THERAPY-Magazin
A persistent vegetative state to working capacity thanks to verticalisation – A case study
Discover how targeted verticalisation and therapy helped a patient in a vegetative state regain independence, return to work, and rebuild her life—against all odds.
Karin Neidhard
Qualified occupational therapist and lecturer
The importance of verticalisation of people in a vegetative state in home care is shown below in the case of a nurse for the elderly, S.S., whose neurologist at the time said to her husband during his first and only home visit: “The child has fallen into the well, there is nothing more to be done – I won’t come back here again and won’t be prescribing any therapies”.
Long-term out-of-hospital care of severely neurologically affected patients in the home environment requires competent interdisciplinary cooperation and a high level of professional expertise. Only in this way can those affected be supported in the best possible way and their caring relatives be informed as much as possible and guided to integrate the progress made in therapy into everyday life.
It can be read in the international literature that verticalisation brings the following benefits in particular:
• vigilance and consciousness are positively influenced.
• the 7 remission stages (according to Gerstenbrand) are passed through more quickly.
• consequential complications such as spasticity, pressure ulcers, contractures, dysphagia, ventilator dependence, etc. can be avoided or reduced by early mobilisation.
• the vegetativum (unconscious nerve system), including circulatory stability, lung ventilation, urinary flow and digestion are positively influenced.
• osteoporosis prophylaxis is also practised.
• spatial and positional sensation, depth sensitivity and body schema are significantly improved.
It can be read in the international literature that verticalisation brings the following benefits in particular:
• vigilance and consciousness are positively influenced.
• the 7 remission stages (according to Gerstenbrand) are passed through more quickly.
• consequential complications such as spasticity, pressure ulcers, contractures, dysphagia, ventilator dependence, etc. can be avoided or reduced by early mobilisation.
• the vegetativum (unconscious nerve system), including circulatory stability, lung ventilation, urinary flow and digestion are positively influenced.
• osteoporosis prophylaxis is also practised.
• spatial and positional sensation, depth sensitivity and body schema are significantly improved.
In December 2015, the nurse for the elderly, who was also ward manager, S.S., suffered a subarachnoid haemorrhage during boxing training due to the rupture of an aneurysm of the posterior right communicating artery. A right decompressive hemicraniectomy and endovascular coiling were performed and a shunt was placed.
Complications that developed in the following weeks were symptomatic of epilepsy following hydrocephalus malresorptivus, meningitis, postoperative haemorrhage with haemorrhages and repeat shunt implantation. As well as this, a PEG was inserted for parenteral nutrition and the patient was fitted with a suprapubic catheter.
S.S. was discharged home in February 2016 in a state of wakefulness; her husband and an outpatient care service looked after her. The patient received physiotherapy twice a week via home visit – she carried out passive movements in bed. During this period, the only home visit by the neurologist in private practice, quoted above, took place with his scathing verdict.
In March 2017, I met the then 42-year-old mother of two school-age children in her owner-occupied attic flat in an apartment building where her parents and siblings also live with families:
Tetraplegic, left half of the body flaccid, right half of the body spastically paralysed, with flexion contracture of the right knee, malpositions due to flexion contractures of both ankle joints, also aphasic but breathing independently and not tracheotomised. All that was possible was unreliable communication via winks to her husband. The patient’s disturbed sense of space and position was also noticeable, which manifested itself in her constant searching for a foothold / bumping against the foot end of the nursing bed, which in turn led to a worsening of the poor posture of both ankles and an increase in bending contractures on both sides.
Complications that developed in the following weeks were symptomatic of epilepsy following hydrocephalus malresorptivus, meningitis, postoperative haemorrhage with haemorrhages and repeat shunt implantation. As well as this, a PEG was inserted for parenteral nutrition and the patient was fitted with a suprapubic catheter.
S.S. was discharged home in February 2016 in a state of wakefulness; her husband and an outpatient care service looked after her. The patient received physiotherapy twice a week via home visit – she carried out passive movements in bed. During this period, the only home visit by the neurologist in private practice, quoted above, took place with his scathing verdict.
In March 2017, I met the then 42-year-old mother of two school-age children in her owner-occupied attic flat in an apartment building where her parents and siblings also live with families:
Tetraplegic, left half of the body flaccid, right half of the body spastically paralysed, with flexion contracture of the right knee, malpositions due to flexion contractures of both ankle joints, also aphasic but breathing independently and not tracheotomised. All that was possible was unreliable communication via winks to her husband. The patient’s disturbed sense of space and position was also noticeable, which manifested itself in her constant searching for a foothold / bumping against the foot end of the nursing bed, which in turn led to a worsening of the poor posture of both ankles and an increase in bending contractures on both sides.
Due to my many years of experience with neurologically impaired patients with impaired consciousness, I recognised my patient’s potential
The two children of puberty age were very distraught, the husband completely overwhelmed with household management, child rearing, care and the alleged lack of prospects for his beloved wife, whom he also sorely missed as a partner.
This resulted in the following occupational therapy treatment goals:
• training and improvement of yes / no communication
• daily mobilisation in the existing multifunctional wheelchair
• contracture treatment using a Johnstone pressure cuff
• initiation of own active movements
• prescription of durable medical equipment after they have been trialled
• contact and referral to a speech therapist
• education and guidance for relatives
• training and improvement of yes / no communication
• daily mobilisation in the existing multifunctional wheelchair
• contracture treatment using a Johnstone pressure cuff
• initiation of own active movements
• prescription of durable medical equipment after they have been trialled
• contact and referral to a speech therapist
• education and guidance for relatives
The following durable medical equipment help to mobilise people in a coma and prepare them for verticalization:
• OrthoTech therapy boot with insertable stabilisers at the ankle and flip-up toe caps with Velcro closure so that spasm-prone, clenched toes can be loosened more easily from the outside and placed physiologically.
• Headmaster neck brace to support head control and improve eye contact when sitting and standing.
• inflatable Johnstone pressure cuff to improve cognition and for contracture prophylaxis or treatment.
• thanks to a change to another neurologist, S.S. was able to be provided with a THERA-Trainer tigo arm and leg trainer on loan after a few weeks. The approval by the health insurance company only took place after objections and justifications / advocacy by the neurologist and by me. The husband exercised daily with S.S. on the tigo arm and leg trainer, and she became increasingly alert and motivated to exercise on her own.
• in December 2017, the patient underwent verticalisation for the first time as part of testing the THERA-Trainer balo standing and balance trainer. Due to her painful flexion contractures and malpositions, the patient was initially only able to stand for 5 minutes despite the therapy boots. The existing contractures and ankle deformities improved with verticalisation so that she could stand for 15-20 minutes at a time until undergoing the corrective surgeries. Despite her pain, my patient kept wanting to stand. Sometimes 3 x 5 minutes in a row, with sitting breaks in the wheelchair, because standing gave her a new perspective and courage to face life. Thankfully, the balance trainer could be borrowed over Christmas and the turn of the year, so that S.S. was given a long trial period. Unfortunately, the approval procedure by the health insurance company again took many months. I have instructed family members and physiotherapy colleagues in the use of the balance trainer to maximise its use.
• OrthoTech therapy boot with insertable stabilisers at the ankle and flip-up toe caps with Velcro closure so that spasm-prone, clenched toes can be loosened more easily from the outside and placed physiologically.
• Headmaster neck brace to support head control and improve eye contact when sitting and standing.
• inflatable Johnstone pressure cuff to improve cognition and for contracture prophylaxis or treatment.
• thanks to a change to another neurologist, S.S. was able to be provided with a THERA-Trainer tigo arm and leg trainer on loan after a few weeks. The approval by the health insurance company only took place after objections and justifications / advocacy by the neurologist and by me. The husband exercised daily with S.S. on the tigo arm and leg trainer, and she became increasingly alert and motivated to exercise on her own.
• in December 2017, the patient underwent verticalisation for the first time as part of testing the THERA-Trainer balo standing and balance trainer. Due to her painful flexion contractures and malpositions, the patient was initially only able to stand for 5 minutes despite the therapy boots. The existing contractures and ankle deformities improved with verticalisation so that she could stand for 15-20 minutes at a time until undergoing the corrective surgeries. Despite her pain, my patient kept wanting to stand. Sometimes 3 x 5 minutes in a row, with sitting breaks in the wheelchair, because standing gave her a new perspective and courage to face life. Thankfully, the balance trainer could be borrowed over Christmas and the turn of the year, so that S.S. was given a long trial period. Unfortunately, the approval procedure by the health insurance company again took many months. I have instructed family members and physiotherapy colleagues in the use of the balance trainer to maximise its use.
In March 2018, my patient began to speak spontaneously without errors.
In April 2018, she started eating and drinking. After initial swallowing, this also normalised through logopaedic training.
In June 2018, her skull was surgically covered with an artificial dome. This optical correction was extremely important for her self-image as a woman. Now her children could look at her again “without being horrified” at her injuries.
This was followed in August 2018 by the surgical correction of the flexion contractures of both ankles and the fabrication of lower leg orthoses with special boots. With her physiotherapist, our patient practised walking on a rollator on her balcony. With the help of the balance function of the balo trainer, we practised improving balance – for example, by catching a balloon while standing.
In October 2018, she trained climbing stairs for the first time with the help of her physiotherapist and her husband using a forearm crutch and lower leg orthoses.
The PEG was removed in November 2018, followed by the removal of the suprapubic catheter in December 2018. We had gradually trained continence with bladder training by disconnecting the catheter.
During a six-week inpatient rehabilitation period in January 2019, S.S. learned to walk on her own without orthoses.
When she returned home, she received occupational therapy training, including fine motor exercises in combination with concentration and visual-spatial perception training. In addition, Mrs. S. practised her sense of space and position according to Prof. Perfetti under the exclusion of eye control.
In November 2019, the patient successfully completed an internship in a geriatric internal medicine department of the hospital where her current neurologist, who prescribed all necessary durable medical equipment, operations and rehabilitation measures, had worked as head physician.
As of December 2019, S. S. was taken on in a six-month employment contract with 17 hours per week in shift work.
In January 2020, she took some driving lessons and also received specialist neurological permission to drive again – she is able to compensate well for the remaining discrete visual field impairments.
Since December 2020, Mrs. S. has been working in a permanent job on a gerontopsychiatric ward in another hospital, her desired field of work, and she was even boxing again. In 2021, she successfully completed further palliative care training and is now a certified hospice worker.
In April 2018, she started eating and drinking. After initial swallowing, this also normalised through logopaedic training.
In June 2018, her skull was surgically covered with an artificial dome. This optical correction was extremely important for her self-image as a woman. Now her children could look at her again “without being horrified” at her injuries.
This was followed in August 2018 by the surgical correction of the flexion contractures of both ankles and the fabrication of lower leg orthoses with special boots. With her physiotherapist, our patient practised walking on a rollator on her balcony. With the help of the balance function of the balo trainer, we practised improving balance – for example, by catching a balloon while standing.
In October 2018, she trained climbing stairs for the first time with the help of her physiotherapist and her husband using a forearm crutch and lower leg orthoses.
The PEG was removed in November 2018, followed by the removal of the suprapubic catheter in December 2018. We had gradually trained continence with bladder training by disconnecting the catheter.
During a six-week inpatient rehabilitation period in January 2019, S.S. learned to walk on her own without orthoses.
When she returned home, she received occupational therapy training, including fine motor exercises in combination with concentration and visual-spatial perception training. In addition, Mrs. S. practised her sense of space and position according to Prof. Perfetti under the exclusion of eye control.
In November 2019, the patient successfully completed an internship in a geriatric internal medicine department of the hospital where her current neurologist, who prescribed all necessary durable medical equipment, operations and rehabilitation measures, had worked as head physician.
As of December 2019, S. S. was taken on in a six-month employment contract with 17 hours per week in shift work.
In January 2020, she took some driving lessons and also received specialist neurological permission to drive again – she is able to compensate well for the remaining discrete visual field impairments.
Since December 2020, Mrs. S. has been working in a permanent job on a gerontopsychiatric ward in another hospital, her desired field of work, and she was even boxing again. In 2021, she successfully completed further palliative care training and is now a certified hospice worker.
The last meaningful activity still to be practised by Mrs. S. is learning to wear 10 cm high heels again without any accidents!
For example, she tried to get her husband to give her high doses of pain medication by crying constantly, in the hope that overdosing would cause multiple organ failure and ultimately death.
It was only through mobilisation with the tigo arm and leg trainer, which increasingly offered her the possibility of self-active movements, that she regained her courage to face life. She found the verticalisation with the balo balance trainer to be crucial for her rehabilitation. According to her own statement, seeing herself at eye level with her family and the therapist again made Mrs. S. want to fight for herself and make progress.
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Karin Neidhard
Qualified occupational therapist and lecturer
Karin Neidhard is a graduate occupational therapist (FH) with over 40 years of
professional experience. From December 1981 to June 1988, she was employed as
an occupational therapist at the BG Accident Clinic in Frankfurt/Main in the specialist
areas of spinal cord injuries, general surgery, hand surgery, neurosurgery and
orthopaedics. Since 1991 she has been working as an employee at the occupational
therapy practice Christa Middendorf in Essen (since 01/01/22 under the new
management of Andrea Klomfaß) and specialises in the treatment of neurologically
severely ill adults, including people in out-of-hospital ventilation and in a vegetative
state. K. Neidhard has been a member of the German Association of Occupational
Therapists (DVE) for over 30 years. She has participated in various further and advanced
training courses with a focus on neuropsychological and neurological-rehabilitative
treatment methods and concepts such as Bobath, Perfetti, basal stimulation,
orofacial regulation therapy according to Castillo Morales, Kinaesthetics and much
more. Karin Neidhard has worked part-time and voluntarily as a speaker and lecturer
for the German Association of Occupational Therapists (DVE), among others, most
recently in March 2019 for the “After-Work Lecture Therapy” series at Münster
University of Applied Sciences. Her publications, including Ergotherapeutische
Untersuchungsreihe neuropsychologischer Störungen – EUNS are published by Schulz-
Kirchner Verlag. In November 2021, she completed her further training as a specialist
therapist in out-of-hospital intensive care (VeRegO/DiGaB).
References:
- Neuro-psychologische Therapie nach Hirnschädigungen, G.Caprez, Rehabilitation und Prävention 17, Springer Verlag, 1984
- Der apallische Patient, Aktivierende Pflege und therapeutische Hilfe im Langzeitbereich, Christa Schwörer, Gustav Fischer Verlag, 1988
- Wieder Aufstehen, Frühbehandlung und Rehabilitation für Patienten mit schweren Hirnschädigungen, P. M. Davies, Springer Verlag, 1995
- Wege von Anfang an, Frührehabilitation schwerst hirngeschädigter Patienten, B. Lipp, W. Schlaegel, Neckar Verlag 1996
- Wachkoma, Betreuung, Pflege und Föderung eines Menschen im Wachkoma, P. Nydahl, Urban & Fischer, 2. Auflage 2007
- Langzeitbetreuung Wachkoma, Eine Herausforderung für Betreuuende und Angehörige, A. Steinbach, J. Donis, Springer Verlag, 2. Auflage 2011
- Schwerstbetroffene Patienten, Expertenbericht 01, J. Ehlers
- pdf-datei www.thera-trainer.de, 2017
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