New research shows that merely observing others perform physical tasks can activate the damaged regions of stroke patients’ brains. Through functional magnetic resonance imaging (fMRI), researchers at the University of Southern California found that the activity was strongest when stroke patients viewed activities they had the most difficulty performing. The activation suggests that the brain is working to compensate for damage caused by stroke, which holds promise for stroke rehabilitation and the development of new therapeutic techniques.
The goal of therapy is to activate motor areas of the affected hemisphere. Watching others carry out tasks is like “priming the pump,” said Carolee Winstein, director of the Motor Behavior and Neurorehabilitation Laboratory at USC. “You’re getting these circuits engaged through the action-observation before they [patients] even attempt to move.”
The virtual exercise could prepare the brain for actual exercise. “If we can help drive plasticity in these brain regions, we may be able to help individuals with stroke recover more of the ability to move their arm and hand,” said Kathleen Garrison, who was part of the research team at USC. One of the researchers suggested that as homework, patients could watch videos of what they will do in therapy.
The simple visual exercise of action-observation has exciting implications for the future of stroke rehabilitation. For more information, read the full article here on Medical News Today.
Long-Term Living Magazine recently highlighted the importance of using proven staffing practices for better business results and employee satisfaction. During a Long-Term Living webinar in March, experts offered the following strategies for optimal staffing:
- Be consistent and fair when creating schedules. Adjust appropriately for high-acuity cases. High-acuity cases should not be left to a few of the same nurses.
- Invite staff to give feedback about scheduling, and listen thoughtfully.
- Avoid wasteful overtime. “Set a policy of no overtime built into the schedule without administrative approval,” said Mark Woodka, CEO of OnShift, a provider of nurse scheduling software and management systems. “If you’re properly staffed, you shouldn’t have overtime.”
- Stay on top of part-timers’ hours. Organizations that go over the hour limits for part-time employees will incur sizeable fines.
A well-run department requires a plan and constant attention to the daily operation of the team. As noted in RehabCare’s white paper, “Optimizing the Performance of a Hospital Outpatient Rehabilitation Department,” when it comes to staffing, program directors should ask themselves: Do we have the appropriate number and skill mix of therapists? Do we have the right combination of therapists, assistants and techs? Have I defined standards of productivity for employees? Answering these questions can help assess where your facility could make staffing improvements.
For more information, read “Staff scheduling strategies for better care and better business” by Pamela Tabar.
A recent study in Canada found that an alarming number of people are not aware of one of stroke’s most common and challenging consequences: aphasia, a communication disorder affecting speech, reading, writing and comprehension. June is National Aphasia Awareness Month, a time to shed light on this debilitating but little-understood disorder.
About one-third of stroke victims suffer some degree of aphasia, which occurs when there is damage to the left side of the brain, its communications hub. The Canadian researchers found that only two percent of those surveyed in public places in a major city could correctly identify what aphasia is, and, the researchers conjecture, this lack of understanding could be detrimental to the recovery of stroke patients who suffer with this condition. (1)
Without social and familial support stroke patients suffering with aphasia often isolate themselves which fuels the fire of depression, according to Sonia Beltran, Rehabilitation Program Director at Kindred Transitional Care and Rehabilitation – Eagle Creek, located in Indianapolis, Indiana.
A 2012 British study looked at the use of speech and language therapy for aphasia following stroke and pulled data from various trials that had been done comparing speech and language therapy (SLT) with: no SLT; social support or stimulation or other SLT interventions that varied in duration, intensity, frequency, intervention methodology or theoretical approach. This study, which pulled data from a wealth of published, unpublished and ongoing research, concluded that SLT can be effective in patients with aphasia following stroke in terms of improved functional communication, receptive and expressive language, but no single type of SLT appeared superior to others. (2)
One of the most important components to stroke recovery is getting to patients early, Ms. Beltran said.
“If we can catch the patients in the first three to six months post-stroke, we really try to maximize on that period of spontaneous recovery to get the patients as close to their prior level of function as possible,” she said.
However, a recent study from the University Geriatrics Institute of Montreal showed that while the post-recovery window is important, language therapy can have a positive impact on patients with long-term aphasia even years after a trauma or stroke.
At Eagle Creek and at other similar Kindred skilled nursing facilities, speech therapy is an important component of the Stroke Recovery Program. The program is designed to be an interdisciplinary approach to stroke rehabilitation that includes physical, occupational and speech therapy. Specifically, this entails use of specialized, on-site equipment and technology; patient and family education; healthy lifestyle programs; a progressive exercise regimen tailored to fit each patient’s needs and abilities; individualized plans of care to meet patients’ specific needs and on-site case management.
“Our challenge is to re-build the neural connections for the affected areas,” Ms. Beltran said. “We have patients with expressive, or spoken language, deficits and others with receptive, or comprehension, deficits which impede their ability to communicate their wants and needs to their caregivers.”
This can lead to a great deal of frustration.
Speech therapists do many exercises with patients, including counting; going through the days of the week and the months of the year; naming tasks; and showing pictures and asking patients to name the item and its function. The therapy is undertaken five to six days a week for 40 minute sessions.
“We’re most concerned with carryover,” said Ms. Beltran. “How is this going to make the patient more functional? Will they be able to communicate that they are in pain or tired?”
Finally, family support is also key to good recovery.
“In my experience, the patients that do the best are those who have excellent family support,” said Ms. Beltran.
1. Heart and Stroke Foundation of Canada. “Hidden stroke impairment leaves thousands suffering in silence.” ScienceDaily, 1 Oct. 2012. Web. 4 Dec. 2012.
The Middle Class Tax Relief and Jobs Creation Act of 2012 contained several provisions specifically focusing on outpatient rehabilitative therapies, including the Medical Manual Review trigger at $3,700 and the establishment of new “G Codes.”
The law specifically directed the U.S. Department of Health and Human Services (HHS) to implement a “claims-based data collection strategy that is designed to assist in reforming the Medicare payment system for outpatient therapy services” and to begin testing such a model in early 2013. The goal of the data collection is to “better understand patient condition and outcomes.” This led to the development of 42 new non-payable functional of G-codes for physical and occupational therapy and speech pathology services also referred to as functional limitation reporting.
Beginning on July 1, 2013, providers will be required to include G-codes and severity/complexity modifiers to indicate the patient’s functional status at:
- The outset of the therapy episode of care,
- Specified points during treatment (progress reports to be furnished on or before every 10th treatment day), and
- Time of discharge.
Applicable claims without the G-codes will be rejected.
In conjunction with using the appropriate G-code, claims require one of seven modifiers that identify the range of a patient’s functional impairment. For example, modifier “CM” would be applied to identify that the patient is “at least 80 percent but less than 100 percent impaired, limited or restricted.”
This coding change aligns with RehabCare’s long-term practice of tracking and reporting the functional outcomes of our patients.
We worked closely with our technology partners to ensure that our hand-held systems were fully tested and prepared for the July 1 implementation date, and we are confident in RehabCare’s ability to appropriately meet the new requirements for therapy patients across the care continuum.
Are you sitting down for this? It turns out that sitting may be shortening your life.
Whether you sit down to work, relax or as a result of your physical health or status, many recent research studies suggest that the ill effects of being sedentary, specifically of prolonged sitting, cannot be offset by blocks of physical activity or exercise. Too much sitting is distinct from too little exercise. Being healthy is not just about increasing physical activity, but also about decreasing inactivity.
So what’s so bad about sitting? In addition to being shown to shorten lives by approximately two years and increase the risk of cardiovascular disease, prolonged sitting is associated with negative consequences related to the body’s blood sugar, the “healthy” cholesterol (HDL), metabolism, mental health, and muscle weakness. Specifically, one study found that sitting for more than three hours per day and watching TV for more than two hours per day may contribute to the development of chronic diseases.2 Another study found that cancer was associated with those employed in sedentary jobs, and this association was independent of recreational physical activity and was observed even among the most recreationally active participants. 3
Fortunately, no matter the reason for a sedentary lifestyle, the ills of extended sitting can be counteracted by adding in more movement throughout the day. Always stand when you can. If you find yourself spending too much leisure time sitting, explore ways to get off the couch while watching television. If you work at a computer or a seated job, take opportunities to stand. Pace or stand while on a call, and walk to a colleague’s office on occasion instead of emailing or calling. Use your lunch time for physical activity. For those recovering from illness or injury, ensure that you follow your health care provider’s recommendations and that you are provided with activities to assist you with safely reducing sedentary time.
The dangers associated with prolonged sitting continue into late adulthood, and we must keep performing small-impact movements to ward off the hazards of remaining seated. It is important to learn age-appropriate ways to stay active throughout the day. We know it can be a challenge to keep up the same level of activity as we get older, which is one reason RehabCare developed the Smart Moves wellness program to empower older adults to incorporate as much physical movement as possible into their daily lives.
Mary Moretti, DPT, PT, is RehabCare’s Director of Clinical Operations and supports the development of clinical programming, protocols and evidence-based practice across all of RehabCare’s clinical settings. Mary also oversees Smart Moves, RehabCare’s wellness program.
- Med Sci Sports Exerc. 2009 May;41(5):998-1005. doi: 10.1249/MSS.0b013e3181930355. Accessed on May 29, 2013 from http://www.ncbi.nlm.nih.gov/pubmed/19346988 .
- Katzmarzyk PT, Lee IM. Sedentary behaviour and life expectancy in the USA: a cause-deleted life table analysis. BMJ Open 2012;2:e000828. doi:10.1136/bmjopen-2012-000828. Accessed on May 29, 2013 from http://bmjopen.bmj.com/content/2/4/e000828.full
- Boyle T, Fritschi L, Heyworth J, Bull F. Long-term sedentary work and the risk of subsite-specific colorectal cancer. Am J Epidemiol. 2011:173(10):1183-1191.
Students who complete clinical internships with RehabCare are encouraged to conduct research or complete an educational training in-service to the rest of the team at the end of their rotation. Completing research and giving presentations enhances the internship experience, and sharing the latest clinical information benefits seasoned therapists.
Kristina Pekovic, SPTA, recently presented her in-service on joint mobilization to her group at Kindred Hospital – Indianapolis. Her presentation was a two hour in-service spread out over the course of two lunch breaks. On the first day, Kristina gave a classroom-type presentation. The second day was more hands on and included demonstrations, allowing Kristina and the therapists to put into practice what they had learned. Kristina was very hard working and met the challenges head on, impressing her colleagues at every turn. Kristina, pictured at the center of the photo, reflected on her clinical:
“I was very blessed at my clinical experience at Kindred Hospital – Indianapolis. My instructor embraced the student-teacher relationship that fostered my learning and encouraged me toward my goals. Everyone on the RehabCare team was very helpful by taking the time to instruct and assist me as a student. They frequently advocated for patients as if they were a member of the patient’s family. Furthermore, the rehab aides created an enjoyable environment by frequently making the patients smile and feel valued. I had an excellent learning experience and would recommend this facility to other students who would like to gain knowledge in geriatrics and long-term care.”
Mentoring a student was fulfilling for Jeff Paris, PTA at Kindred Hospital – Indianapolis. “Having a student was challenging but rewarding,” said Paris. “The opportunity to spend time with a student allowed me to pass on my years of experience to help her with the start of her journey into health care and PT specifically.”
After working with Kristina, Jeff felt encouraged to host a student again. “As my first time having a student here, I gained some valuable experience and feel prepared to handle student clinicals in the future,” said Paris. “Overall, this was a great experience.”
Barbara Wallace is RehabCare’s Director of Student Programs. For more updates on Student Programs and for information about completing a clinical internship with RehabCare, visit The Campus Blog and www.rehabcare.com.
May is Better Hearing and Speech month, a time set aside to honor our speech-language pathologists (SLPs) and focus on their specialties and achievements. Evaluation and treatment of swallowing problems are a large part of an SLP’s job. But in a recent article published in Advance for Long-Term Care Management, Mary Barker, senior clinical supervisor for Speech Therapy Group of Beverly, Mass., and an SLP at Kindred Nursing and Rehabilitation – DenMar, warns SLPs are not the only staff members who should be on the lookout for swallowing issues in residents.
Barker stressed that all employees must be watchful for swallowing problems. Nurses, CNAs, dining room staff, and volunteers also play a critical role in making sure that residents are safely getting the nutrition they need. Unidentified swallowing problems can lead to choking, weight loss, malnutrition, or even aspiration pneumonia – a potentially life-threatening condition. This month, we’d like to remind all staff members to be vigilant about safety issues related to swallowing.
Signs of swallowing problems include:
- Chewing for a long time
- Food pockets in the cheeks or around the gums
- Spitting out food (or food falling out of the mouth)
- Food or liquid getting stuck in the mouth
- Refusing to eat
- Coughing (or excessive throat clearing) during or right after meals
- Reports of food sticking in the throat or chest
- Swallowing multiple times to get food to go down
- Weight loss
- Recurring pneumonia or chest congestion after eating
In addition to watching for swallowing problems, it is important for staff to recognize personal preferences or reactions to food and accommodate them. When evaluating swallowing, the visual and olfactory senses should not be overlooked, said Barker. “Some people will not eat foods that touch other foods,” she said. “Some people are nauseated by seeing foods mixed together on their plate.” Too much food on the plate or foods with strong smells (i.e., broccoli or liver) may also be unappetizing for residents.
Be alert to these potential swallowing issues, and report signs of swallowing problems. We can best ensure our patients’ safety by remembering to be attentive to issues that might fall outside our own area of expertise.