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
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
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
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.”
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.”
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,”
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,”
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
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
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
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
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.
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.”
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
■ 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 (www.myshepherdconnection.org
) 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
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
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
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.
stress to them that these elements will help them ensure a good
discharge and help to enable a successful recovery,” says Pezzano.