RainbowVisions - Rainbow Rehabilitation

RainbowVisionsA News MAgAziNe for Acquired Brain and spinal Cord injury Professionals, survivors and Families

Rainbow Rehabilitation CenteRs inC. www.rainbowrehab.com

Fall 2009 www.RainbowVisionsMagazine.com Volume VI No. 3

In this issue ...

The work of Dr. Donald stein and Colleagues on page 16

Progesterone& Brain Injury

Infection control in health care settings

see page 5

Medical News on

Superbugs

Therapy DisciplinesA look at Neuro-IFRAH Therapy

see page 12

2 Rainb owVisions

T he tide may be changing regarding the

acceptability of cognitive rehabilitation

as a covered service by private insurance

companies. For decades, commercial

insurance companies have, by and large,

disallowed payments or excluded coverage

for cognitive rehabilitation, as the services'

effectiveness was deemed unproven by

payers. The impact of this stance has been

to leave many premium paying survivors

of brain injury without coverage and out in

the cold.

In November 2006, the Brain Injury

Association of America (BIAA) published

a position paper titled "Cognitive

Rehabilitation: The Evidence, Funding and

Case for Advocacy in Brain Injury." The

paper laid out the arguments why cognitive

rehabilitation should be a covered benefit

C O G N I T I V E R E H A B I L I T A T I O N I S

Gaining MomentumBy Bill Buccalo, President

Rainbow Rehabilitation Centers

industryWhat’s News in the

under all private and public health

insurance policies for the treatment of

people with a brain injury. Since that

publication, advocacy for cognitive

rehabilitation has been a major focus of the

BIAA.

In June 2009, the association announced

several encouraging developments in the

effort to gain widespread recognition of

cognitive rehabilitation.

Effective October 2008, Anthem

Insurance Companies, which is a licensee

of the Blue Cross and Blue Shield

Association, revised its medical policy

regarding cognitive rehabilitation stating,

“Cognitive rehabilitation is considered

medically necessary in patients with

significantly impaired cognitive function

after traumatic brain injury (TBI) if all of the

following criteria are met:…” In May 2009,

United Healthcare updated its medical

policy stating in their coverage rationale,

“Cognitive rehabilitation is proven for

the treatment of traumatic brain injury

and brain injury due to stroke, aneurysm,

anoxia, encephalitis, brain tumors,

and brain toxins when the patient can

interactively participate in the program…”

With possible national health care

legislation coming as soon as fall and

ongoing efforts to expand coverage for our

service members to include the best and

most appropriate care, there are immediate

opportunities for the brain injury

community to advocate for the inclusion

of cognitive rehabilitation in these various

plans. There is no better time than now.

These changes in the stance on cognitive

rehabilitation by Anthem and United

Healthcare, coupled with momentum in

several other areas, have the potential to

turn the tide on the long standing denial

of much needed cognitive rehabilitation

opportunities for people with brain injury.

Although long overdue, this is an exciting

change.

...there are immediate opportunities for the brain injury

community to advocate for the inclusion of cognitive

rehabilitation in these various plans.

There is no better time than now.

w w w. ra i n b ow re h a b. co m F A L L 2 0 0 9

Rainb owVisions 3

Features ...A look at Rainbow's Functional Recovery 10

Clinical News – The effects of progesterone on brain injury 16

in each issue ...What’s News in the Industry – Cognitive Rehabilitation 2

Medical News – Superbugs; infection control in

health care settings 5

Technology Corner – Accessible living for a TBI Survivor 8

Therapy Disciplines – A look at Neuro-IFRAH Therapy 12

Industry Conference & Event Calendar 14

Survivor Corner – Congratulations to Rainbow's

high school graduates 26

News at Rainbow

– Three area students receive Rainbow college scholarships 28

– Rainbow's Pediatric programs explored Michigan 28

– Rainbow's Employees of the Season 29

– Meet the therapists and staff at Functional Recovery 30

In this edition of

RainbowVisions, we take an

in-depth look at the work of

Dr. Stein and his discovery of

the effects of progesterone

administered after a

traumatic brain injury.

CoverOn the

Editor – Barry MarshallStaff writer & assistant editor – Nicole BonominiDesigner – Kim PaetzoldStaff photographer – Heidi Reyst/Barry Marshall

E-mail questions or comments to: [email protected]

Copyright Sept. 2009 – Rainbow Rehabilitation Centers, Inc. All rights reserved. Published in the United States of America. No part of this publication may be reproduced in any manner whatsoever without written permission from Rainbow Rehabilitation Centers, Inc. Contact the editor: [email protected].

www.RainbowVis ionsMagaz ine.com

Rainb owVisions 3

SuperbugsControlling

In health care settingssee page 5

4 Rainb owVisions

a letter from the editor ...

To register or for more information call ...

800.968.6644E-mail: [email protected]

www.rainbowrehab.com

Astrongmarketingcommunicationsprogramisa

reflectionofacompany'scommitmenttoitscustomers,

employeesandcommunity.That'swhatI'vefoundat

RainbowRehabilitationCenters.

Earlierthisyear,ItookovertheroleasMarketingManager,

overseeingallaspectsofthecompany'sprintandelectronic

marketinginitiatives,includingthisgreatmagazine.

Bywayofintroduction,I'vespentmorethan23years

inamarketingcommunicationscapacity,workingfor

Domino'sPizzaandProQuestCompany,attheirrespective

headquartersinAnnArbor,Mich.

HavingservedDomino'sPizzaformostofmycareer,it

istherethatIreceivedmostofmy"corporatejournalism"

experience.Iwasluckyenoughtohaveworkedonthe

company'sflagshippublicationfor10years--fiveofthose

yearsservingasitsExecutiveEditor.Thepublication

enjoyedastrongreputationasitcoveredrelevantnewsand

informationforeveryoneassociatedwiththecompany.

RainbowVisions,too,enjoysastrongreputationwithin

theindustryasaleadingpublication

providingcompellinginformation

forsurvivors,theirfamiliesand

professionalsinthebrainandspinal

cordinjuryfields.

Iamproudtobeapartofsuchan

importantmethodofcommunication

totheamazingcommunityofthose

dedicatedtobrainandspinalcord

injuries.Intoday'selectronicworld,

I'llbelookingforwaystoexpand

themagazine'sreachandusing

newmethodsofdisseminating

information.

And,asalways,I'minterestedinhearingyourthoughtsand

ideasonthemagazine.Dropmealineanytime.

Barry [email protected]


Rainb owVisions 5

Continued on page 6

uperbugs continue to be a challenge

to physicians and health care workers

worldwide. The list of offending bacteria

resistant to antibiotics continues to grow

within health care facilities, and some have

spread into the community. Bugs have

become increasingly resistant to available

antibiotics with few new antibiotics on

the horizon. Due to rising deaths, illnesses

and associated costs, consumer groups

and insurance companies are demanding

that health care settings be accountable

when an infection is acquired during a

patient’s stay in a health care facility. The

good news is that the development and

utilization of best practice standards in

infection prevention have been making

some headway in reducing and eradicating

some health care-associated infections.

Prevention of infection is crucial when

treatment options are limited. In some

cases, prevention can be surprisingly

simple.

Multi-Drug Resistant Organisms

(MDROs)

Bacteria are pretty ingenious small life

forms that have mutated, under pressure

from antibiotics, into toxic new strains.

These new strains are tough to treat due

to antibiotics that have been used in the

past and are no longer effective. The

combination of antibiotic overuse and

fewer new antibiotics being developed

have fueled the mutation and spread of

MDROs.

Once MDROs are treated, they can

remain colonized as germs living in the

body, not causing illness to the host. The

bacteria can be transmitted to another

person if prevention measures are not

used effectively. In most instances,

MDRO infections target patients who are

hospitalized, particularly in intensive care

units (ICUs), and those who have a reduced

ability to fight infection due to pre-existing

medical conditions, recent surgeries and/

or indwelling medical devices. Long-term

care facilities have seen an increase in

MDROs from patients either coming from

the hospital or from the spread amongst

their physically compromised patients.

Generally, a healthy person is far less

likely to become infected, but can be

colonized with no symptoms, potentially

posing a risk to others. (For a list of MDRO

offenders that cause infections and deserve

special attention in health care facilities –

see page 6.)

Infection Prevention

Although infection prevention can

be surprisingly simple, it must be done

without fail precisely because the stakes

are high and the problems are complex.

According to Peter Pronovost, M.D., a

I N F E C T I O N C O N T R O L I N

Health Care SettingsBy Marianne Knox, RN, BSN CBIS

The combination of anitbiotic overuse and fewer new antibiotics

being developed have fueled the mutation and spread of

multi-drug organisms (MDROs) or "superbugs."

S

To register or for more information call ...

800.968.6644E-mail: [email protected]


Superbugs

Multi-Drug Resistant Organisms (MDROs)

TheMRSAstaphylococcusaureustest.

“ruthlessly simple” five-step checklist

developed by his Johns Hopkins University

team includes:

• washing hands with soap

• wearing sterile gowns and gloves

• cleaning the patient with an antiseptic

• using sterile drapes

• applying sterile dressings

Special attention to cleaning the

environmental surfaces and equipment

should also be part of infection prevention

strategies. Private rooms are also suggested

for infected patients. If a private room is not

available, cohorting patients with similar

infections and cohorting their care givers is

suggested.

Infection Control Precautions fall into

different categories depending on the

identified infection. However, protecting

the patient by preventing spread of any

potential bug, known or unknown, is

the goal. Infection Prevention Specialists

can assign a particular precaution when

warranted as a notice to health care

workers, family and visitors. Personal

protective equipment should be provided

as needed.

Standard Precautions are used for all

patient care contact, and includes thorough

hand hygiene (washing your hands with

soap and water or using alcohol hand rubs)

and the use of gloves to control infection.

Gowns, masks and eye protection are

also recommended when a splash of body

secretions is possible. Hand hygiene and

personal protective equipment changes are

recommended for care givers whenever

they move between patients, and even

when they perform procedures on the same

patient to different areas of the body.

Contact Precautions are intended to

prevent transmission of particular infectious

agents, including Multi-Drug Resistant

SuperbugsContinued from page 5

The following is a list of MDRO offenders that cause infections and

deserve special attention in health care facilities.

Methacillin Resistant Staphylococcus Aureus (MRSA) is spread by contact

with infected secretions, colonization on the skin or contaminated environmental

surfaces. MRSA has been around for about 40 years in its antibiotic-resistant

form. The non-resistant form has been around for many centuries. It is found in

soil, on common household surfaces and on the skin.

MRSA is easily killed with hospital grade disinfectants and is easily washed off

hands. It is one of the leading causes of sepsis (blood infection) in hospitals, but

has also been commonly found in wounds. MRSA is treatable, but can be tough

to eradicate. Community-acquired MRSA can be spread on surfaces such as

athletic equipment and school desks when bare skin and/or open wounds come

in contact with contaminated surfaces. Treatment and prevention of this strain is

similar to MRSA found in health care settings.

Continued on page 24

6 Rainb owVisions


Acinetobacter Baumannii (XMDR-ACB) is a gram-negative (see sidebar at right),

rod-shaped (bacillus) bacteria commonly found in soil and water, and can also be

found on the skin of healthy people. The resistant form is rarely found outside of health

care settings. It can cause a variety of problems ranging from pneumonia, wounds

or blood infections, urinary tract infections or meningitis. It can be colonized for long

lengths of time in tracheostomy tubes and is spread by person-to-person contact,

contaminated surfaces or contaminated environmental exposure. It can survive on

surfaces for several days and can be very difficult to treat due to some strains being

almost completely resistant to antibiotics. It has been nicknamed “Iraqibacter” as

many soldiers wounded in Iraq acquired the infection while in military hospitals.

Vancomycin Resistant Enterococci (VRE) is a cocci (spherical shaped), gram-

positive bacteria. VRE can cause infection in the urinary tract, bloodstream,

intestine or in wounds. People at risk are those previously treated with Vancomycin,

hospitalized patients with weakened immune systems, recent surgeries and/or

indwelling medical devices. VRE is spread person-to-person by the hands or from

contaminated surfaces. It can live on environmental surfaces for up to one week.

Hospital grade disinfectants will kill VRE and it can easily be washed off hands.

Klebsiella Pneumoniae (MDR - K. Pneumoniae or CRKP) is a gram-negative

bacteria that can cause pneumonia, bloodstream infection, wounds, urinary tract

infections and meningitis. Klebsiella is normally found in the mouth, on the skin, in

feces and in the intestinal tract (where they do not cause disease.) People at risk are

those previously treated with certain antibiotics, hospitalized patients with weakened

immune systems, and those with recent surgeries and/or indwelling medical devices.

Healthy people usually do not get Klebsiella infections. It is spread person to person,

on the hands of caregivers or from contaminated ventilators, catheters, wounds or

contact with feces. This bacteria is not spread through the air. Klebsiella Pneumoniae

can be highly resistant to Carbapenim antibiotics which often are the last line of

defense against gram-negative infections. Contact precautions are necessary for

patients with this infection due to the high resistance to available treatments.

Clostridium Difficile (C-Diff) is not considered a MDRO but can become a problem

as a result of antibiotic overuse. It is bacteria commonly found in the intestine, which

can cause mild to moderate diarrhea – or in more serious cases, colitis. It is usually

kept in check by other intestine bacteria, but after antibiotic use, bacteria reduction

can give the C-Diff an opportunity to take hold and cause infection.

These bacteria produce spores that can live on surfaces for months and are difficult

to kill. Active cleaning of surfaces and diligent hand washing is essential to stop

its spread. The bacteria have become more toxic as time goes on and can cause

damage to the intestines, and on rare occasions, even death.

C-Diff is not resistant to antibiotics and is generally treated with Flagyl or

Vancomycin. Re-treatment is sometimes needed to eradicate this bacteria and is

important to prevent re-infection. Alcohol hand rubs and alcohol-based cleaners are

not as effective as soap and water, high-level disinfectants or bleach. Friction for

cleaning hands or surfaces is important because the spores are tough to remove.

The Bacterial Staining Technique

Gram-negative vs. Gram-positive

One of the most useful staining

reactions for bacteria is called the

"Gram Stain" developed in 1884 by the

Danish physician, Hans Christian Gram.

Bacteria in suspension are fixed to a

glass slide by brief heating and then

exposed to two dyes that combine to

form a large blue dye complex within

each cell. When the slide is flushed

with an alcohol solution, gram-positive

bacteria retain the blue or violet color.

The slide is then flushed with an iodine

solution, followed by an organic solvent

(such as alcohol or acetone). Gram-

positive bacteria remain purple because

they have a single thick cell wall that

is not easily penetrated by the solvent.

Gram-negative bacteria, however, are

decolorized because they do not retain

the crystal violet color (dye) in their cell

wall. The gram-negative bacteria cell-

wall holds the pink or reddish dye once

a counter stain chemical is used.

Pictured above: Acomputergenerated

3-Dimageofgrampositivestreptococci

bacteriawhichgrowinchains.Itretains

thevioletcolorwhendyed.

Rainb owVisions 7

8 Rainb owVisions

A C C E S S I B L E L I V I N G F O R A TBI SurvivorBy Nicole Bonomini, Staff Writer

M

technologyCorner

any people don’t think twice about what it takes to step

through a doorway in their own home, but for many

individuals who have a brain injury, it can be a daily struggle.

To offset the challenges caused by physical disability, home

modifications are available to help them achieve the highest

levels of independence and living space accessibility.

Generally, a ranch-style floor plan is best for people with

disabilities. Homes with stairs and multiple levels are often more

difficult to navigate for those individuals using a wheelchair or

walker to ambulate. Often, modified ranch homes will include

lowered entry thresholds, such as ramped entrance ways or door

thresholds that have been removed.

Rainbow Rehabilitation Center's outpatient client Jon Spencer

is an example of why home modifications are often necessary

for people with disabilities, and serves as an excellent model

of how to successfully implement the modifications. Jon made

huge strides in independence when his home in Milan, Mich.

was built in May 2008. The 2,400-square-foot-ranch was built

with handicap-accessible modifications to allow Jon to do many

household chores for himself – something he had been unable to

do at home since his injury.

Jon, who uses both a walker and a wheelchair to get around, is

able to enter his home easily due to it being only one level. No

steps were used so that access, even to the garage, is by a smooth

entry. Wider hallways allow him to navigate the interior of the

home.

“Everything is big and spacious,” explained Bob Wancha, Jon’s

Modified Homes Allow for Greater Independence


Rainb owVisions 9

mental health therapist at Rainbow. “It has a nice, smooth

entry, van access in the garage, larger doors, and a special

bathtub you can lower yourself into to bathe.”

Along with the tub bench in the tub, the bathroom also

features a roll-in shower and grab bars in the tub and by

the toilet.

Casement windows with hand cranks were installed

so that Jon can open them himself. The walk-in closet in

his bedroom features a roll down metal storm door and

walls reinforced with sheet rock to serve as an emergency

weather shelter, since there is no basement in the home.

The kitchen is also handicap-accessible. Most of the

appliances line one wall with plenty of space between the

counter and an island. The island also includes another

sink and the stove. “The kitchen is awesome because I

can get around in it,” Jon stated happily.

With the back porch spanning the entire back of

...a ranch-style floor plan is best for people with disabilities.

Homes with multiple levels are difficult to navigate.



1 0 Rainb owVisions

R A I N B O W A C Q U I R E S

Functional RecoveryBy Barry Marshall, Editor

R ainbow further expands into the growing home- and community- based services segment

As the future needs of the

catastrophically injured patient continue

to be analyzed, a treatment approach that

utilizes the patient's community and home

as the medium to deliver care seems more

and more commonplace.

Rainbow Rehabilitation Centers wanted

to further serve clients in this growing

segment of the health care industry and

completed the acquisition in February

of Grand Blanc, Mich.-based Functional

Recovery.

Functional Recovery is a natural and

logical addition to the vast continuum of

services already provided by Rainbow

in its residential programs and treatment

centers throughout southern Michigan.

Functional Recovery provides expert

home- and community-based functional

therapeutic interventions for children and

adults with brain injuries, spinal cord

injuries and other neurologic or orthopedic

dysfunction.

"We were looking for a company that

provided great care to its clients with

services that were complimentary to

the continuum of care we provide at


Rainb owVisions 1 1

Rainbow’s NeuroRehab Campus® for adults with brain and spinal cord injuries offers a full Continuum of Care including active therapy, community outings and supported living for individuals with medical needs. Some of the unique features offered through the residential portion of the campus include ...

To tour or for more information call: 800.968.6644

• Two 20-bed homes with private bedrooms and private baths

Each room offers optional cable TV, Internet access, telephone

access and call light / intercom system access

• Physician visits on-site

• Nursing services available on-site 24/7

• Executive Chef

• Professional Treatment Team on-siteE-mail: [email protected]


Rainbow," said Rainbow's President Bill

Buccalo. "We are pleased that Functional

Recovery has joined our team."

When Charlene "Char" Combs opened

Functional Recovery in 1997 to meet

the needs of catastrophically injured

individuals in their home and community

environment, it was one of the first

businesses of its kind in Michigan. The

concept was to help survivors re-learn

skills in their own home or community

environment, i.e., grocery shopping in their

nearby store. Additionally, the survivor

would become familiar with community

resources they may need such as public

transportation, community centers, support

groups, churches or local fitness facilities.

As the company grew, so did its service

offerings. Along with occupational and

physical therapies, speech and language

pathology and neuropsychology provided

by its professional therapy staff, Functional

Recovery also provides:

• Pre-drivers screening evaluations

• Functional home assessments

• Functional home modification

assessments

• Therapy staffing to schools

• Summer Day Treatment programming for

children, teens and young adults

• School reintegration

• Work reintegration and work site

assessments/job analysis

• Community reintegration

Char has taken great personal pride in

the success of Functional Recovery since

she founded it. "I think it's our personal

touch that sets us apart," said Char. "We

treat each individual as a member of our

family."

Simultaneous with the acquisition, Char

accepted the position of program director

at Rainbow overseeing Functional Recovery

as it continues to grow. Char is a registered

occupational therapist with more than 12

years of rehabilitation experience and has

an extensive background in functional

assessment and therapeutic intervention for

individuals with brain injuries.

Today, Functional Recovery is a division

of Rainbow Rehabilitation Centers with

more than 11 professional therapists and

support staff providing a wide range of

therapies and services to clients all across

Michigan.

For more information on Functional

Recovery, visit www.functionalrecovery.

com.

1 2 Rainb owVisions

A L O O K A T

Neuro-IFRAH TherapyBy Kristine L. Mahoney, OTR/L, CBIS

Neuro-IFRAH Certified Occupational Therapist


raumatic brain injuries (TBIs)

may involve a variety of orthopedic,

neurological, environmental,

psychosocial, or other influences that

could impact a person’s abilities, as well

as the rehabilitation process. A variety of

therapeutic supports may be implemented

to offset these complicating factors. For

therapists in the field of brain injury,

continued education is imperative in

developing innovative treatment strategies

for neurological impairments.

A relatively new approach that takes into

account the effect that these impairments

have on every aspect of functioning is the

Neuro-Integrative Functional Rehabilitation

and Habilitation (Neuro-IFRAH) approach.

This approach builds on the occupational

therapy framework and offers a variety

of options for continuing education,

including an intensive certification course

and additional advanced courses that

build upon the concepts taught during the

certification process. These courses are

offered to physical therapists, occupational

therapists, speech language pathologists,

physical therapy assistants, and

occupational therapy assistants to advance

knowledge of treatment interventions for

neuro impairments.

The certification course emphasizes that

all treatment begins with the need for a

proper and comprehensive assessment.

For example, difficulty with raising an

arm may be the result of impaired mobility

T

therapyTBI

Disciplines

The Beginnings of the Neuro-IFRAH Approach

The Neuro-IFRAH approach was originated by Waleed Al-Oboudi, MOT,

OTR/L. The author stated that this approach was named Neuro-IFRAH for the

following reasons:

“The word Neuro- was selected because this approach is intended for

patients who are affected by lesions at the level of the brain stem and above.

The word Integrative was selected to describe that this approach is integrative

on all levels. It is integrative of all systems of the person as well as all

information past and present. It is integrative of all internal as well as external

variables and combinations and products of these variables affecting patient

response, normal or otherwise. It is integrative and inclusive of fields of study

as well as bodies of information. It is integrative in terms of variables related

to therapists, the rehabilitation team, rehabilitation programs, facilities, home,

community, and other environmental variables... is integrative at all these

levels and much more. Any variable that has an affect on the patient needs to

be considered.

The word Functional means to meet intended purpose or need, thus it was

selected because this approach is functional. All aspects of rehabilitation and

habilitation are individualized to meet the patients intended purpose or need.

The words Rehabilitation and Habilitation were selected because this is

what we do in therapy. It encompasses many aspects of therapy, thus there is

no reason to find other words. One aspect of rehabilitation is to restore to the

fullest physical, mental, social, vocational, economic status thus rehabilitation

is not limited. However, our patients are not only re-acquiring skills they are

learning new ones as well. Thus Habilitation occurs throughout alongside with

rehabilitation.”

1 2 Rainb owVisions


Rainb owVisions 1 3

that stems from the pelvis and limited

movement. In seeing this and examining

how all aspects of the body work together,

it was evident that assessment of the

entire body was needed to ensure proper

treatment.

There may be an emphasis on

incorporating proper movement for all

tasks and improved speed of outcomes

with early implementation of proper

movement (i.e., it is more difficult to break

poor habits once they are established).

This proper body movement is especially

important. Once the brain establishes a

pattern of movement after injury, it can be

a difficult and tedious process to re-teach

the neurologic connections to perform the

proper action.

The clinical and therapeutic skills gained

from the course apply to any therapy

intervention. For many clients, when

discussing their personal rehabilitation

goals, the basic activities of daily living are

the areas they wish to address. Examples

are to be able to walk, to maintain personal

KristineL.MahoneyOTR/L,CBIS,Neuro-IFRAHcertified

Kristinehasmorethannineyearsofexperience

inoccupationaltherapy.AgraduateofWestern

MichiganUniversityinKalamazoo,Mich.,Kristine

worksatRainbow'sNeuroRehabCampus®.

About the Author ...

hygiene and to work on some higher level

activities like driving. Lost in the shuffle

can be areas that are not so obvious in

the rehabilitation process. For example, a

father who is able to walk when returning

home may not be able to run and play

sports with his children. These are areas

that can entail very functional activities,

and can be very meaningful for the patient

and his or her family. Because the Neuro-

IFRAH approach emphasizes continued

improvement at a functional level, such

areas can be mastered by the patient, and

should be part of the care plan process.

Certification in the Neuro-IFRAH

approach is beneficial when working with

TBI survivors. The handling techniques

learned, along with the carry-over these

techniques have with patient and caregiver

education, orthotics, proper positioning,

and other methods, has had effective

outcomes for those in therapy.

Garden City Apartments offer a unique

and supportive family environment

where residents with traumatic brain

injury are empowered to work toward

therapy and recovery goals.

Download a brochure at:

www.rainbowrehab.comSelect Education & Publications

Rainbow Literature

Rainb owVisions 1 3

1 4 Rainb owVisions

2009Conference & Event Schedule

October 17 – 20, 2009 Advanced Critical Care and Trauma in San Francisco, CAFor info, please visit: www.contemporaryforums.com

October 19 – 20, 2009 Michigan Association of Community Mental Health Boards Conference at the Grand Traverse Resort in Traverse City, MIFor info, please visit: www.macmhb.org

October 21 – 24, 2009 ARN 35th Annual Educational Conference at the Albuquerque Convention Center in Albuquerque, NM For info, please visit: www.rehabnurse.org

October 29 – 31, 2009 IARP 2009 Forensic Conference at the Double Tree Hotel in Memphis, TN. For info, please visit: www.rehabpro.org

NovemberNovember 5, 2009 Garan Lucow Miller Fall Breakfast Seminar at the Troy Marriott in Troy, MI For info, please visit: www.garanlucow.com

November 10, 2009 CMSA Detroit Chapter Evening Conference at the Farmington Hills Manor in Farmington Hills, MI For info, please visit: www.cmsadetroit.org

November 11 – 13, 2009 MACMHB Suicide Prevention Conference at the Lexington Lansing Hotel in Lansing, MIFor info, please visit: www.macmhb.org

November 12, 2009 Michigan Association for Justice Medical Malpractice Seminar at the Hotel Baronette in Novi, MIFor info, please visit: www.michganjustice.org

November 14 – 16, 2009 Michigan Occupational Therapy Assoc Conference at the Radisson Plaza Hotel in Kalamazoo, MIFor info, please visit: www.mi-ota.com

November 15 – 18, 2009 Case Management Along the Continuum at the Renaissance Nashville Hotel in Nashville, TN For info, please visit: www.contemporaryforums.com

November 18, 2009 MSU Case Management Conference at the Kellogg Hotel and Conference Center in East Lansing, MI For info, please visit: www.nursing.msu.edu

November 18 – 20, 2009 National Worker's Compensation Conference at McCormick Place in Chicago, IL For info, please visit: www.wcconference.com

November 20, 2009 MiARP 18th Annual Conference at the Crowne Plaza Hotel in Novi, MI For info, please call: (800) 476-6368

Fall

SeptemberSeptember 7 – 11, 2009Neurotrauma 2009 - 2nd Joint Symposium at the Fess Parker's Doubletree in Santa Barbara, CAFor info, please visit: www.neurotraumasociety.org

September 15, 2009CMSA Detroit Chapter Evening Conference at the Farmington Hills Manor in Farmington Hills, MI For info, please visit: www.cmsadetroit.org

September 17 – 18, 2009BIA of Indiana Annual Conference at Marten House Hotel and Lilly Conference Center in Indianapolis, INFor info, please visit: www.biausa.org/Indiana

September 24, 2009Detroit Receiving Hospital Stroke Conference at the Ritz Carlton Hotel in Dearborn, MI For info, please e-mail: [email protected]

September 24 – 25, 2009BIA of Michigan Annual Conference at the Lansing Center in Lansing, MI For info, please visit: www.biami.org

September 26 – 27, 2009International Symposium on Life Care Planning at the Lincolnshire Marriott in Chicago, ILFor info, please visit: www.flcpr.org

OctoberOctober 1 – 2, 2009 BIA of Ohio Annual Conference at Double Tree Columbus in Columbus, OH For info, please visit: www.biaoh.org

October 6, 2009ACMA Great Lakes Hospital Case Management Conference at Burton Manor in Livonia, MI For info, please e-mail: [email protected]

October 10 – 12, 2009 AANLCP (Life Care Planning) Conference at the Westin Tabor Center in Denver, COFor info, please visit: www.aanlcp.org

October 11 – 13, 2009 Hospital Case Management Administration at the Hyatt Regency Chicago in Chicago, ILFor info, please visit: www.contemporaryforums.com

October 14 – 17, 2009 NABIS Annual Conference on Brain Injury at the Austin Downtown Hilton Hotel in Austin, TXFor info, please visit: www.nabis.org

October 15, 2009 2009 MSU Conference on Pain at the Inn at St. John's in Plymouth, MI For info, please visit: www.nursing.msu.edu/continuing.asp


Rainb owVisions 1 5

MBIPC Michigan Brain Injury Provider Council

Learn over LunchMeeting times are noon - 2:00 p.m.

(Registration at 11:30 a.m.)Cost: MBIPC Member $25 / Non-member $60

For info or RSVP contact Lisha Clevenger(734) 482.1200 x 169 or [email protected]

October 13, 2009 Topic & Speaker : TBD

Location: ApplauseBanquets&CateringinGrandRapids,MI

November 10, 2009Topic & Speaker : TBD

Location: RadissonHotelinLivonia,MI

December 8, 2009Topic: Project Search (Vocational Training)

Speaker: Maggie KochLocation: ApplauseBanquets&CateringinGrandRapids,MI

For updates on meetings, visit www.rainbowrehab.com

RIN

C

Rehabilitation & Insurance Nursing Council Meetings Members Only

Registration at 11:30 a.m./ Lunch at 12:45 p.m.

September 18, 2009 Topic: Stem Cell ResearchSpeaker: Jack Mosher, PhD

Location: Radisson Detroit-Livonia, 17123 North Laurel Park Drive in Livonia, MI 48152

RSVP to Brian Borkowski at (248) 430-0183

October 16, 2009 Topic: TBA

Speaker & Location: TBA

November 20, 2009 Topic: Individual Education Plans

Speaker: Ellen Bouchard Location: TBA

RSVP to Adrienne Shepperd at (248) 953-4079

For more information contact Adrienne Shepperd: (248) 953-4079

orvisit www.rainbowrehab.com forcurrentupdates

— NOTICE —The conferences and events information listed on these pages is dated information (current as of August 2009). For the most up-to-date information on industry-related conferences

and events, please visit:


Select Education & Publications from the top menu

and then select Conferences & Events

Updated biweekly, www.rainbowrehab.com offers the dates, locations and topics

of the industry's most prominent events.

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September 24 – 25, 2009Visit: www.biami.org

for conference information

1 6 Rainb owVisions

By Heidi Reyst, Ph.D., CBIST

Director of Clinical Administration


Clinical news

Progesterone& Brain Injury

The work of Dr. Donald stein and Colleagues

ho is Don Stein?

I first came across Don Stein in

December 2004 when he was presenting

on his work at the Rehabilitation for

Individuals with Brain Injury: The State of

the Art conference in Washington, D.C. He

presented on the topic of brain plasticity,

and I was blown away. But it was in

meeting Dr. Stein that I began to understand

the true depth of this man, and his devotion

to improving the lives of individuals with

brain injury.

Don Stein is not your typical bench

researcher, at least that is my opinion. His

devotion to his craft and to finding the

answer to the question, “Why do female

W rats fare better than males after brain

injury?” has led him down an interesting

and hard fought path. It was not the typical

path for someone so well regarded in

his field. In fact, his path included years

of being unfunded, under funded and

perpetually questioned by the prevailing

wisdom of brain research, which was the

antiquated idea that the brain does not

have the capacity to heal, better known as

the doctrine of localization of function.

Thomas Burton of the Wall Street Journal

wrote an article in 2007 aptly named

“One Doctor’s Lonely Quest to Heal Brain

Injury,” which chronicled Stein’s quest. The

most incredible aspect of this quest is that

much of Stein’s work started in a trailer at

Emory University in Atlanta, after “normal”

school hours on his own time, with little

to no funding. It wasn’t until the mid to

late 1990s when the Centers for Disease

Control and Prevention and National

Institutes of Health began funding grants

for Stein’s research. It is the fruits of this

research that I would like to focus on for

this article.

Major Findings of Stein and Colleagues

Dr. Stein's quest began at the University

of Oregon in Eugene, Ore. during the

1960s, when he found that some rats

who incurred brain injuries did not have


Rainb owVisions 1 7

Primary Injury

• Lesions

• Hematomas

• Contusions/Lacerations

• Diffuse axonal injury

• Vascular injury

Injury Hours Days Weeks Months

Secondary Injury

• Edema

• Apoptosis and degeneration of nerve cells

• Elevated Intracranial Pressure

• Inadequate Cerebral Perfusion (blood pressure)

• Release of excitatory amino acids

• Generation of free radicals

• Cytokine Release

Figure 1: Brain Injury Time Line

w w w. ra i n b ow re h a b. co m

impairments like other rats. He began researching why, and found

that the rats who were not impaired were invariably female. The

questions raised included whether these differences were due to sexual

dimorphism (structural differences in the brain between males and

females) or some other reason, such as molecular differences. Some of

Dr. Stein’s early research focused on the female hormone estrogen, but

these studies did not bear out. He then turned to progesterone, which

lent far more promise in explaining sex differences in recovery after

traumatic brain injury (TBI).

Like most others, I presumed that progesterone was a female

hormone. As it turns out, it is far more a “brain hormone” than a female

hormone. Both males and females produce progesterone, and during

pregnancy it plays a vital role in brain development.

Progesterone’s Promise

It has been posited that progesterone may play a neuroprotective

role after brain injury. What does that mean and what is it about

progesterone that makes it so promising as a potential treatment? To

answer those questions, we must delve into the world of brain injury

etiology.

Figure 1 (below) highlights what happens when a brain injury occurs.

The primary injury includes the events at the time of injury, which

cannot be reversed, and can include injury types such as lesions,

hematomas, contusions, diffuse axonal injury, and vascular injuries

(Gennarelli and Graham, 2005). Secondary injury includes such events

as vasogenic edema, cytotoxic edema, ischemia, necrosis, increased

intracranial pressure, inadequate cerebral blood flow, increased

intracellular calcium, release of excitatory amino acids, generation


Rainb owVisions 1 7

1 8 Rainb owVisions

Secondary injury effects on the brain can be as harmful or more harmful than primary injury effects. The difference between primary and secondary injury effects is in our potential ability to reduce their effects. As Dr. Stein (2008) noted, “Despite decades of effort, scientists have failed to identify a pharmacological agent that consistently improves outcomes following TBI.” Progesterone is coming to the forefront as an agent that defies that statement. Below are descriptions of the cascade of secondary injury events that occur post brain injury, followed by progesterone’s effect on that event. Information in Stein, Wright, and Kellerman (2008) assisted in articulating this figure.

Edema/Elevated Intracranial Pressure There are three brain volumes that keep intracranial pressure in check: brain parenchyma (tissue), blood volume and cerebrospinal fluid. Should any of the three increase, increases in intracranial pressure will occur unless other strategies keep them in check. The primary result of edema is the increase in intracranial pressure. There are two forms of brain edema that can result in this imbalance of intracranial pressure: vasogenic and cytotoxic. Progesterone reduces cerebral edema – both the vasogenic and cytotoxic – by stabilizing the blood brain barrier, reducing inflammatory reactions.

Types of EdemaVasogenic – this is caused by a breakdown in the blood-brain barrier. There are very tight junctions between endothelial cells that line the brain’s blood vessels. Mechanical disruption to these cells can allow proteins and fluids into the brain parenchyma (brain tissue). It can also be caused by the release of inflammatory cytokines, which increase capillary membrane permeability.

Cytotoxic – this is the result of accumulation of water in the intracellular space of individual cells themselves. This type of edema occurs after injury. This also leads to cells releasing additional toxic agents that cause secondary cell death (Stein, 2008).

Secondary Injury Effects on the Brain

Inadequate Cerebral Perfusion – This can be caused by increases in intracranial pressure. Progesterone exerts its effects on cerebral perfusion by reducing edema, thereby allowing for proper cerebral blood flow.

Apoptosis and Degeneration of Nerve Cells – This is programmed cell death. Progesterone has been implicated in reducing injury induced apoptosis post TBI.

Excitatory Amino Acids – When cells are injured, amino acids are released causing a number of potential problems. When ions like sodium or calcium pass into the cell, breakdowns of the cytoskeleton, membrane dysfunction and free radical formation can occur.

Free Radical Formation – These are highly reactive atoms. When released, they damage endothelial cells and injure brain tissue. They assist in the breakdown of the blood brain barrier and contribute to brain edema of both types. Once the process of free radical formation starts, the problem is perpetuated as damage then results in more release of free radicals. Progesterone may be a free radical scavenger, reducing free radical generation, thereby reducing free radical damage (Stein, 2008.)

Cytokine Release – Cytokenes activate the inflammatory process after brain injury. Progesterone works to reduce cytokene release, thus reducing the inflammatory response after injury.

Figure 2


Rainb owVisions 1 9


of free radicals, and breakdown of the

cytoskeleton with vascular degeneration

leading to cell death.

It is secondary injury that provides

interest when it comes to progesterone’s

promise. To fully understand brain injury,

we must look at it as a process and not

a single event. The primary injury is the

beginning of the event, and the secondary

injury is essentially a cascade of events

that can unfold over days, weeks and

months, which further cause damage to

the brain. These secondary events are what

researchers have targeted.

It is the hope that by reducing the

cascade of maladaptive or deleterious

events that occur, there will be less damage

to the brain, and by virtue, less functional

change post injury. Brain edema accounts

for much of the morbidity and mortality

post TBI (Stein, 2008). Inflammation of the

brain leads to tissue breakdown, which

leads to brain edema and eventual cell

death. It is at this stage that progesterone

is posited to have its effects. As noted in

VanLandingham, Cekic, Cutler, Hoffman

and Stein (2007), progesterone’s effects are

to reduce brain edema, reduce blood brain

barrier disruption and reduce release of

inflammatory cytokines.

Despite research over the years, there

has been no pharmacological agent that

has been shown to improve outcome after

brain injury (Stein, 2008). So the promise

of progesterone is all that more important

given the paucity of alternatives for

reducing morbidity or mortality after TBI.

Findings in Rat Models

To cover what is currently known about

progesterone, we will look to studies

produced in the early to mid 1990s by

Stein and his colleagues to review some

of the key findings. In a study by Roof,

Duvdevani and Stein (1993), they looked

at three groups of rats to determine if

endogenous (natural) levels of progesterone

play a protective role in brain injury.

The first group was males. The second

group was females in proestrus, where

natural levels of progesterone are low and

estrogen levels are high. The third group

was females who were pseudopregnant,

where there are high levels of progesterone

and low levels of estrogen. Each of the

rats received a contusion to the medial

frontal cortex. Post mortem examination

of the brain tissues revealed that

female rats in proestrus (lower levels of

progesterone, but higher levels than males)

had significantly less brain edema than

males. Pseudopregnant (high levels of

progesterone) female rats had almost no

post injury swelling. Taken together, males

with the lowest levels of progesterone

had the most edema. Females in proestrus

(with natural levels of progesterone) had

significantly less edema than males, and

psueopregnant females with high levels of

progesterone had very little brain edema.

In that same study by Roof, Duvdevani

and Stein (1993), they then examined

whether the reduced edema related

specifically to progesterone. They

ovariectomized 17 female rats to reduce

natural levels of progesterone and estrogen.

All rats received a brain injury. The

rats were then assigned to one of three

treatment groups. Group One received

estrogen implants and progesterone

injections.

Group Two received estrogen implants

and oil injections. Group Three received

progesterone only. They found that

simply removing estrogen did not reduce

levels of edema post injury. Importantly,

the female rats that had both estrogen

and progesterone had significantly

less edema than ovariectomized rats

given no hormones (t=2.33, p<. 05), or

ovariectomized rats given estrogen only

(t= 3.59, p < .01). Likewise, female rats

Progesterone & Brain Injury

Continued from page 17

2 0 Rainb owVisions

Dr.DonaldStein

Dr.SteinisaProfessorofEmergencyMedicineandNeurology,

andtheAsaG.CandlerProfessorinthedepartmentof

EmergencyMedicineatEmoryUniversity.Therecipientofmany

researchgrants,Dr.Steinhasmostrecentlybeenresearchingthe

molecularbiologyofprogesteroneanditsrelationtorecovery

afterbraininjury,workfundedbyTheNationalInstitutes

ofNeurologicalDiseasesandStroke(2001-2005).Heisa

prolificresearcher,anaccomplishedprofessorandwriter,and

administratoratEmoryUniversity.Dr.Steinistheauthorofmore

than200articles,bookchapters,reviewsandpapersonthe

subjectofbraininjuryrecovery.

About the Researcher

given progesterone only had significantly

less edema than ovariectomized rats

given no hormone (t – 2.427, p < .05) or

ovariectomized rats given estrogen only (t =

4.055, p < .01).

One can conclude from these findings

that progesterone was the factor in edema

reduction post brain injury. Now that the

group had evidence that progesterone

reduces edema post injury, the focus

turned to determining the optimal timing

for quickly reducing edema. So, they

completed a study to determine how fast

edema occurs. Roof, Duvdevani, Heyburn

and Stein (1996) used both male and

female rats that were given a frontal medial

cortex contusion. They found that swelling

occurred within two hours of injury and

peaked within 24 hours. By seven days

the swelling began to reduce. They also

found that edema was significantly reduced

one hour post injury via injection of

progesterone for both males ((F = 39.33, p

< .001) and females (F = 36.22, p < .001).

Reductions in edema also occurred

when injections of progesterone injections

were given six hours post injury (males;

t= 2.045, p < .05; females; t = 3.102, p <

.01), 24 hours post injury (males; t = 6.45,

p < .001; females; t = 3.925, p < .001),

and 72 hours post injury (males; t = 4.973,

p < .001; females; t = 4.598, p < .001).

Overall, these results demonstrate that

progesterone can reduce edema formation,

and moreover, they show that the treatment

can reduce edema within hours of giving

the treatment.

Taken together, these studies confirm

that in a rat model, progesterone, whether

naturally occurring in the body or provided

from external sources, reduces brain edema

post medial frontal cortex contusion. They

also provide insight into how quickly

edema occurs post TBI (within two hours

of injury in a rat model), as well as how

quickly progesterone can counteract edema

(most effective when given two hours post

injury, but effective up to 24 hours post

injury). The question that comes to mind at

this point is, does this translate to humans?

To find out, controlled trials on humans are

required.

Again, Stein and his colleagues took the

lead with the ProTECT® trial, a Phase II

trial that utilized 100 patients to test the

effects of progesterone administration post

injury (Wright et al, 2007).





Rainb owVisions 2 1

Human Studies

Wright et al (2007) completed a Phase II, double blind, randomized,

placebo controlled trial, funded by the National Institute for

Neurological Disorders and Stroke, National Institutes of Health, and

the general Clinical Research Center at Emory University and Grady

Memorial Hospital. The primary goal of the trial was to assess the

safety of progesterone administration to patients presenting with acute,

moderate to severe TBI. Additionally, they had a secondary goal of

assessing if progesterone provided a benefit for the patients.

The trial consisted of 100 patients who arrived within 11 hours

of injury with a Glasgow Coma Score (GSC) between four and 12

(postresuscitation). Upon arrival to Grady Memorial Hospital, for

patients presenting with the appropriate study characteristics, family

consent by proxy was obtained for study participation. For every four

patients randomized to the intravenous progesterone treatment, one

patient was randomized to the intravenous placebo treatment (control).

Strict treatment guidelines were followed, as were daily rounds to

assess for serious adverse events (e.g., death, immediate risk of death,

or if continued participation could lead to death). See Wright et all

(2007) for their protocols.

Once patients were enrolled, and given either progesterone or

placebo, the teams assessed a variety of measures to examine the

goals of the study. These included duration of coma, duration of post-

traumatic amnesia, and mortality within 30 days of injury. They also

directly assessed whether progesterone had an effect on cerebral edema

via intracranial pressure measurements taken over time. Lastly, raters

utilized the Glasgow Coma Score Extended and the Disability Rating

Scale with the goal to assess functional ability 30 days post injury.

Findings of the Study...

Duration of Coma

Patients with GCS scores four to eight (severe TBI) who

received progesterone had longer comas (10.1 days) than

those who received the placebo (3.9 days).

Duration of Post-Traumatic Amnesia

No differences across groups were found.



HeidiReyst,Ph.D.,CBISTDirectorofClinicalAdministration

Education:BachelorofArtsinpsychology,KalamazooCollege,Kalamazoo,Mich.

Ph.D.,AppliedSocialPsychology,TheGeorgeWashingtonUniversity,Washington,

D.C.,CertifiedBrainInjurySpecialistTrainer,AcademyofCertifiedBrainInjury

Specialists.

Experience:Dr.Reysthasworkedinvariouscapacitieswithinthefieldofbraininjury

rehabilitationsince1991.Shebringsabroadrangeofexperienceasarehabilitation

assistant,residentialprogrammanager,programdirectorand,currently,as

Rainbow'sdirectorofclinicaladministration.Dr.Reystcurrentlyoverseesprofessional

staffallocation,billing&serviceprovision,professionalstafftraining,accreditation

readiness,outcomesmanagementandistheprogramdirectorfortheYpsilanti-

basedOutpatientandDayTreatmentPrograms.Sheassistswithclinicalsupervision,

marketing,day-to-dayoperationsandstrategicandlong-termplanning.

Dr.ReystiscurrentlyamemberoftheboardofgovernorsfortheAcademyofCertifiedBrainInjurySpecialists,amemberofthe

AmericanPsychologicalAssociationandisafrequentvolunteerfortheBrainInjuryAssociationofMichigan.




Mortality 30 days post injury

In all, 77 patients received

progesterone and 23 patients received

placebo. Within 30 days post injury,

13.0 percent of the progesterone group

died versus 30.4 percent of the placebo

group (relative risk [95% CI], 0.43 (0.18-

0.99). Importantly, the researchers noted

that deaths from neurological bases

trended towards fewer deaths for the

progesterone group versus the placebo

group.

They also noted that there were

differences in mortality across the

different levels of severity (moderate

versus severe). For severe TBI patients

(GCS of four to eight), 13.2 percent of

progesterone patients died within 30

days of injury versus 40 percent of those

in the placebo group.

For moderate TBI patients (GCS of nine to

12), 16.7 percent of progesterone patients

versus 14.3 percent of placebo patients died.

Intracranial Pressure Measurements

Intracranial pressure scores did not differ

between those given progesterone versus

those in the placebo group.

Functional Recovery

At 30 days post injury, the researchers

contacted each patient to determine their

functional status. They found for the severe

TBI group, 75 percent were functioning at

a poor level for both the progesterone and

placebo group.

However, for moderate severity patients,

the scenario was quite different. They found

that 56 percent had a moderate to good

recovery (GCS Extended scores) in the

progesterone group, as compared to 0

percent for the placebo group. For the

Disability Rating Scale (DRS) Function

scores, they found that for the severe TBI

group the progesterone scores were 2.9

versus placebo 1.8, and for the moderate

TBI groups the progesterone scores

were 1.5 versus 3.8. This indicates little

difference in the severe group in terms

of disability reduction, and significantly

less disability for the progesterone versus

placebo groups for the moderate TBI

group.

Overall Findings

Results related to the primary goal

of the study, namely that of the safety

2 2 Rainb owVisions


ReferencesGennarelli,T,andGraham,D(2005).

Neuropathology.InTextbookofTraumaticBrain

Injury,Silver,J,McAllister,T,andYudolfsky,S.EDS.

AmericanPsychiatricPublishing:Arlington,VA.

Roof,RL,Duvdevani,R,Stein,DG(1993).Gender

InfluencesOutcomeofBrainInjury:Progesterone

PlaysaProtectiveRole.BrainResearch,607,pp

333-336.

Roof,RL,Duvdevani,R,Heyburn,JW,Stein,DG(1996).

ProgesteroneRapidlyDecreasesBrainEdema:

TreatmentDelayedupto24HoursisStillEffective.

ExperimentalNeurology,138,pp246-251.

Stein,DG(2008).ProgesteroneExerts

NeuroprotectiveEffectsAfterBrainInjury.Brain

ResearchReview,Volume57(2),pp386-397.

Stein,DG,Wright,DW,andKellerman,AL(2008).

DoesProgesteroneHaveNeuroprotective

Properties?AnnalsofEmergencyMedicine,Volume

51(2),pp164-172.

VanLandingham,JW,Cekic,M,Cutler,S,Hoffman,

SW,Stein,DG(2007).NeurosteroidsReduce

InflammationafterTBIthroughCD55Induction.

NeuroscienceLetters,425,pp94-98.

Wright,DW,Kellerman,AL,Hertzberg,VS,Clark,

PL,Frankel,M,Goldstein,FC,Salamone,JP,Dent,

LL,Harris,OA,Ander,DS,Lowery,DW,Patel,MM,

Denson,DD,Gordon,AB,Wald,MM,Gupta,S,

Hoffman,SW,andStein,DG.(2007).ProTECT:A

RandomizedClinicalTrialofProgesteronefor

AcuteTraumaticBrainInjury.AnnalsofEmergency

Medicine,Volume49(4),pp391-402.

of providing progesterone to moderate

to severe TBI patients shows that, “This

analysis suggests, but does not prove,

that progesterone treatment causes no

harms and may be beneficial treatment for

traumatic brain injury.” (Wright et al, 2007,

p. 400)

What is the next step? Given that this

study demonstrated no harm, and that there

may be benefits to progesterone treatment,

the next step is a Phase III, multi-center

clinical trial. Dr. Don Stein and his group

have received a notice of grant award from

the National Institutes of Neurological

Diseases and Stroke, which will fund them

for a Phase III, multi center clinical trial

that is called ProTECT III (Progesterone

for Traumatic Brain Injury.) To view

information about this trial go to www.

clinicaltrials.gov and enter "progesterone

and brain injury." There are 17 centers

participating in the trial, including:

Emory University, Henry Ford Hospital,

Medical College of Wisconsin, New York

Presbyterian Hospital, Oregon Health and

Science University, Stanford University,

Temple University, University of Arizona,

University of California, University

of Cincinnati, University of Kentucky,

University of Maryland, University of

Minnesota, University of Pennsylvania

University of Texas, Virginia

Commonwealth University and Wayne

State University. We wish Drs. Stein, Wright

and their colleagues best wishes for their

study endeavors.

A Specialty Transportation Company We offer personalized, attentive and expert transportation services for individuals with special needs

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Call: 800.306.6406

Rainb owVisions 2 3

MarianneKnox,RN,BSN,CBIS

MariannehasaBachelorofSciencein

NursingfromEasternMichiganUniversity

inYpsilanti,Mich.SheisaRegistered

Nurse,AdmissionsCoordinator,Case

ManagerandamemberoftheInfection

ControlCommitteeatRainbow.With

morethan30yearsofexperienceinthe

medicalfield,Mariannehasextensiveknowledgeandpracticalexperience.

Shehasworkedasanurseinahospitalsetting,inthepediatric,medical,

surgicalandemergencydepartments.ShealsoworkedasaMedicalCase

Manager,EmployeeHealthNurseandaDirectorofOccupationalHealth

Services.Marianneisamemberofthefollowingprofessionalorganizations:

BrainInjuryAssociationofMichigan,AssociationofRehabilitation

Nurses,RehabilitationInsuranceNursesCouncil,CaseManagement

SocietyofAmerica,AssociationForProfessionalsinInfectionControland

EpidemiologyandtheYpsilantiAreaChamberofCommerce.

SuperbugsContinued from page 6

Organisms (MDROs) that are transmitted

by direct or indirect contact with the

patient or the patient’s environment. In

addition to Standard Precautions, wearing

a gown and gloves upon entering the room

and removal of the items before leaving

the room is recommended. Using private

rooms, avoiding sharing of equipment and

having the patient stay in the room, are all

strategies used with Contact Precautions.

Masks and eye protection may also be

required for splash potential.

Droplet and Respiratory Precautions are

also implemented for airborne infections

when warranted.

The majority of health-care associated

infections can be prevented by utilizing

appropriate hand hygiene. Health care

consumers are encouraged to insist that

their health care providers wash their

hands and use gloves.

The bottom line is, infections are

becoming more difficult to treat due to

lack of available antibiotics. Health care

facilities must not accept ongoing MDRO

outbreaks or high infection rates as the

status quo. With appropriate infection

control measures, facilities can significantly

reduce MDROs.

How are health care-associated

infections defined?

Health care-associated infections, as

defined by the Centers for Disease Control

and Prevention (CDC), are infections

that patients acquire during the course of

receiving treatment for other conditions,

or that health care workers acquire while

performing their duties within a health

care setting. Specific criteria must be

met in order to define an infection as

health care-associated. Hospitals are

now being required in 25 states to report

certain hospital acquired infections (HAI).


2 4 Rainb owVisions

Consumer advocate groups are putting

pressure on hospitals to voluntarily report

infection rates, giving consumers safety

information when choosing a health care

provider.

In October 2008, Medicare indicated

that it will no longer reimburse health care

facilities for treatment of certain hospital

acquired infections. Other insurance

companies such as CIGNA, Wellpoint and

United Health Care are following suit.

Among the targeted hospital acquired

infections are:

• vascular catheter-associated infection

• catheter-associated urinary tract infection

• certain surgical site infections

Health care organizations are responding

by instituting rigorous prevention measures

and systematizing processes for care. The

CDC currently recommends a four-pronged

approach including:

• infection prevention

• accurate/prompt diagnosis and treatment

• prudent use of antimicrobials

• prevention of transmission

Some facilities are preemptively

screening patients upon admission and

implementing contact precautions until

negative screening results are found for

target MDROs. Surveillance programs

are monitoring targeted infections in the

hospital and studying the effectiveness

of strategies put into practice. Sharing

information between health care facilities

has also been helpful.

ReferencesAssociationforProfessionalsinInfectionControlandEpidemiology-APIC.org

“BattlingSuperbugs”;KatharineGreider,March2,2009and“Newsmaker:PeterPronovost,M.D.”KatharineGreider,November3,2008-Source:AARPBulletinToday-bulletinaarp.org

CentersforDiseaseControlandPrevention–cdc.gov

CentersforMedicareandMedicaidServicesPreventInfection.org

TheAmericanLegion–Medicalexpertswaryofdangerousgermnowstrikingwar-woundedtroops.TheIraqibacter–legion.org/national/divisions/magazine

Functional Recovery offers physical, occupational and

speech therapy for individuals with brain and

spinal cord injuries.

Home- and community-based therapy services

for children, teens and adults.

For more information call:

E-mail: [email protected]

www.functionalrecovery.com


Rainb owVisions 2 5

2 6 Rainb owVisions

E ach year, new activities and opportunities are

available for high school seniors around the country as they graduate from high school. This year, Rainbow Rehabilitation Centers proudly celebrates the graduation of two of its Pediatric Program clients, Brandy Piper and Alfredo Contreras. Congratulations! Rainbow wishes them every success in the future.

2009

By Nicole Bonomini, Staff Writer

Alfredo Contreras graduated from Harrison High School. He will be attending a post secondary school, Visions Unlimited, to learn additional vocational skills until age 26. In his free time, Alfredo enjoys listening to music, going to the movies and watching television. “I love cooking shows on the Food Network,” he said. Alfredo’s Case Manager, Lynn Kofahl, said that he has come a long way since his admission to Rainbow. Born with cerebral palsy, Alfredo struggled to express himself and his needs. Alfredo is now more self aware and is able to verbalize his needs and desires. “Alfredo is always in a good mood; he is just a happy young man,” Lynn explained. “In the years that he has been at Rainbow, he has really matured and learned to express himself.” Alfredo really enjoyed going to school. He took school very seriously and wanted to succeed.

“I don’t think Alfredo has missed more than one or two days of high school,” Lynn said. “He has done very well and we are very proud of him.”

Rainbow’s high school Graduates

Brandy Piper has exciting plans for her first

year as a high school graduate. On her final

day of school at North Farmington High School,

Brandy moved from a residential home to a new

town house at Rainbow. There, Brandy works on

increased independence skills, such as budgeting,

house management, keeping grocery lists, meal

planning and cooking, and social skills with

roommates.

Brandy’s interests include reading, listening

to music, playing on the computer and spending

time with her friends. The 18-year-old said she is

most interested in rap, hip hop and country music.

Favorite bands include the Rascal Flatts, Mariah

Carey and Martina McBride.

After graduation, Brandy is unsure of what she will do next, though she has several

ideas. She would like to attend community college in Bloomfield Hills or Lansing, Mich. She

is also researching a career as a high school paraprofessional. Brandy enjoys helping others

and cares about the success of her peers. She also enjoys working with and taking care of

children. Neonatal nursing is another career option she is considering.

Dr. Mariann Young, program director at the Rainbow Oakland Center, said she is very

proud of Brandy. “Brandy has done very well. She is very smart. We can’t wait to see her go

to college,” she said.

survivorCorner

2 6 Rainb owVisions


Rainb owVisions 2 7

the house, Jon is able to enjoy the large

backyard. The bedrooms and living room

feature walkouts directly on to the back

patio.

The home also features an exercise room

including weight machines, a sitting chest

press and more.

Before moving into the new ranch home,

Jon lived in a two-bedroom apartment with

his aunts. The apartment was about 900

square feet. “He couldn’t do much because

it was so small,” explained Jon’s aunt,

Kathleen Spencer, who lives with him in

the new house. “He couldn’t use his walker

because it didn’t fit [in the apartment]. The

door had to be removed from his bathroom

and bedroom so that his wheelchair fit.”

Aside from the lack of privacy in

the apartment, Jon was also unable to

maneuver easily around the apartment,

leaving him dependent on others to do this

for him. Now, he is able to navigate around

his home and complete chores alone.

Jon said he has been much happier since

moving into the new home. “I like that I

can do my own laundry, since I am at my

own house. Since I moved in, I have done

every single bit of my laundry on my own.

It’s a lot better than the apartment,” he said.

“I’m happy here.”

The new-found independence and

responsibility that comes with his modified

home has vastly improved Jon’s quality of

life. “I used to walk with my head down,

and now I don’t,” he said. “I’m really

happy with the way things are going, and I

can do a lot more now.”

JonSpencerwasinvolvedinamotorvehicleaccidentonDec.11,2000.He

sufferedabasilarskullfractureandarightthoracicspinalprocessfracture.He

alsowentintocardiacarrestatthesceneoftheaccident,lostconsciousness

andspentsixmonthsinintensivehospitalrehabilitation.Hewasadmitted

toRainbowRehabilitationCenters,ResidentialPrograminMay2001witha

diagnosisofTBIsecondarytoanoxia.

Inthenineyearssincehisaccident,Jonhascomealongway.Afterstartingin

Rainbow’sresidentialprogramhegraduatedtohisownhome,andnowcomes

toRainbowforoutpatienttreatment.Jonisoutoftheactiverehabilitation

phaseandisnowfocusingonmaintaininghistherapygains,improvinghis

socialskillsandvocationalprogramming.

JongrewupinMilanandwashappytoreturntohishometownwhenhis

handicapaccessiblehomewascompletedinMay2008.

Accessible Living


2 8 Rainb owVisions

News @Congratulations

To our 2009 Rainbow Scholarship Recipients!

Rainbow Rehabilitation Centers is

pleased to announce three scholarship

recipients for 2009.

Rainbow awards a scholarship to

graduating seniors from area high schools

in Oakland and Washtenaw counties

who (1) will be full-time students in an

accredited Michigan college or university

and (2) have the intent to pursue a course

of study in health care or health services.

One student from each area district may

be selected to receive a $1,000 award. This

year there are three winners. They are:

• Allison Budd, from

Farmington High School.

She will be attending the

University of Michigan

in the fall for a degree in

Kinesiology.

• Jessica Cooper of

Lincoln High School will

be attending Washtenaw

Community College for

nursing.

• Rahil Dharia, from North

Farmington High School.

Rahil will be attending the

University of Michigan in

the fall to major in biology,

fulfilling pre-medical

curriculum requirements.

Congratulations to our winners! We wish

them all the best in their careers.

Summer Fun!

Rainbow's Pediatric Programs Explored Michigan:

Created by pediatric rehabilitation specialists, Rainbow Rehabilitation

Centers’ Summer Fun! programs help children and teens with brain injuries who

need structure and supervision when school is not in session.

There were two 2009 Summer Fun! programs: Sail into Summer Fun! at the

Rainbow Oakland Center in Farmington, Mich. and Summer Fun! Camp in

Fenton, Mich.

Summer at Rainbow is a fun and educational experience for all age groups.

The programs offered four broad participant groups: Elementary School Age,

Middle School Age, High School Age and Postsecondary Age participants. Some

of the outings this summer were:

• Fishing

• Horseback riding

• Picnic outings

• Overnight camping trip

• Detroit Tigers baseball game

• C.J. Barrymore’s entertainment park

• Talent show

• Water park

For more information, visit www.rainbowrehab.com

Sailing into...

Summer Fun!

Farmington, Mich.

Fenton, Mich.


Rainb owVisions 2 9

Rainbow Employees of the Season – Winter 2009

AnnArborApts: Steven Mezgec

AfterSchoolProgram: Ashley Cabarris

APFKI: Natalie Knox

Arbor: Allison Hoevemeyer

BellCreek: Pamela Dagostino

Belleville: Randy Gallinger

Bemis: Lisa Reese Williams

Briarhill: Danitta Bradley

Brookside: Alex Perez-Alonso

Carpenter:Jodi Anderson

Crane:Marianne Kendrick

Elwell: Therese Simpson

GardenCityApts: Jacquelin Gray

Gill: Johnnie McCall

Glenmuer: Erica Mabry

Highmeadow: Andre Morgan

Maple: Cynthia Schneider

NRC: Angela Barth, Johanna Howes,

LaMarcus Deloach & Salina Brown

PaintCreek:Shane Cole

Rehabilitation Assistants

RehabTransportation:Ted Higginbotham

RIPCoinOakland:Neomi Washington

ShadyLane: Lorain Fambro

StoneyCreek: Lachelle Worthington

Talladay:Lisa Spaeth, Adam Orrison & Mario Harvey

Textile:Dawn Eichenberg

Townhouses-Oakland:Michelle Nelson

Westmoreland:Juanita Horton

Whittaker:Carolyn “Carrie” Fanin

WoodsideI:Rossilyn Allen

WoodsideII:Pamela Scott

ResidentialProgram Managers

Julie Wigand

AdministrativeStaff

Christine “Chrissy” BoujoulianRaena GrishaberLisa Hildebrandt

Ramona Borg

Professional /Therapy Staff

Elizabeth VilickaChristine HerdellNicole Rondini

MaintenanceStaff

Brian HatfieldRobert Adams

Perry KeithWilliam Carlton

Congratulations to our Outstanding Staff!

Ramon Rodgers Systems Administrator

Ramon joins the IT department at the Ypsilanti Treatment Center. He attended the University of Toledo. Ramon has worked in the industry for more than 12 years. Ramon is a Microsoft Certified Professional and CompTIA A+ Certified

Professional.

Professional Hires Spring 2009

Lori Heltunen, SLP

Speech Language Pathologist, CFY

Lori joins the therapy team, working primarily in Rainbow’s adult client programs. She earned her undergraduate degree from Northern Michigan University and obtained her master’s degree from Michigan State University in East Lansing, Mich.

3 0 Rainb owVisions

Charlene (Char) Combs, OTR

Program Director

Char founded Functional Recovery in 1997.

An OT by trade, Char gained her education

from Grand Valley State University and has

more than 12 years of experience in home

and community-based rehabilitation.

Pam BradenTranscriptionist

Pam has been part-time with Functional

Recovery for more than 12 years.

Sheryl Carpenter, OTR

Clinical Manager

Sheryl joined Functional in 2001 as a

Registered OT. Sheryl gained her bachelor's

degree from Baker College in Flint.

Professional Hires –

Marie Emert, MPT

Physical Therapist

Marie received her Master of Physical Therapy

from the University of Michigan in Flint, Mich.

She has more than 11 years of experience.

Marie has been with Functional Recovery since

2002.

Randall Green, OTR

Occupational Therapist

Randall has been a part of the Functional

Recovery team for more than four years,

starting out in the kid’s Summer Camp Program.

Randall received his bachelor’s degree in

Occupational Therapy from the University of

Findlay in Findlay, Ohio.

Gail Henig, MA, CCC-SLP

Speech Language Pathologist

Gail earned her both her undergraduate

and master's degree from Central Michigan

University. Gail has more than 14 years

experience as an SLP and has been with

Functional Recovery since 2008.

Spring 2009

News @

To enhance therapeutic programming for all clients through

additional activities and programming initiatives, Rainbow’s

NeuroRehab Campus® (NRC) launched Get Fired Up!

Campaign in March 2009.

“We wanted to provide activities that would engage all

clients,” explained Jane Delancey, the director of Nursing at

the NRC. To kick off the new programming initiatives, the staff

hosted a Get Fired Up! carnival that included games, arts and

crafts, a magician, cotton candy, popcorn and more.


Get Fired Up!

Spring 2009



Rainb owVisions 3 1

Elizabeth (Betsy) Idziak, MS, OTR

Occupational Therapist

Elizabeth obtained her master’s degree from

Eastern Michigan University and completed

her undergraduate work at Western Michigan

University. She has fieldwork experience

within hospital, educational and geriatric

facilities.

Sarah “Sally” Wiggers Office Manager

Sally joined Functional Recovery in 1999

and has been assisting in all aspects of the

business ever since. She has more than 30

years of business experience.

Andrea Wilkinson Administrative Assistant

Andrea has been with Functional Recovery

since 2000 and handles Billing and

Collections. Andrea has more than 18 years of

administrative experience.

Stephanie Woodward-Craig, PTA

Physical Therapist Assistant

Stephanie just joined the team in 2008 as a

PT Assistant. She earned her degree from Mott

Community College in Flint, Mich.

Since the program launch in March,

there have been additional themed

activities and skills groups on a monthly

basis, often centered on holidays or

monthly themes. Examples include:

• A Night at the Oscars®

• Playoff sports games

• Communication skills groups

• News and current events discussion

groups

• Game night

• Holiday-themed meals, such as a

Chinese buffet for the Chinese New

Year or Irish food for St. Patrick’s Day

• Additional community outings to

baseball games, movies and more.

Get Fired Up!Continued from page 30

P.O. Box 970230Ypsilanti, Michigan 48197

If you do not wish to receive RainbowVisions, please e-mail: [email protected]

Presorted StandardU.S. Postage

PAIDPermit 991

Ypsilanti, MI

Ypsilanti Treatment Center 5570 Whittaker - P.O. Box 970230, Ypsilanti, MI 48197 734.482.1200

Oakland Treatment Center 32715 Grand River Ave., Farmington, MI 48336 248.427.1310

NeuroRehab Campus 25911 Middlebelt Road, Farmington Hills, MI 48336 248.471.9580

For more information call toll free ... 800.968.6644 E-mail: [email protected]


Rainbow Treatment Center Locations:

Home and Community-Based Services:Home Care 5570 Whittaker - P.O. Box 970230, Ypsilanti, MI 48197 734.482.1200

Functional Recovery 8245 Holly Road, Suite 204, Grand Blanc, MI 48439 810.603.0040

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