by Jamie Birmingham, PT, CWS, CLT
Functional outcomes remain at the core of virtually all rehabilitation programs. In the last decade the focus of rehabilitative care has shifted toward quality of life with programs designed to help patients regain the skills necessary to achieve the highest quality of life possible.
NeuLife Rehabilitation, a residential post-acute rehabilitation facility in Mount Dora, Florida, utilizes a treatment approach that may seem unconventional. However, their outcomes-driven therapies are continuously achieving results. The facility, which is accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) in Brain Injury Specialty Programs and Residential Rehabilitation, believes its community-integrated treatment programs help it deliver care that is on the cutting edge of an evolution in neurological rehabilitation.
Planning is at the core of these processes. Before patients are admitted to the facility, a clinical nurse liaison performs a thorough pre-admission evaluation to gauge the level of treatment needed. Once admitted, a series of comprehensive patient evaluations are conducted and the patient’s medical history is reviewed by the interdisciplinary team of clinicians. The team then compiles the information to develop an individualized and multi-disciplinary treatment plan and establish goals for discharge.
Treatment Adapts to Progress
The planning doesn’t end there. Each week the interdisciplinary team meets to discuss each patient and adapt care plans based on progress or challenges for the week. By continually adapting the treatment plans and therapies, patients experience significant functional gains.
NeuLife uses the nationally recognized Functional Independence Measure (FIM) tool to track functional gains during care. The FIM is widely used and accepted as a functional-level assessment tool that evaluates the functional status of patients throughout the rehabilitation process.
FIM is used to establish a baseline functional score at admission and again at discharge to provide a snapshot of the patient progress achieved from admission to discharge. When it comes to diagnoses such as stroke, the ability to quantify the functional ability of patients engaged in a rehabilitation program can be a critical predictor of their functional outcome. The gains achieved during care are helping to provide an average discharge to home rate of 86%, according to the facility’s latest outcomes data.
These functional gains can be attributed to an individualized treatment approach delivered by a multi-disciplinary team. Therapies are centered around community reintegration with the goal of helping patients recover the skills for a higher quality of life. This “all hands on deck” approach has been proven effective for a diverse range of neurological diagnoses, including patients who have experienced a stroke.
According to the National Stroke Association, stroke is one of the leading causes of long-term adult disability, affecting approximately 795,000 people each year in the United States. Studies show that patients who participate in a rehabilitation program following a stroke can experience significant improvements in function.
The individualized treatment programs provided by NeuLife are designed specifically to address the unique needs and wishes of each patient. Each phase of treatment is customized around the distinct goals of the patient and their family. Every member of the interdisciplinary team works hand in hand to provide comprehensive therapies that are designed to help the patient recover the skills to achieve their goals. It is not uncommon to see an occupational therapist, physical therapist, or speech-language pathologist working simultaneously with a patient to conquer challenges and build skills.
Community Integrated Rehabilitation
The Community Integrated Rehabilitation program is the hallmark of the facility’s functional approach toward rehabilitation and its pursuit of the objectives to help patients achieve the highest levels possible of functional independence and quality of life. Significant emphasis is placed on facilitating community re-entry, with hands-on and real-life therapeutic opportunities to bridge rehabilitation to reality. Through a combination of therapies, simulated activities and outings, education and training, patients are able to progress toward a seamless reintegration into the community.
The program is a collaboration between physical therapists, occupational therapists, and speech therapists, and supported by a functional improvement team (FIT) that coordinates therapeutic community outings and skill-building trips via the facility’s accessible vans. Patients also participate in a multitude of simulated activities of daily living to build the skills to properly prepare them for their return home.
Community outings are an important part of the success associated with the facility’s outcomes, and they providing a challenging yet motivating opportunity to practice newly acquired skills. Occupational therapists address not only traditional activities of daily living (ADLs) such as eating, bathing, dressing, toileting, and grooming, but they enhance these traditional modalities with skilled group activities such as meal preparation, as well as community outings that include grocery shopping.
Likewise, physical therapists address movement and mobility issues, utilizing real-life challenges, such as entering and exiting a vehicle, maneuvering a store, or participating in leisure activities such as bowling. Speech and language therapists aid with communication, cognition, and swallowing issues, using community integration platforms as well, such as eating the meal that was prepared, or reading and interpreting a store map. All of the programs are supported by a team of clinical rehabilitation specialists who provide continued support and enhance treatment.
Family: a Component of the Complete Rehab Picture
The staff and program creators believe that the patient’s family plays an integral role in recovery. The effect of a catastrophic injury such as a stroke extends beyond the patient. Oftentimes, the patient’s family and support system are also affected. To facilitate a setting conducive to family participation, the NeuLife facility occupies an 80,000-square-foot facility on 43 acres designed and landscaped to provide a warm, homelike setting. This environment likewise helps promote healing. Family members are encouraged to visit frequently and participate in therapy, including overnight stays. The team works closely with families to develop customized “hands on” care plans. Therapy staff members also utilize technology to communicate with families across the globe. When patients are ready to transition home, the facility provides education and training for the family to ensure a successful transition.
Technology for Optimum Rehabilitation
Oftentimes a stroke will impair an individual’s ability to walk, making restoration of walking skills the primary goal for many patients. Among the resources the clinical team utilizes to help patients achieve this goal are standing frames and body-weight support equipment. These devices can be useful for therapeutic activity directed at gait and mobility training to help patients safely resume standing and walking early in the rehab process.
Body weight support (BWS) technology allows patients to experience the natural movement of walking without the fear of falling. Essentially, the device provides physical support into standing, allowing the therapist to focus on other areas, such as posture and quality of movement, and to ensure proper gait patterns. The compact and portable design of the body weight support device used at NeuLife allows for use in patient rooms, hallways, and in the therapy gym, enabling transfer of skills to daily functional tasks.
Rehab facilities have a variety of BWS technologies to choose from depending on what space and budget will permit. Among the existing BWS technologies are ceiling-mounted trolleys that connect to a harness worn by a patient and can be used over ground or over a treadmill. These devices can provide fall protection while facilitating multiple task repetition.
Another tool frequently utilized by the team is functional electrical stimulation (FES). While electrical stimulation in general has many uses, such as pain management and muscle strengthening, functional electrical stimulation focuses on restoring functional motion and facilitating neurological recovery. By carefully and creatively utilizing electrode placement and timing, the electrical stimulation can be applied during functional tasks, such as standing, transferring, walking, and pedaling.
The electrical stimulation is believed to prime the neurological system, and repetitive yet functional movement is utilized to encourage neurological recovery and carryover to daily activities. This modality is not limited to physical and occupational therapy. The facility’s speech-language pathologist utilizes a targeted form of electrical stimulation known as neuromuscular electrical stimulation to facilitate mastication, bolus control, and overall swallowing rehabilitation.
In addition to working with patients to improve the overall quality of their speech, language, and communication, the rehab team’s speech-language pathologists evaluate each patient to devise an effective treatment plan to improve swallowing. By utilizing neuromuscular electrical stimulation technology, the speech-language pathologists are able to focus on the swallowing exercises while the device provides the electrical stimulation to the targeted area.
Post-stroke patients often experience multiple disabilities simultaneously, requiring the skills of a multidisciplinary team composed of physicians, physical therapists, occupational therapists, speech-language pathologists, nurses, and psychologists. Patients engaged in a program with access to a multidisciplinary team are more inclined to see a reduction in the disabilities and eventually return to the community.
Care delivery models have gradually shifted toward promoting a multifaceted treatment approach, and the results are encouraging. By providing comprehensive programs, NeuLife patients are achieving great results that can be attributed to its multi-faceted and well-rounded treatment programs. RM
Jamie Birmingham PT, CWS, CLT, earned a Bachelor of Science degree in Physical Therapy at the University of Florida. Birmingham is Director of Rehabilitation Therapy Services at NeuLife Rehabilitation, Mount Dora, Fla. Prior to accepting that position Birmingham provided consulting services as an independent clinical consultant for various skilled nursing facilities and home health agencies for more than 10 years. She has more than 23 years of physical therapy and rehabilitation experience. Birmingham is board certified in Wound Management by the American Board of Wound Management and a certified Lymphedema Therapist through the University of Wisconsin-Milwaukee and Cedar Haven Rehabilitation Agency. For more information, contact RehabEditor@allied360.com.
Using the Cyclogram to See the Complete Picture of Propulsion
by Arnaud Gouelle, PhD
The displacement of the Center of Pressure (CoP) while standing quietly is commonly used to assess posture; in individuals without impairment, the CoP tends to move slightly in a small area to maintain the stability of the Center of Mass (CoM). During walking, the CoP plays a similar role to preserve stability, but the CoM progresses noticeably further.
Because gait is a cyclical movement, a similar approach of the CoP’s pathway exhibits a characteristic shape, resembling a butterfly in healthy subjects, whereas, pathological gaits present an alteration in this figure (asymmetry, irregularity). Commonly referred to as a cyclogram, it is a powerful graphical representation that captures, in one picture, several components of the gait cycle that should be considered together to glean functional acuity regarding:
• medio-lateral and antero-posterior weight shifts associated with alternating steps;
• roll-over of the foot;
• asymmetry in propulsion;
• support instability; and
• gait variability.
The cyclogram truly fits the cliché that “a picture is worth 1,000 words.”
When spatiotemporal parameters indicate gait asymmetries, especially length, one can infer that there is a lack of propulsion on the contra-lateral side. However, how is this deficit quantified? Without an objective measure, there are only assumptions and conjecture.
When assessing the impact of corrective devices such as AFOs or stimulation devices to assist the limb in dorsi-flexion or in propulsion, roll-over can be improved while stability is compromised.
Tracking the CoP requires equipment that provides forces/pressures, such as: in-shoe pressure insoles, force plates, pressure plates, instrumented treadmills, or electronic walkways.
Insoles allow unrestricted walking but cannot offer the spatial metrics, such as stride width/length to correlate with the cyclogram.
With force- or short pressure-plates, the patient often alters his or her footfall patterns to target the feet to strike within the sensitive areas.
Moreover, the most meaningful cyclogram should be obtained from several consecutive gait cycles. This can be easily accomplished on an electronic walkway or a treadmill. The walkway requires greater space allocation than a treadmill. However, the propulsive characteristics of footfalls while walking on a treadmill are very different from overground walking.
Utilizing the power of the cyclogram in clinical practice requires a clear understanding of a patient’s functional limitations, including consideration of whether a patient walks with an assistive device such as a cane or walker. Likewise, the clinician’s own treatment objectives and goals are vital in determining the most appropriate system for a facility.