(Kiosk 4) Rehabilitation of Locked in Syndrome; A Case Report Highlighting the Role of Eye-gaze Powered Devices in Optimizing Functional Independence

Case Diagnosis: Locked in syndrome secondary to an acute basilar artery thrombotic stroke.

Case Description or Program Description: A 44-year-old male experienced a basilar artery thrombotic stroke with diffuse paralysis and preservation of vertical gaze, a presentation consistent with locked in syndrome. He had a prolonged acute hospital course complicated by basilar artery re-occlusion requiring stent placement, sacral osteomyelitis, sepsis, and respiratory failure. Three months after initial presentation, he was admitted to inpatient rehabilitation with a tracheostomy and gastrostomy tube, totally dependent for all ADL’s, and communication limited to eye gaze (up is yes and down is no).

Setting: Specialized acute brain injury inpatient rehabilitation unit.

Assessment/Results: He engaged in intensive multimodal therapy in a specialized brain injury inpatient rehabilitation unit. Physical and occupational therapy helped him gain modified independent mobility by utilizing an eye-gaze powered wheelchair. He exhibited excellent obstacle navigation. Speech therapy helped him utilize eye-gaze augmentive communication devices with programmable words, phrases, and the ability to spell out new words. After set-up assistance, the patient was able to navigate his environment and communicate with others.

Discussion (relevance): Locked-in syndrome (LiS) after insult to the ventral pons classically presents with tetraplegia and anarthria with sparing of vertical gaze. Patients with incomplete LiS have additional motor functions with the potential for limited motor recovery. Management focuses on respiration, communication, mobility, and activities of daily living in the short term and maximizing quality of life in the long term. Although prognosis is poor, patients can experience functional improvements when enrolled in early multidisciplinary rehabilitation programs.

Conclusions: This case illustrates the significant role inpatient rehabilitation plays in maximizing functional independence and quality of life for patients with locked in syndrome. Augmentive communication and eye-gaze powered devices have the potential to help patients achieve higher levels of modified independence. Based on the outcomes of this case, patients with LiS should be considered strong candidates for inpatient rehabilitation.