A patient case

It's so difficult not to get attached to the patients here. During my two weeks at the hospital, I became particularly close to one of my patients. Here is her story...

At the age of 19 and 8 months pregnant, Susina (not her real name) at the small frame of 5 foot 6 and maybe 115 pounds began having terrible headaches and neck stiffness.
By the time she got to the hospital, she'd had an intracerebral hemorrhage secondary to a pre-ecclampsia-related condition called "HELLP" (Hemolytic anemia Elevated Liver enzymes and Low Platelet count).
Her blood pressure was severely elevated and as a result of the infarct she became cortically blind and had left sided hemiparesis. Her baby was delivered immediately and fortunately is now a healthy 3-month-old.

However, Susina is now suffering from the physically disabling complications.
The first day I saw her in the clinic, she was carried in by family members and all of her treatment was performed in supine by her PT- mostly PNFs and other manual resistive exercises. Her PT and family were afraid for her to walk because "she is blind and maybe she fall down." While she had 3+/5 quadriceps strength in her left leg, her ankle dorsiflexion was 1/5. I coaxed them into some gait training using an arm crutch and she was able to walk - with left foot drag and knee hyperextension - but she was walking! At first she was very nervous about walking without vision but over the last week we have significantly improved her confidence and gait pattern.

We also performed some vision training using bright objects and mirrors. I had difficulty finding research on this with limited internet access so I just made exercises up! Cortical blindness is unique in that the optic nerve and other ocular structures have no damage. Thus it is solely cortex structures that inhibit what the patient perceives. It was pretty incredible but she was able to gain some vision in only two weeks time. Patients with this condition can have some spontaneous recovery so it is difficult to say whether what we did was related to the change, but she was able to recognize how many fingers were held up on her last visit.

Other treatment aside from gait training included quadruped exercises with a stability ball to improve hip extension strength, seated stability ball exercises with upper extremity movements and reach/grasp training. We also practiced sit to stand and over one week's time she went from max assist with sit to stand and gait to contact-guard assist with the arm crutch!

Susina was excited with her walking and vision progress but still depressed about her overall condition. Particularly, her family babied her a lot and did not want her to hold her infant son for fear that she would "drop him or poke his eyes out." Such interesting cultural perspective! I asked if I could meet her son and one day she brought him in for her PT session and we were also able to do some holding/positioning training with the infant!

The hospital has an orthotist and I prescribed her an AFO. She owed the hospital over 14,000 birr (about 1300 dollars) and she said that she would not purchase it because of financial reasons. Myself and some classmates/professors decided to pitch in and purchase her AFO, proper shoes, and an arm crutch. In the US a custom AFO alone may be around $1000 USD, but here it was 300 birr, or a little under 30 dollars! I was able to accompany the family to the fitting sessions with the orthotist which was really interesting to see.

In the end, Susina was able to ambulate with stand-by assist over flat ground, outdoor conditions (uneven ground) and stairs, with occasional verbal cues for visual assistance. It was so exciting to be a part of her PT and it seemed that we were able to impact her quality of life. Susina had an incredible amount of courage and perseverance. I know her road from here will not be easy- without vision she is especially limited in the Ethiopian trades and even daily cooking,childcare and house duties. I'll never forget her story.