Wow, I haven't written a post in over a month. It just goes to show how busy I've been -with work and everything else in between. Last Wednesday, I realized how much I missed writing and reflecting upon my job when I evaluated my new patient with a diagnosis of "multiple CVAs". I will call him James.
I had read in James' chart that he had aphasia as a result of his multiple CVAs. But I was not aware of the severity of it, and whether it was expressive or receptive aphasia. I knelt down by his bed, which was as low to the ground as the bed controls would allow, and told him I was from occupational therapy. "I'm here to evaluate you. Do you know what occupational therapy is?" Nothing. "James, are you in any pain?" Nothing. He just looked at me, with an occasional grumble here and there. But nothing that made any sense to me. I decided to be as simple as I possibly could be and ask him yes and no questions. I took his hand and told him, "James, squeeze my hand twice if your answer is yes, and once for no". I demonstrated and repeated the instructions again. Then I had him try before asking anymore questions to make sure he knew what I was asking him to do. He just rubbed my hand in his. For one, there was no sequence to what he was doing. And two, he was not squeezing at all. I looked at him and his eyes were tearing up. He looked helpless and almost as if he felt bad for me. I said to him, "I know this is frustrating. We'll just have to find a better way to communicate with eachother." I tried writing "yes" and "no" on a piece of paper and told him to point. He just slapped the paper and growned. Holy cow. This man has global aphasia. Not only can he not express himself verbally, he cannot comprehend language.
I left the room really fast to grab Jason, the physical therapist who was scheduled to eval James that day. He came in with me and, with very direct physical cues and hand-over-hand demonstration, James understood the tasks we were asking of him. We got him sitting up on the edge of the bed, and with max assistance (times two), we got him into his wheelchair. Unfortunately, global aphasia wasn't the only roadblock James had to deal with. Because of his multiple CVAs, James had major flaccidity in his right upper extremity. It was just there -as if it were not part of his body. If you were to lift it up and let go, it would drop back down in full force. He was, however, able to initiate movement in his right lower extremity, which showed great potential for bed mobility and transfer training. On that first day, sitting in his wheelchair, James needed all the force I had pushing against his right side so he could stay sitting upright. If I let go, he'd be on the floor. We had to get him back in bed.
I left that evaluation, baffled. What was I going to do? I felt the same way leaving the next day's treatment, which consisted of 10-minute increments throughout the day to get him sitting on the edge of the bed and back into bed so he wouldn't get bed sores. I wasn't entirely sure what was going on. Some times he seemed like he understood what I was verbally saying. At other times, he looked like he wasn't quite all there. He'd respond well to direct physical cues one time, and the next time, stare at me frustrated. We were going to have a family meeting the next day to figure out the plan of care. I was set on discharging him to an inpatient neuro rehab facility. That was till the next day (Friday) happened.
I was walking down the hall to join the PRN physical therapist's session with him, when I saw her pushing James towards the gym in the wheelchair. At first I was mortified. He is going to tip over and land on his FACE! But then I was excited! He's sitting up! Granted he's leaning off to one side, but he's sitting in the chair without anyone pushing to keep him up. I knelt down beside him and said, "James! How are you?" He looked at me and said awkwardly, "Good". My jaw dropped. How this was happening, I have no idea. And to be honest, I really didn't care.
I joined the PT for half of the session. We got him standing at the parallel bars with max assistance. I got him holding onto the bar with his right hand so he could do some weightbearing to initiate some sort of proprioceptive input into the arm. Then the PT helped me get him onto a mat with his left side (the strong side) leaning against the wall. The PT told me to have him lean against it for a few seconds to give him the proprioceptive input that he needs to be "more towards his left side" (I don't know how else to explain it), then slowly move his shoulders towards midline. Then I'd slowly let go and get him to look up at the full-body mirror in front of him. His feet were planted flat on a wooden block and his right hand was placed open-faced on the mat, allowing him to weightbear through his right side as well. He sat in a static position for 1 minute. This was great! Occasionally, I'd have him reach with his left hand for an object. He would wobble and throw himself off-balance, but this was still progress compared to the day before. I was so happy. I did not understand what happened neurologically between that day and the day before, but it really did not matter at that moment. When James rested again on his left side, he held my hand and rubbed it. It's weird to say, but when I'd look at him, it was as if he was speaking with his eyes and I could tell how he was feeling. He was exhausted. But he was proud of what he did that day.
The family meeting was an hour later that day. And the physical therapist and I decided to continue seeing James for skilled services at our facility, letting our rehab director know how much progress he made overnight. I learned two things that day: 1.) Sometimes things don't make any sense in rehab (or in life for that matter) but, in some circumstances, it really doesn't matter. And 2.) Neuro is where my passion is.
