Spinal injury rehabilitation complicated by psycho-social problems
Clinical Case of the Month Spinal injury rehabilitation complicated by psycho-social problems
Avi Ohry 0
Harold Weingarden 0
Jerzy Kiwerski 1
A Otom 2
WS El-Masry 3
Apichana Kovindha 4
Fin Biering-S?rensen 5
0 Department of Neuro-Rehabilitation, Sheba Medical Center , Tel Hashomer , Israel
1 Rehabilitation Center , Stocer, Konstancin , Poland
2 Rehabilitation Center, King Hussein Medical Center , Amman , Jordan
3 Midlands Centre for Spinal Injuries, RJ & AH Orthopedic Hospital , Oswestry , UK
4 Department of Rehabilitation Medicine, Chiang Mai University , Thailand
5 Centre for Spinal Cord Injured , Hornbaek , Denmark
Correspondence: A Ohry
spinal cord injury; suicide; discharge planning; non-compliance; psycho-social aspects
Colleagues from the USA, Poland, Jordan, England,
Thailand and Denmark were asked to comment on the
admission, care and discharge planning of a patient
who became paraplegic following a suicide attempt.
This case was further complicated by the fact that the
patient was a member of an ethnic minority su?ering
from severe integration problems.
The patient was a 31-year-old man who su?ered a
burst fracture of the L3 vertebra with paraplegia after
jumping from a height of three ?oors. Associated
injuries included fractures of the posterior element of
C6, the ?rst right zib, bilateral calcaneus and a
posterior dislocation of the left elbow. Initial
neurologic status was ASIA A-L3. Treatment of the
L3 fracture included a posterior spinal fusion between
L2 and L4. Past medical history was unremarkable.
There were no signi?cant illnesses, medications, or
illegal drug use.
Prior to the injury, he had been living with his
mother, his girlfriend and his two children. He had
immigrated to Israel from Ethiopia 12 years before
and had completed his army service after his
immigration. He was trained as a house painter,
although he subsequently worked in unskilled labor.
During the period before his injury, he accumulated
debts, became increasingly depressed, left his family
and started to drink heavily.
Upon admission to the spinal unit, he was found to
be ASIA B with hypesthesia below L3. He progressed
normally in the rehabilitation program, including
ambulating with bilateral KAFOs and crutches, and
was independent in all ADL. He had a mixed-type
neurogenic bladder, but had di?culties following an
intermittent catheterization management program.
Psychological assessment indicated that while he
had had a major depressive episode, he was no longer
suicidal. Nevertheless, he wished to withdraw from
society and to live alone in a remote region of the
country. He did not participate in sports or social
activities, nor in the sexual counselling program during
Di?culties in discharge planning:
1 Lack of accessible housing in the area he wanted to
live in (no speci?c funding agency responsible for
providing accessible housing. He had to rely on
local government and community services).
2 Lack of family structure and support.
3 Lack of community services for psychological and
social support to an individual with paraparesis and
a previous suicide attempt.
4 Inability to assure appropriate regular medical
5 Dual disability, physical and psychiatric, in a
member of an ethnic minority, not yet fully
integrated into a westernized culture.
6 Finally, should we admit such patients to the spinal
unit, when we have reasons to believe they will not
be fully integrated into the mainstream of life?
H Weingarden, MD
(Formerly Director of Clinical Services, Rehabilitation
Institute of Santa Barbara, California, USA)
The management questions generated by this case
revolve around the issue of a non-compliant patient,
with a recent suicide attempt. The lack of resources
re?ect the estrangement from his family and the
decision not to work. His refusal to learn the
relatively simple management techniques for a partial
LMN bladder and to participate in the psycho-social
treatment are more recent features of his behavior.
Lack of cooperation with the post-discharge follow-up
should be anticipated.
With regard to questions 1, 3 and 4: very little can
be done if he is adamant in choosing a locale without
accessible housing. It is fortunate that he has achieved
some ambulatory capabilities. I believe that in the
USA, such an individual would be at high risk of
living on the streets, and after several episodes of
medical complications, would end up in a sheltered
care or nursing home facility.
I would make every e?ort to have the family
maintain a unilateral involvement. Even without a
normal family structure, they still may serve as the
emergency lifeline in times of crisis, and perhaps as a
bridge to outside resources should there be a
Questions 5 and 6: being a member of a culturally
distinct and disadvantaged minority does add further
hurdles to a successful treatment outcome. However,
in the USA, if this was a factor in deciding not to
proceed with admission to a SCI facility, the doctor
and facility would be open to an accusation of racism
and to legal action. At the current time in the USA,
many of the decisions whether to provide treatment
are in the hands of `case managers', often nurses with
no experience in SCI care. This has also provided an
opportunity to demand involvement of the insurer or
the state in planning for discharge, as a precondition
for acceptance into the SCI center.
In summary, I would also have admitted this
patient. If, after all e?orts of psychiatric and
psychological help, social work, and general
rehabilitation sta? intervention, he still continues to insist on
an inappropriate discharge, I would agree, as long as
there is no immediate danger. I believe that keeping
the family involved and the availability of the SCI unit
as a resource are important, especially if there is a
change in attitude and an establishment of new life
J Kiwerski, MD
The negative events in the life of this patient were
apparently caused by maladjustment to his new
country, by having to take a job below his
quali?cations and then getting into debt, which finally
led to his becoming depressive.
To assess the patient's potential for adjusting to
his new living conditions as a disabled person, more
information is needed on the exact causes and kind
of the depressive episode, on the possible
pharmacological anti-depressive treatment following the
suicidal jump and its e?ects, whether psychotherapy was
employed, whether there were any attempts to get in
touch with his family, the attitude of his relatives
toward him and possible family support in the
It is quite obvious that the patient's reaction to
di?culties is to withdraw and escape. His wish to live
alone in a remote region where no medical,
psychological or social help is available shows that
he is still depressive and neurotic. Apparently, the only
way to proceed with comprehensive rehabilitation in
this case is to get in contact with his family and by
psychological counselling. Further antidepressive
treatment seems to be advisable.
A Otom, MD
This young man has achieved a satisfactory degree of
independence through his rehabilitation program. His
progress was hampered by his social withdrawal, which
might indicate depression. His personality traits,
behavioral style and the etiology of his spinal cord
injury are guidelines for future care and re?ect the
importance of an individualized, ?exible program.
If this was not done yet, psychiatric assessment with
properly administered psychometric data to evaluate
treatment approaches and to give an insight into
patient potentials could be bene?cial. These data will
reinforce and recognise the person-environment
interaction and provide a basis for scienti?c approaches to
the development of well informed intervention.
Heinman, Schmidt and Semik found that drinking
patterns before and after SCI are strongly related and
limit rehabilitation gains. This can be related to
adjustment problems and hence comes the importance
of referral to prevention services.
Since this patient was trained as a house painter, I
wonder whether he has in fact worked as a painter and
if so, one should think of the possibility of prolonged
exposure to volatile substances. One of my patients
was found to be addicted to solvent (thinner) and had
withdrawal symptoms during hospitalization. This
problem goes hand in hand with alcohol drinking.
Finally, when we face an aberrant behavioral
problem, we should consider psychogenic
disturbances. The Minnesota Multiphasic Personality
Inventory-2 (MMPI 2) has been found to be helpful for
subtle forms of psychotic behavior.
There are individual di?erences in the ability to
adapt to SCI. Reassessment should clarify the high
risk factors which were mentioned. Concrete steps
should be taken through an individualized program
enlisting family support and providing continuity of
care and easy access to care providers. Individual,
family and couple therapy are needed to develop better
coping skills and increase social support. The family
should be trained to enhance the patient's
psychosocial environment. Counselling intervention should
focus on practical and behavioral aspects of coping
and on understanding the individual conceptualization
of the situation.
Favorite leisure activities should be assessed to help
this individual ?nd personal satisfaction as well as
vocational interests after injury, which could possibly
change his social withdrawal.
I do agree that it is extremely di?cult to deal with
such cases, but we have no choice: we need to admit
them to the spinal unit because it is the only place
where they can receive proper management. I must say
that in some of our cases we use every available
method of psychological intervention, including
religious orientation and spiritual beliefs, which play
an important role in accepting rehabilitation
W El-Masry, FRCS
This report highlights the dilemma that is frequently
encountered when dealing with patients with
psychosocial problems previous to spinal cord injury. There
are two questions to answer: ?rst, what do we do with
this patient who does not wish to take advice, has not
complied with rehabilitation and wants to live in an
unsuitable area without family support and without
follow-up? Unfortunately there is very little one can do
once the patient has been through the teaching and
training program and thereafter becomes non
compliant. His choice will have to be respected. The other
question is whether or not to admit similar patients to
a spinal injuries center in the future.
To admit such a patient to a spinal injuries center
has obvious implications on precious resources. There
is also a risk that failure to modulate this patient's
attitude to life in general and to his multiple
disabilities in particular could attract criticism that
the resource expenditure is not cost-e?ective. On the
other hand, not to admit such a patient is akin to his
outright condemnation to a relatively long, miserable
life, without giving him a chance to learn how to look
after himself as a paraplegic.
My opinion is that all patients have bene?ted not
only from the treatment o?ered by a specialist center,
but also from the intensive training, together with
some behavioral modi?cation, which instills in patients
the realization of the importance of self-care in a safe
environment, the risks of complications and how to
prevent them, as well as the importance of regular,
This training becomes particularly e?ective when
enhanced by the contribution from other patients with
similar disabilities. The newly injured patient learns at
least as much from the success, failure and the
teaching of a well matched experienced patient.
The realization of the importance of self-care and
follow-up is sometimes delayed. In some cases this
realization does not occur until after discharge and
when the patient starts to develop complications.
Although in the short term it may seem that this
patient has failed to bene?t from your center, there is
still a possibility he may accept your advice and
treatment at some time in the future. Furthermore, the
assessment of the potential of these patients prior to
admission to a center can be di?cult and misleading.
Having treated a number of such patients, I believe
it is still worthwhile for the majority of these
problematic individuals to be given the chance to
bene?t from a spinal injuries center.
A Kovindha, MD
It seems that there is still a chance to improve this
patient's functional level to household ambulator, with
only AFO and crutches, if he has an intensive physical
therapy program. Then he wouldn't need a
wheelchairaccessible house and would only use a wheelchair
According to his neurological level, like most such
patients he could do self-catheterization without
di?culty if we encourage him su?ciently.
I will not advise letting him live alone, even though
the psychologist con?rmed that he has no longer
suicidal ideas. Most psychiatric patients after suicidal
attempts and after becoming disabled improve, because
they receive more attention from the medical personnel
and their families. We should approach his family,
especially his mother, to accept him and also persuade
him to accept his family. Among Asian people, family
members are strong supporters of disabled relatives. His
mother probably isn't too old yet, still an active person
who can support him. I do not think that his girlfriend
will stay with him any longer. We have found that such
relations often end, but rarely that a wife left her
husband after he became disabled. In Thailand, we also
see many children (some are only 10 years old) help
look after their parents when they become disabled,
especially those of low socio-economic background. If
at the end, there is really no family support, I would
?nd a proper place which accepts disabled people. In
my country, there are homes for the disabled, some
belonging to the government and some to NGOs.
In Thailand we also have immigrants from our
neighboring countries, many illegal. We try our best to
rehabilitate them to their ultimate functional level.
Once they become more functional, we may persuade
them to learn some sheltered work in order to earn
their living. We should give them time and enough
People who attempt suicide always think their lives
have failed and they are useless. If we understand
them, we can help them. We have to be optimistic.
F Biering-Sorensen, MD
Spinal cord injury due to suicide attempts has
increased during the last decade.1 This has also been
shown to go hand in hand with unemployment, living
alone, previous admissions to psychiatric hospitals and
alcohol abuse.1 Kuhn et al.2 considered suicide
attempts to be a `cry for help'. Unfortunately the
situation of the patient often does not change after a
spinal cord injury3. It is of utmost importance that
these individuals receive adequate psychological or
psychiatric support during their initial hospitalization,
as well as during their follow-up.2,4
Regarding the lack of accessible housing in the area,
as well as the lack of social support from the local
community, one can only hope that direct negotiations
with the authorities will help. Otherwise, in the long
run, new legislation has to be implemented to make
sure that the various community services make these
things available in the future.
Regarding lack of family support and lack of
psychological support from the local community, it is
hard to ?nd a solution. This is probably a question of
changing attitudes in society in general. This is a
tremendous task faced by everyone working with the
If spinal cord injured persons cannot be persuaded
to get regular medical follow-up, at least we have to
inform them that if they develop problems related to
their condition they will be welcome at the center. We
cannot and should not force anyone to come to us.
Ethnic minorities will probably always ?nd
themselves less understood in whatever system they are
The question whether we should admit to spinal
units patients who, a priori, will not be fully integrated
into the mainstream of life is an interesting one. First of
all it can be di?cult to know in advance. During these
last years in di?erent countries we receive increasing
numbers of refugees or patients from other parts of the
world, for treatment and rehabilitation. It is generally
very di?cult to ?nd out how to rehabilitate these
patients, as many of them will not stay in our social
system afterwards. Rehabilitation is in part physical,
but also psycho-social, and in particular this
rehabilitation cannot be performed in an appropriate way if the
sta? is not familiar with the society into which the SCI
patient is going to be integrated afterwards.
Our patient su?ers from medical, psychological and
social handicaps. Although his rehabilitation program
was partially completed, we fear that despite our
constant e?orts his return to society may not succeed.5
He has not gained full bene?t from his stay at the
rehabilitation center and his future is uncertain.
All those consulted agreed that such a patient
should be admitted and thus exposed to the bene?ts of
a rehabilitation program. All stressed the importance
of trying to enlist the family's active support,6 while
also persuading the patient not to reject his family. All
agreed the patient should be reminded that the doors
of the rehabilitation center remain forever open to
These responses re?ect the humane, optimistic
attitude of those consulted, the essence of which is
that everyone is entitled to comprehensive
Our own experience with SCI after a suicide attempt
is not good.5,10 When feasible, the best solution in our
view is psychiatric hospitalization with a parallel day
care rehabilitation program. Strong support from
society's various services and agencies is mandatory,
otherwise such patients end up in chronic institutions.
We must do our best, although this may not be
enough in such cases.
1 Biering-Sorensen F , Pedersen W , Muller PG . Spinal cord injury due to suicide attempts . Paraplegia 1992 ; 30 : 139 ? 144 .
2 Kuhn W , Zach GA , Kochlin P , Urwyler A . Comparison of spinal cord injuries in females and males, 1979 ? 1981, Basel. Paraplegia 1983 ; 21 : 154 ? 160 .
3 DeVivo MJ et al. Cause of death for patients with spinal cord injuries . Arch Int Med 1989 ; 149 : 1761 ? 1766 .
4 Hartkopp A , Bronnum-Hansen H , Seidenschnur AM , BieringSorensen F. Survival and cause of death after traumatic spinal cord injury in long term epidemiological survey from Denmark . Spinal Cord 1997 ; 35 : 76 ? 85 .
5 Gur S , Ohry A , Heim M. Rehabilitation of SCIP with previous psychiatric disorders ? fact or ?ction? 5th European Regional Conference of `Rehabilitation International', Dublin, Ireland, May 20 ? 25 , 1990 .
6 Feigin R , Sherer M , Ohry A . Couples' adjustment to one partner's disability: the relationship between sense of coherence and adjustment . Soc Sci Med 1996 ; 43 : 163 ? 171 .
7 Ohry A. Ethical questions in the treatment of spinal cord injured patients . Paraplegia 1987 ; 25 : 293 ? 295 .
8 Rosman N , Ohry A , Rozin R. The social status of the treatment of spinal cord injured patients in Israel . Paraplegia 1982 ; 20 : 80 ? 84 .
9 Ohry A , Ring H . Rehabilitation medicine in Israel. Disabil Rehab 1997 ; 19 : 382 ? 384 .
10 Ohry A , Levy A . Injury proneness: the physiatrist's and psychiatrist's viewpoints . Harefuah 1991 ; 120 : 648 ? 650 .