EPISODE 23

[INTRODUCTION]

[00:00:00] DS: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today. SpeechTherapyPD.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here’s the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On The Ear, you can receive $20 off an annual subscription when you use code Ear21. Just head to SpeechTherapyPD.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription.

You’re listening to On The Ear, an audiology podcast sponsored by SpeechTherapyPD.com. I’m your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor and lifelong learner. While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues and students. Let’s go. We are live and On the Ear, brought to you by SpeechTherapyPD.com.

[INTERVIEW]

[00:01:35] DS: For over a year now, our lives, both personally and professionally, have been drastically impacted by COVID-19. From delays in the supply chain for clinical supplies to comprehensive infection control to the overnight embracing and struggle truly with telemedicine, our landscape as clinicians was flipped upside down. But in the midst of our daily challenges, navigating all these different changes, there were people suffering through this disease, friends and family, colleagues, patients, strangers. Over four million people have died from COVID-19 worldwide and at least 100 million more have recovered after being infected. 

Research is still working to understand these long-term impacts for survivors of COVID-19 on our body systems, but today’s guest is focusing his efforts on how the brain and its language centers are affected by the disease. Dr. Julius Fridriksson, PhD, CCC-SLP is a University of South Carolina health scientist, distinguished professor in the Department of Communication Sciences and Disorders. He is the SmartState endowed chair of memory and brain function and new interim vice-president for research at the University of South Carolina. He is the director of the Center for the Study of Aphasia Recovery, the C-STAR lab and also codirects the U of SC at McCausland Center for Brain Imaging.

His research examines the effects of stroke on everyday life and in developing new treatments for stroke survivors. Much of this research is focused on communication, something that very often is affected by stroke. In 2020, his team at the U of SC Aphasia Lab transitioned their research on the aging brain to focus on the cognitive impacts of COVID-19.

Hey, Julius. It’s such a privilege to have you joining me. How are you doing? You look like you’re right there on the horseshoe. How beautiful. 

[00:03:20] JF: I’m doing great, Dakota. That’s an impressive background, isn’t it? I’m actually in my office at home upstairs.

[00:03:26] DS: It’s pretty realistic. You even look like you’re in the sun, like the lighting is very realistic. It looks great.

[00:03:32] JF: I know. There’s a window in front of me. Actually, the afternoon sun is just peeking in my window. 

[00:03:37] DS: Nice! Okay. Well, I’m so excited to talk about this. I mean, what an amazing way for the worlds [inaudible 00:03:44] and this very relevant disease to collide in such a way. I’m sure you have such a great perspective. Before we get into kind of what your study is about and what you guys are seeing. I’m curious. I know you really come from a background of aphasia research. Could you tell me a little bit more about kind of what your research focused on and then how you ended up studying COVID-19, how that came into play?

[00:04:05] JF: Yeah. I’ve been studying aphasia for a long time for about 20 years now, since I finished my PhD. We mostly work on aphasia recovery, so aphasia treatment, but with a very strong focus on sort of the neurophysiology of recovery. As you’re getting better, what are the brain mechanisms that allow that to happen? We also spent quite a bit of time on just understanding what are the normal speech and language mechanisms and how they’re rooted in the brain, so normal function. It’s a very wide research program.

The reason why we got into studying COVID – just a little bit of background on it. We have gotten funding in 2019 to start a large aging study. This was a considerable amount of money that was provided by the University of South Carolina. The idea was to have a large group of faculty come together and do the study on brain changes and cognitive decline. Now, when COVID came around, of course, like for most people, our plans were dashed, then we had to stop data collection like so many other research labs. 

We were thinking, we had a large staff, and we were already seeing the news that there were possibly some neurological effects of COVID. Everybody talks about anosmia, the effect on smell. Later on, there was a lot of talk about what we now call – well, we don’t call it, but it’s brain fog, which certainly is not a clinical term, but it was something that was being described very frequently. Even by recovered individuals. We thought, well, we have a great opportunity to actually study this, because as you know, here in the midlands, in South Carolina, COVID was rampant and is rampant again now.

We started data collection I think August last year, so a year ago. We were able to test about 120 participants in just a few months.

[00:06:05] DS: Wow!

[00:06:06] JF: That’s sort of how we got here.

[00:06:08] DS: Got you. Wow! It sounds like you guys had to do a pretty big pivot there though. It sounds like you already kind of had the set up for some brain imaging that was probably a part of your original study. But then to just rethink who a participant is in the scenario is very different for you.

[00:06:24] JF: Yeah, it was difficult because, for example, we were not allowed to bring participants into the hospital where MRI center is for studies because naturally, they did not want people in the hospital that didn’t have to be there. Of course, research is not vital. We made a deal with the hospital so that they did all the MRI scanning for us, but we were able to do all the testing online and we were sending people, kids to actually test them and we did everything via Zoom.

[00:06:58] DS: How cool? I didn’t realize that. We’re all converting as clinicians to telemedicine and you’re doing the same thing in your research. That’s definitely a lot of stuff to have to balance and navigate there. Could you tell me a little bit then – I know you mentioned brain fog. I don’t know if there’s a better term for that that we should be using. But some of the other symptoms, I mean, we think of COVID-19 as a really respiratory disease and breathing trouble, people with a history of lung problems kind of being the major symptoms. But what beyond that should people kind of be aware of, maybe things that you have seen in terms of symptoms of COVID-19 that maybe are unexpected?

[00:07:32] JF: I would say concentration, the ability to concentrate was very much affected in a large portion of our sample. If I had to guess what brain fog is, it’s really just this – is this effect on the ability to concentrate for an extended period of time.

[00:07:48] DS: Okay. Got you.

[00:07:50] JF: So doing simple tasks and certainly doing cognitively demanding tasks, for some people, now became impossible or very difficult. That’s something that we saw quite a bit in our sample.

[00:08:01] DS: Wow! Okay. We definitely need to be thinking about, I guess sort of in those working memory executive function kind of tasks we’re already seeing. Do you have any people you’ve interacted with who are demonstrating that, either like while they were currently testing positive or is this something that was occurring of having an onset that was much later?

[00:08:19] JF: It seems to be a mixed bag. Some people experience it right away, but we were surprised that there were quite a bit of people that reported these cognitive problems starting when they thought they were recovered.

[00:08:29] DS: Got you. 

[00:08:31] JF: Yeah. That was a little bit surprising to us. We’re not sure what the mechanism for that would be, but what we certainly found and that was not surprising, that the severity of COVID and we just have people actually rate the severity of the illness that they experience. That severity was very much related to overall cognitive abilities.

[00:08:51] DS: Wow! Okay. That’s a great segue though, because you mentioned the mechanism and that’s probably still not really clear with COVID-19. But I know you’ve worked with other cognitive related things that can impact communication, and language, whether that’s stroke. I don’t know if you’ve done research with TBI, but I know that’s also kind of in this realm. What is happening? What are these injuries? Stroke and aphasia, what are they doing to the brain when it comes to language and I guess, executive function. Those kinds of telltale signs that we see cognitively for these diseases?

[00:09:21] JF: Do you mean aphasia or for COVID?

[00:09:22] DS: For aphasia or TBI. Just some of the ones that we understand a bit better.

[00:09:26] JF: Yeah. With your bread and butter aphasic participants or patients, they have difficulty with a constellation of things from word finding, to syntax, to comprehension, to speech fluency, really much depending on where in the brain the damage occurred. It works a little differently with TBI, especially because a lot of those patients experience what we call diffuse axonal injury. You get damage to axons all over the brain.

I would say, in those cases, you’re more likely to see problems with things like attention, concentration, working memory a little bit different. The aphasic symptoms tend to be very specific to language. Not saying that they can have cognitive problems, but they tend to be mostly on language and speech.

[00:10:15] DS: Got you. Then, how are you seeing some overlap between those kinds of disorders with what you’re seeing with COVID-19?

[00:10:22] JF: One of the things that we used to test people online is the Montreal Cognitive Assessment or the MoCA. It’s used widely in research and certainly in clinical care. I’m sure that some of the people that will listen to your podcast are familiar with it. What we found was that, there was a very strong relationship between word fluency, so the ability to come up with words and overall severity of COVID. Then, I don’t know if you want to get into the brain measures yet, but we also found strong correlations between some of these measures, including the MoCA, some of the language measures and the brain matures.

[00:11:01] DS: Got you. Yeah, let’s circle back into that too, because I’m really curious if you guys have – I’m sure you’re a year in now, you may have a little bit of data. You can tease us with some information on, because I know this is really exciting. Okay. When we think – I guess, yeah, that’s fair. When I was thinking of that TBI versus aphasia, I don’t know enough about this world, but the way you described it, it does sound like they can be extremely different in how they present.

[00:11:22] JF: If I can just add really quickly, Dakota. I think the symptoms that we see in COVID where people have problems are much more akin to what you see in TBI, than what you see in aphasia. It’s very common for TBI patients to have problems with concentration, working memory. I think that there’s a lot of overlap. If I was an SLP who was treating somebody with residual cognitive symptoms following COVID, I would be going to the TBI literature. I really would. Because I think that there’s a lot that can be gleaned from what has been done on TBI that would perhaps transfer over to COVID.

[00:12:00] DS: Wow! That’s really great insight. When we get towards the end here, I’m curious if we could break that down a little bit further too in terms of things that you feel clinicians should consider because I have a feeling with the data that you guys are seeing, we’re going to have a wave of people with communicative cognitive problems you need some kind of intervention and it’s all stemming from COVID-19. We’re going to have a lot of people. That’s really something to think about. 

Do we know at this point like what COVID-19 is doing to the brain? Is it a blood flow issue or an oxygen issue? Do you have any kind of insights into the anatomy and physiology of what’s going on?

[00:12:35] JF: There are two prime mechanisms that have been suggested. One is that, the virus acts on coagulation. It’s actually causing sort of many strobes, very small strobes throughout the brain. That is what something that has been described in literature. The other one is, what we would call sort of white matter, hyperintensities, which is – if you look at a brain scan, either what we call a T2 or a flare scan, it’s just a type of an MRI scan. What you will see is that, almost like little dots in the white matter. This is very much common in dementia, but we found in our study that the number of these white matter hyperintensities was very much related to the cognitive problems that people were having.

Now, there is a caveat here and that we need to have a representative control group to make sure that this is something that is specific to COVID. Once we finish the COVID sample, we pivoted back into testing normal aging people and we’re in the middle right now all testing a large control sample. Then after that, I feel very confident that we’ll be able to talk much more comprehensively about what the mechanisms might be.

[00:13:53] DS: Wow! That’s a really great insight. I know that you worked with the Center for Brain Imaging at USC. I’m curious, just a little bit because I couldn’t tell you for a second how to interpret an MRI or like most of the time what I’m looking at. I get a chance to look at them sometimes if we have a kid who’s referred for a cochlear implant and they’ll include the scan and I’m like, look – maybe they have a diminutive nerve, are their cochlea’s maybe underdeveloped? I kind of was – okay, that doesn’t look exactly normal. But beyond, oh my goodness. No! I’m curious, what in your background led you to so much interest in the brain, and understanding its structures and these things.

[00:14:30] JF: Yeah, it’s a great question. I did my PhD at the University of Arizona. It was a department that was very much focused on adult neuro. I spent a lot of my time in the Department of Neurology. I feel like it was a great sort of setting me up for the rest of my career and that I did rounding with the neurology residents and the medical students. My interest kind of just grew from that. When I came to USC when we got our own brain imaging center, the McCausland Center for Brain Imaging, I started using that and then I became the director. It’s just something that is always – since I was a PhD student, something that has fascinated me and I’m very much interested in trying to figure out what the mechanisms are that will allow somebody to recover from aphasia. I think that one way to look at that is to look at brain structure and function and that’s all I got there. 

[00:15:22] DS: Yeah. That’s really cool. That’s cool. I mean, it’s such an interesting background between communication and brain science. I just think that we can talk about that for a really long time. Speaking of the more communication impacts, so you mentioned – if you could tell me one more time, it was the coagulation similar to like – like several mini strokes. Then what was the other one? White matter?

[00:15:42] JF: White matter hyperintensity. We usually either call it that, which is just what you see on the scan itself or microstructural changes. Literally, basically death of axons in a very small region.

[00:15:56] DS: Got it. If those are kind of happening, are you guys, when you’re looking at a scan, focusing more on where we know – I mean, I guess, centers can be spread around within the brain, but where we know a lot of the language processing happens within the brain. Are you kind of looking at it from a big picture perspective?

[00:16:11] JF: I would say big picture. For validation, we certainly started by looking at the olfactory bulb and the orbitofrontal cortex, because we wanted to understand – we sent everybody a smell kit as a part of the NIH –

[00:16:24] DS: Cool!

[00:16:25] JF: Yeah. We tested them. They had to take the stimuli out of the box and do that –describe what they were smelling. Then we were able to assess the severity of the anosmia. Then what we did was that, we correlated to severity of the anosmia with the structure of the olfactory bulb and the orbitofrontal cortex. Not surprisingly, there’s a strong relationship between the two. The greater the impairment of the sense of smell, the smaller that area is in the brain. 

[00:16:56] DS: Wow! 

[00:16:58] JF: It was nice for validation, but I would say, we need the control sample to make sure that this isn’t just something that was there any way and that it was literally caused by COVID. But if I had to bet, it was caused by COVID, but who knows.

[00:17:14] DS: Especially if they felt like they had normal smell beforehand, right? Like that feels like that makes sense to me. Okay. So then, if we think it could be coagulation or the white matter hyperintensities, I’m curious, do we have a history or reason to believe that those things could cause language or specific cognitive like executive function, memory concentration? What kind of precedent are we basing some of that on?

[00:17:38] JF: There’s a lot of precedents. Most of that comes from dementia research. Looking at Alzheimer’s disease and different types of dementia. It’s very clear that relationship is there. What we have done in the stroke population is that, you can imagine when somebody has aphasia. They have usually a fairly large lesion in the brain. what we do is that, we look at something called brain health. We look at the residual tissue, and whether it has this hyperintensities. Actually, the people who have more of these hyperintensities in the healthy part of the brain are worse off.

[00:18:13] DS: Wow! You’re talking specifically about your COVID-19 researcher or is that something we’ve known from the more dementia Alzheimer’s population?

[00:18:20] JF: More from the dementia, but it certainly shows and get in the COVID as well, in the COVID sample.

[00:18:24] DS: Wow! Oh my goodness! We already know that in our country and in our world, we already have like an epidemic of dementia and Alzheimer’s, dementia-related diseases. Oh my gosh! When we start to think of the long-term impact of whatever COVID-19 is doing to the brain, that’s really – it’s a little scary to think of what’s looming ahead.

[00:18:43] JF: Yeah. It’s kind of difficult to do this in real time, because, especially early on, there were so many studies that came out and you’re like, “I don’t know.” Because there was so much thirst for new knowledge. I think that as time goes on, these pictures will be cleared up. Especially now that the NIH has put a lot more funding into this, but I would say, a year from now, we’ll know a lot more than we did today and we certainly know a lot more today than we did a year ago.

[00:19:11] DS: Maybe we’ll have to check in again next year if you’ve got more data for me, more to talk about there. I think that would be a lot of fun. Now that you mentioned the smell test, I’m actually really curious as to what the protocol looked like for people, especially at home with the at-home kit. Could you break that down a little bit more for me. What was happening when they brought – I guess, what is a big box with – did you supply a computer or a tablet? Then also, what is a smell kit? That’s definitely blowing my mind right now. I’m really curious.

[00:19:36] JF: For people who didn’t have a computer at home that maybe they didn’t have Wi-Fi or whatever, we would literally send them a computer with a hotspot. A part of that package that we send them was also this smell kit. It’s very simple. All you do is that you basically pick up – they’re like strips and you open them up, they’re in a plastic and you smell, and you record. What is it that you’re smelling and you can get a fairly good idea of – the one thing that I didn’t touch on is that, some people – a lot of people actually report what is called phantom smells.

Their sense of smell actually changed. Anecdotally, there was a guy that I know who was one of the earliest people who got COVID in South Carolina. Like three months after he had gotten COVID, he lost probably about 40 pounds. He said that, he still didn’t have any sense of smell and he literally had no joy from eating food.

[00:20:32] DS: Oh my gosh!

[00:20:33] JF: It’s just a part of that. But other people are – people report things like everything smells like smoke. It’s a variety of things.

[00:20:42] DS: Wow! I’ve never heard of the phantom smells. In the smell kit, is it like – sorry, I keep going back to the smell kit. Is it banana? I’m just so curious as to what even kinds of smells. I guess they have to be pretty strong because you want to describe them accurately.

[00:20:59] JF: Yeah. I can’t remember off the top of my head exactly. It’s been probably about a year since I looked at it. But yeah, they’re like everyday smells. 

[00:21:06] DS: Okay. Cool.

[00:21:07] JF: Things that you and I would pick up like this.

[00:21:10] DS: Got you. Okay. I won’t come back to the smell kit. Okay. I’ll leave the smell kit there. What other things – I guess you guys said you did the MoCA. Was that administered?

[00:21:17] JF: Yes, online.

[00:21:18] DS: Via the computer, okay.

[00:21:19] JF: Yeah. We did some language as well. We would have people do picture description to get a hold of their like their discourse ability, things like that. But we also did a lot of questionnaires for mental health, PTSD, depression. The testing itself online was – I can’t say that it was comprehensive because it’s not easy to do that online. But we also sent questionnaires. Those questionnaires were very extensive, looking at solely risk factors, family history, just a large list of things that we collected on these individuals.

[00:22:01] DS: I’m curious, any results from that mental health-related aspect of things? I think that’s a really interesting domain to consider here.

[00:22:09] JF: Yeah. About half of everybody in the study, of 120 people, experienced depression. Think about 20% experienced persistent anxiety, but again, we need the control sample to make sure that this was specific to COVID. But what was interesting about it, is that, the level of severity of the illness was very much related to the level of depression. The sicker you were, the more likely you were to be depressed at a given time after you had recovered.

[00:22:41] DS: Wow! It sounds like a lot of the factors that you’re describing are all related to that severity of the illness. It seems like the more severe your illness, the more severe your cognitive symptoms, mental health wise. Sounds like you said, the olfactory symptoms were more severe in this group as well.

[00:22:56] JF: I would say, overall, if I had to sum it up, is that your overall health, both mental and physical very much determines how you’re going to end up. If you just look at the literature, if you have cardiovascular risk factors, diabetes, hypertension, all the usual things that make you more likely to get things like cancer and heart attack. Those are very strong predictors of your long-term outcome following COVID, and certainly death.

[00:23:21] DS: Wow! That’s just another great reminder, because it seems like – I feel like there’s sort of a mentality of, “Oh! Well, if you get through it, you’re fine. You survived the disease.” But having this idea of these like very severe long-term. I’m curious, with some of the people that you’ve documented, one of the things I really like about C-STAR, that I really get a sense of, both from students and just professionally is that you all do so much to invest in like the people. They aren’t like participants, like you really have a lot of programs to support them in a lot of ways. I feel like you can’t go through a study like this without –you already remembered one gentleman who been one of the first people to even have COVID-19.

I’m curious, are you all planning to do another check on these things later on to see if things have recovered, or resolved or another questionnaire to see? Because one of the new terms I’m hearing as a parent is this idea of long COVID in kids. But I don’t know if that’s a term you’ll use as much in adults.

[00:24:17] JF: It’s very much used in adults. They’re called the long haulers. A lot of the people that we are testing are three to six months post and are still having problems. Those would definitely be individuals, the long haulers. We don’t have plans right now to follow them up this far out. It’s really just a matter of resources. We’re really trying our best to get the control sample in, but I wouldn’t – I think it’s possible that we might do it, but I just don’t know yet. The other thing that is a little bit sensitive is that, these people, a lot of them have problems that they certainly would not want anybody to know about.

If you’re having severe cognitive problems and you’re a teacher, or you are a bus driver, would you want everybody to know? We’re pretty sensitive about contacting them again. Some of them certainly want help and they have contacted us, “Is there anything else for me?” But others are like, “I wasn’t sure whether I was going to do this, but here I am. I’m here just to help out.” 

[00:25:16] DS: Wow! That’s a really good point that I hadn’t considered, especially in a study like this that’s such sensitive information that’s impacting our life and the relationships. I’m curious what, if there were any other specific language related things that you were seeing with some of those tests you did, whether it was the questionnaires or otherwise that stuck out. I’m also curious because you mentioned concentration. Is there a test that you all use that can like give you a numeric value or is that a little bit more anecdotal, you could see within a session that it was like, they are more off task or having trouble focusing?

[00:25:49] JF: Mainly looking at working memory on the MoCA and then just overall cognitive ability on the MoCA. I would have to say that when we did the initial analyses, we had not done the discourse transcription. That’s something that we’ve been putting a lot of effort into. You can imagine with 120 people to transcribe the discourse. With all these people, it takes a long time. We’ve had an army of master students who really been focusing on doing that. We haven’t really looked at those data yet. It certainly is the plan, but it’s been a task and a half to get that done.

[00:26:23] DS: Sure. I think that makes a lot of sense. Are there other factors in some of the participants you’ve had in their life beyond things like the expected, hypertension, diabetes, those kinds of things that we would expect? Anything that maybe people don’t realize could also be an increased risk? Or that, even anecdotally, you’re seeing like the group, this group tends to also be like the high severity group, any kind of connections like that that are sticking out to you?

[00:26:47] JF: Socioeconomic status. 

[00:26:49] DS: So, I think that unfortunately in this country, we’re just – our society is in such a way that people are on the lower spectrum of SES who always seem to get the shaft and COVID is no different.

[00:27:07] DS: You’re saying that in like the severity of symptoms and everything too?

[00:27:09] JF: Yep.

[00:27:09] DS: Wow!

[00:27:10] JF: But then, that is certainly related to overall severity of the disease. But even when we control for things like age and several other factors, SES still is important.

[00:27:22] DS: Wow! Actually, that leads me to another great question. This idea of age, I think there’s also a common misconception that, “Oh! You’ll only really get really sick if you’re older.” But I’m sure you’re seeing some younger people with a lot of these cognitive symptoms. Could you speak to that a little bit?

[00:27:37] JF: Yeah. That’s a great question and it remind me. The MoCA scores that I was telling about, the overall ability and the fluency test on the MoCA, that was actually controlled for age. 

[00:27:49] DS: Wow!

[00:27:49] JF: That relationship is still there, even though you control for age. You’re right, there’s plenty of younger people that have residual effects of COVID.

[00:27:59] DS: Wow! Another great reminder just how far-reaching this can be. One last question when it comes to like the testing materials and things like that. How did you all develop that and where did the ideas come from to include things like mental health? I mean, I guess, if you’re thinking cognitive, you’re going to think of something like the MoCA. But which language test – I guess this is more just a question for you as a researcher. Where did those ideas come from in terms of what you’re going to include in a study like that?

[00:28:24] JF: We were lucky that that aging study that I talked about at the beginning, a lot of that had been designed for that aging study. It’s pretty easy just to kind of transition it straight into the COVID study. That was a battery that was really put together by our large group of faculty. Several folks from the Com D department at South Carolina were involved. For example, Dan Fogerty, he was an [inaudible 00:28:48], Christopher Warfel. Those people had input into what those test were and certainly us who do the adult neuro, we came up with some things as well.

[00:28:58] DS: Got you. That’s cool. It takes a lot of minds to put all the best, to put together the best test battery, I guess.

[00:29:04] JF: Yeah. I have to say, there was a lot of back and forth because some people just wanted to include the stuff that they were most interested in and you have to please a large group of folks, but we came up with a battery in the aging study that takes about two days to complete. The COVID study, it’s probably about, I think maybe about five hours. Don’t quote me on that, but I think it was something like that.

[00:29:27] DS: That’s pretty brief. I feel like for a lot of the factors that you’re looking at here, that’s pretty good. I guess that doesn’t include the MRI too though, right?

[00:29:35] JF: Not the MRI and not the questionnaire. I don’t know of the top of my head how long it took to do the questionnaires, but I would imagine that some people probably took a couple of hours to fill those out.

[00:29:46] DS: Got you. Are there any other early findings that are jumping out at you, that you feel like – are just important for – I mean, our audience here, we have a lot of students, a lot of clinicians, both speech and audiology. Do you feel like there’s some things that you’re learning that you feel would be really important for clinicians to know.

[00:30:04] JF: I would say. I touched on this earlier. I would say that the similarity to mild to moderate TBI, it’s very interesting. I used to, when I was doing clinical care, I worked with TBI patients quite a bit. A lot of the symptoms that I’m seeing here in our sample is very similar to the things that we were assessing. If I was an SLP and I had COVID recoverers on my caseload, I really would be looking into that literature. 

[00:30:34] DS: That’s really great advice. Do you feel like the – I’m curious what the kind of referral pipeline looks like for COVID-19 recovery patients. I feel like for TBI, it might be a little bit more well-known that an SLP can help treat and provide intervention in that situation. But do you feel like the general public or general physicians have this idea or are familiar with these communication and cognitive problems we’re seeing with COVID-19. How do you see that playing out in the future?

[00:31:05] JF: I don’t know for sure, but I can tell you, I was shocked last summer. You know I have a lot of master’s students that work in my lab and some of them were doing their practicums and doing them in subacute nursing facilities. I remember a couple of students that told me that almost everybody in their facility was there for short-term care was a COVID recoverer. 

[00:31:27] DS: Wow!

[00:31:28] JF: Yeah. It seems that a lot of people – I mean, they were probably for cardiac rehab or things like that, but it seems like those students working with the SLPs were working on cognitive problems in those individuals. I would imagine they were doing a lot of just trial and error.

[00:31:46] DS: Wow! Especially last year, there’s still – I mean, it still feels like there’s so much that’s unknown. But last year, I can’t even imagine. You were just winging it. That’s tough.

[00:31:57] JF: Absolutely.

[00:31:57] DS: That’s definitely tough. 

[00:31:58] JF: Yeah.

[00:31:58] DS: I’m also curious what – so I know that you all are in the process of looking for controls right now, for comparative data. Is there anything specific that either you think you might see or are things that might – I don’t know that you’ve had any controls yet. But has there been anything that’s come up in that process that surprised you?

[00:32:15] JF: In the control subjects?

[00:32:17] DS: Yeah. I guess I’m sort of thinking of it like, this would be – this study is amazing, but how helpful would it be to have – I don’t know if you’re counting for this, but like it almost be perspective in a way where you’re testing these controls. Then three weeks later, they’re like, “Hey! Actually, I just had a positive COVID test. Should I come back and do it again?” Like is there any set up for that kind of thing? Does that make sense?

[00:32:39] JF: We don’t have it. But you know what, there was one study that actually did that. It just so happened that – I think it was in Italy. They tested a large group of people very similar to our aging study. Then when the COVID was completely out of control in Italy, they went back and looked at how many of their individuals in their sample actually had COVID in it. I think it was about half maybe. The study was about 80 participants. They had a nice control sample. Now, they didn’t do a lot of testing, but they definitely found very clear differences between those who did and didn’t get COVID, definitely. Yeah.

[00:33:17] DS: Wow! There’s definitely room to explore that a little bit more.

[00:33:22] JF: I have to tell you. I thought that by this time, when we started this last year, I thought by maybe this past January or February, we were scrambling to do the testing because we're thinking, “Well, COVID is going to be over, so we got to make sure that we get this people in who are not that far post COVID.” Man, it’s hard to believe that we are where we are. It’s sad.

[00:33:44] DS: It’s really sad. It’s awful. It’s so awful. I definitely understand that feeling like you’re going to miss it, but wow, yeah. We don’t even seem to be far from it at this point. We’re still well within. I’ve read one thing that you said in an ASHAWire article. Remind me if I’m getting this wrong, it was something about – I don’t know if maybe this is related to the coagulation and the mini strokes or the white matter – I keep struggling with the word. Hyper –

[00:34:11] JF: Hyperintensity.

[00:34:11] DS: Hyperintensities. It was something related to the immune system response, kind of being involved in those systems. Could you maybe speak to a little bit about what you think might be happening, whether it’s COVID-19 or otherwise that’s causing these kinds of things in the brain.

[00:34:23] JF: That was certainly one hypothesis that these cytokines storm so that your body is basically attacking itself, its immune system goes in hyperdrive. There have been studies in the past that suggested that that kind of response causes problems with brain structure. I would say it’s not confirmed, it is just the hypothesis at this time. It would be hard to test it, but it seems possible.

[00:34:51] DS: Okay. Then getting back to how you mentioned, it was similar to TBI and I guess, you thinking back to your experience clinically, working with patients with TBI, what does intervention really look like there and do you know if any data has come out that’s looked at intervention options for post-COVID-19 recovered patients?

[00:35:08] JF: I have not seen any literature on it. I know that there’s a group at the University of Toronto that is basically taking a program, a cognitive intervention that was designed for TBI. It’s doing maybe a phase 1, phase 2 trial in COVID recoverers, but I have not seen any definitive studies that have been published. If I was an SLP, I would certainly focus a lot on just behavior modification, changing the environment, seeing what you can do to actually make the – maybe not improve brain function. Not saying that we can’t do that, but at least initially, focus on what is it that we can do now to make it easier for you to bear this problem.

[00:35:52] DS: Is that sort of coming from your TBI approach?

[00:35:54] JF: Yes. It was Professor Mark Ylvisaker who did that in TBI participants, basically based on behavior modification, trying to figure out what is it that you do well, what are your weaknesses, trying to stay away from those and focusing on one of the things that sort of keep you organized. And modifying your lifestyle so that you’re less likely to have to deal with things that are very cognitively demanding.

[00:36:21] DS: Got you. That approach makes a lot of sense to me. Did your research look at all and anyone who maybe contracted COVID-19 after vaccination? I think a lot of your data probably came out before vaccines were a little bit more available?

[00:36:34] JF: We have not. I can’t remember a single case. It seems like the cases of COVID-19, even when people get it after vaccination, it seems like it’s been pretty mild. Not saying that that could have the same effect, but –

[00:36:49] DS: If you’re linking the severity of the illness though with a lot of the severity of the symptoms, then yeah, I definitely see that connection there.

[00:36:56] JF: Yeah.

[00:36:57] DS: Then now that we have to consider the Delta variant too, which seems to be a more severe illness from what I’m seeing.

[00:37:01] JF: Yeah. I don’t know, Dakota. I mean, I’m not so sure of how we’re going to move forward with this study. There’s so much uncertainty right now. The University of South Carolina, we’re dealing with just whether we can actually mandate that people wear masks. I don’t know. It’s a very uncertain time.

[00:37:19] DS: Absolutely. I’m also wondering if you guys are thinking you’ll get back into the aging brain study. I’m curious when you get into sort of like a situation like this, where your research just takes a total different turn. You’re still using a lot of the same resources, but really, the major questions that you’re examining are pretty different. Do you see yourselves? I mean, I guess it depends on where we end up with COVID-19. But how you get back to your aging brain study that I feel like it’s really important too, like would be really helpful completely unrelated to COVID-19.

[00:37:52] JF: We had started the aging brain study again full force I think in May, this past May. Now, I’m wondering whether we’re going to have to shut it down again.

[00:38:00] DS: Wow! Have you been able to collect any data for that study? Is it looking specifically at poststroke or aphasic participants or is this just aging brain in general, no specific conditions?

[00:38:13] JF: Aging brain in general. We started with folks who are 60 years and up, but we are basically doing the adult lifespan from 20 up to I think 85 or something like that. We’re sampling across the age span.

[00:38:27] DS: Wow! Are there any specific factors that you’re looking for there or things that – is it just seeing how the brain itself changes in that time or are there specific factors you’re looking into?

[00:38:37] JF: Given that large group of faculty members, it’s like, everybody had like their – a couple of things on their wish list that was included. I would say, it’s not as single study per se, it’s a very comprehensive task batter, that includes EEG, MRI and then all of the cognitive testing. Very comprehensive hearing tests, all the way up to all these long questionnaires that we do. The idea is to have this massive dataset that then people can use to publish and get grounds.

[00:39:11] DS: Wow! That’s a great. It’s just a big pool with as much data as you can imagine when it comes to all of these systems working together.

[00:39:19] JF: Yeah. We’re trying to create a dataset that will be – like our MRI scanner is a huge resource for us. We’re trying to create another resource, which is this large data set that anybody among these plenty people and a lot more people could get data to look at a lot of different things. One of the things that I didn’t talk about is that, we collect blood samples for genetic testing. We have quite a few geneticists who are included. It’s pretty comprehensive. 

[00:39:47] DS: That sounds about as comprehensive as it could get. I know that there’s a lot of uncertainty and it’s kind of hard to be hopeful in the midst of all of this, and especially what you guys are seeing, these people who are struggling. They thought they were through it. Then months later, they’re not. I’m curious if there’s been any stories or experiences you’ve had that have maybe given you a little bit of hope or inspired you a bit in this process with the study.

[00:40:11] JF: That guy that I told you who was one of the first people to get COVID in South Carolina, I actually saw him the other day and I asked him how he was doing. He said, his smell came back. He was feeling a lot better. He still had lingering headaches. He said he’d never had headaches in his life before, but now he has them frequently. But, at least his symptoms today are far less severe than they were. This was probably about a year ago. 

[00:40:36] DS: Got you. He started to see a little bit of recovery. That’s one of the things I was curious about too, with checking in on them again. I just feel like, you mentioned the long haulers. What we know is there’s this specific kind of subgroup of people who tend to show these symptoms later. But as far as how long, how can we know. The disease has only been around for a year and a half. Do you have any experience with other people in your study where – I guess this idea of how long is the haul maybe is related to the severity of their initial disease or is that one of the questions you all are thinking about. 

[00:41:11] JF: It’s definitely one of the things we’re looking at. Right now, I would have to say we don’t know. We need probably more data and including more data from COVID recoverers.

[00:41:22] DS: Sure. I guess a lot of time too, because it’s just – until we can see, I’m actually curious a little bit too, the majority of your participants, was the data collected last year, or I guess within the past year.

[00:41:34] JF: I think we stared August last year and we were still collecting data I think march.

[00:41:40] DS: Okay. I was curious, like at what point in the peaks that we’ve seen were maybe some of these people, how far out were they from their disease? Were you asking only for people who had recovered and still had symptoms or is this just anyone who had recovered from COVID-19?

[00:41:56] JF: Most of the people that we actually tested did not think they had any symptoms.

[00:41:59] DS: Oh, wait! That’s really interesting.

[00:42:01] JF: Yeah. But, actually, some of them did have symptoms. Now, whether that was their status before, I don’t know. That’s why they need the control sample. 

[00:42:11] DS: You need your controls. Yeah.

[00:42:11] JF: Yeah. Because you could save all. The only people that are in your study are those who are having problems, but that was not the case. We got a lot of folks who thought they were just like, everything is back to baseline, I’m good.

[00:42:23] DS: Wow! That’s going to be really interesting. One more question when it comes to the MRI. Have you all had a chance to look at some of the data yet?

[00:42:30] JF: I think it’s mainly in white matter bilaterally, these hyperintensities. We haven’t looked at, for example, one of the things that we look at is functional conductivity, so how one region of the brain basically communicates with another region. We’re able to do that with one od our brain scans. We haven’t started looking at that. There’s a lot of things in the MRI data that really just – because of time and resources, we haven’t looked at that yet.

[00:42:58] DS: I was just going to ask, is there anything sticking out in the MRIs. I guess that you’re seeing structurally, it sounds like a lot of it is related to the initial severity of the disease, but is there any particular hemispheres or things that stick out from the MRI data? I’m just curious about that.

[00:43:13] JS: Yeah. I think even if these symptoms were nonspecific to COVID, it actually can give you quite a bit of insight into just how the normal brain works. Because if you’re having these white matter hyperintensities in certain tracks of the brain for example, you can just look at the correlation between that and for example, the discourse measures.

[00:43:33] DS: I guess there aren’t as many – it’s interesting that you have the background of communications and this neurology background, so you can kind of have a little bit of a better sense of what’s going on between the connections there.

[00:43:47] JF: It’s not that – the only thing we’re going to do with is, is just trying to understand COVID. We can actually try to apply these data to understand normal brain speech, language relationships.

[00:43:59] DS: Wow! That’s really cool. Is that related at all to what the aging brain study is doing similarly?

[00:44:05] JF: It’s very much the same thing. I don’t know what it would look like if we just pull them together. That’s definitely something that we will try and maybe just have COVID as a cofactor. There’s a lot of different possibilities.

[00:44:17] DS: I think that could change things up a bit for your data. Is there anything else that you wanted to share about the study or what your lab is doing?

[00:44:25] JF: We are basically back in business with our aphasia studies. That’s the biggest part of what we do. We have a center grant, where we have two clinical trials. One is a drug trial. One is actually looking at the difference of doing in-person therapy versus tele rehab. That stuff is already happening. I really just have my fingers crossed, that we don’t have to shut down any of these.

[00:44:48] DS: Sure. Yeah, I think that’s really fundamental. I know, one of my favorite things I get to see in passing is the aphasia groups. I’m not sure, I’ve never sat in. I’m curious if I can sit in sometimes. There’s like an improv group maybe or like a drama group. Could you speak to that a little bit? What’s going on there?

[00:45:09] JF: So Dirk den Ouden, who you know is a big part of that. He has an acting background and he’s been working with a professor in arts and I guess in theater. They got together a group of people with aphasia and they started putting on these skits and maybe small plays. It’s just tak off. It’s been a lot of fun. I haven’t been intimately involved. It really has been Dirk’s thing, but I think the people with aphasia just had a fantastic time. 

[00:45:36] DS: Yeah. It’s a really cool way to incorporate therapy into like a really expressive modality. It’s a world, honestly, as an audiologist, I wish I knew more about in terms of aphasia and just other cognitive related problems because I see it so often in my patients. I’m actually curious if maybe you could speak to us a little bit too. But one of the things that we do for potential cochlear implant candidates in the evaluation process is we do a cognitive screen or we use the slums. I think we’re considering switching to the MoCA thought. Then that’s a good indicator to know where at cognitively this person is, so (a) we can counsel expectations appropriately have a good plan in place, but also just get them connected to adequate care that this is something that was unexpected for them. We might be the first person who’s ever even considered screening them cognitively.

I’m just curious where whether you think of it from a research perspective or like a clinical perspective, how we’re going to be blending more cognitive related things just into like everyday practice in clinical care. Even if I’m not the person who’s really providing that direct intervention and I don’t have the background to do so, I can just be keeping it in mind, because it feels like there’s just going to be more, and more and more adults who are demonstrating these cognitive deficits.

[00:46:51] JF: Yeah. If I was coming at it from that angle, I will be concerned about things like brain plasticity. Because what you’re doing with a cochlear implant, you’re expecting some changes certainly functional but probably structural as well in response to now, having the implant, this new device. The older we get, the less plastic the brain becomes. But in addition to that, the greater the cognitive impairments that we have, I would expect that the less plastic the brain is. 

[00:47:24] DS: Yeah. That’s certainly something we talk about when we’re counseling them through this too is, the older we get — expectations have to be much more realistic, especially if there’s been deprivation from auditory stimulation and we just have to be really realistic that the brain hasn’t listened to this kind of stimuli in a while and it isn’t as plastic as it would be if you were three years old. We definitely have to take that into consideration with our discussion of expectations.

[00:47:45] JF: Absolutely. 

[00:47:47] DS: When you’re working with future SLPs, SLP master students, do you feel like there’s something that you hope that they take with them from being in your lab in terms of working with this population?

[00:48:00] JF: The aphasia or the COVID?

[00:48:02] DS: Either one, yeah. 

[00:48:03] JF: Evidence-based medicine, I mean, I think that there’s so much emphasis on it. It’s so important in understanding that not all evidence is the same. I mean, clinical trials, pretty much anywhere in medicine and now, certainly in rehabilitation. Clinical trials are really what matter, so we shouldn’t expect anything less when it comes to communication disorders. Whether it’s in aphasia or COVID recoverers. 

I would say, look at the literature, the aphasia literature with regards to clinical trials has come a very long way in the last, I mean, just like five years. It’s been like a transformation, like phase three clinical trials showing that aphasia therapy is very affective. It does improve languagability and quality of life. That stuff is so huge and important. I would say, if nothing else, focus on the large studies that are properly powered that tell you something about what you should be doing in clinic.

[00:49:03] DS: That’s great. That’s really great. Thank you so much for joining me. This is a world that I feel like I know so little about, but it feels like my neighbor in terms of communication disorders, but also with COVID-19 being so prominent. I was so excited that you agree to join me because this research that you all are doing is extremely fascinating and just really important to helping us better understand the far-reaching consequences of COVID-19 beyond respiratory distress. Right? I mean, it’s really, really helpful. Thank you again for joining me. 

If anyone was interested in contacting you to learn more or I know you’re looking for controls for your study, what’s the best way to get in touch with you for any future contact?

[00:49:46] JF: I want to say, shoot me an email. I’m online. You just search for my name. There’s not a lot of Julius Fridrickssons, so you could probably find my email pretty quick. Shoot me an email. If it’s not I who would help you get enrolled, one of our folks would definitely help do that. Also, if you’re just interested in talking to our SLPs or our neuropsych people, they’re amazing. I mean, I’m talking about all this research here, but I want to emphasize that the group that has done this, it’s really a dedicated group of SLPs and neuropsych folks. Those folks would be happy to talk to clinicians.

[00:50:21] DS: That’s really great. It’s best to just go through maybe C-STAR or where would they find them?

[00:50:27] JF: I would say Sara Sayers and Sarah Newman-Norlund. Those two names you can find on the ABC, so Aging Brain Cohort Study. You can find their contact information there. They’re just amazing, amazing people. I’m sure they would be delighted to talk to anybody who might be interested in COVID recoverers and communication problems.

[00:50:51] DS: Perfect. I know we’re going to have a lot of clinicians out there who are seeing a major influx in this population, so maybe being able to connect with them I think is going to be really helpful. Thank you so much again.

[00:51:01] JF: Absolutely. It was great talking to you, Dakota. Have a good night.

[END OF INTERVIEW]

[00:51:07] DS: That’s all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education, through Speech Therapy PD. Check out the website if you’d like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to speechtherapypd.com/ear. That’s speechtherapypd.com/ear.

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