Discovery

Tools of Ohio State’s Innovative Physical Rehabilitation Programs

By Sandra Gurvis

Consistently ranked as one of the top 10 rehabilitation programs in the country by U.S.News & World Report, Ohio State’s Department of Physical Medicine and Rehabilitation and the research, training and empowering patient care services they provide at Dodd Hall not only help patients regain control of their lives but also set the standard for caregivers worldwide.

As recently as the late 1950s, people with disabilities were placed in “homes for the incurable,” forgotten by society in general and deemed hopeless, sometimes even by their family and friends.
 
But Dodd Hall and Ohio State’s Department of Physical Medicine and Rehabilitation (PM&R) have helped change all that, although some of the equipment and techniques are “from the days when patients were being treated for polio,” observes William Pease, MD, the Department’s chair and medical director and holder of the Dr. Ernest W. Johnson Professorship in PM&R. Old–school items like wall–mounted ropes and pulleys to restore upper–body strength are used in tandem with the latest technology and research in robotics, neurorecovery from spinal cord trauma and rehabilitation for stroke and brain injury, among many other programs.

Ohio State’s Rehabilitation Program at Dodd Hall has become the go–to place for those who want to take back their lives after an accident, stroke or other debilitating injury or illness.  Along with being ranked among the top 10 of U.S.News & World Report’s “Best Hospitals” in Rehabilitation for 15 consecutive years, Dodd’s five specialty programs – acute care, brain injury, spinal cord injury, stroke and orthopedics – earned a three–year accreditation by the Commission on Accreditation of Rehabilitations Facilities (CARF), making it the first and only rehabilitation center in Ohio to receive this level of certification.
  
Although recognition is important, “Our focus is on working together as a team to actively involve families and customize services to meet each patient’s needs,” adds Pease. And the results speak for themselves:  According to eRehabdata.com and IT Health Track, former Ohio State Rehabilitation patients demonstrate higher functional improvement and, three months after discharge, have a higher functional ability than those from most other rehabilitation centers in the country.

Putting a Life Back Together Again
Like the nursery rhyme, rehabilitation physicians and psychologists, nurses and therapists, social workers and dietitians face the unique challenges of putting patients’ lives back together again. In addition to being a leader in acute rehabilitation, Ohio State’s Brain Injury Program is one of only 16 model systems for this type of care in the U.S. They work closely with the Traumatic Brain Injury (TBI) Model Systems program, a national network and database for brain injury treatment funded by the U.S. Department of Education. According to the TBI database, an impressive 96 percent of former Ohio State Rehabilitation patients live in home settings.

With brain injuries in particular, “It’s very difficult to predict outcomes,” explains Jerry Mysiw, MD, (pron. “MISS–you”) director of Traumatic Brain Injury Rehabilitation and holder of the Bert C. Wiley M.D. Endowed Chair in PM&R. “Our job is to help people from the time they emerge from a coma to their return to work and school. The relationship can be brief – they can make a wonderful recovery – or it could take 5–10 years for them to rebuild their lives.” To this end, an individual treatment program is developed and based on each patient’s needs, with consideration for orientation, memory, communication and behavior.

As a result of their work with such patients, Mysiw and other Ohio State researchers are setting standards for the care of rehabilitation patients worldwide. For example, they are looking at the length of time a patient is disoriented after emerging from a coma. Symptoms can include “post–traumatic amnesia, short–term memory loss and a high level of distraction,” Mysiw continues. In general, “the shorter the period, the better the outcome. Outcomes may not be as good with longer incidents of disorientation.”

Additional research on sedating agents – “They actually have a paradoxical, worsening effect, while medications that improve alertness and attention get a better response” – and long–term studies that track physical, behavioral, and motor changes, among other aspects, are additional areas of interest. “Our goal is to understand how [various aspects of brain injury] progress over time and to develop better intervention techniques. We look at the full spectrum of activity, from physical strength to muscle tone, to coordination, to balance and more,” Mysiw says.

Helping Patients Walk Again
Ohio State’s Spinal Cord Injury Program is among only seven centers in the country to receive a grant from the Christopher and Dana Reeve Foundation for locomotor training for individuals recovering from incomplete spinal cord trauma. D. Michele Basso, PT, EdD, is clinic director for the grant, while Dr. Mysiw is lead physician and co–investigator and Bob Vanecko administrator. This is in conjunction with what Pease likes to call “forced–use” therapy, also known as constraint–induced (CI) therapy, which is also used in areas ranging from stroke to orthopedics. “An example is restraining the good arm so the patient re-learns how to use the injured one. Often, tasks will simultaneously involve both hands” so as not to become so difficult that the patient becomes discouraged and gives up.

“For the past several years, we’ve been doing clinical trials with ambulation training, forcing the legs into a walking pattern, while the patient is supported by a body harness,” Pease adds. This method involves a treadmill, harness and pulleys, and mirrors so patients can see their progress. The Reeve Foundation grant enables researchers to focus on the fact that the nerves below the injury are still alive, if only as a reflex connection. They can still move in a stepping pattern, allowing for the possibility that the patient may again walk someday. Very few spinal cords are completely cut, so most have some preservation of connections.
 
This has particular relevance to younger patients. “Traumatic spinal cord injury is more common among young, otherwise healthy individuals,” explains Director of Spinal Cord Injury Rehabilitation Sam Colachis, MD. With the strength and endurance of youth on their side, these patients can readily tackle the repetitive and physically stressful challenges of learning to walk again.

Injuries also need to be relatively recent. “Over a period of time, bones can become osteoporetic and weak and lose their flexibility, just like muscles,” observes Pease.

Adds Colachis: “Spinal cord trauma is one of the most catastrophic injuries a person can endure.” In addition to pain, patients must also deal with autonomic dysreflexia, a potentially life–threatening condition in which an irritating stimulus such as an overfull bladder can affect the body below the injury, resulting in hypertension, pressure ulcers, erratic fluctuations in body temperature and other complications. “We’re constantly collecting information and trying to spot trends, so we can educate the community and physicians as to the best care of these patients.”
 
Robots and Other Innovations in Stroke Rehabilitation
Ohio State’s Stroke Rehabilitation Program, the first in Ohio to be awarded CARF accreditation, uses cutting–edge therapies – from experimental trials to treat aphasia and speech problems to electromyography to bring back motor skills. Other advances include vibratory equipment to help restore balance, and a fiber optic device that can see food being swallowed so “we can see exactly what’s going on and prevent choking problems that could affect breathing and respiration,” states Sharon McDowell, MD, director of Stroke Rehabilitation.
 
Among other things, “we’re setting up a state–of–the art gait lab” to help restore walking ability and other movement. McDowell, who received engineering training at MIT, is also working with developing robotic therapy to be used in conjunction with CI in recovering arm movement for stroke patients.

A disadvantage of CI/forced–used therapy is that it can be exorbitant in terms of time and money, requiring as much as six hours of work per day with a physical therapist for several weeks. By their very nature, robots can be more cost–effective and “can work for hours without a therapist,” remarks Pease. “The question we’re examining right now is, ‘will robotic
therapy be as effective?’”

Spasticity – brain injury that sometimes causes muscles to involuntarily contract, creating stiffness and tightness – is also common among stroke patients. “We’re looking at innovative ways of treating spasticity, a combination of nerve blocks, medications and pumps that will help avoid contractions and other movement disorders,” explains McDowell. Additional research involves collaboration with neuro–optometrists and neuroscientists to evaluate and treat vision defects, and advanced functional brain imaging to examine and assess brain recovery.

McDowell, who admittedly finds herself pulled in many directions, obtains her greatest satisfaction not just from her numerous research endeavors but in results with patients.  “Seeing their progress is infinitely rewarding.”

The Full Spectrum
Although each of Ohio State’s rehabilitation programs is relatively autonomous, there’s a constant interchange of information, research and expertise. “In the past, physical and occupational therapists worked independently of each other,” observes Pease, who has edited and contributed to texts on everything from general principles and practices of physical medicine and rehabilitation to specialties such as electromyography and walking problems. “Today they work together to make sure patients not only gain mastery of the required motions but also the practical skills of everyday living.”

Patients of all abilities visit the various gyms in Dodd Hall, the facility at the center of Ohio State’s Rehabilitation Program, each day for specific types of exercise, the mock kitchen to re-learn cooking skills and, if necessary, the wheelchair seating and positioning clinic to improve mobility. There’s even an apartment where they can stay overnight (usually with a family member) to see how well they’ll cope with independent living. “The point is to challenge them to function at the highest level possible,” Pease says.

Research extends to the general population as well. “A new area of study for us is visual impairments,” Pease says. “Due to our aging population, there’s been a major increase in macular degeneration. So, we’re looking at developing visual aids to help with everyday living, such as adapting the kitchen environment and other appliances.” Innovations include surfaces that can be easily identified by touch, items with greater light–dark contrast so they can be more readily seen, even “talking” gadgets that provide temperature and other information. “Although some of these things are available today in high–end appliances, we’re trying to make them affordable for the average person.”
 
Experts at Ohio State are also helping soldiers returning from duty in Afghanistan and the Middle East. “Many returning veterans have wounds that required amputation of major limbs.  They may also be suffering from traumatic brain injuries.” To this end, the U.S. Department of Defense funded the Indiana–Ohio Center for Traumatic Amputee Rehabilitation Research, which is working with researchers in Ohio State’s Rehabilitation Program, and School of Allied Medical Professions (SAMP) to study the long–term effects of these injuries as well as the care they require.

Additionally, and in conjunction with Walter Reed Army Medical Center in Washington, D.C., a project on substance abuse and brain injury in Iraq veterans uses a model developed at the Ohio–State–based Ohio Valley Center for Brain Injury Prevention and Rehabilitation. “We’re doing research on how to help returning soldiers cope,” explains Pease.
 
Founded in 1992 by director and PM&R professor John Corrigan, PhD, with a grant from the U.S. Department of Education, the Center conducts research, provides education and develops programs to improve the quality of life of persons with TBI. The Center, and Corrigan, who received the 2007 Robert L. Moody Prize for Distinguished Initiatives in Brain Injury Research and Rehabilitation, have a particular focus on substance abuse, agitation and measure of outcomes from rehabilitation.
 
The Ohio Valley Center substance abuse treatment program developed for TBI patients at Ohio State is used by healthcare professionals, individuals and families all over the country. “There’s a higher incidence of drug and alcohol abuse among those with brain injuries, which can cause even more complications,” observes Pease. Patients with TBI “often fail to respond to regular community treatment like Alcoholics Anonymous and traditional substance abuse programs.”

As one of the biggest PM&R departments in the country – and with so much to offer – it’s no surprise that Ohio State’s PM&R program remains a hot ticket for medical residents. Along with being one of the most competitive, the residency program draws top students from throughout the U.S. While many graduates go on to other major rehabilitation centers around the country, a large number remain at Ohio State and the surrounding area. As Mysiw says, “I came here for my training, but ended up staying because I fell in love with the place.”

from left: Jerry Mysiw, MD, Sam Colachis, MD, Sharon McDowell, MD, John Corrigan, PHD, William Pease, MD