Closing the Gap on Subluxation with Jenna Barber - Season 2 Episode 8

Welcome to the No Plateau Podcast for stroke and brain injury survivors, their caregivers, and the therapists helping them break boundaries in their recovery journey. Hosted by Henry Hoffman, occupational and clinical therapist. This podcast is intended to supplement stroke and brain injury survivors' recovery journey. Therefore, all content affiliated with this podcast is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. And now here's Henry Hoffman.

Podcast Transcript

Henry Hoffman (00:00:32):
Hello, everyone, welcome to another episode of the No Plateau Podcast. I am your host, Henry Hoffman, and I am excited to be with you today. Today is going to be a really fun topic that I know many therapists want to hear about. It's on creating a stroke shoulder subluxation program, primarily through E-Stim in the acute and subacute setting as a way to mitigate some of those stroke effects. I've had this conversation for over 20 years with clinicians worldwide, and yet it seems that most facilities are not preemptively addressing this issue. Look, we know that subluxation can start in the flaccid arm in as little as three weeks. So why not proactively address the problem immediately instead of waiting for subluxation to kick in down the road? Why pass the buck to outpatient when you have the opportunity to attack it now? So when I used to do these elbow classes in the U.S. and overseas, I would ask therapists a couple of questions. I'd say, raise your hands if you feel subluxation is a problem at your facility. Then I'd say, keep your hands up if you feel E-Stim may help minimize or reduce the effects of subluxation. So the hands would go up and I'd say, keep your hands up if you have a subluxation program for your new admits that qualify. All the hands would go down. Literally, all of them would go down. The most common reasons were everything from cost. E-Stim units were not cheap. They were complicated. A lot of wires. Electrode placement was a fear between clinicians and nursing. Training with nursing was another factor, or just clinical staff. And of course, not all voters specifically are comfortable with this modality. So for a host of reasons, these programs were not offered. Which brings me to my special guest today who has successfully created a subluxation program at her facility. Please welcome Jenna Barber to the podcast. Jenna is currently an occupational therapist at Froedtert. I had to learn a couple of times how to pronounce Froedtert. If you look at the spelling, it's not like it sounds. It's in Wisconsin. She graduated with a bachelor's degree in kinesiology from the city of Wisconsin and then went on to work as a National Academy of Sports Medicine certified personal trainer for two years. Soon after, she obtained her master's degree in O.T. from Concordia University and is currently a full-time employee at Froedtert, practicing in both the acute and outpatient departments with special emphasis on neuro and orthopedic conditions. Well, welcome, Jenna. How are you doing today?

Jenna Barber (00:02:54):
I'm doing great. Thank you so much for having me. I don't think I necessarily have to introduce myself. You did such a good job.

Henry Hoffman (00:03:01):
Yes, well, we're I'm very excited to have you today because I know it's a hot topic. But before we dive in, just for the audience, I'm sure I didn't cover everything. But if you could just share a little bit more about your professional and personal background. That would be great.

Jenna Barber (00:03:14):
Oh, most definitely. So I have been an OT for over seven years now. I'm really starting out. I'm always with Froedtert and then dabbles a little bit in home health, which hasn't been that much to, I guess, kind of talk about. But I am primarily in neuro acute and the last few years I really kind of wanted to go off and specialize in outpatient, not just neuro, but also orthopedic, which I think has really improved my ability to treat neuro knowing kind of the orthopedic side. So I love what I do at the moment. I split my week between working at the hospital and Neuro acute for two days, and then I come over to outpatient and do outpatient for two days. So it's a nice mix for me.

Henry Hoffman (00:03:59):
Yeah, I love that because it's also a continuity of care conundrum in this world, Right. So you're kind of addressing both sides, you know, the issues and concerns that the acute patients are going through and then, you know, the issues and concerns that's going to happen in outpatient. And you can then affect change knowing the problem. So it's awesome. I think a lot of therapies should have that as part of the plan. You know, have them do outpatient, have them do acute, and then we can kind of close the loop. So that's that's great. I was trying to remember, I'm glad we're doing this topic now. We've been talking about this topic for a while. We'll dive into why we're doing this topic. But I was trying to remember how we first met and how that conversation popped up about trialing a subluxation program in a facility. Do you recall?

Jenna Barber (00:04:40):
Yeah, well, so I was getting the program started and I reached out to the Saebo wrap and I was asking if you guys had any handouts that I could use to get to the patients. And I specifically kind of at that time wanted to include placements that were most popular and it brought you. Because you're very passionate about the placements for subluxation. So it kind of opened my eyes to maybe better placement. So that's how we got. Got you on.

Henry Hoffman (00:05:08):
That's right. Now, now I remember that. And well, and I'm going to explain electrode placements in a second for the group because we do get students, we do get patients, but a lot of therapists and some might not be neuro nerds, if you will, that know the latest. So I'll quickly review some of the electrode placements. But you're right that was now that now this is coming full circle. I remember this conversation and then once I provided the information and some of the research behind electrode placement options, I think we started then both discussing the frustrations of not having a really good proactive addressable protocol slash program that we can immediately provide to clinicians and patients, right when they're admitted to the hospital. Is that right?

Jenna Barber (00:05:54):
Yeah. I remember you were impressed. You know, you're like, I need to learn more because you guys might be one of the few acute hospitals who are actually doing a program on their patients. And so you want more people to start doing it. So here we are.

Henry Hoffman (00:06:09):
All way to go. Where to go? Well, let's dive in. But before we dive into your specific program and what we've learned and, you know, questions like how do you set one up to what were the hurdles to lessons learned billing productivity? We got lots of questions before we get into all that. Let me just take a step back and review subluxation a little bit. I won't bore the audience, but I know there are some folks that are going to be watching or listening that are still not 100% sure on the latest. So let me blow off the dust of my subluxation fact and just go over a few things. So subluxation, glenohumeral, subluxation is present in up to 81% of the patients following stroke. I mean, if you read Deep Hurts, studies go from 17% to 81%, but it's literally some studies up to 81%, which is huge. It often occurs by the third week following a stroke in flaccid arms. Now, Jenna, I mean, three weeks. Again, another need. Why we have to have this program. These patients are mitted just after a few days and their arm is floppy and flaccid. And you can imagine over a period of two or three weeks, the stretching of that capsule ligament muscles. I know we have other strategies to support the shoulder positioning strategy, safe handling, but we're not living with the patient 24 seven. So it's going to stretch. It's going to hang. Gravity is definitely going to pull it. Yet most facilities are not even addressing the stretching of the capsule, stretching the muscles internally or its structures. So it is a problem. And so after three weeks, you'd have to imagine even before you're your guidelines, you must be seeing that a ton of that in the hallways with these patients, you know, within the first couple of weeks, right?

Jenna Barber (00:07:51):
Yeah. You know, in my head I thought that was like, oh, we wouldn't. But actually kind of deep dive deep in. And looking back, we do see the sub boxes pretty early and I try to get people who to prevent it in addition to just treat it. But a large majority of our patients already have a sub box in the hospital, right?

Henry Hoffman (00:08:10):
That's exactly right. Now, another interesting tidbit is that for the therapist, when you think about trapezius muscles around Boyds and straight up anterior and those get weak because the scapula abduct don't really rotate and depress and then of course these patients that are flaccid typically their spine flexes laterally during that altering the scope of thoracic relationship. Having said all that, due to the changes of the glenoid fossa position, because you're now in that downward rotated position. Traditionally, for many years, scientists and therapists believe that the labrum can no longer provide sufficient support. There was a locking mechanism to support the head in the glenoid fossa, so if you'd normally rotate your scalp, they thought naturally that it humerus is going to go out of the glenoid labrum where that locking mechanism is and then just pull down. Research now suggests there is very little evidence of a relationship between scapular rotation and South luxation, which is shocking to me. But we got to trust the science because I always thought, Gee, if you really had a lot of rotation downward, that's got to affect the pull of the humerus, but it doesn't. And so research shows that that's that's the case. So that does not mean ignore this gap of thoracic muscles. Ignore training this radius in the round. Boyd's in the traps, but however, the main emphasis should be on strengthening the proximal migraineurs, which we'll talk about When I say proximal greater, I'm referring to muscles that literally lift the humerus back up. So that's the focus. Lifting the humerus back up, sustain that position. Yeah, it's good to strengthen those step of thoracic muscles, but that should not be your primary focus Now with respect to subluxation and pain. For years, literature suggested that there was a direct relationship between pain and superstition. I always thought that. I mean, when you think about dislocating a joint, Joanna, you would think it hurts, right? So forever you would think, Gee, it hurts. But in fact, the science shows that there's not a direct relationship between subluxation and pain. What say you about that?

Jenna Barber (00:10:09):
Not a lot of patients, especially acutely in the hospital, complain about pain with their subluxation. Some, but. But it doesn't correlate. I feel like.

Henry Hoffman (00:10:21):
Yeah, I would agree with that. Let's switch gears and talk a bit more about treatment. I'm just scrolling down these notes that I have. So, and again, a lot of guidelines in many countries. I'll use the UK and Ireland's national stroke guidelines because that's the latest when I read. Some key things to consider: I used to be a taping guy. I used to be a sling recommender. But I got to tell you, it will not reduce your subluxation. It will not minimize your subluxation. It will not prevent subluxation. No slings will definitely prevent further dislocation if used properly. Taping, on the other hand, is a thin, flimsy piece of tape on the outermost surface of your skin. So your arm is 5% of your total body weight. No tape is going to reapproximate the humerus and keep it securely in place. So, consider taping for pain. Maybe that will help. I know there are some studies on that. But don't waste your money or time on taping because you're not going to get the results as far as, quote unquote, reversing or preventing subluxation.

Now, other things we know from these guidelines is that Eastman strengthening are the number one go-tos for mitigating subluxation. And that's what we're going to talk about today. Now, obviously, if the patient has volitional movement, they're not flaccid, and let's say they're three out of five muscle strength, you don't really even need to do is just do pure strengthening, and you're going to strengthen the proximal migrates, and over time, strengthen the cuff and get some stability there. And a lot of it will resolve itself. But for folks that are less than three out of five, they're going to need a little extra boost. And that's where the E-Stim comes in. And we do know that that's a very important tool. It's recommended by many guidelines and discussed in many studies. So I don't think there's too much of a debate there. I think the bigger concern is. Are therapists E-Stim trained and competent and comfortable? So we'll get into that. Traditional therapists also considered, you know, if you're going to do E-Stim forever. Jenna, it was I mean, I graduated in the mid-nineties. Poster deltoid, supra. Poster deltoid, supra, Poster deltoid, supra. Okay, listen to my supervisor, because why not? I'm a new grad, and then you get it's habitual, right? And you don't question it unless you dive deep and look at some of the research. Well, over time, it turned out that the posterior deltoid, of course, continues to be a strong proximal greater, and it's one of the ones you want to focus on. But super became very questionable. And there was a lot of research that talk about Cyprus. Questionable is not a strong proximal migrant, a number one. And number two, it shows that almost 50% of stroke patients exhibit asymptomatic partial tears of their supersprint. So I don't know about you, but I know if I want to be E-Stim in a partially torn tendon, whether even if it doesn't hurt yet. What say you?

Jenna Barber (00:13:14):
Wouldn't work as good, right? Right.

Henry Hoffman (00:13:17):
And it's not even a strong proximal migrant or the strongest proximity of yours. Learn how to tricep. You know, there's a study hall there did a study where long had a tricep and the deltoids and korkor brachial are stronger proximal areas. If you think about insertion in origin, if it inserts, let's say the tricep, if it's attached to the humerus and inserts on the end for glenoid, you contract your triceps, you extend your elbow via your triceps. It's going to lift the humerus. So super is more of a compressor. Not saying ignore it, but if you only have two electrodes, personally I'm not putting one of them on super. Finally, to wrap up the fact sheet I have for best treatment of shoulder subluxation electrode placements over the deltoid muscles are preferred. Che did a bunch of articles on this. They are in fact the strongest proximal migrated to the shoulder type. All right. Did I miss anything? That's again, I talked about slings, talked about tape taping. I'm trying to go over some of the hot topics, obviously, patient handling, positioning, sleep schedule, you know, where is the arm when you're sleeping. All that stuff's important to any other tidbits you want to share that you think I didn't cover?

Jenna Barber (00:14:21):
No, I think you hit it right on the head. It's funny because all those guidelines, right? Like they tell us what to do, but for some of them, it's easier to put into practice the safe handling, the proper positioning and even like slings, you know. But for some reason, that E-Stim is hard to put into real life play.

Henry Hoffman (00:14:41):
Well, that's what we're going to dive into because we're trying to make it very easy to use. Right. And so hopefully things like the program will be a nice start to kind of get the awareness out there. So let's dive deep into that. So why did you actually develop the subluxation program? Take me through the impetus behind wanting to start this program.

Jenna Barber (00:14:58):
Oh, sure. Last year I had the opportunity to teach one of a neuro rehab course at Concordia for just for cement when she was on medical leave. And thankfully, I didn't have to do anything with the course. I just taught what she had. And she spent an entire week on shoulder subluxation and really stressed the importance of all of the points of what we just talked about with a huge emphasis on using E-Stim because that's the only thing that's going to really try to fix the problem. And so it lit something underneath to me that I'm like, Oh my gosh, literally our practice guidelines are telling us that we should be doing this. And yet us as a profession, we're not like, we're not. Why not? And so I was like, You need to start this. And so I went to my leadership and wrote up a proposal with justification, using everything in literature that supports it and asked if we could and try to do it in a way that was easy for therapists, easy for nursing staff, just to see for everybody that it would be attainable. And they went for it specifically, kind of knew about a product that I wanted to use that didn't mess with wires that was super easy to figure out. So I think that played a large play in it for sure. Getting the okay for the program.

Henry Hoffman (00:16:19):
That's really cool. So the first steps, the biggest step right then can you spend a minute then going through so therapists are listening, Therapists are in your position right now. Can we dig a little bit deeper and go through the developmental process of starting the program? I won't get into the actual protocol yet, but literally from point A to point B, point B, getting approval. What are the steps that you recommend? I mean, obviously there's hurdles. What are those hurdles? Is there a budget that you had to propose? What were those challenges? But what would you recommend to the listeners today if they want to start tomorrow? What are the key things they need to do to get their administration to listen?

Jenna Barber (00:17:00):
Yeah. Gather your evidence. So literally, you could Google like 2023 stroke guidelines because they just came out, and it has it right in there with good kind of research articles to support it. And then write up a little like I did a Word document and I said, you know, like, want to start the shoulder sub program for yadda, yadda, yadda. Here's the evidence behind it. Here's the product that I want to use, which I talked about, the stable E-Stim, one which is relatively inexpensive, starting out with just two units. So it wasn't this budget breaker by any sense and asked if we could do a soft trial and just one unit, so just a 30 baby unit to do a dry run. And quite honestly, it really wasn't that hard. You just have to ask and show support. And they said fine. And we're able to order two units and get it going.

Henry Hoffman (00:18:01):
So when you put up the proposal, you sent it to your supervisor. Right. And you explained the need is almost like a needs assessment because you backed it up by science. So sound like you're doing some crazy junk science strategy. You basically told them this is going to help the patient. It's evidence based and know it's important for JCO accreditation and everything else. You do everything. It's evidence based. And if you're not doing it, you've got to wonder why are you accredited? Because you're supposed to be doing everything that's evidence based. So you then the next step is you're requesting for a beta test. And how long did that beta test run?

Jenna Barber (00:18:34):
Just a month until we went hospital-wide.

Henry Hoffman (00:18:37):
Okay, so when you went a month, you did you collect certain data during that test or was it more feasibility just to see how it works?

Jenna Barber (00:18:46):
Going back to therapists and nursing and what's kind of going wrong, how can we tweak this before we kind of launch it out hospital-wide?

Henry Hoffman (00:18:55):

So clearly, you at least probably tracked how many patients used it. What during that beta, what were some of the friction points? And of course, you had to do some training. So again, we'll get into the program in a second. Walk me through. Who did you train? Did you train nursing or did you train therapists or both?

Jenna Barber (00:19:14):
My biggest thing is that I wanted this to be standard practice and easy for everybody. So truly, I tried to leave nurses out of it. They already have stuff on their plate, and they know they have to be aware of the unit itself in case they need to turn it off and remove it. (15.8s): But as far as getting them involved, it's like placing it on and all of that. They're not a part of that. So the largest part of training was my therapist, and during that pilot program, it was the therapists who were on the floor. So we did one in-service with maybe just five or six to really go through the placements and the unit itself and just reviewing shoulder subluxation as a whole. And then once we did hospital-wide, it was another in-service of all of my O.T. is who would have the potential of seeing patients. But really the biggest thing was this one-on-one kind of training that the therapist sees the patient who would benefit from it and then come to us because they haven't done it yet. And we would, in that moment in time, do the training together.

Henry Hoffman (00:20:22):
Okay. So you mentioned nursing not getting involved. So if some of the listeners are connected really well with nursing, what are some of the suggestions you would recommend with nursing training and therapist training? And could both exist? Could they coexist, or would it just be a nursing program that you train nursing to apply? Or would it always be a nurse and therapist working together?

Jenna Barber (00:20:45):
You know, and this is just my opinion. I think nurses and therapists together because, you know, we're doing assessments of the range of motion, muscle strength, subluxation grade. So I think I always want that documentation from the therapists, but by all means, if nurses want to get and have more involvement, that's great. I just mine are so busy that I want to give them a break. We do train them, though, because one of the big things is that the stable E-Stim one is little. And our fear was that we were going to lose them. And so our big thing was, okay, if the patient has to leave the room for any imaging or procedures or anything like that, it has to be taken off of them. And so there might be some rare occasions where the nurse has to turn it off and remove it. And so the nurses did need to have a little bit of training and just not as significantly as the therapists do.

Henry Hoffman (00:21:40):
Got it. Okay, So great. You've answered our question regarding developing the process, getting approval during the beta test. Budget was not an issue because you're only talking about a couple of devices that are not expensive. And then let's transition out to the actual program. So let's try it this way. First, let's pretend the stroke survivor, and I'm a new admission to your facility. And this is just a typical day now at Froedtert under the subluxation program. Walk me through what happens day one new admit with this program.

Jenna Barber (00:22:11):
Sure. Yeah. So we probably see you maybe day one after somebody had a stroke. And at that time we evaluate if you would benefit from it. So regardless, if you currently have shoulder setbacks or hopefully you don't yet we get you started on the program because we want to prevent one from happening at all. So let's say day one, maybe day two with email is pretty hefty and takes a long time. We get it started. The first 1 to 2 sessions. We have the syE-Stim running during her t session itself so we can establish some tolerance. But after that, once we know that the Eastern spine patients comfortable, we see them for regular sessions after say, day two and we then put the E-Stim at the end of our session and leave it on them when we leave. So they have a solid 60 minutes of E-Stim unattended, will come back, take it off, bring it back to the gym for charging. But it's a 60-minute treatment session where we come up with 60. I mean, we can go back to research that, showing that 60 Minutes has improvement, but also that disable one, it automatically shuts off after 60 minutes, which is very helpful for us because then we don't have to run a back saying like, oh my gosh, they had it for longer. So it automatically shut off after 60. We do it Monday through Friday. And truly that's just because we have a higher staff ratio during the week. Then the weekends again is the ability for our therapy team and they where at then once they started they wear it for the entire duration of their hospital stay. And we have this program running at Froedtert Blue Mine Rehabilitation Hospital. So our IPR. So then they keep going through the weeks that they're in inpatient rehab too. And then once they're home. So it's we get to have them on it for a long time, which is good.

Henry Hoffman (00:24:09):
Wow. I'm kind of excited now actually to be a patient now, but never want to be a patient. But it seems like you're really taking care of me. So, okay, let's start back. I get admitted. When am I not a candidate? You mentioned obviously, if I have enough movement, I wouldn't need it. But what are some other examples of patients who are definitely not a candidate for this opposition program?

Jenna Barber (00:24:29):
Yeah, we can go over there's contraindications with electrical E-Stim, so we can go through those. So anybody who has contraindications, which would be systemic cancer, so cancer kind of all over the body, we don't want it. The risk of it spreading. And, you know, if anybody has like metal implantations, we don't want to put E-Stim over the act. What other ones here?

Henry Hoffman (00:24:53):
I'm blanking sorry for not clarifying the ones that you've already had during your beta testing. Yes. And by the way, therapists will have when you have a manual open for any E-Stim device, you're going to see about 4700 pages of contraindications. I always love the one where it says, you know, don't go swimming with your E-Stim device or some crazy stuff. Like the Pacemakers is a very common one usually. And to be honest with you, it's more so in Europe than in the United States. They're actually questioning some of the contraindications. They're questioning the implant ones. Now, obviously, directly over metal is not a good idea, but if it's, you know, not too close. There's a whole group of experts that now feel that that's not really a contraindication. By the way, everything I'm saying here doesn't mean go ahead and do it. This is just me having a conversation. So don't hold me liable. But I've also heard that if you have cancer, it depends where and sometimes you have chemotherapy side effects that lead to tingling nerve issues that you can use for sensory E-Stim. So of course, if you have a tumor over your area, you want to focus on, that's not going to be recommended. And I know there's some doctors who don't recommend if you had brain tumor. So you got to go back to your doctor, get approval. Don't listen to us, get approval from your doctor or read the manual. But yeah, those seem to be the hot ones. You mentioned dosage, so it's 60 Minutes, is it? Once a day or twice a day I was trying to confirm that.

Jenna Barber (00:26:16):
We do it once a day. Ideally, I try to tell my therapist, you know, like once they're established, maybe third on the beginning of their session, and then we start it so we get a little bit more ex. We know more is better, but it's just once a day usually.

Henry Hoffman (00:26:31):
Okay? And after they're comfortable, they know what they're doing. The therapist goes down the hall, turns it on, puts it down. Now, do you ever just educate the patient and maybe the families there? Because, you know, when you look at the saber E-Stim, one, for the people who are listening to the audio version of this, you're not seeing the saber E-Stim one. But if you're watching the video podcast, it is small and it wraps right around the shoulder. Maybe you can just show how it just goes round so any patient or family member can do that. And what we were trying to do when we created that product was, you know, one button, one program, anyone can do it type of strategy to get rid of all the impediments of why people don't do is them or create a program. So have you had scenarios where you're just telling the husband, the wife or the patient, just put this on, I'm not going to come and just turn it on? Or do you always show up to do it?

Jenna Barber (00:27:16):
Well, if it's our units, we'll show up to do it. There have been occasions where the patients early on will buy it right away. That's a little bit rare because we are just acutely in the hospital. So I think it's more prevalent in our inpatient rehab. But once, you know, sometimes the patients and family members will buy their own units, and then they will do it even without us anymore.

Henry Hoffman (00:27:41):
Okay. Okay. So once they use it, you go, then come back. It automatically turns off, you said. So you come back and you pick it up. Yep. So you're eliminating one of the other big issues, which is patients magically or your devices magically becoming lost, quote unquote. Right. So by you controlling the product, you're controlling when you give it to them, when you take it back. These aren't magically going on with patients. That that's the whole goal there.

Jenna Barber (00:28:09):
We have not lost one eye. So we have these laminated signs that we put outside of their room, kind of where our isolation signs are to alert everybody that the patient's wearing this product. Watch out. They can't wear it if they are removed from the room. So I think that has helped to just this awareness like, hey, the product's room, but we haven't lost one. So it's it's been awesome.

Henry Hoffman (00:28:34):
Yeah. How many stroke beds do you have at the acute hospital yet you're at? If you have monthly admits how many are a stroke.

Jenna Barber (00:28:45):
I had a bad answer to this.

Henry Hoffman (00:28:47):
Make it up.

Jenna Barber (00:28:50):
A solid kind of neuro units, and they're both about 30 beds each. We have a really strong neurosurgery program, so we get a lot of brain mess resections, but maybe about school, like 25 to 50%.

Henry Hoffman (00:29:05):
Okay, so how many beds does that total? How many?

Jenna Barber (00:29:10):
Oh, well, then we think they include our neuro ICU. Okay, let's go. 80.

Henry Hoffman (00:29:15):
80 beds that are so 80. So you may get 80 beds full of stroke patients.

Jenna Barber (00:29:20):
Well, of neuro patients.

Henry Hoffman (00:29:22):
Okay, let's let's. Let's do just to keep it a simple math. How many do you think are stroke? Like a quarter of those households. Okay, so let's say 20 beds are stroke patients. Out of the 20. How many do you think would qualify for the subluxation program?

Jenna Barber (00:29:40):
Oh, gosh, probably over half. Okay. Because we want to get them when they have shoulder weakness. So. So if you have your arm over their head, we want to get them on.

Henry Hoffman (00:29:50):
So 10 out of 10 would be actively potentially on the program.

Jenna Barber (00:29:54):
Mm hmm.

Henry Hoffman (00:29:55):
A question that will definitely pop up is how many E-Stim units you need to manage. Ten. Now, remember, there's small hospitals and there's large hospitals. Are you considered middle of the road, or would you be considered a large neuro hospital?

Jenna Barber (00:30:09):
I think we're a large neuro. We're a level one trauma center. Overall, I think we have over 750 beds. So I would say we're pretty big, the largest. Okay.

Henry Hoffman (00:30:20):
So if you're if you're one of the largest and you're only talking ten, maybe ten stroke of subluxation, not a stroke. When you're talking ten stroke survivors, that's really manageable. So even if you had your two units, do you think you could with scheduling? Would you need a couple more? Because one of the things that will ultimately have to be done, regardless of the E-Stim unit you choose, does that be able to be an easy community? You're going have to figure out how many you're going to need, and that can be done through your beta test. From your perspective, is too good for a large E-Stim or a perfect world and you had all the funds, what would you recommend?

Jenna Barber (00:30:59):
Yeah, well, we currently have four now and I feel like I still have a waitlist and we could get more people on. So maybe like maybe five or six. We also and this is just makes it easy and kind of working out some of the kinks we have. And this is talking about the stable one unit so I would say can be different if you use a different product. But each patient has their own wing, like while they're in the hospital because the gel pads kind of stick to it and it's really hard to take the job pad off. So when the patient's in the hospital, they have this wing themselves. Now you can take off the battery and kind of intersperse some, but that could get a little complicated, be like, Hey, you got a battery, I need to use it. So we try to eliminate ADD if you have four units for patients going at one time. So for us, I would love to get maybe like two more units just so that we don't have anybody on a waitlist.

Henry Hoffman (00:31:54):
Right? Yeah, I could see that could be a problem. Well, that was the goal. Try to make it as cheap as possible, as easy as possible. So you could do those things. So hopefully your upper management understands the importance of that. Before we dive into other questions, let me see what else I had on this list here. How many patients at one time do you currently have on the program? When you did that beta testing, what was the most you had at one time?

Jenna Barber (00:32:17):
Because we had two units, we had two going and then we had a waitlist.

Henry Hoffman (00:32:20):
So that so yeah, because you didn't have because technically you could have two units and like 12 wings.

Jenna Barber (00:32:27):
Right, right.

Henry Hoffman (00:32:28):
Alternate the wings with the units. But still you can only do two at a time. So I could see that could be a potential issue. And then we talked about nursing and then for the acute department, how long typically are they staying with you?

Jenna Barber (00:32:41):
Yeah, good question. It depends on their medical stability. Yet we have because we're the level one trauma, we get a lot of patients who come in from outside hospitals. So they're very medically complex. So I want to say our length of stay is maybe a little bit more skewed, but anywhere from a few days to a week and then upwards of maybe a couple of weeks, especially if we're working on discharge disposition with different rehab facility is okay.

Henry Hoffman (00:33:07):
So we know continuity of care is huge. You've attacked problem number one, which is preemptive attack, which is we know subluxation is going to happen. We already know it. The guy's flaccid. You decided to, you know, make a meaningful difference right there and address it. They leave you with premium best practices. How many of those patients are actually going to be going to your facility with which they can actually continue this best practice versus getting lost in the syE-Stim?

Jenna Barber (00:33:36):
Yeah, goodness. I hope a lot and I think it is a higher percentage because we hit the ball running with it with our neuro patients, especially stroke patients. We know that best practice tells us they need to have intensive 3 hours of therapy a day. So we're really that is our goal, to bring them over to our inpatient rehab. So I would say anywhere from upwards 75, maybe 50, it depends on if they can tolerate the 3 hours. But regardless of where they're discharging, even if they're not going to us, we're going to have them on the program. I just might educate a little bit more to a family to be like, Hey, how your therapists do this?

Henry Hoffman (00:34:16):
Yeah, So that's where I was going. You know, most hospitals, not all patients are going to stay within the syE-Stim. So in order to be successful, it's not what you do the first week you're with them, which is the program. It's what happens next, you know, for some of this. Right. It's what happens next. Because just like robotics, just like any other fancy program, if you only do it for a couple of weeks, why even do it? So what can we do or what have you done? Or what do you suggest therapists do that start a program where there is a good handoff. Not only for folks that go to your inpatient and what does that look like, but what's the communication, the handoff, the recommendation for folks that go you don't even know where they're going. They're just not going to your inpatient. So what can you share with that?

Jenna Barber (00:35:06):
Yeah, I think the most important thing is the educating to family and the patient, because they're the biggest advocates themselves to make sure that they know about it, the importance and distress it so that their next facility be like, Can we get this going? How can we get this going? Because they're going to be the ones who want to advocate. We have handouts. I mean, if they're going to a different rehab facility, we fax our therapy notes. And so it's it's in there. But that family inpatient component to advocate for themselves, I think is going to be our best bet.

Henry Hoffman (00:35:39):
So I got an idea, Jana. I got an idea. Why don't we hire a tattoo artist to come in and tattoo, step me over their deltoids? So when the next therapist sees them, or why don't you write? Are there stickers maybe with Froedtert logo? Or I can say I need E-Stim, please help and wrap it around their shoulder. What about that?

Jenna Barber (00:36:01):
I've done post-its. Like I'm there of like, you know, rehab therapists do this told me and I'll write our number down because, I mean, I just want to help and I want our patients better. So, like, by all means, call us. Yeah.

Henry Hoffman (00:36:17):
I know, I know. I wish. I wish. I mean, gosh, that's the goal, right? Okay. The easier path is they transition right into Froedtert syE-Stim. So when they transition right into Froedtert syE-Stim, how are you communicating with subacute therapists?

Jenna Barber (00:36:34):

The inpatient rehab therapists know what to look back on or know. And we have a couple of places in our note that says that they're on the program as well as in each note. It carries over to the program itself the amount of intensity that they need, how long that they do it, yadda, yadda, yadda. And so it's right there in there. And then we do we use WebEx is kind of our instant messaging. So we can even kind of message the therapist giving a heads up, too.

Henry Hoffman (00:37:02):
So, do you envision providing services for the Subacute team and giving them the same training you provided to your acute therapists? So they're…

Jenna Barber (00:37:12):
Impatient? Rehab.

Henry Hoffman (00:37:13):
Inpatient rehab, right?

Jenna Barber (00:37:14):
Oh, yeah. Oh, already done. So, when they started, maybe two months after we did our pilot program, and we did the same kind of training. So I went over there. I appointed a lead person to kind of run it after I did the initial, but we did kind of the same format and it worked well.

Henry Hoffman (00:37:35):
Okay. And again, I think we're going to dive into billing and productivity and lessons learned in a second. But I think the main takeaway at this point is as clinicians, we need to provide evidence-based practice. As our teachers, we want to provide not only evidence-based practice but treatment that's relative to the scope of our own practice, right? And so why are we doing what we're doing? Okay, of course, we're trying to strengthen a joint, the muscle surrounding the joint. Of course, we're trying to prevent, minimize, mitigate, reduce, call it what you want, improve the outcome of someone who has subluxation or will have subluxation for obvious reasons: dressing, bathing, grooming, function, walking. You need to have your arm swinging naturally. Okay, there are a lot of reasons why we're doing what we're doing, and this is all tied into our ultimate goal, which is to improve their functional life. And this is very outcome-oriented, right? So it's important to remember this is not going to be fixed in two weeks. This is going to take months, like any other treatment intervention. I don't care if you're talking about neuroplasticity-based treatment interventions, task-specific training, constraint-induced repetition—all those things take months. We need to get a massive amount of repetitions, right? So we cannot mentally practice our way out of a subluxation. We can't mirror box our way out of a subluxation, right? There's no research to say if you do 30 minutes of mirror boxing mental practice training, your subluxation gets reduced. This is a different beast. This is going to require a ton of strengthening, and it can be volitional, and it also can be boosted with esteem. If you can't do it literally, of course, we have to do position and prevent further dislocation. And some patients, if you cannot get them—when you think about your stages of brainE-Stim recovery—if you can't get them through those stages where they can literally fire their own muscles, it's going to be hard to minimize, reduce, and prevent subluxation. It just is. But if we can get them to the point where they have activation proximally, we have a chance, we have hope. So what we're trying to do is make it a little easier for them to be successful. Us ignoring the problem, us doing what we've been doing for the last five decades and more, which is, yeah, subluxation, hand it over to our pain, let them figure it out after it's a two-inch gap—that is not the answer. That's making matters worse. So the whole point of this effort and what John is doing, which I commend her and her team immensely, is trying to make a difference. And even if we can improve the patient's outcome by 10%, it is well worth making the difference. And research is telling us to do this. It's not like it's another theory that we learned 30 years ago. So that's just kind of re-summarizing why we're doing what we're doing. What a perfect transition. Now that we talk about the importance, let's talk about billing and why our hospitals might make us a little nervous with what best practices are, but maybe not a fritter. So walk us through, because this part I don't know too much about. Good job. Congratulations, Jenna. You've proven that you're an awesome clinician, and you know what you need to do to make patients' lives a little bit better? How are we going to make the accounting department at the hospital's life a little bit better as well? So tell us, how does it work with billing? Did billing change at all? Did productivity change at all? Are you losing money for Froedtert or are you going to keep your job or not?

Jenna Barber (00:40:59):
I'm going to say that, you know, that's one of the kind of maybe excuses that why they don't have something like this syE-Stim because it's just one more thing that we have to do that we're not getting kind of any reward for. One more thing, Ammad, but we do build for X, We use that. If you kind of look at the therapies out there, the zip codes we use unattended E-Stim when we're applying it and we're leaving. So we're not there. It's unsupervised, and it's a code that we can use. And if you kind of look at the weight of codes in the hospital, we use this APC, which is somewhat similar to RV use, which is outpatient. It holds its heavy weight. It's 0.133, I believe, compared to say like a care home management or therapeutic activity code, which is roughly around 0.10.4. So you're not being there; you're building some units. And so it's not like not worthwhile. It's you get productivity, and it's helping the patients.

Henry Hoffman (00:42:08):
So wait a minute. Let me because again, this is good for my own edification. Walk me through what unattended what did you call it, unattended.

Jenna Barber (00:42:16):
Unattended E-Stim or unused electrical stimulation is the code.

Henry Hoffman (00:42:21):
Okay. So when can you build out? You literally put it on the patient, walk away and come back. That's an unintended defined as an unattended E-Stim code.

Jenna Barber (00:42:29):
In that zone. Is it a new code, or has that been around? I mean, again, I haven't been in a hospital in over 20 years. So new for me is within the last 20 years.

Jenna Barber (00:42:37):
Now, I can't answer the 20 years, but I think it's always been around. You know, to us, we're like, no, we can't build something for not being the presence. But we had people thoroughly look into it. And it's that code is amazing what we're doing.

Henry Hoffman (00:42:54):
That's great. And it sounds like you can get good reimbursement for that code, which is even more because you mentioned health compared to three decades old, stuff like that. So what are you only billing that code for the program unattended is some code for what is it for one hour or how many units?

Jenna Barber (00:43:09):
Yeah, unattended E-Stim is a procedural code, so it's just we just spell why stuff how long they wear it. But ideally, this patient is having O.T. most days of the week. So we're going to build our regular session. And then if they wear that E-Stim outside of our session, which that's what our protocol calls for, we'll do our regular billing and then the unattended.

Henry Hoffman (00:43:32):
E-Stim. So this is above and beyond. So, Froedtert, it's real happy about this program, basically, right? You should do an our or a return on investment at some point. It would be good to do that case study next, which is, hey. Here's the additional incremental revenue earned per patient, further length of stay for the next, let's say, ten or 20 patients. Because what you're basically saying to administration and other therapists listening have to convince the administration, while they're not losing money, they're actually going to be making more money because they're maximizing their best practice goals is here's the additional revenue build. Incremental revenue above and beyond by having this program in place. That would be pretty interesting to kind of understand. So there might be a future homework assignment. So productivity. So is there anything that you want to mention about productivity, I guess that's tied to it? It's not like it's changing your productivity, are you? Because you're accounting for everything you do. It's not like you're doing extra but not billing for it. So productivity is not a concern. Not an issue should not be an excuse, is what you're saying when it comes to starting this program, right?

Jenna Barber (00:44:41):
Yeah, because we're billing it. It feeds into our productivity. So if we weren't billing, then it's an added stuff that we have to do, but we're billing for it. So. So it shows in our productivity.

Henry Hoffman (00:44:53):
Okay. So we've taken away that excuse. We've taken away the device excuse because there's devices out there that are super easy. One button get started. No electrode placement issues. You've taken away the excuse that maybe nursing does want to do the program. It's okay. The clinicians are doing it and they're billing for it and it's not affecting their productivity. We've taken away. G We're confused about electrode placement. All we do know the latest guidelines and so you can just wrap it around your deltoid’s middle imposter. Don't try to shoehorn. In fact, you could even do A.D.A. lot. They're still strong proximal graders. You don't have to get funky and try to figure out how am I going to squeeze in? Super somehow. By the way, supers under your trap. You know, sometimes you are hiking, there are patrols. You don't even get an effective contraction a lot of times a supra. So again, I got I got a thing with Supra. I don't know if it's because during my ortho days I had to do a lot of friction massage and tendonitis. Patients had supra at the insertion site. Something something bothers near a supra. So it's coming back. So we're taking we've pretty much taken away all the impediments now. Lessons learned. What would you do differently? I know this is a question that therapists have asked pre-podcast. What would Jana do differently if she was starting the program from the training to the implementation time investment? All the things you've done. Anything you do differently in any lessons learned?

Jenna Barber (00:46:08):
You know, I thought about this, and we currently call the program the Shoulder Subluxation program, but I feel like we're running into patients who could benefit just because they don't have a shoulder subluxation. We've done educating them and reinforcing that like, no, we need to get it before they get one because they have muscle weakness. So I don't know if I would change the program to maybe like shoulder Eastern program. I'm still debating on this one, but I'm really stressing the beginning of it's not just shoulder subluxation; it's for those who don't have one yet to prevent one to happen.

Henry Hoffman (00:46:43):
That's a good point. And by the way, what diagnoses are you currently using, aside from stroke or?

Jenna Barber (00:46:49):
Stroke, brain injury, we will do a brain mass resection. We'll just get a doctor's order that they can use. E-Stim will even tie in some spinal cord injuries, too. So really, really, any neuro as long as the complex is less than six months.

Henry Hoffman (00:47:05):
So this is definitely another topic for another podcast but let me at least bring it up as we wrap up. Now that you've successfully implemented this program, I guess before I even make this comment, what are your goals now? Did you satisfy all your goals or is there another facility within your network you want to train?

Jenna Barber (00:47:24):
I mean, big picture, it's to get like worldwide hospitals, rehab facilities, outpatient therapies. Just everybody doing this. And I hope that the podcast reaches all, but where I can maybe have a little bit more pull is I want all Froedtert hospitals and that's already something in the works. We have two more hospitals that we want to get it going. We're merging with DataCare up in Appleton, Wisconsin, and it's already starting to do the program. So whatever I have in our health syE-Stim, I want this to get going, but everybody needs to do it.

Henry Hoffman (00:47:59):
Well, let me close with a rant, a small rant, because if anyone knows the podcast or lives or watches or sees me or reads my LinkedIn, sometimes contrarian posts, one of the problems that I have with therapists that see neuro patients, which is different than neuro therapists and hospital limitations, and obviously Froedtert, nothing but applauds and accolades to Froedtert. One of the problems I have is we're trying to quickly get these neuro patients out of the syE-Stim, and so we teach them one-handed techniques. What we do know, and I won't bore our listeners on this one, they can go listen to other podcasts I've mentioned this in the past, is we know that that contributes to neuronal cell death. If you ignore your area of the brain, it's impacted and force them to use their healthy limb, ADLs, grooming, exercise, you're slowly killing brain cells. Basically, you're a neuronal murderer. Joanna, are some of these authors murderers, their neuronal murderers? Yes. So but the hospitals tell me. I got to get them independent as soon as possible. One-handed out the door where neuronal murderers. So we need to do more. Now, you just created a template for one specific condition. Why don't we now create another template? Again, small victories here.

Why don't we create a program for in-room, whether it's visual imagery, mental practice, let's just take it. Let's just be super, super easy. Murdock Let's just start with Mir box, which we know is super powerful. If you want to do battle practice, we can do that to you,and let's save that for another conversation. But why can't we just give every new admission? A mere box. And in there, you guys can make them for like $5. And then there's there's commercially available and see, but they're not as cheap. And just give them a more box program while they're with you. What's the difference between giving him a subluxation program to preemptively address one condition and not do the same thing to help rewire the brain, prevent neuronal cell death, and try to, while they're in that acute subacute stage, boost the neuroplasticity with easy things they could do in their room, maybe save it for them at dinner time with her husband or their wife. Maybe they're at the level they can do it on their own, maybe already doing that. But let me just say one thing. Mirror Box can be a program. Mental practice could be a program you just did. E-Stim Maybe do E-Stim first and finger extension accessories. That could be a program. Let me just pause right there. Do those programs currently exist or is that the same boat we're in with the Subluxation program and why we're doing what we're doing now?

Jenna Barber (00:50:40):
Oh, you know, I think there's some that are in inpatient rehab, definitely not acute in the hospital. I mean, personally, I try to especially throw up that great motor imagery. I'll use ladder the ladder ality apps, the mental practice to and then tying them your backs. But it's not a concrete program. You know, you bring up the point of having patients do more outside of therapy because there's so much downtime. They're just sitting around and I feel like the family, the patient, they feel out of control and we can just give them a couple homework things to work on. It's going to help with the neuroplasticity, but then it's going to feel like make them more empowered, too. So I love this idea.

Henry Hoffman (00:51:23):
Yeah, I'm telling you right now it is the analogy I always give. And again, health care, I'm not blaming a specific hospital. I'm blaming our health care syE-Stim and reimbursement syE-Stim. Think of elite athletes. How often do you need to practice? By the way, elite athletes rewire their brain. It's neuroplasticity. It doesn't matter what it is. If I want to learn Chinese tomorrow, it's neuroplasticity. If I want to learn how to throw a football and play a sport, it's neuroplasticity. Of course, there is positive and negative. If I see a drive-by shooting, I'm going to have PTSD. That's negative neuroplasticity. So our brain changes based on the owner's behavior. So no matter what I do, that's going to negatively or positively, you know, cause neuroplasticity. So if you're an elite athlete, how many hours a day are you training for that sport division? One professional hour and hours on a daily basis. Okay. That's to be. That's to maximize your potential through rewiring because you got to put the reps in. What are we telling our brain-injured patients to do? Because the way I approach my patients, I say, look, you're an athlete. We got to train like an athlete if we want progress. If you're not training like an athlete, don't expect progress. Training like an athlete requires hours per day. What does our health care syE-Stim do? Are they really setting these patients up for success? Well, let's let's. One, two. I'm counting on my hand when they're. Yes, they do get their 3 hours of total care in a hospital setting. That's one hour speech. One hour an hour. So my arm is getting one hour maybe, but then I'm getting discharged eventually. And then I'm going to be going home where I'm going to get three times per week, maybe of home care or outpatient for one hour. Then I'm supposed to be doing something at home that might be good or it might not be good. I am nowhere near training like an elite athlete to make the progress I need. So why on earth if we expect athletes to do this, why on earth are we not do enough for patients who have brain injuries that need more than that? And then we wonder why these patients aren't getting better. So not looking for an answer that's just me ranting. But you know what we can do by fighting the syE-Stim is doing what you just did with the subluxation program, Right? That's one notch on your belt. Congratulations. And now the next step is don't stop there. It's very now that you have the blueprint, do that visual imagery, do that, mental practice, do that. You know, East him in the room for wrist and fingers. Do something else because you're not. These patients have to train like athletes. So hopefully you can squeeze that in. Plus be a wonderful mother of two, plus be a wonderful wife and do all the other wonderful things you do. We just need more of Jonas. That's what we need. Thank you for no comment for that one. Right. All right. Well, listen, it's it's already been an hour to keep going. Thank you so much for this wonderful Q&A podcast. Hopefully, some of the clinicians found this helpful. I know. I have. How can folks find you if they want to learn more and dive deep? Can they actually reach out to you?

Jenna Barber (00:54:30):
Oh, most definitely. I'm on LinkedIn. My real name is Jennifer. So you could just look me up on Jennifer Barber, but then also shoot me an email. I don't know if Henry can kind of put it in there, but it's Jennifer Barber at Froedtert dot com, so I would love to help get this started for you. I am a clinician at heart. I want to help people and I don't care if you work up for it or not. I want everybody to have help, so please reach out.

Henry Hoffman (00:54:57):
Awesome. Awesome. Well, thanks so much. I'll definitely add your contact details and I really appreciate your time today and we'll have to continue this discussion and maybe another podcast in six months on another program, right? Oh yeah, I will. Thank you very much, Janos. Great talking. You too.

Jenna Barber (00:55:13):
All right. See you.

Henry Hoffman (00:55:14):
Thank you. And guys, thank you so much for tuning in. If you have any questions, of course you can ping me, direct message me. And of course, if you have some for Jenna, I will forward those on to her as well and I'll put her email and contact information. And thanks again for watching and listening to the No Plateau podcast. Take care.