Podcast | Episode 15: Dr. Cassandra List on Spasticity Management & Treating COVID-19 PatientsClinical Expertise
Jun 30, 2021
Tracy Davis: Welcome to the Brooks Rehabilitation podcast. My name is Tracy Davis. On this episode, we have on Dr. Cassandra List. She’s a medical director of our stroke program at the Brooks Rehabilitation Hospital University Campus. And she specializes in neuro rehabilitation in spasticity management. In the episode, we actually talk about spasticity, what it is and how we treat our patients with spasticity. And we also talk about her time treating COVID-19 patients, whenever we had our COVID unit here at the hospital, she was the lead physician.
Additionally, we talk about what led her to become a physical medicine and rehabilitation physician, some of her schooling experience and what actually wound up bringing her to Brooks. And we also talk about her experiences using these Cyberdyne hybrid assisted limb on stroke patients. We really appreciate you listening to the episode and wants to remind you to go to BrooksRehab.org, to find out more about who we are and what we do. And also you can find us on any social media platform just by looking for @BrooksRehab. Let’s get right into the episode. Dr. List, thanks for coming on the podcast. You want to introduce yourself to everybody?
Cassandra List: Yes. So my name is Cassandra List. I am a physical medicine and rehabilitation doctor. I specialize in neuro rehabilitation and spasticity management. I currently serve as the stroke rehabilitation program director here at Brooks, also as the spasticity medical lead.
Tracy Davis: Great. And so how long have you been at Brooks now?
Cassandra List: It’s going to be almost two years.
Tracy Davis: Two years, wow.
Cassandra List: A year of that was COVID though, so.
Tracy Davis: Oh, that’s true. Yeah, that’s right. And we’ll talk about that in a minute. So just tell me a little bit about leading up, why did you want to get into this field?
Cassandra List: To rehab?
Tracy Davis: Yeah, to rehab, PMNR, yeah.
Cassandra List: Sure. So I was one of those people in medical school who tended to like a lot of the medical specialties. I would go on one rotation, I would like that. And then I’d go on another rotation, and I’d like that. And so I finally had to hunker down and say, well, what is it that I really like? And I really tried to figure out what type of patient I wanted to work with. And what I liked about rehabilitation is that it really is a holistic way to practice medicine because you have to ask those questions about, what is it that you enjoy doing? What is it that affects your life? How does that influence how you function? And so that’s where I found my home in rehab is because we really have to take the whole picture of the patient in order to give them the best recovery possible.
Tracy Davis: Was there a specific time, were you shadowing a PMNR somewhere that you kind of, it just clicked that this is really what’s interesting me?
Cassandra List: Yeah. I was in Chicago at the time in medical school and we actually didn’t have a rehabilitation rotation at my hospital, at my medical school. So I’d actually go and seek it out. So I read about it on paper and then I had to figure out, well, was this really where I fit in. So I arranged for a rotation and that’s where it really clicked. And it so happened to be a neuro rehabilitation specialist, a physiatrist specializing in neuro rehab. And what I found later, which I didn’t realize at the time, rehab is such a broad field. We work with spinal cord injury, amputation, pain management, sports. So I thought I had found my home in rehab, but even at that moment, I found my home in neuro rehab. So I really specifically liked what he was doing. And then from there I went on to do a few rotations. I even rotated at Shirley Ryan AbilityLab, which was formerly named RIC. And just to see the diverse environments from inpatient to outpatient rehab, especially neuro rehab, it was really just secured my decision.
Tracy Davis: Right. So what was the university you went to? What is it like being in Chicago?
Cassandra List: Oh, Chicago is great.
Tracy Davis: I love Chicago.
Cassandra List: Yes. I went to Loyola for undergrad and then I stayed at the University of Illinois in Chicago for medical school. I did my training in Milwaukee at the Medical College of Wisconsin and I stayed on for fellowship in Milwaukee for an extra year. But Chicago … I’m originally a Floridian, but I spent so much time in the Midwest that it’s really a part of my home. So it was great. Sometimes I say, I could have gone to medical school anywhere. Because all you’re doing is going to school, library, but when you did have those breaks, it was nice to explore the city.
Tracy Davis: Right. So tell me, after you were graduated and everything like that. When did Brooks come into the picture?
Cassandra List: Yeah, so I was thinking about coming back to the Southeast. I wasn’t sure if I wanted to come back specifically to Florida, but I just wanted to be closer to home. And Brooks had such a great reputation, so much so that the people that I was working with at the time in Milwaukee were telling me about Brooks and what a great institution it was. And so I reached out to some people I knew and I got in touch with some of the physicians here and got more information and piece by piece, everything worked out. So all I heard was how patient centered it is and what resources they have for their patients. So I really wanted to work in an organization that was very much focused on the patient and that’s what I found.
Tracy Davis: So what is your experience been like since being at Brooks? For almost two years, even maybe outside of the COVID stuff necessarily for now, but what’s your experience been with our whole system and everything that’s at your disposal as a physician.
Cassandra List: It’s been great. Everything that I had been told before I came here was accurate, which is, of course, when you’re starting a new job, you don’t really know what you’re getting into.
Tracy Davis: What’s really real and what’s the marketing-
Cassandra List: Right. Exactly. So everything has been accurate, which has been great. And not only that, but I’ve just learned so much more than I could even comprehend at that time. Just the amount of resources that they have. So from an inpatient perspective, the equipment that the patients can use and have access to, to the outpatient, to having the Aphasia Center, the Clubhouse, the Brain Injury and Spinal Cord Day Treatment Programs. Their recovery doesn’t stop when they leave the hospital.
So I can have a patient who has been through the Brooks system from beginning to now outpatient, from leaving their acute hospital now to outpatient, I’ll explore multiple resources and then continue their long-term recovery through some of our wellness centers. But not only that, but having somebody who maybe just moved to the area and then just be like, look, this is all the things that we can get you involved in. It’s up to you how much you want to do. You want to just do some recreation with adaptive sports? Let’s do that. You want to get into the aphasia center? Let’s do that. So you can really cater to the patient’s wants and needs.
Tracy Davis: Yeah. I don’t even know what’s close to us that even offers all the things that we do offer. It’s not even in Florida or I don’t even know how many states you’d have to go, but it’s very unique.
Cassandra List: It is unique.
Tracy Davis: And we talk about that a lot here on the podcast, but I mean, it is such a huge thing that makes us different than anywhere else. So tell me about the becoming the stroke medical director. How did all that happen? Why did that kind of shift?
Cassandra List: Yes. So as you know, I was trained in neuro rehab, so I’ve always focused on the neuro rehab. As I started to be more of a part of the team here and Dr. Shah was actually moving down or he is moving down to our new hospital, the Bartram Hospital. And so Dr. Paris approached me to see if I would consider taking over the stroke program here and I can’t tell you how excited I was to hear that. It was really, I was humbled and honored and to work with the team. And my focus has been not only maintaining and growing our already great stroke program, but also growing our outpatient stroke program and how we can provide the resources that our outpatients need.
Tracy Davis: Especially after you only been being here for a year or something at that point, that’s awesome. That’s so cool. So tell me a little bit about, you are the point person, the main doctor, for our COVID unit and everything like that. What was that experience like?
Cassandra List: Trying. It was trying. It’s been a trying year for everybody on all fronts, whether you had to work because you were an essential worker or you were out of work or you had to stay at home. It’s just been craziness, as we all know, but the team that I worked with on the COVID unit, they really were the best people to work with. We now see COVID so differently than we did at that time. But if we put ourselves back to that moment where there was, we still don’t know everything, but at that moment, we didn’t know anything.
So they really put themselves, volunteered to be on the forefront of, well, whatever comes our way, we’re going to manage it. And these patients need us and they have been through the worst and they are now on the other side of COVID and recovering. And we’re learning about how to best rehabilitate these patients, but we’re going to give it our all. And it was a trying experience, but a great experience at the same time. I’m sorry we had to go through it, but it was great to see the best of our healthcare teams come out in rehab.
Tracy Davis: Yeah. And especially since these are patients that just happened to have COVID, but they still really needed our services, right?
Cassandra List: Exactly. And it was a mix of patients as well, because it was the patients who were COVID recovered. So they’ve been through the worst of COVID, but they were very, very, very weak. Weak in ways that we haven’t seen in other patients. It’s just the way that it affected their muscles is really pronounced. But then it was also people who just so happened to have COVID. So maybe they had a spinal cord injury, and while they were in the hospital or while they were getting care, whatever it might be, ended up getting COVID as well.
So now you’re not only rehabbing the COVID part of it, but you’re rehabbing their initial injury, their spinal cord injury and how do those two correlate. And not only that, but then things we rely so much on family support and training the family moving forward, how are you going to best help your family member? And with the lockdown, it was very hard to make sure that we’re providing the adequate resources for the families and making sure that they’re comfortable during a time where it’s, you have to be quarantined from them. How do we assist you?
Tracy Davis: Right. And especially because the hospital, we didn’t have family members coming in for a very long time.
Cassandra List: Correct.
Tracy Davis: So, yeah. I’m sure there was a lot of obstacles to tackle.
Cassandra List: Yes. I mean, you hear stories of people, and they’re not far-fetched stories, just, you dropped your family member off at the emergency room and that was it. You didn’t know what was going to happen after that. And so now we’ve lifted a lot of the visitation restrictions in a lot of the hospitals and family members are able to at least see day to day what’s going on with their loved one, which is a stress reliever in itself.
Tracy Davis: Absolutely. So let’s talk about the actual structure of the unit itself. How was it constructed? How was it different than the rest of the hospital?
Cassandra List: So our executive team went straight to work once the pandemic hit and we realized that we were going to be needing to rehabilitate these patients who have recovered from COVID, or for different reasons. And so they went to work to see how we can keep the patients safe. How can we keep the staff safe and how can we keep the rest of our hospital safe? So they constructed a wing, they blocked off a wing of our hospital dedicated to COVID positive patients and made sure that all of our staff members were ready with PPE and knew how to take on and off the PPE. And there was also a dedicated elevator for these patients. So it really was a locked unit where the patients were still getting access to appropriate nursing, therapy, care, but it was a dedicated team for these patients. So like I said, we were all in the trenches together, going through it and learning from each other.
Tracy Davis: Yeah. Absolutely. I definitely saw in-patient really come together and realize that, we’ve got something big to tackle here but we can do it as a team. So that’s excellent. So we talked about the, how COVID effected inpatient patients. How did COVID overall affect the outpatient patients that you see?
Cassandra List: Yes. So certainly in the outpatient, we were affected as well. We, like many other clinics and hospitals, really limited the number of patients that we’re seeing in the outpatient basis. Certainly we had a whole telehealth clinic go up. So we made sure to be able to access our patients as much as we could, but we definitely had limitations in our clinic visits. And so when we did start seeing our clinic patients back, just more their routine rehab follow-ups, I started to notice this trend of how patients were noticing how much weaker they were.
And when I started talking to them about it, we realized, and these are patients who were not necessarily diagnosed with COVID. These are patients who had a brain injury or spinal cord injury or stroke, but they noticed that over the course of the pandemic and being isolated and not being able to access some of their normal routine they’d had started to lose function. And what we started to realize is that a lot of these patients are patients who were in our neuro recovery center several times per week, using their equipment and really putting their all to staying strong and when-
Tracy Davis: Very dedicated patients down there.
Cassandra List: Exactly, exactly. And when they didn’t have access to those resources, we saw that they really started to lose function and they weren’t as strong and as independent as they were. So now they’re coming to me and they’re like, doc, I don’t know what’s happening, but I can’t do the things that I used to be able to help my wife when I transferred out of the wheelchair and now she’s got to do the bulk of the work and helping me get out. And again, what we realize is that there is a lot of work when you’re living with a disability to even maintain the function that you have. So it’s not always just about getting better. There’s a lot of work to be had about maintaining what you have. So I really think that that came through the pandemic is, again, to go back to all the resources Brooks offers is, really take advantage of those resources to not only get better, but just to maintain.
Tracy Davis: And I’m sure there was a lot of adaptive sports stories around the same kind of thing, they weren’t doing their programming as much early on.
Cassandra List: Right. And I mean, of course this is applied to people without disabilities. We all have to stay active, stay healthy, do whatever we can to try to prevent illness from happening. But it certainly in our patients who have disabilities, which is the primary patient population that I work with, it just requires that much more effort to maintain what they have.
Tracy Davis: Great. So let’s move on to the talking about spasticity. So that’s one of your specialties, right? So I think that it’s something that a lot of people … people know what a stroke is and all these other, but when they hear that term, they don’t really know what that means. So what does that mean? What type of patients does that affect? What is it?
Cassandra List: Sure. So the exact definition is a velocity-dependent increase in tone. So what a lot of people will talk about muscle tightness, contractures will sometimes be a word that gets thrown around. What it is, is when there’s been any damage to either the brain or the spinal cord, you’re vulnerable for the muscles to start firing on their own and that’s what we call spasticity. So the muscles get tight because they start to fire on their own because the brain or the spinal cord aren’t communicating with the muscles like they used to.
So they just kind of do what they want and what they want is to get tight because they start contracting, contracting. So a lot of people who have had a brain injury, whether it be a stroke, a traumatic brain injury, if they’ve unfortunately had a brain tumor, multiple sclerosis, which can also affect the spinal cord region or a spinal cord injury, again, traumatic or non-traumatic, are vulnerable to having spasticity. And so we tackle it in a few different ways. And again, we just try to figure out how it’s impacting the patient and how it’s impacting their function. How is it impacting their loved ones and helping to care for the patient? And that’s how we address it.
Tracy Davis: So whenever you have a patient with that, how do you start tackling that as far as bringing in a therapist and how does that whole process work from the team approach side?
Cassandra List: So I tell patients when we’re talking about spasticity, there are several different things that we can do and it’s just a matter of what works for them. So therapies are certainly key, just being able to stretch and move the arm or the leg or the body part that is tight. Bracing options with the therapist, as well as medications. And these would be things like muscle relaxers. And there are a few that we pick and choose for specifically for spasticity type muscle tightness. That might be different than say, if you pull your back.
And then when those things don’t seem to be cutting it, or we’re expecting the spasticity to be a little bit more prominent than we talk about things like botulinum toxins or intrathecal baclofen pumps. And so what specifically botulinum toxins are, is you take about an acupuncture sized needle and you’re going into the muscles that are tight. So you come up with a plan in conjunction with your therapy team. So I’m constantly in communication with our therapists regarding how are they doing in therapy? Which muscles are getting in the way and when they’re trying to walk, are they hitting their foot on the ground, is the foot pointing down and in, are the toes curling-
Tracy Davis: And that’s telling you what muscle is tight and not allowing the flex to happen while they’re walking?
Cassandra List: Exactly, right. So as they’re telling me this, I’m drawing up a plan in my head, which are the most problematic muscles, which one are the ones that we need to attack? Same thing with the upper body. So, are they having a hard time even pulling the arm open so they can’t get in and clean the elbow or they can’t even open the fingers because the fingers are so clenched tight that you can’t open and cut the fingernails. So these are the things, information that I’m gathering from the families, the patient and the therapist, just to get a big picture of what their spasticity and their function, how are those interfering with each other? And then I come up with a plan as to what I think would be beneficial. And we talk about the risks and benefits of the botulinum toxins and how we can make it better. And then we go in and inject a little bit of medication in each of the muscles.
Tracy Davis: That’s great. That’s amazing. We talked a little bit about the pumps and stuff like that earlier. So can you talk a little bit more information about that? What exactly is that?
Cassandra List: So the intrathecal baclofen pumps are another way that we help to tackle the spasticity. And with everything that I talked about, it doesn’t mean that we just have to do one thing. It’s usually a combination of things.
Tracy Davis: I wasn’t going to attempt to pronounce that.
Cassandra List: We call it ITB for short. Intrathecal baclofen pumps. So what it is, it’s about a hockey puck size metal pump that gets surgically implanted into your belly.
Tracy Davis: So it’s not on the outside?
Cassandra List: It’s not on the outside. It sits right under your skin. Most people it’s not too prominent, but some people you can see the little outline of the pump. And then there’s a catheter that goes, still, under the skin all the way to the back. And what it does is it delivers that medication, the baclofen, in micro, micro doses, straight to where the specificity is originating from, which is a spinal cord region. So it helps to calm the spasticity or the muscle tightness directly on where it’s being generated. So the benefit is that you’re delivering a lower dose of the medication, but it’s more effective just because of where it’s being delivered. So you’re not as vulnerable to getting the side effects that we commonly see with baclofen like feeling sleepy or groggy, not everybody-
Tracy Davis: It’s not going throughout your whole system, like if you were to take a tablet or something.
Cassandra List: Exactly. So it’s a great therapy in the right patient. And so that’s something else that we do here in our clinic.
Tracy Davis: So we kind of touched on it a little bit, but I just kind of popped in my head. Tell me about the physician, therapist, nursing, CNA, kind of the team act approach to how that happens on the floors and just anywhere in your experience.
Cassandra List: And I will tell you, that’s another thing that brought me to rehab was that interdisciplinary team approach to caring for the patient. Because when we talk about treating a patient holistically I’m not a professional in each of those areas. I’m not a nurse, I’m a physician. I’m not a physical therapist, I’m a physician. So my role is to oversee the team and their rehabilitation, but the physical therapist specialized in physical therapy and they’re going to be coming up with a plan that they think is best for you from a physical therapy standpoint, based on their expertise. And so we’re all in constant communication and collaboration and how we can all work together to get the best outcome for each of our patients. And the nurses, as well, are critical. They’re doing a lot of our patient education from just the day-to-day standpoint of their medications, if it’s pressure reliefs and how to do those. Keeping us as continent as possible, or coming up with plans for the bowel and bladder management, which are usually big issues for our neuro rehabilitation population.
So we all are working in constant communication. How, as a physician, am I trying to keep them continent as from a medical standpoint? How can we attack their bladder a little bit better? And the nurses are working to implement those specific instructions as to how we can and then giving me feedback on, well, we tried this and it didn’t quite work out. How can we adjust? And then the therapy team is also in the bathroom, helping to toilet them and noticing other things. So we put all that information together to give, again, the best outcomes that we can.
Tracy Davis: That’s amazing. So whenever it comes to the actual therapy of the patient, how much of that is, because I guess I’ve just never even thought about this. How much of that is your direction for the exact protocols of what they’re doing in versus what the therapist is saying? Who’s kind of moving that. I mean, I’m sure it’s maybe a team thing.
Cassandra List: Yes. And I think it also depends on the area of rehab. Like I said, rehab is pretty vast. So for example, if you have a shoulder injury or a rotator cuff injury, that’s something that your rehabilitation doctor, an outpatient musculoskeletal rehab doctor is going to be able to give you specific exercises to say, let’s rehab your arm. Yes, work with a therapist, but maybe if you do these exercises and give you a specific protocol.
From the neuro rehabilitation standpoint, our patients are usually very weak in multiple areas. And it’s not only the weakness, it’s also the coordination or maybe their thinking and their processing isn’t right. So you could give them instructions, but unfortunately they can’t process them. So that’s where we really rely on the team to put their expertise towards the patient. So usually I’m not specifically dictating, you have to do 10 reps of up and down. I leave it to the physical therapist and occupational therapist and the speech therapist and all the other therapists to come up with the best plan that they think would be for the patient.
Tracy Davis: You guys get all on the same page of, this is what’s happening. Okay, we all agree on this. This patient is dealing with all of these things and then they kind of just okay, they know that they can’t start working on maybe the hand if the shoulder is not there yet. So it’s a puzzle piece to put together.
Cassandra List: Yep. And then some other things. So from a physician standpoint, some of the things that I’m thinking of as well is, how can we make this person as independent as possible? So say for, just as an example, yes, we’re working on maybe getting somebody up to walking and that might be a big goal for the patient. But realistically, maybe a motorized wheelchair or manual wheelchair would give them the most independence. It doesn’t mean that we give up on trying to walk if that’s a goal that the patient has, but from a day-to-day perspective, you would have more independence if you’re able to roll into the kitchen and fix yourself whatever, if you had that ability. So that’s where the rehab physician, along with the team, is thinking of these things of, well, yes, we can work on this, but this is what’s going to give you the most independence. So let’s try to focus on that.
Tracy Davis: Absolutely. So what excites you about maybe the future of rehabilitation? Maybe some, you see technology maybe moving in a certain direction with rehabilitation?
Cassandra List: Yes. Absolutely. And I think that that’s where in 10 years, 50 years, 100 years, we’ll see rehab in a completely different light. We’re still very young. We know a lot of things about the brain, but there are a lot of other things that we don’t know about the brain and there’s a lot of research ongoing, but we still have a ways to go. So it’ll be exciting to see what comes out as far as what we can do from not only prevention, say, of stroke or non traumatic brain injuries, but also recovery.
Tracy Davis: Yeah, absolutely. Talk to me about Cyberdyne and using that with stroke patients and stuff like that. How has that affected the patient population that you’ve seen?
Cassandra List: Yeah, so Cyberdyne is a great, great technology that we have here at Brooks. We’re really unique and proud to have that technology available to our patients and the great Dr. Tonuzi runs the program along with the great team at the NRC with Bob. But we’ve recently been able to have more access to the Cyberdyne on the inpatient side. So every stroke patient I can, I get them on the Cyberdyne. Because it’s not only a cool experience. I mean, you look like a storm trooper in this thing. So you’re upright and you feel stronger by just being on it, but also the workout that you get from doing it.
So it’s not only the neurological aspect of recovery and helping those muscles start to regain strength and helping with the spasticity as well. But it’s also a bit of a cardiac aerobic exercise. The patients will say, man, that was tough. So yeah. So every time a patient says to me, I don’t know, I think I can push harder. I’m like, get them on the Cyberdyne. Because they get off of it and they’re exhausted. It’s a tough workout. So it’s been great to be able to have access to that. Not only for our patients in the outpatient, but now on our inpatient units, as well as many of the stroke patients as I can get on it I do.
Tracy Davis: And so everyone knows, for a while it was just spinal cord injury using it, and then now strokes using. And if you don’t know what it is, we have a whole podcast on Cyberdyne as well, but it’s essentially, it lets the therapist dial in how much resistance and how much it helps them walk and stuff like that. So a lot of times, whenever I’ve been down there, you can see that the Cyberdyne is trying to resist them from moving their leg forward, which is making their muscles kind of kick in harder than they have been, really any different than they can even down in any other therapy that we have. Because it’s actually integrated in with their body.
Cassandra List: Right, right. And so that’s, what’s different from the Cyberdyne versus some of the other exoskeletons that are out there, which are all great things for technology, don’t get me wrong. You’re right. But it also, it works to pick up the signals that the patient has. So even if it’s a weak signal in the muscle, the Cyberdyne will pick it up and it’ll help you move through that, take that movement. So it’s a really unique technology and great that we have access to it.
Tracy Davis: And we have, Bob McIver was just showing me yesterday, just some patients that started out. And I love it for me, that does videos, because maybe we’ll be working with this patient on a video. They filmed themselves throughout their process and she filmed herself just being able to move her leg again and then getting on Cyberdyne and still struggling to walk and now she’s out walking on her own. So it’s just amazing that the different things that we had, and that’s the great thing with all this technology is, even though a lot of rehabilitation kind of goes back to the basics of rehabilitation whenever they’re working with them. But a lot of this technology is just opening up way more opportunities for different levels of resistance and modalities and stuff like that, that patients just would have never had in the past. So we’ve got so much technology here, not just it inpatient and NRC, but it’s getting out into a lot of our outpatient clinics too.
Cassandra List: And if I can give one piece of advice to our patients who are listening is, now in the world of video and iPhones and having access to a camera on your phone. Videotape yourself through your recovery. It’s remarkable to see how much you changed. And I think sometimes it’s hard for patients to realize when they’re in the hospital, they’ve been through so much, to realize how far they’ve come. And I really see when families pull out videos and they’re like, oh really? That’s what it looked like? You’ve just been through so much that you don’t even realize how far you’ve come. So really take advantage of having that technology in your hand to see where you’re going.
Tracy Davis: It’s like when you start a diet and you take care of before photo.
Cassandra List: I don’t feel like I’m losing any weight. When you look at picture and you’re like, wow.
Tracy Davis: Wow, look at how far I’ve come.
Cassandra List: Yeah. And it’s added motivation, I think. And that’s, we’re all going to have hard days. What I say is, we’re going to have good days, we’re going to have bad days. Our goal is just to have more good days than bad. And so we just need to keep pushing. And sometimes we need those little reminders that, this is how far I’ve come. I can keep going.
Tracy Davis: Yeah. Absolutely. Because it’s all small steps and they add up to a lot at the end. Well, thank you, Dr. List, for coming on the podcast. Thanks for everything that you do at Brooks.
Cassandra List: Thank you so much. It’s been a pleasure.