What to Expect of Therapy and More

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Retreat & Refresh Stroke Camp

a division of United Stroke Alliance

www.unitedstrokealliance.org

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:

http://strokeconnection.strokeassociation.org

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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.”

“Our goal is to get survivors ready to be discharged safely to their homes. Most of the time that involves individual therapy.”

Rehab Technologies

Although interesting technology is being used, it is not widely adopted because scientific evidence to date does not show that it offers improvement over standard care.

Robots for walking or improving hand use are mostly available in research or academic medical centers. “Robots are very expensive,” Harvey said. On the other hand, electrical stimulation for retraining arms and legs is more widely accepted and cheaper.

Video game systems with motion-sensitive controls (like the Nintendo Wii) and computer programs or games are sometimes used as training tools to incorporate a survivor’s weak side, improve balance or challenge them cognitively.

Harvey is working with a research fellow who’s developing a smartphone app for stroke patients to practice using their weak upper limb. Speech therapists also use tablets and smartphones for both language recovery as well as a device to help survivors communicate with others.

Neuroplasticity

For the first three months after a stroke, the brain is much like a child’s brain, ready to learn, ready to make new connections. This ability for our brains to adjust is known as neuroplasticity and it plays a crucial role in recovery.

“It’s a time of really rapid change in the central nervous system,” Harvey said. “About three months after the stroke, neuroplasticity is becoming more normalized, sort of the same neuroplasticity that everybody else has.” At that point, there’s still plenty of recovery available, but Harvey equates it to learning to play the guitar from scratch: “If I wanted to learn to play the guitar, I would have to get a guitar and take lessons and practice and practice and maybe in a year or two, I’d be able to play some basic songs on the guitar,” he said. “That’s a skill that I would have to learn. Survivors can still improve their function, but it requires lots of practice to improve skill.”

 

Am I Getting Appropriate Care?

Though survivors can continue to improve their function for a long time, there is only one opportunity to get the most out of the heightened neuroplasticity during the early weeks and months of rehab following a stroke. Knowing that you’re getting appropriate care that is helping you make progress toward your goals is important.

There are some signs to watch for to be sure you’re getting appropriate care. According to Harvey, too much group therapy is something to be wary of, “Acute inpatient rehabilitation should mostly focus on one-to-one therapy.”

Does the facility have equipment like treadmills with body weight support, parallel bars and walkers to get them on their feet? “Acute stroke rehabilitation should get people on their feet and work on walking,” Harvey said, “If they’re spending more time working on a mat just doing leg strengthening, rather than performing function, then you should be concerned because what survivors really need is practice walking and they will gain strength.”

If they’re focusing only on compensatory strategies and survivors are spending more time in a wheelchair than on their feet, that’s an issue.

If caregivers or survivors don’t like what they see happening, Harvey says they should speak to the physician in charge because they are ultimately responsible for the care of the patient. There may be a legitimate reason for the altered therapy, but families should get an explanation.

“Working with a therapist is not a business transaction, it’s a relationship.”

By its very nature, therapy is personal, and sometimes conflict arises between patient and therapist. Harvey says that when this happens, they rarely assign a new therapist, preferring instead that the people work out the problem. “We encourage them to communicate about it and to be honest about what the issues are and see if they can come to an understanding,” he said. “That’s what you’re supposed to do in life, isn’t it? So, it’s part of the therapy to do that. Now if that conflict cannot be resolved, then a manager can arrange for a different therapist. But we try not to do that because that’s just not the way to deal with things in life. Working with a therapist is not a business transaction, it’s a relationship.”

When It Is Time To Leave

Discharge protocols differ from facility to facility but often involve a home assessment, caregiver education, family involvement, home therapy referrals as well as information on driving and community resources.

“What we usually do is family education and training and then we order equipment, if that is needed,” Harvey said. “We arrange for follow-up including with a neurologist and also for outpatient therapy. That may be home therapy, but it could be outpatient therapy. Some patients may go from an inpatient rehab facility to a nursing facility before they transition home. But when you do transition home, it’s important to have follow-up outpatient therapy and continue rehabilitation after discharge.”

Actual inpatient therapy, Harvey points out, is an important, but small, part of the whole rehabilitation process. “Inpatient care is intended to help a patient be safe to return home, but it does not address all the functional and rehabilitation needs a patient has. Stroke recovery takes three to 12 months and beyond, and inpatient is usually less than three weeks.” To maintain gains and work on evolving needs, patients must continue to work at recovery.

Caregivers

Caregivers play a crucial role in a survivor’s recovery. “It’s important for caregivers to understand how much the survivor can do and what they can’t do so they assist them to the level they need but don’t over-assist them,” Harvey said. “Survivors need to continue working on independence. It’s always good to have some things that you’re working on improving at home. For example, if you can’t put on your shirt on your own maybe that’s something that the patient can work on doing and improving at home and the family can support this. Encourage them to continue working on getting more independent.

“The other thing is to remember that rehabilitation is lifelong. I tell all my patients, all of us should have time when we take care of our bodies, when we exercise, when we work on strength or conditioning, and people with stroke are the same. They should always be working on their body, always taking care of it.

“The last thing you want is for a stroke survivor to go home and say, ‘I had a stroke so I can’t do anything anymore.’ Maybe you can’t do everything you used to, but there are certain things that you can do and there are certainly ways that you can improve your performance if you just focus and work on it a little bit every day. We can all practice being better people in this world, and stroke survivors are no different.”

For more, download our free PDF, Making Rehabilitation Decisions.

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