News from the UPMC Institute for Rehabilitation and Research
Fall 2007
In This Issue
From the Chairman’s Desk
Page 3
By now, many of our readers will have heard that Dr. Ross Zafonte has accepted the chairmanship
of the Department of Physical Medicine and Rehabilitation at Harvard Medical School and has been
appointed chief medical officer for Spaulding Rehabilitation Hospital, a Harvard-affiliated teaching
hospital. Dr. Zafonte served as chairman of the Department of Physical Medicine and Rehabilitation
at the University of Pittsburgh since 2000. The Department grew substantially in size and prestige
during his chairmanship.
Specialty care for lymphedema
Page 4
Is his TBI different from hers?
Page 5
Faculty presentations
Page 6
Speakers, Thinkers, and da Vincis
Congressional testimony on TBI
Page 7
Disability, aging, and disparity
Top 5 in the NIH
Dr. Zafonte leaves the University of Pittsburgh Medical Center (UPMC) an outstanding legacy in
rehabilitation medicine. Although his accomplishments here in Pittsburgh are too numerous to list, chief
among them are his efforts leading to creation of the UPMC Institute for Rehabilitation and Research
(IRR), the Department’s rise to the top five in funding from the National Institutes of Health, and the
establishment of two Model Systems centers — for traumatic brain injury and spinal cord injury —
funded by the National Institute on Disability and Rehabilitation Research.
In Dr. Ross Zafonte, Harvard Medical School is getting a caring clinician, an accomplished researcher,
a passionate educator, a gifted administrator, and an incomparable leader. With our wish for his
continued success comes our unhesitating resolve to continue building on the foundation he
established at UPMC.
Page 8
Faculty publications
Michael L. Boninger, MD
Professor and Interim Chairman
Department of Physical Medicine and Rehabilitation
Associate Dean for Medical Student Research
University of Pittsburgh School of Medicine
Physiatry offers wholistic approach for perinatal musculoskeletal complaints
By Gwendolyn Sowa, MD, PhD
Assistant Professor of Physical Medicine and Rehabilitation
Musculoskeletal complaints are increasingly common in pregnancy, particularly
as more women delay conception into their 30s and 40s. Unfortunately, these
issues are frequently ignored or — worse — misdiagnosed, leading to unnecessary
tests and procedures. However, when addressed early, musculoskeletal issues can
be safely and simply managed during pregnancy, preventing later dysfunction
and chronic pain syndromes.
Most pregnancy-associated and postpartum musculoskeletal pain relates to
positioning and posture. With the changes in the woman’s center of gravity and
rapidly increasing weight during pregnancy, low back pain (LBP) becomes a frequent
complaint. While the increased intra-abdominal pressure and altered forces can lead
to disk disruption and increased incidence of lumbosacral radiculopathy, new-onset LBP in pregnancy is
frequently myofascial in origin. In addition, disruption of the core — through relaxation of the pelvis and the
effects on the pelvic floor — predisposes women to LBP and pelvic pain. Rectus diastasis, which is not
uncommon in pregnancy, further contributes to this disruption of the muscular core, and cesarean delivery
can result in significant core dysfunction. Muscle energy techniques and simple core exercises, which can
be safely initiated during an uncomplicated pregnancy, may help to decrease postpartum pain and improve
recovery after delivery.
continued on next page
Physiatry offers wholistic approach for perinatal musculoskeletal complaints (Continued from Page 1)
Carpal tunnel syndrome (CTS) is another ailment frequently
occurring during pregnancy, owing in part to the edema seen
especially in the third trimester. Patients with CTS will benefit from
early referral to physical therapy for stretching, strengthening, fitting
for an orthosis if necessary, and education regarding activities that
exacerbate symptoms. Conservative management is recommended,
as symptoms frequently improve after delivery and ensuing diuresis
and weight loss. In refractory or severe cases, steroid injections may
be performed safely in otherwise uncomplicated pregnancies.
Rectus abdominis (normal)
Rectus diastisis (separated)
Increased tension on the rectus abdominis musculature (left) during pregnancy
may lead to rectus diastasis, or separation (right). Multiparity and multiplegestation pregnancy increase the risk. Rectus diastasis may contribute to low
back pain through disruption of the muscular core.
Pelvic pain is common during pregnancy and postpartum. After
gynecological dysfunction is ruled out, consideration should be
given to commonly overlooked myofascial pelvic pain. Persistent
sacroiliac dysfunction and separation of the symphysis pubis after
delivery can contribute to the myofascial pain normally experienced
after the trauma of vaginal delivery. When left untreated, such
symptoms can lead to persistent impairment and disability.
Similarly, misdiagnosis frequently results in unnecessary surgery
and chronic pain syndromes. Such muscular imbalances
can frequently be corrected
through properly directed
muscle energy techniques
and strengthening, and physiatrists working along with
women’s health therapists
to correct such imbalances
through medications, injections, and pelvic floor therapy
(external and internal) when
indicated. Such an approach
frequently results in excellent outcomes for patients
frustrated by multiple treatment failures.
Overuse injuries are common
during the postpartum period. Continued hormonal changes and poor
biomechanics while lifting and caring
for the baby only exacerbate the
problem. Lifting even an 8-pound
infant can impose a significant strain
on the spine when coupled with poor
biomechanics and a weakened core.
Instruction in proper body mechanics
can help alleviate LBP and prevent
additional injury. Simple advice
(suggesting that the crib railing be
lowered before placing the baby to
sleep) or simple instructions (such as
how to stabilize the core when lifting
or bathing the infant) can prevent
additional strain.
Correct lifting. Feet are set at shoulder
width, one foot slightly ahead of the
other. Squat down, bending at the hips
and knees, not the back. Holding child
close to body, lift slowly by
straightening hips and knees.
Postpartum neck pain is another common complaint, particularly in
nursing mothers as they strain to ensure that the baby is properly
positioned. New mothers should be taught to bring the baby to the
breast, not the breast to the baby, to prevent strain on the neck and
periscapular musculature. Once the baby has fallen asleep in their arms,
new mothers are often hesitant to reposition, even if doing so would
relieve pain. Women should be instructed in simple posture and
“opening” stretches, such as scapular retraction. Use of positioning aids,
such as pillows and lumbar supports, should be encouraged to ensure
proper posture. Such simple interventions can have profound impact on
pain and quality of life in women adjusting to a life-changing and already
challenging event.
Physiatrists are uniquely posed to diagnose and treat perinatal
musculoskeletal issues.They can address biomechanics, treat pain, and
perform interventional procedures when indicated. Early referral can
prevent unnecessary dysfunction and development into a chronic pain
state.The wholistic approach commonly employed by physiatrists — not
only in treating the pain but also in addressing the resultant dysfunction,
social enablers, contributions of mood disturbances, and situational
factors — can result in excellent outcomes. Moreover, because of
the multidisciplinary nature of physical medicine, the physiatrist is well
positioned to coordinate the care of this frequently complicated patient
population. Physiatrists trained in pain management and
musculoskeletal medicine, working with physical therapists who focus
on women’s health, can fill an important gap in the treatment of women
with musculoskeletal impairments during pregnancy and in the
postpartum period.
Dr. Sowa specializes in treatments for neck pain and back pain and general
rehabilitation for patients with musculoskeletal injuries, including pelvic pain and
sacroiliac joint dysfunction. Her research interests include investigation of the
effects of mechanical forces on intervertebral disk disease.
Lymphedema demands long-term management
By B. Candice Pack, DO
Assistant Professor of Physical Medicine and Rehabilitation
Lymphedema is a
chronic and potentially
debilitating condition.
The subcutaneous buildup of high-protein lymph
results from failure of
the lymphatic system to
manage the given lymph
load. Lymph is produced
when tissue fluid, cells,
fat, and other substances are collected by
initial lymph vessels — the lymph capillaries —
from interstitial spaces. Chronic mechanical
insufficiency of the lymphatic system leads to
high-protein edema with fibroblast deposition
and fibrosis, as well as other tissue changes
that result in hypoxia. These changes give
the characteristic effect of tissue hardening,
impaired tissue healing, and increased risk for
recurrent infections.
Lymphedema is estimated to affect more
than 3 million Americans, but the true incidence
is unknown, as the condition is probably
grossly under-recognized and generally
underdiagnosed. The most common cause of
lymphedema worldwide is lymphatic filariasis,
which affects more than 120 million people,
according to the World Health Organization.
In the United States, lymphedema is most
commonly associated with breast cancer.
Although upper-extremity lymphedema is
widely recognized as a potential complication
of some breast-cancer treatments, lymphedema can also involve the lower extremities,
head and neck, viscera, trunk, or genital
region. Secondary lymphedema may be a
complication of radiation therapy or surgical
excision of lymphatic vessels or nodes. It
may also occur as a result of obstruction
due to mass, infiltration due to malignancy,
chronic infection, filariasis, chronic venous
insufficiency, or obesity.
Primary lymphedema is generally either
hereditary in nature or resulting from genetic
alteration. It is most often classified as follows:
congenital lymphedema — being present at
birth; lymphedema praecox — occurring after
birth, but prior to age 35; and lymphedema
tarda — occurring after the age of 35.
Lymphedema praecox, the most common
primary form, occurs more often in females,
often around the time of puberty or
pregnancy. Primary lymphedema can be
unilateral or bilateral; if bilateral, the typical
distribution is asymmetrical.
Lymphedema is primarily a diagnosis of
exclusion. Diagnosis is based on a comprehensive history and physical examination;
lymphoscintigraphy can be a useful adjunct,
providing information regarding lymphatic
vessel anatomy and functional capability.
Once a diagnosis is made, recommended
treatment typically includes complete decongestive therapy, a two-phase approach.
Initially, therapy involves an intensive
phase in which the patient undergoes a series
of visits with a health professional who is
specifically trained and preferably certified.
This usually occurs on an outpatient basis.
The intensive phase involves manual lymph
drainage, specialized bandaging, range-ofmotion exercise, meticulous care of skin and
nails, education, and training. The manual
lymph drainage is a specific technique used
with lighter touch than standard massage.
Its purpose is to promote drainage of lymph
using lymphatic collaterals, stimulate
contractile forces, and break up fibrosis.
The intensive phase is followed by a
maintenance phase, which is managed by the
patient or caregiver. Patients are typically
measured for garments to wear daily to
maintain volume reductions on a long-term
basis. Mobility, as appropriate, and adherence
to a program of meticulous care of skin and
nails are crucial to maintaining the gains
realized in the intensive treatment phase.
Currently, there are no FDA-approved
medications to treat lymphedema. It is a
manageable condition, but without adequate
treatment, lymphedema usually progresses
and becomes more resistant to treatment,
resulting in declining therapeutic responses.
Untreated or inadequately managed lymphedema eventually interferes with mobility,
self-care, and activities of daily living.
Longstanding untreated lymphedema
may progress to lymphangiosarcoma, also
known as Stewart-Treves syndrome, an
aggressive malignancy with a poor
prognosis once diagnosed. It is thus
imperative that health care providers
recognize the signs and symptoms of
lymphedema and provide early referral
for specialized lymphedema treatment.
Although physicians from a variety of
specialties have additional training in
lymphology, many are physiatrists with
special interest in women's rehabilitation,
cancer rehabilitation, or wound care. It is
important for patients to be under the care of
a physician with expertise in lymphedema
and experience in coordinating the care of
patients with this complex condition.
Copyright 2007 Nucleus
Medical Art, Inc.
All rights reserved.
The most common cause of upper-extremity lymphedema
in the United States is poor lymph drainage following node
excision (or high-dose radiation) for breast cancer. The
axillary lymph nodes that drain the breast also drain the
arm and hand.
This is immediately followed by bandaging with short stretch bandages to
maintain volume reduction and provide
resistance against muscular contractile forces
to further assist in drainage.
Dr. Pack’s practice focuses on rehabilitation
issues in women’s health, including post-radiation or
post-surgical rehabilitation for breast cancer patients,
lymphedema management, back and pelvic pain,
therapeutic exercise during and after pregnancy, and
postarthroplasty rehabilitation.
Study investigates effects of gender in traumatic brain injury
Perhaps because the incidence of
traumatic brain injury (TBI) is higher in men
than it is in women, the large majority of
clinical and animal research on TBI has been
with males. Women account for about 25
percent of the TBI population, and recent
research suggests that female hormones may
afford acute neuroprotection1,2. However,
clinical studies evaluating gender differences
in TBI pathophysiology and outcome have
found that functional outcome is worse for
femaleTBI patients3.
Determining the role of endogenous
hormones in acute neuroprotection and
later functional recovery is a major focus
of the study, “Evaluating the impact of
neuroendocrine hormones on pathophysiology and outcomes after TBI.” This ongoing
study is part of the work of principal
investigator Amy K. Wagner, MD, of the role
of hormones and markers of pathophysiology
in the brain-injury recovery process.
Understanding the role of sex hormones
both during the acute phase and in later
outcome is important to optimize TBI
interventions for both genders.
Researchers in the current study are
analyzing post-TBI serum and cerebrospinal
fluid (CSF) for levels of several hormones and
biomarkers of neurotrauma. During the first
week following injury, blood samples and CSF
are collected for analysis. Follow-up includes
neuropsychological assessment at six and 12
months post-TBI.
Early assessments suggest that, among
people who initially survive their injuries,
global outcome and disability levels appear to
be better for females. Preliminary analyses
also demonstrate disruptions in CSF levels of
several biomarkers of injury, some of which
appear to be influenced by gender, over the
first six days post-injury. Biomarker analysis
currently includes levels of cell injury,
antioxidant reserves, and protein oxidation.
CSF analysis over the first five days
following injury reveals a disruption in
hormone levels. CSF cortisol levels are
markedly elevated in the setting of low levels
of progesterone, testosterone, and estrogen.
In addition, gender appears to influence the
time course for production of some hormones
in the CSF.
Initial analysis also reveals disruption in the
pattern of serum hormone levels over the first
five days post-TBI. The association of serum
hormones with pituitary function suggests that
hypogonadotropic hypogonadism may occur
in males early after injury. Ongoing work will
determine the duration and severity of this
phenomenon, as well as the relationship of
pituitary function and female peripheral
reproductive hormone status. Preliminary
analysis suggests an association between
serum and CSF progesterone levels. These
data also suggest that CNS progesterone, a
substrate for neurosteroidogenesis, depends
in part on progesterone levels in the periphery.
This association may also have implications
for systemic progesterone supplementation as
a treatment forTBI4.
One of the key unknown aspects of this
study is how hormone/biomarker levels
change over time following TBI, and also
whether patterns of change differ across
particular groups of TBI patients. Trajectory
analysis can be used to track changes in
groups of individuals and to model trends
over time. Initial analysis suggests that
subjects can be clustered based on temporal
patterns of CSF hormone and biomarker
concentration. In some cases, biomarker
clustering patterns have been linked with
mortality. These findings have implications
for novel ways to use biomarkers with
outcome prognostication inTBI.
Recently, IRB approval was granted for 30
control subjects to participate in an additional
portion of the study for the purposes of
obtaining blood and CSF. Dr. Wagner and
fellow researchers plan to use these samples
to establish baseline, or control, values for
TBI-related biomarkers and hormones
being evaluated, using contemporary ELISA
techniques, rather than relying on literaturebased control values.
These data will facilitate direct comparison
of CSF sex-hormone levels in brain-injured
patients and further validate conclusions
drawn about injury biomarker, gender
and hormonal patterns observed in patients
With established baseline values for
blood and CSF samples, continued analysis
of hormone and biomarker changes (both
acute and chronic) after TBI, and further
trajectory analysis, a clearer picture is
emerging of the role of sex hormones on
outcome in traumatic brain injury.
Roof RL, Hall ED. Gender differences in acute
CNS trauma and stroke: neuroprotective
effects of estrogen and progesterone.
J Neurotrauma. 2000;17:367–81.
2. Stein DG. Brain damage, sex hormones, and
recovery: a new role for progesterone and
estrogen? Trends Neurosci. 2001;24:386–91.
3. Wagner AK, Hammond FM, Sasser HC,
Wiercisiewski D, Norton HJ. Use of injury
severity variables in determining disability
and community integration after traumatic
brain injury. JTrauma. 2000;49:411–9.
4. Wright DW, Kellermann AL, Hertzberg VS,
et al. ProTECT: a randomized clinical trial of
progesterone for acute traumatic brain injury.
Ann Emerg Med. 2007;49:391–402, 402.e1-2.
[Epub 2006 Sep 29]
Speaking of Rehab
Faculty members of the UPMC Institute for
Rehabilitation and Research remain active and
visible at national and international meetings.
Following is a sampling of recent presentations.
25th Annual National Neurotrauma
July 29 to Aug. 1, 2007 • Kansas City, Mo.
American Academy of Physical Medicine
and Rehabilitation 68th Annual Assembly
September 27 to 30, 2007 • Boston, Mass.
Rehabilitation Therapy: Does It Work? (Dash P,
Wagner AK)
A number of UPMC IRR faculty members participated
in the 68th Annual Assembly of the American Academy
of Physical Medicine and Rehabilitation in Boston.
TBI — Evidence Basis for Clinical Practice and Future
Venues for Research. (Zafonte RD)
Symposium lecture
Gwendolyn A. Sowa, MD, PhD, presented a talk on
“Emerging technology for the treatment of lumbar
intrinsic disc pain,” in an educational session at the
meeting of the Physiatric Association of Spine, Sports
and Occupational Rehabilitation (PASSOR).
Scientific Paper Presentation — Clinical Pearls
Delayed and chronic buspirone treatment after
experimental traumatic brain injury enhances spatial
acquisition. (Kline AE, Olsen AS, Zafonte RD, Sozda CN,
Aslam HA, Cheng JP)
Poster Presentations
Intervertebral disk cells respond to different
magnitudes of tensile stress with alterations in gene
expression. (Sowa GA, Coelho JP, Iucu C, Georgescu H,
Chu A, Kang J)
Power wheelchair lease provision in terminal
illnesses: a humane and cost-effective solution to
a difficult problem. (Horton JA 3rd, Schmeler MR,
Bundy A, Petro T)
Course Instruction, Workshops, and Roundtable
Neurological Round Table — Agitation Roundtable
Discussion. (Camiolo-Reddy C, Lombard L, Zafonte R)
Neuroleptic Agents: Uses and Abuses in Rehabilitation.
(Elovic E, Lombard L, Zafonte R)
Paroxysmal Autonomic Overactivity Syndromes
Following Acquired Brain Injury. (Baguley IJ, Zafonte RD)
Evidence-Based Practice of Spinal Cord Injury: The
Latest Clinical Practice Guidelines. (Boninger M, Groah
S, Sabharwal S)
Gadgets and Gizmos: Advances in Mobility.
(Cooper R, Hoover R, Koontz A)
Evidence Basis for Outcome Studies in Brain
Injury/Stroke, Spinal Cord Injury, and Chronic Pain.
(Grabois M, Ragnarsson K, Zafonte R)
Rehabilitation Implications of Solid Organ Transplant:
Issues, Complications, Implications, and Future
Prospects. Bartels M, Rashbaum I, Zafonte R
Lumbar Spine Interventional Management. (Akuthota V,
Bogduk N, Issac Z, Slipman C, Sowa GA)
The high affinity peripheral benzodiazepine receptor
ligand DAA1106 binds specifically to microglia in a rat
model of traumatic brain injury: Implications for PET
imaging. (Sriram V, Wagner AK., Wang G, Slagel SL,
Chen X, Lopresti BJ, Mathis CA, Wiley CA)
Empirical evaluation of typical and atypical environmental enrichment paradigms on motor recovery
and acquisition of spatial learning and memory after
experimental brain trauma. (Sozda CN, Cheng JP,
Luthra P, Aslam HA, Olsen AS, Hoffman AN, Zafonte
RD, Kline AE)
Chronic administration of the typical and atypical antipsychotics, haloperidol and risperidone, impair
functional outcome after experimental brain trauma.
(Hoffman AN, Aslam HA, Cheng JP, Luthra P, Sozda
CN, Olsen AS, Zafonte RD, Kline AE)
Buspirone, a 5HT1A receptor agonist, facilitates the
acquisition of spatial learning in a clinically relevant
experimental traumatic brain injury paradigm. (Olsen
AS, Sozda CN, Hoffman AH, Luthra P, Cheng JP, Aslam
HA, Zafonte RD, Kline AE)
The effect of rewarming on the acute protein kinase
response after murine CCI following therapeutic
hypothermia. (Jenkins LW, Kochanek PM, Dixon CE,
Kline AE, Clark RSB, Alexander H)
Delayed and chronic administration of the 5HT1A
receptor agonist 8-OH-PAT enhances motor function,
facilitates acquisition of spatial learning, and improves
memory retention after controlled cortical impact
injury in adult male rats. (Kline AE, Cheng JP, Aslam
HA, Luthra P, Hoffman AN, Zafonte RD, Jenkins LW,
Sozda CN, Olsen AS)
Serum and cerebrospinal fluid hormone levels in a
population with severe traumatic brain injury. (Rogers
EH, Postal BA, Fabio A, Yuan Z, Corominal A, Loucks
TL, Dixon CE, Berga SL, Wagner AK)
Coming soon: Neuroscience 2007
Nov. 3 to 7, 2007 • San Diego, Calif.
The following abstracts have been accepted for
publication or poster presentation during
Neuroscience 2007 — the 37th Annual Meeting of the
Society for Neuroscience this November in San Diego.
Human speech cortex long-term recordings [5]:
formant frequency analyses. (Brumberg JS,
Andreasen DS, Bartels JL, Guenther FR, Kennedy PR,
Siebert SA, Schwartz AB, Velliste M, Wright EJ)
Real-time continuous neural control of a 4-DOF
prosthetic arm. (Perel S, Velliste M, Schwartz AB)
Human speech cortex long-term recordings [3]: neural
net analyses. (Wright EJ, Andreasen DS, Bartels JL,
Brumberg JS, Guenther FR, Kennedy PR, Miller L,
Rebesco J, Schwartz AB, Siebert SA1, Velliste M)
Neuronal responses in somatosensory cortex to multichannel microstimulation of primary afferent neurons.
(Hokanson JA, Wagenaar JB, Weber DJ)
A computational model for selectively stimulating
peripheral sensory neurons. (Bourbeau DJ, Hokanson
JA, Weber DJ)
Accurate recording and nonlinear representation of
hand kinematics. (Clanton ST, Spalding MC, Rohlin KD,
Schwartz AB)
Hand synergies during reach-to-grasp, and the affects
of object selection on principal components. (Spalding
M, Schwartz AB)
Neural adaptation to 3-dimensional, rotational perturbations in a closed loop brain–computer interface.
(Chase SM, Fraser GW, Schwartz AB, Kass R)
Quantifying somatosensory neuronal responses using
conditional mutual information. (Wagenaar JB, Sudre
GP, Ventura V, Weber DJ)
How feedback affects M1 neurons during hand
movement. (Wu S, Schwartz AB)
Effects of chronic pretreatment with methylphenidate
on changes in striatal dopamine neurotransmission with
a single methylphenidate challenge in an experimental
model of brain trauma. (Harun R, Clossin D, Dixon CE,
Michael AC, Wagner AK)
Striatal dopamine transporter and D2 receptor binding
and executive functioning after TBI: an initial PET
study. (Scanlon JM, Price J, Ricker J, Conley Y, Becker
C, Lopresti B, Drewencki L, Deslouches S, Fabio A,
Wagner AK)
Chronic administration of the typical and atypical
antipsychotics, haloperidol and risperidone, impair
functional outcome after experimental brain trauma.
(Hoffman AN, Aslam HA, Cheng JP, Luthra P, Sozda CN,
Olsen AS, Zafonte RD, Kline AE)
Empirical evaluation of typical and atypical environmental enrichment paradigms on motor recovery and
acquisition of spatial learning and memory after
experimental brain trauma. (Sozda CN, Cheng JP,
Luthra P, Aslam HA, Olsen AS, Hoffman AN, Zafonte RD,
Kline AE)
Buspirone, a 5-HT1A receptor agonist, facilitates the
acquisition of spatial learning in a clinically relevant
experimental traumatic brain injury paradigm. (Olsen
AS, Sozda CN, Hoffman AN, Luthra P, Cheng JP,
Aslam HA, Zafonte RD, Kline AE)
Dr. Boninger receives lectureship
Michael L. Boninger, MD, was been invited to
present the Eighth Annual Ben L. Boynton, MD
Lecture in Physical Medicine and Rehabilitation
October 17 at the Rehabilitation Institute of
Dr. Boninger
Dr. Boninger’s lecture was entitled, “Repetitive
Strain of Shoulder and Wrist: What Can We Learn
from Wheelchair Users?”
The Boynton Lectureship was established by the Boynton family
in memory of Dr. Boynton and in recognition of of his achievements
in the field of physical medicine and rehabilitation.
The Boynton lecture series is offered through the Department of
Physical Medicine and Rehabilitation at Northwestern University
Feinburg School of Medicine, Chicago.
Dr. Cooper wins da Vinci Award
Dr. Cooper
Rory A. Cooper, PhD, director of the
Human Engineering Research Laboratories, was
selected to receive the 2007 da Vinci Lifetime
Achievement Award from the National Multiple
Sclerosis Society Michigan Chapter and the
Engineering Society of Detroit. The award
was presented on September 28, 2007 at the
Ritz-Carlton in Dearborn, Mich.
The da Vinci Awards® recognize individuals, organizations, and
corporations in the fields of engineering, construction, and technology
for “innovations that empower people at all levels of ability” by
employing principles of universal design.
Dr. Ambrosio featured for new ideas
Fabrisia Ambrosio, PhD, MPT, was
the subject of June 2007 installment of
“The Thinkers” — a monthly series in
The Pittsburgh Post-Gazette, Pittsburgh’s
morning daily, highlighting people from
western Pennsylvania who are “on the
forefront of new ideas in their fields.” The
article of 1000-plus words, which appeared in
Dr. Ambrosio
the June 25 issue of the Post-Gazette, reported
on Dr. Ambrosio’s work on shoulder injuries in users of manual
wheelchairs; the disparity in quality she sees among different
types of wheelchairs and the types of patients likely to use
them; the injuries that often result from use of a poor-quality
wheelchair; and the pound-foolishness of health insurers that do
not reimburse for light-weight, high-quality, motorized chairs.
The second part of the article discussed the work that
Dr. Ambrosio is doing with muscle-derived stem cells
and their potential for leading to breakthrough treatments for
muscular dystrophy. This work is ongoing in the Growth and
Development Laboratory of Children’s Hospital of Pittsburgh
of UPMC.
Dr. Ambrosio is an assistant professor and research scientist in
the Department of Physical Medicine and Rehabilitation, as well as
a postdoctoral associate at the Human Engineering Research
Laboratories (HERL), where she studies muscle strength and muscle
injury in users of manual wheelchairs.
The da Vinci Lifetime Achievement Award honors a lifetime of
significant contributions to advancing accessibility.
House Committee on Veterans Affairs hears from Dr. Zafonte on TBI
Traumatic brain injury (TBI) has become “the signature
injury” of the present conflicts in Iraq and Afghanistan. Of
those treated at Walter Reed Army Medical Center for any
kind of injury received in one of these operations, 65 percent
have TBI as either a primary diagnosis or a concurrent injury.
Because of the magnitude of the problem, the House
Committee on Veterans Affairs held a Traumatic Brain Injury
Symposium, during which they heard testimony from family
members, advocates, and medical experts including Ross D.
Zafonte, DO, then chairman of the Department of Physical
Medicine and Rehabilitation at UPMC.
Dr. Zafonte told the committee that there is a clear clinical
need for a screening process for the “mild” cases, a
process that is readily exportable to the field and capable
of being generalized across a broad community. Another
important component is a sophisticated method of
evaluation. Dr. Zafonte related that current research is
at the forefront of identifying biomarkers for differential
diagnosis, selection of therapeutic options, and
prognostication in TBI.
“We need adaptability in a network to be able to bring
clinical care and innovative programs and standards
of care up to speed rather quickly. We should look
to programs like the National Institute on Disability and
Rehabilitation Research TBI Model Systems ... as an infrastructural component of
what we want to do.
Dr. Ross Zafonte addresses members of the House
Committee on Veterans Affairs. Dr. Orest Boyko is in
the foreground.
“This issue is very dear to my heart,” Dr. Zafonte told the
committee. “For the past 17 years, I have been involved in
clinical care and research involving people with TBI. My work is mostly focused
on developing innovative therapies for recovery.”
Dr. Zafonte’s brief remarks emphasized the importance of understanding TBI not
merely in terms of the immediate insult, but as an evolving disease process that lasts
well beyond the time of the initial insult, progressing over days, perhaps even weeks.
“I am hopeful that this kind of strategy will bring a new world of opportunity to those
brave Americans who have given so much to our country.”
Aging, health, and women with disabilities
By Betty Y. Liu, MD
Assistant Professor of Physical Medicine and Rehabilitation
As advances in
medical technology extend life expectancy,
we can expect to see
increases in both the
absolute number and
the percentage of
Americans above age
65, among whom 16.9
percent of women and
9.1 percent of men report at least one type
of functional limitation affecting daily life1.
Multisystem changes occur with advancing age, independent of disability status,
and the general trend suggests that a majority
of the approximately 30 million American
women with disabilities can anticipate normal
longevity. In women with disabilities, however,
the convergence of several factors may
magnify the aging process and how it uniquely
affects their health2.
Evidence suggests an increased incidence
of osteoporosis in a population that is already
susceptible as a result of diminished weight
bearing or decreased muscle activity.
Moreover, many women with disabilities
take medications — such as anticonvulsants,
antidepressants, or long-term corticosteroids
— with adverse-effect profiles that include
accelerated bone resorption or impaired bone
mineralization. Mobility limitations also
decrease metabolism, increasing the risk of
obesity, which carries additional risks,
especially for diabetes and cardiovascular
Individuals using manual wheelchairs or
crutches for many years frequently suffer from
upper-extremity repetitive-stress injury.
Overuse syndromes of the upper extremity
can be particularly problematic for women
because of their comparatively low upperbody strength.
Ideally, mindfulness of the effects of aging
in women with disabilities will inform
symptom evaluation and recommendations
for preventive care, including routine
screening for lifestyle risk factors such as
tobacco use, nutrition, sexual activities, and
cancers. Symptoms associated with agingrelated conditions must not be routinely
attributed to a patient’s disability. Complaints
of chest tightness and dyspnea in a 40-year-old
woman with tetraplegic cerebral palsy (CP)
should not be dismissed as CP-related thoracic
spasms.The differential diagnosis must include
consideration of cardiac disease, pulmonary
disease, and environmental factors.
need to improve health care for women
with disabilities has led to establishment of
centers that address advocacy, health, and
educational issues.
Physical barriers continue to present
obstacles in some areas of women’s health
care, despite the enactment of the Americans
with Disabilities Act of 1990. One example is
apparent in many facilities that provide
routine mammography: Most machines
cannot be lowered to wheelchair height, and
limitations in shoulder range of motion may
prevent proper positioning and produce
unsatisfactory views.
The Comprehensive Healthcare Center
for Women with Physical Disabilities at
Magee-Womens Hospital of UPMC is one of
only a handful of facilities in the nation
created to provide a barrier-free environment
where women with physical disabilities can
receive comprehensive, multidisciplinary,
patient-focused health services.
Anecdotal reports show that many women
will tolerate suboptimal physical accessibility if
the health care personnel are considerate and
helpful. Attitudinal barriers, whether overt or
subliminal, are sometimes the most difficult to
Economic issues are another major
consideration for women with disabilities, a
disproportionate number of whom occupy
lower socioeconomic strata. Poverty limits
options for healthy nutrition, contributing
to obesity, diabetes, and hypertension. Lack
of resources also restricts choice in health
insurance, on which coverage for durable
medical equipment, medications, and services
For a variety of reasons, rates of preventive
care services are lower for women with
disabilities than for women without disabilities.
According to a 2003 survery3, for instance,
among women 40 years of age and over, 65
percent of those with disabilities had received
mammography services during the two years
prior to the survey, compared with 71 percent
of those without disabilities. Recognition of the
When disparity in access to health care
becomes obsolete, dedicated centers such as
this one will not be the only places that
women with disabilities can go for the health
care services that many Americans take for
Tezzoni LI, McCarthy EP, Davis RB,
Harris-David L, O’Day B. Use of screening
and preventive services among women with
disabilities. Am J Med Qual. 2001;16:135–44.
2. Welner SL, Simon JA, Welner B. Maximizing
health in menopausal women with
disabilities. Menopause. 2002;9:208–19.
3. Department of Health and Human Services
Centers for Disease Control and Prevention.
Disability and Health in 2005: Promoting
the Health and Well-Being of People with
Disabilities. Available at
Department ranks third for NIH research funding
According to data compiled by the National Institutes of Health, the Department
of Physical Medicine and Rehabilitation at the University of Pittsburgh ranked
fifth-highest in total NIH funding during fiscal year 2006. During the same year, the
Department ranked third among the nation’s more than 50 departments of physical
medicine and rehabilitation in terms of research-only NIH dollars — those awards
used for direct support of original research.
Recently published
Following is a sample of recently published scholarly works by IRR faculty researchers.
Peer-reviewed papers
Arenth PM, Ricker JH, Schultheis MT. Applications of functional near-infrared
spectroscopy (fNIRS) to neurorehabilitation of cognitive disabilities. Clin Neuropsychol.
Zhu J, Li Y, Shen W, Qiao C, Ambrosio F, Lavasani M, Nozaki M, Branca MF, Huard J.
Relationships between TGF-␤-1, myostatin, and decorin: Implications for skeletal muscle
fibrosis. J Biol Chem. 2007 Jun 27; [Epub ahead of print]
Dicianno BE, Spaeth DM, Cooper RA, Fitzgerald SG, Boninger ML, Brown KW. Force
control strategies while driving electric-powered wheelchairs with isometric and movementsensing joysticks. IEEE Trans Neural Syst Rehabil Eng. 2007;15:144–50.
Book chapters
Dicianno BE, Tovey E. Power and mobility device provision: Understanding Medicare
guidelines and advocating for clients. Arch Phys Med Rehabil. 2007;88:807–16.
Ricker JH. Implications of Functional Neuroimaging in Neurorehabilitation. In: Hillary FG,
DeLuca J, (Editors). Functional Neuroimaging in Clinical Populations. The Guilford Press,
New York, 2007.
Kline AE, Wagner AK, Westergom BP, et al. Acute treatment with the 5HT1A receptor
agonist 8-OH-DPAT and chronic environmental enrichment confer neurobehavioral benefit
after experimental brain trauma. Behav Brain Res. 2007;177:186–94. [Epub 2006 Dec 12]
Ricker JH, Arenth PM. Functional Neuroimaging of Traumatic Brain Injury. In: Zasler ND,
Katz DI, Zafonte RD (Editors). Brain Injury Medicine: Principles and Practice. Demos Medical
Publishers, New York, 2007.
Koontz AM, Yang Y, Boninger DS, Kanaly J, Cooper RA, Boninger ML, Dieruf K, Ewer L.
Investigation of the performance of an ergonomic hand-rim as a pain-relieving intervention for
manual wheelchair users. Asst Technol. 2006;18:123–49.
Published abstracts
Hoffman AN, Aslam HA, Cheng JP, Luthra P, Sozda CN, Olsen AS, Zafonte RD, Kline AE.
Chronic administration of the typical and atypical antipsychotics, haloperidol and risperidone,
impair functional outcome after experimental brain trauma. J Neurotrauma. 2007;24:1273.
Mercer JL, Boninger M, Koontz A, Ren D, Dyson-Hudson T, Cooper R. Shoulder joint
kinetics and pathology in manual wheelchair users. Clin Biomech (Bristol, Avon).
2006;21:781–9. [Epub 2006 Jun 30]
Jenkins LW, Kochanek PM, Dixon CE, Kline AE, Clark RSB, Alexander H. The effect of
rewarming on the acute protein kinase response after murine CCI following therapeutic
hypothermia. J Neurotrauma. 2007;24:1274.
Vadalà G, Sowa GA, Kang JD. Gene therapy for disc degeneration. Expert Opin Biol Ther.
2007;7:185–96. [Review article]
Vadalà G, Sowa GA, Smith L, Hubert MG, Levicoff EA, Gilbertson LG, Kang JD. Regulation
of transgene expression using an inducible system for improved safety of intradiscal gene
therapy. Spine. 2007;32:1381–7.
Kline AE, Cheng JP, Aslam HA, Luthra P, Hoffman AN, Zafonte RD, Jenkins LW, Sozda CN,
Olsen AS. Delayed and chronic administration of the 5HT1A receptor agonist 8-OH-DPAT
enhances motor function, facilitates acquisition of spatial learning, and improves memory
retention after controlled cortical impact injury in adult male rats. J Neurotrauma. 2007;24:1245.
Wagner AK, Kline AE, Ren D, Willard LA, Wenger MK, Zafonte RD, Dixon CE. Gender
associations with chronic methylphenidate treatment and behavioral performance following
experimental traumatic brain injury. Behav Brain Res. 2007;181:200–9. [Epub 2007 Apr 20]
Olsen AS, Sozda CN, Hoffman AH, Luthra P, Cheng JP, Aslam HA, Zafonte RD, Kline AE.
Buspirone, a 5HT1A receptor agonist, facilitates the acquisition of spatial learning in a clinically
relevant experimental traumatic brain injury paradigm. J Neurotrauma. 2007;24:1245.
Wagner AK, McElligott J, Chan L, Wagner EP, Segal NA, Gerber LH. How gender impacts
career development and leadership in rehabilitation medicine: A report from the AAPM&R
Research Committee. Arch Phys Med Rehabil. 2007; 88: 560–8.
Rogers EH, Postal BA, Fabio A, Yuan Z, Corominal A, Loucks TL, Dixon CE, Berga SL,
Wagner AK. Serum and cerebrospinal fluid hormone levels in a population with severe
traumatic brain injury. J Neurotrauma. 2007;24:1244.
Wagner AK, Postal BA, Darrah SD, Chen X, Khan AS. Deficits in novelty exploration after
controlled cortical impact. J Neurotrauma. 2007;24:1308–20.
Sozda CN, Cheng JP, Luthra P, Aslam HA, Olsen AS, Hoffman AN, Zafonte RD, Kline AE.
Empirical evaluation of typical and atypical environmental enrichment paradigms on motor
recovery and acquisition of spatial learning and memory after experimental brain trauma. J
Neurotrauma. 2007;24:1245.
Wagner AK, Ren D, Conley YP, Ma X, Kerr ME, Zafonte RD, Puccio AM, Marion DW, Dixon
CE. Sex and genetic associations with cerebrospinal fluid dopamine and metabolite production
after severe traumatic brain injury. J Neurosurg. 2007;106:538–47.
Venneti S, Wagner AK, Wang G, Slagel SL, Chen X, Lopresti BJ, Mathis CA, Wiley CA. The
high-affinity peripheral benzodiazepine receptor ligand DAA1106 binds specifically to microglia
in a rat model of traumatic brain injury: implications for PET imaging. J Neurotrauma.
Zafonte RD. Update on biotechnology for TBI rehabilitation: A look at the future. J Head
Trauma Rehabil. 2006;21:403–7.
Zafonte RD. Brain injury research: lessons for reinventing the future. The 38th Zeiter
Lecture. Arch Phys Med Rehabil. 2007;88:551–4. [Published lecture]
For more information about
UPMC Institute for Rehabilitation and Research
School of Medicine, Department of Physical
Medicine and Rehabilitation
School of Health and Rehabilitation Sciences,
Department of Rehabilitation Science &
UPMC Center for Assistive Technology Health System
Human Engineering Research Laboratories
Rehab Neural Engineering Lab
for assistance with patient
referrals, please call UPMC
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