What to Expect in Stroke Rehab
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.
What to Expect of Therapy
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.”