Principles of Rehabilitation after Spinal Cord Injury

Anthony S. Burns

HISTORICAL BACKGROUND

Spinal cord rehabilitation program can trace its roots to World War II (WWII). Prior to WWII, the prognosis for long-term survival following a severe spinal cord injury (SCI) was dismal, and there was little need for spinal cord rehabilitation. During World War I, 80% of individuals with severe SCIs typically died within 2 weeks of injury, and even up to 1934, the mortality rate for American paraplegia in the United States exceeded 80% (1,2); with the majority of patients succumbing to sepsis from urinary tract infections and pressure ulcers.

WWII led to an unprecedented number of spinal cord injuries. In response, the United Kingdom established the National Spinal Injuries Centre at Stoke Mandeville Hospital in Aylesbury, England in February 1944. The SCI unit at Stoke Mandeville employed a comprehensive, multidisciplinary approach that promoted the reintegration of injured individuals into society. Sir Ludwig Guttmann was the first medical director and is considered by many to be the father of SCI medicine. Prior to the war, he had been one of Germany’s leading neurosurgeons at the Jewish Hospital in Breslau before he fled to England in 1939. Guttman espoused some fundamental principles for SCI units (1).

Management of a unit by an experienced physician who is prepared to give up part or all of his own specialty
Sufficient allied health professionals, for example, nurses and therapists to cope with details of care
Technical facilities to establish workshops and vocational outlets
Attention to social, domestic, and industrial resettlement
Regular aftercare, or extended care, over the lifetime of each individual

Employing these principles, Stoke Mandeville enjoyed great success and came to be emulated around the world. At the conclusion of WWII, the Canadian Veterans’ Affairs Department established a dedicated facility for individuals with SCI. As a result, on January 15, 1945, the Lyndhurst Lodge was established in Toronto, Ontario. The same year, the United States Department of Veterans Affairs followed suit and established six SCI units. In Australia, the Royal Perth Hospital in Western Australia established an SCI unit in 1954, led by Dr. G.M. Bedbrook. Other Australian centers would follow. Other SCI centres were established in the United Kingdom and other European countries.

In 1970, the first model spinal cord injury system (MSCIS)was awarded by the United States Rehabilitation Services Administration to Good Samaritan Hospital in Phoenix, AZ. The success of this demonstration project led to the establishment of six additional centers in 1972. The MSCIS program continues to this day and is administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the United States Department of Education. The program has included 26 SCI centers over the years. Designated model systems must be capable of providing the entire continuum of care, from acute medical management to rehabilitation and lifelong follow-up. Grantees also contribute data to a National Spinal Cord Injury Database.

Spinal cord medicine continues to mature and develop as a medical subspecialty. In 1980, the United States Department of Veterans Affairs established fellowship programs for SCI. In 1996, the United States Accreditation Council for Graduate Medical Education approved spinal cord medicine as a subspecialty, and the first examination was given in October 1998. Subspecialty certification is conferred through the American Board of Physical Medicine and Rehabilitation; however, any current Diplomate in good standing with a member Board of the American Board of Medical Specialties is eligible, if they otherwise meet training requirements.

ROLE OF SPINAL CORD REHABILITATION

An SCI is a catastrophic event, and the rehabilitation and health maintenance of individuals with spinal cord
injuries is a challenging endeavor. In addition to the accompanying loss of function and independence, the affected individual is predisposed to a constellation of secondary complications. From the perspective of the rehabilitation specialist, goals center on the prevention of secondary complications during the acute phase, facilitating the initiation and provision of indicated rehabilitation services, supporting natural recovery and maximizing function, reintegration of the injured individual into society, and long-term maintenance of health. Not surprisingly given the magnitude of the above challenges, this is best achieved through a multidisciplinary model capitalizing on the contributions of many skilled professionals. As is discussed below, the setting and experience of the team is also important.

REHABILITATION SETTING AND TEAM

ADVANTAGES OF COHORTING AND REGIONALIZED CENTERS

Cohorting SCIs in specialized centers facilitates the accrual of the critical mass of individuals required for staff to gain meaningful experience and maintain acquired skill sets. Cohorting also allows the performance of research studies required to move the field forward and improve outcomes.

Donovan et al. (3) in 1984 postulated that SCI patients would experience improved outcomes if treated in a “coordinated” (specialized) system, and it has subsequently been demonstrated that specialized spinal injury units, encompassing rehabilitation, are associated with improved health outcomes. In the United Kingdom, Smith (4) found that individuals who received their rehabilitation through dedicated SCI programs experienced fewer health complications such as pressure-related skin injury, chest infections, urinary tract infections, constipation, uncontrolled autonomic dysreflexia, problematic spasms, disrupted sleep, and depression. Functional outcomes were also better for eating, drinking, grooming, dressing, showering, transfers, wheelchair mobility, and managing bowel and bladder function. Individuals were also less likely to report relationship problems with partners, family, and friends and more likely to have a partner, paid employment, voluntary employment, and satisfaction with sex.

Similarly, patients admitted to Model Systems in the United States experience fewer medical complications such as pressure ulcers. Additional benefits include reduced mortality, increased efficiency (e.g., functional index measure gain per day), reductions in mean length of hospital stay, associated cost savings, and higher rates of discharge to the home or community (5,6).

THE REHABILITATION TEAM

The extensive medical and rehabilitation needs of an individual with a SCI cannot be met by one clinical discipline. The provision of care by an interdisciplinary team is therefore essential, and in North America the core rehabilitation team has traditionally consisted of physical therapy, occupational therapy, rehabilitation nursing, rehabilitation psychology, social work or case management, and a physician.

Occupational therapy focuses on upper extremity function for the performance of activities of daily living (ADLs). Treatment strategies address strengthening, range of motion, fine motor control, as well as accessibility of the environment both at home and in the community. Assistive devices and splints are often incorporated into the treatment plan to facilitate and promote functional independence.
Physical therapy focuses on aspects of mobility such as ambulation, wheelchair mobility, and transfers. Maximizing mobility requires one to address strength, balance, coordination, and endurance. In addition, bracing and other orthotics are often incorporated into the treatment plan.
Rehabilitation nurses provide daily care, monitor health, participate in patient education, and collaborate with the rehabilitation team to maximize patient independence with self-care activities.
Social work provides important emotional support and adjustment counseling, identifies required community resources and supports, helps address important social needs (e.g., finances, housing), and facilitates community reintegration through discharge planning. Case managers can serve many of these functions but do not provide counseling.
Physicians diagnose conditions and underlying impairments, participate in goal setting and formulation of treatment plans, monitor and manage medical issues, and contribute to educational needs.
Rehabilitation psychology provides important mental and emotional support by addressing important issues including the screening and treatment of depression, substance abuse, comorbid brain injury and accompanying cognitive assessment, and client adjustment to new impairments and limitations.

Depending on the characteristics and impairments of the individual patient, the participation of additional disciplines may be indicated including speech language pathology, recreational therapy, respiratory therapy, and rehabilitation aides. Regular team meetings and good communication are essential for the team to be effective.

GOAL SETTING AND REHABILITATION OUTCOMES

Goal setting is fundamental to the rehabilitation process, as the goals determine the nature and focus of clinical interventions. For these reasons, it is important that goals be realistic and progress measurable. The determination of goals should also be multidisciplinary to insure that important needs are not overlooked. The National Spinal Injuries Centre at Stoke Mandeville Hospital has developed a formal needs assessment checklist (7). In order to meet the individualized needs of the patient, rehabilitation goals should be defined within the framework of identified needs and in partnership with the patient (8). Global goals should also be operationalized. As an example,
achieving independence with bladder management can be operationalized into learning how to perform intermittent self-catheterization.

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