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Learn about a treatment option for adult upper limb spasticity. Learn More


Hello everyone, welcome to another episode of the No Plateau podcast. I am your host, Henry Hoffman, and I'm excited to be here with you today. Today we are going to be talking about inpatient rehab process following stroke, things to consider, and things to definitely not do or avoid. The first few weeks following a stroke are critical, and we, as OTs, can either help or hurt the outcome for many of our patients. So to help me discuss all of this, I invited a wonderful colleague of mine, who spent a fair amount of time in the inpatient rehab setting. Please welcomeCortney H. Jessee, who is an occupational therapist and a board-certified stroke rehabilitation specialist. Welcome,Cortney, how are you?

Podcast Transcript

Cortney H. Jessee(00:43.342):
I'm good, how are you,Henry?

Henry Hoffman(00:44.697):
Good, good, I'm so glad to have you here. And I think before we dive in, it'd be great if we could just learn a little bit more about you. We do have patients and therapists as our audience, so feel free to share a little bit more about yourself.

Cortney H. Jessee(00:57.166):
Sounds great. I have been an OT for six years now, and that's hard to believe, and predominantly in the inpatient rehab setting. It was always my first love. It's become full circle for me these past two years treating in Winston-Salem, North Carolina, because this is where I first knew what OT was. I had a cousin who was in his inpatient rehab stay for his spinal cord injury, and then shortly after that a family member had to travel to Winston for also their rehab care. And keep in mind, I grew up in a very rural area. So the closest availability to stroke rehab is an hour and a half away. And so to be able to still work with folks who are from my hometown, as well as to support this area of North Carolina, has just been a blessing. I recently made the switch to outpatient neurorehab, a specialty clinic, which has been my jam recently, but my heart will always be inpatient. And so it's been kind of my call recently to support that comprehensive stroke process. So I'm very excited to talk today.

Henry Hoffman(02:00.653):
Awesome, awesome. Well, I'm just super excited to have you. Today's topic's pretty exciting. But before we dive in, because inpatient rehab is a huge part of the recovery process, but since we do have a lot of patients listening, before we dive in, I figured it'd be good for the patients and some of the clinicians to spend a few minutes teeing up the conversation as we discuss how the brain heals and when it needs to recover and what that process is like.

So just for a quick review following any ischemic stroke, and the majority of these are going to be ischemic where there's a clot or lack of oxygen. The brain cells at the core lesion site that's also known as the umbra, they die due to interrupted blood flow. They're no longer viable. They're not coming back. And so the area immediately surrounding that umbra or that infarct, some people call it the perilesional area. That is the penumbra. And so during the stroke, the penumbra experiences a what they call cortical shock. It's not dead, it's impacted. It's barely hanging around. It has lost a lot of blood flow, but it's not as severe. And so during the next several months, this subacute stage that we're calling, this is, you know, you have your acute stage, you have your subacute and chronic stage. Depending on who you read, the subacute stage could be seven days to three months. Some people say it's six months, some even say nine months. I like to keep it around the three-month time frame from the folks I read from but during the next several months. The hope is that the injured but not dead cells in that penumbra area will reactivate. So that means the networks and the functionality can be restored. They call that, you know, the spontaneous recovery. So if you've treated stroke patients before, if you're a stroke survivor or a loved one, you may have witnessed spontaneous recovery.

Most spontaneous recovery tends to occur within the first three months, and that's when you quickly get movement back or speech or cognition or mobility. You know a couple ways spontaneous recovery occurs. One way is it's going to be permissive hypertension, which basically means cautiously raise blood pressure, which sounds a little odd, but to ensure that penumbra remains oxygenated and viable, you have to increase the blood flow. Another way is to decrease the swelling. Following a stroke, there's a lot of edemas in the brain.

And when you have a lot of swelling, that decreases the oxygen in the brain, which causes that swelling, which cuts out blood supply. So we want to decrease the swelling, that's usually handled through natural ways as well as through medication. But between those two efforts, the hope is you're going to regain neuronal connectivity, and that's going to reactivate the epinephrine. Now there's good news and bad news. The good news first is while spontaneous recovery mostly occurs on its own, the brain also exhibits this increased firing rate.

Henry Hoffman(04:50.429):
It almost enters what they call a heightened state of plasticity, where the rewiring operates on a turbo drive speed, if you will. Now recall forever. We were, we were thinking that the adult brain was hardwired. You know, that you wouldn't have a chance to rewire if you're an adult brain. Thankfully Dr. Merzenich had some breakthrough studies in the late nineties that showed that the adult brain is actually softwired. So neuroplasticity could exist.

So that's the good news. Now here's the bad news,Cortney. The bad news is during this critical timeline, which we're going to talk about today, is that inpatient rehab in that subacute stage, many patients do not get the necessary stimulation or feedback. And so they have something that Edward Taub from constraint-induced movement therapy and for the folks listening, CIMT or constraint-induced movement therapy is when you restrain your healthy limb, forcing to use your impaired side for a period of time. And that force use helps with rewiring the brain improving function. Well, the man responsible for constraint-induced movement therapy is Dr. Edward Taub, and he coined the term learn-on-use. And learn-on-use means you just learn not to use your impaired side. If your good arm can do it, why am I going to waste time having my impaired arm do it when I'm trying to get my shirt on or whatever? And that was actually originally developed through rodents and animal models. Sorry, that's my dog getting a little overly aggressive with the neighbors.

So learn-on-use is real. And so, they have something that's called use it or lose it. And so, if you actually use the limb, you're going to actually potentially make new synaptic connections. However, if you don't use it, those neural pathways, they start to become weak, and those connections start to just die off, and that's called synaptic pruning. And so, it's like you're removing and dying off neuronal cells, like a, pruning them like a tree or a bush, they just start to die off if you don't use them. So that's use it or lose it. So, the problem is, the bad news, just to wrap this up, and then we'll get into your questions, I'm just trying to frame this for the patients and some of the therapists is, the good news is neuroplasticity is alive and well, and there's no expiration date of neuroplasticity. The bad news is we're just not doing enough in the inpatient setting, and you have this learn-on-use. We're already set up for failure because we can't use the limb as much as we need to.

Henry Hoffman(07:13.281):
And then the real problem is with, you know, the first major hit job for these patients is the insurance company doesn't want you in the inpatient hospital for as long as you need to be. The second hit job is a lot of these patients don't get enough stimulation to the affected side because we, as clinicians, we're taught in school, we've got to get them independent. We've got to teach them how to put on their shirt independently one-handed with their good arm. We need to get them independent with transfers using their strong side. You know, we're not saying.

Cortney H. Jessee(07:20.489):
Okay. Right.

Henry Hoffman(07:39.757):
Hey, let's spend the next two hours just forcing you to use your impaired side to do all these important critical activities. No, because that will slow down your independence, which will slow down your discharge will not make the hospital look good with discharge notes. And then that will impact, uh, there, which impacts their recovery. So it's really a awful circle of hell, in my opinion. And so because these therapists just are not going to engage in, you know, um, forced use as much as they need to.

These patients are living these one-handed compensatory lives while in the inpatient setting and just trying to accelerate the ADL independence. And so I just want to leave with one more comment. And during this critical window of the one or two weeks, Dr. Teresa Jones, she's a neuroplasticity and motor learning professor from the University of Texas. She said it best. Her quote is, it's not just disuse, but also using the healthy hand on its own that can disrupt progress. And I can tell you,

I was just as guilty back in the day. Gee, you know, Mrs. Jones, you know, she's a Brunnstrom stage one, and we'll get to that in a minute, and she could barely move her impaired side. Let me just strengthen her good arm. Let me give her some therapy, let me do some theraband on her good arm, and make her good arm stronger. And guess what that does? When you strengthen your, and this is through animal models as well as human models, if you just focus on that good arm more, and you don't focus enough on the affected side, you're going to shorten the time, it's gonna worsen the function of the impaired limb, and you're gonna prune away all those cells that are needed for synaptic growth. So it's a downward spiral after that. So long-winded description, I apologize, but I want at least set the stage,Cortney. And I just want to now talk about patients that transition from the acute stage, and they go right into inpatient.

Cortney H. Jessee(09:18.83):

Henry Hoffman(09:32.237):
How much education did they really get in that first seven days in the acute stage? And what is your job as a therapist, the first 24, 48 hours from an education standpoint, just to kind of get them going? Because, and explain to the audience, what is the average length of stay?

Cortney H. Jessee(09:49.022):
Absolutely. Just did a course with some acute care therapists last week, kind of talking about their process. And many of the therapists from acute care, you know, they focus on their jobs in positioning, beginning to kind of educate the patient on what stroke they've had, but also gearing them up for inpatient rehab, which we know typically length of stay is 10 to 14 days, right? And at that point, the patient may have been in the acute care hospital for one to three days, right?

And so the education there is, okay, your loved one is going to inpatient rehab. They're going to be there, you know, 10 to 14 days. And at that point, what I've learned in my experience is, the education is, and they're going to help get the affected limb working again, right? But we know that to not particularly be true, right? Because when you transition to inpatient rehab, within that 24 to 72 hours, there are some things that are required by your rehab team, again, to begin even qualify for inpatient rehab.

You have to demonstrate need from at least two of the three disciplines, PT, OT, speech, to be able to then go and demonstrate the high-level intensity participation, which is three hours of therapy per day, three active hours of therapy per day. And we already know based on everything you just said,Henry, that in itself is not enough for our folks post stroke, however, what is required within that first 24 to 72 hours is an assessment of patient's functional mobility and their ADL status, their ability to communicate and their cognitive performance. And that's done by your PT, OT, and speech. Your OT is usually your first person to enter the door. So imagine me and my voice and my peppiness coming in at 6.30 in the morning. I don't know if that's everybody's favorite. But that's when we first get to, for a lot of our folks, it's the first time they're having an in-depth ADL. And I am team shower all the way.

But for a lot of our folks, that initial ADL is the first capturing of if that patient went home in this moment, what level of assistance would they be required to perform the required tasks? Their bathing, their dressing, their toileting, their feeding, their swallowing, their ambulation. What level of assistance would they be? And a lot of our patients come in, and I saw this a lot during the pandemic when I was in the heat of my inpatient rehab career.

Cortney H. Jessee (12:14.054):
Many of our patients are marked as dependent care, right, requiring 100% assistance. And so from that evaluation, right, happening usually back to back to back, our patients get hammered with just performing an ADL task. Usually there's not a ton of skilled education done in that first 24 hours because we're doing what's required as therapists. We're evaluating and then we're providing the appropriate equipment in the room.

For that term of their stay, you know, their next 10 to 14 days, to be able to elicit and demonstrate change in the ADL status. And again, looking at just, you know, does an accurate home evaluation, do you have stairs, do you have a ramp, do you have any of these Relative Adaptive Strategies already in your home to kind of give a forecast of your success?

And then after that 72 hours, I mean after we see those kind of initial evaluations, and again, most patients don't get a ton of skilled intervention in that first time because they're trying to check off the boxes. Then the rehab team, as far as your medical director, your doctors, as well as your case managers and your therapy team get together and have a comprehensive team meeting. And from those scores, then usually length of stay is sent off.

Through our IRF-PAI, which is now our GG codes, and you'll hear those terms thrown out, hopefully by your therapist, and that determines length of stay. And in my experience, a lot of inpatient rehabs do this well as far as then providing specific diagnosis programming, but some do not. And that's, as my job as a therapist, what I like,

To see done within that 72 hours is not just a more comprehensive ADL, but the education of our staff. So that way the ADLs become second nature and are performed well and safely to get the patient home and support ADL performance. But then I can spend my job focusing on the recovery of that hemibody or getting a full, more in-depth evaluation of the scapula, the shoulder, or even their vision. Because a lot of our patients in inpatient rehab are

Cortney H. Jessee (14:31.266):
trying to learn these hemibody techniques to be independent, trying to perform functional mobility, but they don't have their optimal vision, right? And a lot of inpatient, where a lot of inpatient rehabs don't even, our patients are not getting that in-depth vision assessment until they go to outpatient, they see an optometrist. So that 72 hour, every 72 hours is busy for the patient as far as their medical kind of programming. Patients also get group.

Henry Hoffman (14:48.685):

Henry Hoffman (14:58.017):
So let me ask you this then. Sorry, good. So let me ask you this. Okay, so after the 72 hours, and tell me what are hospitals doing right? And give me examples of ones that are doing wrong. When it's thinking about neuroplasticity, again, the quote from Teresa Jones, it's not just disuse, but also using the healthy hand on its own can disrupt progress. So if you're focusing on ADLs, using the healthy hand on its own because the impaired side's not working sufficiently, you're disrupting.

So this is the, you know, Dr. Dromrik, the late Dr. Dromrik said it best, it's a cerebral sweet spot as far as the timeline. This is a time when we need to be maximizing reps. Now, on the one hand, we don't want to be too intensive because we do know from animal models, the first seven days, if you're too aggressive, you can actually cause more harm than good. But after that seven days, if I'm a stroke survivor, for the folks listening, you know, caregivers,

Cortney H. Jessee (15:36:258):
Yeah. Yeah.

Henry Hoffman (15:55.025):
After seven to 10 days, you know, I want my therapist to start engaging that affected side as much as possible to increase those neural networks because we know with spontaneous recovery the um It's at a heightened state of neuroplasticity at this point. So it's on turbo drive, right? So the last thing I want to be doing Courtney is if I lined up 10 patients Went down the hall and said raise your hand if you want to learn how to put your shirt on one-handed With your good arm or raise your hand if you want to get your hand back

Cortney H. Jessee (16:21.922):

Henry Hoffman (15:55.025):
How many of them are going to raise their hand, say, no, no, I don't want my hand back. Teach me how to be independent one-handed. So everyone's in alignment when it comes to patients and therapists that believe in neuroplastic principles. I guess the only people that are not in alignment is the normal systems that are taking place at these inpatient hospitals. So from your experience, who's getting it right, who's getting it wrong, and how does that work?

Cortney H. Jessee (16:48.511):
That's such a tough question.

Henry Hoffman (16:48.985):
Don't call out a hospital name, of course. But as far as, so now you're 72 hours in, in a perfect world, what are you doing with these patients?

Cortney H. Jessee (16:58.35):
You're getting them out of bed for meals. You're positioning them appropriately when they're in the room. You are providing education because we know,Henry, flexor synergy, our spasticity, that transition from level one to level two, Brumstrom, can occur, I think it's three to 10 days, right? And a lot of our folks, yeah.

Henry Hoffman (17:16.653):
Well, let me interrupt you real quick, because a lot of patients don't know the Brunnstrom stages. So there are six stages of Brunnstrom. Brunnstrom is a Swedish physio, late Swedish physio, excellent therapist who created his predictive model called Brunnstrom stages. It was named after her, of course. And there are six stages, and it progressively gets better. And this is, according to Sydney, you're gonna start out as a flaccid stage. And patients listening, or caregivers, you probably recall when you suffered your stroke.

Cortney H. Jessee (17:21.486):
Thank you.

Henry Hoffman (17:44.501):
You barely could move. Some of you barely could move in the hospital setting. And then as you started to progress, you went from a flaccid, no moving state to starting to get that spasticity. That's that tightness in your hand or your biceps or your elbow or your leg. And then as you progress through the Brunnstrom stages, your spasticity increases and to the point where you're in synergy. So no matter if you try to raise your arm or open your hand or turn, your movements are all the same.

It's all synergistic movement, whether it's elbow flexion, finger flexion. And then as you progress and improve, God willing, you then can break out of synergy. And meaning, instead of every time you go to raise your arm, your elbow flexes, this time when you go to raise your arm, your elbow can relax and straighten, or your fingers can start to open. And then final stage is just a little bit of tone and more isolated movement to normal movement. So when we say early Brunnstrom,

And when Courtney says Brunnstrom stages one and two, what we're referring about is you barely have any movement or you're just starting to get some spasticity. And personally, before you finish your thought, my perspective is, you know, we know through, I like to use the evidence-based review stroke rehabilitation from Dr. Teisel, which is, you know, the Canadian Partnership of Stroke Recovery. And by the way, patients, therapists, just go towww.ebrsr.comfor everything. When I think about,

These patients, you know, day three, day four, admitted to the hospital, rehab hospital, and if they're an early Brunnstrom, you know, stage one or two, don't have movement, you're not gonna be able to do what the greatest interventions are. Now the greatest interventions, and I wanna get your opinion on this Courtney, is and what we know to date based on over 1500 randomized control trials, and I use the EBRSR as an example, is task specific training and or

constraint-induced movement therapy. Now with constraint-induced movement therapy, most of the studies are gonna be at a chronic stage, not a acute, subacute stage. So let's just for today, let's just call it task-specific training because that is purposeful, meaningful, it's functional. And to me, I call that the leading actor of interventions. The leading actor, okay, that's the main event is task-specific training because it's repeated, it's measurable, it's motivation. The supporting actors and actresses are gonna be your VR.

Henry Hoffman (20:09.749):
Which is virtual reality, your electrical stimulation, your robotics, your mental practice, your mental imagery, and we can dive into these, but the main actor, the leading actor is gonna be task-specific training, and the problem, Courtney, when you said stage one, stage two, you're not picking up an object if you're stage one, stage two at Brunstrom, okay? The only way you're gonna pick up an object and do a functional task is if either electrical stimulation's involved, so you're doing what's called functional electrical stimulation, where you

Cortney H. Jessee (20:30.955):


Henry Hoffman (20:39.393):
Literally have electrodes on your flexors of your hand or your extensors of your hand, you have a trigger button, and you go to pick something up, and you use eSTEM to augment the movement. That's one way or another way to incorporate the hand is using some type of orthotic device. That's, you know, we use disabled devices, but other devices that are gonna functionally allow you to pick something up and let go of it. So if you're early Brunnstrom, and research wants you to do task training, you can't do it unless you augment that with eSTEM or orthotics. Now, when you get to Brunnstrom stage 456,

Cortney H. Jessee, OTD, OTR-L, CSRS (21:03.072):

Henry Hoffman (21:08.289):
You don't need East End and orthotics because you're doing your movements to do those tasks. So let me stop there for a second because there was a lot to unpack, but I just wanna make sure the audience knew about the print stream stages. And, of course, tell me if you agree about the main lead actor being task training.

Cortney H. Jessee (21:17.742):

Cortney H. Jessee (21:25.87):
I 100% agree, and you know I'm Team East End, functional East End all the way. The thing is, though,Henry, in my experience, I've had to really even go back to the basics even before that, right? Just educating our patients that they need to be sitting upright in their wheelchair to eat dinner, right? Transferring out of bed to sit in a regular chair just for their posture's sake, for their shoulder's sake. Why can't they have their hand in their lap? Why that sling they had in acute care to transfer was great, but it's no longer great anymore. Right. And the problem is, and I think the whole purpose of this podcast being the no plateau podcast is again, if we don't start at those basics, we can't get to our task-specific training. And so how much are we for being proponents of the plateau? I think that's the true plateau, not the myth of, you know, your first three months.

Is where you're going to get the most outcome, right? There's some evidence to that, but I don't agree with it. I think when we're not teaching things like positioning, even in bed at night, you know, where are we putting pillows? Why are we putting pillows to our nursing staff? If those things are done correctly, I as a therapist can start doing what a lot of people consider as extra. And I'll just give you a brief example, right? Our patients would go to dining group a lot, okay? If I had a patient that just so happened to be in stage two or three of Brunnstrom.

You better believe I'm taking the mobile arm support and offered some anti-gravity assist, and I'm providing eSTEM so they can hold that fork for the first time. That's not extra to me. That's not extra to me because positioning was done appropriately by my CNA staff the night before because they felt empowered to do so, right? My physical therapist felt empowered to leave the eSTEM I put on their shoulder on during their physical therapy session right before they went to lunch, right?

And also that sling that they loved so much, hey, I'm offering maybe a better type of support now. I'm providing different input, right? If those things are done correctly, and I've seen inpatient rehabs do it and do it appropriately, and how they empower caregivers, it shouldn't be so hard. And those things, because, you know, my job is to be evidence-based and figure out how to transfer that to someone when they're transitioning home or in inpatient rehab. These other things that we know work and are successful.

Cortney H. Jessee (23:49.394):
If they're done consistently, it significantly impacts the ability to then begin task-specific training at the end of their rehab stay.

Henry Hoffman (23:58.089):
Yeah, you bring up a really good point there. You bring up a really good point because, yeah, so definitely I was jumping the gun a little when it talks about getting into the neuroplastic drivers, and those are things you hope to address in your 10 to 14 days, but you bring up a good point to, hey, let's hit the, let's pause for a second, talk about the basics, and since you brought it up, let's spend a few seconds on stroke shoulder. And you know,

Cortney H. Jessee (24:24.21):
I'm Rick.

Henry Hoffman (24:25.541):
Yeah, so the evidence, so again, if you go back to EBRSR or stroke engines, another good one, you know, if you look at the research, some of the myths out there are that slings will reverse subluxation. Taping will reverse subluxation. So we do know for sure from the evidence that you're not going to reverse magically reverse subluxation with taping and slings. The research does suggest that it is beneficial for pain management that you can reduce pain through taping and slings.

And it also suggests that you may prevent further dislocation if during transfers and mobility, the arm is just not continuing to be stretched. And that seems to be obvious, right? I mean, the more the weight, I mean, subluxation kicks in within three weeks. So if you have a flaccid arm, it's gonna happen within three weeks. So what can we do preemptively in that subacute setting to minimize that stretching of the inert and non-inert structures at the joint capsule and the proximal.

the dynamic stabilizers, the muscles. And so we know taping and slings don't count on them to reverse the subluxation or prevent it. You can maybe minimize the dislocation, slings, but for taping, we did radiograph studies years ago where, and remember, this is a thin piece of tape on the most superficial part of your body, and your skin's very pliable. There's no way it's gonna re-approximate a humerus into a joint. So you're fooling yourself.

If you think it, now remember there's kinesio tape, which is a flimsy stretchy stuff from Walgreens. That's been around forever and I love that for certain conditions, just not for lifting up a five-pound humerus. And then there's McConnell taping, which is that static, non-elastic athletic tape, and that was used a lot too, but when you x-ray that, you're not seeing a re-approximation, it's not even sustaining that thoughtful re-approximation. Yeah, so, go ahead. Okay.

Cortney H. Jessee (26:13.898):
No, it's not consistent with caregivers. Right, I just, yeah. I was just gonna say, caregivers, I think therapists, when they do get the opportunity to step away from ADLs because they're not being crushed by the demands of what inpatient rehab requires, caregiver walks in and sees this elaborate taping and their eyes get really big and think, I have to do that every day for my loved one. When I could have spent two seconds

Henry Hoffman (26:40.269):

Cortney H. Jessee (26:43.626):
Showing them how to use a neuromuscular electrical device, either a wireless one, which Sabo makes an amazing one, that's my favorite thing, and if I had to go back to inpatient rehab, all my patients would have that, right? But we know that cortical activation, you need six to eight hours of intervention, eSTEM, right? I can spend less time and help my caregiver, my patient, feel more confident in when to use this.

So that way when they do reach that next step of task-specific, they feel more equipped to manage their condition. And that's the whole point, right? So many young therapists and students that I would have, East End freaked them out. And I'm thinking, I wouldn't do an intervention without it because it shouldn't take, you know, if we know our anatomy and we can show our caregivers and our patients what we're looking for and positioning and help them feel like they're not gonna mess it up, right?

And what to look for, the outcomes are just, they're significantly more impactful. It also makes our jobs a lot funner, right, when that part's efficient, and then I'm now talking about, and you love cooking, let's get back to that, and here's some safety, and oh my goodness, look, your elbow has a little bit of flexor synergy, let me show you how to manage that. So that way when you are six months down the road and you went through your home health and you come to me for inpatient rehab, my job and your job is, that much more impactful and successful because I'm not worried about a sublux shoulder. I would hope from this podcast that we could eradicate the severity of subluxation in inpatient rehab and during that post-acute, subacute rehab to where when they come to me, that's all I'm focusing on is task-specific because reps matter. AndHenry, I was just gonna say, you know, Sabo came out with,

Henry Hoffman (28:27.445):
Yeah, well, you agree. And I think what was good.

Cortney H. Jessee (28:34.874):
Really great infographic and I use it all the time in my practice of I think it's seven reps on average are being done during a treatment session, right, and we know that's not yeah, it's not going to generate cost of change so if I'm an inpatient rehab and I'm most likely getting zero reps with my patient, right, because I'm maybe not taking the time, I'm intimidated by neuromodality right, how many reps are they gonna get at home?

Henry Hoffman (28:42.985):

Yeah, the Hayward study, right.

Cortney H. Jessee (29:03.774):
If I don't provide that education. It's still zero.

Henry Hoffman (29:05.473):
Right, well, there's a couple of things there to unpack. I mean, first, yeah, we're not stimulating the patient enough as far as Langhorn, Hayward, excuse me, Lang. They all did good rep studies showing there's just not enough in an OT session, inpatient session. We're barely scratching the surface regarding reps. Now, of course, we also know not all reps are treated the same, and we'll save the neuroplasticity.

Henry Hoffman (29:35.233):
But regardless, we do need to have a lot of reps, and we do need to have some intensity at the right time. But we also need to get them to that point where they actually have enough strength to even use their limbs. So, you know, finishing up the shoulder discussion, we've already talked in other podcasts about East End and, you know, electrode placement for East End. When I was working on the Sabostim 1, that wireless one, I would tell therapists, we'd be in a course, and I would say, "Raise your hand if you believe East End."

Cortney H. Jessee (29:35.918):
Ha ha ha!

Henry Hoffman (30:04.413):
Should be embraced for treating shoulder subluxation. And all these inpatient therapists would raise their hand. And I would say, "Keep your hands up if you have an eSTIM subluxation protocol," and all the hands would drop. So we're all on the same page that we need to do eSTIM for subluxation. By the way, the research is pretty conclusive that stimming can actually be beneficial for reversing subluxation. Remember, you're strengthening your proximal stabilizer. So what we're trying to do is re-approximate the humerus. So for the patients listening,

When you have that gap, that space that exists because of gravity due to a weak limb, the only way you're ever gonna re-approximate that humerus is not gonna be through weight bearing, it's not gonna be through stretching, it's going to be through strengthening your deltoid muscles. That's your strongest proximal muscles. The only way you're gonna strengthen your deltoid muscles is either I, you can volitionally do it on your own, which is great, let's do lots of repetitions of that,

Or you're gonna need help with electrical stimulation. You're gonna need some current that's gonna make a contraction that's gonna cause your humerus to migrate upward. And what we do know is that deltoids being the strongest proximal migrators, we know long head of triceps, we know biceps, all of them play a really good role. And we also know the supraspinatus, which used to be one of the top popular locations, is actually not one of the best locations. In fact, half of the stroke survivors have partial tears.

So who wants to be stimming a partially torn supra? Number one, it's asymptomatic, so they don't realize they have that tear. And number two, it's not a super, super strong proximal migrator, it's more of a compressor. But we've already had that conversation in the past podcast. So I think as we transition, and let's use a real-life example here. So we're there for 14 days, it's now day three, it's day four, by now we've, in a perfect world, we've educated them on the Brunnstrom stages, they know what stage they're at.

We know what their next goals are to get to the next stage. And we're gonna say, hey, this is how we're gonna do that. I'm hoping we've educated them on things that they can do. So if they are low Brunnstrom stages, meaning I can't move my limb much, what are things they can do in their room? I mean, for me, I'm thinking mental practice. So, people have heard about mental practice where you imagine you're physically doing a task, even though you're not doing it because your arm's impaired.

Cortney H. Jessee (32:13.175):

Henry Hoffman (32:22.773):
You're imagining you're buttoning your shirt or you're drinking with your affected hand, picking up a cup and bringing it to your mouth. And what that means for your brain, it fires the same neuronal connections as if you were physically doing it. So it's very, very strong research on mental practice. Another one is Mirbox. I'm hoping that we're setting them up with Mirbox where you, again, for the patients, Google it if you don't know it, but Mirbox therapy is where you put your impaired limb; it's occluded inside a...

Cortney H. Jessee (32:39.47):
Great. Yeah.

Henry Hoffman (32:51.769):
Covered area that you can't see, and your healthy limb or your hand is in front of a mirror you're looking at the reflection of the mirror so it looks like your impaired limb, and you are stimulating mirror neurons if you will which allow you to rewire your brain. It's very strong research on mirror therapy and things like that, coupled with eSTIM, coupled with positioning that you mentioned. Do you think these hospitals are doing that while they're sitting there qatching Geraldo for four hours; I got nothing else to do. What do you think the real situation is, and are we doing those basic things that we know work?

Cortney H. Jessee (33:28.502):
I don't think it's happening as frequently as it should. I know part of it, again, it's just time management of your therapist; you know, something happens, and half of your session, your patient's gotta go to the bathroom. I know also one of the things that I said, you know, as a therapist, I'm not doing this enough is providing, giving our patients credit and our caregivers credit to also do their own research. But also we need to guide them in that direction. Like you're talking about mirror therapy and you're talking about mental practice.

One of the things that I would do is I would introduce mental practice at the end of one of my group sessions, right? And then I would give them a QR code to do Sabo Mind, right? And also other YouTube-related mental practices that they could do that night in their room, right? Having them also be a self-advocate, right? Also having a little bit of initiation. And then my favorite thing was when a caregiver said, "Hey, I listened to the Sublux QR code you gave me. Again, another Sabo link. I think it was Scott Thompson.

Did that, but I also thank you, had a great article on the website, Henry. I read about this; they say that eSTIM's effective, where can I get it? And then I would immediately handle the Amazon, link to one that has wireless or the Sabo website, right? Communicating that all these resources are out there, but if we can keep them all in one place that the patient can access them now and later, and then they ask about intervention, I was, as a therapist, I'm going, "Heck yeah, let me get you a Mirabox.

Heck yeah, here's some exercises, right? Or hey, if you're gonna do those, please do them sitting up in the chair. And not just teaching self-range motion that's not functionally appropriate at that time or could be detrimental to their care. And that's not necessarily evidence-based, right? These things don't require high-tech intervention. And while I think in inpatient rehab, we do have access to VR and we do have access to things that move the distal extremity.

We want to, but what's the point if we're not setting them up with those foundational skills that they can do in the room when they're not in therapy and what they can take home with them.

Henry Hoffman (35:31.513):
You know, you bring up a good point there about, you know, we all love flashy, fancy technology. I mean, it's just our human nature to want to see those things. I think robotics are helpful when we're trying to get a lot of repetitions in that, you know, when there's not one-on-one therapy, then maybe there's a way to get extra repetitions in. Why not? But when you think about the evidence-based review and you think about, you know, the way Dr. Teisel did

All the systematic reviews of the 1,500 studies on upper limb recovery, these are a lot of RCTs. Over 200 were robotics alone. He classified them into categories of beneficial and beneficial means greater, let's see, it was beneficial, I have it in my notes somewhere. Yeah, greater than 66% of the studies reported a positive effect for that intervention.

So if the topic was constraint-induced movement therapy, which is deemed beneficial, that means a greater than 66% of the studies showed that it was beneficial. So there's a list of also inconclusive studies, and inconclusive means 50 to 65%. So if 50 to 65% of those studies reviewed were only beneficial, they would be considered mixed. And anything below 50% would consider, may not be beneficial.

I got to tell you, there's like 15 interventions that are in the beneficial and mixed group that we do all the time. You know, robotics and VR and all the things I like to consider at the right time, those are all inconclusive. Those weren't slam dunk beneficial. Beneficial was constraint-induced movement therapy, task training, you know, mental practice mere box. Those were considered beneficial. So if you're only with a patient for 14 days, one does wonder.

What is the ultimate need for a $300,000, $200,000, a $150,000 piece of technology that they're only gonna try for three or four days? You're not gonna have enough carryover to have any long-term benefits. So should we rather spend that, no disrespect to the high-tech industries, should we rather spend our time, by the way, if constraint-induced task training and all these other ones are considered beneficial, those are free, okay, or very close to free.

Cortney H. Jessee (37:40.536):

Henry Hoffman (37:45.964):
Thank you.

Henry Hoffman (37:57.777):
Or shouldn't we rather spend our time on these very highly accessible, easy to educate, easy to use interventions that they can then use at home immediately? Because guess what? And we'll transition to this in a second. Life neuroplasticity starts, and it begins after, after spontaneous recovery kind of ends. That's when it really gets hard, but they can still rewire. And that's where they're going to need this stuff the most.

So give me your thoughts about, you know, I'm sure robotics has a place somewhere. I'm sure expensive VR has a place somewhere. I don't think it's 100% absolutely necessary. If we already know constraint-induced movement therapy test training are beneficial, I guess maybe for the dense severe hemiplegic patient doesn't qualify for CIMT and test training. I guess that's that window where they could benefit from robotics. What say you?

Cortney H. Jessee (38:52.194):
So I mentioned during my introduction that I came from a very rural area, right? And many of my patients, if they don't get inpatient rehab after their stroke, that's it. That's it for them, right? So I'm not, I am not personally going to spend a ton of time on the robotics if I know specifically that the care, it's more of a priority for me that the caregiver has training of how to, have how to not microdose what they're doing with their arm, but to know what to do when we start to get that recovery post-stroke, right? I'm not gonna spend my 10 days just putting, I had one therapist called it CVATV, where you'd stick a patient on those high robotics and you just let them go. And there is evidence of error augmentation and things like that, and your arm kind of figuring it out. But, you know, where's the skill in that if we're not also following up with eSTEM on their shoulder or then taking them in with their caregiver later and going, okay, the reason we did that was we're trying to elicit this movement.

This is how you do it at home, right? And alsoHenry Hoffman, similar to this point, you know, I think about things like the GRASP program, which is, there's multiple levels, and I've used it before, and it has tons of different exercises, stretching, that I think are helpful for all levels of stroke, and it is a very nice progression. But you know, sometimes with our stroke survivors, it's like going to the gym for the first time, and there's a million pieces of equipment.

And you don't really know what to start, so you just get frustrated, and you walk out. What if we spent more intense time providing a patient with maybe five different exercises that they do as many repetitions as they can and that they are successful at at least 50% of the time to support error augmentation and relearning in a shorter stint of time with the use of their e-stim? Give them five exercises, make them do it as hard as they can for three minutes. You got 15 minutes of really hard work.

Then you've gotten a lot of reps in. Versus, I have to have this heavy piece of equipment, I need to be spending three or four hours a day at a time and just kind of guessing how many reps I'm getting. What if then those short stints of neuroplasticity happened in a very functional and productive way? Not only inpatient rehab, but at home.

Henry Hoffman (41:09.429):
Well,Cortney, you bring up the point of the hour, right? When you think about neuroplasticity, you think about Clime and Jones and the 10 principles, the brain pays attention to what it finds important. That's the end of the day, that's the bottom line. So if you have a limb that is somewhat functional, capture that by doing something that's motivating to the patient because the brain pays attention to what it finds important. Is it gonna find something important if it's shoot the ducks?

Or some silly game, or is the patient gonna be more motivated because it's something purposeful and meaningful? I mean, how old school is that, right? But that seems to be the strongest evidence is keep it functional, which is basically what OTs do all the time, right? So I do, again, no disrespect to high-tech world. I definitely think robotics Eastern, or name the modality, has its place. But sometimes it's old school that wins. And are you gonna get a 70-year-old lady

Cortney H. Jessee (41:49.083):
All right.

Henry Hoffman (42:07.885):
Who's a stroke survivor to get super excited about shooting the ducks or playing some animated video game or is it gonna be something that they really enjoy doing, which is solitaire or crochet or something that's meaningful or petting their dog. And guess what? The brain loves that, more synaptic connections. There's so much evidence that there are stronger synaptic connections when you do something that the brain finds motivating to the owner. So, yep.

Cortney H. Jessee (42:20.514):
Right? Or petting their dog. Yeah, like, right.

Cortney H. Jessee (42:32.374):

Cortney H. Jessee (42:36.038):
And Hannah, you just said is inpatient rehab is a great stage to begin that. And I just, I just feel like maybe just maybe, and I don't know how much of it is because sometimes as a therapist, you know, there's burnout is real. But if we were empowered to do those little things, which are big for our patients and figuring out and spending more time instead of learning these high-tech items and these interventions, what if we spent more time?

Taking a small part of someone's day in a very big way and showing them how to perform that repeatedly, are we then decreasing the likelihood of plateau because we're driving a plastic change? And it's not extra and it's not, and to me, it makes my job more meaningful and a lot easier, right, as a therapist. And it's something my caregiver can do to help them with. So, ton of opportunities, for sure.

Henry Hoffman (43:29.986):

Henry Hoffman (43:33.109):
Yeah, so as we transition, as we wrap this up today, you know, the next step is the patient's getting ready to leave, right? And I always tell the patient, you know, I kind of educate them on neuroplasticity and I see a ton of chronic stroke survivors. And I talk about how there's no expiration date on neuroplasticity. In fact, there's positive neuroplasticity example and there's negative. I mean, if OCD, depression, you know, drug addiction, those are negative examples of neuroplasticity.

And you can go through cognitive behavioral exercises and rewire your brain differently. But the positives are gonna be learning a new skill, playing a sport, singing, learning a new language, okay? So the good news is we can rewire at any time we wanna rewire. Now, so the good news there for the patient is once you're discharged, this is where the fun really begins. And you have to, I'm gonna save this for another podcast, as you transition to outpatient, there's gonna be a lot of questions you're going to ask as you interview for the right therapist. Cause the next step is home health where a therapist will come to your house and work with you. Or hopefully you're going right to an outpatient clinic two to three times per week. But you, you gotta be careful where you go. You don't want to go to an outpatient clinic where they see 10% of their caseload is neuro. You know, it can’t be Bill’s physical therapy clinic where the number one clients that go there are hip and knee. Okay, you want to go to a stroke.

Cortney H. Jessee (44:47.446):

Henry Hoffman (44:59.773):
Or a neuro center. So look for the word neuro hopefully in the title. And what I'd like to do as a handoff to these patients when they're ready to leave inpatient is discuss what they should be doing next at home based on their stage. And then give them a little teaser of what's to come once they advance to the next stage. Don't plateau them with a program only at their current stage. Guess what, you just plateaued them. Because once they improve, they need to know what to do next. So.

Cortney H. Jessee (45:14.744):

Cortney H. Jessee (45:23.147):

Cortney H. Jessee (45:26.472):

Henry Hoffman (45:29.045):
You know, just spend a few minutes as we wrapped this up explaining what's your handoff look like and what would you hope to do as you wrap up your inpatient and send them on their way for outpatient.

Cortney H. Jessee (45:29.386):

Cortney H. Jessee (45:40.546):
You brought a really good point. I was reading this book on transformative learning. And it was talking about more the texture of life. Most of life is re-learning and unlearning than it is actual learning. And I was like, oh my gosh, that is the brain. That's 100% the brain. So yes, as an inpatient rehab therapist, I've got to support that re-learning and unlearning appropriately. So for me, my favorite thing, I do a neuro-hit circuits. So a hurt circuit, excuse me.

I'm a high-intensity, therapeutic exercise routine. They help me teach, name, and learn five exercises at the level they're at. So when they're discharging, they're continuing to do those at home. They're opportunities for the caregiver to then grade those related five, right? Generalizing, so they're not just literally grasping at straws. And then I'm leaving them with resources to say, okay, you know, you may start experiencing this related to your level of recovery.

These are three resources that would be great to step to next, right? When looking at your outpatient options, right? Ask these five questions, right? Your patient was doing this medically in inpatient rehab, right? Baclofen, maybe at this point, you know, are they still on that when they come to outpatient? Talk to your therapist about what other medical interventions are appropriate. And those are like my five bullet points, right? I'm not trying, you know, at that point, they're just trying to get their patient home, set up the DME, be successful.

Right? So anything I do in those last three days should be generalized and I should be re-educating the caregiver with video modeling and support as much as possible. That's where it's really fun to be a therapist, right? Because you get to see that brief hope and that image of your reward and where they could be, right? And then the hopes from them are I hope that my patients, those patients from inpatient rehab then come to a therapist like me, an outpatient, who sees the generalization and the movement they have.

We start the ground running, we waste no time. So my advice is there's so much things we can do to keep it simple and efficient for our patients, but the most important thing is to empower the patient, the caregiver to know they're not a shot in the dark, right? There is hope for recovery and this isn't it. Even if they leave with a flaccid upper extremity, things to look out for and know what to do next. That's transformative learning, right? Yeah.

Henry Hoffman (48:07.329):
Yeah, well, I think that's awesome. And one final note, which I didn't mention earlier, which is, we're still wrestling with what is that sweet spot of timeline. It's somewhere in the subacute stage where we think patients can benefit the most as far as doing your intense, meaningful task practice. Dr. Dramac published a study in 2021 that showed that at the 90-day mark, 60 to 90-day mark,

Cortney H. Jessee (48:07.883):
That's the joy.

Henry Hoffman (48:36.629):
Was the ideal time. Now, you know, I think there's still room for debate there, whether do we wanna start in the first 30 days, but they did a nice study that showed that 60 to 90 days was the sweet spot. So regardless, even if it's not in the inpatient setting, it's gonna be soon after. And I think what's critical for patients to learn is number one, you're gonna have your, you know, whether you're a future patient listening or caregiver listening or just had a stroke,

you know, the hospital is there to save your life following a stroke. So for the first seven days, you have no choice where you go. And for the most part, you're probably just going, you're gonna have a lot of a choice where you're gonna be going for your inpatient rehab. But don't be too frustrated because if you're only gonna be there for 10 to 14 days, it's not like you're gonna miraculously recover. I know there's gonna be some spontaneous recovery going on for some. It seems like the biggest critical timeline where decisions are gonna matter the most is gonna be at your 60 to 90 day mark.

And what are you doing at that 60 day mark and that 90 day mark and who are you being seen by? Because if that's the best time, that's the heightened state of neuroplasticity and you're working with someone who's doing old school weight bearing, stretching, handling techniques, you need to get out of there, get the keys and get in the car, okay? So that's gonna be another podcast which is, hey, what are we doing during that 60, 90, 120? Because that I think is gonna be the most critical timeline. So as we wrap up, Courtney, this was awesome. I'm so glad.

We were able to kind of have a little bit of a back and forth. I hope some of the patients and caregivers, and maybe some therapists, learn something new today. Do you have any final thoughts as we wrap up?

Cortney H. Jessee (50:16.366):
I just want to encourage any OTs out there who are either starting their time in neuro or they've been doing neuro for a while that your jobs are impactful no matter what part of recovery you are in someone's stroke. And the little things matter. Going back to, we're talking about that 60 to 90 day mark, that's wonderful, but how great would it be in days zero to 30 to be a part of your patient's foundation for...the optimal success, right? And I want therapists to feel empowered to do those small things for consistency in a patient's life and to give our caregivers and our patients hope. And I'm very fortunate in my job in outpatient that I get to be at that 60 to 90 day mark, right? But I was also that patient at that zero to 14 day mark too. And so I understand that efficiency is key.

There are ways to combine resources and empower your patient to learn and research and educate themselves, but also you'd be a partner in that intimate part of their recovery. So I hope that today's podcast provided some of that, but also to not be proponents of the plateau. That's.

Henry Hoffman (51:28.481):
Well, I'll tell you what, your patients are blessed to have you. And I'll tell my wife, right when we're done, I'm calling my wife saying, look, if anything ever happens to me, get me to Winston-Salem, right? Is that's what is it? Novot Health? Because you have the whole package, right? You have the whole package. So you're we need more of you. That's what we do. And we've had the honor of having others on as guests. And at this point, I'm realizing you guys are diamonds in the rough. And so, at least you have your.

Cortney H. Jessee (51:43.124):
Yes, sir. Thank you.

Henry Hoffman (51:57.757):
Neck of the woods covered and your coworkers and your boss and the team there should be blessed to have you. So thank you very much for being part of the podcast today.

Cortney H. Jessee (52:07.786):
And thank you for all that you do as well. Your patients are getting better for your efforts, so thank you.

Henry Hoffman (52:12.611):
Awesome. Well, we'll appreciate that. We'll put your contact details in the show notes if anyone ever wants to get in touch with you, that's in the neighborhood. And until next time, folks, thanks for listening and looking forward to seeing you next time.

Cortney H. Jessee (52:25.09):

Thank you.

Henry Hoffman(52:28.553):

All right, perfect.

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