Better-Educated People Recover Better From Brain Injuries

Better-educated people appear to be significantly more likely to recover from a moderate to severe traumatic brain injury (TBI), suggesting that a brain’s “cognitive reserve” may play a role in helping people get back to their previous lives, new Johns Hopkins research shows.

The researchers, reporting in the journal Neurology, found that those with the equivalent of at least a college education are seven times more likely than those who didn’t finish high school to be disability-free one year after a TBI serious enough to warrant inpatient time in a hospital and rehabilitation facility.

The findings, while new among TBI investigators, mirror those in Alzheimer’s disease research, in which higher educational attainment — believed to be an indicator of a more active, or more effective, use of the brain’s “muscles” and therefore its cognitive reserve — has been linked to slower progression of dementia.

“After this type of brain injury, some patients experience lifelong disability, while others with very similar damage achieve a full recovery,” says study leader Eric B. Schneider, Ph.D., an epidemiologist at the Johns Hopkins University School of Medicine’s Center for Surgical Trials and Outcomes Research. “Our work suggests that cognitive reserve — the brain’s ability to be resilient in the face of insult or injury — could account for the difference.”

Schneider conducted the research in conjunction with Robert D. Stevens. M.D., a neuro-intensive care physician with Johns Hopkins’ Department of Anesthesiology and Critical Care Medicine.

Outcome of 769 TBI patients

For the study, the researchers studied 769 patients enrolled in the TBI Model Systems database, an ongoing multi-center cohort of patients funded by the National Institute on Disability and Rehabilitation Research. The patients had been hospitalized with a moderate to severe TBI and subsequently admitted to a rehabilitation facility.

Of the 769 patients, 219 — or 27.8 percent — were free of any detectable disability one year after their injury. Twenty-three patients who didn’t complete high school — 9.7 percent of those at that education level — recovered, while 136 patients with between 12 and 15 years of schooling — 30.8 percent of those at that educational level — did. Nearly 40 percent of patients — 76 of the 194 — who had 16 or more years of education fully recovered.

Schneider says researchers don’t currently understand the biological mechanisms that might account for the link between years of schooling and improved recovery.

“People with increased cognitive reserve capabilities may actually heal in a different way that allows them to return to their pre-injury function and/or they may be able to better adapt and form new pathways in their brains to compensate for the injury,” Schneider says. “Further studies are needed to not only find out, but also to use that knowledge to help people with less cognitive reserve.”

Meanwhile, he says, “What we learned may point to the potential value of continuing to educate yourself and engage in cognitively intensive activities. Just as we try to keep our bodies strong in order to help us recover when we are ill, we need to keep the brain in the best shape it can be.”

Adds Stevens: “Understanding the underpinnings of cognitive reserve in terms of brain biology could generate ideas on how to enhance recovery from brain injury.”

Motivation may play a role

Dr. Howard Derman, a neurologist and co-director of the Methodist Concussion Center in Houston, called the new research “interesting” but said other unexamined factors — such as patient motivation — may also account for the discrepancy in recovery between less-educated and more-educated brain injury patients.

“I’m not refuting the observation, I’m just saying that in my mind, [the researchers] can’t just say it’s because these people are using [more] of their brain before being injured than the others,” Derman said. “Cognitive reserve might be one factor, but there are other issues that are ongoing that are equally persuasive as to why those people might do better.”
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