Interdisciplinary Rehabilitation for Stroke Jessica Berry, MD Natasa Miljkovic, MD, PhD Antonette Murphy, RN, BSN, Clinician Kelly Vitti, PT, GCS, NCS
Role of the PM&R Physician Consultation in acute care Inpatient rehabilitation Transition to home/community Outpatient clinic and follow-up care
PM&R Consultation in Acute Care Aid in determining most appropriate post-acute disposition Recommendations to assist with acute management Delirium/agitation Spasticity Neuropathic pain Arousal/neuro-stimulation Bracing/equipment
Inpatient Rehabilitation (IPR) Criteria Need for at least 2 rehab disciplines (PT, OT and/or SLP) Able to tolerate >3 hours of therapy (5 days a week) Medical Necessity (PMR Physician and nurse available 24/7) Rehab diagnoses
IPR Criteria: additional considerations Family support Home setting Discharge plan Long-term prognosis Insurance
Alternative Post-acute Care Settings Skilled Nursing Facility (SNF) Transitional Rehab Unit (TRU) PT/OT per week Less (1-2 hr/day) More (2+ hr/day) PMR Physician oversight No Yes NP oversight daily Varies Yes MD weekly Yes Yes Nurse 24/7 Yes Yes
Inpatient Rehabilitation Interdisciplinary approach PT, OT, SLP Neuropsychology Orthotics/custom bracing Rehabilitation Case Manager Stroke Education
Rehabilitation Nursing In Stroke Recovery Antonette Murphy RN, BSN, Clinician 8
The Rehabilitation Staff Nurse The primary focus for the rehab nurse is to: Assist the patient to obtain and maintain maximum function with their new disability and/or chronic disease Assist patients and their families to adapt to an altered lifestyle 9
Nursing Responsibilities Managing Medical Necessities Tracheostomies Feeding tubes Chronic diseases ( HTN, HLD, DM etc.) Infections Incision care Skin issues Bowel and Bladder 10
Nursing Responsibilities Educating patient and family is a key component of discharge planning The key topics we focus include: Medications Assistive equipment Managing chronic diseases Promoting safe independent functioning Fall risk/harm preventative measures Encouraging/celebrating each patient accomplishment 11
Barriers to Positive Patient Outcomes Lack of understanding of diagnosis Unexpected loss of control Feelings of being overwhelmed Frustration/anger Fear of the unknown 12
Team Approach.. Nursing Therapy Patient Neuropsych Physiatrist
The Team Approach Formal Communication Team huddles Occur twice a week Brief discussion with the team Focus is on day to day issues Weekly staffings Mandatory weekly meetings to discuss patient s progress towards their goals and discharge disposition 14
The Team Approach Informal Communication Transfer signage in rooms and bathrooms Post fall huddle forms Mod I green dots on door frames Team Hand off 15 This Photo by Unknown Author is licensed under CC BY-SA
Team Approach Stroke education group Prayer Group Stroke Camp 16
STROKE CHAMPS! ONE STEP AT A TIME ONE WORD AT A TIME ONE TASK AT A TIME 17 FOR A HEALTHIER YOU
PT, OT and SLP in Stroke Recovery Kelly Vitti PT, GCS, NCS 18
Common Deficits Hemiparesis Balance Neglect or Inattention Ataxia Apraxia Distractibility Swallowing impairment Cognitive changes Mobility issues Visual field cuts Aphasia
Team work Real time communication Formal communication Treatments in rooms, hallways and gym Co treatments 20
Dysphagia Instrumental assessment Modified Barium Swallow Study Fiberoptic Endoscopic Evaluation of Swallowing Diet recommendations Modify consistencies Treatment recommendations Modify size of bolus/rate of intake Positioning Strategies (cough-swallow, controlled/effortful swallow, head turn)
Aphasia A language impairment that encompasses both input and output modalities. Working together to improve functional communication of basic wants, needs and ideas using multiple modalities Gestures Visual aides Writing/Reading Establish context Manipulate environment to reduced internal/external distractions Communication strategies
Visual and Hemi-body Neglect Ignoring one side of the body Reduced awareness of deficits Postural changes
Visual and Hemi-body Neglect
BITS Visual Perceptual Technology used for Visual field loss Visual-spatial neglect Cognitive challenges Eye hand coordination
Occupational Therapy ADLs IADLs Upper limb strengthening and ROM Splints Taping Neuro-facilitation 26
Physical Therapy Strengthening Balance Assessments and Interventions Gait training Analysis and Intervention Technology Orthotics 27
Gait Training Body weight supported treadmill Lite Gait Andago
Gait Rounds Weekly evaluation Progress with ambulation Need for bracing Adaptive equipment Combined approach PT PM&R physician Orthotist patient
30 Gait Training
31 Follow up
32 Gait Analysis
33 Three Weeks Post
Interdisciplinary Team Meetings Patient progress updates (use of FIM) Team goal setting Determination of estimated rehab length of stay Functional status at admission Functional goals/time to reach goals Ultimate discharge destination (home vs SNF) Medical comorbidities/barriers insurance
Neuropsychology Services in IPR Counseling adjustment to disability Mood (depression/anxiety) Stroke education Cognitive testing Available daily
Transition to Home/Community after IPR Home health services Outpatient therapy services Adaptive equipment Office of Vocational Rehab (OVR) Outpatient PM&R Stroke clinic follow-up Outpatient neuropsychology services Stroke support group
Outpatient PM&R follow-up Continue to address functional status/needs Assist with coordination of care Spasticity management Medications Botulinum toxin injections Intrathecal baclofen pumps Pain Neuro-stimulation/attention Orthotics/bracing Additional needs Adaptive driving evaluation Referral for community education
38 Thank You!!