Long-term Care: dealing with spinal injuries

Robert Millett meets two physiotherapists who lead a specialist team delivering care to people with spinal cord injuries.

Physiotherapists at a centre in north west London are helping people with spinal cord injuries to get fit, achieve personal rehabilitation goals and receive lifelong care. Benita Hexter and Sue Paddison are clinical specialist physiotherapists at the London Spinal Cord Injury Centre, part of the Royal National Orthopaedic Hospital NHS Trust in Stanmore, Middlesex. They lead a 14-strong team of physios, physio technicians and administrative staff. The team also works closely with other professionals, including occupational therapists, orthotists, dietitians and speech and language therapists. 
One of 12 such centres in the UK, the Stanmore unit provides lifelong care for children and adults with spinal cord injuries – whether caused by trauma or a pathology. Typically, patients lose muscle function and sensation, and autonomic function in various parts of the body is affected. 
Ms Paddison explains that physios assess patients with trauma within 24 hours of admission. An assessment system tool, the International Standards for the Neurological Classification of Spinal Cord Injury, helps the physios gain an understanding of a person’s level of function and informs their treatment decisions. ‘We are interested in finding out what patients can feel, what they can move, how strong their muscles are and if they have any developing stiffness,’ Mrs Hexter explains.
Non-traumatic admissions can be due to metastatic cancers or primary cancers of the spinal cord and column, slipped discs, spinal strokes and bleeds and cauda equina syndrome. ‘Inpatients used to be exclusively traumatic,’ says Mrs Hexter. ‘But over the last 10 years the demographic has changed and it is now mandated that spinal cord injury centres should manage people with both traumatic and non-traumatic injuries.’
Most of the centre’s 34 beds are reserved for men. ‘It’s 50-50 for non-traumatic admissions but there is an almost five to one ratio of men to women for trauma patients,’ Mrs Hexter explains. ‘That’s simply because more men tend to come off motorbikes, or take part in activities like rugby.’ 

Patient-centred care

Most patients are referred by professionals in acute care settings, with most referrals coming from London and south east England. As well as receiving one to one-treatment sessions, many patients take part in group activities such as sports and wheelchair skills. The physios provide manual therapy and techniques to help patients improve their movement. Therapy sessions take place on the wards and in critical care, as well as in the centre’s gym, sports hall, swimming and hydrotherapy pools. ‘Our remit is to prevent deterioration, work on achieving the highest function and, where possible, encourage neurological improvement,’ says Mrs Hexter.
Inpatients tend to stay from six to 12 weeks, although some move on within three. The upper limit for an initial admission plan is around five months, Mrs Hexter explains. ‘We try to get patients home and into their own environment as soon as possible, so they don’t become institutionalised.’ Some patients have permanent tetraplegia (also known as quadriplegia) or paraplegia, and will need a wheelchair for the rest of their lives. 
From the outset, the focus of rehab is on basic functions and mastering movements such as transferring in and out of a wheelchair, or on and off a bed. After this, rehab goals become more personalised and the physios tailor activities to each individual’s needs. ‘They may go home and want to get on the floor to play with children, for instance, so then they come back in and commit to learning that skill,’ says Mrs Paddison.
The physios also put an emphasis on providing patients with exercise education at an early stage. ‘When we first meet them we try to help them have an understanding, so they can make an informed choice, and instil healthy habits early on.’
Mrs Hexter explains that some patients can find it difficult to avoid having a sedentary lifestyle, as exercising can be challenging. ‘Fitness is a big issue for most, because it’s very hard to keep fit as a wheelchair user,’ she says. Meanwhile, medical advances mean patients live longer than in the past, and are susceptible to secondary conditions such as diabetes, heart disease and obesity.
In response, the physio teams use the latest technology to help improve patients’ fitness, wellbeing and participation. ‘For instance, functional electrical stimulation bikes are core to our work and have been for many years,’ says Mrs Paddison. The bikes allow many people with spinal cord injuries to stretch their exercise thresholds. ‘If you don’t have any activity in your lower limb muscles, reaching that threshold is really difficult, if not impossible for some people,’ says Mrs Hexter. ‘By using electrical impulses patients can exercise big muscle groups simultaneously and give the heart and lungs a proper workout.’
As well as special bikes, the physios use assistive technology including active and passive ergometers, anti-gravity treadmills, dropped foot stimulators and a range of standing and exoskeleton devices. The physios say they feel ‘hugely fortunate’ that charitable funding means they can provide patients with access to such equipment. Another boon is the on-site Aspire Leisure Centre, the first fully accessible training centre in Europe for both disabled and non-disabled people. ‘The average person couldn’t afford to have access to these types of things, but they are available to our patients and members of the public can pay to use them in our gym,’ says Mrs Hexter. 

Building lifelong relationships

Patients admitted to the centre are never officially ‘discharged’ from the service, unless they choose to be, explains Mrs Hexter. ‘We are able to accept their self-referrals as long as they are still under the care of our unit, which means that this is a lifelong service and we are invested in resolving their problems for them throughout their lives.’ As a result, the physios sometimes treat returning patients who were injured decades ago. ‘We have a patient in at the moment who I hadn’t seen since I first looked after him 22 years ago,’ says Mrs Paddison. 
Mrs Hexter explains that it is often necessary to re-admit a patient for intensive rehab or an outpatient episode. ‘It can take months and years for people to reach a steady state physically, following a spinal cord injury, and it’s not appropriate for them to remain an inpatient until then,’ she says. ‘So it’s far better for them to get out into the community, use and refine their skills and return when the time is right.’
The likelihood of a patient returning in the long-term often depends on the severity of their injury, Mrs Paddison explains. Some leave the centre with ‘less obvious physical symptoms’ and return later with problems relating to their bladder, bowel or sexual function. ‘But other patients have massive physical manifestations and their impairments are huge,’ says Mrs Paddison. ‘So they are always going to need ongoing support and care in their lives.’ 
Mrs Paddison, who has been in her role since 1993, says she feels lucky to have seen patients progressing over the years and has forged many friendships. ‘I’ve seen people move on and make fantastic careers, start families and watched paediatric patients grow up and have successful lives.’ Mrs Hexter, who has spent 15 years in the field, agrees: ‘The opportunity to help people through the early stages of their injury, see them discharged and stay in touch as their lives move on is a privilege second to none.’
Plans are afoot to expand capacity,  and to explore new models of care to improve accessibility and drive down waiting times. ‘These are exciting times for us as the centre had been granted a six-bed expansion and we have three new team members to welcome in coming months,’ says Mrs Hexter. Mrs Paddison sums up the role of physios at the centre by describing their jobs as ‘absorbing, exhausting and very special’.  She adds: ‘Our service is constantly growing and developing, as research and new technologies constantly change the way we manage patients.’fl
Robert Millett

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