Begining of a Second Life

Mr. Seiler is 65 years old, a former butcher and still a vigorous individual very much engaged with the life pursuits of his retirement, living in Switzerland. Although divorced, he and his wife had raised three children who were all now middle aged. During the dawn of his recent retirement, Mr. Seiler had enthusiastically continued working and enjoying life. After the close of his long career, he carried on working in a field that was no less demanding — farming — regularly assisting farmers in his region in all manner of activities. Mr. Seiler’s recreational activities were just as testing as an all around athlete involved in sports such as skiing, hiking and jogging. He even spent evenings as a talented “rock ’n roll” dancer. All in all, a life that could tire even a younger man. An unexpected farming accident would leave Mr. Seiler with acute incomplete tetraplegia.

Read more: General Introduction

As the recovery from neurological deficits depends upon the severity of injury, completeness and level of injury are important factors. Whether the injury is complete or incomplete contributes to future outcomes.

In other words those with ASIA B or D SCIs (incomplete) often show a more substantial recovery than those with ASIA A (complete) injuries.2

... the fewer the deficits at the acute stage regarding to initial level of injury, motor strength and whether the injury is complete or incomplete, the higher the rate of recovery.
Read more: Factors Influencing Recovery

The Fall

Mr. Seiler had agreed to assist a local farmer, herding and feeding his sheep along the farmer’s mountain farm. As he dispersed feed one morning to the sheep along the shear mountainside, one of the wilder spirited animals ran at him and leapt upon him, immediately knocking him over and sending him down the sloping surface. He fell rapidly, plummeting about ten meters before coming to a stop.

As I was tumbling down the mountainside, I thought to myself, ‘My God, when am I going to stop!’ I was so conscious during the whole fall, as I came to a halt, I was freezing, shaking — I couldn’t move my arms and legs; I was so very afraid. Like the cliché, I really did see my life pass before me. Now I continue to relive this over and over!

Mr. Seiler

Read more: Mr. Seiler's story

The Rehab Cycle

The rehabilitative treatment at the Early Rehabilitation Unit began with the health care team’s assessment of both the patient’s perspective and the health professionals’ perspective and was defined to last for four weeks.

As with each Rehab Cycle, these perspectives were based on Mr. Seiler’s body functions and structures, activities, participation and environmental and personal factors. The information and data obtained here would inform the next phases of the cycle.

Read more: Assessment

The functioning status of Mr. Seiler was illustrated in the team meeting within the presentation of the ICF Categorical Profile (Table 2). Based upon this initial assessment of Mr. Seiler, goals were defined by the health care team, taking both perspectives into account. The Global Goal, Service-Program Goal and Cycle Goals were established. The Global Goal was set as reintegration into participation considering Mr. Seiler’s hobbies but also the wish to work again.

Read more: Goal setting

Each intervention target was assigned to the appropriate health care team members who included Mr. Seiler’s physician, nurse, physical and occupational therapist. An assessment of each of the intervention targets was performed at the beginning of the Rehab Cycle using specific tests or examinations by the responsible health professional (see Table 3).

A number of interventions performed are worth highlighting. While the health care team hesitated in allowing Mr. Seiler to attempt walking, they finally agreed given his rapid recovery and enthusiasm. Walking was included as an intervention target to meet Cycle Goal 2. This intervention was carried out by either the nurse or physical therapist who accompanied and supported Mr. Seiler during brief walking activities.

Read more: Assignment and Intervention

One month after the accident, the initial, early post-acute care Rehab Cycle was completed with an evaluation of its progress. Encouragingly, Mr. Seiler’s recovery had surpassed expectations of both the health care team and the patient himself. The positive course of the recovery of the initially impaired body structures contributed to this result. Additionally, his engagement, motivation and self-discipline all contributed significantly, clearly paying off in his positive results. Each of the intervention target goals was achieved and remarkably six of the intervention targets exceeded their expected outcome values. Overall, this led to the achievement of all three cycle goals. The cycle goal for moving in different locations was also achieved beyond expectations. Taken together, these stepwise accomplishments resulted in reaching and surpassing the anticipated Service program goal of greater independence in daily living. Included here are a number of personal reflections on Mr. Seiler’s recovery:

Read more: Evaluation

The case study of Mr. Seiler sought to show that rehabilitation of traumatic SCI patients occurs not only within the early post-acute rehabilitation phase, but involves a continual process that begins at the time of the accident, extends through acute care and beyond to a patient’s optimal recovery. Such a recovery benefits from contributions of both health professionals and the patient. All of the rescue personnel and health care team members involved in this process, in addition to the patient him or herself, have a major impact on the functional outcome.

Read more: Discussion

  1. Marino RJ, Ditunno JF, Donovan W, Maynard F. Neurologic recovery after traumatic spinal cord injury: data from the model spinal cord injury systems. Arch Phys Med Rehabil. Nov 1999; 80: 1391-1396
  2. Bernhard M, Gries A, Kremer P, Böttiger B. Spinal cord injury - prehospital management. Resuscitation. 2005; 66:127-139
  3. Sekhon L, Fehlings M. Epidemiology, demographics and pathophysiology of acute SCI. Spine. 2001; 26(24S):S2-S12
  4. Ditunno JF, Sipski ML et al. Recovery of upper extremity strength in complete and incomplete tetraplegia: a multicenter study. Arch Phys Med Rehabil. April 2000; 81: 389-393
  5. Lisa-Ann Wuermser, Chester H. Ho, Anthony E. Chiodo, Michael M. Priebe, Steven C. Kirshblum, William M. Scelza. Spinal Cord Injury Medicine - 2. Acute Care Management of Traumatic and Nontraumatic Injury. Arch Phys Med Rehabil. Mar 2007; 88 Suppl 1: 55-S61
  6. Crock HV, Yoshizawa H, Yamagishi M, Crock MC. Commentary on the prevention of paralysis after traumatic spinal cord injury in humans: the neglected factor - urgent restoration of spinal cord circulation. Eur Spine J. 2005; 14: 910-914
  7. Burns A, Ditunno J. Establishing Prognosis and Maximizing Functional Outcomes After Spinal Cord Injury: A Review of Current and Future Directions in Rehabilitation Management. Spine. 2001. 26(24S): S137 –S145.
  8. Fawcett JW, Short D, et al. Guidelines for the conduct of clinical trials for spinal cord injury as developed by the ICCP panel: spontaneous recovery after spinal cord injury and statistical power needed for therapeutic clinical trials. Spinal Cord. 2007 45: 190-205
  9. Spinal Cord Injury Information Network. Predicting Outcome (Prognosis) in Spinal Cord Injury. Website: http://www.spinalcord.uab.edu/show.asp?durki=21502&site=1021&return=21511; Accessed: Dec 12, 2007.
  10. Boldin C, Raith J, Florian Fankhauser F, Haunschmid C, Schwantzer G, Schweighofer F. Predicting Neurologic Recovery in Cervical Spinal Cord Injury With Postoperative MR Imaging. Spine 31(5): 554 –559
  11. Geisler F, Coleman WP, Grieco G, Poonian D, and the Sygen Study Group. Measurements and Recovery Patterns in a Multicenter: study of Acute Spinal Cord Injury. Spine 26(24S): S68–S86
  12. Malik M, Lovell M. Current spinal board usage in emergency departments across the UK. Int. J. Care Injured. 2003; 34: 327–329
  13. Porter K, Allison K. The UK emergency department practice for spinal board unloading. Is there conformity? Resuscitation. 2003; 58: 117-120
  14. Yeung, JHH, Cheung NK, Graham CA, Rainer, TH. Reduced time on the spinal board: effects of guidelines and education for emergency department staff.Int. J. Care Injured. 2006; 37: 53-56
  15. Hodgetts T, Smith J. Essential role of prehospital care in the optimal outcome from major trauma. Emergency Medicine. 2000; 12: 103-111
  16. From the British Red Cross, How to deal with a spinal injury. Website: http://www.redcross.org.uk/standard.asp?id=75194, accessed: Jan 16, 2008
  17. Hall E, Springer J. Neuroprotection and Acute Spinal Cord Injury: A Reappraisal. J Am Soc Exp Neuro. Jan 2004; 1: 80-100
  18. Chapter 8: Blood Pressure Management after Acute Spinal Cord Injury. Neurosurgery. Mar 2002; 50(3 Suppl.): S58-S62
  19. Goldsmith H. Can the standard treatment of acute spinal cord injury be improved? Perhaps the time has come. Neurologic Research. Jan 2007; 29: 16-20
  20. McKinley W, Barnard B et al. Outcomes of Early Surgical Management Versus Late or No Surgical Intervention After Acute Spinal Cord Injury. Arch Phys Med Rehabil. Nov 2004; 85: 1818-1825
  21. Fehlings M, Perrin R. The Timing of Surgical Intervention in the Treatment of Spinal Cord Injury: A Systematic Review of Recent Clinical Evidence. Spine. 2006; 31(11 Suppl.): S28 –S35
  22. Scivoletto G, Molinari M, et al. Early versus delayed inpatient SCI rehabilitation: an Italian study. Arch Phys Med Rehabil. Mar 2005; 86: 512-516
  23. Sumida M, Uchida R, et al. Early Rehabilitation Effect for Traumatic Spinal Cord Injury. Arch Phys Med Rehabil. Mar 2001; 82: 391-395
  24. Little J, Harris R et al. Incomplete Spinal Cord Injury: Neuronal Mechanisms of Motor Recovery and Hyperreflexia. Arch Phys Med Rehabil. May 1999; 80: 587-599