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Tuesday, March 27, 2012

Asking the Right Questions

By Richard C. Senelick, MD


If you read the first three parts of this series, you should be an informed consumer and understand what it takes to maximize your recovery. Real progress in medicine depends on always doing what is right and best for our patients. It has been proven that comprehensive rehabilitation services following a major medical event, such as a stroke, will:

* increase an individual’s functional independence

* enhance self-esteem and quality of life

* promote the safe return to home and work

* increase the individual’s chances of returning to live at home

* decrease both transfers back to acute care hospitals as well as discharges to nursing homes

    It may not be easy to convince your insurance company to support inpatient rehabilitation, but you and your case manager need to fight for your right to choose. You want to make sure that you are given adequate choices that meet your specific needs. If you are not given an appropriate number of choices you should:

    • Ask your physician to intervene as your advocate, but be sure to establish that the physician is independent from the plan making the decision.
    • Review your insurance policy and benefits to see what you are entitled to receive.
    • If you are not happy with the decision, insist on an appeal with your insurance carrier.

    How do you make an intelligent choice once you have been given a list of facilities? Here is a checklist that I have found helps patients and families make a decision that works best for them.

    The Check List

    You can print out this list of questions and take it with you when you visit a rehabilitation facility. It is important to visit and take a tour, for many families and patients are surprised to find themselves wheeled into a Nursing Facility that performs rehabilitation and not a Rehabilitation Hospital or true rehabilitation facility.

    *  Will a rehabilitation doctor see the patient, and how often will the patient be seen? Patients sometimes leave acute care hospitals sooner than they used to, and still need frequent medical visits. Be certain that a rehabilitation doctor will visit at least 3 times a week and that a combination of primary care and rehabilitation doctors will see the patient 6-7 times a week. Close medical follow-up is critical and prevents transfers back to the acute care hospital.

    *  Do they have all the necessary members of the team on site: physician, speech therapist, physical therapist, occupational therapist, dietitian, counselor or psychologist, specialized rehabilitation nurses, respiratory therapists, case managers and access to the necessary medical consultants who, if needed, will come see your loved one? It takes a large team to do it correctly.

    *  How many hours of therapy per day will the patient receive? Remember that dose matters, and that rehabilitation hospitals are required to provide at least three hours of therapy a day.

    *   What is the staffing ratio of licensed nurses? Nurses are your “front line” caregivers and are there 24 hours a day, 7 days a week. They are one of the critical factors in keeping you healthy and out of trouble. Some nursing homes may have only one registered nurse (RN) covering the entire facility.

    *  Are the nurses certified in rehabilitation (CRRN) and Advanced Cardiac Life Support (ACLS)?

    *   What percentage of the center’s patients with the same problem are discharged back to their homes?

    * What percentage of the center’s patients return to acute care hospitals? Skilled nursing facilities have a discharge rate back to acute care of close to 25% while the number for Rehabilitation Hospitals averages 10%. This is a reflection of the ability to maintain a higher level of care for sick patients.

    *  Will you be assigned a case manager who will help deal with all of your needs, including equipment and discharge plans?

    Ask to see the therapy areas and what types of technology they have to deal with various physical problems.

    *  Do they have a pool for aquatic therapy? Many patients benefit from doing therapy in water because it eliminates gravity and makes movement easier.

    *  How do they deal with behavioral problems? Do they have special enclosure beds or other techniques to avoid having to medicate people who become confused or agitated?

    *  What type of programs do they have to address cognitive problems? Who performs the cognitive therapy?

    These may seem like a lot of detailed questions to ask, but your success or that of your loved one is going to depend on picking the correct facility. You are now armed with new knowledge to make the best possible choice for you or your loved one. Good luck.

    You can direct specific questions to me through my role as a WebMD Stroke Community expert.

    Richard C. Senelick, MD is a physician specializing in both neurology and the subspecialty of neurorehabilitation. He is the Medical Director of HealthSouth RIOSA, The Rehabilitation Institute of San Antonio, and an associate clinical professor in the Department of Neurology at the University of Texas Health Science Center in San Antonio. He has authored several books on stroke, spinal cord injuries, and brain injuries. Dr. Senelick is an expert in the WebMD Stroke Community

    Photo: Creatas

    Posted by: WebMD Blogs at 1:36 pm


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    Tuesday, March 20, 2012

    Where You Go For Rehabilitation Makes a Difference

    By Richard C. Senelick, MD

    Nurse and Patient

    “Secondary to dying, nursing home placement for an older person who was in the community is the worst possible outcome.” Kramer et al

    You or one of your family members are in the hospital and your doctor has just told you that you will need a course of rehabilitation. Your doctor has been your family doctor for years, and all of your children have been born at the same hospital, but no one in your family has ever needed rehabilitation.

    A short time after your doctor leaves your room a case manager enters and gives you three choices. One is an inpatient rehabilitation hospital and two are skilled nursing homes that provide rehabilitation services. How do you choose? Will your choice influence your ability to improve and reach your maximum potential? Absolutely!

    What is the Difference?

    My first article in this series spoke about the importance of “Dose-Function–Motivation.”  Which will give you the greatest dose of therapy that performs functional tasks in a setting that motivates you to get better – an inpatient rehabilitation hospital or a skilled nursing facility (SNF)?

    You have to ask some questions: Does a stroke patient do as well in a SNF as in an inpatient rehabilitation hospital? Is that patient as likely to be discharged home and back to the care of their loved ones? The answer to both questions is, “definitely not!” I don’t just say this because I work in an inpatient rehabilitation hospital, but because the medical literature supports this position. I know that my position will upset some very good people who work in skilled nursing facilities, but the facts support my statements.

    Evidence-based medicine is the gold standard for clinical decision-making, whether we are deciding what medicine to use or what is the best choice in rehabilitation. Just as you wouldn’t take a pill that had not undergone rigorous testing, you need to follow the evidence when making a decision about rehabilitation. As early as 1997, a major study in the Journal of the American Medical Association compared stroke patients who received their rehabilitation at a rehabilitation hospital (IRF) versus a SNF. Those who received their rehabilitation at an IRF were three times more likely to be discharged home. That’s right, three times more likely to sleep in their own bed, eat with their families, and kiss their grandchildren goodnight. Knowing this, where would you want to go if you had a stroke?

    Noted researcher Pam Duncan, PhD, looked at the same problem of poorer outcomes in patients who went to nursing homes for rehabilitation and determined that the practice of utilizing nursing homes “is now shown to be potentially cost ineffective and detrimental to patient recovery.” Not just less effective, but detrimental.

    Similar data has been published for joint replacements, hip fractures and medical diagnoses such as cardiopulmonary conditions. People are being sent to skilled nursing facilities to save insurance companies money, but the price in what it means in outcomes is being paid by the patient.

    What We Know

    Intensity of Rehab Drives Success: The evidence is clear that success with rehabilitation is dose-related. The intense therapy provided in a rehabilitation hospital is superior to the less intense setting of a skilled nursing facility.

    Functional Focus of Rehab is Crucial: Animal and human research demonstrates that it takes functional tasks to “rewire” the brain and restore function. Most skilled nursing facilities do not have access to the many technological advances described in my last article that promote repair of the nervous system.

    Even Modest Functional Improvement Affects the Future of the Severely Impaired: Too often, healthcare providers assume that severely affected patients are not candidates for an IRH. This is not true. If these people are provided proper rehabilitation, the majority of patients are returned to their homes and families.

    Rehab Hospitals Are Superior to Nursing Homes for Achieving Greater Gains and Going Home: The data speaks for itself. Patients who go to an IRH achieve higher functional gains and are more likely to go home than those who go to a skilled nursing facility (nursing home).

    Hopefully, you are now a better informed consumer. In our final article on this topic, I will give you a checklist to use when deciding how to choose a rehabilitation facility and some tips on how to obtain the best possible care for yourself or your loved ones.

    Richard C. Senelick, MD is a physician specializing in both neurology and the subspecialty of neurorehabilitation. He is the Medical Director of HealthSouth RIOSA, The Rehabilitation Institute of San Antonio, and an associate clinical professor in the Department of Neurology at the University of Texas Health Science Center in San Antonio. He has authored several books on stroke, spinal cord injuries, and brain injuries. Dr. Senelick is an expert in the WebMD Stroke Community

    Photo: iStockphoto

    Posted by: WebMD Blogs at 2:54 pm


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    Thursday, March 15, 2012

    Sad Effects

    By Krista Kellogg


    When you live with a chronic disease like psoriasis and psoriatic arthritis, you become intimately acquainted with the concept of trial and error. From the everyday accommodations we must make for ourselves to the very medications and treatments that are prescribed to us in an effort to mitigate the effects of our disease.

    Because for many of us there is no cure and because there are a rainbow of variations of disease conditions, there is no panacea. While we can find comfort and relief from time to time, many of us are always anticipating the inevitable: the day the meds stop working or we stop taking them for one reason or another. For me, the number one reason I stop taking a medication is because it has no effect on my psoriasis. The number two, and far more frustrating reason, is because of negative side effects.

    My journey with psoriasis has led me down the road of failed treatment many times. Sometimes the experience is dramatic, like the time a had an acute reaction to a biologic drug that left me covered in hives and gasping for breath or most recently, when I realized that the super potent topical steroids that I have been using (successfully) were also causing crushing headaches. Because the steroids nearly cleared my feet (a minor miracle for someone like me), I convinced myself that they were simply tension headaches brought on by the stress of a new job. Four weeks after weaning myself off the steroids, I am headache free… and my feet are once again a disastrous collection of cuts, cracks, and flakes. Such is the dance with palmar-plantar psoriasis; such is the dance of a living with a chronic disease. It is easy to lose hope.

    Albert Einstein said that the definition of insanity is doing the same thing over and over again and expecting different results. Coping with a chronic disease and the seemingly never-ending rollercoaster of failed treatment after failed treatment flies in the face of this genius observation. In fact, in order to cope with and live fully despite chronic disease, I think to a certain extent, it is necessary to live in denial of this logic. There is a deep and roiling sadness living and breathing inside of me about my disease. The chronic pain weighs me down like an anchor sometimes, tempting me to give up, laughing at my efforts to treat and control. For me, the only way to move on to the next experiment is to forgive and forget. I must forgive my body for betraying me and try to forget that it always will… try fitting that on the side of a pill bottle.

    Krista Kellogg was elected to the National Psoriasis Foundation Board of Trustees in 2006 and currently holds the position of chair-elect. She was elected to the National Psoriasis Foundation Board of Trustees in 2006. She is chair of the Board Governance Committee and a member of the Development, Finance and Outreach Committees. She also served as chair of the 2011 National Volunteer Leadership Conference. Krista has palmar-plantar psoriasis.  She lives in Miami, Florida, where she is the Senior Marketing Manager at Akerman Senterfitt.

    Photo: Image Source

    Posted by: WebMD Blogs at 3:18 pm


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    Tuesday, March 13, 2012

    How Does Rehab Work?

    By Richard C. Senelick, MD


    You were blind-sided by a stroke, brain injury, or a spinal cord injury. As you sit in your hospital room, you wonder what the future might hold. The hospital case manager tells you that you will be going for a period of rehabilitation, but what does that mean? How will it help? You know what the inside of a regular hospital looks like, but no one in your family has ever needed rehabilitation.

    Putting Things Back Together

    When a stroke or brain injury damages your brain, it has damaged the connection between nerve cells. Remember your mother telling you to think with your “grey matter?” That grey matter is billions of nerve cells that are connected to each other by wires (axons) that carry the messages to move your arm or ask someone to pass the butter.

    Think about your garden — or a garden you’ve seen on television. When you cut a bush or plant back to prune it, the plant grows back bigger, more lush, and healthier. It sprouts beautiful new growth. After a stroke or brain injury, the wires in your brain, those axons and dendrites of a nerve cell, start sprouting new “stems,” new growth to seek out new connections. This is called collateral sprouting, and this regeneration is an important element of neural plasticity – the brain’s ability to repair itself. With the right type of rehabilitation, those new stems can be directed to connect the correct way and traffic in the brain can hum along as it did before.


    If you remember my mantra from the first article, you will see how “Dose-Function-Motivation” are the key to your improvement. We know from both animal and human research that with the right amount and type of therapy, we can both instruct other areas of the brain to take over the function of the damaged brain and also direct the damaged axons to connect with nerve cells that work. This is what rehabilitation does.

    If you want to learn a new skill, you must repeat it many times. Just as multiple repetitions (practice) improve your piano playing or golf swing, so do multiple repetitions of a task help drive the axons to connect with the nerve cells that will restore function. It may seem like your therapist is pushing you hard, but it takes hard work. One hour a day isn’t enough.

    Imagine a young child learning to use their hand. When my grandchildren were younger, I carried a tin of jelly beans in my pocket. When they called out, “Gramps, beans, more beans,” I would initially watch them take their hand and grab a fist full of jelly beans, spilling a few on the floor. As their brain matured and the insulation on their axons developed, I would ask them to take only a single bean. They would take their thumb and index finger, form a pincer shape, and carefully extract the one color they most treasured.

    It isn’t much different in therapy. After a stroke or brain injury, your hand may only form a crude, clumsy grasp as you try to place soft ping pong balls in a large basket. But after many attempts and exhortations from your therapist, your brain starts to make the correct connections and you find yourself forming that same pincer grip from many years ago and placing a small peg in small hole. Success!

    Technology is Our Friend

    In the first few weeks or months after a stroke it may be difficult to perform these tasks without help. New, exciting technologic advances like the Ness 200®, Saeboflex®, and AutoAmbulator® help the patient achieve their goal of performing many repetitions of a functional task. For example, the AutoAmbulator helps a person who cannot walk stand upright on a treadmill and move their legs in a smooth walking fashion. This replication of walking helps drive the proper new connections in the brain that allows the person to walk. Be certain that the rehabilitation hospital you are considering has access to all the latest technologic advances. This is your chance to get better and it does make a difference.

    Next time, we will look at the different types of places that offer rehabilitation and why where you go does make a difference.

    Richard C. Senelick, MD is a physician specializing in both neurology and the subspecialty of neurorehabilitation. He is the Medical Director of HealthSouth RIOSA, The Rehabilitation Institute of San Antonio, and an associate clinical professor in the Department of Neurology at the University of Texas Health Science Center in San Antonio. He has authored several books on stroke, spinal cord injuries, and brain injuries. Dr. Senelick is an expert in the WebMD Stroke Community

    Photo: Stockbyte

    Posted by: WebMD Blogs at 3:36 pm


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    Friday, March 9, 2012

    How to Find Smiles

    By Karin Gelschus

    Positive Note

    I’ve gone from having a fully functioning, half-marathon running body to wondering what else is left to go wrong. When I first was diagnosed with Systemic lupus erythematosus, the disease and its inhibitors consumed my every thought. I figured I’d become more positive over time, but instead, I found myself growing more depressed as my symptoms persisted. Looking for anything to turn my gloomy thoughts around, my best friend offered to attend a support group with me. Unfortunately I left feeling discouraged and even more depressed after talking about all the bad things that accompany a chronic illness. It was too much for me. I had too long of a life left to spend my days focusing on the unfairness of it all.

    How could I not let this get me down?

    I started to leave post-it notes of encouraging words and inspirational quotes around my house. A sticky note on my alarm says, “You’ll feel better once you get moving.” In my gym bag a note reads, “Fight like a girl!” On my bed frame, “Sanctuary.”

    As I did it longer, I became a little more creative. The coffee pot reads, “Caffeine is your new best friend, enjoy!”  In permanent black marker, the bottom of my pill box says, “We make you feel better.” These notes put brief smiles on my face and refocus my thinking to positive thoughts.

    It’s unrealistic to think it’s possible to be positive and happy all the time. There are moments when the frustrations of being tired and sore get the better of me. One morning I read the note on my alarm and whipped it across the room. Despite the shooting pain up my arm, I smiled. It felt good to lose it for a moment. I realized I’ll have moments of complete and utter frustration, sadness, anger, and helplessness all at the same time, but that’s all those moments will be – brief and temporary. They will never again consume my thoughts because I don’t let them. I refuse.

    In the midst of pain, fatigue, and drugs, it can be hard to scrape together optimistic thoughts, so ask your family and friends for help. They are full of positivity, warmth and love. Whether it’s post-it notes, tea breaks, or something else, find your smiles throughout the day. It can make an obnoxious alarm clock a little less annoying.

    Everyone has their own way to stay positive and get themselves out of a slump, like this story from Beth, a cancer survivor who was determined to have a positive influence on her physical, spiritual, mental and emotional healing.

    How do you stay positive? Share your tips and stories in the comments below.

    Karin Gelschus was diagnosed with lupus at 23. She currently works as an interactive marketing specialist at CaringBridge, a nonprofit providing personal websites that connect people experiencing a health challenge to their family and friends.

    Photo: iStockphoto

    Posted by: WebMD Blogs at 3:14 pm


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    Tuesday, March 6, 2012

    Why Rehabilitation is Important

    By Richard C. Senelick, MD


    You never expected to get sick or injured—it was the furthest thing from your mind. Just the day before you were jogging around the block and playing catch with your son, but now you find yourself in the hospital. How will you ever get home and get your life back on track?

    We never think we will need rehabilitation. We worry about a heart attack or cancer, but most of us don’t see ourselves in a wheelchair or living with a severe disability. Yet, there are almost 50 million people with disabilities in the United States. Rehabilitation is the key to getting back to functioning at a level where you can live at home, enjoy your family, and hopefully work.

    This weekly, four-part series of articles will help you understand:

    • Why rehabilitation is important.
    • What actually takes place in a rehabilitation hospital.
    • Why it makes a difference where you go for rehabilitation.
    • What you should do if you find yourself or a loved in need of rehabilitation.

    The Glass Ceiling

    Hilary Clinton spoke about how her presidential candidacy cracked women’s glass ceiling, but 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 proper rehabilitation, patients are unlikely to 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:

    •          The physician or insurance company didn’t think they would get better so they did not give them the intensive therapy needed

    •          The patient confirmed their theory by showing little improvement.

    Just Like School

    Going for therapy and rehabilitation is just like going back to school, because you may have to learn new information. If you were 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 yourself from your bed to a chair. You may need to learn to read again, speak clearly, or improve your memory. Rarely is it easy, and I always told 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.

    Dose Matters

    When we take a medication for a medical problem, we carefully adjust the dose. Too little or too much antibiotic and the infection gets worse or never goes away. 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. Nursing homes do not.

    Function Matters

    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 do tasks and therapy that require the use of your right arm. Performing these tasks will help rewire your brain. The more “functional” tasks you perform the more you will improve and more positive changes will take place in your nervous system.

    Motivation Matters

    The person who is motivated and tries 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 caregivers and therapists, but also by their surroundings. Think of working in a brightly lit office with a great view versus one in the basement with a drab cubicle. Rehabilitation can be the same. Are you at a place that specializes in rehabilitation or is it just part of a facility that does other things?

    So, don’t forget: Dose, Function, and Motivation matter.

    In the next article, we will review the process of rehabilitation and how it helps repair the brain and nervous system.

    Richard C. Senelick, MD is a physician specializing in both neurology and the subspecialty of neurorehabilitation. He is the Medical Director of HealthSouth RIOSA, The Rehabilitation Institute of San Antonio, and an associate clinical professor in the Department of Neurology at the University of Texas Health Science Center in San Antonio. He has authored several books on stroke, spinal cord injuries, and brain injuries. Dr. Senelick is an expert in the WebMD Stroke Community.

    Photo: Digital Vision

    Posted by: WebMD Blogs at 3:28 pm


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