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Going Beyond Physical Rehabilitation for Stroke Recovery & Prevention

Caitlin Whyte (Host): Recovering from a stroke is a difficult journey, no matter who you are. And today we will be discussing the benefits of addressing that recovery from an integrative approach with Dr. Ayanna Kersey-McMullen. She is the Medical Director of the Stroke Rehabilitation Program at Good Shepherd.

This is Transforming Lives and Inspiring Hope, a Good Shepherd Rehabilitation Network podcast. I'm your host, Caitlin Whyte. So, Doctor to start us off, we'll start with some basic questions. What is physiatry and how does it differ from other branches of medicine or from a general physician?

Ayanna Kersey-McMullen, DO, MSPH (Guest): Physiatry is a field of medicine that focuses on function and the recovery and the maintenance of function for people who have chronic disability. So, the ways in which it differs from other fields of medicine is that while we do manage concrete medical issues, everything goes back to function for us. So, for instance, someone who may have had a stroke, if I'm an inpatient physician, I may be managing things like diabetes during the time that they're in the hospital or chronic pain related to their stroke or things like what we call spasticity, which is increased tone in the limb, as it relates to the stroke. But ultimately, our primary goal is to make people as functional and as independent as they possibly can be with their medical conditions and with their impairments.

Host: Now as the Director of Good Shepherd Stroke Program, do you mostly see patients who have already suffered a stroke or ones who are being proactive and trying to prevent one?

Dr. Kersey-McMullen: That's a great question. I see a combination of people. One would expect that I would see people who have already experienced stroke, but because these things that I'm focusing on is helping them to recover from the effects of the stroke. But then I also have patients who are referred to me to try to prevent any adverse outcomes as a result of chronic medical conditions, such as what we call the metabolic diseases. So obesity, diabetes, hypertension, hyperlipidemia, which is a fancy word for a high cholesterol. All of these things can, in and of themselves put people at a higher risk for developing stroke or heart events, as well. And so I am often also seeing patients to try to prevent those outcomes for themselves, in addition to seeing patients along the spectrum of physiatry.

So, that might include someone who has cerebral palsy, or muscular dystrophy or spinal bifida or multiple sclerosis. I may see any of those patients for things such as spasticity management, which includes things like what we call chemo denervation, which is using things like botulinum toxin, or the brand name for that is Botox to try to help prevent changes in people's tones, a tone in their limbs that will then prevent them from using those limbs properly, may cause pain, may cause difficulties in managing their hygiene, may cause contractures. So, spasticity management is a big part of what I do as a rehab doctor, but I also may see someone who has an amputation as a result of, again, things like poorly controlled diabetes or vascular disease.

In fact, I'm not sure if you're aware of this, but this month is Diabetes Awareness Month and yeah. And so one of the leading cause of amputations in the United States, particularly lower limb amputation, is uncontrolled diabetes. So, diabetes is a very bad actor and it's important that we address that in all of the possible ways that we can. And so amputation is one of the things that can happen to people when they have poorly controlled diabetes. But also I may see someone who has musculoskeletal issues, so pain in their joints and limbs and muscles that is impairing again, their function, that is causing chronic pain and if getting in the way of their day-to-day life.

So, I have the ability to treat some of those not just with things like injections into those joints or injections into the muscles themselves. But also as an osteopathic physician, I have the ability to use my hands in order to do soft tissue and bone manipulation, to help people to improve their perception of pain and their experiences of the pain and dysfunction.

Host: Well, it sounds like the stroke program covers so much over at Good Shepherd. Let's focus right now on patients who have suffered a stroke. So, is there a standard approach to care for a patient who has recently suffered a stroke?

Dr. Kersey-McMullen: I would say yes, in that there are things that we specifically do in medicine to, from a pharmacologic or medication standpoint, when a person has experienced stroke. So medications like statins, which help to keep the cholesterolinn check or the use of things like aspirin or anti-platelet medications in order to prevent blood vessels from developing clots in the blood vessels that can increase your chance of experiencing a second stroke. Those are some of the standards of care.

And of course, things like managing chronic medical conditions that increase your risk of having a stroke. All of those are the standard of care in terms of medically treating a stroke. But from a rehab standpoint, there are also medications that we may use more frequently for people who have experienced certain types of strokes. So for instance, there are two main types of stroke. There are the ischemic strokes and the hemorrhagic stroke and the ischemic stroke essentially means that someone has had a clot that formed in a certain area or a clog in the vessel or a clot that moves from another area. And as a result of that, it will cut off the vital blood supply and nutrients to that part of the brain and therefore the tissue around that area will die. That's what ischemia means. And then for those particular patients, we made use a medication called a SSRI, a selective serotonin re-uptake inhibitor, such as a medication called Prozac to help with motor recovery and to also manage mood. But for strokes, which are called the hemorrhagic strokes, which are bleeding strokes. The primary reason for developing that is, poorly controlled hypertension. And then therefore the main focus is on making sure that we have better control of the hypertension. So, it really just, it depends on what the mechanism is of the stroke and what we're trying to address.

Host: Well, within that standard approach to care, you mentioned a lot of medications, but what about the staff? What would the care team of a stroke patient look like and who does it include?

Dr. Kersey-McMullen: Oh, sure. So, the staff of a, of a stroke rehab patient would include a physician like myself, who is Board Certified in Rehabilitation and has a special emphasis on stroke care. It may or may not include another type of advanced practice provider, such as a physician assistant or nurse practitioner assisting the physician with care. It also would include more often than not, a Certified Rehabilitation Nurse. And that as a nurse who has received special training in rehabilitation and understands the challenges, specifically for rehab patients and our protocols for helping them to recover. It would also include, more often than not, PT, physical therapy, OT, occupational therapy, and SLP, which is speech language pathology. And that is to manage things of the lower body, the upper body, as well as swallowing, cognition and speech. And then in the inpatient setting, you may also have a care manager who is going to help to manage the social needs of the patient when they're here and by social needs, I mean, social work needs, their insurance needs, equipment needs, things that they're going to need in order to have a successful transition to home.

It may plus or minus include a registered dietician who I personally think is a very important part of our team to help with recommendations for diet and nutrition and a rehab psychologist as well, who may be helping to manage behavior and mood as a result of that. And that's very important because what we do know from the literature, is that people who experience stroke, have a higher risk of developing depression.

And when that depression is not well-controlled, that they often do not do as well in recovery from their stroke. So, it's important that we manage mood when we are helping people to recover from the stroke. So, that is what a comprehensive inpatient rehab stroke team will typically look like.

Host: Well, I'd love to shift our conversation a bit now. A few questions ago, you were focusing on diabetes. You just mentioned depression. Can you explain what lifestyle medicine is now and integrative wellness and why those are useful tools for those trying to recover from an illness or manage a chronic condition?

Dr. Kersey-McMullen: Oh, yes. I love to talk about this because of these are things that people don't know as much about. So, lifestyle medicine is an area of medicine that utilizes elements and interventions that are related to things such as a whole food and often plant predominate or plant based diet, physical activity, stress management, and emotional wellness, sleep, smoking succession and avoidance of risky substance use such as alcohol. I talked about tobacco or recreational drugs and positive psychology and connectedness. And the goal for all of that is to use evidence-based medications and other interventions to help people to improve and manage their lifestyles with the goal of maintaining, managing or reversing chronic disease.

So, you may be asking yourself, okay, well, how is that different from conventional medicine? Conventional medicine, though the focus on that has always been, I would say more focused on medications and surgical interventions in order to treat disease and more often than not, that approach of medicine of which I practice both types of medicine. That approach of medicine is more of the physician and the healthcare team directing the care of the patient. Whereas in lifestyle medicine, very much like rehab medicine, very much like for physiatry, the patient has to be in the driver's seat. So, we are providing the information and providing the guidance, but the patient has to actively participate in making the necessary changes, necessary behaviors and activities in order to promote their recovery and their wellness.

Whereas integrative wellness or integrative medicine seeks to address whole person needs. So, physical needs, social needs, emotional, mental, environmental, and spiritual. And also we'll use a combination of both conventional medicine as we talked about, complimentary medicine and alternative medicine. So, things like maybe acupuncture or Reiki or massage therapy may be included in integrative medicine as well.

Host: I love that. Putting the patient in the driver's seat. And that kind of leads me into my next question. We're going to talk about nutrition now. Where does nutrition come into play when it comes to stroke recovery and the prevention of future strokes?

Dr. Kersey-McMullen: Absolutely. So I think as I, I said before, nutrition and diet is a key part of recovery. And what we know in more recent research is that there is a direct correlation between diet and nutrition and the lifestyle of people and their health outcomes. And we really, in medicine, I will be very transparent in saying that we didn't always do a fantastic job of understanding that and explaining that to our patients so that we can empower them to make better choices about their diet. You probably could appreciate that very often diet and nutrition is really only talked about in the context of aesthetics. So, what do you look like? Are you skinny enough? You know, but the reality is, that you can be very thin on the outside and still be what we call fat on the inside.

Meaning that you have fat around your vital organs, your liver, your heart, that puts you at an increased risk of having some very serious outcomes. So, it was not just about, are you looking cute, but are you living, are you living well, is the most important thing. And so diet and nutrition is a big part of it.

In fact, some of our studies are now showing that people who eat a diet that is heavy in animal products in particular, are at higher risk of having hypertension, heart disease, cancer, stroke, diabetes, obesity, and cancer. And so we're just now really catching up to the science of that. And that's where things like lifestyle medicine comes into and diet, dietitians, nutrition is such a big part of that.

Host: Well, let's get into some specifics then. What type of nutrition plan do you recommend for your stroke patients?

Dr. Kersey-McMullen: Sure. So, I think it's probably fairly obvious, cause I've said this multiple times, but I really try to help my patients to lean into a diet that we call whole food plant predominant or plant-based diet. But do I expect all of my patients to walk out of my office as a vegan? No. And a lot of people aren't quite ready for that, but certainly making sure that my patients are understanding the importance of low to no consumption of heavily processed foods, having a diet that is rich and high in plants such as vegetables and fruits.

In fact, the current recommendations for the diet needs are at least five servings of vegetables and fruit every day with the majority of those being vegetables. And so most Americans who follow what we call the SAD diet or the Standard American Diet, sort of ironic, don't get anywhere near the number of plants that they should be getting in their diets. But also really encourage having, you know, being very mindful and aware of added salt and added sugars in the food and also not eating foods that are made in a lab. Really learning to make one's own food. And when you're not maybe a skilled, you're not a skilled chef at home, using foods that are going to be more healthful options.

So, if you're a person perhaps who maybe doesn't feel as comfortable buying a bunch of fresh vegetables, because you're afraid that they may not hold up as well, or you may not cook them as well, frozen foods are a great option for that, because then you can just take out the portion that you need and put the rest in the freezer.

So, it's really just learning, helping people to learn about what are healthful foods that will be helpful in your recovery and not hinder your recovery. And we talk about that a lot in my clinics. What is helpful and what is hindering you. And also being more aware of the hidden ingredients, the hidden sugars or hidden salts in processed foods, and being really clear about that and really undoing some of the messaging that has been given to patients about what is considered to be health food, and what isn't health food based on the research that we have available to us at this time.

Host: Well Doctor, my last question here, I think you've done a pretty good job of answering already, but why should someone who has suffered a stroke choose Good Shepherd for their rehabilitation?

Dr. Kersey-McMullen: I love this question. So, I think that a person who has experienced stroke or any rehabilitation diagnosis should come to Good Shepherd for recovery because we have a very long history of treating people with impairments in function and disability. We are passionate about what we do and committed. And we have for a very long time, you know, we were the only provider in the valley and now we share that with other providers in the valley, but we certainly have the years of experience and the years of expertise to backup what we're doing. I think another reason is the people. I work with some really amazing people who really believe in what we do and we go the extra mile for our patients. And I think it's important for you to go to a facility where people are committed to providing not only providing good care, but providing this idea of service.

I see medicine as an act of service. So, everything I do and in my work from day to day is coming from what I call a spirit of service. And I think that you'll find that throughout the staff at Good Shepherd, we provide care from a spirit of service.

Host: Well, we covered a lot in a brief amount of time. Doctor, thank you so much for joining us today. Good Shepherd is a destination for Transforming Lives and Inspiring Hope. Call 1-888-44REHAB, that's 1-888-44REHAB. Or visit us online at goodshepherdrehab.org.