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Melanie Cole (Host): Welcome. Our topic today is comprehensive inpatient rehabilitation after stroke, and my guest is Dr. Ayanna Kersey-McMullen. She's a physical medicine and rehabilitation specialist at the Good Shepherd Rehabilitation Network. Dr. Kersey-McMullen, after someone suffers a stroke, they're usually in an acute care setting for a period of time. Tell us about the importance of seeking comprehensive post-acute care, and what does that look like?

Dr. Ayanna Kersey-McMullen, DO, MSPH (Guest): Sure. So I think it's important for us to sort of frame a perspective on strokes and why it's important for you to go to an acute comprehensive rehab after stroke. As you may be well aware, stroke is the main cause of long-term disability worldwide, or at least one of the major causes of disability. And when we look at the United States alone, we have about 800,000 people with new or recurrent strokes each year. Most of those patients will have significant sensory and motor impairment, and if you're looking at issues of recovery from a stroke, the continuum of improvements is going to occur over about two years after a stroke.

So when you look at the options for rehab, when you compare skilled nursing care facilities to inpatient rehab, the studies show that people who participate in inpatient rehab or comprehensive inpatient rehab have better outcomes than those who go straight to outpatient or to go to a skilled nursing care facility.

Melanie: So what are some of the levels of post-acute care for stroke patients? What's available?

Dr. Kersey-McMullen: So you have a combination of different options available for outpatient or for inpatient rehab. After stroke you have your inpatient rehabilitation, which Good Shepherd is a comprehensive inpatient rehabilitation facility. You also have skilled nursing facilities, which is going to require less time for a patient to participate. So when you're in an inpatient setting, you're going to be expected to do at least three hours a day, five days a week of inpatient rehab, versus in a skilled nursing care facility, you're looking at more along the lines of maybe one to two hours a day, a few days a week.

You also have home-based rehabilitation where outpatient therapists from PT, OT, and speech come into the patient's home and provide rehab, but again, that may be only about an hour a day, a few days a week. And then of course you have outpatient rehabilitation for stroke, newer rehab, which may be about two to three hours, a few days a week, but again, will not have the comprehensive approach.

The beauty of being in an inpatient rehab is not just that you're going to get rehabilitation services from a therapist, but you're also going to have the services of an inpatient physician, like myself, a physiatrist, you'll have a rehab specialty nurse, you'll have access to care management, to rehabilitation psychologists who specialize in providing psychology services for people who have had rehab diagnoses, and you will have- just the intensity of services that you will get in this setting are going to be different from what you get in any other level of services.

Melanie: Rehabilitation technology, Dr. Kersey-McMullen, is an important tool for the best possible stroke recovery. Please tell us about some of the rehab technologies that are available today for stroke patients.

Dr. Kersey-McMullen: So you can have things as- what I would consider low tech, as lower extremity orthotics for improving motor function and ambulation to lower extremities, splinting that will assist with stretching, positioning, spasticity control, or even subluxation minimization, to high tech options such as the exoskeleton, which is a robotics exoskeleton for gait training or motor arm support for recovery of upper extremity function.

Melanie: Dr. Kersey-McMullen, how do you evaluate the impact of programs such as yours on outcomes for the patient?

Dr. Kersey-McMullen: I think it depends on the patient and what their disposition was when they left us and the frequency in which I'm seeing the patient. So generally when I see my patients, it's within six weeks after they're discharged from inpatient rehab, and some of that depends on the severity of their stroke, improvements in function, whether or not they've had any adverse outcomes, if they have needs for chemodenervation, or spasticity control, or if they need closer follow-up for lifestyle modifications.

One of the ways that I- one of the things that we do in my program is really trying to help empower patients to understand better how to make lifestyle choices that will minimize their risk of having additional strokes in the future. And just a caveat that the things that we try to explain to our patients is that having a stroke in and of itself is a risk factor for having another stroke, but there are modifiable factors that patients can prevent going forward to lessen their chance of having another stroke in the future. So things such as controlling their blood pressure, controlling their blood sugar, exercising, not smoking; all of these things can help lower the risk of them having a stroke in the future.

So the way that I evaluate the impact in my program in terms of outcomes is when I see my patients actually knowing their typical blood pressure, their blood sugar including their hemoglobin A1C, which is an important tool that we use to determine how well people's blood sugars are controlled over the course of three months. When I see how they're able to make modifications in their lifestyle and that's reflected in lower medication doses or elimination of medications altogether, I count that as a victory. I also get really excited when I see that my patients are able to advocate for themselves with me and other providers and understanding the right questions to ask to lower their risk for stroke in the future.

So it's not just a matter of whether or not concretely if they have another stroke or if they have some other adverse outcomes, but whether or not they've been able to improve their own independence, whether or not they've been able to make the necessary lifestyle changes they need to make in order to improve their overall health, and also how well they're able to advocate for themselves going forward.

Melanie: Tell us about some of the transitional programs and what that entails. How do you follow up with the patient, and for other providers that may be seeing this patient after the fact, what would you like them to know about some of the challenges and adherence based on what you were just saying in your last question?

Dr. Kersey-McMullen: So again, generally I will see my patients within six weeks of their discharge. The typical stroke patient, early on I may see them every three to six months, just to see how they're doing in terms of their outcomes from their stroke, and whether or not they're developing any additional adverse reactions to having had a stroke such as spasticity. For some of my patients that require they undergo things such as Botox or oral medications to try to control that, because that will impact their ability to increase their own volitional motor control.

But things- you asked me a little bit about challenges and adherence and follow-up. I would say the things that stick out in my mind the most are things like motivation, whether or not patients have social support at home, and who can help them to do things as simple as getting to their doctor's appointments. Whether or not- when they leave this setting, whether it's going home or going to a skilled nursing care facility. Are they really carrying over the things that they learned when they were in the inpatient setting?

Another barrier is whether they have access to community resources. A lot of the time, one of the things that prevents patients from doing what we ask them to do is just not having transportation to get from one thing to another. So in my patient population in particular, we're asking them to go to therapy a few days a week. If they don't have access to transportation, how are they going to get to their therapy? Inpatient- or rather home therapy is not going to be as comprehensive as what you're going to do in an outpatient basis. So that's a big deal when patients don't have transportation.

And then also one of the challenges that I find with a lot of my patients and my population is helping them to adapt their own cultural norms to needed lifestyle changes. So for patients of mine who their diet may be very heavy in carbohydrates, and not quite as heavy in fresh fruits and vegetables, maybe it's just an access issue. Maybe it's just about the cultural norms in terms of the way they prepare food. Trying to meet them at least halfway so that they can do the things they need to improve their overall health, but also to honor their cultural norms and how they do things within their own community is really important to me.

Melanie: Then in summary, Doctor, please tell other physicians what you'd like them to know about complete and comprehensive stroke care at Good Shepherd Rehabilitation Network, and when you feel it's important for them to refer.

Dr. Kersey-McMullen: Again, the studies show that patients who participate in inpatient rehabilitation early on after their stroke generally will do better than patients who don't go to inpatient rehab. So any patient who has residual functional deficit in mobility, strength, ADL management, speech, cognition, or swallowing, will benefit from an inpatient rehabilitation stay as long as they require at least two of any of these therapy types.

So in order for you to qualify to be in an inpatient setting, you need to at least have PT and OT or PT and speech, but it has to be a combination of two out of three of these major services, and you have to have medical issues that require monitoring.

The other option for some patients who have been out in the community for a while, particularly for patients who are pretty far removed from their initial stroke but they may have some regression in their functional outcomes, is to be evaluated for a second chance program. And the reason why I really advocate for this program is because sometimes patients, particularly if they did not have an opportunity to go to an inpatient rehab, maybe they went straight to a skilled nursing care facility at the home, or their family took them home, they weren't really well-educated on what they needed to do to recover from their stroke, they have an opportunity to come back into an inpatient setting as long as they meet the guidelines that I mentioned earlier to do sort of a tune-up of rehab with the goal that hopefully if they're not home, that we can help get them home, or if they are home, that we can improve their overall functional outcomes and reduce the risk of them developing some adverse reactions, and reduce the burden of care in the outpatient setting.

So for instance, patients who may have hemiplegia as a result of their stroke, and they're sitting in a wheelchair most of the hours of the day, and they may have urinary incontinence as a result of their stroke, and because they're sitting in a chair for a long period of time, they're more likely to develop some kind of contracture. By coming in an inpatient setting, we can work on all of those issues. We can work on helping to improve their continence care, we can work on teaching them about pressure relief. We can work on contracture prevention and teaching patients’ families how to stretch their family member so that they don't develop contractures in the first place. We can work on titrating medications to help prevent- to reduce spasticity and prevent contractures to begin with.

So being in an inpatient setting has a lot of benefits, even for patients who are a little bit further removed from their stroke, if they've had some regression or they're just not having as much progression and recovery after their stroke.

Melanie: Thank you so much, Dr. Kersey-McMullen. That was great information and so important for other providers to hear all of the services that are available for comprehensive inpatient rehabilitation after stroke at the Good Shepherd Rehabilitation Network. Thank you again. This is Be Well, the podcast from the rehabilitation experts at the Good Shepherd Rehabilitation Network. For more information on resources available at the Good Shepherd Rehabilitation Network, please visit www.GoodShepherdRehab.org. That's www.GoodShepherdRehab.org. This is Melanie Cole, thank so much for listening.