Mr. Babinski was sitting with his granddaughter when his right arm and leg became weak. He tried to tell her there was a problem, but he couldn’t speak. He promptly arrives at your hospital and you expertly navigate the decision to give him tPA, manage his hypertension and call upon the diabetes educator to improve his diet, but when it is time for his transfer for rehabilitation, do you give this decision the same amount of care and consideration you gave to your other medical decisions?
It is important that physicians approach the prescription of rehabilitation care as carefully as they consider which anti-hypertensive medicine to choose. We often abdicate this responsibility to the family or a case manager, yet this decision is just as important as the decision to give tPA or change a person’s diabetic medication. Here are a few things you should consider.
The Glass Ceiling
The glass ceiling effect still exists in many aspects of our society. Many women still do not have the same opportunities as men. Likewise, children who are deprived of a proper education have fewer opportunities. The same concept is true for the disabled. If we assume that a stroke survivor or other rehabilitation candidate is too impaired to participate in rehabilitation, we are creating a glass ceiling for that individual. Without the right kind of rehabilitation, patients will likely not reach their full potential.
The decision to refer a patient for rehabilitation may be the first — and the last — chance for them to get the type of rehabilitation that will lead to their maximum recovery. A decision to withhold access to aggressive therapy creates a self-fulfilling prophecy:
- Someone doesn’t think the patient will get better
- So, they do not offer them the intensive therapy they need
- Since they didn’t get the therapy they needed, the patient confirms their theory by showing little improvement.
Just Like School
Going for therapy and rehabilitation is just like going back to school, because your patient may have to learn new information. If you are going back to school later in life, you may have to “relearn” information that you had previously acquired. In therapy, there are tasks that may require physical activities like learning to walk again or learning to transfer from a bed to a chair. She may need to learn to read again, speak clearly or improve her memory. Rarely is it easy and I always tell patients and families that it will be the hardest thing they will ever do. Like school or learning a new skill there are certain principles that make a difference.
Boxed Insert: If rehabilitation is like school, then the “school” you go to makes a big difference.
When we order a medication for a medical problem, we carefully adjust the dose. Too little or too much antibiotic and the infection gets worse or you create additional problems. The same is true of rehabilitation. The intensity and amount of therapy matters. Much like it takes hours of practice to learn and improve playing a musical instrument, it takes hours of therapy to retrain the brain, nervous system and muscles. Typically, an inpatient rehabilitation hospital will provide 3 hours of therapy a day. Many lesser facilities, such as skilled nursing facilities do not. You do not want to “under dose” your patient.
If you want to learn to play a piano, you need to practice on a piano and not just read about it. The same is true for rehabilitation. If you have had a stroke and have lost the use of your right arm, you will need to practice tasks and therapies that require the use of your right arm. Performing these specific tasks will help rewire your brain. The more “functional” the tasks that you perform, the more you will improve and more positive changes will take place in your nervous system.
The person who is motivated and works harder has a better chance of getting better. It is not always the brightest student who is the most successful: hard work can make a huge difference. People undergoing rehabilitation are motivated by their physicians, caregivers, therapists, but also by their surroundings. Think of working in a brightly lit office or hospital with a great view versus one in the basement with no windows. . Where you send your patient for rehabilitation does make a difference.
Are you referring your patients to a place that specializes in rehabilitation or is it just part of a nursing home or facility that does other things? The medical literature, including the latest May, 2016 American Heart Association/American Stroke Association “Guidelines for Adult Rehabilitation and Recovery,” (http://stroke.ahajournals.org/content/early/2016/05/04/STR.0000000000000098.full.pdf) addresses this issue After reviewing the highest level of scientific evidence (Class 1A) they conclude that “the consistency of the findings in favor of IRF( Inpatient Rehabilitation Hospital) suggests that stroke survivors who qualify for IRF services should receive this care in preference to SNF-based care ( Skilled Nursing Facility).”
So, don’t forget: Where you send your patient for rehabilitation does make a difference. You wouldn’t send your child to an inferior school, make the same type of choice for your patients.
Richard C. Senelick, MD
Dr. Senelick is a neurologist who specializes in neurorehabilitation. For 30 years he was the medical director of HealthSouth Rehabilitation Institute of San Antonio (RIOSA) and is currently the editor- in- chief of HealthSouth Press.