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Aging with spinal cord injury.

THE PROCESS OF AGING

Aging is characterized by physical, psychological, and social changes. The physical changes consist of a gradual decline in functioning of some organ systems, maturation of other systems, and altered susceptibility to certain diseases.

There is tremendous variability in the rate and pattern of age-related functional changes, so that aging occurs at different rates and in different ways for different individuals. Thus, a large proportion of older adults enjoy good health into their later years, while others may suffer the adverse effects of some minor or major physical changes.

Some of these age-related physiological alterations may be more prominent in individuals who have spinal cord injuries. This occurs because of the types of organic changes that accompany spiral cord injury (SCI) and the degree of physical stress placed on the body by the performance of activities of daily living (ADL).

Unfortunately, to date there have been few formal studies on the subject of aging with a spinal cord injury. Thus, there is little objective data, but much speculation, on the types and magnitude of the physical changes in aging SCI people. Fortunately, there has been a recent growing interest in studying and documenting the physical changes of aging among SCI individuals, and a number of studies are currently underway to investigate these changes.

CAUSES OF DEATH IN SCI

One way to learn about the problems experienced by SCI people as they grow older is to study the causes of death. Historically, progressive kidney disease resulting from chronic urinary retention and infections was by far the major cause of death in SCI patients. However, improved methods of bladder drainage, quicker attention to treating urinary problems, and stricter monitoring of kidney function in long-term SCI patients have contributed to a marked reduction in the incidence of kidney disease. In fact, the National SCI Database recently reported that only 3% of deaths in SCI patients were from urinary-tract disorders.

At present, pulmonary diseases are considered the biggest cause of death (21%) among SCI people. These problems, primarily pneumonias, probably arise from a decrease in the ability of aging SCI patients to cough and clear secretions from the respiratory tract. In addition, heart disease, cancer, stroke, and other common diseases of aging are increasing in frequency as causes of death. As SCI people are living longer, they are subject to the same types of illnesses to which others are prone as they age.

INTERNAL ORGAN SYSTEM CHANGES

In SCI patients, changes in the structure and function of the internal organs (such as the heart, lungs, kidneys, and gastrointestinal tract) most likely parallel those of non-SCI people. The progressive decline in function may be made more rapid and obvious in those with SCI, however, because of their particular problems.

For example, kidney function has shown a slow but steady decline in both non-SCI and SCI individuals. Although the kidneys can withstand a large amount of change before there are enough problems to cause complete failure, persistent problems related to emptying the urinary tract may pose a big enough burden on the kidneys to more rapidly impair function in SCI than in non-SCI people.

The same may be true for bowel functioning, where both SCI and non-SCI may experience difficulty as they age. However, the frequency with which these problems are faced by SCI patients throughout their lives makes them more likely to have age-related bowel disorders earlier--and more often.

Likewise, the heart of people with SCI may be placed under considerable stress because of their need to perform difficult upper-body exercises to carry out daily living skills, such as transfers and pressure reliefs, all of which may tax the cardiovascular system. Further, the respiratory system is known to be impaired because of decreased ability of its muscles to allow air to move in and out of the lungs.

Despite a large body of knowledge regarding the early changes in breathing ability of SCI patients (there is short-term improvement during the first year), there is virtually no information on the longterm changes. This is important, because there are age-related changes in the lungs of non-SCI individuals. A study of the subject is currently in progress at the Midwest Regional SCI Care System, Rehabilitation Institute of Chicago.

NEUROMUSCULOSKELETAL CHANGES

A considerable amount of recent interest has been directed toward studying pain and other musculosketal problems of long-term SCI patients. One of the most common conditions is a persistent dull and achy shoulder pain. This probably occurs because of the repeated stresses and strains placed on their shoulders and arms as they perform routine activities: push-up pressure reliefs, pushing the wheelchair, and transferring. These are activities that the arm is not best suited to perform; thus it is not surprising that commonly reported conditions such as pain, dislocation, tendinitis, and others were seen in 51% of long-term SCI patients in one study. Another study found that arm pain was present in 52% of patients in the first five years after injury, in 62% at ten years, in 72% at 15 years, and in 100% at 20 years.

Another frequently seen problem in long-term SCI patients is carpal tunnel syndrome. In this condition, a nerve (the median nerve) that supplies the hand is repeatedly compressed at the wrist, resulting in hand pain. This probably occurs because of repeated trauma to the hand and wrist with transfers and wheelchair propulsion. One study found incidence rates of this syndrome were 0% at one year after injury, 30% at 1-10 years, 54% at 11-30 years, and 90% at 31 or more years.

An additional problem in people with SCI is that of syringomyelia, the development of a cyst in the spinal cord around the level of injury. This can cause pain and loss of motor or sensory function. It occurs in about 5% of SCI patients and is seen in both long-term and recently injured SCI individuals. It is not known if syringomyelia is affected by aging.

AGING IN PERSPECTIVE

It is important to recognize the variability and unpredictable nature of the aging process for SCI and non-SCI individuals alike. For many people, sufficient reserves in their system allow tolerance of some of these physiological changes of aging without hampering daily functioning or impairing their quality of life. On the other hand, some SCI patients might note a gradual and progressive decline in function. Awareness of the potential for these changes allows successful implementation of both disease prevention and health-promotion methods as means of reducing the impact of age in daily functioning.

IMPROVING WITH TIME

Although paraplegic for 62 years, 75-year-old George Thomas is still very much young at heart. His life story reads like the old adage he firmly believes: "You'll never know unless you try!"

Born in Butte, MT, in 1916, Thomas was injured at age 13 while hunting, when a stray bullet severed his spinal cord. He wasn't given much of a chance to survive--no one with such an injury was, at that time. But his parents didn't give up, his four older brothers didn't give up, and Thomas himself certainly didn't give up.

What was rehabilitation like back then? "Rehab? What's that?" snorts Thomas. His family cared for him, physically and mentally. His mother saw to his physical needs, and his father exercised the boy's legs. His first wheelchair was an old wood-and-wicker model sold by Montgomery Ward. "After the first year or so, I was out of that chair more than I was in it," he says. "I lay on the floor on my stomach a lot."

There were no easy ways to do necessary things--things we take for granted. Thomas attended a three-story high school in Missoula, MT where his classmates carried him and his wheelchair from floor to floor. Years later, when he learned to drive, his first hand controls were made by blacksmith.

"If you really concentrate, you can do an awful lot," says Thomas. And, true to his belief, he started "doing." After graduation from high school, he began working as an apprentice dental technician, for the astronomical salary of $ 5 per week. By the time he married in 1939, that sum had grown to a whopping $27 per week, which, according to Thomas, "wasn't really that bad for those times."

During World War II, Thomas and his brother headed farther west to try their luck in Seattle, which was booming with wartime industry. The brothers started a dental lab. Over the years, Thomas had problems from sitting long hours at the laboratory. He therefore resorted to lying on his stomach at home. His brother would bring work from the lab and Thomas would do it at home. "When you're in business for yourself," says Thomas, "there's no one else to do it." Their teamwork grew into a successful business that was located in the same spot for 31 years.

Life's path has taken many turns for George Thomas. Along the way from those early days in Butte, he also fathered four children, dabbled in real estate, and became a pilot. At age 46 he was a member of the Seattle Flyers wheelchair basketball team, where he was known to his teammates as "Dad."

The grandfather of seven attributes his long survivial to physical activity. "I just don't understand why paras stay in their chairs all the time," Thomas says. "I'm a firm believer in getting out of my wheelchair and letting my blood circulate!" His van does not have a lift--he claims he needs the workout of getting in and out of the vehicle.

Thomas and his wife now live in the Seattle area in the summer and in Mesa, AZ, during the winter months, In 1990 he bought a clinical chair that would help exercise his legs. He had several suggestions to modify it for better use by paras, so he contacted DynaFlex Inc., of Tennessee, manufacturer of RomFlex Rehabilitation Systems. They liked what they heard, flew him to the home office, and ultimately followed his advice, designing an "easy" chair for home use.

Thomas advocates the therapy concept of continuous passive motion (CPM), which reportedly has beenused successfully in the treatment of recuperation from surgery, chronic low-back pain, stroke, multiple sclerosis, and paraplegia, among others. The philosophy promotes movement and exercise of the body, rather than immobilization.

The Thomas/RomFlex equipment performs the exercise, so there is no manual muscle activity. "When I'm really tired," says Thomas, "I get into my chair and let it exercise me. It's so relaxing that sometimes I spend the entire evening there--exercising all the while. It's like having a massage." AS he gets older and is not so strong as in his youth, Thomas says the chair is a boon for continued exercise for his legs, buttocks, and back muscles.

In the past, says Thomas, he has had his share of urinary infections, pressure sores, and the other medical complications so common to wheelchair users. However, he has learned to deal with such problems and has beaten the odds given for his survival those many years ago. Mike Coleman, of RomFlex, says Thomas is the longest-injured para they know about.

After 62 years in a chair, what's next for George Thomas? We won't know until he tries!

Editor's note: Dr. Elliott J. Roth is affiliated with the Department of Physical Medicine and Rehabilitation, Northwestern University Medical School, and Midwest Regional Spinal Cord Injury Care System, Rehabilitation Institute of Chicago.

REFERENCES

Devivo, M.J. "Life Expectancy and Causes of Death for Persons With Spinal Cord Injuries." Apple, D. F., and L. M. Hudson. Spinal Cord Injury: The Model. Washington, DC: NIDRR, 1989.

Geisler, W., et al. "Survival in Traumatic Spinal Cord Injury." Paraplegia, 21:364-373, 1983.

Gellman, H., et al. "Carpal Tunnel Syndrome in Paraplegic Patients." Bone, J. Joint Surgery, 74:517-519, 1988.

Menter, R. R. "Aging and Spinal Cord Injury: Implications for Existing Model Systems and Future Federal, State, and Local Health Care Policy." Apple, D. F., and L. M. Hudson. Spinal Cord Injury: The Model. Washington, DC: NIDRR, 1989.

Nichols, P.J.R., et al. "Wheelchair User's Shoulder? Shoulder Pain in Patients With Spinal Cord Lesions." Scand, J., Rehabilitation Medicine, 11:29-32, 1979.

Rossier, A. B., et al. "Posttraumatic Cervical Syringomyelia: Incidence, Clinical Presentation, Electrophysiological Studies, Surinx Protein and Results of Conservative and Operative Treatment." Brain, 108:439-461, 1985.

Roth, E. J. "The Aging Process: Physiological Changes." Psychological Aspects of Geriatric Rehabilitation., ed. R. Hartke. Rockville, MD: Aspen Publishers, 1991.

Roth, E.J. "Pain in Spinal Cord Injury." Spinal Cord Injury, ed. G. M. Yarkony. Rockville, MD: Aspen Publishers, 1991.

Trieschmann, R. B. Aging With a Disability. NY: Demos Publications, 1987.
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Author:Roth, Elliot J.
Publication:PN - Paraplegia News
Date:Apr 1, 1991
Words:2101
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