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Paraplegic Rehabilitation in South Africa

Early Rehabilitation with a Brace

The orthopedic surgeon deemed the operation successful; the fracture was stable. Two weeks after the operation, he was casted in preparation for his brace. After consultation with the surgeon, he was allowed to longsit with a Jordain Brace TLSO about three weeks post surgery. Paraplegics should assume a longsitting position as soon as possible, as it enhances function.

Zamani was given a narrow adult wheelchair with an eggbox cushion. Zamani was taught to lift himself regularly in his wheelchair to relieve pressure.

Medical Treatment

The doctor continued to visit Zamani regularly. Zamani experienced no more pain and analgesics were stopped.

The doctor led the team rounds every other week where Zamani's goals were discussed. A medical team meeting was held with Zamani to discuss his rehabilitation program and associated time frames. Zamani asked questions and he also expressed his difficulty in accepting his disability.

Nursing

The nurses were responsible for getting Zamani up in his brace daily. Log rolling was done to put on the brace with care to prevent movement at the fracture site.

Nurses assisted with dressing and washing. Zamani could do this independently two weeks after surgery, because he could longsit. The nurses were still responsible for putting on his brace.

Bladder Control

An indwelling catheter was still in situ. Bladder tests were done after three months.

Bowel Control

Zamani was on a full balanced diet. Senokots® were taken at 12h00 and Dulcolax® suppository at 20h00. He preferred to have bowel movements in bed at this stage. This was done every second day and he managed well.

Physiotherapy

Zamani got up with his brace and attended the spinal gym for the first time on December 6, 1995.

Intermediate and Final Rehabilitation Goals

Following a spinal cord injury, the individual re-enters the community with specific impairments that impact upon his previous experiences of personal, social and community interaction.

Thus, the rehab team must ensure the patient is functionally independent and can resume his previous activities within limitations of his current disability and with the necessary support systems.

Zamani attended physiotherapy every morning between 10h00 and 12h30. To relieve pressure, he was taught lifting in his wheelchair every ten minutes.

Re-assessment

Another assessment was done with his brace on. There was no change in his neurological condition. Zamani could push his wheelchair to the physiotherapy gym and could transfer to highsitting with assistance. Zamani's balance in highsit was very good due to his T11 innervated stomach muscles. It was impossible to test his abdominal muscles accurately because he was wearing a brace and was not allowed to do trunk flexion.

The following activities were done:

• Rolling on the side and prone with brace on.
• Sitting up from lying on back and prone.
• Balance in long- and highsit. Lifting arms, rhythmic stabilization techniques, moving in and out of the position, throwing a ball.
• Transfer training in highsit and longsit.
• Strengthening exercises to improve arm strength. Both body weight and weight resisted exercises were done. A weight, 70% of his one repetition maximum was deemed appropriate to improve strength.
• Independent passive movements of his legs in longsitting were taught. His ability to do this was limited due to the brace, and the physiotherapist assisted him.

Walking Rehabilitation

Standing in the tilt-table was done for three days prior to standing between the parallel bars.

Standing balance with legbraces was practiced between parallel bars.

Zamani started swing-through gait training within one week after standing rehabilitation was started.

Therapeutic walking rehabilitation with elbow crutches was taught. With assistance, he could walk 150m without resting. Further training was done after his brace was removed.

Occupational Therapy

Assessment was to determine his functional ability.

Treatment

1. Transfers to the bed and the toilet were taught. Zamani managed these quickly.
2. Endurance training by pushing his wheelchair on a specifically laid out slalom course. Speed was recorded in time and this encouraged Zamani to improve his time.
3. Basic wheelchair manipulation was taught.
4. Balance in sitting was improved.
5. Elementary principles of handling the wheelchair were taught: pushing forward on even surfaces, ascending and descending slopes, and turning the wheelchair.
6. Backwheel-balancing was started to enable Zamani to move forward on his back-wheels and to go through a gutter, a curb, sandy and gravel patches, and travel on grass.
7. Ideas for a home industry were discussed: leather work,shoe repairs, picture framing, etc.
8. Education groups: topics such as the anatomy of the spinal cord and pathology of the condition were discussed.

Social Worker

Zamani attended individual and group sessions on coping and handling of his disability. Since he wanted to return to the university, problems that he might experience were dealt with.