Traumatic Brain Injury

Welcome to Medical Rehab Matters. In this episode, we're talking about traumatic brain injury or TBI. This topic is so important that we're talking about it for the second time in this series. I'm Patricia Sullivan, Director of Communications for AMRPA, and Whitney is co-host Dr. Robert Krueb, immediate past chair of the AMRPA Board of Directors and Vice President of Medical Affairs for the Mary Free Bed Rehabilitation Hospital Advisory Group. Our guests are Dr. Richard Coons, an Associate Professor in the Physical Medicine and Rehab Department at BCU, and Chief Medical Officer of the Sheltering Arms Institutes Department of Physical Medicine and Rehab. And Dr. Daniel Klice, an Assistant Professor in the Physical Medicine and Rehab Department at BCU, and the Rehab Psychology Advisor at Sheltering Arms. Welcome to the 10th episode of Medical Rehab Matters. Today we're talking about traumatic brain injury and brain injury in general. We have two physicians here, or doctors here, who have described themselves as "ohemispheres of the brain." So, we should do a distinct conversation. I'm really excited about this episode. Really appreciate both Dr. Coons and Klice's participation from the Sheltering Arms Rehabilitation Institute, located in Richmond, Virginia, and look forward to hearing more about that organization and what you're doing, the great things you're doing down there. But I just wanted to open it up as we're talking about traumatic brain injury. And I'm not sure if folks really recognize how big of an issue this is nationally. We have 5.3 million, actually more than 5.3 million Americans living with a permanent brain injury related disability in the United States. Approximately under 8,000 hospitalizations, 36,000, 500 deaths annually. And the causes of TBI certainly can be varied, but the most common is a fall. And as the population continues to get older in this country, demographically, we're going to be seeing more and more of this. So it really is going to be a growing healthcare crisis, I think, moving forward. And we really do need prevention, public awareness, and increasing access to brain injury facilities and experts like yourselves to manage this difficult problem. So with that, welcome and Richard, why don't we start with you? Thank you, Dr. Kruim. Really a pleasure to be here with you. One of the things we had mentioned just prior to going live here was that you would ask why VCU partnered with sheltering arms to build the institute that I'm sitting in right now. And the answer to that question, I think, is multifaceted in nuance, but I think that what the important-- Before you did the answer, I just want to-- for those who don't know, VCU is Virginia Commonwealth University. Thank you. And SAI is sheltering arms institute. And my role here is I'm the chief medical officer of the institute. My background as a physician is in brain injury rehabilitation, inpatient and outpatient. And that's Dr. Klyse and I work very closely on that unit for, say, about the past decade. But sheltering arms and VCU were both working in the inpatient rehabilitation space. Sheltering arms has been around for 130 years. They've had a very long history here in the region. And really the short answer of why this partnership arose, this collaboration was because we discovered that we had in this region, in the Richmond region, we had a tremendous amount of rehabilitation expertise. But we lacked the economy of scale that you have with a larger institution. And so we had the VCU units inpatient rehabilitation units and then two inpatient sheltering arms locations and each of those with a smaller number of beds. And we were all doing the same work with the same patient populations. And mind you, so for example, many of the providers, the physicians working at sheltering arms, the therapists, the nurses, in fact, trained at VCU, which is where a focus of training is in the region. And so the providers all had relationships. We knew each other. And it just made sense. And so by pooling our resources and coming together here, we were able to make the kind of changes that I think really anyone in the inpatient rehab space would be very familiar with. Anyone who works in the inpatient rehab space and has seen the kinds of when you remodel a unit or you try to update your rehab unit, if you're in a building that was built 20, 30, 40 years ago, you have fundamental limitations in what you can do. So for example, if you want overhead body weight support system, you have to either inherit a space or build a space that will allow you to do it. And so not to belabor this too much, but that was the kind of thought processes that went into this pooling our resources, pooling our expertise, and then going to an offsite free standing location, where as a matter of new construction, we could have the most up-to-date rehabilitation technologies possible. Now to that last point, I think that's a very important aspect of this, because all too often I think the public really is troubled or challenged to really differentiate the differences between going to a rehabilitation hospital, to get their care versus going to a skilled nursing facility that promotes itself as having rehabilitation, right? And I think that the scale really comes into play when you talk about being able to really afford the latest technologies, which can be quite expensive, right? Whether it's robotics or virtual reality or whatever the weight-supported technology that you alluded to before. So again, I really, as you see the value and I see that going on around the country actually where there is some consolidation going on, where folks trying to get to that certain scale that allows one to operationally provide those types of technologies for the reimbursement that's being offered. That's right. There are many nuances to this type of move, right, from an inpatient rehabilitation unit, right, to an inpatient rehabilitation hospital is quite a big step. But we felt like that was the most rational way to grow and improve the rehabilitation resources for our community in the state generally. Through this collaboration, we're the biggest rehabilitation operation now in this region. So that it allows us to help more community members to get more community members access to care. So let's talk about brain injury for a moment from a 30,000-foot view. I gave some epidemiologic high-level statistics. What are you seeing boots on the ground in terms of a change in the type of patient that's coming in? Are you seeing a change? Those are certainly have a lot more safety built into them, safety mechanisms. What are you saying that's different from when you got started 20 years ago or so? I would say probably the most conspicuous difference to me as a provider really maps onto the conflicts in the Middle East, in Iraq and Afghanistan, with traumatic brain injury truly being the signature injury of those conflicts. Now, my personal experience is colored a little bit by the prominence of the Richmond McGuire Veterans Administration because that is one of the, I think, four leading sites for TBI treatment of veterans, a lot of the research that's being done there. But what I've noticed is the injury, the demographics of the injury beyond the war have not changed a whole lot. People fall, as you mentioned, and there's any number of ways that they fall, reasons that they fall, a lot of those are, I don't know, at least seem to me unchanged. But what I do notice is that the community now has, and I think Americans generally speaking, but I know it's in the community here in Richmond, people have a better understanding of this injury. They don't know a whole lot about it, but they're certainly understand. Most people understand that traumatic brain injury is a common injury that veterans are returning from conflict with now. And because of that, maybe people are more likely to have experience knowing a person who has had these kinds of injuries. I think a lot of work still needs to be done in that area to your point, Dr. Crude, that there is still a lot of unknowns and confusion and fear and about these kinds of injuries and how they impact the communities that those patients with these injuries live in. But at least I see better awareness about it. You know, I wanted to also comment, it just struck me as you were talking about the impact of really us being essentially a war for the last generation. I had the opportunity to visit the Intrepid Center in Washington, D.C. And that's a center, I believe, affiliated with Walter Reed. And the amazing results that they have in terms of getting brain injured, active soldiers back to active duty, really amazing results. And I think like in many areas of medicine, a lot of innovation and breakthroughs occur in the military setting first and then come out to the public after that. So again, I don't know if you have any comments, either of you on that, but I'm curious to hear. Yeah, absolutely. Be happy to touch on that. We'll also kind of hold the perspective you set for us around the. the 3000 foot overview. I think the challenge that has become more acute for us over the last decade or so is that patients who have a traumatic brain injury tend to come to the impassion rehabilitation setting quicker than they did. They spend less time in an acute care setting, oftentimes with a higher level of medical acuity than they might have in the past, so that they're sicker. They have more sort of delicate medical management that's required. And then also the overall length of state that we are able to achieve in the impassion rehabilitation setting is shorter and shorter. So we get folks who have a higher level of acuity. We have less time to sort of help to prepare for the transition back into their communities. And where do we want to invest our resources, what problems do we want to try to address? How do we agree all of the expertise and skill of the team to bear coherent way to make the biggest difference that we're doing, the ethic of care, for folks to be able to single back home. Your point about the National Intrepid Center of Excellence is a really important one, right? And I think the civilian sector has long benefited from the advances that have been made out of unfortunate necessity due to some of the challenges that our service members and veterans have faced as a result of higher engagement and conflicts abroad. And I think the NICO, the National Intrepid Center of Excellence has a great example of those folks who are really at the Vanguard who are trying to year out what are the active ingredients in one of our states we can, where in resources we can marshal during the ethic of care to get a great outcome. I think the challenge to results from that is that dismantling programs life that-- and I don't mean like winding them down. But I mean kind of looking at the component pieces to decide who with-- when you have limited resources, which ones do you want to invest in, right? So obviously the Department of Defense, Department of Veterans Affairs, invest Greek resources that are truly necessary to try and support their recovery of veterans and service members with the history of brain injury when we try to translate those programs into the civilian sector. Oftentimes we just have to be very strategic about, what can we realistically implement, borrow, who's going to pay for it, and how do we make sure that we use it as effectively as possible, being good stewards of their resource to get the most high-serturn on our investment for patients who are with us for, and preparatively, to trail a brief amount of time. Really great comments, Dr. Clizon. And something I would-- so I would-- kind of a couple of things in there that really jumped out of me that I think one of the places where brain injury, in particular, is getting squeezed from the perspective of shortened inpatient rehab stays and issues around medical necessity. That work that the team is trying to do in the inpatient setting is so critical to make that transition back to the community. And I think it's really important to jump off of that a little bit and point out that transition whole is not definitive with regard to brain injury recovery, right? That patient and their family or their caregivers at that time that they're discharging from the inpatient rehab brain injury unit if we're talking moderate severe TBI, they are at the very beginning of their recovery process. And so those transitions can be really fraught for patients and their families and the community more generally. And I think particularly with regard to the cognitive impairments that I think most folks listening to this talk would understand that if a patient is in, let's say an automobile accident with severe injuries to include in addition to severe traumatic brain injury, polytrauma, long bone fractures, intraabdominal injuries, the reality is that it is in fact the polytrauma and the injuries, the functional deficits that relate to mobility and ADLs. That is really what continues to drive the brain injured patients inpatient state, not their cognitive impairments. And as those two diverge, right, as physical impairments either aren't there or are getting better, you may still have profound cognitive impairments that are, that the pressure is still to transition the patient back to the community. And they may not, in many ways, be ready for that. Or at least it's going to be a very difficult management issue in the community compared to on a controlled space like a brain injury unit. So I just want to clarify a phrase you used a few seconds ago, ADL is activities of daily living, right? So like, getting dressed and going to that. That's right, bathing, dressing, feeding oneself, all the activities of daily living. Yeah, thank you, sorry for that link. Oh, that's why I'm here. [MUSIC PLAYING] You've been talking about veterans and people in the military, active duty service, people have been injured in war. But the CDC has weighed out in a report that older people, people 55 to 64 and then 65 to 74 and then over 75, in increasing levels, they are the ones who are in hospitals for TBI. Dr. Clis mentioned people being sicker. How does that integrate? Is the fact that they're older and possibly sicker, leading to falls that cause brain injuries or am I reading that wrong? Yeah, it can be a little bit of-- it's a little of both, right? So sometimes for the elderly population, the fall itself leads to the primary diagnosis to an issue. But in that said, they may still be admitted to the hospital, come to the inpatient rehabilitation unit, but they have several comorbidities just by virtue of age and general health. Yeah, we should clarify that I think we were talking about when Dr. Krugas, what is changed or what's different. It's the injuries in the stuff we're seeing coming out of the conflicts in Iraq are not a matter of volume to your point, but rather that that has driven research and inquiry in the area and awareness of the injuries in large part. But you're right, as the baby boomers, if you look at civilian demographics, they are the bulk of the folks that are coming in with these injuries and their falls and sub-dural hemorrhages, these kind of things, but that's more acquired or at least could be. So the patient either has several comorbidities that were preexisting, that affect their medical management in the rehabilitation space versus they've just had such a serious injury that it includes a lot of other trauma and organ systems that are dysfunctioning beyond the brain and nervous system. So when the patients come home, what kind of help or support or education do the families and caregivers need before they get there? Yeah, so that's kind of the tricky piece about traumatic brain injury is the variety of ways that disability or impairment might end up being expressed following a injury like that. When you get together, a brain injury re-epti and you're going to have providers who are all focusing on different aspects of recovery, the physical therapist focusing on mobility, strength, balance, these types of things, the occupational therapist, like Dr. Kench described, focused on the activities of daily living. So everyone's kind of looking at this piece of the puzzle in the context of the overall recovery trajectory and it really depends on what the most salient needs might be. Now for someone with a very severe traumatic brain injury, a family might need to be prepared to do a lot of hands-on care-giving for some of those basic ADLs, activity of daily living, things like toileting or being dressing, right? That may be something that someone requires a lot of assistance with or simply doing the transfer out of a bed to a wheelchair or wheelchair to a standing position. Someone might be on a modified diet where speech pathologist has been working on and then impaired swallow. So a family might need to be prepared to coach. So one through seat swallow strategies, as well as prepare an altered diet that would reduce the risk of some sort of chocopetanar aspiration of it. So I mean, on the severe end, it might be a lot more that hands-on medical oriented management of a person is just kind of day-to-day functioning through those typical activities. Layered on top of that, on top of the physical impairment, right, you might have what Dr. Kench is describing a variety of cognitive impairments, either impairment across multiple domains or specific things like, problems with learning memory or attentionate concentration that affects a house and when it interacts interpersonal with people. That can wreak havoc for families where you know, now there's a huge reversal of roles, right? Think of a married couple who were used to relating to each other's partners now ones in a caregiving role, really taking care of the other one. That can affect not only that dynamic and how it might play out with other members of that family who were part of this entry event, young children or older adults who might also be on the home, but you know, just basically things like intimacy that we think are important to relationships. Irrespective of like physical impairment that affects sexual functioning, but just sort of the cognitive and emotional awareness all that we need to be intimate partners with people, right? Like I said, what I've heard before is, you know, the spouse who may not remember that they were engaged into an activity. Earlier that day, and this now can play, why don't we ever have this part of our release stream or someone who can't perspective to take to sort of do that? That might also be expressed as really problematic or inappropriate behaviors in the community. Someone who doesn't have the ability to inhibit a response that could be aggressive or really inappropriate. Someone who might not be able to think through the consequences of their actions and is there for it higher risk for coming into contact with a law enforcement officer, right? Who may not have the immediate recognition that this person does have a disability given the invisible aspect of of brain-driven self-absence that polychroma, right? The signs of injury, the cast or a wheelchair, what have you, you know, it might not be obvious to someone that this person has been through a significant medical event. So we ask families, I think, to do a lot, right? So they may be training on these specific types of skills for management of the medical, physical, cognitive, behavioral aspects of brain injury. And I think we do a decent job in that short length of state that we have of orienting people towards the information that they need and in fact, and a lot of the research that we do around families perspective on needs that are met by an patient care. Folks are generally satisfied that they get good information about, you know, what's going on is my loved one, what kind of problems do we have? I think where people begin to identify unmet needs is after they've made it a transition to the community, there's clearly a lack of access to emotional support, whether that's formal or informal, the ability to talk with someone who's loved one has been through a similar experience. And so, you know, we try to lean heavily on our charity partners like brain-dream associations that are local and then have support groups for that. I mean, those people, those organizations are truly cool, people members of rehabilitation teams, because they are up the community. They have people who have the perspective of having been through something like this before. But then also the instrumental needs to come quite salient for people. And that may be lost productivity. If I'm in a charity having roles with family, then I'm not able to work, right? I'm not able to bring home some of the resources that have otherwise supported our family in that lively, but is lost, or just being able to take time for yourself to go do the things that you need to do that you've otherwise taken for granted. So, you know, I think we have, for better or worse, shifted a lot of the responsibilities for that post-acute care on the charity team's families. We ask a lot of them. We try to put the resources together for them, but it is a tall order. - All really excellent points. And it's almost unfair to have one episode where we're gonna cover, you know, the all-encompassing about brain injury, because it's such a multi-layered, complex issue, we get a multiple episodes, right? Just on different facets. And that probably is the intent moving forward. This is really meant to be a high level sort of introduction to it, but I think, you know, we could just go back to when a patient is more in the acute, the sub-acute phase of brain injury and, you know, come into a rehabilitation hospital for treatment. The expertise and the understanding of the staff, you know, whether it's the nurses, the therapists, and communicating that to the families, the fact that the patient is having trouble focusing with attention, processing information, you know, you or I, right, we can go to a cocktail party and have a conversation, but for folks with brain injury very often, there's all this sound and weight noise that is hitting them and they can't process it at all. And it gets interpreted as confusion. It can make them disoriented, agitated. And if you don't know how to treat it appropriately, we understand what's going on. And while this doesn't happen anywhere near to the frequency that it did maybe 10 or 20 years ago, it still does, people are inappropriately medicating these patients, sedating these patients, right? Well, they're agitated. Well, let's give them, let's give them how-dol or some other kind of suppressant. And you're actually prolonging the confusion and agitation or making things worse and losing valuable time, right, and managing these patients. So, you know, Dr. Koon, if you could just sort of take my lead there and talk about that a little bit, that would be great. That's a great point that you're bringing up. So the clinical situation that you described, there is one place for that patient who one place only, right? And that's an inpatient rehab facility with brain injury specialty expertise. Like a skilled facility is gonna have trouble managing those patients, the acute care services oftentimes to your point are really overwhelmed. You have to have that specialized neuro rehabilitation team, if you're gonna effectively get these patients from the ICU and that job really does start in the ICU, not on the step down, not at our front door in the earth. There is no neurosurgeon in my facility that I don't know very well. Maybe some of the spine guys, right? But you know what I mean? Like generally speaking, I know all my traumatologists, I know all of my neurosurgeons, I know all my neurologists because you are working with these folks within 24 hours of that patient being admitted. To your point, these patients can be confused for something more like dementia, right? And you're going down a management pathway, if that's the perspective that is not gonna end well. And you know, that's not gonna work for those patients. If you can provide these patients a safe, secure unit with the right type of staff, you can actually reduce their medication list, you can create a much more optimal environment. Again, it's worth pointing out that that's precisely where we're being squeezed right now, the shortening those days. These patients, in fact, need more time in those environments to be able to really get them to a place where cognitively they're able to transition home. And I wanna add something to Dr. Clices comments. And this really from what you asked as well, Patricia and Dr. Krueb Ledwith, when it comes to that elderly population and the folks who are having falls and they're on anti-coagulants and they're more prone to bleed, this oftentimes is the difference between them going back to the community at all. Because the heavy lift that we ask the families to do to provide that supervision, right? 24/7 supervision for an elderly patient who is living independently, that may be the difference between them being unable to successfully go back to the community and live independently and winding up in another post-acute care location. And I've seen many times where it's precisely because the family simply cannot not go to work. They cannot, they can't take that time away from work that is necessary. And so you really have to make sure that you are effectively using your resources in the acute care environment and the earth environment to create as promising of a situation as you can and for the best outcome. Certainly is a lot of work that needs to be done from a public health standpoint. Oh yeah. There's a there's a death of, you know, transitional living programs and other things that would allow, you know, Dr. Klice, your colleagues to really help with this behavioral management programs and other things that would allow the patient ultimately, hopefully to get home. Yeah, you're setting the table in the earth environment and I keep saying, you know, in patient rehabilitation facility, but you're setting the table in the work we do in this setting for the next 12 to 18 months and even beyond that. And if you can't successfully do that, you're gonna have more issues and you're gonna try, you're gonna be trying to address issues in the outpatient setting that are not well, that the outpatient setting is not well suited to. And so you're up against, I think you're what you correctly point out, the dearth of resources. And even when the resources are there, they're not accessible by everyone because of the high cost. This is probably also a good point for us to segue into some of the ideas. So we do TBI, we're a member of the TBI model systems. And a lot of our research is on resilience, patient and family resilience precisely because knowing that the family is largely responsible and gonna do the heavy lift, resilience really comes into play on how well patients may make that transition into the community. And if you could pick that up, Dr. Clice, I think there's some good information there. - Dr. Clienz, I appreciate you're making the point about resilience because, you know, we've been talking about how multi-form the problem is for families and trying to manage the different aspects of impairment or disability after brain injury. And so, you know, it would be really unfortunate to paint the picture that this is just gonna be devastating for everybody, right? 'Cause that's not necessarily true. People do recover well for brain injuries and families do well. And there are positive aspects of having been in that caregiving role that are really valuable to people. A lot of the times what we'll see is that, you know, caregiving families not only rise to the occasion, they're really knocking out of the park and those are people we need to learn. What's the magic here? What are the skills or the ways of seeing things or the ways of coping with adversity that make them so successful in that way? You know, so we talk about a lot of different constructs and brain injury and among caregiving families, things like resilience, which you know, people have sometimes talked about as the ability to bounce back from from a desk that you've met. And we like to think of it more as like bouncing forward. I think whatever colleagues just courts might have coined that term and saying, you know, it's not just kind of bouncing back to where you were, but growing from that inflection point in the life of the family where trauma interrupted their normal way of doing things, or things like post-traumatic growth, right? You've had this event that has, you know, kind of shattered your understanding of the way things are. But the upside to that is now that the table is clear to build fresh and stronger, right? And we often will frame that for patients and families in the end patient setting is like, this is an opportunity to get healthy across the board, right? And we can talk about things like, you know, preventing secondary injuries or illnesses. That's a result. So we can focus on kind of the dysfunction or, you know, risky behaviors, whatever it was, it might have brought someone to the experience of brain injury, but thinking about the wellness pieces of how do we thrive and do good going forward from here and staying as healthy as possible. So it's so important to make the point that, you know, this isn't just sort of a brain injury recovery, it's not a monolithic thing, it's not sort of an experience that all families are going to find to be devastating, but there are people who do really well, and we would do well to not only focus on the problems, but also the things that go right and how we can learn from that, replicate it, offer interventions for people to try and develop those skills or ways of seeing things, and that's a lot of the focus of the work that we do. And the brain injury is a very broad category of injury, right? It's a concussion is a brain injury. You've fallen, Mac your head, like I did when I was five, I had a concussion, and it's, it goes out way to the other extreme, right? So we have to remember that when we're talking about it, I think. I like thinking we're talking about, they're being hope. The stroke is very similar to brain injury. I mean, it is a brain injury, right? You're the medical people tell me when I'm wrong. But people recover from stroke. They get back amongst up there, or not all of their function, they can speak, they can live lives. We had a person on our first episode who had very severe stroke, and 15 months later he was driving, he got his license back, he was driving again, and could speak when in May 2020, he couldn't. So there is hope, right? I think that's true of brain injury too. I mean, I've seen great traumatic brain injury from a fall that the surgeons, and they go back to practicing surgery. I mean, where they, when they came to the rehab hospital setting, I mean, they didn't know where they were. They didn't know who they, you know, they couldn't get up and walk or anything. But so people make, there are amazing recoveries through, you know, the expertise of an interdisciplinary team, and there were those with lifelong issues that need, you know, to be addressed on a chronic basis. And I think a lot of the kinds of facilities like the sheltering arms that we're talking to today, it's not just about that inpatient care, it's a continuum of care. They really are, you know, you're, they become your patients for life, you know, for, for the most part. I mean, with brain injury, the right, there's a, there's a continuum of severity of injury, and then there's a continuum of, of the robustness of recovery. Let's say you, but what's weird about brain injury, folks who work in the concussion clinic will all describe, we've all had that conundrum of like, I have patients with mild TDI who are doing worse functionally than a patient who had a severe TDI and made a remarkable recovery. And while there's a lot more attention to brain injury these days, and certainly in the research lane, there is a lot more to be done because that is, you know, that's a hard question for me to answer is a brain injury specialist like why is one person, you know, doing so much better than another when, when, you know, a lot of disease states, the severity of the disease or injury will is a very good predictor, right? And certainly, I'm not saying that's not the case with, with TBI, but there's some real oddities that, that you come across and there's a fabulous article by Dr. White, John White from early odds where he, he talks about precisely the, the research issue of how difficult it is in the rehabilitation space to identify what are the active ingredients of a good recovery. You know, someone goes into the inpatient rehab unit and they're seeing a physical therapist, an occupational therapist, a speech therapist, a recreation therapist, the dietician, Dr. Coons. Now, I would like to think that Dr. Coons coming by and rounding each morning is the active ingredient of their recovery. I know that's not, I know that's not the case, right? It's, I think most of us at work in this business would agree it's the sum of the, it's the sum total. That's, that's not a good research answer, right? You know, that, so I think that's why you see a lot of the, the folks in our end of this business who are doing, are doing the research are really, really focused on, on that part of it. How can we tease apart? What works because it's incumbent upon us to show that what we're doing matters, we know it does, but we need to really be able to, to, to, to identify that and show it also, of course, because that's, what will allow us is, is Dr. Crue pointed out to, to best direct our resources because our resources are limited. We can't do everything. If I can continue with your point, great, come. If you're in patient, we had environment of care, he's just notoriously difficult to study with a kind of methodological rigor and the reasons for that are, you know, we, like you alluded to Patricia, we, we see a wide range of different types of people and different types of injuries who come to the patient setting. There are a ton of moving parts, right? In a short amount of time, it's kind of really hard to, you go back to that just man-to-ling metaphor, like saying, was this part of that part to really making the big difference here? And sometimes it's not even that you can identify an individual component that's really getting a big return on its investments, the interaction factor of all these different things and a dynamic team in a short amount of time sort of taking a holistic approach, right? But it's still worth trying to do, right? I don't think we can just kind of say, come to rehab because it's a good thing, because we think that work and we, we've seen that work, right? I think the ingredients that we're trying to hone in on are, how do we structure with therapeutic activities and treatments that we do in there, right? So, you know, if you ask someone who's doing rehab therapies with an occupation therapist or a physical therapist, how relevant does that feel? What they're doing to the patient in terms of their psychosocial context? You know, you can do tabletop exercises, you can do, you know, work repetitive types of therapeutic tasks. It doesn't feel real and connected to an everyday thing that someone does that's meaningful and important to them, right? So how do we contextualize the treatments that we do and make them relevant to people? How do we tie, treat the intensity of those treatments? How we push people hard enough to make it meaningful without pushing them too hard or not pushing so hard that, you know, we're not really challenging them to maximize on the recovery potential they have during that phase of their treatment rehabilitation for brain injury. We think it's really important to be able to include family members, people who are going to be part of that person's context going forward. I make sure that they are integrated into the treatment plan. And then also, you know, I think the big thing is we're just focusing on engagement. Being sure that we're not kind of overly defaulting to a preoccupation with productivity standards. I mean, the estimated of therapy, although that's important, but what do you do with that time, right? Like how engaged is the person in that activity? And to go back to your point, Dr. Krumig, like, you know, a patient who has agitation and is getting treated with medications to essentially sedate them, aren't able to engage very appropriately in rehabilitation therapy. So, you know, we have a critical phase of recovery where I think we have an opportunity to really maximize gates and set people on a positive trajectory going forward, right? Like we have a say in this business, whether it's true or not, but the faster you start to get better, the better you tend to get overall. So how can we jump start that recovery process really maximize the engagement for folks early on in that rehabilitation program and make sure that they do get set up on a path where we can say, we just got great momentum and we're going to try and keep that going into the community. I do want to sort of just switch gears just to slightly here and talk about some of the medical complications that can arise with traumatic brain injury because they in themselves can create a lot of morbidity and even mortality, but also because of everything we've been talking about with cognitive issues and how you approach treating some of those complications of the brain injury itself can negatively impact the cognitive aspect of it. That's why it's so critically important to have a rehabilitation physician who really has a global perspective and neuropsychologists and therapists to really understand this because you need that feedback. So when you order a medication, Dr. Kuhns, you need to know what affected that have. You're not going to be in the gym eight hours a day watching what happens, but you need people who understand so they can report back to you. And so just to sort of feed you a couple of things that I'm thinking about, whether it's managing spasticity, which I'll allow you to define if you'd like, being on to look out for, you know, with an urgent bladder, this patient have a UTI, for instance. Those are two, you know, common things, I guess, that you see in a rehab facility that could impact how you approach and treat those or miss that, could lead you down the wrong road, or again, could negatively impact the patient's ability to participate or benefit from the rehab itself. Yeah, so you mentioned spasticity, which that's one of my main interests as a sub-specialty matter. And that's exactly right. So, you know, spasticity, all my medications for spasticity have cognitive side effect profiles, right? So to your point, you know, I prescribe a, and I'm a pretty conservative person. I'm sorry. Yeah, so spasticity is, is, is, is most basic is disordered motor control. I think what most, for, for any lay listeners, if you picture in your mind, the hemiplegic posture of a patient who has had a stroke where one of their arms is clutched to their chest and internally rotated, flexed at the elbow and the fist kind of up near their shoulder. That's a, this is sort of like a classic spastic presentation that you might see at the grocery store, you know, some place you are. So, but they did present in many different ways, but it's fundamentally like a tightening of the muscles and almost invariably weak, unable to move the arm. And as Dr. Krueger alludes to that, if that is not effectively managed, as soon as you see it, you can wind up with a, with a fairly profound functional deficit. If, for example, as I just described, three years out from injury, your patient has that hemiplegic posture I described, you've got a big problem that's going on. I'm sorry to interrupt, but if I could just add to that, because I want to make sure that the audience truly understands what we're talking about here. Right, if you or I decide that we want to take a drink of water, we really don't go through any kind of conscious process. We just extend our arm, right, then we, we grab the glass, we flex our elbow and we manipulate our wrist and we take a swallow of the drink. But when you have a brain injury, you lose the ability to sort of automatically subconsciously, modulate muscle activity. So when I'm reaching for that glass, I'm shutting off my elbow flexors and activating my elbow or it's stenders so that I can extend my arm to reach for the glass. But when you have a brain injury, your elbow flexors or biceps in this instance doesn't shut off. In fact, it becomes overactive and the result of that is a patient who can't make meaningful, purposeful movements. And it can get mistaken for actually lack of strength or weakness, which they're very often is weakness. But there's underlying ability to purposefully move your extremity in this instance, your arm, that if understood and managed effectively, you can actually get meaningful functional recovery. And that's really what we're talking about here. Yes, that's exactly right. And this is one of the, when you have to make that argument for, you know, why is acute and patient rehab important for these patients? That's the reason. These are not phenomenon, clinical phenomenon that other providers are generally familiar with treating, you know, like I said, my neurosurgeons and the traumatologists that I work with, they certainly know how to identify those, but they call us and say, hey, help us out here. You know, let's get started on addressing this spastic phenomenon that Dr. Krujius gave a really nice description of because that simple task of picking up a glass and drinking it can be a remarkably laborious process for someone with these kind of injuries if they can complete it at all. So in your, you know, in the inpatient setting, you're confronted with that scenario and you need to decide whether to use oral medications and localized injections, physical modalities, dynamics, one thing, right? And you need to take in the whole picture of what impact, whatever treatment modalities that you're going to choose in it may be, you know, multiple, what impact that might have on other things that you're working on, like cognition. Yeah. And so to your point, if you start down the road, going with this example of spasticity of starting an oral medication or doing a botulinum toxin injection or something to, you know, something to address the issue, you need feedback from those neurotrained therapists down the hall in the gym about what are the outcomes of that intervention that you have done as the physician? It is impossible for me to manage that spastic problem by myself. It is simply not possible. It's not amenable to a vital sign or something, some just lab work that I can get that tells me how to further manage it. I need input from a specialist in motor control, for example, of the upper limb, right? In that case, it might not even be the physical therapist. It may be the occupational therapist. It is so important that you have that multidisciplinary team with those neurotrained specialists, if you've got them, that can give you online immediate feedback about your interventions, the side effects of them, the therapeutic effects of them. And, you know, to Dr. Cruz Point, you frequently, let's just say you start back with him, which is a commonly used medication in these situations. And the therapist might come back and say, well, you know, Dr. Cruz, yeah, the arm is a little looser, but boy is he tired. We're sedated. And look, we always say in brain injury, we kind of joke that in brain injury, a lot of times if your management is a physician, you go over to the hive looking for the honey, but all you get is the bees. And you have to kind of run away and kind of rethink how you're going to approach that hive, because the side effect profiles are everything in brain injury. And I would go with it and be on that is often is not it's the side effect, so to speak, right? The side effect. What is the side effect? The side effects of things I don't want. It's still a it's still what the medication does. In many cases, in brain injury, what a provider and another specialty might consider an unacceptable side effect is precisely what I'm looking for. You have to as a brain injury provider, you have to maintain a fairly nimble approach to your to your medications and their side effects. I would just want to say, you know, I think what makes for a highly functioning neuro rehab team is a team that is going to be really focused on communicating intentionally about these types of things, right? There's a lot of information that you shared because things change quickly, right? So if Dr. Coons is going to be trying a different dosage or a new medication in the morning, you know, everyone needs to know about that. So they can't be monitoring for the effects and he needs to be in a position to hear feedback about that so that we can all kind of be on the same page about what's changing, what's happening? How do we not miss a tribute, something new that we're seeing to a problem that actually could be readily fixed by getting the feedback to the right person, right? So I think the team have to work hard to communicate that they also have to be willing to be in a position for everyone to accept responsibility for whatever the problem is, right? Specificity is not just a physician's problem. It's everyone's problem on the team, right? Or that neurogenic bladder is going to lend itself to a team-based intervention around something like a toileting program. Adjutation is not something that we want to treat with medications. We want to create an environment that prevents that from happening and also where there are people who are in a skillful position to respond to it, to shape it, to use it therapeutically to try to address it without creating all kinds of new problems down street. So you know, the team has to be focused on that communication. They have to be willing to take on a variety of problems that don't necessarily fit with what they would say as a willhouse or what someone else would say as a willhouse by the St. Token. You know, it can't become a turf battle, right? Like no, only the psychologists can handle depression. Well, that's not necessarily true, right? Everyone can be a position to address adjustment to injury disability from their competence and expertise. And then finally, I think all of that kind of gets aimed at solutions that are parsimonious, right? So we're looking for at the end of the day what's going to be the right balance of things that satisfies the problem that we have. It doesn't overly complicate this, right? Like, you know, I've got a surefire way to fix agitation. That's like, how about all day long, right? But that's not the best fit. In fact, what's going to be? So how do we strike the right balance so that all of the different pieces of the puzzle that the team is looking at are honored, you know, right? Like, these are all goals that are established with the patient. They're all problems that are important, but they're not working. The interventions, the solutions are not working at cross purposes with each other. And so that's where, you know, a good team is going to communicate about that, be willing to tolerate each other having a piece of the pie and looking for the most parsimonious solution to the problem. I will think that a sedated patient is not going to learn how to manage their emotions. It's really hard to rehab a patient who's not awake. That's true. Yeah, yeah. The howl doll shuffle is not consistent with goal attainment. Dr. Clis's point is there's really an important one. It's come up four or five times already in this conversation, right? That it's really important that you need a specialized team that can manage a TBI patient without just relying on medication because that's not going to get you very far. I want to take a moment to really reinforce the idea about the team dynamics. Everyone in the rehabilitation space understand it's a team sport. No one member of an interdisciplinary rehabilitation team can do their job alone. nobody is. it may be the case manager, but nobody, I think really, generally speaking, can do this. And I just, the case manager definitely needs to work with the rest of us. But beyond that, the TBI is a very difficult diagnosis to treat. For a lot of the reasons we've talked about, the particularly in that acute inpatient setting when the injury is relatively new, the patient and family are still adjusting to, what could be a quite profound change in their life. The team dynamics are critical. It's important that team members trust each other, that they respect each other, that the team interacts well under pressure. And in that sense, it's maybe not all that different from the way they talk about sometimes the importance of how teams interact in a code or in a yellow trauma bay. And it's not quite for those same reasons, but because it is really important that everyone is seeing the same thing and talking about the same thing when we see something that doesn't look right. Dr. Klice alluded in his comments to the transdisciplinary approach that our team here at Shelton Arms Institute takes to this work, where we really focus on having team members practice at the top of their license. And I think using the analogy, like Dr. Klice is not the only member of the team who can interface in a positive way with a patient to affect their depression, right? All team members have a hand in that therapeutic process. It doesn't mean that I'm gonna bill for psychology services or something, but I'm certainly going to bring from my wheelhouse what I can to that part of the process. And if that's just medication management, then it's just medication management, but it may involve other things in how I talk to the patient, what how I educate their family about my medication choice and what role that medication has as part of the multi-pronged effort to address adjustment concerns. You know, I mean, but what I wanna get at is that the team dynamic there is really critical. It's really important. - That seems to be a thing that we're finding through all forms of, for all diagnoses that lamp people in patient medical rehabilitation. - Yeah, it's a team sport, it really is. For the same things that make it successful, or like we talked about a few minutes ago, or the things that make it hard to research, that make it hard to peer behind the curtain and really get under the hood to find out what's working. Again, it's all of us working together. That's the answer, but you know, we gotta prove it. (upbeat music) - I'm just wondering if we should have a commenter to you about the challenges with payers. You know, Dan, you brought it up early on, but just in terms of either getting approval, I'm not sure getting approval is sometimes it is, getting approval to come to the rehab hospital versus, you know, fighting for those extra few days to ensure that there's a good plan of discharging the patient. And if you think you can speak to that, you know, the first, some of the challenges or frustrations that you might experience, you know, again, either in the admission process itself, nobody, you know, there to answer the phone on a Friday afternoon and now hospitals left to decide what to do with this patient over the weekend, potentially sending them to the wrong level of care or holding on to them, whether or not in the right setting, and then on the other end of it, discharge ones. - As you mentioned, it's a huge problem in brain injury in particular. I think my challenges as a provider, you know, over the years is having that discussion with a medical director at an insurance company and trying to help them understand that the iron is hot now when you're in that earth setting. And the gains that we are able to make during that period are predictive in many ways of the long-term outcomes and they support the long-term outcomes. And it's hard, it's hard sometimes to help the insurer understand that it's in everybody's best interest to spend this money now, to use these resources now so that we don't have a patient who requires that many more resources for years. Remember that with our younger, now the older folks, we've talked a bit about some of these, you know, if you have a 21-year-old young man who, you know, is in an automobile accident, you are looking at potentially decades of medical costs and support needs, we should be doing everything we can in those critical that first year, year and a half, but we're talking here really about the inpatient setting to set up that patient and their family and their community for success. And what that success looks like is of course different for every patient, but that's a real challenge and that's something that I think that all of us that work in this space really need to advocate, support us and support the patients and the families now, it's critical because once you get into the chronic phase of these types, the types of deficits that come with brain injury and we'll just go back to spasticity as an example we're already using, the medical cost of that problem will not go away for the rest of that patient's life. And the best that you can get out in front of it and manage it ahead of time, the better off everybody's gonna be. And I can't say I've been, I can't say I've been outrageously successful in my anecdotal conversations over the years with medical directors who may not be rehabilitation providers at all, I've had conversations with vascular surgeons or someone where I just, I can tell we're not on the same page and it's not because they don't wanna hear what I'm saying, they're maybe not the right specialist and I'm just pulling that out of the hat, right? But someone from a specialty that's so far away from what we're doing, that it's hard to have that conversation in a constructive way. And so I think that's, we need to, I think as a business, as a group of providers and people in this space, that's something I think we should all think about. How can we better let the world know what we do and why it's important and why we can't let these things fester, they have to be dealt with ASAP. - Yeah, I mean, I bring up some really good points and it's definitely timely and relevant given the fact that there is bipartisan legislation proposed in Washington to make some meaningful reforms, put some guardrails around Medicare Advantage funds and how they do their business. I would hope we're all in agreement that there's only a finite amount of money available right for healthcare. And so we do need to be good stewards of those resources, but at the same time, we don't wanna be any wives and pound foolish and there are certain things that just need to be acknowledged like hospitals or 24, 7, 365 operations. And if you're gonna be in the healthcare insurance business, you need to be open too. - You have a brain injury expert who's trying to discuss the case with the insured because of the fact that there's a difference of opinion, you should be able to speak with someone who's got some working knowledge of the issues that you're discussing and things of that nature. And an appeal should happen in a reasonable amount of time and not three days, or even five days. It's just unrealistic in today's world and not in the best interest of the patient. At the end of the day, anything we do should really be about the patient. - Yeah, the patient is always at the center, it should always be at the center of any medical team and that is to include the payer. - Did the center of any discussion? (upbeat music) - I wanna thank both you, Dr. Kourin's and Dr. Klyse for your time, we've been very generous, we really appreciate it. - This episode is brought to you by Morris Therapeutics, part of the Morris Group, a privately held and the owned company. Morris Therapeutics is committed to improving the lives of patients who suffer from movement disorders, specificity and neurological conditions. Focusing on 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. Thanks for listening to Medical Rehab Matters, I'll podcast by the American Medical Rehabilitation Providers Association. AMRPA would like to thank podcast sponsor Merced Therapeutics for its support, as well as our Gold and Platinum Association sponsors. Our Platinum sponsors are Biones, Casa Collina Hospital and Centers for Healthcare, and Select Medical. Our Gold sponsors are CERNAR, JFK Johnson Rehabilitation Institute, Las Rehab, and the Center for Improvement and Healthcare Quality. You can learn more about Medical Rehabilitation at AMRPA.org. (upbeat music)