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Physiatry provides patients a holistic rehab plan Discipline just catching up in region

A handbrake inactivated. The shaky leg of a chair. An unnoticed bump on the road. Trivial things, But how many times have such minor oversights cost people dearly.  Siddiq was cleaning his SUV on a pleasant weekend, two years ago. The vehicle was in neutral and the handbrake was not on. Gravity gained and pulled the car  down the incline, crushing Siddiq against a wall behind him.  His hip joint and leg were severely injured. Doctors informed him later that it could have been fatal had he taken the full force of the crushing weight on the middle of his body. He had to undergo several surgeries to gain back his ability to walk. Several months later, he could walk, but not without a stick and an awkward limp. It was to correct this awkwardness that Siddiq went to the Physical Medicine and Rehabilitation Center in Sulaibikhat, where the force of truth about man’s frailty hit him hard. He met patients who told stories of how a moment’s oversight or thoughtlessness flipped their lives, binding them to a wheelchair or bed.

The Physical Medicine and Rehabilitation Center deals with a branch of medicine called physiatry, which is a relatively new discipline. It aims to enhance and restore functional ability and quality of life to those with physical impairments or disabilities. Dr Unnikrishnan, a specialist at the center, says physiatry is just catching up in the region. Kuwait has the most advanced physiatry department in the Middle East.
Physiatry is also called rehabilitation medical specialty. Prior to this center, Kuwait had physiotherapy departments, which were primarily providing exercise regimes to patients.  Back then, there was no medical intervention in physiotherapy, which kept the possibility of complications open. For example, patients could develop spasticity.

Spasticity is a feature of altered skeletal muscle performance resulting in unusual tightness, stiffness, or pull of muscles, leading to abnormal body movements. It can be corrected through appropriate drugs. There’s no scope of correcting spasticity under physiotherapy as that branch of science does not contain medical interventions.  However, physiatry involves a big team of specialists from various specialties, including physiotherapy, who work together to provide the patient a holistic rehabilitation plan.
One of the patients Siddiq met at the center was in a vegetative state due to a spinal injury from a fall off a chair. He was changing a light bulb standing on it. It had a shaky leg that gave way.

Samar, an engineering student, met his fate precisely for the opposite reason to Siddiq’s. He cranked up the handbrake, but at the wrong time. He was having a joy ride in his new car, gifted for his birthday. As he whizzed through the road testing the car’s speed tolerance, his inquisitive right hand explored the car’s features. Lost in the thrill of the ride and in a moment of indiscretion, Samar yanked up the handbrake, banging his head into the wheel. He was in coma for three months. With the impact to his frontal lobes, Samar has lost his higher thinking skills. Even a task such as extracting a moral from a story is now impossible for him. This was an engineering student training in some of the highest forms of mathematical abstractions that a human brain can perform.

Samar can walk a bit, but is mostly restricted to a wheelchair, and barely manages basic life functions such as brushing his teeth and bathing.  The center in Sulaibhikhat focuses on training crippled patients to be independent. That’s the basic idea behind rehabilitation, says Dr Unnikrishnan. “Rehabilitation means to get the patient back to his or her previous functional level. It’s not always possible. The first task is to make the person mobile.” The success of physiatric intervention depends on a lot of factors such as the seriousness of the injury, the ability of the body to convalesce, the psychological state of the patient and support from family. In extreme cases, where the patient is paralyzed from neck down, there’s nothing much that a physiatrist can do.

Explaining the process, Dr Unnikrishnan says that when a patient arrives, “we make a plan considering the injuries and the condition of the patient. In some cases of head injuries, the patient shows unexpected recovery, and accordingly we alter our plans.” In addition to medical doctors, the physiatry team includes physiotherapists, occupational therapists, speech therapists and psychiatrists.

Work Site Accidents
Accidents happen at work sites due to inattention to safety regulations. An Indian electrician, 48, was sucked into a heavy machine when he inadvertently entered his hand into it. He suffered multiple fractures and was paralyzed from a spinal injury.  The tragedy gets worse when you are the breadwinner of the family, as it affects your dependents too. This electrician had college going-children, whose lives were shaken off course by the incident. Some local Indian associations came forward with financial support to help the distraught family, which offered some solace to their grief. From Dr Unnikrishnan’s point of view, the biggest challenge in physiatry is getting the patient to accept the fact that his life is never going to be the same again, and make him adapt to the new way of life.

Patients undergo a phase of denial as soon as they are confronted with the reality of their situation. They grapple with teleological questions such as “Why should I have this fate when I have done no harm to anybody?” Dr Unnikrishnan feels that this mindset does not help rehabilitation. “Denial makes recovery more difficult. In the West, the patients are told the prognosis on the very first day. The truth is broken quite bluntly.” However, culture and beliefs demand different approaches. In this part of the world, the news is broken in a more circumvent manner.

Faith in Miracles
Moreover, patients here, especially those from the subcontinent, have a tendency to pine for a miracle. While inexplicable recoveries do happen, these are extremely rare. In a big majority of cases, the initial prognosis gets borne out. One near miraculous recovery at the center was experienced by a patient who one day collapsed in his workplace. He was diagnosed as having Gillen Barre syndrome, which causes the weakening of the nervous system. He underwent treatment at the center for 9 months.  The prognosis in his case was that he would be incapacitated for the rest of his life as the disease was in an advanced stage. At the time of getting discharged, he had faintly gained some power in his hands. He was rolled out on a wheel chair. A year later, the patient came to the hospital to greet the doctors. He came walking. Prayers did the trick for him, he said.

Some people take risks bordering on insanity in a bid to economize effort. Attempts at crossing the ring roads are one such example. Aziz is an expatriate whose life literally hinges on a screw today.  He was hit by a car while trying to cut across the sixth ring road. Among the many bones that broke on that day was a cervical bone too. It’s technically called a c2 fracture, or a hangman’s fracture, because it’s the same bone that snaps when a person is hanged, and ricochets against the medulla oblongata, resulting in immediate death.  However, for Aziz the broken c2 just held on, and the expert surgeons at Al Razi Hospital performed a highly improbable surgery by inserting a screw into the neck to fix the bone in place. Given the extent of his injuries, Aziz made swift recovery and he left the center walking.
The best part of the recovery was the realization of the gross blunder in risking life to save a little energy. He had failed to judge the speed of the oncoming car, and fully owns the responsibility of the accident.

Lifestyle Diseases
For Dr Unnikrishnan, foolhardiness is not only about a moment’s oversight or thoughtlessness. Neglecting health falls in the same category. Hypertension is increasingly becoming common in the population, thanks to new lifestyles and food habits. However, many hypertensive patients are loath to taking medicines, because of their unfounded ideas about drugs. “Many think that medicines cause side effects, and look upon a lifelong dependence on drugs as a kind of enslavement.” The physiatrist dismisses such ideas as mindless because hypertension is a fluctuating phenomenon and sometimes it can shoot up to dangerous levels, resulting in paralysis.  What could have been prevented by popping a tablet into the mouth once a day, is allowed to grow to a point where the body’s functionality is lost.
In some communities, there’s a misplaced distrust for allopathic drugs, and an almost blind faith in traditional or alternative medicine, which are not always effective in controlling hypertension.

Similar is the case with diabetics. One reason for the procrastination of treatment by patients of these lifestyle diseases is that these diseases do not create any discomfort like pain. When blood sugar level shoots up, the patient suffers symptoms like frequent urination and tiredness, which are not taken too seriously. The center receives many hypertensive patients who have suffered stroke. This is quite common among people from low socio-economic strata. The middle-class is a little more aware on these health issues. The poor put off treatment to save money, or their work timings may not allow them to visit a doctor. Once a patient suffers stroke, yes, there’s a high chance of recovery. However, the same level of mobility as before can never be fully restored. This hits productivity. In some developing countries, patients who lose a part of their functionality are trained in some productive skills such as computers to help them earn a living.

All these complications are so easily preventable if only one takes that little extra care in diet and exercise. Avoiding exercise is another side of negligence. People often take refuge behind excuses such as lack of time to avoid exercising. We just need to give ourselves 20 to 30 minutes a day to live a healthy life, notes Dr Unnikrishnan. Strokes and heart attacks at a young age are getting more and more common. This is especially true of the subcontinent population. Studies have shown that people from the subcontinent have smaller blood vessels and they tend to be over stressed. Smaller blood vessels increase the risk of heart attacks. In Kuwait, a good part of the day is spent in climate-controlled indoor environment. Therefore, energy requirement is low. But intake of food is more. Next to cancer and road accidents, the biggest killer in the world is lifestyle diseases.

Psychology of Rehabilitation
Depression is an inevitable part of the rehabilitation process. When your life is suddenly turned upside down, and you begin to depend on others even for your basic needs such as going to the bathroom, it can have a big impact on your mind. At the Physical Medicine and Rehabilitation Center the patients are regularly talked to in a positive manner. “We discuss rehabilitation plans with the patient and engage them in the process. The family is also involved. The patient is gradually initiated into accepting the situation and adapt to a new reality.” The mental graph of a patient progresses from denial to depression and acceptance. The question is how quickly you move from one phase to the next.  Dr Unnikrishnan draws more support for the need for exercise highlighting the faster recovery of patients who were active in their lives.

People who exercise regularly develop collateral circulation in their systems and hearts. Exercise increases muscle mass. Heart is also a muscle. When the mass increases, the need for oxygen increases and in order to compensate our body generates new blood vessels. So, when there’s a block in one vessel there are alternate channels which soften the intensity of heart attack or stroke.
Studies show that among people who are active or those who regularly practice physical art forms like yoga or Thai Chi, the risk of fall in old age is very less.

Pressure Sores and Blood Clots
An attendant problem of patients who are bedridden or wheel chair bound is that of pressure sores. Usually, when we sit or lie down for a while, we shift positions as pressure builds up at a spot.  However, patients who have lost sensation don’t perceive the pressure. This causes pressure sores, and can get worse when the patients are moved or dragged upon these sores, causing shears.  When there’s pressure, blood circulation goes down in that part of the body. For a sensate person, the body notifies him by way of discomfort and he shifts body weight almost as a natural reflex.  The center trains patients in wheelchairs to regularly adjust their sitting posture by heaving their body up using their hands. Blood clots can also occur as a result of prolonged inactivity. Blood clots in the veins can be very dangerous as they can travel up to the heart and block blood supply to the lungs, causing breathing difficulty.

The center had given an appointment to a leg-fracture patient. When his time was due, the center found that he was admitted in Jahra Hospital for a blood clot block in the heart. The patient had been so inactive in his wheelchair that a blood clot had formed which traveled up to his heart. This is another kind of oversight that patients pay dearly for. Patients must apply whatever little mobility they have to move their limbs to prevent blood clots. The good thing about pressure sores is that it first affects the skin, manifesting itself as discoloration. If unattended, and the patient continues to apply pressure on the same area, it progresses to the second and third grades, when the injury reaches the bone.

By Valiya S. Sajjad
Arab Times Staff

By: Dr Unnikrishnan

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