilitation treatment team. The quality of life for those affected by brain injury depends on having the opportunity to receive not just the standard rehabilitation one might get following knee surgery but rather specialized, experienced and effective treatment specifically designed to address the unique difficulties they face including difficult behavior.

Does MTBI Contribute to Neurodegenerative Disease?

Thursday, July 25th

The estimates for exactly how often MTBI or concussion happens vary widely.  However, concussion is quite common, and the total number of concussions in a year vastly outnumbers all new diagnoses of cancer combined in the U.S.  Many concussions go unrecognized and unreported, making it far more difficult to understand the frequency of concussions.

Generally, it is thought that the brain recovers well after a single concussion.  However, concussions vary by the amount and nature of the forces applied to the brain.  Further, some concussions are referred to today as “complicated concussions” because evidence of damage to the brain is apparent in CT or MRI scans, though the person suffering the concussion seems to recover reasonably well.

It is estimated that between 5% and 20% of individuals who sustain a concussion will have one or more symptoms that last a year or longer.  It is not entirely clear why symptoms persist for some individuals and not for others.

We now know that endocrine dysfunction can be caused by a concussion in some individuals.  We also know that sleep disorders can occur after concussion in some individuals or may be present before the injury.  Both of these factors, along with other general medical conditions, can complicate a person’s recovery.

Several neurodegenerative diseases have been found to occur in greater incidence in association with a single concussion.  These include conditions like Alzheimer’s disease, amyotrophic lateral sclerosis, multiple sclerosis, a variety of endocrine disorders, epilepsy, brain tumor, schizophrenia, depression, psychosis, and dementia.  However, the causal link to concussion as either an initiator of disease or accelerator of the disease has yet to be precisely determined.

Aging and a person’s genetic make-up likely complicate the picture further and can contribute to both onset and acceleration of disease.  We cannot predict accurately who will develop a neurodegenerative disease, though an important indicator can be found in a person’s family history.  That said, we still have no way to guarantee who will and who will not develop such conditions.

The only clear point is that avoiding concussion is well-advised.  Once one or more concussions occur, the individual should consider significant lifestyle modifications, many of which are common sense and advised for many other health conditions.  The person should be alert to developing conditions by working closely with their physician.

These include avoiding the use of caffeine, alcohol, over the counter sleep aids, and recreational drugs.  Diet should be well-balanced, avoiding high carbohydrate intake, and maintaining an appropriate body mass index (weight).  Ideally, the diet should be rich in antioxidants and low fat (~17%).  Daily exercise should be included in one’s routine, just as one includes other daily hygiene care.  Exercise should be under the supervision and advice of a physician and should be 30-60 minutes of cardiovascular exercise at least six days per week.  Sleep should be 7-9 hours daily, and a rigorous sleep routine of regular sleep and wake times should be protected.  A physician should screen annually for endocrine and sleep disorders, in particular, sleep apnea.  And sleep apnea should be managed with breathing support.

Strokes in the Young Adult Population are on the Rise

Monday, May 13th

(Note:  This is a guest blog from Brent E. Masel, M.D, the Executive Vice-President for Medical Affairs for CNS and a Clinical Professor of Neurology at the University of Texas Medical Branch in Galveston. In this article, Dr. Masel addresses the increasing rate of strokes in young people).

 As is well known, stroke is one of the leading causes of disability and death in the United States. We all assume this is a problem of the elderly. For the most part, it is; nevertheless, it is increasingly becoming a significant problem in the younger population.

Interestingly, the incidence of strokes in the US amongst patients older than 65 years has decreased over the past few decades. Population studies, however, have shown an increase in strokes in young adults. Nationally, approximately 11% of strokes occur in young adults.

We are now seeing an increased prevalence of traditional cardiovascular risk factors in adults aged 18 to 64. The prevalence of three or more conventional risk factors such as hypertension, elevated cholesterol, tobacco use, and obesity has nearly doubled in young adults when compared to older populations. Additional “lifestyle diseases” that increase the risk for stroke include substance abuse such as cocaine and possibly cannabis. Cervical artery dissection (tearing of the carotid artery in the neck), usually caused by trauma to the neck is an essential cause of stroke in the young adult population.

Migraine may be a cause of stroke in a large percentage of patients, especially those with well-defined premonitory symptoms. The risk of stroke in women with migraines is especially increased in those who are heavy smokers. Oral contraceptive use has long been known to be a possible cause of stroke in young females, again, with an increased risk with heavy smoking.

It should also be noted that despite a comprehensive evaluation, in a considerable portion of young stroke patients, no clear cause is found.

A stroke in a young adult carries a significant risk for post-stroke complications. A Dutch study showed that the risk of mortality is four times higher in young patients who have strokes compared to those who don’t. Post-stroke depression is common at all ages and is undoubtedly very important in the young. It also may be related to increased mortality in the young adult population. Other factors that may contribute to a poor outcome include post-stroke pain, cognitive deficits, fatigue, and sexual dysfunction.

Children are not immune to strokes. An extensive survey in the United States found an incidence of stroke of .58 per 100,000 children aged 1 to 14 years. The most common causes were blood vessel disease and sickle-cell disease. Approximately 17% of children with sickle cell disease will have a clinically silent stroke as detected by MRI. 10%-15% of children with sickle cell disease will have a stroke by age 20. Sickle cell disease, therefore, is an important potentially preventable cause of stroke in children and young adults.

Interestingly, a chickenpox infection in the preceding year was noted in 31% of children aged 6 months to 10 years who had a stroke compared to a 9% rate in the general population. The risk of chickenpox associated stroke is estimated to be one in 15,000 children.

So what can the reader take away from this blog?

Strokes in the young adult population are on the rise even though it is decreasing and the older adult population. To a great extent, many of the risks of having such an unfortunate event can be modified by lifestyle changes. We encourage the readers of this blog to take inventory of their lifestyle choices and take control of their health.

Sleep Evaluation and Treatment Support Patient Outcome

Tuesday, March 12th

(Note:  In this guest blog from Grace Griesbach, Ph.D., and CNS’ National Director of Clinical Research, she explains that proper sleep is a vital component in the rehabilitation of brain injury).

Historically, quotes referring to sleep have been associated with well-being. This is not without substance. The importance of sleep is appreciated when one considers that it is observed across the vast majority of animal species. In humans and other higher mammals, lack of sleep has been demonstrated to impact physical, cognitive and emotional functions negatively. Physical consequences of sleep deprivation include compromised immune responses, as well as hormonal and metabolic alterations that in turn will impact overall health. Sleep also promotes emotional and psychological well-being. As for cognitive functions, sleep has been shown to facilitate learning and memory.

Moreover, animal studies have shown that neural plasticity changes allow for better memory to occur during sleep. Sleep driven neural plasticity is also evident during brain development and during times when healing is necessary. Given the multiple functions of sleep, it is evident that sleep-related problems should not be ignored.

Unfortunately, the prevalence of sleep disorders following brain injury is notably higher compared to the general population. Many of those that have endured a traumatic brain injury or stroke have difficulty initiating or maintaining sleep. Daytime sleepiness (hypersomnia) and fatigue are frequently reported complaints that are associated with insomnia. Apnea, a common breathing-related sleep disorder, is frequently observed during the chronic brain injury period. Apnea is defined as breathing cessation for fixed periods during sleep and contributes to arousals throughout the night; promoting fragmented sleep.

Sleep follows a particular overnight pattern consisting of repeated sleep cycles. Each cycle is comprised of one rapid eye movement (REM) stage and three non-REM stages. These stages are defined by different brain activity patterns that have been associated with particular physiological and neural plasticity processes.

Studies focused on proper sleep closely examine brain wave activity and body physiology throughout the various sleep stages. Some stages are particularly important for memory, emotional well-being, and cognitive function, and may be compromised by interrupted sleep. The golden standard of evaluating sleep is with an overnight polysomnography study performed by a certified sleep technologist. The technologist places electrodes on the scalp of the patient to record brain activity. Breathing, heart rate, oxygen levels, and limb movement are also recorded during sleep. Results from these recordings are sent to a board-certified sleep medicine physician, who creates a report on the diagnosis and a treatment plan.

Centre for Neuro Skills (CNS) offers a comprehensive multidisciplinary approach to rehabilitation. This entails addressing key factors that impact recovery such as sleep. CNS has opened sleep laboratories within the residential buildings of our programs in Dallas, Texas and Bakersfield, California. All CNS facilities can arrange for a sleep evaluation at one of the labs, based on a patient’s needs and treatment plan. Sleep evaluations of CNS patients allow for the detection of sleep-related issues that are likely to hinder recovery. CNS sleep facilities also provide research opportunities to deepen understanding of sleep-related issues after brain injury. Findings from these studies will help improve treatment and develop new therapeutic strategies.

Next Steps in Worker’s Compensation for Treating Brain Injury

Monday, January 7th

(Note:  This is part two of a two-part series on issues affecting worker’s compensation, brain injury rehabilitation, and appropriate patient care).

The focus in health care today is often on the high cost of care and ensuring access to care through legislative reform.  Change in recent years has focused largely on preventative care and care for common medical conditions.  However, health care after catastrophic injury, such as brain injury, is vastly more complicated.

Few individuals receive the full measure of treatment after brain injury that we now know will bring them to their ultimate recovery and functional status possible – due to uninformed financial restrictions to accessing care.  We have learned that early treatment is better than late treatment, in part, because we can prevent the development of unnecessary complications.  Expert treatment avoids inappropriate medications and surgeries while promoting and optimizing the neurological recovery of function.

“Patient-centered care” must be combined with the notion that “the dollars follow the patient” to enable this maximized recovery and return to the most meaningful and productive, as well as, the least expensive and least restrictive life after brain injury.  Catastrophic brain injury presents unique challenges in comparison to other health conditions. A brain injury can affect multiple organ systems quite randomly, and it is often said that no two patients are the same.  The tremendous variability requires medical treatment that is both comprehensive and expensive.  Furthermore, the cost of treatment has not and will not be reduced to a pill or a surgery.  So, treatment of brain injury requires a regiment of physicians, allied health professionals, case managers, attorneys, and family members, in addition to combination therapies that may also include surgeries and medications. Simply put, there is no medical condition today that is as complicated as brain injury.

Further, care pathways and endpoints of treatment are evident in most medical conditions. Appendicitis, as an example, is a medical condition that can almost always be treated the same way – but this is less the case for brain injury. Each patient recovers differently depending upon a host of variables that include the injury itself, the person’s educational, vocational and social history, the person’s pre-injury medical status, the person’s genetic factors, other system involvement, the timing of emergency treatment, the etiology of the injury, the expertise of the treatment given, the duration of treatment provided. Factors that affect access to treatment are also variables and may include access to insurance, socioeconomic status, patient and family education, and awareness of advocacy by treaters of appropriate treatment options.

What are the cost savings of a full-time comprehensive postacute rehabilitation program?

When treatment duration is determined by patient progress alone, rather than interference by financial restrictions, the data shows us that many patients seem to reach maximized recovery after injury when exposed to intensive and expert medical rehabilitation.  These patients’ outcomes are stable or improving at extended follow-up 5 to 7 years post-injury. Additionally, the financial benefit to an insurance company or society is tremendous – at an average of $1.5 million per person lifetime. Incredibly, some patients’ recoveries have resulted in more than $7 million in lifetime savings. When the expense of these treatments is contrasted to the financial savings alone, the return on investment is truly immense.

Is access to health insurance vital for TBI recovery?

Health insurance is not yet routinely providing all the treatment one would reasonably prescribe in the first year after injury. This is not to say recovery doesn’t extend beyond this point in time; rather it says that this is the most rapid and easily modifiable recovery period. The solution is found in collaborating with the teams of professionals who work to determine how benefits are applied and medical researchers who are on the hunt for the most productive and efficient treatment.  It is doubtful that recovery from brain injury will ever be reduced to a pill or a surgery.  Recovery will remain dependent upon intensive, expensive and well-executed therapies combined with thoughtful use of appropriate medications and surgeries.

Next Steps in Worker’s Compensation for Treating Brain Injury

Monday, November 5th

(Note:  This is part one of a two-part series on issues affecting worker’s compensation, brain injury rehabilitation, and appropriate patient care).

The ultimate goal for the person with a traumatic brain injury (TBI) who participates in a comprehensive postacute rehabilitation program is to return to a productive life after discharge. Many times that involves returning to work. If the person sustained a brain injury in the workplace, he/she enters into the worker’s compensation continuum of care treatment system and is entitled to certain benefits that aim to reduce medical and living costs.

However, the public health care options available do not offer much in the way of treatment for TBI or stroke patients, as those options provide people with a considerably smaller chance at returning to higher productivity.

A collaborative report from the California Traumatic Brain Injury Advisory Board states, “For those significantly or profoundly impacted by this injury, reintegration into the community is overwhelming due, in part, to limited services and insurance coverage for critical medical and social rehabilitation. Moreover, persons with TBI often need help with community reintegration multiple times and at different junctures, because of the complexity of their injury and changes in their medical condition, living arrangement, or caregiving situation. (2010)” 1

Centre for Neuro Skills (CNS) has a legacy of success in the worker’s compensation industry and has helped thousands of people to return to productive lives. Since our inception in 1980, we’ve focused on community integration through an individualized, goal-oriented approach to therapy.

Postacute TBI rehabilitation that incorporates various therapeutic disciplines, including occupational therapy and vocational rehabilitation, can simulate real-world work environments, assisting people in re-learning skills for independent living. Through neurobehavioral therapy and behavior analysis in postacute care, clinicians can individualize the treatment needs of each person – increasing their participation in rehabilitation and community activities. This enables them to practice skills needed for independent living and provides them with a greater chance of a productive life post rehabilitation.

Can the benefits of postacute rehabilitation continue long-term?

A 2016 research study, led by Grace Griesbach, Ph.D., National Director of Clinical Research for CNS, investigated whether benefits of postacute rehabilitation for TBI are sustained after discharge from a full time comprehensive postacute rehabilitation program.

In the project, moderately to severely injured people with TBI who participated in a full-time comprehensive postacute rehabilitation program were interviewed one year after discharge. “In the analysis of employed and unemployed subjects, it was revealed that 43.75% had an occupation of equal position to that before an injury. Those that were working also showed positive levels for social participation, cognitive function, and social satisfaction,” the paper states. Additional analysis revealed that as many as 66% returned to some form of paid employment.

These findings support the durable outcome and beneficial effects of postacute TBI rehabilitation long-term, it noted, “concluding that individuals with a good rehabilitation outcome are more likely to regain their former occupation and quality of life.” 2

Do these findings also conclude that access to health insurance is vital for TBI recovery? I’ll address that topic in part two of this blog, Next Steps in Worker’s Compensation for Treating Brain Injury, which explores cost savings, reporting, data collection, and public health care options that are currently available.


  1. California Traumatic Brain Injury Advisory Board, Advancing California’s Traumatic Brain Injury Service System, Department of Mental Health, May 2010.
  2. Charan Singh, Sarah Finley, Sharon Umphress, Craig Persel, Grace S. Griesbach, Outcome After Post-Acute Rehabilitation in Traumatic Brain Injury Patients, Vol. 97, Issue 10, e100, Archives of Physical Medicine and Rehabilitation, October 2016. Accessed at:

The Importance of Length of Stay in Brain Injury Rehabilitation

Monday, July 16th

The usual course of medical interventions involves determining a diagnosis and an appropriate, relevant treatment.  Once a determination is made, treatment options can be considered.  Treatment options are developed over time and often, though not always, have a rigorous science behind them that serves to guide the implementation of that treatment.  For example, an infection might be treated with one of several different antibiotics.  The antibiotic selected must be the most potent drug for the bacterial infection – and it must be administered in a particular dose, a specific number of times per day, for a specific number of days.  Additionally, a drug may come with advisories to avoid certain circumstances or other medications – for instance, a drug can cause increased sensitivity to the sun, and grapefruit juice can interfere with certain types of medication. Finally, few medicines are universally effective for all patients, and most can result in undesirable side effects.

There are very few drugs that have been explicitly developed for traumatic brain injury.  In fact, rehabilitation is the most effective treatment known for reducing disability following traumatic brain injury.  Little has been done to understand the dosing parameters similar to the manner in which medications are prescribed to represent the best use of rehabilitation.

In a research project completed at CNS, we were able to review the response to rehabilitation in nearly 400 people with traumatic brain injury.  We found that response to treatment was different depending upon the severity of injury and time since the injury.  People with mild to moderate levels of disability (who were more than one year since injury) showed improvements due to rehabilitation when treatment extended to 90 days or more.  However, people with severe disability (who were more than one year since injury) required at least 180 days to show improvements.

People with either moderate or severe disability (who were less than one year since injury) showed improvement after 90 days of treatment – while those with severe disability showed even further improvement after 180 days of treatment.

These findings are important as they describe how people with different levels of disability also respond to a standard treatment intervention differently – both related to the severity of their disability and the elapsed time since their injury.  Expectations for how long a person should be treated, what rehabilitation efforts should be, as well as cost, must be similarly adjusted.  A “one size fits all” approach cannot be expected to result in a person achieving their highest level of recovery after a brain injury.

These findings argue for individualized dosing of rehabilitation following traumatic brain injury and, consequently, have implications for how payers and providers view application of rehabilitation following traumatic brain injury.