Stroke and Inpatient Medical Rehabilitaiton

[Music] Welcome to Medical Rehab Matters. Today we'll be talking about stroke and inpatient medical rehabilitation. We thought it was important to start this series on the topic of stroke for a number of reasons. Stroke impacts about 800,000 people in the United States each year, and more than two-thirds of them receive inpatient rehabilitation services after they're released from the hospital. Stroke is the leading cause of long-term disability and the fourth leading cause of death, and about 25% of medical rehabilitation patients are there because of a stroke. According to the National Stroke Association, 10% of people who have a stroke recover almost completely with 25% recovering with minor impairments, and around 25% of people who recover from their first stroke will have another within five years. I'm Patricia Sullivan, your co-host, along with Dr. Bob Crute. Our first guest is Dr. Joel Stein. Dr. Stein is a professor of rehabilitation and regenerative medicine at Wheel Cornel Medical College. He is the faciatrist in chief at New York Presbyterian Hospital, as well as a professor and chair of the Department of Rehabilitation Medicine at Columbia University College of Physicians and Surgeons. Welcome Dr. Stein. Thank you. It's a pleasure to be here. Hi, Patricia. I'm Joel. Really excited about our first episode here, and particularly excited to have Joel Stein. Dr. Stein joining us. He was my first attending for my first PM in our rehabilitation experience as a resident. We're excited to talk to Joel about stroke rehabilitation. Stroke is the number one diagnosis that you'll find in an inpatient rehabilitation hospital. And one of the leading causes or may actually be the leading cause of disability nationwide. So great topic for us to kick off the podcast with. I certainly have been caring for stroke patients for many years and engaged in research in this area. And I have to say there's still a lot we don't know about stroke rehabilitation, but I think we have certainly been making progress. And I'm pleased to see that you're focusing in on it. And it's certainly a very big piece of inpatient rehab across the country. You know, I think one of the concerns that I've had during the pandemic is the concern that some patients and families might actually think it'd be best to delay rehabilitation services and sort of wait out the pandemic. Clearly that would not be the wise approach. And maybe you could just comment, you know, from your own facilities, what they're doing to ensure safety for both patients and their family members. Sure. So it's been interesting during the pandemic, first of all, to see that the number of people coming to the hospital for stroke actually went down rather surprisingly during the height of the pandemic. I think less so in subsequent waves, but especially early on. And the presumption is that the number of people having strokes hasn't changed, but that some people were avoiding coming in for care, even for cute, which is really quite start on the interestingly that trend, I think has reversed. And now we're seeing in hospitals nationwide a large volume of patients with all diagnoses and certainly back to the usual number of strokes. There are of course a small number of people who have neurologics of quality and possibly stroke resulting from from COVID, but that's I think a topic for another day. In terms of the impact on rehabilitation, first of all, I think it's imperative that people recognize that there is a window of recovery after stroke and your best ability to improve to make the neurologic gains are early after stroke. Let's jump into really the meat of it. There's been a lot of advances certainly in the last 10 years or so with regard to use of technology. I know you're a big proponent, an early adopter of robotics and things like virtual reality. I'm really curious how world-class institution like Columbia Presbyterian is utilizing some of those techniques to better patient outcomes. Sure. So I think there's a lot of interest in rehabilitation broadly and certainly stroke rehabilitation in particular and how we can optimize outcomes. What can we do to really enhance how our patients do in terms of recovering their ability to move their arms and legs, their ability to care for themselves and walk and their speech if that's affected. And there's several approaches that have been employed. So there's a lot of interest in trying to enhance stroke recovery and using these different techniques potentially to do so. What's interesting is that really our number one tool and our most effective approach that's yet been demonstrated to enhance recovery after stroke is actually exercise therapy. And I'm using exercise here in the broadest sense of practicing movement, of practicing walking, those sorts of functional tasks that involve moving and practicing daily activities. So the question is what's the role of technology they are and the answer is that it is an adjunct and a tool. But we have to keep our eye on the ball that the magic is really in the movement and in the exercise and that the technology is a way of facilitating that. So you mentioned virtual reality and virtual reality is a great example of something that encourages movement that may provide a game like environment to encourage people to perform the exercises that we know they need to do. It's very difficult for many people to complete exercises. Everybody if you ask the room of 100 people, how many of you think exercises good for you, they'll all raise their hands. But if you ask them how many of you are actually exercising, you'll see only a subset of them. So I think everybody acknowledges that exercise is an important component of stroke recovery, but yet it's hard for patients to do it consistently. Using a technique like virtual reality, you can turn this into a game, you can make it fun, you can make it interesting and engaging. And it's easy to sort of minimize that as bells and whistles, but actually that's a critically important piece of this because it gets to the issue of compliance. No treatment works if you don't use it. And so this is a way of getting people to do the exercises we know they need to do. In terms of virtual reality and gaming systems, there's a variety of commercially available systems that are used for entertainment purposes, some of which have been repurposed to some degree for this population. And studies that show that stroke survivors use them well, I think you have to really think about your audience. You know, if this is an 85 year old who is computer full book, it might not be your best choice, right? It might not really work for them. And maybe they're better off playing cards if that's what they're used to doing. If you have a younger person who's very technophilic, who likes to use these sorts of things and maybe used to play computer games, that's a great person for something like virtual reality. In terms of robotics, robotics take this one step further and they can provide physical assistance to someone who has weakness. And that really in some ways mimics what many of our PT's and OT's do when they assist patients in completing an upper limb task or practicing their walking. But again, we have to remember it's basically helping them do the exercise. It's not a magic thing that works on them. It helps them do it. We've been involved in a number of research studies trying to develop better robots easier to use. And hopefully, ultimately allow people to do more exercise on the run at home. One of the challenges with the first generation of robotic devices has been that they are very large and clunky and really have to be used in a clinic setting. Nothing wrong with that. That can be very useful, but it doesn't allow us to increase our dose of therapy. We really want people to be able to get more therapy. And ultimately, the way to do that is for them to be able to do it at home, at least for a portion of their treatment rather than doing it all in our settings. So I'm very interested in my research recently has been looking at developing more wearable devices, things that people can strap on and use at home and practice exercises throughout the day. So our goal, ultimately, is to develop wearable robotic devices so that people can take them home. It's not going to take the place of in-person physical or occupational therapy, but it is a way of extending that into the home environment so that individuals who are recovering from stroke can practice more and get help practicing from these devices. In terms of younger people in particular, I think that many times there's a comfort and an affinity for technology, a desire to use the latest and greatest. So I do see that oftentimes younger people are more excited about these technologies and are often asking me when I see them in the clinic, what is available, what's new, there's no question that some people are more open and interested in this than others. I think one of the areas that we've really just started to scratch the surface on is the whole concept of neuroplasticity and how patients have areas of their brain that can potentially take on functions from areas that may have been damaged. I'm interested in your thoughts in terms of how potentially robotics and other interventions sort of take advantage of that concept. So neuroplasticity is really a critical piece of our development of our lives on a daily basis in a way that we don't really think about, but our brains are changing every day in response to stimuli. Sometimes that's obvious, for example, if you're a tennis player and you're not very good and you get some lessons in your practice, you can get better. Well, what's happening there? That's mostly your brain, right? That's there's a lot of things that I can do. there may be a little bit in your arm too, that muscles a little stronger, but a lot of that is the motor control piece that's happening at the level of the brain. When you learn new material, that is plasticity in your brain. So thankfully, that plasticity continues after stroke and plays a major role in the recovery process that we see where people do regain substantial portions of what's been lost from a stroke. And that's the other parts of the brain, as you say, taking on some of those lost functions. It's an imperfect process, and we do believe that we can stimulate it and encourage it. And that's part of our job and rehabilitation is to try and help that. The use of these technologies really is as a way of providing a form of exercise therapy to enhance the brain's natural plasticity and recovery processes. There are other treatments that are being explored that have the potential to actually modify plasticity directly. And those include things like non-abbaser brain stimulation. This is the idea is that by providing electrical stimulation or sometimes magnetic stimulation to the brain, that it may make it more able to form these new connections. And that is something that's still in the experimental phase. It's not being used clinically, but is an intriguing approach that certainly I'd love to see happen. And we're hopeful that that will ultimately prove useful. One of the issues that we confront in rehabilitation is that there are sort of two conflicting needs. One is to get people home and safe. And the other is to try and help their brain recover as much of its loss function. And when you only have a limited amount of time in rehab, sometimes it's not quite sure what's the priority. How do we spend our time? And so there's no simple answer to that. We have to do both. We certainly need people to be safe when they go home. And we do use what we call compensatory approaches. For example, teaching someone to walk with a cane, giving them a brace for their leg, teaching them how to dress with one hand if the other hand's not working. And I think those are critical pieces of rehabilitation. We're not going to move away from those. But at the same time that we're teaching people how to dress with their other hand, we may also be trying to stimulate recovery of their affected hand. When you talk about learning how to dress with your other hand, that's one of the things that you learn in occupational therapy. That's correct. Occupational therapist focus on what we call activities of daily living, often abbreviated as ADLs. These are the things that we do every day without really thinking about. We get dressed, we get tuned from the bathroom, we rush our teeth, we feed ourselves. And those are what occupational therapists dedicate their treatment to. And physical therapists tend to focus more on mobility, walking, getting up from a chair, that sort of thing. There's clearly overlap. The mobility is obviously an important part of, for example, getting tuned from the bathroom. [MUSIC PLAYING] I think another area that is often underappreciated is the particular expertise of rehabilitation nurses. I mean, they are the glue. They're there 24/7, 365, taking care of these patients, reinforcing treatment plans, off-shift, and whatnot. If you could just comment on how that differentiates a rehabilitation hospital from some of the other settings. I think there's two issues here. One is staff expertise. And the other is staff in levels. I think they're both important. In general, rehabilitation hospitals, rehabilitation units are better staff from a nursing ratio. How many hours of nursing care each patient receives a day is greater than saying that a subacute or skilled nursing facility. So that's very important. And then there's the expertise issue. And there is special certification available to nurses in rehabilitation, nursing, and many of them have it. And even those that don't learn from those who do. So really, that is a very important part of the care that we provide. Do you have any suggestions or words of advice for family members and certainly patients with regard to the paddestrop? They're in the acute hospital now. And how do they advocate for themselves to ensure that they have the option of going to a rehabilitation hospital? I think it's a huge issue. And unfortunately, I think there's a lot of variation in care from institution to institution. It's not ill intent, but just lack of familiarity. I think that some facilities, some institutions just do this a lot more. They have more comfort and expertise in selecting the right level of care. And others just don't have the same level of the same depth that expertise. And so whatever's convenience or easy tends to be the selection. One sort of simple piece of advice for family members and friends of people who are in the hospital with a stroke is to remember that the name rehab facilities name doesn't tell you very much. Anybody can include that in their name. And even the fact that it's interactive looking building isn't really the answer. What you really want to understand is, first of all, what is the level of care? Because there are distinct certifications and different licensure for so-called acute rehab, which is also called hospital level rehab, or sometimes called IRF or inpatient rehab facility. Those are the facilities that are at the highest level of rehabilitation the most intensive. They are sometimes more challenging to find or to get into, but they're well distributed across the country. And the data suggests that, in general, if you're able to participate in that kind of care, at the outcomes are better. There are some people who aren't appropriate for whatever reason. Maybe they have dementia before their stroke, and they can't really participate in rehabilitation. Or they have a very mild stroke, and their major problem is our other things. And maybe that's not the best facility for them. But for people who qualify for and have access to an intensive rehabilitation program, the data suggests that those people do better. And I'll reference the American Part Association guidelines that were published in 2016 that specifically make that recommendation. And I was a part of those. So I just in disclosure, I want to be clear that I am referencing something I had a hand in. But I think that the recommendation, I think, is a strong one. That doesn't mean that subacute care or skill nursing facility isn't important, isn't a key piece of care. There are many people who go to an acute rehab, and then have to go to a subacute or a skilled nursing facility afterwards, because they're not ready to go home. But I think if you're in doubt, as a family member, as a consumer, it's important to, first of all, understand what type of facilities are being recommended. Make sure this isn't just because they're across the street or nearby, or convenience, or affiliated, but that they're really the best facility in the region. And advocacy plays a role here. There's no question. And I have certainly seen it time and again, where a family member's pushing for the right care for their family member has made an important difference. When Dr. Kruegen and I were talking about this episode earlier, he had mentioned that when patients are leaving and going home, that there's a lot of work that has to be done to prepare the home to prepare the family. How does that work? In my experience, I would say the two hardest days in the time course of stroke from beginning to end is the first day when it happens, when the sort of the shock and the medical emergency of it all, and the day of the home. Because that day is a very stressful day. No matter how much preparation has gone on, no matter how much training, no matter how much you think you know what you're getting into, there are surprises. There are architectural barriers. You didn't anticipate the wheelchair won't fit through a doorway. The person who had a stroke forgets that they're not safe to walk by themselves and they get up and they fall. You realize that you didn't get the right medications from the pharmacy or you don't understand how to take it. The home attendant didn't show up on time or went to the wrong address or whatever. There's a lot that happens in that first day or two. And people should be prepared for that. I think it's important that people, first of all, take off from work and maybe have some extra help for a day or two just to get settled in and to realize that transition can be quite challenging. And then people adapt. They settle in, they get a new routine. And I think most people do great in the home environment. And we're grateful that so many of our patients are able to return home. There is a big burden for caregivers. It's been well documented that family members and other caregivers, friends and roommates and all that dedicated, tremendous amount of time and energy to this support and care off and direct care of people who are stroke survivors. And typically we've got any compensation and that's a real challenge. It's an economic challenge. It's an emotional challenge. Oftentimes there's not the support people don't acknowledge what they're going through and they don't get the psychosocial support that they need. There are caregiver support groups. I think it's important that people who are engaged in caregiving take care of themselves as well. They need to make time to eat properly, to exercise. And I find that some are good about it, but many are not. That they're so focused on the needs of the person they're caring for that they don't take care of their own needs. And in the end, you want to be in good shape yourself so you can care for others. There are patients who make really fantastic recoveries. Absolutely. There certainly is every reason to be hopeful. There's new therapies and treatments that are under study and being developed and to not take advantage of the opportunity, it would just be in the state. Well, I want to thank you again for your time today for all this wonderful information that you've shared with us. Truly my pleasure. I really appreciate the invitation. It's great to see all friends. Bob and I usually run into each other at conferences, but now we have to do it on podcasts. So it's great to be together today. Thank you so much for the invitation. This episode is brought to you by Morris Therapeutics, part of the Morris Group. a privately held and-owned company. Mercer Therapeutics is committed to improving the lives of patients who suffer from movement disorders, spasticity, and neurological conditions. Focusing on advancing neuro-modulator technology, Mercer Therapeutics offers Xiamen, a uniquely purified therapy that's FDA approved for six therapeutic indications in the United States. Please note that Xiamen has a boxed warning and good result in potentially serious, therapeutic threatening side effects. Visit xiamen.com for important safety information and proper striving information, including a boxed warning. You will also find information on how to connect with a local sales representative, reimbursement specialist, or medical science liaison. In this next segment, we're pleased to talk with Dr. Argy Helis, Director of the Center of Excellence in Stroke Detection and Diagnosis at the Sheikh Khalifa Stroke Institute, and Professor of Neurology at Johns Hopkins Medicine. Also joining us will be Dr. Jacqueline Berserkowski, a physical medicine and rehabilitation physician at Moss Rehab, and Brian Reed, who is treated by Dr. Berserkowski at Moss, will start with Dr. Helis. Thank you so much for joining us. Some people don't understand the difference between speech and language. Can you explain that? Sure. Speech is actually the motor production of language. It's what we hear when another person talks. That speech, language is the symbolic properties of representations and functions, such as the word choice and grammatical structure, so speech is a physical manifestation of language. So when a patient has a stroke, it's the left side of the brain, where the speech and language lives. Right, and the right side of the brain is, most people are left and mispeared dominant for language, and most left-handers are also left and mispeared dominant for language, but they can be right and mispeared dominant for language. So people who have a stroke on the left and mispeared typically have aphasia, speech can be affected by dysarthria as well. So that is a motor problem because of weakness or reduced range of motion or increased tone in the lids tongue, palate, vocal cords. That is most common after brain stem strokes, but can also occur, especially after bilateral strokes or occasionally after strokes and then trinal capsule on either side of the brain. But worse if it's on both sides. So if we could maybe just take a step back for a second, I think when most people in the general public think about the speech therapists, thinking about the ability to talk, but when we think about it in the medical community, when it comes to something like a stroke, the speech language pathologist is such a critical component to the team in that they're not only addressing the speech, but as we just talked about really communication and also cognition is such a critical piece. And then really early on, right, is the whole swallowing mechanism that speech gets involved in because that's such a high risk for complications that often many of the other members of the team, if it's not in a stroke center, don't really have a real appreciation for us. I'm wondering if you could just sort of comment on some of what I just mentioned. Sure. Speech pathologist started getting very involved in swallowing back when I was a speech pathologist in the early 80s and the muscles that control speech are the same ones that control swallowing. And so it was an appropriate discipline to really manage the swallowing problems of value with them. And we began to understand then that especially people who have dysarthria, so speech production problems frequently have swallowing problems as well and that they can get pneumonia from that. Now that's been appreciated for a long time, but it used to be thought, well, you just keep people in PO for a couple of days and then they'll be able to swallow and that didn't always happen that they often didn't swallow safely even after the first few days. So people started doing video-floor stoppic swallowing studies where they would take a video of the person swallowing different consistencies of liquids and foods because it turns out people choke the most on thin liquid because they tend to go down, but we used to say the wrong pipe, which is true if they go into the larynx and into the lungs instead of going down into the esophagus. Some people have what's called silent aspiration, so they were getting especially thin liquids into their lungs without ever coughing or showing any evidence that they had swallowing problems. So that's something speech pathologist do routinely now is using a variety of mechanisms. They evaluate whether the person's at risk for getting pneumonia by swallowing, by having liquids and or solids, going to the larynx called aspiration when they're swallowing. When you said NPO, you mean nothing? I know it's a lab abbreviated for nothing. Yes, so I meant that people used to just keep them, you know, said, "Well, you can't swallow anything the first few days." So that's also very difficult, right? Then you get dehydrated and that can cause complications. You miss out on nutrition. So then some places they just put a nasogastric tooth into the person and we still do that until we can figure out if they can swallow safely and what they can swallow safely and how they can swallow safely. So the speech pathologist is very involved with the team, letting them know, "Well, now the person can swallow, but they can only swallow thick liquids, so you have to thicken their liquids, you have to mash up their solids, etc. for them to swallow safe." Yeah, and I think that's a really big component of quality of life. We all take it for granted. But being able to eat and certainly drink regular fluids is really a pleasing thing that we all look forward to and you can imagine that if you're in the hospital and dealing with the other physical issues surrounding something like a stroke to not be able to eat regular foods and to have to put thickener into your fluids, it's not fun and it's something where we really do everything we can to move the patient as quickly as possible to advance their diet. But again, if done too quickly, we can really create a lot of complications. So this really is an early focus as you just described. The only of it common I would just make is the whole cognitive component and other manifestations of stroke because it really is a complex medical condition can also impact the ability to eat. It's not just the swallowing mechanism itself, but does the person have awareness that there's food in their mouth and they may be pocketing food and/or liquids? And that's why it's so critical that the other members of the team, the rehabilitation nurse that we petitive exercising and practicing, so to speak, with all of them, meals that the patient has given is so critically important so that we can as quickly as possible put into effect compensatory strategies that will allow the patient when they go home and even when they're in the hospital to start to be able to advance their diet and get the pleasure from eating. I wanted to ask about the problems with cognition and language and speech. It's three different things. You're all going to kind of merge together as, I can't tell you what I need. You don't understand what you're asking of me. I would think that's very frustrating. It is very frustrating. So there are people who understand what you're saying, but they can't produce the words. People, for example, have a focus of Asia, have a great deal of difficulty getting the words out and have difficulty producing grammatical sentences to communicate. But they do understand what you're saying. But that's very frustrating, because they know what they want to communicate and they can't just, you know, you occasionally will have a tip of the tongue phenomenon where you can't think of a word you want to use. And it's so frustrating. I know this word, but I think it's long, it's kind of on the tip of your tongue. But you can imagine if that's happening every time you have a mouth trying to say something that's very frustrating. And other people have more difficulty understanding people with what's called Bernicke's of Asia, have difficulty understanding what people say. And that's frustrating in a different way because they can speak, they can articulate words, but it doesn't make sense. And they don't even understand that they're not making sense. So they may talk in jargon and say, "Is that a bit deuda and design?" You know, the thing that went over there, sometimes they're producing English words, sometimes just non words. And they think they ask you to bring them up glass water. And you didn't. And then you bring them up pillow instead. And that you can imagine that's very post as well. And you know, you bring up an excellent points and some of the other things that I've seen also that are fairly common is if someone, you know, speaks multiple languages, right, though often revert back to whatever their first languages in terms of understanding or doing better with understanding spoken word. And I think the speech language pathologist, their role is so critical early on to help guide the rest of the team as to what is the best way to communicate with this patient because if we can't begin to communicate and get some learning going, it's very hard to get carry over with all of the different physical, cognitive, swallowing, all of those things that we're all working on on a daily basis. So Brian Reed has been able to join us. He was a patient at Moss Rehab. And my understanding is Brian suffered a stroke a few months ago and he has graciously agreed to join us to talk about his experience. Thank you, Brian, so much. So we've been talking about speech and language and cognition problems that a lot of stroke patients face. Did you have problems in that regard? I definitely had problems with my speech and language and cognition. It was a long road coming back to recovery. Now I feel a lot better, but it's been almost 15 months. And I'm just starting to move along with my life. I just got my driver's license back this week and I feel good about it. I got very lucky. I got very lucky with my stroke because I was in really bad shape when I was first admitted to the hospital. I was a three person assist with the walker and I had no energy, and I couldn't remember anything. I could not remember anything. And that has slowly come back. That's, you know, it's been a long road and I still have a long way to go, but now I can actually function somewhat normally. So Brian, we were just talking about some of the speech, language, and other, you know, swallowing problems that many who suffer a stroke have to, you know, deal with early on and potentially, you know, chronically. Can you just share with us briefly what some of your challenges were early on in terms of those things? Early on eating was a challenge. Swallowing was definitely a challenge. I had a feeding tube for a while. Then they got rid of that, but everything was finally ground up. All the food that I could eat was I remember that, you know. That's one thing. My memory issues are really bad from the first few months of my stroke. I can't remember much, but I do remember the liquid-fied food and the swallowing issues, and I would put too much food in my mouth, but that went away after a while. I got lucky, you know, it went away after a while. So that kind of relates to what you were talking about earlier, Bob, about quality of life, that it's tough, drinking all your meals or having everything to be ground up, that's got to be challenging, but you seem like you're doing great. I feel like I'm doing much better. I can eat normally, I can sleep normally, I can dress myself, I can take a shower by myself, and I can drive a car. And you got your rehabilitation that you went to one of the best places in the country, and mass rehabilitation, correct? I feel it was great. I mean, this staff there was just unbelievable. They really helped me so much. Every single day, it was new, and they helped me a lot. So just for the benefit of the audience, because you categorize it as it just went away, I think it's so important that early on, as the body is first adjusting to the stroke, and given time to heal, that we ensure that someone like yourself is safe, so that you don't ask for it, so that you don't get into ammonia, and things go in the wrong direction. Then the body has some time to heal itself, as well as the brain, and there's the ability to regain some function. But then the rehabilitation team is really exercising your brain, as well as your swallowing muscles, as well as your cognitive abilities, so that you can regain some of those functions. And in your case, it seems like things are really coming back to the point where it's going to be really difficult for anyone to know, moving forward, that you've had a problem. So that's just one of the most. Thanks. I feel that that was a big part of my recuperation, to being being a safe, comfortable environment, but they also worked me really hard at the same time. I got very tired. I had fatigue, and they gave me breaks during the day, a half hour, and then I'd go back out for another hour, and then a half hour. It was well spaced out, and it was completely organized. I mean, they took care of me really well, and I appreciated that, especially now, looking back on it. I've heard horror stories about people recovering from stroke, but it wasn't that way at moss, not at all. It was excellent. That's great to hear. So you worked with the team, right, Brian? There was a team of people working with you. Yes. And one of them was the speech and language pathologist, or the speech therapist. Right. Jenny. Yeah, she was great. Dr. Hill, maybe you could just comment on when stroke patients are in the acute care phase of managing whatever caused their stroke and stabilizing them. Once that critical time has occurred, now it's time to move them on to more intense longer term rehabilitation. In the current system, the options are certainly going home and getting home care, going home and going to outpatient, going to a skilled nursing facility where you can get some rehabilitation services, or going to an acute inpatient rehabilitation hospital. And if you could just give us a little insight as to how you view where stroke patients should go, certainly the American Heart Association and the American Stroke Association has updated their clinical guidelines and strongly advocates for an interdisciplinary program. But if you could just share your own thoughts on how your team approaches it, I think the audience would appreciate that. Sure. At Johns Hopkins, we're actually starting in 10s. We have even in the acute care period when they're getting their evaluation like transbrasset, hearted ram, imaging of the neck vessels. At the same time, they're still getting three hours of therapy a day, usually smaller units, sort of six half hour visits with the therapist, we're trying to do it every single day so that they can start. We don't want to force them too hard in the acute period. We want them to get some enough rest, but we also don't want people just lying around being bored. So we're starting therapies early and that also allows us to get an idea whether or not the person can tolerate that much therapy. So that's one of the big decision points. We actually leave it up to the therapists to decide what would be best for them to go home or to a treat rehab or to a subacute rehabilitation facility, which is not really subacute. It's the same time period, but it's a little less intensive therapy if they can't really tolerate active participation for three hours a day. So to go to a acute rehab, they really need to be able to participate in three hours a day. Also sometimes, it just depends on how many therapies they need. If they just have a facial, a language problem, you don't need to go to a acute rehab for that where you would be getting a few hours of physical therapy and occupational therapy a day if your main problem is speech language. So those people typically go home, but there are also people who can go home safely and they want to go home, but they still need a comprehensive interdisciplinary team. So there are comprehensive outpatient rehabilitation programs where that different disciplines still work together. I did that for a long time when I was a speech pathologist is I was the director of neurologic rehabilitation of an comprehensive outpatient rehabilitation facility and would still meet weekly with all the therapists taught about education, would try to coordinate therapies. Sometimes people are doing co-therapies now. So a speech therapist done an occupational therapist might work together on following recipes to cook something because they have reading difficulties and they need to work a little bit on how to structure the recipes so they can follow it. Whereas the occupational therapists may be working more on the actual cooking skills and using their arms and so on. So sometimes people are doing therapies but it is very important for the family to express their wishes and needs and talk to the therapist. So every morning webstero patients will talk about every single patient on the wards with rehab and the nurses and the therapists and the doctors altogether to talk about okay how are they progressing? What's going to be the best place for them to go when they leave this acute unit? Should they go to an patient we have to make tolerate that? Would they prefer to be at home? Do they have transportation to get to an outpatient facility every day? So there are a lot of factors but everybody needs to have their input. I think some of the other factors that are frequently not as clear or evident are even if you would go to a sub-acute and again I would agree with you it's not the time period it's really more about the intensity of services that are being offered in a skilled nursing facility. Very often even if they have speak language pathologists and they often do they have a tremendous number of patients that they need to see and cannot dedicate the time that a patient might need or otherwise benefit from and they may not be at that facility either every day or even every week. So the consistency of the therapist working with the same person who really knows your case I think is so critically important early on and to have that team be consistent so the same physical occupational and speech therapists I think you know can't be underestimated and then finally the nursing staff having nurses who truly understand rehabilitation often certified in rehabilitation in an acute rehab hospital versus a skilled nursing facility really can can make a world of difference because again they're the ones that are there 24/7 who can reinforce a lot of the things that the neurologist the rehabilitation physician and the therapist are working on while they're there you know during normal you know we'll call it work hours whatever that is eight o'clock to four or five o'clock in the afternoon and then finally the rehabilitation physician something near and dear to my heart obviously while there are some that do go to skilled nursing facilities most facilities still do not have access to a physician with that specialty perspective seeing patients on a regular basis so I think all of those things need to be considered when you're determining what's the best setting for the patient. And of course the one thing that we don't have any control over is the patient's insurance so sometimes people have insurance that will pay for a subacute facility like I said that's a misnomer but that kind of place but they won't pay for a acute rehab or they won't pay for outpatient or they have restrictions sometimes on the number therapy sessions a person can have that's not ideal but it's just realistic and the family may not have resources to pay for additional therapy one thing that we've been able to do is we have a few aphasia treatment trials in the acute to subacute period where we've actually been able to go to subacute facilities and carry them out in addition to their regular therapy so they're getting the sick they're getting at therapist come and work on it a therapy program but it's paid for by national institutes at home rather than their insurance and sometimes we can do that at home too even if they don't have insurance. I'd like to introduce Dr. Barsokowski one of the questions I have is about family and how important are they to a patient's recovery how do you work with them oh shoulder they're incredibly important and absolutely probably almost as important as the patients recovery themselves my first point of contact with the family is typically so obviously of course and in Brian's case he was with us during the pandemic so you can imagine this life changing thing has happened and people cannot see their loved ones oftentimes my first point of contact during the pandemic in particular or if the family's unable to come during the day because they work is a phone call and my first question to them is how are they doing sometimes it's the first time they've been asked that question is how are they been doing because you get a lot of sense from them you know about what's been going on and their understanding of the situation and then I oftentimes go into the education piece and tell them okay this is kind of review everything from acute care oftentimes the acute care side of things is so quick or it might feel quick or it's a blur to not just the patient but also the family that I just recap I do a nice the recap of everything that I know from the documents I've received I talk about the stroke location and what would we would expect so if they're having memory problems I might say this is really typical for this location I wouldn't be surprised here's what you can expect and there's just a lot of education and a lot of questions and I allow for a lot of questions from their perspective and I think a lot of just frequent check-ins our hospital we do family instruction I think a lot of hospitals have moved towards doing that and so towards the end of a patient stay with us families come in for instruction with the therapy team and with myself and nursing to get more hands-on experience so for us it's really making the family just as part of the recovery process as we can Brian I wanted to ask you if you had anything that you wanted to share about your experience something people would be surprised by or just something you think other people in your position would want to know well I know that you guys were talking about having a choice whether to go to rehab or go to the hospital or stay in home and I didn't have that choice because I was airlifted so I was totally unconscious for the first couple weeks and I was on a ventilator I was in ICU I had no recollection of it I can't remember having any of course I had no choice because I was unconscious my wife made decision she made the decision so I'm glad she did I'm glad she made because she was given the choice whether she wanted to or not because I was in really bad shape and she had to sign the papers to have this surgery you know and it turned out to be a pretty dramatic surgery but thank God she signed it and I'm doing better today because of it it's awesome you know thank you Darjara Pillow's do you have anything you would like to to add? No I just think I can't emphasize enough the importance of rehabilitation speech and language therapy for helping the families understand how to communicate best with the patient as well as helping the patient learn to communicate again we didn't really talk much about the cognitive actors but that's also something speech language pathologist do is address problems with brain-in-tune memory but also attention or executive functions sometimes they work with people who have right-in-the-spear strokes that can affect attention and cognitive skills also can affect emotional communication like being able to use your tone of voice to communicate people with aphasia tend to do that very well they rely on their tone of voice when they can't think of the words and gestures and facial expressions but people with right-in-the-spear strokes sometimes have difficulty with those things and so that speech and language pathologists can address those kinds of issues as well Dr. Burst of Palsky? I'm certainly biased but I'm always going to recommend certain I think we have is a great great place the best place for someone after a stroke I unfortunately missed the beginning part of it but Brian I don't know if he emphasized enough just his recovery how far he really came you know I mean Brian couldn't remember me did not know where he was did not know what happened to him but has worked incredibly hard with the resources that have been able to be given to him so I just cannot emphasize enough that it's just it's just he's one of these patients that you just I mean this is he's a big reason why I do what I do Well I want to thank all of you for your patients for your participation and for what you've shared with us today I think it's all really important I hope this will help some people thank you so much for having us thank you very much thank you for joining us Brian that's great thanks very much thank you very much thank you to a good recovery movement forward thanks for listening to Medical Rehab Matters a podcast by the American Medical Rehabilitation Providers Association AMRPA would like to thank podcast sponsor Mercer Aputics for its support, as well as our Golden Platinum Association sponsors. Our Platinum sponsors are Bioness, Casa Kalina Hospital and Centers for Healthcare and Select Medical. Our Gold Sponsors are JFK Johnson Rehabilitation Institute, Moss Rehab, and the Center for Improvement and Healthcare Quality. You can learn more about medical rehabilitation at AMRPA.org. [Music]