|Author: Bettijane Eisenpreis|
|PT Helps Patients with Brain Injuries|
|Physical Therapist Steve Dawson frequently begins working with patients as soon as they are considered medically stable. Some are severely affected by stroke; others have not fully emerged from coma. His self-assigned mission is to bring them back into life.
ÏI went into physical therapy because I wanted to have a positive influence on the lives of people who suffer from physical impairment. Helping others Ò I really believe this is why we are on this earth,Ó says Dawson, Clinical Coordinator of the Department of Professional Development at INTEGRIS Jim Thorpe Rehabilitation Hospital in Oklahoma City, OK.
After receiving his bachelorÌs degree in physical therapy, Dawson did postgraduate work in neuroscience and rehabilitation, becoming an instructor in Neuro Developmental Treatment (NDT). ÏNDT is a management philosophy approach that is used with people with central nervous system (CNS) dysfunction or pathophysiology like stroke, head injury, brain tumor,Ó he explains. ÏWe deal with anything above the level of the spinal cord. The main aim of the NDT approach is to promote restoration of function within the patientÌs brain or CNS and then facilitate functional use of the impaired body segments.Ó
In 1996, the management of Jim Thorpe recruited Dawson to improve the knowledge and skill of the facilityÌs staff relating to NDT. Dr. Pam Clark, psychologist and Director of Neuro Rehabilitation and Research Division of INTEGRIS says, ÏI have known Steve Dawson for ten years and am extremely impressed by his ability to connect with his patients and their family members. He is a master instructor on NDT techniques and willingly and enthusiastically shares his expertise with clinicians.
ÏIf I ever have the unfortunate incident of a stroke,Ó continues Dr. Clark, ÏI would want Steve Dawson to be my physical therapist. I donÌt know of a higher compliment to give a professional.Ó
Surprisingly, patients do not have to breathe on their own, or to be fully conscious to be treated [by Dawson]. ÏOur facilityÌs major focus is inpatient acute neuro rehabilitation,Ó Dawson explains. ÏTo qualify, a patient must be able to tolerate three hours of rehab a day. The spirit of our guidelines is that people should be active participants in the rehabilitation process and have achieved a level of medical stability so that their entire systems can tolerate the rigors of rehabilitation for at least three hours every day.Ó
ÏWe do work with some coma patients,Ó Dawson explains, Ïbut we like them to be able at least to respond to general stimuli, something beyond reflexive response. To realize the optimal benefit of therapy, the person must eventually have the ability to want to work at getting better.
ÏThe most heart-warming experience IÌve had is to start with somebody in a coma when there is nothing going on. You sit or stand him up and, all of a sudden within your own nervous system, you feel a connection,Ó he said. ÏThe person is starting to come out of it. Eyes will open up; people will turn and look at a family member and connect or smile, because of something you did that provided a stimulus to wake up their nervous system and get them back on the road to life.Ó
ÏI remember seeing a young patient a week after he sustained a spinal cord injury. He was still in a casted torso apparatus because the surgery on his spine was not yet stabilized. And after six months of on-again, off-again therapy, the boy walked out to his truck with long leg braces on and crutches and changed the oil. He had beaten all the odds to get that done.Ó
Whether consulting with other therapists or working directly with patients, Dawson emphasizes Ïworking smarter,Ó by treating patients on a case-by-case basis. ÏIf a patient is fifty years old and has a stroke, he or she is ready for therapy a week later. But if an older person had been sick for a month and then has a stroke, that person may need to work at getting stronger and engaging in the environment. After sixty days of that type of intervention, the patient may come into rehab. We need to maximize our efforts relative to the patientÌs ability.Ó
ÏWe must look at where the patient is developmentally,Ó Dawson says. ÏMost adults, if they are intact, active individuals, operate vertically Ò sitting or standing up. Even though somebody may not have much use of the stroke side when we start therapy, we try to get him or her into a position to where we can stimulate the nervous system to recognize and use the impaired side again. ItÌs a lot easier to work the muscles on that side and get the responses we want if the patient is vertical. In order to effectively support weight on their impaired side, to take a step, to keep their torso erect, they must operate in the vertical plane.Ó
An important part of DawsonÌs job is mentoring. ÏA therapist may call me and say, ÎI have racked my brain and tried everything I know and the patient doesnÌt seem to be progressing as I would like. What do I do now?Ì
ÏI may either ask the therapist to try an approach while I watch, or I may work with the patient myself. I demonstrate how I might work with the patient in specific activities that should be therapeutic to specific impairments and limitations. The therapist and I talk, both during and after the therapy session. I may suggest certain types of strategies or interventions. I donÌt tell a peer professional exactly what to do, but I give my projections and recommendations along the lines that I would try to work.Ó
Dawson conducts in-service workshops, forums and study groups. ÏWe look at specific problems the therapists are having, or we may study interesting articles and recent developments in the field. Before I present an in-service, we do a survey to find out what topics people want to hear about. I may research the topic myself or bring in a guest presenter.Ó
In addition to his consulting role, Dawson is, first and foremost a physical therapist. ÏOnce I receive an order for evaluation and treatment of a patient, I review the chart, history and medical conditions,Ó he says. ÏThen I perform an evaluation of all the systems of the patientÌs body, including skeletal, neurological, cardiopulmonary. I try to get the patient to move and engage with the environment so that I can see where impairments are causing functional limitations. Why canÌt she get up out of bed? Why canÌt he put his pants on? Why canÌt they walk?
ÏI look at the cause of the impairments. I have to decide whether the condition is orthopedic, musculoskeletal or biomechanical. Have they twisted their arm so that their shoulder girdle doesnÌt work, or is it neurological and they canÌt recruit the correct muscles in the right timing and sequencing for the arm to work well? If the problem is neurological, thatÌs my department.Ó
ÏWe look at the entire body and decide why canÌt the patient recruit the necessary muscles to get the function done. Is something impeding the process? For example, he may be stabilizing too much with his other side. I might have to give that other side a different job. If a patient is sitting up on the side of the bed and he feels out of balance, he grabs on with the arm that still works well. That doesnÌt help him activate the impaired side. I may give him something to hold with his good hand, creating an opportunity for the other side to hold him up.Ó
Working within the limitations of managed care presents Dawson with challenges and opportunities. ÏAs a rule, insurers will allow patients to remain in a facility like ours for three to four weeks ,Ó he says. ÏAt that point they can either go into home health or outpatient therapy. If they are not progressing Ò surely it wouldnÌt take you four weeks to realize this - they may be sent to a skilled nursing facility or nursing home.Ó
To Dawson, these first weeks are only a first step on the road to recovery. ÏI think we need to look at rehab as a process, which is different for each person,Ó he says. ÏStill, a typical patient is not going to reach his full potential in a year, or even in six years. ItÌs going to be a lifelong endeavor. It usually takes skilled intervention to help them realize their potentials. I donÌt mean that they have to be in therapy once or twice a week for six years, but they need to seek out therapies or interventions as they encounter new challenges along their life continuum.
ÏIf stroke affected a woman at a time when she was retired and all she wanted to do was to get around in her house, sit in her rocking chair and occasionally walk around her property. She may have a spouse who is doing a lot for her, and between the two of them, they manage. Something happens to the spouse, and now the lady is left on her own. She may need more, but also itÌs a challenge. Improvement or recovery or restoration of functional mobility is not on any timetable.Ó
In order to continue to help patients who no longer live near the Jim Thorpe facility, Dawson and his team are conducting research on Îtelerehabilitation.Ì ÏWe use audiovisual real-time transmission, the kind that is used for teleconferencing in business,Ó Dawson reports. ÏIn the pre-pilot phase, we ask patients to go to a hospital convenient to them and work with the therapists there, under our long-distance supervision. They will also work with with family members, caregivers, or extenders.Ó
In a recent article by Dawson, ÏThe New Frontier: Telerehabilitation,Ó (PT Case Reports) he is doing further studies to assess the efficiency of this approach and refine this exciting intervention medium.
The Jim Thorpe team is also involved in other research projects testing the efficacy of NDT intervention for stroke patients, as well as projects on balance and spinal-cord injury.
Dawson always to find challenges in his work. ÏIf I ever feel that it is just a job and I am not making a positive difference in somebodyÌs life, I will either do whatever I can to learn more, or IÌll leave the profession,Ó he asserted.
But he isnÌt leaving any time soon. ÏI continue to be awed by the driving force in people to change. People need to keep living, and that means changing. My driving force to help people get better and live their lives again, because getting better in medical terms without being able to live life again doesnÌt really help. The push is not only in terms of management environments Ò when to introduce rehab, when to do home health, but also to strive for more understanding of the brain and how it works so that our interventions or strategies can be more appropriate as to how the brain can recover. These are the driving forces that will keep me going for the rest of my career because it makes an impact on peopleÌs lives. The plasticity of the brain is beyond our imagination.Ó
Steve Dawson, PT, received a bachelor of science degree from the University of Missouri, Columbia, MO, in 1978. His postgraduate work in neuroscience and rehabilitation was done at Northeast Missouri States and at Texas WomenÌs University. He is a certified PT instructor in Neuro-Developmental Treatment (NDT).
Bettijane Eisenpreis is is a freelance writer from New York. She is on the staff of NEWS-Line for Physical Therapists and PT Assistants.