CASE STUDY |
(The client's name has been changed to honor the family's request for confidentiality. All other details of the case are factual.)
Jerome Smith
A Middle-aged
Man Who Had Suffered a Left Cerebral Stroke
In mid July 1994 we saw a middle aged man who had suffered a left cerebral stroke nearly ten years prior to our evaluation. He had received excellent and extensive medical care and medical rehabilitation therapies for the first two years after this cerebrovascular accident (CVA). At this point his therapy was discontinued with the statement "There is nothing more we can do. Whatever functions he has not regained within two years after the CVA, he will not regain." The family was advised to accept the situation and find ways to cope. His parent located a special educator with years of experience dealing with individuals with various learning and language disorders, some of them stemming from neurological disorders.
It was this educational therapist who referred Jerome for a HANDLE assessment. She had been working with Jerome twice a week for a number of years, to provide him some mental stimulation. She was frustrated that he had shown no progress in his ability to respond to conversation or in his ability to perform most self-help tasks and activities of daily living. He had learned to hold a pencil in his left hand and, with great effort, to write his name and a few other words or numbers, when given verbal cues as to the sequence and some visual reminders as to the shapes. His parents also were extremely frustrated, as was Jerome himself, although he could not tell us verbally.
Jerome had been a brilliant engineer prior to his CVA. He had been right handed, and extremely articulate. When we met him, he was basically unable to speak, other than to utter a slurred "yeah" when he was asked a yes/no question. His answer was usually reliable. He could tell you his name, which again was very slurred. He could repeat some words and even short sentences immediately after hearing them. He had lost most of his comprehension of conversation and of events--he could no longer "see" what things meant. In fact, his father had listed his main referral concerns for Jerome as visual-perceptual-motor dysfunction, and the goals they hoped to achieve were to enhance Jerome's ability to read and write, and for him to "see" and interpret what the sees. His father also noted that Jerome seemed oblivious to his environment at almost all times, especially if he was walking. His gait was still unsteady, and his stamina low. Jerome had also exhibited short term memory problems, making it very difficult for him to remember the question he was asked, or to remember what he had just done or heard for longer than a few seconds. He had been diagnosed with Agnosia and Anomia, simply meaning that he did not seem to recognize sensory stimuli or recognize their significance, and he was unable to name objects.
Upon evaluation it was evident that Jerome was a perfectionist. He would work and overwork his already weak systems in order to get as perfect of a result as he could, evidenced in the animal tracing page. He did not remember what it meant to "trace." But after he saw the example of tracing the horse's head, he then traced the kangaroo. He would not stop without finishing, although it took many minutes and great labor. Jerome wrote his name with the same laborious efforts. When he was asked to write his name with his eyes closed, he would not. He agreed to be blindfolded, and then wrote his name with much greater ease and better results than with his eyes opened.This was an important sign to us, since we realized that Jerome could tap into both visual memory and kinesthetic memory.
Jerome was able to perform a simple task of finger-tapping, touching the thumb of his left hand to each finger in sequence, with great ease. With tenacious effort, he learned to perform a finger-tapping pattern involving skipped sequence, but could not sustain this pattern independent of the evaluator's modeling. His right hand was immobile, and so could not attempt this task. In fact, Jerome had almost no sensation of the existence of his right arm and hand, except for some control of his right shoulder.
We were delighted to see that Jerome could cross his left hand beyond his midline, and touch his right ear. His ability to find his right ear, and then his nose, and then his right ear again, was a sign that he still had some sense of proprioception on which he could rely. We were also pleased to see, that when assisted to hold his head still, he could track a moving object with his eyes, although the clicking of his jaw as he did this indicated the degree of tension produced by this task. As hard as he tried, Jerome could not bring his two eyes to converge (focus together) on a half inch bead. Jerome also displayed that his visual stress was eased when objects he was too look at were in brightly lit spaces, or when they were highlighted with orange or yellow.
Other significant things Jerome showed us in evaluation were that his two body sides no longer worked in synchronous rhythmic fashion with one another. His left side--connected to the right side of his brain)--was receiving and responding to stimuli much faster than his right side. This was a very important clue to the root of Jerome's the breakdown in comprehension.
Each of the little things we observed in evaluation led us to construct a customized program for Jerome, one that his educational therapist incorporated in his twice weekly sessions. We also suggested a few passive activities that Jerome's untrained caregivers could help him with at the group home where he lived. These latter activities included placing 2 pound weighted cuffs on his right wrist and ankle for about fifteen minutes a day, when Jerome was sitting comfortably and watching television.
As we were demonstrating one particular activity--a form of tapping on the joints of his right arm--Jerome's facial expression suddenly changed. He was concentrating deeply, and seemed amazed at something. When asked, "What's happening? Do you feel your right arm and hand?" he answered with an into action of delighted surprise "Yeah!" His right hand, immobile for ten years, began to move that day, and Jerome has, incidentally, regained full use of his right hand, and returned to being right handed.
Other activities we advised for Jerome included one we call "The Archer" which relies on kinesthetic memory to guide visual tracking and focus, and one we call the "Peacemaker" to enhance his tactile and proprioceptive senses of his body. We wanted to enhance these functions, so they could again become automatic, freeing Jerome's energy for thought processes. We also devised activities that Jerome could do that would integrate the two sides of his body, and therefore his brain. We incorporated rhythm into these, since rhythm is a great organizer, and since Jerome's natural rhythms had been impaired. We also needed to strengthen Jerome's vestibular system so that it could support all the simultaneous activities it governs. All of the activities we suggested Jerome do or be moved through required less than a half hour to perform.
Within just a few weeks, his educational therapist began reporting changes. Jerome's short term memory was improving, gait and general movements (e.g., taking stairs, turning corners, getting into and out of a chair) were all becoming natural. His right hand and arm were becoming alive. He was so much more alert and responsive, it was at times surprising.
By September the family felt it was time for us to re-evaluate Jerome, since his progress had been so remarkable. We saw him nine weeks after our initial evaluation. Buy this time he was actually conversational! His speech was still somewhat belabored, but he enjoyed carrying on a conversation. That means, of course, that he was finding the words he wanted to express his ideas, and he was retaining the sequence of the conversation in short term memory. He was able to remember three and four part directions and to perform them accurately in time and space. His father was delighted that they could again go for after dinner strolls and carry on a conversation while walking. He as able to deal with numerical sequence, which was important to him not just for keeping track of time and money, but also as a social skill, since he had enjoyed playing cards prior to his stroke.
We restructured Jerome's customized activity plan. We had new goals. Jerome wanted to be able to dance, to get up smoothly from the floor unassisted, and to get back to reading for enjoyment. No one yet thought of Jerome's vocational retraining, moving to a more independent living situation and getting a job as immediate goals. But, yes, these were all now things that would be considered someday.
Jerome's educational therapist remained in touch with us for about another half year. He continued to progress steadily on the programs we had designed. She no longer needed our guidance, because Jerome had now moved to a level of capacity that was well within her realm of continuing to guide his progress without HANDLE intervention. We know that Jerome has continued to improve, for the simple reason that if he were not doing this, we would have heard again, from his therapist, from his parents, from his caregivers, and from Jerome himself. We cannot tell you where Jerome is now, in terms of his total life situation. One thing we know, he is a more functional, happier, fulfilled individual than the Jerome we first met. And despite the length of time (ten years) that came between his injury and our intervention, within less than 3 months, we had helped Jerome reach goals that had been deemed hopeless.
