Bridging the Gap
Monday August 17, 2009
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Spinal cord injury is devastating, often robbing people of their ability to care for themselves and contribute to society. PTs and others in healthcare could be doing much more to help these patients regain independence, but healthcare providers’ hands are often tied by inadequate insurance coverage.
In the U.S., the number of people with SCI was estimated to be roughly 300,000 in 2007, according to the National SCI Database. From 1973 to 1979, the average age at injury was 28.7; however, as the median age of the general population has increased, so has the age of those injured. Since 2005, the average age at injury has increased to 39.5.
“Both groups [the young and elderly] have falls, but the geriatric group will do a low impact fall, such as a fall in the home [and become paralyzed],” says Jennifer Hastings, PT, PhD, NCS, clinical associate professor and director of clinical education in the physical therapy department at the University of Puget Sound in Tacoma, Wash.
SCI 101
People with complete SCI have no neurologic communication going through the level of injury, but with incomplete injuries, there is some preserved nerve transmission.
“Basically [with incomplete injuries] the nervous system is still communicating at the site of injury, so with that the potential for a recovery of motor function and sensory function is much greater,” Hastings says.
Just how much neurological information does or doesn’t get through depends on the severity of injury. People with tetraplegia have spinal cord damage at the cervical area, where the nerves that innervate the hands and arms exit the spinal cord. Paraplegia means the injury has occurred below the cervical level and, depending on how far below, these patients have relatively good use of their hands but impaired control of their trunk and leg muscles, according to Edelle Field-Fote, PhD, PT. Field-Fote is associate professor at the University of Miami School of Medicine and director of the Neuromotor Rehabilitation Research Laboratory at The Miami Project to Cure Paralysis in Miami.
Supporting Recovery
Postinjury hospital and rehabilitation lengths of stay for these patients have been shrinking dramatically.
“In 1974, we had a 115 days average across all levels of spinal cord injury as an inpatient rehabilitation stay. That isn’t ICU; that’s when they get into rehab. Today, it’s 36 days, average. That would be if you dove into a lake and woke up at 23 years old completely paralyzed and debilitated. That’s 36 days for rehab,” Hastings says.
The average acute care stay is down to 15 days, according to Hastings, which means that PTs start care when these patients are more acute and more likely to be on ventilators.
PTs need to advocate for patients, aiming to get them the best equipment, such as high-end manual or power wheelchairs. Arguing with insurance companies about patients’ needs and the evidence supporting the need for mobility works, she says: “I personally have gotten everything that I want out of insurance.”
According to Field-Fote, during inpatient rehabilitation, PTs usually will instruct patients with SCIs how to transfer, stand, and get about in their wheelchairs; maintain skin health; devise appropriate splints or braces; and, depending on the patient’s capacity for strength recovery, maintain their level of strength. Upper extremity training following SCI focuses on the brain, not the spinal cord, Field-Fote says. The aim is to help the brain better get the information through the damaged area of the spinal cord to the limbs.
In addition to repetitive practice, another approach to therapy that has been shown to be effective for SCI is sensory stimulation. “This is a low level of stimulation that is not meant to cause the muscle to contract; it is meant to excite the brain so that the brain can be more effective at sending information down through the injured areas of the cord,” Field-Fote says.
Bridge to Function
Field-Fote’s research shows that significant neurological recovery takes place in the months and even years after the injury. The problem is that those with tetraplegia are discharged from the hospital so fast that PTs can often only teach compensatory strategies that may or may not be efficient.
“The problem is that nobody tells [patients about their capacity for neurological recovery], so they keep doing these compensatory strategies when they have the possibility to do much more normal, flexible strategies of movement that would be much more effective for them and make them much more functional,” she says.
In recent years, researchers have focused on locomotor training for patients with SCIs. “We know, now, that intensity of training is critical. There have been several studies published — my own among them — that indicate it doesn’t matter so much what kind of training they do, but it must be done intensively and it must be walking training. So, cycling training doesn’t end up making you a better walker. It must be locomotor training,” Field-Fote says.
PTs also should be aware of the many assistive technologies available for these patients. “Some of the things that are exciting are brain machine interfaces, which take signals from the brain with electrodes that are placed on the scalp and convert them into signals that can drive things like robots or, in the case of a recent publication, that can drive a stimulator that can activate muscles,” she says.
Building on Success
Community hospitals generally are not equipped with the multidisciplinary teams these patients need for optimal recovery. Psychology, for example, is a critical component that not only helps patients deal mentally with their issues, but also helps to plug them into community resources.
“Very many people are treated in community hospitals and ... don’t have access to a team approach to rehabilitation, which includes PT, OT, nursing, orthotics, psychology, dietary — all those things are so critical to the person with spinal cord injury,” Field-Fote says.
Overall, these patients will lead much more sedentary lifestyles than people who do not have these injuries, which puts them at greater risk than the general population for obesity, cardiovascular disease, diabetes, and other chronic conditions, according to Marie Vazquez Morgan, PT, PhD, assistant professor in the department of rehab sciences in the program of physical therapy at Louisiana State University Health Sciences Center in Shreveport, La.
PTs should not only educate patients with SCIs about the need for long-term prevention of these illnesses, but also encourage them and give them the tools to remain active. Therapists can recommend community exercise resources, as well as local gyms that might be accessible for those with disabilities; or, depending on their level of injury and ability to get out, provide simple solutions such as resistance bands for at-home strength training.
“Educate the patients that they need to work out at least four or five times a week, 30 minutes at a time to get [the] heart rate up,” Morgan says. Morgan has made the use of body weight-supported treadmill training at the LSU center, available on an ongoing basis to patients with SCIs. The training has many benefits: promoting cardiovascular health, movement, and even the psychological satisfaction of looking in the mirror and standing to simulate walking. According to Morgan, hers is the only facility that offers body weight-supported treadmill training. “I do it as part of the wellness program, and I charge them a small fee because they need to get it done,” she adds.
Ironically, the problem is that few PTs and others know to refer patients to the program, so Morgan and colleagues are working to get the word out.
Hastings also has devoted part of her practice to continuing rehab for these patients. “I had a young girl who was a senior in high school at 17 years old, and she had gone through all the rehab and had outpatient therapy, but she couldn’t shower herself. It took me one week, working with her in her home, to teach her what she needed to be independent enough to shower,” Hastings says. “By the end of something like six weeks, she was 100% independent and moved back East to go to college. But if she hadn’t run into me — a therapist who works outside the system — she wouldn’t be able to do that.
“We need to get back to doing our full job, and we need to argue with the system,” she concludes.
In the U.S., the number of people with SCI was estimated to be roughly 300,000 in 2007, according to the National SCI Database. From 1973 to 1979, the average age at injury was 28.7; however, as the median age of the general population has increased, so has the age of those injured. Since 2005, the average age at injury has increased to 39.5.
“Both groups [the young and elderly] have falls, but the geriatric group will do a low impact fall, such as a fall in the home [and become paralyzed],” says Jennifer Hastings, PT, PhD, NCS, clinical associate professor and director of clinical education in the physical therapy department at the University of Puget Sound in Tacoma, Wash.
SCI 101
People with complete SCI have no neurologic communication going through the level of injury, but with incomplete injuries, there is some preserved nerve transmission.
“Basically [with incomplete injuries] the nervous system is still communicating at the site of injury, so with that the potential for a recovery of motor function and sensory function is much greater,” Hastings says.
Just how much neurological information does or doesn’t get through depends on the severity of injury. People with tetraplegia have spinal cord damage at the cervical area, where the nerves that innervate the hands and arms exit the spinal cord. Paraplegia means the injury has occurred below the cervical level and, depending on how far below, these patients have relatively good use of their hands but impaired control of their trunk and leg muscles, according to Edelle Field-Fote, PhD, PT. Field-Fote is associate professor at the University of Miami School of Medicine and director of the Neuromotor Rehabilitation Research Laboratory at The Miami Project to Cure Paralysis in Miami.
Supporting Recovery
Postinjury hospital and rehabilitation lengths of stay for these patients have been shrinking dramatically.
“In 1974, we had a 115 days average across all levels of spinal cord injury as an inpatient rehabilitation stay. That isn’t ICU; that’s when they get into rehab. Today, it’s 36 days, average. That would be if you dove into a lake and woke up at 23 years old completely paralyzed and debilitated. That’s 36 days for rehab,” Hastings says.
The average acute care stay is down to 15 days, according to Hastings, which means that PTs start care when these patients are more acute and more likely to be on ventilators.
PTs need to advocate for patients, aiming to get them the best equipment, such as high-end manual or power wheelchairs. Arguing with insurance companies about patients’ needs and the evidence supporting the need for mobility works, she says: “I personally have gotten everything that I want out of insurance.”
According to Field-Fote, during inpatient rehabilitation, PTs usually will instruct patients with SCIs how to transfer, stand, and get about in their wheelchairs; maintain skin health; devise appropriate splints or braces; and, depending on the patient’s capacity for strength recovery, maintain their level of strength. Upper extremity training following SCI focuses on the brain, not the spinal cord, Field-Fote says. The aim is to help the brain better get the information through the damaged area of the spinal cord to the limbs.
In addition to repetitive practice, another approach to therapy that has been shown to be effective for SCI is sensory stimulation. “This is a low level of stimulation that is not meant to cause the muscle to contract; it is meant to excite the brain so that the brain can be more effective at sending information down through the injured areas of the cord,” Field-Fote says.
Bridge to Function
Field-Fote’s research shows that significant neurological recovery takes place in the months and even years after the injury. The problem is that those with tetraplegia are discharged from the hospital so fast that PTs can often only teach compensatory strategies that may or may not be efficient.
“The problem is that nobody tells [patients about their capacity for neurological recovery], so they keep doing these compensatory strategies when they have the possibility to do much more normal, flexible strategies of movement that would be much more effective for them and make them much more functional,” she says.
In recent years, researchers have focused on locomotor training for patients with SCIs. “We know, now, that intensity of training is critical. There have been several studies published — my own among them — that indicate it doesn’t matter so much what kind of training they do, but it must be done intensively and it must be walking training. So, cycling training doesn’t end up making you a better walker. It must be locomotor training,” Field-Fote says.
PTs also should be aware of the many assistive technologies available for these patients. “Some of the things that are exciting are brain machine interfaces, which take signals from the brain with electrodes that are placed on the scalp and convert them into signals that can drive things like robots or, in the case of a recent publication, that can drive a stimulator that can activate muscles,” she says.
Building on Success
Community hospitals generally are not equipped with the multidisciplinary teams these patients need for optimal recovery. Psychology, for example, is a critical component that not only helps patients deal mentally with their issues, but also helps to plug them into community resources.
“Very many people are treated in community hospitals and ... don’t have access to a team approach to rehabilitation, which includes PT, OT, nursing, orthotics, psychology, dietary — all those things are so critical to the person with spinal cord injury,” Field-Fote says.
Overall, these patients will lead much more sedentary lifestyles than people who do not have these injuries, which puts them at greater risk than the general population for obesity, cardiovascular disease, diabetes, and other chronic conditions, according to Marie Vazquez Morgan, PT, PhD, assistant professor in the department of rehab sciences in the program of physical therapy at Louisiana State University Health Sciences Center in Shreveport, La.
PTs should not only educate patients with SCIs about the need for long-term prevention of these illnesses, but also encourage them and give them the tools to remain active. Therapists can recommend community exercise resources, as well as local gyms that might be accessible for those with disabilities; or, depending on their level of injury and ability to get out, provide simple solutions such as resistance bands for at-home strength training.
“Educate the patients that they need to work out at least four or five times a week, 30 minutes at a time to get [the] heart rate up,” Morgan says. Morgan has made the use of body weight-supported treadmill training at the LSU center, available on an ongoing basis to patients with SCIs. The training has many benefits: promoting cardiovascular health, movement, and even the psychological satisfaction of looking in the mirror and standing to simulate walking. According to Morgan, hers is the only facility that offers body weight-supported treadmill training. “I do it as part of the wellness program, and I charge them a small fee because they need to get it done,” she adds.
Ironically, the problem is that few PTs and others know to refer patients to the program, so Morgan and colleagues are working to get the word out.
Hastings also has devoted part of her practice to continuing rehab for these patients. “I had a young girl who was a senior in high school at 17 years old, and she had gone through all the rehab and had outpatient therapy, but she couldn’t shower herself. It took me one week, working with her in her home, to teach her what she needed to be independent enough to shower,” Hastings says. “By the end of something like six weeks, she was 100% independent and moved back East to go to college. But if she hadn’t run into me — a therapist who works outside the system — she wouldn’t be able to do that.
“We need to get back to doing our full job, and we need to argue with the system,” she concludes.
Lisette Hilton is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.
Monday August 17, 2009