She inspired the nation with her fairy-tale recovery. Now Rep. Gabrielle Giffords must inspire herself through the ordeal of rehabilitation, and doctors say it's likely to be the hardest work she'll ever do.
Just a couple of decades ago, rehab was little more than physical therapy for shuffling stroke victims and wheelchair-bound quadriplegics, a last resort after doctors had done all they could.
Now it's a sophisticated science at the forefront of treating people like Giffords, who was shot in the forehead two weeks ago while meeting constituents in Tucson. An early start on rehab is key to limiting permanent damage, and the Houston hospital where she will be treated uses high-tech tools to push the brain to rewire itself.
The Arizona congresswoman arrived Friday at the Texas Medical Center, where she is expected to spend a few days in intensive care before moving to TIRR Memorial Hermann rehab hospital. Dr. Gerard Francisco, the hospital's chief medical officer, said Saturday that she was "even more alert today" and progressing nicely with therapy.
Instead of doctors making you well, rehab means "teaching you how to help yourself" to get your life back, said Dr. William Donovan, a former medical director of the rehab hospital who still works there part-time.
It's frustrating when your muscles and mind won't work the way you want them to. Emotional challenges, post-traumatic stress and physical problems like seizures, headaches and infections loom as risks that could complicate her recovery.
No one can predict how she will do, or what her "new normal" will be, as the hospital's CEO, Carl Josehart puts it. A CT scan on arrival showed "really minimal" injury for the mortal wound she had, said Dr. Dong Kim, neurosurgery chief for University of Texas Health Science Center.
The type of bullet, its path, good trauma care and her general health before the injury bode well for her, but "a bigger impact on recovery is the amount of family and social support after the injury," said Mark Sherer, a neuropsychologist at the rehab hospital.
After doing a head-to-toe mapping of her injuries and abilities, "we'll have to figure out how to meet each and every deficit," Francisco said.
The first step: setting a goal, such as being able to live independently or to return to work or school.
"We try to tailor that to what's realistic," Josehart said.
His hospital is a modern, six-story, red-brick building with hacienda-style arches and signs with the "O" in Memorial Hermann made into a hopeful yellow sunburst. The rooms are standard hospital ones — no VIP suites, the doctors quip.
A large gym can treat 30 to 40 patients at a time with state-of-the-art equipment. There are therapy pools, treadmills with harnesses to help support weight and sophisticated recumbent bikes that send electrical signals to help muscles move.
A day's stay costs several thousand dollars, and the hospital treats a mix of public insurance, private pay and uninsured patients. About two-thirds have brain injuries — everything from gunshot wounds to strokes — and most of the rest are spinal cord injuries.
"In the early days of rehabilitation — 20, 30 years ago — it was not uncommon for patients to be in a rehab hospital for a year," Josehart said.
Now, three to six months is a very long stay, partly due to better treatments and new technology that allow more care to be given at home — portable lifts to help people out of wheelchairs, for example.
How does someone get better in rehab?
"Practice, practice, practice, and I'm not being facetious," said Dr. Paul Schulz, a UTHealth neurologist who works at the hospital.
A patient having trouble speaking — as doctors suspect Giffords might — could be given a Ouija board and asked to form words on it. Or encouraged to sing what they are trying to say to a familiar tune like the ABC's or Happy Birthday while tapping their fingers, said Dr. David Lacey, medical director of rehab services at Wake Forest University Baptist Medical Center.
That engages more body systems and encourages new connections and nerve growth, he explained.
"Sometimes you can break through the speech deficit by using the auditory pathway. They can get the word out rather than just thinking of the word and saying it," said Lacey, who is not involved in Giffords' care.
At the Houston hospital, therapists sometimes test cognitive function by showing patients the word "red" written in blue, and ask them to read the word. Impaired people often say "blue," distracted by the color, and that can signal the need for training like flash card drills, Schulz said.
"You have to do it with a lot of empathy because you don't want to frustrate the person," he said. "A lot of times you say 'very good' even if it's not the right answer because you want to keep them motivated on the task."
Computer games like Nintendo's Wii can be used to enhance coordination, and as rehab progresses, patients can join basketball and hockey teams or do gardening and other hobbies. They go on field trips to the grocery store or the airport to practice going through security screening and boarding a plane.
Doctors hope Giffords will do all these things, but Lacey cautions:
"Very positive early recovery does not guarantee an excellent long-term outcome. It certainly puts her more in that category of people who are likely to do much better, but some patients can plateau and not progress much further."
Mark Steinhubl wishes he could give Giffords advice. The 20-year-old was shot in the head two years ago in downtown Houston and had rehab at Memorial Hermann. He still can't see out of one eye or hear out of one ear, but he can walk and talk and is a sophomore majoring in chemical engineering at Texas A&M.
"She needs to realize that it won't be instantaneous like I thought it would be," he said. "I felt like I was accomplishing something every day, meeting a benchmark."
When he came into the rehab hospital on a stretcher, "I couldn't even sit up," Steinhubl said. When he left a month later, "I didn't walk out, I ran out."