Five Questions With: Dr. Bruce A. Lazarus

The Center for Rehabilitation at Memorial Hospital of Rhode Island has been awarded a three-year accreditation and designation as a Stroke Specialty Program from the U.S. Commission on Accreditation of Rehabilitation Facilities (CARF), based on an on-site review in October.
The center is an integral part of Memorial’s Stroke Program, which offers early risk evaluation and prevention, emergency time-sensitive assessment and treatment, a dedicated Stroke Unit, acute in-hospital rehabilitation, outpatient rehab and home care.
Dr. Bruce A. Lazarus, director of the Center for Rehabilitation, answered questions about stroke rehabilitation and the CARF designation.

PBN: How big a share of your work involves stroke patients, and how do they come to you?
LAZARUS:
One-third of the patients admitted to the center have had a recent stroke, and a quarter of patients who receive care for their acute stroke at Memorial receive inpatient rehabilitation at the center. When a stroke survivor is neurologically and medically stable enough to participate in and tolerate an intensive rehabilitation program – including at least three hours per day of physical, occupational and for some, speech therapy – the patient is discharged from acute care to rehabilitation. On average, this transition occurs 10 days after the acute stroke but may be as early as a few days in uncomplicated cases.

PBN: What share of patients require inpatient versus just outpatient care?
LAZARUS:
The extent of the disability, the complexity of the medical co-morbidities, and the social supports are considered when determining the best setting for rehabilitation after a stroke. Mild-stroke patients – especially those with relatives who are available and able to give some assistance – often can be managed at home, receiving home care or outpatient therapy. Those with more severe strokes, resulting in care needs and disabilities that initially are too difficult for a family to manage, usually require and can benefit from inpatient rehabilitation.

PBN: What kinds of services do stroke patients receive at the center?
LAZARUS:
Our interdisciplinary team is able to provide the comprehensive care that is necessitated in stroke rehabilitation. Physical therapists focus on ambulation and transfers while occupational therapists teach patients to perform activities of daily living. Those with communication and swallowing difficulties are seen daily by a speech therapist, while the center’s psychologist evaluates and treats impaired cognition, perception and mood.
Around the clock, our certified rehabilitation nurses reinforce the techniques being taught by the other disciplines, prevent medical complications, and re-train toileting – which, if not successful, often is a barrier to returning home. Simultaneously, the team helps the family learn about and adjust to the challenges ahead.
Memorial is the only adult rehabilitation center in Rhode Island with the LiteGait body-weight support system … which has showed a dramatic improvement in ambulation even when only used for seven minutes per day for two weeks. [In general], the comprehensive, individualized, cutting-edge care we provide has resulted in a greater improvement in function in a shorter time frame compared to national averages for our stroke patients.

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PBN: How substantial a level of recovery are you able to achieve?
LAZARUS:
Until recently, the focus of stroke rehabilitation has been on teaching patients to function despite their neurologic deficits by utilizing adaptive techniques and equipment such as a brace or a cane. Now, the emphasis is moving toward helping patients truly recover neurologic function, not just compensate.
We know that the adult brain is not hard-wired with fixed neuronal circuits. The brain has the capacity to change structure and function during learning or in response to enriched environments. Interestingly, acute stroke seems to prime this brain plasticity by inducing a unique microenvironment for surviving axons to establish new connections. But optimal conditions for behavioral and environmental-driven changes in neural circuits are time-limited, probably present only in the first few months after stroke.

PBN: Is preventing future strokes a major issue for you as well?
LAZARUS:
With a more than 10-percent risk of recurrent stroke within a year, prevention of stroke is paramount. Anti-platelet therapy with aspirin or clopidogrel and anti-coagulation [therapy] with warfarin are utilized to prevent thrombotic and embolic strokes. These medications – and the control of risk factors such as hypertension, diabetes, hyperlipidemia and smoking – are usually initiated on acute care.
During rehabilitation, the treatments are fine-tuned, and intensive education of the patient and family are provided. As a hospital-based acute-care rehabilitation unit, we are able to treat co-morbidities such as congestive heart failure and coronary artery disease and prevent medical complications including deep-vein thrombosis, aspiration pneumonia, urinary tract infection (UTI), pressure sores and falls.

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