Archive for October, 2012

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A Tribute to Dr. Guttmann

October 20, 2012

Ludwig Guttmann was born in Germany in 1899 and met his first spinal injury patient in 1917 while working at the Hospital in Konigshutte. A coal miner had broken his back in an accident in the mine. As was generally the case at the time, the miner died five weeks later from sepsis. By 1933 Dr. Guttmann was considered the top neurosurgeon in Germany, but with the arrival of the Nazis in power, he was consigned to working at the Jewish hospital in Breslau. Being a Jew himself he was not allowed to practice medicine professionally. In early 1939 he managed to leave Germany with his wife and children and came to England as a refugee, where he soon resumed his career as a doctor, specialising in neurosurgery.

In September 1943 the British Government asked Dr. Guttmann to establish the National Spinal Injuries Centre at Stoke Mandeville Hospital in Buckinghamshire. There were many soldiers wounded with spinal injuries and Guttmann believed that he could help them survive such injuries and go on to live fulfilling lives. Until Dr. Guttmann began this work, spinally injured patients tended to live for only about six months before dying, either from urinary tract infection or from septicaemia as a result of pressure sores. It wasn’t so much neurosurgery as the improvements he made in the nursing skills that enabled patients to survive, but surviving is only half the battle. The real challenge is to find a way of living following a spinal injury and this is where his rehabilitation strategy came into play.

Dr. Guttmann used sport as a way of motivating people to carry on with life as a wheelchair user. Sport, or games, not only provided for exercise, but more importantly for social engagement. Partaking in not just activity, but physical activity, enabled people to realise that there could be life after spinal injury. On the same day that the Olympics started in London in 1948, the first Stoke Mandeville Games were held. The Games became an annual event and soon an international event. They then evolved to become the Paralympics which was initially the Paraplegic Olympics and only later grew to encompass all types of disability.

Nearly seventy years after survival with spinal injury became a real possibility, very little has changed. The nursing skills have continued to improve and it is no longer just the paraplegics that can be saved, but also tetraplegics with neck breaks and even those with such a severe spinal injury that they cannot breath unaided and require the constant support of a breathing machine. However, the rehabilitation strategy has stayed exactly the same, being based upon conscious muscular effort to achieve limited mobility as a wheelchair user, with encouragement to take up sport figuring strongly. The question is, did Dr. Guttmann have it so right in his rehabilitation strategy that it is still the best way forward today or are we stuck in the past and failing to move on from the good work that Guttmann started.

When I broke my back, sixteen years ago, I knew no other approach than to achieve what I could through my own conscious muscular effort and this was the approach promoted within the physiotherapy gym in the spinal unit. At the back of my mind I never gave up hope of recovering from the injury, but it was always drummed into you that you had to accept that paralysis was permanent and had to learn to live with the bodily function you were left with. So this is what I did and after seven months I left hospital and did my best to embrace life as a paraplegic. I’m sure that people in spinal units this summer will have been inspired by the paralympics, but for me it was posters of paraplegics skiing and climbing hills that inspired me. A charity called Back Up, started by a skier who broke his back, organise outward bound events for the spinally injured and three months after leaving hospital I was in the Lake District on an adventure holiday with Back Up. We climbed a hill, canoed, sailed, camped, abseiled, rode a horse and had a fantastic time. There seemed no better way of realising what could be achieved as a paraplegic.

There’s more to life than holidays, but nonetheless I continued to pursue the active outdoor life, trekking around with dogs, climbing hills, rafting down rivers and camping out. This may not have been games or paralympics, but it was the social sporting activity that Dr. Guttmann advocated and it was giving me a life worth living. However, there is only so much you can push yourself to physically achieve as a paraplegic without further affecting your state of health. The reality is that all paraplegics are terribly badly damaged and live in bodies that lack the ability to function properly in the sense of physical activity. My dog can live with three legs, but no animal could live as a paraplegic. Only a human can do so because only a human can use his mind to compensate for lack of physical ability, but there is a price to pay for this. As paraplegics we have to cheat our own bodies in order to undertake all aspects of our physical lives. In gentle day to day living this does not present too much of a problem, but the more we excel in physical activity, the more we compound the problems and further heighten the disability.

It wasn’t long before I realised that active exercise, particularly anything competitive, was not the way to conquer spinal injury. A certain amount of activity is necessary to maintain a degree of strength and function, but I learnt that the art of living with disability is to always be kind to the body and to learn to do things in ways that puts the least stress upon it. I have actually always lived an active outdoor life, but more and more became extremely careful not to use my body beyond its limits. It wasn’t until I met Leonid Blyum and became involved in Advanced Bio-Mechanical Rehabilitation that I found the path that needed to be trod in order to conquer spinal injury. The body is so depleted in quality by a spinal injury that it is impossible to recover through conscious effort, but through the techniques of ABR Therapy it is possible to deliver a mechanical input into the body, by hand, to slowly but surely rebuild the damaged structure. Something that I have been doing for the last eleven years with a great deal of success in making substantial progress towards conquering spinal injury.

There may be those that curse Dr. Guttmann for ensuring that people survived following a spinal injury, but personally I thank him and believe that he undertook enormously important work in the progress of mankind’s evolution. However, if we are to honour Dr. Ludwig Guttmann we must not think that the future of spinal injury rehabilitation ends with his work and we must always strive to find a way of improving the lot of the spinally injured. Guttmann showed it was possible to survive a spinal injury and helped people to find a life through sport. Now we must take this further and learn to instil true health back into para and tetraplegics. I hope that I can do something to show the way.

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Legless Lenny

October 10, 2012

Two weeks ago my beautiful young lurcher dog broke his back leg running through the woods. Just how he did it I don’t know, but he emerged from the woods holding his left back leg up with it swinging slightly. I knew then that it wasn’t good. He’d either dislocated his hip or broken his leg high up. I sat on the ground and proceeded to examine him. I checked his toes, the bones in his foot, his ankle joint, his knee, his hip and finally his thigh bone (femur). I held either end of this bone and immediately felt that it was broken in two. It was obvious that this was very serious. Such a break is difficult to mend in a human and often requires weeks of traction; something that is out of the question with a dog who does not have the capacity to deal with incapacity. After consulting the vet who was adamant that strapping the leg to the body would not work, there were only two options. To pin or plate the bone which would require a prolonged period of healing with no guarantee of great success and may leave the dog with a gammy leg, or to amputate the leg. The cost alone of an operation to try and save the leg prohibited that path, so unless I put the dog to sleep, which I did consider, the only thing to do was to amputate. He had his leg removed the following day and came home.

Lenny the Lurcher

There are aspects of this affair that I would like to explore here. Firstly there is the life and well being of the animal. As a dog owner it is always difficult to know what to do for the best. We are responsible for the animal and have a duty to do right by them, but there is no definitive right or wrong. With humans there is the Hippocratic Oath to preserve life at almost any cost, but with animals there always comes a point when it is fairer to end their life than to preserve it and we do at times have a duty to kill the animal. Even if money was no option, an operation to save the leg may not have been the best way forward. An animal is a conscious creature, but only a human is conscious of his own consciousness. A human will accept the trauma of the moment knowing there is light at the end of the tunnel, but an animal cannot see what the future may bring and lives in the moment, knowing only the pain and suffering that the long recovery from such an operation entails. With an amputation the healing is quick and the dog can get on with life, albeit with three legs. After two weeks, the extensive bruising is gone, the tenderness is gone, the join in the skin is well healed and the fur is growing back. I hope I made the right decision.

I have seen a number of dogs over the years with only three legs and have often thought that I would not allow a dog of mine to live in such a condition. Front legs are more important to the mobility of a dog than back legs and had it been a front leg that couldn’t be saved then I would have put him to sleep. Had it been my husky and not my lurcher that broke her leg then I would have had her put to sleep, but a lurcher is a very different dog. My first dogs were Border Collies (sheepdogs) and the bond you have with such a dog is through their ‘subservience’. That in a way is the middle ground, while a husky is one end of the spectrum. Of all the dogs I have known, a husky is the closest to their wild cousin, the wolf, and the bond I have with her comes from her true pack nature. It is a relationship built upon respect rather than subservience and although it is possibly the strongest bond I have ever had with a dog, the animal is somehow distant and aloof. The gentle nature of my lurcher is the opposite end of the spectrum. The bond with him is through his ‘insecurity’. This dog is closer to my heart than a dog has ever been; not out of favouritism, but because of the nature of the bond. His insecurity brings him in close. A three legged husky would be a burden to herself and to me, but my lurcher can continue to be the dog he has always been to me. He will always be close to my heart and will serve me well with three legs.

Now we come to the dogs ability to cope physically with his loss. A heavy blundering dog would not deal well with the loss of a limb, but a light agile lurcher is ideally suited to coping with three legs. We were only a hundred yards from home when the accident happened, but he walked home with a broken leg even if he was very slow. He walked out of the vets following the operation and has got on with life ever since. To start with he wanted to act on my every move, as before, but each time he got up to follow me he suddenly realised he couldn’t walk properly. He was also nursing a extremely swollen and bruised stump which didn’t make it easy to adapt to the loss of a limb. The twist in his spine as he tried to position his only back leg to support him, while walking, was severe and I began to question what I was putting him through. After a week he appeared to become resigned to his condition and began to decline to follow me. He would come outside but then wanted to lie down more than go anywhere. He was showing sense and self preservation, but at the same time I couldn’t let him give up and I encouraged a sensible amount of activity each day. Now after two weeks his spirits are starting to lift again and he’s moving around with greater ease.

It’s interesting how a dog adapts to the loss of a limb. A dog has three basic gaits, walk, trot and gallop. He has not got back into running at full gallop just yet, but I have seen a similar type of dog, with three legs, run so fast that it was not obvious that the dog had anything wrong with it. Funnily enough, the faster a dog runs the less a missing back leg matters. It is while walking that the disability is most obvious. When a dog walks they move one foot at a time, leaving three feet on the ground at any one time, so always providing a tripod of support. With a missing back leg the dog has to alter the process of walking. He can quite easily balance on one front and one back leg, so moving the front legs is not a problem. However, moving the back leg leaves him only the two front legs to balance on which is not really feasible so he has to make a definite hop. The centre of gravity in a dog is always nearer to the front legs than the back and so there is always more weight taken through the front feet. In order to make it easer to facilitate the necessary hop, the dog extends and lowers his head to bring the centre of gravity even further forward, lessening the weight through the back foot and making that hop as easy as possible, while producing a walking motion where the head bobs up and down. I have read that in walking only 40% of the energy required for movement is provided by muscular action and the remaining 60% is ascribed to the conservation of energy of the body pendulum. Unfortunately, this body pendulum effect will no longer work so efficiently and it is quite obvious that it is taking more muscular action to move the back leg. To start with the bobbing of the head and the positive hop looked very awkward, but he is soon getting the hang of it and his walking motion is rapidly smoothing out and now with only negligible twist in the spine.

Once he speeds up he breaks into a trot. My husky has a pace gait rather than a trot with lateral pairs of legs (front and back leg on the same side) moving together, but the lurcher trots with diagonal pairs of legs moving together. Obviously he only has one diagonal pair left, so he trots by moving the front right leg on its own followed by the front left and back right leg together. The extending and lowering of the head to move the centre of gravity forward is less pronounced in trot and instead the dog seems to compensate by taking greater advantage of the elastic energy stored in the legs with this gait. There is much more of a spring in his step and he uses this to create a higher vertical movement of the pelvis so that it takes longer for his rear end to fall back down and in so doing he misses out the step that should have been taken by the other back leg. This will inevitably put greater stress on the remaining back leg, but there is little weight to his back end and hopefully this will not trouble him. Already he is trotting at much the same speed as before and although there will always be that higher lift of the pelvis he is achieving a very smooth action that remarkably appears to take little extra effort than when he had four legs.

I hope that as he continues to settle into his new found way of being, he will, in his own good time, run once again in a gallop. In this gait both front legs move together followed by the back legs and the whole body is incorporated in the motion. Often one leg in each pair is slightly in front of the other, but even so, the missing back leg should make little difference to his ability to run. The remaining back leg will strengthen to compensate.

When I see him running flat out across the fields and tussling with my husky, then I will no for sure that I made the right call.