Appointment Icon

St. Luke's Emergency Department

First Available Time :

Jones Regional Medical Center Urgent Care - Anamosa

1795 Highway 64 East
Anamosa, IA 52205

Current Estimated Wait:
Closed

UnityPoint Clinic - Express (Lindale)

153 Collins Road Northeast
Cedar Rapids, IA 52402

Current Estimated Wait:
Closed

UnityPoint Clinic - Express (Peck's Landing)

1940 Blairs Ferry Rd.
Hiawatha, IA 52233

Current Estimated Wait:
Closed

UnityPoint Clinic Urgent Care - Marion

2992 7th Avenue
Marion, IA 52302

Current Estimated Wait:
Closed

UnityPoint Clinic Urgent Care - Westside

2375 Edgewood Road Southwest
Cedar Rapids, IA 52404

Current Estimated Wait:
Closed


Ep. 198 - LiveWell Talk On...Stroke Rehabilitation (Kevin Komenda, DPT, NCS)

episode 198

Ep. 198 - LiveWell Talk On...Stroke Rehabilitation

   Subscribe so you never miss an episode!

   Apple Podcasts | Google Podcasts | Spotify | Pandora | iHeart Radio |   
   Google Play Music | Stitcher TuneIn SoundCloud 


Host: Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Kevin Komenda, DPT, NCS, sr. physical therapist, St. Luke's Hospital

Dr. Arnold:
This is LiveWell Talk On...stroke rehabilitation. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's. May is national stroke awareness month and joining me on the podcast today is Kevin Komenda, a senior physical therapist and a colleague that I've worked with in the past at St. Luke's, to discuss rehabilitation for stroke patients, common post-stroke issues, types of therapy used, and much more. Kevin, welcome to the podcast.

Kevin Komenda:
Thanks for having me, Dr. Arnold. I like talking about stroke, it's important.

Dr. Arnold:
Yeah. So, as a physician, you have a patient that has a stroke and for the listeners, my job is to, if they're in that window of possible intervention to reverse it, we're going to intervene with blood thinner or cerebral angiogram and reverse it. And then we're going to say, okay lets modify risk factors for stroke, right? Then, my job's kind of done at that point, and that's where you guys take over. So I guess I'm trying to stress that stroke rehabilitation is a huge part of treating a stroke.

Kevin Komenda:
You know, it really is. Once the patient is medically stable that's time for, like you said, the therapists to come in and assess. All right, what kind of needs does this person have to regain function and participate in their life again in a meaningful way. And so many factors, as far as location of stroke and how big the stroke was, help kind of lead us to what we're going to need to do for follow up and for therapy.

Dr. Arnold:
So kind of take us through, we have a patient that's had a stroke, what does rehab look like? How are goals determined? Just walk us through that for a patient.

Kevin Komenda:
Yeah. You know, so the initial stroke occurs, like you said doctors and the staff get them medically stable. And then when they're ready, they'll come to inpatient rehab. And that consists of being able to tolerate over three hours of therapy a day, intensive physical, occupational, and speech therapy. And so we meet the patient and help determine what their needs are. Some people that have a stroke on the left side of their brain have lost the ability to speak, or maybe the ability to understand the spoken language. And so then they get speech therapy. We work with their weak side of their body. Essentially in a nutshell, I explain to people that my job is to provide a person after a stroke with a safe environment to practice the activities that you and I take for granted on daily basis. Getting out of bed, standing up, walking to the bathroom, be able to brush your teeth, do your daily routine. They'll work on that with occupational therapy, be able to walk out into the living room and maybe climb and go up and down stairs. We work on all those things with our patients and you'll find folks be, they'll be very motivated because they're trying to get back to their life. And if they don't work on these things and we provide that safe environment for them to get the repetitions of activity, the brain without that enriched environment to practice those things, the brain doesn't heal as well. And they have less chance to get home. So we provide that environment to practice those things and hopefully discharge them home.

Dr. Arnold:
Now I've been in practice 27 years and I'll tell you this, people/patients are okay with dying. Right?

Kevin Komenda:
Yeah.

Dr. Arnold:
They're like, you know, I'm 72. I've had a great life. Really, you hear that from them.

Kevin Komenda:
Yeah.

Dr. Arnold:
But they're all petrified of having that half a stroke that leaves them disabled. I mean, I think that's their biggest source. People worry about that and then getting some sort of aggressive cancer. Those are like the two things that really weigh on people's mind.

Kevin Komenda:
I agree with you. Yeah.

Dr. Arnold:
So stroke is not just an old person disease. Can you talk about maybe the youngest patient you had and what they had wrong with them, as compared to kind of the normal elderly patient?

Kevin Komenda:
Yeah. You know, I think you make a really good point about you know, I've had a good life, all this, I'm ready to be done. But they survive it. And now what? And it's amazing to see the psychological turnaround of these individuals of wanting to throw it in, to seeing like, oh man, you know with work I can walk again. I can participate. I can go to my grandchildren's baseball games and basketball. And you see this huge turnaround psychologically on a lot of our individuals. I find it to be one of my most highly motivated populations. And it's just getting that initial buy-in and they kind of get over that fear and they learn that they can still be very productive and be happy and enjoy their families again. And thankfully they can do those things. With a lot of therapy and a lot of hard work, we see some tremendous outcomes. There are folks that it's too much. And for those individuals, sometimes they'll go to a skilled nursing facility or go to a nursing home. And they're just so affected that they can't, the brain has just been too damaged to have the improvement. And thankfully that's fairly rare. But we do see that as well. I don't know if that answers your question, but I find them to be some of the more motivated patients I work with because once they survive it, the goal is to get better. They see it's achievable and it's pretty cool to work with that and be a part of that team.

Dr. Arnold:
Now when a younger person has a stroke, is their outcome just as the same or is it better than an elderly patient? That's kind of a self-answering question because we know elderly have other risk factors and comorbid conditions. You know, I always say patients don't die from their stroke. They die from the pneumonia and the bladder infection that causes sepsis right after their stroke, you know?

Kevin Komenda:
Yeah, you're right. And we see better recoveries with younger folks. Their brains are just more fertile for regrowth, regeneration, creating new pathways. We've unfortunately in the past year, we had a 12 year old post-stroke. And it's rare, but it happens and her outcome has been really good. She's back to running, trying to participate in her basketball league. You know, it's the middle aged with young children at home, those individuals. I was just telling somebody, I've had a few tremendous recoveries in my career. In Minnesota I worked with a guy who had a stroke while fighting a fire as a firefighter and he had a nearly 100% recovery. Now he was a big strong guy and motivation was through the roof, but we see some great outcomes with those younger patients. They may not get back to running marathons, but they can get pretty close.

Dr. Arnold:
And I think you brought up a good point earlier that it's just not physical therapy, you know? So even a smaller stroke will benefit with rehab.

Kevin Komenda:
Yeah.

Dr. Arnold:
Because occupational and speech.

Kevin Komenda:
Yeah. It's all about the location of that stroke in the brain and what it affects. Our speech therapists are really great at working on can this person expressed themselves. And if not, what technology is out there now with iPads and all kind of different ways to communicate and really utilizing that. Our occupational therapists here in inpatient rehab, they really work with the upper extremity, the arm. Often the arm is more affected than the leg and getting that hand dexterity back so you can tie your shoes, so you can type, so you can hold onto a phone and dial it. All those things takes a ton, a ton of practice. It takes a lot of therapy to get those things back. So it's really a team effort, which I love.

Dr. Arnold:
Yeah. This is may be a tough question to answer, but I think listeners are listening for this answer. Post a stroke, when is it as good as it's going to get? I tell patients, keep working at it and stay optimistic. I've seen people improve up to a year after it. But in your experience, what have you seen? I think that weighs heavily on people's minds.

Kevin Komenda:
Yeah. What research has shown is those first three months after stroke are where you're going to have your biggest gains. Where you'll go from, I can't even move my leg, I can't stand to be able to walk and climb stairs. Those first three months are so critical. And that's why I have a job. I'm in those first three months and providing that intensive rehabilitation to get those gains. If that didn't happen, there would be no need for me. Now things level off.

Dr. Arnold:
That's why we have six west. The rehab wing.

Kevin Komenda:
Yeah, a hundred percent. That's why I have a job. The brain is elastic and can heal. After that first three months, things slow down. But I tell people, I say, never say never about recovery. Because, I'm like you Dr. Arnold, I've seen people a year later recover things that they couldn't do before. All of a sudden their hand will start to move in a better way, a different way. So, you know, I really try to keep my patients motivated, don't give up. But the real honest conversation is after the first three months, things really do slow down and you have to stay on top of it if you want to continue to see more gains.

Dr. Arnold:
I don't know if you've seen this in your career, but I’ve seen this a dozen times. Patient has a stroke that left maybe a left side of weakness that improved over time with rehab. Okay. And then they get an overwhelming, let's say pneumonia and are admitted hospital, like 3-5 years later. And that left side of weakness comes back.

Kevin Komenda:
Yeah.

Dr. Arnold:
And I've always thought it's kind of left/right brain making up for stuff, you know? And when the brain gets distracted, that weakness comes back. And sometimes that's shocking to people, because you know, here they've recovered and they're like— And I always say, don't worry about it. It's going to, you know, come back. And have you ever seen that?

Kevin Komenda:
Yes, for sure. We do see that almost kind of a back slide. I think they're just skating on such thin ice. They're kind of on the edge of this cliff and they're surviving and doing it. And if anything nudges them off of that cliff a little bit, it really can be a big setback. And whether it's the brain, like you said, the brain distracted with recovery of other things and they just are using fewer neurons and fewer muscle fibers in their leg or arm. And anything that knocks that off course, it's a setback. And so we see a lot of repeat customers and they do improve after those setbacks again and get back to baseline for the most part. But it's scary for them.

Dr. Arnold:
Yeah. Well, you know, most patients are treading water on a good day and you start handing them bricks. Like, i.e., a brick of pneumonia, a brick of sepsis and it gets difficult to say the least.

Kevin Komenda:
Absolutely.

Dr. Arnold:
I think the other thing that I kind of see on my side is, okay, let's say they have weakness in their right hand. So in the morning the doctor rounds and you know, okay, it's made some progress overnight. Then all day long, the patient is checking to make sure it's still there. The family comes in, move your hand, mom, move your hand. So then like 4:00 PM rolls around and like now the hand's just completely fatigued. Right? You know, like, oh my gosh, my stroke is getting worse.

Kevin Komenda:
Right.

Dr. Arnold:
No, you've just been running a marathon with your hand all day. You know, I don't know if you see that, but I always—

Kevin Komenda:
We do. That neuro-fatigue, we even see it on inpatient rehab at the end of a week on Friday, we'll sometimes see decreased performance because they're fatigued. And I talk to my patients about sleep hygiene is so key. To sleep and recovery in between, and even taking naps during the day. And that's been clinically proven to help your recovery is just to recharge that brain and let it rest. Like you said, if you keep trying to do something over and over, you wear it out. Get a nap, take a rest. And then by, you know, after weekend on Monday morning, we'll see people do things they couldn't have done the previous week. They got some rest and recovery and we see some great progress on Mondays.

Dr. Arnold:
I'm glad to hear someone reaffirm that taking naps are good, because I love to. But my wife, she's such a hard worker. She's like the sun's up, you don't sleep when the sun's up. Seriously, I mean she never takes naps, you know. Never.

Kevin Komenda:
Well, she should check it out. It's a wonderful thing.

Dr. Arnold:
Yeah, I totally agree. I think it should be a hobby, or maybe an occupation.

Kevin Komenda:
There we go.

Dr. Arnold:
Well, how long are people usually up on rehab?

Kevin Komenda:
Yeah, for our stroke population it's around between two to three weeks. I think our average length of stay post-stroke is right around that two week mark. I just had a gentleman stay here for five weeks, and in insurance we showed progress and let kind of help keep paying on that stay. Around that two week mark with some variation up and down from that, depending on severity.

Dr. Arnold:
And is that followed up with some outpatient sort of continued therapy?

Kevin Komenda:
I would say 100% of our patients that are discharged from inpatient rehab, either go to outpatient therapy or do in-home therapy.

Dr. Arnold:
In-home, yeah.

Kevin Komenda:
Depending on their level and their ability to get to outpatient therapy, but they all continue on with something.


Dr. Arnold:
You know, I know you're more rehabilitation, but I think we should go over signs of a stroke. Maybe we should have started with that at the beginning, because I think listeners should know. What are the signs of an acute stroke?

Kevin Komenda:
The big national campaign is to think of the acronym FAST. And so the F of FAST is face. You look for a facial droop. If you see that in somebody, that's a 911 call. The A in FAST is their arm. You'll see arm weakness. If they're all of a sudden dropping their coffee cup and then their face is drooping, that's 911. This S in FAST is speech. So you'll have a slurred, mumbled speech. And again, that's some of their facial droop. And if it's on the left side of their brain, they could be having a damage to their speech center of their brain. And then the T is time. We're in about a three hour window for some of those clot busting drugs to get from the onset of the stroke to get to the ED where they can deliver the proper meds. It's a short time window. And even if that's for a clot and for a bleed, it's so important to get into the hospital because they may have to do emergent surgery to relieve pressure on your brain so you don't perish. Time is of the essence, as you know.

Dr. Arnold:
Especially younger patients, you know, they can certainly benefit from that early craniotomy. MCA, middle cerebral artery strokes.

Kevin Komenda:
Absolutely. And we see after a bleed, it can be a life threatening situation, but those patients actually have more recovery than our patients that have had a stroke post clot. So that time is so important.

Dr. Arnold:
Yeah. I always encourage patients, you let us determine whether or not it's a stroke or not. Don't sit at home and say, well, I don't think this is. Let us. You know, they'll say, when should I come to the ER? Whenever you have symptoms. We'll send you away and pat you on the back and say that wasn't a stroke, everything's cool. Or, we'll intervene and preserve function of the brain.

Kevin Komenda:
I mean, we've had so many patients that have driven themselves to the hospital because they were in a state of denial and they were actively having a stroke while driving. Just because they don't want to believe it's true. They think they're going to be okay. Or it'll happen in the morning, but they don't come in until the evening. And your advice is just absolutely correct. When you feel like something's wrong, let the doctors determine how severe it is and what needs to be done. Don't try to make that choice yourself.

Dr. Arnold:
Right. Absolutely. Well, all the guests or almost all the guests, get asked why they started something. So take me through your path to being a physical therapist.

Kevin Komenda:
Yeah. I was a biology major. I grew up in Nebraska. I was a chemistry minor, bio major, wondering what to do with my life to a degree. Playing college football, I damaged my knee pretty bad. I had surgery, underwent the recovery process and the rehab and I discovered physical therapy. And I kind of got into it, got into physical therapy school after that. Was in Rochester at Mayo clinic and did a clinical rotation on their inpatient rehab site and worked with some folks post stroke, post spinal cord injury. And I just absolutely fell in love with that patient population. We're a part of a team with our physiatrist, which is our physical medicine rehabilitation doctors, our ODs, our speech therapists, our nursing staff, our rec therapists. And I love being part of that team and working together to help patients succeed. And I've been doing it for over 20 years now.

Dr. Arnold:
Definitely, I think inpatient rehab is one of the most upbeat, optimistic, positive job fulfilled units in the hospital. Because they get to see their patients get better.

Kevin Komenda:
Yeah.

Dr. Arnold:
You know, I find that's true out in the wound clinic too. You know, they keep coming back and you can visually see them getting better. Where like, you know yeah, your heart failure patient's no longer in heart failure, but you don't get to actually see them improving because they're not there long enough. So you guys do a great job. It is a crown jewel of the hospital, quite honestly, our inpatient rehab.

Kevin Komenda:
Well, thank you. And it's so great to be a part of this team. All the way from the acute care they receive here at St. Luke's, all the way up through six west and then on outpatient, just being a part of that is very special and it's really fulfilling.

Dr. Arnold:
Awesome. Hey Kevin, thank you for joining me. This has been great information. Again, this is Kevin Komenda, senior physical therapist at St. Luke's Rehabilitation. For more information on rehab services at St. Luke's call St. Luke's Physical Medicine and Rehab, 319-369-7331.

Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers about our podcast. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.