Like Riding a Bike, But Not After a traumatic brain injury, a patient's life skills return, although slowly. But even as she “gets back on the bike,” she realizes she not the same person. E-luminations
E-luminations  |   October 01, 2017
Like Riding a Bike, But Not
Author Notes
  • Amy K. Gray-Smith is a fourth-generation Coloradoan who works full-time as a sonographer for Kaiser Permanente. Come rain, snow or sunshine, she still rides her bike to work every day.
    Amy K. Gray-Smith is a fourth-generation Coloradoan who works full-time as a sonographer for Kaiser Permanente. Come rain, snow or sunshine, she still rides her bike to work every day.×
Article Information
Attention, Memory & Executive Functions / Traumatic Brain Injury / E-luminations
E-luminations   |   October 01, 2017
Like Riding a Bike, But Not
The ASHA Leader, October 2017, Vol. 22, online only. doi:10.1044/
The ASHA Leader, October 2017, Vol. 22, online only. doi:10.1044/
My traumatic brain injury was like riding a bike—something that, once learned, is not forgotten—but in this case it's a painful and emotional realization that as I get back on that bike, I'm not the same person anymore.
On Nov. 9, 2016, a car hit me from behind as I rode home on my bicycle from my job as an ultrasound technologist. The clocks had changed just the week before, so we were all adjusting to the new early sunset. Despite my lights and reflectors, the driver never saw me. Traumatic amnesia prevents me from remembering anything that happened. Fortunately, the accident occurred within sight of Parker Adventist Hospital, a Level II trauma center. They were able to stabilize me quickly and assess the damage: multiple fractures to the pelvis, L1 spinal burst fracture, shattered right clavicle, left scapula fracture, punctured lung, internal bleeding and a mess of road rash.
That night, I had my first surgery to stop internal bleeding in the pelvis. That prepared me for my next surgery in the morning, a 10-hour procedure to remove fluid buildup in the spine and fuse five vertebrae. A CT scan afterward revealed a hidden injury, bleeding in the frontal lobe.
The worst information was yet to come—a traumatic brain injury (TBI) that may have some long-term impairment. That evening a small hole was drilled in my skull to measure intracranial pressure (ICP), and since it was stable, so I had more surgeries. The medical team stabilized my pelvis with an external fixation device and reconstructed my clavicle with a titanium plate. The scapula would be left to heal on its own. Let the healing begin.
Jessica, a speech-language pathologist, was assigned to provide speech-language treatment during my stay in the ICU. My husband, Marc, watched during the therapy sessions and noted that I was often confused and agitated. Although I had the ability to respond to questions and commands, I don't remember any encounters with her. I wrote in my therapy journal, “Most days have been a blur. Some memories last long, others are lost. Today most everything seems scripted. Just try to follow the plan, go with the flow.”
Unfortunately there was one more significant event yet to come. About two weeks into my ICU stay, the side rail of my bed somehow came down and I fell onto the floor, breaking my pelvis again. I needed another surgery to realign my pelvis and replace the screws and fixation device. Let the healing begin again.
Time in the ICU passed in a fog. Sleep was fleeting and mixed with hallucinations. I remember dreaming that I had been climbing mountains and scrambling up the Boulder Flatirons. I believed these dreams were true and even called Marc in the middle of the night to tell him I could walk and climb, “Come pick me up now. I'm ready to come home.” It didn't occur to me this was impossible. I was very frustrated to be trapped in this place with people and things that I didn't understand.
I do remember the last of my 19 days in the ICU. I was told that I was going to be transported to Spaulding Rehabilitation but didn't understand why. I actually thought I was going home. That night two EMTs took me by ambulance to Spaulding. When they wheeled me in, I was very upset that I wasn't at home. I spent all night agitated, confused and unable to sleep.
The next day I met my new physiatrist, who explained the type of brain injury I had and how he and his staff were there for my TBI recovery. He discussed the resources I had available in this controlled, low-stimulus wing of the hospital. My first week was rough. I refused to sleep, hallucinated, made up stories and realized I had lost most my reading and math comprehension.
My rehabilitation psychologist had harsh but true words about me being impulsive and disinhibited. Before the accident I was physically and mentally strong, but now I was weak and frail. Accepting that I had a brain injury was difficult for me. A medication regimen allowed me to relax and finally sleep—a huge step, as sleep helps heal the brain.
The daily schedule is posted by the nurse's station, so I could see where I was supposed to be. I had three therapy sessions per day: physical, occupational and speech-language. Physical therapy would teach me how to exercise, stretch, stand and move with my considerable limitations. Occupational therapy involved learning to transfer in and out of a wheelchair, use the bathroom, bathe and dress. Speech-language therapy worked on mental skills and was the most challenging and evolving process for me.
Annie was my primary SLP. The first test she administered was a Montreal Cognitive Assessment (MoCA). I was unable to see the 2D animals, remember the words she asked me to remember or comprehend most of the tasks. My handwriting was very small and nearly imperceptible. I had considerable difficulty with basic math and reading comprehension.
But the challenge I had to conquer first was to simply accept that I even had a brain injury. I was frustrated to see the numbers and words in front of me but to be unable to perform the task. But I wouldn't give up. Annie assured me that I didn't need to relearn these skills, but simply to be shown the steps in the process. And she would get me there.
After my sessions with her I would sit in the hallway for hours and practice my math and reading using all the tools she gave me. During my second week at Spaulding my mental endurance slowly improved. I learned how to control my apprehension, anxiety and memory. The goals she set for me during my recovery were to improve attention and mental sharpness, deductive reasoning, organization, planning, problem-solving and executive function by using brain games and puzzles to improve short-term and delayed memory. This would continue to be a focus as an outpatient.
By December 16, about five weeks after my accident, I was able to complete a logic test that measured my ability to think clearly and follow directions while being timed and monitored. Speech-language therapy taught me to find comfort while being monitored and tested by slowing down and taking my time to find the answers, and to take a break if I got tired. If we ran out of time during the session, the questions became homework, and I would sit in my wheelchair in the hallway for hours and practice reading comprehension and basic math. My work would be checked during the next session. I did not feel judged during the sessions and this allowed me to feel comfortable even if I didn't know the answer.
I became more alert, able to communicate appropriately and eventually return to a level of independence. Doing this in a low-stimulus environment was a very helpful aspect of my rehabilitation
In my final days at Spaulding I demonstrated the ability to move safely and slowly under set restrictions. I eventually completed a difficult math puzzle that took me four hours and finally passed the MoCA exam. I could now see the 2D animals, remember the words and comprehend all tasks that I failed the first time. The most helpful thing the Spaulding SLPs did was teach fundamentals, while encouraging me to slow down and complete the task no matter how long it took.
After 21 days at Spaulding it was time to go home. As an outpatient, I would transition to the therapists on my primary insurance, Kaiser Permanente. There I would continue with physical and speech therapy.
After the holidays, I started outpatient therapy once a week. In the meantime, Spaulding encouraged me to stay mentally and socially active. I prepared for the mental aspect by continuing to read and do puzzles. Marc and I were both trained at Spaulding on how to manage my fatigue and keep me safe at home.
But because of the TBI, being out in the real world was difficult to cope with, as my brain had a hard time processing the noises, distractions and movement. For example, when Marc drove me home, seeing the oncoming cars, traffic lights and GPS prompts while also moving was scary and exhausting. Also, spending time in the grocery store could get overwhelming.
Physical therapy helped me go from a wheelchair to a walker, from a four-pronged cane to walking sticks, and finally just my own two feet.
Lois, my new SLP, began by testing my executive functions and quickly realized that my memory was what needed the most attention. She taught me the Rancho Levels of Cognition and gave me memory tips and compensatory strategies to improve my skills. Her testing helped me focus on goal-directed behavior. She gave me verbal fluency tests where she would state a sentence, then ask me to put the sentence in alphabetical order and finally repeat in reverse. Towards the end of our training I was able to complete higher-level tasks like attention process training and critical thinking puzzles.
The most supportive thing I learned from Lois was to take my time to get tasks done right. She did this with the utmost patience. This final stage of rehabilitation and recovery prepared me to return to the life I had before and my career as an ultrasound technologist. Six months after the accident I returned to work with management supervision, training and a reduced patient schedule. This job requires me to perform complex tasks while interpreting ultrasound images with a professional and comfortable bedside manner. My job is physically and mentally challenging. I find it quite rewarding.
Some of the lessons I've learned since my accident are to have the patience to finish what I've started and, when I come to a roadblock, take a brain break, then come back when rested. I have been much more successful with this new approach. Speech-language therapy focused on routine tasks so I would be comfortable with returning to home and work. Furthermore, I've appreciated the opportunity to focus on simple but challenging goals that I didn't have to work so hard for prior to this accident. In other words, I'm no longer taking the simple things for granted.
The training I received will be things I use for the rest of my life. The TBI still leaves me somewhat mentally fatigued, but now I know how to manage it. I no longer have a sense of urgency, and being in the present moment allowed for a seamless transition back to work.
Physically, I'm not the same. I reminisce a lot and feel ambivalence wondering if I'll get it back. And if I do, will I want it? I've had the opportunity to almost lose life and, therefore, I have a different fire. I don't have same spunkiness or physical energy and have learned to have no expectations. I have had the courage to get back on my bike, now with humility and respect for life.
My resilience, resources and support system paved the way for physical recovery. My brain, however, has fascinated me with how it has recovered. I know it was because of the dedicated and outstanding care I received. Recently, Marc and I visited the Parker Adventist ICU and Spaulding. I walked in on my own two feet, looked everyone in the eyes and said, “thank you.” Hugs aplenty. The genuine looks of astonishment were another chapter in my healing process.
1 Comment
November 3, 2017
Kylie Davis
Thank you
Amy, thank you for sharing your story with ASHA. Every SLP who works with brain injury should read this. Your article was well written and insightful. Well done!
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October 2017
Volume 22, Issue 10