EXPERT MEDICAL OPINION

REPORT

Speciality: Neurology and Neuro rehabilitation

Selected Medical Experts:

Alex J. Fay, MD, PhD

Assistant Professor of Neurology
University of California School of Medicine
San Francisco, CA

Ross Zafonte, DO
Earle P and Ida S Charlton Professor and Chair
Physical Medicine & Rehabilitation
Harvard Medical School
Chief, Physical Medicine & Rehabilitation
Massachusetts General Hospital
Boston, MA

Richard Zorowitz, MD
Attending Physician, Outpatient Services
MedStar National Rehabilitation Hospital,
Washington, DC
USA

Advance Medical Case Manager: Rajaá Kaddaha, MD

Case Number: C93947

Date: September 27, 2017

 Expert Medical Opinion Report

Index

Expert Selection Process ...................................................................................2

Summary of Clinical History ...............................................................................3

Questions to the Expert ......................................................................................6

Report by Alex Fay, M.D. ...................................................................................7

Report by Ross Zafonte, M.D...........................................................................10

Report by Richard Zorowitz , M.D. ...................................................................12

Curriculum Vitae Alex Fay, M.D. ......................................................................19

Curriculum Vitae Ross Zafonte, M.D. ..............................................................21

Curriculum Vitae Richard Zorowitz, M.D. ........................................................25

Legal disclaimer ................................................................................................27

 Expert Medical Opinion Report

Expert Selection Process

The Medical Committee of ADVANCE MEDICAL has analyzed the case and the medical
files that have been attached to the release form in order to identify the critical
documentation needed to fulfill a comprehensive medical opinion process.

Comments on the medical files

The Medical Committee has considered that the case was sufficiently documented in
order to render an Expert Medical Opinion report. No additional information has been
requested.

The Clinical Committee has proposed a review of the case by:

Alex J. Fay, MD, PhD

Assistant Professor of Neurology
University of California School of Medicine
San Francisco, CA

Ross Zafonte, DO
Earle P and Ida S Charlton Professor and Chair
Physical Medicine & Rehabilitation
Harvard Medical School
Chief, Physical Medicine & Rehabilitation
Massachusetts General Hospital
Boston, MA

Richard Zorowitz, MD
Attending Physician, Outpatient Services
MedStar National Rehabilitation Hospital,
Washington, DC
USA

2
 Expert Medical Opinion Report

Summary of Clinical History

This is a 16 years old boy who was involved in a car accident in August 2016 and
suffered multiple traumas with right parieto-temporal subarachnoid bleed and right
sided brain contusion and as a consequence left sided spastic hemiparesis. His
family is seeking a second medical opinion on the diagnosis and its management.

Source of information

Telephone interview with the patient father and medical records provided by him.

Current condition

This is a 16 years old boy previously healthy who suffered a car accident (he was the
driver of a car) in August 2016, suffered multiple traumas with right parieto-temporal
subarachnoid bleed and right sided brain contusion s/p right craniotomy, and
elevation of depressed bone fracture. He had multiple maxilla and facial skull
fractures, bilateral lungs contusions, right second rib and clavicular and scapular
fracture. He also suffered D9 compressive fracture, and underwent spinal fixation
D6- D11. Also had right scalp trauma with tissue loss.

He was non- ambulatory with left sided hemiparesis. He did undergo short term
physical rehabilitation and father reported that his child had benefited dramatically
from rehabilitation program as he is now able to walk using a walker, (see video
attached) he walks with certain limb and he needs to raise his leg to help ambulation,
he tends to fall frequently if not using the walker. Currently dependent on a walker.
Still unable to climb stairs.

His left hand still with some spasticity and limitations, he is unable to hold a cup or
any objects in the left hand.

He remains with left sided weakness and left eye ptosis. (see videos mages of his
current physical ability)

He was now advised home exercise program focused on walking and ADL training
with the right hand and global extensor movement training and spasticity
management at home. He is denied long term rehabilitation program.

He had received one injections of Botox in the left hand to manage spasticity and
advised a follow up Botox injection in several months.

Social history: from Saudi Arabia, had 2 brothers and one sister and good family
support, no history of smoking, no alcohol or substance abuse.

Current medication: Keppra was given for a short term and now off
medications.

Past surgical and medical history: None

3
Family history: non-contributory

The following records were provided by the patient father:

Physical evaluation in Feb 2017:

4
Neuropsychiatric assessment:

July 2017

The patient is seeking a second medical opinion on his diagnosis and its
management.

5
 Expert Medical Opinion Report

Questions to the Expert

The patient seeks a second medical opinion on the following issues:

What is the best management for his condition at this stage?

What kind of rehabilitation would you recommend and for how long?

What other advice would you offer this patient to avoid long term complications of his
current condition?

What is your opinion on brain tissue transplant to improve his clinical status?

What other recommendations would you offer this patient and his family?

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 Expert Medical Opinion Report

Report by Alex Fay, M.D.

1. Summary of Clinical History:
This case concerns a 16-year-old young man, who was the driver in a motor
vehicle accident in August 2016, and sustained a significant traumatic brain injury
and associated injuries to the head, neck, spine, and ribs. The brain injuries he
sustained were predominantly to the right side of his brain, and resulted in
impairments in use of the left side of his body.

Brain MRI from August 9, 2016, shows swelling and injury most significantly in
the right frontal and parietal lobes, in the part of the brain that initiates
movements of the left arm and leg. In addition, there are small areas of
hemorrhage throughout the right frontal and parietal lobes, and some smaller
hemorrhages in the left frontal lobe. There is restricted diffusion in the right frontal
and parietal lobes, indicating acute injury to neurons in the brain areas that
control movement and sensation of the left side of the body.

The notes provided state that he had significant left-sided weakness of the arm
and leg that improved with rehabilitation, to the point that he was able to walk with
a walker, but he is still unable to climb stairs. He has received botox for treatment
of spasticity in the left hand, which has somewhat improved function of the left
upper extremity. In addition to his motor difficulties, neuropsychiatric testing has
shown difficulties with attention, memory, and visuospatial tasks. It is unclear
from the notes whether he has had any specific interventions to improve his
cognitive symptoms.

The three videos shown demonstrate difficulty in raising the right forehead,
weakness of the left arm with dystonia or the left hand, and a hemiparetic gait
with increased muscle tone in the left leg with circumduction. I cannot evaluate for
the presence of spasticity without examining the patient myself, but his arm
weakness and gait are consistent with the location of his brain injury. The
weakness in his right forehead muscle may be related to direct trauma to the
temporal branch of the right facial nerve.

2. Comments on the work-up, treatment, and prognosis

The patient’s MRI scan findings correlate well with the motor and cognitive
deficits that he has had, resulting from the traumatic brain injury. The area of
injury to the right frontal and parietal lobes is extensive, and there is also
evidence of significant injury to the anterior frontal lobes. A full recovery of left-
sided motor abilities is unlikely, but there is still room for functional improvement
that might allow him to walk more independently, and have more use of his left
arm. He underwent intensive rehabilitation, and clearly improved while receiving
therapy services. It is unclear why rehabilitation services could not be continued,
but I am not convinced that the patient has achieved the full benefit of prolonged
rehabilitation services. Further physical and occupational therapy through a
neurorehabilitation center should be pursued, along with other modalities that I
discuss below.

Especially since botox injections of the left arm appear to have been helpful,
more extensive botox injections of spastic muscles in the left arm and leg should
be considered. With continued therapy, the patient might have improved range of
motion and strength, as well as functional independence. He will likely reach a

7
plateau of recovery at some point, but ongoing exercise program and intermittent
botox injections may help him to maintain this level and avoid development of
worsening spasticity over time.

3. Specific Recommendations
A. Continued intensive physical and occupational therapies: Improvements in
function following traumatic brain injury and stroke can still be seen years
after the injury. Likewise, without ongoing therapy, there may be worsening of
function over time if spasticity or dystonia increase. Thus, ongoing physical
and occupational therapy are recommended, even though this patient’s injury
occurred more than a year ago. In addition to working with therapists,
orthotics or other devices may be helpful in improving function and mobility.
Intensive therapies should be continued until his functional improvements
have reached a plateau for 3-6 months, at which point therapies should
continue, but focus on maintaining muscle strength and function. Additional
techniques, such as transcranial magnetic stimulation, have also shown
promise in facilitating recovery in patients with traumatic brain injury, and
could be considered empirically or as part of a research trial. There may be
added benefits to memory, attention, and mood from transcranial magnetic
stimulation, as well.

B. Management of Spasticity and Dystonia, Medical and Surgical Options:

Treatment of dystonia and spasticity will be important for improvement of
function and regaining some degree of dexterity, especially in the left hand. If
there are joints that are fixed in place, it may be necessary to have one or
more surgical tendon releases or tendon transfers. Then, botulinum toxin can
be an effective strategy for treating spastic muscles and improving motor
function. Botulinum toxin is particularly effective if spasticity is limited to a few
muscles. There are oral medications that may also help with spasticity: these
include baclofen, gabapentin, dantrolene, and clobazam, which can help to
release excessive muscle tone, but may also be somewhat sedating.

Should the above medications not be effective, there are limited reports of
surgery that can be helpful for spasticity, such as selective dorsal rhizotomy,
and dystonia (deep brain stimulation). Selective dorsal rhizotomy is a surgery
that is typically used for children with brain injury at birth, but there are reports
of its use after traumatic brain injury and stroke, and it may help with
ambulation. Such a surgery should only be considered after other options
have been exhausted, and with a neurosurgeon who has extensive
experience in selective dorsal rhizotomy. Deep brain stimulation involves
implanting an electrical stimulating device into a part of the brain that controls
movement and muscle tone, and may be helpful with dystonia. It would be
worthwhile to consult with a neurosurgeon with experience in deep brain
stimulation to discuss the risks and benefits of this surgery. There are
relatively few reports of its use in traumatic brain injury-related dystonia, but it
might be helpful in this patient’s case.

Transplantation of stem cells to areas of brain injury is an active area of

research, with some positive results in preclinical (animal) models and early
stage trials in humans. However, there is not yet clear evidence for efficacy in
humans. I would not recommend any type of stem cell therapy for this patient,
unless it were part of a well-run clinical trial. There are several ongoing trials
for traumatic brain injury, which can be reviewed on the National Institutes of
Health website clinicaltrials.gov.

8
C. Management of Cognitive Difficulties: Finally, the patient seems to have
some difficulties with attention, memory, and visuospatial tasks. A trial of
medication to help with attention is warranted. There are two main classes of
stimulants to help with attention problems, methylphenidates and
dextroamphetamines, and a psychiatrist will be able to guide you through a
trial of one or more of these medications. There is less evidence for
medications such as donepezil and memantine for memory difficulties after
traumatic brain injury, but these may be considered under the guidance of a
neurologist or psychiatrist. Memory difficulties in young people are often
related to attention deficits, so a trial of a stimulant medication would be my
first recommendation. Finally, as I mentioned above, transcranial magnetic
stimulation is a non-invasive technique that has shown some benefit in
attention, memory, and mood in patients with traumatic brain injuries and
strokes.

4. Scientific References
A. Bose P, Hou J, Thompson FJ. Traumatic Brain Injury (TBI)-Induced
Spasticity: Neurobiology, Treatment, and Rehabilitation. In: Kobeissy FH,
editor. Brain Neurotrauma: Molecular, Neuropsychological, and
Rehabilitation Aspects. Boca Raton (FL): CRC Press/Taylor & Francis;
2015. Chapter 14.
B. Clayton E, Kinley-Cooper SK, Weber RA, Adkins DL. Brain
stimulation: Neuromodulation as a potential treatment for motor recovery
following traumatic brain injury. Brain Res. 2016 Jun 1;1640(Pt A):130-
138.
C. Iaccarino MA, Bhatnagar S, Zafonte R. Rehabilitation after
traumatic brain injury. Handb Clin Neurol. 2015;127:411-22.
D. Gump WC, Mutchnick IS, Moriarty TM. Selective dorsal rhizotomy
for spasticity not associated with cerebral palsy: reconsideration of
surgical inclusion criteria. Neurosurg Focus. 2013 Nov;35(5):E6.
E. Huang CH, Huang CC, Sun CK, Lin GH, Hou WH.
Methylphenidate on Cognitive Improvement in Patients with Traumatic
Brain Injury: A Meta-Analysis. Curr Neuropharmacol. 2016;14(3):272-81.
Review.
F.Kwon CS, Hasegawa H, Sokratous G, U-King-Im JM, Samuel M, Ashkan K.
Globus Pallidus Internus Deep Brain Stimulation for Traumatic
Hemidystonia Following Penetrating Head Injury. World Neurosurg. 2016
Aug;92:586.e1-4.
G. Gennai S, Monsel A, Hao Q, Liu J, Gudapati V, Barbier EL, Lee
JW. Cell-based therapy for traumatic brain injury. Br J Anaesth. 2015
Aug;115(2):203-12.

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 Expert Medical Opinion Report

Report by Ross Zafonte, M.D.

Summary and Background: The case is that of a 16 year old male with a history of
automobile accident in August of 2016. The person appeared to sustained –
polytrauma with a noted lung contusion, rib, as well as clavicular and scapular
fractures. He was also noted to have a T9 compression fracture and required fixation
of T6-T-11.
Intracranial injury was suggestive of SAH and notable Right brain contusion with a
depressed skull fracture. Maxilla and additional facial fractures where also noted.
Imaging was suggestive of a right sided injury. He required a right sided craniotomy
and elevation of depressed skull fracture.
Reported Exam findings are notable for Left ptosis and Left sided weakness (
suggesting focality and possible intracranial compression and or CRN II
involvement). Spasticity is reported as a remaining concern and a note suggests
Ashworth 2 spasticity in the left upper and 1-2 in the left lower. The person ambulates
with a walker. Of concern, he falls frequently and is unable to do steps in a safe and
independent manner. Treatment for his left upper extremity has included Botulinum
toxin
Data reports some concern with attention and delayed memory as well as
Visuospatial skills.
Current Medications: Reported as none
PMH: none
What is the best management for this condition at this stage?
Optimally the person should be reevaluated by a team with specific expertise in
severe traumatic brain injury. Of note a series of functional and behavioral metrics
should be established for this person
A plan to address cognitive behavioral, motor, gait and medical co morbid issues
should be established. For example, what is the etiology of the falls, does the person
have the proper orthotics or possibly need a gait lab evaluation. Do we have risk
factors for Hydrocephalus. What can be done to enhance independence and mitigate
falls. Metrics and targets for spasticity treatment should be pursued.
What kind of rehabilitation would you recommend and for how long?
Likely this would best occur in a day program or based on international practice a in
patient stay. A gait analysis, consideration medication plus focused toxin . A
Cognitive and behavioral plan should include screening for depression and anxiety ,
a formal evaluation of functional memory and a targeting of functional attention. The
role of pharmacotherapy or focused training techniques should also be considered.
What advice would you offer this patient to avoid long term consequence?
A comprehensive evaluation that examines neuromedical concerns would be of
value. A consideration of an evaluation of the neuroendocrine system, assuring
swallowing competency and examine for metabolic abnormalities is warranted. A gait

10
safety evaluation as well as the consideration of follow up neuroimaging may be
warranted. Neuropsychologic testing or enhanced metrics may help. As stated above
Neuroimaging could be of value.
Persons with such injuries remain at risk for seizures and hydrocephalus. In
addition, in several studies provide a suggestion of increased risk for
neurodegenerative disease even after a single severe TBI has been proposed. Life
span in a US longitudinal data set was reduced between 7-9 years overall- however
prognosis in any single person is not possible and much can be done in the positive
including: Managing sleep, staying aerobic active,. Evaluating risk for dysphagia,
remaining cognitively active.

What is your opinion of brain tissue transplantation in this clinical state?

The role of transplantation in Traumatic brain injury is not established. Clear
concerns also exist ie proper transplantation location, technique and cell type. This
therapy is not yet suggested and a clinical research center of excellence should see
the person and comment prior to any considered use.

What other recommendations? Such recommendation would be based on a more

comprehensive history and exam. What can be said is that his person should be
evaluated by a team of clinicians with experience in traumatic brain imjury and have
a strong biopsychosocial evaluation.

The opinions rendered herein are related to over 20 years of clinical care and
experience and are not in any way meant to establish a treating relationship.
The opinions are based on a global observation on complex patients like t this one
presented to me. Should further information become available, these opinions are
subject to change.

Thank you very much.

Ross D. Zafonte, DO
Earle P. and Ida S Charlton Professor and Chair
Department of Physical Medicine and Rehabilitation
Chief, Physical Medicine and Rehabilitation
Massachusetts General Hospital
Senior Vice President of Medical Affairs
Spaulding Rehabilitation Hospital

Chief, Physical Medicine and Rehabilitation

Brigham and Women’s Hospital

11
 Expert Medical Opinion Report

Report by Richard Zorowitz , M.D.

Summary of the Patient’s Clinical History.

The patient is a 16-year-old boy with no significant medical history, who suffered
multiple trauma in August 2016 after a motor vehicle collision (driver of the car). He
was found to have a right parieto-temporal subarachnoid hemorrhage; right-sided
brain contusion; multiple maxillary and facial skull fractures; T9 compression fracture;
bilateral lungs contusions; right second rib, clavicular, and scapular fractures; and
right scalp trauma with tissue loss. Surgical procedures included: right craniotomy
and elevation of depressed bone fracture; and spinal fixation T6- T11.

Initially, the patient had left-sided weakness and was non-ambulatory. He completed
short-term physical rehabilitation, after which the patient could ambulate using a
walker. He walks with a limp and needs to raise his leg to advance it. He falls
frequently if he does not use the walker and is unable to ascend or descend stairs.

The patient still exhibits left-sided weakness and left eye ptosis. His left hand is
spastic and is incapable of holding any objects. He was advised to continue a home
exercise program focused on mobility and activities of daily living using the right
hand. He was rejected from a long-term rehabilitation program. He received one set
of onabotulinumtoxin (Botox®) in the left hand to decrease spasticity and was
advised to undergo a repeat set of injections in several months.

In July 2017, the patient underwent a neuropsychiatric evaluation, at which time his
Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) score
was 78 (borderline). He scored above average (117) in immediate memory, below
average (86) in visual-spatial construction, below average (96) in language,
extremely low (48) in attention, and below average (84) in delayed memory. He was
found to have no mood disorder. His level of cognitive functioning was classified as
a Ranchos Los Amigos stage VII. He had no risk of violent behavior, environmental
disorientation, unsafe actions, suicide, sexual or physical abuse, initiating sexual or
inappropriate behavior, or being a victim of financial fraud. Overall, he had
diagnoses of traumatic brain injury with left-sided weakness and mild neuro-cognitive
disorder and without behavioral disturbance.

The patient is from Saudi Arabia and has good family support. He has two brothers
and one sister. He denies any tobacco, alcohol, or illicit drug usage. He has no
significant medical or surgical history aside from the current episode. His family
history is non-contributory. He took levetiracetam (Keppra®) for a short time but now
takes no medications.

COMMENTS ON THE SCENARIO

The diagnosis and treatment appear to be appropriate for this diagnosis of moderate
traumatic brain injury. Traumatic brain injuries can be classified by several different
means:

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• Glasgow Coma Scale (GCS): The most common method of classifying a
traumatic brain injury is by the Glasgow Coma Scale. The GCS is a scale rated from
3 to 15 points, used to assess a patient's level of consciousness and neurologic
functioning. Its scoring is based on three criteria: best motor response, best verbal
response, and eye opening. Patients with mild traumatic brain injury usually have a
GCS score of 13-15. Patients with moderate traumatic brain injury usually have a
GCS score of 9-12. Patients with severe traumatic brain injury, usually have a GCS
score of 3-8.

• Duration of loss of consciousness: Patients are classified as mild if a mental

status change or loss of consciousness is less than 30 minutes. Patients are
classified as moderate if a mental status change or loss of consciousness lasts 30
minutes to 6 hours. Patients are classified as severe if a mental status change or
loss of consciousness lasts greater than 6 hours.

• Post-traumatic amnesia (PTA): Post-traumatic amnesia is the time elapsed

from injury to the moment when patients can demonstrate continuous memory of
what is happening around them. PTA is classified as follows: very mild, < 5 minutes;
mild 5-60 minutes; moderate 1-24 hours; severe 1-7 days; very severe 1–4 weeks;
extremely severe > 4 weeks.

• Primary and secondary injuries: Primary injuries are induced by mechanical

forces and occur at the moment of injury. The two 2 main mechanisms that cause
primary injury are contact (e.g., an object strikes the head or the brain strikes the
inside of the skull); and acceleration-deceleration (e.g., motor vehicle collision, where
the head may be shaken upon impact of the vehicles). Secondary injuries usually
are delayed from the moment of impact, and may superimpose an injury on the brain
already affected by a mechanical injury.

• Focal and diffuse injuries: A focal injury usually includes scalp injuries, skull
fractures, and surface contusions, and generally are caused by contact. A diffuse
injury usually includes diffuse axonal injury (DAI), hypoxic-ischemic damage,
meningitis, and vascular injury, and generally are caused by acceleration-
deceleration forces. These injuries are commonly found together.

The Rancho Los Amigos Levels of Cognitive Functioning Scale assesses the patient
in the first weeks or months following an injury, and does not require cooperation
from the patient. Ranchos Los Amigos Scale scores are based upon observations of
the patient's response to external stimuli. They provide a descriptive guideline of the
various stages a brain injury patient will experience as he recovers from the brain
injury:

• Level I: No Response. Patient does not respond to external stimuli and

appears asleep.
• Level II: Generalized Response. Patient reacts to external stimuli in
nonspecific, inconsistent, and non-purposeful manner with stereotypic and limited
responses.
• Level III: Localized Response. Patient responds specifically and
inconsistently with delays to stimuli, but may follow simple commands for motor
action.
• Level IV: Confused, Agitated Response. Patient exhibits bizarre, non-
purposeful, incoherent or inappropriate behaviors, has no short-term recall, attention
is short and non-selective.

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• Level V: Confused, Inappropriate, Non-agitated Response. Patient gives
random, fragmented, and non-purposeful responses to complex or unstructured
stimuli - Simple commands are followed consistently, memory and selective attention
are impaired, and new information is not retained.
• Level VI: Confused, Appropriate Response. Patient gives context
appropriate, goal-directed responses, dependent upon external input for direction.
There is carry-over for relearned, but not for new tasks, and recent memory problems
persist.
• Level VII: Automatic, Appropriate Response. Patient behaves appropriately in
familiar settings, performs daily routines automatically, and shows carry-over for new
learning at lower than normal rates. Patient initiates social interactions, but judgment
remains impaired.
• Level VIII: Purposeful, Appropriate Response. Patient oriented and responds
to the environment but abstract reasoning abilities are decreased relative to pre-
morbid levels.

Cognition (basic thinking skills) includes our ability to pay attention and focus on
tasks. It also affects ability to think, organize, discuss and remember things. These
skills are needed for learning, solving problems, and making decisions. After a brain
injury, problems with these mental skills may be seen. There are also changes in
how a person acts. The way a person with a brain injury talks, acts or performs daily
tasks may look confused, unusual, odd, childlike, or different than before their injury.

The Ranchos Los Amigos Levels of Cognitive Functioning help the rehabilitation
team communicate between themselves and to the family and care givers what each
patient can do in a standardized manner. This helps the rehabilitation team set goals
that are within the patient's current ability level, and allows them to track progress.
These levels also give the team an idea of what to expect in the future, since the
lower the initial level, the less likely that the patient will make a full recovery.

QUESTIONS

1. What is the best management for his condition at this stage?

At this time, the patient should continue outpatient physical therapy, occupational
therapy, and speech-language pathology. If available, he also should receive
counseling from a neuropsychologist and consult with a child life specialist and/or
educator who treats children with traumatic brain injury. The patient and family
should identify a physician with expertise in Brain Injury Medicine (e.g., physical
medicine and rehabilitation, neurology). Realistic functional goals probably include
maximizing independence in mobility, activities of daily living, speech, cognition, and
swallowing.

Traditional approaches to traumatic brain injury rehabilitation include physical therapy

for mobility; occupational therapy for activities of daily living and functional cognition;
speech-language pathology for speech, cognition, and swallowing deficits; and
neuropsychology for adjustment to disability, cognition, and neurobehavioral therapy.
The physician directs and coordinates the rehabilitation plan and provides medical
input into the program.

Alternative methods of traumatic brain injury include craniosacral therapy, hyperbaric

oxygen treatment, biofield therapies, and meditation/mindfulness. However, none of
these interventions has sufficient evidence to demonstrate significant benefit.

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Neurostimulant therapy also may be a good way to facilitate functional recovery after
traumatic brain injury. While evidence is still limited, methylphenidate and
acetylcholinesterase inhibitors (e.g., donepezil) might enhance cognitive functions
after traumatic brain injury. On the other hand, one large study concluded that
modafinil (Provigil®) is not likely to be effective for post-traumatic brain injury fatigue.
Thus, it may be prudent to start methylphenidate and/or donepezil for
neurostimulation.

Benzodiazepines act on gamma-aminobutyric acid (GABA) receptors to create

anxiolytic, sedative, anti-spasticity, anti-convulsant, and amnestic effects. Side
effects may include: amnesia/memory loss; increased daytime fatigue; decreased
concentration; and decreased alertness. Since traumatic brain injury also may cause
these effects as well, the repeated use of benzodiazepines may slow or impair
neuronal recovery after focal injury. Thus, benzodiazepines should be used in
traumatic brain injury only as needed for short periods of time.

2. What kind of rehabilitation would you recommend and for how long?

The patient should continue outpatient physical therapy, occupational therapy, and
speech-language pathology as long as he continues to make functional gains. If
available, he also should receive counseling from a neuropsychologist and consult
with a child life specialist and/or educator who treats children with traumatic brain
injury. The fastest improvements after a traumatic brain injury occur approximately
during the first six months after injury. The patient may continue to improve between
six months and two years after injury, but this varies for different people and may not
happen as fast as the first six months. Improvements slow down substantially after
two years but may still occur many years after injury. Rates of improvement vary
from person to person. Most people continue to have some activities limitations and
participation restrictions, although they may not be as bad as they were early after
injury.

3. What other advice would you offer this patient to avoid long term
complications of his current condition?

Infections are very common after a brain injury, and often are a cause of death. The
most common locations of infections are the lungs and bladder. When fever occurs,
infection needs to be ruled out.

Deep venous thromboses (blood clots that form in the legs) are very common in
people with brain injuries, occurring in up to approximately 40 percent of patients.
Especially in immobile patients, clots can form and break off from the blood vessels
of the leg and travel to the lungs where they can cause pulmonary emboli.
Prevention includes the use of anti-coagulant medications and/or sequential
compression devices.

Seizures may occur in up to 5 percent of patients with brain injury, but in up to 50

percent of patients with a penetrating injury. Anti-seizure medications may be given
initially to prevent seizures. However, patients who have one or more seizures,
especially that occur at least 7 days after the injury, may require treatment for longer
periods of time.

Hydrocephalus occurs when there is a build-up in the fluid spaces of the brain known
as ventricles. This extra fluid can compress the brain and cause changes in a

15
patient’s level of arousal, problems with balance, and urinary incontinence, resulting
in a slowing of the patient’s functional recovery.

Heterotopic ossification is a less common complication that consists of formation of

extra bone in the body, most commonly in the large joints of the body (e.g., hip or
shoulder). Approximately 10 to 20 percent of patients with traumatic brain injuries
(not anoxic brain injuries) develops it. Heterotopic ossification can cause pain,
swelling, inflammation and tightening of the joint. No one knows why patients with
brain injuries are likely to develop heterotopic ossification.

Hypertension occurs in fewer than 10 percent of patients with brain injuries.

Hypertension usually occurs because of damage to the part of the brain that controls
blood pressure.

Spasticity is one of the most common complications after brain injury. Spasticity
consists of tightness of certain muscles when they cannot fully relax. Spasticity can
impede activities of daily living and can be painful. He should continue onabotulinum
toxin injections to prevent the development of contractures.

Pressure sores may occur for several reasons: pressure on the skin and tissues;
sliding down in a bed or chair, which can cause the skin to fold over itself (shear
force); being pulled across bed sheets or other surfaces, which can cause friction
burns; and excess moisture, such as from sweat, urine, or feces. Risk factors for
pressure sores include immobility; poor bladder or bowel control; poor nutrition;
decreased alertness; aging; smoking; and medical conditions that interfere with
healing, such as diabetes.

In order to prevent complications, the patient should remain as active as possible and
consult periodically with a physician with expertise in Brain Injury Medicine, as well
as a primary care physician.

4. What is your opinion on brain tissue transplant to improve his clinical status?

Brain tissue transplants (e.g., stem cells) appear to be helpful in improving function
after traumatic brain injury, but remain experimental. If the patient wishes to pursue
a research protocol using stem cell therapy in traumatic brain injury, he should
search for such research protocols on the website, www.clinicaltrials.gov.

5. What other recommendations would you offer this patient and his family?

Functional gains do not occur unless the patient continues to practice with a therapist
or at home with a home exercise program. While there is no guarantee what the
ultimate outcome will be, the patient at least will lose anything he has gained.

REFERENCES

Bazarian JJ, Cernak I, Noble-Haeusslein L, Potolicchio S, Temkin N. 2009. Long-

term neurologic outcomes after traumatic brain injury. Journal of Head Trauma
Rehabilitation 24:439-451.

Brooks JC, Strauss DJ, Shavelle RM, Paculdo DR, Hammond FM, Harrison-Felix CL.
Long-term disability and survival in traumatic brain injury: Results from the National

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Institute on Disability and Rehabilitation Research Model Systems. Archives of
Physical Medicine and Rehabilitation 2013; 94: 2203-2209.

Cantor JB, Ashman T, Bushnik T, Cai X, Farrell-Carnahan L, Gumber S, Hart T,

Rosenthal J, Dijkers MP. Systematic review of interventions for fatigue after traumatic
brain injury: a NIDRR Traumatic Brain Injury Model Systems study. The Journal of
head trauma rehabilitation 2014; 29(6): 490-497.

Coronado VG, Thurman DJ, Greenspan, AI, et al. Epidemiology. In: Jallo J, Loftus
C, eds. Neurotrauma and Critical Care of the Brain. New York, Stuttgart: Thieme,
2009.

Diaz-Arrastia R, Kochanek PM, Bergold P, Kenney K, Marx CE, Grimes CJ, Loh LY,
Adam LG, Oskvig D, Curley KC, Salzer CW. Pharmacotherapy of traumatic brain
injury: state of the science and the road forward: report of the Department of Defense
Neurotrauma Pharmacology Workgroup. Journal of neurotrauma 2014; 31(2): 135-
158.

Dikmen SS, Corrigan JD, Levin HS, Machamer J, Stiers W, Weisskopf MG. 2009.
Cognitive outcome following traumatic brain injury. Journal of Head Trauma
Rehabilitation 24:430-438.
Ji-Yao J, Guo-Yi G, Wei-Ping L, Ming-Kun Y, Cheng Z. J Neurotrauma 2002: 19(7):
869-874. doi:10.1089/08977150260190456.

Fleminger S. Managing agitation and aggression after head injury. Minimum use of
drugs and early care in rehabilitation units are recommended. BMJ 2003; 327(7405):
4-5. PMCID: PMC1126369. DOI: 10.1136/bmj.327.7405.4.

Horn EM, Iman FE, Harrington TR. Prognostic utility of magnetic resonance imaging
in traumatic brain injury. Barrow Quarterly 2003; 19(3).

Johansson B, Wentzel AP, Andréll P, Mannheimer C, Rönnbäck L. Methylphenidate

reduces mental fatigue and improves processing speed in persons suffered a
traumatic brain injury. Brain injury 2015; 29(6): 758-765.

Liepert J. Update on pharmacotherapy for stroke and traumatic brain injury recovery
during rehabilitation. Current opinion in neurology 2016; 29(6): 700-705.

McAllister TW. Neurobiological consequences of traumatic brain injury. Dialogues

Clin Neurosci. 2011; 13(3): 287–300.

MRC CRASH Trial Collaborators. Predicting outcome after traumatic brain injury:
practical prognostic models based on large cohort of international patients. BMJ
2008; 336: 425. doi:http://dx.doi.org/10.1136/bmj.39461.643438.25

Ouellet MC, Beaulieu-Bonneau S, Morin CM. Sleep-wake disturbances after

traumatic brain injury. The Lancet Neurology 2015; 14(7): 746-757.

Paterakis K, Karantanas AH, Komnos A, Volikas Z. Outcome of patients with diffuse

axonal injury: the significance and prognostic value of MRI in the acute phase. J
Trauma-Injury Inf Cri Care 2000; 49(6): 1071-1075.

Shin SS, Dixon CE, Okonkwo DO, Richardson RM. Neurostimulation for traumatic
brain injury: A review. Journal of neurosurgery 2014; 121(5): 1219-1231.

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Stein SC. Classification of head injury. In: Narayan, RK, Wilberger, Jr., JE,
Povlishock, JT, eds. Neurotrauma. McGraw-Hill, 1996: 31-41.

FINAL CONCLUSIONS

The patient is a 16-year-old boy with no significant medical history, who suffered
multiple trauma in August 2016 after a motor vehicle collision (driver of the car). He
was found to have a right parieto-temporal subarachnoid hemorrhage; right-sided
brain contusion; multiple maxillary and facial skull fractures; T9 compression fracture;
bilateral lungs contusions; right second rib, clavicular, and scapular fractures; and
right scalp trauma with tissue loss. Initially, the patient had left-sided weakness and
was non-ambulatory. He completed short-term physical rehabilitation, after which the
patient could ambulate using a walker. He continues to exhibit left-sided weakness
and left eye ptosis, walks with a limp, and needs to raise his leg to advance it. He
falls frequently if he does not use the walker and is unable to ascend or descend
stairs. He received one set of onabotulinumtoxin (Botox®) in the left hand to
decrease spasticity and was advised to undergo a repeat set of injections in several
months. My recommendations include:

• Physician: The patient and family should identify a physician with expertise in
Brain Injury Medicine (e.g., physical medicine and rehabilitation, neurology).
Realistic functional goals probably include maximizing independence in
mobility, activities of daily living, speech, cognition, and swallowing.

• Rehabilitation: The patient should continue outpatient physical therapy,

occupational therapy, and speech-language pathology. If available, he also
should receive counseling from a neuropsychologist and consult with a child
life specialist and/or educator who treats children with traumatic brain injury.
As long as the patient continues to make functional gains, he should continue
all therapies.

• Neurostimulant therapy: Neurostimulant therapy also may be a good way to

facilitate functional recovery after traumatic brain injury. While evidence is
still limited, methylphenidate and acetylcholinesterase inhibitors (e.g.,
donepezil) might enhance cognitive functions after traumatic brain injury.
Thus, it may be prudent to start methylphenidate and/or donepezil for
neurostimulation.

• Prognosis: The fastest improvements after a traumatic brain injury occur

approximately during the first six months after injury. The patient may
continue to improve between six months and two years after injury, but this
varies for different people and may not happen as fast as the first six months.
Improvements slow down substantially after two years but may still occur
many years after injury. Rates of improvement vary from person to person.
Most people continue to have some activities limitations and participation
restrictions, although they may not be as bad as they were early after injury.

I am saddened to read about what happened to your son. I wish you the best of luck
with his future treatments and recovery.

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 Expert Medical Opinion Report

Curriculum Vitae Alex Fay, M.D.

Alex J. Fay, MD, PhD

Assistant Professor of Neurology
University of California School of Medicine
San Francisco, CA

Education:

1998 BS, University of Virginia, Charlottesville, VA

2006 PhD, University of California, San Francisco, CA
2010 MD, University of California, San Francisco, CA

Postdoctoral Training:

2011 – 2012 Junior Resident in Pediatrics, St. Louis Children’s Hospital, St.
Louis, MO
2012 – 2013 Junior Resident in Adult Neurology, Barnes-Jewish Hospital, St.
Louis, MO
2013 – 2015 Resident in Pediatric Neurology, St. Louis Children’s Hospital, St.
Louis, MO
2015 – 2016 Fellow in Neuromuscular Neurology, Washington University, St.
Louis, MO

Academic Appointments:

2016 – Present Assistant Professor of Neurology, University of California School

of Medicine, San Francisco, CA

Hospital or Affiliated Institution Appointments:

2016 – Present Neurologist, Pediatric Brain Center and Multidisciplinary

Muscular Dystrophy Association Clinic, University of California
Benioff Children’s Hospital, San Francisco, CA

Licensure and Certification:

2015 American Board of Psychiatry and Neurology with Special

Qualification in Child Neurology
2016 American Board of Psychiatry and Neurology with Special
Qualification in Neuromuscular Medicine

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Most Recent Publications:

1. Jenkinson EM, Rodero MP, Kasher, PR, et al. Mutations in SNORD118 cause the
cerebral microangiopathy leukoencephalopathy with calcifications and cysts. Nat.
Genet. 2016 Aug 29.

2. Ng BG, Shiryaev SA, Rymen D, et al. ALG1-CDG: Clinical and Molecular

Characterization of 39 Unreported Patients. Hum Mutat. 2016 Jul;37(7):653-60.

3. Fay, A.J., Guilliams, K., and Gurnett, C. Chapter 21. “Neurologic Diseases” in Washington
Manual of Pediatrics, Second Edition” Philadelphia: Wolters Kluwer, 2016.

4. Fay, A.J., * Linn, K., * Meddles, K., Isbell, S., Lin, P.N., Thair, C., Heaps, J., Paul,
R., Mar, S. “HIV-Related Cognitive Impairment of Orphans in Myanmar with
Vertically Transmitted HIV Taking Antiretroviral Therapy.” Pediatric Neurology
(2015). Aug 13.

5. Fay, A.J., Noetzel, M.J., and Mar, S. “A Case of Pediatric Hemorrhagic Brainstem
Encephalitis Associated with HHV-7 Infection.” Pediatric Neurology (2015). Jun.
27. 10.1016/j.pediatrneurol.2015.06.016.

6. Fay, A.J., Mowry, E.M., Strober, J., and Waubant, E. “Relapse Severity and
Recovery in Early Pediatric Multiple Sclerosis.” Mult. Scler. J. 2012
Jul;18(7):1008-12.

7. Fay, A.J.,* Haddick, P.C.G.,* and Jan, L.Y. “Voltage-Gated Ion Channels” in
Contemporary Handbook of Neuropharmacology. David R. Sibley, Editor. Indianapolis,
IN: Wiley Publishing, 2007.

8. Fay, A.J.,* Shaw, R.M.,* von Zastrow, M. , Puthenveedu, M.A., Jan, Y.N., and Jan, L.Y.
Microtubule Plus-Ends Target Gap Junction Proteins to Adherens Junctions. Cell (2007)
128(3): 547-60.

9. Fay, A.J., Qian, X., Jan, Y.N., Jan, L.Y. SK Channels Mediate NADPH Oxidase-
Independent Reactive Oxygen Species Production and Apoptosis in Granulocytes.
PNAS (2006) 103: 17548-17553.

10. Fay, A.J. Direct Targeting of Connexin-43 to Adherens Junctions and SK Channel
Regulation of Granulocyte Reactive Oxygen Species Production. Doctoral Dissertation,
University of California, San Francisco, 2006.

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 Expert Medical Opinion Report

Curriculum Vitae Ross Zafonte, M.D.

Ross Zafonte, DO
Earle P and Ida S Charlton Professor and Chair
Physical Medicine & Rehabilitation
Harvard Medical School
Chief, Physical Medicine & Rehabilitation
Massachusetts General Hospital
Boston, MA

Education:

1981 BS, University of Georgia, Athens, GA

1985 DO, Nova/Southeastern University of Health Sciences,
Southeastern College of Osteopathic Medicine, Fort Lauderdale,
FL
2008 BA, Harvard University, Boston, MA

Postdoctoral Training:

1986 – 1989 Resident, (Chief Resident, 1989), Rehabilitation Medicine, Mount

Sinai School of Medicine, New York, NY
1991 Program Fellow in Research Enrichment, National Institute on
Disability and Rehabilitation, Missouri Arthritis Center, University
of Missouri, Columbia, MO
1998 Leadership Program for Physicians in Academic Health Centers,
Harvard School of Public Health, Boston, MA

Academic Appointments:

1989 – 1991 Instructor, Physical Medicine & Rehabilitation, Thomas

Jefferson University, Philadelphia, PA
1991 Assistant Professor, Physical Medicine & Rehabilitation,
University of Missouri, Columbia, MO
1992 – 1994 Assistant Director, Physical Medicine & Rehabilitation, Wayne
State University, Detroit, MI
1992 – 1997 Assistant Professor, Physical Medicine & Rehabilitation, Wayne
State University, Detroit, MI
2000 – 2007 Professor and Chair, Physical Medicine & Rehabilitation,
University of Pittsburgh, Pittsburgh, PA
2000 – 2007 Professor, McGowan Institute for Regenerative Medicine,
University of Pittsburgh, Pittsburgh, PA
2007 – Present Earle P and Ida S Charlton Professor and Chair, Physical
Medicine & Rehabilitation, Harvard Medical School, Boston,
MA

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Hospital Appointments:

2007 – Present Vice President of Medical Affairs, Physical Medicine &

Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA
2007 – Present Vice President of Medical Affairs, Physical Medicine &
Rehabilitation, Brigham and Women’s Hospital, Boston, MA
2007 – Present Chief, Physical Medicine & Rehabilitation, Massachusetts
General Hospital, Boston, MA

Awards and Honors:

2003 Prince Fellow Lectureship, Rehabilitation Institute of Chicago,

Northwestern University
2004 National Excellence in Teaching Award, New Jersey Medical
School
2005 President’s Citation Presentation, AAPMR
2006 Walter Zeiter Award, AAPMR
2006 Pioneer in TBI research, Brain Injury Association
2007 Alumni of the year award, Nova University
2007 Visiting Professor - graduation day, University of Kentucky
2007 Visiting Professor, University of Washington
2007 Visiting Professor, Carolinas Medical Center
2008 Distinguished Academician Award, Association of Academic
Physiatrists
2008 Peter Sharp Professor, PM&R, Weill Cornell Medical School
2008 James Ray Day Lecturer, PM&R, University of Michigan
2008 Annual Graduation Day, PM&R, University of Miami
2008 Gertszen Professorship and Keynote lecture, Department of
PM&R, University of Colorado
2008 Teacher of the Year, Harvard Department of PMR
2009 Rosenthal Lectureship, Harvard Medical School
2009 B. Stanley Cohen Lectureship, Sinai Hospital
Baltimore/University of Maryland
2009 Champions in Health Care Award, Boston Business Journal
2009 Rusk Lectureship, University of Missouri
2010 Swenson Day Lectureship, University of Utah

Professional Societies:

2003 – 2007 Association of Academic Physiatrists

Chair of Legislative Affairs Committee, 2003-2005
Awards Committee, 2006-2007
2007 VA Special Committee on TBI

Most Recent Publications:

1. Fridman E, Calvar J, Bonetto M, Gamzu E, Krimchansky B, Meli F, Leiguarda R,

Zafonte R. Fast awakening from minimally conscious state with apomorphine.
Brain Injury. 2009;23:172-177.

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2. Formisano R, Cincinelli P, Buzzi M, Brunelli S, Zafonte RD, Vinciola V, Gabrelli A,
Sabatini U. Blink reflex changes in parkinsonism following severe traumatic brain
injury correlates with diffuse axonal injury. Med Sci Monitor. 2009;15:101-106.

3. Margiles S, Hicks R, Combination Therapies for Traumatic Brain Injury Workshop

Leaders (Zafonte RD). Combination therapies for traumatic brain injury:
prospective considerations. J Neurotrauma 2009;26(6):925-929.

4. Bonninger M, Whyte J, DeLisa J, Zafonte R, Chan L. Building a research

program in physical medicine and rehabilitation. Am J Phys Med Rehabil.
2009;88:659-666.

5. Devine J, Zafonte RD. Physical exercise and cognitive recovery in acquired brain
injury: a review of the literature. PMR. 2009;1:560-575.

6. Barth J, Camiolo-Reddy C, Zafonte R. Sports concussion in an adolescent. PMR.

2009;1: 769-773.

7. Picard G, Tan C, Zafonte R, Taylor A. Incongruous changes in heart period and

heart rate variability with vagotonic atropine: implications for rehabilitation
medicine. PMR. 2010; 1:
820-6.

8. Chew E, Zafonte RD. Pharmacological management of neurobehavioral disorders

following traumatic brain injury – a state-of-the-art review. J Rehabil Res Dev.
2009;46(6):851-79. Review.

9. Carlile M, Nicewander D, Yablon SA, Brown A, Brunner R, Burke D, Chae H,

Englander J, Flanagan S, Hammond F, Khademi A, Lombard LA, Meythaler JM,
Mysiw WJ, Zafonte R, Diaz-Arrastia R. Prophylaxis for venous thromboembolism
during rehabilitation for traumatic brain injury: a multicenter observational study. J
Trauma. 2010 Apr;68(4):916-23.

10. Zafonte R, Friedewald WT, Lee SM, Levin B, Diaz-Arrastia R, Ansel B, Eisenberg
H, Timmons SD, Temkin N, Novack T, Ricker J, Merchant R, Jallo J. The
citicoline brain injury treatment (COBRIT) trial: design and methods. J
Neurotrauma. 2009 Dec;26(12):2207-16.

11. Watanabe T, Elovic E, Zafonte R. Chronic traumatic encephalopathy. PM R. 2010

Jul;2(7): 671-5.

12. Henzel MK, Munin MC, Niyonkuru C, Skidmore ER, Weber DJ, Zafonte RD.
Comparison of surface and ultrasound localization to identify forearm flexor
muscles for botulinum toxin injections. PMR. 2010 Jul;2(7):642-646.

13. Sozda CN, Hoffman AN, Olsen AS, Cheng JP, Zafonte RD, Kline AE. Empirical
comparison of typical and atypical environment enrichment paradigms on
functional and histological outcome after experimental traumatic brain injury. J
Neurotrauma. 2010 Jun;27(6):1047-57.

14. Fridman EA, Krimchansky BZ, Bonetto M, Galperin T, Gamzu ER, Leiguarda RC,
Zafonte R. Continuous subcutaneous apomorphine for severe disorders of
consciousness after traumatic brain injury. Brain Inj. 2010;24(4):636-41.

23
15. Naumann M, Carruthers A, Carruthers J, Aurora S, Zafonte R, Abu-Shakra S,
Boodhoo T, Miller-Messana M, Demos G, Brin MF. Meta-analysis of neutralizing
antibody conversion with botulinum toxin type a across multiple indications. Mov
Disord. 2010 Oct 15;25(13): 2211-8.

16. Seel RT, Sherer M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, Hammond
FM, Kalmar K, Pape TL, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N.
Assessment scales for disorders of consciousness: evidence-based
recommendations for clinical practice and research. Arch Phys Med Rehabil.
2010 Dec;91(12):1795-813.

17. Pitman RK, Kaelin D, Zafonte R. Point/Counterpoint. Posttraumatic stress disorder

versus traumatic brain injury. PMR. 2010 Nov;2(11):1051-4.

18. Steel RT, Sherer, M, Whyte J, Katz DI, Giacino JT, Rosenbaum AM, Hammond
FM, Kalmar K, Pape TL, Zafonte R, Biester RC, Kaelin D, Kean J, Zasler N.
Assessment scales for disorders of consciousness: evidence-based
recommendations for clinical practice and research. Arch Phys Med Rehabil.
2010 Dec; 91(12):1795-813.(PMID:21112421).

19. Zafonte R. Neural plasticity, potential novel therapies that may enhance neural
plasticity in the future, and the role these treatments may have in persons with
neurological injuries. Introduction. PMR 2010 Dec;2(12 Suppl 2):S207(PMID:
21497316).

20. Garzon-Serrano J, Ryan C, Waak K, Hirschberg R, Tully S, Brinner EA, Chipman

DW, Schmidt U, Kasotakis G, Benjamin J, Zafonte R, Eikermann M. Early
mobilization in critically ill patients: patients’ mobilization level depends on health
provider’s profession. PMR. 2011 Apr;3(4):307-13 (PMID: 21497316).

21. Arenth PM, Russell KC, Ricker JH, Zafonte RD. CDP-choline as a biological
supplement during neurorecovery: a focused review. PMR. 2011 Jun;3(6 Suppl
1):S123-31. (PMID: 21703569).

22. Zafonte R. Diagnosis and management of sports-related concussion: a 15 year-

old athlete with a concussion. JAMA. 2011 Jul 6;306(1):79-86. Epub 2011
May31.(PMID: 21632470).

23. Tan WH, Goldstein R, Gerrard P, Ryan CM, Niewczyk P, Kowalske K, Zafonte R,
Schneider JC. Outcomes and predictors in burn rehabilitation. J Burn Care Res.
2012 Jan-Feb;33(1):110-7.

24. Shenton ME, Hesham H, Schneiderman J, Bouix S, Pasternak O, Kubicki M,

Rathi Y, Vu M-A, Westin C-F, Stern R, Zafonte R. What is known about brain
injury in mild traumatic brain injury using advanced magnetic resonance imaging
techniques? A review of MRI and DTI findings (In press: Critical care Med).

25. Kasotakis G, Schmidt U, Perry D, Benjamin J, Ryan C, Tully S, Hirschberg R,

Velmahos G, Bittner E, Zafonte R, Waak K, Grosse-Sundrup M, Cobb J,
Eikermann M. the surgical intensive care unit, outcomes, morality prediction. (In
press: Critical Care Med).

Expert Medical Opinion Report

24
Curriculum Vitae Richard Zorowitz, M.D.

Richard Zorowitz, MD
Attending Physician, Outpatient Services
MedStar National Rehabilitation Hospital,
Washington, DC
USA

Education and Training:

• 1981 B.S., Northwestern University

• 1985 M.D. Tulane University

Specialty Certifications:

• American Board of Physical Medicine and Rehabilitation

• Spinal Cord Injury Subspecialty, American Board of Physical Medicine and
Rehabilitation

Previous Work Experience:

• Internship in internal medicine at the Long Island Jewish Medical Center, New
Hyde Park, NY
• Residency in physical medicine and rehabilitation at the Rehabilitation
Institute of Chicago, Northwestern University, IL.
• Medical Director of the Piersol Rehabilitation Unit at the Hospital of the
University of Pennsylvania in Philadelphia.
• Chief, Department of Physical Medicine and Rehabilitation, Johns Hopkins
Bayview Medical Center

Faculty Appointments:

• Former Associate Professor of Physical Medicine and Rehabilitation, Johns

Hopkins University

Honors:

• Phi Eta Sigma Honor Society

• Tau Beta Pi Engineering Honor Society
• Visionary in Practice Society, National Stroke Association
• Best Doctors, Aiken, SC
• Marquis Who's Who in America

25
Research Interests:

Stroke rehabilitation outcomes, dysphagia, spasticity, and the hemiplegic shoulder.

Post-Stroke Rehabilitation Outcomes Project, sponsored by the National Institute for

Disability and Rehabilitation Research (NIDRR).

Medical Societies:

Dr. Zorowitz is a member of the American Academy of Physical Medicine and

Rehabilitation (AAPM&R) and Association of Academic Physiatrists (AAP). He is
chairman of the Rehabilitation and Recovery Advisory Board and Professional
Advisory Committee of the National Stroke Association (NSA). He also is co-
chairman of the Standing Scientific Committee on Stroke Rehabilitation of the
American Stroke Association (ASA). He has participated on consensus panels of the
Joint Commission on Accreditation of Healthcare Organizations (JCAHO) Primary
Stroke Centers, the Commission on Accreditation of Rehabilitation Facilities (CARF)
Stroke Subspecialty Program, and currently participates on consensus panels of the
ASA Comprehensive Stroke Centers and American Medical Association Work Group
for Performance Standards in Stroke and Stroke Rehabilitation.

Representative Publications:

Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K,
Reker D, Zorowitz R. AHA/ASA?Endorsed Practice Guidelines. Veterans
Affairs/Department of Defense Clinical Practice Guideline for the Management of
Adult Stroke Rehabilitation Care. Executive Summary. Stroke 36: 2049-2056, 2005.

Conroy B, Zorowitz R, Horn SD, Ryser DK, Teraoka J, Smout RJ. An Exploration of
Central Nervous System Medication Use and Outcomes in Stroke Rehabilitation.
Arch Phys Med Rehabil 86(12, Suppl 2), S73?S81, 2005.

Zorowitz, R.D., Smout, R.J., Gassaway, J.A., Horn S.D. Prophylaxis for and
Treatment of Deep Venous Thrombosis After Stroke: The Post-Stroke Rehabilitation
Outcomes Project (PSROP). Top Stroke Rehabil 12(4): 1-10, 2005.

Zorowitz, R.D., Smout, R.J., Gassaway, J.A., Horn S.D. Antiplatelet and
Anticoagulant Medication Usage During Stroke Rehabilitation: The Post-Stroke
Rehabilitation Outcomes Project (PSROP). Top Stroke Rehabil 12(4): 11-20, 2005.

Zorowitz, R.D., Smout, R.J., Gassaway, J.A., Horn S.D. Antihypertensive Medication
Usage During Stroke Rehabilitation: The Post-Stroke Rehabilitation Outcomes
Project (PSROP) Top Stroke Rehabil 12(4): 21-27, 2005.

During Stroke Rehabilitation: The Post-Stroke Rehabilitation Outcomes Project

(PSROP) Top Stroke Rehabil 12(4): 37-49, 2005.

26
 Expert Medical Opinion Report

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