That was the response from a patient, who walked for the first time Wednesday since his stroke nine weeks ago, when I told him his head was moving forward twice as fast as his legs and thus twice as fast as me. His message came with a fist bump and a smile.
When told we would receive this patient directly after he spent four or five weeks in acute rehab and accomplished nothing more than hoyer lift and the occasional sliding board transfer, we all completely balked. We are not set up for high needs patients. We lack equipment. (How do we not have a single commode with a drop arm? How do we not have parallel bars?) We lack RN training for that level of mobility and the imperative of having the patient always doing as much work as they can. We lack the ability to schedule therapists to cover such high need patients due the complexity of set up, problem solving, the need for high repetition, and extensive family training. Our Swing program, meant to act as a short-stay pseudo rehab in an area where actual rehab facilities do not exist, is reserved for ambulatory patients who will definitely discharge home in no more than two weeks' time. So to take on a patient who was declared to be maximum assist/dependent for all basic activities seemed inappropriate, both for our facility and out of respect for the pt's needs.
We are now excessively happy to have been proven wrong.
Turns out that the therapist note from acute rehab did no justice whatsoever to the patient's presentation. They also seem to have done nothing with the patient during those weeks, wasting a very neuroplastic time frame with minimal to no functional training. Maybe they didn't know how to treat lateropulsion. Maybe they were kinda lazy and didn't want to do the work required for his level of need. Maybe they just didn't realize that the only way you get return into a flaccid limb is by progressive and supported weight bearing, and that you have to push the not-quite-ready activities in order for the previous steps to truly improve. Maybe they forgot that standing, someway somehow, is one of the most basic tenants of rehab.
Regardless, we received the patient with a still completely flaccid right arm and right leg, and his sense of balance and assistance during mobility was to strongly push himself over onto his flaccid side. After a mere two and a half weeks he has a good deal of functional tone in his leg, meaning when in a standing position his leg will accept weight even though it cannot control it and he cannot move his leg voluntarily, and he has walked with moderate assistance and the arm rails along the hallways of the hospital (which we cleared through maintenance prior to initiating). And he only pushes when he is tired or the activity gets set up funny and is extra challenging.
Yesterday morning, ambulation day #1, he/we did four repetitions of 12 feet. Yesterday afternoon was more of the same. This morning was two repetitions of 14 feet followed by transfer training with a freshly facilitated stand portion of a stand-pivot method.
Plus in outpatient I have recently acquired a slew of neurological patients: a spinal cord injury fresh out of Craig Hospital, a subdural hematoma, inclusion body myositis, what was assumed to be super severe diabetic neuropathy by the referring doctor but is more likely a spinal cyst....
Meaning? I'm totally geeking out. And even though I'm
exhausted from the lack of infrastructure and lack of greater institutional
support for providing an acute rehab do-over, I'm having a lot of fun.
As a neuro geek of a therapist who gave up a complex neuro caseload in
NYC for a different extra-professional life (i.e. having a life outside
of work), I though I had given up neuro by coming to such a small rural
community that lacks a neurologist within two to three hours in any
given direction. And until the last few weeks it has been 95% orthopedic.
Now I finally feel like my therapist self again.
