Appeared in Hospital News, October 6, 1999
When we think of rehabilitation, do we think of the person or their environment? The answer depends on the experience and focus of the treating health care professionals. Does ongoing treatment rule out technology (and vice versa) or are the two combined for a multidisciplinary approach? How can the value of these treatments be measured? Of course the answers are as varied as the clients and their needs, but the points to consider are the same.
First of all, who is the client? Are they male or female, or are they old or young? The clients preaccident lifestyle and personality are the primary factors when rehabilitation is being decided upon. For instance, a sixty five year old may choose less treatment than a sixteen year old. Time may be an issue to one; whereas, the ability to look normal may be more important to the other. A person who led an active lifestyle probably has more self motivation for physical exercise than a person who led a sedentary lifestyle. Effective rehabilitation considers the pre-morbid tendencies of the person and attempts to combine these tendencies with appropriate rehabilitation strategies.
Secondly, what are their needs? Does the person have a permanent injury or a temporary injury; a spinal cord injury or a brain injury; an amputated limb or soft tissue damage....you get the point. This seems to be straight forward, but how do you decide if an injury is permanent or temporary, and how do you decide which intervention is needed? It is easy to lock people into medical categories, but the truth is that in many cases they don't fit. For example, one person's amputation may be straight forward, or it may become infected and need ongoing treatment for several years; a brain injury may depend on the location and severity. In the past, a permanent injury such as a severe brain injury or spinal cord injury did not receive ongoing treatment after one or two years post injury; however, there now appears to be diverging opinions on the subject.
Dr. Avi Nativ, Director of Neurogym, uses interactive EMG and Balance biofeedback to help clients retrain muscle control. He believes that muscles can be trained to be functional as long as a minimal neuromuscular pathway is available. The Institute for Human Potential in Pennsylvania also bases their program on the potential plasticity of the brain. Dr. Nativ recently had great success with a spinal cord injured client who was able to train abdominal muscles below the level of the thoracic injury. My step-daughter has an acquired head injury. When government funded treatment stopped, because they felt she had plateaued, two years after her injury, my wife didn't know what to do. She did not believe that our daughter had reached her potential, so she eventually found Dr. Nativ who agreed with her. Dr. Nativ established an intense physiotherapy program for our daughter. The results were remarkable! She went from being unable to sit independently to riding a tricycle after just one year.
How can the benefits be measured? The financial cost of the treatment was high, but our daughter was now able to sit and propel herself independently and her cardiovascular system was healthier. If we had purchased assistive devices to help her, the cost may have been lower financially, but much higher emotionally and physically.
The key to the biofeedback program is the interactive nature of the movement and the intensity of training. The client has to have a certain amount of self motivation in order to continue with the program. Some people appear to have more motivation than others in order to follow a physiotherapy regime. This may be true based on the persons' personality, but it may also be that the motivating factor has not been found. I think it is important to discover the clients hopes and dreams for the future and to use this information to motivate them. For example, I worked with a young gentleman who stated that he would, "rather eat cat food, than work a nine to five job". He was a musician prior to the accident, so I established a Musical Instrument Digital Interface (MIDI) home recording studio for him. He was provided with the means to fulfill his dreams, and the rest was up to him. In our daughter's situation, she was too young to understand the ramifications of her treatment, so her motivation was simply to please her Mom.
In cases such as our daughters, the treatment promoted independence, when this is not feasible the client may look to technology for the solution. Assistive devices range from specialized cutlery to environmental electronic systems that enable the client to control doors and stereos. For instance, I use voice recognition software which allows me to write by using my voice. My injury was such that I was unable to regain my hand function, although I am able to hold a pen. Typing was very slow, but with the software I was able to produce over one hundred words a minute.
Does one solution preclude the other, not necessarily. I recently read an interesting article discussing the use of power wheelchairs. It stated that is generally assumed that people using power wheelchairs have less physical exercise. This makes sense at first glance; however, we do not assume that people with cars have less physical exercise. To most of us they are unrelated, and similarly in some cases of disability, exercise and mobility are separate issues as in the case of Danny Wright of Ohio. Danny, aged eight, has used a power wheelchair since the age of four, yet he still receives regular physiotherapy and occupational therapy. In other cases a person may choose to utilize an assistive device while physically working towards a goal that excludes that device. They may use it as a way of bridging a gap, like the use of a crutch for someone who is recuperating from a broken leg.
As previously stated, you may need to experiment with assistive devices and treatments to find out which is better suited for your client, and remember to consider as many aspects of their life, past, present, and future.
