Penn PM&R’s Traumatic Brain Injury (TBI) Research Program

Research Highlights

Penn PM&R's Traumatic Brain Injury (TBI) Research Program recruited Randel Swanson II, DO, PhD. as its lead physiatrist, in close collaboration with Douglas H. Smith, MD, director of Penn Neurosurgery's Center for Brain Injury and Repair (CBIR). Dr. Swanson served in the United States Marine Corp between 1997 and 2001, and the United States Army National Guard during 2001 and 2002, obtaining the rank of sergeant. He was trained medically at Rowan University School of Osteopathic Medicine in Stratford, NJ, and received his PhD in cell and molecular biology at the Rutgers Graduate School of Biomedical Sciences in Stratford, NJ. He participated in PM&R residency training at the Temple University School of Medicine in Philadelphia. He recently was funded by the National Institutes of Health's Rehabilitation Medicine Scientist Training Program.

The focus of his current research under the Center for Brain Injury Recovery and Repair entails development of novel blood-based diagnostic and prognostic biomarkers for TBI. Dr. Swanson is the co-investigator for the Pennsylvania Consortium on Traumatic Brain Injury (PACT) grant, a multi-institutional research program (Penn, Children's Hospital of Philadelphia, MossRehab, and University of Pittsburgh) under the leadership of Dr. Douglas Smith, the principle investigator. This research program aims to advance TBI diagnostic strategies across all severities of TBI. Clinically, Dr. Swanson is a key member of the Polytrauma Network Site for Veterans Integrated Network-4 based at the Corporal Michael J. Crescenz Veterans Affairs Medical Center in Philadelphia. This program has provided rehabilitation care for several thousand veterans who have TBIs over the past 12 years.

Recently, this research program was joined by Stephen Hampton, MD who has been recruited as a neurorehabilitation faculty member. Under the Center for Brain Injury Repair, Drs. Swanson and Hampton, along with Veterans Affairs/Philadelphia Polytrauma Neuropsychologist, Rosette Biester, PhD, are taking the lead in the clinical assessment and rehabilitation of a cohort of U.S. government personnel and their family members who were stationed in Havana, Cuba during late 2016 and 2017, and who are presenting with neurological symptoms and signs resembling acquired brain injury. This clinical presentation is hypothesized to represent a novel form of acquired brain injury. The underlying mechanism of action for this syndrome is thought to be related to exposure to an uncharacterized energy source. The cluster of neurological manifestations includes cognitive/behavioral (memory problems, difficulty concentrating, executive dysfunction, hyperirritability) oculomotor (light sensitivity, convergence insufficiency, abnormal smooth pursuits, saccadic dysfunction) and central and peripheral vestibular impairments (balance problems, tinnitus, dizziness/vertigo, nausea) as well as hearing loss, insomnia and headaches. This is hypothesized to be a novel clinical entity suggestive of a widespread "brain network disorder." Other collaborators on this project include three therapists who are employed by Good Shepherd Penn Partners (Diana Duda, PT, DPT, Mary-Fran Madden, OTR/L, and Darlene Mancini, CCC-SLP.), and Michael Galloway, OD (Optometry).

The preliminary findings of this project have been recently published in JAMA with Dr. Swanson and Dr. Hampton as the first and second authors, respectively:

Swanson, R.L., Hampton, S., Green-McKenzie, J., Diaz-Arrasta, R., Grady, S., Verma, R., Biester, R., Duda, D., Wolf, R.L., Smith, D.H. Neurological manisfestations among US government personnel reporting directional audible and sensory phenomena in Havana, Cuba. JAMA.dol:10.100/jama.2018.1742, published on line February 15, 2018.

This clinical and research team examined 11 women and 10 men (21 of the 24 individuals with suspected exposure) who had an average age of 43, and whose assessments were initiated on an average of 203 days after initial onset of symptoms. For 18 of these 21 individuals, "there were reports of hearing a novel, localized sound at the onset of symptoms in their hotel rooms or homes" in Havana. Additionally, the individual reports of these sounds often were described as "directional, intensely loud, and with pure and sustained tonality" — "buzzing", "grinding metal", "piercing squeals", "humming", as well as "associated with pressurelike sensory or vibratory stimuli", much akin to "air 'baffling' inside a moving car with the windows partially rolled down." These sounds were reported to have lasted between several seconds to up to more than 30 minutes. The range of reported symptom experience was from immediate for most of the affected individuals to several weeks after exposure to the sounds. Given that audible stimuli are not known to be a mechanism of brain injury, no firm conclusions can be drawn as to how the reported sounds are related to the manifestation of symptoms. The hypothesis that a "sonic weapon" was causal is disputed. Rather, the reported sounds are hypothesized to be a byproduct of an unknown cause, such as the crack of a gunshot.

Furthermore, brain magnetic resonance imaging was unremarkable among those assessed in this study. The clinical and research team did not believe that malingering underpinned such a manifestation of neurological symptoms, perhaps suggestive of "collective delusional disorders", and some of the cognitive tests used during the assessments of these individuals were robust to preclude conscious or unconscious factors from influencing cognitive performance.

According to the JAMA publication, 14 of the 21 individuals were initially held from work while receiving comprehensive outpatient neurorehabilitation, with seven of the 14 able to enter a graduated return-to-work program at the time of the publication, thus persisting disability is inferred. Three of these individuals who had moderate to severe sensorineural hearing loss have been fitted with hearing aides. Many of the individuals who had cognitive impairments have responded well to cognitive remediation therapies provided by occupational and speech therapists. Moreover, physical therapy to improve balance and other vestibular problems, and neuro-optometric vision therapy to address visual disturbances have also reported to have been beneficial.