gplNAL INJURIES— The Challenge of Current Rehabilitation pESEMBER 1975 F I S I O T E R A P I E 5 by Ida Bromley, M.C.S.P. Superintendent Physiotherapist S toke M an deville H ospital, England. There are m an y d e finitions o f re h a b ilita tio n — a good js __“T o make fit, after disablem ent, fo r playing a on t in the w orld” . One of the m ajor challenges today Pa a]j parts of the w orld, is not only to fit the patient for his environment, b u t also to prepare the environm ent receive the disabled citizen. This does not only mean the home, but the wider aspects of the com m unity as a whole, <%_ travel by train or ’plane — access to p u b lic b u ild in g s — allowing disabled drivers into pedestrian precincts in cities and so on. There are also those aspects involved in the attitude of the able-bodied com m unity in providing em ploym ent or sharing leisure activities. T he prevalent em phasis on the disabled being second class citizens is com pletely at variance with the m odern approach to rehabilitation. For the patient with spinal cord injury the initial demand is that the patient should become as independent as possible within the limits imposed by th e level of the lesion. That is — the p atien t must gain control over h im ­ self and his environm ent. There a re Several Major Factors a p a r t fro m th e u su a l ones of age, sex, p re v io u s m edical h isto ry , w h ich influence the re h a b ilita tio n o f these p a tie n ts. I. The height o f the lesion — this obviously determines the residual m otor power, and the essential facto r of the presence o r absence o f ‘bridge muscles’. T h a t is those muscles which have a 'high segm ental innervation and a low distal attachm ent. They thus form a bridge between the paralysed and non-paralysed areas of the body, e.g. Trapezius — C l-4 — with attachm ent on the lower spine. Latissim us dorsi — C 6 , 7. 8 , seen so m agni­ ficently on the mine dancers and the A bdom inals T6-T12 with attachm ents on the pelvis. ... Physical Proportions o f the Patient. H eight and weight are obviously significant factors but the essential question fo r the spinal patient is ‘D oes he have the ‘monkey syndrom e’? ’ — i.e. does he have long arm s and a short trunk? T he basis for many activities of daily living is the ability of the p atient to lift his buttocks by pushing down on his hands. T he longer th e arm s in relation to the length of the trunk the easier it is to lift. 3. Previous Activities o f the Patient affects his c o ­ ordination and his ability to relate to his surroundings. If he is we'll orientated in space and has a good body image his rehabilitation will be both easier and speedier. An Officer from the H ousehold C avalry had a lesion at C6 . His training had involved taking his jacket on and off whilst jum ping fences controlling his horse with his legs. In spite of his C 6 lesion he achieved sitting balance 'n a week. C onversely a theologian with a n incom plete LI lesion needing only a long and a short caliper took months to learn to walk. H e hardly knew he had two •egs, never mind which was the right or left. The Motivation of th e patient not only affects the speed of his return to independence, but also how much ”e will achieve. M ost patients thrive in the com petitive atm osphere of the spinal unit. Y et to some the success of those around makes him feel even m ore inadequate. As everything seems quite beyond his capabilities he sees no p oint in even trying. 5. Spasticity. T he aim of m odem treatm en t involving good positioning and adequate physiotherapy is to obtain a degree of balanced spasticity w ith which the patient can cope satisfactorily in every day life. Sometimes, how ­ ever, fo r no know n reason, it becomes a form idable foe, a m ajor problem which prevents activities which should be com patible w ith the level of the lesion. All these factors affect not only the speed o f reh ab ilita­ tion, but also w hat can finally be achieved. Functional Independence In order to look a t the independence achieved by patients w ith lesions at different cord levels, we need first to look briefly at w hat is involved. (1) T he patient needs to learn to care fo r his body — to feed, wash, dress, attend to his own bladder and bowels, and care fo r his insensitive skin. (2) H e needs to be able to transfer in and out of the w heelchair — to bed, car, toilet, b ath , easy chair, etc. — to sit up in bed, tu rn over, and lift and move his paralysed limbs. (3) H e needs to be able to manage his w heelchair — both to move him self w ithin it, and to be able to m anoeuvre it in the environm ent. (4) And, if possible, he needs to learn to walk with calipers and crutches to increase his independence in the com m unity. (5) F inally he needs to be resettled at hom e — to be able to tran sp o rt himself in the com m unity, and to retu rn to em ploym ent and fam ily life. Levels F o r the purpose of functional independence fo r patients with complete lesions we can divide the cord from C4-L1 into six categories, according to the m ajor muscle groups involved. T hose patients with lesions above C4 occasion­ ally, though rarely, reach hospital, unless the lesion is incom plete and those below L I are too good fo r the purposes of this study. We therefore have the following groups: C4 — with head control only. C5/6 — with partial elbow and wrist control. C7 — good elbow and wrist control but little or no hand function. C8-T5 — good hand function — no abdom inal muscles. T6-T9 — partial innervation of the abdom inal muscles. T10-L1 — w ith good abdom inal muscles. In relating these groups to the activities to be achieved, it is obvious th a t the independence gained in any activity by a higher group will be achieved more easily, speedily and com petently by the low er groups. C4 The patients w ith lesions at this level have head control only, they have no protective reflexes, no protec­ tion from the effects of prolonged pressure and any independence can only be achieved by m echanical means. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 6 P H Y S I O T H E R A P Y DECEMBER, 1975 Several environmental control systems have been develop­ ed over the past decade o r so. T he most p o p u lar in Britain is probably the PO SSUM C ontrol. Possum being L atin for “I can” o r “I am able” and the letters P.O.S.M. standing for P atient O perated Selector Mechanism. This electronic system is m outh operated by gentle suction or pressure dow n a tube. R espiration is n o t affected as only the air in the bucchal cavity is required. T he system is designed to give th e p atien t control of up to 1 1 electrical devices such as an alarm , 'light, radio, door lock, tele­ phone, etc. As the p atient applies suction to the tube a light travels down a selector panel and the p atient stops sucking when the light reaches the required control. P.O.S.M. also produces a control system for an electric typew riter. By m eans of a key of com bined puffs and sucks for each letter o f the alphabet such patients can learn to type u p to 40 words a m inute. A m outh stick with a dental bite is used by many patients, fo r simple activities such as turning the pages of books, using the telephone, etc. Since a fem ale p atient found the trick and taught the therapists, patients with C4 lesions have been taught to swim! They can propel themselves slowly through the w ater by moving the head from side to side. A lthough such a patient can never be independent in the water, great satisfaction is derived from this free movement. One of the current challenges o f rehabilitation is to provide fu rth er mechanised aids for these patients with the highest lesions. Second group are those lesions at: C5/6 In this group are the patients whose initial injury is at C5. T he lesion then descending to C 6 on one or both sides. Extensor carpi radialis is present on one side and maybe bi-laterally, b u t it is not n orm al in strength. T he patient has no triceps. In recent years the greatest im provem ent in independ­ ence has been achieved by th is group. T hese patients can learn to feed, wash, shave, type and write using sim ple gadgets, and to dress the up p er h alf of the body. Some may learn to dress the low er h alf but speed usually makes this im practical except fo r emergencies. Mat Work As alwavs lifting and moving depends upon balance and strength. T o keep the centre of gravity forw ards o f the hip joints when lifting, the head and shoulders and therefore the trunk m ust be kept well flexed, e.g. To lift to the le f t — the p atien t places his left hand ab o u t a foot aw ay from his side and a little in fro n t o f the hip joint. Leaning well forw ards he pushes down on his hyper­ extended elbows, com pensating fo r the paralysed triceps, and degresses his shoulders. A t the sam e time he rotates his head and shoulders to the opposite side, i.e. the right, lifting himself to the left. To get from lying to sitting without using a monkey pole or other aid:- Starting with his arm s to one side the patient flings his head, arm s and shoulders to the opposite side, fotr ex­ am ple, to th e left, with such impetus th a t he throw s him self on to both elbows. Leaning well over the left elbow he moves his right arm over to the right and balances on both elbows. Keeping his head flexed, and shoulders protracted, he balances on the left elbow and flings the right arm behind him. T ra n s fe rrin g th e w e ig h t to th e r ig h t a r m he flings th e le ft a rm b e h in d in a sim ila r m an n e r. Then he ‘walks’ his hands tow ards his body until his weight is over his legs. Transfers for all patients with spinal cord injury fall into 3 categories: (a) T hose in which the feet are lifted and the trunk moves horizontally, e.g. chair to bed. T his is the m ost stable method and th erefore the easiest, b u t it requires strength. (b) T hose in which the feet are kept dow n and the trunk is moved horizontally, e.g. chair to toilet. T hese need skilled sitting balance. (c) T hose in which the feet are dow n and the trunk moves vertically, e.g. chair to floor. These are the m ost difficult requiring a high degree o f both balance and strength. Patients with lesions at C5/6 can usually accom plish group (a), i.e. ch air to 'bed and car, b u t n o t usually any in categories (b) or (c). T o Transfer to the Plinth 3 m anoeuvres are involved: To bring the buttocks forwards in the chair to avoid lifting over the wheel. T he p atient places 'his le ft hand behind his hip and pushes it forw ard either w ith th e forearm pronated and using extensor carpi radialis, o r w ith the forearm supinat- ed and using biceps. H e then either repeats the procedure on the right of" uses both hands to push b cth hips forw ards at the sam 6v time. To lift the legs H ooking th e right elbow behind the right ch air handle fo r balance he places his left wrist u n d er the right knee and lifts the leg. He holds th e right 'leg flexed by resting his left hand on the right arm rest, and then changes th e hand which su p p o rts his knee, to free the left hand to push the foot on to the plinth. T h e left leg is lifted in a sim ilar m anner, and crossed over the right. Lastly: To Transfer The Trunk H e gives a series o f lifts as practised on the m at, until he transfers his trunk to the plinth. Patients a t this level can transfer into a car. M ost find it easier with a sliding board. D uring the tran sfer the trunk needs to be so flexed th at the nose is alm ost on the steering wheel at the m om ent o f lifting. They can drive a car with autom atic transm ission and especially adapted hand controls. These young patients are often very inventive — one such p atien t is keen o n clay pigeon shooting. H e has found a m ethod of supporting the b arrel of his gun b v ^ m eans of a pole and spring and adapted the release so v th at he can fire it with his m outh. A nd he even wins! Wheelchair Management is lim ited, to pushing over sm ooth surfaces, turning ro u n d and going u p and down sm all inclines. To turn now to the group with lesions at: C7 T hese patients have c o n tro l over th e elbow and wrist joints, as triceps an d the wrist flexors are both innervated. Aside from this they fall into tw o groups — those with little or no finger m ovem ent, and those with good hand function. Building on the activities achieved by the p atient with a lesion at C5/6, th e C7 lesion can dress th e low er h alf of his body. T hose w ithout finger m ovem ent cannot look after their own bladder and bowels, they cannot p u t on the condom urinal or insert suppositories satisfactorily. T hose with good hand function will be independent in this respect. Transfers G ro u p (a) transfers, chair to bed and car, can be accom ­ plished easily and most can tran sfer w ith the feet down R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) p E S E M B E R 1975 F I S I O T E R A P I E 7 ■id and easy chair, and to th e b ath , usually finding t 0 ader over the bath end. 11 T hey can tu rn in d e p e n d e n tly in bed, p o sitio n in g th e pillow betw een t h e knees. Wheelc*,air Management These patients can m anage the w heelchair m ore effi- • tlv being able to rem ove the footplates a n d pick ^■ects u p from th e ground. They can m anage over un- ven ground and even ‘bounce’ the chair over small elevations. The patient with a lesion at C7, with or w ithout hand function, can support him self standing between parallel bars a n d may walk in bars. The next group is those with injuries between. C8_T5 spinal segments. This group o f patients have good hand function but tr u n k control is lim ited as th e abdom inal m uscles are flkalysed. They are com pletely independent in caring for th e body, including caring for the bladder and bowels. Transfers All transfers including those in group (c), i.e. chair to floor and chair to b ath can be mastered. Wheelchair Management There is total control o f the wheelchair including balance on the rear wheels. Gait is not usually functional fo r these patients but most learn to walk well in bars or on a rollator to gain all the usual benefits, help to minimise osteoporous, prevent contractures, etc. Groups T6-T9 and T10-L1 The main difference betw een the last tw o groups, i.e. those with lesions betw een T6-T9 and those with lesions between T10-L1, is in the pow er of th e abdom inal muscles, and the only real difference in the activities of daily living is in relation to gait, except, o f course, th at all activities are easier and speedier for th e group w ith norm al abdom inal muscles. Both groups should be able to w alk independently on crutches, be able to exit from the chair on to crutches, an d to go up and dow n stairs using one rail and one crutch. A lthough som e of the T6-T9 gro u p certainly use their w alking fo r functicnal purposes, it is true to say th a t for the most part only those in th e T10-L1 group have a really functional gait. If gait is to be functional it must be speedy. T herefore sw ing-through gait is essential even fo r the very young. In our experience patients who have no speed when walking will give it up. F o r the p atient with a functional gait it is useful to be able to get to and from the floor on to crutches. To get up from the floor T he p atient positions his crutches1 with the tips forw ards and in fro n t o f his head. H e puts his hands through the fo rearm supports and pushes up on his hands, using his abdom inal m u sd es a t the sam e time to control the pelvis and prevent his legs from sliding backwards. H e walks his 'hands tow ards his feet trailing the crutches. W hen his weight is over his feet, and the patient really needs to push his bottom backw ards, he lifts one crutch (right) and puts his weight on it. H e balances on the right crutch an d positions the left crutch. W ith the weight on b o th crutches he walks the crutches tow ards his feet until he is standing upright. One o f o u r patients w ith a lesion at T i l , recently said th a t the two m ost im p o rtan t things he had learnt was to balance on the rear wheels and to be independent on crutches. This m an is an oceanologist who has returned to his job, and in spite of his paralysis, drives his one-m an subm arine, and goes aqua-lung diving to a depth of 100 ft. H e travels all over the w orld by him self, walks in to ’planes, wheels his chair over sand and even in to rivers when necessary. Few people have his requirem ents in relation to mobility in the com m unity, but surely the challenge o f rehabilitation is to fit the p atient to fulfil his particular role in the world. This paper w as read at the Jubilee Congress o f the South African Society o f P hysiotherapy July 1975 in Johannesburg. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )