Fall 2012 - Shepherd Center by zhouwenjuan


									  shepherd center | FALL 2012

the pinnacle of rehabilitation care


               The paTh To

               developing world
               of pm&r

               Tech Talk

    Shepherd Center
    2020 Peachtree Road, NW
    Atlanta, Georgia 30309

    Jane M. Sanders

    Shepherd Center Editorial Board
    Anna Choo Elmers, M.D., Chair
    Gerald Bilsky, M.D.
    Mitch Fillhaber
    Donald Peck Leslie, M.D.
    J. Tobias Musser, M.D.
    Erik Shaw, D.O.
    Keith Tansey, M.D., Ph.D.
    Gary Ulicny, Ph.D.

    Advisory Council
    Susan Conners
        Brain Injury Association of America
    Carolyn Geis, M.D.
        Halifax Health, Center for Neuroscience                The Pinnacle of Rehabilitation Care is distributed semi-
    Darryl Kaelin, M.D.                                        annually to physical medicine and rehabilitation physicians
        Frazier Rehabilitation and Neuroscience Institute
    Thomas S. Kiser, M.D., MPH                                 and their staffs nationally. The publication aims to advance,
        University of Arkansas Medical Center, Dept. of PM&R
    Lawrence Lottenberg, M.D.                                  through education and communication, the field of brain
        University of Florida College of Medicine,             and spinal cord injury rehabilitation medicine. With input
        Department of Surgery
    William S. Pease, M.D.                                     from the publication’s advisory council, The Pinnacle of
        The Ohio State University, College of Medicine,
        Dept. of PM&R                                          Rehabilitation Care seeks to fulfill this goal by providing its
    Kristjan Ragnarsson, M.D.                                  audience with relevant content and distinctive perspectives
        The Mount Sinai Medical Center
    Gregory Worsowicz, M.D.                                    meant to spur dialogue and provide a collective avenue
        University of Missouri, School of Medicine,
        Dept. of PM&R                                          to link physicians, medical organizations and research
                                                               institutions across the country.
    Design Soloflight

    Contributing Writers
    Elizabeth Lenhard, Michelle Cohen Marill,                  Shepherd Center specializes in medical treatment, research
    Richard Sine, Paul Donsky                                  and rehabilitation for people with spinal cord injury,
    Contributing Illustrators                                  brain injury, multiple sclerosis and other neuromuscular
    Jon Reinfurt, Soloflight
                                                               conditions. It is one of only a few freestanding rehabilitation
    Contributing Photographer Christopher Martin               facilities in the United States that has an intensive care
    The Pinnacle of Rehabilitation Care is published           unit and acute-care capabilities. Shepherd Center is
    semi-annually by Shepherd Center, a private, not-
    for-profit hospital specializing in medical treatment,     ranked among the top 10 rehabilitation hospitals in
    research and rehabilitation for people with spinal         the nation by U.S. News and World Report. For more
    cord injury, brain injury, multiple sclerosis and other
    neuromuscular conditions. E-mail change of address         information, see shepherd.org.
    information or requests to be removed from our
    mailing list to pinnacle@shepherd.org, or by mail to
    Shepherd Center, Attn: The Pinnacle of Rehabilitation
    Care Mailing List, 2020 Peachtree Road, NW, Atlanta,       Our Mission is to help people with a temporary or permanent disability caused by injury
    Georgia, 30309. The Pinnacle of Rehabilitation Care        or disease, rebuild their lives with hope, independence and dignity, advocating for their
    accepts no advertising.
                                                               full inclusion in all aspects of community life while promoting safety and injury prevention.

                                                          issue 4 | FALL 2012

10   “ This device has real functional
       possibilities in the home or
       office environment.”
      claire harTigan, mpT

                                         6    tHe patH tO
                                              Best practices from acute-care
                                              hospitals shed light on better
                                              transitions between levels of care.

                                         10 pOWer FOrWard
                                              A new exoskeleton makes walking
                                              possible for some people with SCI.


                                         2    poinT of view
                                              DEVELOPING WORLD
                                              Experts provide perspectives on the
                                              growing field of international PM&R
                                              practice and policy.

                                         14   Tech Talk
                                              GENDER AND POST-SURGICAL
                                              A new study shows gender can be a
                                              factor in the risk for complications
                                              following neurosurgery.

                                              BENEFITS OF EARLY SURGERY
                                              Recent study results show surgery
                                              within 24 hours of SCI may improve
                                              patient outcomes.

                                              TRIAL FOR COMBINED ISCHEMIC
                                              STROKE THERAPY
                                              A new approach to treating ischemic
                                              stroke undergoes trial.

                                                                 1   the pinnAcLe oF rehAbiLitAtion cAre
                                            poinT of view

                                                      PoInT of VIEW

                                 The panel            Developing World
                   Ahmed AboAbat, M.H.A., Ph.D.
                                                      Experts provide timely perspectives on the growing
                      Rehabilitation Consultant,      field of international PM&R practice and policy.
                  Medical Director and founder
                                                      By ELIzABETH LENHARD
                  of the Rehabilitation Hospital
               (CARf Accredited) at King fahad
              Medical City, Riyadh, Saudi Arabia
                                                      November’s American Academy of Physical Medicine
                                                      and Rehabilitation (AAPM&R) annual assembly, to be
                Lance Sloan, M.B., Ch.B., f.R.C.P.
                                                      held in Atlanta this year, will include the International
                    Consultant in Rehabilitation
                                                      Society for Physical and Rehabilitation Medicine
                   Medicine, fife Rehabilitation
              Service, nHS fife (part of national     (ISPRM). On Nov. 16, the two organizations will present
                 Health Service Scotland) (CARf       an international symposium chaired by Puerto Rican
                   Accredited); Honorary Senior       physiatrist William Micheo, M.D.
                Lecturer at the University of St.
                                                          This global gathering of physiatrists will include
                         Andrews, fife, Scotland
                                                      presentations on the implementation of International
                                                      Classification of Functioning, Disability, and Health
Abhishek Srivastava, M.B.B.S., M.D., D.n.B., Ph.D.
                                                      (ICF), international developments in PM&R research and
                      Specialist in neurological      disaster relief. Occurring just days after the Nov. 6 U.S.
                  Rehabilitation and Director at
               the Center for Physical Medicine       presidential election, much of the hallway banter will
                    & Rehabilitation, Kokilaben       surely focus on the future of healthcare policy and its
                Dhirubhai Ambani Hospital and         impact on rehabilitation medicine in the United States.
                    Medical Research Institute,           In advance of the symposium, Pinnacle polled a panel
                                  Mumbai, India
                                                      of PM&R experts from India, New Zealand, Saudi Arabia
          Xianghu Xiong, fAfRM (RACP), M.B.B.S.
                                                      and Scotland. They discussed PM&R practice and policies
                                                      in their parts of the world.
               Medical Director, Burwood Spinal
               Unit, Christchurch, new Zealand

Pinnacle: It’s been 11 years since the World Health Organization              example, the management of spasticity is being changed. Previously,
(WHO) endorsed ICF. How is this new way of looking at health and              the management was mainly about reducing the degree of muscle
disability being implemented in PM&R practice and/or research?                tone. Now, there are many techniques that use spasticity for certain
Dr. Sloan: As a service, we use the ICF model in the assessment               functions, like standing.
and rehabilitation planning process. It is the foundation underlying
PM&R practice, and I think that is recognized in Scotland. We are             Dr. Srivastava: ICF is not used much in the developing world due
involved from shortly post-injury right through to hospital discharge         to lack of impetus, lack of awareness among clinicians and lack of
and potential return to work. As part of the process, for instance,           uniformity in standards of care in PM&R practice. In India, a coun-
when a patient is near discharge from the inpatient program, our              try with a huge population, there are only 500 active, trained phys-
therapists will do a home visit to assess the patient’s function with-        iatrists. Rehabilitation services are not coordinated by physiatrists
in that setting. They’ll assess the patient’s ability on stairs, the access   or, in fact, by any trained physicians. It’s provided by a therapist in
in and out, equipment needed to help in the kitchen and/or bathroom,          isolation. And due to a lack of uniformity in the training curriculum,
and the need for care support. They’ll identify any further goals             the implementation of standards of care is difficult.
that need to be set and liaise with community colleagues regarding
those. After discharge from the inpatient program, we follow up
with them as outpatients. This includes assessing their potential to          Pinnacle: International classification and standardization of
return to work. Again, this will involve multidisciplinary input.             practice is an important element of success. However, are there
                                                                              ways in which the differences in PM&R practices around the world
Dr. AboAbat: From our perspective, ICF helped us to systematically            are a good thing? In other words, is there something to be said for
focus on capitalizing on strength and capabilities. For                       tailoring PM&R practice to the community in which you’re working?

                                                                                                                             3   the pinnAcLe oF rehAbiLitAtion cAre
                        poinT of view

                                                                                      “What do you hope conference attendees will
                                                                                         learn from the International Symposium?”

    Dr. Xiong: I do believe that appropriate classifications and   Pinnacle: Can you share any exciting developments in PM&R
    related recommendations of management should be pro-           research in your country?
    moted internationally. However, we should always have          dr. sloan: There is important work on neuroregeneration being
    PM&R practice tailored to the communities as appropriate.      done at the University of Glasgow, where the focus is on strokes,1 and
    An example is the comprehensive spinal cord service            the University of Edinburgh, which is focusing on demyelination.2
    system in New Zealand and Australia, where patients with       My own service in Fife is involved in a multicenter trial looking at the
    significant spinal cord injuries (SCI) can receive immedi-     effect of dopamine in post-stroke rehabilitation.3
    ate systematic care and rehabilitation followed by coordi-
    nated and comprehensive lifelong follow-up. Such a sys-        dr. srivastava: I’ve co-authored studies involving neuroplasticity
    tem incorporates the rehabilitation into acute medicine,       and neuroregeneration following brain injury and stroke,4 as well as
    surgery, and even emergency and ICU care. Then there’s         research about newer modalities like instrument-based locomotor
    long-term follow-up of the patients in terms of health-re-     training, music therapy, yoga and Ayurveda improving rehabilita-
    lated surveillance and promotion of function in the com-       tion outcomes for those with neurological disability. 5, 6
    munity – returning to work, returning to social and family
    roles, and being an overall successful contributor to soci-    Pinnacle: The U.S. healthcare system is at a historic crossroads.
    ety. This approach may not be possible in a less-resourced     Can you fill us in on how health insurance and medical policies
    community where the focus would be more in the area of         are affecting the field of rehabilitation in your country? What
    prevention and management of complications for people          changes do you anticipate in the near future?
    with significant spinal cord injuries – where the primary
    goal is simply survival.                                       dr. Xiong: In New Zealand, we fortunately have a very good public
                                                                   system, namely the Accident Compensation Corporation. It covers
    dr. srivastava: Exactly. Rehabilitation medicine is a new      all sorts of conditions that are injury- or trauma-related, including
    specialty in India. Leave aside the general population,        medical treatment of injuries. Under this system, the philosophy is
    even most physicians are not aware of it. It’s not a subject   ‘non-fault,’ and patients with injuries get coverage in a very timely
    in the undergraduate medical school curriculum, and            manner. Therefore, there’s not a strong focus on litigation. However,
    only a dozen places offer residency positions in PM&R.         we do have challenges, especially in relation to patients with high-
    The average daily wage in India is $2. In those areas,         cost services, including serious spinal cord injuries, traumatic brain
    accessibility and affordability of healthcare is a big con-    injuries (TBI), multi-trauma patients, and those with chronic pain
    cern. These people are unable to afford even primary or        and disabilities. I would anticipate in the near future that there will
    acute care. Bearing the cost of long-term rehabilitation       be a stronger focus on rehabilitation so that better functions can be
    services is even more difficult. But average daily income      achieved with less of a care burden for society.
    is growing in urban centers, especially in big cities like
    Mumbai, where I practice. People who can afford reha-          dr. sloan: My own service is part of the National Health Service in
    bilitation services and want a better quality of life are      Scotland. Budgets are devolved from the central government to each
    asking for them.                                               area’s health board. Therefore, we have an annual allotted budget.
                                                                   Like everyone, we have faced difficult financial times in recent years,
    dr. aboabat: In Saudi Arabia, it’s cultural and religious      and there is little prospect of any significant development money in
    needs that many times drive our rehabilitation goals.          the near future. The local five-year strategy just announced by our
    Because families here are very supportive, we rarely find      district health board has a number of priorities, which include meet-
    a patient living alone. Therefore, most of the patients are    ing ER waiting times, reducing length of stays in acute hospitals and
    not very interested in learning to negotiate the activities    developing services for older people. Because rehabilitation is not
    of daily living. Their goals mainly target religious ob-       stated as a priority, we are going to have to be innovative and look to
    servance. How will they perform prayer (salat)? And for        propose services, which will assist these other goals.
    men, how will they go to the mosque five times a day?
                                                                   dr. aboabat: Our government believes in providing the highest pos-
                                                                   sible medical and rehabilitative services to all Saudis free of charge

as deemed appropriate, and that will not change any time soon.
Right now, we do not have any financial restrictions for provision
of our services, and our top priority is provision of the highest
quality services. If at some point in time we have financial limita-
tions, then it may affect our priorities.

dr. srivastava: Rehabilitation is a new concept in India, and thus
we are facing major challenges. The good thing is that, because of
insurance, some people are able to afford medical and rehabilita-
tion care. The flip side is that the insurance companies don’t allow
integrated inpatient care for rehabilitation-only purposes. With
                                                                                                                                                             * “Rehabilitation is a new concept in
time, we expect that as more of the population has medical insur-                                                                                              India, and thus we are facing major
ance, the disease-specific support groups can exert pressure on
the state and insurance companies to provide increased coverage
for people with disabilities.                                                                                                                                  challenges. The good thing is that,
Pinnacle: What do you hope conference attendees will learn from
the International Symposium? What aspect of the symposium are
                                                                                                                                                               because of insurance, some people
you most looking forward to?
dr. srivastava: The International Symposium should focus on                                                                                                    are able to afford medical and
standardizing some aspects of PM&R practice, especially the as-
sessment and documentation of impairments and disability. (The
ICF model is a good example.) But there should be a discussion                                                                                                 rehabilitation care. The flip side is
on how PM&R practice needs to be tailored to the socio-economic
demographic profile and the problems of the community.                                                                                                         that the insurance companies don’t
dr. Xiong: I always regard the International Symposium as an
excellent platform for education, communication and professional                                                                                               allow integrated inpatient care for
networking. The results from well-planned research projects
should be presented, and the state of the art in various sub-spe-
cialties should be addressed and promoted. Personally, my inter-                                                                                               rehabilitation-only purposes.”
ests are in the field of spinal cord injuries, traumatic brain injury
and pain medicine. I also have interest in the systems of care in
the field of rehabilitation medicine, such as in relation to spinal                                                                                            ABHISHEK SRIVASTAVA, M.B.B.S., M.D., D.n.B., PH.D.
cord injuries and traumatic brain injury.
                                                                                                                                                               Specialist in neurological
1 www.gla.ac.uk/researchinstitutes/neurosciencepsychology/researchcentres/centreforstrokeandbrainimagingresearch
2 www.cnr.ed.ac.uk
3 www.eme.ac.uk/projectfiles/084361protocol.pdf
                                                                                                                                                               Rehabilitation and Director at
4 Abhishek Srivastava, AB Taly, A Gupta, S Kumar, T Murali. Post stroke Balance Training: Role of Force Platform with Visual Feedback Training. Journal of
  Neurological Sciences 2009; 287:89-93                                                                                                                        the Center for Physical Medicine
5 Abhishek Srivastava, A Gupta, AB Taly, T Murali. Surgical Management of Pressure Ulcers during Inpatient Neurological Rehabilitation: Outcomes for
  Patients with Spinal Cord Disease. Journal of Spinal Cord Medicine 2009; 32(2): 125-131                                                                      & Rehabilitation, Kokilaben
6 Abhishek Srivastava, A Gupta, AB Taly, T Murali. Surgical Management of Pressure Ulcers during Inpatient Neurological Rehabilitation: Outcomes for
  Patients with Spinal Cord Disease. Journal of Spinal Cord Medicine 2009; 32(2): 125-131                                                                      Dhirubhai Ambani Hospital and
                                                                                                                                                               Medical Research Institute,
                                                                                                                                                               Mumbai, India

                                                                                                                                                                                                                    5   the pinnAcLe oF rehAbiLitAtion cAre

Best practices from acute-care hospitals shed light
   on better transitions between levels of care.

                 By MICHELE COHEN MARILL

                                                      7   the pinnAcLe oF rehAbiLitAtion cAre

                      ong before his discharge, the patient was a red flag for readmission,
                      and his physicians and nurses knew it. A man in his 50s with C-2
                      quadriplegia, he was dependent on a ventilator and had a history of
                      pressure ulcers. In fact, a couple of times during his stay at Shepherd
                      Center in Atlanta, he was rushed into the intensive care unit and required
                      cardiopulmonary resuscitation.
                       Yet nine months after discharge, the patient had defied the odds. Thanks
                     to careful planning and education, the patient and his family handled the
                     inevitable health issues without a single hospital admission.
     Preventing hospital readmission is a challenge when caring for patients with the
    complex medical consequences of spinal cord injury (SCI) or traumatic brain injury (TBI).
    But it is also an imperative, especially as payers shift to reimbursement for outcomes
    rather than services.
       Acute-care hospitals face a penalty for a high rate of prevent-     Shepherd Center in Atlanta. He is leading a team to redesign a
    able readmissions within 30 days of discharge for certain condi-       post-discharge program for Shepherd patients.
    tions. Their best practices can help guide rehabilitation facilities      Something may trigger their concern, such as cloudy urine or
    to a successful transition for their patients.                         a low-grade fever. “They’re uncertain. They’re not confident in
       “The crucial factors are good medical care in the institution,      managing their care, so their default is to go to the emergency
    well-planned discharge and frequent, appropriate follow up,”           room,” Dr. Jones says. Patients need formal and informal ways to
    says Kristjan T. Ragnarsson, M.D., professor and chairman of the       get answers and support, he adds.
    Department of Rehabilitation Medicine at Mount Sinai School of            A system of follow up enables some acute-care hospitals
    Medicine in New York City.                                             to achieve low readmission rates, says Sharon Silow-Carroll,
       Medical care is a continuum, and outcomes will be viewed            M.S.W., M.B.A., managing principal with Health Management
    across that continuum. With healthcare reform, a new para-             Associates, a health policy research and consulting organiza-
    digm is emerging as providers collaborate across the silos of          tion in New York City. Silow-Carroll analyzed best practices
    care – acute care, post-acute care, skilled nursing facilities,        related to reducing avoidable readmissions in a report for The
    home health and community-based care, says Cheri Lattimer,             Commonwealth Fund, a private foundation that supports health-
    R.N., executive director of the National Transitions of Care           care research.1
    Coalition and the Case Management Society of America in                   At the best-performing hospitals, patients arrange a post-dis-
    Little Rock, Ark.                                                      charge appointment with a physician even before they leave the
       “It’s really a quality improvement process in delivering a          hospital. Nurses call within 24 to 48 hours of discharge to check
    better healthcare experience to patient and family caregivers,”        on patients. And in some cases, telemonitoring devices provide
    she says.                                                              information to nurses via a phone line, or patients are instructed
                                                                           to call in every day with their vital signs.
                                                                              “Communication is just so critical,” Silow-Carroll says. Some
    avoiding The emergency room                                            electronic medical record systems provide patients with a portal to
    Consider how the SCI patient and family caregivers feel when they      send questions to physicians or other providers and to access their
    first arrive home after post-acute rehabilitation. They saw educa-     discharge instructions or other information, she says.
    tional videos, had one-on-one instruction and even practiced per-         Social media also may provide new ways to reach discharged
    forming caregiving duties, including bowel and bladder care. They      patients. Shepherd Center is building a web-based portal that
    have written discharge instructions and a guidebook.                   will give patients a Facebook-like forum to interact and seek
       Still, they feel completely overwhelmed. “There’s that moment       information, Dr. Jones says.
    of anxiety when you first get home and say, ‘Now what?’” says             Shepherd Center also plans to connect patients with peer
    Mike Jones, Ph.D., vice president of research and technology at        mentors, people who have been living with a similar medical

         Pneumonia                       Urinary tract infection is the most common cause of hospital readmission for patients with spinal cord injury.1
    is a frequent cause of
   rehospitalization among              About one in five people who receive post-acute                                pressure ulcers are a leading cause
   patients with tetraplegia             rehabilitation care for traumatic brain injury are                           of rehospitalization for patients with
                                        hospitalized within a year of discharge. The most                           paraplegia (T-1 to s-5 asia grades a, B, c).1
     (C-1 to C-8 American
                                        common reason is orthopedic or reconstructive
   Spinal Injury Association
                                           surgery. Seizures and psychiatric difficulties                        More than one-third of patients with SCI are
    [ASIA] grades A, B, C)1               increase five years after the initial discharge.3                      rehospitalized within the first year after discharge.2
                                                                                                            1. Cardenas DD, Hoffman JM, Kirshblum S and McKinley W. Etiology and incidence of rehospitalization after traumatic

About half of Medicare patients who are readmitted within 30 days
                                                                                                               spinal cord injury: a multicenter analysis. Arch Phys Med Rehabil 2004; 85:1757-1763.
                                                                                                            2. Davidoff G, Schultz JS, Lieb T, et al. Rehospitalization after initial rehabilitation for acute spinal cord injury: incidence and
                                                                                                               risk factors. Arch Phys Med Rehabil 1990; 71:121-124.

 of a hospital stay had not seen a physician after their discharge.4
                                                                                                            3. Marwitz JH, Cifu DX, Englander J, and High WM. A multi-center analysis of rehospitalizations five years after brain injury.
                                                                                                               Journal of Head Trauma Rehabilitation 2001; 16:307-317.
                                                                                                            4. Jencks SF, Williams MV, and Coleman EA. Rehospitalizations among patients in the Medicare fee-for-service program. N
                                                                                                               Engl J Med 2009; 360:1418-1428.

condition. They will meet those peers while they are in the facility.           Meanwhile, the Center for Medicare & Medicaid Services (CMS)
“Peers will be leading the instructional program,” he says.                  is penalizing hospitals with high 30-day readmission rates for cer-
   A new Shepherd Center program called 3-2-Free puts patients in            tain conditions. SCI and TBI are not yet part of that initiative, but
charge in their last days before discharge as a kind of dress rehearsal      rehabilitation physicians may still be affected by the paradigm
for being on their own. For example, patients request their medication       shift, Dr. Ragnarsson says.
and transport themselves to therapy appointments. In essence, pa-                “It has to do with value: Who can provide the most cost-effective
tients must demonstrate they are able to care for themselves.                care with the same outcome?” he explains. “Those are going to be
                                                                             the winners.”
undersTanding The new normal                                                    It won’t be possible to avoid all readmissions, especially among
Patients are a captive audience for education, but rehabilitation            medically fragile patients. But those high-risk patients can benefit
providers face a greater challenge educating other providers in              from special attention at discharge. For example, Shepherd Center
the community. There are only about 12,000 new cases of SCI each             is developing a SWAT team model to support the most vulnerable
year,2 which means many primary care physicians have never                   patients, such as those discharged with a feeding tube or ventilator,
cared for a person with SCI.                                                 Dr. Jones says.
  It’s easy to misinterpret findings that look abnormal, but are actu-          “Many problems are unavoidable, but that doesn’t mean they
ally within the normal range for a patient with SCI, says Anna C.            need hospitalization,” he says.
Elmers, M.D., a physiatrist at Shepherd Center. For example, an                 Ultimately, a program to prevent hospital readmission involves
emergency room physician may suspect pneumonia (a common                     a focus on quality. “If there is a financial incentive for a hospital
cause of readmission) after viewing the chest X-ray of a patient             or rehabilitation center to keep that patient healthier, then you are
with quadriplegia.                                                           really looking at promoting patient- and family-centered care and
  In fact, that X-ray may show atelectasis caused by the inability to        better health outcomes,” Silow-Carroll says.
clear secretions, explains Andrew Zadoff, M.D., Shepherd Center’s
                                                                             1. Silow-Carroll S, Edward JN, and Lashbrook A. Reducing hospital readmissions: Lessons from top-performing hospitals. Synthesis Report. The
medical director of intensive care and pulmonary services. A quick           Commonwealth Fund, New York, N.Y., April 2011.
                                                                             2. National Spinal Cord Injury Statistical Center. Spinal cord injury facts and figures at a glance. February 2012, Birmingham, Ala. Available at
blood test would reveal that the patient’s white blood count is not          www.nscisc.uab.edu/PublicDocuments/fact_figures_docs/Facts%202012%20Feb%20Final.pdf. Accessed on July 12, 2012.

elevated. “We’re trying to get people to understand that our patient
population is different,” he adds.
  Having ready access to previous X-rays and medical records
can help forestall problems. In some cases, patients might be dis-
charged with a copy of their most recent X-rays, which were ana-                   A VICToRy foR TBI PATIEnTS
lyzed by a pulmonologist, Dr. Zadoff explains. Electronic medical
records also could improve the connection between primary care                     Close to 10 million Americans are living with disabilities
physicians and specialists.                                                        caused by traumatic brain injury (TBI) and stroke.1 But
  Good transitions rely on a link between the levels of care, Lattimer             even patients with insurance often find it difficult
says. Case managers can help identify services in the community                    to get the rehabilitation care they need.
and facilitate communication among providers, she adds.
                                                                                   That will change with new national standards for public and
a BeTTer paTh for cosT and QualiTy                                                 private insurers put in place by the Affordable Care Act, says ford
Preventing unnecessary readmissions is good medicine, but it is                    Vox, M.D., a physiatrist who treats patients with brain injury at
also good business. The Affordable Care Act encourages new                         Shepherd Center in Atlanta. Dr. Vox shared his views on how the
models of payment that reimburse for outcomes rather than fee for                  Affordable Care Act will benefit patients with TBI in The Atlantic
service – and this makes readmissions costly for providers.                        at http://bit.ly/PHmi2c.
  Rehabilitation providers may receive bundled payment, which is
payment for an episode of care, or they may become part of an ac-                  1 Brain Injury Association of Pennsylvania, www.biapa.org/site/c.iuLZJbMMKrH/b.1761669/k.D748/Glossary.htm.

countable care organization (ACO), in which doctors and hospitals
have financial incentives to coordinate the care of a patient.

                                                                                                                                                                                                   9      the pinnAcLe oF rehAbiLitAtion cAre

   P werX
Forw rd
  new exoskeleton makes walking
 possible for some people with sCI.

                                                        11   the pinnAcLe oF rehAbiLitAtion cAre

                          or some people with spinal cord injury (SCI), powered exoskeletons
                     promise a great leap forward in mobility and a range of related
                     physiological and psychological benefits. But designing a device that
                     is compact and lightweight enough to promote independence, yet still
                     affordable enough for widespread use, has proven to be a challenge.
                          A new device produced by a team of engineers at Vanderbilt
                      University in Nashville in collaboration with clinical personnel at
                      Shepherd Center in Atlanta, may be a breakthrough in the field. The
                      Vanderbilt exoskeleton weighs just 27 pounds and can snap apart to fit
     into a backpack. Unique among such devices, the exoskeleton is designed to allow a
     person with paraplegia to carry the device to a public place on the back of a wheelchair,
     assemble it, put it on, take a walk and return to a wheelchair without assistance.

     The Vanderbilt exoskeleton is the first of its kind to incorporate       notes. That profile includes some people with SCI as high as
     functional electrical stimulation, or FES, in which small                the lower cervical cord. The wearer controls the device by
     electrical pulses are applied to paralyzed muscles.                      leaning his body forward, backward or to the side. Dr. Goldfarb
     Research shows FES can enhance muscle strengthening                      compares it to a “legged Segway.” It has been tested on steps,
     and neuromuscular re-education. Now on the verge of                      curbs and slopes up to five degrees.
     commercialization, the device may also become the most                      Dr. Goldfarb’s team is now testing the FES function, which
     affordable exoskeleton on the market. The FDA has already                activates the patient’s musculature while working in tandem
     approved two other exoskeletons for clinical use. Meanwhile,             with the exoskeleton’s motors. “We use as much of the subject’s
     trials of the Vanderbilt device at Shepherd Center have                  muscle as possible and fill out the rest with the exoskeleton,” Dr.
     revealed some potential advantages of this exoskeleton.                  Goldfarb explains. “We want the control system to fuse with the
                                                                              musculature in a seamless way so the motors don’t fight
     a collaBoraTive efforT                                                   the muscles.”
     The Vanderbilt team has been consulting with Shepherd clinicians            By connecting the device to a laptop, the team can estimate
     on the device’s design. “I know as an engineer that if you try to do     the user’s contribution to the walking motion. For example, FES
     this without involving people with deep clinical expertise, it’s going   to Gore’s muscles contributes about 35 percent of the torque and
     to fail,” says device inventor Michael Goldfarb, Ph.D., head of          power of his walk in the exoskeleton. The FES operation does
     Vanderbilt’s Center for Intelligent Mechatronics.                        not noticeably affect the device’s operation, except the user’s
        Shepherd Center physical therapist Clare Hartigan, MPT, and           power contribution can extend its battery life. Dr. Goldfarb
     her colleagues helped the Vanderbilt team understand the impact          anticipates that a future version of the exoskeleton will use
     of an exoskeleton on people with paraplegia, including issues with       implanted, wireless electrodes to administer FES.
     skin care, blood pressure, spasticity and functional progression.
        “This device has real functional possibilities in the home
     or office environment,” Hartigan says. “I believe it has
     great promise as a gait training device, especially the FES
     component. Incorporating FES into gait is a huge advantage.”

     a four-hour walk
     Exoskeletons may never replace wheelchairs, Hartigan says,
     because chairs are so fast, safe, reliable and cost-effective. But
     the most common orthoses – leg braces and the FES-enabled
     Parastep system – used by people with paraplegia to aid mobility
     put most of the wearer’s weight on the shoulders. That design
     causes fatigue and risks a debilitating shoulder injury. So,
     these devices tend to go unused, Hartigan says. Exoskeletons
     carry the wearer’s weight, which makes walking much easier.
     Former Shepherd Center patient Michael Gore, a T10 complete
     paraplegic who has been testing the device for the researchers,
     has used the device for as long as four hours at a time.
       The Vanderbilt exoskeleton can be used by any person with
     the tricep and grip strength to use a stability aid, Dr. Goldfarb

a sTep Beyond                                                        Principal Engineer Ryan J. Farris says, “The price point for
The Vanderbilt team has finalized a licensing agreement for          the [Vanderbilt] device will be significantly lower than the
commercial sale of the device by Parker Hannifin Corp., a            published costs for either the ReWalk or the Ekso system.” The
Cleveland-based maker of motion and control technologies             company’s manufacturing experience and infrastructure should
ranging from aircraft wheels to pneumatic valves. The                help keep the price low, Dr. Goldfarb adds.
Vanderbilt device will be a relatively late entrant to a rapidly        For Gore, the Vanderbilt exoskeleton has been “the closest
growing field of powered exoskeletons.                               I’ve been to walking since my injury.” Of all the devices, he felt
   Two exoskeletons have received FDA approval for clinical          it was the easiest to learn and provided the greatest sense of
use – Ekso Bionics’ Ekso and Argo Medical’s ReWalk. Shepherd         control. Wearing it helps to relieve pain and provides exercise
is the only clinic to have tested both of these and the Vanderbilt   at the same time, he notes. And for people with paraplegia who
device, and Gore is the only subject to have used all three,         battle depression, Gore says, “Being able to stand up in the
Hartigan says. Based on exoskeleton testing at Shepherd              house or in public makes you feel a lot better emotionally.”
Center, Hartigan, Gore and Shepherd Center Medical Director             People who are interested in participating as research
Donald Peck Leslie, M.D., note some distinct advantages of the       subjects in the Vanderbilt exoskeleton trial at Shepherd Center
Vanderbilt device, which Parker Hannifin aims to submit to the       should complete the intake form available at
FDA for approval in late 2013.                                       www.shepherd.org/research.
   One issue is the degree to which the devices promote
                                                                     1 “Ekso’s Exoskeletons Let People Walk. Will Anyone Actually Wear One?” Fast Company, March 19, 2012. Accessed at
independence. The Ekso and the ReWalk, for example, each               www.fastcompany.com/magazine/164/ekso-bionics.

weigh about 45 pounds and require the wearer to use a
backpack. Because of their weight, size and design, both of
these devices also require a second person to transport and          Testing, testing...
set up the device before it is worn. The Vanderbilt device, by          There is a dearth of published data about the effectiveness of powered exo-
                                                                        skeletons – in part, because some have not been developed in academic
contrast, is designed to be transported, assembled, donned and          settings, says Vanderbilt University’s Michael Goldfarb, Ph.D., inventor of
doffed independently.                                                   the Vanderbilt exoskeleton.
   Another is the devices’ therapeutic value. The ReWalk’s
                                                                        As part of a five-year research and development project funded by the
double-crutch based gait mechanism does not allow the                   national Institutes of Health, the Vanderbilt engineering team is collaborat-
reciprocal arm swing of normal gait, Hartigan says. “A device           ing with Shepherd Center clinicians to test and evaluate the device. Based
that uses an upper- and lower-extremity reciprocal gait pattern         on data gathered in July 2012, the team plans to publish this fall the first
                                                                        journal paper employing standard metrics for functional efficacy and exer-
may be more intuitive to learn. For patients with SCI, a device         tion. The metrics include the Six-Minute Walk Text, Ten-Meter Walk Test,
that replicates ‘normal’ gait may potentially be more effective as      and the Timed Up and Go Test. These three functional gait assessments
a therapeutic tool.”                                                    have already been performed with research participant Michael Gore walk-
                                                                        ing with long leg braces on and then repeated with Gore walking with the
    Cost is another issue. An article in Fast Company magazine          Vanderbilt exoskeleton. Shepherd Center researchers expect to continue
earlier this year priced the Ekso at $130,000, though the               this testing with additional research participants.
company says it is aiming to produce a personal Ekso to
                                                                        Meanwhile, Dr. Goldfarb indicated in July that the numbers were look-
retail for $50,000 to $75,000 in 2014.1 Reports have indicated          ing good during trials with Gore, who was using the exoskeleton to walk
the ReWalk will cost $85,000 or more. Parker Hannafin                   through Shepherd Center.

                                                                                                                                                                                         13   the pinnAcLe oF rehAbiLitAtion cAre
     illustration by soloflight text by Paul Donsky


                            “Regardless of patient age, aggressive treatment of severe
                           TBI, including decompressive hemicraniectomy and invasive
                             monitoring, are cost-effective from a society perspective.”

                                                                                                               aggressive TreaTmenT of TBi may Be cosT-effecTive
                                                                                                               A study from researchers at the                                                      outcomes – at a cost of nearly $100,000
                                                                                                               University of Pennsylvania puts a                                                    less than “routine” care.1
                                                                                                               new perspective on the econom-                                                          “Regardless of patient age, aggres-
                                                                                                               ics of treating people with severe                                                   sive treatment of severe TBI, including
                                                                                                               traumatic brain injuries.                                                            decompressive hemicraniectomy
                                                                                                                  Spending for aggressive treat-                                                    and invasive monitoring, are cost-
                                                                                                               ment may be more expensive than                                                      effective from a society perspective,”
paTienTs wiTh sci may BenefiT                                                                                  routine care, but over the long run,
                                                                                                               it yields lower costs and better qual-
                                                                                                                                                                                                    says study’s lead author, Robert G.
                                                                                                                                                                                                    Whitmore, M.D., chief resident at the
from early surgery                                                                                             ity of life, according to the study,
                                                                                                               which appeared in the May 2012
                                                                                                                                                                                                    Department of Neurosurgery
                                                                                                                                                                                                    at Perelman.
                                                                                                               issue of Journal of Neurosurgery.                                                       The study is the first to show the
Surgery within 24 hours of a traumatic cervical                                                                   The researchers, from the                                                         financial benefit of intensive treat-
spinal cord injury (SCI) may significantly improve                                                             Perelman School of Medicine, looked                                                  ment of TBI patients. The results could
patient outcomes, according to a study from                                                                    at outcomes from 1,000 patients with                                                 impact the care of the 1.5 million
researchers at Thomas Jefferson University in                                                                  traumatic brain injury (TBI). After 20                                               each year who sustain TBIs,
Philadelphia, the University of Toronto and other                                                              years, patients who were treated ag-                                                 Dr. Whitmore says.
                                                                                                               gressively had significantly improved
major U.S. trauma centers.                                                                                                                                                                          1 Journal of Neurosurgery, May 2012, Volume 116, Number 5, Pages 1106-1113.

   The study, published Feb. 23, 2012 in the on-
line journal PLoS One, followed 222 patients for six
months after surgery. Those who were operated on
less than 24 hours after injury were 2.8 times more
                                                                                                               Trial under way for comBined
likely to experience “significant” neurological im-
provement of at least two grades on the American
                                                                                                               ischemic sTroke Therapy
Spinal Injury Association’s impairment scale.1
   The study is one of the first to indicate that the                                                          Researchers at vanderbilt University are leading an international clinical trial
timing of surgery after a traumatic SCI matters,                                                               testing the efficacy of a relatively new approach to treating ischemic stroke that
says study author Alexander vaccaro, M.D., Ph.D.,                                                              involves both medicine and the use of a vacuum-like device that gently suc-
professor of orthopedics and neurosurgery at                                                                   tions blood clots.
Thomas Jefferson. Previous research had indi-                                                                     The standard treatment for ischemic stroke involves the use of a clot-busting
cated that surgeons would wait up to five days                                                                 drug within 3 to 4 1/2 hours of the onset of symptoms. But often, the research-
in some cases to operate on a patient with SCI
without affecting outcomes, he says.                                                                           ers say, patients don’t arrive within that timeframe, or they have clots that are
   “This study tells you not to delay surgery if pos-                                                          too large to dissolve.
sible because it’s in the patient’s best interest to                                                              The vanderbilt trial, led by J. Mocco, M.D., is evaluating a combined therapeu-
do it earlier,” Dr. vaccaro says.                                                                              tic approach using clot-busting medication and the vacuum-like device, known
   To read the journal article, go to www.plosone.                                                             as the Penumbra System. The study will involve about 692 patients from 75
org/article/info%3Adoi%2F10.1371%2Fjournal.                                                                    treatment centers worldwide.
                                                                                                                  The Penumbra System was approved by the FDA in December 2007.1 If the
1 PloS One, online, Feb. 23, 2012. www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0032037
                                                                                                               study shows the Penumbra System is effective, Dr. Mocco says, “There will be a
                                                                                                               tremendous shift in the availability of this potentially life-saving therapy.”
                                                                                                               1 Endovascular Today, September, 2009, pages 62-66 http://bmctoday.net/evtoday/2009/09/article.asp?f=0909_06.php

                                                                                                                                                                                                                                  15     the pinnAcLe oF rehAbiLitAtion cAre
                illustration by soloflight text by Paul Donsky
                                                                                                                             “Preventing the loss of bone in
                                                                                                                             people with SCI should reduce
                                                                                                                             the number of fractures and
                                                                                                                             may improve their health,”
                                                                                                                             RICHARD SHIELDS, P.T., PH.D., UNIvERSITy OF IOWA

                        elecTrical sTimulaTion
                      may slow Bone densiTy loss
     A study from researchers at the University of Iowa suggests that      patients receiving low-dose and no-dose loads was, on average,
     bone density loss in people with spinal cord injury (SCI) may be      40 percent lower than that of patients receiving high-dose loads.
     slowed significantly by using electrical stimulation on muscles          While previous research has suggested that building up mus-
     to simulate weight-bearing activity.1                                 cle tissue could slow the loss of bone density in people with SCI,
        The loss of bone density is a common complication of SCI, plac-    the Iowa study is the first to quantify the most effective load dose
     ing patients at great risk of fractures and other medical problems.   of stimulation, says Richard Shields, P.T., Ph.D., director of the
        The study, published in the December 2011 issue of                 University of Iowa physical therapy and rehabilitation science
     Osteoporosis International, compared the bone density of pa-          graduate school programs.
     tients who received “high doses” of stimulation equivalent to            Dr. Shields’ research team is pursuing a large-scale clinical
     150 percent of their body weight to patients who received “low-       trial to determine if these results can be generalized to all peo-
     dose” loads of 40 percent of body weight and “no-dose” loads          ple with SCI.
     of 0 percent body weight. Patients performed weight-bearing              “Preventing the loss of bone in people with SCI should reduce
     simulations at home five times a week for three years.1               the number of fractures and may improve their health,” he says.
        The results showed that only high-dose loads were effective.
     For example, the study found that bone density in the femur of        1 Osteoporosis International – 2011, DOI: 10.1007/s00198-011-1879-4


Doctors have long struggled to treat                   use and communication) were more
people with severe brain injuries who are              common in the amantadine group.
either in a state of limited consciousness             Five of the six behaviors were still
or in a “vegetative” condition.                        more common in this group two weeks
   But a team of researchers has shown                 after the drug was stopped, but the
that amantadine, a drug used to treat                  differences between groups diminished.1
the symptoms of Parkinson’s disease,                       Amantadine is known to boost
can speed recovery for patients with                   levels of dopamine, a neurotransmitter
severe brain injury. The findings were                 active in parts of the brain that control
published in the March 1, 2012 edition of              movement and alertness. Doctors have
the New England Journal of Medicine.1                  used the drug off-label in brain injury
   The study followed 184 patients                     rehabilitation, but the study is the first
with severe brain injuries. About half                 large randomized trial to demonstrate its
received amantadine over a month-                      effectiveness, Dr. Whyte says.
long period, while the rest were given                    “Until now, we have taken care of TBI
a placebo. All were treated within four                patients medically and tried to maintain
months of being injured.1                              their bodily health while we waited for
   Those who received amantadine                       neurologic recovery to occur, but we had

showed faster improvement, says study                  no firm evidence that we could influence
co-author John Whyte, M.D., Ph.D.                      that recovery directly,” he explains.
director of the Moss Rehabilitation                    “We’re still a long way from an ‘optimal’
Research Institute near Philadelphia.                  treatment, but I think we’re more

                                                                                                                    a FaCtOr In
   After four weeks of treatment, all six              confident that it’s not a futile search.”
behavioral indicators of consciousness
(such as command following, object                     1 New England Journal of Medicine, Vol. 366, pages 819-826

   “More research is needed before the                                   of electrical stimulation                  COMpLICatIOns
                               ERIK SHAW, D.O., SHEPHERD PAIN INSTITUTE
                                                                                                                    A patient’s gender should be taken into ac-
                                                                                                                    count when considering the risks of brain
                                                                                                                    or spinal surgery, according to a study
                                                                                                                    from researchers at Columbia
 spInaL COrd stIMuLatIOn MaY ease                                                                                   University and the University of Michigan.1
                                                                                                                       The study, published in the April 2012
                                                                                                                    issue of the journal Neurosurgery, found
  CHrOnIC paIn In peOpLe WItH sCI                                                                                   that men are nearly twice as likely as

                                                                                                                    women to experience complications fol-
                                                                                                                    lowing neurosurgery.1
Research from a team of rehabilitation specialists suggests that electrical stimula-                                   The researchers, led by Abdulrahman
tion of the spinal cord may be an effective treatment for chronic neuropathic pain in                               M. El-Sayed, Ph.D., with the Department
people with spinal cord injury (SCI).                                                                               of Epidemiology at Columbia University,
   In the study, 12 people with varying degrees of spinal cord injury were treated                                  evaluated the surgical outcomes of
with electrical stimulation, which blocks pain by interrupting the nerve impulses                                   918 people and found that about 20
that generate pain sensation. After a week-long trial (percutaneous or surgical), 10                                percent of men faced post-surgical
of the 12 experienced pain relief of greater than 50 percent, says the study’s principal
                                                                                                                    complications compared to 11 percent
                                                                                                                    of women. The complication rates in
investigator, Erik Shaw, D.O., an interventional pain management specialist at the                                  men were twice as high even after
Shepherd Pain Institute at Shepherd Center in Atlanta.                                                              adjusting for other factors, such as age,
   The findings were presented in a poster at the May 2011 meeting of the International                             tobacco use and high blood pressure.
Neuromodulation Society. While the results are encouraging, Dr. Shaw says more                                         While the study did not set out to ex-
research is needed before the use of electrical stimulation becomes widespread                                      plain the difference in outcomes, Dr.
in combating chronic neuropathic pain. Electrical stimulation should be used only                                   El-Sayed says various factors might play
after more conservative therapeutic measures, such as medication and physical                                       a role, such as the effects of estrogen,
therapy, are exhausted, he adds.                                                                                    which is known to protect brain health.
   Researchers note that the use of spinal cord stimulation clinically for pain manage-
ment is distinct from spinal cord stimulation being studied experimentally for augment-                             1 Neurosurgery, Volume 70, Issue 4, Pages 959-964
ing stepping and managing spasticity in Shepherd Center’s SCI Research Program.

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