AA

Rehabilitation

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. 

In Canada, the median length of inpatient rehabilitation stay for traumatic SCI was 59 days, with longer stays for those with complete injuries or tetraplegic injuries ranging from 49 days for those with incomplete paraplegia to 101 days to those with complete tetraplegia (CIHI 2006a). SCI has the longest inpatient rehab length of stay over all other rehabilitation patient groups except for burns (CIHI 2006b, 2008). 

Functional recovery is often measured by the Functional Independence Measure (FIM), an 18 item scale that is intended to measure caregiver burden and includes tasks related to cognition, mobility, bowel and bladder management and self-care.  During inpatient rehabilitation, patients with complete tetraplegia have the lowest FIM admission score and make less change compared to those with incomplete or paraplegic injuries (CIHI 2006a). Persons with the dual diagnosis of spinal cord injury and traumatic brain injury achieve smaller functional gains in rehabilitation (Macciocchi et al. 2004).

Compared to traumatic SCI, the non-traumatic SCI rehabilitation length of stay is shorter, with a lower FIM change and fewer medical complications including deep venous thrombosis, orthostatic hypotension, pressure ulcers, wound infections, spasticity, and autonomic dysrelfexia (McKinley et al. 2002a, 2002b).  The shorter length of stay may be a result of the less severe injury.  However, the earlier discharge in metastatic tumors may reflect the terminal nature of the disease and patients and family may wish for the remaining time to be spent at home.

Regarding recovery following SCI, greater improvements in ASIA motor scores at time of discharge from rehabilitation led Sipski and colleagues (2004) to postulate that women may exhibit more natural neurological recovery than men. Men however, displayed better functional capacity compared to the neurologically matched women (Sipski et al. 2004).  With respect to post-SCI mortality, being male was found to be a modest risk factor for survival according to a proportional hazards regression analysis (Strauss et al. 2006). Differences have also been observed between men and women in the experience of living with SCI.  Women, for example have been found to experience higher rates of depression (as assessed by the Center for Epidemiologic Studies Depression Scale; CESD), with nearly half the female SCI population studied being considered at risk for clinically significant depression (as compared to one quarter of the male population) (Fuhrer et al. 1993).  A relationship between depressive symptoms as measured by the CESD and the Mobility dimension of the Craig Handicap Assessment and Reporting Technique, suggested that the gender differences in depressive symptoms might be mediated by the degree of mobility individuals with SCI experience in their home and community environments (Fuhrer et al. 1993).