HOUSTON — As Rep. Gabrielle Giffords spends her days relearning how to speak, walk and care for herself, her therapists are carefully tracking every moment and often posing one critical question: When can she go home?
Experts say they expect her medical team to make that call in the coming weeks because Giffords is at the point in her therapy where doctors typically make such decisions about transitioning brain injury patients into outpatient care. Giffords has spent the last 2½ months undergoing intense therapy at TIRR Memorial Hermann in Houston since she was shot Jan. 8 in Arizona.
"I would expect a release in mid-April, right around the 10 weeks," said Dr. Steve Williams, chairman of rehabilitative medicine at Boston University.
The decision many are waiting for is whether Giffords will be able to travel to Cape Canaveral, Fla., to watch her astronaut husband, Mark Kelly, command the space shuttle Endeavour's last flight in late April. Some are also wondering if she'll recover to run for office again and challenge for an open Senate seat in Arizona in 2012.
Last month, doctors said Giffords was making "leaps and bounds" in her recovery as she speaks more and more every day and walks with assistance. They said there was a good chance she could attend the launch, but insisted no final decision had been reached.
Experts say the more crucial, long-lasting decision revolves around when she will be released.
Kristi Lanier, a speech pathologist at TIRR Memorial Hermann, said a team of therapists meets weekly to review progress and assess a patient's program and needs. Discharge is always the backstory.
"That's the crux of the question going around," said Lanier, who is not treating Giffords. "That discussion starts on day one."
Doctors and Giffords' family have several options for the next step in her care.
The congresswoman could stay in Texas, possibly moving into her husband's home near Houston and allowing her to undergo outpatient therapy in the TIRR clinic. She could also return home to Arizona, where she has a home and where her family lives. In both states, Giffords would have a valuable network of family and friends to assist in her recovery — key factors in deciding where to send patients.
Family or caretakers are trained before a patient is released, said Dr. Cara Camiolo Reddy, the medical director of the brain injury program in UPMC's Rehabilitation Institute. In most cases, therapists visit a patient's home, advising the family on what changes may need to be made to guarantee their safety and to ensure their needs are met.
Everything Giffords does at TIRR Memorial Hermann is geared toward preparing her for release. Every day, she undergoes several hours of physical, speech, occupational and music therapy that focus on various brain functions.
A speech pathologist such as Lanier would assist with everything from ensuring a patient can safely swallow to helping them relearn speech. Sometimes, Lanier uses a board with large capital letters to help a patient with initial communication. One patient used the chart recently to tell Lanier that she likes gospel and country music.
At TIRR, another key therapy is music. Amy Culpepper, one of two neurologic music therapists at TIRR, uses a guitar, drums, maracas and other musical instruments to "fire up" the brain. Sometimes, she works alongside a speech pathologist or physical therapist, using rhythm and beat to help a patient relearn walking or talking. Culpepper has not treated Giffords, but family and friends have described the congresswoman singing "American Pie" and "Happy Birthday" to her husband.
Often, one of the first things music therapists do is teach a patient to put functional phrases — such as "I want to go to the bathroom" — to music. Eventually, they will be able to say it. Similar methods are used in group therapy to assist with memory and orientation tasks. Here, the therapist will help patients remember the day of the week, the month, the year or even the city and name of the hospital by putting the information to a simple tune.
"The reason that music is so effective is because when you're using music, you are actually firing or engaging a lot of the brain," Culpepper said.
Catherine Cooper Hay, an occupational therapist at TIRR, may have one of the jobs that most concretely prepares a patient for release. Her tools include everything from a full kitchen and a garden to a plastic cup and soda bottle to help a patient with the coordination skill of pouring a drink.
For discharge, Hay said she looks at whether a patient can dress and groom themselves and whether they can sit upright for most of the day, critical to any patient who will be going on to an intensive outpatient program. While in her care, she plans and goes on outings with patients and their families. They go to restaurants, the zoo, the mall, and once even had a tour of the Houston Astros baseball stadium. Some patients interested in flying again are taken to the airport and practice going through customs and security.
The final step before a release is an intensive handover with the outpatient facility. Sandra Lloyd, director of TIRR's outpatient facility — Kirby Glen Memorial Hermann — said documents, case work, medical history, goals and progress are reviewed. The patient then has an in-depth outpatient assessment to assist with goal setting.
Kirby Glen offers a "challenge track" that can help a patient acquire the skills needed to return to work, learn to drive again, go to school or regain independence. Physical, occupational and speech therapists are assisted by social workers, vocational counselors and neuropsychologists to help the patient meet their goals. Patients can come to the clinic between one and five times a week for therapy and it generally lasts no more than three months, Lloyd said.
"We are all about getting you able to reintegrate into the home that you came from and the world that you came from," Lloyd said.
But even after the outpatient program is complete, patients have a rigorous home exercise and therapy routine. Sometimes, they can be sent back to the outpatient clinic a year or more after the injury if their doctor feels they could still improve.
"Traumatic brain injury doesn't get better overnight. It's a progression," Lloyd said. "And it will continue at home for years and years."
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