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INTRODUCTORY REMARKS
by
William A. Spencer, M.D.
THE SPINAL CORD INJURY MANAGEMENT CONTINUUM
"SHORT-TERM CARE AND LONG-TERM OUTCOMES"
Your attendance at this comprehensive overview of the management of
spinal cord injured persons is most hopeful. Spinal Cord Injury (SCI) is
thought to be uncommon. This is statistically accurate since the typical
incidence is 35-50 per million civilian population, or 10,000 to 15,000
newly injured persons per year in the United States. Less well known is
the likelihood that ten times this number, or 100,000 to 150,000 persons
are on hand at all times. This number is increasing because of the effec-
tiveness of our trauma systems and emergency ambulance systems. After the
drama of the life-saving first hours or days, what then? Is it possible to
make the life saved worthwhile? Isn't the 'complete' spinal cord injury
incurable and therefore the situation hopeless? Of course not! Now, legions
of persons with spinal cord injury are returning to a satisfactory life.
They have succeeded through the indomitable adaptability of the intact
human brain and the benefits of anticipatory, acute (first-phase) care.
Systematic follow-up, with function oriented restorative care and compre-
hensive rehabilitation, insures participation in many aspects of a produc-
tive daily life and increasing opportunity to exercise options of self
direction.
The mystique persists that this uncommon condition is relatively un-
important. How untrue this is in respect to personal, family, and societal
impact, medical and related costs, and national consequences of loss of
productivity. This low incidence problem is a huge socio-economic catas-
trophe, although it is often unrecognized as such and ignored on statistical
grounds of numbers affected. Taking an overall lifetime cost estimate of
$500,000, which is low by worker's compensation insurance experience, and
underestimating family, financial, and societal productivity losses - expected
future years' obligations are in the range of $75.0 billion! What does this
mean personally?
Recently, costs of motor vehicle injuries (MVI) alone were second to
cancer and above heart disease and stroke in direct and indirect costs. $23.1
billion was spent for cancer and $14.4 billion was spent for MVI. Since MVI
causes only one-third of all trauma deaths and 7% of all injuries, these
figures are shocking. The SCI data base from the spinal cord injury system of
centers reveals that less than one-half of all spinal cord injury must be
caused by MVI. Thus, spinal cord injury, along with head injury, is a large
cause of severe disability and accounts for a large proportion of the expenses
incurred from accidents of all causes.
4
What is the impact of the incredibly small, current investment in control
of severe disability - the personal consequences of such an impairment and
the resulting loss of function?
(1) Under-resourcing in facilities and manpower;
(2) Tardy application of the knowledge of management methods and
use of technology produced by research and 'model' systems in
the last decade;
(3) Fragmented, incomplete, multi-party, roller-coaster financing
of comprehensive care; and
(4) Lack of access to services by many persons who could benefit.
Instead, at present, many such persons face a miserable dependency
and the family and the public face costly, long-term, institutional
care or premature death from preventable or controllable compli-
cations.
Isn't it tragic that we largely ignore control of all severe disability,
a socio-eocnamic problem which collectively consumes at least 7.5% of the
Gross National Product? Proportionately, we spend less than 1% of this on
restorative and rehabilitative care for all persons with severe disability.
This includes the spinal cord injured person.
In all of the research, development, and special model systems, we
invest less than $10 to $12 million per year. For all causes of work disability,
loss of self care and socialization, we spend 1,000 times less on research and
development and technology for control of disability than on 'cure' of disease
or for prevention of injury.
Restorative care, like preventive care, will be the rising star of future
health care practices as soon as we are able to demonstrate widely that bene-
ficial outcomes are possible for persons like those with spinal cord injury.
We also need to join in support of those affected and their friends in their
effort at public awareness and political priority. Increased private and
public investment in resources is needed. The cost effectiveness of this
investment is staggering. Three of four lifetime dollars could be saved as
a burden on all of us. One-third of the immediate early care costs can be
saved by specialized spinal cord centers.
Your attendance here is a signal of the growing professional concern and
and interest in this largely private, not-for-profit effort. You will share
your experiences with us and we will share with you what has been learned from
our experiences of some 25 years with more than 2,000 persons with spinal cord
injury, including some followed for nearly two decades. You will see how
specialized programs yielded special centers and how careful clinical obser-
vation, research, development and technology have helped anticipate disability
and its preventable or controllable complications. TO be effective in care,
causes of disability and complications must be addressed from the time of
injury. You will learn how these persons achieve independent living, personal
productivity, and participation in life's responsibilities and rewards. You
5
will hear and see the value of a system of relationships between trauma
centers and spinal cord injury centers in restorative and rehabilitative
facilities. We are giving greater emphasis upon preservation of residual
functions, the encouragement of adaptive responses of mind and body, and
ways to minimize environmental handicaps. These concepts and procedures
will be yours to sample, discuss, and question.
We welcome your participation, trust you will further develop in your
own settings this relatively new concept of centers for special problems
like spinal cord injury. I, personally, look to you to further the demon-
stration of how competence depends upon carefully analyzed clinical exper-
ience and proper use of technology driven by the process of individualization
of care. Finally, the provision of opportunity for the patient as a 'person'
to develop increasing self reliance and independence without your assistance
is an objective to have in the forefront of clinical decision making.
We will all share in the reduction of personal, social, and economic
losses attending severe disability through these future developments. We
need America's handicapped citizens because their real numbers currently
equal at least the 10.8% of working age adults who are currently unemployed
in a time of recession and depression. In spinal cord injured persons, we
have, in trust, the future lives of young adults averaging 21 years of age
who will show the value of their survival that many of you work SO hard to
accomplish. They, in turn, will not disappoint us if we comprehensively,
personally, and competently assist them!
6
NAME
MANUFACTURER
Scimedics Laminaire
Scimedics
Scimedics Polyaire
Scimedics
Scimedics Postureform
Scimedics
Scimedics Lux Aire
Scimedics
Spenco Gel Flotation Pad
Spenco Medical Corp.
Stainless Comfy Foam
Stainless Medical Products
Stainless Ester Foam
Stainless Medical Products
Stryker Gel Flotation Wheelchair Cushion
Stryker Corp.
Sun Mate Dynafoam II
Dynamic Systems
Sun Mate Laminaire
Dynamic Systems
Sween Gel Float
Sween Corporation
Talley Rippleseat
Talley Surgical Instruments, Ltd.
Temper Foam
Kees Goebel/Ali Med.
FIGURE 8
41
SG
Seating for Pressure Relief: the individual with insensitive skin
I. Statement of the Problem
A. Pressure ulcers, decubitus ulcers, pressure sores are defined as local-
ized areas of cellular necrosis. They are a frequent and potentially
life-threatening complication for the individual with absent or dimin-
ished sensation.
B. Levels of tissue deterioration are:
1. First degree: Epidermal - outer epithelial portion of skin
2. Second degree: Dermal - of or pertaining to the skin
3. Third degree: Subcutaneous - beneath the skin
4. Fourth degree: Intramuscular - within muscle
5. Fifth degree: Osteoarticular - pertaining to or affecting bones or
joints
C. Etiology
1. Pressure from oversitting, poor care in bed, worn out wheelchair,
mattress or cushion
2. Trauma during transfers, as the result of a fall or from riding
over rough terraine for an extended period of time
3. Psychological stress that results in physiological changes in tissue
II. Philosophy: Prevention
A. Clinical guidelines
1. Good personal hygiene
a. keep skin clean and dry: moisture from perspiration or incontinence
can precipitate skin breakdown, especially on already stressed tissue
2. Nutrition
a. eat a well balanced diet
b. adequate protein
C. if unable to tolerate 3 meals a day, try eating 6 smaller
meals; do not miss a meal
3. Skin assessment: skin checks at least twice a day - once in the
morning and last thing at night
a. redness or skin color changes that do not disappear within
30-45 minutes should be considered potentially dangerous and
the area free of pressure for up to 24 hours if possible
42
4. The mattress surface: In most situations, individuals with physical
disabilities can sleep on a standard hospital or commercially avail-
able home-use mattress. Those individuals with specific pressure-
related problems are advised of the various therapeutic mattress
surfaces available for home use. In a recent study, several different
therapeutic mattresses were evaluated for their pressure relief prop-
erties. The mattresses included one standard hospital mattress and
the following therapeutic mattress surfaces:
a. Egg Crate - 2 inch thickness
b. Egg Crate - 4 inch thickness
C. Gaymar Alternating Air Pressure Mattress
d. Lapidus Alternating Air Pressure Mattress
e. Roho Dry Flotation Mattress
f. Stryker Gel Mattress Inserts
1) From this study, it appeared that trochanteric pressure
under the sidelying patient was lowest on the Roho, followed
by the Egg Crate 4 Inch Mattress. It must be emphasized
however, that no mattress surface should be used indiscrim-
inately.
5. Weight shifts: a method to periodically relieve pressure and reduce
the potential for skin breakdown. Weight shifts are performed either
independently or with varying degrees of assistance depending on
strength and range of motion of the patient. The following regimen
is offered as a suggestion for a routine program of weight shifts.
a. Paraplegics should perform a weight shift every 30 minutes for
a duration of 15 seconds.
b. Quadriplegics below the C-5 level should perform a weight shift
every 60 minutes for a duration of 30 seconds.
C. Quadriplegics above the C-5 level, who require full assistance
to accomplish a weight shift may attempt the 60 minute/30 second
regimen but may find it necessary to emphasize a program of
building sitting tolerance rather than a program that emphasizes
weight shifts.
d. There is considerable controversy among rehabilitation professionals
about the effectiveness of weight shifts in preventing pressure
sores. Our philosophy advocates weight shifts as one aspect of
a preventative program. The above regimen is only a suggestion.
We realize that there will be some variation among patients.
43
6. The wheelchair is important in maintaining the skin's integrity. The
wheelchair must be properly measured and prescribed and kept in good
condition.
7. The wheelchair cushion, is perhaps, the most significant factor that
influences pressure and its consequences for the individual with a
physical disability. The type, condition, age, and usage of a cushion
will greatly effect sitting tolerance and skin condition.
8. Education of the patient and his family: make the patient responsible
for his own skin care.
III. Classification of Wheelchair Seating (Figure 1)
A. Purpose of cushions
1. To relieve pressure
2. To stabilize the body for balance and functional positioning
3. To distribute weight, especially away from bony prominences
B. Categories of static cushions
1. Air filled cushions (Figure 2)
2. Floatation cushions - filled and gels (Figure 3)
3. Polymer foams (Figure 4)
C. The "perfect" cushion
1. Controls distribution of body weight, over the greatest available
contact for sitting
2. Relieves pressure under bony prominences (to below the capillary pressure)
3. Stability - for wheelchair mobility, propulsion, transfers
4. Ease of motion for weight shifting
5. Does not impede independence-lightweight, easy to transfer
6. Stabilizes temperature optimally
7. Controls excessive moisture
8. Permits air exchange
9. Reliable, does not deteriorate, does not "bottom out"
10. Comfort is very subjective and not the most important
11. Reasonable cost
D. Wheelchair cushion cover is an important consideration in that it will
effect the pressure relief properties of the cushion itself.
1. It should be washable
2. It should allow flow of air (breathable)
44
3. It should absorb moisture
4. A cotton knit material is a good fabric for cushion covers although
a polyester knit would be acceptable
IV. Selection of Wheelchair Cushions: Individual Evaluation
A. Considerations
1. Diagnosis
2. Number of hours spent in wheelchair each day
3. Kinds of activities done from the wheelchair
4. Usage environment: climate, pollution, humidity, temperature, terrain,
continence of individual
5. Living arrangements: independent or dependent
6. Individual's tissue history: pressure ulcers, surgery to correct
ulcers, decreased sitting tolerance secondary to specific medical
or social factors
7. Body build: the pressure relief needs of thin patients are different
from the needs of heavier individuals
8. The wheelchair: impact loads and usage environment that effect wheel-
chair suspension systems
9. Pressure and its distribution
B. Individual evaluation for pressure relief devices
1. Use of pressure monitoring devices
a. Pressure Evaluation Pad
b. Scimedics
C. Research prototypes
2. Specialty items: alternatives to commerically available pressure
relief wheelchair cushions
a. Wedging (Figure 5)
b. Laminants
C. Cut-outs: Stanford cushions, Australian Cushions, South African
Cushions
V. Tissue Pressure Management as a Comprehensive Program: Research, Education,
Clinical Service (Figure 6)
A. Research - Research efforts have been mainly in the following cate-
gory: design and fabrication of devices utilizing a wide variety of
materials and techniques.
45
1. It would seem that several other directions for research would be useful.
These include:
a. Identifying the long-term effects of using a specific type of
cushion or seating surface;
b. Developing a mechanism for sharing developments in this field;
C. Manufacturing of potentially promising devices;
d. Developing and refining of clinically useful pressure evaluation
devices.
B. The education of individuals with physical disability, their families and all
members of the health-care delivery team is an essential part of tissue
management
1. Rap sessions for hospitalized patients
2. Workshops
3. Seminars
4. Lectures
C. Tissue Management Clinic - to provide a multidisciplinary approach to
the prevention and treatment of pressure-induced tissue trauma (Figure 7).
VI. Projection for the Future
A. Development, fabrication and modification of clinically useful evaluation
tools
B. Cooperation and collaboration between industry (manufacturers and
distributors of rehabilitation equipment) and rehabilitation and re-
habilitation engineering professionals, in research and clinical
practice to objectively, conscientiously and rationally develop
products for use by individuals with physical disabilities
C. Development and evaluation of new materials to be employed in pressure
relief devices (Figure 8)
1. Flolite - Hanson Industries from ski-boot material
2. Elasto gel - from Southwest Technologies, Inc.
3. Foam-in-Place Systems
VII. Conclusion
Pressure sore prevention is a major concern for the rehabilitation and rehabili-
tation engineering teams. However, ongoing research efforts indicate that
there is no single pressure relief device or material that is optimum for all
46
groups of individuals with physical disability. In addition, it has been
demonstrated that many factors, alone or in combination, are responsible for
tissue breakdown. Therefore, comprehensive programs that offer clinical
service and education, as well as the incorporation of technology into the
tissue management of these individuals will greatly enhance their potential
for achieving their highest level of functional independence.
47
Case Management: An Interdisciplinary Approach
M. R. Sanderson, M.S.W.
J. T. Salhoot, M.S.W.
INTRODUCTION
The array of services available to the patient in a rehabilitation hospital
setting has increased dramatically in the past several years. Along with the
traditional medical and functional services, we now have specialties such as
respiratory therapy, neurophysiology, recreational therapy, urodynamics, nursing
education programs and a whole series of services aimed at addressing the indepen-
dent living needs of persons with a disability. All of these services and programs
make demands upon a patients daily schedule, often times in a haphazard and non
productive way.
This burgeoning service system has led to a concurrent awareness of the need
to develop new models of patient (case) management in order to insure individual-
ized, prioritized and timely service provision. While physicians have tradition-
ally been seen as the manager of a patient's case, and indeed, may be the most
appropriate choice during the acute medical phase of care, other clinical persons
should be utilized in the role as a patient moves toward a psychosocial, community
living focus.
MODELS OF CASE MANAGEMENT
In 1980, The Institute for Rehabilitation and Research added a variety of
educational independent living services to its rehabilitation delivery system.
These new services are offered along with medical, functional, psychosocial
and vocational services. They are provided at the 22 bed TIRR Annex which
primarily serves persons with spinal cord injuries and multiple amputations.
These patients are generally transferred to the Annex from the main hospital
when they are medically stable and ready to pursue advanced functional and
Copyright © 1983 by The Institute for Rehabilitation and Research, Houston, Texas
90
independent living skills training. They may also be admitted from the community
setting specifically for the specialized services and/or follow up care. The
problems of managing this complex and varied system of care to insure that a
patient receives the services he needs when he needs them was recognized early in
the planning process. A number of models of case management were considered in
order to design a system which could be individualized according the unique needs
of each patient. Three models received primary discussion.
The first involved the development of a special department which would pro-
vide only case management services. We felt, however that its two major draw-
backs would outweigh the possible advantages. First, it would add another layer
of management and administrative cost to an already complex system. Second, the
removal from day to day clinical practice would reduce the awareness of the
practicalities and actualities of providing services.
The second model under consideration was based on choosing a discipline
already established to add this function to its normal service program. The
disciplines within our setting which would seem to be logical choices
were either social work or vocational counselors. However, the planning group
thought that the inclusion of only one discipline would lend a bias to the pro-
cess and perhaps narrow the focus of the management team.
The third model, and the one ultimately chosen, involves using clinicians
from the departments of social work, physical therapy, vocational, occupational
therapy and nursing to serve as case managers on a half time basis while con-
tinuing their clinical practice during the rest of the time. Billing for their
case management services is handled through regular department structures.
This model has several advantages for our particular setting. It allows
us to utilize a departmental and service structure which is already in place.
The diversity in backgrounds among the case managers provides a rich source of
91
experience and knowledge about the full spectrum of rehabilitation with a
variety of perspectives about service provision. And, the continuance of clinical
practice insures a working knowledge of the service delivery system and the feasi-
bility of making changes in programming as needs are recognized.
Every patient at the Annex is assigned a case manager. These mangers are
assigned according to the patient's primary physician and teams are organized
around the physician's and case manager's patient load. The average case load
per manager is five.
Supervision of the case managers is provided by the administrative personnel
of the TIRR Annex. Weekly meetings with administrators and case managers provide
a forum for discussion of individual cases, the development of assessment skills
and procedures, the documentation of system problems which impede timely service
delivery and the exchange of knowledge among the various disciplines in the per-
formance of case management responsibilities.
QUALIFICATIONS OF CASE MANAGERS
There are several qualifications which we feel are necessary for effectively
performing the functions of this role. First, the person must have three years
experience within the rehabilitation field in a major clinical department with
participation in team meetings and planning. Since each rehabilitation setting
differs, we further require that the person has worked in our facility for at
least one year. These clinicians are generally senior level therapists who have
shown leadership abilities within their own disciplines. They must demonstrate
the ability to understand the total process of rehabilitation in relation to a
patient's needs for living within the community and be able to assess those needs.
Consequently, they need to have good interpersonal skills in working with patients
on their case load as well as with other staff members. Case managers must also
be comfortable in assuming a leadership role within the team and be willing to
92
bear the responsibility for taking an active role in insuring that service plans
designed by the team are implemented to meet patient needs.
ROLE AND RESPONSIBILITIES
The case manager function is designed to facilitate integrative and indivi-
dualized program and service planning for patients. A key component of this
process is an assessment of patient life goals with care provision subsequently
related to the attainment of these goals. Case managers carry both the responsi-
bility and authority to insure team planning is relevant to a patient's goals and
that service provision is prioritized to meet those goals. To accomplish this,
the manager is designated leader of the team and continually reviews service plans
in relation to desired outcome. Decisions are made at this level drawing on team
expertise regarding changes of approach, service timing issues, patient progress
and scheduling conflicts. Since the role of the case manager as practiced at
TIRR is a relatively new concept for patients, it is important for the manager to
clarify the role and establish a working relationship with the patient early
in the process.
In accomplishing these various functions; the case manager must work at the
individual patient level, within the team process, and at the systems maintain-
ance and design level.
Assessment
The assessment process forms the cornerstone for effectively managing the
process of rehabilitation for each patient. This multidimensional assessment
is used to determine patient needs, establish goals and design service plans.
Assessment information is categorized in six major areas: Health Status, Func-
tional Abilities, Productivity, Living Arrangements, Financial Status and Psy-
chological Well-Being. These categories have been chosen as they appear to
relate closely with those areas which are important for successful functioning
93
within the community. The case manager derives input from the patient, team
members, referral information, history and physical, family members, past
hospitalization records and sponsors. The role of the manager in the assessment
process is to integrate the information from all sources to reduce fragmentation
of care and to develop a total picture of the person with his unique needs in his
community setting. Goals are established from the assessment and listed in
priority order. Wherever possible, goals are stated in terms of patient outcomes
rather than system process. The focus of the rehabilitation process is directed
toward what the patient wants to accomplish in his home setting and the case
manager needs to insure that this viewpoint is maintained. The goals are dis-
cussed with the patient and are mutually agreed upon. Service plans are then
developed around the prioritized goals. It is important to note that needs to
be addressed are defined by the patient and team. Service provision to meet
those needs is designed by the team and manager and presented to the patient.
This distinction is an important one in that we cannot expect a patient to be
sophisticated enough about our system to know what services are available, how
he might access them, or how the services might help meet his stated needs.
Thus, while we encourage and expect active participation on the part of the
patient in setting goals, determining needs, and participating in the program,
the professional staff retains the responsibility for designing service packages
to best address patient goals.
Leading Team Rounds
As manager of the rehabilitation process, a primary responsibility of the
case manager is to lead patient/team rounds which occur once a week. The patients
are included in this process. In our patient goal oriented format, the focus of
rounds becomes an interdisciplinary sharing of information about progress toward
the accomplishment of stated goals. The manager leads the discussion about ser-
vice provision and draws on the teams expertise in laying out plans for the
94
coming week. Documentation of this process serves as the major tracking tool
for the patient's progress during the admission. Notes are dictated by the case
manager.
Ongoing Service Planning
In addition to assessment and the leadership of team rounds, the case manager
performs a number of ongoing monitoring and oversight functions. The manager is
responsible for reviewing a patient's schedule to insure that appropriate services
are indeed being scheduled to meet patient goals. If scheduling conflicts occur,
the manager will decide which appointment takes priority. She may wish to con-
sult with other team members in making this decision.
The case manager meets with the patient on a periodic basis to discuss the
overall course of the rehabilitation program. When the patient has questions
about care, the case manager can direct him to the appropriate person to provide
the needed answers. An important function of the manager is to educate the
patient about using the system to meet his needs.
Case managers may call for planning and problem solving meetings with team
members whenever warranted. They may also need to work closely with consulting
medical services to insure appropriate timing of service provision.
Follow Up Services
Follow up/monitoring services are provided by case managers for our patients.
Timing and number of contacts is determined by individual patient need. Issues
for follow up are determined in the last team meeting with the patient and recorded
on the final progress note.
If the patient is experiencing problems in the community, he is directed to
the appropriate TIRR service, community agency or contact person. It is not the
responsibility of the case manager to solve problems but rather to insure the
appropriate referral linkages for the patient are identified. Documentation of
follow-up contacts aid in evaluating trouble spots within the rehabilitation service
system.
95
CONCLUSIONS
The case management function has been in the developmental and impl mentation
phase for the past two years. With our experience several observations can be
made regarding the successes and problems attached to both the model of management
chosen and the day to day operations of the role itself. The use of practicing
clinicians who split their time between case management and provision of services
within their own disciplines has, indeed, had several advantages. One, the sharing
of a number of different perspectives during the case management planning sessions
has insured that all develop an awareness of the multifaceted nature of the rehabi-
litation process and the varied possibilities for service planning. Two, the
managers stay abreast of new services which are offered as they are active members
of clinical departments. Three, since clinical supervisors in all disciplines
from which case managers are drawn assign patients to therapists in relation to
case manager assignments, the managers have the opportunity to know their patients
from both perspectives. Therefore there is an integration of roles which allows
several functions to be accomplished during one scheduled appointment. In com-
paring those instances where a case manager is not seeing a patient as a practicing
clinician to those where they are, it appears that in the latter situation there
is a more thorough understanding of the patient, his goals and needs and his day-
to-day accomplishments.
There are two areas within this model, however, which can cause difficulties
unless carefully monitored. First, because of the joint assignment in most
instances of case management and therapist roles, it often occurs that as one's
patient load grows as a manager it also increases as a therapist. During peak
periods where one physician may have a disproportionally large number of patients
in the facility, managers must be switched from one team to another to prevent
any one manager carrying more patients than can adequately be handled in either or
96
or both roles. Therefore the system must be responsive to day-to-day fluctua-
tions and each manager should be comfortable in working with a number of dif-
ferent teams. And, second, this model demands that managers be able to work
successfully under two supervisors: Within their departments regarding clinical
skills and under the administrative supervisor for case management functions.
Cooperative and collaborative relationships must be maintained between these
two supervisory levels to insure that the staff persons dually assigned are
not caught in the middle of conflicting needs or expectations.
One advantage of the system relates to the documentation needs of the manage-
ment function. in most cases, the existing systems for documentation have been
used to prevent the addition of yet another level of record keeping. Assessments
and progress notes are handled through the regular dictation system which has
long been established for physician records. In order to meet accrediting re-
quirements, these notes are signed by both the case manager and the physician,
thereby eliminating the need for separate notations.
As case managers are supervised by administrative personnel who have direct
authority for overall service provision and program structure, thereis an imme-
diate feedback loop as systems problems which impede appropriate delivery of
services are documented. Changes can be made more quickly and directly in the
rehabilitai system itself than would be possible if case management were a
departmental function further removed from the administrative function.
And, finally, the use of case managers in our setting has:
(1) increased the relevance of the service packages designed for individual
patients, (2) insured that these services are delivered in a timely fashion,
(3) reduced the fragmentation of care often found in a multidisciplinary setting
(4) provided a level of accountability for the unfolding of the process of rehabi-
litation for individual patients and (5) improved the documentation records used by
sponsors and community agencies who maintain ongoing contact with patients,
97
CONSUMER PUBLICATIONS
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Paraplegia News
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TIRR/SW-RP-P/12-82
Reprint from ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION. Vol. 63. November 1982
549
Trochanteric Pressure in Spinal Cord Injury
Susan L. Garber, OTR, Laura J. Campion, MS, RN, Thomas A. Krouskop, PhD
Texas Rehabilitation Engineering Center, Houston, TX 77030
ABSTRACT. Garber SL, Campion LJ, Krouskop TA: Trochanteric pressure in spinal cord injury. Arch Phys
Med Rehabil 63:549-552, 1982.
Pressure-induced tissue breakdown is a frequent and life-threatening complication for individuals with spinal
cord injury. These patients are frequently positioned on their sides to relieve back and sacral pressure while they
are in bed. This position causes high trochanteric pressure with the potential for the development of pressure
ulcers. In addition, the individual with a spinal cord injury has accompanying absent or diminished sensation, and,
therefore is not aware of the pressure overload. In this study the positions that will reduce the possibility that
trochanteric ulcers will develop are identified. The Pressure Evaluation Pad (PEP), a pneumatic pressure monitor-
ing system, has been used to study the effect of different leg positions on trochanteric pressure. The pressure
under the right trochanter was monitored as the contralateral leg was positioned in various degrees of hip and
knee flexion or extension. The procedure was repeated for the left trochanter. A study of 50 subjects demon-
strated that a position of 30° hip flexion and 35° knee flexion (with lower leg behind midpoint of the body)
produced lower contralateral trochanteric pressure than the traditional position of hip and knee flexion across
the body. Additionally, thinner patients were found to have higher trochanteric pressure than average weight or
obese subjects. Standardizing a method for the positioning of patients on their side can be a significant deterrent
to the tissue erosion that greatly interferes with the rehabilitation process.
The breakdown of skin that overlies bony prominences is
All patients had been admitted to the hospital for a compre-
a frequent and life-threatening complication for the patient
hensive rehabilitation program and none had had any surgical
with a spinal cord injury. 12 The trochanter is especially
procedure for the correction of pressure sores.
vulnerable to extremely high pressure and ultimate erosion
Procedure. The pressure monitoring system used in this
when the patient is positioned in bed on his side after surgery,
study consisted of a printed circuit containing a 12 x 12
on the sacrum or ischium, or during routine side-back-side
matrix of pneumatically controlled contact switches.⁵ The
turning procedures. In fact, approximately 17% of all pressure
circuit was connected to a readout board containing 144 light
sores seem to occur over the trochanter.
emitting diodes that became illuminated with pressure in the
Body positioning is a daily activity that is important for
corresponding switches (fig 1). Each subject was positioned
patients confined to bed. 10 A plan for positioning should in-
on his side in bed on a standard hospital mattress with the
clude placing the patient in the position that is most likely
pressure measuring device under his trochanter. Pressure was
to decrease pressure and diminish the risk of skin ulceration.
first recorded while the patient was in the traditional position
Opinions differ on the best position to reduce pressure.
(fig 2) in which the superior leg was positioned across the
Traditionally, there have been many techniques that were
body in 55 or 65° of hip flexion and in 80° of knee flexion as
utilized to decrease tissue breakdown. Turning every 1 to 2
measured with a goniometer. The bottom leg was in a neutral
hours with gradual and individually increasing frequency
position. (The amount of hip flexion in this position was
between turns is a routine procedure for this purpose. 1-4,7,8
determined by the patient's joint mobility and comfort.
In addition to turning, there are many well-known devices
Trochanteric pressure in this position was the same in either
that are used to decrease pressure and tissue breakdown. These
55 or 65° of contralateral hip flexion). One pillow was placed
include therapeutic beds, mattresses, positioning aids such as
lengthwise between the legs to prevent pressure at the knees.
sheepskins, pillows, wedges, foams, and alternating air mattress-
The patient was then repositioned so that the superior leg was
es, all of which are thought to distribute pressure more evenly
placed in 30° of hip flexion and 35° of knee flexion, with the
and therefore decrease the risk of tissue breakdown. 1,2,4,9
lower part of the superior leg behind the midpoint of the body
Variation in the magnitude and location of trochanteric
and resting on a pillow. The bottom leg remained in a neutral
pressure is accomplished by positioning the top leg in varying
position. For both positions a pillow was placed behind the
degrees of hip and knee flexion or hip and knee extension.
back for stability. The magnitude of trochanteric pressure was
However, there does not seem to be any data that describes
recorded and the entire procedure was repeated on the op-
the quantitative measurement of the pressure under the
posite side.
trochanter with variation in the position of the opposite leg.
Statistical methods. Calculated data are given in terms of
In this study trochanteric pressure was monitored in relation-
the mean ± standard error of the mean (SEM) and are ex-
ship to variation in position of the opposite leg.
pressed in millimeters of mercury (mmHg). Statistical sig-
METHOD
This study was supported by grant 23-P-57888/6 from the National
Institute of Handicapped Research, Department of Education, Washing-
Subjects studied. Of the 50 subjects with spinal cord
ton, DC 20202.
injury who participated in this study 47 were males and
Some of the data reported here were presented at the 56th Annual
3 were females ranging in age from 14 to 62 years. Twenty-
Session of the American Congress of Rehabilitation Medicine, Honolulu,
November 12, 1979. Submitted for publication September 18, 1981,
three were paraplegic and 27 were quadriplegic individuals.
and accepted in revised form January 12, 1982.
Arch Phys Med Rehabil Vol 63, November 1982
550
TROCHANTERIC PRESSURE IN SCI, Garber
Fig 2-Traditional sidelying position; superior leg in hip and
knee flexion across body.
Fig 1-Use of the Pressure Evaluation Pad (PEP) to monitor
trochanteric pressure of patients in bed in the sidelying
high subtrochanteric pressures observed in these subjects when
position.
positioned in the traditional position of superior hip and knee
flexion, the proposed extended position decreased subtro-
nificance was assessed using the student t test (paired, 2-tailed)
chanteric pressures by 21 to 34mm Hg (p<0.001). There-
and analysis of variance as was appropriate.
fore, it seems apparent that for these patients, traditional
methods of positioning clearly produce inordinately high
RESULTS
localized tissue pressure and may contribute, in part, to the
high rate of tissue breakdown observed in these patients.
In normal volunteers (table), subtrochanteric tissue pressures
Possibly the effectiveness of the extended position may not
in the traditional sidelying position (hip and knee flexion)
be applicable for all immobilized patients with spinal cord
were determined. Similar pressures were also observed in
injury. In order to investigate this possibility, it was necessary
spinal cord injured subjects. These similarities in magnitude
to investigate pressure in paraplegic (fig 5) and quadriplegic
of pressure, therefore, indicate that resulting ulceration can-
(fig 6) individuals. In the paraplegic individuals, subtrochan-
not be explained solely on the basis of the spinal cord injury
teric pressures in the traditional flexed position were sig-
alone. This is further demonstrated by the similarities observed
nificantly higher than those pressures observed in normal
in the ischial pressure of normal volunteers and the spinal
volunteers (table, p<0.05). These pressures, however, were
cord injured seated in wheelchairs on various foam cushions. 11
Because of the observation of high subtrochanteric pressure
in the spinal cord injured subjects, it was necessary to investi-
gate a number of body and extremity positions which might
produce a reduction in localized tissue pressure. The tradition-
al position (fig 2), was studied first and was found to produce
high trochanteric pressures. In preliminary studies (unpub-
lished data), the extended position was found to produce the
most consistent reduction in subtrochanteric pressure. This
modified position (fig 3) consists of the subject lying on
her/his left side. The lower leg (left) is positioned in a neutral
position of minimal hip and knee flexion. The superior leg
(right) is extended behind the lower leg and rests in 30° of
hip flexion and 35° of knee flexion. Pillows are placed behind
the back, under the head, and between the legs at the knees.
The effect of leg extension was then investigated in the
spinal cord injured subjects (fig 4). Compared to the relatively
Subtrochanteric Pressures in Patients with Spinal Cord Injury
and in Normal Volunteers in the Traditional Sidelying Position
Mean pressure (X)*
Subjects
(mHg)
studied
n
Right side
Left side
Normal volunteers
30
80.3 +, 3.47
79.4 ± 4.49
Spinal cord injured
50
86.0 + 3.57
87.4 ± 2.83
Fig 3-Position that produces lower trochanteric pressure;
*Denotes mean + SEM in mmHg
superior leg extended behind lower leg.
Arch Phys Med Rehabil Vol 63, November 1982
TROCHANTERIC PRESSURE IN SCI, Garber
551
100
100
95.6
90
90
89.9
86.0
87.4
80
80
79.6*
-
70
70
64.8
MEAN PRESSURE (X)
60
MEAN PRESSURE (X)
60
58.9+
53.4*
50
50
40
40
30
30
20
20
10
10
0
0
Right Trochanter
Left Trochanter
Right Trochanter
Left Trochanter
n : 50
n 50
n = 22
n 23
LEG POSITION
LEG POSITION
Flexion
Extension
Flexion
Extension
X = mean + S.E.M. in mm/Hg
X = mean + S.E.M. in mm/Hg
=
significantly different pressure in extension vs. flexion (p < .001)
If
significantly different pressure in extension vs. flexion (p < .05)
+
=
significantly different pressure in extension vs. flexion (p < 001)
Fig 4-Effect of leg position on trochanteric pressure in sub-
Fig 5-Effect of leg position on trochanteric pressure in
jects with spinal cord injury.
paraplegic subjects.
not significantly different from those observed in the over-
customary sidelying position (hip and knee flexion across
all population of spinal cord injured patients (table). Modi-
the body) in both paraplegic and quadriplegic individuals
fication of leg position in the paraplegic individuals reduced
produced unacceptably high subtrochanteric tissue pressures.
subtrochanteric pressure 16 and 21mmHg on the right and
left sides respectively.
Similar studies were also carried out in 27 quadriplegic
individuals (fig 6). Pressures in the traditional position of
hip and knee flexion in the quadriplegic individuals were as
100
high as those observed in normal volunteers (table). Reposi-
tioning of the superior leg to the extended position reduced
90
85.3
trochanteric pressure 26 and 32mmHg on the right and left
80
78.2
sides respectively (p<0.001). Thus. it is apparent that the
70
extended position is equally effective in quadriplegic subjects
MEAN PRESSURE (x)
60
52.6*
53.0*
and paraplegic subjects.
50
40
DISCUSSION
30
20
It has been demonstrated that pressure exerted over a bony
10
prominence, whether ischial in the person seated in a wheel-
chair or trochanteric in the person in the sidelying position
0
Right Trochanter
Left Trochanter
in bed. is similarly high in both normal subjects and those
n 27
n 27
with spinal cord injury. The effects of prolonged pressure over
a bony prominence has been the breakdown and ulceration of
LEG POSITION
that tissue that overrides the bone.
Until recently. there has not been a systematic investigation
that compares patient positioning as a preventive measure in
Flexion
Extension
tissue breakdown. The Pressure Evaluation Pad (PEP) allows
quantification of tissue pressure and has been used previously
X = mean S.E M. in mm/Hg
to evaluate pressure relief devices for the wheelchair and
.
=
significantly different pressure in extension vs flexion (p< 001)
bed.5 In this study. the nursing practices of turning and
positioning of immobile patients have been investigated.
Fig 6-Effect of leg position on trochanteric pressure in
Results of this study clearly demonstrate that the usual and
quadriplegic subjects.
Arch Phys Med Rehabil Vol 63, November 1982
552
TROCHANTERIC PRESSURE IN SCI, Garber
Reduction of trochanteric pressure is achieved by a redistribu-
References
tion of the pressure onto the larger ipsilateral gluteal surface.
1. Bell F, et al: Pressure sores: their cause and prevention. Nurs Times
This arises from rotation of the pelvis posteriorly. Substantial
740-745, May 16, 1974
reductions of 20 to 40% in these pressures can be produced
2. Bliss MR, McLaren R, Exton-Smith AN: Preventing pressure sores
by a simple modification of the position of the superior leg.
in hospital: controlled trial of large-celled ripple mattress. Br Med J
Although this reduction in pressure is significant, the tissue
1:394-397, 1967
3. Dowling AS: Pressure sores - their cause, prevention, and treat-
that overlies the trochanter may still be vulnerable to break-
ment. Md State Med J 19:131-134, Jun 1970
down if other pressure sore prevention techniques such as
4. Gale LC: Prevention and care of decubitus ulcers. Physician's
good hygiene, nutrition, and turning in bed are not also used.
Associate 1:18-22, 1971
5. Garber SL, Krouskop TA, Carter RE: System for clinically evalu-
ating wheelchair pressure-relief cushions. Am J Occup Ther 32:
CONCLUSION
565-570, 1978
6. Manley MT: Incidence, contributory factors and costs of pressure
The prevention of pressure sores is a major objective in
sores. S Afr Med J 53:217-222, 1978
the care of individuals with physical disabilities. Although
7. McElhinney E: Pressure sores - prevention and treatment. Physio-
there are numerous mattresses and devices to reduce pressure
therapy 54:283-285, 1968
8. Pinel C: Pressure sores: refresher course. Nurs Times 72:172-
when in bed, spinal cord injured patients are still threatened
174, Feb 5, 1976
with increased amounts of pressure on bony prominences
9. Rogers EC: Nursing management in relation to beds used within
that can lead to tissue compromise and a delayed rehabilita-
national spinal injuries centre for prevention of pressure sores.
tion program. Positioning and turning is therefore a vital
Paraplegia 16:147-153. 1978-1979
10. Rottkamp C: Experimental nursing study: behavior modification
component of the spinal cord injured patient's care. For the
approach to nursing therapeutics in body positioning of spinal
person confined to bed, the tissue over the trochanter is
cord-injured patients. Nurs Res 25:181-186, May-Jun 1976
highly vulnerable to breakdown in the traditional sidelying
11. Souther SG, Carr SD, Vistnes LM: Wheelchair cushions to reduce
positions. Modification of that position has resulted in a re-
pressure under bony prominences. Arch Phys Med Rehabil 55:
460-464, 1974
duction of trochanteric pressures, thus reducing the potential
12. Taylor RG: Spinal cord injury: its many complications. Am Fam
for the tissue erosion that greatly interferes with the re-
Physician 8:138-146, 1973
habilitation process.
ADDRESS REPRINT REQUESTS TO:
Susan L. Garber, OTR
Texas Rehabilitation Engineering Center
Texas Medical Center
1333 Moursund Avenue
Houston, TX 77030
Arch Phys Med Rehabil Vol 63, November 1982
Early Psychosocial Intervention in Severe Trauma: Alliances for Treatment
Betty J. Bartels, M.S.S.A., Department of Social Work
The Institute for Rehabilitation and Research
The individual who survives severe traumatic injury faces a complex, technical
maze of medical and nursing care. Physical treatment in the acute period predominates
as the activity primary for continued life support. But the physical treatments do not
occur in isolation of the psyche. Since emotional stress accompanies any physical threat,
emotional survival is also at stake following trauma.
Popularized concepts of the holistic health movement and ecological health models
of person-in-environment now underline the importance of treating the person as a
bio-psycho-social being. (1,2) There is fast-growing evidence that treating the whole
person is not only humanitarian -- but that integrated physical and emotional care can
promote positive outcomes in illness and disability. (3,4) Indeed, a patient's psycho-
social experiences during acute care essentially lay the groundwork for long-term
adjustment to physical disability.
The focus of this chapter is on patient and family experiences of severe trauma
which result in catastrophic loss of physical function, i.e., the psychosocial aspects
of injury and of the hospital environment. The dynamics of the treatment environment
can powerfully influence coping and total outcome. (5,1) Methods and strategies are
suggested for use in the acute-care environment to promote positive coping by patients
and families. Finally, severe responses to injury are explored emphasizing indicators
for psychiatric consultation.
Psychosocial Components of the Crisis
Survival Struggle The uncertainty of life and death confronts many traumatically
injured persons following the accident. Immediate life threat may result from the
severity of injury, and often occurs from delay or complications with rescue attempts.
A 30 year old man sustained quadriplegia from trauma when his sports
car overturned. He vividly recalls the near-death experience of
waiting for hours for assistance, as he lay bleeding and helplessly
trapped in the vehicle.
A 20 year old man experienced immediate paralysis at the cervical
level after diving into a sandy bank in Clear Lake. Floating face
down, he expected his life to, end from drowning. He was uncertain if
his friends would pull him from the water of if he wanted them to.
Physical-Sensory Deprivation Trauma patients undergo a dramatic decrease in
sensory and social stimulation during acute care. (4,6) The effects of the physical
trauma itself, plus a combination of anesthesia, medication for pain, sleep disruption,
and the disorienting bustle of intensive care unit (ICU) activities probably each
contribute to a clouding of the sensorium. (7) Basic attempts at self-protection and
coping may result in avoidance behavior, withdrawal, or emotional disassociation of
the patient from his surroundings. (8) The ICU can literally become an incubator,
shielding out familiar stimuli and inducing alienation.
Loss of Body Control Particularly for the patient population of physically
active, independent adults, traumatic injury creates a stressful situation of forced
dependency and physical helplessness. In spinal cord injury, motor functioning, sensation,
bowel and bladder control and sexual functioning are likely to be lost or impaired;
loss of essential function and phantom sensations typically accompany traumatic limb
loss. Such drastic functional loss may trigger fear and confusion over the sense of
disorientation with one's body. Physical loss of control represents an emotional threat
because it limits one's ability to maintain personal control (8).
Interpersonal Relationships The hospitalized trauma patient is literally up-
rooted from his life-space. The person finds himself in an ICU or hospital ward,
suddenly cut off from his family life, work activities, recreation. Particularly when
internal coping resources are depleted from the crisis of injury, a person experiences
intensified needs for emotional support, attention, and affection. Yet, these needs
occur at a time when support from social and family contacts is greatly decreased. (1)
Furthermore, the ICU climate is generally not conducive to intimate communication
about personal concerns -- which is the basis for mutual emotional support.
Besides the physical separation forced by hospitalization and restricted visiting,
other factors may weaken the family support system, which normally provides protective
and nurturing functions. Weller and Miller describe the helplessness and panic observed
in families, noting common anxiety responses of excessive hovering or fleeing due to
being overwhelmed. (9) Families and friends immobilized by stress may have difficulty
providing appropriate support. Diminished internal and social supports consequently
leave the patient with strong dependence on the acute-care staff to sustain his
interpersonal needs.
Family Role Changes Another aspect of the isolation of the patient from family
is disruption of role performance and role expectations. Family systems operate with
varying degrees of interdependence for performing necessary tasks to maintain survival
and family activities. With catastrophic injury and consequent prolonged hospitalization,
there is typically an overwhelming shift in responsibilities to the spouse or other
family members.
The 19 year old wife of a young welder during initial hospitalization
for C-5 quadriplegia was suddenly barraged with total family responsi-
bilities following his injruy. Her part-time secretarial job 200 miles
away was the only financial support for their family of 4. Her job was
also necessary to maintain health insurance needed for his rehabilitation.
She was faced with juggling priorities of producing income, managing
child care, and arranging eventual relocation of the family -- while
providing the major emotional support to her husband during his difficult
hospitalization.
Social Stresses Other psychosocial factors of traumatic injury involve the
concrete stresses on the social situation. Among the problems faced by patients and
families after injury are loss of income, dilemmas with transportation, housing needs
allowing accessibility to the hospital, and child care responsibilities. Due to increased
expenses at a time when income may be decreased, financial stresses often limit the
capacity to manage the other problems. Community. resources for immediate personal and
financial needs are inadequate and difficult to access. For many families, negotiating
agency systems to obtain public assistance constitutes yet another stress of personal
dignity and patience.
As prior to injury, families have varying capacities to cope with emotional and
concrete stresses. Positive coping capacities usually include flexibility, good
problem-solving skills, and abilities for developing and maintaining strong networks
of social support. Those functioning with fewer personal resources may need emotional
support and professional assistance from hospital staff. Intervention of direct-care
staff by offering emotional support can be strengthened by initiating consultation
with the social worker for full assessment and appropriate referrals which link families
to additional resources.
Psychosocial Management of Trauma
The degree of emotional impact from these psychosocial components in traumatic
injury must be considered unique to the individual patient and family system. Immedi-
ate psychological consequences have been conceptualized in terms of stages of emotional
adjustment (8,9) and models of therapeutic management of trauma. (6) There is wide
speculation that shock, depression and denial are necessary and universal reactions to
sudden, catastropic injury. In her review of literature on the process of adjustment
after injury, Trieschmann emphasizes that persons with traumatic injury are a hetero-
geneous group whose behaviors and emotional responses are highly individualized. (7)
She notes there is not evidence at this time of classical stages of adjustment. (10)
That is, positive adjustment can occur without depressive phase, and active denial may
play a minor role with some patients. In fact, absence of these has been shown to
correlate with positive outcomes. (7) The sequence and duration of adjustment responses
are also believed to be variable for individual patients and families. (9,11)
Data does suggest that personality traits and coping styles tend to be maintained
after traumatic injury. (7) In fact, there appears to be an intensification of pre-
injury traits (12), such as self-blame or dependency. In view of individualized coping
responses, it is wise to have no clear expectation that a patient or family must follow.
predictable response patterns.
It may be unrealistic for direct-care staff to fully assess and understand a
patient's emotional experiences during acute care. Whatever the range of psychosocial
responses, it is safe to assume the experiences surrounding injury constitute a life
crisis by causing disruption in some aspect of lifestyle. Forces in the treatment
environment will influence the patient and family and will shape their reaction to
treatment, whether psychosocial functioning appears to be positive or poor. Positive
patient-environment interactions can minimize negative aspects of trauma and treatment,
as well as positively contribute to the process of returning to health.
How can the hospital environment and the staff as a dynamic part of the environ-
ment be responsive to patient and family needs? It is possible to glean some insights
on environmental strategies from both crisis theory and the body of knowledge about
coping with stress and illness.
Rapoport describes the tasks of effective crisis intervention in terms of the
following goals:
1) establishing trust and engaging in an "alliance for treatment";
2) reestablishing a sense of autonomy;
3) mobilizing hope;
4) facilitating decisions and goals for action. (13)
The focus is on the immediate time and place, and primary strategies include clarifica-
tion of basic information to diminish anxiety. The major objective of crisis intervention
is to sustain and support the individual toward a state of equilibrium, in which he is
self-sustained by usual coping resources.
Theories of coping and adaptation suggest that there are two modes of coping
with stress, and influencing change in the social environment. (1,5) That is, internal
coping within the individual, versus environmental alteration to minimize stress.
While palliative efforts can be offered to the individual and family to enhance their
coping, "fixing the person" remains an unrealistic and often ineffective objective.
On the other hand, rich resources for supporting an adaptive emotional response to
trauma lie in the person's external environment. The acute-care setting is complex and
dynamic, with opportunities for positive emotional interactions which facilitate coping.
The challenge becomes one of developing ways to use and modify the patient-care
environment as a means of improving psychosocial functioning of the patient and
family.
Many attempts have been made in the literature to describe what is essential for
successful interactions with the environment, i.e., for coping. White suggests that
adaptive behavior involves management of three variables: securing adequate information,
maintaining autonomy and freedom of movement. (14) From an ecological perspective,
Germain states that patients require certain "environmental nutriments¹ for effective
coping with illness and disability:
1) opportunities for taking action and making decisions;
2) staff behaviors and patient services that regard patients'
coping efforts and support their sense of dignity;
3) provision of necessary information in the appropriate amount
and at the appropriate time;
4) organizational policies and procedures that respect patients'
lifestyles, cultural values, and social supports. (5)
Using these concepts as a foundation, specific strategies and staff interactions
within the hospital environment are proposed.
Environmental Strategies and Staff Responses
Establishing Trust: Building "Alliances for Treatment"
Develop good working relationships early with patient and family members,
based on clear communication:
1) Active listening to needs and concerns.
INTERACTION PATTERNS -- STYLE I
HOSPITAL ENVIRONMENT
STAFF
PATIENT
FAMILY
FIGURE 1
INTERACTION PATTERNS -- STYLE II
HOSPITAL ENVIRONMENT
STAFF
PATIENT
FAMILY
FIGURE 2
2) Giving information to welcome and orient patient and family
to hospital system and introduce care procedures.
Effective Communication System
1) If patient is nonvocal, set up nonverbal communication system
as soon as possible (e.g., blinking, clicking system).
2) Establish communication patterns to allow flow of
information between patient, staff and family.
The systems-diagrams (Figures 1 and 2) illustrate two situations of interaction
patterns occuring in the hospital environment. Broken lines depict unidirectional
communication, and solid lines show two-way interactions. Figure 1 demonstrates a
situation characteristic of the early period in acute care: one-way communication
emanating primarily from staff to patient and family, with family interacting with
patient from its place outside the system. As treatment alliances develop, ideally
there should be movement toward Style II interaction patterns (Figure 2). The family
is brought inside the system, now with strong two-way communication between all three
essential elements -- the patient, family, and staff.
Opportunities for Control and Action
Staff responses in the acute-care environment traditionally foster learned
helplessness by reinforcing helpless behavior, such as pain, calling for help, etc.
Reinforcing independent behavior helps to improve treatment outcomes and long-term
adjustment to disability. (7) Whenever possible, minimize helplessness and dependency
of the patient by providing opportunities for decision-making, control and manipulation
of the environment:
1) Establish care routines in which the patient can participate.
2) Allow patient decisions about negotiable aspects of his care, e.g.,
time of procedures, amount of family participation in care, etc.
3) Set up immediate environment to allow access to personal belongings
and needed items, e.g., TV, telephone, cosmetics, etc.
4) Allow for patient privacy and ways to be alone if he needs quiet time.
5) Encourage physical movement and mobility within medical limitations.
6) Offer opportunities for daily decisions, e.g., regarding visiting times
and number of visitors, menu choices, etc.
Providing Information
Providing clear, accurate information can reduce anxiety and helplessness:
1) Basic, simple information -- avoid technical, complex explanations.
2) Frequent, repetition of explanations of care procedures.
3) Clarification: Let the patient know:
what is happening to him,
what is being done to and for him, and why,
what he must do to cooperate with his care.
4) Reassurance -- calm, positive communication.
5) Accuracy (non-speculation): Offer and clarify the information you do have;
resist pressures to supply answers to questions you cannot answer.
(Giving inaccurate or misleading information may be more detrimental
than saying "I don't know. ")
Family Participation in Care Procedures
Build "alliances for treatment" with family members who can be essential sources
of support. Involving family members in simple care procedures can reduce patient/family
isolation, and minimize anxiety and helpless feelings:
1) Inform family of the care plan and allow them to participate in some
aspect, e.g., feeding, positioning, personal hygiene.
2) Allow adequate space and time for visiting.
3) Encourage hospital policies and procedures that support family
involvement, e.g., parking, family visiting area, minimized
interruptions at visiting times.
Prognosis Information and Response to Denial
Giving prognosis information when it signifies "bad news" is a specialized aspect
of communication with patients and families during acute care. Within the initial two
weeks of hospitalization, a large percentage of patients actively desire information
about implications of their injury. (10) Judgements by medical personnel about giving
prognosis information may be difficult: how much to say, at what time, in what
manner? In general, it is most helpful to provide truthful yet conservative
predictions about outcomes in response to prognosis questions.
Basic concepts which may guide such judgements include:
1) People need information about their injuries, but only in the amount
and at the appropriate timing that they can hear it.
2) It is as unfair to withhold information, as it is to bombard them
with future predictions that cannot be proven so early.
3) It is possible to provide honest information without taking away hope.
A model for supportive use of prognosis information is shown below:
SUPPORTIVE USE OF PROGNOSIS INFORMATION
Appropriate Timing and
Amount of Information
Hope -- Positive Expectancy
Mobilization of Strengths
Motivation for Rehabilitation
Sensitivity to preserving hope can foster positive patient expectations, which serve
as the basis for mobilizing his strengths toward a positive outcome. In contrast,
negative consequences of giving extreme predictions of prognosis are illustrated below:
PROGNOSIS INFORMATION: EXTREME PREDICTIONS
Positive Prognosis
Negative Prognosis
Reinforcement of Denial
Anger
Hopelessness
Despair
Unrealistic Expectations
Failure
Unwillingness for Rehabilitation
Refusal to Cooperate with Treatment
Premature Return to Activity
Mistrust of Staff
"Doctor-Shopping"
The use of denial as a coping mechanism in the acute phase of care is often
viewed negatively. It may take the form of minimizing the injury or its implications;
in some patients, the possibility of permanence never occurs consciously. Denial
of long-term disability in the early phase is a valid, useful, and healthy defense.
(7-10,12) It serves to contain the flood of emotion that can immobilize any further
coping. Since future-focused negative prognosis is likely to trigger stronger denial,
a more effective approach is to assist the patient in focusing on the present reality
in order to plan for the next step -- rehabilitation for maximizing what he has.
Indicators for Psychiatric Consultation
A range of emotional coping responses to trauma and acute care is natural and
expected. Taking into account individual patient differences and limited assessment
information during early care, it is important to note severe, dysfunctional reaction
patterns that may indicate a need for psychiatric consultation. Indicators are outlined
as follows:
1) Persistent lack of reality orientation, beyond a temporary
disassociation or clouding of the sensorium.
2) Dysfunctional psychogenic symptoms, for which there may be a
physiological basis, but diminished psycho-emotional tolerance
of symptoms. For example,
a. A non-medical appetite disorder in a young quadriplegic
woman with extreme anxiety and GI problems. Her refusal
to eat sabotaged her rehabilitation program.
b. Pre-occupation with neurogenic pain in a C-5 quadriplegic
male, whose back pain intensified with his depression,
blocking participation in therapy.
3) Severe depression, with a history of depression precipated by loss.
Pre-injury emotional loss is believed to be linked to severe depression
as a syndrome after traumatic loss due to injury. (8) For example, loss
of a parent or loved one early in life. This is distinguished from sadness
or mourning as a natural response to loss.
4) Suicidal ideas that develop into a plan. This persistent preoccupation with
suicidal thinking, or specific planning for suicide is distinguished from
statements about not wanting to live, which may be in the normal range of
emotional responses.
Conclusion
The person with severe trauma requires technical expertise, immediacy, and life-
saving action. Such concentrated focus on emergency and critical care often obscures
the broader need of treating the whole person. Management strategies which support
emotional adjustment in the acute-care environment strongly influence positive long-
term outcomes in rehabilitation.
The process of learning to live with one's disability begins at the moment of
injury and continues through life. (7) Dynamics of the treatment environment affect
this continuum: interactions with patients and families which encourage participation,
hope and independence in a caring and enabling environment can mobilize strengths for
rehabilitation and long-term adjustment to disability. Therefore, a traumatically
injured person and his family require individualized, comprehensive care which is
responsive to both physical and emotional needs. Maximizing a person's physical
function becomes futile if psychosocial disability prevents him from using it.
January 1983. This paper has been submitted for publication as a chapter in
Rehabilitation Psychology: A Comprehensive Textbook for Allied Health Professionals,
ed. David W. Krueger, M.D.
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