Spinal Cord Injury

[Music] Welcome to Medical Rehab Matters. Today we're talking about spinal cord injury and inpatient medical rehab. Nearly 18,000 new spinal cord injuries occur in the US each year. And nearly 300,000 people live with spinal cord injury. Whether from a traumatic event, such as a car accident or other cause, spinal cord injuries can have life altering effects. In this episode, you'll hear from Dr. James Wilson and Dr. Michael Kelly from Metro Health in Cleveland. But first, we talk with Dr. Kristi Farkomi, a fellowship trained board certified neurosurgeon with advanced neurosurgery associates and Northside Hospital in Lawrence Field, Georgia. [Music] So welcome. Thank you for being here. Thanks for having me. So I'm really excited about this topic and to have both the colleague and a friend, Kristi Farkomi with us. We're now neurosurgeoned who I have had the privilege of working with for a number of years in the past. To discuss an important topic, which is spinal cord injury and something that continues to be a public health issue in this country. The demographics around it have changed a little bit. And I thought we would open up by just me listing a few statistics that I was able to get from the National Spinal Cord Injury Statistical Center. There's about 18,000 new spinal cord injury cases each year and the United States, approximately 300,000 people living with spinal cord injury in the United States with an average age of injury being 43, which has increased actually from 29 years of age during the 1970s. And that's something I plan to discuss with Kristi during this program. About 78% of new spinal cord injuries are male, which we can talk about as well and isn't surprising. And in these times of health equity, it's interesting and I think important to point out that there's a higher prevalence than incidents among non-Hispanic African-American males as well in this country. We can also talk about the causes, motor vehicle accidents continue to be the number one cause, but vehicles are also much safer than they used to be and falls continue to I think increase in terms of causation of injury and we can touch on it as well. So with that, Kristi, welcome to the show. If you could maybe just sort of share your perspective on spinal cord injury at a high level, maybe commenting on a couple of the things that I just mentioned and sort of how you approach it and where rehabilitation fits in to that process when it fits in, we can go into them in a little more detail. So welcome. Thank you. So one of the things that you pointed out is that the mean or median of onset or injury is rising. And it's leading to more of a bimodal distribution of injuries. So classically, people think about the young man injured in a vehicular accident. That's the most classic. But we're seeing more and more elderly folks getting injured with falls, ground level falls as demographic United States changes so we have a older, more fragile population. I think we're going to see you continue to shift in the median age injury and different injury patterns. One of the frustrating things about studying spinal cord injury systematically from a surgical standpoint is that it's a very heterogeneous disease. Now we see that you have a 23 year old man and you also have an 85 year old woman. They both have a cervical spinal cord injury, let's say. But their physiology and even their mechanism and their spinal anatomy is markedly different. So that's one of the frustrating things from a study standpoint with respect to spinal cord injury. In your experience, are we seeing less injuries happening as a result of car accidents? And maybe some of that being replaced by falls or are lowly vehicle accidents sort of still while still the number one diagnosis how those numbers going down. I think they're going down a bit because as you said, cars are definitely safer. But you can still can sort those safety mechanisms by not wearing a seat belt by driving impaired. And also motorcycle helmets don't confer much protection for spinal cord injury. They do confer protection on motorcycles for head injury. But unfortunately, we're seeing a fair amount of spinal cord injuries from motorcycle accidents as well. I mentioned from a health equity perspective, if you think about socioeconomic status, the fact that maybe those that are living in the inner city don't have the same financial means maybe operating vehicles that don't have some of the safety mechanisms in place where maybe they're tires, they're tread on the tires or they don't have snow tires at all. But there's a lot of different factors that I think go into why we see a higher incidence in prevalence in certain populations and certainly gun violence in the city is some of their primary reason. Correct. I'm glad you mentioned that. We are seeing more missile injuries with respect to gun violence. And fortunately, the spinal cord is a relatively small target. So it's unusual for somebody to sustain a spinal cord injury from a missile injury. But it still happens. It's a much more difficult scenario to treat because of that. Not only is there the violence of the injury, but there's a blast mechanism with the physics of that that can actually cause damage that's not initially seen. It can propagate with time. So the injury you're confronted with, the emergency department may not be what that patient is left with unfortunately. The other sort of area of spinal cord injury that I wanted to sort of get your perspective on is metastatic disease or primary disease with cancers. I think as treatments have improved and surveillance has improved, we're able to keep patients alive longer. And so I think we're seeing more metastatic disease potentially involving the spinal cord. What's your experience with that? Is that accurate or am I off-basin? That's, it's definitely accurate. And one of the things I've had to work with my neurosurgical and orthopedic colleagues in spine to atrips is there's a sense of nihilism with respect to cancer cure. Oh, they have metastatic spine disease. There's nothing you can do. As you know, cancer cure is evolving very rapidly, particularly with the advent of biologics and take a disease like multiple myeloma which classically involves multiple levels of the spine and can cause weakness or paralysis. The oncologists have multiple layers of treatment that they can bring to bear to control that disease systemically. So I encourage my spine colleagues not to use yesterday's expectations for cancer cure for today's patients. We can stabilize and treat patients and prevent injury much more easily than we can treat a completed injury. So, you know, I think from a public health perspective, prevention, prevention, prevention is certainly, you know, probably the most cost-effective thing we can do. And I think for years and you and I have partnered on some of those things whether it's some let's not meet by accident, you know, gun turn programs at hospitals and other inner city agencies promote car seat checks for kids car seats, you know, use of seat belts and so forth. You know, those are the things that we can really do to impact things at a high level. But once somebody does experience a spinal cord injury, it obviously can have an unbelievably impactful effect on their lives, the loved ones' luggage and really, you know, to society in terms of the cost of ongoing care. But at the same time, there's been so many advances in treatment and technology and I'm hoping we can touch upon, you know, some of those, you know, certainly from your perspective in the suit phase and where does the rehabilitation team fit into that? So I mentioned the concept of being discouraged and realistic regarding cancer cure that surgeons have a guilty of that a little bit with respect to spinal cord injury. And I'll be more specific, particularly with regard to timing of surgery. So the thinking was if somebody comes in with a complete motor injury, that's it. But Michael feelings and other people around the world have challenged that notion. And they're now, similar to what happened with stroke care, I think what's going to happen in the next 10 years is that there's going to be a much more aggressive surgical stance regarding spinal cord injury. And there's already been several studies that have looked at early surgery defined as, you know, one study designs it is within 24 hours. Several other studies have looked at surgeries in eight hours. And they're finding that there's not an increase in complication risk, but there's an increase that statistically significant in motor levels gained with earlier surgery. So it used to be patient comes in injured, you try to prevent hypotension, you treat them supportively. And then if they needed a stabilization for a spinal fracture, you do that in a couple of days. The paradigm is moving to as long as the patient isn't unstable from other injuries. The paradigm is shifting to more rapid early surgery to decompress the spinal cord and stabilize the spine. In some cases that will give dramatic results with respect to long track function regain. In other cases it might give a segment or two of benefit that, you know, as you know better than I do, that can be the difference between full independence and independence with minimal dependence with support. So that's probably the most exciting thing is proving to ourselves as surgeons that early intervention is going to make a difference for patients. What should families be on the lookout for what advice do you have for them? What should we know? Probably first and most important is kind of the physiologic depression. You'll meet people that in the first week after injury will say, "I don't want to be alive." And if you can encourage the families, you know, support that person through that, the studies show that the vast majority of people then regain the will to live and the energy to move on. But if you don't support the family and the patient through that and they don't understand it, that it's self-limited, then they can't be as helpful to the patient as they could be. It's a normal phenomenon that almost universally happens. I think also, Chris, and please share your perspective on this. I think in this day and age of managed care and, you know, shortening the stays in the hospital and moving patients, you know, through the system, so to speak, that there's a real risk of patients not necessarily landing in the best spot for them to really get the rehabilitation they need by a truly, you know, team that understands spinal cord injury and can mitigate, you know, complications, educate the patient and family, and get the best outcomes. Doing all that really, I think, helps address some of those psychological effects as well. Correct. And your industry leaders that will be listening to this, they understand the difference between a Q-rehab and sub-Q-rehab much better than the Ayers do, unfortunately. So, as you said, a payer will often want to get the patient from the higher intensity, higher cost, a Q-reupsetting, to a sub-Q-reupsetting, which often is not equipped to adequately care for patient with spinal cord injury in any meaningful way. Can patients, families advocate for them in these circumstances? Again, and I've advocated for patients as well, but you know, sometimes the treating physician, you know, the physiatrist and the surgeon need to be shoulder to shoulder and say, "No, this is not acceptable for our patient. We need better for our patient. We expect better for our patient." And just educate the insurance carrier, usually the physician. And if you explain it to them and say, "Look, this person needs more. It's not simply a transition to lower acuity and then home kind of thing." They need more for their overall recovery. I think, unfortunately, far too often in today's world, it's either the case manager or the hospitalist who's left to make these decisions where the trauma team or the neurosurgeon or others feel like it's not their role to get involved. And one of the things I've always admired about you, Chris, and others that I've had the opportunity to work with is really being patient-centered and doing what's in the best interest of the patient and making sure that that is expressed, whether it's in the documentation and chart, to the case manager, to the treatment team, to the rehab team, your engagement and neurosurgeons and trauma surgeons in general, I think is critical to this process. And, you know, one of our key roles as physicians is to advocate for our patients. And I'm not talking about jumping up and down, you're like, and screaming, although I wanted to do that on many occasions. But just, you know, really speaking to my physician colleague who happens to work for an insurance company, just saying, "Here's the clinical scenario. Here's the receipt benefit if this person continues the intercubriabaltation. Here's the risk if we truncate that and send them to a lower level of care." Yeah, and I think, in some instances, that lower level of care may be the appropriate level of care. I think it's just really important that physicians who are knowledgeable in this area really get to make those decisions. And it's not those decisions are an administrative decisions. Correct. So, on a slightly different topic, you were saying something earlier that maybe realized, you know, somebody's in an accident. They might have a spinal cord injury and they might have a TBI and they might have other injuries, a different nature. Our spinal cord patients from accidents usually more complex than just quote unquote a spinal cord injury. Yeah, I mean, it also depends on the mechanism. So, if somebody, if somebody unfortunately dives into an unfamiliar, audio water and has an isolated cervical spine fracture, that's going to be isolated, but they have, if they are that motorcyclist who has a high speed motor vehicle collision, they may have a head injury. They may have complex abdominal injuries or the beauty of extremity injuries and a spinal cord injury. And those are the patients that the acute care is very nuanced. Like, when can I take this patient's surgery? And the trauma surgeons will say as soon as they're stable, from their liver loss ratio, they're other lights threatening injuries. So, we often have to wait patiently. I think some of the other complications that will have an opportunity to discuss more with our next guest, things like autonomic dysreflexia, hypotension, neurogenic bowel and bladder, you know, these are things that often don't necessarily present themselves while the patient's in the acute care hospital. Patients often, their spinal cord sort of goes to sleep and it takes, you know, a number of weeks before it awakens, sort of speaking, some of these things become evident. So, I think for all those reasons, it's really important that wherever they're going, that there's a nurse and a physician and the others that really understand these problems to avoid complications. Yeah, I know you're exactly right. And even years down the line, somebody that's astute enough to recognize fasticity onset or if they do develop a serenix or something else that can potentially threaten their function, somebody needs to be able to be sophisticated enough to recognize. Oh, after spinal cord injury, this can happen several years later, we need to watch out for it. There is, you know, something called a complete versus an incomplete spinal cord injury and it has ramifications with regard to prognosis and recovery. And I'm just curious when you're talking to families and patients, I'm sure you're quoting statistics with regard to recovery. But I always try to point out that, you know, even if you're told that there's a 90% chance of something, there's 10% who beat those odds. And while a spinal cord injury can be life changing and often is, I can't tell you how many patients make meaningful recoveries over the course of weeks, months, the first two years of recovery. So can you sort of just sort of give your perspective on that recovery timeline and how you discuss that with families in the acute phase? Right. So as you mentioned, there's a number of patients that will have an incomplete injury. Not that there's any magic about it, but the first 24 hours are critical. So if an elderly person comes in and they fell three days ago and they haven't had any sent through your motion movement in their lower extremities, it's unlikely that you're going to get them bound. A converse would be a young person that has an incomplete injury after, you know, a car accident or a football injury, they can still, you know, move their big toe and they still have some reserved sensation. Those are the people that I'm inclined to be extremely aggressive with because I know the signal is getting through albeit impaired. And those are the people that will be very aggressive and usually take the surgery as soon as we safely calm. I mean, rather be in the situation where we did, even if it didn't work, we did something and we were aggressive to try to get them every bit of function they could preserve or gain gain back. And I think it's important for families to and patients to have that hope and to understand that the odds and the statistics are just that odds and statistics. And people deserve chances to be that other side of the coin, so to speak. Correct. I'll often tell families that the yard's snick for recovery is months, not hours or days, because it's the second most sophisticated organ in the body after the brain. And while it can heal, it's extremely complex. So it's healing takes a long time. So it sounds like you're both saying it can be a tough long road, but there is a certain degree of help. And I'll tell the families to please get some rest and please pace themselves because it is a marathon. And the patient, their loved one is going to need them two months from now, six months from now. And if they burn out in the first two weeks, that's not going to help. I just want to take this opportunity, Chris, to thank you, and to really thank all trauma services and teams for the incredible work that you all do. I mean, these injuries occur at all hours of the day. It can be Christmas or whatnot. And, you know, the team needs to be stand ready to take care of them on a moment's notice. And it is truly, herculean work and appreciated by all of us. It's our pleasure. It is hard work, but it's very fulfilling work. Well, thank you very much for your time today. We really appreciate you standing here. It's great meeting you. This episode is brought to you by Morris Therapeutics, part of the Morris Group, a privately held, family-owned company. Morris Therapeutics is committed to accruing the lives of patients who suffer from movement disorders, spasticity, and neurological conditions. Fobusing and advancing neuro-modulator technology, Morris Therapeutics offers Xiamen, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamen has a boxed warning and could result in potentially serious life-threatening side effects. Visit xiamen.com for important safety information and full-prescribing information, including a boxed warning. In this next segment, we speak with Dr. James Wilson, who's board-certified in physical medicine and rehab, and Dr. Michael Kelly, a board-certified neurosurgeon. Dr. Kelly and Wilson are part of Metro Health, one of 14 spinal cord model systems in the United States. Welcome, everybody. We're with Dr. James Wilson and Mike Kelly from Metro Health to talk about spinal cord injury. Welcome, gentlemen. Thank you both for being here. Thank you, Dennis. Thank you. Good morning. Bob, do you want to start? Yeah, welcome to both of you. And thank you again for joining us. Really excited to be speaking with both of you. Given that Metro Health is a model system in spinal cord injury, really would like our audience to understand what that means in terms of a system's approach to spinal cord. So maybe Dr. Kelly, if you would kick it off, that would be great. Yeah, thanks again for having us. So to give a little background about Metro Health, we're in Cleveland, Ohio, Northeast, Ohio. And I can speak to the kind of acute surgical side of things, and I'll leave it up to Dr. Wilson to kind of to talk about the rehab side of things. But we have a unique situation here at Northeast, Ohio, because we're an integrated trauma-care network. So Metro Health is a level 1 trauma center and is part of the northern Ohio trauma system or not, which is a regional trauma system that works across a separate healthcare system. So you can join us with the Cleveland Clinic of University hospitals. We work together on a data sharing collaborative and kind of transfer protocols to get patients to the right place at the right time. So we have two level 1 centers in Cleveland, one that's down in Acro-O-Hio, and then several level 2s and level 3s. And we coordinate care for spinal cord injury patients across this network of hospitals, so that patients who have severe injuries could see at level 1 centers. So there's transfer protocols that are shared. We have quality review committees that are set up to review patient care pathways. And a lot of what motivated this from a surgical side, from a spine surgical side, and acute care surgery side of things, was the data that was coming out of the last 10 years to suggest that early surgery, early decompression for patients with spinal cord injury is associated with improvements in functional outcomes, their logical outcomes, as well as reduction in length of stay, ventilator days, costs, and all those other things. Traditionally, a spike of injuries from a surgery perspective was not treated the way maybe a acute stroke would have been treated or some traumatic brain injury. And that's obviously changed across the country over the last decade or so. And there's much more of an urgency to see in care of these patients and getting patients operated and decompress as soon as possible to help with recovery and neurological outcome. The regial care system we have here allows for those patients to be transferred immediately and cared for immediately, which is a very good thing. There's data sharing across hospital systems. And that kind of feeds into the spinal cord injury model systems, because Metro Health is the SCI, the spinal cord injury rehab center for the region. And so we're able to coordinate care and get these patients SCI rehab much quicker and figure out ways to get them access to care in ways that are beneficial to the patients and avoid prolonged length of stay at the good hospital, ICU setting. So we're on a acute care neurosurgery and spine surgery viewpoint. This is a kind of a unique system and we're able to kind of look at outcomes and assess quality metrics and do those things across the system which feed into the model systems care pathway. So that's kind of a little bit from the acute care side of things. I'll turn over Dr. Wilson for the rehab side. Yeah. And before we do that, I'm just curious, you know, from a neurosurgeons perspective, a trauma, trauma, telegis perspective, where is the current thinking in terms of how quickly rehabilitation should get in there and start mobilizing the patient and doing their thing? That's a great question. I think it's all about that in treating these patients early and quickly, because the sooner it's a patient comes in with a spinal cord injury and they need surgery, more quickly we get to those patients and get them decompressed or stabilized, the more they can be mobilized. And so we found actually in studies here and other, and elsewhere that you reduce the complications associated to cubit eye and pneumonia and prolonged activation. And the benefit too is Dr. Wilson can attest is that IICI rehab team sees patients pretty much immediately. As soon as they're stabilized in the ICU to begin the rehab process. So getting a patient to surgery if they need it and getting them stabilized or decompressed allows them to get out of the ICU faster and get to rehab more quickly. And in Metro, we have the SA rehab doctors involved in the care upfront. Basically, you know, as soon as they're stabilized in ICU, we get a spot where they do rehab involved. And they can help us to work on ventilator weaning and transitions to rehab almost immediately. These things are very beneficial to patients, the regressions delays to care, and then hopefully improvements in functional outcomes. So all these things happen in Metro pretty much immediately. And it all starts with day attacin, definitive care from a surgery standpoint as soon as possible. And I think that really sets the tables for a lot of these other things to happen after that. Dr. Wilson, from your perspective, why isn't so critical for these patients to come to a spinal cord program and then the re-rebellutation hospital set? So the spinal cord population is just a very special group of individuals. That unfortunately, it's as close as they can get to being a rare disorder without actually being diagnosed as a rare disorder. So there are very specialized kinds of techniques and processes and therapy that we do in a spinal cord center that other groups just aren't aware of or aren't familiar with. Even in the trauma ICU and other places, they're really specializing in this. You know, it's still a small proportion of their total population. And so getting a nurse is there really routinely, comfortable working with spinal cord patients can sometimes be difficult. So I do agree that getting them into a specialized center like into the acute rehab setting as early as possible, as soon as the state is possible, is really important. There's so many potential complications that need to either be avoided or managed effectively, whether it's neurogenic bound blood or ornament dysflexia, skin breakdown and so forth. And having a team that really understands those problems, rehabilitation nurses, therapists, obviously, physicians is so critically important. So can you just speak to that? I 100% agree. That's usually how I end my interactions with new patients when I've met them that the biggest focus for me in their acute care stay is preventing complications. And that when the nurses say to turn, they have to turn, they say, you know, to do this for their bowels and do this for their bladder that they really need to listen. You know, we want to get them into working hard and doing therapy and rehabilitation as soon as we can, but you have many complications is really, really important. And honestly, it's one of the biggest focuses of our acute rehab stay that patient education, family education, having them understand how to direct their own care, what things they need, what things, how to ask for help to prevent further medical and other, neurologic complications, it's a big focus. Most spinal cord injuries are a result of accidents or other traumatic events. Does it complicate things like it's time to move or to participate in your own care? They have other trauma, it's their third meal, they're other severe injuries they may be dealing with. Yeah, and I'm sure Mike can touch on this some as well, but it's sometimes hard for us to set up hard fast protocols because patients are just so complicated individuals that there's a patient we want to bring over, but they can't put weight through their arm because they also broke their arm or they had a spinal cord injury, but that same traumatic injury happened around their chest and now they're lungs are having difficulty and we need to adjust those things first. So yeah, it's a complicated picture. That's a great question, but you should I think from the acute care side of things, it's so critically important to have a team that, you know, it's great to describe the system and well, it will machine from like a 10,000 foot view, but you really want traumatologist, trauma general trauma surgeons, where's the beauty? surgeons, neurosurgeons, all the other care folks involved working consistently daily with each other and integrating care that way. So a lot of the way care gets delayed for spinal cord injuries, if there's other injuries that prevent us from doing surgery. So if a person has a bad lung or heart injury or a bad stomach injuries or potentially a vaturetic brain injury, that oftentimes can be complicated as to how to, you know, cue lean or feed for that patient. We, in Metro, we have a obviously very experienced team, but I think it's also a very integrated team. So oftentimes we'll take patients to surgery with multiple things going out of the same time with multiple services involved. So the pathologist may do an open abdomen for a bad belly injury. And that doesn't preclude us from then taking the patient to surgery to deal with their spinal cord injury during the same anesthesia and see if you get to patient and manage you maybe ICPs carefully from a neurosurgery standpoint while we're dealing with a spinal cord injury. There's many things going out at the same time. And if, you know, time is spinal cord so to speak, a huge setty, getting these patients appropriate intervention in a safe fashion is important. And I think having integrated team that's comfortable doing that, having an anesthesia team that's comfortable doing that is really why it's critically important to get patients to, to, you know, at integrated level one center where they can get that care upfront. I'll just add, you know, after a spinal cord injury, it can affect really any body system in the person's body. And so most of my job ends up being interdisciplinary across different specialties and building relationships between the trauma department, the spine surgeon, you know, plastics, urology, pulmonary, all these different kinds of groups getting by and can be difficult different places because the evidence is different and their experiences are different. And so being able to have a coordinate approach is really important. We've had a couple of projects recently where we've had to take evidence from different disciplines and kind of compare it and contrast it and see how we're going to have a unified approach to things like blood pressure management, ventilator, reigning, primary care, even simple things like that. >> And I mean to speak to Dr. Wilson who's saying, we meet at least monthly about more than that for research projects, quality issues and all those other things. I actually learned a lot about the side of things that I don't know, which is the rehabilitation side of things. And I think, I mean, I want to speak for you directly, Chase, but I think you learned a little bit about the acute care side of things. And that makes us better at what we're doing because I can kind of anticipate issues that you may have in the rehab setting and try to address those upfront. And you may understand a little bit better about things that are related to the acute hospital state. And yet it avoids the silo effect because then we understand each other's rules better, can anticipate the issues that each other will encounter. And we need regularly to deal with those things. And that's again, that integrated care network is critical for that. >> You had mentioned earlier about how most spinal cord patients are traumatic injuries. And I know Michael tell you he's probably the first one to advocate for the group that is non-traumatic, that people with chronic degeneration in their spine, you know, multiple sclerosis, probably a majority of patients that are non-traumatic. And there's recent effort in the model system to expand the patients that we're researching because we have good research on the traumatic group. And we have not good research on the non-traumatic group. And that nationally, we're hoping to really put more effort into that. It's really going to, I think, more than double our number of patients that we're really considering as spinal cord patients. >> So, guys, you write that out James, because from a surgeon's standpoint, I see patients who have chronic cervical or cervical thoracic myelopathy. And these patients are just a longer version of the acute spinal cord injury that we see. They have many of the same needs, but they're not treated the same way because they don't go through the same processes. They don't have the benefit of a trauma center on these other things. But it's so critical to intervene and take care of these folks and then get them to a rehab center that can help them with their spinal cord injury. It's not seen the same way, but it should be chronic myelopathy versus acute spinal cord injury. The needs of these patients are often type very similar. And I'm so glad you mentioned that because looking at these as a group is important. It's a much larger population and they have many of the same needs. [MUSIC] >> Where do people with a spinal cord tumor fall into that? Are they considered traumatic injuries? >> They're not considered traumatic injuries in general. We care for them to see what a gene job is. You can speak to this as well. But their seat is a separate set of patients, but their needs are often types of very similar. >> Okay, that makes sense. And one other thing that we talked about with Dr. Comey the other day that I thought we wanted to talk about again today a little while. The average age of spinal cord injury patients has gone up a lot since the 70s from about 29 to 43 years old. And Bob and Dr. Comey were talking the other day about, is that because of an aging population and more injuries because people are falling because they're so much older. Do you have any comment on that? >> I'm happy to comment on it because I see it a lot. >> I think fall risk and assessment is a part of this programmatic approach to spinal cord injury. So we tend to look at trauma as type 0.0 and then everything that happens after that. And we say, well, this happened, now let's deal with it. But there's a preventative side to trauma and the fall question is huge because once a patient certain age, certain COVID falls or they've had a spinal cord injury, we're largely recovering mold with this. I think this is another place that we from a systematic approach to spinal cord injury have worked to do. We can make an impact, which is identifying patients who are at fall risk, which we can do through the Medicare annual wellness visits and those kinds of things. There's ways that prior care doctors and general medical doctors and cardiologists such can integrate with spinal cord injury to identify those who are at risk for falls to get ahead of this. And then also why are they falling? Is it polypharmacy or my lopathy, right? So a lot of patients I see in clinic are these sort of silent my lopathies that are having more issues with hand dysfunction or gaitens to fill your falls. There's really no systematic way to identify these patients and get them treated quickly. Eventually, we've been using a cervical myelopathy screening protocol to identify and capture this population sooner. But these are patients who you could stop from getting a spinal cord injury if we can find them sooner and get ahead of it because as the population ages as fall becomes a major, you know, driver of spinal cord injury, identifying these patients as a risk factor first can prevent a lot of the morbidity we see after the event. You said polypharmacy is that is multiple. Multiple medications. As we get older and we have our blood pressure pills and our directs and our, you know, all our other medications, oftentimes that can make people prone to fall, disinist and things like that. So there's lots of reasons that can contribute to falling. But I think, you know, trying to identify those sooner and come up with care pathways. And certainly if there's a spinal cord cause to this, identifying that upfront is critical. Yeah, I mean, makes 100% right that primary prevention is really where we put a lot of our focus. And it's just difficult because it's changing the behavior and the activities and the infrastructure of the entire nation. There are obvious examples, you know, seatbelts, cord rails, speed limits, things like that that in the last 30 years have really changed, you know, the outcomes of spinal cord injury patients. You know, even better, you know, emergency medical services has really changed what we're seeing in terms of the spinal cord populations. Once they've had the injury, it's a difficult situation, whatever we can do for prevention is really important and cost effective. My understanding is, um, Metro Health's PM and R department or physical medicine and rehabilitation department has the care, largest, I believe, and I age grant support in the country. And I know, Dr. Wilson, you are doing some research in the spinal cord area. Do you want to just sort of make me for a minute or two talk about some of your research interests? So yeah, we have the third largest NIH funding for PMR in general in the last year, where the spinal cord injury model system, so that's part of the, it's a called NIDLE, it's the National Institute of Disability Independent Living's part of the Health and Human Services Department. And so that's a grant that helps collaborate across different systems. There's 14 different systems, which were one. And we combine data to create a database, but we also have site-specific projects and then module projects where we work, I mean, multi-set our research across the country. And so it's really a research designation, but it is certainly a marker of quality that during the application, we're talking about our clinical care and the coordination care and how we're addressing, you know, every aspect from life to death, from their initial EMS interactions, their acute care stay, their rehab, their post acute rehab, and then lifelong follow-up. I would say if you're looking for a spinal cord injury center, certainly, you know, going to a model system would kind of raise the floor of what your expectations should be from an SCI center. There are lots of good skilled quality spinal cord injury rehabilitation centers that are not model systems, but that's kind of what that designation means. You know, with all the new technologies that are coming out in the rehabilitation sector, whether it's robotics, virtual reality, and so forth, I think being in a research center, you know, gives you an opportunity to sort of look at some of those technologies and see what, you know, what makes sense, what doesn't make sense to validate things and so forth. But from just from your perspective, you know, even if you haven't researched it, where do you feel that these newer technologies fit into the paradigm of caring for spinal cord pocket? You know, we're still honestly figuring it out, that the number of actual treatments for a spinal cord injury. are still limited, still much more limited to that. The early decompression, the early surgery is one of the few really evidence-based approaches for a spinal cord patient. Technology is wonderful, and it does a lot of different things. It allows patients more independence. It allows them to have more hope and other psychological benefits. It can have an augment their traditional rehabilitation. And so I think it's got certainly a very important role. Unfortunately, the research is still lagging behind that there are lots of studies using stimulation, either epidural stimulation, where they're actually putting an implant around your spine or transcutaneous stimulation, where they put a patch on your skin, stem cells, robotics, functional electrical stimulation. Many of them have good evidence, but they're still not ready for prime time in kind of everyday standard of care or kind of use. So it's really a work in progress. There are a lot of centers that have more technology, less technology, and it has a lot to do with those other kinds of things that it hasn't do with, allowing their staff to be able to treat multiple patients at once, allowing patients the experience to do things like standing and walking when they weren't able to do otherwise, and kind of having more hope for the future of things like that. - To add to what Dr. Wilson was saying, I think also from a research standpoint, the way you can see patients over time matters, and what do I mean by that? One of the things that we do is we connect data sets across time, so I can connect our trial registry acute hospital data to functional outcome data in spinal cord injury, and we can do that across our population in North East Ohio. And what that allows you to see is from the time of injury to long-term follow-up, how does the acute period relate to a subacute period relate to a long-term follow-up period? And that integrates with technology, because Metro-Aleth and a combination with the functional electrical stimulation networks throughout the Northeast Ohio does some pretty cutting-edge things with functional electrical stimulation. But if you don't understand the acute injury window and how that plays in the long-term outcomes, that you're limited, you're siloed in how you look at patient outcomes and data. So integrating data has been a key, like a crux of what we've been doing here in North East Ohio for a long time. That window of trauma and all the information we gather there, all the data, linking that to long-term outcomes and getting a complete picture of the patient is important from an observational standpoint, and that identifying subpopulations that make benefit from technology is critically important. In order to do that, you need to be able to see all of these patients over time to be able to identify those subpopulations that make benefit from technology. And that's why, again, integrating care is important, but integrating research efforts and integrating data across time is important, and that's been a focus of research here in Metro-Aleth for a while now. - That was, I know one of your areas of interest is electrical stimulation and EMG, both for predicting spinal cord injury recovery, as well as potential therapeutic benefits. I remember using electrical stem, even at the shoulder to avoid subluxation while we waited for motor recovery to, you know, hopefully, will happen. I also remember participating in a surgery where actually the surgeons were being guided by other surgeons in Cleveland, in fact, as they were implanting electrodes in this spinal cord injured individuals' muscles in their upper extremity, and post-operatively, he was able to lift up a can of coke and bring it to his mouth, which was really remarkable. So, you know, where has that gone? And what is the thinking today? Where does, you know, electrical stem fit in? Both were preventing measures, as well as therapeutic? - Well, I guess I was start by saying that it's case Western and Cleveland, as a whole, has been a setter for our functional actual stimulation for decades, and that we've been able to apply it to multiple different kinds of functions and body systems. So, we can talk in a second about some of the, you know, reaching, standing, walking, kinds of activities that people usually think of. But there are researchers here that are using it for a bowel and bladder function. So, you're able to pee when you want to pee and you don't have to use a catheter and things like that. There are researchers here that are doing research and clinicians that are using it for respiratory functions. So, you're able to breathe when normally you'd have to use a cancal ventilator, as well as coughing. Simple things like clearing your throat, becomes literally important for our patients that are at risk for pneumonia and other kinds of complications. So, it has kind of a wide range of potential applications. You know, it's cardiovascular. People are doing studies in terms of stimulation and your blood pressure, your heart rate, those kinds of activities as well. I think the direction that we've been headed in a lot of ways is improving the coordination of these different systems that it's great to be able to stimulate your hands so it can open and close. But without being able to control your shoulder and your elbow and your trunk and all these other parts, it's not really functional. And so, the newer iterations of the stimulator symptoms are trying to coordinate multiple different activities so you can really address all the needs of a person. - And, you know, I remember, years back, SIP and Puff kind of technology for manipulating one's environment, their wheelchair mobility and so forth. - Intentative heat stress or higher. (laughing) - Okay, I didn't know that. At higher level, you know, for higher level spinal cord injuries, cervical injuries. But in today's world, with, you know, Google Alexa, Google Home iPods and so forth, why home? You can really manipulate your environment, surf the web. I mean, never before have people been able to have the freedom with the spinal cord injury that they've had before. And potentially really go back to work and have a real life. So, could you, could you comment on that? - I love it when people go back to work. Yeah, I love when people will stop being patients and they get back into their regular lives. They're like, I'm parents and workers and caregivers and spouses and all those kinds of regular person activities. One of our current efforts that we're putting together is a SIPH of technology clinic. And so that would be a more coordinated approach to some of this technology. So people could come in, really get educated, really get exposed to some of these more high tech in the home kinds of options. Unfortunately, much of the technology that we're prescribing for people is still out of pocket. It's either reimbursed rate that's too low or it's not reimbursed at all. And so, you know, I spent a lot of my time as a clinician talking to researchers saying, well, you have this idea, but it might not be practical for reasons that's why I'd be. And this is the box that it kind of needs to fit in to be able to take off around the country. So, one of the difficulties that we see through all with in-home technology like the Alexa is that they can get Alexa, but the Alexa doesn't necessarily work on the same network as their light switch. And the lights switch may not work on the same network as their television. And so, you know, I was talking to a patient recently that spent thousands of dollars on a very nice television, but he couldn't turn it on because the interface from one to the other just didn't work. And so, we're working with community partners, people that have had spinal cord injuries, that have experience with these kinds of technology, you know, therapists that are specialized, and then really trying to find better funding sources or reliable funding sources for people that get the technology that makes a huge difference in their lives. I mean, like you said, we have the technology, but some people, they get home and they can't get in at their house because they can't open the door. And if they just had an automatic door opener, they'd be able to achieve that. And so, we spent a lot of time trying to advocate for them and get those resources. - So, how does the family participate in that part of the patient's life after rehab, when they go home, when they are trying to get back to a normal life? What is their family left to do to help them? - It can be a very difficult situation. Some people are more independent. Many people with spinal cord injuries, even if they're not walking, they can achieve all the goals that, you know, like you said, they can go back to work, they can drive a car or all those kinds of things. Some people need more help and a lot of time that does fall into the family. And it can be difficult for relationships that someone used to be a spouse and a peer is now a caregiver. It can be difficult, certainly financially, that besides the cost of the admission and the rehabilitation, the cost of the men go follow up, you know, the lost weight is for the person that has a spinal cord injury and then the lost weight is for the family members that now are providing care for their love with long term. In the beginning, it's a lot about education and finding out how best to help the family member. We want to try and help them connect with peers and support as well in a long term kind of fashion. But it's a difficult situation for many people. But I believe the research does show that many patients and families that they can get through that a keeps date, you know, whether it's depression or whatnot, they tend to come out of that and many go on to lead productive, you know, wonderful lives. - Yeah, many people do. And especially when they have kind of the support and the resources, you know, you know, Ohio, we have the Office of Ohioans with disabilities, which is kind of a vocational rehab group that again, provides more resources and support, job training, all kinds of things, you're going back to work. Many, many people are able to achieve that level of independence that they're able to achieve all the goals independently that they have. For some people, it's a lifelong struggle. So it's very close to the person. - I'd like to sort of finish up this focus on sort of of care delivery, you know, we're not still in the right place. where things are going in healthcare, hospital lengths of stay are shortening annually, populations getting older, there's not enough dollars to go around. And I see and get very concerned about the marketing that suggests that subacute rehab can provide the services that patients with spinal cord injuries may need. I mean, subacute rehabilitation, I think, has a role in home care, but I'm just curious, really both of your perspectives on for this complex patient population after their lives are saved and they're stabilized, where should they really be looking for rehabilitation? What do you tell the families? What should a family member listening to this now? Well, maybe has a loved one that is currently in the acute things of this? What should they be thinking about and advocating for for their loved one? So you're right. There are some people that, based on the classifications, they probably should be headed to a subacute rehab, a skilled nursing con situation. And I said, say that the people that we've tried that with often come out without the education, without the equipment that they need, they get home, I see them in the office, sometimes months later, and they're asking me very simple basic questions that they should have learned at the very beginning of their stay. This is a different population. And I think that maybe if we're talking about hip fractures and other things that are a little more routine, that you're so-and-so-what-you rehab might be able to handle those better. But a group like this, there's just so many potential complications, so many so much specialized education at the page of the family needs that they really can't get it unless they're going to a specialized sniff. If there was a SCI specialized nursing unit, then maybe that would work. But even in our area alone, there's within 25 miles, there's hundreds of skilled nursing units. So you really just don't know where they're going to go, what kind of cure they're going to get. - My experience with that even is, even if they have a physiatrist that might be rounding once a week, the nursing ratio is often one to 15, one to 20. I mean, these are patients that need to be four-year lifted early on, these are patients that need balance bladder programs, that they don't have that education or that understanding of, and that really leads to terrible complications, potentially, of skin breakdown, bladder infections that can lead to your osceosis. So I struggle in the current business model for nursing homes, how they could ever really provide in today's world the kind of care that these patients need in the suit phase. - No, you're right, that even if they have a physiatrist, a physiatrist should be educated to be able to do basic spinal cord injury care. And I think that at most good units, the difference is really the therapist and the nurses and the rest of the team that they don't go through a residency program for education about spinal cord patients like we do. So you're right, the outcomes are just poor when they go to a skilled nursing unit. I will say that so a metro we're trying to do is, hopefully in the winter, we're opening a subcutory have unit in our acute rehab unit. And so let's kind of the last gap in their care that there are patients that need more time that need a lower intensity of therapy. And so if they can go from the life flight EMS to the acute ICU to the step down floor to our acute rehab unit, to then, and acute rehab unit where they're seeing nurses and therapists and doctors that are already kind of specializing in spinal cord injury care and then getting transition to the community outpatient. That would be ideal. And that's honestly how the VA system works. It's really just not been a functional system in the rest of the country yet. So we're hoping that to make some gains with that in the coming future. - I think from a program or system standpoint, I think it's really important that we use quality research to kind of address efficacy for treatments. I think it's on us to do that, right? So when it is setting of the ministry resources and difficulty getting patients to the appropriate care, and the Sanbhaas is providers and caretakers of those with spinal cord injury to, in a sense advocate or fight for these folks by looking at the things that we're doing and see if they're effective, by looking at the treatments that we're doing it and looking at from a research quality standpoint, saying is this making a difference or not? And when we find that there's efficacy to really push for that, when we've done that, I mean, again, early surgery is a great example of that. It's become very widespread and accepted now. Nobody's gonna debate or push you on this and because you have the data to show for it. And I think that's really important in making the argument is saying, look, we looked at this and it has this effect. And then it's very difficult to argue that you shouldn't be doing this. And then on flip side of it too, is that you know you're doing good work when you get calls from, I mean, I get calls from surgeons around to say, how do I get my patients? And they're out of control. How do I get my patients and SCI rehab? It's known among clinicians, especially surgeons, I got this person who needs this. How do I get them in, right? That's very reassuring from what we're doing sandwiched. Yeah, let's get these folks in. And then it's on us, this final surgery, you know, providers to say, how do we get out in the public to show how important this is? We know all the clinicians know of the value of this. We have to be able to show this to the larger public, to ensure this to, you know, those that, so they got really even to say, this is why this matters as is valuable. And these are the arguments for it. And it's on us as researchers and providers to do that. Well, we hope this helps a little with this podcast. Yeah, we really do try and engage, you know, the clinicians, the researchers, you know, there's a push across the system to engage with the community, work with some of the community groups, the advocates for our patients. You know, I had a patient that's very experienced in spa or injury and was in my clinic the other day asking, if I can find a way to advocate for him with the DME companies that, with the current staffing shortages and other changes with COVID, that the response time, you know, you have a broken wheelchair and you're just really stuck, you know, you can't do much. And when they're saying that it's gonna be eight weeks and you have to bring the chair in yourself, I don't know how you bring a power chair in that's broken. There are just things that we struggle with all the time to advocate for our patients with, you know, like I said, I hope the podcast like this will help kind of get the message out that these are important issues that can't be delayed and can't be, let the stay in the status quo. So for the non medical people, DME is durable medical equipment? Yes. (upbeat music) Well, I really wanna thank you both for, you know, taking time out of your busy schedules to be with us today. We appreciate all that you do in looking research wise at new treatments and making lives better for patients who unfortunately have suffered a spinal cord injury. You know, please keep up the good work and thank you to Metro Health as well. Thank you. Thank you. (upbeat music) Thanks for listening to Medical Rehab Matters. I'll podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor nurse therapeutics for its support, as well as our Gold and Platinum Association sponsors. Our Platinum sponsors are Bionus, Casa Collina Hospital and Centers for Healthcare, and Select Medical. Our Gold sponsors are CERNAR, JFK Johnson Rehabilitation Institute, Loss Rehab, and the Center for Improvement and Healthcare Quality. You can learn more about Medical Rehabilitation at AMRPA.org. (upbeat music)