Esther Bay, PhD, ACNS-BC Clinical Associate Professor, Nursing pdq@umich.edu

Esther Bay, PhD, ACNS-BC
Clinical Associate Professor, Nursing
pdq@umich.edu

Your research is very focused on traumatic brain injury (TBI). What makes you so passionate about innovating TBI care?

Studying traumatic brain injury is challenging and I have been inspired by the patients and their journeys back into functioning—they really have a challenge because so often, their appearance is fine! I began my nursing career in trauma ICUs when folks with severe TBI didn’t make it or went to nursing homes.  In the 80s, I noticed something—they got better and spent a long time in rehab! When I began my doctoral program here in the School of Nursing, I indicated interest in cognitive, behavioral, mood and symptom management after mild to moderate TBI.  My team said that was too much; pick one area and know that well.  I settled on depression, but have always studied the other components because the brain is the hub of everything.  That’s what attracted me to bench scientist Bruce McEwen and his allostatic load stress theory model focus on chronic stress and preventing this because it has brain consequences.  My patients totally get the concept; my peer reviewers in journals and grants still have questions.  So essentially, I am trying to translate bench to bedside because it will benefit patients.  Fortunately, some of the bench scientists at UCLA are providing us with better science to show that the biological stress response after TBI is hyper-responsive and perhaps affects recovery and chronicity. That’s why I need a team like MCIRCC; they do both basic & clinical research!

You are interested in what happens to patients after TBI. Can you tell us a little bit about your findings in developing these behavioral interventions?

I began developing an explanatory model for why 25% of those with mild to moderate TBI didn’t get better; they continued to have cognitive, mood and behavioral issues (sleep problems, fatigue).  I used findings from bench scientists in depression and allostatic load stress theory to explain this phenomenon through hormones, specifically and first cortisol.  Then the questions began; what about cytokines, what about sex differences? What I did know was that the cortisol levels (salivary 12-hour profiles) were hypo-responsive in those with chronic mild to moderate TBI.  I persisted with this line of inquiry through R-applications, pilots, and DOD applications; there were always more questions from the reviewers than I could answer.  I proceeded then with post-doctoral studies in UM PM&R – the NIA was interested in studies with older adults and TBI and the allostatic load theory was well-developed in the healthy aging studies.  Then I was persuaded to try intervention work and a new set of pilots began with mindfulness therapy after mild to moderate chronic TBI.  The patients loved the 8-week intervention compared to our active control healthy living after trauma work and we showed that symptoms, mood, and stress was effectively reduced compared to active control.  Mindfulness scientists are developing neuroscience knowledge. Scientists have begun to show its potential to alter cognitive (executive function), behavioral, stress, and symptom burden through improvements in functional connections between amygdala and pre-frontal cortex, and decreases in inflammatory markers.  A large trial from Sam McLean at UNC along with many other ED researchers has shown that the mechanism for stress hyper-responsivity early after mild TBI is explained by genetic variants in glucocorticoid receptor sensitivity.  Those are the folks who develop chronic issues after MVC.  Therefore, mindfulness therapies may be effective for this type of cohort. Behavioral interventions may lead to a more clear understanding of the  explanatory mechanisms leading to chronicity after TBI.  

You've been working on TBI-related research for a long time. What do you see as the future of TBI care?

The only future for TBI-related care is to establish a team science approach that is multidisciplinary.  TBI potentially affects all aspects of the brain so personalized, tailored therapies that can be self-managed by the patients and/or families are the future.  Pharmacological therapies have failed for decades; we must have something to offer folks so they can get back to their daily living circumstances.  How to age with a TBI and/or multiple TBIs is in its infancy.  Prevention and early aggressive therapies are the mainstay for now, but we really need to also help those over age 75 manage after a TBI.  Those behavioral therapies will most likely focus on dyad work between caregivers and the patient.  

The Fourth of July is right around the corner. Do you have any traditions for the big holiday weekend?

I am fortunate to have a cottage a the foot of the National Lakeshore of Lake MI.  The 4th of July in that area is filled with tourists who do very extensive firework displays that are stunning.  Unfortunately, my hunting dogs do not like these high-pitched sounds, so we remain in the southeast portion of the state where it is quiet and less intense and their lives are spared mini-displays of flashing lights and high-pitched tones.  Fortunately, many of our friends enjoy the quiet times offered in southeastern MI while others celebrate with loud displays!