Dr. Bruno Giordani is a professor in the Michigan Medicine departments of Psychiatry, Neurology, and Psychology, as well as the U-M School of Nursing. He is the associate director of the Michigan Alzheimer’s Disease Research Center, the chief psychologist for the Department of Psychiatry, and the senior director of the Mary A. Rackham Institute. Dr. Giordani’s research includes neuropsychological, electrophysiological, and imaging approaches in the assessment of cognitive change, emphasizing cross-cultural and low-resource settings and computer-based cognitive assessment and training. He is a longtime fellow in two Divisions of the American Psychological Association—Society of Clinical Psychology (Division 12) and Neuropsychology (Division 40).
We sat down with Dr. Giordani to discuss his concussion work and interests.
Michigan Concussion Center: Talk about your career path. How did you become interested in neuropsychology?
Dr. Bruno Giordani: I started in graduate school studying psychophysiology at the University of Virginia. I was examining how the cardiovascular and other different body systems respond to social or even physical (e.g., cold pressor) challenges My curiosity was piqued as to how different body systems can respond in different ways, and I switched over to neuropsychology to better understand how cognition and brain systems affect a person’s ability to respond to challenges in their environment. Eventually, I just got lost in neuropsychology and brain/behavior relationships.
After graduate school, I did an internship in clinical psychology at the University of Virginia, with much time spent in our Epilepsy Center and EEG laboratory. After that, I got a postdoc position in neuropsychology at the University of Michigan. Here, I became more and more interested in brain changes from injury and aging. I was a postdoc during the start of the Michigan Alzheimer’s Disease Research Center and the Positron Emission Tomography (PET) center, so there was lots to do. After my postdoc, I was recruited to Mount Sinai in New York to their Aging and Alzheimer’s program and stayed there until returning to Michigan.
MCC: When did you realize you were interested in concussion?
BG: I gained experience in neuropsychology while in graduate school at one of the first national epilepsy centers, which in turn landed me a job in a neurosurgery department at the University of Virginia through my internship time. The department was particularly interested in traumatic brain injuries (TBI), so I saw many patients from mild to severe TBI. We routed all concussion or head injury cases to the UVA Medical Center, as there were no other hospitals or primary care centers in the outlying areas. During this time in the 1980s, no one considered mild TBI or concussion an issue to discuss. We were able to publish a series of papers (perhaps the first) on mild TBI, highlighting the issues involved and the clear problems we saw for some persons, especially those without strong support programs at home or work. Three months after injury, we still had about a third of persons previously employed who had not returned to work. People simply didn’t believe this. This led to another paper on moderate TBI that found the return-to-work predictors were dramatically different from those in mild head injuries. The predictors in mild TBI were primarily age, education, support factors, and socio-economic status. We discovered that socio-economic factors played a key role in return-to-work. Our moderate and severe studies showed the key role that injury-related factors played. We looked at other populations to study, including boxing and hockey and so I left Virginia with an idea that I could bring this work to Michigan, but it just didn’t work out. At the time there was just no interest here in bringing these issues forward. That is quite a bit different, now.
MCC: What is the role of a neuropsychologist in managing concussion, and where does one fit within the areas of concussion prevention, management, and treatment?
BG: Simply put, the role of the neuropsychologist is to give a good picture of how a patient is doing cognitively and academically at the time of the assessment and then to provide expectations for what may happen over time and to help provide options for care and planning in return to athletic activities, school, or work. The role of the clinical neuropsychologist is not just to administer computer or paper-and-pencil measures as “laboratory values.” The interpretation and assistance piece is important. There is a difference between the computerized tests that may be given as part of an evaluation at the time of concussion and return to play with how that relates to academic success. We are dealing with student athletes and we have to pay as much or more attention to the return to academics as everything else. We help develop a model for how someone may have looked before the injury and work that information into better understanding of their recovery. Our tests can help do that, clearly. Behavioral and personality issues and motivation for academics, these all can be affected by concussion. Saying that concussion explains it all is just not sufficient. All the risk factors, such as past injury, past educational experiences, learning or attention difficulties, or mood and motivation, they all have to be considered.
I think Michigan NeuroSport has a good model of how they see concussion cases. They look for initial cognitive complaints but don’t assume the patient looks fine. A lot of patients get neuropsych evaluations, and in some cases, it’s a more complex issue due to pre-existing learning and attention deficits or other issues involving return to play or return to academics. It’s important to have a good cognitive assessment to predict what a return-to-school plan is going to look like and to keep monitoring for changes over time. I have seen attention disorder issues as a long term follow-up problem after students return to school. Good discussions and coordination with the student, their family, and their schools are important.
MCC: What other kinds of concussion research have you done and are interested in?
BG: I have been doing some TBI work in Africa with some of my past trainees there. In Uganda, for example, folks ride on boda bodas, our equivalent of a cab, except they are motorcycles, and they are driven between and around traffic all day and all night. In the evenings and nights, the emergency departments are full of head injury and trauma cases from boda accidents. We have done an initial trial follow up of patients who have been in the emergency room who have been treated and discharged after mild or moderate injuries, and who continue to have cognitive difficulties well into the future. This is really interesting and important work, but funding is hard, especially at this time.
MCC: There is data suggesting a link between concussions and CTE, which some believe is a form of Alzheimer’s. Can you talk about the link between the two?
BG: Alzheimer’s is dictated by localized deposits of amyloid in specific areas of the brain. Certainly there is also a downline factor of tau abnormalities in those areas as the disease progresses, however. In CTE, you don’t see that same pattern—Tau deposits, often around blood vessels, are the key. So you can say they are linked by a decline in function and effects on the ability to complete basic adaptive living tasks, but there is a heavy overlay of behavioral deficits often in CTE that doesn’t appear early in most forms of true Alzheimer’s (though there are some types of dementia that show that early in the course). Now, given that fact amyloid appears in the brain maybe 20 or more years before there are any symptoms in Alzheimer’s and that tau is an integral part in the appearance of symptoms in Alzheimer’s, it makes you wonder about certain individuals being far higher at risk for combined CTE and Alzheimer’s disease. It’s possible that if you followed patients who had the brain pattern of CTE on tau scanning, you might see the development of Alzheimer’s earlier, but that hasn’t been done yet.
MCC: What other research would you like to tell us about?
BG: My aging and dementia work, here, has led to a number of interesting things lately, including a very large grant in collaboration with other colleagues here and at U-M Dearborn Engineering. Given that driving is an everyday complex activity with lots of attention and problem solving needed, we are looking at whether we can use everyday driving to warn us of the earliest signs of cognitive decline. This work involves a lot, with a simulator, fixed course, longer naturalistic driving, and lots of information collected from the car and from high tech ways of collecting physiological data from the driver. Drivers’ cars are fully outfitted with monitoring systems, as well.
I also spend a fair amount of time (during non-COVID times) doing research overseas in different parts of Sub-Saharan Africa. This work is a real passion and interest of mine. We have also been able to take part in quite a bit of resource building there, to the point that our African colleagues are turning out more grants than we are. I have primarily worked with children in Africa to do something different than aging, here. We first looked longitudinally at cognitive and behavioral issues in children with malaria and HIV or exposed to HIV. We developed our computer cognitive-based training paradigms on what areas of cognitive and behavioral deficits we saw in both of these patient groups, especially as they tried to return to school. We have had good luck with our computer training paradigms, showing changes up to a year following training in terms of cognitive and behavioral measures. It is interesting that only recently, I have managed to bring my aging research to the African side, where we are now looking at computer based training and learning paradigms that hopefully will assist older HIV patients at risk for further cognitive decline.
MCC: What do you see as the current barrier towards the next level of understanding of concussion?
BG: I think the variability in concussions. The question is, how does the work people do in labs with accelerometers and helmets translate to the real world where people fall differently? A neurosurgeon by the name of Tom Gennarelli talked about seeing two patients have essentially the same injury, same type of fall, outside of his office, but the two individuals had dramatically different outcomes from their concussions (though their jobs were similar). People are built differently and get hit differently, and that is why imaging may be so important. The utility of more complex imaging such as Diffusion Tensor Imaging (DTI) that is now used more extensively for head injury and the use of other types of imaging and blood-based biomarkers is really interesting. It will be exciting to see how the Concussion Center will leverage these approaches.
MCC: What excites you about being a member of the Concussion Center?
BG: It’s amazing to me that there is a center here where people are willing to talk about real areas of concern and talk about the research that will direct us towards solutions. The work Steve [Broglio, director of the Michigan Concussion Center] and others here have done in looking at lingering effects of concussion is really interesting. Our campus is growing rapidly with multiple centers and institutes all begging to look at different aspects of the same problem or how different problems share issues. The Concussion Center, hopefully, will explore the interactions they may have. For example, there is an opportunity, here, to join a number of other centers on campus studying aging with impressive databases of patient health information, including those with or without cognitive concerns. There might be a real way to move concussion and head injury history into these studies or just considering how to look at all of the older individuals out there who take falls. We often are worried about broken hips, but how many of these individuals have cognitive deficits as a result of hitting their head as they fell? There are a lot of interesting things to consider. It is interesting and a lot of fun.
Additionally, the work NeuroSport does is critically important. They look at injured high school athletes, conduct neuropsych testing, and make predictions for how the athletes should return-to-school and play. These types of clinical issues are critical and provide a wealth of potential research avenues. The synergy of the Concussion Center and NeuroSport Program is a great opportunity for researchers at Michigan.