Her Worst Nightmare
In the early morning hours of April 7, Hunt woke up to a loud buzzing in her head. She was confused, nauseous and unable to see. After insisting that her husband, a state police officer, call an ambulance, she was violently sick to her stomach.
Hunt had a CT scan and other tests at St. Luke's Hospital in New Bedford, MA, and recalls being aware of her surroundings but unable to communicate. The last thing she remembers was being intubated and then wheeled to a medical helicopter for transport to Beth Israel Deaconess Medical Center in Boston, MA. She doesn't remember the ride.
Her next memory was of waking up in a hospital bed unable to see. She could hear people swarming around her. The only thing she could move on her right side was her thumb.
Hunt was told she had had a stroke. Officially, she had a spontaneous vertebral artery dissection that was trying to heal itself when it caused two brain stem blood clots.
When Hunt thinks back on the first sign of symptoms, she recalls seeing spots on New Year's Day. She was sure it was nothing.
Vertebral artery dissection (VAD) is a flap-like tear of the inner lining of the vertebral artery. Located in the neck, the vertebral arteries supply blood to the brain. VAD symptoms may include head and neck pain and common stroke symptoms such as difficulty speaking, vision loss and impaired function. The life-threatening tear can be spontaneous or traumatic.
An increasingly recognized cause of stroke in patients younger than 45 years of age, VAD is often confused with the more common carotid artery dissection (dissection of the large arteries in the front of the neck).
Experts have varied opinions on the causes of VAD. Many believe that the condition's risk factors may include chiropractic manipulation, migraines, strenuous yoga and other exercise routines, to name a few. "There are theories about why this happens and how it happens but
Susan Sherman, PT, team leader at Southcoast Brain & Spine Center in Darmouth, MA, works with Meg Hunt on core exercises.
the fact is, we don't know exactly how it happens," said Sandra Gibson, PT, Southcoast Brain & Spine Center in Dartmouth, MA.
According to Gibson, it's important that people know to call a doctor when they have an unusually bad headache or numbness or tingling in the face. "Don't think that these symptoms will just go away with time or that they are nothing," she cautioned.
On April 11, Hunt was admitted to the inpatient unit of Braintree Rehabilitation Hospital in Braintree, MA. She was dealing with the loss of hearing in her right ear. She was on a Heparin drip until her International Normalized Ratio (INR) could be deemed normal. Her roommate was a fellow stroke patient but unlike Hunt, she was in her 80s.
"Every patient is a lesson because they all have different backgrounds and levels of motivation," observed Kerri Kennedy, PT, Braintree Rehab. "From Meg, I learned about interacting with a younger patient and the emotional challenges that go along with it."
Kennedy found Hunt's case challenging because she doesn't typically have young patients in her setting. "I had to pick my brain to come up with new activities to challenge her," she explained.
Following an evaluation with Kennedy, Hunt was issued a hemi walker. She could only walk 20 feet with the hemi walker before fatiguing. "I felt unsteady and like I had vertigo," Hunt said. "But mainly I was frustrated because I couldn't understand why I couldn't do more."
When Hunt arrived at Braintree, she was beginning to regain some movement on her right side. She had hip flexion and extension but no ankle flexion and she was vaulting on the left side to get her right side forward. She needed moderate assist for transfers and mobility.
Because she was a fall risk, two aides needed to assist her when visiting the bathroom. "The toilet paper holder and the handle to flush were both on the right side and I had little function on that side," she recalled. "It was humiliating that I couldn't even do that part for myself."
Most of the PT sessions focused on strengthening her right leg with exercises such as squatting. She went to a walking group each day and worked on quad control and sit to stand. Her rehab sessions also consisted of functional electric stimulation to work her tibialis anterior and hamstring and an automated body weight supported treadmill training device for gait training.
"It was challenging working with Meg because she wanted to work at a higher level than she actually could," Kennedy shared. "We did 30 minutes of mobility exercises each day but she wanted to do an hour. When I let her try one day, she fatigued around 35 minutes. It was a hard lesson for her to learn."
Hunt walked independently with a cane and brace upon discharge, with the goal of progressing to indoor/outdoor walking without a device. She was using a non-reciprocal pattern on the stairs and was determined to get back to normal, Kennedy explained.
Making Progress in Outpatient
"When you look at Meg's CT scans, it's completely amazing," said Susan Sherman, PT, team leader at Southcoast Brain & Spine Center. "You see her vertebral artery flow and then it just vanishes. It was a clean severance and it looks like a bomb went off."
At Southcoast Brain & Spine Center, Gibson conducted the initial evaluation to identify her deficits and determine the plan of care. When Hunt first arrived, she presented with significant disability on her right side. Her lower right extremity showed weakness at her hip and recurvatum at her knee. Her core instability was significant.
"When she first arrived, she was not weight shifting to the right side completely and she had a little bit of toe drag," stated Heather Robinson, PT, Southcoast Brain & Spine. "Strength was an issue for Meg."
Robinson believes in a functional approach. "A patient who safely works on balance on an unsteady surface is going to make a faster recovery than working on a solid surface," she explained. With Robinson, Hunt worked on weight shifting and balance on a trampoline and progressed to catch-throw on a bosu.
According to Robinson, younger stroke patients rebound more quickly. "Some older patients do very well but it may just take them longer," she stated. "Balance is generally more of an issue with older patients but when safe, I have them participate in the same activities."
But Hunt's deficits did not end with her core and lower extremity. She was having difficulty completing daily activities, such as blow drying her hair, which required regaining strength and coordination in her upper extremity.
Hunt has been going to PT and OT sessions twice each week since her discharge from Braintree Rehab.
"We initially worked on functional activities such as bending over to put on her shoes and socks, tie her shoes and grasping a coffee mug to bring it to her mouth," stated Brian Knutsen, OTR/L, CHT, president of Buzzards Bay Hand Therapy LLC in Marion and Lexington, MA. "Now that she has progressed, we are working on more refined movements."
Her OT sessions have mainly addressed proximal stability of the shoulder, gross upper extremity strength and fine motor control and coordination.
"When Meg first came to me, she was relatively acute after her stroke," Knutsen relayed. "I expected her progress to be slow and steady as is common with neuro cases. Meg's rapid progress was an interesting challenge for me. I constantly updated her treatment plan to stay relevant and keep up with her recovery."
Knutsen has had Hunt work on work-specific tasks such as sustained shoulder positioning while she holds a dry erase marker to prepare her to write on a board in a classroom for prolonged periods.
"We worked together as a team for Meg's recovery," said Sherman. "Each of us has her own styles and beliefs. I focus on core stability, Heather has a functional rehab approach and Sandy uses a neuro-developmental approach."
Hunt refers to her PTs as her "3 brains." Because she is unable to work right now, Hunt likes to think of therapy as her job.
"Recovery depends on the patient, the severity of the stroke, her fitness level prior to the event and how much exercise she is doing on her own." Robinson observed. "Meg caught on to the exercises relatively quickly, partly because she was an athlete prior."
The therapists have given Hunt a home exercise program. She supplements the program by going to the gym and doing Pilates privately four times a week.
"Meg has rapidly run through all of the developmental sequences which is a reflection of her perseverance and dedication," Sherman observed.
According to Gibson, the therapists will continue to see Hunt twice a week. Patients are reevaluated every 30 days to reassess goals and treatment plans.
At this point, Hunt has hardly any recurvatum on the right side, she can bend her knee smoothly and kick through, and she's not keeping the knee flexed at mid-stance, according to Robinson. Her weight shifting has improved and her core has gotten stronger.
"It's amazing to see what Meg has been able to accomplish and recover through hard work and dedication," Sherman said. "In my 26 years as a therapist, I've never seen a patient who has worked harder or has been as involved in her own recovery."
Hunt's personal goals at this point are somewhat more focused. "I would like to be able to write out a check and type on the computer without fatiguing," she stated. And, of course, the goal to get back to running is never far from her thoughts.
"Many patients following stroke are very focused on their ultimate prognosis," Knutsen said. "This is a challenging question for the therapist to answer especially early on in the rehab process."
Knutsen feels confident that Hunt has every opportunity to make a full recovery given her rapid recovery, positive attitude and commitment to rehab.
"Meg was in the best shape of her life," Sherman told ADVANCE. "If she had had any less core stability and lower extremity and cardiovascular strength leading into the stroke, the outcome would not be the same."
Rebecca Mayer is senior regional editor of ADVANCE and can be reached at firstname.lastname@example.org