Amanda Wilde (Host): For survivors of traumatic brain injuries, holistic rehabilitation can make a profound difference. The THRIVE Program helps patients to adjust to traumatic brain injury by gaining new knowledge and skills, as well as providing support and resources. We'll talk about the THRIVE Program and its benefits with its creator, Clinical Neuropsychologist, Dr. Crystal Fullen. Dr. Fullen is the Director of the THRIVE Program at the University of Arkansas for Medical Sciences. This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. I'm Amanda Wilde. Dr. Fullen, welcome.

Chrystal Fullen, Psy.D.: Hi, Amanda. Thank you for having me today.

Host: I'm particularly interested in this workshop. I've had a head injury, I know many people who have, but I don't think that qualifies as a traumatic brain injury, even though it took like a year to recover from. So can you explain exactly what a TBI or traumatic brain injury is?

Chrystal Fullen, Psy.D.: There are lots of different types of head injuries, so it's kind of an umbrella term. And sometimes a head injury and a TBI are also used interchangeably. Essentially, with a traumatic brain injury, what we're talking about is when there is a trauma to the brain. And the best, simplest way to think about that is there's a blow to the brain from an external force.

So typically this happens in two ways. You can have an open head injury or a closed head injury. When you have an open head injury, that's when something is actually piercing the skull and entering the brain. So this would be a TBI from something like a gunshot wound or a stabbing. You can also have a TBI from something like a closed head injury, and that is when you have something like a fall, and your head hits against something or an object is hit against the outside of the head. Or even someone's in a car accident and that velocity of going really fast and then suddenly stopping that exceeds the capabilities of the brain inside the skull. And what happens is that blow, that force, changes the way the brain works. So that is really the nutshell description of TBI.

Host: So, when this has happened to someone, whether they've had an open or closed head injury, are there common symptoms that let us know that a traumatic brain injury has happened?

Chrystal Fullen, Psy.D.: Yeah, there are a couple of different ways that people sort of diagnose traumatic brain injury. The first one being, of course, that there's like obvious visible signs of trauma to the head. Of course, they can also use things like a CT or an MRI to look at the brain to see if there's any bleeding or swelling or shifting that can also provide evidence to that.

And then also people have other signs and symptoms, right? They can become unconscious, lose consciousness. They can be altered to the degree that they might not really know where they are or what's happening or, when the time is, they can be disoriented.

And so those are some of those early signs that let us know that a TBI has happened. Down the road, with TBI, people tend to have symptoms that map onto the type of injury they had. So, someone with a closed head injury might have a different symptom experience than someone with an open head injury.

And there are also different severities. So you can have a mild traumatic brain injury, which is actually, our word for concussion. So even a concussion qualifies as a brain injury. When you look at symptoms across the board, there are some characteristics that can be shared. Typically, people will have changes in things like their cognitive abilities, so their thinking skills.

 So, things like attention can be a little bit more tricky after a traumatic brain injury. Things like processing speeds, sometimes the ability for someone to kind of quickly work through information can change. And then a lot of times people will struggle with psychological symptoms too. Can be a little bit more difficult to control and regulate mood, and people might generally just experience more anxiety or low mood as associated with like the adjustment period coming out of that head injury as well.

Host: And then there are different levels of severity, I assume, how do you track that?

Chrystal Fullen, Psy.D.: The way that that's tracked is usually, it starts at the scene. The EMS is called to the scene of a car accident, right? They get there, they start doing assessments right away that let people know how alert someone is, how much they're able to track, if they're able to follow commands, which gives us insight into how severe that brain injury is.

Also, with things like CT and MRI, those are other ways we can determine severity. So, there are a couple of different measures that are used all together to tell us, is this mild, is this moderate, or is this severe? And when you have a milder injury, the expectation for your recovery is far greater. We expect people to really fully recover from mild traumatic brain injuries, as much as possible. Sometimes people don't, but we really expect and hope that they do. Their recovery trajectory is a lot quicker than those with moderate to severe head injury is where we really feel like, know from research that people will struggle with symptoms for years down the line, and they may not get back to their pre injury level.

Host: What do you see in the statistics in Arkansas as far as number of traumatic brain injuries?

Chrystal Fullen, Psy.D.: In the state of Arkansas we have some data. We have at UAMS the Department of Digital Health and Innovation and they are responsible for the Brain Injury Program and those folks run a TBI registry for the state. And between the years of 2013 to 2023, so that 10 year span, we had 4,156 TBIs recorded in the hospitals in the state of Arkansas. So, coming in, meeting criteria, for a moderate to severe traumatic brain injury.

So this doesn't include anyone with a mild traumatic brain injury. But for those moderate to severes, we have a little over 4,000 in that 10 year period. And of those folks that came in with traumatic brain injuries, 69 percent of them survived their injury and are now still living in Arkansas, potentially with some ongoing symptoms because as I said, with moderate to severe TBI, people can continue to struggle with some of those symptoms years after their injury.

Host: And are there unique issues with TBIs associated with living in Arkansas?

Chrystal Fullen, Psy.D.: Yeah, I think because Arkansas is more of a rural state, it can make it really difficult for people to get the help that they need. Sometimes people live far from a major city with lots of medical resources. Transport can be difficult. Sometimes people don't have great insurance. So even when they get to a doctor, maybe their insurance doesn't cover the services that they need or it only covers a limited amount of rehabilitation. And then two, unfortunately, we don't really have enough providers in the state that specialize in traumatic brain injury as well. So even when people do get to doctors, they might not necessarily get all the services that they need, that that doctor wants to refer them to, because they're just not available. And if they are available, they can also be heavily waitlisted.

Host: So this must be what gave you the idea to build a free program, which is what THRIVE is. You mentioned cost, you mentioned living rurally and lack of specialists. What are some of the solutions needed to address those issues?

Chrystal Fullen, Psy.D.: Really to have programming as much as possible that is available to people for free or low cost, which is very difficult to do because there are a lot of resources that are used to create any kind of medical service. And then of course, the other big thing is trying to provide services that can reach more people in an efficient way.

So, how can we do something, virtually through telemedicine, for example, that we can also do in office? So, also making those resources available to people who can't get to major medical centers. And that's one of the two biggest things about THRIVE that we love is that you don't need insurance to come and we rotate out the groups because THRIVE is a group intervention.

 So we'll always do one in person, one online, one in person, one online, go back and forth that way so that as many people in the state who need THRIVE can access it.

Host: So, reaching as many folks as possible?

Chrystal Fullen, Psy.D.: Yes.

Host: And is thrive really for people with moderate to severe head injuries versus the more mild outcomes?

Chrystal Fullen, Psy.D.: Yes, absolutely. We do that because those are the folks who we expect to have persistent change that might not fully remit. Whereas with mild, we're hoping that those changes will remit and people will get all the way better essentially. Sometimes with mild traumatic brain injury, you know, people do continue to have problems and difficulties that can be treated, but the treatment sometimes looks a little bit different versus that of mild to severe traumatic brain injury.

Host: So let's talk a little bit more about the workshop. What is THRIVE in terms of what will happen to a participant there?

Chrystal Fullen, Psy.D.: Participants start THRIVE by undergoing a really quick telephone intake with one of the social workers through the Brain Injury Program, and then on the first day, it's really about getting comfortable with the main facilitators of the group, who are normally a neuropsychology team made up of me and typically one of our residents, and then getting familiar with the group.

We have anywhere between five to 15 participants per group. We tend to have smaller numbers of participants in our in-person group, and then we can almost handle more participants, in an online virtual platform. And we actually try to do that too, because of how many people can't get to Little Rock for the actual group.

And then THRIVE each week goes over a topic that tends to be something that gets in the way of full recovery. So we work on cognition with cognitive rehabilitation strategies. We work on adjustment to injury and emotional wellness using psychological strategies. We work on things like family, relationships, making sure people have enough support.

We do a lot of work to link people up to resources and not every week, but I think, 10 out of the 14 weeks of THRIVE, we have an expert from the community come to the group to share how that discipline, can help with recovery in traumatic brain injury. So, for example, we'll have folks come in from sleep medicine.

We'll have the doctors come in from physical medicine and rehabilitation. We'll have speech therapists, physical therapists, occupational therapists. Last night we had our THRIVE meeting and we had someone coming in from the Arkansas Rehab group to share how the state can help people with vocational rehabilitation services and getting them back to work, if that is something that they're inclined to do.

So, we really try to bring the resources to the group and help maximize referrals out of THRIVE back into the community as well.

Host: I think that's a great description of holistic medicine. You're addressing the emotional, the physical, including rehabilitation and family connections and just considering the whole picture and the whole person. What kind of outcomes have you seen associated with THRIVE?

Chrystal Fullen, Psy.D.: One of the best outcomes that we have seen is that we've increased folks who have been through the group, through that treatment, we've increased their ability to return to the community in different ways. So when we think about return to the community in the TBI world, we're thinking about how can we get people back to the things that they love doing, that they want to do, whether that's work, connecting with their families, getting back to church, volunteering, anything that fits their current ability level, and helps them meet their goals and feel fulfilled. Because a lot of times after a traumatic brain injury, especially more severe, people aren't working. They can't go back to their previous jobs. They're trying to find something new, but nothing fits. They're looking for resources.

They can't find them. It can be a very, very messy dynamic. What THRIVE really aims to do is increase that participation, increase people getting back to the community, and we've seen that. So people will volunteer more. And one of the things we love about THRIVE, is we really try to embody that.

 So, we have also made volunteering available through the THRIVE workshop. So, if you participate in the THRIVE workshop and finish, you can also volunteer to be a peer support mentor so someone with a brain injury who's gone through the program, who is trying new things, who is working toward their goals; they can help mentor folks with newer traumatic brain injuries who are joining THRIVE to help facilitate connection, community, guide with goal setting, and really just motivate and mentor.

Host: Yeah, getting together with peers just is so important and people who are further along in the process understand in a way that no one else can and your results are really so encouraging because quality of life really is everything. What do you see in the future for the THRIVE program?

Chrystal Fullen, Psy.D.: Yeah, so the biggest change that's upcoming with THRIVE is we'll sometimes do nights when we have family who are invited to join, because it's really just patient centered as a group intervention. But every now and again, we'll have a night where, a caregiver, family member, friend can come and join the participant at the group, learn more about TBI, really kind of share their experiences and we can help fill any knowledge gaps and provide support and strategies, helpful strategies to promote that wellness as well in the homes. And we have noticed that there has been just so many folks who want to learn more, want to be more helpful to their loved one with a brain injury and we have as a result, started working on designing a caregiving group that is not a support group, but also like THRIVE, an intervention that allows people to really learn from the specialists who are so important in TBI.

All of the allied health teams, PT, OT, speech, PM& R, neuropsychology. I'm probably forgetting a million people, but essentially bringing those folks to the caregivers as well and creating a unique workshop where they can kind of share some of the things that have been difficult for them, and then for people with really, really significant changes following their TBI, inability to maybe express themselves with language, maybe difficult behavioral symptoms, that we can kind of work on those with evidence-based strategies that they can then employ in the home, as well to kind of improve quality of life for like the whole family unit. So that, group is starting February. One of my residents, Dr. Docherty, he and I are working on developing that out, right now. So we're really excited about bringing that group. We'll run it once annually virtually for the state of Arkansas so that we can really help the caregivers as well.

Host: It must be so rewarding for you to see the success and now build upon the success of the THRIVE Program. Perhaps your research and the program itself will serve as a model for others addressing traumatic brain injury.

Chrystal Fullen, Psy.D.: Yeah, thank you. Amanda. You know, I'm super humbled by it honestly. I think that the folks with brain injury work so hard to get back to the lives that are meaningful for them. That really motivates me. And then I couldn't have done any of this without the IDHI's Brain Injury Program. They have been so amazing.

They actually have a grant that allows us to give this program to the community for free. And they just are so supportive and let me try all of my ideas and some of them have worked and THRIVE is one of them. So I'm just grateful, and I just want to keep doing what we're doing because it's really, it means a lot when people come and they tell us, Hey, you know, this helped me get back to church. This helped me get back to work. This helped me get back to school. I mean, those things are huge.

Host: It is huge. It's everything. Thank you for sharing the THRIVE program, and I'll look forward to seeing it expand over time.

Chrystal Fullen, Psy.D.: Thank you so much, Amanda.

Host: That was Clinical Neuropsychologist Dr. Crystal Fullen, Creator and Director of the THRIVE program at the University of Arkansas for Medical Sciences. For more information, email Diane Campbell at dcampbell4.@uams.edu. If you found this podcast helpful, please share it on your social channels and check out the entire podcast library for other topics of interest.

This is UAMS Health Talk, a podcast from the University of Arkansas for Medical Sciences. Thanks for listening.