Lyndhurst is one of the only places in Canada with an interdisciplinary peripheral nerve transfer rehabilitation program.
Moving themselves from a wheelchair into bed. Putting on their own contact lenses. Making omelets for their kids on the weekends.
These are some of the goals patients at Toronto Rehab with spinal cord injuries set before undergoing a new surgery and rehabilitation to help them regain the use of their hands.
They’re part of a peripheral nerve transfer program partnership between Toronto Rehab’s Lyndhurst Centre site and Sunnybrook Hospital. Sunnybrook offers the procedure itself, while Lyndhurst offers universal screening to determine who would benefit from the operation and offers a comprehensive rehabilitation program afterward.
Lyndhurst is one of the only places in Canada with an interdisciplinary peripheral nerve transfer rehabilitation program, which has attracted interest from healthcare teams across the country and beyond.
“We’ve had visitors from all over the world come to see what we are doing and how we’re creating great outcomes with these patients,” says Dr. Cathy Craven, Medical Director of the Spinal Cord Rehabilitation Program at Toronto Rehab and Senior Scientist/Neural Engineering and Therapeutics Team Leader at KITE Research Institute.
Dr. Craven and her team recently shared this information more widely through a new paper published in Disability and Rehabilitation. It outlines how she and an interdisciplinary team planned and established the peripheral nerve transfer clinic using a quality improvement lens.
The goal is for the publication to serve as a blueprint for other hospitals. “In the healthcare field, trust and transparency are so important,” says Dr. Craven. “We’re hopeful that by sharing what we’re doing and how we’re doing it, people can emulate it.”
Creating the Peripheral Nerve Transfer rehabilitation program
Peripheral nerve transfer surgery poses several challenges. First, only a minority of people with spinal cord injuries benefit from it. It's also time-sensitive: For many, the surgery needs to be done early after an injury to be effective. And it needs to be followed with months or even years of specialized rehabilitation.
But for patients who are good candidates, it can be life-changing. Being able to use their arms and hands again dramatically increases their independence and ability to reintegrate into the community.
Dr. Craven brought together physiatrists, neurophysiologists, surgeons, and rehabilitation specialists to create Lyndhurst's peripheral nerve transfer program. “I think of myself as kind of an orchestra leader,” she says. “I tried to use my expertise in quality improvement and my role as medical director to bring the best players into the concert hall and put together a rockstar program that best meets patients' needs.”
The process they developed begins when patients with spinal cord injuries come to Lyndhurst. All those patients undergo electromyography (which uses small amounts of electricity to measure nerve and muscle function) to determine whether they're good candidates for peripheral nerve transfer surgery. This screening is done early in patients' care to ensure no one who could benefit from the surgery is missed or offered it too late.
The team then sends patients who can benefit and are interested in the procedure to Sunnybrook. Usually, they’ll have PNT on both arms; less often, only one. In the procedure, surgeons take a redundant nerve from the forearm or shoulder and transfer it to the elbow, wrist, and fingers.
Parvin Eftekhar, an Occupational Therapist and Affiliate Scientist at the KITE Research Institute, provides assessments and education to patients and their families from the pre-operative stage through rehabilitation. That includes helping patients decide whether they want the surgery, coordinating care between the plastic surgery team at Sunnybrook Health Sciences Centre and the long post-surgery rehabilitation process. Eftekhar provides two years of personalized rehabilitation after the operation, and assesses the results for four years afterwards.
Future research
The recently released paper on the clinic’s inception is the first of many studies being conducted on the program, says Dr. Craven. That’s thanks to the fact that several researchers are partially affiliated with the peripheral nerve transplant team, many of whom are also clinicians.
A second paper by Eftekhar is expected to be published this fall. It covers the perspectives of people who received the transplants and their caregivers on the procedure.
Others on the team are studying the outcomes of medical screening, the use of biomarkers to predict recovery, and novel rehabilitation approaches. They're looking for answers to questions, including why some people regain hand use faster than others and which rehabilitation strategies lead to better outcomes.
That research will help improve the way peripheral nerve transfers are offered at Lyndhurst and worldwide. “PNT is very new, and the world is still learning about it,” says Eftekhar. “We want to help lead that understanding.”
This tight feedback loop is critical to the clinic’s success, says Dr. Craven. “This is a great example of what it means to provide care in an academic research hospital. In an academic setting, you can use expertise in quality improvement and patient care and research and combine it to create a better world for the patient.”