Spring 2017 Vol. 6, No. 1 Brain Stimulation via the Tongue: MedStar NRH Studies PoNS™ I N S I D E : for Balance Restoration A new study at The investigation is evaluating a unique device called a Portable Rehabbing Bilateral Joint MedStar NRH is Neuromodulation Stimulator—PoNS™ for short. The device utilizes Replacement >>Page 3 sequenced patterns of electrical stimulation on the tongue in testing the value conjunction with physical therapy as a direct route to the cranial of cranial nerve nerves and brain stem. non-invasive “PoNS™ has been designed to boost neuroplasticity and regulate the neuromodulation electrochemical environment of the brain,” says Michael Yochelson, (CN-NINM) to MD, MBA, principal investigator of the study and vice president of improve vestibular medical affairs and chief medical officer at MedStar NRH. function after mild- “The concept is fairly simple. Stimulation of the trigeminal and moderate traumatic facial nerves via the tongue may activate neural impulses directly brain injury (TBI). in the brainstem. With sustained stimulation the impulses can travel throughout the brain and potentially jump-start a cascade of changes to the neural network and create new channels for the release of neurotransmitters,” Dr. Yochelson explains. Amputee Care: From PoNS™ is a small device that fits comfortably in the mouth and Pre-Surgery to Post- releases mild electrical stimulation to the tongue. Theoretically, Prostheses >>Page 4 combining neuro-stimulation with physical therapy will boost neuroplasticity and facilitate a better recovery even in patients who Next Generation ZeroG™ sustained TBI more than a year ago. at MedStar NRH >>Page 5 Continued on page 2. Developing Tool for Urinary Tract Infection MedStar NRH is testing the use of the PoNS™ device to stimulate Prevention >>Page 6 the tongue during therapy to improve balance. Knowledge and Compassion Focused on You Continued from page 1 Brain Stimulation via the Tongue... MEDSTAR NRH “Some preliminary research on a small number of people showed greater improvement in patients who utilized the device,” says Dr. Yochelson. “The hope is CONCUSSION CLINIC this larger clinical trial will help clarify its effectiveness.” IN BRIEF “ PoNS™ is a small The Concussion Clinic is a unique device that fits outpatient service of the MedStar comfortably in the NRH Rehabilitation Network that offers highly specialized services mouth and releases mild for people suffering from the electrical stimulation lingering—and often life altering— to the tongue to results of mild traumatic brain boost neuroplasticity injury (TBI). The program includes and facilitate a better assessments by a physician and/or neuropsychologist that include: recovery.” • Neurologic examination If PoNS™ proves useful in improving function after mild traumatic brain injury it • Balance testing could have wide-ranging appeal. More than 5 million Americans are living with a • Review of medications traumatic brain injury and between 30 and 65 percent of them suffer dizziness and a • Neuropsychological assessment lack of balance while sitting or standing. • For athletes, if previous screening was done with ImPACT, testing Study Parameters may be repeated Patient recruitment for the study is just underway at MedStar NRH and in five other Treatment is individualized to help medical centers in the U.S. and Canada. Patients must have suffered a concussion patients with long-term cognitive (mild TBI) or moderate TBI, be at least one year post injury and continue to have and/or physical impairment, but do problems with balance. Participants will be randomized into two groups: During not require hospitalization. When exercise and physical therapy, all groups will use the PoNS™ device; the control indicated, physical therapy for group will utilize sham stimulation and the treatment cohort will use the active concussion rehab and vestibular stimulation protocol. therapy, occupational therapy and Speech-Language Pathology is In a typical 20 to 30-minute PoNS™ session, the patient performs a set of physical available to patients. exercises, tailored toward their disability. Each of the exercises are paired with specific patterns of electrodes being activated on the PoNS, which in turn stimulate Recommendations are also made individual nerve endings on the tongue. Over time these nerve impulses from the about: tongue in association with specific activities help to form new neural pathways—and • Return to school, sports, and the patient regains control of that function. work “Patients will participate for five weeks,” explains Rahsaan Holley, OT, study • Accommodations for school or coordinator. “For two weeks, they will complete three hours of therapy at MedStar work, if appropriate NRH. Then they will continue to exercise at home for an additional three weeks. They • Recovery period follow-up will use the PoNS™ device during their therapy at MedStar NRH and at home. A • Further treatment if symptoms do baseline evaluation will be performed at the beginning of the process, and a follow- not improve as expected up assessment will examine any change in function.” The Concussion Clinic is available at outpatient centers throughout Potential of Neuromodulation the region. To learn more, go to “If outcomes prove positive, the technique could be used as a treatment tool for medstarnrh.org/concussionclinic. multiple diagnoses,” says Dr. Yochelson. “We’ve been examining neuromodulation through the use of external stimulation for some time,” he says. “But now it appears it may be an effective way to change and regulate the electrochemical environment of the brain and enhance neuroplasticity.” This is the focus of the MedStar NRH Center for Brain Plasticity and Research, Dr. Yochelson notes. “The PoNS™ study is one of a number of investigations examining ways to harness and boost neuroplasticity. We know that it underlies all cerebral learning and training and is the linchpin in recovery for a host of neurological disorders.” 2 MedStar National Rehabilitation Network MedStar NRH Experts Rehab Bilateral Joint Replacement Patients Joint replacement is among the most While not all patients require inpatient evaluation of patients’ equipment needs— common surgeries in the U.S., with a rehabilitation following joint replacement, and elimination of barriers they may face million procedures performed annually. those undergoing bilateral surgery can in their homes,” Mumma adds. The result is benefit from this type of intense care. outcomes that exceed national benchmarks. That number is expected to grow Patients will spend a minimum of three- exponentially in the next two decades— “We work hand-in-hand with orthopaedic hours-a-day in therapy during the average surgeons at a number of facilities such as with the number of knee replacement week-long stay. surgeries performed each year alone the Hospital for Special Surgery and with MedStar Health orthopaedic surgeons estimated to reach 3.5 million by 2030. Interdisciplinary Team including Drs. James Tozzi, Evan Argintar, of Orthopaedic Experts Among these surgeries will be a growing Savyasachi Thakkar, Brian Evans and Mark number of simultaneous and staged “The benefit of our inpatient treatment Zawadsky,” says Dr. Bunning. “These are bilateral joint replacement surgeries— program is our patients’ access to collegial relationships that truly benefit which is fast becoming today’s preferred multiple rehab professionals who take an our patients.” choice for many men and women. But integrated team approach and 24-hour- bilateral joint replacement comes with a-day coverage to diagnosis and manage some special considerations during any medical issues,” says Sherry Mumma, post-surgery rehabilitation—a challenge PT, DPT, ATP/SMS. the MedStar NRH Inpatient Orthopaedic “We are taking care of the whole Program is especially trained to meet. patient with a team of orthopaedic “Our program team provides rehabilitation experts including physical services to more than 200 joint replacement therapists, occupational patients a year—and that includes both therapists, nurses, case bilateral replacements, as well as an managers, recreation increasing number of revision surgeries. therapists, nutritionists and In fact, as patients live longer revision social workers,” she explains. surgery will become more commonplace. “Our goal is to maximize By 2030, it’s expected that 190,000 knee function and independence replacement revision surgeries will be so patients will be safe in their performed yearly,” says Robert Bunning, home environment. To reach MD, clinical director of the program. that goal, we work to increase range of motion, strength and Comprehensive Care for Complex Cases endurance,” she adds. “We have the level of experience that is “We understand that invaluable for patients—especially those recovery from bilateral joint whose recovery is more complex because replacement is complex,” says of chronic health conditions. This high Jennifer Offutt, OT. “So we level of skill is particularly important to work collaboratively on the promote the fullest possible recovery physical, psychological and from bilateral joint replacement,” he adds. pharmacological elements “Because we take an integrated, of recovery. That includes multidisciplinary approach to treatment, building confidence because we’re very good at managing those most patients experience fear of falling, of movement Deborah Morgan chronic health problems—as well had bilateral knee as preventing the most serious and of pain.” replacement complications