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 In High-Tech World: Stroke Rehab Remains Personal

Providers must help patients adjust goals as therapy progresses.


Shepherd Center patientRepeated noninvasive transcranial magnetic stimulation, virtual reality games and activities, robotics. High-tech innovations are making stroke rehab easier, more effective, and—yes—even fun for patients of all ages.

However, practitioners and caregivers agree that there is no substitute for personal attention, encouragement, support, and compassion. In short, high-tech is nothing without high-touch.

‘Don’t Give Up’ Mentality

“Every day people come through these doors who some others might give up on. We don’t,” says Katie O’Shea, PT, DPT, GCS, MBA, rehabilitation program manager at PowerBack Rehabilitation in Voorhees, N.J. Interacting with stroke patients in a meaningful way is standard procedure at PowerBack Rehabilitation, a Genesis HealthCare facility.
“Someone who’s had a stroke comes to our facility, and we will ask them about their hobbies and what things they like to do. They often reply that no one has ever asked them that before,” she says. This makes them feel better about their situation and their hope for recovery, she suggests.
These efforts need to consider the changing paradigm of stroke rehab and recovery. As Laura Beving of the National Stroke Association (NSA) explains, “We used to think that whatever progress stroke survivors make in the first six months is all you can expect. Now we think that they can develop new neuropathways and that progress can occur long after six months.”
Beving offers a personal example. “My dad had a stroke, and we were told that where he was in six months was where he likely would stay. We were told he would never be able to swallow again,” she says. “But years after his stroke, he is back to a fairly normal life. He is riding his bike and enjoying himself. It just took a while to get there.”

The Art Of Medicine And Stroke Rehab

Even experienced practitioners often have misperceptions about what to expect from stroke rehab. “Thirty years ago, stroke education took about 15 minutes and consisted of ways to keep the person comfortable. There are still lots of practitioners and others out there who got this message, and it’s never been corrected. I hear it all the time,” says Beving.
Getting everyone on the same page through communication and education is the first step. Then the team can work together—along with the patient and family—to devise an individualized care plan that has the greatest chance of success.
This is all part of the “art of medicine,” says David Smith, MD, CMD, president of Geriatric Consultants of Central Texas in Brownwood. “We need to learn a lot more than we usually do about the patient’s personality, life events, and coping skills before they had their stroke.“
Mary Van de Kamp, MS, CCC, SLP, senior vice president of quality and care management at Kindred Healthcare in Louisville, Ky., adds, “I don’t think we spend enough time asking patients what they want. This is an opportunity for us to gain a better understanding of patient goals.”
Van de Kamp observes that while independence is a common goal for most stroke survivors, “what you or I think independence is may be very different from what the patient thinks.”
To understand what the stroke survivor wants, Van de Kamp says, “We need to understand what they did before their illness.” For most people, this doesn’t mean climbing mountains or running marathons. It could be something as simple as “going out for breakfast with the guys once a week.”

Always Be Supportive

Even when team members don’t understand a goal, it is important to be supportive. Van de Kamp says, “We had a patient who had played basketball before his stroke, and an important goal for him was to play again. The physical therapist thought it was a lofty goal, but she worked with him. He’s now in a wheelchair basketball league and enjoys the sport he loves. While it’s not the same as it was before, we were able to help him find a way to participate in an activity that is important to him.” 
Shepherd Center patient during rehab
These are the kinds of results the team can have if they “sit down, talk creatively, and seek alternative means to get to goals,” says Van de Kamp. “We don’t want to make promises we can’t keep, but we also don’t want to discourage aspirations. One of the most critical skill sets we can use is to listen to patients and not impose our feelings on them.”
Getting people involved from day one means lots of communication, says O’Shea from PowerBack Rehabilitation. “We involve the patient right away in discharge planning, and we explain the role of various members of the therapy team,” she says. “We work with the patient to establish goals. This is essential because we can have the best plan, but it’s not going to work if that’s not what the patient wants.”
O’Shea explains that her management team meets every morning to discuss operational issues and any problems or concerns involving specific patients—for example, someone is having a problem with pain or depression. Weekly, they hold a utilization review meeting to discuss specific details of discharge planning for each patient. “We involve the whole team to discuss issues such as barriers to discharge and what resources we can provide to overcome them,” O’Shea says.

Cheering Patients On

Motivating patients is an important part of these discussions.
“We have numerous programs and activities to meet patients’ individual interests and hobbies. For instance, we have a gardening group, an aquatic program, and shopping trips to a local Rite Aid. But if our initial efforts to get patients involved and engaged in their recovery aren’t successful, we ask if we can bring their family in for a team meeting where we can discuss concerns, limitations, and other issues out in the open,” says O’Shea.
For example, the discussion might reveal that a patient and her daughter used to go to lunch and for manicures every Saturday, so they will arrange for the two to lunch together every week and get manicures in the onsite salon. Returning to a sense of normalcy, even on a small scale, can make a big difference to a stroke survivor, Smith says.
Everyone on the team gets involved in these efforts to motivate patients.
As O’Shea says, “Our administrator has been known to personally talk to patients who need a boost. Our recreation department director also has been a huge advocate because she knows patients more on a personal level.” PowerBack also has a psychiatrist on staff to talk about the pathology of nonparticipation.

Keeping Track Of Emotions

Monitoring the patients’ mental and emotional health is essential, says Barbara Resnick, PhD, RN, CRNP, FAAN, FAANP, professor of nursing at the University of Maryland School of Nursing, as “depression is prevalent in about 75 percent of stroke patients.”
Oupatient therapy
Smith notes that treating depression profoundly affects stroke rehab, but it can present a special challenge. “Post-stroke depression is almost like a different disease—it is more difficult to treat and often more resistant to medication.” He adds that depending on where the stroke was in the brain determines the risk of depression. Stroke in the frontal lobe where emotions are is where depression is most prevalent.
Left untreated, depression can adversely affect stroke recovery. “It’s easy for people to throw in the towel. Caregivers need to know never to give up. Progress can happen forever, and we can’t allow function to further decline,” Resnick says.
Even when the team successfully treats depression in a stroke patient, they have to monitor the patient’s progress and watch for signs of nonparticipation or decline. “We may have to circle back to find out what the problem is. Are they in pain? Are they afraid of falling? Has the depression returned? The earlier we can identify these problems, the quicker we can fix them and help move the patient’s recovery forward,” says Smith.
While empathy is important, O’Shea cautions that staff have to keep a professional distance. For example, she notes, “We recently had a younger patient come in. Because they could relate, our younger staff bonded with her immediately. They had a great deal of sympathy for her,” she says.
However, because of their personal connection to her, they weren’t providing the structure that she needed. “We started little by little educating staff—‘Today you saw this, tomorrow you should expect that, and here is how you should react.’ Once they saw different techniques having different results, there was more buy-in on their part.”
While staff need to keep a professional distance, they do need to empathize. For example, Beving says, “It is important to call [patients] survivors, not victims. They have some diminishment, but it doesn’t mean that they have to hang up their lives and stop living. You need to work with them on things they can do,” she says, adding, “It’s important to help stroke survivors focus on the positive ways they can still continue.”
For example, maybe Mr. Jones can’t play ball with his grandson anymore, but he can read with him or watch sporting events together.

Teams Win When They Share

“We are fortunate to have a close-knit team between our operational and clinical sides. We understand and support each others’ roles. That is key,” says O’Shea.
“For a successful team, you need this education piece, as well as strong, ongoing communication. We have morning meetings with all disciplines at the table together. Perhaps more than some conditions, stroke rehab requires the involvement of just about every discipline—including physical therapy, speech-language therapy, occupational therapy, dietary, recreational therapy, social work, and nursing.”
By involving all of these disciplines in regular meetings and interactions, there are multiple opportunities to hear about challenges and discuss them from various perspectives. Having all of these different viewpoints facilitates effective and efficient problem solving.
For example, O’Shea notes that one team member mentioned that a patient wasn’t drying himself after bathing. Another suggested that maybe the towel was too heavy for someone with still-weak upper body strength. They substituted smaller, lighter towels, and it solved the problem.

Recovery A Family Affair

Of course, staff aren’t the only ones who need stroke education and regular communication. “Family members need to understand clinically what stroke does, what to expect of their loved one as he or she is recovering, and how they can respond,” says O’Shea.
Shepard Center patientInvolving both the patient and family members in care planning is essential. However, don’t expect this to be a one-time activity. “You need to revisit goals for living the best possible life as the person recovers,” says Beving, stressing, “Hope is wonderful, but hope is not a plan.”

Smooth Transitions

Ensuring smooth transitions for stroke patients can mean the difference between a successful discharge home and returns to the hospital. “We need to make sure that everyone throughout the care continuum is on the same page. Teleconferences or Skype meetings between team members from different settings can help,” says Beving.
As the patient transitions to his or her home, Beving suggests having an occupational therapist or social worker “go to the home and do a trial run.” She notes, “Mobility is a huge issue, and people don’t always see the risks associated with things such as a loose rug or dark hallway. Identifying things in advance that could be potentially catastrophic is essential.”
Van de Kamp agrees that facilities need to consider what the patient will face at home.
“For example, falls are common reasons for a return to the hospital. We have to determine in advance what safety requirements and support systems will enable patients to return home.” Families and caregivers need to understand what the person can and can’t do so that they can prepare accordingly, she says.
In making communication connections to ensure the patient’s safe transition home, don’t forget the primary care physician, Van de Kamp says. “One way we can promote the patient’s ongoing health and wellness is to stay in touch with the primary care physician while the patient is in the long term care facility. That relationship is critical, especially since we know that if a patient sees the primary care physician within seven days of getting home, they have a better chance of staying there.”
High-risk patients may need some additional attention, Van de Kamp says. “We have care transition managers that follow high-risk patients until they are safely at home. These team members advocate for the patients, make sure information moves with them between settings, identify resources, and fill gaps in support and services.”

Innovations In Stroke Rehab

Many high-tech innovationa are proving useful in stroke rehab:
■ Repeated noninvasive transcranial magnetic stimulation (nTMS) has been shown to help treat some stroke-related conditions. Specifically, low-frequency stimulation has been associated with motor recovery, and high-frequency stimulation has helped recovery from post-stroke pain. Stimulation of both hemispheres has been associated with reduced spasticity.
■ Robotic devices have been used to help deliver well-defined, repetitive exercises for patients with severe physical weakness. This technology can help prove a labor-efficient exercise program that requires less direct therapist supervision.
■ The MediLodge Group of rehab facilities is using virtual reality technology with a focus on virtual exercise and activity. In theory, when the brain sees the virtual movements, it fires neurons and triggers new brain connections. MediLodge also has television screens throughout its facilities to enable virtual visits with family and friends, telemedicine interventions, and conversations with physicians.
■ The Shepherd Center, a rehab facility in Atlanta, has a special website with personal portals for each patient. These portals contain resources such as videos showing how to use a supportive device, fact sheets, and dietary information. The site ( also has general information about living with stroke, stroke symptoms, prevention, life after stroke, and home modifications.
Clearly, while not every facility can afford the latest technology, Beving suggests that providers become as tech-savvy as they can. “The biggest things I see coming for stroke rehab are changes in technology. The more tech-savvy rehab facilities can be, the better off they will be. Facilities should remain open to the technology revolution in the therapy world.”
Van de Kamp adds, “Strong departments have both good equipment and a comprehensive approach. You can’t have the newest and best equipment without competent therapists to treat patients.”
Of course, there are stroke rehab innovations that are more high-touch than high-tech. For example, high-intensity interval training is showing promise. This technique employs bursts of concentrated activity, alternating with recovery period, to maximize the exercise’s intensity and impact.

The Reimbursement Issue

Employing services, programs, and interventions that are efficient and effective is not only important to improving patients’ health. It also can protect their bottom line and help ensure they get the care they need.

Shepherd Center pathologist, patient and physical therapist“We are challenged by regulations that are defined by time rather than personal needs. Sometimes requirements intended to provide guidance are prohibitive to getting the patient to the right place at the right time for the right services,” says Van de Kamp. While the Centers for Medicare & Medicaid Services (CMS) is working on this challenge, she says, “the ability for us to match patient needs to the setting and services is critical.”

In the new world of health care, hospitals will be putting more emphasis on sending stroke patients to the facility where they will have the best chance of recovery. Therefore, facilities that have strong track records with their stroke rehab programs should share this information with hospitals in the area. These facilities also should work to establish partnerships with hospitals to maximize recovery for stroke patients and prevent readmissions.

“We have nurse care coordinators whose responsibility it is to work with our acute-care hospital partners. This enables us to provide smooth care transitions, maximize the impact of rehab, prevent readmissions, and, ultimately, ensure safe and sustainable discharges,” says Garry Pezzano, senior vice president of clinical practice at Genesis Rehab Services in Kennett Square, Pa.

Pezzano’s company also has a 24/7 CareLine that helps with the admission process and presents an opportunity to match patients up with the right facility for them. “We need to provide professional resources to help patients and families make decisions. This can be difficult for people who already are dealing with so much—both financially and emotionally,” he says. “If we can provide services and support to help them make a placement decision, we can take some of the burden off them.”

When he works with families looking for placements, Pezzano suggests that they:

■ Find a facility that gives the patient the best chance for recovery. Find out who the care team is at the facility and how these individuals will communicate with them.

■ Talk about how you will participate in therapy.

■ Get a sense of how well-equipped the therapy room is and how accessible it is. Make sure they will be involved in goal setting.

■ Have good resources to help them understand reimbursement and what services are covered.
“I stress to them that these elements will help them ensure a good discharge and help to enable a successful recovery,” says Pezzano.
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