Rehab: From Bedside To Community

Rehabilitation has been defined by the World Health Organization as a progressive, dynamic, goal-oriented and often time-limited process, which enables an individual with an impairment to identify and reach his/her optimal mental, physical, cognitive and social functional level.  Enhancing quality of life is regarded as an inherent goal of rehabilitation services and programs given their focus on interventions to minimize the impact of pain and physical and cognitive impairment, and on enhancing participation in work and everyday activities. SCI rehabilitation involves a multitude of services and health professionals and is initiated in the acute phase and continues with extensive and specialized inpatient services during the sub-acute phase.  Inpatient rehabilitation is an important stepping stone towards regaining and learning new skills for independent living.  Here patients engage in an intensive full day program with services which may include nursing, physical therapy, occupational therapy, respiratory management, medical management, recreation and leisure, psychology, vocational counseling, driver training, nutritional services, speech pathology, social worker, sexual health counseling, assistive device prescription and pharmaceutical services.  Rehabilitation continues with planning for discharge back to the community and finally, re-integration into former or new roles and activities within the community.  Family and peers have important roles throughout the rehabilitation process.

Background – Spinal Cord Injury

The spinal cord extends from the foramen magnum (opening at the base of the skull) to the conus medullaris (most distal bulbous part of the cord) at the level of the first and second lumbar vertebrae.  It consists of 31 segments associated with 31 pairs of spinal nerves (8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal).  The ascending sensory nerves within the spinal cord receive and transmit sensory information to the brain.  The descending motor nerves transmit information from the higher brain structures to various parts of the body to initiate motor functions such as movement and to regulate autonomic functions such as respiration and blood pressure.  The spinal cord is also critical for transmitting and integrating information within the spinal cord.

Figure 1: The Spinal Cord

Spinal cord injury (SCI) which results in disruption of the nervous transmission can have considerable physical and emotional consequences to an individual’s life.  Paralysis, altered sensation, or weakness in the parts of the body innervated by areas below the injured region almost always occur.  In addition to a loss of sensation, muscle functioning and movement, individuals with SCI also experience many other changes which may affect bowel and bladder, presence of pain, sexual functioning, gastrointestinal function, swallowing ability, blood pressure, temperature regulation and breathing ability.  Numerous secondary complications may arise from SCI including deep vein thrombosis, heterotopic ossification (the formation of pathological bone in muscle or soft tissue), pressure ulcers and spasticity.

The recovery can be long from the acute hospital admission to the return of full participation in the individual’s community.  Even those individuals who make significant gains in rehabilitation may experience difficulty when returning to pre-injury activities.  Thus, SCI has a severe effect on quality of life. It also has an enormous cost on the health care system. Dryden et al. (2005) examined the health care costs following a SCI in Canada.  The acute and rehabilitation care represented 68.2% of the total health care costs incurred over the first 6 years for an individual following an injury to the spinal cord. The direct costs of a spinal cord injury were estimated at $146,000 Canadian in the first year for a person with a complete traumatic injury and $42,000 for an incomplete injury.  Annual costs in the subsequent 5 years post-injury were reported to be $5400 Canadian per person with a complete injury and $2800 for an incomplete injury (Dryden et al. 2005).  Compared to age and gender-matched controls, individuals with SCI discharged from hospital are more likely to be re-hospitalized, have physician contact and use more hours of home care services (Dryden et al. 2004) See SCIRE’s review on the costs of SCI, for more detailed information on the costs of diagnosis, costs of prevention and treatment of secondary conditions, and the direct and indirect costs of SCI. The need for evidence-based SCI rehabilitation programs has never been greater given the enormous cost of SCI rehabilitation, the growing demands on the Canadian health care system and the devastating impact that an SCI has on the quality of lives of individuals.