DECEMBER 1981 P H Y S I O T H E R A P Y 93 SPINAL CORD INJURY — HOPE THROUGH R EH A B ILIT A T IO N AND RESEARCH L A N E F L IN T , B.A. (Unisa)* SUM M ARY The incidence o f spinal cord injuries in industrial c o u n t r i e s is increasing. R eh a b ilita tio n an d vocational ( r e t r a i n i n g o f these persons in w heelchairs is essential. This article describes a specific rehabilitation program m e from the acute phase to the fin a l goal, nam ely v o c a ­ tional integration. A ll m em bers o f the rehabilitation team are involved. i n t r o d u c t i o n v Few illnesses are m ore devastating — physically and (Rentally — th an spinal cord injuries. D am age to this vital area can result in paralysis of any or all ex­ tremities (The H arm arville Story, 1979). Until W orld W ar II, few paraplegics survived long after the onset of their paralysis. T h e initial shock was a major cause o f death ; if th e p a tie n t survived the shock of his traum a, u rinary com plications and o ther medical problems m ade a return to good health al­ most impossible (G regory, 1978). Saltm an (1960) says that “because of their high susceptibility to disease, especially in the kidneys and bladder, o f the 400 A m eri­ cans with spinal paralysis carried off th e battlefields of World W ar I, 90 percent were dead w ithin a year of receiving their w ounds.” Since World W ar II, the prognosis with regard to survival of those paralysed by injury to, o r disease of, the spinal cord, has im proved to an am azing degree. The pioneer work of Sir Ludwig G u ttm an n at Stoke M andeville and later o f w orkers at Lodge M oor, Shef­ field, and other well established centres has dem o n ­ strated th a t in a great m ajority of such patients, varying degrees o f recovery and good resettlem ent can and should be achieved (Thom pson and M urray, 1967). M ortality, both early (w ithin three m onths of injury) and late, has decreased significantly over the last 30 years. This is due to th e establishm ent o f the specialised ^spinal injuries centres, which have opened in most rts of the world since Sir Ludwig G u ttm a n n pioneered 2 fam ous Stoke M andeville U n it in A ylesbury, Buckinghamshire, E ngland, 30 years ago. Early m ortality (up to 80% in 1944) has been reduced to between 5 - 1 5 % depending on th e level and severity o f th e cord lesion, the presence or a b ­ sence of severe associated injuries, age, pre-accident health and the expertise o f early and continued m an ­ agement (M eyer and M alick, 1978). CAUSES ? ' 90% due to spinal cord injuries. I0 /fc -2 0 % due to tum ours, infections, m ultiple • i n o / ° S1S’ cor>genital defects, etc. a c c i d e n t ^ SI3*na* corc* *ni u ries due to tran sp o rt ® Rem ainder due to dom estic and industrial accidents, sports, falls and penetrating wounds. G reatest single cause is car accidents. author*P*e8*C since 1966. F reelan ce jo u rn alist and Received 28 July 1980. OPSOMMING D ie probleem van paraplegie en kw adriplegie raak in ge'industraliseerde lande al hoe m eer om vangryk. D ie rehabilitasie en beroepsinskakeling van hierdie persone in rystoele raak ’n absolute noodsaaklikheid. In hierdie artikel word daar g e k y k na die probleem , vanaf die akute fuse to t die einddoel van rehabilitasie, naam- lik beroepsinskakeling. A lle lede van die rehabilitasie- span w ord in die poging betrek. INCIDENCE • In Sw itzerland approxim ately 15 new cases per an­ n um p e r m illion population. • In A u stralia approxim ately 19 new cases per an n u m per m illion population. • In A m erica approxim ately 50 new cases per an n u m per m illion population. A t present th ere is a popula­ tion o f ab o u t 125 000 spinal cord injuries with about 10 000 new cases a year. • Based on these statistics th ere are approxim ately 12 500 paraplegics and quadriplegics in South A frica (Flint, 1978). AGE A N D SEX • 70% un d er 40 years of age. • M a le /fe m a le ratio approxim ately 9 to 1 because males participate in m ore dangerous sports and oc­ cupations. COST Paraplegia is expensive.t • R 54 000 - R 90 000 in first year fo r acute rehabili­ tative treatm ent. • P rojected lifetim e care fo r quadriplegic is R300 000 - R375 000 and for a paraplegic is R160 000 - R205 000. • Estim ated loss to the country in G ross N ational P ro d u ct is R1 - R l , 2 m illion per person affected. T hus, it is very clear th a t reh ab ilitatio n of spinal cord injuries has becom e an absolute necessity and the concept o f rehabilitation starts at the scene o f the accident. PREVENTION T he prevention of accidental injury com es by ed u ­ cating th e public through th e com bined efforts o f in ­ dustry and governm ent. Awareness of th e im portance of seat belts, the proper use of vaccines and the possi­ bility of h ereditary defects w ould help to low er the incidence o f spinal cord disease. CARE A N D H A N D L IN G OF A CU TE SPINAL CORD IN JU R Y A t the scene o f the accident correct care is essential. F u rth er flexion o f the spine m ust no t occur and victims should be tran sp o rted on firm stretchers. Preferably, they should be transferred to a specialised spinal cord injury centre w ithin 48 hours o f the accident so th a t rehabilitation can sta rt im m ediately. Psychological traum a resulting from paralysis can also be d ealt with better in these units. t Figures based on cost of tre a tm e n t in A m erica. 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. ) R EH ABILITATIO N T R E A TM E N T A T A SPINAL CORD IN JU R Y In these centres p atien ts are ta u g h t an d encouraged to achieve the greatest possible independence. A d d i­ tionally, a tten tio n is paid to good skin care, bow el and b lad d er control, including an increased fluid in tak e to prev en t the fo rm atio n of kidney stones. W eight bearing fo r at least an h o u r or tw o a day is im p o rtan t to p re ­ ven t the decalcification o f bones. Bracing and exercise of jo in ts m ay be necessary to p rev en t deform ities. M uscle spasms can be very p ainful an d th e p a tie n t is ta u g h t to co n cen trate on th e task a t han d to try and overcom e this problem as there is no ideal m edi­ cine o r surgery available. A lm ost everyone w ith a spinal cord injury is plagued w ith the ‘blues’ an d a psycholo­ gist or m edical social w orker m ay help to prevent or shorten this. T oday one of the m o st successful an d typical re­ hab ilitatio n program m es fo r spinal cord in ju red people exists a t H arm arville R eh ab ilitatio n C enter, P ittsburgh, Pennsylvania, U .S.A . an d is th erefore chosen as an example. “ W e have m ade it o u r task a t H arm arville to help the spinal cord injured p a tie n t and his fam ily rebuild th e ir lives, to ad ju st to th e physical an d m ental p ro ­ blem s th a t have b efallen them . W e o ffer n o m iracles or sure cure — ju st th e oppo rtu n ity to m ake th e m ost of each p a tie n t’s potential. H arm arville offers its p atien ts post-acute rehabilitation, afte r the injured p er­ son’s physical cond ition has been stabilised a t a n acute care facility. T h e Spinal C ord T re a tm e n t C enter P ro ­ gram consists o f fo u r distinct phases, all designed to bring the individual p atien t to a m ore satisfying and productive life” (The H arm arville Story, 1979). A closer look a t the fo u r phases o f reh ab ilitatio n at tt\e H arm arville C enter revealed the following: Phase I: Facing the Future F o r th e first week o r two, the new spinal cord p a tie n t a t H arm arville tries to come to grips w ith his situation. M an y will never walk again, som e only w ith crutches an d braces. T h ere will be com plications in skin care and new things to learn a b o u t bow el and b la d d e r control. T h e p atien t faces a fu tu re frau g h t w ith new realities, m any of them unpleasant. I t is during Phase I in th e Spinal C ord. T reatm en t Program m e th a t the H arm arville team ap proach (H ar­ m arville Story, 1979), gets in to action. Because each p a tie n t has un iq u e physical an d m ental characteristics, the m anaging physician puts together a team o f specia­ lists designed to m eet the p a tie n t’s individual needs. T h e team w orks closely w ith th e p atien t an d his fam ily to provide th em w ith a general u n derstanding o f spinal cord injuries an d a specific explanation of th e indivi­ dual injury. I t is in this phase th a t instruction begins in skin care an d com plications, b la d d e r and bow el care program m es, th e use o f m edications an d th e basic therapy program m e. T h e team consists o f th e follow ing services: M edical: H eading the team is the m anaging p h y ­ sician w ho supervises the o th e r team m em bers and who, together w ith the general m edical specialist, deals w ith th e p a tie n t’s m edical com plications during the program m e. Social Services: L iaison between the patient, fam ily an d team , discussing com m unity resources (including follow -up services) and solidifying discharge plans. Nursing: W orks w ith the physician on rounds, teaches the p a tie n t how to han d le skin care, b lad d er an d bowel problem s, in addition to providing general nursing care. Psychology: D evelops a psychological p ro file o f the 94 p atien t to d eterm ine his intellectual capacity and em o­ tional strengths. Also helps the p atien t to ad ju st social­ ly an d em otionally to his new life situation. V ocational I Educational'. A ids the p a tie n t in d eter­ m ining his vocational and educational goals and assists in re-entry into th e com m unity. P hysiotherapy: E valuates th e p atien t’s strength, range o f m ovem ent, w heelchair m obility, and ability to be­ com e m obile th ro u g h a program m e of m uscle streng­ thening and re-education. O ccupational Therapy: Tests an d m axim ises func­ tio n al ability and provides o rth o tic devices to aid the p a tie n t in self-care and personal independence. R ecreation: Assesses w hat hobbies o r sp o rt the p a tie n t can perform , evaluates com m unity accessibility fo r recreation an d avocational activities. H om em aking: W orks w ith p atien t to teach self-suf­ ficiency a t hom e, evaluates and helps plan m odifica­ tions needed in th e home. D ietary: D evelops a n u tritio n al care plan based upon individual needs, activities and preferences w henever, possible. ( . T he first phase generally lasts one to tw o weeks. By the end o f th a t tim e, the reh ab ilitatio n te a m has a good idea of th e p a tie n t’s capabilities. A staff conference is held to m ap o u t a realistic program m e to re tu rn the p a tie n t to his com m unity. T h e patient, in tu rn , has com e to un d erstan d his situ atio n and is being prepared fo r th e co m m itm ent needed to resum e an active life. Phase II: A Time for Rebuilding T h e p a tie n t m ust be m edically stable, relatively free o f com plications and have a good tolerance for eith er sitting o r standing to e n ter the second phase. It is in this phase th a t the fam ily and com m unity be­ com e m ore intim ately involved with the p a tie n t’s care an d the overall program m e. H eavy em phasis is placed upon physical and fu n c ­ tional activities designed to get th e p a tie n t ready fo r a retu rn to th e com m unity. P h y sio th erap y continues w orking on range of m ovem ent, a program m e o f iso­ m etric an d dynam ic exercise aim ed a t strength, balance activities an d instruction in transfers, w eight shifts and w heelchair m obility. In this phase the p a tie n t is provided w ith dynam ic splinting, as needed, to aid self-care. O th er supportive and adaptive equipm ent such as m obile arm sup­ ports, environm ental control units, tape recorders, homa- exercise eq u ip m en t and low er extrem ity bracing, are i i ^ troduced in this p a rt o f the program m e by occupa­ tional th erap y and physiotherapy. O ccupational therapy also explores pre-vocational p o ten tial and prospects fo r driver training. A m ost effective tool used during this six-week p eriod is socio-physical group therapy. All patients participate in a social event, such as m a t exercises in physiotherapy. T his program m e enables p atien ts to in teract and gain first-hand u n derstanding of how the overall program m e works. A P h ase II p atien t has th e o p p o rtu n ity to observe and experience how p atien ts in Phases I I I an d IV have advanced in the treatm en t program m e during these types o f socio-physical events. A n in fo rm atio n b u d d y system also exists fo r p a tie n ts’ fam ilies so th a t they can le a rn fro m th e ex­ periences o f those fam ilies w ho have com pleted the p ro ­ gram m e. T his dialogue allows form er- an d new -patient fam ily m em bers to p articip ate in discussions and con­ structive criticism o f the program m e and to review any difficulties encountered in the com m unity. Social Services m o n ito r these discussions to gain feedback on the treatm en t program m e. DESEMBER 1981F I S I O T E R A P I E 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. ) W eekly psychology group sessions also exist and enable patients to deal openly with such subjects as th eir handicaps, social barriers, frustrations, sexual functioning and tran sp o rtatio n problem s. P atien ts are encouraged to p articip ate and express th e ir feelings about the program m e so they m ight learn fro m each other. T h e initial visit hom e is the first tangible rew ard for the p a tie n t’s h ard w ork. I t provides the opportunity fo r the p atien t to experience the reality o f his new life situation outside th e reh ab ilitatio n centre. Follow ing th a t im p o rtan t first visit hom e, the reh ab ilitatio n team reviews the problem s the p atien t encounters and de­ vises ways to solve them . T he H om em aking D ep artm en t then schedules a hom e visit during P h ase I I an d a hom e econom ist accom panies the p a tie n t to assess and evaluate w hat th e p atien t will need to becom e self- sufficient at home. T he hom e econom ist analyses architectural barriers, determ ines equipm ent needs and m eets w ith local p e o p le such as co n tracto rs and representatives of spon­ soring agencies who will be involved w ith eventual m odifications to th e p a tie n t’s hom e. F o r the first time, the p atien t and fam ily can sit in on a p a tie n t staffing conference to review the progress o f the reh ab ilitatio n program m e and discuss those problem s th a t have been encountered. T his conference usually is held after th e hom e visit so th a t problem s relating to p a tie n t care a t hom e can be reviewed. By the end of P h ase II th e p atien t should be able to recognise an d u n derstand the specific m ed i­ cation and dosages he is receiving. T h e patient, w ith o r w ithout fam ily assistance, should be able to handle weight shifts to prev en t skin problem s, do push ups and propel the w heelchair on even o r uneven terrain. Phase III: A R etu rn to the C om m unity A fter six to eight weeks of th e program m e, the patient shifts in to a third phase th a t places em phasis upon com m unity resources. O utings w ith m em bers of the R ecreation D e p a rtm e n t give th e spinal cord p atien t exposure to active life in th e com m unity. U sing a new ­ ly acquired van designed to tran sp o rt w heelchair patients, the recreation sta ff takes patients to restau­ rants, shopping centres and m useum s to help introduce o r rebuild outside interests. ■ Special em phasis is placed on sport. T h e patients are E x p o sed to a full range o f lifelong sports th a t w heel­ chair patients can undertake. T hose w ith p a rtic u la r in ­ terests are encouraged to com pete in w heelchair sports. T hese recreational outings also serve to expose the patient to any possible environm ental b a rrie r problem s he m ay en co u n ter and give him the chance to over­ come them . C om m unity leaders are invited to p artici­ pate in the p a tie n t’s discharge planning as an aid to providing recreational outlets fo r th e spinal cord patient. T he V ocational D epartm ent accelerates its program m e in this phase, placing the p atien t in eith er a fo rm er or new job. T h e co-operation of prospective em ployers in providing work opportunities and rem oving arch itec­ tural barriers to m ake jobs accessible, is solicited. Sim ilar visits are m ade to schools fo r students seek­ ing to resum e th e ir education. V ocational counsellors, ajong with hom e econom ists, m eet w ith educators to aid the p atien t in the tran sitio n back to school. W ork­ ing with the V ocational D e p a rtm e n t in getting patients back to work or school is the driver training and evalu­ ation section. E ach p a tie n t is evaluated according to DECEMBER 1981 P H Y S I O the level of injury an d functional capabilities to see if he can resum e driving or can get his licence fo r th e first time. In addition to providing d irect d riv er training, the program m e recom m ends the type of vehicle best suited fo r th e p atien t and any adaptive equipm ent needed. By now th e p atien t should have achieved a fu n c­ tional level th a t can be m aintained thro u g h continued physical th erap y and exercise. W heelchair tolerance should have increased from 6 to 10 hours. T he p atien t should be able to m ake successful w eekend hom e visits and should be able to lie on his face fo r 6 to 8 hours. T h e fam ily involvem ent in the re h ab ilitatio n program m e should have becom e m ore freq u en t an d consistent. Fam ily m em bers should aid in th erap y a t least once a week and work with com m unity representatives to aid the transition o f the p a tie n t from H arm arville to home. Phase IV : A New In d ep en d en t L ife T he spinal cord p atien t has reached th e final stage: the tran sitio n to independent living. D u rin g his last week a t the C enter, th e p atien t and his fam ily tak e full charge o f bowel and b lad d er care, skin care and m edications. T h e p atien t and fam ily are placed in th e transitional living ap artm en t in H arm arville. T h eir p erform ance in independent living situations is tested to see how reliable they are. T he p atien t begins each day, just as he w ould at hom e, getting ready fo r work o r school. A ccom panied by a team m em ber, he reports to work or school to see how a daily routine works out. By p utting the p atien t in a practical situation, the team can evaluate how well he and his fam ily m anage on th e ir own. T h e day th e p a tie n t is discharged fro m H arm arville his treatm en t is by no m eans over. H e will retu rn fr e ­ quently d epending upo n his needs d u rin g th e first year, follow ing com pletion o f the fo u r phases. T h e V isiting N urse A ssociation an d o th e r hom e health care services act as liaison betw een the C enter and th e patient, helping with exercises, physiotherapy, nursing and su p p o rt services. M edical an d urological follow -ups are done routinely tw ice a y ear to ensure the p a tie n t’s overall condition is stable an d controlled. As tim e progresses, these checkups are m ade once a year. T h e H arm arville Spinal P ro g ram is a team approach which involves team m em bers in all aspects of the p a tie n t’s life. T he p atient is considered ready fo r the p rogram m e when he is m otivated to com m it him self to hard work and sacrifice tow ards a new life. R eferences G regory, M . F . (1978). Sexual ad ju stm en t — a guide fo r the spinal cord injured. A ccent on living, Inc., B irm ingham , 111. M eyer, C. M. H. and M alick. M. H. (1978). M anual on m anagem ent o f the quadriplegic u p p e r extrem ity. H arm arv ille R e h ab ilitatio n C entre, Inc., P ittsburgh, P enn. S altm an, J. (1960). A head, a h eart, and tw o big wheels. Public A ffairs P am p h let N o. 30. P ublic Affairs C om ­ m ittee, U.S.A. T he H arm arv ille Story (1979). A special re p o rt: H arm ar- ville’s spinal cord tre a tm e n t program m e. V ol. V II N o. 1. P ittsburgh, Penn. T hom pson, M. A. and M urray, W . A. (1967). P araplegia at hom e — a p ilo t survey o f the m an ag em en t and re h ab ilitatio n o f paraplegic patients in Scotland. Livingstone, E d in b u rg h and L ondon. T H E R A P Y 9 5 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. )