Advancing rehabilitation science
A PHHP and Brooks Rehabilitation collaboration is accelerating the translation of new science to improve care
Never underestimate the power of the hallway conversation.
A decade ago, Emily Fox, Ph.D., P.T., a UF PHHP faculty member who also served as a Brooks Rehabilitation research scientist, was talking with clinician colleagues at Brooks Rehabilitation in Jacksonville about a new trend among their patients with spinal cord injury. While in acute care, several of these patients had received diaphragm stimulators to help improve their breathing and speech. Now as Brooks patients, their health care providers had little information on how to properly manage their patients with the device.
Back at the University of Florida, Fox described these patients to David Fuller, Ph.D., a PHHP professor who specializes in respiratory science. This spurred Fuller to conduct basic science studies of diaphragm stimulators in an animal model, which spawned clinical research questions tested in studies conducted at UF Health Jacksonville, UF Health Gainesville and Brooks Rehabilitation. The result was clinically-informed science resulting in new knowledge that is directly impacting patients with diaphragm stimulators.
Now formalized as the Brooks-UF PHHP Research Collaboration, people who exchange ideas in university hallways and in health care facility hallways are a whole lot closer.
“None of that would have occurred without all those conversations and my fortunate opportunity to stand in both hallways,” said Fox, now the director of the Brooks-UF PHHP Research Collaboration and an associate professor in the PHHP department of physical therapy.
When scientists and clinicians get together, patients benefit
The Brooks-UF PHHP Research Collaboration was established a decade ago to advance rehabilitation science with a goal of immediate patient impact. University scientists and trainees work alongside clinicians to identify research questions and carry out studies. This unique access gives academic researchers a better understanding of challenges clinicians face in the clinic, and together, teams are better able to design studies focused on improving rehabilitation practice that can be more easily implemented in a real-world setting. With Brooks’ three inpatient facilities, more than 50 outpatient clinics and two long-term care facilities, as well as home health care, specialty services and community programs extending throughout north and central Florida, clinicians and scientists can examine research questions in a large and diverse patient population that covers the spectrum of post-acute care.
“The Brooks-UF PHHP Research Collaboration is focused on research that has the potential to impact patients, including the delivery of care and the health of communities. That is our mission,” Fox said. “Through this collaboration, we bring together diverse views and diverse clinical and scientific expertise. From the academic side of PHHP to the clinical work at Brooks, this collaboration values a shared expertise for the benefit of patients.”
From the Brooks perspective, the collaboration offers an academic partner with resources and expertise to help providers answer clinical questions and improve the care of their patients. Respect for the important role clinicians play in the scientific process is reflected in institutional culture, said Mark Bowden, Ph.D., P.T., the vice president of clinical integration and research at Brooks Rehabilitation.
“All of the Brooks-UF PHHP Research Collaboration scientists have been clinicians and we all know that you can’t go into a hospital and tell providers what they need to be doing because research says it needs to be done,” said Bowden, also a 2009 graduate of the college’s doctoral program in rehabilitation science. “There is no better way to lose an audience of clinicians than to not take their voice as valid. When we engage with them it’s from a standpoint of ‘What are the limiting factors that we need to understand better?’ ‘How might we be able to work with you to implement this outcome measure, idea, technology or intervention?’ If you engage with clinicians from the standpoint of how we can all work together to improve the clinical experience for patients, then you’ve got an audience.”
Over the past five years, the collaboration has led to more than $25 million in research funding from outside agencies, 150 peer reviewed publications, 11 doctoral trainees and 10 postdoctoral fellows. But most importantly, the collaboration has generated real improvements to patient care, particularly in the areas of spinal cord injury, chronic pain, stroke and cancer.
“The collaboration gives PHHP and Brooks Rehabilitation — two different institutions which are each very successful and prestigious in their own rights — an opportunity to jointly produce clinical research and train the next generation of clinician leaders across these different disciplines of rehab,” said Meryl Alappattu, Ph.D., D.P.T., a research associate professor of physical therapy and a Brooks research scientist. “That’s only going to benefit patients and patient care for the future.”
Advancing respiratory health after injury or sudden illness
Cory Fisher (center) takes steps alongside Dr. Emily Fox (right) and Jessica Dunn, D.P.T., N.C.S., Brooks clinician scientist.
Photo by Nathaniel Guidry
For individuals who experience a spinal cord injury or stroke, respiratory health is one of the primary concerns during the recovery process.
“Regaining independent breathing is often a challenge, so diaphragm stimulation has been used as a strategy to help people wean off the ventilator,” Fox said. “We’ve taken this approach to the next step, examining whether diaphragm stimulation has a therapeutic impact, not just to replace a ventilator, but to strengthen the diaphragm muscle tissue and nervous system to intrinsically stimulate breathing and hopefully help patients become ventilator free.”
But strengthening the diaphragm isn’t the only hurdle in respiratory recovery from a traumatic injury or illness.
“Even if we make breathing stronger, there’s still damage to the nervous system,” Fox said. “Intermittent hypoxia, or exposing patients to brief periods of reduced oxygen, is a strategy used to strengthen connections within the nervous system that has decades of research behind it. We’re applying this to patients with spinal cord injury, implementing respiratory strength training exercises to strengthen the nervous system and ultimately make rehabilitation more effective.”
In a current Department of Defense-funded study conducted at Brooks Rehabilitation, Fox hopes to optimize this approach of combining intermittent hypoxia with respiratory strength training, and explore how different biomarkers can impact treatment effectiveness.
“This science has the real-world potential to translate into patient care,” Fox said. “Our human clinical trials and what we do through the Brooks-UF PHHP Research Collaboration is a big part of these efforts to innovate clinical practice.”
The driving force behind her research is learning from her patients and what they need most, she said.
“One of my patients told me that when he was out at social events or having conversations, he would have to pause his talking due to shortness of breath. After participating in a clinical trial with us, he noticed that he didn’t have to stop and catch his breath anymore when out with friends or during conversations. It’s these anecdotal stories, not just the data, that show patients are seeing a benefit and the work we are doing matters.”
Developing a full picture of pain and the patient experience
In their pain research, Dr. Joel Bialosky and mentee Jill Hayes, a PHHP doctoral student in rehabilitation science, frequently focus on spinal pain. According to the World Health Organization, low back pain is the number one cause of disability worldwide.
Photo by Betsy Hansen Brzezinski
For Brooks-UF PHHP Research Collaboration investigators and P.T. faculty members Joel Bialosky, Ph.D., P.T., and Jason Beneciuk, Ph.D., D.P.T., it’s important to view a condition as complex as chronic pain through a holistic lens that considers a host of factors, including patient expectations, patient-therapist communication and trust, and patient beliefs about their pain experience.
When it comes to pain, context matters.
“When you’re in school as a physical therapy student, a lot of times you’re focused on learning techniques. Where do I put my hands? How much force do I use? How do I watch a patient do something and then make recommendations?” said Bialosky, a clinical professor of physical therapy and a Brooks research scientist. “And while technique certainly plays a role, I think you could argue that someone could be the best technical therapist in the world, but if you can’t relate to the patient, if the patient doesn’t think that you’re going to be able to help them, you may have suboptimal outcomes.”
Among Bialosky’s current research projects is a study conducted in collaboration with Brooks Rehabilitation physical therapist Amber Custodi, D.P.T., P.T., that explores the characteristics patients may prefer in their therapist. In most practices, patients are typically assigned to their physical therapist based on scheduling and availability.
“But the thought is that outcomes could potentially be enhanced if the therapist and the patient were better matched to each other,” Bialosky said. “I hope that we can continue to shed light on the relationship between the patient and the physical therapist.”
Dr. Jason Beneciuk and Dr. Anita Davis, Brooks Rehabilitation physical therapist, demonstrate how they may pause during treatment to receive patient feedback in real-time. Intentional communication between patients and physical therapists can help build the therapist-patient therapeutic alliance, and is a cornerstone of a recent feasibility study Beneciuk led on patient and therapist shared decision-making.
Photo by Nathaniel Guidry
Beneciuk, a research associate professor of physical therapy and director of musculoskeletal research at Brooks Rehabilitation, led a Patient Centered Outcomes Research Institute-funded study designed to establish musculoskeletal pain research priorities some years ago with eye-opening results.
“As researchers or clinicians, we think of reducing pain and improving function as the most important clinical outcome,” Beneciuk said. “Interestingly, our patient partners told us that’s important, but what’s really the most important outcome is the ability to self-manage their pain symptoms, which is very similar to the concept of pain self-efficacy. What we took from this is that pain self-efficacy should be included as a primary outcome for many of our future studies.”
A UF team, including Bialosky and Beneciuk, collaborated with Brooks Rehabilitation and other health care systems across the country to create a multidimensional psychological screening tool for patients with musculoskeletal pain. Unlike previous tools, the Optimal Screening for Prediction of Referral and Outcome Yellow Flag, or OSPRO-YF tool, also includes positive factors, such as pain acceptance and self-efficacy. Some research suggests that these positive psychological factors may be better predictors of someone’s resilience for dealing with pain than negative factors, including pain catastrophizing and depressive symptoms, Beneciuk said.
OSPRO-YF is endorsed by the Academy of Orthopaedic Physical Therapy and has recently been adopted systemwide by Brooks Rehabilitation. The tool is loaded on outpatient therapists’ iPads for the screening of patients with musculoskeletal pain conditions.
“The Brooks-UF PHHP Research Collaboration is a true collaboration,” Beneciuk said. “UF faculty engage clinicians as early as possible in discussing research ideas and during the development phase of projects. Brooks clinicians played a vital role in the development and validation of the OSPRO-YF tool. We now have an efficient tool that is being used in clinics as part of a psychologically-informed practice approach to patient care.”
Taking the long view on health and wellness after stroke
Among Dr. Dorian Rose’s current studies is a Veteran’s Health Administration Rehabilitation Research and Development-funded project that employs backward walking with the goal of improving balance and agility in patients post-stroke. With the help of brain imaging, she is also measuring how the intervention changes the brain. Better balance lays the foundation for patients to participate in cardiovascular exercise, an important strategy for preventing a second stroke.
Photo by Betsy Hansen Brzezinski
The greatest risk factor for stroke, says UF P.T. research professor Dorian Rose, Ph.D., P.T., M.S., FAPTA, is a previous stroke. While stroke rehabilitation programs are critical for recovering function, the importance of improving heart health in order to prevent a second stroke is frequently overlooked.
“When someone has a stroke they may not be able to move parts of their body and we’ve tended to primarily focus on these impairments of movement,” said Rose who is also affiliated with Gainesville’s Malcom Randall Veterans Affairs Medical Center. “If you had asked me 20 years ago about my research agenda for individuals post-stroke it would have been recovery of motion needed to walk or get dressed. But understanding the bigger picture, that so many patients with stroke need to exercise their heart and without that, they are at real risk for a second stroke, I’ve shifted some of my focus. My motivation is to keep people moving.”
When viewed as a chronic condition, long-term stroke management often falls short. Many patients’ insurance plans only cover a limited number of outpatient therapy sessions following hospital discharge. After that, patients may be given advice from their primary health care provider to “get exercise.” Without specific guidance and coaching, however, patients may not know how or where to start.
In 2009, Trevor Paris, M.D., FAAPMR, system chief medical officer at Brooks Rehabilitation, asked Rose to lend her expertise to a new concept designed to fill this gap. In partnership with First Coast YMCA, the team developed the Stroke Wellness Program, the region’s first. The program features customized exercise programs and offers important social benefits and a sense of belonging and community. The program was among 10 programs named a Program of Excellence by the Hospital Charitable Services Awards in 2014.
But are participants exercising at the intensity needed to prevent a second stroke? That question became the basis for a study Rose is currently conducting in collaboration with Brooks. Funded by the Florida Department of Health, the study tests the American Heart Association post-stroke exercise guidelines, examining their utility and whether participants who receive respiratory muscle training experience improved cardiorespiratory fitness outcomes and quality of life. Over three months, participants work one-on-one with a physical therapist to complete a strengthening, cardiovascular and flexibility training program, plus respiratory exercise. After completing the study, participants are encouraged to continue their progress by transitioning to the Stroke Wellness Program at the Y.
“People in the study are loving this because their insurance benefits for continued rehabilitation have run out and they realize that they hadn’t made as much improvement as they would have liked and now they’re ready to work hard,” Rose said. “This project has been a bridge for people to return to exercise and gain confidence that they can do it. It has really met a felt need in our community.”
Growing new clinical research programs in pelvic health and cancer
Dr. Meryl Alappattu’s work focuses on cancer rehabilitation and pelvic health, including urinary leakage and pelvic pain after childbirth. She hopes to reduce stigma around pelvic health so people can talk openly about these issues and get the help they need.
Photo by Nathaniel Guidry
While it’s common for physical therapists to specialize in general orthopedics, those focused on pelvic health are less common. Meryl Alappattu is working to change that.
She focuses on addressing challenges related to pelvic floor dysfunction, including urinary leakage, pelvic pain and pelvic pain after childbirth.
“I work with people across the lifespan,” Alappattu said. “These issues are common across the board, but are often considered taboo topics to talk about. One of my goals not just as a researcher, but as a physical therapist as well, is to continue to encourage openness and discussion about these topics. This includes reducing stigma, so people know they can seek out resources without having to suffer in silence or feel embarrassed,” she said.
Alappattu recently completed a project with Brooks oncology navigator, Ashley Perry, D.P.T., M.T.C., and colleagues from the University of South Carolina and West Virginia University that examined the benefits and feasibility of having a physical therapist serve as a point person for individuals receiving rehabilitation services during and after cancer treatment.
“Now, we have other health systems, including the oncology rehab teams from UF Health and the Malcom Randall Veterans Affairs Medical Center, wanting to implement our findings,” Alappattu said. “Other people are looking at what we are doing and trying to replicate our program. This is a testament to how the Brooks-UF PHHP Research Collaboration is setting a standard and how a cancer navigation program can work.”
For many years, there wasn’t a big emphasis on quality of life for cancer patients; the goal was remission. In the last 20 years, the goal has evolved to also emphasize survivorship. Now, health care institutions collectively recognize that once cancer treatment is over, it’s not the end of the journey.
“People can have issues post-cancer treatment, such as fatigue, muscle weakness, pelvic floor dysfunction, surgical pain or challenges with activities of daily living,” Alappattu said. “One of the goals with cancer rehabilitation is being able to identify other health care providers or disciplines to see patients through the rest of their treatment or rehabilitation. It’s taking a holistic view of the patient and maximizing outcomes to ensure they are getting all the needed care beyond just medical or surgical therapies for cancer.”
Looking ahead
The Brooks-UF PHHP Research Collaboration’s goals for the next few years are keenly focused on growth.
“We have really only scratched the surface in terms of the potential ways to work together,” Fox said. “As a college, our expertise and faculty have grown. There are so many ways for PHHP leaders and investigators to advance their work, translate it or take it in different directions, particularly with a rehabilitation focus, with a strong partner like Brooks Rehabilitation. Brooks is also growing its footprint as a leading rehabilitation health care organization with a strong research infrastructure and clinical training opportunities. There is incredible yet-to-be-tapped potential in how we work together.”
The collaboration plans to increase funding, studies and the number of College of Public Health and Health Professions faculty, students and postdoctoral involved in these efforts. Fox wants to engage the expertise of faculty and students from across all the college’s disciplines to include other clinical and research perspectives, from speech and hearing to epidemiology and health services research.
For example, Chiung-ju (CJ) Liu, Ph.D., OTR/L, an associate professor of occupational therapy, is bringing her experience in enhancing older adults’ functional ability to her new role as a Learning Health Systems Rehabilitation Research Network, or LeaRRn, scholar. With financial support from LeaRRN and the UF Office of the Provost, Liu is working with administrators and clinicians at Brooks Rehabilitation Skilled Nursing Facility – Bartram Crossing to identify areas for improved patient outcomes and future projects to pursue under the Brooks-UF PHHP Research Collaboration.
Brooks Rehabilitation has made a substantial investment in research through new research centers, its Institute for Higher Learning and learning health system initiatives. The alignment of these initiatives with the activities of the collaboration and mutual goals among Brooks and the College of Public Health and Health Professions leadership, places both institutions in an excellent position to grow the collaboration and see real results for patients, Bowden said.
“If the ultimate question is, ‘How well do people do when they get home?’ we now have the ability to answer that question, and I think that’s super exciting,” Bowden said.
