Rehabilitation for Spinal Cord Injury
Advances in medicine now mean that those who have sustained a spinal cord injury (SCI) have both an increased chance of survival and an improved ability to lead a fulfilling life through the rehabilitation process. At JMW, we will do everything we can to support our clients and ensure they have the best possible rehab post-injury.
This process follows three main stages: acute rehabilitation, inpatient rehabilitation and outpatient rehabilitation. This article will provide information about these three stages and also look at the different types of therapy that can be used at each stage.
As every spinal cord injury is unique, there are five main goals for rehabilitation:
- To improve the quality of life after injury
- To maximise independence
- To use care and support effectively where necessary
- To encourage meaningful activity as much as possible
- To facilitate neurorecovery whenever and wherever possible
Each rehabilitation programme is tailored to you - the injured person - your specific injury and personalised goals. Typically, the programme will involve several specialists who combine experience and skill in SCI rehabilitation, emotional support, and physical therapy like physio and occupational therapy (OT).
These specialists can include:
- Case managers - these are experienced SCI nurses, occupational therapists or physios whose job is to manage your rehabilitation team, work with you to set goals and help organise your rehab
- Rehabilitation consultants or SCI consultants who advise on clinical issues
- Physiotherapists and occupational therapists who provide neuro specialist rehab and support
- Psychologists, counsellors and psycho-sexual counsellors
- Nurses who input care, tissue viability, bowel and bladder care
- Specialist peer support - we work closely with charitable partners like the SIA whose local Support Network provides peer support, nurse advocates, campaigning and advice for SCI members of the SIA
Charities and support organisations may also be involved to work together with the specialists, and the injured person, to work towards the goal of improving daily life. We will signpost you to charities that may assist with adaptive housing, equipment, activities like wheelchair skills and adaptive sports such as skiing, outdoor activity courses or local wheelchair basketball or other sports.
Stages of Therapy
There are three main stages of any typical spinal cord injury rehabilitation:
Stage 1: Acute Rehabilitation
Short-term treatment administered immediately after the injury. You are likely to be in an NHS hospital initially unless injured abroad. If you are on the NHS SCI pathway, you will be seen by an outreach nurse from your local specialist spinal injury centre while you are in a major trauma centre. You may be accepted for a bed at the specialist spinal cord injury centre for your region.
Acute rehabilitation is administered as soon as medical attention can be given to the injury.
The spine is immobilised at the earliest opportunity, often by paramedics or ambulance staff. If required, respiratory aid is administered. The steroid methylprednisolone may also be administered to decrease inflammation around the cord, known as spinal shock, and reduce damage to the spinal nerve cells.
This allows doctors at the major trauma centre to:
- Complete a full neurological assessment
- Diagnose the severity of the injury
- Predict the most likely extent of recovery
- Do any necessary surgery to the fractured spine or other injuries
- The patient will then be treated by a multidisciplinary team in an intensive treatment unit (ITU), critical care or a neurological rehab or orthopaedic ward as is appropriate
Following this assessment, the patient then progresses to stage two.
Stage 2: Inpatient Rehabilitation
Various intensive therapies conducted in hospital. This may be at your major trauma centre, a regional centre for spinal cord injuries or another rehabilitation unit.
At this stage, the primary focus after recovery from surgery or any emergency treatment is to identify the level of strength and function in the legs and arms, and consider the necessary rehabilitation to improve independent living in the longer term.
This rehabilitation if you are on the NHS SCI pathway may be in your regional specialist spinal injuries centre, or another rehabilitation centre with appropriate neuro-rehab experience.
The multidisciplinary (MDT) will then go on to address wider issues such as bowel and bladder training, psychology, exercise, sexual function, diet and nutrition, and general daily living.
During this stage, the patient learns how to adapt to their injury, and where possible works on independence in acts of daily living, with the goal of returning home. Helping with adapting accommodation or finding alternative accommodation is an important part of this process. Family members are encouraged to understand the needs of their loved ones and prepare for the next stage - life outside of the hospital.
Support at this stage from the Spinal Injuries Association’s (SIA) trusted partners and from their network support managers, who have experience of living with spinal cord injury and can talk about their lived experience, is of great practical benefit to people who are newly injured with SCI. SIA can advise on benefits, and have a fantastic nurse advocacy service to help support your clinical needs when you are discharged.
Stage 3: Outpatient Rehabilitation
This may be via a rehabilitation prescription after you have left hospital, either at home or in another hospital or rehabilitation centre.
Once the patient is discharged, ideally rehabilitation continues. This may carry on over 18 months or two years to try and get the best recovery possible. There are some skills that are learned and honed by living independently and applying skills taught at the rehab unit. However, there will also be NHS outpatient treatment that may come from the GP implementing the rehabilitation prescription provided on discharge.
For people who have a legal claim, there are opportunities to provide bespoke, private rehabilitation. Organised by the case manager with clinical and therapeutic input as necessary, this enables you to maximise your physical and psychological outcomes post-injury with the aim of living the life you want, to suit you and your family. This will include helping with the purchase of the best equipment for therapy, aids and equipment for daily living and transport.
As well as physiotherapy and OT, there will be an opportunity for vocational rehabilitation to do meaningful activity, go back to studying for a new career or be engaged in the voluntary sector. Vocational activity can be very good for people and adds to self-worth when introduced at the right time. The rehabilitation team continues to work together to improve all aspects of the injured person’s life.
Sessions can vary from weekly, daily or multiple times a day, depending on the person’s specific needs. The aim is to gradually reduce the sessions as the patient’s abilities improve, encouraging them to live independently. Even then, to keep healthy post-SCI, it is optimal to try and have some therapeutic input at a lower level on a life-long basis. Your legal claim will provide for this where possible.
No matter the severity of the injury, rehabilitation required after a spinal cord injury is lengthy and requires a lot of patience and hard work.
A very strong rehabilitation team that works together with a committed patient can make significant gains in helping the injured person come to terms with their new life and embrace their future positively.
A therapy plan will be created that takes into account the level of injury sustained, the nature of the injury, and the immediate and long-term impact of the injury on the individual. Each plan is tailored to the patient and will be developed as rehabilitation progresses and goals are achieved.
Physical therapists work to strengthen muscle groups, improve neurorecovery and, where possible, improve general motor skills. In addition, in cases of tetraplegia with breathing compromised, therapists may assist with chest physiotherapy and, if required, help the patient to develop a coughing technique with the aim of keeping the windpipe clear.
As the patient improves, the focus on mobility rehabilitation in cases of incomplete paraplegia or incomplete tetraplegia may widen to include treadmill and gait training. Some specialist equipment exists to enable ‘walking’ post SCI for therapeutic reasons. Advances in technology are bringing great opportunities to try innovative rehab equipment.
Coping strategies may gradually be introduced to deal with spasms and pain symptoms, such as chronic aches and pins and needles. Pain management assessment and treatment may be needed and is available nationwide at specialist centres.
There are two types of occupational therapy that a patient might receive - inpatient and outpatient.
With the aim of promoting independence and preparing the patient for life outside of the hospital, inpatient occupational therapy focuses on improving skills such as balance, feeding, techniques for self-grooming, dressing, strength coordination and how to use adaptive equipment where needed.
Outpatient therapy continues to develop these skills, but also continues to monitor and develop new targets as the patient progresses, such as focusing on posture, motor function and changes in sensation.
Specialist OTs can also advise on seating and posture and help to choose an appropriate wheelchair for you.
Emotional support is a vital part of rehabilitation from the very beginning of the patient's journey to better help them and their family come to terms with the life-changing nature of the injuries.
By addressing well-being and emotional stability, the therapist will hope to help the patient adapt to their new life, and treat depression if it arises.
Sex and Relationships
Psychological therapy or counselling for the injured person and their loved ones is vital. In many cases, the problems caused by impairment of sexual function are improved by support from a psycho-sexual counsellor. They can advise on relationships and how to improve intimacy.
Advice on fertility and having children post-SCI is often needed as this is a major fear of many newly-injured SCI people. The SIA peer support team will share their experiences – many people go on to have children after sustaining an SCI. Females with SCI can still conceive and deliver a baby. Males may be advised on whether their fertility is likely to be affected by the injury and can be advised in some circumstances to retrieve and store their semen to prevent it from deteriorating, which can happen in the years after injury.
This rehabilitation develops the patient's physical and mental abilities and supports them to return to work, voluntary work, or further study to enable a change of job or career or to help find a vocation they would now like to pursue. This may later involve helping the person to find work and liaising with their prospective employers to prepare them for a successful return to the workplace, ensuring that there is a complete understanding of your new needs in the workplace.
A complementary form of therapy is recreational therapy. This includes sports that help to encourage both an active mind and body, as well as help social interaction with other people in a similar situation. There are a large number of wheelchair sports clubs nationwide, which encourage physical activity and socialisation with other people. Wheelchair tennis, basketball and rugby are played all over the UK in recreational and competitive teams. There are wheelchair athletics clubs and a number of cycling groups welcoming hand cyclists too.
For people who are not keen on sport, there are groups who participate in art and gardening, and knit and natter groups among others that can be a good outlet for hobbies and friendship.
Family Life and Care Needs
During rehabilitation, it is important to enable the family to get back to normal, so the injured person participates as before in day-to-day activities. Helping with adaptive transport to facilitate the school run, or getting a motorised front wheel or offroad wheelchair to enable country walks are positive for the family as a whole, as well as the injured person.
The first holiday organised after someone has been injured is something the case manager can help arrange to ensure the travel and accommodation go smoothly and are suitable for the family to have a great time.
The single most important part of your claim will be to ensure you can afford whatever care and support you will need for the rest of your life. This takes account of the ageing process and how your needs may alter. Also factoring in the care and support you and your partner may need now or in the future for looking after a family, going on holiday, facilitating hobbies and activities. We try to ensure any care enables you and your loved ones to do whatever you would like to, without the full responsibility for providing day to day care falling to those nearest and dearest to you. This is a personal choice, so your needs are considered medically but what is recommended will be tailored to your situation so you decide how much care and support will help and we factor this in for you. The rehabilitation process enables you to think about the future too.
Rehabilitation is a vital part of the legal process. The effects of the accident can be devastating but careful bespoke rehab will hugely improve the quality of life for the individual concerned.
Read more about the Spine and You by clicking on the links below.