William H. Donovan, MD, is widely known for his expertise in treating people with spinal cord injury and amputations. After joining the TIRR Memorial Hermann medical staff in 1980, he served as director and principal investigator of the Texas Model Spinal Cord Injury System grant, awarded by the National Institute on Disability and Rehabilitation Research (NIDRR). Following in his footsteps and moving TIRR Memorial Hermann forward in the pursuit of excellence in spinal cord injury care is Matthew E. Davis, MD, clinical director of the Spinal Cord Injury (SCI) Program at the rehabilitation hospital. The two physiatrists share their insights about the past, present and future of SCI treatment at TIRR Memorial Hermann.
Dr. Donovan: To answer that question, we have to go back to the early days of the hospital and Dr. William Spencer’s original concept. As a young pediatrician just out of the Army, he was recruited by Baylor College of Medicine and the National Foundation for Infantile Paralysis to lead a staff of clinicians at the Southwestern Poliomyelitis Respiratory Center. After the polio vaccine eradicated the disease, Dr. Spencer refocused the clinical knowledge developed from the rehabilitation of patients with polio to the care of patients with catastrophic injuries and illnesses.
By 1960, the rehabilitation team was creating innovative treatments. Dr. Paul Harrington, who was chief of surgery, developed the Harrington rod for the stabilization of the scoliotic spine, an innovation that was recognized in Time magazine as breakthrough technology and is still in use today. Two years later, the Spinal Cord Injury Program was established, and in 1972 it was named a Model Spinal Injury Treatment System by the forerunner of the National Institute on Disability and Rehabilitation Research.
Dr. Spencer believed that as medicine became more specialized, it was also becoming too fragmented. He believed in bringing specialists to the patient, instead of shuffling patients from specialist to specialist in a fragmented model of care.
Dr. Spencer believed that as medicine became more specialized, it was also becoming too fragmented. He believed in bringing specialists to the patient, instead of shuffling patients from specialist to specialist in a fragmented model of care. This is especially important in the care of patients with spinal cord injury, who have multi-system challenges.
Dr. Spencer pulled together a talented group of physicians from various specialties. He knew that SCI patients might have complications like scoliosis that required treatment by orthopedic surgeons; others might have pressure ulcers that required the expertise of plastic surgeons. So TIRR Memorial Hermann developed a comprehensive care system for spinal cord injury patients, and all around the country hospitals began to recognize that SCI patients required much more specialized care.
Dr. Davis: Bill Donovan’s leadership and the accomplishments of other physicians helped build TIRR Memorial Hermann’s reputation. He led the development of the department of Physical Medicine and Rehabilitation at McGovern Medical School at UTHealth, which put us on the map for education in our discipline. PM&R was established as an independent department under his leadership in the mid-1990s, and the department started an accredited residency program with fellowships in traumatic brain injury, spinal cord injury and musculoskeletal medicine. Working with Martin Grabois, M.D., at Baylor College of Medicine, they formed the Baylor/UTHealth Alliance, a unique educational opportunity for residency training in PM&R. The alliance of the two institutions put us at the forefront of medical training in our field.
Dr. Donovan: Over time the comprehensive care system available to patients with spinal cord injury was eroded. Many of the changes that took place were driven by cost. When managed care took hold in Texas in the 1990s, health insurance companies looked for ways to lower costs. Length of stay was the biggest ticket item, and the decision of how long a patient stayed in the hospital was progressively withdrawn from the purview of the doctor and health care team to the insurance company. Hospitals, including rehabilitation hospitals, had to look for ways to improve efficiency. Patients who needed only nursing care could be transferred to long-term care facilities. Those who needed physical therapy, occupational therapy or speech therapy but didn’t require nursing care could be treated on an outpatient basis, which led to the proliferation of outpatient centers.
All this saved the insurers money, but it fragmented care, and spinal cord injury patients were particularly hard hit because continuity of care is so important to their wellbeing. The danger was that providers in the facilities they were referred to – acute care, long-term care, skilled nursing facilities – would be unfamiliar with the unique needs of SCI patients. So we had a yin pulling us to meet patients’ needs and a yang pushing us to cut corners and save costs, which put our patients in a difficult position. We tried to counteract that by making sure that as patients move from one facility to another, those facilities are geared up to provide good care. The Memorial Hermann Health System has done a good job of protecting patients by building a system that includes acute care, long-term care, inpatient and outpatient rehabilitation, skilled nursing facilities and so on. As a result, physicians can implement policies and procedures across the system to help prevent some of the complications SCI patients are vulnerable to and treat those that do arise.
Dr. Davis: Patients with spinal cord injury have traditionally thought of their physiatrist as their primary care physician because a spinal cord injury can affect nearly all functions of the body. In the 1960s, 70s and 80s patients went to specialized SCI centers, including TIRR Memorial Hermann, for care. Later, the Centers for Medicare & Medicaid Services (CMS) developed a very clear and much more limited definition of rehabilitation – a minimum of three hours of therapy a day and other restrictions that diminished the scope of practice of physiatrists and worked to the detriment of patients. Today, we’re working to reestablish that relationship through the Outpatient Medical Clinic, where patients have access to a broad range of services delivered by specialists, ranging from cardiology, neurology, urology and urogynecology to internal medicine, psychiatry, and obstetrics and gynecology.
Most primary care physician offices aren’t as wheelchair accessible as our clinic, and many patients with spinal cord injuries simply don’t go to the doctor because they feel their needs aren’t adequately addressed. The Outpatient Medical Clinic has exam rooms large enough to accommodate power wheelchairs and power lifts to transfer patients to an examination table. Patients tell us that things go more smoothly at our clinic. Our goal is to continue to expand the number of specialties and subspecialties at the clinic to serve the needs of spinal cord injury patients and others who consider a rehabilitation hospital their medical home.
We’ve also had to find innovative ways to respond to shorter lengths of stay. When spinal cord injury patients arrive at TIRR Memorial Hermann, their whole world has been turned upside down. They’re going through a major psychological adjustment, and we have a month to get them to buy into what they need to do to be safe when they return home. To help compensate, TIRR does a two-phase admission for SCI patients. During Phase I, we educate them about their condition and begin the initial stages of rehabilitation. When the cervical collar or other orthosis comes off after 12 weeks, we bring them back for Phase II. During that second phase, patients are more adjusted to the changes in their lives and are able to participate more completely in therapy.
I started my career in the Veterans Administration System, where cost containment and length of stay were less of an issue. I was particularly attracted to TIRR Memorial Hermann because of these and other innovations. The hospital has done a good job of responding to change and advocating for people with disabilities at the community, regional and national levels.
Dr. Donovan: We’ve always emphasized the importance of patient education but with shorter admissions, we had to deliver it in bigger morsels and in faster ways to impress upon SCI patients and their families that there’s no time to waste. We know that people who are in stressful situations can’t absorb information as rapidly, so we’ve had to put information on paper or DVDs so they can go back and refresh their memory about complications that don’t occur very often.
With the two-phase admission process, patients are not as anxious about going home because they know they’re coming back, and when they do come back, they have a better sense of self-direction. They’ve had some time to develop an understanding of the effects of their spinal cord injury and come to terms with some of the lifestyle changes they’ll have to make. They understand the relevance of their treatment plan more clearly.
Dr. Donovan: When you have a good system of care, you want to keep the tried-and-true elements and continue to improve by adding evidence-based innovations. Multicenter research plays such an important part in the advancement of SCI treatment. We know that the gender ratio in SCI is four to one, male to female. Any one center would have a hard time collecting information about efficacy of a treatment from the perspective of women, so by working together at the national level we can accomplish much more. I’d like to see even more multi-center collaboration in our field.
Dr. Davis: Technology has advanced dramatically in the area of orthotics and robotics and that trend will continue. Body weight-supported treadmill ambulation was a major innovation, and we now have the Bioness Vector Gait & Safety System™, an advanced overground gait and body weight-support system that allows patients to practice intensive physical therapy early in their rehabilitation. Early research suggests that walking over ground, rather than on a treadmill, may have a more beneficial effect on neuroplasticity.
Our therapists are using robotic arm exoskeletons to begin therapy for patients who have no voluntary activation of the arm muscles yet and bionic walking-assistance systems to help spinal cord injury patients stand upright and walk. We have an active research program through the NeuroRecovery Research Center and UTHealth Motor Recovery Lab at TIRR Memorial Hermann studying the efficacy of these and other systems. We’re also studying brain stimulation combined with robotic arm therapy and have a number of research projects focused specifically on the needs of women. In the last two years, the hospital has expanded its outpatient therapy presence across the city of Houston through clinics at Memorial Hermann Memorial City Medical Center, Memorial Hermann Northwest Hospital and Memorial Hermann The Woodlands Hospital, in addition to TIRR Memorial Hermann Adult and Pediatric Outpatient Rehabilitation at Kirby Glen, which opened in southwest Houston the early 2000s.
I’d like to see a return to the model of prevention. Our advocacy efforts at the national level are focused on influencing the implementation of the Affordable Care Act in ways that end the fragmented system of care for SCI patients. If I dream big, I would like to see SCI centers, which are now evaluated solely on functional independence measure (FIM) scores, be evaluated on re-hospitalization rates and total health care expenditures during the first five years after SCI. Patient education, which is so important with SCI patients, is not currently reimbursed by CMS. We believe that early education of patients reduces health care costs in the long run.
Our goal with spinal cord injury patients is to maintain hope and at first, for most patients, that hope is centered around walking. We work with them to adjust their definition of success, and eventually, they come to understand that life is about more than just walking. We work on neurorecovery and adaptive rehabilitation at the same time – walking and participating in life in new ways. We encourage patients to keep moving forward with their lives while they’re working on their neurological recovery. We never know exactly how neurological recovery will occur. Even those who eventually will walk may not do it for at least six months to a year, so they learn how to use that time wisely by doing meaningful things with family and friends and beginning to go about life with a disability. That’s the start of community reintegration, which is our ultimate goal for each of our patients.