Sunnybrook researchers find early physical medicine and rehabilitation consults benefit critically injured patients

Dr. Larry Robinson

Sunnybrook researchers find early physical medicine and rehabilitation consults benefit critically injured patients

Dr. Larry Robinson, Director of the St. John’s Rehab Research Program at Sunnybrook Research Institute.

Dr. Larry Robinson, a senior scientist and director of the St. John’s Rehab Research Program at Sunnybrook Research Institute, has shown that among people with traumatic injuries or burns, early consultation with a physiatrist (physical medicine and rehabilitation doctor) is associated with a shorter hospital stay.

Seeing a physiatrist during acute care is associated with shorter hospital stays

As a medical student, Dr. Larry Robinson considered specializing in neurology or psychiatry. Then he found his path. “I ultimately chose physical medicine and rehabilitation, because I thought we could have an impact on almost everyone we encounter—not necessarily [on] curing them, but a positive impact in terms of improving function,” says Robinson, a senior scientist in and director of the St. John’s Rehab Research Program at Sunnybrook Research Institute (SRI).

Physical medicine and rehabilitation doctors, called physiatrists, evaluate and treat people whose functional abilities, like dressing, walking and self care have been impaired. These impairments can result from conditions like stroke, musculoskeletal disorders, spinal cord injuries, burns and trauma.

Robinson is chief of rehabilitation services at Sunnybrook. As one of two major trauma centres in the Greater Toronto Area (the other is St. Michael’s Hospital), Sunnybrook admits between 800 and 1,000 severely injured people annually. He studies the impact of early physical medicine and rehabilitation consultation on people treated for traumatic injuries at Sunnybrook.

In a recent study, he and his colleagues found that consultation with a physiatrist within eight days of admission was associated with a shorter stay, fewer complications and less use of benzodiazepines and antipsychotics. These drugs, while good at keeping patients calm, can hinder learning in the long term. Physiatrists generally discourage use of them as it can impede recovery. The study was published on Jan. 1, 2019 in the Journal of Physical Medicine & Rehabilitation.

In the study, the team initially compared outcomes of trauma patients in acute care who did not receive treatment from a physiatrist, with those of trauma patients who did receive treatment. There were no significant differences between the two groups in length of stay, readmissions or complications.

Where meaningful differences emerged, however, was in outcomes of trauma patients in acute care who saw a physiatrist within eight days of admission, and those of patients who saw one after eight days in hospital. On average, trauma patients who saw a physiatrist sooner had a length of stay that was 11.8 days shorter. The severity of injury was similar between the two groups.

The findings led to Sunnybrook increasing the number of physiatry consults in acute care, converting the single part-time position into a full-time one. Moreover, Robinson is working with St. Michael’s Hospital to recruit a physiatrist for its trauma program on the basis of the research.

“This study suggests that there’s no financial drain; in fact, there’s probably financial benefit to have the consultant see the patients early on—it’s associated with earlier discharge from acute care and maybe less complications,” says Robinson, who was recently recognized with a Five-Year Exceptional Leadership award as director of the division of physical medicine and rehabilitation at U of T.

This July marks Robinson’s fifth-year anniversary at Sunnybrook and, when he officially will become a Canadian citizen. Originally from the U.S., he was recruited from the University of Washington, where he worked for 25 years.

He has also published a study co-authored by SRI senior scientist Dr. Marc Jeschke on the impact of physiatry on people admitted to hospital for burns. The research compared outcomes before and after the introduction of physical medicine and rehabilitation consultation to Sunnybrook’s acute burn care program.

Robinson and colleagues found that while the addition of a burn physiatrist did not shorten burn patients’ length of stay in acute care, it significantly reduced length of stay in the rehabilitation hospital. Compared to the 109 people who did not see a physiatrist after their burn injury, the 104 burn patients who received physical medicine and rehabilitation stayed in the rehabilitation hospital six fewer days (24 versus 30 days).

“It looks like having the burn physiatrist involved does improve efficiency for our rehab stay. Patients generally want to get home sooner, and don’t want to stay in the hospital any longer than they need to. Plus, it saves cost—at $500 per day, that’s $3,000 per patient,” says Robinson of the study, which was published on May 22, 2019 in the Journal of Burn Care & Research.

Ultimately, he says, integrating physiatry into acute care is better for patients because it eases the transition to an in-patient rehabilitation facility. “Transitions are points of risk in any patient’s journey. By bringing the physiatrist into acute care, we can start the patient’s and family’s rehabilitation earlier and help them know what to expect in in-patient rehab. We can start to prepare the groundwork for their rehab by keeping them off drugs that would be a problem, maintaining their range of motion and starting strengthening programs. So it’s not a distinct time in acute care, and a distinct time in rehab; it’s really a continuum,” he says.

Sunnybrook is one of Ontario’s 23 research hospitals that contribute to a healthier, wealthier, smarter province. Look for other RESEARCH SPOTLIGHT posts on our Healthier, Wealthier, Smarter blog or join the conversation about why health research matters for Ontario on Twitter, using the hashtag #onHWS.

North American first: Sunnybrook studies scalpel-free brain surgery to treat depression

Sunnybrook focused ultrasound depression

North American first: Sunnybrook studies scalpel-free brain surgery to treat depression

For the first time in North America, researchers at Sunnybrook Health Sciences Centre are investigating the safety and effectiveness of using MRI-guided focused ultrasound to help patients with treatment-resistant major depression.

Focused ultrasound is an incision-free, image-guided technology that targets specific areas of the brain using high frequency ultrasound waves.

In this trial, focused ultrasound will be used to cause a lesion in a region of the brain (the anterior limb of the internal capsule) to disrupt a pathway of the brain that has been established as being active in depression. This pathway is considered to be a “highway” connecting the frontal lobes to the emotional centres of the brain, including the amygdala and hippocampus.

“Although we are in the early stages of investigating the safety and efficacy of focused ultrasound in patients with depression, it has the potential to be another treatment option,” says Dr. Nir Lipsman, principal investigator of the trial, and Director of the Harquail Centre for Neuromodulation at Sunnybrook.

Each year, 1 in 5 Canadians will experience a mental health problem or illness, and at some point in their lives, about 24 per cent of adults will experience an episode of major depression.

“I’ve struggled with depression for 30 years and tried just about every treatment in existence,” says Linda Bohnen, the first patient in North America to be treated with focused ultrasound for depression. “What I’m hoping will happen is a slow but steady improvement in my mood and functioning.”

“For patients with major depression who aren’t responding to existing standard treatment therapies, circuit disruption techniques, such as focused ultrasound, make it possible to treat areas deep in the brain noninvasively, without surgical incisions,” says Dr. Anthony Levitt, co-investigator and Chief of the Hurvitz Brain Sciences Program at Sunnybrook.

Focused ultrasound was successfully tested in a world first trial at Sunnybrook and other medical centres for use with patients with essential tremor, which led to Health Canada and FDA approval in 2016. Philanthropic investment has been a major catalyst behind Sunnybrook’s advances in focused ultrasound technology and research. Leading donors to this work are the Weston Brain Institute, The Beamish Family Foundation, FDC Foundation, Slaight Family Foundation, Harquail family through the Midas Touch Foundation and the Connor and Robinson families.

Dr. Kullervo Hynynen, Director of Physical Sciences at Sunnybrook Research Institute, worked with industry partner INSIGHTEC for almost two decades to develop the technology.

“This is innovation, medicine and science coming together to go beyond existing treatments for patients with depression,” says Maurice R. Ferré MD, INSIGHTEC’S CEO and Chairman of the Board of Directors.

“Focused ultrasound is a noninvasive alternative to surgery or radiation that offers the potential to treat more patients with major depression, as well as other psychiatric disorders,” says Dr. Neal Kassell, Chairman of the Focused Ultrasound Foundation. “Sunnybrook has become a leader in focused ultrasound research for brain disorders, and the Foundation is pleased to support this innovative trial.”

Phase I of the trial will involve six patients, ages 25-80 years old, over a one-year period who will undergo one round of focused ultrasound, and then assessed for severity of depression and level of functioning at one month, three months, six months and 12 months.

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Sunnybrook is one of Ontario’s 23 research hospitals that contribute to a healthier, wealthier, smarter province. Look for other RESEARCH SPOTLIGHT posts on our Healthier, Wealthier, Smarter blog or join the conversation about why health research matters for Ontario on Twitter, using the hashtag #onHWS.

Health & Community Leaders Talk: Barry McLellan

Ontario's health research hospitals make our province healthier, wealthier, and smarter

Health & Community Leaders Talk: Barry McLellan

The HWS campaign is a platform for collaboration. That’s why this blog series is co-authored by community and health leaders from across the province to share their insights on why health research matters for Ontarians and our economy. Barry McLellan, President and CEO of Sunnybrook Health Sciences Centre, shares what health research has meant to him, and how it has made a difference in the day-to-day lives of patients. Thank you, Barry, for adding your voice to the HWS conversation.

Who are you?

Name: Dr. Barry McLellan
Organization & Title: President and CEO, Sunnybrook Health Sciences Centre

Dr. Barry McLellan_Sunnybrook Health Sciences Centre

1. What does health research mean to you?

Seeing health research translate to a better quality of life for our patients is one of the most impactful and inspirational things I have seen during my career.  Sometimes that impact is immediately visible.  When researchers from Sunnybrook and Toronto Western Hospital used MRI-guided, high-intensity ultrasound, they profoundly changed the life of a patient with ‘essential tremor’.  The patient went from being unable to hold a cup of water without soaking himself, to drinking the water without spilling a drop.  Research breakthroughs can also be a sign of what is to come.  Recently, Sunnybrook clinicians achieved a world-first research breakthrough by using focused ultrasound waves to open the the human blood-brain barrier.  The future implications are vast for patients living with currently impossible or hard-to-cure illnesses, from brain cancer to certain forms of depression, stroke, Parkinson’s disease and Alzheimer’s disease.

In a hospital setting, care driving inquiry, or practice-based research, is also an exciting realm. Health professionals who directly care for patients and families know what needs to be improved and how best to improve it.

I am proud of Sunnybrook’s commitment to engaging patients in shaping research.  The hospital engages patients and families in the development of research proposals, where they can offer insight to the investigative team on how the efforts of a study may benefit or impact care of current or future patients.  Sunnybrook’s Burn Centre developed a survey to gauge the challenges faced by family members of burn survivors, helping to determine what questions should help shape a new research study.

For me, health research is about advancing cutting-edge treatments that improve the day-to-day life of our patients, at the same time engaging our patients and families and ensuring we provide opportunities to support the brightest minds in Ontario to continue to do this.

2. How does health research contribute to a healthier, wealthier, smarter Ontario?

Health research is inextricably tied to a healthier, wealthier and smarter Ontario.  Advances in treatment cannot help but lead to better care for Ontario’s population, improving quality of life and helping them to live longer.  Sunnybrook’s research arm is driven by the overarching goal of making discoveries and delivering these discoveries to patients.  With total research funding of $95.8 million for 2014 to 2015, Sunnybrook Research Institute alone has 300 scientists and clinician-scientists, with a 1,212 research staff in total.

In 2015, the Federal Economic Development Agency for Southern Ontario invested $20 million in Sunnybrook Research Institute to help develop and commercialize innovative technologies in image-guided therapeutics.  The funding is matched by a $21 million investment from 28 industry partners.  This success builds on a $14 million investment in 2012 from FedDev Ontario and private sector partners.  The commitment to an “end-to-end” solution cannot help but make Ontario healthier, wealthier and smarter.  By attracting and supporting the best researchers, CAHO hospitals are helping to fuel a knowledge-based economy.  Sunnybrook is proud to play an active role as a CAHO hospital, and in making Ontario healthier, wealthier and smarter.

 

Stay tuned on our blog for more Health and Community Leaders Talk posts and share your insights on Twitter with #onHWS. To learn more about why health research matters for Ontario and how you can support it, download the Healthier, Wealthier, Smarter Policy Platform and check out our other blog posts and videos.