When we hear this phrase said by the operators of a rehabilitation clinic or hospital: ¨the patient does not cooperate¨ our world falls apart.

We have just passed the most critical stage where we did not even know if our relative would survive the stroke and now we find ourselves in a moment where we are doing everything in our might to reorganize the whole family's life.

We have decided and want to get to the top of the hill, even though some inconveniences that have not really mattered. But when the physiotherapist tells us that our relative unfortunately does not cooperate and does not actively participate in the physiotherapy, we feel that is going to be more difficult to reach the objective. In other words as if now we have to fight another enemy.

Let me advice you that it is not another enemy, it is the same enemy that we have had since the stroke, but that now requires specific therapeutic attention.

WHAT PATIENTS ARE USUALLY TOLD THAT ARE UNCOOPERATIVE?

Typically there are two types of patients who are tagged like that.

● Patients with right hemiplegia, aphasia, and apraxia.
● Left hemiplegic patient with consciousness and attention disorders.

These two types of patients represent a great amount of the total who have suffered a stroke, therefore the phrase ¨the patient does not cooperate” affects dozens of patients every day.

Let us see in detail why these two types of patients are classified as uncooperative.

PATIENTS WITH RIGHT HEMIPARESIS

In most cases, after an ischemia or cerebral hemorrhage that has affected the left hemisphere of the brain, additional to the mobility problems that we will have on the opposite side of the body. In this case the right, we can also be subjected to language alterations: aphasia.

I have defined those language disorders, and not words, since the difficulty of the patient with aphasia is not only pronouncing words but often also understanding other people´s words. Therefore we are faced with a communication disturbance specially when associated to the aphasia because there is also an apraxia condition.

For a better understanding of the apraxia, I suggest reading this page but meanwhile I advise you that the apraxia is some sort of “body aphasia” that is to say a difficulty of understanding and reproducing movements. You can then imagine that for these patients it is almost impossible to communicate. They do not understand the instructions from the outside, cannot answer nor speak, and cannot even make gestures to communicate since the comprehension of the movements is affected to the point that very often they cannot even make a “yes” or “no” movement with their head. If we ask them to do something, they do not understand us and if we simply ask them to imitate us, unfortunately they are not able to fully understand our movements thus are incapable of reproducing them.

When we face this type of patient, We, the professionals cannot pretend to behave as if everybody were the same. We must take into account their deficiencies in communicating because it may seem that they intentionally do not want to cooperate but they are really locked up in a sort of “glass cage” that does not allow them to adequately relate with the outside world. I want to write this, because when the members of the family who write to me every day, always mention this phrase giving it as true and regretting it, my answer is always the same. It is not the patient’s responsibility but the therapist’s.


“The patient’s cooperation is directly proportional to the suitable demands proposed by the therapist”
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When I am called for professional courses in clinics, to teach the Neurocognitive rehabilitation after a stroke, I always include in the program - the treatment for patients with right hemiplegia, in order to show that even with the gravest patients that apparently we are not able to communicate with. We have the opportunity and the duty to always offer the best rehabilitation.

To get a better comprehension of some of the difficulties of the right hemiplegic patient with aphasia and apraxia, I will show you a brief video where I carry out the De Renzi test on one of my patients, and where you can have the opportunity to see how difficult it is to copy my movements, even with his left leg which in theory should be “healthy”.
VIDEO:

The patient that you have just seen in the video is one of those that are classically defined as uncooperative but that in reality the collaboration is not his problem. His problem is the interaction and it is up to us. The therapists, the ones that have to adopt the adequate strategies in order to create a better communication link.

In the next video, I want to show you an exercise done with an aphasia and apraxia patient.

There is a double reason why I am showing you this video. One reason is that I want to show you the different ways you can build a therapeutic conduct with a patient with whom it seemed impossible to communicate. The other one is that not only with the adequate precautions the patient collaborates, but also that the one who proposes the exercise is not a professional but a relative. In fact, the therapist that you saw on the video is not a professional. She is simply the daughter who learned a simple exercise where the first brick was laid for an effective communication: the indication.

PATIENT WITH LEFT HEMIPARESIS

For the right hemiplegic patient who has some speaking disorders, it is easier to understand that the degree of cooperation does not depend on a deliberate election, but it is rather the result of his communication difficulties. For the hemiplegic patient who has maintained all of his speech abilities intact. It is more complex to take this step.

Unfortunately, sometimes after the relatives hear the phrase “…..patient who does not cooperate”, they believe and also let them know that it is the patient’s fault. Even in the case of the person who has suffered a stroke on the right cerebral hemisphere and hence paresis on the left side of the body. in addition to the motor problems, he often presents cognitive type problems.

These problems specially imply the attention and the consciousness. One of the main cognitive problems of the left hemiplegic patient is the attention, and for them especially in the first weeks. It is in generally very difficult to pay attention, but particularly in respect to the body and in some cases a complete omission of all that happens on his left side.

To go deeper on this syndrome, that is called neglect, I recommend this article.
When the cerebral injury also implies the frontal lobes, additionally and often we can be witnesses of consciousness disorders of his pathological state: anosognosia. The people involved in this problem are not thoroughly aware what has happened to them and that is why they do not perceive the suitable form of the therapeutic intervention. Imagine then, how difficult it is for the patient to face a classic therapy with a weak link in respect to the body and a difficulty to take the logical step from the crippling event that he suffered to the needed therapeutic intervention to which he should comply with.

These patients are classified as apathetic and irritant and are held responsible for such intentional behavior without considering that they have an additional problem to the hemiparesis, but the problem in itself is that it participates in the lack of movement.

In this case, it is also unacceptable to listen to the tag “patient uncooperative”. Since in this case it is also the therapist’s talent that takes him to study the most adequate and suitable therapeutic proposals for the consciousness and the attention.

In this latter case, I often find myself facing the problem with the members of the family who carry out the in family rehabilitation. In fact, they are surprised and ask me why they should always be proposing themselves to do the exercises, while the real interested one find the motivation to work difficult.

In this case please acknowledge that it is compatible enough with the injury. This attitude is one of the problems caused by the stroke and not a wish of doing nothing for the patient. Let us remember that there is not a person more motivated to want to recover his own life than the patient.

Unfortunately the cerebral injury has compromised some logical and rational steps that may allow the proper attitude in respect to the cure of the problem. I hope that this article helps relatives who live similar situations to adequately understand the cooperation issue and the professionals who are treating patients with these characteristics to take a minute before pen in hand are going to write in the clinic history his alibi “uncooperative patient”.