Frontiers In RehabilitationA Newsletter for Physicians | Fall 2009

Functional Magnetic Stimulation:Emerging Technology Improves Respiration After Spinal Cord Injury Page 6

Dear Colleague,As the new Chair for the Department of Physical Medicine and Rehabilitation, I would first like to thank my predecessors, Dr. Frederick Frost and Dr. Vinod Sahgal, for their leadership and tireless efforts in making our department a center of excellence in rehabilitative care.

I am also pleased to inform you that our department has become part of Cleveland Clinic’s renowned Neurological Institute (NI), a family of premier clini-cal centers that includes the:

• Lou Ruvo Center for Brain Health • Brain Tumor and Neuro-Oncology Center • Cerebrovascular Center • Epilepsy Center • Mellen Center for Multiple Sclerosis • Center for Neuroimaging • Neurological Center for Pain • Center for Neurological Restoration • Neuromuscular Center • Center for Pediatric Neurology and Neurosurgery • Sleep Disorders Center • Center for Spine Health

Altogether, more than 250 medical, surgical and research specialists in the NI see over 140,000 patients annually, perform 7,500 surgeries each year, and receive $18 million in annual funding for neurologically related research in collaboration with the Lerner Research Institute. Funding includes 91 NIH and 167 non-NIH grants.

Within our own department, we are committed to delivering world-class rehabilitation services. This entails providing superior physician and therapy services to our patients, and pursuing innovation in our clinical practice.

We will soon open a new inpatient unit on our main campus, and have hired a number of outstanding physicians and therapists to expand our services, which include cardiac rehabilitation, women’s reha-bilitation, neurorehabilitation and musculoskeletal rehabilitation.

We are also working with Cleveland Clinic’s Center for Allied Health and Department of Government Relations to form academic affiliations with local universities and to address the shortage of qualified therapy professionals. This will help us meet the workforce needs of a rehabilitation network that is rapidly changing and evolving.

In this issue of Frontiers in Rehabilitation, we will introduce you to:

• the pioneering work by Dr. Yu-Shang Lee in advancing the science of spinal cord regeneration through a combination of peripheral nerve grafts, growth factors and rehabilitation to promote locomo-tor and bladder function in a rat model

• the unique perspective of Dr. Steve Landers, Medi-cal Director of Cleveland Clinic Home Care Services, on making “house calls” for the vulnerable elderly, in a summary of his January 2009 JAMA editorial

• the identification of functional magnetic resonance imaging by Dr. Janice Zimbelman and her colleagues as a potential imaging biomarker for the earliest stages of neural dysfuction prior to the onset of Hun-tington’s disease

• functional magnetic stimulation, a noninvasive method of neural stimulation, and its efficacy in improving inspiratory and expiratory function for patients with spinal cord injuries

We welcome your comments about this publication as well as your inquiries. We look forward to being partners with you and sharing knowledge so that, together, we may provide the best care possible to our patients.

Respectfully,

Vernon W.H. Lin, MD, PhD Chairman, Department of Physical Medicine and Rehabilitation

216.445.7350 or linv@ccf.org

2

Group maps showing differences in the volume of

neural activation for the control subjects, pre-HD

subjects far from predicted onset and pre-HD

subjects close to predicted onset. Note the larger

activation volume of the pre-SMA and cingulate in

pre-HD far subjects, compared with pre-HD close

and control subjects. This larger activation volume

may be compensating for reduced subcortical ac-

tivation in pre-HD far due to early neural dysfunc-

tion.

Reprinted with permission from the American Journal of

Neuroradiology (Am J Neuroradiol 25:1715–1721, November/

December 2004).

We believe that functional magnetic resonance imaging (fMRI) has the potential to serve as an imaging biomarker to identify the earliest stages of neural dysfunction in individuals before the onset of Huntington’s disease (pre-HD).

Huntington’s disease, an autosomal dominant disorder leading to selective degeneration of basal ganglia structures, is typically diagnosed with the onset of motor signs (manifest HD), although there is evidence that cognitive changes occur prior to this.

The estimated age of disease onset can be calculated using a regression equation based on the number of trinucleotide CAG repeats in the genetic coding for Huntington’s disease along with current age.

Participants in two cross-sectional studies we conducted have demonstrated changes on fMRI – in the absence of neuro-psychological, behavioral and structural measures – more than 12 years before the predicted onset of manifest HD.

We are now following this study population longitudinally with funding from the National Institutes of Health and the CHDI Foundation. If we are able to confirm the findings from our earlier studies, then fMRI results may be used in combination with CAG repeat length and current age to more accurately predict the onset of manifest HD. In addition, fMRI could potentially be used to monitor the progression of neural dysfunction and to assess treatment efficacy in clinical trials.

Dr. Zimbelman, of the Schey Center for Cognitive Neuroimaging at Cleveland Clinic, is affiliated with the Department of Physi-cal Medicine and Rehabilitation. Physicians may reach her at 216.444.8666 or at zimbelj@ccf.org.

Relevant Publications

Zimbelman JL, Paulsen JS, Mikos A, Reynolds NC, Hoffman RG, Rao SM. fMRI detection of early neural dysfunction in preclinical Huntington’s disease. J Inter Neuropsychol Soc 2007;13:758–769.

Paulsen JS, Zimbelman JL, Hinton SC, Langbehn DR, Leveroni CL, Benjamin ML, Reynolds NC, Rao SM. fMRI Biomarker of Early Neuronal Dysfunction in Presymptomatic Huntington’s Disease. Am J Neuroradiol 2004 Nov/Dec;25:1715–1721.

Image of the Issue: Functional MRI and Pre-Huntington’s DiseaseBy Janice L. Zimbelman, PT, PhD

Frontiers In Rehabilitation | Fall 2009 3

Vulnerable Elders: Moving the “Medical Home” Where It BelongsBy Steven Landers, MD, MPH (Adapted from his commentary, “The Other Medical Home,” JAMA 2009 Jan 7;301(1):97-90.)

The growing population of older adults with multiple coexisting chronic conditions and functional limitations presents a significant challenge to the United States healthcare system. These vulner-able elders account for the majority of expenditures in the Medicare program, yet in spite of the high spending, they often suffer without the holistic, coordinated and integrated care that could address their complex health care needs.

Need for non-encounter-based care

Primary care physicians have traditionally been respon-

sible for taking a whole-person approach to care inte-

gration and coordination. However, existing Medicare

payment policies have pushed the typical office-based

practice toward high volumes of brief encounters. These

practices are often unable to provide the non-encounter-

based care coordination needed by the highest-risk elders

who frequently transition between different venues of

care and multiple types of providers.

In light of these challenges, primary care organizations

and policymakers, including the Medicare Payment Ad-

visory Commission (Med-PAC), have embraced a reform

called the “Medical Home.” If enacted, the Medical Home

initiative would provide additional capitation reimburse-

ment to primary care practices that are able to provide

added accessibility, quality improvement, care coordi-

nation and self-management support for patients with

chronic conditions.

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Missing: care in the home

Ironically missing from the “Medical Home” initiative as

currently articulated is an emphasis on care provided in

the actual homes of high-risk, low-mobility older patients.

Many of the vulnerable elders driving the high costs at

which the Med-PAC reforms are aimed have significant

functional limitations, and they may not be regularly able

to access office-based primary care.

The medical home initiative could be improved by add-

ing elements that make the immobile patient’s home

the main venue for primary care. Such reforms would

empower informal caregivers, home health aides, social

workers, home health and hospice field nurses, and home

care therapists to provide ongoing direct care in the home

under the leadership of primary care physicians.

Strengthening home care/hospice benefits

Home health providers and hospice agencies can bring

a multidisciplinary team of clinicians into the patient’s

home to partner with family caregivers. However, Medi-

care’s existing home health and hospice benefits limit

the ability of these teams to take on a more prominent

ongoing care role, and do not facilitate needed physician

leadership and collaboration.

The home health and hospice benefits could

be strengthened by:

• expandinghomehealthepisodesbeyond60-day

periods for certain high-risk patients

• ensuringalooseinterpretationof“homeboundstatus”

• providingpaymentfor“hospitalathome”programs

• expandingaccesstopersonalhomehealthaidecare

• removingtherequirementforaprognosisofsix

months or less for hospice care, and allowing those

with end-stage illnesses and palliative goals to receive

in-home hospice services

• revisingtheself-referral“Stark”laws,whichapplyto

home health agencies

• mandatingactivemedicaldirectorsforhome

health agencies

• improvingreimbursementforin-home

physician services

• providingphysicianreimbursementformultidisci-

plinary team meetings and geriatric assessment, and

• enhancingmedicaleducationinitiativestoaddress

geriatric issues.

Physicians who would like to comment or contact

Dr. Landers, Medical Director of Cleveland Clinic Home

Care Services, are encouraged to call him at 216. 636.7870

or email him at landers@ccf.org.

Frontiers In Rehabilitation | Fall 2009 5

Studies have shown that an emerging technology pioneered by Department of Physical Medicine and Rehabilitation Chairman Vernon W.H. Lin, MD, PhD, can improve respiratory function, a major cause of mortality and morbidity in patients with spinal cord injury.

“Functional magnetic stimulation, or FMS, is a very promising technology that can be applied to patients with spinal cord injury and many other neurological diagnoses,” says Dr. Lin, whose team has worked on the technology for the past 20 years. “FMS has shown clinical efficacy in inspiratory/expiratory muscle training, ventilatory assistance and cough production.”

In FMS, an electromagnetic field generated from a round mag-netic coil passes easily through structures such as skin, fat and bone to activate nerves and muscles.

“The beauty of FMS is that it is relatively noninvasive and can be applied outside the patient’s clothing,” explains Dr. Lin. “Placing the coil on someone’s back, we can produce a very effective cough, and if we move it up a little bit, we can also generate some inspiratory capacity by stimulating the phrenic nerves and the muscles contributing to inspiratory function.”

Useful in tetraplegia and paraplegiaFMS of the cervical and upper thoracic nerves generates signifi-cant inspiratory volume and pressure, of particular benefit to patients with high cervical (C3 - C5) quadriplegia who have both inspiratory and expiratory muscle dysfunction. FMS of the lower thoracic nerves has the potential to help patients with paraplegia by stimulating an effective cough and conditioning the expiratory muscles to improve coughing ability.

In a study published in the Archives of Physical Medicine & Rehabilitation, Dr. Lin’s team reported that training expira-tory muscles for four weeks using FMS resulted in significant improvement over baseline in voluntary maximal expired pres-sure (116 percent), volume (173 percent) and flow rate (123 percent).

Improving quality of life“When we are able to noninvasively stimulate the nerves and muscles below the level of injury, we hope to improve pa-tients’ quality of life, and boost their medical health in order to prevent the complications of long-term disability,” says Dr. Lin. “Patients who partially regain some of the functions that they have lost can live to their best potential.”

FMS offers many advantages over functional electrical stimula-tion (FES) for patients with spinal cord injuries. It does not require surgery, electrode implantation or application of elec-trodes to the skin with gel. This avoids common complications like wire breakage, implant failures and skin infections. FMS is also less painful and better tolerated by patients.

“Unlike needle electrode stimulation, FMS is free of any trau-matic risks due to the absence of contact with the stimulated structures,” says Dr. Lin. “No side effects have been reported with FMS. Risks of thermal injury from the heated magnetic coil in prolonged stimulation can be prevented by using a thermistor-controlled FMS unit and effective magnetic coil cooling system.

Contraindications to FMS include metal implants in the abdo-men or spine, which are subject to mechanical forces exerted by the induced currents. Cardiac pacemakers are a possible contraindication, since a magnetic stimulator placed directly over the device could induce sufficient current and voltage to damage its internal electronics.

Pioneering Functional Magnetic Stimulation Improves Respiration in Patients with Spinal Cord Injury

6

Dr. Lin (right) and colleagues demonstrate how the noninvasive magnetic stimulator can be applied over clothing to activate respi-ratory muscles in spinal cord injury patients.

On our cover: The “racetrack” coil was designed in the Cleveland Clinic Functional Magnetic Stimulation Laboratory, under the direction of Dr. Lin, for spinal nerve activation.

Testing a ‘racetrack’ coilCleveland Clinic’s FMS laboratory is collaborating with the Louis Stokes Cleveland VA Medical Center’s FMS Laboratory on a clinical efficacy trial of a modified FMS coil. Designed by our engineers, the “racetrack” coil will be tested in a six-week human trial. They will measure the coil’s effect on strengthen-ing of inspiratory and expiratory muscles, compared with a standard respiratory muscle conditioning protocol.

Aiming for portabilityCleveland Clinic’s FMS Laboratory is working on improving the magnetic stimulator’s engineering and power supply to develop a small, portable FMS unit. “We are about five years away from developing a prototype for demonstration,” says Dr. Lin.

The current unit’s lack of portability and bulkiness are major drawbacks to use of this tool in patients’ homes and various clinical settings. “We can definitely take advantage of some of the more advanced battery technologies that are now avail-able,” he adds.

Dr. Lin and colleagues remain excited about the application of FMS, not just in spinal cord injury, but also in other neurologic conditions. “FMS has demonstrated efficacy not only in improv-ing inspiration and expiration, but also in improving bladder and bowel function, and preventing deep venous thrombosis,” he says. “We also have good reports from early animal studies on its potential for pain management. The future is bright.”

Dr. Vernon Lin is board-certified in Physical Medicine and Rehabilitation as well as Spinal Cord Injury Medicine, and serves as Editor-in-Chief of Spinal Cord Medicine: Principles and Practice. Physicians may reach him at 216.445.7350 or at linv@ccf.org.

Relevant Publications

Lin VWH, Zhu Ercheng, Sasse S, Hsiao IN. Optimal Arrange-ment of Magnetic Coils for Functional Magnetic Stimulation of the Inspiratory Muscles in Dogs. IEEE Trans Neural Syst Rehabil Eng 13(4):490-496, 2005.

Lin VWH, Hsiao I, Sasse S, Deng X. Functional Magnetic Venti-lation in Dogs. Arch Phys Med Rehab 85:1493-1498, 2004.

Hsiao IN, Lin VWH. Improved coil design for functional mag-netic stimulation of expiratory muscles. IEEE Trans Biomed Eng 48:684-94, 2001.

Lin VWH, Hsiao I, Zhu E. Functional magnetic stimulation for conditioning respiratory muscles. Arch Phys Med Rehab 82:162-166, 2001.

Singh H, Magruder M, Bushnik T, Lin VWH. Expiratory mus-cle activation by functional magnetic stimulation of the thoracic and lumbar spinal nerves. Crit Care Med 27:2201-2205, 1999.

Lin VWH, Singh H, Chitkara RK, Perkash I. Functional mag-netic stimulation for restoring cough in patients with tetraplegia. Arch Phys Med Rehab 79:517-522, 1998.

Lin VWH, Hsieh C, Hsiao I, Canfield J. Functional magnetic stimulation of the expiratory muscles: a non-invasive and new method for restoring cough. J Appl Physiol 84(4):1144-1150, 1998.

Lin VWH, Romaniuk JR, DiMarco AF. Functional magnetic stimulation of the respiratory muscles in dogs. Muscle Nerve 21:1048-1057, 1998.

Frontiers In Rehabilitation | Fall 2009 7

Expiratory reserve volume (ERV) improvement. Changes in lung volume (L) throughout the conditioning protocol. *Versus baseline, p < .05.

Reprinted with permission from the Archives of Physical Medicine

and Rehabilitation (Arch Phys Med Rehabil Vol 82, February 2001).

Maximum expired pressure (MEP) improvements at total lung capacity (TLC) and functional residual capacity (FRC). Changes in airway pressure (cmH2O) throughout the conditioning protocol. ( ), MEP-TLC; (■), MEP-FRC. *Versus baseline, p < .05.

Spinal cord injury (SCI) is one of the most damaging, immobi-lizing and irreversible injuries that a human being can survive. Most individuals with SCI experience multi-organ dysfunction. In addition to motor and sensory deficits, they often experience neurogenic bladder and muscle atrophy that contribute to a tremendous burden of care, increased mortality and morbidity, and a compromised quality of life.

In Cleveland Clinic’s Neural Regeneration Laboratory, Yu-Shang Lee, PhD (above), and his team are laying the groundwork for the development of surgical treatments that will allow maximal recovery of spinal-cord-related functions.

CNS regeneration achievable“Our research in experimental rodent models proves that nerve regeneration is achievable,” says Dr. Lee. “We have been able to stimulate the re-growth of nerve fibers damaged after SCI using surgical bridging techniques.”

The results offer promise for promoting reconstruction of the spinal cord. These methods have already shown success in improving motor function in animal models. “What is most promising is the potential for bridging techniques to improve autonomic function, such as bladder and bowel control,” says Dr. Lee. “These are among our greatest concerns for quality of life among SCI patients.”

Once deemed impossible, advances in regeneration of the spi-nal cord now offer hope for thousands of persons with SCI.

Preclinical Research Signals Eventual Promise in Improving Function for Spinal-Cord-Injured Patients

8

Evidence of the growth of tyrosine hydroxylase (TH)-positive fibers from peripheral nerve graft (PNG) into the distal end spinal cord in complete T8 spinal cord transection. Many TH-positive fibers are found in the graft area, and a limited number of TH fibers are able to grow beyond the interface.

Higher magnification of photos demonstrates TH fibers (arrows) at the PNG/spinal cord interface (upper-right in B) and further growing into spinal cord (arrows) in C.

Several TH-positive fibers can be observed at 2.5 mm below the PNG.

Scale: 400 µm.

Bridging is key to recoveryHe believes that bridging – use of peripheral nerve graft tech-niques accompanied by application of acidic fibroblast growth factor – is a promising interventional modality to promote functional recovery. “This approach encourages more axons to cross the damaged site and make proper connection with the target neurons,” explains Dr. Lee.

In his laboratory, he has achieved 30 percent restoration of su-praspinal hindlimb control by reconnecting the sectioned spinal cord in rats. He has also demonstrated a reduction in hindlimb skeletal muscle atrophy following bridging surgery.

In the experiment, rehabilitative therapies were used alone or in combination with other interventions to gauge recovery of locomotor performance. A combination treadmill exercise proto-col improved the animals’ kinematic features and coordination of electromyographic signals from hindlimb skeletal muscle.

Combined strategy for bladder controlDr. Lee and his team have observed that bridging surgery promotes recovery of bladder function. He anticipates even greater success using the enzyme chondroitinase ABC (ChABC) together with peripheral nerve graft and acidic fibroblast growth factor to stimulate axon growth while removing glial scar inhibitors at the distal end of constructed bridges. “This particular combination strategy allows axons to grow rapidly, exit the bridge and reconnect the sectioned spinal cord.”

Dr. Lee plans to examine the safety and efficacy of the bridg-ing techniques in higher-level mammals, as an important step toward application of these techniques in humans.

Physicians may reach Dr. Lee in the Neural Regeneration Laboratory in Cleveland Clinic’s Neuroscience Institute at 216.445.5040 or at leey2@ccf.org.

Relevant Publications

Lee YS, Lin CY, Caiozzo VJ, Robertson RT, Yu J, Lin VW. Repair of spinal cord transection and its effects on muscle mass and myosin heavy chain isoform phenotype. J Appl Physiol 2007 103(5):1808-1814.

Lee YS, Lin CY, Robertson RT, Yu J, Deng X, Hsiao I, Lin VW. Re-growth of Catecholaminergic Fibers and Protection of Cholingergic Spinal Cord Neurons in Spinal Repaired Rats. Eur J Neurosci 2006 Feb;23(3):693-702.

Lee, YS, Lin CY, Robertson RT, Hsiao I, Lin VW. Motor recovery and anatomical evidence of axonal re-growth in spinal cord repaired adult rats. J. Neuropathol Exper Neurol 63: 233-245, 2004.

Lee YS, Baratta J, Yu, Lin VW, Robertson RT. aFGF promotes axonal regeneration in young adult rat spinal cord organotypic slice cultures. J Neurotrauma 19, 357-367, 2002.

Lee YS, Hsiao I, Lin VWH. Peripheral nerve grafts and aFGF restore partial hindlimb functions in adult paraplegic rats. J Neurotrauma 2002 19(10):1203-16.

Micturition behavior in peripheral nerve graft (PNG) + acidic fibroblast growth factor (aFGF) animals. The frequency of voiding in the repaired group (PNG+aFGF) is significantly higher than in the transected group. The largest voiding volume per micturition in the repaired group is significantly lower than that of the transected group. Both indicators in the repaired animals are closer to normal than in the controls.

Frontiers In Rehabilitation | Fall 2009 9

Frost F. Stroke. In: Walsh D, ed. Palliative Medicine. Philadelphia, PA: Saunders/Elsevier; 2009:1040-1044.

Frost FS, Mukkamala S, Covington E. Self-inflicted finger injury in individuals with spinal cord injury: an analysis of 5 cases. J Spinal Cord Med 2008;31(1):109-116.

Hou JY, Reger SI, Sahgal V. Durable medical equipment. In: Walsh D, ed. Palliative Medicine. Philadelphia, PA: Saun-ders/Elsevier; 2009:565-573.

Khoshknabi DS, Davis MP, Ranganathan VK, Siemionow V, Walsh D, Kirkova J, Yue GH. Combining objective and sub-jective outcomes in cancer- related fatigue: illustrations from a single case report. J Palliat Med 2008 Jul;11(6):829-833.

Landers SH. The other medical home. JAMA 2009 Jan 7;301(1):97-99.

Lin VWH, Deng X, Lee YS, Hsiao IN. Stimulation of the ex-piratory muscles using microstimulators. IEEE Trans Neural Syst Rehabil Eng 2008 Aug;16(4):416-420.

Lin VWH, Juraschek SP, Xu L, Jones D, Turek J. California regional registered nurse workforce forecast. Nurs Econ 2008 Mar;26(2):85 105,121.

Shah RR, Haghpanah S, Elovic EP, Flanagan SR, Behnegar A, Nguyen V, Page SJ, Fang ZP, Chae J. MRI findings in the painful poststroke shoulder. Stroke 2008 Jun;39(6):1808-1813.

Wang XF, Yang Q, Fan Z, Sun CK, Yue GH. Assessing time-dependent association between scalp EEG and muscle activa-tion: A functional random-effects model approach. J Neurosci Methods 2009 Feb 15;177(1):232-240.

Zhang L, Butler AJ, Sun CK, Sahgal V, Wittenberg GF, Yue GH. Fractal dimension assessment of brain white matter structural complexity post stroke in relation to upper-extremi-ty motor function. Brain Res 2008 Sep 4;1228:229-240.

Chae J, Jedlicka L. Subacromial corticosteroid injection for poststroke shoulder pain: an exploratory prospective case series. Arch Phys Med Rehabil 2009 Mar;90(3):501-506.

Daly JJ, Hrovat K, Pundik S, Sunshine J, Yue G. fMRI meth-ods for proximal upper limb joint motor testing and identifi-cation of undesired mirror movement after stroke. J Neurosci Methods 2008 Oct 30;175(1):133-142.

DiMarco AF, Kowalski KE, Geertman RT, Hromyak DR, Frost FS, Creasey GH, Nemunaitis GA. Lower thoracic sopinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-Sponsored clinical trial. PartII: clinical outcomes. Arch Phys Med Rehabil 2009 May; 90(5):726-32.

Fang Y, Dally JJ, Sun J, Hvorat K, Fredrickson E, Pundik S, Sahgal V, Yue GH. Functional corticomuscular connection during reaching is weakened following stroke. Clin Neuro-physiol 2009 May; 120(5):994-1002.

Liang HW, Landers SH. Who receives house calls? J Am Geriatr Soc 2008 Aug;56(8):1581-1582.

Marusiak J, Jaskolska A, Kisiel-Sajewicz K, Yue GH, Jaskol-ski A. EMG and MMG activities of agonist and antagonist muscles in Parkinson’s disease patients during absolute sub-maximal load holding. J Electromyogr Kinesiol 2008 [Epub ahead of print] PubMed PMID: 18456512.

Podichetty VK, Reddy A. Acupuncture, transcutaneous elec-trical nerve stimulation, and topical analgesics. In: Walsh D, ed. Palliative Medicine. Philadelphia, PA: Saunders/Elsevier; 2009:1398-1404.

Rosenstein L, Ridgel AL, Thota A, Samame B, Alberts JL. Ef-fects of combined robotic therapy and repetitive-task practice on upper-extremity function in a patient with chronic stroke. Am J Occup Ther 2008 Jan;62(1):28-35.

Schilling DL, Dixon P. Occupational and physical therapy. In: Walsh D, ed. Palliative Medicine. Philadelphia, PA: Saun-ders/Elsevier; 2009:277-278.

Yang Q, Fang Y, Sun CK, Siemionow V, Ranganathan VK, Khoshknabi D, Davis MP, Walsh D, Sahgal V, Yue GH. Weak-ening of functional corticomuscular coupling during muscle fatigue. Brain Res 2009 Jan 23;1250:101-112.

Yao B, Liu JZ, Brown RW, Shagal V, Yue GH. Nonlinear features of surface EEG showing systematic brain signal adaptations with muscle force and fatigue. Brain Res 2009 May 26; 1272:89-98.

Yavuzsen T, Davis MP, Ranganathan VK, Walsh D, Siemion-ow V, Kirkova J, Khoshknabi D, Lagman R, Legrand S, Yew GH. Cancer-Related Fatigue: Central or Peripheral? J Pain Symptom Manage 2009 Jun 8. [Epub ahead of print]

Publications by Physical Medicine & Rehabilitation and Related Faculty 2008-2009

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Services for Physicians

Physician Directory View all Cleveland Clinic staff online at clevelandclinic.org/staff.

Physician Liaison Referring physicians have a direct and personal link to Cleveland Clinic with our Physician Liaison. For help with any interaction involving Cleveland Clinic, contact Physician Liaison Kate Kenny at clevelandclinic.org/ContactKate.

Improved Communication, Improved CareCleveland Clinic DrConnect is a complimentary service providing our referring physicians with secure, online access to the electronic medical record information related to a patient’s treatment progress. To receive your next patient report electronically, please log onto clevelandclinic.org/drconnect to establish your own DrConnect account.

Online Medical Second Opinions Request a secure online medical second opinion from Cleveland Clinic specialists. For more information, visit clevelandclinic.org/myconsult.

Resources for Your Patients

Cleveland Clinic’s Department of Physical Medicine and Rehabilitation serves patients with mobility, self-care, communication, swallowing and cognitive impairments. Our more than 150 physiatrists, physical and occupational therapists, vocational rehabilitation counselors and rehabilitation nurses provide inpatient and outpatient rehabilitation after orthopaedic surgery, stroke, spinal cord injury or transplant, and for neurological disorders, cancer and pulmonary disorders. Special programs are targeted at driving rehabilitation, golfing with disabilities and other areas.

Appointments Rehabilitation Physiatry: 216.445.7342Physical/Occupational Therapy: Adults, 216.445.8000; Pediatrics, 216.444.6572 Return to Work Services/Vocational Rehabilitation: 216.444.WORK (9675)Orthotics and Prosthetics Center/Wheelchair & Seating Clinic: 216.445.9000

Medical Concierge Complimentary assistance for out-of-state patients and families: 800.223.2273, ext. 55580, or email medicalconcierge@ccf.org

Global Patient ServicesComplimentary assistance for national and international patients and families: 001.216.444.8184 or visit clevelandclinic.org/gps

Frontiers in Rehabilitation, published by the Cleveland Clinic Department of Physical Medicine and Rehabilita-tion, provides updates on diagnostic and therapeutic techniques and current research for physiatrists, neurolo-gists and neurosurgeons.

Please direct correspondence to: Vernon Lin, MD, PhD, ChairmanDepartment of Physical Medicine and Rehabiliation/C21 Cleveland Clinic9500 Euclid Avenue Cleveland, OH 44195

Physicians may also reach Dr. Lin at 216.445.7350 or at linv@ccf.org.

Medical Editor: Frederick Frost, MD Editor: Cora M. LiderbachDesigner: Irwin KriegerPhotographers: Neil Lantzy, Scott Goldsmith

The Department of Physical Medicine and Rehabilitation is part of the Neuroscience Institute, one of 26 institutes at Cleve-land Clinic that group multiple specialties together to provide collaborative, patient-centered care. The department offers full cross-disciplinary rehabilitation for people with physical, psychosocial, cognitive and vocational impairments. Patients receive coordinated care across a continuum that spans inpatient rehabilitation, skilled nursing and outpatient therapy at Cleveland Clinic facilities throughout the region. Cleveland Clinic is a non-profit, multispecialty academic medical center. Founded in 1921, it is dedicated to providing quality specialized care and includes an outpatient clinic, a hospital with more than 1,000 staffed beds, an education institute and a research institute.

Frontiers in Rehabilitation is written for physicians and should be relied upon for medical education purposes only. It does not provide a complete overview of the topics covered, and should not replace the independent judgment of a physician about the

appropriateness or risks of a procedure for a given patient.

© The Cleveland Clinic Foundation 2009 09-REH-003

Cleveland Clinic Physician Resource GuideGeneral Referrals to Cleveland Clinic 24/7 hospital transfers or physician consults 800.553.5056

Department of Physical Medicine and Rehabilitation Referrals 216.445.7342 or 800.223.2273, ext. 57342

On the web at clevelandclinic.org/frontiers

Frontiers In Rehabilitation | Fall 2009 11

The Cleveland Clinic FoundationPhysical Medicine and Rehabilitation9500 Euclid Avenue / AC311Cleveland, OH 44195

Co-chairs: Vernon Lin, MD, PhD, and Frederick Frost, MD, Cleveland Clinic Department of Physical Medicine and Rehabilitation

Sept. 23, 2009 (Pre-Course to the Congress on Spinal Medicine and Rehabilitation in Dallas, Texas)

This one-day intensive review will feature an in-depth review of more than 20 essential spinal cord injury topics, including:

• Spinal cord anatomy, epidemiology, imaging and pathologies

• Neurocritical care, surgery and neurological assessment of acute SCI

• Management of neurogenic bladder and bowel, and sexual dysfunction

• Management of pain, spasticity and musculoskeletal dysfunction in SCI

• Cardiovascular, endocrine, metabolic and respiratory care in SCI

• Nutrition, immunological factors and pressure ulcer management

• Psychosocial adjustment and SCI rehabilitation

• Functional restoration of the upper limb in tetraplegia

• Nontraumatic myelopathies and dual diagnosis of SCI and brain injury

• Disorders affecting children and adolescents

To register for the pre-course, visit

www.asia-ascip2009.org/registration_home.php.

Cleveland Clinic Ranked One of America’s Top HospitalsCleveland Clinic is ranked one of the nation’s top hospitals, according to the latest U.S.News & World Report’s annual survey of “America’s Best Hospitals.” U.S.News also ranked Cleveland Clinic’s Rehabilitation program among the top 20. For details, visit clevelandclinic.org.

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