In terms of my own case load, I have at least 4 patients with spinal cord injury (SCI). Three cases are mid- to low-thoracic injuries, so these patients have full use of their arms and at least the top half of their trunk if not most of their trunk. One interesting case is concomitant with a gun shot wound to the head and thus traumatic brain injury (TBI) on top of an incomplete lesion somewhere around C1-C4 (meaning cervical nerves in the upper neck). Neurologically, patients are assigned one designation according to the highest spinal nerve level that is intact for both motor and sensory. I keep wishing they would include full ASIA assessment scales, just because that's easy to look at to get an initial idea of the patient. But I suppose it doesn't matter too much since we complete a full evaluation and treat their deficits accordingly. Some patients know their level whereas others have the dual TBI that may or may not be evident, so the only concrete indication may be the ICD-9 codes that give a range like C1-C4.
This latter patient, the C1-C4 with concomitant TBI, I will call Mr. A. He is an interesting case. This morning went fast since every patient showed up, and they were all on time to boot. That meant I had to suffice with a verbal run-down of what they've been working on lately instead of checking the plan of care listed in the notes. My CI included all the functional information, but I didn't realize til part way through that she didn't say his diagnosis. From his facial expressions, motoric patterns of speech and sharp wit I at first thought cerebral palsy. From his left arm and leg I'd have though stroke. Then I noticed a very faint line of absent hair indicative of a craniotomy suture scar, so wondered TBI. The SCI is incomplete, but the TBI was much more impactful. And yet he is super uber fun and quite capable aside from tone limitations. He called me "Laura the explorah" while working with the OT before our session, and he couldn't stop talking about his 2 year old granddaughter who gets to stay with him and his wife for 2 months this summer. Mr. A is the kind of patient that you wish were duplicated throughout your schedule -- motivated, excited, full of life and interest, genuine with every laugh.
There is another patient I described to a school colleague who I've realized is interesting enough to post, and this patient was the main impetus of wanting to talk PT today. I'll call him Mr. B. He is, unfortunately, not my patient but Ron's. Guess you could say I'm jealous he got this case. Mr. B had a a long succession of very small strokes some time ago, and no one knew until months had passed and the subsequent accumulation of small strokes had taken a huge chunk of out his independence. Now he is attending PT for chronic issues. The interesting part of Mr. B's stroke presentation a very particular and isolated manifestation of Parkinsonism. And for those who may not know, Parkinsonism means "characteristics of" rather than actual, primary Basal Ganglia/Substantia Nigra/extrapyramidal disease. Mr. B only experiences difficulty with initiation for sit-to-stand the beginning few feet of ambulation. His feet festinate like crazy, there's no arm movement to assist anything, you can see his left leg starting to pick up but not being able to cross the threshold. Check here for a visual of what a Parkinsonian gate looks like. The festinations experienced by the man in the video when turning are similar to what Mr. B experiences when he tries to start walking.
On my first day in this affiliation one of the aides (who are AMAZING, by the way) was helping him stand and them walk over to the stationary arm bike, but he got completely stuck once standing and spent at least 2 minutes festinating in place by the time the aides realized he was "stuck" much more severely than before. Another aide got my CI to help. They tried having him step over a line marked on the floor, step over their foot, move as big as he can, tgo around objects.... These were all attempts to trigger the external cueing needed to "unlock" a patient. They aren't weak or unable, they just need something outside of them, such as stepping over an object, to make the motor patterns fire. None of these worked for another 2 minutes. So Mr. B was getting quick the jitterbug workout for at least 4 minutes in total until finally they got him to turn (still in his festinating pattern) slightly to the left to go around an orange cone placed in front of him. He took a few quick shuffles, each moving perhaps an inch forward, and then BOOOOM! Just like that, he walked as though he had no ailments at all. He walked perfectly to the arm bike, side stepped to get around an object, took the cane that he suddenly had taken for a walk (rather than use) and hung it off a nearby, unused machine, and mounted the bike seat without any problem. Each stride was smooth as a whistle, weight shift from foot to foot was marvelous, and any decreased arm swing during gait seemed a mild remnant of the stroke. It's as though the Parkinsonism just washed away and disappeared. Amazing. Absolutely amazing.
This is why I am so interested in neurological physical therapy. There's nothing clear cut, all patients present differently even if they have similar diagnoses, and you never know what is going to come out along the way.
On another note, I've been posting kitteh [sic] videos on YouTube. I'm turning into a cat lady. But take heart that after another year or two, once I complete school and leave NYC, I will have a dog dog [sic] to compliment my kittehs. Imagine a boxer, pitbull, husky, or great dane kind of dog dog all snuggled up with the kittehs! Gee, its not obvious at all that I'm ready to move on with live. Not obvious at all... *cough*ahem* Here's one video of Merus to get you started, with Nathan's Civil War show contributing the sound score:
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