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The linchpin of occupational therapy is the practice of routine daily activities, such as brushing one's teeth, standing up to pull on pants, writing, cooking, and so much more. OTs have many techniques to promote recovery. Sometimes, they work on subcomponents, the essential foundations of movement, such as recruiting silent muscles to “wake up,” strengthening, flexibility, and dexterity, or on individual skills like literally raising one’s arm or grasping an object. Different equipment is available to facilitate these efforts. For example, Matt’s therapist used a vibrator along the forearm muscle fibers to stimulate muscle activity and electrical stimulation to artificially produce a muscular contraction while simultaneously challenging him to attempt to squeeze the muscle and raise or flex his hand. On several occasions, Matt was rigged to a Deltoid Aid, a framework of pulleys, springs, and slings that encircled him from above. Counterweights offset the weight of his arm and assisted just enough to enable him to lift his arm in front, out to the side, or across his body.
By virtue of Matt’s obvious inabilities, not all functional interventions could be attempted at this time, and some required multiple people to carry out. With the help of a mechanical lift, two therapists sat Matt on the edge of a mat table. Since Matt’s balance was almost nil, one therapist propped him just so and held on tightly to prevent him from toppling over. A second therapist batted a balloon for Matt to stretch out and tap back to her. Unlike very instructive exercises, “Do this or do that,” this enterprise was intended to elicit an automatic response to a familiar type of activity, bypassing the need to process the command cognitively. The balloon effectively caught his attention while the exercise worked his core and arm muscles and gave him a sense of accomplishment playing this simple game.
As Matt’s coordination and the dexterity of his dominant left hand improved, the emphasis of therapy shifted. A Connect 4 game was set before him, with instructions to fill it. Matt was at a loss for what to do. He picked up a chip, manipulated it, and put it back down. The next time he picked a chip up, the OT guided his hand to one of the slots and demonstrated how to release it, but he waivered forward and backward around the playing board without purpose before placing it on the table again. In time, and most likely by luck, he dropped it down a slot. For the next week, he did better and better with practice—not lightning fast by any means, still pausing and hesitating until he filled the board one day. When given a pen and paper, Matt scrawled “buy” in response to my departure one day, followed by his first name, “Mathew”—how extraordinary.
Connect 4
Other tabletop activities included affixing clothespins to a tall pole or the edge of a large coffee can. A sloped pegboard with one-inch-diameter pegs was placed in front of him. He had to learn to manipulate the pegs, reach up, and fit them into an open slot. Later, he would be challenged to reach farther up the board, alternating colored pegs or filling every other row or column. In his free time, family members wheeled him to the OT gym to work on these activities and different games and puzzles to reinforce what he was learning. As in the ICU, the therapists here welcomed our involvement and were always complimentary of our efforts to work with Matt on our own time.
Glimpses of right thumb movement were first observed in early June. Over the next few weeks, this was followed by slight forearm activity and, days later, by an occasional movement of the index finger and even later by other fingers. Nothing predictable or guaranteed, but something.
Nursing and occupational therapy collaborated on bathing skills. Sitting in a shower chair, Matt helped wash his chest, belly, and right arm and shampoo his hair. The OT demonstrated how to don a shirt using one arm and encouraged him to do his best, but Matt was only modestly engaged. Since OT found it easier to motivate him to do activities in the rehab clinics, she spent more time and effort there.
Matt’s recovery of bowel and bladder control was very slow. It took two months before he progressed to using the toilet and, at best, averaged one success out of a dozen attempts. The nursing staff created a toileting routine and schedule. It was time-consuming for the aides since they couldn’t leave Matt alone. Standing in the bathroom, waiting and waiting, they hoped and perhaps even prayed for Matt to tinkle. To facilitate urination, the staff tried a variety of tricks, such as running water, sticking his fingers in water, playing music, singing, or whatever they could think of to help relax his bladder sphincter and give him a sense of what needed to be done. But no go (pun intended).
I fretted. I desperately wanted this business taken care of before he came home. A coworker approached me, explaining that based on his experience, a young man like Matt would regain bowel and bladder control; it was not a matter of if but when. He encouraged me to be patient. I had to accept that Matt would most likely come home wearing pull-up diapers and in need of the same care I had given him as an infant. Baa humbug—I dearly had wanted toileting to be resolved at Sunnyview.
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