"You can't teach an old dog new tricks..." (Elise)

I have heard this saying many times before: “You can’t teach an old dog new tricks.” Often it was used in response to trying to ask an older adult to try a different method/technology to complete a task, such as using a remote control for the television or trying to make phone calls on a cellular phone. The saying suggests that an older person who has a technique for doing something may either find it too difficult to learn something new or is not interested in trying a different way. Research shows that this is quite false—the brain is capable of learning new things regardless of age (or even certain injuries) due to neuroplasticity, which is the brain’s ability to generate new pathways or re-distribute neurons (cells) to perform functional or cognitive tasks.

This quote came to mind this week as I worked with some of my patients on the pressure ulcer management service. Patients who have been injured for many years are very different in therapy from those with new injuries. You might think this is a pretty obvious statement. As a physical therapist, it’s been interesting for me to try to define my role with the new patient population I am working with. For the past 2 years, I have been working with individuals who sustained a spinal cord injury recently. In fact, very recently—anywhere from 2 weeks ago to a few months prior depending on the severity of the injury and the number of medical complications during their acute care stay. I was almost shocked this week when I interviewed some of my patients on the pressure ulcer management service. The three main people I worked with this week have been living with a spinal cord injury for between 25-40 years! That’s quite a change! When I spoke to my patients regarding equipment preferences, transfer techniques, and pressure relief methods, they were quick to inform me about their routine and hesitant to listen to my suggestions for alternatives.

I am learning a lot about maintaining patient-centered care and compromise. During a seating evaluation with one of my clients, we discussed the need for a new power wheelchair. His old chair was completely worn down due to his living environment: daily navigation of rugged, unpaved, and hilly terrain on his ranch. In no time, he stated the name, make, and model of the rear-wheel drive power wheelchair he wanted. This was a surprised to me! I was so accustomed to my clients with “newer” injuries choosing the mid-wheel drive power wheelchair design; the positives of these chairs (in my mind) seemed to completely outnumber those of a rear-wheel drive chair. For example: the smaller turning radius and better suspension provide a smooth and more accessible model. My client would not budge. He was comfortable in how the rear-wheel drive maneuvered, familiar with accessing home and community environments in it, and had no desire to order a chair that was completely new and different. It makes sense to me now, especially knowing he had been in the other chair for 11 years!

Even if his choice was not “justified”, a patient-centered therapist will always allow the patient to make the ultimate decision regarding their care. Certainly, we can provide education regarding other equipment options, access to trial equipment for demonstration, and even suggest a network of current equipment users to contact. It is important to remember that our clients are the ones who will be using the equipment every day and have an extensive knowledge of their own body and living environments. I am looking forward to learning many things from my new patients, as their “injury age” provides them with a certain wisdom that I could not possess. I am certain that information and experience I gain will only help me to better serve and work with individuals who sustain spinal cord injuries at all aspects of the acuity continuum (acute à chronic).

Switching It Up (Elise)

One of the great things about being a PT is the many different patient populations we can work with and many different environmental settings (home, hospital, outpatient, nursing home). I find it a challenging and stimulating part of my job that I can be exposed to different patient diagnoses. Next week I'm moving to a new service at the hospital. Although I'll still be working with individuals post-SCI, my new caseload will include many other diagnoses including congenital diseases (spina bifida, cerebral palsy), multiple sclerosis, etc. I'm going to be the PT on the Pressure Ulcer Management Service.

Pressure ulcers are a serious issue. In addition to the above diagnoses, older adults are very susceptible to skin problems as a result of normal aging. The combination of thin skin (more prone to damage), low body weight (less cushion over the bones), decreased nutrition (poor nourishment to skin), less movement during sleep, and slower skin repair (by cells if skin is broken) places older adults at increased risk for pressure ulcers. Furthermore, diabetes and vascular diseases (common in older adults) decrease the blood supply to the skin placing it at high risk for damage. Finally, decreased mental capacity/dementia can make an older person unable to consider or perform preventative measures against pressure ulcers.

A pressure sore does not just occur out of "thin air"; it is generally preceded by illness or disease associated with weakness and debility requiring significant time spent in bed or in a wheelchair. If a person is unable to move around to shift their weight, or is not regularly turned in bed, excessive pressure on the skin over bony areas causes decreased circulation to that area and eventually skin breakdown. Pressure alone is not the only cause of sores; incontinence, shearing or friction (i.e. during transfers) are also common contributors. Some important means of prevention include: turning at night every 2 hours, performing regular pressure relief/weight shifting in wheelchair every hour, maintaining equipment (wheelchair cushions), keeping good hygiene, and eating a well-balanced diet. We stress these means of prevention with all of our newly spinal cord injured patients, and to individuals who are weak/debilitated at the hospital.

Pressure sores are graded on a scale from Stage I to Stage IV (most severe). I will be working with individuals whose sores have progressed to Stage III or IV; this means that the skin has been broken and the wound is very deep-- to the muscle or even the bone. After debridement of the wound (surgical cleaning) and/or "Flap Surgery" (which "transplants" a muscle from the lower leg over the existing wound), the patients require an extensive hospital stay. During the course of their stay, my role is to re-evaluate their current equipment (wheelchair, cushion, etc.) to ensure that it does not contribute to future sores. I can use a specialized computer system (Pressure Mapping System) to measure the pressure underneath each of the sitting bones of the pelvis. By placing a mat underneath the patient while they are seated on the cushion, I can immediately visualize on a computer the pressure differentials on the cushion to determine if it is the best option for the patient. [If you're interested in learning more about pressure mapping, check out: http://www.xsensor.com/medical-video.php. This is just one of many companies that have mapping systems available.] After I perform mapping, I can order a new cushion or modify their existing cushion. In addition, I will assess their current wheelchair for any repairs or changes that might decrease their seated pressures.

I'll be updating you on my switch to this new patient care area- and the great things I am learning and the challenges I am facing!

The Effect of Age on Adjustment to Injury (Elise)

I have been thinking a lot this week about how age can affect one's adjustment to injury. On the spinal cord injury (SCI) service, I work with individuals of all ages who are dealing with a tremendous loss of function and independence. Lately, I've observed a difference in how patients react to the changes in their bodies and in their lives.

In general, I feel like many of my young patients seem to more visibly/verbally express their emotions/feelings about the changes in their body. One patient in particular said, "I've barely even had a life. I was just starting to get out on my own and be my own person. Then this happened." A common theme with younger adults is how "unfair" the injury and situation is. In contrast, my older patients have more rarely expressed anger or denial in regard to their change in status. They seem to be more quiet in dealing with their body changes... and more accepting. Maybe they think that there were going to be changes to their body with aging anyway? Maybe it helps that most of the older patients are married, have had children (currently living at home or grown), worked a job, and got to see some of the world? Maybe they have more psychological resources to overcome life challenges because they have experienced more?

I decided to look to the literature this week to see what affect age has on adjustment post-injury. The literature does not support my hypothesis. A study by Krause et al. that examined adjustment over the course of 30 years post-injury showed that spinal cord injuries which occurred later in life resulted in an individual being more likely to have lower subjective well-being, poorer health, and a less active lifestyle. Dorsett et al. indicated that the two most significant factors leading to depression after SCI are 1) self-rated adjustment; 2) medical complications (pressure sores). Older adults are at higher risk for developing post-injury complications due to the aging nature of their systems: ex) less resistance of skin, less reserve in cardiac system, etc). Varma et al. showed that because older adults have more pre-existing conditions (ie. cardiac disease, diabetes, joint deterioration), their adjustment was less post-injury compared to younger individuals. It makes sense... but I was still surprised!

Certainly a number of factors affect an individual's response to injury: social support, educational level, employment history, financial resources, pre-morbid health, and prior coping methods (to name a few). The nature of the injury is also an important consideration: Was it a traumatic or gradual/degenerative? Was it violence-related, sport-related, or employment related? Over my years in working with individuals with SCI, I've come to realize that personality and outlook on life are probably the most crucial traits to adjustment post injury. Someone who can face adversity, have the motivation and desire to overcome many obstacles, have the willpower to set high goals, and to find positive in most situations-- they are the ones most likely to thrive post-injury. So maybe age doesn't matter that much after all...