The multi-disciplinary team approach in the holistic rehabilitation of Spinal Cord
Injury (SCI) cases in Bangladesh.
Centre for the Rehabilitation of the Paralysed (CRP) established in 1979 has always
maintained the importance of its goal to provide holistic rehabilitation including physical,
emotional, social and economic aspects with a lifelong follow up of each SCI person.
The multi disciplinary team who ensures this holistic rehabilitation is made up of
doctors, nurses, physiotherapists, occupational therapists, social workers, peer and
spiritual counselors, vocational trainers and an advocacy and networking officer.
The power point presentation aims initially to give a potted history of CRP’s journey then
to concentrate on the different areas of specialty of the multi-disciplinary team
members:
Doctors deciding on either a conservative course of action – immobilization with skull
traction on a homemade turning bed (Stryker frame) or surgical fixation with the
introduction of implants, reducing the period of bed rest but needing to balance this with
the high cost of implants and attendant possible dangers of surgery.
Nursing with its emphasis on prevention of life threatening challenges of pressure sores
and urinary complications.
Physiotherapy and occupational therapy commences immediately on admission with
special attention being given to chest therapy ensuring a sufficient vital capacity. Any
active movement in upper and lower limbs is encouraged accompanied by
strengthening exercises while full range passive movement is given to those joints
where movement is limited. Occupational therapists provide the necessary splinting to
keep the fingers and wrists in the correct position to prevent any possible contractures.
As the fracture-dislocation site becomes stable and the patient is allowed to start
mobilization, gradual sitting practice over the side of the bed commences. Both physio
and occupational therapists work on transfers from bed to wheelchair, wheelchair to
exercise plinth, wheelchair to rickshaw etc. A special tilting wheelchair has been
produced at CRP, with the collaboration of another local NGO and an Australian
therapist, a specialist in SCI. This enables the early cervical injured person to recline
immediately should they start to feel faint due to the slowed venous return.
Physiotherapists aim to enable the paralysed person to be as mobile as possible
whether as a wheelchair user or if there is sufficient recovery then with the aid of
calipers and crutches or other walking aid. The “active rehabilitation area” a type of
“assault course” for wheelchair users ensures that they can mount and dismount a ramp
safely, also manage steps and travel over different surfaces such as gravel, grass and
mud. A hand operated lift has been installed at CRP to enable the wheelchair user
(where no electric powered lift exists) to move up and down a building.
The focus of occupational therapy is to enable the paralysed person to regain the ability
to engage in the activities of daily living such as feeding, dressing, toileting. Cervical
injuries join a regular “hand class” to increase function where such aids as a writing
splint may be provided. Activities including gardening, looking after goats and chickens
are also encouraged giving the wheelchair user the confidence that he/she can continue
on their return home. Games and sports, part of recreational activities along with
singing and other performing arts are also encouraged.
On completion of time in the ward, the patient progresses to the “half way hostel” where
they will spend the last few weeks before discharge to gain as much independence as
possible. This includes using the tube well from their wheelchair and getting used to
managing without a fan and using a hurricane lamp for light if their home has no
electricity.
CRP’s aim is that a person should return to the work they did before their accident.
However, where many spinal injuries happen as a result of manual laboring jobs such
as falling from a height, (most commonly fruit trees) or carrying a heavy head load such
as a sack of rice which shifts, then new means of earning a living need to be found.
CRP currently runs four different vocational trainings:
1.
2.
3.
4.
Tailoring
Electronics repair
Computer operating
Small shop keeping``
As a special adaptation for paraplegic baby taxi drivers, the foot brake has been
converted into a hand brake enabling them to drive and continue their work.
A team of social workers follow up persons with SCI when they go home to check how
fully they have adapted to life in a wheelchair and have integrated into the local
community. Quadriplegics are escorted home initially by the “Good Start” project which
ensures that transport and a therapist accompany them to overcome the initial
requirements of access to the home (often involving the making of a ramp of earth to
the front door), possibly widening the front door or bathroom door. When on religious
holidays many staff members return home to all areas of Bangladesh, they are required
to follow up any previous SCI person within a certain radius of their home. This enables
CRP to collect a large amount of information at the same time sensitizing all CRP’s
staff, particularly those who are non medical, about the condition of our previous SCI
patients.
Successful physical rehabilitation leads to emotional adjustment and both then enable
the paralysed person to be re-trained and thus able to become the bread winner of the
family once again. Social rehabilitation happens to a large extent when members of the
community see a wheelchair user able to earn a living and not turn to begging.
Together the successfully rehabilitated people in the society have huge challenges to
face such as lack of accessibility to buildings, lack of access to educational institutes
and places of employment both physically and as a place to study or find employment,
because in the mind of many of the general public a person in a wheelchair has
overnight become incapable of doing anything, causing them often to be completely
ostracized by the society. Keeping this group of previous generation SCI sufferers
working together to form a more equitable and fair society, the Spinal Injury Association
of Bangladesh (SIAB) has recently been set up. Prevention of accidents is another very
important area on which SCI members work along with the support of CRP’s Advocacy
and Networking Officer.