February 7, 2011 — One month after a close-range gunshot wound to the head, Congresswoman Gabrielle Giffords, D-AZ, has continued to defy the odds and recover at a much faster and more consistent pace than her physicians expected — to the extent that her husband, astronaut Mark Kelly, says that he feels comfortable leaving her bedside in April to command the space shuttle Endeavor on its 2-week final mission to the International Space Station.
After the shooting that left 6 dead and 13 others injured, there was widespread speculation as to whether Kelly would drop out of the mission to remain by his wife's side, but, in a press conference held on Friday, the astronaut said Giffords' recovery has been smoother than anyone anticipated.
|Congresswoman Gabrielle Giffords and astronaut Mark Kelly|
"On January 8 [the day of the shooting], I was in Tucson at my wife's bedside in the ICU [intensive care unit], talking to her neurosurgeon and trauma surgeon about her prognosis, and I thought I would be sitting in that ICU by her bedside as much as 2, 4, or 6 months later," he told reporters.
"But as she progressed day to day, it started to become evident she might not be in the ICU even for 2 weeks."
Progress Every Day
Kelly was also warned to prepare for regular setbacks in Giffords' recovery, but none have occurred. "Since that first day, she's never gotten worse. So we got her checked in here, and since then she's made progress every day."
"Here" is the nationally renowned TIRR Memorial Hermann Rehabilitation Center in Houston, Texas, where Giffords was moved from the University of Arizona Medical Center in Tucson to begin rehabilitation and to be closer to where Kelly lives and trains at the Johnson Space Center.
I thought I would be sitting in that ICU by her bedside as much as 2, 4, or 6 months later. But as she progressed day to day, it started to become evident she might not be in the ICU even for 2 weeks.
Giffords' team of neurologists and rehabilitation specialists confirmed at a press briefing that the congresswoman's recovery has been unexpectedly rapid.
"We have noticed daily improvements in Giffords' neurological condition, and we are very pleased about that," said neurosurgeon Dong Kim, MD. "In terms of recovery in brain issues, this is really at lightning speed."
Kelly noted that Giffords is currently in rehabilitation activities for up to 6 hours a day, and Dr. Kim said the congresswoman is progressing in speech and other areas.
|Dr. Don Kim|
"Her speech function is improving quite a bit, along with everything else," said Dr. Kim, who is director of Mischer Neuroscience Institute at Memorial Hermann and professor and chair of the Department of Neurosurgery, UTHealth Medical School, in Houston.
"We're working on conditioning, strengthening, maintaining her range of motions, and we are performing activities to try to prevent the kind of complications from being in bed for a long time."
Giffords' recovery has been called nothing short of a miracle, and physicians largely attribute her survival to the fact that the bullet passed only through the left side of her brain and did not cross to the right hemisphere or into the more critical deeper sections of the skull.
Her physicians in Tucson confirmed that she has movement on both sides of her body, but that one side had shown slower responsiveness than the other.
Her speech function is improving quite a bit, along with everything else.
Physicians have scaled back on releasing further details of Giffords' condition; however, in an interview with Medscape Medical News, Dr. Kim said strategies for brain injury patients in general may include efforts to try to counter the propensity of the nonaffected side of the body to compensate for deficits on the opposite side.
"There's some evidence that forcing someone to try to use function on the side that is not working can help the recovery process," he explained. "For instance, if you have a weakness in one hand and you are compensating by doing everything with the other hand, then function in the affected hand may not recover as well.
"So the rehabilitation effort may therefore focus on continuously using the affected side."
Some centers have even tried an approach of placing a cast on the good hand to try to force the use of the other hand, Dr. Kim said.
Recovery can largely depend on healing that occurs at the cellular level and the extent of neuroplasticity, in which the brain may adapt to its injury by reassigning tasks that were previously handled by sections that are now damaged.
"When there's an area of the brain that is permanently injured and won't recover, sometimes we'll see patients regain that function anyway when a different part of the brain that didn't previously perform that function will take on the ability," Dr. Kim said.
"We know that certainly happens, but it's unfortunately very age dependent — the younger we are, the more likely that is to happen."
Neuroscientists at TIRR Memorial and elsewhere are currently investigating methods for enhancing neuroplasticity, possibly with pharmacologic tools; however, the efforts at TIRR Memorial are currently in the animal testing stage.
Further along is potentially groundbreaking research the center is conducting on the potential of stem cells to regenerate neurons that have been damaged.
"The Holy Grail would be to truly regenerate the injured part of the brain that is not going to come back, and we have a robust stem cell program here to try to generate new tissue," Dr. Kim said.
"What's different about our program [from other centers] is we've already run a trial following pediatric trauma, neurotrauma, and stroke patients."
Rehabilitationists are likely well into the process of identifying the nature and extent of any deficits resulting from Giffords' injury; however, the road to recovery in such cases can be different for each patient, said physical medicine and rehabilitation specialist David Lacey, MD.
"From a rehabilitation perspective, the approach is extremely dependent on the individual, depending on the type of trauma, the age of the patient, the patient's genetics, and even their gender," said Dr. Lacey, medical director of rehabilitation and executive medical director at Wake Forest University Baptist Medical Center in North Carolina.
"We know, for instance, that women do better than men, and we think there may be some beneficial effects to progesterone that are neuroprotective."
Secondary factors, aside from the primary injury to the brain, are also significant, he said. "Factors that are important include whether the patient was hypoxic, whether their blood pressure was low, and whether they had a lot of swelling with increased intracranial pressure."
Next Phase Can Be 'Most Trying'
Once the full picture on the nature of the deficits are assessed, the next phase of rehabilitation can be the most trying, Dr. Lacey said.
"In traumatic brain injuries, cognitive deficits are usually the more significant impairment than the motor or sensory deficits," he said.
"Your challenge is to try to find the key to unlock that door to allow the patient's function, personality, and cognition to come out while allowing your therapies to get in, and sometimes that's the most challenging thing."
Most agree that the best time to begin rehabilitation is as early as possible, and the level of progress from those efforts can often help predict the patient's longer-term outcome, Dr. Kim said.
"In general, the 3- to 6-month period and sometimes 3- to 9-month period after the injury is the most fertile part of the recovery process; however, patients often say they'll see improvement continue for years," he said.
I have every intention that she will be there for the launch.
"In addition, I would say sometime in the first 1 to 3 months, we as physicians get a pretty good idea of how someone will be a year or 2 later."
Meanwhile, Kelly has his own predictions about the pace of his wife's recovery. When asked by reporters whether he expects Giffords to watch him blast off on his shuttle mission on April 19 from Cape Canaveral, Florida, his response was, "Absolutely.
"I have every intention that she will be there for the launch," he said. "There really shouldn't be any reason why she can't be at the launch."
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Cite this: Giffords Continues to Progress at 'Lightning Speed'; Kelly Will Command Shuttle Mission - Medscape - Feb 07, 2011.