About brain injury

No day is the same, but the similarity is that there are new challenges every day'

Written by Miranda Hazeu, occupational therapist and figurehead, WZH Nieuw Berkendael The Hague. (All names are fictitious)

An ordinary weekday. The alarm goes off. I get up, shower, get dressed, have breakfast and go in the car on my way from my hometown Rotterdam to The Hague. On the way to a day full of challenges. I have been working in WZH Nieuw Berkendael for over 25 years now and no day is the same.

I park my car and walk in through the entrance. I am greeted by Kees: "Hello, are you off the phone today?" "No Kees, the sign in your room says who is your point of contact today and who will call you today."

Mail and planning for today
I start up the computer and read my mail. Today I drop by Pieter because I see in the mail that there is a pressure spot on the big toe. Then I look at my appointments with clients for today. It promises to be a varied day.

Kees
Today, together with the psychologist, I map out the state of consciousness using a measuring instrument agreed upon in the EENnacoma network. Kees follows today with his eyes, so this means a higher score than the previous test (3 days ago). And, much more importantly: a first sign of minimal consciousness! I will use the following that Kees now does with his eyes during therapy to provoke Kees to make choices by looking at something. I adjust both hand splints and move on to the next client.

Pieter
Pieter came to full consciousness almost a year ago. Pieter can indicate yes and no, which allows him to answer closed questions correctly. He has severe motor limitations in arms and legs. Pieter's personal supervisor had emailed me about a pressure spot on the big toe. Pieter is very sensitive to pressure spots and that is why I have often looked at the lying position together with various care workers.

Pieter is lying on the bed when I enter his room. I check his lying position and see that the big toe is not completely free, despite the lying orthosis. I feel a very increased muscle tone in the leg and notice that the leg can no longer be fully supported in the lying orthosis.

Time for consultation with a healthcare worker and doctor. Because the situation suddenly seems to have changed, the doctor has to rule out a number of physical things (such as a urinary tract infection).

We agree that this afternoon I will watch a nurse from the ward when they put Pieter to bed for the afternoon rest. Finally, I contact the advisor of the lying orthoses. To be on the safe side, I want to schedule an appointment to assess the lying position and see if the current lying orthosis is still adequate.

Pieter is now in his adapted wheelchair. I check the sitting position and see that the pressure spot on the big toe cannot have arisen in the wheelchair. I will report this back to the care worker with whom I consulted earlier today.

Residential training
Abdul was admitted with a disorder of consciousness. An intensive process was started aimed at raising consciousness and after 3 months Abdul was fully conscious. At that time, there were still significant motor and cognitive problems.

The rehabilitation process then focused on motor development, cognitive progress and more independence during general daily living activities (ADL).

Situation a little over a year after admission: Abdul walks the distances indoors with the help of the walker, is almost ADL independent and comes to the therapy appointments himself. He started practicing with a mobility scooter.

Abdul now 'lives' in the training apartment in WZH Nieuw Berkendael. The stay in the training apartment has the following starting points:

• Self: autonomy, individuality, own strength.

• Together: standing strong together, added value in working together

• Stability: safe environment, future-proof

• Development: personal growth

There is a kitchen in the training apartment. Abdul tries to pick up his own life again, in preparation for being discharged home. He takes care of breakfast and lunch himself, cleans up and makes his own coffee and tea. The past few weekends, Abdul has been home to slowly build up the discharge home.

Today I discuss with him the weekend leave forms that I have given and that both he and his partner have filled in. No problems emerge. In the home situation, Abdul actually seems to function a little better. In the conversation with Abdul and his partner next week we will discuss the final discharge date. I think that's so beautiful that, after a long rehabilitation process with step by step progress, Abdul will now soon be going home again.

'Every client requires a specific approach'

Thea
My next appointment is with Thea. Thea has been admitted to us with a rare clinical picture that has caused brain damage. As a result, there is tetraparesis, among other things. Thea can now give a good voice again, after the tracheostomy tube has been removed.

Some function is now returning in both arms (left more than right). In her legs there is occasionally some slight tightening, but Thea indicates that she has no control over this yet.

Today the physiotherapist and I have an appointment for a combination treatment with Thea. We are going to try the standing table. Thea finds this very exciting and scary. Especially the idea that she is not in control herself is difficult for her.

Together with Thea, we take the time to discuss how she is still in control as much as possible. We agree that she will say 'stop' if she wants to wait a while before further verticalization. In addition, Thea says that it helps her if she can hold a hand. We agree that the physiotherapist operates the standing table and feels the muscle tension when Thea is standing. I stand in front of her and she can hold my hand.

When slowly getting up on the standing table, Thea's tension clearly increases. I feel a clammy hand and Thea repeats that she finds it "really scary, but good". She tries to push the boundaries herself by always wanting to stand up a little more. Once she is upright, the tightening of the muscles in the legs can be felt. Thea bursts into tears when the physiotherapist tells her this. She says that she was afraid that there would be nothing to feel in her legs and is very happy that something is happening now.

LIN Program
Recently, the LIN program has been established within EENnacoma. LIN stands for Long-Term Intensive Neurorehabilitation. This program follows the Early Intensive Neurorehabilitation in the Leijpark. The goal of the LIN program is to raise awareness through therapy and stimulation. Therapists, care workers and family work together in this.

The coming period will be dominated by the implementation of this program. Some things from the program we already do in the requested way, for some points we have to make an improvement/implementation plan.

Today I have an appointment with a project officer of WZH to see how WZH Nieuw Berkendael can get support with this. We find the ultimate assurance especially important here. In the conversation with the project officer, it becomes clear once again how specific the care for our group of clients is.

Transition team
The next item on my agenda is a meeting of the internal transition team. We meet every two weeks. Today the planning for the coming period is on the agenda. To this end, we have divided the criteria for the DEC and REC into themes. Today we will link this to short-term working groups with a clear assignment. It takes us more than an hour, but we are certainly one step further in the transition process.

Susan
Susan was admitted to the LIN program last week. After the VIN in the Leijpark, she does not yet have full consciousness. That is why I now have the LIN programme.

Together with a colleague from healthcare, I look at the different splints. There was a clear transfer from the Leijpark, but because the splints are made by a different supplier, there are always small differences that I discuss with the caregivers.

The most important thing for today is that I request a tailor-made wheelchair for Susan at the care office. Together with the advisor of the wheelchair company, I look at and assess the posture in the temporary wheelchair. More care for the head is necessary. The head now turns to the right and I want to compensate for this with a headrest, since Susan communicates with her eyes and a good starting position of the head is necessary for this.

I call partner to pass on that I have looked at the splints together with a care worker and also that I will make a request for a customized wheelchair. Partner still has some questions about the therapy, so the conversation takes a little longer than planned. However, I think it is important to take the time to answer the questions he has.

End of working day
This was just part of a working day of mine. I see a great diversity of target groups, each with its own way of approaching. The steps the client makes, no matter how small they sometimes are, makes me enjoy every day. The day has flown by again. And the great thing is... Tomorrow is a new day full of challenging clients and issues!