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[Healthy Aging with Disabilities] [1997]
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Lex Frieden Collection: Records on Disability Rights
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Originally Processed With FOIA(s):
foia Number:
S
S
FOIA
MARKER
This is not a textual record. This is used as an
administrative marker by the George Bush Presidential
Library Staff.
Record Group/Collection:
Donated Historical Materials
Collection/Office of Origin:
Frieden, Lex, Collection
Series:
Related Materials
Subseries:
Grants
OA/ID Number:
52088
Folder ID Number:
52088-003
Folder Title:
[Healthy Aging with Disabilities] [1997]
Stack:
Row:
Section:
Shelf:
Position:
Withdrawal/Redaction Sheet
(George Bush Library)
Doc. No. / Type
Subject/Title
Date
Restriction
Classification
01. Form
Merit Review Application [redaction] (1 pp.)
4/30/97
C
Page 1 of 1
Collection:
Record Group:
Donated Historical Materials
Office:
Series:
Subseries:
WHORM Cat.:
File Location:
[Healthy Aging with Disabilities] [1997]
Pinksheet Number:
MB10692
OA/ID Number:
52088-003
Date Closed:
8/17/2016
FOIA/Sys Case #:
2016-2624-S
Re-review Case #:
P-2/P-5 Review Case #:
Withdrawal/Redaction Sheet
(George Bush Library)
Document No.
Subject/Title of Document
Date
Restriction
Class.
and Type
01. Form
Merit Review Application [redaction] (1 pp.)
4/30/97
C
Collection:
Record Group:
Donated Historical Materials
Office:
Series:
Subseries:
WHORM Cat.:
File Location:
[Healthy Aging with Disabilities] [1997]
Date Closed:
8/17/2016
OA/ID Number:
52088-003
FOIA/SYS Case #:
2016-2624-S
Appeal Case #:
Re-review Case #:
Appeal Disposition:
P-2/P-5 Review Case #:
Disposition Date:
AR Case #:
MR Case #:
AR Disposition:
MR Disposition:
AR Disposition Date:
MR Disposition Date:
RESTRICTION CODES
Presidential Records Act - [44 U.S.C. 2204(a)]
Freedom of Information Act - [5 U.S.C. 552(b)]
P-1 National Security Classified Information [(a)(1) of the PRA]
(b)(1) National security classified information [(b)(1) of the FOIA]
P-2 Relating to the appointment to Federal office [(a)(2) of the PRA]
(b)(2) Release would disclose internal personnel rules and practices of an
P-3 Release would violate a Federal statute [(a)(3) of the PRA]
agency [(b)(2) of the FOIA]
P-4 Release would disclose trade secrets or confidential commercial or
(b)(3) Release would violate a Federal statute [(b)(3) of the FOIA]
financial information [(a)(4) of the PRA]
(b)(4) Release would disclose trade secrets or confidential or financial
P-5 Release would disclose confidential advice between the President
information [(b)(4) of the FOIA]
and his advisors, or between such advisors [a)(5) of the PRA]
(b)(6) Release would constitute a clearly unwarranted invasion of
P-6 Release would constitute a clearly unwarranted invasion of
personal privacy [(b)(6) of the FOIA]
personal privacy [(a)(6) of the PRA]
(b)(7) Release would disclose information compiled for law enforcement
purposes [(b)(7) of the FOIA]
C. Closed in accordance with restrictions contained in donor's deed of
(b)(8) Release would disclose information concerning the regulation of
gift.
financial institutions [(b)(8) of the FOIA]
(b)(9) Release would disclose geological or geophysical information
PRM. Removed as a personal record misfile.
VA
Department of Veterans Affairs
MERIT REVIEW APPLICATION
1. TAB NO.
2. APPLICATION NO.
3. REVIEW GROUP
4. REVIEW DATE
5. FACILITY NO.
Center
580
7. SOCIAL SECURITY NO.
B. DATE OF LAST
6. LOCATION HEALTH CARE FACILITY (VAMC, OPC, CITY, STATE)
SUBMISSION MR
VAMC, Houston, TX
A.
(C)
N/A
B.
9. PRINCIPAL INVESTIGATOR(S) (Last Name, First Name, M.I.)
DEGREES
TELEPHONE NO.
A. Sherwood, Arthur M.
Ph.D.
(713) 798-5153
B. Monga, Trilok N.
M.D.
(713) 794-7117
10. PROGRAM TITLE (72 Characters maximum)
Healthy Aging with Disabilities
11. AMOUNT REQUESTED EACH YEAR
$750,000
$750,000
$750,000
$750,000
$750,000
$3,750,000
1ST
2ND
3RD
4TH
5TH
TOTAL
12. VA EMPLOYMENT STATUS
13. SALARY SOURCE
14. TYPE PROGRAM
B
FULL TIME
RESEARCH CC 103
B
PATIENT CARE
X
NEW
PART TIME
/8 TIME)
RESEARCH CC 104
HSR&D
ONGOING
A
CONSULTING
HRS/WEEK
RESEARCH CC105
RR&D
SUPPLEMENT
ATTENDING
HRS/WEEK
RESEARCH CC106
OTHER VA
NO. PROJECTS IN PROGRAM.
A
WOC
30 HRS/WEEK
CAREER DEVELOPMENT CC 108
15. PROGRAM
COST CENTER
822
124
16. PRIMARY RESEARCH PROGRAM AREA
PRIMARY RESEARCH SPECIALTY AREA
A. 62 Spinal Cord Injuries
A. 07 Bioengineering
B. 61 Rehabilitation
B. 59 Rehabilitative Medicine
17. VA HOSPITAL SERVICE AND SECTION
A. Research
B. Physical Medicine and Rehabilitation Service
18. ACADEMIC RANK, DEPARTMENT AND AFFILIATION
A. Associate Professor, Physical Medicine and Rehabilitation, Baylor College of Medicine
B. Professor, Physical Medicine and Rehabilitation, Baylor College of Medicine
19. PROGRAM USE (Each Item must have a response)
HUMAN SUBJECTS
YES
NO
INVESTIGATIONAL DRUGS
YES
x
NO
RADIOISOTOPES
YES
X
NO
ANIMAL SUBJECTS
YES
NO.
INVESTIGATIONAL DEVICES
YES
X
NO
YES
X
BIOHAZAROS
NO
20. SUMMARY OF RESEARCH/DEVELOPMENT SUPPORT FOR THREE PRIOR YEARS
TOTAL VA
TOTAL NON-VA
GRAND TOTAL
FY
1994
$69,391
-0-
$69,391
FY
1995
$95,544
-0-
$95,544
FY
1996
$175,013
-0-
$175,013
21. DATE ENTERED ON DUTY VA, OR EXPECTED DATE OF ENTRY VA
A. 1993
B. 1987
SIGNATURE amShuod PRINCIPAL INVESTIGATOR(S)
DATE
Trilok Thmough N. Monga, M.D.
4/30/97
Arthur M. Sherwood, Ph.D.
SIGNATURE ACOS FOR RESEARCH AND DEVELOPMENT
DATE
Glenn R. Cunningham,
M.D. Grean R. Cunnengham
4-30-97
VA FORM
10-1313-1
Page 1
JUN 1990
Bush Library Photocopy
SHERWOOD
SUMMARY DESCRIPTION OF PROGRAM X / PROJECT
PRINCIPAL INVESTIGATOR(S)
A. Sherwood, Arthur M., Ph.D., P.E.
B. Monga, Trilok N., M.D.
TITLE OF PROGRAM PROJECT (Not to exceed 72 character spaces)
Healthy Aging with Disabilities
KEYWORDS (MeSH terms only, minimum three)
aging; spinal cord injuries; skin; aged; disabled; comorbidity
BRIEF STATEMENT OF RESEARCH OBJECTIVES (Do not use continuation sheets)
Research has shown that the previously assumed "natural decline associated with aging" is not necessarily
inevitable; increased activity and other health promoting behaviors may prevent and indeed even reverse these effects.
Because the disabled veteran faces issues of aging earlier than the non-disabled, the cohort for studies growing out of
this proposal will include those over the age of 50 who have disabilities from injuries and chronic diseases.
Houston has a well-established history of distinguished research in the field of rehabilitation medicine. Likewise,
individuals, programs and institutions that have focused their efforts on gerontology and geriatrics have established a
strong presence in the community of educators, clinical practitioners and researchers. Thus, the Houston VAMC
Rehabilitation Research and Development Center is a natural fusion of these two strong disciplines. Establishment of
this Center will complement the internationally renowned educational activities and the strong set of existing,
community-based research programs.
The proposed Center will conduct research which will lead to the elimination of preventable secondary problems
and the reduction of risks for all secondary conditions related to patients' disabilities. Research results will seek to
promote early initiation of treatment, to develop more holistic intervention programs, to educate patients and family
caregivers, and to develop better assistive devices, including mobility aides. Bringing together an interdisciplinary team
of physicians, nurses, therapists, engineers, and educators, the Center will design, implement and evaluate programs
for the prevention of complications from common secondary conditions such as pressure ulcers, malnutrition, and
mobility limitations. Combining the nucleus of activity within the VAMC with existing intramural and extramural
clinical, research and educational activities, we envision new opportunities for research through collaborating agencies
which will further serve the community of aging disabled veterans. The research will encompass physical, mental, social
and spiritual dimensions in a holistic framework that will result in creation of a model program for the care of these
individuals.
Three broad goals will guide the activities of the Center: promotion of excellence in interdisciplinary research
focused on the health needs of the aging disabled veteran; providing exemplary research-based practice models for
implementation by health care providers to the target population; and developing a center of excellence which creates
a learning environment that fosters mentorship, collaboration, and exchange of information for the education of clinical
practitioners and patients/families within the target population. These goals will be addressed by 1) solidifying
interdisciplinary relationships among investigators and clinicians and establishing new collaborations with local
institutions, 2) identifying the unique needs of the target population (veterans over 50 with disabilities), VS. the general
aging population; 3) training a cadre of skilled clinicians and educators in geriatrics and rehabilitation research and
practice and 4) extending practice initiatives into the community care setting. The Center will solicit, review and fund
locally generated research projects consistent with goals and covering physical, mental, social and spiritual aspects of
the aging disabled veteran. Projects may be "proof of concept level, seed money level, or full projects. The Center will
employ faculty practitioners from area schools to facilitate collaborative research efforts.
Establishment of this Center with the corresponding research infrastructure will lead to enhanced opportunities
for collaborative, interdisciplinary research in the Houston VAMC. Center initiatives will lead to new clinical
interventions which will decrease the number of secondary complications in the disabled veterans. Enhanced research
skills of Center personnel will enable the Center to address an increasing number of important clinical problems.
Education programs aimed at the consumer, family caregiver and general public will convey strategies leading to more
healthful lifestyles, increased independence and a consequent increased quality of life for the disabled veteran.
Dissemination to a clinical audience beyond the HVAMC will propagate these benefits throughout the Veteran's Health
Administration (VHA).
VA FORM
JAN 1990
10-1313-2
Houston VAMC Rehab R&D Center Page 2
Healthy Aging with Disabilities
I. Introduction
Background: Research has shown that the previously assumed "natural decline associated with aging" is not
necessarily inevitable; increased activity and other health promoting behaviors may prevent and indeed even reverse
these effects [Shock et al., 1984]. Inactivity may result from individual choices in lifestyles as well as from an
underlying impairment. Prevailing clinical practice presumes the inevitable decline of these individuals. Because the
disabled veteran faces issues of aging earlier than the non-disabled, the cohort for studies growing out of this proposal
will include those over the age of 50 who have disabilities from injuries and chronic diseases. Recognized in Healthy
People 2000 [1991] as a special population at higher risk for problems as they age, disabled veterans exhibit
"accelerated aging". It is time to discard the prejudices of ageism and disabilities [Pawlson and Brody, 1988].
Houston has a well-established history of distinguished research in the field of rehabilitation medicine. Likewise,
individuals, programs and institutions that have focused their efforts on gerontology and geriatrics have established a
strong presence in the community of educators, clinical practitioners and researchers. Thus, the proposed Houston
VAMC Rehabilitation Research and Development Center is a natural fusion of these two strong disciplines.
Establishment of this Center will enhance clinically-based rehabilitation research to complement the internationally
renowned educational activities and the strong set of existing, community-based research programs.
Mission: It is fitting therefore, that the proposed Center, consistent with Healthy People 2000 recommendations,
conduct research which will lead to the elimination of preventable secondary problems and the reduction of risks for all
secondary conditions related to patients' disabilities. Research results will seek to promote early initiation of treatment,
to develop more holistic intervention programs, to educate patients and family caregivers, and to develop better
assistive devices, including mobility aides. Bringing together an interdisciplinary team of physicians, nurses, therapists,
engineers, and educators, the Center will design, implement and evaluate programs for the prevention of complications
from common secondary conditions such as pressure ulcers, malnutrition, and mobility limitations. Combining the
nucleus of activity within the VAMC with existing intramural and extramural clinical, research and educational
activities, we envision new opportunities for research through collaborating agencies which will further serve the
community of aging disabled veterans. The research will encompass physical, mental, social and spiritual dimensions in
a holistic framework that will result in creation of a model program for the care of these individuals.
Goals: Three broad goals will guide the activities of the Center:
to promote excellence in interdisciplinary research focused on the health needs of the aging disabled veteran;
to provide, through interdisciplinary and collaborative strategies, exemplary research-based practice models for
implementation by health care providers to the target population; and
to develop a center of excellence which creates a learning environment that fosters mentorship, collaboration, and
exchange of information for the education of clinical practitioners and patients/families within the target
population.
These goals will be addressed by 1) solidifying interdisciplinary relationships among investigators and clinicians
and establishing new collaborations with local institutions, 2) identifying the unique needs of the target population
(veterans over 50 with disabilities), VS. the general aging population; 3) training a cadre of skilled clinicians and
educators in geriatrics and rehabilitation research and practice and 4) extending practice initiatives into the community
care setting.
Significance: Establishment of this Center will lead to enhanced opportunities for collaborative, interdisciplinary
research in the Houston VAMC. These initiatives will lead to new clinical interventions which will decrease the number
of secondary complications in the disabled veterans. Enhanced personal research skills will enable the Center to address
an increasing number of important clinical problems. Education programs aimed at the consumer, family caregiver and
general public will convey strategies leading to more healthful lifestyles, increased independence and a consequent
increased quality of life for the disabled veteran. Dissemination to a clinical audience beyond the HVAMC will
propagate these benefits throughout the Veteran's Health Administration (VHA).
Houston VAMC Rehab R&D Center 3
II. Background:
Aging in America
In 1995, an estimated 99 million people in the US had chronic conditions characterized by persistent and recurring
health consequences lasting for periods of years. 41 million were limited in daily activities by their chronic conditions. 12
million are unable to live independently - most of them are dependent on caregivers for additional help [Hoffman and Rice,
1996]. By 2030 nearly 150 million Americans are projected to have a chronic condition, 42 million will be limited in their
ability to go to school, to work, or to live independently. The US is currently spending $470 billion (in 1990 dollars)
annually on the direct costs of medical services for persons with chronic conditions, including nursing homes and other
institutional care. "The US does not have a coherent approach to caring for people with disabling chronic conditions. As a
result, increasing numbers of people live with deteriorated health; others find that the services they need do exist, but are not
accessible. Individuals suffer, and society at large pays a toll in lost productivity and avoidable health care expenditures"
[ibid.].
It is essential to "distinguish between the true effects of aging and those processes, including disease, that also may
appear or become more pronounced with time but are biologically irrelevant to the underlying mechanisms of human aging."
[Shock et al., 1984]. "Although the incidence of disease increases with age, aging and disease are not synonymous. Aging is
a normal concomitant of the passage of time that takes place in everyone; disease occurs in only a part of the population."
[ibid.]. Data from the Baltimore Longitudinal Study of Aging (BLSA) led to the conclusion that there is no one uniform age
course for all variables. The evidence is conclusive that there are a variety of changes with age. One pattern is stability, or
the absence of any meaningful change with age in important functions or aspects of the person, ranging from resting heart
rate to personality characteristics. A second primary pattern is characterized by declines with age that are due not to aging
per se but to illnesses associated with age. [ibid.]. "Analysis of BLSA longitudinal data indicates that a precipitous drop in
any physiological or behavioral function is likely to be a manifestation of a pathological condition. A corollary is the
hypothesis that, in variables that remain essentially stable over the adult life span, any significant change may be a
manifestation of pathology." [ibid.]. It is the intention of the interventions employed in the Center research to minimize the
effects of complications from pathology (disability, decline, chronicity) to allow for normal (healthful) aging to progress.
We wish to further identify, develop, and test interventions (in our research) to strengthen physiologic, mental and
emotional, and spiritual competence and prevent, delay, or repair concomitant decline (previously accepted as a normal
process of aging).
Model: Integration of mind, body and self
In considering the approach to be taken to rehabilitation of the aging veteran with
disabilities, it is essential to consider all aspects of the individual as suggested by Covey
[1991] and others [Conlin, 1980]. In a medical context, emphasis may be placed primarily on
Physical Veteran Mental
physical needs, which must take precedence, as suggested by Maslow's hierarchy of needs
Individual
[1970]. However, cognitive dysfunction in the elderly makes evident the requirement to deal
with mental dysfunction also. A holistic view of the individual demands consideration of
social and spiritual dimensions as well. Described below are issues related to aging with a
disabilities leigos
disability from each of the areas shown in Figure 1.
Figure 1. Dimensions of self
Physical Changes Associated with Aging with a Physical Disability
Most of what is known about aging with a physical disability is based on studies of people with SCI and polio
survivors. Findings indicate that the physiological consequences of aging with a disability are more severe than the
physiological consequences of aging without a disability. In the general population, there is an increase in medical problems
as one ages. However, deterioration of various body systems appears to occur earlier in persons with disabilities than in
persons without disabilities [Bedbrook, 1985; Halstead & Rossi, 1987; Krause & Crewe, 1991]. Cardiovascular problems
that increase with age in persons with disabilities include hypertension, arteriosclerotic cardiovascular disease, dependent
edema and low HDL [Menter & Hudson, 1995; Smith, 1989; Trieschmann, 1987]. Neurological disorders that are more
common in the disabled population than in the general population are carpal tunnel syndrome and ulnar nerve atrophy
Houston VAMC Rehab R&D Center - 4
[Corbet, 1987; Gerhart, 1992; Trieschmann, 1987]. Respiratory problems in persons with disabilities that increase with age
are breathing difficulties, reduced vital capacity, reduced forced expiratory volume, reduced inspiratory capacity, reduced
negative inspiratory force, and pulmonary insufficiency [Halstead & Rossi, 1987; Menter & Hudson, 1995; Reynolds,
1992; Trieschmann, 1987; Whiteneck, 1993]. Genitourinary consequences include increased bladder cancers, renal
disorders, pyelonephritis, kidney stones, bladder resections, incontinence, and increased urinary tract infections [Corbet,
1987; Gerhart, 1992; Mentor & Hudson, 1995; Trieschmann, 1987; Whiteneck, 1993]. Gastrointestinal effects of aging
include increased bowel cancers, rectal problems, sluggish bowel action, hemorrhoids, spastic colon, and ulcers [Corbet,
1987; Mentor & Hudson, 1995; Trieschmann, 1987; Whiteneck, 1993]. Problems of the skin include increased pressure
ulcers, abscesses, cellulitis, contact dermatitis, changes in regulation of body temperature, and decreased skin tolerance,
[Mentor & Hudson, 1995; Reynolds, 1992; Trieschmann, 1987; Thiyagorajan & Silver, 1984; Whiteneck, 1993; Whiteneck
et al., 1992]. Musculoskeletal consequences of aging with a disability include muscle weakness, muscle pain, joint pain,
osteoporosis, fractures, joint degeneration, joint deformity, reduced flexibility, contractures, spasticity, and scoliosis
[Corbet, 1987; Gerhart, 1992; Halstead & Rossi, 1987; Hohmann, 1982; Mentor & Hudson, 1995; Reynolds, 1992; Smith,
1989; Trieschmann, 1987; Whiteneck, 1993; Whiteneck, et al, 1992; Young, et al., 1982]. Endocrine and metabolic
changes that occur with age are disorders of carbohydrate and lipid metabolism, stasis of body fluids, changes in
metabolism of drugs sometimes resulting in adverse drug reactions, abnormal glucose intolerance, and diabetes Mentor &
Hudson, 1995; Trieschmann, 1987; Whiteneck, 1993]. The immune system becomes compromised resulting in reduced
resistance to infection, increased resistance to antibiotics, and silent sepsis [Reynolds, 1992; Trieschmann, 1987]. Other
physiological consequences include reduced endurance or stamina, fatigue, obesity, malnutrition, and autonomic dysreflexia
[Corbet, 1987; Gerhart, 1992; Halstead & Rossi, 1987; Menter & Hudson, 1995; Reynolds, 1992; Smith, 1989;
Trieschmann, 1987, Whiteneck, 1993].
The physiological changes noted above lead to functional changes. These include decreased mobility [Trieschmann,
1987; Whiteneck, 1993]; decreased ability to do basic activities of daily living such as eating, dressing, and toileting
independently; decreased independence in performing instrumental activities of daily living such as cooking, housekeeping,
and grocery shopping; less time out of bed; less time out of the home; and a decreased ability to perform work activities
[Whiteneck, 1993]. Such changes in function also may mean that a person is no longer able to live independently [Zarb, et
al., 1990].
Psychological Changes Associated with Aging with a Disability
Aging with a disability is often associated not only with a decrease in physical independence but also with a decline in
psychological independence or a sense of autonomy and control over one's life [Butt & Fitting, 1992; Trieschmann, 1987;
Smith, 1989; Whiteneck, et al., 1992; Reynolds, 1992; Zarb, et al., 1990]. Fear, worry, and uncertainty about the future
increase [Trieschmann, 1987]. Aging can also be a threat to one's sexuality [Zarb, et al., 1990]. The physiological and
functional changes may lead to a loss of self-confidence, self-esteem, and self-reliance [Reynolds, 1992; Trieschmann,
1987]. However, some people who are aging with a disability have a sense of satisfaction about the fact that they were able
to survive [Whiteneck, et al, 1992]. Some may achieve self-realization or spiritual growth as well as maturity and wisdom
[ibid.]. Some people who are aging with a disability become more satisfied with their lives while others become less
satisfied [ibid]. When survival is the only focus in life, the quality of life is diminished. Like younger people, some aging
people become irascible, stubborn, angry, egocentric, and they resist change [Trieschmann, 1987]. Although some people
become better adjusted with age [Mentor & Hudson, 1995; Whiteneck, 1993], others have reduced emotional strength to
deal with daily challenges and they may become depressed [Trieschmann, 1987; Whiteneck, 1993. This, in turn, may lead to
a lessening of the will to live and, in some cases, may lead to suicide [Trieschmann, 1987]. At a time when they are most in
need of help and assurance, many individuals who are aging with a disability feel that they have been abandoned by the
medical community [ibid.].
Social Changes Associated with Aging with a Disability
As the physiological, functional, and psychological changes associated with aging with a disability take their toll,
changes begin to occur in the social realm. Social roles begin to change [Mentor & Hudson, 1995; Whiteneck, et al., 1993].
Some people may not be able to continue their role as a wage earner, leading to early retirement [Mentor & Hudson, 1995;
Houston VAMC Rehab R&D Center - 5
Whiteneck, et al., 1993]. Caregivers may also be aging and become unable to maintain the level of care they had been
giving [Whiteneck, 1993]. In some cases, divorce may occur [Trieschmann, 1987]. A loss of mobility as well as
psychological changes may lead to isolation. Recreational options may become diminished [Smith, 1989]. The community
at large may not be receptive to persons with disabilities leading to segregation and inequality [Whiteneck, 1993]
At a time when income may be decreasing due to retirement or a reduction in work hours, the cost of living may
increase. In response to the physiological, functional, and social changes, additional assistive equipment may be needed or
existing equipment may need to be repaired or replaced. Additional home modifications may become necessary and there
may be a new or increased need for paid personal assistance services. Others may need to pay for nursing home care. The
imbalance between income and basic living costs leaves many people who are aging with a disability living in poverty
[Berkowitz et al., 1992; Smith, 1989; Trieschmann, 1987, Whiteneck, 1993; Whiteneck et al., 1992].
Spiritual Changes Associated with Aging with a Disability
Consideration of biological, psychological, and social factors of aging is a part of helping older persons to cope with
their own aging [Naus, 1978]. However, integration of all these factors into the persons' spiritual context is useful in
understanding the individual and particularly their responses to the stresses introduced by personal life experience [Harris
and Harris, 1980]. Because of the caregiver's own discomfort dealing with these issues, this dimension is often ignored to
the detriment of the patient [Berggen-Thomas and Griggs, 1995]. Spiritual issues and stories may be particularly intense for
disabled elderly, although this issue has not been particularly explored. Evidence of the impact all dimensions of the self
(Fig 1) have on physiological functioning demands systematic study in the development of improved practice guidelines,
which include more extensive assessment of the needs of those aging with disabilities [Bruce et al., 1994].
III. Relevance to VA Population
Need for Research on the Aging Veteran Population with Physical Disabilities
The majority of the research studies cited above have included primarily civilian, rather than veteran samples. There is
a need to assess the status of veterans with physical disabilities who are late-middle aged or older. Individuals receiving
their medical care at VA medical centers may differ from other populations in a number of yet unknown ways. Such
differences may have important implications for service provision in the future. The studies which will be implemented
under the auspices of the proposed Center will begin to elucidate the special needs of aging veterans with physical
disabilities. The proportion of aged compared to younger veterans is greater than the proportion of aged in the population as
a whole, placing even greater emphasis on the need for research into issues of the aging disabled veteran. There will be an
increasing number of individuals disabled early in life (e.g., spinal cord injured) who will be members of the future older
population [Pawlson and Brody, 1988].
The proposed programs, research, and affiliation collaboration in research projects will complement HVAMC and
Veteran's Integrated Service Network (VISN) goals in a number of tangible ways. 1) Provision of new clinical and
scientific information for comprehensive care of patients which can be incorporated into clinical guidelines or pathways to
provide efficient and cost effective patient care. The anticipated consequences of this effort include decreasing the length of
stay of the veteran patient and the concomitant cost. The quality of care will be enhanced by incorporation of research
findings into practice which will lead to increased customer satisfaction with the care provided. 2) Utilization and
dissemination of research results will be communicated to VAMC staff and extended into community health care settings in
order to promote the highest quality continuum of care of the veteran patients. 3) Implementation of guidelines for
recognized high volume diagnoses, such as ischemic heart disease, hypertension, COPD, diabetes mellitus, and obesity will
be incorporated into our practice guidelines for promoting healthy aging. Research will be conducted to provide clinical
guideline variations for the elderly with disabilities. 4) The elderly disabled will participate in all medical center initiatives
for prevention of disease, such as influenza, cancer screening, alcohol abuse, etc. especially since our goal is to promote
research that enhances "healthful" living styles. 5) As appropriate (see specific research projects below), the Agency on
Health Care Policy and Research (AHCPR) clinical practice guidelines will be implemented in our research protocols and
Houston VAMC Rehab R&D Center - 6
practice setting. 6) Implementation of the Consumer Advocacy Council exemplifies our approach to the goal of customer
satisfaction by including consumers of veteran health care services in the advisory structure of the Center.
IV. Operational Plan
A. Center Environment
The Houston Center has been designed to effectively utilize
External
Texas Medical 2
resources available in the community to empower research
Advisory
VAMC
Center Affiliated
Committee
Institutions:
efforts in the VAMC. Through collaborative partnerships with
the various institutions of the Texas Medical Center, we have
Baylor College of
Medicine
assembled a team of qualified investigators and collaborators
University of Texas at
Houston
who represent an extensive breadth and depth of experience in
Texas Woman's
University
geriatrics/gerontology and rehabilitation research and related
Houston
MD Anderson Hospital
topics. The structure is based on several premises: 1) the best
RR&D
and Tumor Institute
Research
Advisory
University of Houston
collaborations grow from mutual interest of individual
Committee
Center
Rice University
Texas A&M University
investigators, 2) multi-institutional collaborations can optimize
University of Texas
Medical Branch at
the performance of all through "resource" sharing (expertise,
Galveston
facilities, etc.), 3) clinical outcomes can best be improved
Consumer
through "hands-on" clinical interactions and 4) a mentoring
Advocacy
Council
process is the most effective way of enabling young researchers
to effectively pursue research goals.
Figure 2. Houston VAMC Rehabilitation R&D Center.
The context in which the proposed Center will operate is
outlined in Figure 2. This organization was developed in order to enhance existing and promote new interactions among the
various institutions, with specific incentives for collaborative projects. The proposed plan will be implemented during the
first six months by the Center co-Directors in conjunction with the Executive Committee. To provide appropriate
institutional and community feedback for the Center, three advisory committees will be established, a Research Advisory
Committee, a Consumer Advocacy Group, and an External Advisory Committee.
The Research Advisory Committee (RAC) will be comprised of content experts in rehabilitation, geriatrics and
gerontology drawn from within the VAMC and from the Houston community at large. The global task of the RAC will be
to promote interactions with institutions in the TMC and surrounding community. This committee will meet quarterly to
identify areas of investigation and review progress toward the goals of the Center. The initial task of this group will be the
formulation of the policies and procedures for reviewing the grants to be funded through the Center, and establishment of
the Grant Review Committee. The committee will maintain a roster of affiliated, non-resident members to serve as reviewers
for grants submitted for major funding through the Center, and will themselves function as reviewers as appropriate.
The Consumer Advocacy Council will be comprised of interested individuals drawn from the VA population, the
elderly persons with disabilities, including a representative of the PVA, and representatives of some target groups (e.g.,
SCI, stroke, amputations) and primary caregivers of others (traumatic brain injury, Alzheimer's). This group will meet
semi-annually, and will review and reflect on Center procedures and progress.
The External Advisory Committee will be comprised of nationally recognized individuals drawn from outside the
Houston area to provide suggestions and guidance on overall directions for the Center. The group will meet twice, once in
Houston near the beginning, and once linked to a national meeting. Telecommunications will be employed to solicit input
(teleconferencing, e-mail, etc.) to make interactions cost-effective. The group will be chaired by Gale Whiteneck, Ph.D.,
Director of Research of Craig Hospital and Director of a Rehabilitation Research and Development Center on Aging in
SCI, The remaining members will be recruited with the assistance of the Chairman.
Finally, the major institutions in the immediate environment of the Texas Medical Center are listed (Figure 2). It is
anticipated that many of these will actively participate in Center activities through collaborative research projects, through
placement of clinical personnel, and through student projects.
Houston VAMC Rehab R&D Center - 7
B. Center Structure
The structure of the proposed Center is depicted in Figure 3. The Center will be led by the Medical Director, Trilok
Monga, M.D. and the Scientific Director, Arthur Sherwood, Ph.D., working closely together in administering Center
activities. Dr. Monga will monitor the clinical relevance and application of research conducted through the Center and Dr.
Sherwood will oversee the administrative and scientific matters to capitalize on their complementary strengths and interests.
An executive committee, comprised of the Center co-Directors, the Associate Chief Of Staff for Geriatrics, the Chief of the
SCI Service and the Administrative Officer of the PM&R Service will meet monthly to deal with emergent problems,
evaluate progress and priorities toward Center goals.
1. Clinical Core: At the heart of the RR&D Center is the
Clinical Core which forms the foundation from which all
Medical
Scientific
research activities will be initiated. A consortium of Houston
Director
Director
VAMC (HVAMC) practitioners including medical and nursing
services of Geriatrics and Extended Care, Physical Medicine
and Rehabilitation, and Spinal Cord Injury (Figure 4)
Research
constitutes the Center Clinical Core. The individuals within
Advisory
Executive
Committee
Committee
these combined services have substantial experience in
designing and implementing clinically-based research programs
Clinical
and draw upon the strength of existing clinical programs both
Core
within the HVAMC and in the Texas Medical Center as a
Research
whole.
Education
Support
Core
The Clinical Core will innovate, initiate, execute and
Core
evaluate clinical research protocols with the support of the
Research Support Core. Primary functions of Clinical Core
staff members will be to a) mentor others in the development of
Design/
Technical
postgraduate
consumer
Analysis
Support
education
education
research proposals, b) initiate individual research protocols, c)
provide input for development of continuing education
activities and d) evaluate outcomes from Center activity.
Figure 3. Houston Rehabilitation R&D Center Structure
Practitioners at all levels of professional development and expertise including staff physicians and residents, professional
nurses, physical therapists, occupational therapists, clinical psychologists, social workers, vocational rehabilitation
therapists, and others will actively take part in Center programs. Individual staff members have the potential and with the
Center's support, will have opportunities to develop expertise in research methods and implementation of projects in
individual areas of expertise. Qualified staff members will also serve as preceptors to other health care professionals
brought into this environment for either continuing education, training initiatives, and/or research protocol development.
Additionally, the Clinical Core will collaborate with the Education Core to identify needs for continuing education
through informal and formal requests for information. The clinical practice educational requirements of the staff and others
in training will be identified early so as to promote the goals of the Center and maintain high standards of practice.
Dissemination of research results into clinical practice will be a high priority
effort of both Clinical Core and Education Core team members.
Geriatrics and
Physical Medicine
Extended Care
and Rehabilitation
The Clinical Core activities will be administered by a Nurse
Rehabilitation
R&D Center
Researcher (Dr. Wilson) who, with the support and guidance of the Medical
Clinical Core Staff
Director, will assure the daily implementation of clinical activities and
Physician
Nurse Researcher (Ph.D.)
monitor progress on the various projects. Activity in the three related
Clinical Psychologist
Rehab. Engineer Specialist
Faculty Practitioner
Services will enhanced by the involvement of a co-Investigator Physician
Program Evaluation Specialist
from that Service. In addition to these individuals, a Clinical Psychologist, a
Rehabilitation Engineering Specialist and a Program Evaluation Specialist
Spinal Cord Injury
will be part of the Clinical Core Team. The functions of the Clinical Core
Team will be to a) promote the development of clinically based research
projects b) coordinate research protocol execution with Research Support
Figure 4. Clinical Core
Houston VAMC Rehab R&D Center - 8
Core members, c) provide guidance and identification of clinical preceptors for staff development of expertise in research
methods, d) support approved clinical research projects, e) evaluate the utility of interventions developed from ongoing
research and f) coordinate the clinical practice of the faculty practitioners.
Faculty practitioners who are recruited for the Clinical Core will work along with their HVAMC counterparts. Their
primary functions will be to: a) implement research projects, b) provide patient care as a part of the "discovery process for
new idea formulation", c) supervise their academic students who have HVAMC approved projects, d) evaluate procedures
and research projects carried out in the Clinical Core, and e) assist staff with dissemination of project results through
publication. The process of communication of the Clinical Core is that of dynamic interaction with extension of
collaboration to other Core components, Research Support and Education, respectively (Figure 3). Faculty practitioners will
participate in scheduled, periodic consultation and evaluation sessions relative to their research experience. They will work
collaboratively with the Clinical Core Team to accomplish the overall goals of the Center.
Collaboration with other institutions will be encouraged through identification and placement of faculty practitioners to
the Center setting to promote research, practice, and education. Individuals recruited will be qualified educationally and
demonstrate expertise in clinical practice. These individuals are envisioned as role models to the staff and will be able to
promote research proposal development among VA staff, develop and implement their own research initiatives, and provide
direct patient care services to our specialized veteran population as a mechanism to conduct research, evaluate outcomes
and identify new research topics. Qualified individuals include Ph.D. level Advanced Practice Nurse (CS or NP) from
nursing faculty of the University of Texas Health Science Center or Texas Woman's University (TWU), a Ph.D. physical
therapist or occupational therapist from TWU, Schools of Occupational and Physical Therapy, and a Ph.D. dietitian from
TWU, Department of Nutrition and Food Sciences in the College of Health Sciences.
Faculty practitioners will be appointed by a formal selection process to the Center and will liaison directly with the
Clinical Core team members to assist in creating an infrastructure that encourages research in the delivery of health
services. All appointed affiliation practitioners will meet the eligibility requirements for employment in the VHA and will
meet practice requirements for clinical privileges and/or scope of practice requirements depending on professional degree,
licensure and practice area.
2. Research Support Core: A significant feature of the Center will be the Research Support Core, which is charged
with assisting and promoting research in the Center. The majority of research supported through the Center is anticipated to
have a clinical focus, but this Core group will familiarize and assist those desiring to work in the Center in all aspects of
their work. They will provide assistance in experimental design, in design and implementation of data collection
instruments, in acquisition and processing of data, (from surveys to biochemical to electrophysiological), and in analysis of
results and report and paper preparation. They will facilitate the necessary approval processes for executing projects. They
will assist in establishing necessary linkages to other services within the HVAMC and in the Texas Medical Center as well.
Two senior researchers will lead this group, Rabih Darouiche, M.D., and Thomas A. Krouskop, Ph.D., P.E. Their
complementary strengths will be used to assure that investigators working through the Center will have access to all
necessary support services. They will be supported by a research associate and by a biostatistician. Together with the staff
of the Clinical Core, these individuals will have a primary support role for clinicians and researchers working through the
Center.
In addition to the support role, an additional primary task will be undertaken by the Research Core in the development
of a database to capture information from patients seen through the clinics and admitted to the services for inpatient care.
This database will have two basic components: 1) a registry of all patients over 50 years of age with disabling conditions, 2)
a sample database containing detailed information on a sample of patients over 50 years of age admitted for inpatient
services.
The objective of the registry is to collect basic demographic, social, medical and disability data on every patient seen
by the three services in the Center. This data will be used as a resource to identify specific areas for further research and
provide patient information for research studies developed by the Center. The objective of the sample database is to collect
detailed information on a random sample of disabled individuals who receive care in the services of the Center. A variety of
types of information will be maintained, including medical, physical, functional, social situation, type and duration of
Houston VAMC Rehab R&D Center 9
disability, general health, ethnicity and quality of life issues. To capture this data, two questionnaires will be developed; a
baseline questionnaire and an annual follow-up.
The baseline questionnaire will be designed to capture data from the time of onset of disability to the present. The
baseline questionnaire will cover the areas of medical history, present medical status, impairment characteristics, social
history, community integration and functional status. This questionnaire will be completed through interview and medical
record review. The second questionnaire, an annual follow-up, will differ from the baseline in that it will only cover the time
since the last interview. Therefore, the focus of the questionnaire will be on what has changed since the last interview. Das This
will allow a much shorter questionnaire to capture the necessary data. Like the baseline, the annual follow-up questionnaire
will be completed through both interview and medical record review. In the later years of the Center, the information will be
used to facilitate follow-up studies. Data collected will be coordinated with other similar local and activities. An overview of
the sampling procedures to identify subjects for the database are provided in Appendix I.
3. Educational Service Core: Educational activities will be promoted through integration with existing Baylor
College of Medicine PM&R personnel who are well-experienced in such activities. A core of personnel provide services
such as the production of two quarterly newsletters targeted toward individuals with SCI and traumatic brain injury,
videotape and audiotape production, pamphlet and monograph production, workshop and conference planning coordination
for professionals and persons with disabilities, two comprehensive databases on audiovisual and written educational
resources, assistance with writing research dissemination articles for lay journals/publications, research training and a
rehabilitation specific library with a full time librarian with computerized literature search and Internet services.
The educational personnel also provide facilitation of resident, student, post-doctoral fellowship and continuing
education services. Educational rotations are offered at seven hospital affiliation sites in the Texas Medical Center
providing experiences in inpatient and outpatient settings for individuals in all age ranges who have disabilities from
amputation, arthritis, traumatic brain injury, stroke, SCI, burns, cancer, neuromuscular disease, cardiorespiratory disease,
to musculoskeletal disorders. The BCM PM&R department, where most of the Center staff hold primary faculty
appointments, currently provides such experiences for 35 residents (one of the largest PM&R residency programs in the
U.S.), 6 post doctoral research fellows and 4 post-doctoral clinical fellows in PM&R, neuropsychology, electromyography,
independent living services, sports medicine, and women with disabilities. Twelve of the residency slots are at the HVAMC,
and all residents rotate through the PM&R and SCI Services. Some specific educational activities currently offered include
a weekly research education and development seminar, weekly PM&R case conference, weekly grand rounds, EMG
educational series, PM&R core journal club, PM&R current journal club, 4 two day courses annually on PM&R topics
such as sports medicine, therapeutic injections, prosthetics and
orthotics, ethical issues in rehabilitation, a 9 day PM&R Board
Center funding
idea formation
Review Course, the annual William A Spencer Lectureship and the
annual Lewis A Leavitt Lectureship.
proof-of-concept
The above services will be utilized to disseminate results
obtained from the Center's research projects and to develop
pilot
educational materials that will increase understanding of professionals
and consumers and offer interventions in minimizing the effects of
research project
aging on individuals with disabilities.
intervention
C. Support for Investigator-initiated Projects
demonstration
The research activities of the Center will be focused on the
external funding
dissemination/
Center theme and mission. However, within those broad parameters,
utilization
investigator-initiated research will be encouraged to promote
evaluation
maximum efficiency in utilization of resources, both human and
outcome
financial. Three types of research activities will be directly supported
assessment
through the Center budget, ranging from modest amounts of money
for a limited time, to substantial support over a period of years for
Figure 5. Stages in actualization of an idea.
major projects. (Figure 5).
Thickness of the arrows denotes relative Center
funding levels devoted to each stage.
Houston VAMC Rehab R&D Center 10
Proof-of-concept studies for start-up projects will be funded for a maximum of $1000, to be expended over
maximum of 3 months, with no salary support. These studies will make it possible to test ideas which investigators wish to
pursue without expending great effort in proposal writing or significant resources. The intended outcome from such projects
would be the submission of proposals for "seed money" projects, the second level of support. Approval for such studies will
be made by the co-Directors. Perhaps of greater importance than the financial support offered will be the research support
personnel in place in the Research Support Core as well as the staff in the Clinical Core who will provide guidance and
support as well as some limited manpower to implement ideas.
Seed money studies would be funded for up to $5000, for up to 6 months, with limited (non-PI) salary support
possible. Such projects would be designed to develop full-fledged proposals for VA merit review, for NIH or for NIDRR
support, or for Pilot Projects through the RR&D Service.
10
Finally, a limited number of full projects will be supported through the Center as typified by those selected for
inclusion in this proposal. Such projects could be funded for (typically) for a total averaging $50,000 to $60,000 per year
for one to two years, with encouragement and assistance for the investigator to seek additional funding.
Seed money and full projects would follow a similar approval process, to be determined by the co-Directors in
consultation with the Research Advisory Committee. It is anticipated that the approval process will include a written
proposal as well as an oral presentation to an appropriate forum.
IV. Research Activities
Individuals exhibit needs in multiple, interrelated dimensions, all of which must be appropriately addressed in order to
achieve the desirable quality of life for those individuals. Some of the identified areas of need for aging disabled persons are
in the area of maintenance of function with aging, clinical indicators, quality-of-care measures, nutrition, technology and
assistive devices, and role function and psychosocial aspects [Pawlson and Brody, 1988]. The goals identified in Section I
(Introduction) are more explicitly addressed in the table of specific objectives summarized in Table I, and detailed in
Appendix II. While the areas described below address primarily physical aspects of disability, other dimensions will be
actively solicited in future years (Figure 6).
Major research projects to be supported through Center funding will be
RFP
spiritual
carefully selected on a competitive basis from interested investigators within
RFP:
the VAMC and from related educational institutions. To be consistent with the
social
Dimensions of Self
RFP:
Spiritual
premises and goals, contributions will be solicited which respond to one or
mental
Social
more of these objectives, and cover all aspects of the aging disabled veteran as
depicted in Fig. 1. In preparation for this proposal submission, thirteen such
Mental
proposals were submitted, representative of the diversity of activity in the
Physical
Houston area in this field. Future proposals will emphasize different
0
12
24
36
48
60
dimensions of self as depicted in Figure 6.
Months
The projects below are representative of the high level of interest in
Figure 6. Proposed Timetable for
Houston for this area of investigation. The projects are presented as examples
Research Area Initiation
of the expertise readily available, but are not intended here for scientific
Horizontal bars indicate continued support of
review, due to space limitations. The first year research projects which
the indicated area; sequence follows the
focus on the physical dimension, will be initiated within three months of
hierarchy of need concept. Each new
awarding of the grant, subject to negotiations for the level of funding available beginning would be emphasized by an RFP.
(negotiated indirect rate, e.g.). The projects described below represent but a
small sample of the expertise available to the Center to address these needs. As time progresses through the five year period,
the funding applied to such projects will decrease as funding will be diverted to evaluation, education and dissemination and
other sources of funding will be found for these projects.
Houston, VAMC Rehab R&D Center - 11
A. Intervention to Reduce Pressure Ulcer Risk (Rodriguez, Rintala, Garber, Markowski)
Background: Pressure ulcers are a very onerous and expensive complication affecting persons with limited móbility,
impaired sensation, and/or cognitive dysfunction¹ Persons with a disability and the geriatric population are at high risk
for the development of pressure ulcers⁴⁶. There is a need to develop stronger motivators to effect behavioral changes that
would translate into reduced pressure on the anatomical sites at risk. Previous research has established that men with a SCI
whose urinary glucosyl-galactosyl hydroxylysine (glu-gal) excretion exceeds 100 umoles per day and whose ratio of glu-gal
to galactosyl hydroxylysine (gal) is higher than 3.5 are 4.5 times more likely to develop a pressure ulcer within the next 2 to
5 months than persons with lower excretion.¹
hogque
Hypothesis: Providing a numerical value to quantify the degree of individual risk to each subject will strengthen his/her
beliefs in susceptibility and will prove to be a greater motivator for adhering to good skin care practices than either standard
care or intensive educational interventions.
Objective: The purpose of this study is to test whether the incidence of recurrent pressure ulcers can be decreased by
providing feedback to the persons at risk on the results of an individualized, quantitative, objective laboratory-based test:
Does this information have a more profound impression on a patient's mind that will lead him/her to alter his/her behavior
in ways that will better protect his/her skin? Further, this test can be repeated as needed to reinforce the need to maintain the
improved behavior at a relatively modest cost without the need for a clinic visit (the urine sample can be sent through the
mail). This study should provide a means of determining the most efficient and cost effective way of reducing incidence of
recurrent pressure ulcers.
Expected Outcome: Success rates (Ulcer free time) for each of the groups will be analyzed using survival analysis.
Successful completion of this project will demonstrate a significant reduction in the incidence of recurrent pressure ulcers in
the population at risk. This will translate into a large savings in the cost of rehabilitation and subsequent hospitalizations
since the cost of treating one pressure ulcer has been estimated as high as $60,000.³ In addition to the monetary benefits,
prevention of pressure ulcers would greatly enhance the quality of life of the subjects by increasing their mobility and their
opportunities for work and study.
Methods Summary: All persons over the age of 50 with decreased mobility and/or decreased sensation attending the
Geriatric, Rehabilitation Medicine, or Spinal Cord Injury outpatient clinics will constitute the sampling frame. The subjects
will be divided into three groups. All will collect overnight urine samples which will be assayed for collagen glycosides
content using high pressure liquid chromatography with dabsyl chloride as the derivatizing reagent. One group will be told
the results of the assay and will be given an assessment of their risk The second group will be given only an educational
intervention. The third group will be called to remind them to collect the urine. Survival analysis will be used to compare
ulcer-free time between the three groups.
Outcomes. The main outcome measure will be the survival analyses of ulcer free time of the three groups. In 1977, a
skin clinic was established at The Institute for Rehabilitation and Research focusing on prevention through a comprehensive
clinical and educational program. This program resulted in reducing recurrence rates from 33% to less than 5% in the
population studied¹⁰. We expect that an objective assessment (the glycoside assay) will be just as successful as an
educational intervention but at a lower cost since the subject does not have to come to the clinic to receive an assessment.
Further, the educational component can be used in conjunction wit the glycoside assay for a synergistic effect.
B. Malnutrition in the Institutionally Disabled Elderly (Wright, Ghusn)
This preliminary study into the phenomenon of malnutrition and its clinical sequelae in the disabled elderly is the first of
several steps planned to provide insight into a very wide-spread and serious clinical problem not yet fully understood or
systematically investigated. Because of the dearth of research conducted to ascertain the various clinical implications of
malnutrition in disabled elderly patients, we neither know the magnitude of the problem nor its consequences in this elderly
population. (Not even a validated definition for malnutrition in the elderly disabled exists in the literature at this time.) We
are conducting this pilot study to characterize the relationhship of protein, energy, and micronutrient intake to pressure ulcer
incidence and healing, immune function, cognitive functioning, ability to perform population specific activities of daily
living, and quality of life in disabled elderly persons nresiding in nursing homes.
Hypothesis: Malnutrition is associated with compromised immune, integumentary, functional, and psychobehavioral
functioning in the institutionalized disabled elderly.
Houston VAMC Rehab R&D Center 12
The first specific aim of this pilot study is to obtain preliminary data needed to:1) estimate the prevalence and describe
the progression of malnutrition in a select group of disabled elderly, and 2) ascertain the relationship of identified
malnutritive states to selected population-relevant immunologic, integumentary, functional, and psychobehavioral clinical
indices.
The second aim is to formulate a definition of malnutrition among institutionalized disabled elderly patients which will
be used in a large scale nutritional intervention trial to test the effectiveness of interventions developed to prevent and treat
malnutrition and its clinical sequelae in the disabled elderly.
Background and Significance Malnutrition has been reported to prevail in 30 - 85% of the nation's 1.5 million elderly
currently residing in nursing homes[1 - 6]. While data on the incidence of malnutrition in disabled veteran nursing home
population are unavailable, it is believed that those figures would not be unlike the general population's. Most specific to
the disabled, the NHANES I Epidemiologic Follow-up Study [7] identified low caloric intake as a primary factor associated
with greater disability. Nutritional deficiencies in any population, however, although frequently not recognized, are common
underlying causes of adverse clinical outcomes. Malnutritional states are associated with decreased functional status and
quality of life and increased morbidity and mortality in various study populations [8 - 11]. In one study conducted by a
Department of Physical Medicine and Rehabilitation in Canada [12] to determine associations between nutritional status
and length of stay and functional outcome, data collected led to the conclusion that "malnutrition was the most potentially
modifiable variable relating to length of stay and functional outcome in their sample of forty-nine inpatient rehab stroke
patients. Such detrimental effects ultimately lead to poor health status despite increased health care services and
expenditures.
Because of the dearth of research conducted to ascertain the various clinical implications of malnutrition in any type of
nursing home patients, specifically, we know neither the magnitude of the problem nor its consequences in the disabled
institutionalized elderly veteran population. It is realized that the problem of malnutrition may indeed be reduced by
identifying, preventing, and correcting modifiable causes [8]. But in order to better treat the clinical sequelae of malnutrition
while attempting to improve the nutritional intake of nursing home patients admitted to our care, we must gain a greater
understanding of the problem, define sensitive, specific, and reliable diagnostic indices, and identify interventions specific to
the manifestations of this serious clinical phenomenon.
Diagnosing malnutrition in the institutionalized elderly is a complex task and is not yet within the standard of practice in
many acute and long term care settings [1, 12 - 18]. Even when attempted, it is proved a difficult task due to a variety of
non-nutritional physiologically related factors. First, anthropometric and bioimpedance measures and biochemical markers
employed in nutritional assessments are standardized for adults 25-55 years of age. Second, chronic disease states,
individual variations in resting metabolic rate and daily caloric expenditure, poly-pharmaceutical regimes, and the effects of
aging on various body systems are all known to confound nutritional status. We wish to develop a better working definition
of malnutrition that will be most relevant to our study population to use in a large-scale intervention trial to evaluate
selected nutritional interventions on clinical outcomes critical to our patients.
Study Design In a prospective descriptive study, nutritional status of a select group of disabled elderly patients is
tracked for one year. Selected clinical outcomes and biochemical indices of immune, integumentary, functional, and
psychobehavioral status are examined in light of nutritional status at 1, 6, and 12 months. Characterization of distributions
and correlations performed on the data will indicate if malnutrition is associated with decreased immunological,
integumentary, functional, and psychobehavioral functioning in the disabled elderly. Which of the commonly recognized
indices of malnutrition serve as primary indicators of compromised clinical outcomes in the sample will then be ascertained.
Sample: Subjects (n = 100) are recruited from among the select group of institutionalized disabled veterans. To control
for as many non-nutritional physiological intervening variable effects as is feasible, patients will be enrolled into the study
only if they are >50 years old and meet minimum health criteria.
Study Procedures Nutritional assessments including consumption studies, anthropometric measurements,
biochemistries, and body composition determination by bioelectrical impedance are performed to ascertain the prevalence
and progression of malnutrition in the sample. Simultaneously, selected clinical outcomes and biochemical indices of
immune, integumentary, functional and psychobehavioral status are examined in light of nutritional status (adequately
nourished versus malnourished) at 1, 6, and 12 months (Specific Aim #1). Specific Aim #2 will be accomplished by
Houston VAMC Rehab R&D Center 13
ascertaining which of the commonly recognized indices of malnutrition serve as primary indicators of compromised clinical
outcomes in the sample.
Statistical Evaluation Analyses of data collected are planned: 1) characterization of distributions of the sample on each
nutritional parameter, according to type; centering and variation indices will be performed; 2) the progression of nutritional
status over time will be tracked by examining repeated time measurements of each nutritional parameter; 3) the relationship
of nutritional status and specified clinical measures will be characterized by repeating the above analytical plan for each
clinical index and by examining clinical indices according to assessed nourished versus malnourished status, and 4)andam
specification of estimates necessary for future proposed trial will be made.
C. Developing a clinical algorithm in management of sexual dysfunction in people with disabilities (Monga,
Herskowitz, Kerrigan)
Background: Research indicates marked decline in sexual functioning with impaired arousal in patients with physical
disabilities (stroke, traumatic brain injury and spinal cord injury). 1-11 For example, Monga et al. reported erectile difficulties
in 62% of male stroke patients, and poor vaginal lubrication post-stroke in 71% of female patients.¹ However, most studies
ignore the broader aspects of sexuality, such as sexual fantasy, drive and satisfaction. Objective data is lacking to support
these problems. Treatment options have not been tested. Recently we used a validated instrument (Derogatis Inventory
Sexual Functioning -DISF)¹² to describe sexual functioning in patients with amputations¹³, head and neck cancer¹⁴.¹⁵ and
chronic pain. 16,19 There are no guidelines as to what extent these people should be investigated. We propose a clinical
algorithm for managing sexual dysfunction in people with disabilities with specific reference to stroke patients.¹⁷
Objectives: (1) To develop a clinical algorithm, through the consensus of an expert panel, managing sexual problems in
elderly stroke patients. (2) To conduct pilot testing of this clinical algorithm at the HVAMC. (3) To evaluate sexual and
psychological functioning of stroke patients managed with this clinical algorithm and compare the findings with those
patients managed in a traditional rehabilitation program.
Hypothesis: (1) Patients managed with the use of clinical algorithm will report significantly improved sexual
functioning (measured on DISF scale) as compared to the control group (2) Patients treated with appropriate specific
interventions, (e.g. vasodilator injection, psychological counseling) will report significant change in coital frequency and
satisfaction with sexual functioning.
Expected outcome: Successful completion of the project will: (1) provide a clinical algorithm that could be used in other
impairment groups such as TBI and amputees; (2) provide a better understanding of sexual functioning in these patients; (3)
provide objective findings regarding etiology and severity of erectile difficulties in male patients with CVA; (3) improve the
sexual functioning of these patients and (4) provide outcome measures with treatment interventions such as psychological
counseling and vasodilator injections.
Methods Summary: During the first phase of the study, a clinical algorithm will be developed. Stroke patients admitted
to Stroke Rehabilitation Program at Houston VA Medical Center will be encouraged to participate in the evaluation of
sexual functioning. Patients over 65 years of age with a recent first CVA and cognitive ability to understand the
questionnaire will be included. During the second phase patients with other impairments such as traumatic brain injury and
amputations will be studied. The proposed Clinical Algorithm will be refined by an expert panel that will consist of
Physiatrists, Psychologist, Urologists, and Nurses who are actively involved in the rehabilitation of stroke patients and also
participate in management of sexual problems in people with physical disability. The implementation phase of the clinical
algorithm will begin with random assignment to two patient groups: (1) patients going through the clinical algorithm (2)
patients treated in a traditional rehabilitation program. Evaluation will include (1) recording basic demographic data,
medical co-morbidities, medication, alcohol use, neurological and functional deficits(measured by FIM scale). The
assessment of sexual and psychological functioning (3) male patients will be studied in the sleep laboratory on two
consecutive nights to establish their erectile capability within one week of admission to rehabilitation medicine service and
at the time of discharge, and 12 months post discharge. Instruments include: Sexual functioning: Derogatis Inventory of
Sexual Functioning (DISF). 16 Five domains of sexual functioning (sexual arousal, behavior, orgasm, drive/relationship and
sexual fantasy) are assessed in detail and a total T score for sexual functioning is also obtained.
Houston VAMC Rehab R&D Center 14
D. Improving Outcomes for Stroke Patients: A Psychoeducational Program for Family Caregivers (Ostwald, Hickey,
Lim)
In the current health care environment, stroke hospitalizations are short, and much of the recovery process occurs in the
home. However, the shortened hospitalization results in little or no time to adequately prepare family caregivers to assist
with recovery from stroke nor to be prepared for the caregiver role. As a result, caregivers do not have a general
understanding of stroke nor the specific disabilities, needs, and interventions related to their family member. In addition,
they do not understand the caregiver role, caregiver burden, nor how to maintain their own health [Hickey, 1996]. Clearly,
the caregiver is instrumental in promoting recovery; however, the unique aspects of caring for the elderly stroke patient in
the recovery phase have been explored in only three studies [McLean et al; 1991; Draper et al., 1992; Hickey, 1996].
The proposed study will provide the family caregiver with detailed and specific information that assures an accurate
understanding of the disease affecting the person with stroke. In addition, it provides skill training based on the AHCPR
Clinical Guidelines [Gresham et al., 1995] to help caregivers to understand and manage patient symptoms. The entire
four-week intervention is designed to 1) improve the functional outcomes of stroke patients who are discharged home with
the assistance of a family caregiver and 2), reduce the burden and depression of family caregivers who are caring for stroke
patients at home.
Hypotheses: The hypotheses to be tested are: 1). Stroke patients whose caregivers attend the intervention group will
demonstrate better functional outcomes that those patients whose caregivers in the control group receive only written
educational materials. 2). Stroke patients whose caregivers attend the intervention group will experience fewer emergency
room visits and hospitalizations due to avoidable complications (dehydration, pressure sores, etc.) than those whose
caregivers in the control group receive only written educational materials. 3). Primary caregivers in the intervention group
will demonstrate decreased depression as compared with those in the control group who receive only written educational
materials. 4). Primary caregivers in the intervention group will demonstrate decreased burden as compared with those in the
control group who receive only written educational materials.
The successful completion of this project will improve the outcomes of stroke patients who are cared for at home by
family caregivers while maintaining their own health. The results from this study will provide a cost-effective model for
nurses and other health professionals to establish stroke caregiver psychoeducation programs to educate and support family
members who find themselves in these roles.
Methods Summary: Patients with stroke and their family caregivers (n = 100) will be recruited from the Houston
VAMC, allowing for drop-out. A random assignment experimental design will be used. Family caregivers in the control
group will be given the Consumer Version of Clinical Practice Guideline #16, Recovering After a Stroke. All patients and
caregivers will be assessed prior to discharge and at four additional points after the intervention. The intervention group will
attend four sessions of the psychoeducational group. The intervention consists of four structured workshops containing
lectures and experiential exercises aimed at helping caregivers to gain management skills and to increase their ability to
cope with the day-to-day management of the stroke patient.
Repeated measures ANOVA will be used to test hypotheses one, three and four for Group X Time effects. For
hypothesis two, utilization data will be collected from all caregivers and confirmed through hospital records. The two
groups will be compared over the year and the cost effectiveness of the intervention will be determined.
If successful, this relatively low-cost intervention could be incorporated into routine care offered to caregivers who are
assuming home care for stroke patients. It could be incorporated into the regular offerings of the VA system and managed
care organizations. It could also be adapted and tested for other groups of disabled veterans who are discharged home with
other conditions.
E. Assessment of Physical Activity Patterns in Individuals with Spinal Cord Injury (Holmes, Frey, Harrison)
There are many methods of assessing physical activity [Paffenbarger, Blair, Lee, and Hyde, 1993]. Currently, the most
accurate method for measuring daily energy expenditure in free-living humans uses doubly labeled water [Schoeller and
Racette, 1990], involving oral administration and subsequent measurement of elimination of the stable isotopes deuterium
and oxygen-18. Only one study has used a questionnaire to study physical activity in people with SCI [Noreau et al., 1993].
Accelerometers have been used extensively in physical activity assessment studies among the able-bodied, but have not been
validated in people with SCI.
Houston VAMC Rehab R&D Center 15
The objectives of this study are fivefold. First, to validate the use of accelerometry as a measure of physical activity in
people with SCI. Second, to assess physical activity patterns in people with spinal cord injury using accelerometry and a
previously validated questionnaire (Godin and Shephard, 1985). Third, to examine the differences in physical activity
patterns between people with and without SCI. Fourth, to evaluate the effects of aging on physical activity patterns in
people with SCI. Fifth, to examine the differences in activity levels among people with high- and low-level injuries.
The hypotheses of this project are as follows: (1) the accelerometer is a valid instrument for measuring physical activity
in people with SCI; (2) people with SCI are less active than the non-disabled; (3) physical inactivity increases at an earlier
age among people with SCI; and (4) people with high-level SCI are less active than people with low-level SCI.
Expected Outcome: Successful completion of this project will impact rehabilitation by: (1) indicating if people with SCI
are less active than the non-disabled; (2) indicating if people with SCI exhibit risk for hypokinetic disease due to physical
inactivity; (3) validating a field-based measure of daily physical activity that can be used by rehabilitation specialists; (4)
determining the effects of age on physical activity and if interventions need to be developed according to age; and (5)
assisting rehabilitation specialists in developing rehabilitation programs that emphasize habitual physical activity, thus
possibly preventing future health and psychological problems. This study will provide the baseline data needed to develop
future projects aimed at elucidating physical activity patterns in people with SCI and the relationship between physical
activity patterns and risk for chronic disease in this population. This research will also assist in the development of physical
activity surveillance studies that address individuals with other types of disabilities. This research will be used to solicit
funding from government agencies such as the NIH and CDC.
Approximately 30 males with SCI will participate in the validation phase of the project (Phase 1). Approximately 75
subjects will participate in the activity surveillance phase (Phase 2) of the project. Subjects will be divided into the
following age groups: 18-30; 31-40; 41-50; 51-65; >65. Five subjects without SCI, five subjects with tetraplegia, and five
subjects with paraplegia will be recruited for each age group (75 total). All subjects with SCI must be able to operate a
manual wheelchair community distances and be at least six months post-injury.
Methods: Neurological impairment will be assessed using ASIA guidelines. Detailed descriptive statistics will be
collected on all subjects. The project will be divided into two phases.
Phase 1: Thirty subjects with SCI will participate in the accelerometry validation study. The current standard for
estimating daily energy expenditure is using dóubly-labeled water. A control urine sample will be taken before orally
administering pre-weighed doses of 2H and 180. Urine samples will be taken 5 hours, 7, 14, and 21 days after dosing.
Isotope concentrations will be measured using mass spectrometry. Subjects will wear Computer Science Application (CSA)
accelerometers during the 21 days of energy expenditure measurement. Summed acceleration movement data in activity
counts, the intensity of movement per unit time will be accumulated over the 21 days. Correlations between accelerometers
and doubly-labeled water will be calculated to determine: (1) the applicability of accelerometers in estimating energy
expenditure in this population; and (2) the best anatomical site for wearing the accelerometer.
Phase 2: Approximately 75 subjects (5 without SCI, 5 with tetraplegia, 5 with paraplegia in each of the 5 age groups)
will wear a CSA portable accelerometer during waking hours throughout a seven day assessment period. Acceleration data
will be collected in 5 second intervals and activity counts averaged over each minute. All subjects will be provided data
sheets to record when the device is worn. Activity will also be assessed using a leisure-time physical activity questionnaire
previously validated by Godin and Shephard [1985].
The validity of accelerometry as a measure of physical activity will be determined using regression analysis. Differences
between activity levels (accelerometer and questionnaire scores) of control and subjects with SCI will be determined using a
5x3 (age group X level of injury) repeated measures ANOVA.
Recommendations for developing physical activity programs in this population will be developed and marketed.
F. Materials and Human Factor Design to Improve Crutches (Holmes, Magee, Krouskop)
Background: Over the past fifty years, there have been monumental advancements in the fields of prosthetics and
orthotics. Space age materials and computer aided design techniques have been used to fabricate a new generation of
artificial limbs and braces which have improved the functionality of persons who have limb loss, neurological or
musculo-skeletal deficiencies. In contrast, the basic design of crutches has been unchanged for millennia. Chronic crutch use
has resulted in fatigue, repetitive stress disorders, nerve trauma and osteoarthritis (1,2). Consequently there is a need for a
Houston VAMC Rehab R&D Center 16
new crutch design that reduces the loading on the upper extremities of chronic users so that the population of aging crutch
users will be better able to retain independence in their mobility.
Objectives: We propose to redesign the crutch so that it supports the wrist in a manner that reduces the likelihood of
injury and incorporates shock absorbing elements that reduce the loads responsible for repetitive stress injury to the upper
extremity joints.
Hypothesis: The hypotheses that will be tested in this project is whether the forces transferred to the hand and wrist of
crutch users can be reduced by designing shock absorbers into the crutch and can the handles used on crutches be designed
to reduce the pressure exerted on the carpal tunnel.
Expected Outcome: The results of this project will be increased understanding of the force transfer from the crutch to
me shoulder of patients who use crutches and a novel design for a new generation of crutches that are more biomechanically
better than current crutches.
Population: Aging veterans who use crutches to assist in ambulation.
Methods: Over a two year period, we propose to explore the utility of space age composite materials, e.g. fiber
reinforced plastics, impact absorbing polymers, and non-slip materials to develop a new generation of crutch that can help
persons with paraplegia, amputees, post-polio survivors, and other chronic crutch users to increase mobility with decreased
risk of damage to the joints of the upper extremity. We will use finite element analysis to evaluate different crutch
geometries and develop a design that can support the hand-wrist-forearm complex in a geometry that reduces the risk of
carpal tunnel pressures and damage to the wrist joint space. Shock absorbing materials such as filled urethanes and
mechanical shock absorbers such as air cylinders will be investigated to design a shock absorbing system that can be
incorporated in the crutch frame to reduce the impact loading on the upper extremity. An advisory group of chronic crutch
users will be convened to evaluate the designs that are developed during the project before the device is fabricated.
The efficacy of the design will be tested in the motion analysis lab at Texas Woman's University to track the hand,
wrist, and forearm movement during ambulation. Only flat surface, indoor walking will be evaluated to minimize the
possibility of injury due to falls. Three-axis accelerometers will be attached to both the crutch and the hand of the user to
measure the reduction in loading achieved. Anti-skid materials developed in the space program will be examined for use in a
new generation of crutch tip that will reduce the likelihood of slip. Tire technology to squeegee water out from under the
contact area will be incorporated into the design of new crutch tips which can be used in wet environments and other
situations where current crutches tend to become unstable.
Summary
In summary, these projects offer the prospect of significantly impacting the practices of rehabilitation medicine for the
management of aging people with disabilities in specific, short-term ways. Successful completion of these projects will be
followed by educational activities aimed at patients and family caregivers as well as health care providers to promote
widespread dissemination. Each project will be carefully evaluated in terms of meeting its objectives as well as its impact on
the clinical management of patients, and will be extensively
disseminated when evaluation is completed, as outlined below.
Utilization
Dissemination
V. Evaluation:
Efficiency
The greatest challenge for this project has to do with efforts to
Outcome/Impact
Outcome
Assessment
evaluate the impact of the Center's research projects on the lives
Practice Outcomer
Patient Outcomer
of aging veterans with disabilities. The success of the Center in
Lawning Outcomes
preventing secondary problems and reducing the risk of veterans
Program Monitoring
Process
Coverage, Delivery
for development of problems related to their disabilities will be
addressed in four ways: structure, process, outcome and efficacy
Structure
Program Design and Key Concepts
Program Effectiveness,
Increased Research
(Figure 7). The structure of the Center (Section IV, Figs. 2-4),
Improved Clincal Skills
Increased Collaborations
which involves initial and ongoing internal and external review of
Program Mission: reduced secondary complications
proposed research, will assure that the research projects relate
Foundation
directly to the goals of the center and that they are
Figure 7. Evaluation Pyramid
Houston VAMC Rehab R&D Center - 17
methodologically sound. In addition, the structure (Fig 3) will facilitate coordination of activities between the three cores
(clinical research and education) and from the beginning, insure that significant findings are incorporated into education and
clinical programs within the VA system and disseminated to the community as a whole. The involvement of the three
Service Chiefs in the Executive Committee to ensure that quality of personnel is maintained.
The process evaluation will be addressed by the Center's co-directors
RESEARCH: eliminate secondary complications TIKS
and clinical and research personnel assigned to evaluation. They will
1. Excellence in targeted research
monitor the ongoing activities of the Center, including progress of the
2. Solicit investigator-initiated proposals
3. continuous evaluation of design, cost, and relevance TD
individual research projects. Included will be the degree to which the goals
4. data base on special requirements
of
and objectives (Table 1) have been addressed. They will review the
5. basis for development of practice guidelines.
methods and procedures for each research project with the project
6. value to clinical practice
directors and will establish time lines for completion of activities. These
CLINICAL PRACTICE: research based practice models
time lines will then be monitored to detect problems related to subject
1. new research collaborations
2. Disseminate research results
recruitment, attrition, material acquisition or other methodological issues.
3. learning environment
The personnel assigned to data management and analysis will work
4. Introduce role models
5. results in a continuum of care.
closely with the research committee and with each project director to
ensure that the integrity of the data is maintained. The statistician will
EDUCATION: practitioners and patients/families
work with each project to establish a data management system that will be
1. programs for patients, family caregivers
2. educate a cadre of clinicians
congruent so that data from different projects can be aggregated across
3. publication and/or educational activities
common variables. In addition, specific methodological consultation will
4. programs/learning activities for professionals
5. patient and staff education/demonstration programs
be available on an as-needed basis.
Outcomes will be evaluated throughout the five-year period of the
Table 1: Summary of Goals/Objectives
grant. Focus will be placed on evaluating patient outcomes. Each project
See Appendix II for full text
will have specific hypotheses or research questions to be addressed that
are outcome related. These outcomes will focus on the prevention and
reduction of risk of secondary problems related to disability in aging veterans. Specific outcomes may reflect increases in
knowledge, changes in attitudes, initiation of new behaviors, development of new assessment techniques or assistive devices.
For instance, in the area of mobility, the outcome measures might include distance traveled (ambulation or wheelchair), time
out of bed, number of steps taken each day; in the area of psychosocial research, the measures might include life satisfaction
scales, depression scales, health beliefs, and locus of control tests. Technology and assistive device utilization measures will
include the time that the device is used, the tasks accomplished by using the device, compatibility with use environments and
various lifestyles. In addition, the clinical core committee, with the directors, will monitor the practice of staff within the
three units involved in the Center. They will monitor the staff to detect improved practice in rehabilitation. In particular, as
projects are completed, they will observe for the implementation of new knowledge, attitudes, behaviors, and technologies
that increase the quality of life of the veterans and their families. In addition, as information from the projects is
disseminated during Years 3 through 5, the educational staff will monitor changes in knowledge and attitudes of those who
attend the educational conferences, seminars, etc. that are expected to arise from this Center.
Finally, the efficacy, of each project will be determined. This will involve looking at the outcomes and costs of the each
project. The Director of the Center will oversee this process with the assistance of the project directors and consultants who
have specific expertise in cost utility analysis. Projects will track such information as cost of developing technology versus
the cost of developing secondary complications because of the lack of technology and the cost of an intervention versus the
cost of care because of the lack of intervention. For example, the cost of emergency visits and hospital admissions for
complications of stroke will be compared for patients and families who receive special home care instructions and those who
do not. This information will be of particular importance when determining the impact of the Center on the practice of
rehabilitation. If we can show that the projects are efficacious we will have a greater impact on the entire rehabilitation
field. This type of information will be included in written reports that detail the experience with the intervention, oral
debriefings between the evaluation team and the research team, and formal presentations of the results of the evaluation
process to the Clinical Advisory Committee.
The ultimate measure of the success of Center will be improved quality of life for aging veterans with disabilities and
their families.
Houston VAMC Rehab R&D Center - 18
VI. Dissemination:
Information targeted to individuals with SCI and their families will be written for journals and newsletters such as SCI
Life, Mainstream, EPVA Action, Accent on Living, Paraplegia News, New Mobility Sports and Spokes, and NCCSCI
Dialogue. Similarly other groups will be targeted to receive results of research; including stroke groups, family/caregiver
forums, etc. Information that is appropriate for database and computer bulletin board dissemination will be sent to Project
Enable, SYNAPSE, Handicap News and Special Needs. A WWW site will be developed by the Rehabilitation Engineering
Specialist for immediate dissemination of information to professionals and consumers. This site will be linked to existing
related sites (Huffington Center on Aging: http://www.bcm.tmc.edu/hcoa/; UT Houston Center on Aging -
GOLIVED
http://sonl.nur.uth.tmc.edu/coa/coa.htm; and others - http://www.sni.net/rehab/Mets/training.htm, etc.). This will be done
similarly to the site developed by the Scientific Director for the Houston Society for Engineering in Medicine and Biology
(http://www.hsemb.bcm.tmc.edu/). A recent news article stated that a majority of the 70,000 purchasers of Web-TV are
older and use it to find health related information. These newer technologies will be explored to find creative ways of
informing and assisting the aging disabled.
Findings directed to rehabilitation professionals will take the form of presentations at professional meetings such as the
American Congress of Rehabilitation Medicine, American Spinal Injury Association, American Academy of Physical
Medicine and Rehabilitation, American Association of Spinal Cord Injury Psychologists and Social Workers, American
Physical Therapy Association, American Occupational Therapy Association, Association of Rehabilitation Nurses,
Gerontological Society of America, IEEE Engineering in Medicine and Biology Society, National Association of
Rehabilitation Counselors, National Rehabilitation Association, International Rehabilitation Medicine Association and the
Rehabilitation Engineering Society of North America. Manuscripts will be sent to appropriate, peer-reviewed journals to
include Journal of Rehabilitation Research and Development, Archives of Physical Medicine and Rehabilitation,
American Journal of Physical Medicine and Rehabilitation, Journal of Rehabilitation, Journal of Rehabilitation Nursing,
Journal of Neuroscience, Stroke, Spinal Cord and Rehabilitation Psychology. In addition, book chapters and edited books
will include the findings of the Center's research.
Other forums for dissemination of
information will include conferences and
teleconferences, workshops and seminars with
outsblish center
published proceedings. Specific projects may
recruit AA, Esse. Cam 1
result in creation of fact sheets, brochures and
Initial project funding -$
video tapes (budgeted in the 3rd through 5th
advisory committees 4
years). Consideration will be given to
develop need grant guidelines .5
development of a newsletter.
need funding requests $
review, selection -7
VII. Timetable
FACTURE celleberatoris
I I I
recruit technical - 10
Establishment of the Center will take place
Initiate, fund - projects profing) 11
over a period of 3 months, during which time
detaboas plat study 12
offices will be set up and administrative staff
- sellection, analysis 13
recruited. The Executive Committee will finalize
EAC of priortties 14
selection of the Review committee and advisory
activities 16
committees, and finalizing guidelines for grant
refine rections procedures 18
submission and review and of criteria for
second phase seed funding 17
recruitment of the faculty practitioners, in
project evaluation 18
collaboration with Clinical Core personnel. A
final report properation . 13
database will be constructed during the first
0
1
2
3
4
5
half-year, and data collection activities
years
continued throughout the life of the Center.
Figure 8. Center Timetable
Houston VAMC Rehab R&D Center 19
Additional proposals will be solicited for review beginning in the sixth month and continuing through the end of the third
year.
A major review of program policies and practices will take place in the end of the third year by the External Advisory
Committee. Following external and internal review, policies will be adjusted as required, and the second phase of funding
begun. Evaluation activities will continue throughout virtually the entire 5-year period. Beginning in the fourth year, new
education/dissemination staff will be recruited.
Funding of individual projects will be staged in over a 3 month period as sub-contracts are negotiated. Faculty
practitioners will be staged in over the first two years to provide an opportunity to assess the effectiveness of the structure
as envisioned.
VIII. Resources
A. Clinical Program
1. Physical Medicine and Rehabilitation Service The Physical Medicine and Rehabilitation Service, the largest within
VISN 16 and one of the largest within the VHA, provides services to veterans in a 27 county area of Southeast Texas. The
Service operates a 40 bed comprehensive rehabilitation inpatient program, inpatient and outpatient consultation services,
electromyographic and nerve conduction studies. Comprehensive rehabilitation programs are provided for patients with such
diagnoses as stroke, neurological disorders, and musculoskeletal disorders through a physician directed interdisciplinary
team consisting of rehabilitation nursing, appropriate therapies, psychologists, and social workers. Treatment delivery is
carried out in the various disciplines supervised by the Service including physical therapy, occupational therapy,
kinesiotherapy, audiology/speech pathology, and vocational rehabilitation therapy. Specialty programs are offered in
cardiac rehabilitation, driver training for the disabled, therapeutic aquatics, pain management, and a sheltered workshop. A
Neuromuscular Function Laboratory conducts research on fatigue and postural disturbances. In each treatment setting the
patients physical, psychological, social and emotional needs are addressed. Additionally, the service is pursuing
accreditation from The Rehabilitation Accreditation Commission. Documentation of compliance criteria is nearing
completion and anticipated site survey is April 1998.
In FY 96, 316 different inpatients were managed on the rehabilitation bed unit. The service responded to over 6500
consultation requests and performed 1200 electroneurodiagnostic evaluations. A total of 84,200 therapy treatments were
provided with about 30% of these rendered to outpatients.
2. Spinal Cord Injury Service: The VA Medical Center, Houston is the only Center in VISN 16 that provides specialized
care for the acute and chronic spinal cord injured veteran. The Service is a component of the Texas/South Central Regional
Spinal Cord Injury System, which is a voluntary multi-institutional group of spinal cord injury services at Teaching
hospitals in the Houston/Galveston area. The system representing these institutions was developed to respond to the need for
early and coordinated referral of the spinal cord injured patient to centers with extensive experience in the treatment and
rehabilitation of spinal cord injury.
Major Functions and Levels of Care The VAMC Houston Spinal Cord Injury Service consists of a 40 bed inpatient
unit, Outpatient Clinic, Home Care Program, Urodynamics Lab, Brain Motor Control Laboratory and Spinal Cord Injury
Research Laboratory. The Service provides intensive medical rehabilitation to acute spinal cord injured veterans, sustaining
medical care for chronic spinal cord injured veterans and independent living services to eligible spinal cord injured veterans
in the community. The Houston VAMC Spinal Cord Injury Service serves a predominantly male population. In addition to
a comprehensive inpatient rehabilitation program including ventilator dependent patients, the Service sponsors a SCI Home
Care Program as well as 14 clinics. These include urology, plastic surgery, wheelchair and orthotics, and recreational,
vocational and training programs.
In FY 96, the SCI Service had 364 admissions, an occupancy rate of 78%, an average daily census of 29.2. and treated
395 patients, with 1891 outpatients. The average length of stay was 30.2 days, and the population was approximately
evenly distributed between those with paraplegia (167) and quadriplegia 9187).
3. Geriatrics and Extended Care Service
Houston VAMC Rehab R&D Center 20
The goal of the Geriatrics and Extended Care Service is to utilize the resources of the VAMC, and where appropriate,
Baylor College of Medicine's Huffington Center on Aging (HCOA) and other resources within the Texas Medical Center
(TMC), to make the Houston VAMC one of the premiere VA centers for the treatment of patients, research and education
in geriatrics and gerontology. The Houston VAMC has been the driving force for development of geriatrics and gerontology
within the TMC and, if "past is prologue," the HVAMC should continue to be a leading force in geriatrics and gerontology.
The Hospital Based Home Care Program - The HBHC is one of the Geriatrics and Extended Care programs
administered by the Department of Veterans Affairs Medical Center. This program delivers primary health care in the
home, through a VA Hospital Based Interdisciplinary Team to homebound and often bedridden eligible veterans whose
caregivers are capable and willing to assist in their care. The program is designed to meet the long-term care needs of the
chronically ill aging veteran population, providing medical care, skilled nursing services, rehabilitation therapy, social work
services, and dietetic services with a focus on supporting and teaching the caregiver to care for the patient. In addition, the
program offers Respite Care, Caregiver Support Group, and Senior Companion Services
Nursing Home Care Units - The 120 nursing home beds are fully in operation. The average number of admissions is 10
admissions per month with an average occupancy rate of 94.8% as compared to 92.7% for last fiscal year. A new falls
program has been implemented in the nursing home care unit.
Education and Research in Long term care The nursing home care unit has been used for training of our geriatric
fellows (2 fellows for FY 93-94), physician assistant students (15), and GNP students. A continuing education program was
developed for the GEC staff. Topics included: Nutrition and aging, nutrition and wound healing, care of gastric tubes,
principles of interdisciplinary care planning, wound care and principles of treatment, drug use in the elderly, dealing with
difficult people, enzymatic wound debridement, nutritional assessment in the elderly and dental care in the elderly.
B. Current Research
At present, the Core faculty have seven VA merit review research projects, listed below:
Effects of Medications on Spasticity in Spinal Cord Injury: A Quantitative Study: Priebe/Sherwood; Prevention of Recurrent Pressure Ulcers after
Myocutaneous Flap: Holmes; Use of Tretinoin to Prevent Pressure Ulcers in Spinal Cord Injury Patients: Markowski; UTI Prophylaxis Using Bacterial
Interference Following SCI: Darouiche; Recurrence of Bacteriuria and Progress to Symptomatic UTI in SCI Patients: Darouiche; Upper Limb Amputee
Services: The VA Approach as a Model Service System: Monga; An Objective Indicator of Risk of Developing a Pressure Ulcer: Wilson
C. Affiliations: Interinstitutional Collaboration
Because of the VAMC's strategic location in the Texas Medical Center (TMC) and its proximity to several institutions
of higher learning, the opportunities for interinstitutional collaboration are outstanding. The investigators who will be part
of the proposed Center have enjoyed many collaborative relationships in the past with the 26 institutions and organizations
in the TMC.
1. Baylor College of Medicine (BCM): The VAMC is an affiliated teaching hospital of BCM. Most of the VA
personnel are BCM faculty, either in the Department of Physical Medicine and Rehabilitation (PM&R) or the Huffington
Center on Aging (HCOA). Baylor has the necessary clinical, educational and research resources necessary to support the
proposed work.
a. Physical Medicine and Rehabilitation: The most prominent collaboration is with PM&R and The Institute for
Rehabilitation and Research (TIRR). This collaboration draws upon nearly 35 years of effective efforts in addressing the
needs of persons with severe disabilities, particularly SCI. The PM&R/TIRR collaboration allows for rapid access to
clinicians, academicians, researchers, and educators from a variety of disciplines through an affiliation agreement that, in
effect, allows institutional boundaries to be overcome in the completion of mutually agreed upon projects. Recently an
agreement between the University of Texas-Houston Medical School's PM&R Department and Baylor's PM&R
Department resulted in the creation of an Alliance which effectively merges these two departments, thereby further
strengthening the overall efforts.
Furthermore, the staff of the Center will have direct access to resources of the Texas Model Spinal Cord Injury System
and the Brain Injury Research and Prevention Center (BIRC), both based at TIRR, as well as the Research and Training
Center on Independent Living at TIRR and the Region VI ADA Disability and Business Technical Assistance Center (both
operated through TIRR's ILRU Program). The BIRC also Houses the U.S. Department of Education National Institute for
Rehabilitation and Research's Rehabilitation Research and Training Center on Interventions in Traumatic Brain Injury.
Houston VAMC Rehab R&D Center 21
Access to these resources provides avenues for collaboration with provider organizations, consumer groups, and advocacy
organizations throughout the Southwestern United States and nationally.
Educational opportunities are greatly enhanced by virtue of the recently approved Master of Science n Rehabilitation
Technology, which seeks to contribute to the education of health care providers better prepared to utilize new technologies
in care and treatment of persons with disabilities, and who can contribute to the next generation of technological tools that
are needed to better serve our country's population of people with physical disabilities. The program combines didactic,
clinical and research phases for a student body drawn from a variety of related backgrounds.
b. Huffington Center on Aging The mission of the Huffington Center on Aging (HCOA) is to improve the condition of
older people through the programs of research, education, and training in BCM Departments, Institutes, Divisions and
Centers, and other institutions in the Texas Medical Center; to disseminate the knowledge gained by this research and apply
it to the care of older people; and to increase the number of academic geriatricians and gerontologists. The HCOA combines
vigorous and award-winning basic and clinical research programs to effectively address the needs of the geriatric
population. Research teams in cell senescence and geroethics were awarded two prestigious U.S. awards in gerontology.
The HCOA was one of seven aging centers in the U.S. awarded grants by the John A. Hartford Foundation for an exciting
new initiative to add more geriatric teaching to internal medicine and family practice residencies. The Texas Consortium of
Geriatric Education Centers headquartered at Baylor College Medicine continues to be one of the top GECs in the country.
2. University of Texas-Houston Health Science Center: Center on Aging
The Center on Aging at the University of Texas-Houston Health Science Center (UTHHSC) is committed to providing
leadership for the initiation, coordination, and facilitation of interdisciplinary aging-related research, education, and
community service programs within the UTHHSC, as well as for academic institutions, community agencies and
organizations, and the health care service providers throughout Texas. The Center is committed to the following goals: 1)
initiate and support interdisciplinary research projects that optimize the well-being of older adults and their caregivers; 2)
share research findings and successful educational models that contribute to the improvement of health care provided to
older adults; 3) develop and support interdisciplinary professional and continuing education programs that enhance the
knowledge and skills of current and future health care providers; and 4) advocate for equal access to high quality and
culturally competent health care for all older adults. The Center is a part of the Texas Consortium of Geriatric Education
Centers and initiated the formation of a state-wide Alliance of Geriatric Education Centers. The Center has a contract with
the Area Agency on Aging to run the federally-mandated Long Term Care Ombudsman Program for all of Harris County.
It also houses the Joseph C. Valley, Sr. Memorial Library, a collection of aging-related books, journals, videos and other
materials, that is open to the health care professionals of the Houston-area.
D. Facilities and Equipment
The Center's activities will be localized primarily in the PM&R Service and the SCI Service of the Houston VAMC,
described above. The Center offices will (initially) be housed in space immediately adjacent to the PM&R In-patient
Nursing Unit, in Rooms 2B-152 and 2B-154. These rooms, comprising a total of 400 square feet, will be used to house the
Scientific Director and his administrative assistant, and will provide space for faculty practitioners from affiliated
institutions. In addition to the clinical facilities described above, the Center will incorporate laboratories already in
existence, including the BMCA Laboratory, the Urodynamics Laboratory, the Muscle Function Laboratory and will make
use of facilities at other existing laboratories such as the Collagen Research Laboratory at Baylor will be available to
support projects within the Center. Major equipment in these laboratories include an isokinetic dynamometer, a postural
measurement system, a multichannel EMG system, a 32-channel evoked potential system and a urodynamics flow and
pressure measurement system. The Collagen Research Laboratory equipment includes scintillation counter, HPLC
chromatograph, electrophoresis equipment, spectrophotometer, refrigerated centrifuge and analytical scales.
In addition, new laboratories, developed through private foundation funding, are being transferred to the VAMC
(scheduled for mid-June) which will enable comprehensive sensory examination using both evoked potential (visual,
auditory, somatosensory) and sensory quantification techniques, and motor control using EMG amplifiers with a 16 channel
inkjet recorder (Siemens Mingograph) and several 16- and 32-channel analog-to-digital computer systems, interconnected in
a local area network with a total of 10 gigabytes of hard disk storage and a combination of SGI Unix workstations and
pentium-based PCS, along with appropriate mass storage on DAT and CD-ROM.
Houston VAMC Rehab R&D Center 22
VIII. Literature Cited
Bedbrook GM (Ed.) (1985). Lifetime care of the paraplegic patient. Edinburgh: Churchill Livingstone.
Berggren-Thomas P. Griggs MJ. Spirituality in aging: spiritual need or spiritual journey?. Journal of Gerontological
Nursing 1995 Mar;21(3):5-10
Berkowitz M, Harvey C, Greene CG, & Wilson, SE (1992). The economic consequences of traumatic spinal cord injury.
New York: Demos.
Bruce ML. Seeman TE. Merrill SS. Blazer DG. The impact of depressive symptomatology on physical disability:
MacArthur Studies of Successful Aging. American Journal of Public Health 1994 Nov;84(11):1796-9
Butt L, & Fitting, M (1992). Psychological adaptation. IN: GG Whiteneck, SW Charlifue, KA Gerhart, DP Lammertse, S
Manley, RR Menter, & KR Seedroff (Eds). Aging with spinal cord injury. New York: Demos.
Conlin MM. Essentials of geriatric care. Primary Care; Clinics in Office Practice 1980 Dec;7(4):595-605
Corbet B (1987). The options group: Perspectives on aging with spinal cord injury. New York: North American
Reinsurance Corporation.
Covey SR. The seven habits of highly effective people. National Medical-Legal Journal 1991 2nd Quarter;2(2):8
Gerhart KA (1992). Personal perspectives. In: GG Whiteneck, SW Charlifue, KA Gerhart, DP Lammertse, S Manley, RR
Menter, KR Seedroff (Eds). Aging with spinal cord injury. New York: Demos.
Halstead LS, Rossi, CD (1987). Post-polio syndrome: Clinical experiences with 132 consecutive outpatients. In: LS
Halstead & DO Weichers (Eds). Research and clinical aspects of the late effects of poliomyelitis.
Harris R. Harris S. Therapeutic uses of oral history techniques in medicine. International Journal of Aging & Human
Development 1980-81;12(1):27-34
Healthy People 2000: National Health Promotion and Disease Prevention Objectives Public Health Service, Publication
#017-001-00473-1, Government Printing Office: Washington, D.C., 1991.
Hoffman C, Rice D: Chronic Care in America: A 21st Century Challenge, Prepared by the Institute for Health and Aging,
University of California, San Francisco for The Robert Wood Johnson Foundation, Princeton, New Jersey, August,
1996.
Hohmann GW (1982). The challenge of gerontology in spinal cord injury. Craig Hospital: Fifth annual John S. Young
lectureship. Englewood, CO.
Krause J, Crewe N (1991). Chronologic age, time since injury, and the time of measurement: Effect on adjustment after
SCI. Archives of Physical Medicine and Rehabilitation, 72, 91 -100.
Menter RR, Hudson LM (1995). Effects of age at injury and the aging process. In: SL Stover, JA DeLisa, and GG
Whiteneck (Eds). Spinal cord injury: Clinical outcomes from the model systems.
Naus P. The elderly as prophets. Hospital Progress 1978 May;59(5):66-8, 72
Pawlson LG, Brody SJ: Rehabilitation and Geriatric Education: Perspectives and Potential, Conference Report,
December 4-7, 1988, Arlington, VA, The Circle, Inc: McLean, VA.
Reynolds GG (1992). Becoming successful health care consumers. In: GG Whiteneck, SW Charlifue, KA Gerhart DP
Lammertse, S Manley, RR Menter, & KR Seedroff (Eds). Aging with spinal cord injury. New York: Demos.
Shock NW, Greulich RC, Andres R, Arenberg D, Costa PT, Jr., Lakatta EG, Tobin JD: Normal Human Aging: The
Baltimore Longitudinal Study of Aging (BLSA). (from the Gerontology Research Center, NIA, NIH). Washington DC:
US Government Printing Office, 1984.
Smith I (1989). Aging with spinal cord injury. Rehab Management, June/July, 28- 35.
Thiyagorajan C, Silver, JR (1984). Aetiology of pressure sores in patients with spinal cord injury. British Medical Journal,
289, 1487-1490.
Houston VAMC Rehab R&D Center - 23
Trieschmann RB (1987). Aging with a Disability. New York: Demos.
Weeks L. Starck P. Liehr P. LaFontaine K. (1996) Graduate nursing education. What are the benefits and costs to
hospitals? Journal of Nursing Administration 26, 20-30.
Whiteneck GG (1993). A proposal for a rehabilitation research and training center in aging with spinal cord injury. An
unpublished research proposal. Englewood, CO: Craig Hospital.
Whiteneck GG, Charlifue, SW, Gerhart KA, Lammertse DP, Manley S, Menter RR, Seedroff KR (Eds.) (1992). Aging
with spinal cord injury. New York: Demos.
Young JS, Burns PE, Bowen AM, McCutchen R (1982). Spinal cord injury statistics. Phoenix, AZ: Good Samaritan
Medical Center.
Zarb GJ, Oliver MJ, Silver JR (1990). Ageing with spinal cord injury: The right to a supportive environment. London:
Thames Polytechnic/Spinal Injuries Association.
Literature Cited by Individual Projects
A. Intervention to Reduce Pressure Ulcer Risk (Rodriguez, Rintala, Garber, Markowski)
1. Richardson RR, Meyer PR (1981) Prevalence and incidence of pressure sores in acute spinal cord injuries. Paraplegia
19:235-247
2. Young JS, Burns PE (1981) Pressure sores and the spinal injured. SCI Digest 3:11-23
3. Wharton GW, Milani JC, Dean LS (1987) Pressure sore profile: Cost and management. ASIA Abstracts Digest 1987:
115-119
4. Rodriguez GP, Claus-Walker J, Kent MC, Garza HM (1989) Collagen metabolite excretion as a predictor of bone- and
skin-related complications in spinal cord injury. Arch Phys Med Rehabil 70:442-444
5. Daniel RK, Priest DL, Wheatley DC (1981) Etiologic factors in pressure sores: An experimental model. Arch Phys Med
Rehabil 62:492-498
6. Crenshaw RP, Vistnes LM (1989) A decade of pressure ulcer research: 1977-1987. J Rehabil Res Dev 26: 63-74
7. Rodriguez GP, Garber SL (1994) Prospective study of pressure ulcer risk in spinal cord injury patients. Paraplegia
32:150-158
8. Yu-Tzu MN, Catanzaro M (1987) Health beliefs and compliance with a skin care regimen. Rehabil Nurs 12:13-16
9. Garza HM, Bennett N, Rodriguez GP (1996) An improved rapid method for the isolation, purification and identification
of collagen glycosides. J Chromatography 732: 385-389
B. Malnutrition in the Institutionally Disabled Elderly (Wright, Ghusn)
1. Abbasi, A. and Rudman, D. (1993). Observations on the prevalence of protein-calorie undernutrition in VA nursing
homes. Journal of the American Geriatrics Society 41(2):117-121.
2. Lansey, S., et al. (1993). The role of anthropometry in the assessment of malnutrition in the hospitalized frail elderly.
Gerontology 39:346-353.
3. Kerstetter J., et al. (1992). Malnutrition in the instituthonalized older adult. Journal of the American Dietetic
Association 92:1109-1116.
4. Mion, L., McDowell, J., and Heaney, L. (1994). Nutritional assessment of the elderly in the ambulatory care setting.
Nurse Practitioner Forum 5(1):46-51.
Houston VAMC Rehab R&D Center - 24
5. Keller, H. (1993). Malnutrition in institutionalized elderly: how and why? Journal of the American Geriatrics Society
41(11):1212-1218.
6. Nelson, K., Coulston, A., Sucher, K. and Tseng, R. (1993). Prevalence of malnutrition in the elderly admitted to long
term care facilities. Journal of the American Dietetic Association 93(4):459-461.
7. Hubert HB, Bloch DA, & Fries JF. (1993). Risk factors for physical disability in an aging cohort: the NHANES I
Epidemiologic Follow-up Study. Journal of Rheumatology 20(3):480-488, March.
8. Abbasi, A. and Rudman, D. (1994). Undernutrition in the nursing home: Prevalence, consequences, causes and
prevention. Nutrition Reviews 52(4):113-122.
9. Giovanni, B., Franzoni, S., Rozzini, R., Ferrucci, L., Boffelli, S., and Trabucchi, M. (1994). A nutritional index
predicting mortality in the nursing home. Journal of the American Geriatrics Society 42(11):1167-1172.
10. Sullivan, D., and Walls, R. (1994). Impact of nutritional status on morbidity in a population of geriatric rehabilitation
patients. Journal of the American Geriatrics Society 42(5):471-477.
11. Thomas, D., Verdery, R, Gardner, L., Kant, A., and Lindsay, J. (1991). A prospective study of outcome from
protein-energy malnutrition in nursing home residents. Journal of Parenteral and Enteral Nutrition 15(4):400-404.
12. Mowe, M., and Bohmer, T. (1991). The prevalence of undiagnosed protein-calorie undernutrition in a population of
hospitalized elderly patients. Journal of the American Geriatrics Society 39:1089-1092.
13. Finestone HM, Greene-Finestone LS, Wilson ES, & Teasell RW. (1996). Prolonged length of stay and reduced
functional improvement rate in malnourished stroke rehabilitation patients. Archives of Physical medicine &
Rehabilitation 77(4):340-345. April.
14. Sullivan, D., Moriarty, S., Chernoff, R., and Lipschitz, D. (1989). Patterns of care: An analysis of the quality of
nutritional care routinely provided to elderly hospitalized veterans. Journal of Parenteral and Enteral Nutrition
13(2):249-254.
15. Roubenoff, R., Roubenoff, R.A., Preto, J., and Balke, W. (1987). Malnutrition among hospitalized patients: A problem
of physician awareness. Archives of Internal Medicine 147(Aug):1462-1465.
16. Christensen, K., and Gstundtner, K. (1985). Hospital-wide screening improves basis for nutrition intervention. Journal
of the American Dietetic Association 85:704-706.
17. Mitchell, C. and Lipschitz, D. (1982). Detection of protein-calorie malnutrition in the elderly. American Journal of
Clinical Nutrition 35 (Feb):398-406.
18. Hill, G., Pickford, I., Young, G., et al. (1977). Malnutrition in surgical patients: An unrecognized problem. Lancet
1:689-692.
C. Developing a clinical algorithm in management of sexual dysfunction in people with disabilities (Monga,
Herskowitz, Kerrigan)
1. Monga, TN, Lawson, JS, & Inglis, J., (1986). Sexual dysfunction in stroke patients. Archives Physical Medicine
Rehabilitation 67(1): 19-22.
3. Fugl- Meyer, AR, & Jaasko, L. (1980) Post-stroke hemiplegia and sexual intercourse. Scandanavian Journal of
Rehabilitation Medicine 7: 158-166.
4. Boldrini, P., Basaglia, N., & Calanca, M.C., (1991). Sexual changes in hemiparetic patients. Archives Physical Medicine
Rehabilitation 72, 202-207.
5. Monga, TN, (1993). Sexuality post stroke. In Teasell, R. (ed). Long term consequences of stroke, In State of the art,
Philadelphia, Hanley and Belfus.
Houston VAMC Rehab R&D Center 25
6. Monga, TN, DeForge, DA, Williams, J., & Wolfe, LA, (1988). Cardiovascular responses to acute exercise in patients
with cerebrovascular accident. Archives Physical Medicine Rehabilitation 69: 937-940
7. Monga, TN, Miller, T., & Biederman, H.J., (1987). Autonomic nervous system dysfunction in stroke patients. Archives
Physical Medicine Rehabilitation 68: 630.
8. Monga, TN, Monga, M., Raina, MS, & Hardjasudarma, M. (1986). Hypersexuality in stroke. Archives Physical
Medicine Rehabilitation 67(6): 415-417.
9. Monga, TN, & Ostermann HJ, (1995). Sexuality and sexual adjustment in stroke patients. In: Trilok N. Monga, (ed).
Sexuality and Disability. Philadelphia, Hanley and Belfus.
10. Monga TN: Sexuality and Disability: Past, Present and Future. Key Note Speech. Proceedings, The First
Mediterranean Congress of Physical Medicine and Rehabilitation, Herzliya, Israel, pp. 194, 1996.
11. Monga, TN, & Lefebvre KA, (1995). Sexuality an Overview. In: Trilok N. Monga (ed). Sexuality and Disability.
Philadelphia, Hanley & Belfus, 1995.
12. Derogatis LR: The DISF/DISF-SR Manual. Baltimore (MD): Clinical Psychometric Research, 1996.
13. Bodenheimer C, Kerrigan A, Monga TN: Sexual functioning in lower limb amputees. Proceedings, The First
Mediterranean Congress of Physical Medicine and Rehabilitation, Herzliya, Israel, pp. 200, 1996.
14. Monga U, Monga TN: Sexual and psychologic functioning in head and neck cancer patients. Proceedings, The First
Mediterranean Congress of Physical Medicine and Rehabilitation, Herzliya, Israel, pp. 204, 1996.
15. Monga U, Tan G, Ostermann HJ, Monga TN: Sexuality in head and neck cancer patients. Arch Phys Med Rehabil
1997, 78:298-304.
16. Monga TN, Tan G, Ostermann HJ, Grabois M: Sexual functioning in patients with chronic pain. Arch Phys Med
Rehabil 77:833, 1996.
17. Kerrigan A, Monga TN, Zabransky R: A proposed critical pathway in management of sexual dysfunction in patients
with physical disabilities. Proceedings, The First Mediterranean Congress of Physical Medicine and Rehabilitation,
Herzliya, Israel, pp. 202, 1996.
18. Zinreich ES, Derogatis LR, Herpst J, et. al., Pretreatment evaluation of sexual function in patients with adenocarcinoma
of the prostate. Int J Radiat Oncol Biol Phys 1990; 19:1001-1004.
19. Monga TN, Tan G, Ostermann HJ, Grabois M: Sexuality and Psychological Adjustment in Chronic Pain Patients. Arch
Phys Med Rehabil (submitted for publication).
20 Beck AT: 1970; Depression: causes and treatment. Philadelphia; In Marcella AJ, Sanborn KO, Kamboka V, et al.
Inventories of depression among normal population of Japanese, Chinese Clin Psycol 30:281-297.
21. Speilberger CD, Gorsuch RL, Lushene RE: 1970; Manual for evaluation questionnaire. Palo Alto, CA; Consulting
Psychologist Press.
22. Ware JC, Hirshkowitz M: Characteristics of penile erections during sleep recorded from normal subjects. J Clin
Neurophysiol 1992; 9:78-87.
23. Kessler WO: Nocturnal penile tumescence. Urol Clin North Am 1988; 15:81-86.
D. Improving Outcomes for Stroke Patients: A Psychoeducational Program for Family Caregivers (Ostwald, Hickey,
Lim)
1 Draper BM, Poulos, C. J., Cole, A. M. D., Poulos, R. G., & Ehrlich, F. (1992). A
comparison of caregivers for elderly stroke and dementia victims. J Am Geriatr Soc, 40:
896-901.
Houston VAMC Rehab R&D Center - 26
2. McLean J, Roper-Hall A, Mayer P, Main A. (1991). Service needs of stroke survivors and their informal cares: A pilot
study. J Advanced Ntrsing, 16: 559-564.
3. Hickey, J. V. (1996). Preparation of family caregivers for recovery from stroke: How
well are we doing? J Neurovascular Disease, I(1): 12-20.
4. Gresham, G. E., Duncan, P. W., Stason, W. B. et al. (1995). Post-stroke rehabilitation.
Clinical Practice guideline, No. 16. Rockville, MD: U.S. Department of Health and Human
Services. Public Health Service, Agency for Health Care Policy and Research. AHCPR
Publication No. 95-0662. May 1995.
5. Ostwald, S.K., Hepburn, K., Caron, W., Burns T. Mantell R, Vanloy W, Krasnoff A, Blount K, Reckinger D (1995)
Decreased caregiver burden and negative reactinos to disruptoive behaviors in persons with ADRD: Preliminary Report.
The Gerontologist 35 (Special Issue)
E. Assessment of Physical Activity Patterns in Individuals with Spinal Cord Injury (Holmes, Frey, Harrison)
Assessment of Physical Activity Patterns in Individuals with Spinal Cord Injury
Anson, C.A. & Shepherd, C. (1996). Incidence of secondary complications in spinal cord injury. International Journal of
Rehabilitation Research, 19(1), 55-66.
Blair, S.N., Kohl, H.W., Gordon, N.F., Paffenbarger, R.S. Jr. (1992). How much physical activity is good for health?
Annual Review of Public Health, 13, 99-126.
Centers for Disease Control and Prevention. (1996). A report of the Surgeon General: Physical activity and health:
At-a-glance. Atlanta: CDC.
Centers for Disease Control. (1997). Physical activity and health: A report of the Surgeon General. (on-line),
http://www.cdc.gov/nccdphp/sgr/.
Computer Science and Applications, Inc. (1995). Wrist activity monitor technical manual. Available: CSA, 2 Clifford
Drive, Shalimar, FL 32579.
Dearwater, S.R., LaPorte, R.E., Robertson, R. J., Brenes, G., Adams, L.L., & Becker, D. (1986). Activity in the spinal
cord-injured partient: an epidemiologic analysis of metabolic parameters. Medicine and Science in Sports and Exercise,
18(5), 541-544.
Morgan, W.P. & Costill, D.L. (1996). Selected psychological characteristics and health behaviors of aging marathon
runners: A longitudinal study. Behavioural Science, 17(4), 305-312.
National Instituties of Health. (1996). Physical activity and cardiovascular health consesnus statement. Journal of the
American Medical Association, 276(3), 241-246.
Noreau, L., R.J. Shephard, Simard, C., Pare, G., & Pomerleau, P. (1993). Relationship of impairment and functional
ability to habitual activity and fitness following spinal cord injury. International Journal of Rehabilitation Research, 16,
256-275.
Paffenbarger, R.S. Jr., Blair, S.N., Lee, I.M., & Hyde, R.T. (1993). Measurement of physical activity to assess health
effects in free-living populations. Medicine and Science in Sports and Exercise, 25(1), 60-70.
Powell, K.E., & Blair, S.N. (1994). The public health burdens of sedentary living habits: theoretical but realistic estimates.
Medicine and Science in Sports and Exercise, 26(7): 851-856.
Riddoch, C.J., & Boreham, C.A.G. (1995). The health-related physical activity of children. Sports Medicine, 19(2),
86-102.
Houston VAMC Rehab R&D Center - 27
Rimmer, J.H., Braddock, D., & Pitetti, K.H. (1996). Research on physical activity and disability: an emerging national $
priority. Medicine andScience in Sports and Exercise, 28(8), 1366- 1372.
Schoeller, D.A. & Racette. S.B. (1990). A review of field techniques for the assessment of energy expenditure. Journal of
Nutrition, 120, 1492-1495.
Strawbridge, W.J., Cohen, R.D., Shema, S.J., & Kaplan, G.A. (1996). Successful aging: predictors and associated
activities. American Journal of Epidemiology, 144(2), 135-141.
U.S. Department of Health and Human Services, Public Health Service. (1991). Healthy People 2000: National health
promotion and disease prevention objectives-full report, with commentary (DHHS Publication No.91-50213).
Washington, DC: Author.
Williams, Klesges, R.C., Hanson, C.L., & Eck, L.H. (1989). A prospective study of the reliability and convergent
validity of three physical activity measures in a field research trial. Journal of Clinical Epidemiology, 42, 1161-1170.
Wong, W.W. (1996). Total energy expenditure of free-living humans can be estimated with the doubly labeled water
method. In: Coburn, S.P. & Townsend, D.W. (Eds.), mathematical modeling in experimental nutrition, vitamins,
proteins, methods, advances in food and nutrition research (pp. 171-180). San Diego: Academic Press.
Wong, W.W., Lee, L.S., & Klein, P.D. (1992). Deuterium and oxygen-18 measurements of microliter samples of water in
physiological fluids to hydrogen gas for 2H/1H isotope ratio measurements. European Journal of Clinical Nutrition, 46,
69-71.
Yamasaki, M., Irizawa, M., Komura, T., Kikuchi, K., Sasaki, H., Kai, K., & Ohdoko, K. (1992). Daily energy expenditure
in active and inactive persons with spinal cord injury. Journal of Human Ergology, 21(2), 125-133.
Zhong, Y.G., Levy, E., & Bauman, W.A. (1995). The relationships among serum uric acid, plasma insulin, and serum
lipoprotein levels in subjects with spinal cord injury. Hormone & Metabolic Research, 27(6), 283-286.
F. Materials and Human Factor Design to Improve Crutches (Holmes, Magee, Krouskop)
1. Werner R, Waring W, Davidoff G: Risk factors for median mononeuropathy of the wrist in postpoliomyelitis patients,
Arch. Phys Med Rehab 1989: 70:464-467.
2. Waring WP, Werner RA: Clinical management of carpal tunnel syndrome in patients with long-term sequelae of
poliomyelitis, J Hand Surg. 1989, 14:865-869.
Houston VAMC Rehab R&D Center - 28
CURRENT FUNDS AND FIRST YEAR REQUEST FOR PROGRAM
X
/PROJECT
PRINCIPAL INVESTIGATOR(S)
A. Arthur M. Sherwood, P.E., Ph.D.
B. Trilok N. Monga, M.D.
TITLE OF PROGRAM, PROJECT
Healthy Aging with Disabilities
PERSONNEL
ROLE IN PROGRAM
% EFFORT
CURRENT YEAR
FIRST YEAR
FUNDS
REQUESTED FUNDS
Arthur M. Sherwood, Ph.D., P.E.
Scientific Director
75%
*
Trilok Monga, M.D.
Medical Director
35%
-
Jon Markowski, M.D.
Co-Investigator
10%
-
Robert Luchi, M.D.
Co-Investigator
5%
Henry Ostermann, Ph.D.
Administrative Officer
20%
TBN (GS-6, Step 5)
Administrative Assistant
100%
$35,200
Clinical Core
Paulette Wilson, Ph.D., R.N.
Clinical Core Coordinator
30%
-
Peter Lim, M.D.
Co-Investigator
20%
-
Ann Holmes, M.D.
Co-Investigator
20%
-
Husam F. Ghusn, M.D.
Co-Investigator
20%
-
Kevin Magee, Ph.D.
Rehabilitation Eingineering Specialist
50%
*
Susan Robinson-Whalen, Ph.D. (GS13)
Clinical Psychologist
50%
$36,403
Susan Garber, M.A.
Program Evaluation Specialist
30%
TBN
faculty practitioner
50%
***
TBN
faculty practitioner
50%
***
Research Service Core
Thomas A. Krouskop, Ph.D., P.E.
Research Service Director
10%
*
Rabih Darouiche, M.D.
Associate Research Service Director
10%
I
Daniel E. Graves, M.S.
Biostatistician
25%
*
(TBN -GS-6)
Research Assistant
50%
$16,000
Education Core
Karen A. Hart, Ph.D.
Education Director
10%
*
Carol Bodenheimer, M.D.
Associate Education Director
20%
-
(TBN)
Educational Specialist
#
#
TOTAL
$87,603
CONSULTANT SERVICES
R. Edward Carter, M.D.
$1,000
David P. Cardus, M.D.
$1,000
external reviewers
$750
Research Methodologist
#
TOTAL
$2,750
EQUIPMENT (Justify any item over $3000 on VA Form 10-1313-4)
Pentium 133 mHz, 32 Mb, 4Gb disk computer and software
$3,000
Fax machine
$1,000
HP Laserjet 5
$1,000
TOTAL
$5,000
SUPPLIES (Itemize)
office supplies
$1,600
TOTAL
$1,600
ALL OTHER EXPENSES (Itemize)
travel
$5,000
*
- Subcontract to Baylor
$244,546
*** - Subcontract for faculty practitioners
$50,000
Research Project Contracts
$353,502
TOTAL
$653,047
TOTAL OPERATING EXPENSES
$750,000
VA FORM
10-1313-3
Houston VAMC Rehab R&D Center
Page 3
JUN 1990
29
ESTIMATED EXPENSES OF PROGRAM
X
/PROJECT
DESCRIPTION
$ AMOUNT EACH YEAR
1ST
2ND
3RD
4TH
5TH
PERSONNEL
$87,603
$89,355
$91,142
$125,965
$128,484
CONSULTANT SERVICES
$2,750
$3,000
$4,000
$3,000
$1,000
EQUIPMENT
$5,000
$0
$0
$4,000
$0
SUPPLIES
$1,600
$1,600
$1,600
$1,600
$1,600
ALL OTHER EXPENSES
$653,047
$656,045
$653,258
$615,435
$618,916
TOTAL OPERATING EXPENSES
$750,000
$750,000
$750,000
$750,000
$750,000
Explain differences in the operating expenses between years
Personnel expenses are projected to increase at 2%/year. Additional equipment for training is anticipated for the third year.
Consultant services which cover external reviews will be reduced in the last year as new projects are reduced.
In Year 3, percent effort increases for Hart, and in Year 4, new staff is added and a new computer purchased.
JUSTIFICATION OF ITEMS PAGE 3
Personnel:
(#- Indicates individuals anticipated to begin after the first year. With one exception (Hart), the level of
effort from the named individuals below will remain constant throughout the five-year Center grant period.)
Arthur Sherwood, Ph.D., P.E., will serve as the Scientific Director of the Center, and will be responsible
for the administrative and scientific component of the Center's operation. He has many years' experience
working in an interdisciplinary group as Director of Research, and will work closely with all investigators to
assure their appropriate integration into the system. In addition, he will provide technical support in data
acquisition and analysis as appropriate. Dr. Sherwood will share overall responsibility for management of the
Center with the Medical Director. He will devote 3/4 time to the Center, while remaining active in his personal
research interests in motor control and surface electromyography. Dr. Sherwood will apply the research methods
developed for studies of motor control in SCI to problems of central fatigue, posture and ambulation in aging
disabled subjects.
Trilok N. Monga, M.D., Chief of the Physical Medicine and Rehabilitation Service, will serve as the
Medical Director. Dr. Monga will provide the critical medical direction for assuring that the Clinical core is
focused to accomplish the stated goals. He will work closely with the four Service Coordinators (Drs. Lim,
Holmes, Ghusn and Wilson in PM&R, SCI, Geriatrics and Nursing, respectively) to provide appropriate medical
guidance in Center projects and programs. Dr. Monga will pursue his interests in quality of life issues and muscle
physiology as they apply to the aging disabled veterans. He will devote 3/8 time to these efforts. Together, Drs.
Sherwood and Monga will ensure the effective integration of the Center into the Houston VAMC structure.
The direct involvement of Janusz Markowski, M.D. (Co-Investigator) Chief of the Spinal Cord Injury
Service and Robert Luchi, M.D., (Co-Investigator) Associate Chief of Staff for Geriatrics in the Executive
Committee of the Center will provide the necessary administrative and operational link to assure seamless
integration of the Center activities with the three primary Services (PM&R, SCI and Geriatrics/Extended Care).
In addition, they will participate in the clinical activities and educational and scientific meetings of the Center. Dr.
Markowski is well-recognized and regarded for his expertise in care of the SCI veteran, and has an active,
ongoing research program. He will devote 10% of his time to Center activity. Dr. Luchi is an internationally
renowned expert in the field of geriatrics and, as head of Geriatrics at Baylor, currently has a number of related,
major research efforts ongoing in the field, and will devote 5% of his time to the Center.
Henry Ostermann, Ph.D., the Administrative Officer of PM&R, will serve as the recording secretary of
the Center Executive Committee, and provide general administrative support as needed in Center activity. He
will devote 20% of his time to the Center.
An Administrative Assistant, GS-6 level, step 5, will be recruited to provide support full-time to the
above individuals in the implementation and daily activities of the center. This AA will assist in report preparation
and general administrative issues related to the involvement of outside researchers, including data entry. In
addition, support for preparation of papers and presentations developed from Center projects will be provided.
VA FORM
10-1313-4
Houston VAMC Rehab R&D Center
JUN 1990
30
Page
JUSTIFICATION OF ITEMS PAGE "3" (CONTINUED)
Clinical Core
Paulette Wilson, Ph.D., R.N., (Clinical Core Co-ordinator) Associate Chief of Nursing Service for
Research and Education, will be responsible for overall coordination of clinical activities with the Center. She
will work under the supervision of Dr. Monga as Medical Director, and will assist in implementation of clinical
research, education and service programs. She will work directly with the other staff assigned to the Core and
the faculty practitioners to ensure their effective integration into the clinical programs of the three Services. She
will spend approximately one-third of her time on Center activities.
Three physician coordinators, each representing his/her respective service, will work as Co-Investigators
to assure effective participation of each Service in the Center activities. Peter Lim, M.D., Assistant Chief of the
Physical Medicine and Rehabilitation Service has a particular interest in stroke rehabilitation, which he will
pursue in addition to general coordination duties. Ann Holmes, M.D., the Assistant Chief of the Spinal Cord
Injury Service, is a capable young investigator physician with current merit-review funding and as a SCI
individual herself, has a special interest in promoting further research in SCI. Husam Ghusn, M.D., the Chief of
the Extended Care Service, has a particular interest in studies of muscle mass and its response to intervention in
the elderly veterans, will coordinate activities with the large Geriatrics and Extended Care Services of the
VAMC. Each of these individuals have submitted independent research projects for review and inclusion in
Center programs, and each will devote approximately 20% effort to the Center.
Kevin Magee, Ph.D., Rehabilitation Engineering Specialist, will provide technical support for Center
clinic activities. Dr. Magee's broad background ranging from cognitive science to robotics and computer science
makes him an outstanding addition to the center core staff. He has served a three-year post-doctoral fellowship in
rehabilitation research where he has become very familiar with the research resources in the Texas Medical
Center and particularly Baylor College of Medicine, the University of Texas-Houston Health Science Center and
his alma mater, Rice University. He has been actively involved in developing a new Master of Science degree
program in Rehabilitation Technology at Baylor and will provide a valuable link between those students
interested in applying research results to clinical practice and the proposed Center program. He has also
developed very effective linkages with the school of Occupational Therapy at Texas Woman's University and the
Harris County Hospital District programs in Rehabilitation Medicine. Dr. Magee will help organize the clinical
evaluation of research results. He will design and develop data collection instruments used to evaluate functional
outcomes of research results. Dr. Magee will be involved a total of 50% time.
Susan Robinson-Whelen, Ph.D., Clinical Psychologist, will be recruited to work 50% time in the Clinical
Core. One of the unique characteristics of the veteran's population is the high prevalence of psycho-social
problems such as depression and substance abuse. The focus of the HRR&DC is the prevention of secondary
complications resulting from physical and cognitive impairment. Many of the interventions to be studied involve
patient and family education, biofeedback, and other behavioral modification measures. It is essential that a.
psychologist be a part of the Core clinical team to effectively identify psychological problems, suggest strategies
for dealing with them, implement interventions to address them, and evaluate outcomes in the psychosocial
realm. Dr. Robinson-Whelen will also contribute to the development of instruments that measure psychological
aspects of disability and aging. She will also work to identify factors which place aging disabled veterans at
greater risk of developing secondary problems (depression, e.g.) or hinder their recovery process. She will
consult with other researchers and practitioners in the Center to assist with the development and implementation
of their research and clinical projects.
Susan Garber, M.A., OTR, FAOTA, who will serve as Program Evaluation Specialist, is an
experienced clinical researcher with more than 20 years experience in the Department of Physical Medicine and
Rehabilitation at Baylor. She will be responsible for designing the database to be implemented during the first
year. Ms. Garber will focus on developing appropriate instruments and procedures for evaluating the research
results. She will develop procedures to gather data that can be used to measure: (1) the efficacy of the clinical
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services provided by professionals who use the research results and (2) consumer satisfaction with services
provided. Ms. Garber will devote 30% of her time to Center Core activities.
Two faculty practitioners will be recruited in the first year (anticipated in 4th and 10th months) to work
in the Center at 50% time. These individuals will spend approximately half of the allotted time providing patient
care services to facilitate identification of new research areas, conduct projects and evaluate intervention
strategies and research outcomes. The remaining portion of their efforts in the Center will be devoted to
development of research programs, interaction with medical staff and supervision of students in the clinical
environment. Based on prior experience [Weeks et al., 1996], it is anticipated that these individuals will prove
invaluable in accomplishing the clinical practice, research and educational goals of the Center.
Research Service Core
Thomas A. Krouskop, Ph.D., P.E., Director of Rehabilitation Engineering for Baylor College of
Medicine, will serve as Research Service Director. His vast experience in directing rehabilitation research,
particularly through the Rehabilitation Engineering Center activities at Baylor, will be employed in facilitating the
research conducted through the Center. Dr. Krouskop will devote 10% of his time to these efforts. He is very
familiar with the Texas Medical Center (TMC) environment and will be able to promote interactions and
facilitate collaboration. He will provide direction for the personnel assigned to the Research Service Core, as well
as research design consultation. He will devote 10% of his time to the Center.
Rabih Darouiche, M.D., Director of the Spinal Cord Injury Research Laboratory of the SCIS, will serve
as Associate Research Service Director. Dr. Darouiche has extensive experience in research with 18 funded
research projects, which will greatly enhance his ability to promote and facilitate research in the Center. Dr.
Darouiche is intimately familiar with the clinical laboratory operations and resources available in the VAMC, and
will serve as the primary facilitator for Center researchers needing access to clinical, laboratories. He will devote
10% of his time to this project.
Daniel Graves, M.S., Biostatistician, will serve as the consultant biostatistician for the project. In
addition, he will be responsible for the design and maintenance of the database on aging with disabilities, and will
carry out quality control on the entered data. He will consult with all investigators in the design of research
carried out through the Center, and will assist in analysis as well. He will devote 25% of his time to this project.
Education Service Core
Karen A. Hart, Ph.D., Director of Education of the Department of Physical Medicine and Rehabilitation,
Baylor College of Medicine and Vice-President for Education, The Institute for Rehabilitation and Research, will
serve as Education Service Core Director for the Center. Dr. Hart has extensive experience in the development
and implementation of educational programs and strategies for both professionals and (health-care) consumers.
She will design and implement educational strategies to disseminate both research designs and results as
appropriate growing out of the Center efforts. Because of her strategic location within Baylor and TIRR, she will
be able to draw on multiple resources in staff and facilities to make this process efficient. Dr. Hart will work
together with Dr. Bodenheimer in the development of educational programs. In the third year, she will increase
her involvement to 20% time in order to begin implementation of the educational processes as described in the
narrative. In the fourth and fifth years, she will direct the work of the Educational Specialist to be employed half-
time through the Center, with the anticipation that the Center will engage in significantly expanded educational
programmatic activities during that time.
Carol Bodenheimer, M.D., Staff Physician, PM&R Service, will serve as Associate Education Service
Core Director. Dr. Bodenheimer is the assistant residency training program director for the Department of
PM&R and she recently completed the Master Teacher program and received a fellowship has a strong interest in
education of physicians residents, medical students and other allied health professionals She will assure that the
educational and dissemination efforts of the Center remain appropriately focused on clinically meaningful themes
and topics. She will devote 10% of her time to the Center.
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JUSTIFICATION OF ITEMS PAGE "3" (CONTINUED)
(TBN) Educational Specialist (GS-11, Step 5): This individual will be hired to work 50% time in the
fourth year to assist Dr. Hart in implementation of the educational activities. The Specialist will provide direct
support of educational program presentations, brochure preparation, and similar activities.
Consultants:
distinguished, senior clinician in the field of spinal cord injury with many honors and distinctions. Dr. Carter has a
R. Edward Carter, M.D., Medical Director, The Institute for Rehabilitation and Research (TIRR), is
of agreed to work as a consultant on this project to enable use of his extensive experience, particularly in the areas
respiratory care of SCI, and his growing knowledge of long-term (>20 year) SCI issues.
in the area of his particular expertise, cardiovascular systems behavior. Dr. Cardus has more than 30
David Cardus, M.D., likewise is a distinguished member of the Baylor faculty who has agreed to consult
Scientific Director (Sherwood) of more than 25 years.
experience conducting research in issues of cardiovascular function, and has a history of working with years the
External reviewers will be recruited by the Research Committee on an ad-hoc basis to provide scientific
scrutiny of the submitted projects. They will be drawn from outside the Houston metropolitan area, and will
fees. provide their critique by mail. They will be reimbursed $75 per review, consistent with local VAMC consultation
(TBN): Research Methodologist. Beginning in the second year, we anticipate recruiting senior-level
qualitative research methods and operations research may be utilized.
individuals will be chosen according to Center and project needs at the time. It is anticipated that specialists in
consultant researchers to provide additional support for analysis of data and report generation. Specific
Equipment:
Sherwood, will provide major items of equipment for laboratories and his personal office. Four thousand dollars
The listed items will be necessary to set up the Center administrative offices. The Scientific Director, Dr.
additional staff recruited in that year.
is allocated for an additional computer in Year 4 which will be required to permit the productive work of the
Supplies:
etc. and storage media (CD-ROM, magnetic tape, disks).
In for addition to routine office operation, supplies will be those needed for brochure preparation, mailings,
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