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The Rehabilitation Reader - Stroke Rehabilitation

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					The Rehabilitation Reader                                            Stroke Rehabilitation                                                                   2008
                                    The University of North Carolina Department of Physical Medicine & Rehabilitation
                                                 Our Mission: Optimizing Health and Function through Excellence in Rehabilitation

The Long Walk Home
Stroke Survivor Keeps the Faith, from “Blinking Eyes” to Talking, Walking and Independence
“I took for granted that I had a clean bill of health,   was put in a room and stabilized. “That was the         Lewis continues to look forward. “I want to be able
before my stroke,” says Marilyn Lewis. “I was an         weekend, so I didn‟t see a doctor at the rural hospi-   to take care of myself,” she says. “My goals are to
active member of Curves, eating my oatmeal, and          tal until Monday,” Lewis recalls. “On Monday, they      walk by myself and to drive by the end of this year.”
managing my cholesterol, hypertension and blood          ran the first and only tests on me, including an MRI.
pressure with medications. I thought I was doing         My family was told I had suffered a brain stem          Now in her own apartment, and volunteering to help
everything right.”                                       stroke, and that there was not much hope.”              aspiring therapists learn about stroke patients,
Lewis, a former accountant at North Carolina State       Lewis‟ family immediately made the decision to          Lewis also credits her faith as a major healing factor.
University, had little reason to suspect a major         transfer their loved one to UNC Hospitals, where        “When I was in the hospital and could not speak, my
health problem. Additionally, she and her family         more facilities existed.                                faith in God brought me through, helping me focus on
were not prepared to recognize the symptoms of her                                                               the next step to overcome this turn my life had
stroke, which appeared suddenly, and without pain.       “All I could do was blink my eyes when I first trans-   taken. I know I‟ll get my independence back if I keep
No one in her family had ever suffered from a            ferred to UNC,” Lewis recollects.                       working hard and take it one day at a time.”
stroke.
                                                         While Lewis was still in the UNC Stroke Center, Antje
“I was at my parents‟ house in Bladenboro, about 15      Thiessen, a speech therapist on UNC Hospital‟s Inpa-
miles south of Lumberton, the Saturday before Fa-        tient Rehabilitation Center team, worked with Lewis
ther‟s Day,” she remembers. “I cooked lunch, and we      using a communication board.
sat down to eat in the family room. Up to that point
everything was fine.”                                   “I would look at the letters and my family and Antje
                                                        would try to figure out what I was saying,” Lewis
After eating lunch, Lewis began changing the linen on relates, looking back on those days. “I communi-
her father‟s bed. “All of a sudden I bent over and felt cated, „Antje, can you fix me?‟”
a tingle in the back of my neck,” she recalls. “It
didn‟t hurt; just a tingle. I sat down and said, „Mama, With Thiessen‟s help, Lewis came to the Rehabilita-
something‟s wrong.‟ Mama said, „Just rest, baby.‟” tion Center for more intensive and comprehensive
                                                        therapies.
But Lewis already felt her legs going “out from un-
der” her when she tried to stand. Her brother, Lee, “In rehab at UNC we worked really hard,” Lewis
picked her up and laid her on the couch. He then        continues, “but we had so much fun, because every-
noticed she had trouble swallowing, and decided to one there is so encouraging. The therapists, nurses,
call 911.                                               and doctors focused on the things I could do.”

“Thirty minutes later, an ambulance came to take me      Lewis also received encouragement from her family,
to Southeastern Medical Center in Lumberton,” Lewis      as well as from NC State colleagues. “My family    Marilyn Lewis (center, standing), members
remembers. “I arrived at 2:30 PM Saturday after-         always stayed with me. They took turns during the of her UNC Rehabilitation Center team, and
noon.” But it was not until after 3:00 AM Sunday         night.”                                            a home caregiver, Charlotte Grimes (right,
morning, more than twelve hours later, that Lewis                                                                seated), at a recent volunteer session.

                             UNC Rehab Center, Stroke Therapy Featured on TV
                                                                                                                  INSIDE THIS STROKE ISSUE:
                             Teena Dixon (left) and her physical therapist, Susan Gisler, PT, DPT
                             (right), talked with local NBC-17 health and fitness reporter, Julie                 MATCHING RESOURCES TO PATIENTS                    2
                             Henry, about the benefits of exercise in stroke therapy.                             STROKE & DEPRESSION                               3
                             To watch the video and read the WNCN article, see our news                           SUPPORT GROUPS                                    3
                             column on the PMR web site:
                             www.med.unc.edu/phyrehab                                                             RESEARCH AND ACTION IN THE STROKE BELT            4
 The Rehabilitation Reader                                                 Stroke Rehabilitation
            From the                 Dear Friends,                             mation, please contact our direc-     external communications, please
                                                                               tor of development, Nicole            feel free to offer your suggestions
            Director                 Along the theme of this stroke            Pratapas, at 919-966-8494 or          and feedback using the self-
                                     issue, I am proud to announce that        nicole_pratapas@med.unc.edu via       addressed, postage-paid envelope
                                     our Inpatient Rehabilitation Center       email. Any amount will help stroke    included with hard copies of this
                                     continues to surpass the national         patients become more functional       issue, or drop us an email at
                                     average in the functional improve-        along the continuum of care.          rehab_reader@med.unc.edu any
                                     ment of stroke patients within the        Thanks to all of you who donated      time. You also may offer com-
                                     same length of stay.                      through our previous issue, and       ments and suggestions, or give a
                                                                               for your continued support.           donation, directly from our web-
                                     As always, our external communi-                                                site.
                                     cations reflect the heart of our          I also am excited about our ability
                                     mission by highlighting endeavors         to continue the dialog from these     With this stroke issue we continue
                                     such as Dr. Patricia Gregory’s            newsletters through our web site.     our thematic series. In the near
                                     research and clinics in the ―stroke       We encourage you to learn more        future, look for issues about pedi-
                                     belt‖ of North Carolina (featured         about our patients and programs       atric rehabilitation and spinal cord
     Michael Y. Lee, MD, MHA         on page 4). Projects such as her          on our new pages:                     injury, among others.
                                     Lumberton outreach require addi-          www.med.unc.edu/phyrehab
                                     tional funding not provided by the                                              Michael Y. Lee, MD, MHA
                                     state. If you would like more infor-      As we continue to grow in our         Professor and Chair

                        At UNC, Stroke Rehab Begins with Networking, Empowerment
                        Acute rehab is becoming a shorter experi-           opportunity to ask questions of anyone   ―Support groups help patients gain
                        ence for patients due to variation in insur-        around the table – their doctors,        more control of their lives,‖ Meyer
                        ance coverage. With this in mind, members           nurses, therapists, and other            notes. ―Patients and families begin to
                        of the interdisciplinary team at the Inpatient      specialists.‖                            educate themselves further. They
―Patients and           Rehabilitation Center aim to use managed                                                     regain a sense of hope. They come to
families begin to       care to the patient’s greatest benefit.             Care conferences give all participants   the awareness that there are many
                                                                            a chance to discuss the sudden and       things in their lives they can
educate themselves      George Atkinson, MD, a stroke rehabilitation        often overwhelming changes – in life-    change.‖
further. They regain    specialist, makes sure that patients within         style, communication, role in the fam-
a sense of hope.        the Inpatient Rehabilitation Center benefit         ily, and income – after a stroke or      The support group provides a kind of
They come to the        not only from state-of-the-art therapies,           other catastrophic event.                model for group trust, opening the
                        but from the wisdom of all participants in                                                   door to social involvement in the
awareness that          recovery.                                      Part of Meyer’s job is to understand          community. Many patients stay in
there are many                                                         the patient’s social network as well as       touch with members of the rehab
things in their lives   ―The biggest challenges to people recovering his/her level of independence prior to          team while visiting outpatient clinics,
                        from stroke include being patient, especially hospitalization. This provides insight         volunteering, attending support
they can change.‖       about neurological and functional recovery, into opportunities and barriers to               groups, and by sharing progress and
                        getting through down times, and working on future independence.                              lessons through writing.
—Tom Meyer, MSW         lifestyle changes to prevent a second
                        stroke,‖ Dr. Atkinson says.                    Typically individuals continue some           ―We had a patient who started his
                                                                       course of therapy after discharge             recovery from zero,‖ Meyer recalls.
                        Patient care conferences, which are sched- from acute rehabilitation. Meyer pro-
                                                                                                                     ―After discharge, he kept in touch
                        uled during a person’s rehabilitation journey, vides information on options for con-
                        provide a springboard to ongoing care plan- tinuing care and guides the patient and          with us by email. He also shared
                        ning and support networks.                     family in the decision-making process.        deeper reflections: how his experi-
                                                                       Meyer also provides information about         ence changed his sense of what’s
                        ―Our care conferences are truly interdisci- resources and community support                  important in life.‖
                        plinary,‖ says Tom Meyer, MSW, social          groups tailored to the individual’s
   Page 2               worker. ―The family and the patient have the geographic area.
The Rehabilitation Reader                                                                                                                2008
Depression and Stroke: What You Need to Know
By Christine Styles, BA, Rehabilitation Psychology Intern, Cara O'Connell -Edwards, PhD, and Karla Thompson, PhD

After a stroke it is not uncommon        blue, crying more easily, or losing    toms. Very often, a combination of medi-
to feel that one’s plans for life        interest in hobbies or previously      cation and counseling is the most effec-
                                                                                                                              Over one-third of all
have been forever changed….              enjoyed activities.                    tive option for managing the symptoms         stroke survivors
                                                                                of depression and preventing relapse.         experience
―It was like waking up in a foreign      One of the challenges for doctors      Many of our patients also have told us        depression following
country...Suddenly I found myself        and stroke survivors is that some      that making a plan for the day, such as
struggling to do the smallest            of the symptoms that may occur         structuring activities (especially exer-      stroke.
things, like feeding myself or tying     after a stroke, such as changes in     cise), helps them stay upbeat.
my own shoe…‖                            appetite, fatigue, and decreased                                                     The good news is
                                         energy, may also be symptoms of        Here are some local resources to con-
―I had to depend on my wife for          depression.                            sider:
                                                                                                                              that depression can
everything—she dressed me in the                                                                                              be treated.
morning and took me to the bath-         Depression following a stroke may      UNC Stroke Support Group
room in the middle of the night…‖        be more common than you might          For stroke survivors and caregivers
                                         think. In fact, it is estimated that   2nd Wednesdays, 1:00-2:00 PM
These are just a few of the many         over one-third of all stroke survi-    UNC Wellness Center, Meadowmont
challenges that individuals might        vors experience depression follow-     919-966-8044
face on a daily basis when recov-        ing stroke. The good news is that
ering from a stroke.                     depression can be treated, and         Brain Injury Support Group
                                         research suggests that treating        For survivors of stroke, traumatic brain
Having to depend on family,              depression after stroke may result     injury, brain tumor, and caregivers
friends, or even strangers to help       in better cognitive recovery as        3rd Wednesdays, 1:00-2:00 PM
with everyday activities like bath-      well.                                  UNC Wellness Center, Meadowmont
ing or dressing can create feelings                                             919-966-9501
of frustration or embarrassment.         The rehabilitation treatment team
                                         or other qualified healthcare pro-     Department of Physical Medicine & Re-
In addition to the physical changes,     fessional can provide you with the     habilitation Psychology Services
many of the stroke survivors we          information you need to know           919-966-8812                          Dr. Karla Thompson (seated,
meet also describe emotional             about treating depression after                                           right) with Inpatient Stroke
                                                                                                                   Mentors. For more information
changes, such as ―feeling differ-        stroke.
                                                                                                                   about this motivational pro-
ent‖ after their stroke. Some of                                                 Support group information is up- gram, available for inpatients
the more common emotional                What is the first step? Seek sup-        dated monthly under the ―Local & at the UNC Rehabilitation Cen-
changes that may occur after             port! Your doctor may suggest            Global Outreach‖ page on our web ter, please see our web site.
stroke include feeling down or           medication to treat your symp-              site.

Depression may be one of several symptoms that  Medical conditions such as high blood pressure       Look on our web site for more information on stroke:
can occur after a stroke. George Atkinson, MD,         and blood sugars
assistant professor in Physical Medicine & Reha-                                                       How to prevent a stroke
bilitation, advises that you also monitor these   Pain in an affected limb
                                                                                                       Common symptoms at the onset of a stroke
other complications with your primary care
                                                 Call 911 if you experience the following:
physician after your stroke:                                                                           What Marilyn Lewis (featured on our cover page)
                                                   Worsening weakness or numbness                      taught a nurse and therapist about stroke patients
 Spasticity (tightness) in a weak arm or leg,
  especially if it interferes with function        Worsening speech                                   Inspirational journeys, from our stroke mentors

 Skin breakdown, especially if the patient is     Worsening mental status                           Go to: www.med.unc.edu/phyrehab (features column)
  less mobile
                                                   Seizures
                                                                                                                                               Page 3
                                                                                        Physical Medicine & Rehabilitation Research
                                         PMR Assistant Professor Addresses Stroke Rehabilitation Disparities in North Carolina
                                         By Patricia Gregory, MD, and Kim Faurot, MPH, Research Associate
Physical Medicine & Rehabilitation        The high rates of stroke in the southeastern region                                                  ties with greater minority populations. In addition,
        Campus Box 7200
   University of North Carolina           of the United States earn it the epithet “the Stroke                                                 because rehabilitation and stroke neurology
   Chapel Hill, NC 27599-7200             Belt”. Rates of stroke in North Carolina (NC) are so                                                 specialists are not available in rural areas,
          919-966-5165                    high that it ranks eighth in stroke prevalence in the                                                rehabilitation and stroke prevention care often is
  www.med.unc.edu/phyrehab
                                          US, with 26,846 strokes in 2005. Within NC, stoke                                                    not coordinated.
     Michael Y. Lee, MD, MHA*             rates are highest in the eastern part of the state,
        Professor and Chair               especially among minorities; both African Ameri-                                                     To address this problem, Dr. Gregory has applied
      Joshua J. Alexander, MD             cans and American Indians have higher rates of                                                       for grant funding to provide stroke neurology and
         Associate Professor              stroke than whites.                                                                                  rehabilitation consultations via telemedicine.
       George Atkinson, MD
        Assistant Professor               Access to the best stroke care is limited in rural                                                   Telemedicine technology allows patients to see a
                                          areas. Only half of the state’s population lives                                                     specialist without leaving their community. Pa-
       Susan A. Gaylord, PhD              near hospitals that provide full stroke care ser-                                                    tients in rural NC can have a visit with Dr. Gregory,
         Assistant Professor              vices; only two of the 13 certified primary stroke                                                   a PM&R specialist, and Ana Felix, MD, a stroke
      Patricia C. Gregory, MD*            centers in NC are located in the rural south and                                                     neurology specialist, by two-way camera over a
         Assistant Professor              eastern region of the state where stroke preva-                                                      secure internet line. This way, Dr. Gregory can
                                          lence is highest.                                                                                    review rehabilitation progress and make recom-
         Andrew Lynch, MD
         Assistant Professor                                                                                                                   mendations to improve recovery. The patients also
                                          Stroke complications are minimized in a primary                                                      can ask Dr. Gregory to address any questions they
          Vera Moura, MD                  stroke center because of availability of resources.                                                  might have.
         Research Instructor
                                          Patients have access to a team of rehabilitation
   Cara O’Connell-Edwards, PhD            professionals and can receive early intensive reha- The Department of Physical Medicine and Reha-
        Assistant Professor               bilitation to ensure that they regain as much func- bilitation already is using telemedicine to ensure
     Jongbae Park, KMD, PhD*              tion as possible.                                   that children with disabilities have access to a
        Assistant Professor                                                                   pediatric rehabilitation specialist, Joshua Alexan-
                                          Patricia Gregory, MD, assistant professor in the    der, MD, associate professor. Dr. Gregory plans
     Paul Thananopavarn, MD               Department of Physical Medicine & Rehabilitation to use a similar system to provide patients in rural
        Assistant Professor
                                          at UNC, has committed herself to evaluating and     counties access to the same stroke rehabilitation
      Karla L. Thompson, PhD              improving access to stroke rehabilitation among     care we have here in Chapel Hill.
         Assistant Professor              the underserved.
        Heather Walker, MD*
         Assistant Professor              She has interviewed dozens of stroke survivors in  For more information about how to help
                                          rural areas to find out about their rehabilitation    fund the stroke telemedicine project,
        Tanya E. Zinner, MD
         Assistant Professor              experiences after a stroke. In addition, she has      contact Nicole Pratapas, director of
                                          examined stroke care processes in a rural hospital.   development, at 919-966-8494 or
     Susan Evers, MPH, CHE*
  Associate Chair for Administration                                                            nicole_pratapas@med.unc.edu via email.
                                          Her work confirms the findings that stroke rehabili-
      Mike Hartge, RN, CRRN*              tation care is limited for people in poor rural coun-
      Patient Services Manager
        Rehabilitation Center
          Nicole Pratapas*                                                                                                                                       The slide at left, courtesy of the
       Director of Development               Figure 1.13. Cardiovascular Disease Hospital Discharge                                                              North Carolina Justus-Warren Heart
                                             Rates by County of Residence, N.C., 2001-2005                                                                       Disease & Stroke Prevention Task
      Jennifer Satinsky, MA*
    Managing Editor & Webmaster                                                                                                                                  Force, shows where most people in
                                                                                                                                                                 North Carolina experience stroke—
      Eileen Spahl, RNC, M.Ed.                                                                                                                                   usually in rural areas where medical
            Clinical Director
         Inpatient Psychiatry &                                                                                                                                  resources are more limited. For
          Rehabilitation Center                                                                                                                                  related slides and information, see
                                                                                                                                                                 the following site:
           *Members of the                           Hospital Discharge Rate
                                                             726.0 – 1,461.7
 Rehabilitation Reader Editorial Board                       1,461.8 – 1,968.1                                                                                   www.startwithyourheart.com
                                                             1,968.2 – 2,341.4
                                                             2,341.5 – 2,990.2
  There’s always more on the web!                            2,990.2 – 3,911.2

For related articles and issues of the         Discharge rates per 100,000 population age-adjusted to the U.S. 2000 standard population.
                                               ICD-9-CM Codes 390-459; principal diagnosis only.

 Rehabilitation Reader, see our web
                                               Data Source: N.C. Hospital Discharge Database, State Center for Health Statistics.
                                           The Burden of CVD in N.C. – January, 2008           N.C. Justus-Warren Heart Disease & Stroke Prevention Task Force

 site: www.med.unc.edu/phyrehab