Spinal cord injury rehabilitation. 4. Individual experience, personal adaptation, and social perspectives

Independent sailing with high tetraplegia using sip and puff controls: integration into a community sailing center

BACKGROUND

We are continually rediscovering how adapted recreational activity complements the rehabilitation process, enriches patients' lives and positively impacts outcome measures. Although sports for people with spinal cord injuries (SCI) has achieved spectacular visibility, participation by high cervical injuries is often restricted due to poor accessibility, safety concerns, lack of adaptability, and high costs of technology.

METHODS

We endeavor to demonstrate the mechanisms, adaptability, accessibility, and benefits the sport of sailing creates in the rehabilitative process. Our sailor is a 27-year-old man with a history of traumatic SCI resulting in C4 complete tetraplegia.

RESULTS

The participant completed an adapted introductory sailing course, and instruction on the sip-and-puff sail and tiller control mechanism. With practice, he navigated an on-water course in moderate winds of 5 to 15 knots.

DISCUSSION

Despite trends toward shorter rehabilitation stays, aggressive transdisciplinary collaboration with recreation therapy can provide community and natural environment experiences while inpatient and continuing post discharge. Such peak physical and psychological experiences provide a positive perspective for the future that can be shared on the inpatient unit, with families and support systems like sailing clubs in the community.

CONCLUSION

Rehabilitation theory directs a team process to achieve patient self-awareness and initiate self-actualization in spite of disablement. Utilization of local community sailing centers that have provided accessible assisted options provides person-centered self-realization of goals as assisted by family and natural supports. Such successful patients become native guides for others seeking the same experience.

Electromechanical abdominal massage and colonic function in individuals with a spinal cord injury and chronic bowel problems

STUDY DESIGN

A prospective intervention of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with spinal cord injury (SCI).

OBJECTIVES

To evaluate the effects of noninvasive abdominal massage using an electromechanical apparatus on bowel function in individuals with SCI and chronic bowel problems. This easy-to-use apparatus can be applied by the patients at home without the help of a therapist.

SETTING

Homes of community-living individuals.

METHODS

Twenty-one subjects with SCI were instructed to use the massage apparatus daily for 20 min during a 10-week period. Compliance, effects, side effects and user satisfaction were assessed using questionnaires.

RESULTS

Fifteen subjects completed the 10-week period. Although some characteristics of defecation changed positively for some of the subjects (time to result, amount, consistency), none felt better or more confident after using the massage device. In addition, some individuals experienced negative side effects (predominantly pain or discomfort). The overall satisfaction with the device is ambiguous, with half of the group judging the device as insufficient and the other half as at least adequate.

CONCLUSION

The use of an electromechanical massage device does not improve bowel function in most individuals with SCI who have chronic bowel problems. Why some subjects benefit and others do not should be investigated in future studies.

Advances in the rehabilitation management of acute spinal cord injury

Aggressive assessment and management of the secondary complications in the hours and days following spinal cord injury (SCI) leads to restoration of function in patients through intervention by a team of rehabilitation professionals. The recent certification of SCI physicians, newly validated assessments of impairment and function measures, and international databases agreed upon by SCI experts should lead to documentation of improved rehabilitation care. This chapter highlights recent advances in assessment and treatment based on evidence-based classification of literature reviews and expert opinion in the acute phase of SCI. A number of these reviews are the product of the Consortium for Spinal Cord Medicine, which offers clinical practice guidelines for healthcare professionals. Recognition of and early intervention for problems such as bradycardia, orthostatic hypotension, deep vein thrombosis/pulmonary embolism, and early ventilatory failure will be addressed although other chapters may discuss some issues in greater detail. Early assessment and intervention for neurogenic bladder and bowel function has proven effective in the prevention of renal failure and uncontrolled incontinence. Attention to overuse and disuse with training and advanced technology such as functional electrical stimulation have reduced pain and disability associated with upper extremity deterioration and improved physical fitness. Topics such as chronic pain, spasticity, sexual dysfunction, and pressure sores will be covered in more detail in additional chapters. However, the comprehensive and integrated rehabilitation by specialized SCI teams of physicians, nurses, therapists, social workers, and psychologists immediately following SCI has become the standard of care throughout the world.

Spinal cord injured persons’ conceptions of hospital care, rehabilitation, and a new life situation

BACKGROUND

The basic aim of spinal cord injury (SCI) rehabilitation is to help patients return to a life worth living. It is therefore important that the staff at spinal units and rehabilitation centres understand how the patients experience their rehabilitation and their adjustment process to the new situation.

AIM

To describe SCI persons' experiences of their rehabilitation process.

METHOD

Nineteen SCI persons were interviewed. Data from the tape-recorded interviews were analysed according to a modified descriptive version of the phenomenographic analysis process.

RESULTS

Six categories that describe the informants' conceptions of their rehabilitation process emerged: access to information, participation in planning rehabilitation, emotional support, feelings of vulnerability, adjustment to a new life situation, and emotional consequences of the injury.

CONCLUSION

Straightforward information, participation in the planning of the rehabilitation programme and emotional support were important factors influencing the rehabilitation process after the SCI. Professionals working with SCI rehabilitation should make use of patients' experiences in order to develop better rehabilitation programmes that focus on the individual needs of the patient. People are individuals and failure to take this into account can impact negatively on quality of life and the effectiveness of the rehabilitation.

Satisfaction with sexual life among persons with traumatic spinal cord injury and meningomyelocele

PURPOSE

To study satisfaction with sexual life and self-assessed sufficiency of sexual counselling in persons with traumatic spinal cord injury (SCI) and meningomyelocele (MMC).

METHOD

A postal questionnaire on aspects of health and functioning was answered by 190 persons with traumatic SCI who had been treated in the Spinal Injuries Unit in Sahlgrenska University Hospital, Göteborg, Sweden and 41 persons with MMC who were admitted to the Young Adult Teams in Göteborg, Borås and Skövde, Sweden.

RESULTS

On a numerical scale from 0 (dissatisfied) to 10 (satisfied) the median of satisfaction with sexual life was 3 for the men and 4 for the women among the persons with traumatic SCI. In the MMC group the median of satisfaction with sexual life was 5 for the men and 8 for the women. Sexual dissatisfaction increased with increasing age in both groups. Inconvenience caused by urinary and faecal incontinence, as well as neuropathic pain increased sexual dissatisfaction in the men with traumatic SCI. A total of 69% of the men with traumatic SCI and 56-59% of the participants in other subgroups reported that the sexual counselling they had received was sufficient.

CONCLUSIONS

The results corroborate findings from earlier studies that satisfaction with sexual life is rather low among persons with SCI. Especially ageing men with traumatic SCI who have sustained injury at an older age are a challenge for rehabilitation. The high satisfaction with sexual life in the women in comparison with the men with MMC is a finding not reported earlier. Our results suggest that adequate treatment of incontinence and pain might improve even sexual satisfaction. Sexual counselling should be given to all individuals with SCI and to their partners. Sexual counselling for young adults with MMC is an important part of the rehabilitation process.

The impact of spinal cord injury on sexual function: concerns of the general population

STUDY DESIGN

Secure, web-based survey.

OBJECTIVES

Obtain information from the spinal cord injured (SCI) population regarding sexual dysfunctions, with the aim of developing new basic science and clinical research and eventual therapies targeting these issues.

SETTING

Worldwide web.

METHODS

Individuals 18 years or older living with SCI. Participants obtained a pass-code to enter a secure website and answered survey questions. A total of 286 subjects completed the survey.

RESULTS

The majority of participants stated that their SCI altered their sexual sense of self and that improving their sexual function would improve their quality of life (QoL). The primary reason for pursuing sexual activity was for intimacy need, not fertility. Bladder and bowel concerns during sexual activity were not strong enough to deter the majority of the population from engaging in sexual activity. However, in the subset of individuals concerned about bladder and/or bowel incontinence during sexual activity, this was a highly significant issue. In addition, the occurrence of autonomic dysreflexia (AD) during typical bladder or bowel care was a significant variable predicting the occurrence and distress of AD during sexual activity.

CONCLUSION

Sexual function and its resultant impact on QoL is a major issue to an overwhelming majority of people living with SCI. This certainly constitutes the need for expanding research in multiple aspects to develop future therapeutic interventions for sexual health and SCI.

The Effect of Modafinil on Self-Esteem in Spinal Cord Injury Patients: A Report of 2 Cases and Review of the Literature

We report on 2 cases of the effect of modafinil on the self-esteem of patients with spinal cord injury (SCI). The first patient was a 33-year-old man with history of polysubstance abuse and a C6 American Spinal Injury Association (ASIA) grade A injury, who presented for follow-up to the outpatient rehabilitation clinic for depression, decreased motivation, and lowered self-esteem. The patient had tried a selective serotonin reuptake inhibitor (SSRI) without success, and reported increasing social and legal stressors. Within 1 month of starting on modafinil, he reported increased self-esteem and motivation, as well as decreased self-consciousness. The second patient was a 36-year-old woman with history of depression and a T11 ASIA grade A injury. She tried various SSRIs for depression and adjustment issues before she was started on modafinil. She lost weight and became more assertive and less self-conscious within 1 month after starting on modafinil. These 2 cases suggest that modafinil should be studied as a therapeutic option for treating lowered self-esteem in patients with SCI.

Spinal cord injury medicine. 4. Optimal participation in life after spinal cord injury: physical, psychosocial, and economic reintegration into the environment

This learner-directed module on spinal cord injury (SCI) presents a variety of perspectives of the process of personal and environmental adaptation for reintegration. Adaptation is unique to each person and does not predictably follow stages. Models used for understanding the process include biopsychosocial, ICIDH-2 (International Classification of Functioning, Disability and Health), and sector divisions of the environment. Home modification requires home (intermediate environment) evaluation and sociospatial behavioral mapping for planning and appropriation of remodeling in proportion to functional need and use. Options for access to the natural environment include specialized wheelchairs, climbing rigging, kayaks, and sail boats. Sports participation with adaptations is expanding and includes a larger variety of organizations and leagues. Economic needs are effectively anticipated with development of a life care plan. Procreative options to overcome infertility after SCI include vibratory stimulation for ejaculation, intravaginal insemination, intrauterine insemination, in vitro fertilization, and intracytoplasmic sperm injection. Approaches to requests for withdrawal of life-sustaining care include depression screening, pain evaluation, and assistance in accomplishment of person centered goals. Overall, community reintegration after SCI is continually improving because of better acceptance, accessibility, and technology for building adaptations.

OVERALL ARTICLE OBJECTIVES

(a) To review models and theories of medical intervention and disablement and (b) to demonstrate their application in rehabilitation practice by designing unique treatment plans that meet patient person-centered goals.

Bladder management and quality of life after spinal cord injury

OBJECTIVE

This study examines the quality of life among individuals with spinal cord injury requiring assistance for bowel and bladder management vs. those with independent control of bowel and bladder.

DESIGN

Two groups of 53 individuals each were matched case for case on age, education, sex, race, and lesion level. Outcome measures included the Satisfaction With Life Scale, the Craig Handicap Assessment and Reporting Technique (CHART), and the SF-12.

RESULTS

Satisfaction with life was significantly lower among dependent individuals with impaired bowel and bladder functioning as compared with individuals with independent bowel and bladder control. Similarly, dependent individuals reported greater self-reported handicap (CHART) than independent individuals in the areas of physical independence, mobility, and occupational functioning. However, dependent and independent individuals did not differ in the areas of social integration and economic self-sufficiency. Item analysis on the CHART item assessing number of social contacts initiated in the previous month suggested that dependent individuals may have difficulty initiating new social contacts. Independent individuals reported better overall physical health (SF-12) than dependent individuals. Mental health (SF-12), however, did not differ across groups.

CONCLUSIONS

Individuals with impaired bowel and bladder control reported lower quality of life on several domains compared with those with independent control of bowel and bladder. Though the two groups did not differ in self-reported social integration, dependent individuals may have greater difficulty creating new social relationships.

Avaliação da Variabilidade da Frequência Cardíaca em Pacientes com Lesão Medular

Introdução. A lesão da medula espinal é considerada grave síndrome neurológica incapacitante, ocorre principalmente em adultos jovens. A variabilidade da frequência cardíaca vem sendo utilizada como meio não-invasivo para avaliar o controle neural do coração analisando as flutuações. Objetivo. avaliar a variabilidade da freqüência cardíaca em pacientes com trauma-raquimedular submetidos a um teste incremental de membros superiores. Método. Quatro indivíduos do sexo masculino com diagnóstico de traumaraquimedular realizaram um teste incremental de esforço máximo no cicloergômetro de membros superiores. Todos os registros dos batimentos cardíacos foram feitos com o emprego de um cardiofrequencimetro (Polar® S810 Heart Rate Monitor). Esses batimentos registrados foram direcionados a um computador por meio de uma interface IR de emissão de sinais infravermelhos, para que se pudesse proceder a análise da variabilidade da freqüência cardíaca pelo uso do software Polar Precision Performance. Resultados. Os valores da variabilidade da freqüência cardíaca são maiores no indivíduo com trauma-raquimedular mais alta (T1) quando comparado com os indivíduos com trauma-raquimedular mais baixa (T3, T6, T10). Conclusão. A variabilidade da frequência cardíaca foi maior no indivíduo com TRM nível T1 quando comparado com os indivíduos com TRM mais baixo (T3, T6, T10).

Perceived difficulty in dealing with consequences of spinal cord injury

OBJECTIVES

To determine the perceived difficulty in dealing with consequences of spinal cord injury (SCI) and to explore patterns of how these complications are perceived.

DESIGN

Postal survey.

SETTING

General community.

PARTICIPANTS

Individuals with traumatic SCI (n = 430).

METHODS

Subjects (n = 877) were selected from The Miami Project database and were sent a questionnaire in which they were asked to rate their difficulty in dealing with 10 consequences of SCI, on a scale ranging from 0 (not hard at all) to 10 (extremely hard).

RESULTS

The questionnaire was returned by 430 individuals (49%). Five consequences (decreased ability to walk or move, decreased control of bowel, decreased control of bladder, decreased sexual function, and pain) were rated highest (means, 8.2 to 6.2). High ratings of feeling sad were associated with high ratings of most other consequences, and a cluster analysis revealed interrelationships between the ways the various consequences were perceived.

CONCLUSIONS

Several consequences of SCI are frequently perceived as being very difficult to deal with. Sadness may influence how well a person deals with other consequences of SCI. The observed patterns in perceived difficulty dealing with complications of SCI need to be explored further because they are important in our understanding and treatment of the medical conditions that may follow SCI.