I first met “Sandra” over 3 years ago when I was asked to assess her in the neurosurgical ward after being transferred from the Neuro-ICU. Thus begun a journey that continues to this day, illustrating the challenges and rewards of working in the specialty of rehabilitation medicine. I recall seeing two patients that day with aneurysmal subarachnoid haemorrhage. The other was “Leah”, a 69-year-old female transferred from another hospital with a Fisher grade 4, WFNS grade 5, SAH with a GCS of 3, due to a ruptured aneurysm arising from the right middle cerebral artery bifurcation with associated intracerebral and intraventricular blood. She underwent clipping of the aneurysm, subsequently required a VP shunt for hydrocephalus, and intraarterial therapy for moderate cerebral vasospasm. Four weeks after admission, she was still drowsy, was only able to follow simple instructions, had weakness in her left leg more than the arm, demonstrated neglect of her left side, and still required full nursing care including a hoist to lift her out of bed.
Despite this, it was agreed that she would be better served temporarily moving into an aged care facility providing high level care, with regular physiotherapy onsite, rather than one of the recently opened disability group homes funded by the NDIS.
However, three months after discharge from MetroRehab, and eight months since her SAH, and despite intensive outpatient physiotherapy, she had developed a flexed right knee that was not able to be straightened, with an associated pressure ulcer in her popliteal fossa. Many would call this a fixed flexion contracture, a term I generally try to avoid due to the implications on reversibility. In the interim she had developed evidence of hydrocephalus on imaging. I referred her back to her neurosurgeon and eventually proceeded to VP shunt insertion. However, this was postponed by several months due to the development of an extensive DVT in her right leg, precipitated by the severe spasticity causing immobility in that leg.
It took us a further four rounds of botulinum toxin injections into her calf and hamstrings, over the subsequent 12 months, coming in and out of various rehabilitation programs including multiple brief inpatient admissions and day program attendances at MetroRehab, with the use of various splints and casts on her leg, and outpatient physiotherapy at the nursing home, for her to improve to the point of being able to walk independently, with only a slight limp. Over the same 12-24 month period, she continued to gradually improve cognitively and functionally, and with further rehabilitation, she was able to physically perform ADLS with the use of both arms and speak in full sentences with emergence of her infectious personality, albeit with ongoing memory impairment.
In 2020, three years since her initial presentation, partly due to COVID-19, she has moved out of the nursing home into the care of her family. She continues to improve cognitively, is running up and down stairs, is considering moving into a group home for people with disabilities appropriate to her needs, and in the longer term is considering some form of employment, with the assistance of the Royal Rehab Brain Injury Community Rehabilitation Team.
Even if someone has been given an unfavourable prognosis, it is never too late to revisit the question of whether rehabilitation may be of benefit, especially as options for pharmacological management and evidence for new technologies emerge.