|Shown above, with a client, Yaffa Liebermann, PT, GCS, CEO of Prime Rehabilitation (right), believes in setting measurable and attainable goals before starting therapy.|
Early and often” once referred to the way people voted on Election Day in certain big-city political precincts. Now it refers to the way rehab therapy is delivered to stroke and neurological trauma patients.
“We like to start therapy within days of the stroke victim’s injury and then provide as much therapy to that person as they can safely handle during the time with us,” says Nick Helmkamp, MS, PT, a Level II physical therapist assigned to the inpatient stroke and orthopedic program at Mary Free Bed Rehabilitation Hospital in Grand Rapids, Mich.
One thousand miles east at Spaulding Rehabilitation Hospital in Boston, the goal is to begin working on stroke patients inside of 3 days after admission. “The earlier we can get the patient involved in therapeutic activity and exercise, the more likely we are to see a good outcome and a rapid return to the community,” says Joel Stein, MD, chief medical officer at Spaulding Rehabilitation Hospital and an associate professor in the Department of Physical Medicine and Rehabilitation, Harvard Medical School.
However, therapy must not begin too early. The stroke patient must first be medically stable.
“Patients are medically stable if they are determined to be experiencing no further neurologic deterioration,” Stein says. “Most stroke patients within 24 hours are neurologically stable. But there can also be complications of stroke such as pneumonia and heart arrhythmia, which need to be addressed before the patients can be deemed medically stable.”
Helmkamp says stroke patients can enter the Mary Free Bed Hospital program only after meeting various criteria above and beyond medical stability. Among them is evidence suggesting an ability to tolerate 3 or more hours of daily therapy, 7 days a week. “The patient also needs to demonstrate potential for significant functional improvement and must have a viable discharge plan that includes supportive family or friends ready to be involved once the patient arrives home,” Helmkamp says.
Of course, before therapy can commence, there also must be measurable and attainable goals in place. Yaffa Liebermann, PT, GCS, CEO of Prime Rehabilitation Services Inc, Oakhurst, NJ, an organization specializing in the development of comprehensive and customized therapy programs, suggests that an overarching goal of stroke therapy should be to emphasize and establish correct habits. “The patient must learn how to assume a correct posture or correct poor posture,” she says. “Therefore, we want to inhibit abnormal movement and provide experience of normal movement. To do this, we first must understand and analyze how patients deviate from normal movement, determine why they deviate from normal movement, and gauge their ability to bear weight on the weak side’s arm, leg, and trunk.”
Helmkamp describes his institution’s goal-setting approach as being task-specific and functionally based. “If someone has difficulty walking, that’s what we focus on—walking,” he says. “If someone has speech deficits, then we either have speech therapy bump up its intensity, or incorporate speech-related goals in our sessions.”
PATIENT, FAMILY INVOLVEMENT
Liebermann says it is a good idea to solicit patient input when setting goals. “Ask the patient what he wants to achieve in the treatment,” she says.
Stein—author of several books, the most recent of which is Life After Stroke—believes goals should always be individualized. “Our Spaulding Rehabilitation Hospital approach to goal-setting usually occurs through a team process that includes help from the patient and the family,” he says. “Importantly, the goals established are those relevant to the patient.”
Helmkamp’s colleague at Mary Free Bed Hospital is Jason R. Bomia, MS, OTR, Level II occupational therapist. Bomia, too, thinks family involvement in goal-setting—and in the therapy itself—is crucial. “Since we can’t follow the patients home, we hope that the families will become the at-home therapists,” he says. Accordingly, the team “encourages families to participate right away, as soon as the patients are admitted to our program. This enables the family to not only learn what we’re doing but begin to guard the patient or cue the patient if there are safety concerns.”
The “Prime of Life” stroke rehabilitation program offered by the Rehabilitation Institute of Chicago (RIC) recognizes younger individuals who have suffered a stroke must often look to a rehab program to restore their ability to care for children, sustain a career, or a return to an intimate relationship. The program comprises traditional therapies infused with novel techniques specific to fulfilling the goals of younger patients, including: constraint-induces movement therapy, robot-assisted walking therapy, arm therapy, clinical drug therapy trials, and aphasia management.
The youngest populations affected by neurologic impairment are given particular consideration by the pediatric rehabilitation and education program at the Florida Institute for Neurologic Rehabilitation Inc. The modern, 23-bed facility has adopted an interdisciplinary, family-centered approach to treatment, and offers resources and programs designed to teach children the skills needed to live in the least restrictive environment and successfully re-enter their home community and educational system. FINR has also created a “TBI School” that offers educational services provided by certified teachers and maintains a low instructor-to-student ratio. The facility has also built in a 24-hour a day social skills teaching environment.
This new thinking about starting therapy as early as possible—not just for stroke patients but for those who have sustained a neurologic event such as a traumatic brain injury, since the advantages of jumping right in are identical—requires at least a few changes in the way an institution provides the therapeutic interventions chosen in the goal-establishing process.
“Intensity of therapy is one area we’ve had to look at,” Bomia says. “We have to make sure we’re getting patients up near or above the 3 daily hours of therapy. Typically, a full therapy day will start the day after they’ve been admitted; getting them right into a routine is one of the big issues. As they’re able to tolerate more therapy, we increase the intensity with additional sessions.”
The Mary Free Bed Hospital approach to therapy for stroke and neurologic patients is primarily hands-on. Says Bomia: “It’s hands-on because we want to be able to guide and educate the patient on the best and safest way to perform any given motion or exercise.”
Stein takes much the same position when describing the thinking at Spaulding Rehabilitation Hospital. “Modalities can be useful at times, but for the most part they have limited application in stroke rehabilitation,” he contends. “Mainly, stroke rehabilitation is about activity practice and therapeutic exercise conducted individually or in small groups. But, without question, technology also has a place in stroke rehabilitation—functional electrical stimulation (FES) and robotic devices, for example,”
Bomia concurs. “Within the last 2 years, we’ve incorporated FES devices into our program and they’ve made an enormous difference in many cases,” he says. “One of the ways they help is by giving patients a needed sense of accomplishment. They typically aren’t actively moving the hand, but FES enables them to use the hand to pick up objects from off the table.”
The applications of FES in stroke therapy are numerous. In one such use, FES can be implanted to provide neuroprosthetic assistance in swallowing: a problem for stroke patients is the tendency to aspirate while swallowing, which can create pulmonary trouble—an implanted FES can provide dynamic control over the vocal folds and thereby prevent aspiration. Other stroke-related applications for FES include relief of chronic shoulder and low back pain, correction of footdrop in hemiparesis, and aiding upper extremity motor relearning.
Bomia says that another useful piece of technology is a custom, dynamic orthotic splint that is spring-loaded on the outside of the patient’s wrist and forearm to allow opening of the hand. “We use this mainly on the outpatient side of stroke therapy, but we are beginning to explore ways to incorporate the [splint] during inpatient rehabilitation,” he says.
ELEMENT OF FUN
Gait training and community mobility exercises factor into the stroke therapy program at Spaulding Rehabilitation Hospital, where an ambulatory trainer is used to help selected patients, and provide a therapeutic advantage. “We’re right on the Charles River, so we take our appropriate patients out on the water for sailing or kayaking in specially adapted equipment,” Stein says. He adds that Pilates and yoga for core stabilization are used sparingly in the Spaulding inpatient program (more so in the outpatient component).
Liebermann is keen on standing-position weight-bearing and weight-shifting exercises for her stroke patients. “Standing to the weak side is a successful way to regain movement,” says the author of the soon-to-be-completed book Life After Stroke & Functional Exercises for Survivors and Caregivers. “The stroke survivor tends to stand only on the strong leg and to lean on the strong arm. He should try to shift the weight onto the weak leg and lean on the weak arm. Bearing the weight on both legs normalizes tone, increases low tone, and decreases high tone. It also provides normal movement experience and normal sensory experience. And it allows energy to flow from the strong leg to the weak leg.”
Liebermann recommends movement training as well, but cautions that it is best conducted “in the actual activity to be performed.”
In any stroke therapeutic exercise, repetition is key. “It’s important because whatever the patient achieves in today’s session will be decreased by 75% by tomorrow,” Liebermann says. “So we have to introduce the movement again so the patient will relearn the movement and reestablish the muscle pattern to perform the movement. Usually, I find that five repetitions in one session of any given movement will help the patient to remember it.”
Repetition is not the only vital ingredient. Equally essential is the element of fun. “Fun helps keep patients mentally engaged in the therapy and enthusiastic,” Stein says. “That’s one of the reasons we’re exploring virtual reality therapy, because we expect that many patients will enjoy it.”
TRIUMPHS KEEP COMING
Mary Free Bed Rehabilitation Hospital is an 80-bed, freestanding nonprofit facility. The daily census in its stroke program ranges from 10 to 20 inpatients.
At Spaulding, the program can accommodate about 30 inpatients, 40 in a pinch. The average stroke patient stays there 2 to 3 weeks. Some are then discharged to a subacute or skilled nursing facility, but most go directly home. At home, they might receive a few weeks of rehab services brought to their door by home care providers and then enter Spaulding’s outpatient rehab program to build on the gains achieved during the inpatient stay. “A very few of our stroke program patients are discharged to a long-term care facility indefinitely because they no longer have the ability to manage in the community,” Stein clarifies.
The stroke program at Spaulding is a bit different from the one at Mary Free Bed, but the common denominator is that both are seeing impressive results from having adopted the “early and often” approach to therapy. “Our patients are being put on the road to recovery sooner, and, as a result, they are traveling along that road at a faster clip than once was the norm,” Bomia says. “The triumphs come with just about every discharge. For us as therapists, it’s enormously satisfying.”
Rich Smith is a contributing writer for Rehab Management. For more information, contact .
Building a Stroke Center
A successful therapy program for stroke and neurologic trauma patients requires good organization. Yaffa Liebermann, PT, GCS, CEO of Prime Rehabilitation Services Inc, Oakhurst, NJ, contends in her forthcoming book, Life After Stroke & Functional Exercises for Survivors and Caregivers, that such organization should be built around the following personnel tasked with specific responsibilities:
Physical therapist. Evaluates the new stroke patient and creates a program wherein the individual regains functional abilities lost to neurological deficits. Therapy includes gait training, transferring, balance, and lower extremity strengthening in conjunction with an emphasis on breathing. Safety issues are addressed for all activities.
Occupational therapist. Evaluates, plans, and develops a training program for the individual that helps him to perform the activities of daily living, including bathing, grooming, dressing, and feeding, while assisting the patient in developing awareness of energy conservation. Safety issues are also addressed by occupational therapy.
Speech-language pathologist. Evaluates, plans, develops, organizes, and implements patient care programs through the utilization of selected speech and language, and swallowing testing and treatment procedures. Provides instruction to the dietary department concerning the consistency of food for the resident and works to improve functional communication skills.
Rehabilitation technician. Transports patients to and from the therapy area, and supports and assists therapists. Copies and files the therapists’ written case documentation.
Physiatrist or other medical doctor. Oversees clinical evaluations and treatment progress.
Admissions clerk, social worker, and nursing staff. Provide overall coordination of all activities and services.