Stroke Rehabilitation

Report
STROKE REHABILITATION
REBUILDING A LIFE
Marla Rose, Speech Language Pathologist
Trinity Hospital
OBJECTIVES

Discuss the multiple levels of rehabilitation
Therapeutic services provided from acute care to
home.
 Therapeutic rationale for intervention and for
discharge planning

WHO ARE WE TALKING ABOUT



In UNITED STATES, approximately 795,000
people suffer a stroke each year.
Approximately three-quarters of all strokes occur
in people over the age of 65.
Approximately one fourth of strokes occur in
people under the age of 65.
TRINITY HOSPITAL - 2011

165 admitted with stroke as primary diagnosis
83% Ischemic
 11% Intracerebral hemorrahage
 5% Subarachnoid hemorrhage


Average age: 70.5 years

Discharge disposition




42% Home
23% Inpatient rehab
13% SNF
7% Expired
REBUILDING A LIFE

Stroke is the leading
cause of serious, longterm disability in the
United States.
ROAD TO RECOVERY
RECOVERY STATISTICS

Much variability in statistics

Most improvement noted in the first 6 months


5% show continued improvement up to 12
months
47 – 76% achieve partial or total independence in
ADLs
MULTIPLE LEVELS OF REHABILITATION
Home – Independent
Home + Outpatient tx
Home + Home Care
Skilled Nursing Facility
Inpatient Rehab
Acute Care
FACTORS PREDICTING ADL OUTCOMES
Advanced age
 Comorbidities
 Myocardial infarction
 Diabetes mellitus
 Severe stroke
 Severe weakness
 Poor sitting balance

Visuo-spatial deficits
 Mental changes
 Incontinence
 Low initial ADL
scores
 Delay in initiating
rehabilitation
following onset

REHABILITATION TEAM
Patient and family
 Physicians
 Physical Therapist
 Occupational
Therapist
 Speech-language
Pathologist

Nurses
 Dietician
 Social Worker
 Orthotist
 Mental Health
 Insurance Company
 Community Resources

ACUTE CARE
ACUTE LOS: 4.6 DAYS

PT/OT:






Diagnostic intervention
Range of motion
Introduce activity/exercise
Assess potential for more aggressive intervention
Provide patient/caregiver education
Assist with discharge planning
ACUTE CARE
ACUTE LOS: 4.6 DAYS

SLP





Diagnostic intervention
Assess cognitive - communication skills
Assess for potential to participate in more aggressive
intervention
Provide patient/family education
Assist with discharge planning
ACUTE CARE

SLP





Assess swallowing and make recommendations
Monitor swallowing function
Assess for potential to participate in structured
intervention
Provide patient/family education
Assist with discharge planning
ACUTE DISCHARGE PLANNING

Home with outpatient therapy

Home with Home Health Therapy

Inpatient rehab

Skilled nursing facility

TEAM members: patient and family; physicians;
inpatient rehab medical director; case managers; social
workers; therapists; 3rd party payer.
REHABILITATION THEORY


Evidence from clinical trial supports early
initiation of therapy.
Early improvement (3 – 6 months):
Resolution of local edema
 Resorption of local toxins
 Improvement of local circulation
 Recovery of partially damaged neurons

REHABILITATION THEORY

Ongoing improvement (for many months)

Neuroplasticity – the ability of the brain to modify
its structural and functional organization
New synaptic connections
 Activating latent functional pathways
 Utilization of redundant neural pathways

REHABILITATION THEORY


To influence brain re-organization we must DO
SOMETHING to facilitate the lost skill. Therapy
exercise must promote USE rather than non-use.
Repetitive, skilled, functional movement is
beneficial in facilitation of brain re-organization.
MEDICARE’S EXPECTATION



Therapeutic services provided require the skilled
services of a qualified therapist.
The patient’s condition will improve significantly
in a reasonable and generally predictable length
of time.
Therapy results in recovery or improvement in
function.
INPATIENT REHAB
Trinity Hospital – St. Joseph’s Campus
INPATIENT REHAB
WHAT YOU NEED TO KNOW

3 hour rule

Must benefit from at least 2 therapy disciplines

Length of stay
Determined by Medicare
 Admit severity
 Co-morbidities


Goal is to discharge patients home
ADMIT SEVERITY:
HOW IS THIS DETERMINED?

Functional Independence Measure: FIM

National rating scale, 1 – 7
7 = Independent
 1 = Total Assistance


Reflects the burden of care; how much
assistance is required for the patient to carry out
ADLs.
FIM
Eating
 Grooming
 Bathing
 Upper body dressing
 Lower body dressing
 Toileting
 Bladder Management
 Bowel Management
 Bed to chair transfer

Toilet Transfer
 Tub/shower transfer
 Locomotion
 Stairs
 Comprehension
 Expression
 Social Interaction
 Problem solving
 Memory

INPATIENT REHAB
HOW IS IT DIFFERENT

Therapy intensity

Mandatory participation

Therapy staff

Social Worker

Medical director – visits patients daily

Nursing staff and the scope of their
responsibilities
MEDICAL COMPLICATIONS
Pulmonary aspiration, pneumonia – 40%
 Urinary tract infection – 40%
 Depression – 30%
 Musculoskeletal pain – 30%
 Falls – 25%
 Malnutrition – 16%
 Venous thromboembolism 6%
 Pressure ulcer – 3%

NURSING STAFF

They’re not ONLY nurses

They’re NURSE THERAPISTS
INPATIENT REHAB NURSING STAFF
Daily, frequent contact with patients
 Reinforce therapy strategies
 Provide frequent opportunities to practice what
patients are learning in therapy
 They MUST know patients’ level of functioning in
16 FIM areas

Current level
 Where they are progressing
 Where they are not progressing
 How their level of functioning influences the
discharge plans.

INPATIENT REHAB OUTCOMES
# of stroke patients
 Average Age
 ALOS (days)
 D/C Home
 D/C SNF
 Ave FIM gain points

(target: 28 points)
2011
51
72
13
80%
16%
28
2007
72
73
14
74%
17%
22
PHYSICAL THERAPY


Exercises to address the sensory-motor
physiology
Apply the physiological gains to functional ADLs
OCCUPATIONAL THERAPY


Exercises to address the sensory-motor
physiology
Apply the physiological gains to functional ADLs
SPEECH-LANGUAGE PATHOLOGY


Exercises to address the sensory-motor
physiology of swallowing
Apply the physiological gains to functional
swallow
SPEECH-LANGUAGE PATHOLOGY


Exercises to address neurological processing
and/or physiology for communication skills
Apply gains to functional communication
interactions
SKILLED NURSING FACILITY

Scenario #1


Patient transferred from acute care immediately
following stroke.
Scenario #2

Patient transferred from inpatient rehab with
Good progress made and positive prognosis
 Poor progress made and guarded prognosis

SKILLED NURSING FACILITY
Philosophy of brain re-organization - same
 Rate of progress will likely be slower
 Intensity of therapy will likely be less
 Possibly less daily activity
 Nursing staff ‘hands-on’ will likely be less
 Primary physician will not see patient daily
 Eventually may begin to include exercises
designed to develop compensatory skills

HOME WITH HOME CARE

Scenario # 1


Patient discharged from inpatient rehab with
recommendations to continue therapy.
Scenario #2

Patient discharged from acute care with
recommendations for therapy.
HOME WITH HOME CARE
Philosophy of brain re-organization - same
 Rate of progress may possibly be slower
 Intensity of therapy will likely be less
 Possibly less daily activity
 Advantage of addressing ADLs in their home
 Motivation
 Nurse is available on limited basis
 Eventually design therapy goals and exercises to
address work and social needs
 Eventually begin to include exercises designed to
develop compensatory skills
 HOME BOUND

HOME WITH OUTPATIENT THERAPY

Scenario # 1


Scenario #2


Discharged home from inpatient rehab with
recommendations for outpatient therapy.
Scenario #3


Discharged home from acute with recommendations
for outpatient therapy.
Discharged home from SNF with recommendations
for outpatient therapy.
Scenario #4

Discharged from Home Care services with
recommendations for outpatient therapy.
HOME WITH OUTPATIENT THERAPY
Philosophy of brain re-organization - same
 Rate of progress will eventually be slower
 Intensity of therapy will likely be less
 Possibly less daily activity
 Motivation
 Eventually design therapy goals and exercises to
address work and social needs in addition to
ADLs
 Eventually begin to include exercises designed to
develop compensatory skills

THROUGH ALL LEVELS OF REHABILITATION

Patient goals

Medicare/3rd party payer expectations

Neuroplasticity theory

Target actual functional use BEFORE
compensatory training

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