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Neurorehabilitation

University of Maryland Rehabilitation and Orthopedics Institute (UM Rehab)

2200 Kernan Dr. Baltimore, MD 21207 (410) 448-6400

 

Hi - Welcome to Neurorehabilitation - we're happy to have you rotating on the rehab unit with us on UMROI!

Depending on which service you are scheduled to rotate with, please reach out to the respective attendings via Tiger Connect to confirm the time for rounds prior to your rotation:

Dr. Peter Gorman and Dr. Melita Theyagaraj for SCI

Dr. Glenn Kehs for Stroke

Dr. Eugenio Rocksmith and Dr. Amar Mangalapudi for TBI

FYI the EPIC context to log into is UMROI GEN NEUROLOGY to see the current census.

I am attaching here your rehab "passport" for this rotation, which is a list of learning activities you should plan to complete during the rotation (you should pick at least 5 to get signed off on). I'd suggest that you coordinate with the attending on your first day of the rotation to discuss which of those learning activities you'd like to complete. You can print out a copy to get signed-off on during the rotation.

I'm also attaching some recommended readings specific to stroke rehabilitation. Please reach out to us by Tiger Connect or email if you have any questions. Hope you have an edifying rotation!

Dr. Robynne Braun

Dr. Ty Lai

KEY CONTACTS

Robynne Braun, Co-Director, Stroke Rehabilitation Unit, rbraun@umm.edu

Peter Gorman, Division Chief, pgorman@umm.edu

Glenn Kehs, Director, Stroke Rehabilitation Unit, gkehs@umm.edu

Richard Peters, Director, TBI Rehabilitation Unit, rpeters3@umm.edu

Eugenio Rocksmith, Co-Director, TBI Rehabilitation Unit, erocksmith@umm.edu

Melita Theyagaraj, Director, Multitrauma Rehabilitation Unit, mtheyag@umm.edu

ROTATION DESCRIPTION

The UM Rehab Neurorehabilitation rotation is one of the unique components of Neurology training at the University of Maryland.  This rotation offers residents at the PGY2 and PGY3 levels an opportunity to learn about the rehabilitation phase of treatment for our patients with stroke, traumatic brain injury and spinal cord injury. The Neurorehabilitation rotation will provide exposure to a broad range of rehab strategies that can enhance recovery and improve function (e.g. therapeutic exercise, spasticity management, adaptive equipment, pain management, assistive technology, and prevention/treatment of secondary complications).  This rotation will strengthen residents’ ability to (i) understand the degree of recovery expected with neurologic deficits of varying types and severities (ii) prevent secondary complications that may impede recovery and (iii) gain a working knowledge of the rehab care continuum, including how patients are triaged to the appropriate level of therapy (i.e. acute, post-acute, outpatient or home health).

ROTATION STRUCTURE

Residents will rotate at UM Rehab for 2 weeks during each of their PGY2 & PGY3 years, and may choose to rotate on the Stroke, Traumatic Brain Injury or Spinal Cord Injury unit. There is no requirement to rotate through all of the units, although at least one rotation through the Stroke Unit is expected. In the future (2018-9 academic year) if logistics permit, an attempt will be made to combine two-week rotations into a 4-week block so as to provide a more continuous experience.

  • Stroke Rehab Unit: During this block, residents will learn to manage patients who are undergoing rehab following an ischemic or hemorrhagic stroke. This block is designed to be a logical continuation of what you learn about stroke on the NCCU, Stroke and General Neurology services. Rotating on the stroke rehabilitation unit will help residents to learn about the natural history of stroke-related deficits and the time course for recovery in patients with hemiplegia, aphasia, neglect syndromes, neurogenic pain, sensory abnormalities, spasticity and motor planning/sequencing deficits after a stroke. 

  • TBI Rehab Unit:   During this block, residents will learn to manage patients who are undergoing rehab following traumatic brain injury or other non-stroke related brain insults (e.g. anoxic encephalopathy). Most of these patients are the victims of polytrauma, and may also have complex musculoskeletal injuries as well as behavioral/psychosocial issues.  This training block will help residents learn how to manage common issues in TBI including sympathetic storming, acute agitation, seizures, neuro-ophthalmologic abnormalities, spasticity and cognitive impairments. 

  • Spinal Cord Injury Rehab Unit: During this block, you will learn to manage patients who are undergoing rehab following a spinal cord injury or newly acquired spinal cord dysfunction. There will also be on occasional other patients recovering from Guillain-Barré and related conditions. As with TBI, the majority of these patients are victims of traumatic events, though some may have other etiologies such as spinal cord infarction, multiple sclerosis or transverse myelitis.  Complicating medical issues are commonly encountered including fractures, soft tissue injuries or respiratory insufficiency.  Rotating on the SCI unit will help residents to understand SCI-specific care needs including the management of autonomic dysreflexia, neurogenic bowel/bladder, spasticity, neurogenic skin and neuropathic pain.

  • Subspecialty Clinics: At UM Rehab, several subspecialty clinics are also held (e.g. clinics for refilling/setting Baclofen pumps and for Botox injections).      These clinics offer unique opportunities for residents to gain hands-on experience with these procedures. The Neuro-Urology clinic also provides an opportunity for residents to gain experience in the diagnosis and management urinary retention and/or incontinence issues that frequently accompany neurological disorders.

ROTATION SCHEDULES AND RESPONSIBILITIES

  • During each two-week block, residents will attend to their daily responsibilities from ~7AM to ~ 5PM. Residents will pre-round on their assigned patients at ~ 7- 8AM (depending on attending schedule/preference) and discuss them with the attending during bedside rounds later in the morning.    

  • Residents are responsible for writing progress notes, orders, admission H&Ps, discharge summaries and prescriptions for their patients.  They are also encouraged to present their own patients during interdisciplinary Team Rounds, which occur daily at 11:30.

  • Residents are expected to maintain fundamental knowledge of all patients on the service who are under the care of their attending.  Residents will be expected to carry 5-7 patients for whom they act as the primary provider (i.e. writing orders and notes, communicating with patients, families, nursing, therapists, consultants and case management/social work). They will also admit new patients to the unit and write their admission orders and H&P. 

  • Residents are also encouraged to spend time observing treatment sessions in PT, OT and Speech to improve their understanding of how the rehab treatment plan is developed and refined for each individual patient. The therapists at UM Rehab are excellent and more than happy to teach the residents about their field.

  • Residents are excused from morning report during their rotations at UM Rehab. However, it is understood that they will attend Grand Rounds and case conference on Wednesday morning at the VA during Sept through June.

  • Residents are excused from afternoon inpatient responsibilities on their Continuity Clinic days, and they should inform the rehab attendings of these dates in advance

A general schedule for the rotation follows. Please check with individual attendings regarding the timing of rounds. Please also note that the 11:30 team meetings may not occur on every unit every day.

MONDAYS:

On the first Monday of the rotation, residents should arrive at 8:00am for a quick orientation to the unit and to discuss learning goals and expectations with the Attending.  On the second Monday of the rotation, residents should follow up with their inpatients from the previous week and write their progress notes.  If time permits, they may also attend morning spasticity clinic as described below.

Morning

  • Neurorehabilitation & Spasticity Management Practice: Mondays 8am-12:30pm; 1:30-4:00

    • The resident should check with the inpatient attending with whom they are working, and when they have time can attend this clinic where they will have an opportunity to learn about management of chronic Neurorehabilitation needs of patients with cognitive, motor, affective, sensory, and other impairments from brain and spinal cord injury from etiologies such as stroke, MS, trauma, and Parkinsons’s Disease.  Residents will have the opportunity to practice procedures such as chemodenervation with limited EMG and e-stim guidance and management of intrathecal baclofen pumps. 

  • Interdisciplinary Team (11:30):

    • On each unit the physicians, nurses, PTs, OTs, Speech Therapists, Case Mangers and Social Work coordinators will meet as a team to discuss the plan of care and progress for each patient. Residents are expected to participate in that meeting and provide report/updates on their own patients. This allows the resident to gain a better understanding of how the various disciplines work together and to understand the obstacles that can arise with insurance issues, social issues and placement problems.

Afternoon

  • Monday Clinical and/or Administrative Rehab Physician Meetings:

    • On four Mondays per month at 12:30 there will be a meeting, usually in the Ober Room, focusing on different topics: 1st Monday: Spasticity – management of baclofen pump and spasticity clinic issues, 2nd Monday: Rehabilitation Research at UM Rehab, 3rd Monday: Rehabilitation Physician Staff meeting, 4th Monday: M&M.

    • These meetings provide residents with opportunities to broaden their systems knowledge by learning about the inner workings of the hospital.  Examples include the Spasticity Meeting which highlights the interdisciplinary approach to outpatient management of spasticity, as well Staff Meetings and Research Meetings that enhance participants’ knowledge of the hospital’s policies, procedures and administrative hierarchy.

 

TUESDAYS:

Morning

  • The Resident is expected to pre-round on their assigned inpatients and write progress notes. If there are new admissions during the day (usually in the afternoon), the resident is expected to write the orders and H&P, or if the patient was admitted by the hospitalist overnight, the resident is expected perform a consultation. This will provide an opportunity for the residents to experience and actively manage acute and chronic medical/neurologic issues for our patients undergoing rehab (e.g. neurogenic bladder, wounds).

  • Morning Didactics: Time permitting, readings from the Recommended Reading List will be chosen based on current patient cases of interest on the unit and/or residents’ request for review of specific areas. These brief sessions will allow for ongoing learning in the context of clinical care.

Afternoon

  • If duties on the unit permit, residents may participate in the afternoon clinics listed below. 

    • Stroke Rehabilitation Clinic with Dr. Kehs

    • Spinal Cord Injury Clinic with Dr. Theyagaraj

    • Urology clinic with M. Rittmiller, P.A. This will provide the resident with an opportunity to learn about urodynamic testing and other clinical implications for neurogenic bladder and other neurologic-urologic overlapping problems.

  • The remainder of the afternoon should be spent attending to inpatient needs and gaining an understanding of the rehabilitation process by observing patients in their therapies.

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WEDNESDAYS:

Morning

Neurology Grand Rounds at the VA

Afternoon

The resident is expected to check in with the attending after Grand Rounds. If there are no active inpatient issues or admissions to address, they may attend afternoon clinics as described below.

Baclofen Pump Clinic with Dr. York

  • This is another unique feature offered at UM Rehab that is not offered at our main campus. The resident will be given the opportunity to clinically evaluate patients whose spasticity is so severe that they require baclofen pumps. Moreover, the resident will learn how to interrogate, adjust and refill these pumps. The resident is expected to perform at least one pump refill during their time on the rotation.

 

THURSDAYS:

Morning

Pre-rounding, attending rounds, admissions as above. .  If time permits, they may also attend morning SCI clinic as described below.

Spinal Cord Injury Clinic with Dr. Gorman

·       This clinic provides exposure to the outpatient management of spinal cord injuries and its chronic complications. The resident should be educated on the ASIA scoring scale (if not already on the spinal cord injury unit).

Interdisciplinary Team: (see prior description)

Afternoon

It duties on the unit permit, the resident may participate in afternoon clinics described below.

·       Neurology Clinic with Dr. Rocksmith

·       Baclofen Clinic with Dr. York

 

FRIDAYS

Morning

Pre-rounding, attending rounds, admissions as above, Morning Didactics: (see prior description)

Interdisciplinary Team: (see prior description)

Afternoon

The remainder of the day should be spent attending to inpatient needs and gaining an understanding of the rehabilitation process by observing patients in their therapies.

syllabus

COMPETENCY-BASED LEARNING GOALS & OBJECTIVES

Goals and Objectives apply to all rotations unless otherwise indicated to be specific to STROKE, TBI, SCI

 Patient Care

  • Perform a history and examination, formulate appropriate assessment and treatment plan as it relates to rehabilitation care, including assessment of impairments, activity limitations (disability), and participation restrictions (handicap).

  • Prescribe appropriate rehabilitation therapy services, wheelchairs, orthotics, ambulation assistive devices and other medical equipment based on patient’s needs.

  • Managing coexisting medical conditions associated with stroke (hypertension, diabetes, hyperlipidemia, congestive heart failure, etc.) (STROKE)

  • Prevent and manage secondary stroke complications (aspiration, dehydration, depression, DVT, infections, malnutrition, skin breakdown, recurrent stroke, etc.) (STROKE)

  • Manage coexisting injuries and medical conditions associated with TBI (orthopedic and internal injuries, agitation, other behavioral disturbances, etc.) (TBI)

  • Prevent and manage secondary TBI complications (aspiration, generalized and focal spasticity, malnutrition, DVT, skin breakdown, infections, etc.) (TBI)

  • Manage coexisting injuries and medical conditions associated with SCI (Orthopaedic and internal injuries, bowel/bladder dysfunction, pain syndromes, orthostatic hypotension, etc.) (SCI)

  • Prevent and manage secondary SCI complications (auto dysreflexia, DVT, infections, skin breakdown, generalized and focal spasticity, mood disturbances, etc.) (SCI)

 Medical Knowledge

  • Learn the indications for and limitation of commonly used rehabilitation patient assessment scales (F.I.M., Rancho Los Amigos Scales, ASIA Scale, etc.)

  • Understand the clinical manifestation, functional deficits and prognosis associated with common stroke syndromes. (STROKE)

  • Understand mechanisms, clinical manifestation, and recovery patterns of traumatic brain injury. (TBI)

  • Understand pathologic mechanisms for traumatic and non-traumatic spinal cord injury. (SCI)

  • Learn expected functional outcomes based on level on injury and ASIA classification. (SCI)

 System-based Practice

  • Interact effectively with other members of the rehabilitation team.

 Interpersonal and Communication Skills:

  • Communicate effectively with patients, families, referral sources and primary care providers.

key readings

INTRODUCTION TO NEUROREHABILITATION

 

STROKE REHAB

 

SPINAL CORD INJURY

  • Merritt’s: Chapter 47 Traumatic Spinal Cord Injury

  • Merritt’s: Chapter 16 Acute Spinal Cord Syndromes

  • Continuum: Spinal Cord Injury

  • PVA Clinical Practice Guidelines: Neurogenic Bowel Management in Adults with SCI

  • PVA Clinical Practice Guidelines:  Bladder Management for Adults with Spinal Cord Injury

  • PVA Clinical Practice Guidelines:  Autonomic Dysreflexia

 

TRAUMATIC BRAIN INJURY

  • Merritt’s: Chapter 46 Traumatic Brain Injury

  • Merritt’s: Chapter 39 Subarachnoid Hemorrhage

  • Merritt’s: Chapter 113 Paroxysmal Sympathetic Hyperactivity after Acute Brain Injury

  • Continuum: Traumatic Brain Injury

  • Continuum: TBI Enhancing our ability to improve communication with families

  • Journal Article: Agitation After TBI, Considerations and Treatment Options

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SPASTICITY

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LINK TO MOST RECENT CONTINUUM ON NEUROREHAB