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In Theory and Practice: Moss Rehabilitation Research Institute

For many rehab providers, research remains secondary to treatment. Scientific inquiry—both time-consuming and expensive—must be relegated to the background due to the enormous demands of the clinic. At MossRehab, however, a team devoted entirely to research operates within the infrastructure of the rehabilitation hospital. Collectively called the Moss Rehabilitation Research Institute (MRRI), these researchers work side-by-side with MossRehab’s many clinicians, and the two groups have developed a true symbiotic relationship, sharing both patients and knowledge over the years.

Founded in 1992 by director John Whyte, MD, PhD, and associate director, Myrna Schwartz, PhD, the Institute has conducted research projects running the gamut from basic cognitive science to applied interventional rehabilitation research. Their main topics of inquiry cover a wide range of clinical areas, with a particular emphasis on language and aphasia, attention problems over time and space, disorders of consciousness, macro-outcomes related to traumatic brain injury and skilled action.

Over the years, the researchers at MRRI have added several key concepts to the body of rehabilitation literature. Dr. Whyte’s responsiveness studies showed that certain research methods applied during clinical evaluation could definitively determine if patients with disorders of consciousness were following commands. Language researchers at MRRI have studied or developed a number of theoretically-motivated treatments for aphasia, including MossTalk Words®, a computer-assisted treatment program, and SentenceShaper®, an augmentative communication device. The Aphasia Center, under the clinical direction of  clinician researcher Ruth Fink, MA, CCC, SLP, utilizes these and other research-based treatments and embeds patients in a supportive social milieu while they receive services. The Naturalistic Action Test (NAT), developed by Dr. Schwartz and researcher Laurel Buxbaum, PsyD, shifted neuropsychological assessment from traditional pen-and-paper tests to a series of real-life tasks, such as sandwich making, with a standardized scoring system. A study published in Neuropsychological Rehabilitation showed the NAT had stronger predictive validity for patient function than traditional tests.
 
Researchers Benefit from the Clinic

Being embedded within a large rehabilitation hospital provides several benefits for the researchers at MRRI. With 197 beds at MossRehab and care teams assigned to each diagnosis, the most evident advantage is easy access to large groups of patients with similar diagnoses.

For most of her career, Dr. Buxbaum has studied hemi-spatial neglect in her Cognition and Action Lab. Thanks to a steady presence of right hemisphere stroke patients, she was able to develop a Virtual Reality Lateralized Attention Test (VRLAT) for assessing neglect, which has proven to be highly sensitive. Now, having shifted her attention to the treatment of neglect, Dr. Buxbaum plans to develop a Right Hemisphere Stroke Center at MossRehab, a true translational treatment center in which research findings will be applied in the clinic. Patients will undergo treatment with wedge prism lenses, which shift visual attention to the left, as well as with stimulant medication where appropriate, and will be measured at baseline and discharge with the VRLAT test to monitor improvement.

“We will be using evidenced-based treatments and an assessment method that was developed under research protocols conducted here at MRRI,” said Dr. Buxbaum.

Indeed, having her lab operate within the confines of a large rehabilitation hospital has been, and continues to be, an immense boon to Dr. Buxbaum’s research. But working so closely with practicing clinicians has provided a second, less immediately apparent benefit: a change in perspective.

“The members of MRRI believe that interacting with clinicians who treat patients every day grounds us in what the needs of those patients really are,” Dr. Whyte said. He cited an anecdote of a bioengineering expert who had developed a device that would remind perons with brain injury to perform certain tasks. If the patient went into the bathroom, for example, the device would remind him to brush his teeth. But Dr. Whyte, having witnessed firsthand these patients being cared for in the clinic, surmised that the device was impractical. “The real question,” he said, “was what gets the patient into the bathroom in the first place?”
 
Clinicians Benefit from MRRI

For MossRehab clinicians, the presence of MRRI provides an outlet for creativity and inquisitiveness that is often absent from the standard clinical environment, which under current productivity requirements can become intensely monotonous.

“There’s a risk that clinicians who are more creative, more inquisitive, more analytical, will not be happy doing that forever,” Dr. Whyte said. “But if you embed that within an environment where there are discussions about how to conceptualize these problems and learn more about what we don’t know, that provides a level of intellectual stimulation that attracts good clinicians as well as good researchers.”

And just as MRRI researchers have benefited from the practical lessons of the clinic, MossRehab clinicians have benefited from the strict analytical thinking of their researcher colleagues.

“Sometimes clinicians arrive at conclusions that are not supported by the evidence in front of them,” Dr. Whyte said. “We’ve introduced the analytic thinking of research into the clinic so our clinicians won’t make logical errors that ultimately have very concrete effects on patients.”

Dr. Whyte cited an example in the use of PRN tranquilizers on patients with behavioral disturbances. He explained that clinicians tend to have disproportionate faith in these drugs because they administer them when a patient is at his worst. By choosing to intervene at the peak of the patient’s behavioral disturbance, he explained, the clinician will always see a positive result because the patient can only get better at that point in time.

“When a clinician and I agree on a different way to assess a PRN drug, we often find that it’s not as effective as once thought,” he said. “By applying analytic thinking to clinical practice, we have really changed clinicians’ perspectives on a problem, just as applying clinical experience to research has grounded some loftier ideas in reality.”

Looking Forward

As 2009 begins, MRRI finds itself on the brink of expansion. New office space recently acquired on the MossRehab grounds will allow new programs to be created while reuniting current programs on a single campus. MRRI has received approval to develop a new program on Motor Control and Mobility Rehabilitation, which will parallel and complement the current program on Cognitive Neuroscience and Cognitive Rehabilitation. Dr. Whyte recently announced the hiring of Steven Jax, PhD, an expert in motor learning after stroke who will work in both the new motor control program and the existing cognitive program. Plans are in place to hire three to four more investigators over the next few years.

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