(Updated) Perhaps no one was more disappointed to hear that the shuttle Endeavour‘s launch was scrubbed on Friday than Congresswoman Gabrielle Giffords. Despite the fact that she was hidden in the Kennedy Space Center away from public scrutiny, she was as dominant in viewers’ minds as the astronauts who were scheduled to operate the shuttle piloted by Giffords’ husband, Capt. Mark Kelly.
Update [8 p.m.]: Even President Obama, who continued with his scheduled visit to Kennedy Space Center on Friday despite the scrapped launch, spent about 10 minutes visiting with Giffords and her husband, according to White House officials, before meeting the remaining NASA crew. Kelly greeted the President in a corridor: “I bet you were hoping to see a rocket launch today,” he said. Obama replied: “We were hoping to see you.”
Her doctors have not yet decided whether Giffords can remain in Florida until the launch is rescheduled, but the fact that she was able to make the trip at all was a victory — one for which the 40-year-old representative from Arizona had fought hard since being shot in the head in Tucson in January. According to the team of neurosurgeons, physical medicine experts and therapists managing her rehabilitation in Houston, Giffords’ recovery to this point has been remarkable. And even though there is still a long way to go before doctors will be able to determine how much of the pre-shooting Gabby, as she is known, will return, it seems she is already well on her way.
“You see a glimpse of the personality of the politician,” says Dr. Gerard Francisco, the lead physician of the brain injury rehabilitation team for Giffords at TIRR Memorial Hermann Hospital. “It’s very clear the Congresswoman is a people person.”
According to Giffords’ mother and husband, Francisco says, “Gabby is who Gabby was.”
It’s been 16 weeks since a bullet passed through Giffords’ left brain, leaving her briefly unconscious, and damaging her ability to speak normally or control the right side of her body. We spoke with Giffords’ doctors about the kinds of changes her brain has undergone over past few months, and how the physical and cognitive rehabilitation that occupies most of her days has helped her to regain the functions she lost.
Dr. Dong Kim, chair of neurosurgery at Memorial Hermann, oversees Giffords’ neurosurgical care. He says that in cases of traumatic brain injury, recovery often depends on the injury itself — on what caused the trauma, and how severely it rattled the brain. In auto accidents, for example, in which injury can be diffuse and affect many different areas of the brain, recovery may be more difficult than from a bullet wound, which causes more localized damage.
Beyond that, it is difficult to predict how much brain function will be recovered. Immediately after a trauma, many of the long connections that nerve cells send from the brain to the remotest parts of the body are severed; some of these are only temporarily interrupted, but others will be permanently dissolved. There is no evidence that rehabilitation can reverse this damage, but it can accelerate the recovery of other neural networks that can compensate, by picking up essential functions, and bring the patient as close to fully functioning as possible.
This rewiring of the brain is crucial, and much of the patient’s rehabilitation is geared toward encouraging it. Rehab includes cognitive therapies to reinforce language, memory and concentration skills; physical therapy to keep muscles toned and motor nerve signals active; and occupational therapy to practice functions of daily living such as dressing and cooking. During recovery, undamaged parts of the brain begin to compensate for critical connections that were lost to injury, stepping in to take over compromised functions. “There is emerging evidence that with the appropriate type of therapy and the appropriate amount and duration of therapy, it has the potential to help rewire the brain,” says Francisco. “We think that what we are doing with rehabilitation can facilitate neurologic recovery as well.”
Much the way that antibiotics treat infections, Francisco says rehabilitation needs to be used in the right amount at the right time and for the right length of time to gently coax delicate nerve networks back from the shock of a brain injury.
That’s why many therapies begin as soon as a patient is stabilized. As far as physical deficits go, such as weakness or paralysis in the arms or legs, whatever function a patient is going to recover will likely occur in the first year after the injury. Francisco and Kim are especially encouraged by Giffords’ rapid early progress; she is not only making great strides in movement, but she is also able to say words, and, even if slowly, also managing full sentences. All of the Congresswoman’s medical staff say they are able to have conversations with her and that she is making her wishes and feelings known — including firmly giving her husband the boot from her room at the end of a tiring day.
Cognitive improvements may continue to accrue for years after a brain injury, says Kim, as long as the patient continues to reinforce skills and exercises she learned in rehabilitation. According to a recent report in the Arizona Republic, Giffords still doesn’t remember the shooting itself, which is not unusual, but she has been told that others were killed in the rampage — news that unsettled her for many weeks. Because words still come frustratingly slowly, and she isn’t able to express herself fully in flowing sentences yet, her family and physicians have decided not to tell her that her close aids were among those injured and killed.
Giffords labors anywhere from three to six hours a day to improve her speech, gait and ability to function independently. Her doctors say she is much more self-sufficient now than when she first arrived in Houston to begin her recovery. But she still has at least one major procedure ahead of her. In the hours after the shooting, surgeons removed a portion of Giffords’ skull to relieve the pressure building up in her brain. That piece must be replaced.
Her scalp has been sewn back up to cover the gap, and while the missing piece poses no medical risk, the soft spot does make her vulnerable to additional trauma if she were to fall or hit her head. Many patients who have had such a craniectomy wear a helmet to protect the brain. CNN reported that upon arriving in Florida for the scrubbed launch, Giffords wore a helmet.
Some time soon, Kim will be replacing that missing piece of bone to close up Giffords’ skull. It’s not clear yet whether he will transplant the original piece that surgeons removed in Tucson — there have been some reports that the bone was contaminated by the bullet — or whether the team will create a new fragment to replace it. The synthetic skull insert would be made of inert plastic and carefully sculpted by a computer; using CT scans of Giffords’ skull, it would be shaped exactly to fill in the missing portion.
In most cases involving gunshot wounds, says Kim, the original bone isn’t replaced because of contamination by contact with the bullet, and because the bone is often fragmented. (Conversely, with stroke patients, the removed portion of the skull can be frozen and preserved for transplant back into the patient, since there is no contamination introduced by an outside injury.) “You don’t want to put the bone back too early, before all the swelling is gone,” says Kim. “On the other hand, you don’t want to wait until the brain has recovered or changed so much that the area where the flap is has sunken in. Or changed so much that there is too much space underneath the skull, where blood and fluid can accumulate and lead to infection.”
Whether he decides to use the original bone or a synthetic piece, Giffords’ own bone cells will eventually migrate to the site and “heal” the gap, so that within a year, the space will be replaced by a solid piece of bone.
A major consequence of replacing the skull fragment is that brain-injury patients tend to improve more after the repaired, a phenomenon that doctors can’t quite explain. “We don’t know if it’s physiologic,” says Kim. “[It may have] something to do with the pressure [in the brain] becoming more normal that’s helpful to the patient, because some time after the swelling goes down, the brain pressure is abnormally low.”
Depending on how Giffords progresses, Kim says she may have the surgery to replace the missing piece in the next few months.
In the meantime, as she continues to improve on her speech and walking, Giffords will also transition to more occupational therapy, which is focused on making her more comfortable with doing things on her own once she returns home. Therapists work with patients on everything from buttoning a blouse to shopping and, in some cases, even driving. In making the trip to Florida, Giffords already seems to be mastering some of these more advanced skills; for instance, she had to prove that she could safely negotiate the potentially uneven walkways that exist beyond the wide, clear hallways of the hospital.
The Florida trip was Giffords’ first since beginning rehabilitation, and it almost certainly whet her appetite for more. And that, say her doctors, is one reason they cleared her to travel. She may not have been able to watch Kelly launch into space, but she worked hard to make the trip, and there’s no better motivation to continue with her rigorous rehab than the promise of what awaits her once she’s done.
At the Kessler Institute for Rehabilitation in New Jersey, patients undergo the same type of intensive therapy as Giffords. Watch below: