Caring for the Severely Impaired Patient
There is new evidence in the physical therapy world that creates a paradox. The patients who benefit the most are the patients who receive the least therapy. Everything I read demonstrated that the more impaired patients made the greatest improvement when provided with the most intense therapy. This was true in the acute, subacute and chronic stage. Higher-functioning patients tended to have similar results regardless of intervention, intensity or duration. Lower-level patients improved by leaps and bounds.
Severely impaired patients often require two people. It takes them twice as much effort to do less than half the work. They fatigue quickly. Cognitive problems interfere with participation. They are usually the first ones skipped when caseloads get heavy. Therapy durations may be longer but actual time in therapy is less. I walk away exhausted when I have a few of these on my caseload.
Traditional teaching says these patients have poor rehab potential. The evidence is saying something else. The AVERT (A Very Early Rehabilitation Trial) found up to a fourfold increase in good outcomes when these patients received early mobilization. Body-weight support is being found to be most effective for stroke patients who are non-ambulatory at the start of therapy.
Brains are the most plastic immediately after injury. Later plasticity is dependent on what happens in those early months. It seems we're doing these patients a disservice when we regularly skip them or substitute ROM exercises for more functional activities. Getting them moving can be exhausting work for the therapist.
Even chronic patients were benefiting. It seems dense hemiplegics and lower-level brain injuries benefit just as much from intense therapy even later in the game. Sometimes it takes the brain a longer time to heal and get to a place where it can process the input from therapy. I wonder if some of these patients are being discharged for lack of progress just as they finally begin to be able to participate.