The Mayo Clinic Model

Frazier Rehab Institute employs an interdisciplinary approach to brain injury care

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LOUISVILLE Interdisciplinary is perhaps one of the new health care buzzwords of the 21st century. Championed by the Mayo Clinic in Rochester, Minnesota, the interdisciplinary model requires the medical team to work in collaboration to best serve the patient’s needs.

The model is catching fire across the medical spectrum, but according to Darryl L. Kaelin, MD, medical director of Frazier Rehab Institute and chief of the division of Physical Medicine & Rehab for the University of Louisville (UofL), “Frazier’s interdisciplinary approach [to brain injury care], where physicians come together to treat patients in one place and interact with each other about what the plan of care will be, is unique to Louisville and Kentucky.”

Frazier’s brain injury and stroke programs constitute almost half of its overall admissions. Considering the sheer volume of patients, Kentucky’s location in the “stroke belt,” and Frazier’s connection to the level one trauma center at UofL, Kaelin cites the necessity of their expertise in the field. “We developed one of the first community-based brain injury programs for stroke and brain injury patients, which focuses on reintegrating back into the community and increasing a person’s independence in the home,” he says.

While their connection to UofL provides an inflow of traumatic brain injury (TBI) patients, Frazier is also adept at treating non-traumatic brain injury patients, which, loosely defined, can encompass brain tumors, hypoxic or anoxic events, stroke, Parkinson’s disease, and brain lesions in multiple sclerosis patients. The integration of the team is crucial, as neurologists, neurosurgeons, and other specialists are involved in the patient’s medical care.

Frazier’s brain injury program includes inpatient and outpatient rehab options. When subacute rehab is in the best interest of the patient, the team relies on UofL physicians who visit those locations and can oversee care.

Inpatient care provides intensive rehabilitation and “allows patients with some medical instability to remain in the hospital while recovering from non-traumatic brain injury,” says Kaelin. Not only is the team interdisciplinary – including a physician, nurse, case manager, physical therapist, occupational therapist, speech therapist, psychologist, nutritionist, and chaplain – the physiatrist’s approach is holistic, encompassing body systems beyond the musculoskeletal.

The outpatient options are twofold: a comprehensive day program and traditional outpatient therapy administered several hours per week. “The comprehensive day program is designed for people with cognitive deficits that result in a loss of independence. They may have weakness, gait problems, or vision problems resulting from brain injury but most share a common deficit in thinking or behavior,” says Kaelin. The diverse physical and cognitive aspects of brain injury are yet another component necessitating a multi-specialty team.

Community reintegration takes therapy from the gym into the patient’s community environment, preparing them for skills like crossing streets and navigating architectural barriers.

Therapy alone is not the only tool in the physiatrist’s arsenal. “It is very clear there are certain medications that can help protect the brain, speed recover, and ultimately improve the thinking ability of both people with TBI and non-traumatic BI,” says Kaelin. While there are no medications FDA-approved specifically for brain injury, physicians often borrow medicines intended for ADD, Parkinson’s, and Alzheimer’s to help rebalance neurochemical pathways.

Where Therapy Meets Technology and Research

One of the more exciting and innovative programs underway at Frazier is the EMERGE program for TBI patients, which began in April 2013. An acute rehab program designed to help patients “emerge” from a coma or nearcoma state to a more interactive and participatory level, EMERGE has been quite successful so far in helping patients return home with their families and reducing health care costs.

Rehab therapists also have the benefit of constantly improving technology. Functional electrical stimulation to excite arm and leg strength is a part of daily therapy. Locomotor training manually moves limbs to regain neuroplasticity and encourage neurorecovery. While not yet the standard of care, Kaelin predicts in the next five years transcranial magnetic stimulation will be used on a daily basis. “If you stimulate the brain while doing therapy, patients actually recover faster than with just therapy alone,” he says.

In addition, its affiliation with the university means Frazier is involved in leadingedge research and training the next generation of PM&R physicians. Kaelin currently is involved in several studies, including pharmacology research looking at medication to reduce emotional lability after neurologic injury, evaluating a new bracing system for neck and limb contracture, and researching agitation after brain injury with residents.

With Frazier’s rich 60 year history and the collaborative expertise of its partners, Frazier’s brain injury patients do not have to travel to Minnesota to receive one-stop comprehensive care.