2. Spiro meters, inhaling and exhaling exercises through balloon blowing, whistles, blowing balls and other enjoyable activities.
3. Teaching huffing and coughing to remove secretions from the lungs, recommending some positions of postural drainage in consultation with doctors.
b) Teaching movement exercises:
These are to ensure flexibility of joints, movement of ankles is particularly important right from the initial stages and to prevent clots and deep vein thrombosis, which further prevents other complications.
c) Prevention of pressure sores:
Physiotherapists teach families the safe way of turning on the sides of the bed every two hours. They also teach the person to inspect their bodies twice each day completely, using a
long handled mirror to see the body parts.
The physiotherapist guides in using the proper bed/cushion which relieves pressure to some extent (this could be a water bed/cushion, air, gel, foam, even coir, low cost cardboard or soft cotton). Physiotherapists also teach weight relieving manoeuvres of two hourly turning in bed: sitting up with legs straight, legs bent, turning onto the stomach, lying on the sides with blocks and to do push ups from the wheelchair.
They teach good nutrition, measures to prevent moisture from urine, sweat, soaked clothes, creases in clothes and bed linen, and the discomfort of being near hot, sharp objects which might damage the skin.
To strengthen the working muscles, initially active movements are done and later resistance is added with weights, springs, pulleys and thera bands. Particularly the arms and the trunk are focused on to make bed mobility, shifting, transfers, standing up and walking, easy, as also manoeuvring the wheelchair. The physiotherapist has to be very careful in strengthening. It has to be very gradual as many people may have weak bones (osteopenia and osteoporosis).
e) Transfers-/ Sitting Balance:
This very important skill makes a big difference in restoring the confidence and joy of living for a person with SCI. Once sitting balance gets better, shifting with good elevation by the person with SCI or with assistance is done in bed to move sideways, up and down. Transfers are done from bed to chair initially. Level transfers are done for a person with tetraplegia using a transfer board. Also, in our Indian context as much daily activity is done at floor level, transfers are done from wheelchair to floor. Later transfers from wheelchair to vehicle are attempted.
f) Wheelchair training:
Physiotherapists teach wheelchair skills, of propulsion, on level surfaces, transfers from wheelchairs, staying active whilst sitting, doing pressure relief manoeuvres, taking care of posture and alignment, learning to handle the different parts of the wheelchair. Next comes manoeuvring the wheelchair on gentle inclines, outdoors over gravel and uneven surfaces, going through doors and, in and out of the toilet. Advanced skills of falling and getting back into the wheelchair are also taught by the physiotherapist. Those who have mastery over these skills also teach how to use a tricycle outdoors.
Also, along with the person with SCI and the family, the physiotherapist chooses the wheelchair best suited to individual needs without compromising on safety, comfort and function. In selected instances two wheelchairs may be needed, one each for indoors and outdoors. A physiotherapist is a resourceful person who guides the person with SCI and their families on the purchase of manual or motorised wheelchairs, or gets them linked up with trusts and foundations that support the purchase or loan of these aids and appliances.
Working closely with doctors and orthotic engineers, the physiotherapist works at giving necessary support /stability to the neck, mid and low back; either with a hard cervical collar, or other types of spinal frames/corsets, knee-ankle-foot orthosis or ankle foot orthosis, etc. Along with orthosis, the physiotherapist judiciously decides on the process of the parallel bar walking, walking with walker as well as walking with different types of crutches.
h) Gait training:
The physiotherapist first makes the person with SCI stand on a tilt table, slowly achieving full verticalisation. Compressive bandages to the legs and an abdominal binder will help during this process of achieving full upright standing. A physiotherapist, while he/she emphasises the benefits of standing and walking ,to make bones strong, let the bladder and bowel work well, prevent calcium washout, prevent renal calculi, stretch muscles, elevate mood, has to be realistic and work with the person with SCI whether it is practical and realistic and safe, or wheelchair mobility is a better option.
i) Pain & Wound management:
Physiotherapists also assist in the management of wounds by giving ultraviolet radiation, infrared rays as also ultrasound therapy and ice cubicle stroking all of which are done with utmost aseptic precautions.
Persons with SCI, develop pain in the neck, shoulder, wrist, and fingers because of constant wheelchair propulsions, transfers, use of crutches and other assistive devices. Physiotherapists treat the pain by transcutaneous nerve stimulation, ultrasound, infra red and, in selective cases, shortwave diathermy to neck/shoulders, does neural mobilisation, myofascial release and massage to relive pain and adhesions. While giving heat modality the therapist sees that sensations in that apart are intact and is vigilant that overheating of the tissues does not happen.
j) Caring for the carers:
For the first 3-6 months and in some instances for longer, persons with SCI will need assistance for movement and physiotherapy. Thus the physiotherapist has to train the carers, the family members and attendants/helpers as well, in proper techniques of mobilisation, strengthening, lifting and transfers.
k) Bladder training:
Transurethral electrical stimulation may help in detrusor contraction and voiding, credes maneuver-manually pushing
down on the bladder is taught, as is bladder stimulation by suprapubic jabbing.
A physiotherapist trains and motivates the person with SCI to take active interest in sports – especially ball games, racquet sports and wheelchair sports and to participate in annual meets in the city or outside where paraplegic sports are conducted. These keep one's aerobic capacity tuned and rebuild confidence.
In short, a physiotherapist's role is very vital at all stages of rehabilitation. The therapist is cognizant and prevents negative effects of cardio-respiratory de-conditioning, prevents pneumonia, atelactasis, deep vein thrombosis, pressure sores, contractures and deformities, renal calculi, osteoporosis, postural hypotension through graduated exercises, verticalisation slowly and weight bearing. The therapist strengthens all innervated muscles, keeps up the mobility in the joints where active movement is not possible, enhances bed mobility skills, and transfers with/without assistive devices. He/she improves dynamic sitting balance, wheelchair skills indoors and outdoors, for getting in and out of vehicles and weight relieving manoeuvres. A therapist teaches walking with lower limb orthosis, with modified walkers, crutches, indoors and if possible outdoors.
Besides supporting the person with SCI to develop functional independence in attaining motor skills, the therapist cheers, boosts the morale, raises the spirit, and infuses positivity in the person with SCI and their families and care-givers. Physiotherapists emphasise on independence for daily living movement skills, not just walking, staying active, but also in engaging in sports such as swimming, racquet sports, table tennis, throw ball, cricket, wheelchair riding each day, as well as going out in morning sun, which enhances ones well-being and quality of life, and to say yes to life and joyful living.
The author is an Associate with Nina Foundation and also professor at MGM School of Physiotherapy in Navi Mumbai
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CHRISTIAN MEDICAL COLLEGE (CMC) , VELLORE
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REGIONAL SPINAL INJURY CENTRE, CUTTACK
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Epitome of inspiration
S Ramakrishnan - a person with cervical level spinal cord injury who cannot move even a finger - exemplifies service to community in its purest form.
Rare is an individual who has done so much for those around him despite facing the most challenging situations of life.
An accident during naval officer selection altered Ramakrishnan's world in 1975, as he became totally paralysed below the neck. He was an engineering student when this life-changing event took place. This high-level cervical spinal cord injury meant that Ramakrishnan had to face the world, depending just on his intelligence and communication skills. For all else, he needed help at every turn.
Helping him overcome and transcend debilitating physical constraints are a razor sharp intellect, unfailing memory, innate ability to connect, expertise in marshalling local resources in a remote village setting, his embrace of emerging forms of communication and leadership skills honed over the years, as well as the unstinted support of his wife, Chitra.
What started as a small operation in 1981 - in Ayikudy, a valley near Tenkasi, Tamil Nadu, is today, a shining example for everybody. That he managed to develop such an institution when the scope for communication and networking was minimumal, only adds to the magnitude of his achievement.
Amar Seva Sangam, named after Dr. Amar Singh Chahal who helped in the rehabilitation of Ramakrishnan, completed 30 years of excellence in 2011. Its services now transcend the world of children with disabilities, to making a difference in many-a-village within its vicinity and beyond. From a humble origin, Amar Seva Sangam today sports a multi-faceted dimension.
A spinal rehabilitation centre, a home for those with physical disabilities, a caring facility for children with special needs, general and special schools, vocational training centres imparting a variety of skills from the ancient to the contemporary, a nodal centre for government programmes, village adoption programs and an open university study program - are all integral parts of Amar Seva Sangam.
"Live To Serve" is the motto of Amar Seva Sangam. Hospitality gets a new meaning in Ayikudy. To meet Ramakrishnan in person, is an experience rarely matched. You cannot miss his meticulous eye for detail and a deep respect for every form and degree of support. Spending most of his day lying down, he is however, always at work with a clock, mobiles, computer and caregivers.
Greeting every person with Namaskarams, Ramakrishnan has also been active in developing informal networks of people with disabilities in different parts of India. These linkages have helped many to find a friend and a source of support - an important element in community based rehabilitation.
He will forever remain a source of inspiration, hope and possibility in the face of adversity.
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LIFE’S LIKE THAT
ALL IN A DAY’S WORK
LIFE’S LIKE THAT
NITIN GOYAL, Head of Regional Treasury, Asia Pacific and India, Nokia Siemens Networks, Gurgaon, writes regularly for various publications. For us at Ability Foundation he is a friend and a travel guide. And boy! does he travel! Given half a chance he'd be wheeling his chair on to the icy slopes of Alaska. Or is it Antarctica? He tells us how he manages it.
Travelling is an integral part of our lives. We move out of our homes almost every day to live out our lives. And to work towards achieving our goals. With a physical or intellectual impairment, this very basic component of our life becomes a chore and makes us struggle at least for some time until we fall into a pattern.
Take me, for instance. I am a paraplegic and I use a wheelchair. I have a VW Vento with automatic transmission (gears) in which our friend, Mr. Ferdinand Rodricks, has installed a set of hand controls. It is a simple lever system installed between the steering wheel and the dashboard which is connected to the foot pedals. When I pull the hand control lever towards me, it pushes the accelerator down and races the car, while when I push the lever down, it pushes the brake pedal to slow down or stop the car. I have been driving such cars for over twelve years and find them very comfortable and reliable. It is a simple innovation that has provided me with tremendous independence. The day I drove a car alone for the first time, was the day I felt I had truly put paraplegia behind me.
ROUTINE TRAVEL TO OFFICE
I live in Gurgaon and my office is at the other end of the city requiring about 30 minutes of drive each way. I put the wheelchair next to my car while my wife/mom/dad hold it to prevent it from slipping. I transfer myself into the car and drive to the office. I keep another wheelchair folded in the back of my car. In the office, a comfortable parking space is reserved for me. A security guard takes out my chair and sets it against the car. I transfer into it and move into the office. The start of another good working day.
TRAVEL WITHIN THE CITY
Ah! The weekend's here! Time to relax and to shake off work blues! But of course, there's shopping to be done and bills to be paid off first and an infinite amount of permutations and combinations involved. Each market and shopping mall has its own characteristic architecture and over a period of time we have learnt our ways around them. We have identified the ones where it is easy to move around in a wheelchair.
Sometimes, we drive to the market and I sit in the car while my wife buys the stuff. She may bring out things to show me and discuss some matters (usually the shopkeeper sends someone along). If I wish to go into the shops to look around, she pulls out the wheelchair from the boot, opens it and sets it beside the car. I transfer myself to the chair and off we go.
In Mega Mall, we can park in the surface parking and use the ramp to get in. In Plaza Mall, we need to go to the basement to use the lift as there are stairs on the surface. In Sector 14 market, there are few places where I can get onto the pavement. In Sector 15, I need to take help as the pavement
LIFE’S LIKE THAT
is more than a foot high… and so on and so forth.
When we go to the movies, I take help from the theatre attendants to lift me and help me into the theatre chairs. We make sure to buy aisle tickets to ease this. Earlier, I used to sit in the wheelchair itself and take it up or down stairs to the intended row of seats for which we had tickets. But, it's not easy navigating the stairs and people keep bumping into me while passing. Then there was a court judgment on a movie hall fire case and movie theatres refused to allow wheelchairs in the aisles. I too found the seats more comfortable. How do I escape if there is a fire? Well I guess that's a separate issue. No, none of the movie halls around have special places for wheelchairs.
Often, we encounter stairs and steps. I ask the people around to help and have always found them eager. Once at a cinema hall, we had to go up to the third floor and the lift turned out to be under repair. We asked for help from other moviegoers and two young men helped me up to the third floor!
I usually do not worry about accessibility of a place until we reach there. Rarely have we decided not to pursue our quest just because it would be too strenuous.