Vol. 16 Issue 24
Learning to Walk Again
One woman's amazing journey toward regaining mobility
A 39-year-old woman named Sarah can often be found slowly, carefully manipulating and moving different objects while standing. If you'd met Sarah Scantlin during the summer of 1984 and asked her what she hoped to accomplish by her 40th birthday, these tasks would never have made the list of the then-18-year-old's dreams. If you'd met her five years ago, you could never have guessed she would one day accomplish anything so amazing.
Sarah was hit by a drunk driver in September 1984 as she crossed a street with her friends. Traumatic brain injury left Sarah unable to walk, talk, eat or breathe on her own. For most of the past 21 years, she remained in a minimally responsive state, paralyzed and able to communicate only with eye blinks. Her family was told not to expect anything more.
Now she not only breathes on her own and stands with the use of a standing table where she practices manipulating and moving objects; she also swallows pureed foodand she says she wants to learn to walk again.
Long Road to Recovery
Traumatic brain injuries (TBIs) affect 1.4 million Americans every year, and 80,000 to 90,000 of those people sustain a long-term disability. How many exist in a minimally responsive state is unknown, but physicians and rehabilitation professionals who work with these patients know that "awakening" from a minimally responsive state after 20 years is rare. Achieving the kind of progress Sarah has made is considered extremely remarkable.
Rehabilitation therapists at Golden Plains Health Care Center in Hutchinson, KS, where Sarah is a resident, continue to work diligently to help her reach the highest level of function.
Walking didn't seem like a possibility at all shortly after Sarah's accident, when a lobotomy was performed on the left side of her brain, or for the six weeks she was in a coma. It was just as unlikely when Sarah moved to the Golden Plains facility, where she remained minimally responsive and completely incapable of functioning physically, although she was aware of her surroundings, breathing without mechanical assistance, and communicating with one blink for "yes" and two for "no."
Doctors warned her family that she would not walk or talk again, and for 18 years no progress was observed by the interdisciplinary team that cared for her, interacted with her, and provided restorative treatment to help prevent contractures during that time.
It all began to change dramatically three years ago, when Sarah began screaming out as the television channel was changed or when her parents left at the end of a visit.
The facility's activity director began working with her every day to encourage her to speak, and finally, in January 2005, Sarah quietly said the word "okay." A few days later that was followed by the words "I love you."
After two decades without speaking, Sarah was responding with her own voice and was soon saying "Hi Mom" on the telephone. Over the next month, after consultation with Sarah's physician, an individualized treatment program was developed, including aggressive physical, occupational and speech therapy regimens. In February, surgery at the University of Kansas (KU) Medical Center helped reduce many of the contractures Sarah had developed in her limbs, and Botox injections helped reduce cervical tone, thereby allowing freer mobility.
A few months later, after returning to Golden Plains Health Care, Sarah's intensive rehab program began.
Meeting the Challenges
The major challenges facing Sarah's therapy team have included normalizing lower-extremity muscle tone, improving postural control/core stability, achieving unsupported sitting balance, increasing muscle strength, and contracture management. The team has also worked with Sarah to provide appropriate pressure relief techniques and devices to maintain skin integrity and to assess for and provide adaptive and assistive equipment.
Her treatment has already included hundreds of hours of physical, occupational and speech therapy activities, initially working with her as much as three and one-half hours each day.
In addition, wheelchair positioning has been an important part of the program. Sarah was fitted with a tilt-in-space wheelchair in order to maximize her functional level. Padded lateral head supports assist with head/neck control. The ability to change the tilt of the chair throughout the day, along with an air-and-gel cushion, assists with pressure distribution and helps prevent skin breakdown.
Sarah follows directions well, and throughout the months of therapy, her determination and spirit have been strong. She often sits in her wheelchair four to six hours a day. She has increased neck musculature strength, improved postural tone, shows active range of motion in upper and lower extremities, and is able to move her shoulders in order to pick up and manipulate and move objects while in the standing table.
Recently, Sarah reached a plateau in physical therapy, requiring her to be discharged from Medicare services. Occupational and speech therapy continue. Sarah is also in a restorative program six times a week where restorative nursing assistants, who have been trained by rehab, perform exercises to prevent further contractures.
They continue to use the standing table three times a week to assist in minimizing lower extremity tone and provide weight-bearing/upright motor control activities. Eventually she may qualify for a Baclofen pump to further help reduce spasticity and tone.
If her status changes, she may re-qualify for physical therapy. Sarah has already achieved more than anyone thought possible and has shown immense determination. Going forward, the physical therapy team has several goals to pursue, including improving her sitting balance to the point that she can sit without assistance on the edge of her bed or on the mat table; increasing active functional range of motion, and transferring from wheelchair to mat with assistance of one person instead of the two currently needed.
A coordinated interdisciplinary team effort with open communications and frequent therapy staff meetings has been vital in maintaining an effective treatment program. The entire team is committed to helping her achieve goals and celebrates each new achievement.
Staff in-services are utilized to re-educate staff members as progress is made, new equipment or techniques are implemented, or her positioning or splinting needs change. As with most patients, motivating Sarah has been a critical factor for success. The therapists developed a close relationship at the start, letting Sarah know they care about her as a whole person, not just her therapy achievements. Team members praise and encourage her throughout the day and celebrate each milestone as Sarah makes functional gains.
Sarah has come a long way in a few months' time. Her care team and her family know that with this kind of program, progress sometimes will be slower than what the patient and the team would like. Achievements are often measured in very small increments. Yet, 10 months ago, Sarah wasn't moving, verbally communicating or eating at all. She's taken several amazing steps toward her goalsincluding progress in dozens of areas such as improving muscle strength, balance and range of motion.
She also talks to her parents and caregivers, swallows pureed nourishment on her ownand has proven that she's determined and hard working. Only the future will show how much Sarah and her therapy team can accomplish.
Robin Kenyon is director of facility operations and has been with RehabWorks for two years and has nine years of health care experience. RehabWorks, one of the nation's largest contract therapy providers in the long-term care industry, offers physical therapy, occupational therapy and speech language pathology services to the entire health care continuum from pediatrics to geriatrics. The company can be found on the Internet at www.rehabworks.com
According to statistics from the Center for Disease Control, out of the approximately 1.4 million Americans who sustain a traumatic brain injury each year:
• 50,000 people die;
• 235,000 are hospitalized and survive;
• 80,000 to 90,000 experience long-term disability.
Source: Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, 2004, http://www.cdc.gov/ncipc/pub-res/TBI_in_US_04/TBI_ED.htm/pdf, accessed 9/14/05