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T I R R
M E M O R I A L
H E R M A N N
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THE INSTITUTE FOR REHABILITATION AND RESEARCH
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IN THIS ISSUE
4 MESSAGE FROM THE CMO
FEATURES
1Research Center Opening
5NIDRR Grant to Evaluate Memory
Remediation with Donepezil
Following Traumatic Brain Injury
6From Total Assist to Independence:
Braxton Taylor Benefits from the
Resources of TIRR Memorial
Hermann’s Spinal Cord Injury
Program
7Rehabilitation for Dysautonomia:
TIRR Memorial Hermann and
Children’s Memorial Hermann
Hospital Collaborate to Treat a
Complex Genetic Disorder
9Profiles in Caring: Lisa Thomas, CNS,
RN, CRRN, APRN
10Techniques for Ensuring Active
Engagement in Robotic Therapy of
Upper Limb Function
PERSPECTIVES ON RESEARCH
12Hair Cortisol: A Potential Biomarker
of Emotional Distress among
Persons with Traumatic Brain
Injuries
16MESSAGE FROM THE CEO
Digital Version
To opt in for a digital version
of this newsletter, please email
tirrcommunications@
memorialhermann.org.
TIRR Memorial Hermann Celebrates a
Milestone with the Opening of a New
Research Center
TIRR Memorial Hermann opened its
doors in 1959 as the Texas Institute for
Rehabilitation and Research (TIRR),
one of the country’s first rehabilitation
hospitals. Over the span of 55 years, the
institution has grown into a national
leader in interdisciplinary rehabilitation,
clinical care, education and research.
Last fall, the hospital celebrated another
milestone when the TIRR Memorial
Hermann Research Center was completed
and diverse research programs came
together under one roof for the first
time, creating new synergy between
researchers, disciplines and programs.
“Historically, our research programs
have developed their protocols independently of each other,” says Mark Sherer,
Ph.D., ABPP, FACRM, senior scientist and
director of research at TIRR Memorial
Hermann and a clinical professor in the
departments of Physical Medicine and
Rehabilitation at Baylor College of
Medicine and UTHealth Medical School.
“Because of the lack of space on our
Campus, they were housed in several
locations, including leased space outside
the Texas Medical Center. Many of us
had the idea of a research institute where
cross-pollination of ideas could take place,
but we had no idea that the possibility
of renovating a building so close to the
hospital would arise.”
TIRR Memorial Hermann owned a
long-vacant 42,000-square-foot building
adjacent to the main hospital facility,
purchased from UTHealth and formerly
known as the UT Speech and Hearing
Institute. During the 1970s and 1980s,
the building housed Baylor College of
Medicine research programs and TIRR
Memorial Hermann offices in space
leased from UTHealth.
“The availability of a building so close
to the hospital gave us the opportunity
to bring all of our researchers together to
promote synergy between the researchers themselves and also between the
researchers and the hospital’s clinical
team,” says Gerard Francisco, M.D., chief
medical officer at TIRR Memorial
Hermann and professor and chair of the
department of Physical Medicine and
Rehabilitation at UTHealth Medical
School. “In most institutions research
is conducted in silos that do not foster
collaboration. Early on, we made the
decision to change the status quo by
designing an open layout that would
New Research Center continues on page 2
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New Research Center continued from page 1
encourage communication. We hope
that bringing researchers in disparate
disciplines together will change the way
research is done in our field.”
Lex Frieden, director of the Independent
Living Research Utilization (ILRU) program, one of several research programs
located in the new center, remembers
the building before the renovation. “The
original structure looked like a threestory, above-ground bunker. Concrete
made the building seem chilling, and
there were few windows, which gave it
the uninviting feel of a fortress. The
artificial lighting was old neon that gave
off an eerie blue haze and made some
people physically ill. Despite the fact that
it was not a comfortable building, many
talented people did good, meaningful
work there. The new building gives a
sense of reawakening that’s inspirational
to people like me who knew it when it was
old and tired. Suddenly, we see new space.”
The dramatic transformation took
more than three years to accomplish, from
funding to finish. “We knew we needed
to grow our Campus and also find room
nearby for our researchers,” says Carl
Josehart , CEO. “The old building was
about the right size. We explored the
idea of demolishing it and rebuilding,
but we discovered it had good bones. It
was structurally sound, and a renovation
required a smaller investment, which
felt fiscally responsible. It was also more
environmentally friendly because we
could repurpose an existing structure.
We wouldn’t have sacrificed function to
keep the building, but we wanted to honor
the contributions that came out of it and
breathe new life into it.”
Funds raised through the Memorial
Hermann Foundation’s successful
Revolutionizing Neuroscience initiative
helped make the renovation a reality.
Filled with natural light, the new building
invites interaction between the interior
and exterior. An indoor dining room
extends onto an outdoor patio, and its
location across from Hermann Park allows
researchers who work in one of the
world’s largest medical centers to look
outside and see green lawn and foliage.
2
TIRR MEMORIAL HERMANN
Landscaping, color choices and photos
of Hermann Park that decorate the 1st
floor are among the elements that foster
the idea of nature brought inside.
Dr. Sherer remembers the building
from his first tenure at TIRR Memorial
Hermann and Baylor College of Medicine
from 1991 to 1997. “It’s remarkable that
we’ve been able to repurpose a building,”
he says. “Few of the interior walls were
structural, which allowed for their
removal, creating an open space. An
overhead walk connects our building to
the hospital. These are separate buildings
built at different times yet the overall
effect pulls them together, creating the
feeling that they were always connected.”
Robots used for research and patient care
Josehart calls the smooth move into
the new building a testament to the
thought that went into its planning and
the success of the design in meeting the
researchers’ needs. “There’s a sense that
we’ve always been there,” he says. “People
moved in and went right to work. Computers were on, and people were talking
on the phone. No one looked lost. In
designing the building and planning the
move, we were able to use the same skills
we use to help people plan for a smooth
transition back to the community.”
In the new building, researchers work
together in the same space and share
the same elevator, coffee room and
copiers, offering opportunities for new
relationships to develop. “The history of
rehabilitation is replete with collaboration, which has led to breakthroughs in
treatment and community reintegration,”
Frieden says. “That same legacy applies
to our move to the new building.”
Internationally renowned academic
physiatrist William H. Donovan, M.D.,
who retired as medical director of TIRR
Memorial Hermann and chair of the
department of Physical Medicine and
Rehabilitation at UTHealth Medical
School in 2009, after 28 years of service,
says a long-term dream has finally been
realized. “We recognized the benefits of
having researchers close to clinicians
but never had the opportunity to make
that happen,” Dr. Donovan says. “TIRR
Memorial Hermann has always excelled in
translational research, taking knowledge
gained through research and applying
it in the clinical setting. The proximity
of researchers studying traumatic brain
injury and spinal cord injury fully
integrates the hospital’s mission of
research, teaching and clinical care. Close
collaboration between researchers and
clinicians was the original intention of
TIRR Memorial Hermann’s founder, Dr.
William A. Spencer. Were he alive today,
he would surely be most pleased.”
A sweeping, open pathway leads from
the parking lot in front of the building to
the doorway, inviting staff and visitors
to enter. “It’s about a hundred steps from
the hospital. You can leave the hospital
through the back door, go down a sidewalk, take a right turn and you’re in the
new building,” says Frieden. “It’s the
personification of the vision of many
people but Carl invested a lot of himself
into making the research center a reality.
He didn’t turn any screws or pound any
nails, but he provided the leadership we
needed. It’s a significant step forward for
us as an institution.”
Dr. Sherer considers it far more than
a renovation. “Open space has replaced
concrete cubicles, with a nice balance
between privacy and connectedness,”
he says. “If you want to stop by and talk
to a colleague, you can. If you want to
work uninterrupted in your office, you
have privacy and quiet. It’s a rebirth.” u
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TIRR Memorial Hermann Milestones
1951The Southwestern Poliomyelitis
Respiratory Center opens in an
annex to Harris County’s Jefferson
Davis Hospital, the teaching
hospital for Baylor College of
Medicine, in response to the polio
epidemic sweeping the nation.
1959TIRR, the Texas Institute for
Rehabilitation and Research, opens
its doors in the Texas Medical
Center. As polio becomes less of
a universal threat, the hospital
focuses on the rehabilitation of
patients with spinal cord deterioration caused by disease or trauma,
pioneering the interdisciplinary
team approach to rehabilitation.
1962TIRR establishes its Spinal Cord
Injury Program and is designated
a national Rehabilitation Research
and Training Center (RRTC) for
Rehabilitation Medicine by the
Vocational Rehabilitation Administration of the U. S. Department
of Health, Education and Welfare.
Research conducted through its
affiliation with Baylor College of
Medicine makes the hospital an
international leader in improving
patient care.
1963TIRR becomes an important early
research partner with NASA.
1964TIRR founder and director
William A. Spencer, M.D., is
named Physician of the Year by
President Lyndon Johnson’s
Commission on Employment of
the Handicapped.
1970An annex to TIRR, acquired
through donated funds, increases
the hospital’s inpatient bed
capacity and makes possible a
unique residential program.
1972TIRR’s Spinal Cord Injury Program is named a Model Spinal
Injury Treatment System. The
Cooperative Living Program and
the Maximum Independence
Center, the nation’s first residential independent living programs
for people with severe physical
disabilities, are started at an
annex near downtown Houston.
1977The Independent Living Research
Utilization (ILRU) program is
established as a national resource
center providing research,
training and technical assistance.
1978The hospital changes its name to
The Institute for Rehabilitation
and Research to emphasize its
national and international service.
1984TIRR opens its inpatient Brain
Injury Program.
1985The National Institute on Disability and Rehabilitation Research
(NIDRR) designates TIRR as a
national Research and Training
Center on Independent Living.
1987NIDRR names the hospital’s Brain
Injury Program a Model System.
1990U.S.News & World Report announces its first America’s Best
Hospitals list. TIRR is named in
this nationwide survey of physicians
and has been included every year
since. The innovative Challenge
Program begun at TIRR as part
of the Brain Injury Program, in
keeping with TIRR’s philosophy of
community-based service
programming.
1992The Southwest Disability and Business Technical Assistance Center
(DBTAC), one of 10 federally
designed regional technical
assistance centers on the Americans
with Disabilities Act (ADA), is
TIRR Memorial Hermann Journal is published
four times a year by TIRR Memorial Hermann.
Please direct your comments or suggestions
to Editor, TIRR Memorial Hermann Journal,
TIRR Memorial Hermann, 1333 Moursund,
Houston, TX 77030, 713.797.7229.
Carl E. Josehart, CEO
Gerard Francisco, M.D.
Chief Medical Officer
Mary Ann Euliarte, RN, M.S.N., M.B.A., CRRN
Chief Nursing Officer /Chief Operations Officer
Mark Sherer, Ph.D., ABPP, FACRM
Director of Research
Susan Thomas, Editor
Karen Kephart, Writer
Steve Stanley, Designer
established at TIRR.
1993UTHealth Medical School establishes a department of Physical
Medicine and Rehabilitation. TIRR
affiliates with the medical school
that same year.
1996The departments of Physical
Medicine and Rehabilitation at
Baylor College of Medicine and
UTHealth Medical School form
the Baylor/UTHealth PM&R
Alliance.
2001 Outpatient Rehabilitation opens
at the Kirby Glen Center.
2006TIRR joins the Memorial Hermann
Health System and becomes TIRR
Memorial Hermann, one of 12 hospitals in the not-for-profit system
known for clinical expertise,
patient-centered care, leading-edge
technology and innovation.
2012 TIRR Memorial Hermann begins
the creation of a comprehensive,
integrated rehabilitation network
extending beyond the Texas Medical
Center to outlying communities in
the Greater Houston area.
2013 T he TIRR Memorial Hermann
Research Center opens adjacent to
the hospital, uniting the hospital’s
research programs under one roof
and creating an integrated Campus
where the critical components of
clinical care and research come
together for the benefit of patients.
Material in this publication may not be
reproduced in whole or part without
permission from TIRR Memorial Hermann.
Winter 2014
We have opportunities for outstanding
rehabilitation professionals. If you are
interested in joining our team at U.S.News
& World Report’s No. 3 rehabilitation hospital,
contact Derrick Anderson, recruitment
consultant, at 713.797.7281 or
derrick.anderson@memorialhermann.org
All available opportunities can be viewed at
memorialhermann.org.
www.tirr.memorialhermann.org, www.ilru.org
T H E I N S T I T U T E F O R R E H A B I L I TAT I O N A N D R ES E A R C H
3
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M
F
FEATURES
MESSAGE FROM THE CMO
As Braxton
Taylor’s story
illustrates, it
takes an entire
team to guide a
patient from
illness or injury
to a return to
meaningful
participation in
Gerard E. Francisco, the community.
M.D., CMO
There is no one
right way to accomplish that goal; we do
it by working together to touch each
aspect of the individual’s life.
That collaborative approach is mirrored
in our research program. The new TIRR
Memorial Hermann Research Center
houses professionals in four seemingly
disparate labs who work together
synergistically to bring innovations
to the bedside, the therapy gym, the
outpatient care setting and the community. Investigators in the Neurorecovery
Research Center, the Brain Injury
Research Center, the Spinal Cord
Research Program and the Independent
Living Research Utilization program
share the common goal of transforming
lives and instilling hope in people whose
lives have been significantly altered by
illness or injury. Those shared goals create
fertile ground for the discovery of solutions
that will reduce activity limitations and
participation restrictions on the individual level, and remove environmental
and social barriers in the community.
Rehabilitation doesn’t stop when a
patient walks out our door. It ends only
when the people we treat are valued
participants in the world around them.
Gerard E. Francisco, M.D.
Chief Medical Officer
TIRR Memorial Hermann
Chair, Department of Physical Medicine
and Rehabilitation
UTHealth Medical School
Save the Date: June 6-8, 2014
Advancing Wellness and Independence
After Spinal Cord Injury
Spinal Cord Symposium
A multidisciplinary course for
rehabilitation professionals to learn
more about spinal cord injury.
A variety of topics are available from which
professionals from each discipline can choose
to best match their individual learning needs
and the needs of their healthcare settings.
The goal is to provide teaching so that each
professional can practice effectively in any
setting that serves persons with spinal cord
injury.
Who should attend?
Physicians, occupational therapists, physical
therapists, speech-language pathologists,
registered nurses, case managers, social
workers, respiratory therapists and neuropsychologists.
TIRR Memorial Hermann
Friday, June 6, 11:30 a.m. – 5:30 p.m.
Saturday, June 7, 8 a.m. – 5 p.m.
Sunday, June 8, 8:30 a.m. – 12:30 p.m.
To receive more information, please email:
tirrcommunications@memorialhermann.org
FEATURED IN THIS ISSUE
Rhonda Abbott, PT
Administrative Director
Director of Therapy Services and Clinical Programs
Brain Injury and Stroke, Spinal Cord Injury and
Specialty Rehabilitation Programs
David B. Arciniegas, M.D.
Senior Scientist, Medical Director for Brain Injury
Research, TIRR Memorial Hermann
Executive Director of the Beth K. and Stuart C.
Yudofsky Division of Neuropsychiatry and Professor,
Menninger Department of Psychiatry and Behavioral
Sciences, Baylor College of Medicine
Adele Bosquez, PT, D.P.T., ATC, LAT
Physical Therapist, Spinal Cord Injury and Specialty
Rehabilitation Programs
Teresa Cramer, PT, D.P.T., PCS
Pediatric Clinical Coordinator
TIRR Memorial Hermann Outpatient Rehabilitation
at the Kirby Glen Center
Jessica Dalmolin, D.P.T.
Physical Therapist, TIRR Memorial Hermann Adult
and Pediatric Outpatient Rehabilitation at the Kirby
Glen Center
4
TIRR MEMORIAL HERMANN
Matthew Davis, M.D.
Clinical Director, Spinal Cord Injury Program
William H. Donovan, M.D.
Former Medical Director, TIRR Memorial Hermann
Former Chair, Department of PM&R, UTHealth
Medical School
Gerard E. Francisco, M.D.
Chief Medical Officer and Director of the
NeuroRecovery Research Center
Professor and Chair of the Department of PM&R,
UTHealth Medical School
Lex Frieden
Senior Scientist, Director, Independent Living
Research Utilization
Professor of Biomedical Informatics and Professor
of Rehabilitation, UTHealth Medical School
Professor of Rehabilitation, Baylor College of
Medicine
Carl Josehart
Chief Executive Officer
System Executive for Rehabilitation Services
Marcia K. O’Malley, Ph.D.
Senior Scientist, Director of Rehabilitation
Engineering, TIRR Memorial Hermann Associate
Professor of Mechanical Engineering and Materials
Science, Rice University
Director of the Mechatronics and Haptic Interfaces
(MAHI) Lab, Rice University
Adjunct Associate Professor of PM&R, Baylor College
of Medicine
Adjunct Associate Professor of PM&R, UTHealth
Medical School
Angelle Sander, Ph.D.
Director, Brain Injury Research Center, TIRR
Memorial Hermann
Associate Professor of PM&R, Baylor College of
Medicine
Mark Sherer, Ph.D., ABPP, FACRM
Senior Scientist, Director of Research and Director
of Neuropsychology, TIRR Memorial Hermann
Clinical Professor of PM&R, Baylor College of
Medicine and UTHealth Medical School
Lisa Thomas, CNS, RN, CRRN, APRN
Director of Clinical Education, TIRR Memorial
Hermann and the Memorial Hermann Rehabilitation
Network Affiliated with TIRR Memorial Hermann
TIRR Memorial Hermann Awarded NIDRR Grant to Evaluate
Memory Remediation with Donepezil
The National Institute on Disability and
Rehabilitation Research (NIDRR) has
awarded $3 million to TIRR Memorial
Hermann to perform a five-year study
to determine whether the medicine
donepezil is an effective treatment for
memory deficits resulting from traumatic
brain injury (TBI).
Memory deficits are among the most
common chronic and functionally
important consequences of TBI. Basic
science studies and clinical trials suggest
that persistent deficits in verbal memory
are associated with chronically reduced
levels of the neurotransmitter acetylcholine in the brain. While medications, such
as donepezil, that increase the amount
of acetylcholine in the brain appear to
improve memory and other cognitive
problems, research conducted to date has
not provided the level of evidence needed
to establish best practices. Investigators
at TIRR Memorial Hermann hope evidence
gained from the new trial will influence
the practices of prescribing healthcare
providers and contribute knowledge that
will improve the lives of persons with
TBI and their families.
Entitled “Multicenter Evaluation of
Memory Remediation after TBI with
Donepezil” (the MEMRI-TBI-D Study),
the 10-week trial will evaluate the effects
of 10 milligrams of donepezil, administered daily, on verbal memory problems
among adults with TBI in the subacute or
chronic recovery period. The study will
enroll 160 persons with TBI and functionally important memory problems at
four study sites across the country.
Principal investigator/project director
for the MEMRI-TBI-D Study is David B.
Arciniegas, M.D., senior scientist and medical director for brain injury research at
TIRR Memorial Hermann and executive
director of the Beth K. and Stuart C.
Yudofsky Division of Neuropsychiatry at
Baylor College of Medicine. Neuropsychologist Angelle Sander, Ph.D., director of
the Brain Injury Research Center at TIRR
Memorial Hermann and associate professor
of physical medicine and rehabilitation
at Baylor College of Medicine, is co-principal investigator. Drs. Arciniegas and
Sander are joined by co-investigator Mark
Sherer, Ph.D., ABPP, FACRM, director of
research and director of neuropsychology
at TIRR Memorial Hermann and clinical
professor of physical medicine and
rehabilitation at Baylor College of
Medicine. As the recipient of the grant,
TIRR Memorial Hermann will lead a
national team of collaborators at Spaulding Rehabilitation Hospital in Boston,
Moss Rehabilitation Research Institute
in Philadelphia, Indiana University in
Indianapolis and Craig Hospital in
Englewood, Colo.
“We’re fortunate to bring this group
of investigators together to conduct this
clinical trial,” Dr. Arciniegas says. “The
MEMRI-TBI-D Study capitalizes on the
extensive successful research on brain
injury rehabilitation within and between
the participating centers. It also will
benefit from this groups’ expertise in the
study of pharmacologic and rehabilitative
treatments for cognitive problems
resulting from traumatic brain injuries.”
The announcement of the grant
coincides with the opening of the TIRR
Memorial Hermann Research Center, the
new home of the Brain Injury Research
Center (BIRC). BIRC was founded in the
1980s to conduct research that improves
outcomes for persons with brain injuries.
The principal goal of research conducted
at the Center is to reduce barriers to daily
function and enable persons with TBI to
return to full participation in life.
The goals of the MEMRI-TBI-D Study
complement those of other research projects under way at BIRC. “Our aim is to
determine if donepezil, a medicine that
addresses one of the chronic neurochemical deficits produced by traumatic brain
injury, improves memory performance
in persons with TBI,” Dr. Arciniegas
says. “If this treatment is successful,
persons with memory problems after
TBI will experience improvements in
day-to-day memory.”
Enrollment will begin in spring 2014;
each study site will enroll 10 participants
per year over the 48-month period of
active recruitment. “The quality of the
evidence yielded by this study will directly
affect the way healthcare providers serve
persons with memory problems after TBI,”
Dr. Arciniegas says. “Since donepezil is
available in a generic form, it also offers
the promise of an affordable treatment
option for many persons with TBI and
their families. If donepezil is found to
be effective in individuals with memory
problems after TBI, we hope that these
findings will inform the practices of
rehabilitation programs across the
country and internationally.” u
T H E I N S T I T U T E F O R R E H A B I L I TAT I O N A N D R ES E A R C H
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From Total Assist to Independence: Braxton Taylor
Benefits from the Resources of TIRR Memorial Hermann’s
Spinal Cord Injury Program
When 20-year-old Braxton Taylor arrived
at TIRR Memorial Hermann in August
2013, he was unable to walk, transfer,
eat or manage other activities of daily
living without total assistance. When he
was discharged on Halloween, he could
walk with assistance and was independent
in most aspects of daily care, a tribute
to his motivation and the resources of
TIRR Memorial Hermann’s Spinal Cord
Injury Program.
Born with Arnold-Chiari malformation,
Taylor began to experience symptoms
– weakness on the right side and headaches – when he was in high school. A
neurological disorder of the cerebellum,
the part of the brain that controls balance,
Arnold-Chiari malformation occurs when
parts of the cerebellum and brain stem
are pushed downward into the foramen
magnum, a funnel-like opening to the
spinal canal, and into the upper part of
the spinal canal. The result is pressure
on the cerebellum that can affect
functions controlled by this area of the
brain and block the flow of cerebrospinal
fluid (CSF) to and from the brain.
Diagnosed in 2008, Taylor has had
neurosurgery every year since then for
treatment of the disorder and related
conditions. In July 2013, he suffered a
cerebral hemorrhage in the left frontal
lobe of the brain that left him with
hemiplegia.
“Braxton was admitted to the Spinal
Cord Injury Program because so many
of his needs paralleled those of our cord
injury patients, but in fact, he benefited
from nearly every inpatient program we
have,” says Adele Bosquez, PT, D.P.T., ATC,
LAT, a physical therapist in the Spinal
Cord Injury and Specialty Rehabilitation
Programs. “In complex cases like
Braxton’s, it truly takes an entire team.”
Led by physical medicine and rehabilitation specialist Lisa Wenzel, M.D., Taylor’s
6
TIRR MEMORIAL HERMANN
team included therapists, nurses, case
managers and social workers who practice
a unified, interdisciplinary approach to
patient care. “I had big goals and worked
hard to accomplish them,” says Taylor,
who has completed three semesters at St.
Mary’s University in San Antonio and
plans to begin online courses to continue
his education in the interim. “The team
at TIRR Memorial Hermann was really
good at helping me get there. My main
goal was to be able to walk and live more
independently, and they threw everything
they had at me. The variety of equipment
was very cool.”
Among the tools he worked with is
the Bioness Vector Elite Gait and Safety
System™, a harness support device that
runs on a ceiling track, allowing him to
practice walking over ground while his
therapists gradually decreased the amount
of his weight the device was carrying.
“When patients are relearning how to walk,
one of the significant barriers to progress
is fear of falling,” says Matthew Davis, M.D.,
clinical director of the Spinal Cord Injury
Program. “The Vector takes away that
risk and gives our staff the comfort and
assurance that the patient is safe. It’s
particularly useful for developing
competency in patients with incomplete
spinal cord injury and those like Braxton
who have the potential to walk again.”
Taylor also benefited from other
technologies, including the Hocoma
Armeo®Spring, an ergonomic arm
exoskeleton with integrated springs that
enhances function and neuromuscular
control; FES Bike, which applies small
electrical pulses to paralyzed muscles to
restore or improve their function; specially
designed knee-ankle-foot orthoses
(KAFOs) that stabilize the joints and
assist the muscles of the leg; and an
Ekso™ exoskeleton, a wearable bionic
suit that enables individuals with
lower-extremity weakness to stand and
walk over ground to improve strength,
mobility and endurance.
In occupational therapy, Taylor worked
to improve his balance. “Braxton has
good, strong core musculature, but his
sense of balance is off,” says Bennett Cope,
OTR. “We worked on finding his center of
balance and realigning it, and later began
working on functional tasks, such as
dressing, eating and other activities of
daily living. He’s a very, very smart kid
with a strong work ethic. We could tell
from day one that he was very practical in
his approach to rehabilitation. He threw
in ideas of his own and would never say no
to anything we asked of him in a therapy
session. I’d see him doing his homework
after his sessions, and he worked with his
nurses to stay on top of his care. When
he was admitted, he was only able to take
one or two bites of food unassisted. When
he left, he could eat on his own.”
Taylor participated in TIRR Memorial
Hermann’s community dining program,
in which patients with spinal cord injury
and others dine in a group at local
restaurants to regain confidence. As part
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of the hospital’s community reintegration
program, he attended an outing at the
University of Houston focused on overcoming barriers to returning to school.
He also joined FAME (Functional Arm
Movement for Everyone), a program
focused on increasing awareness and
functional use of the impaired upper
extremity.
“A social worker made sure he and his
family were aware of other programs he
qualified for,” Bosquez says. “We helped
him find transportation near home and
gave him resource information for the
Texas Department of Assistive and
Rehabilitative Services.”
Cope and Bosquez worked with Taylor
to find an appropriate wheelchair. “He
didn’t want a power wheelchair because
of the size and weight, but he didn’t have
the strength to use a manual wheelchair,”
Cope says. “We found the right manual
chair for him and added a power function
for maximum independence.”
A week before discharge, he participated
in an in-house pass program that allowed
his mother, Rosalyne Taylor, to stay with
him for 24 hours to develop a hands-on
understanding of the help he would need
at home. “We’ve always had a good
Spinal Cord Injury Program, and with
all the technology we’ve added, we can
offer our patients much more today than
we could even a year ago,” Bosquez says.
Terree Funesti, RN, WCC, CRRN, clinical
manager of the Spinal Cord Injury Unit,
remembers Taylor as a “real gentleman
who told his nurses every day how much
he appreciated them. We really liked
him, and like many young people, he fit
into our unit like family. The beauty of
rehabilitation nursing is that we see
inpatients through their entire experience at the hospital. They come to us in
such an acute condition and we help
them gain their independence medically
so they can get downstairs to the gym.
Encouraging them to use the skills they
learn in therapy and watching them
transition from total assistance to
independence is incredibly rewarding
for us as nurses.”
Rhonda Abbott, PT, administrative
director of therapy services and clinical
programs, points to Taylor’s case as
exemplary. “This is one of many cases
in which we all pull together with the
patient in unique, personalized ways to
truly address function, community and
meaningful participation,” she says.
“We have the ability to do it all at TIRR
Memorial Hermann, but what really makes
us special is having creative therapists
who can identify a young man’s needs and
come up with a program designed to meet
his specific goals. Making a difference
in lives like Braxton’s and those who love
him is where it’s at.”
Taylor says he’s come a long way in a
relatively short period of time. “I walk
with a walker and a little assistance to
help with my balance issues,” he says.
“I wouldn’t be where I am today without
TIRR Memorial Hermann and my faith.
They’re all great people to work with –
motivating and very supportive.” u
Rehabilitation for Dysautonomia: TIRR Memorial Hermann
and Children’s Memorial Hermann Hospital Collaborate to
Treat a Complex Genetic Disorder
Eighteen-year-old Justin Lamb is one of
many patients to benefit from a unique
collaboration between TIRR Memorial
Hermann and the pediatric neurology
and pediatric cardiology services at
Children’s Memorial Hermann Hospital.
Working together, the two institutions
have developed a program that provides
a complete continuum of care for children
and adolescents with dysautonomia, a
complex genetic disorder that affects the
autonomic nervous system and can cause
life-threatening medical complications.
“Dysfunction of the autonomic nervous
system can cause a number of health
problems related to the functions it
controls, including heart rate, blood
pressure, digestive tract peristalsis and
Justin Lamb celebrates his 18th birthday
sweating, among other things,” says
pediatric neurologist Ian Butler, M.D.,
Adriana Blood Professor in Neurology
and director of the division of Child and
Adolescent Neurology at UTHealth
Medical School, who with pediatric
cardiologist Mohammed Numan, M.D.,
operates a combined child neurology
and cardiology clinic for dysautonomia
patients at Children’s Memorial Hermann
Hospital. “Because of the complexity of
the disorder and array of symptoms it
produces, these kids are easy to miss and
difficult to diagnose. Like Justin, they
end up going from specialist to specialist.
Years may pass before their parents have
a conclusive diagnosis.”
Dysautonomia continues on page 8
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Dysautonomia continued from page 7
Born in 1995 at 36 weeks, Justin had
health challenges from birth. “He had
severe GI symptoms, so we saw a gastroenterologist,” says his mother Meredith
Lamb. “He had migraines that were
treated by his pediatrician. Later he
developed some problems with walking,
but his health issues never dramatically
improved or worsened until he contracted
the H1N1 flu virus in 2009. The flu
started a downward spiral that we later
learned is characteristic of dysautonomia.”
From influenza, Justin went to pneumonia and pleurisy. When he developed
more serious problems with walking and
began posturing his hands strangely, his
mother took him to an orthopedist, who
recognized his symptoms as neurological
and referred them to Dr. Butler.
On one visit to Dr. Butler, Lamb
mentioned that her son had experienced
dizziness, which, along with his overall
presentation, prompted the neurologist
to consider dysautonomia. He referred
Justin to Dr. Numan for a tilt-table test,
the gold standard for diagnosis of the
disorder. Patients are strapped to the tilt
table lying flat, then tilted upright to
about 70 degrees. The 30-minute test is
considered positive if the patient
experiences symptoms associated with a
drop in blood pressure, such as fainting
or cardiac arrhythmia.
“The tilt-table test reproduces the
clinical manifestations of dysautonomia,
giving us a clear indication that the autonomic nervous system is malfunctioning,”
says Dr. Numan, an associate professor
in the division of Pediatric Cardiology at
UTHealth Medical School. “This is
particularly important because it’s very
common for dysautonomia patients to be
misdiagnosed with psychological disorders.
They suffer from overwhelming fatigue.
They have nausea that’s not always
explainable. They complain bitterly of
pain in their shoulders, back and legs.
Some complain of tingling in their hands
and feet. The body is trying to compensate
for lack of oxygenated blood, and it shuts
down blood flow to muscles and non-vital
organs. Their physicians order one
diagnostic test after another. When there
8
TIRR MEMORIAL HERMANN
are no findings – a common occurrence
with dysautonomia – the disorder is
mislabeled as psychogenic. But the kids
are suffering, and they get depressed when
they’re unable to find help.”
After the tilt-table test, Justin was
diagnosed with dysautonomia. Dr. Numan
also found an atrial septal defect of the
heart and closed the hole in an endovascular repair in December 2011.
For Justin and other children and
adolescents with dysautonomia, acute
care is only the first step in treatment.
“These children become deconditioned
very quickly,” Dr. Butler says. “We use
medications to increase the vascular
volume to the brain because the blood
tends to pool in the legs and pelvis. Many
are in physical therapy. When we started
looking for a medical home for our
dysautonomia patients, it seemed natural
to approach TIRR Memorial Hermann.
We contacted hospital leadership, and
they put together a round table. We
discovered we were speaking the same
language. We do tilt-table testing; they use
a tilt table therapeutically. Our patients
do well in aquatic therapy; they have a
strong aquatic program. It was a good fit.”
Teresa Cramer, PT, D.P.T., PCS, pediatric
clinical coordinator at TIRR Memorial
Hermann Outpatient Rehabilitation at
the Kirby Glen Center, spent time
observing the two physicians and their
patients in clinic and learned about
symptoms and health issues. “This is
familiar territory for us,” Cramer says.
“Frequently, patients with traumatic
brain injury or spinal cord injury have
autonomic nervous system dysfunction.
Dysautonomia symptoms can range from
very mild to very debilitating, and these
patients need specialized care. We put
together a core team to work with Drs.
Butler and Numan, and trained our staff
using what we learned from them and from
the pertinent rehabilitation literature.
The result is a multimodal approach to
therapy that provides dysautonomia patients with the help they need consistently.”
Jessica Dalmolin, D.P.T., was Justin’s
physical therapist at TIRR Memorial
Hermann Outpatient Rehabilitation at the
Kirby Glen Center. “With dysautonomia
patients we emphasize cardiovascular
exercise to increase blood flow to the
muscles in positions that decrease
orthostatic stress, including supine, prone,
recumbent and sitting positions,” she says.
“As they build up tolerance we add more
upright exercise, incorporating yoga,
Pilates and light weights, as well as balance
and stretching exercises. We slowly
progress to a standing position. They
exercise with a heart rate monitor so we
can track their exertion during the
session, and we ask them to monitor their
symptoms at home by keeping a journal.
They record any exercise they do at home,
how long they slept, if they had any lightheadedness, headaches or brain fog after
their therapy session. If they’re exhausted
the day after their session, we know we
have to adjust their therapy program. The
journal helps us personalize treatment
to their particular needs.”
Justin’s journal gave Dalmolin a good
picture of what he experienced during
the week he kept it. “He’s a great kid with
a really supportive mom,” she says. “She
let him lead and take charge of his own
treatment, but if he had questions, she
was there to help. Like many kids with
dysautonomia, Justin was very in tune
with his body and well educated about the
disorder. He was willing to work hard
and was not afraid to let me know when
symptoms or fatigue got the best of him.
His mom is a great advocate for him and
for the dysautonomia population.”
Meredith Lamb and her family, including
24-year-old son Marc who has a milder
form of dysautonomia, are committed to
raising awareness about the disorder.
In May 2013, they formed the Lamb
Foundation for Dysautonomia Research
to raise funds in support of studies
being conducted at Children’s Memorial
Hermann Hospital and UTHealth
Medical School. Drs. Butler and Numan
have several research projects under way
or completed, including the role of
histamine and mast cells in dysautonomia,
cerebrospinal fluid neurotransmitters,
immunomodulation treatment protocols
and DNA studies utilizing whole exome
analysis of families.
It’s not uncommon for more severe
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cases of dysautonomia to rob teenagers
of their high school years. “Justin still
has good days and bad days,” his mother
days. “The bad days made him miss his
entire high school experience. He tried
to go back to school twice but became
sick and came home again. We did an
online high school program and he did
pretty well in his sophomore year, but
then he was too sick to keep up. We tried
home schooling. He will get his GED,
and we will move on.
“Dr. Butler, Dr. Numan and TIRR
Memorial Hermann are family now,”
Lamb adds. “We spent years going from
specialist to specialist. We’re very
grateful for the help we’ve found.” u
Justin resumed physical therapy and
began aquatic therapy at TIRR Memorial
Hermann-The Woodlands’ new outpatient
center in December 2013. TIRR Memorial
Hermann accepts physician referrals for
children and adolescents with dysautonomia at several locations in Houston.
To refer a patient for rehabilitation,
please call 1.800.44.REHAB (73422).
Profiles in Caring: Lisa Thomas, CNS, RN, CRRN, APRN
It’s no surprise
that Lisa
Thomas was
recognized in
2013 as a Good
Samaritan
Foundation
Excellence in
Nursing Bronze
Medalist, an
award program created to recognize
“nursing’s best and brightest.” An
advanced practice nurse and clinical
nurse specialist in adult health, she brings
energy, expertise and enthusiasm to her
role as director of clinical education for
TIRR Memorial Hermann and the hospital’s
growing citywide rehabilitation network.
“With our strong emphasis on standards
of practice and quality improvement at
TIRR Memorial Hermann, we’re working
in a rapidly changing environment,” says
Thomas, who oversees four educators,
library services and education resources.
“With every change, whether it’s a new
policy, a new process or a new product,
there’s an educational component we
have to address with nurses, therapists
and residents. Because the hospital is
constantly expanding the boundaries of
rehabilitation with new knowledge and
new techniques, we stay busy as educators.”
Thomas grew up with a scientific bent.
“I’ve always enjoyed the sciences in general,
and I considered different disciplines
before deciding to become a nurse,” she
says. She had a strong role model in her
grandmother, a diploma-trained nurse
with the Memorial Sisters of Charity who
retired after 50 years of service, the last
20 of which she spent at The University
of Texas MD Anderson Cancer Center as
an oncology nurse.
Thomas’s first exposure to rehabilitation came when she was in high school in
Alvin, Texas. “My grandfather had a stroke
and moved into my parents’ home, where
he lived for the next 20 years,” she says.
“His presence raised my awareness of
caregiver challenges and care coordination issues. I was impressed by how much
improvement his early rehab stay made
in his recovery.”
After graduating from high school,
Thomas received a full scholarship to
the University of Houston pre-pharmacy
program. When she made the decision to
become a nurse, she transferred to The
University of Texas Medical Branch at
Galveston, completing her bachelor’s in
nursing in 1994. She was employed by
hospitals in Houston, Vero Beach, Florida,
and Dallas, before accepting a position as
a weekend staff nurse at TIRR Memorial
Hermann in 2003. She was soon promoted
to the newly created position of weekend
night operations administrator, a role
that provided her a first glimpse of the
big picture and raised her awareness of
the need for process improvements. In her
new position, she began staff education
and auditing of results, as well as patient
and family education.
In 2005, while working at the rehabilitation hospital, she was accepted into
the Master of Science Clinical Nurse
Specialist-Adult Health program at Texas
Woman’s University (TWU). She graduated,
was certified as a clinical nurse specialist
and applied for licensure through the
state as an advanced practice nurse in
2009. She completed final coursework
for her post-master’s certification in
nursing education that same year.
She was still a weekend operations
administrator when she brought a
clinical group from TWU to TIRR
Memorial Hermann, serving as adjunct
faculty for them. When she transitioned
to a fulltime education role, she helped
train her adjunct replacement. The hospital
continues to host students from TWU.
Actively engaged in research, Thomas
is currently working on a collaborative
project to examine the experience of
amputees who see themselves in the
mirror for the first time following their
amputation. “This is a powerful patient
experience that crosses multiple disciplines, including physical therapy,
occupational therapy and nursing,” she
says. “Our research partner at TWU has
examined the experience of women after
mastectomy in ways that help them recover
and form a new view of themselves. We’re
very interested in investigating how
these findings might apply to patients
who have undergone upper- or lowerextremity amputation.”
The first in her family to earn a
bachelor’s degree, Thomas is currently
enrolled in the Doctor of Nursing Practice
program at UTHealth School of Nursing,
with an expected graduation date of May
2015. Designed for nursing executives,
the program encourages a broader, more
Profiles in Caring continues on page 12
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Techniques for Ensuring Active Engagement in Robotic
Therapy of Upper Limb Function
S
By Marcia K. O’Malley, Ph.D.
High intensity and high repetition upperlimb movements are necessary for
recovery of function following neurological injury, since such actions are
capable of inducing brain and spinal
plasticity. Robotic devices are uniquely
suited for delivering such intensive,
repetitive therapy. However, studies
have shown that passively moving the
limb through prescribed trajectories is
not necessarily efficacious. In order to
derive maximum benefit from robotassisted rehabilitation, it is critical that
the implemented control algorithms,
which govern how the robotic device and
the participant interact, promote the
participant’s active engagement in therapy.
My research group at Rice University has
been developing novel approaches for
ensuring cognitive engagement of the
patient during robotic rehabilitation of
the upper limb following stroke or
incomplete spinal cord injury. In this
article I present several techniques that
we have used, including the development
of objective measures of motor impairment
that can be used for frequent feedback to
the therapist and patient regarding their
progress, robotic control architectures
intended to promote engagement and
intentful movements by the participant,
and the design and implementation of
compliant robotic hardware systems that
facilitate novel control approaches such
as interaction control.
In our early work (Celik et al., 2010),
we analyzed the correlations between
four clinical measures (Fugl–Meyer
upper extremity scale, Motor Activity
Log, Action Research Arm Test and
Jebsen-Taylor Hand Function Test) and
four robotic measures (smoothness of
movement, trajectory error, average
number of target hits per minute and mean
tangential speed) used to assess motor
recovery. Data were gathered as part of a
hybrid robotic and traditional upper
extremity rehabilitation program for nine
stroke patients. Smoothness of movement
and trajectory error, temporally and
spatially normalized measures of
movement quality defined for point-topoint movements, were found to have
significant moderate to strong correlations
Validation of real-time trajectory recalculation. The subject initially moves faster than
the desired trajectory, causing several recalculations with corresponding decrease in
total allocated time. After a transient, the total time remains roughly constant at 0.8 s.
10
TIRR MEMORIAL HERMANN
with all four of the clinical measures.
The strong correlations suggest that
smoothness of movement and trajectory
error may be used to compare outcomes
of different rehabilitation protocols and
devices effectively, provide improved
resolution for tracking patient progress
compared to only pre- and post-treatment
measurements, enable accurate adaptation of therapy based on patient progress,
and deliver immediate and useful
feedback to the patient and therapist.
More recently, we have focused on the
development of novel control algorithms
that govern how the robot and participant
interact during robot-assisted upper limb
therapy (Pehlivan et al., 2013). A class of
controllers named “assist-as-needed”
addresses the requirement of promoting
active engagement by providing only
appropriate assistance during movement
execution. Often, these controllers depend
on the definition of an optimal movement
profile, against which the participant’s
movements are compared. We have
proposed an assist-as-needed controller
that introduces a novel feedback gain
modification algorithm, making the
controller adaptive. By modifying the
gains of the feedback part of the adaptive
controller directly, we are able to change
the action of the adaptive controller
based on the amount of error allowed
during movement execution, while
simultaneously estimating the forces
provided by the participant that contribute
to movement execution. We have also
implemented a real-time trajectory
generation algorithm based on a physiologically optimal and experimentally
validated asymmetric wrist movement
profile. The feedback gain modification
and trajectory generation algorithms
have been experimentally validated with
our custom RiceWrist robotic rehabilitation system, with the modified assist-asneeded adaptive controller decreasing
its feedback control action when a subject
moothness of movement and
trajectory error, temporally
and spatially normalized
measures of movement quality
defined for point-to-point movements,
were found to have significant
moderate to strong correlations with
all four of the clinical measures.
shifts his behavior from passively riding
along with the robot during movement to
actively engaging and initiating movements to the desired on-screen targets.
Finally, we have proposed the inclusion
of physical compliance in our robotic
hardware in order to enable implementation of interaction control techniques
(Sergi et al., 2013). In the rehabilitation
scenario, such control schemes assist
motion by applying variable levels of
mechanical assistance, with the capability
of adapting to and capitalizing on the
residual contributions of the subjects.
Moreover, evidence from human trials
with stroke subjects (Hogan et al., 2006)
and from preliminary studies on animal
models of spinal cord injury (R. van den
Brand et al., 2012) confirms the hypothesis that interaction control schemes are
more capable of promoting plasticity
through mechanical interaction compared
to motion control. In force-feedback interaction control, the force of interaction
between the robot and the environment
is measured and fed back to the controller
driving the actuators, which specifies
new desired force or position/velocity
commands. In a Series Elastic Actuation
(SEA) architecture (Williamson, 1995;
Robinson, 2000), compliant elements
with deflection/force measurement
capabilities are intentionally introduced
in series between the actuator and the
load, effectively acting as a mechanical
filter that decouples the non-linearities
of geared actuators from the output and
enables implementation of force-feedback
control laws. The introduction of physical
compliance with well-known properties
enables the deployment of accurate
interaction control schemes, thus
mimicking the traditional therapistbased physical therapy, essentially based
on the adaptive and compliant transfer
of support forces. We have developed a
prototype version of our RiceWrist
robotic device (Gupta et al., 2008) that
incorporates series elasticity, and we
will be clinically evaluating its performance in the near future.
Whether we leverage the sensors on
the robotic device to compute performance measures that track participant
performance throughout therapy and
provide frequent feedback to the therapist and the individual as a means of
motivating their engaged participation
in therapy, or implement novel hardware
design and control architectures enabling
active physical interaction between
patient and robot, the overall objective is
the same – to motivate the participant to
remain cognitively and physically
engaged during the course of robotic
upper-limb therapy, in order to facilitate
maximum recovery of movement
coordination. u
(ICORR), Seattle, Washington, June
24-26, 6 pages.
Celik, O., M.K. O’Malley, C. Boake, H.
Levin, N. Yozbatiran, and T. Reistetter.
(2010) Normalized Movement Quality
Measures for Therapeutic Robots
Strongly Correlate with Clinical Motor
Impairment Measures, IEEE Transactions
on Neural Systems and Rehabilitation
Engineering 18(4): 433-444.
Marcia O’Malley, Ph.D. is director of reha-
Gupta, A., M. K. O’Malley, V. Patoglu,
and C. Burgar, “Design, Control and
Performance of RiceWrist: A Force
Feedback Wrist Exoskeleton for Rehabilitation and Training,” The International
Journal of Robotics Research, vol. 27,
no. 2, pp. 233–251, Feb. 2008.
Hogan, N. et al., “Motions or muscles?
Some behavioral factors underlying
robotic assistance of motor recovery,”
The Journal of Rehabilitation Research
and Development, vol. 43, no. 5, p. 605,
2006.
Robinson, D.W., “Design and Analysis
of Series Elasticity in Closedloop,” PhD
thesis, MIT, pp. 1–123, Dec. 2000.
Sergi, F., M. Lee, and M.K. O’Malley (2013)
Design of a series elastic actuator for a
compliant, parallel wrist rehabilitation
robot, Proceedings of the IEEE International Conference on Rehabilitation
Robotics (ICORR), Seattle, Washington,
June 24-26, 6 pages
van den Brand, R., et al., “Restoring
Voluntary Control of Locomotion after
Paralyzing Spinal Cord Injury,” Science,
vol. 336, no. 6085, pp. 1182–1185, May
2012.
Williamson, M.M. “Series Elastic
Actuators,” PhD thesis, MIT, pp. 1–83,
Sep. 1995.
bilitation engineering at TIRR Memorial
Hermann. An associate professor in the
Mechanical Engineering and Materials
Science department and director of the
Mechatronics and Haptic Interfaces
(MAHI) Lab at Rice University, Dr.
O’Malley is a co-founder of Houston
Medical Robotics. She holds a joint
appointment in computer science at Rice,
and is an adjunct associate professor in
the departments of Physical Medicine
and Rehabilitation at both Baylor College
of Medicine and UTHealth Medical School.
At Rice, her research interests focus on the
issues that arise when humans physically
interact with robotic systems. She is former
chair of the IEEE Technical Committee
on Haptics and a former associate editor
for the IEEE Transactions on Haptics.
Pehlivan, A.U., F. Sergi, and M.K. O’Malley
(2013) Adaptive Control of a Serial-inParallel Robotic Rehabilitation Device,
Proceedings of the IEEE International
Conference on Rehabilitation Robotics
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Profiles in Caring continued from page 9
holistic view of nursing practice that
includes leadership style, administrative
practices, navigation of the healthcare
system and proper placement of patients
across the continuum of care.
The program aligns well with her
professional interests. “It’s about getting
the right care to the right people at the
right time,” she says. “That’s a major focus
across the Memorial Hermann Health
System, and at TIRR Memorial Hermann,
we’re interested in sharing what we’ve
learned with other rehabilitation
providers. As educators, we have a
unique opportunity to drive change that
impacts both individual patients and
whole populations.”
In addition to providing clinical
education to hospital and system staff
members, Thomas makes quality
improvement presentations at state and
national conferences. She also works with
nurses from four different schools who
complete rotations at TIRR Memorial
Hermann – students at TWU, Houston
Baptist University, Houston Community
College and San Jacinto Community
College.
“I like having the opportunity to give
new nurses a broader view of our profession that extends to other disciplines,”
she says. “I also find a lot of satisfaction
in helping to improve quality across the
entire continuum of care. We don’t stop
measuring outcomes when patients leave
the hospital. It’s important to help each
patient meet his or her individual goals
for return to function or adaptation to
disability and improved quality of life.” u
P
PERSPECTIVES ON RESEARCH
Hair Cortisol: A Potential Biomarker of Emotional Distress
among Persons with Traumatic Brain Injuries
By David B. Arciniegas, M.D.
In our National
Institute on
Disability and
Rehabilitation
Research-supported study of
acceptance and
commitment
therapy (ACT)
for the treatment
of emotional distress among persons
with traumatic brain injury (TBI) in the
subacute and chronic recovery periods,
we are performing a pilot study of an
innovative method of assessing a physiological correlate of emotional distress
through sampling of cortisol levels
attained from hair samples of the study
participants.
Chronic psychological stress produces
similarly chronic over-activation of the
body’s stress-response system. Cortisol
is a component of that stress-response
system, the levels of which are increased
during periods of high stress. Although
12
TIRR MEMORIAL HERMANN
short-term increases in cortisol can help
the body manage illness or injury effectively, long-term increases in cortisol levels
are associated with a broad range of
adverse health effects that compromise
physical and emotional wellbeing and
function. In the context of TBI, longterm increases in serum cortisol levels
may, quite literally, add insult to injury.
Hair cortisol sampling enables evaluation of the average levels of serum cortisol
produced over the month preceding
sampling. Cortisol circulating in the
bloodstream is incorporated into hair at
the time it is produced by hair follicles.
Once it is incorporated into the hair, it
does not diffuse out of it as hair grows or
as it is exposed to the elements or hair
products (e.g., shampoo, conditioner).
As a result, the amount of cortisol in the
hair serves as a stable marker of the
average levels of cortisol circulating in
the blood at the time during which that
hair is produced.
For the vast majority of people who
have hair on the scalp vertex – the very
back of the top-most part of the head –
that hair is produced at a rate of about 1
centimeter per month. Measuring the
amount of cortisol in a 1 cm sample (50
to 100 strands of hair) allows us to
estimate the average daily levels of
cortisol circulating during the month
over which that segment of hair was
produced. When that 1 cm hair sample
is taken from the segment closest to the
scalp, hair cortisol levels provide an
estimate of the average daily levels of
circulating cortisol during the month
preceding sampling.
The sampling method is cosmetically
benign, and is usually unnoticeable to
even the most appearance-conscious
individuals. To put a sample of 50 to 100
strands of hair in context, most people
lose at least 50 to 100 hairs from their
head every day. Accordingly, most people
do not notice a loss of hair in this amount
when the sampling for hair cortisol level
determination is performed. Additionally,
the sample is obtained by making a part
in the hair (for those wearing their hair
long enough to part) and by using thinning shears to obtain hairs at the base
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of the part. The use of thinning shears
leaves cosmetically unchanged the area
under the parted hair from which the
sample is taken.
Using this cortisol sampling method,
we will be evaluating the correlation
between hair cortisol levels among persons
with TBI and scores on the Brief Symptom
Inventory 18 (BSI 18). The BSI 18 is a
short, self-report assessment of depressive, anxious and physical symptoms that
are common among persons experiencing
emotional distress, including persons
with TBI. The BSI 18 asks participants
to report on the levels of symptoms they
experienced over the last seven days. We
will be asking the group of participants
in the hair cortisol portion of our study
also to report on their level of symptoms
over the last month.
If we observe a correlation between
proximal 1 cm segment hair cortisol
levels and BSI 18 scores, then we will
have identified a biomarker of emotional
distress among persons with TBI. This
biomarker will help us understand the
biological effects of emotional distress by
providing us with a quantifiable estimate
of the level of activity of the immune
system associated with emotional health/
A
ACCOLADES
TIRR Memorial Hermann was featured as an
ROI Case Study in the American Nurses
Credentialing Center’s Pathway to
Excellence™ e-Newsletter distributed on
October 10, 2013. The hospital’s outcomes
were cited as “continually exceeding
expectations” with a below-average fall
rate, a five-year track record of no cases
of ventilator-associated pneumonia
(VAP), fewer catheter-associated urinary
tract infections (CAUTIs), fewer pressure
ulcers and an increase in CRRN (certified
rehabilitation registered nurse) certifications. “Our nurses are driving process
change for the good of patients and staff,
and gaining recognition for their
David B. Arciniegas, M.D., is senior scientist
and medical director for brain injury
research at TIRR Memorial Hermann
and executive director of the Beth K. and
Stuart C. Yudofsky Division of Neuro-
psychiatry and professor of psychiatry,
neurology and physical medicine and
rehabilitation at Baylor College of
Medicine. He is co-investigator in a novel
innovative preliminary investigation of
the effectiveness of acceptance and
commitment therapy (ACT) for reducing
emotional distress, improving healthrelated quality of life and increasing
participation in the community for
persons with TBI. If the study is successful, it will provide a foundation for
future multicenter comparative effectiveness trials in which ACT can be evaluated in comparison to traditional
cognitive behavioral therapy and
psychotropic medications. The principal
investigator of the trial is Angelle Sander,
Ph.D., director of the Brain Injury Research Center (BIRC) at TIRR Memorial
Hermann. Additional co-investigators
on this project are Mark Sherer, Ph.D., ABPP,
FACRM, director of research and director
of neuropsychology at TIRR Memorial
Hermann, and BIRC researchers Kacey
Maestas, Ph.D., and Allison Clark, Ph.D.
Please contact Dr. Arciniegas at david.
arciniegas@bcm.edu with questions or
comments about the hair cortisol aspect
of the ACT study.
outstanding work,” says Mary Ann Euliarte,
RN, CRRN, COO/CNO.
Meilani Mapa, M.D., assistant professor
and vice chair of the department of
Physical Medicine
and Rehabilitation
at UTHealth
Medical School,
represented TIRR
Memorial
Hermann and
UTHealth PM&R
at The University
of Texas System
Meilani Mapa, M.D. Clinical Safety
and Effectiveness Conference and
Recognition Event held in September
2013 at the Grand Hyatt Hotel in San
Antonio. The conference, entitled
“Building the Bridge: Public Policy and
Public Health Effect Health Care
Reform,” brought together doctors,
clinicians and students from across the
UT System. Dr. Mapa presented her
quality improvement project “Reducing
Acquired Urinary Tract Infections on
the Inpatient Rehabilitation Unit” with
Viola Hysa, M.D., who will complete her
residency at the Baylor College of
Medicine/UTHealth Alliance for
Physical Medicine and Rehabilitation in
2014.
Staff of the Brain Injury Research
Center won two of three awards presented
for posters at the 90th annual meeting of
the American Congress of Rehabilitation
Medicine held in Orlando, Florida, in
November 2013. “A preliminary model
of social integration and emotional
Accolades continues on page 14
distress. It also may provide a biomarker
with which to evaluate the biological
effects of psychotherapy, including ACT
or medications, for depressive and
anxious symptoms among persons with
TBI. In other words, measuring hair
cortisol levels may facilitate identification
of the neurobiology of emotional distress
and the effects of psychological and
pharmacologic treatments on the body’s
stress-response system.
The NIDRR-supported study of ACT
for emotional distress among persons
with TBI is in its very early stages. When
we begin enrolling participants, we also
will begin the hair cortisol-sampling
component of that study. We anticipate
acquiring data sufficient for testing of
the relationship between hair cortisol
levels and BSI 18 scores in the next one
to two years. Once analyzed, these data
will be submitted for peer review and
possible publication in a brain injury
rehabilitation-oriented journal. u
T H E I N S T I T U T E F O R R E H A B I L I TAT I O N A N D R ES E A R C H
13
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delegate-at-large
to the Texas
Physical Therapy
Association.
Accolades continued from page 13
functioning for persons with TBI,” the
second place winner, was authored by
Monique Pappadis,
CHES, CCRP
Margaret A.
Struchen,Ph.D.
Monique Pappadis,
CHES, CCRP,
Margaret Struchen,
Ph.D., Angelle
Sander, Ph.D., and
Diana Mazzei, LPC.
Authors Lynne
Davis, Ph.D., Angelle
Sander, Ph.D., Jay
Bogaards, CCRP,
and Monique
Pappadis, won third
place for “MPAI-4
discrepancy
ratings of abilities
predict memory
and executive
functioning
performance
after traumatic
brain injury.”
The TIRR
Memorial Hermann
Pharmacy was one
of only nine sites
in the United
States selected
by the American
Society of HealthSystem Pharmacists to participate
in the 2014-15
Antimicrobial
Angelle Sander, Ph.D. Stewardship
Impact Program.
Led by Carolyn
Alessi, the project
will involve an
interdisciplinary
team: Susan
Loughlin, Pharm.D.,
BCPS, Terree Funesti,
ADN, WCC, CRRN,
Lindsay Toenges,
Diana Mazzei, M.A., CIC, Lisa Wenzel,
LPC
M.D., Ben Portnoy,
M.D., Audrey Wanger, Ph.D., and Lourdes
Cuellar, RPh.
Rhonda Abbott, PT, administrative
director and director of therapy services
and clinical programs, has been elected
14
TIRR MEMORIAL HERMANN
Heather Taylor,
Ph.D., and Glendaliz
Bosques, M.D., are
Rhonda Abbott, PT
Heather Taylor,Ph.D.
co-investigators of
a new study under
way at TIRR
Memorial Hermann and
UTHealth
Medical School.
Entitled Pediatric
Multicenter Evalu
ation of Notable
SCI Outcome
Instruments, the
three-year study
is funded by the
Craig Neilsen
Foundation. u
I
IN PRINT
Park WH, Li S. Responses of finger
flexors and extensors to TMS during
isometric contraction. Muscle Nerve,
Nov 2013;48(5):739-44. u
O
ON THE PODIUM
Adair C, Phillips D. Seven Meaningful
Days. Educational session presented at
the Texas
Occupational
Therapy Association Annual
Conference, Sugar
Land, Texas,
November 2013.
Cooper Hay C,
Scully T, Sieber R,
Vanlandingham C.
Catherine Cooper
Hay, OTR
Using the iPad in
Occupational Therapy Brain Injury
Rehabilitation. Educational session
presented at the Mountain Central
Conference of the Texas Occupational
Therapy Association, Sugar Land, Texas,
November 2013.
Gutierrez A ,
Thayer B. Educational Classes for
Spanish-speaking
Patients with
Spinal Cord
Injuries. Educational session
presented at the
39th Annual
Ann Gutierrez,RN,
Association of
CRRN, CBIS
Rehabilitation
(ARN) National
Education
Conference,
Charlotte, N.C.,
October 2013.
Gutierrez A ,
Reimers A . Target
Zero for Catheterassociated
Becky Thayer, M.S.N., Urinar y Tract
RN, CRRN
Infections
(CAUTIs). Educational session presented
at the 39th Annual Association of
Rehabilitation (ARN) National Education
Conference, Charlotte, N.C., October 2013.
Hartman L . Neuro-IFRAH Certification
Course in the Treatment and Management
of Adults with Hemoplegia from a Stroke
or Brain Injury. A 14-day educational
session presented
at TIRR Memorial Hermann,
Houston, October
and November
2013.
Jennings J.
Advancing
Rehabilitation
of the Upper
Julie Jennings,
Extremity after
PT, NCS
SCI: Innovation
and Stimulation. Presented at the
Academy of Spinal Cord Injury Professionals (ASCIP) Educational Conference, Las Vegas, Nev., September 2013.
Martin L, Shields C. Vestibular Assessment and Treatment in Individuals with
Concussion. Course presented at the
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Texas Physical Therapy Association
Annual Conference Student Conclave,
Arlington, Texas, October 2013.
Sander AM. A systematic approach to
treating family caregivers of persons
with traumatic brain injury. Invited
lecture presented at the Contemporary
Forums conference, Brain Injuries: A
Multidisciplinary Approach to Rehabilitation, Washington, D.C., October 2013.
Sander AM. Addressing sexual functioning in rehabilitation of persons with
traumatic brain injury. Invited lecture
presented at the Contemporary Forums
conference, Brain Injuries: A Multidisciplinary Approach to Rehabilitation,
Washington, D.C., October 2013.
Taylor HB,
Robinson-Whelen
S, Hughes RB,
Wenzel L , Nosek
MA. Examining
the MHI-5 as a
Depression
Screening
Measure. Invited
presentation at
Lisa Wenzel, M.D.
the American
Congress of Rehabilitation Medicine
90th Annual Conference, Orlando, Fla.,
November 2013.
Taylor HB, Robinson-Whelen S, Hughes
RB, Wenzel L , Nosek MA. Depression and
Depression Treatment of Women with
Spinal Cord Injury: Are We Doing
Enough? Invited presentation at the
American Spinal Cord Injury Association
40th Anniversary Meeting, Chicago, Ill.,
May 2013.
Thomas H. Development and Validation
Process for the Spiritual Wellness
Assessment. Educational session
presented at the Academy of Spinal Cord
Injury Professionals Annual Conference,
Las Vegas, Nev., September 2013.
Young K , Davis K , Euliarte MA . Management of Breastfeeding with Spinal Cord
Injury: China’s Story. Educational session
presented at the 39th Annual Association
of Rehabilitation (ARN) National
Education Conference, Charlotte, N.C.,
October 2013. u
P
POSTER PRESENTATIONS
Davis LC, Sander AM, Bogaards JA , Pappadis
MR. MPAI-4 discrepancy ratings of
abilities predict
memory and
executive
functioning
performance
after traumatic
brain injury.
Presented at the
90th Annual
Meeting of the
Lynne Davis,Ph.D.
American
Congress of Rehabilitation Medicine,
Orlando, Fla., November 2013.
De Joya A , Taylor K. The Effect of Circuit
Training in a Modified Constraint
Induced Movement Therapy Program.
Presented at the 90th Annual Meeting of
the American Congress of Rehabilitation
Medicine, Orlando, Fla., November 2013.
Giardina M. Altering Shank Kinematics
in Midstance via AFO Design to Improve
Gait Speed and Endurance in an
Individual with TBI. Presented at the
Texas Physical Therapy Association
Annual Conference, Arlington, Texas,
October 2013.
Pappadis MR, Struchen MA , Sander AM,
Mazzei D. A preliminary model of social
integration and emotional functioning
for persons with TBI. Presented at the
90th Annual Meeting of the American
Congress of Rehabilitation Medicine,
Orlando, Fla., November 2013.
Martin L , Shields C. Vestibular Assessment and Treatment in Individuals with
Concussions for the Student Conclave.
Taylor K , De Joya A . The Effect of Circuit
Training in a Modified Constraint
Induced Movement Therapy Program.
Presented at the 90th Annual Meeting of
the American Congress of Rehabilitation
Medicine, Orlando, Fla., November 2013.
Thomas H. Development, Pilot, and
Validation Process of a Spiritual
Wellness Assessment. Poster presentation at the George Washington Institute
of Spirituality and Health, Washington
D.C., July 2013. u
About TIRR Memorial Hermann
TIRR Memorial Hermann is a 119-bed
nonprofit rehabilitation hospital, a
network of outpatient therapy clinics,
a rehabilitation medical home and a
network of inpatient rehabilitation units.
Founded in 1959, the Texas Medical
Center facility has been named one of
America’s Best Hospitals by U.S.News
& World Report for 24 consecutive years.
Rehabilitation teams at the hospital
provide services for individuals with
strokes, brain injuries, spinal cord
injuries, amputations and neurodegenerative diseases.
TIRR Memorial Hermann is creating
a comprehensive, integrated rehabilitation network beyond the Texas Medical
Center, in outlying communities where
people live and work. TIRR Memorial
Hermann Outpatient Rehabilitation on
the Campus of Memorial Hermann
Memorial City, TIRR Memorial Hermann
Outpatient Rehabilitation on the Campus
of Memorial Hermann Northwest and
TIRR Memorial Hermann-The Woodlands
further extend services that have been
offered at TIRR Memorial Hermann
Outpatient Rehabilitation at the Kirby
Glen Center since the southwest Houston
facility opened in 2001.
TIRR Memorial Hermann is one of 12
hospitals in the not-for-profit Memorial
Hermann Health System. Memorial
Hermann is known for world-class clinical
expertise, patient-centered care, leadingedge technology and innovation. The
system, with its exceptional medical
staff and more than 20,000 employees,
serves Southeast Texas and the Greater
Houston community.
T H E I N S T I T U T E F O R R E H A B I L I TAT I O N A N D R ES E A R C H
15
Memorial Hermann Health System
Nonprofit Org.
U.S. POSTAGE
PAID
Permit No. 3156
Houston, TX
7737 Southwest Freeway
Houston, TX 77074
tirr.memorialhermann.org
M
MESSAGE FROM THE CEO
When I was
recruited to TIRR
Memorial
Hermann in 2006,
one of my first
tasks was to guide
an independent
rehabilitation
hospital as it
transitioned to its
Carl E. Josehart, CEO new role as a
member of the 12-hospital Memorial
Hermann Health System. I felt the great
sense of responsibility that comes with
being entrusted with a national treasure.
During more than 50 years of service,
TIRR Memorial Hermann has played a
leadership role in the history of Houston
and the history of rehabilitation. To move
forward as The Institute for Rehabilitation
and Research and pave the way for future
contributions to our discipline, we knew
we needed to harness the synergy created
by uniting all our research programs
under one roof.
The new TIRR Memorial Hermann
Research Center rises three stories into
the Houston sky about 100 steps from
our hospital. From funding to finish, the
dramatic transformation of an abandoned
building took nearly three years to
complete. By renovating a part of our
history, we’re celebrating our past and
honoring the contributions that came out
of it. The third-story bridge connecting
the research center and hospital represents more than access: it reinforces our
triple mission of clinical care, education
and research in a way that will sustain us
well into the future.
Bridges are built for crossing from
one side to the other. While we were
breathing new life into an old building,
we were also positioning TIRR Memorial
Hermann as the anchor for a rehabilitation network grounded in excellence and
stretching across Houston. As our patients
have taught us, reinventing ourselves is
not easy, but it’s a necessary endeavor if
we are to move ahead.
To learn more about TIRR Memorial Hermann and our healthcare providers, visit our company page at LinkedIn.com
TIRR is a registered trademark of TIRR Foundation.
Carl E. Josehart
Chief Executive Officer
TIRR Memorial Hermann
System Executive for Rehabilitation
Services
Memorial Hermann Health System
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