Early Days after Spinal Cord Injury
Simple things like voiding and defecating are not an everyday ordinary thing and can be a source of embarrassment for the patient. Dressing now requires special tools unfamiliar to the new spinal cord injured patient. Everything the person does requires a protocol and nothing is automatic any more.
The future can be a difficult thing to contemplate and is often a source of fear for the patient. The idea is that the patient must move ahead little by little, learning new skills if necessary and wading into the question of whether they can continue to work in the field they had been working in. These things must be taken one step at a time.
Initial Hospitalization for SCI
A patient with a spinal cord injury must receive immediate medical attention as soon as possible after the acute injury. Emergency medical personnel must use C-collars and backboards to protect the spine from possible further injury for transport to the hospital. Some patients with high cervical injuries need immediate respiratory support in order to save their lives. IV steroids are often used as soon as the patient is transported in order to decrease edema of the spinal cord.
At the hospital, a rapid assessment of the patient’s injuries must be maintained. Breathing and circulation are priorities in the emergency setting. The extent of the neurological injuries is assessed after the patient is hemodynamically stable with normal vital signs and adequate breathing.
CT scanning or MRI scanning are undertaken as soon as the patient is stable. These can confirm the presence of fractures and can identify any spinal cord trauma that has occurred as a result of the injury. Patients are usually sent to the ICU after stabilization in the emergency department, where they will be closely monitored. Surgery is a probability after the patient is stable enough. Surgery will take the pressure off the spinal cord and sometimes bone fragments are removed or spinal vertebrae are fused. Metal plates, bone grafting, and screws are used to keep the bones in the proper position.
Back braces or neck collars are used within a few days of surgery. They help the patient to get out of bed and begin rehabilitation. The braces and neck collars prevent too much shifting of bones as they begin to heal from their fractures. A halo brace is used by some sufferers of neck injuries. In such cases, a halo surrounds the head with pins that are drilled into the skull. Rods connect the halo to a chest vest so that the spine is completely immobilized as it heals. The brace can be uncomfortable but it really helps diminish the incidence of further injury.
Often specialists in physical therapy and rehabilitation are included as members of the care team. A Dr. of physical therapy is called a physiatrist. Many larger hospitals employ them to evaluate the patient’s rehabilitation needs. Physical and occupational therapists are also used on a daily basis to begin to teach the patient the skills necessary to begin to be functional again. Paralysis can lead to a shortening, atrophy or distortion of muscular or connective tissue so joint contractures must be dealt with as well.
It all starts with range of motion exercises to keep the muscles and joints flexible. They are often performed several times a day by therapists and nursing staff members. Even loved ones can learn how to passively move the extremities during these early stages of recovery. Occupational therapists tend to focus on the shoulders, elbows and hands, while physical therapists deal with larger movements, such as transferring from bed to chair and back again. Speech and language therapists get involved when issues such as swallowing are a problem. They help determine how best to nourish the patient with a cervical injury.
Physical therapy can be very uplifting and can bring about increased mobility for even quadriplegics. There is a ‘sip and puff’ wheelchair that is specifically used to maneuver the chair through a stick and a puff of air the patient exhales or inhales.
The patient often goes straight from ICU to a rehab center, which can be a big shift in thinking and activities. During rehabilitation, the patient is expected to work every day on goals that can bring about increased mobility and function of the remainder of the patient’s abilities. There can be specialized wings in a big hospital devoted to rehabilitation or the patient will be discharged from the hospital in order to spend time at a free-standing rehabilitation clinic.
The goal of rehabilitation is to teach the patient how to function in this “new” life they are dealing with. Patient participation is absolutely essential to the recovery of the patient. They are expected to be as independent as possible during this phase of therapy. It is hard work but is the only thing that will help the patient move on from their acute injury. Patients learn new skills and ways to work with what abilities they still have, while compensating for what they can no longer do.
Rehab can be a difficult transition for the individual and his or her family. It signifies the permanence of the patient’s injuries and the finality of the injury begins to set in. Many patients and family members feel conflicted about rehabilitation and they may just beginning to grapple with the finality of the problem.
There is an interdisciplinary team of people dedicated to helping the patient recover to the extent that they can. The team usually involves the following individuals:
- Rehabilitation nurse
- Physical therapist
- Therapeutic recreation specialist
- Speech and language therapist
- Occupational therapist
- Case coordinator
The physiatrist is a physician who oversees the patient’s rehabilitation process and essentially oversees the entire team. Rehab nurses help with routine nursing care as well as rehab services. Teaching the family and patient about rehabilitation is the job of the rehab nurse. Catheter care is taught to families and patients. Bowel programs are started and maintained by the rehab nurse.
The physical therapist works with transferring, muscle strengthening and means of transportation, whether it is a wheelchair or an ambulation device. They teach the family the various transferring techniques so that everyone is on board with what needs to be done physically around the patient’s mobility.
Occupational therapists work on the practical activities of daily living. They deal with basic toileting, dressing, eating, grooming and transfer training. The patient may need to be working with the occupational therapist in a makeup kitchen in order to practice cooking skills while disabled.
Speech language pathologists will help with those who have a tracheostomy or who have swallowing difficulties. (A tracheostomy is the surgical formation of a temporary or permanent opening into the trachea following the removal of the trachea). The patient needs to work on clearing the airway so that pneumonia does not develop from improper swallowing techniques. Communication techniques are taught to clients who have tracheostomies. The speech language practitioners also help with any cognitive retraining that may need to be done in cases of memory and other cognitive impairment.
Psychologists are helpful in dealing with the neurological implications of the patient’s injury. If, for example, there was a closed head injury as part of the patient’s injuries, the neuropsychologist can assess this and address issues of brain trauma in a paralyzed patient.
Therapeutic recreation therapists help with teaching the patient leisure skills with their new injury. Many sports can be reframed for the paraplegic patient and there are even activities for patients to do involving painting with their mouths. Outings are scheduled so the patient can learn how to maneuver in the outside world when it comes to going to the movies or out to eat.
There is some overlap between the services provided by the members of the interdisciplinary team but this is usually fine as the patient needs all the help he or she can get from differing viewpoints.
Rehab is a time of reflection on the patient’s abilities and disabilities. The entire experience can seem overwhelming but over time, most patients get the hang of things and begin to see things in a more positive light. Feelings of loss are normal and usually are somewhat transitory as the patient recovers and learns more skills.
Family support during rehab makes a lot of difference in how the patient does during this part of recovery. Those with good family support tend to do much better in the rehabilitation setting. Families should be encouraged not to pity the patient but support them in all they need in order to recover. The more positive the family is, the better the patient’s recovery will be.