After an individual experiences a stroke, it can be a long and tedious journey rehabilitating and helping them to return to an independent lifestyle. Rehabilitation for a patient who has had a stroke is different for every person and family admitted to the hospital. Each patient can have different impairments as a result of their stroke, and each has unique needs and situations at home that require an individualized plan of care. Stroke rehab is both a mind and body experience requiring a team approach to address the emotional and physical needs of each patient.
The stroke rehab process at our facility, Rehabilitation Hospital of Indiana, starts with an initial evaluation where therapists ascertain a patient’s deficits and also their goals for when they go home. Using that information, a treatment plan is established that is specific to each person.
The Rehabilitation Hospital of Indiana uses a program model for the treatment of patients. Our stroke rehab program includes:
- physical therapy,
- occupational therapy,
- therapeutic recreation,
- rehab psychology,
- neuro psychology,
- physicians, and
Through the program model, PTs are able to interact daily with other patients who have a similar diagnosis. The group and peer interaction provides patients with support and motivation as they face struggles and challenges; at the same time, it also provides opportunities to celebrate the success of meeting goals.
Therapists evaluate and continually assess strength, range of motion, trunk control, posture, and balance as patients progress, and modify the treatment plans daily as they improve. There is not a specific protocol, plan, or time frame that someone follows in rehab; the therapist observes and assesses a patient’s progress and implements new strategies in order to improve their independence toward getting in and out of bed, walking, grooming, and dressing, as well as everyday activities like going to the grocery store and eventually returning to work and driving.
RESTORING MOBILITY AND INDEPENDENCE
In deciding on the correct technologies and techniques to help increase a patient’s mobility and independence, therapists use many techniques to restore mobility. Some are as simple as self-stretching activities or exercise bikes for the arms and legs. Others are as complex as electrical stimulation in association with function to help retrain muscle activation in proper timing. Posture and alignment of the body are vitally important in regaining muscle strength. Someone might be able to live their life with poor posture before a stroke, but after their stroke, they might have impairments to the motor areas of the brain, so they can’t get away with it anymore. Our bodies were designed to be lined up in a certain way and that’s how the muscles function best—we need everything lined up to make the muscles work the best.
HELPING STROKE PATIENTS COPE WITH CHANGE
Does rehab help people cope with the changes they face? Absolutely!
Most people want to get home and function like they did before the incident. Therapists work hard to make that happen, but when it is not possible, for any number of reasons, therapists are very good at providing support as patients adjust to their new methods of movement and function. The therapy gym and the nursing units can be seen as huge summer camps or support groups. Everyone is going through similar changes and learning to deal with their injury in life. The support offered by therapists, psychologists, and doctors is bolstered by the support patients receive from fellow survivors.
SUCCESS RATES AND OUTCOMES
The first strategy in stroke rehab is to rehabilitate and get a patient back to the way things were before, but that is not always possible. If impairments cannot be overcome or muscles cannot be retrained because of the severity of the stroke, or because of other medical or physical problems, we work to compensate for those impairments. Therapists educate constantly—both the patients and their families. As families become knowledgeable and comfortable with the needs of their loved one and how they can meet some of those needs themselves, the success rate of returning home improves.
For 2009, Rehabilitation Hospital of Indiana had a 62.77% rate of discharge to home, accounting for a total of 231 patients, as compared with a weighted national average of 59.94% and weighted regional average of 58.31%. Eighteen percent of our patients were discharged to a skilled nursing facility. The remainder of our patients were discharged to another rehab facility or assisted living, or, due to medical issues, returned to acute care.
Our facility uses the Functional Independent Measurement (FIM) scale to track the functional improvement of our patients. For 2009, the average increase of FIM score across all areas was 1.39. Individual score average increases ranged from .23 for tub/shower transfer to 1.85 for problem solving. Scores for bed/chair transfer over length of stay averaged 1.76, for walking/wheelchair 1.73, and 1.00 for stairs.Our facility is exceeding or meeting the average national changes for discharge FIM scores across these three areas.
THE INCIDENCE OF RECURRENT STROKE
Nationally, there are approximately 800,000 strokes per year; 500,000 of these are first-time strokes, and approximately 300,000 are recurrent. Patients are at a greater risk of having additional strokes during the first year following the initial stroke. (Information supplied by Angela Carbone, MD, physical medicine and rehabilitation specialist at Rehabilitation Hospital of Indiana.)
Unfortunately, there are times when we do see patients again after another stroke event. Very frequently, they find the second bout of rehab a little easier because they know what to expect; they know it will be hard work everyday, but they also know the prize at the end is improved independence and a return home. With repeated strokes, the remaining deficits can compound each other. Patients might have more limitations after the subsequent strokes and may require more assistance or supervision at home.
FACING LONG-TERM ISSUES
Depending on the severity of the stroke, a patient can experience mild lingering issues, or deficits that change their lifestyle forever. Returning to independence is almost always the goal that is stated by patients on evaluation at rehab. Issues that may limit the return to full independence include:
- visual deficits that are addressed by neuro-optometry and occupational therapy,
- ongoing balance deficits,
- cognitive impairments, which limit safety,
- problem solving,
- ability to manage one’s household functions,
- swallowing difficulties because of weakness in the muscles of the mouth and neck, and
- ongoing muscle weakness or spasticity that could require medical management to address.
All of these potential ongoing deficits will affect a patient’s ability to return to work, return to their preferred leisure and social activities, and return to independence at home. These can be supported by outpatient therapy services, vocational rehab, recreational therapy, and local support groups. An integral part of our stroke rehab process is to help patients and families prepare for these long-term issues. We offer classes and support groups for both inpatients and outpatients that focus specifically on the poststroke patient population.
DEVELOPING INDIVIDUALIZED TREATMENT
Developing an individualized treatment plan starts with the initial evaluation to assess current deficits a patient is experiencing and what abilities they have maintained post-stroke. Each therapist uses the information gathered on the initial evaluation to establish client-centered goals to work toward, and a treatment strategy to obtain these goals. Short-term goals are established to work on smaller components of function that are the building blocks of increased independence. Long-term goals are set for each patient according to what they need to achieve in order to return to community living. Everyone must have the fundamentals of movement before they can walk down the street by themselves, unload the dishwasher, or go for a bike ride. A lot of small steps along the path result in bigger gains that can be appreciated by the patient and family.
Rehabilitating the family of people who experience brain-related issues can be almost as important as rehabbing the stroke patient. Family is always welcome and encouraged to attend therapy sessions. They must become familiar with what the patient’s abilities are and what assistance they are comfortable providing. From helping the affected family member with getting dressed, taking medications, walking to the living room, or getting in and out of the car to go to doctor’s appointments, family members have to understand and feel comfortable with these caretaking responsibilities.
Before a patient is discharged from rehab, there are always family training sessions that are spent solely on making sure everyone is ready to go home. If families feel they need a “trial run” before taking their loved one home, our facility offers a Transitional Living Apartment. Family and the patient stay in the apartment overnight for 1 to 3 nights to learn if the patient’s needs can be met by family members. The family members are also encouraged to participate in psychology sessions or interact with the physicians to get all of their questions and concerns addressed.
Just as Rehabilitation Hospital of Indiana provides support for the patient who experienced the stroke, it is also a big source of support for the family. Our stroke program model allows family members to interact in a manner similar to that enabling patients to interact. They frequently exchange phone numbers and gain friends that are ongoing sources of support and friendship long after rehab is over.
Laura Jarmer, PT, is NDT-certified to treat adults with hemiplegia. She is currently lead physical therapist at Rehabilitation Hospital of Indiana, Indianapolis, where she specializes in treatment of stroke and brain injury. Rebecca Fielding, OTR, is the lead occupational therapist at Rehabilitation Hospital of Indiana, where she treats a variety of diagnoses, including brain injury, stroke, and orthopedic. Both Jarmer and Fielding are part of the Stroke Rehab Program at Rehabilitation Hospital of Indiana.
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