Rehabilitation Process of Persons With Spinal Cord Injury
Spinal cord injury (SCI) can occur at any time to any individual. Acute SCI is an unexpected event that can result from a fall or a car accident, no matter how minor. It can occur from diving into too shallow water, or it can occur because of a wrong move during a sports event, and it often persists for the lifetime of the person who acquires it. Young, Burns, Bowen, and McCutchen (1982) point out that most spinal cord injuries occur predominantly in younger people, with the most common age being 19, and that fifty percent of all injuries occur to individuals under the age of 25. Though young age is not a determining factor in acquiring an SCI. It can also occur during birth, or from a fall at age one-hundred and one. Although over eighty percent of SCI persons in the United States are young men in the prime productive years of their lives, they come from all races, places, ages, occupations, educations and income brackets (Corbet, 1985). An SCI plays no favorites and it may even be a result from disease (Chronic SCI).
According to the New England Journal of Medicine (1991) the incidence of acute spinal cord injury in the United States today is about 10,000 per year. With the latest advances in medical treatment and technology, less than 10 percent of these persons die following their injury, as compared to years ago.
Once an injury to the cord has occurred, whether the result of an accident or chronic illness, and a person develops paralysis, there are certain steps that need to be taken in relation to the rehabilitation of the person. This rehabilitation will enable the SCI person to return to the Environment of social and vocational functioning as best as can be managed. It should be mentioned here that not all spinal cord injuries result in extensive rehabilitation, though for the purpose of the present paper I will be focusing on those who do need extensive rehabilitation to enable them to return to the community following their injury and be productive members of society.
Before returning to the world outside the rehabilitation center, however, the SCI patient must learn a number of things to aid them in this enormous step towards independence.
One of the first experiences one has after an SCI are emotional in nature. No two people experience the exact same feelings following a spinal injury. What the SCI person feels is totally unique to them. Some feel stunned after their injury, as if what was happening to them was not real. Other people are actually happy after their accident for the main reasons that they are still alive and still have their mental faculties intact.
During the initial phase of rehabilitation the strongest emphasis is on the SCI patient regaining as much strength and movement as is possible in either their arms and/or legs, depending on the locality and severity of their injury. A full understanding of SCI and what it entails is another factor to be learned during the beginning stages of rehabilitation.
In order to understand the effects of SCI, it is important to first understand the structure of the spine and spinal cord. The hard bony frame located from the base of the neck to the tail bone is called the spine, which is divided into segments called Vertebrae. The vertebrae make up the spinal column by joining each other from end to end. It is within the spinal column that the spinal cord is inclosed. The spinal cord connects to the base of the brain and runs down the spinal column to the first Lumbar vertebrae. The very end of the spinal cord contains a group of nerves called the Cauda Equina. The two major functions of the spinal cord are to carry nerve messages to and from the brain and body, and to carry nerve messages within the cord itself. These nerve messages are responsible for Motor movement and sensation. (Harmarville Rehabilitation Center, Inc. (1983).
An injury to the upper spine, in the Cervical vertebrae’s of 1 through 8 results in Quadriplegia, while an injury from the first Thoracic vertebrae or lower results in Paraplegia.
Once a person acquires a spinal cord injury, extensive rehabilitation is needed in order to return that person to their optimal functioning. Cull and Hardy (1977) say that the two most important areas of function for the SCI person are in mobility and transportation and in communication. Mobility and transportation refer to the patient’s ability to move about freely in their immediate surroundings. To do this the patient would have to be able to be independent in mobility. For the SCI patient this can only be done with the assistance of devices such as a walker, leg braces, or in most cases a wheelchair, depending on the severity of their injury. Communication skills for the SCI patient, i.e., writing, typing, reading, and using the telephone can be accomplished by using adaptive devices. For example, a splint which fits over the fingers on the hand will enable the SCI person to hold a pencil in which to write with.
Other types of rehabilitation include physical, and Occupational Therapy. Physical Therapy includes an exercise program geared toward muscle strengthening, while occupational therapy involves the redevelopment of fine motor skills.
During the rehabilitation process bladder and bowel management programs are also initiated. Because the bladder and bowel functions are located in the Sacral region of the spinal cord, below the level of injury in both quadriplegia and paraplegia, control of these functions are lost after injury (Hanak and Scott, 1983). Therefore, to avoid complications, a strict regimen is applied to control of these areas in order to ensure proper emptying at appropriate times.
As with any type of physical injury, medications are needed to keep such systems regulated and for preventive measures of other conditions brought about from the initial injury.
For the spinal cord injured person, when dealing with the bladder management program, for example, Autonomic Dysreflexia (the elevation of the blood pressure due to complications below the level of injury), can occur if the bladder does not fully empty. Some preventative medications that aid in the emptying process are dibenzyline and ismelin. These medications are prescribed by the Physiatrist and are for relaxing the sphincter muscle of the bladder to enable proper emptying. Therefore, avoiding the pressure of a full over distended bladder which causes undue complications below the level of injury, while at the same time avoiding autonomic dysreflexia.
If autonomic dysreflexia occurs and the source is not found, the blood pressure will continue to rise, causing a cerebrovascular accident (CVA) or even death. In this case, certain emergency medications can be used to lower the blood pressure before a CVA can occur. Such emergency medications are Hyperstat, Apresoline, Levophed, and Aramine (Harmarville, 1983).
A person with SCI may need to use a variety of other medications to counteract conditions caused by the injury. In addition to bladder management medications, the need to reduce Spasticity (involuntary muscle movements) also requires medications. The medications used primarily for spasticity are muscle relaxants called Baclofen (Lioresal) and Valium. These muscle relaxants serve their purpose for reducing spasms, though they do cause the side effects of drowsiness, and possible heart deterioration with the use of Baclofen. An antibiotic such as Macrodantin may also be used on a daily basis to help prevent urinary tract infections from occurring.
There is much emphasis, during rehabilitation, on reeducating the SCI patient as to the basic survival skills originally learned as an infant, e.g. grooming, and toileting. The physical limitations placed on a person with SCI are the reasons this reeducation needs to be initiated. In addition to the redevelopment of basic survival skills, there is a need to reevaluate the work setting of a person with SCI (Cull & Hardy, 1977).
Vocational rehabilitation enables an SCI patient to return to the work world once a return to the community as been established. A vocational counselor works directly with the patient in determining what the future holds for the person, whether in the work place or returning to school.
An initial interview between the patient and the vocational counselor enables the counselor to “determine the patient’s attitude toward his Disability and future” (Ruge, 1969). Ruge (1969) goes on to state that if the patient reflects feelings of Denial about the permanence of his disability, it is best to reschedule his vocational evaluation until he is able to accept the reality of his condition.
If an SCI patient was attending school or previously employed before the disability, the vocational counselor will contact the school or employer to recommend alternative methods for continuing, if necessary. Some of these alternative methods may be modifications, scheduling, and transportation or parking availability.
If the patient was unemployed, or unsure of a career decision, the counselor will administer tests to define the skills and interests of the patient. From there the patient and counselor can work out a plan for future employment or schooling. Gainful employment can be an important goal to set while in rehabilitation. Unfortunately, in a study on SCI persons’ vocational resettlements, Crisp (1990) has indicated a very low rate of employment, usually below 40 percent of SCI persons find employment.
Before a person with a spinal cord injury can even attempt to find employment following discharge from the rehabilitation facility, they must acquire a new set of social skills that will enable them to interact with the world outside the rehabilitation center. The ability to groom oneself or to transfer from bed to wheelchair or to apply feeding devices, does not ensure that the person will function completely once outside the rehabilitation center (Trieschmann, 1980).
Once a person acquires an SCI and then ultimately moves on to a rehabilitation facility, they find consolation, safety, and a togetherness bond between themselves and others within the rehabilitation center. While in the rehabilitation center SCI persons feel they are no different than the others around them. They all have a disability. The environment which surrounds them suits all their needs. Behind the walls of the center, and within their cliques of “others like them,” SCI persons feel just as “normal” as they did while in a clique of able-bodied person’s before their disability. Only when SCI persons are faced with their first “Outing” into the public, usually through recreational therapy, does the anxiety of leaving the protective walls of the center hit them. They may not want to go. Some may refuse to go, and other’s who are hesitant may eventually give in and opt for a change of scenery.
This social outing for the SCI person provides for a high dose reality check. They find that not everything out in the public is as accessible as behind the walls of the rehabilitation center. For the first time they may notice people staring at them. If they use adaptive devices to eat with, they may feel self-conscious and disinclined to use them in front of other “normal” people, for fear of being stared at.
The social encounters a person with SCI faces are the only type of rehabilitation –and maybe just the most important type of rehabilitation– that cannot be attained behind the protective walls of the rehabilitation center. The only way a person with an SCI can attain a societal role is through the actual experience of being one with society, of contributing to society, and dealing with what society contributes to them.
Once a person with a spinal cord injury is discharged from the rehabilitation center and is a functioning part of society, other factors and social implications may come into play. For instance, social isolation (Trieschmann, 1980) may occur because of the need for the SCI person to have assistance in transportation to everywhere they may want to go. They may feel as if they are being a burden on the people they depend on, and therefore decline to ask for assistance in travel. Therefore, isolating themselves within their home, and away from the community.
In conclusion, spinal cord injury affects every aspect of an individuals life. It is only through the retraining and reeducation provided through rehabilitation and actual experience that a person with a spinal cord injury can obtain a maximal role in society.
Corbet, B. (1985). National Resource Directory Massachusetts: National Spinal Cord Association.
Crisp, R. (1990). Return to Work After Spinal Cord Injury. The Journal of Rehabilitation, 56, 28.
Cull, J. G., & Hardy R. E. (1977). Physical Medicine and Rehabilitation Approaches in Spinal Cord Injury Springfield Illinois: Thomas.
Hanak, M., & Scott, A. (1983). Spinal Cord Injury New York: Springer Publishing Company.
Harmarville Pamphlet (1983). Autonomic Dysreflexia Pittsburgh.
Harmarville Rehabilitation Center, Inc. (1983). Learning and Living Pittsburgh: Harmarville.
Ruge, D. (1969). Spinal Cord Injuries Springfield Illinois: Thomas.
Trieschmann, R. B. (1980). Spinal Cord injuries New York: Pergamon Press.
Walker, M. D. (1991). Acute Spinal-Cord Injury. The New England Journal of Medicine, 26, 1885-87.
Young, J., Burns, P., Bowen, A. M., and McCutchen, R. (1982). Spinal Cord Injury Statistics Phoenix, Arizona: Good Samaritan Medical Center.
by Jerry Carter