A crucial part of Gabby Giffords's intensive brain injury rehabilitation at The Institute for Rehabilitation and Research (TIRR) in Houston involves serial assessments and counsel by a neuropsychologist, a superspecialized breed of clinician many people know little about.
Rehabilitation teams count count on expert neuropsychologists to administer formal standardized tests and analyze those results in light of clinical data. The best neuropsychological reports are veritable Rosetta stones.
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Last week I had the opportunity to chat with Mark Sherer, TIRR's chief neuropsychologist. Now that Giffords is two weeks into the program, it's very likely that Dr. Sherer himself or one of his colleagues at TIRR has already conducted Giffords' initial neuropsychological assessment.
If Giffords and her family do indeed have Dr. Sherer's counsel at this time (naturally he cannot say), they're benefiting from one of the top minds in the field of brain injury medicine today. An internationally recognized master at describing the states of confusion that characterize severe brain injuries, Sherer's research shows clinicians how we can divine meaning and importance out of the cacophony of signals our most troubled patients give us.
Football might have had something to do with Sherer deciding to devote his career to the treatment and study of brain injury by way of psychology. Not the game's propensity for generating concussions, as you might expect, rather the culture that surrounds Dixie's Crimson Tide. Sherer grew up in the northwestern Alabama town of Tuscumbia. He lived in the small town until the day he moved away for graduate school, going on to earn his Ph.D. at the University of Alabama.
"I went to my first football game in the fall of 1976 at Legion Field in Birmingham. There were 85,000 people there, which was ten times as many people who lived in the town I grew up in," Sherer says, the amazement in his voice still there. "Bear Bryant comes out on the field and the people just go crazy. It made quite an impression on me."
"There should be a whole field of psychology about the phenomenon. People value themselves because of their affiliation with people they never even met. It interests me still."
Today Sherer is a leader in a science at the interface of human behavior and neuroscience. He brings to bear the field of psychology's understanding of behavior, emotional adjustment, and human motivation to the clinical interpretation of brain dysfunction.
"People usually don't just want to know how impaired someone's memory is," Sherer points out. "They want to know how that memory impairment affects their world and their ability to function in it, and their ability to adjust to the situation that they find themselves in."
Most people, if they are aware of neuropsychology, think about the post-mortemesque science of detailing impairments after catastrophic injuries for legal and life planning purposes. Admittedly my favorite bit of neuropsychological jujitsu is along this line: smoking out the malingerers. Lawyers love it, and as a clinician who has been subjected to a case, I do too. People do fake brain injuries, for reasons both known and unknown to themselves. Most will meet their match in an adept neuropsychologist's examining room.
But when it comes to brain injury, after the car crash, the obvious head wound, the CT and the MRI, maybe even the neurosurgery, diagnosis is trivial. What occupies most neuropsychologists are the complexities of treatment, of coping with life given a diverse array of cognitive impairments that vary in the way they interact with the underlying psychology and the surrounding environment.
Neuropsychologists help patients and their families problem solve practical solutions as life goes on.
No neuropsychological examination, no matter how many hours it takes, no matter how many test batteries are administered, no matter the sheer cerebral processing power harnessed during its interpretation, is an autopsy. It's never the final word.
Research shows that the early neurocognitive tests given to patients like Giffords are highly predictive of future outcomes, however Sherer estimates that other variables can make the best prognosis 30 to 40 percent off the mark.
"The patient's memory continues to evolve, the support system around them continues to evolve. All of those things complicate making a prediction. That's why we give lots of caveats when we make those recommendations," he says.
When it comes to returning to work, he adds, "we don't know how the committed the family may be to making the job work for that person no matter what."
The ineffable plays a key role in human recovery from any neurological impairment.
In precisely the right setting, like the most competent Fortune 100 CEO, any of us can overcome limitations in our own natural intelligence and talents to do the extraordinary. That superconductor effect, which the highest functioning among us use daily to thrive in the most demanding positions, simply becomes more magnified if we suffer a severe brain injury.
Now we rely on our network simply to achieve grace in ordinary living. It's readily apparent when our supports crumble.
Last year, Sherer and his team at TIRR Memorial Hermann's Brain Injury Research Center added a little more to the body of research that consistently tells us how strong families contribute to the best possible recovery from brain injury.
In cases of severe TBI like Rep. Giffords's, the social support system her husband has at his disposal, which appears to be among the finest ever assembled, bodes well for full future social reintegration, as does his own emotional health and their track record together as a highly functioning family prior to this incident.
There's little doubt families are neurostimulating agents themselves, no prescription required. I and most of my fellow rehabilitation physicians encourage family involvement in therapy as possible, and our rehab teams often include psychologists who make it a mission to support family members. They're at risk for burnout, grief and reactive depression and need coping strategies themselves.
Last week Giffords's husband, astronaut Mark Kelly, announced that he will fly his previously scheduled April mission aboard space shuttle Endeavor. Though guided by what he knew his wife wanted, this must have been an extremely difficult decision. It's safe to say theirs is a wholly unique situation in the history of brain injury medicine, and the counsel that the brain injury specialists at TIRR should have offered Captain Kelly isn't at all clear.
Faced with a similar decision, and knowing what I do about the value of a good neuropsychologist, I would have sought out Dr. Mark Sherer's advice. I hope Kelly got to do so.