Patients with catastrophic injury face a higher severity of illness requiring complex medical management. As medical complexity evolves in the course of rehabilitation, Shepherd Center assures access to specialized medical needs. A team of experts including physiatrists, internal medicine/pulmonology intensivists and specialized clinicians collaboratively manage the most medically complex, traumatic patient care needs.
In today’s podcast, Shepherd Center chief medical officer Michael Yochelson, M.D., MBA, discusses complex rehabilitation care and efforts to minimize conditions that could result in setbacks for patients.
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The Ongoing Medical Needs of Patients With Catastrophic Injury
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Learn more about Michael Yochelson, MD, MBA
Michael Yochelson, MD, MBA
Michael Yochelson, M.D., MBA, is the chief medical officer at Shepherd Center. He is a board-certified neurologist and physiatrist who has also served in an academic capacity as a professor and vice chair of clinical affairs in the department of rehabilitation medicine and professor of clinical neurology at Georgetown University.Learn more about Michael Yochelson, MD, MBA
Transcription:
The Ongoing Medical Needs of Patients With Catastrophic Injury
Melanie Cole (Host): A catastrophic injury is a serious life changing event often resulting in limitations and complications that can last a lifetime. As medical complexity evolves in the course of rehabilitation, Shepherd Center assures access to specialized medical needs. Here to discuss complex rehabilitation care and efforts to minimize conditions that could result in setbacks for patients, is Chief Medical Officer of Shepherd Center, Dr. Michael Yochelson. Welcome to the show Dr. Yochelson. So, what are some conditions or comorbidities that could result from traumatic brain injury or spinal cord injury?
Dr. Michael Yochelson, MD MBA (Guest): Thanks Melanie. It’s a pleasure to be here. So, as you know, at Shepherd Center we do treat some of the most complex injuries, traumatic brain injury and spinal cord injury and we need to consider the other things that come along with that. So, some of the things we need to worry about with patients who have had spinal cord injury as comorbidities, include pain, chronic pain, issues with their bowel and bladder function that can be both debilitating socially as well as lead to infection, different types of infections are very common, urinary tract infections, pneumonia, skin and wound infections and pressure sores are some of the more common things we see. Spasticity which is increased muscle tone can be a chronic problem and very disabling for this population and then because of immobility you can have a lot of other medical conditions such as osteoporosis, cardiac issues, and general deconditioning that come along with spinal cord injury.
With traumatic brain injury, we also have a number of comorbidities that we will see very frequently. These include things like headaches, depression, fatigue or sleep disorders, sexual dysfunction, seizures, certainly less commonly seizures or Parkinsonism but those are things to watch for and then cognitive disorders as a direct result of the traumatic brain injury and then longer term developing an earlier onset or more severe dementia. Patients with traumatic brain injury can also have spasticity, the increased muscle tone I mentioned and again can be very disabling to the patient and cause pain as well.
Melanie: When somebody has just had this injury, and they are in the intensive care or they are in hospital and then they move to their rehabilitation center. Then those needs change, Dr. Yochelson, so what do you see as sort of the first most important thing to direct attention to? Is it emotional needs and coming to terms with whatever has happened? Is it the family and all of that or are there the immediate medical needs like whether they have an ostomy now or any of those kinds of things? How do you kind of triage that?
Dr. Yochelson: Well, that’s a great question. Certainly, in the acute hospital, they are more concerned about making sure they are saving the life of the patient, I mean these are catastrophic injuries and so the neurosurgeons and the trauma surgeons have to do whatever is necessary to save them, but once they have gotten to rehabilitation, they tend to be more stable medically, although still with a lot of complexities and so we never take our eye off of the medical management and treatment of these patients. But you are absolutely right. Now we are beginning to discuss with the families the long-term prognosis, what it’s going to be like when their loved one gets home, the support that they are going to need and for the patient’s themselves who may be now dealing with a lot of emotional issues as a result of their disability.
So, it really is imperative that they are in an interdisciplinary team that understands their injury. So, it is not just the medical component. It’s the therapies, the physical and occupational therapy, the speech therapy, but it is also very important the involvement of psychology and typically with brain injury it is our neuropsychologist who can help with both the cognitive piece as well as the mood changes, behavioral changes and then on the spinal cord side, often it our rehab psychologists who are helping them to cope and adapt with the changes that are now going to be permanent changes in their life. It doesn’t mean obviously, they are not going to improve, our goal is to improve their function and make them as independent as possible. But it’s life changing, no matter what the final outcome is.
Melanie: So what do you tell the families and the patient themselves of some really great tips. Things they can do maybe to build up their immune function so that they can fight off some of these other diseases and then let’s speak about some of those other things that like diabetes and cardiovascular problems. But what do you tell them to build up their immune system? What can they do?
Dr. Yochelson: So, probably the most important thing that they can do for their overall health is going to be physical activity, now in the spinal cord population depending on the level of their spinal cord injury if they are quadriplegic that is very limiting. And so, certainly with equipment and newer techniques that there is more that they can do now than there was years ago and that’s ever changing. But physical activity is going to be imperative just as it is for any of the rest of us, but the difference is, particularly if they are a spinal cord patient, they tend to be more sedentary than the rest of us because we get up and walk around all the time just because you need to walk to the kitchen or to the bathroom and they are in their wheelchair much of the time. So, exercise is important, getting them into an exercise program that with their disability they are able to perform either with assistance or by themselves. Diet is really important and it’s really just a basic well-balanced diet but particularly because of the decreased activity, they have to be very careful not to gain a lot of weight. Certainly, in our spinal cord population, tends to be little bit younger. They often were very active and, so they could whatever they wanted and go and run it off and they can’t do that anymore so, eating a well-balanced diet, supplementing with the vitamins, making sure that they are getting adequate protein intake; that’s particularly important for wound healing and protection of the skin. And then truly the mental health piece of it is critical and so it is not all about the physical health, but it is also the mental health and, so we always are paying attention to assessing for depression, for anxiety and making sure they are appropriately treated whether that’s through medications, through counseling and psychology or even other modalities.
Melanie: Well, that would seem to be a big issue certainly with going back to work or reentering the community. So, what do you tell families about the available resources to help reintegrate them and to get them to a point where they feel confident enough that they are going to try to go back to work or do some independent things?
Dr. Yochelson: That’s a great question. So, we do everything we can obviously, to make them as independent and functioning in the community as we possibly can. Inpatient rehabilitation unfortunately is not the end of their rehab period. And so, typically, when they come to Shepherd, they may stay for a month or so give or take depending on their injury and what their needs are, but that’s not the end of their rehabilitation period. So, they will transition to either our day program or outpatient programs or if they come from outside of this area we will help them transition back to an appropriate program closer to home. But we do talk about the fact that the transition back to work or back to school is not going to be immediate and so this is really a much longer-term discussion. We do discuss that as we go here. We also discuss that throughout the outpatient programs and we can help them through vocational rehabilitation and some of our other therapy services to determine what can they do when they go back to work. For many people, if they have a desk job that is requiring a lot of thinking and cognition that may be troublesome for someone who had had a traumatic brain injury with cognitive impairment, but might be fine for someone who is paraplegic with a spinal cord injury and conversely, somebody who has more of manual type job and they are now in a wheelchair bound may not be able to get back to that type of work and yet someone with a TBI might be able to and so we do help them to do that. Obviously, there are people who are not going to be able to get back to work at all, but we do everything we can to give them the resources to make them as independent within the community as possible. So even if it is not back to work, what are some of the avocational things they can do, things to recreation.
We have a tremendous adaptive sports program here and it’s really amazing to see everyone going through this type of program, what it does for them both physically and emotionally and so I think it’s important that we not just think about can I get back to work, what can I do at work, although that’s obviously a very important piece. Because it has a huge financial impact to the family as a whole. One of the things we always have to consider also and this is the challenge that we sort of live within our environment is somebody can get back to work but if they can only get back to work at a type of job that’s far lower paid than the type of job they had before; the fact that they can get to any job may mean that they lose their disability benefits or their disability income and so we have to really weigh that as well what are the benefits of getting back to work in a limited capacity versus finding other things that they can do and so it’s important that they have that social network just personally around them but also through a rehab facility like Shepherd to understand what are the resources in the community for them.
Melanie: Dr. Yochelson, when do you consider a patient as reaching their maximum medical improvement? Is there a point that you say okay, this is basically, physiologically where you are going to be and so, that it doesn’t necessarily raise their hopes for other things? Is there one of these MMIs or is there none – somebody can – there is no maximum medical improvement, they can keep improving?
Dr. Yochelson: Well, so I think that it depends on how you look at maximum medical improvement. So, I would say to be sort of very high-level kind of on average about one-year post injury you have probably reached your maximum medical improvement. That does not mean that you can’t continue to improve. But your level of improvement is probably going to be fairly slow beyond that and it may not have such significant functional gains that it would get you to a different level in terms of getting back to school, getting out into the community and for some diagnoses for example if someone is a complete spinal cord injury and is quadriplegic; the functional improvement may actually be fairly early on. Again, that doesn’t mean that they shouldn’t be having ongoing therapy to have some small gains because small gains in that population have a tremendous impact to that person. But from a functional standpoint, probably within that first year after injury, most people will reach MMI. There can clearly be ongoing improvement beyond that particularly with brain injury when you are talking about the cognitive recovery, that can certainly go on for a couple of years I have had patients where there has been some degree of improvement probably five years out, but after that first year or so, it gets quite slow and so if you are talking from a payor and insurance standpoint; MMI is probably met from the individual’s perspective, there can continue to be some improvement.
Melanie: So, in summary Dr. Yochelson, wrap it up for us what you would like the listeners to know about the resources available at Shepherd Center for these complex care for patients with catastrophic injury.
Dr. Yochelson: Absolutely. So, at Shepherd Center it’s a really great place to come if you do need this type of care. Of course, we wish no one needed to have rehabilitation after brain injury or spinal cord injury but the reality is it exists out there. So, the resources that we have both in terms of our staff, our personnel who are all well-trained in this type of rehabilitation really sets us apart from other rehab hospitals. Our average length of stay is longer. The equipment that we have – we have very specialized equipment for spinal cord patients, for brain injury patients and all of these really together make it the ideal place for someone who has these particular needs and we do have a program called Beyond Therapy so even when the insurance says you’re done, no more services, no more therapy. It is a private pay program, but it is a very good program for patients to really be able to optimize their own therapy beyond just sort of the typical routine therapy and we have seen great outcomes as a result of that.
Melanie: Thank you so much for being with us today, Dr. Yochelson. This is Shepherd Center Radio. For more information please visit www.shepherd.org . That’s www.shepherd.org . This is Melanie Cole. Thanks so much for listening.
The Ongoing Medical Needs of Patients With Catastrophic Injury
Melanie Cole (Host): A catastrophic injury is a serious life changing event often resulting in limitations and complications that can last a lifetime. As medical complexity evolves in the course of rehabilitation, Shepherd Center assures access to specialized medical needs. Here to discuss complex rehabilitation care and efforts to minimize conditions that could result in setbacks for patients, is Chief Medical Officer of Shepherd Center, Dr. Michael Yochelson. Welcome to the show Dr. Yochelson. So, what are some conditions or comorbidities that could result from traumatic brain injury or spinal cord injury?
Dr. Michael Yochelson, MD MBA (Guest): Thanks Melanie. It’s a pleasure to be here. So, as you know, at Shepherd Center we do treat some of the most complex injuries, traumatic brain injury and spinal cord injury and we need to consider the other things that come along with that. So, some of the things we need to worry about with patients who have had spinal cord injury as comorbidities, include pain, chronic pain, issues with their bowel and bladder function that can be both debilitating socially as well as lead to infection, different types of infections are very common, urinary tract infections, pneumonia, skin and wound infections and pressure sores are some of the more common things we see. Spasticity which is increased muscle tone can be a chronic problem and very disabling for this population and then because of immobility you can have a lot of other medical conditions such as osteoporosis, cardiac issues, and general deconditioning that come along with spinal cord injury.
With traumatic brain injury, we also have a number of comorbidities that we will see very frequently. These include things like headaches, depression, fatigue or sleep disorders, sexual dysfunction, seizures, certainly less commonly seizures or Parkinsonism but those are things to watch for and then cognitive disorders as a direct result of the traumatic brain injury and then longer term developing an earlier onset or more severe dementia. Patients with traumatic brain injury can also have spasticity, the increased muscle tone I mentioned and again can be very disabling to the patient and cause pain as well.
Melanie: When somebody has just had this injury, and they are in the intensive care or they are in hospital and then they move to their rehabilitation center. Then those needs change, Dr. Yochelson, so what do you see as sort of the first most important thing to direct attention to? Is it emotional needs and coming to terms with whatever has happened? Is it the family and all of that or are there the immediate medical needs like whether they have an ostomy now or any of those kinds of things? How do you kind of triage that?
Dr. Yochelson: Well, that’s a great question. Certainly, in the acute hospital, they are more concerned about making sure they are saving the life of the patient, I mean these are catastrophic injuries and so the neurosurgeons and the trauma surgeons have to do whatever is necessary to save them, but once they have gotten to rehabilitation, they tend to be more stable medically, although still with a lot of complexities and so we never take our eye off of the medical management and treatment of these patients. But you are absolutely right. Now we are beginning to discuss with the families the long-term prognosis, what it’s going to be like when their loved one gets home, the support that they are going to need and for the patient’s themselves who may be now dealing with a lot of emotional issues as a result of their disability.
So, it really is imperative that they are in an interdisciplinary team that understands their injury. So, it is not just the medical component. It’s the therapies, the physical and occupational therapy, the speech therapy, but it is also very important the involvement of psychology and typically with brain injury it is our neuropsychologist who can help with both the cognitive piece as well as the mood changes, behavioral changes and then on the spinal cord side, often it our rehab psychologists who are helping them to cope and adapt with the changes that are now going to be permanent changes in their life. It doesn’t mean obviously, they are not going to improve, our goal is to improve their function and make them as independent as possible. But it’s life changing, no matter what the final outcome is.
Melanie: So what do you tell the families and the patient themselves of some really great tips. Things they can do maybe to build up their immune function so that they can fight off some of these other diseases and then let’s speak about some of those other things that like diabetes and cardiovascular problems. But what do you tell them to build up their immune system? What can they do?
Dr. Yochelson: So, probably the most important thing that they can do for their overall health is going to be physical activity, now in the spinal cord population depending on the level of their spinal cord injury if they are quadriplegic that is very limiting. And so, certainly with equipment and newer techniques that there is more that they can do now than there was years ago and that’s ever changing. But physical activity is going to be imperative just as it is for any of the rest of us, but the difference is, particularly if they are a spinal cord patient, they tend to be more sedentary than the rest of us because we get up and walk around all the time just because you need to walk to the kitchen or to the bathroom and they are in their wheelchair much of the time. So, exercise is important, getting them into an exercise program that with their disability they are able to perform either with assistance or by themselves. Diet is really important and it’s really just a basic well-balanced diet but particularly because of the decreased activity, they have to be very careful not to gain a lot of weight. Certainly, in our spinal cord population, tends to be little bit younger. They often were very active and, so they could whatever they wanted and go and run it off and they can’t do that anymore so, eating a well-balanced diet, supplementing with the vitamins, making sure that they are getting adequate protein intake; that’s particularly important for wound healing and protection of the skin. And then truly the mental health piece of it is critical and so it is not all about the physical health, but it is also the mental health and, so we always are paying attention to assessing for depression, for anxiety and making sure they are appropriately treated whether that’s through medications, through counseling and psychology or even other modalities.
Melanie: Well, that would seem to be a big issue certainly with going back to work or reentering the community. So, what do you tell families about the available resources to help reintegrate them and to get them to a point where they feel confident enough that they are going to try to go back to work or do some independent things?
Dr. Yochelson: That’s a great question. So, we do everything we can obviously, to make them as independent and functioning in the community as we possibly can. Inpatient rehabilitation unfortunately is not the end of their rehab period. And so, typically, when they come to Shepherd, they may stay for a month or so give or take depending on their injury and what their needs are, but that’s not the end of their rehabilitation period. So, they will transition to either our day program or outpatient programs or if they come from outside of this area we will help them transition back to an appropriate program closer to home. But we do talk about the fact that the transition back to work or back to school is not going to be immediate and so this is really a much longer-term discussion. We do discuss that as we go here. We also discuss that throughout the outpatient programs and we can help them through vocational rehabilitation and some of our other therapy services to determine what can they do when they go back to work. For many people, if they have a desk job that is requiring a lot of thinking and cognition that may be troublesome for someone who had had a traumatic brain injury with cognitive impairment, but might be fine for someone who is paraplegic with a spinal cord injury and conversely, somebody who has more of manual type job and they are now in a wheelchair bound may not be able to get back to that type of work and yet someone with a TBI might be able to and so we do help them to do that. Obviously, there are people who are not going to be able to get back to work at all, but we do everything we can to give them the resources to make them as independent within the community as possible. So even if it is not back to work, what are some of the avocational things they can do, things to recreation.
We have a tremendous adaptive sports program here and it’s really amazing to see everyone going through this type of program, what it does for them both physically and emotionally and so I think it’s important that we not just think about can I get back to work, what can I do at work, although that’s obviously a very important piece. Because it has a huge financial impact to the family as a whole. One of the things we always have to consider also and this is the challenge that we sort of live within our environment is somebody can get back to work but if they can only get back to work at a type of job that’s far lower paid than the type of job they had before; the fact that they can get to any job may mean that they lose their disability benefits or their disability income and so we have to really weigh that as well what are the benefits of getting back to work in a limited capacity versus finding other things that they can do and so it’s important that they have that social network just personally around them but also through a rehab facility like Shepherd to understand what are the resources in the community for them.
Melanie: Dr. Yochelson, when do you consider a patient as reaching their maximum medical improvement? Is there a point that you say okay, this is basically, physiologically where you are going to be and so, that it doesn’t necessarily raise their hopes for other things? Is there one of these MMIs or is there none – somebody can – there is no maximum medical improvement, they can keep improving?
Dr. Yochelson: Well, so I think that it depends on how you look at maximum medical improvement. So, I would say to be sort of very high-level kind of on average about one-year post injury you have probably reached your maximum medical improvement. That does not mean that you can’t continue to improve. But your level of improvement is probably going to be fairly slow beyond that and it may not have such significant functional gains that it would get you to a different level in terms of getting back to school, getting out into the community and for some diagnoses for example if someone is a complete spinal cord injury and is quadriplegic; the functional improvement may actually be fairly early on. Again, that doesn’t mean that they shouldn’t be having ongoing therapy to have some small gains because small gains in that population have a tremendous impact to that person. But from a functional standpoint, probably within that first year after injury, most people will reach MMI. There can clearly be ongoing improvement beyond that particularly with brain injury when you are talking about the cognitive recovery, that can certainly go on for a couple of years I have had patients where there has been some degree of improvement probably five years out, but after that first year or so, it gets quite slow and so if you are talking from a payor and insurance standpoint; MMI is probably met from the individual’s perspective, there can continue to be some improvement.
Melanie: So, in summary Dr. Yochelson, wrap it up for us what you would like the listeners to know about the resources available at Shepherd Center for these complex care for patients with catastrophic injury.
Dr. Yochelson: Absolutely. So, at Shepherd Center it’s a really great place to come if you do need this type of care. Of course, we wish no one needed to have rehabilitation after brain injury or spinal cord injury but the reality is it exists out there. So, the resources that we have both in terms of our staff, our personnel who are all well-trained in this type of rehabilitation really sets us apart from other rehab hospitals. Our average length of stay is longer. The equipment that we have – we have very specialized equipment for spinal cord patients, for brain injury patients and all of these really together make it the ideal place for someone who has these particular needs and we do have a program called Beyond Therapy so even when the insurance says you’re done, no more services, no more therapy. It is a private pay program, but it is a very good program for patients to really be able to optimize their own therapy beyond just sort of the typical routine therapy and we have seen great outcomes as a result of that.
Melanie: Thank you so much for being with us today, Dr. Yochelson. This is Shepherd Center Radio. For more information please visit www.shepherd.org . That’s www.shepherd.org . This is Melanie Cole. Thanks so much for listening.