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Does Recovery and Progress Really End…. The Story of Louis

No brain injury is the same and therefore comparison between individual’s pathway to recovery is very difficult. As a result, do we, as therapists really know what stage in an individual’s rehab when we can realistically predict their outcome, or they’re likely level of progress. It has previously been stated that after a brain injury there is a ‘window’ of recovery, changes are likely to plateau or stop after approximately 2 years post-injury. This opinion has begun to change and the ceiling of recovery following a brain injury can no longer be refined to a specific period of time, but only be considered on an individual basis.

Louis’s story is a great example of when recovery continues far beyond those previously recommended 2 years.

Louis’s Story:

Louis sustained a traumatic brain injury at the age of 19 as a result of a road traffic accident. Louis was at university at the time of his accident, when during a night out he was hit by a taxi.  He sustained a major brain injury. The initial prognosis was very poor; Louis’s family was advised that he wouldn’t make it as he was showing limited signs of recovery during the immediate period following his injury. On the day that Doctors recommended Louis be allowed to pass, against all odds spontaneous recovery began and Louis started to show improvements. Louis’s journey from this point onwards was going to be long and demanding on both Louis, his family and friends.

Louis spent approximately 18 months in an in-patient setting receiving the necessary rehabilitation he required at that time. Towards the end of this period, Louis began to disengage from therapy and his recovery began to plateau. The decision of the inpatient team was for Louis to return home and receive ongoing therapy within the community setting hoping that a return to a familiar setting with more normal routines may aid further recovery. It was at this time, nearly three years ago when I meet Louis, my therapeutic relationship with him and his ongoing rehab journey began.

L’s physical presentation:

On initial assessment L presented as follows:

  • Left hemiplegia
  • Full-time powered wheelchair user for all mobility needs
  • Independent but effortful bed mobility – reliant on use of right upper limb and lower limb++, able to independently move from lie to sit in an effortful gross movement pattern
  • Independent sitting balance with a midline shift to the right – able to improve with verbal prompts
  • able to stand with assistance of one to facilitate position of left lower limb – pattern of sit to stand through max use of right upper limb, pulling into stand, with midline shift to right and minimal weight bearing at left lower limb – reluctance to weight bear over left lower limb+++, hypersensitivity present leading to behavioural outbursts
  • Transfer – slide board with supervision of one
  • Left upper limb presented with a flexor tonal pattern. Flicker of movement present at the shoulder, with no voluntary activity distally. Range and position of the wrist/hand was being managed by a thermoplastic splint.
  • The left lower limb presented with an extensor tonal pattern with secondary soft tissue shortening resulting in loss of range into dorsi flexion – unable to access PG. Low tone proximally with significant loss of hip control and proximal activity.
  • Trunk – reduced activity and linear extension through left side with some shortening and rotation at the right through over use of the right upper limb and compensation for left-sided weakness. Limited activation of core++.
  • Louis was able to communicate effectively with no language deficits
  • cognitive deficits+++
  • Short-term memory deficits+++
  • Fatigue issues +++
  • Presence of behavioural outbursts when fatigued and/or physically challenged

Treatment and input over the last three years has ranged from two sessions per week to one session and even a period of approximately 5 months with no input, allowing time for independent progress and recovery. Louis currently receives one physiotherapy session per week to maximise ongoing progress. From initial assessment treatment progression has followed the below pattern:

  • Implementation of structured daily routine to manage fatigue and in turn allow greater learning and carry over, also indirectly managing behavioural outbursts
  • Education and teaching to care staff
  • Implement and progression of daily exercise program to improve core activity and hip control
  • Improve midline in stand, increase weight bearing through left lower limb, increase stand tolerance, reduced over use of right upper limb in stand
  • Improve pattern of sit to stand to improve equal weight bearing and reduce use of right upper limb
  • Progress transfer skills – progression from slide board to step round transfer with quad stick and physical assistance and verbal prompts of one, to independent step round transfer with quad stick, to step round transfer without aid or assistance
  • Manage position of left wrist and hand with implementation of saebo flex splint
  • Manage range at left lower limb through regular Botox recommendation and soft casting regime, and progress tissue length through weight-bearing exercises
  • Exploration of mobility – mob with quad stick and assistance of two, worked on progressing mobility by reducing heavy use of right upper limb on quad stick, now able to mobilise unaided with supervision of one only indoors
  • Progressed to outdoor mobility – now able to mobilise outdoors with close supervision of two to manage falls risk due to distraction by external stimuli
  • Treadmill training
  • Accessing steps
  • Educations and joint sessions with personal trainer

neuro physio

Consideration and influences on L’s progress:

Limiting factors –

Due to Louis’s presentation, there are several perceived limitations to his overall progress. For example, significant changes in cognition/memory/motivation/initiation/insight/fatigue, would all usually be considered negative influences on carryover and ability to learn, therefore limiting overall progression and outcomes. Louis’s Family and care team, (Louis has one to one care 6 days a week from 8am-6pm) have been able to provide a consistent, structured approach and routine that has counteracted these negative influences and has allowed continued progress to be made with the guidance and input of therapy staff.

Lack of initiation and insight –

Louis has always struggled to make informed decisions regarding his rehab as he struggles to see the influence his actions have over his progress and therefore struggled to formulation his own rehab goals. As a consequence of this his progress has been mainly managed via external help, professional advice and family influences. Although Louis has struggled to initiate his own progress he has always been willing to engage and enjoyed therapy input, therefore, enabling progression.

Task practice and repetition

Louis’s family hired a personal trainer alongside physiotherapy input so that he was able to continue with aspects of his therapy program more regularly. This has had the most impact on Louis’s level of mobility. His personal trainer, with physio guidance, has allowed Louis regular practice of mobility skills, access to treadmill training and regular engagement in home exercise programs to improve strength and control. This has refined Louis’s gait pattern significantly.

Challenge to independence

Progressing Louis’s mobility skills and gait pattern had to be considered carefully. What overall functional gains would/could be made? Louis was independent in the use of his powered wheelchair and therefore had freedom around the home environment. For him to progress is mobility he needed to practice mobilising more regularly, this, in turn, meant less use of the wheelchair and therefore less independence. Was I simply taking away a certain level of his independence as he would likely always require assistance/supervision for mobility? Louis struggled to initiate mobility practice due to memory deficits and reduced insight, so practice had to come from external cues and assistance via the care staff, which ultimately meant reducing Louis’s independence further.

Overall Progress:

Louis has progressed from a young man who was a full-time wheelchair user, unable to stand in the midline, with minimal acceptance of weight bearing at the left, to an individual able to mobilise outdoors with supervision for up to 45 minutes covering up to a distance of 1 mile. Through the determination of care staff, family, his personal trainer and regular physiotherapy input to manage  Louis’s physical abilities have progressed significantly. He now has non-wheelchair days incorporated into his weekly timetable were his only mobility around the home is walking, meaning that he has been able to turn mobility practice into a functional gain. Louis is in the process of turning his gains in outdoor mobility into further functional goals by mobilising to local environments i.e the hairdressers, the newsagents etc

Louis has also been able to access several steps giving him improved access to the wider community and greater access to different environments.

This level of progress, particularly the rate of progression of Louis’s mobility and quality of his gait pattern has been most evident at approximately 4 years post-injury, showing that not every individual has a limit on the progress that can be made. If input is available and a structure supportive routine is in place enabling continued practice, then progress may continue way into an individual’s future.

Overall thoughts:

I have to admit that I am guilty of anticipating that Louis’s deficits as described above would be limiting to his overall progress. However, I now have a belief that it is the consistent support and structure of Louis’s family and care staff and their willingness for him to continue to progress that’s has had a huge impact on his current abilities. The opportunity that Louis has been given to continue to receive regular and consistent physiotherapy input since returning to the home environment for what is now nearly three years has given him and his body the means to continue to improve.

Another huge part of Louis’s physical success, as mentioned earlier is the access he has had to a personal trainer twice per week. Louis has received input from the personal trainer for over a year and through close support and educational sessions with myself, the personal trainer has allowed for increase practice and task repetition which has, in turn, impacted greatly on Louis’s physical ability.

Louis’s journey has shown me that if a person has the opportunity to access ongoing treatment and support, enabling them targeted, specific exercise/task practice then progress may continue long into their future.

Considering Louis’s physical abilities approximately 3 years ago the progress his has made is outstanding. Louis has an exceptional support system and has had the opportunity to engage in continued physiotherapy input for a prolonged period enabling ongoing physical progress and continued functional gains.

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