WEST ORANGE, N.J. — In the therapy gym for the minimally functional, Jodi Levin props a patient between cushions, kneels behind him and then braces him with her arms. She directs his mother to select photos of his brother and his father. At the coaxing of Ms. Levin, an occupational therapist on the brain injury unit of Kessler Institute for Rehabilitation, the mother holds one photo to the left side of the patient’s head, the other to the right.
“Look at Dad’s picture,” Ms. Levin urges. “Dad’s on the left. Find Dad. You can do it!”
The patient, wobbly and glazed, tries mightily to understand her command and then heed it by compelling his neck to turn. He almost makes it.
Gently letting him go, catching him as he flops, Ms. Levin explains to his mother, “Now I’m working on trunk control.” The man flinches. “It’s the basis of everything,” she continues. “For getting in and out of bed, brushing teeth, getting dressed.”
Eight weeks earlier, the patient, 18, wearing a helmet and protective leather gear, had been riding his motorcycle to community college. As he came over a hill, the car in front slowed abruptly; to avoid hitting it, the teenager swerved and was hit by an oncoming car.
Remarkably, his body survived relatively unscathed. But he suffered a severe traumatic brain injury. He cannot yet swallow food, control his bowels or regulate his body temperature. His brain cannot yet send messages to his limbs. He cannot speak.
When he arrived here, his eyes were open but unseeing. He has already come a long way.
His care is overseen by neurologists and physical medicine doctors. But it is the job of Ms. Levin, his occupational therapist, to plan exercises that will help him develop or adapt skills to live as safely and independently as possible. She also educates and supports family members as they adjust to their loved one’s new normal.
Now Ms. Levin puts her grimacing patient, who wears nerve stimulators 12 hours a day, onto a therapeutic exercise bike. The machine moves the pedals, but as he initiates more movement, it will calibrate. She straps him in, jesting, “I can’t wait for you to yell at me and tell me this stinks.”
The boy’s mother watches Ms. Levin tearfully. “Some people talk around my son as if he’s not there,” the mother says. “But Jodi talks right to him.”
Ms. Levin, 28, has worked on the brain injury unit here for six years. Daily, she confronts the fallout from behavior that has been reckless or cruel, with injuries caused by drug overdoses, drunken drivers and drive-by shootings. Many of her patients have had strokes or brain tumors. She has also treated Iraq war veterans, who are now trickling into nonmilitary facilities like Kessler largely because of the persistence of their relatives.
Her treatment plans adjust to the serendipity or horror of a split second: a hit during a football game, a slip on an icy patch, a veering car. Annually in America, there are 1.5 million traumatic brain injuries, a category that includes external blows to the head but excludes damage caused by illness.
The extent of destruction to a brain, the possibility of recovery for each patient, hinges on so much — and so little. Ms. Levin’s definition of optimism for one patient may be regaining the ability to drive. For another, it may be the ability to blink in assent.
When patients sustain frontal lobe injuries, their personalities can be affected. They may unexpectedly become agitated or angry and have difficulty filtering inappropriate language. On occasion Ms. Levin’s hair has been pulled. She has been kicked, groped and bitten. “The families are so embarrassed,” she says. “I keep explaining that it’s the brain injury, not the patient.”
Yet even in her brief career, there have been advances in occupational therapy, which can address many mental and physical disabilities. Ms. Levin, who has a master’s degree in the field, has been adding computer-generated programming to her capacious toolbox, which includes blocks, flash cards and cutlery adapted for stroke victims. The prognosis for many patients is improving.
At the same time, though, insurance companies are demanding more frequent updates, with proof of functional rather than cognitive progress. Otherwise, requests for further therapy may be rejected.
In reality, Ms. Levin says, cognitive ability often precedes functional progress. “A young brain won’t plateau at month two or three,” she says in frustration, during lunch break. “Recovery from a brain injury is not like the flu. It takes a long, long time.”
On this early day in the new year, Ms. Levin has seven patients. Three are 18-year-old men. The winter holidays often bring a surge of adolescent patients and their victims to acute rehabilitation centers. Elsewhere in the unit’s two gyms, therapists work with patients who were passengers in car accidents. Another influx of this kind of patient tends to arrive shortly after spring break.
Her second teenage patient, a bright high school athlete, went to a party at which prescription and illegal drugs were swapped. He was the only youth there whose body reacted starkly. He went into cardiac arrest and his brain lost oxygen, before doctors were able to revive him.
During his session this day, Ms. Levin places her face close to his, and makes simple, cheery conversation, trying to hold his gaze. “Hi!” she says. He stares back, eyes widening, eyebrows raised in concentration and effort. His jaw lowers. “Hi,” he mouths silently.
“That’s a breakthrough!” she says joyfully.
Ms. Levin sets weekly achievable goals for her patients. “I invite families to watch my sessions,” she says, “so when they visit, they don’t say, ‘Is that all he can do?’ I want them to see how hard the patient is working to achieve holding up his head.”
She sees her third 18-year-old in an adjoining gym for more functional patients. The boy is healing from an operation in which doctors temporarily removed a section of his skull to accommodate brain swelling. His jaw is wired shut. He has visual and cognitive impairment.
In early December, he drove after having a couple of drinks, crashed, flew through his windshield and hit his head.
But last week, after interviewing his family about his activities, Ms. Levin had him playing tennis with a balloon. A few days ago, he halted his wheelchair before a vending machine, correctly counted his coins and got a soda. On this day, holding a trained therapy dog by a leash, he walks haltingly across the gym. She hands him a word-search exercise: he picks out three-letter words. By the end of the month, Ms. Levin expects him to go home and to start outpatient therapy.
“He’s a miracle,” she says.
As for her feelings about his own role in his injury, Ms. Levin says, “Everyone deserves a second chance to redeem themselves.” Nonetheless, she adds, she would like to show videotapes of her patients to high school students.
One patient in particular haunts her. He was a 21-year-old drunken driver who survived a terrible accident. After many months, he left Kessler in good shape, mentally and physically. Ms. Levin happened to work a rotation in an outpatient clinic and continued treating him.
“He’d come in and boast, ‘Hey Jodi, I was out drinking last night, blah, blah, blah,’ ” she recalls. “He was my biggest failure.”
She glances around the gym, at therapists and doctors working with patients in various states of alertness. A father tenderly kisses a young woman on the forehead as she stares vacantly. An elderly woman tries to sort plastic knives from forks.
“I had a young boy, about 20, who had been in a car accident,” Ms. Levin says. He had been driving at night, was blinded by headlights and, in the ensuing crash, was ejected.
He was in a coma. He had brain surgery, plus broken legs and wrists. Ms. Levin treated him for three months. He left Kessler with a walker. During her outpatient rotation, she continued working with him.
“He still has memory deficits,” she says. “He repeats himself. But he covers it well. He can drive now, and he has a job stocking shelves.”
The accident was three years ago. He talks of going back to college, perhaps to study occupational therapy. “He called recently and said, ‘Can you help me find an O.T. school that will accept me?’ ”
She smiles tremulously. “When you have one good patient like that,” she says, “he sticks in your head. He gives me my drive. I think, ‘It can happen.’ ”
source: NY Times article by Jan Hoffman, in the “Science Times” section, on 1/15/08. www.nytimes.com. Science Times comes in every Tuesday edition of the Times; it is full of useful, odd, amazing information.