I started this series three weeks ago. Today, I'm concluding with more information that should be helpful in showing you what to expect during and after leaving the rehab facility.
As with the previous articles, this one was first posted on the American Stroke Association's StrokeConnection website by Jon Caswell:
Most IRF stroke programs have many elements to support the many aspects of stroke recovery. These may include:
individual therapies
group therapies
teaching strategies to compensate for functions that aren’t fully recovered
psychological, emotional support
establishing daily and weekly routines
goal setting
education on: cause of stroke; preventing another stroke; medications; diet; protection of skin; management of spasticity; stretching; caregiver training; community resources after discharge
Different members of the team handle different aspects. For example, secondary prevention is generally something a physician and member of the nursing staff do more than the therapists. On the other hand, setting functional goals tends to fall more to the therapists than the nurse and physician.
“Our goal is to get survivors ready to be discharged safely to their homes,” Harvey said. “Most of the time that involves individual therapy. Occasionally we give group therapy. We often have an upper-body exercise group for people who need to strengthen their weak arm. Or a speech group where patients communicate with each other under the supervision of a speech therapist, but mostly it’s individual therapy.”
In stroke rehab, there is constant balancing of recovery and compensation. In IRFs, the goal is to work on recovery first — strengthening arms and legs and using whatever strength is regained to help perform functional tasks. “In some cases, that’s impossible, so if a person’s balance is very severely impaired and walking is unsafe, we may shift focus to practice on wheelchair propulsion, which is a compensatory way to move around. But the goal is to help this person be able to do what they need to do as independently as possible. And that either is going to be recovery back toward normal performance or improvement of function based on compensatory strategies with or without devices.”
A couple of weeks ago, I posted for you a list of questions to ask your health care providers as you look for a rehab facility. Before that, I posted an article telling you about rehab. Today, I'm continuing with more information that should be helpful in showing you what to expect during your rehab experience.
As with the previous articles, this one was first posted on the American Stroke Association's StrokeConnection website:
Following a stroke, about two-thirds of survivors receive some type of rehabilitation. This is a time of both hope and anxiety for stroke families: hope that the survivor will make a good recovery; anxiety or fear about what happens next and what to expect. In this second of our two-part series on rehab, we want to alleviate some of the mystery and hopefully some fear and anxiety around the inpatient rehab part of the stroke recovery journey. We talked to Richard L. Harvey, M.D., section chief for Stroke Rehabilitation at the Shirley Ryan AbilityLab (formerly Rehabilitation Institute of Chicago) and one of the authors of the American Stroke Association rehab guidelines, about what survivors and their families can expect in an inpatient rehab facility (IRF). Once medically stable, survivors are discharged either to an IRF, a skilled nursing facility (SNF) or home. (For more on the difference between IRFs and SNFs, see our previous article in this series.)
Determining What's Needed
Dr. Richard Harvey
Once admitted to the inpatient rehabilitation facility (IRF), a physiatrist (or a neurologist with rehabilitation experience) does a general assessment of the survivor’s abilities. “The physiatrist determines that, indeed, the person is ready for rehabilitation,” Harvey said. This is when therapy and other medical orders are written.
Sometimes there are medical precautions that must be kept in mind and made clear in the medical orders for staff and therapists to follow. “For example, some patients need to have a fairly high blood pressure after their stroke to maintain good blood flow to the brain. There may be limitations to what the survivor can do because of that, and the physiatrist will want the therapist to monitor blood pressure closely while they’re doing therapy. Medical precaution is important information that would be placed into the medical orders.”
Once the orders are written, actual therapy begins the next day. Each type of therapist seeing the survivor performs his or her own thorough assessment of specific functions such as motor skills and communication. These measure how independently the survivor is able to function using a standard measuring tool, such as the Functional Independence Measure (FIM). It measures a wide variety of activities such as dressing your upper and lower body, going to the toilet, walking, climbing stairs, communication, problem solving and memory. Each category receives a score between 1 (completely unable) to 7 (complete independence); total score possible is 118 points. “Patient goals are critical to care planning and their thoughts are gathered on admission by the physician and nurse and also on the next day by the individual therapists,” Harvey said. Results of these assessments and discussions provide a baseline from which to set goals and guide the kind of therapy the survivor receives. “We set goals for what we hope survivors can achieve at discharge and that drives the rehabilitation therapy that we do,” Harvey said. “The therapy will focus on achieving those goals. So, a physical therapist sets goals for walking and mobility. An occupational therapist sets goals for dressing and other ADLs [activities of daily living], and a speech therapist works with communication, swallowing, and memory and cognition. They all have specific goals. Nursing is involved as well and helps with things like bladder and bowel control, skin care and nutrition.”
Working Toward Those Goals
After the assessments are done and goals set, the rehabilitation team meets to discuss the results and the patient’s goals. “Then we will figure out how long it’s going to take to accomplish the goals, and we set the discharge date,” Harvey said.
This is a target date. The team meets weekly to evaluate progress. If the target date no longer seems feasible, a new plan is proposed. If a survivor’s progress seems slow, the team works to determine why and adjusts the plan accordingly. The rehab team works closely with the patient and family to develop a mutually agreeable plan. There is communication all along the way and plenty of opportunities to assess readiness for discharge and come up with next steps.
Patients’ perspectives are sought and considered throughout their stay in an IRF. “Any concern raised by the patient is addressed by the team,” he said. “If one team member cannot address it, that team member will seek out the team member who can. Communication between rehabilitation team members is critical and constant.” The rehab team meets and reassesses performance every week. At those meetings, any barriers to progress are addressed. “For example, if the patient has muscle spasticity that’s interfering with their ability to walk, we might start a medication to treat that. Or if they need any special splints or braces, we make that determination at that meeting,” he said. These team meetings are rarely, if ever, attended by survivors or family members. However, family members are welcome at therapy sessions, which should occupy at least three hours a day in an IRF. “Lots of times we schedule time for the family to come in and learn to assist the patient,” Harvey said. “If the patient needs help when they go home, we want the family to assist them at the right level, to do it safely so that neither the patient nor family member gets injured. We want them to provide the right amount of help. We often work with the family one-on-one to train them on how to do this. But it’s also helpful for caregivers to be around and see what’s going on in therapy. It helps them feel engaged in the whole process. Of course, many families can’t do that because of work, but usually at some point, we need the family to come in and spend some time with us to get an idea what’s going on.” In addition, caregivers can be educated in the fine art of saying no and setting limits. --------------------------------------------------------------------------------- Next week I will pass on more information about therapy, therapy technologies, things to look for to make sure the survivor is getting appropriate care at the facility, and things you should consider when it's time for discharge. ******************************************************************************** Copyright of the above article is owned or held by the American Heart Association,Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to American Heart Association and American Heart Association News. See full terms of use.
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In 2016 the American Heart Association posted an article about a new electrical stimulation therapy (EST) that improved hand dexterity for stroke survivors. In November of 2017 a rehab facility posted an article about functional electrical stimulation (FES). This appears to be a different name for the same treatment. Included here is the 2016 article posted by AHA.
A new electrical stimulation therapy improved hand dexterity for stroke survivors more than an existing technique, in a study released today. Strokes, which strike about in 800,000 people in the United States each year, usually result in some degree of paralysis on one side of the body that can make it hard for survivors to open a hand. A common therapy in stroke rehabilitation uses low levels of electric current to stimulate paralyzed muscles to open the hand, improve muscle strength and possibly restore hand function. A therapist sets stimulation intensity, cycle timing and repetitions. In the new experimental therapy developed by researchers at the MetroHealth System, Case Western Reserve University and the Cleveland Functional Electrical Stimulation Center, patients control the stimulation to their weak hand by wearing a glove with sensors on the opposite, unaffected hand. When patients open their unaffected hand, they receive a corresponding amount of stimulation that opens their weak stroke-affected hand. This puts patients back in control of their hand and enables them to participate in therapy with the assistance of electrical stimulation. For the study, 40 stroke survivors received therapy using the new glove for 12 weeks and 40 received the common therapy. Both groups used an electrical stimulator on their own at home for 10 hours a week, plus 3 hours per week practicing hand tasks with an occupational therapist in the lab. Hand function was measured before and after therapy with a standard dexterity test that determined the number of blocks participants can pick up, lift over a barrier and release in another area on a table within 60 seconds. Researchers found: Patients who received the new therapy had greater improvement on the dexterity test (4.6 blocks) than the common group (1.8 blocks). Patients who had the greatest improvements in hand dexterity following the new therapy were less than two years post-stroke and had at least some finger movement when they started the study. These patients saw an improvement of 9.6 blocks on the dexterity test, compared to 4.1 blocks in the common group. Patients with no finger movement also saw improvements in arm movement after the new therapy. At treatment end, 97 percent of the participants who received the new therapy agreed that they could use their hand better than at the start of the study. Researchers plan to perform a multi-site study to confirm their results, as well as measure quality of life improvements for patients. While the researchers speculate that the new therapy may be changing neural connections in the brain that control hand dexterity, additional studies are needed to determine what effects it may have on the central nervous system. The study also demonstrates that stroke patients can effectively use technology for self-administered therapy at home, said Jayme S. Knutson, Ph.D., an assistant professor of physical medicine and rehabilitation at Case Western Reserve University School of Medicine in Cleveland, Ohio. “Home-based therapy is becoming increasingly important to offset increasing healthcare costs and to meet the need for high doses of therapy that are critical for attaining the best outcomes,” he said. “The more therapy a patient can get, the better potential outcome they will get.” The study is published in in the American Heart Association journal Stroke.
-------------------------------------------------------------------------------------------------------------------------- Copyright is owned or held by the American Heart Association,Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to the American Heart Association News. See full terms of use.
Last week I promised to provide you with a list of questions to ask your health care providers about rehab for stroke survivors, so today I'm making good on that request. Rehab is a huge benefit to survivors and a proven "must do". This list is rather large. And that should tell you how important it is to get the right place and the right care. I hope this helps you.
The following was first posted on the American Stroke Association's StrokeConnection website:
THE PATIENT AND FAMILY BOTH NEED TO CHOOSE THE FACILITY/PROVIDER THAT WILL BEST MEET THEIR NEEDS AND GOALS.
START WITH THESE QUESTIONS:
What types of rehab care will my insurance cover? Do you have a stroke rehab program? If so, how many patients are in it? How do you assure high-quality care? What do you look for in terms of progress, and how often do you evaluate it? Where does rehab occur? What therapy programs are available? How do you help caregivers? What is done to help prevent falls? Do you have a program that addresses balance issues?
QUESTIONS BEFORE DISCHARGE
What is the extent of my loved one’s stroke damage? What areas of the brain have been affected? What is the prognosis and expected course for recovery? What types of services are likely to improve the outcome? Does this depend on the areas of the brain where the stroke caused damage? What is my loved one’s ability to engage in various post-acute services? What is my/my loved one’s medical/health situation and complexity, and what other medical services will be required?
QUESTIONS ABOUT POST-ACUTE SETTING(S)
Is the rehab facility certified to care for people with a stroke? What is the maximum amount of rehab services my loved one can receive? How intense will it be? What medical services are available? What special clinical training do the nurses, social workers and dieticians have? How does the setting measure functional recovery, and what outcomes are typical for stroke patients?
PRACTICAL TOOLS AND EMOTIONAL SUPPORT
AMERICAN STROKE ASSOCIATION RESOURCES AVAILABLE THROUGH STROKEASSOCIATION.ORG:
Support Network: Online community to connect patients and loved ones with others during their journey.
Stroke Connection Magazine: Helpful information and personal perspectives for survivors and family caregivers that’s available quarterly in digital format.
TTES Newsletter: Monthly newsletter provides patients and caregivers information on stroke-related research and resources.
Stroke Family Warmline 1-888-478-7653: Connects stroke survivors and their families with specially trained ASA team members — some of whom are stroke family caregivers — for support, information or just a listening ear.
Stroke Support Group Finder: To find a group near you, enter your ZIP code and a mile radius.
Tips for Daily Living Library: This volunteer-powered library gathers tips and ideas from stroke survivors, caregivers and healthcare professionals all over the country. They’ve created adaptive and often innovative ways to get things done.
Life After Stroke on StrokeAssociation.org: The American Stroke Association website has a wealth of information for recovery and helping stroke survivors and those who care about them become independent and have a quality of life.
Let’s Talk About Stroke Patient Information Sheets: Downloadable sheets in a question-and-answer format that are brief and easy to follow and read.
Caregiver Resources: The American Stroke Association has many resources for caregivers, including downloadable guides, checklists and journal pages to help you in the day-to-day efforts to support your loved one’s recovery and your own health.
• Stroke Discharge Checklist • Caregiver Guide to Stroke • Daily Home Care Guide
******************************************************************************** Copyright of the above article is owned or held by the American Heart Association,Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to American Heart Association and American Heart Association News. See full terms of use.
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What you do in rehab depends on what you need to be independent.
Areas you may need to improve include:
Self-care skills such as feeding, grooming, bathing, toileting and dressing,
Mobility skills such as transferring (from chair to bed or bed to chair, etc), walking or self-propelling a wheelchair,
Communication skills in speech and language,
Cognitive skills such as memory or problem solving,
Social skills for interacting with other people.
WHEN DOES REHAB BEGIN?
Your doctor decides when you’re stable and able to benefit from it. Most rehab services require a doctor's order.
WHAT IS A REHAB PROGRAM?
A program may include:
• Rehabilitation Nursing
• Physical Therapy
• Occupational Therapy
• Speech-Language Pathology
• Audiology
• Recreational Therapy
• Nutritional Care
• Counseling
• Social Work
• Psychiatry/Psychology
• Chaplaincy
• Patient/Family Education
• Support Groups STROKE REHAB SHOULD INCLUDE:
• Training to improve mobility and ability to do daily tasks
• Tailored post-stroke exercise program
• Access to cognitive/engagement activities (books, games, computer)
• Speech therapy, if stroke caused difficulty speaking or swallowing
• Eye exercises, if stroke caused a loss of vision
• Balance training for those with poor balance or with a fall risk
• Adaptive strategies to help you function within a “new normal” CHOOSING THE RIGHT SETTING YOU CAN REHAB AT:
• Inpatient Rehabilitation Facilities
• Skilled Nursing Facilities
• Home (through Home Health Agencies)
• Outpatient Care Your needs determine which type(s) is best for you.
INPATIENT REHABILITATION FACILITY (IRF) An IRF can be a separate unit of a hospital or a free-standing building that provides hospital-level care to stroke survivors who need intensive rehabilitation. IRFs provide at least three hours a day of active rehabilitation at least five days a week with:
• Physical Therapists
• Occupational Therapists
• Speech Therapists
• Nurses (available 24/7)
• Doctors typically visit daily
The AHA/ASA recommends IRF care if you can tolerate at least three hours a day of stroke rehabilitation. Medicare generally covers your care in an IRF. You will need to pay your Medicare Part A deductible and coinsurance. Some Medicare supplemental (“Medigap”) insurance policies will cover part or all of your deductible and coinsurance so check your insurance coverage. Private insurance coverage for IRF care varies.
SKILLED NURSING FACILITY (SNF) A SNF provides rehabilitation care and skilled nursing services for patients who:
• Are not well enough to be discharged to home and cannot tolerate the more intensive amount of therapy provided by an IRF.
• Can benefit from having a a registered nurse on site for a minimum of eight hours a day (on a physician’s plan). Need nursing and/or rehabilitation.
• Don’t need daily supervision by a physician, although the care provided must still be based on a physician’s plans. A SNF can be a standalone facility, but when it is in a nursing home or hospital it must be a separately licensed unit, wing or building. Medicare will generally cover up to 100 days in a SNF. You will pay nothing for the first 20 days. There will be a co-pay for days 21-100. Some Medicare supplemental (“Medigap”) insurance policies will cover part or all of your co-pay so check your insurance coverage. Private insurance coverage for care at a SNF varies. LONG TERM CARE FACILITY • Long term care facilities provide long-term basic nursing care and assistance for people who need help with everyday activities, such as dressing or bathing. This is residential care for people who can’t live in the community. • Long term care facilities provide limited rehabilitative services except for those receiving care through a separate SNF wing or unit. • Long-term care is generally paid out of pocket, by long-term care insurance or through the Medicaid program. Medicare and most private health insurance (comprehensive medical) policies do NOT cover long term care facilitiy care. LONG-TERM ACUTE CARE HOSPITALS • Provide extended care to those with complex medical needs (such as those on a ventilator) due to a combination of acute and chronic conditions. • The average length of stay is 25+ days. • Medicare, Medicaid and most private health insurance plans cover this care, although you may have copays or coinsurance. HOME OR OUTPATIENT • Provided by home healthcare agencies or in outpatient office. • Medicare, Medicaid and some private insurance plans cover home health care. Medicare and many private insurance companies impose caps on the number of outpatient therapy sessions they will cover. Medicare has an “exceptions process” that will allow you to get additional sessions if they are medically necessary. --------------------------------------------------------------------------------- Next week I will post a list of question to ask health care providers when seeking rehab facilities. --------------------------------------------------------------------------------- Copyright is owned or held by the American Heart Association,Inc., and all rights are reserved. Permission is granted, at no cost and without need for further request, to link to, quote, excerpt or reprint from these stories in any medium as long as no text is altered and proper attribution is made to the American Heart Association News. See full terms of use. *******************************************************
