Interdisciplinary management of individuals with SCI

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Introduction

Cohen and Mohrman define a team as”a group of individuals who work together to produce products or deliver services for which they are mutually accountable”. [1] The shared goals of the team are made manifest by mutual and cordial interaction by team members, and the roles of each professional in the team are mutually interdependent and accountable to enable achievement of set goals. Similarly, Eduardo Salas defines a team as a “distinguishable set of two or more people who interact dynamically, interdependently, and adaptively toward a common and valued goal, objective or mission, who have been each assigned specific roles or functions to perform, and who have a limited life-span of membership.” [2][3] Basically a team consists of a group of people with complementary skills who are committed to a common purpose, performance goals, and approach, for which they hold themselves mutually accountable.

"The premise underlying team care always has been that assorted professionals, each contributing their own discipline's expertise and closely cooperating through oral (team rounds, informal hallway discussions etc.) and written communication (medical record entries, reports etc.) are able to achieve outcomes that are superior to those of a lone clinician, or of a number of different clinicians each practicing independently of all others." [4] Reliance on multifaceted team-based care enables an evolving health care system to address the changing patient needs with regard to physical, psychological, and social aspects of health. Successful management of Spinal Cord Injury requires a team approach  It is generally considered to be best practice for individuals with a spinal cord injury to be treated by a specialist team, with specific training and in a dedicated spinal cord injury clinic or rehabilitation centre. [3]

Types of Teams

The terms “multidisciplinary,” “interdisciplinary,” and “transdisciplinary” are increasingly being used interchangeably to define health and social care teams and outline the various degrees of involvement of the multiple disciplines within the team environment, but there are clear difference between these different approaches to care. [5][6][7]

Multidisciplinary

According to Jefferies & Chan (2004), multidisciplinary team working is described as the main mechanism to ensure truly holistic care for patients and a seamless service for patients throughout their disease trajectory and across the boundaries of primary, secondary and tertiary care. The Multidisciplinary Team (MDT) is a team of professionals that includes representatives of different disciplines e.g. Physiotherapy, Occupational Therapy etc., who coordinate the contribution of each discipline with little overlap to assess and treat the patient separately with discipline specific goals. There are different definitions and descriptions which capture important features of multidisciplinary work. Each discipline could function autonomously, working in parallel towards a shared goal; acknowledging one other’s contributions and sharing successes. [8] The patient’s progress within each discipline is communicated through written documentation and regular team meetings and as such does not emphasize an integrated approach to care. This type of team approach is predominantly what we see in an acute hospital setting. [3][5]

  • Each discipline works in parallel with clearly defined roles with the team
  • Each discipline sets their own individual, specific goals with the patient and communicates these goals and outcomes with the team through written documentation or within team meetings where appropriate 
  • In most cases the team is Consultant / Physician led 

Interdisciplinary

Interdisciplinary teams differ from multidisciplinary teams in that they overlap practice with shared goals coordinated into a unified management plan, rather than working individually, allowing for group decision making and group responsibility, with the patient considered an active member of the team. Each team member in an interdisciplinary team build on each other’s expertise to achieve the common, shared goals. Patient progress is communicated through written documentation and regular team meetings as in the multidisciplinary approach but reports tend to focus more on the common overall patient goals rather than on discipline specific goals. [3][4] According to Fergusson (2014) an interdisciplinary care plan generally is developed by cosidering the following questions:what are the issues, who will be involved, what will the interventions be, what are the goals of the intervention, and when will re-evaluation occur? [5] The interdisciplinary team is very common in inpatient spinal cord injury rehabilitation centers. Interdisciplinary teams involve: [3][4][9][10]

  • Professionals involved in joint problem solving
  • Overlapping, patient focused teatment goals
  • Collaboration with other disciplines
  • Regular communication between team members
  • Active involvement of the patient 

Transdisciplinary

Transdisciplinary teams share roles across disciplinary boundaries so that communication, interaction, and cooperation are maximised among team members with an overlap of responsibilities that allows flexibility in problem solving and produces closer interdependence of team members. Team members jointly communicate, exchange ideas and work together to come up with solutions to problems from day one of working with the individual. In this approach, there is no hierarchy among the disciplines, and there is a higher level of communication and cooperation among the individual members of the organization. [2][3]  Flexible boundaries and interchangeable roles and responsibilities encourage the exchange of information, knowledge and skills.The interwoven nature of transdisciplinary teams broaden the skill sets of each therapist due to their exposure and substantial interaction with others outside their discipline, but it also allows the team of professionals to work together to reinforce and maintain goals not normally monitored. With a truly transdisciplinary team, the typical boundaries of each professional discipline tend to disappear. [3][5][10]

The individual and family are central to this type of team and are respected as equal, and valued team members, often the final decision makers in the team. As such this model is an extension of the interdisciplinary team and seen as a family friendly approach, operating within a family centred practice model. This model is frequently used in environments where there are inadequate numbers and / or unavailability of specific disciplines e.g developing countries, rural or isolated communities, leading to other team members taking on these missing roles. [3][6][5][11]

  • Professionals have an overlap of responsibilities
  • Flexibility in problem solving 
  • Closer interdependence of team members
  • Active involvment of the patient and family

Comparison of Teams

According to Kirshblum (2013) and Fergusson (2014) the collaborative approach is the fundamental difference between both the interdisciplinary and transdisciplinary team approach in comparison to the multidisciplinary team, which does not emphasize an integrated approach to care. [5][8] In the multidisciplinary approach each discipline approach a situation or problem from their own perspective and then share findings, often presenting problems with development of a cohesive management plan. This interdependance is also seen with interdisciplinary teams, but efforts are much more collaborative and team members work together toward a resolution, building on each other’s expertise to achieve common, shared goals. While with a transdisciplinary teams the lines are more blurred, and the typical boundaries of each professional discipline tend to disappear.  The interdisciplinary approach to patient care has shown better results for team effectiveness in comparison with a multidisciplinary approach. [10][9][11][12]

In Spinal Cord Injury Management health care teams tend to function across all three types of teams depending on the needs of the individual, the environment and specific phase of management. [11][13] There will be elements of the traditional multidisciplinary team where single professionals are working within their specialist skill set e.g. neurosurgeon, rehabilitation physician, physiotherapist; however, much of their work will meet the criteria for the interdisciplinary team as they build towards the rehabilitation phase working closely together to develop goals with the patient and working toward these agreed goals; then there are areas where there is real  “blur” in responsibilities where skills of the team members overlap functions more as a transdisciplinary team. [3][10][9][13][12][14]

Team Composition

Team composition will vary depending on the type of team structure used, the phase of treatment, the environment and specific resources available. Exactly who is included in the team will vary through each of the different phases of management, with the roles often dependent on the specific health system set up and resources available locally. For example, during the acute phase team members may include a spinal surgeon, a general physician or neurologist / spinal cord injury specialist, an anesthesiologist, intensive care nurses, specialist respiratory and acute neurology physiotherapists, occupational therapists, speech and language therapists, dieticians, social workers, and trauma psychologists. While during the rehabilitation phase of treatment, the team members might include a rehabilitation physician with specialism in spinal cord injury, urologist with an interest in neurourology, specialist spinal cord injury rehabilitation nurses, physiotherapists who have skills in motor learning, balance, strength, cardiovascular, gait and wheelchair mobility, rehabilitation therapists who have an interest in disability sport and recreation programs, occupational therapists who have skills in facilitating independence in self-care, seating prescription and adaptive aids, social workers who work with families as well as patients, dietitians, clinical psychologists and neuropsychologists, peer counselors, family members and care support workers and, most importantly, the patient. [3][4][6]

The composition of the team at each phase within the spinal cord injury service must be appropriate to the types of service being provided and the needs of the individual with a spinal cord injury. The individual with a spinal cord injury should be central to all decision making and be an integral member of the team that is providing the care. The rehabilitation process should also incorporate an educational element that empowers individuals and their family / carers to take an active role in their present and future management. The ultimate functional desires and expectations of the individual need to be included in the decision-making process.

Physiotherapist

Physiotherapists play a key role throughout all phases of spinal cord injury management. Initially physiotherapists assess physical impairments related to poor respiratory function, weakness, spasticity, limited sensation, reduced joint mobility, poor posture, and restricted fitness and target this areas in order to address activity limitations related to bed mobility, transfers, gait, wheelchair mobility, and upper limb function. In the acute stage physiotherapists manage respiratory status, and limb range of movement, which may include breathing and cough techniques, stretching, positioning, and active exercises for non-paralysed muscles which may continue through the rehabilitation in conjunction with motor learning and functional task training. Physiotherapists use a variety of interventions to assist with achieving maximum independence, which may include: [3][6][14][15][16]

  • Chest Clearance including Cough Assist
  • Range of Movement and Contracture Prevention
  • Posture Control and Balance Re-education
  • Strength Training
  • Cardiovascular Training
  • Motor Learning
  • Functional Transfers; In and out of bed, shower, toilet, car, from floor
  • Functional Mobility; Wheelchair or Gait depending on level and type of injury

Occupational Therapist

Occupational therapy focuses on maximising a person’s ability to perform a wide range of activities of daily living and are responsible for assessing the impact of spinal cord injury on these activities. They provide strategies and environmental adaptations to facilitate independence and build on skills. Occupational Therapists use a variety of techniques to assist with achieving maximum independence, which may include: [3][6][14] 

  • Teaching Task Adaptation
  • Modifying the Environment e.g. changing the home environment or providing equipment aids 

  • Upper limb therapy for reach, grasp and object manipulation 
  • Fabrication of splints to improve hand position or to allow a person with limited hand movement to perform various daily activities e.g. writing splints
  • Provision of, and training in the use of, equipment or aids to maximise 
independence and safety in the performance of daily living tasks

  • Advice regarding home modifications and community access
  • Seating assessment and prescription of wheelchairs, cushions and postural supports
  • Retraining in domestic and community tasks e.g. meal preparation, shopping
  • Personal care assessment and retraining
  • Education of Family / Carers 


Speech and Language Therapist

Speech and language therapists are experts in the assessment, diagnosis and management of complex swallowing and communication impairments and provide treatment for swallowing, motor speech, voice, and cognitive - communication disorders that result from a spinal cord injury and/or co-occurring injuries. They also play a key role in the assessment and management of individuals with a  tracheostomy  to optimise respiratory function and develop weaning programmes. Speech and Language Therapists use a variety of techniques to assist with achieving optimum swallow, speech and respiratory function, which may include: [19]

  • Cognitive - communication treatment (e.g. for attention, processing speed, and memory)
  • Swallowing assessment and therapy e.g. fibre-optic endoscopy, videofluoroscopy, pharyngeal strengthening exercises, use of neuromuscular electrical stimulation
  • Communication treatment
  • Motor speech and/or Voice Therapy for patients with or without a tracheostomy and/or ventilator
  • Respiratory Treatment Inspiratory and Expiratory Muscle Training
  • Patient-family education

Dietician

Maintaining optimal health is key post a spinal cord injury and the importance of good nutrition and dietary advice is increasingly recognized due to the risks associated with both malnutrition, particularly in the early postinjury period and obesity long term in individuals with a spinal cord injury. Good eating habits and nutrition plays an important role in achieving and can assist with weight control, skin integrity, bladder and bowel management, and optimize immune system function. Clinical dieticians provide assessment, dietary education and counselling, and dietary treatment and management. Clinical dieticians nutritional management goals 
are achieved through the following services: [3][6][14]

  • Assist with recovery and rehabilitation.

  • Improve and maintain nutritional status. 

  • Improve and maintain immune system function. 

  • Maintain weight within healthy weight range. 

  • Assist with bladder and bowel management. 

  • Preserve normal body composition. 

  • Preserve bone density
  • Prevent and manage complications associated with spinal cord injuries e.g. urinary tract infections, constipation, 
pressure areas

Social Work

Participation, community reintegration, and social support are the key focus of social work. They assist with personal and family problems as well as offering information and advice about a range of practical services including financial issues, benefits, entitlements, services, and assistance that are available to people with a spinal cord injury. Social workers also provide a key role in adjusting to life with a spinal cord injury providing support to cope with the social and emotional effects of a spinal cord injury and provide information on return to work and employment and / or education opportunities depending on the needs of the individual and their family. Specific roles that the social worker may assist with include: [3][6][11]

  • Emotional Support 
  • Social Support
  • Community Reintegration
  • Financial Assistance
  • Accommodation 
  • Education 
  • Employment 

Assistive Technologist

Assistive technology and adaptive devices, both low tech and high tech, are key for many people with a spinal cord injury to assist with independence in daily living activities i.e. pressure relief mattresses, moving beds, switches and controllers, computers and power wheelchairs. Assistive technologists often play a key role during the rehabilitation and post discharge phase of spinal cord management. These individuals tend to have a background in either rehabilitation engineering and/or occupational therapy. The solutions provided are usually designed to enhance communication, mobility and access to computers, educational materials and environmental control, thus promoting greater independence by enabling the person with a spinal cord injury to perform tasks that they were previously unable to accomplish or had great difficulty accomplishing. [3]

Psychology and Neuropsychology

Clinical Psychologists specialise in the prevention and management of a wide range of psychological and general health problems affecting individuals and families and are responsible for detailed assessment of cognitive, perceptual, and emotional / behavioural problems. They use observation, interviews and standardised tests to understand people’s issues and choose from many psychological treatments and counselling techniques, which are aimed at enhancing sense of control over problems and recognising resources an individual has for approaching difficulties. They aid in the development of strategies to manage these issues working closely with the individuals with a spinal cord injury, their family, physicians, and nurses and may recommend further referral to a psychiatrist where counselling and supportive therapies are insufficient to deal with an individual’s psychological issues. [3] Neuropsychologists also have a very important role in helping the individual and the team addresses any cognitive dysfunction that may only become apparent once rehabilitation begins. They can advise the team if the rehabilitation program needs to be orientated in a specific way to help deal with particular deficits such as poor auditory memory or visuo-spatial impairments. Specific concerns that the psychologist addresses may include: [3][6][11] 

  • Feelings of Depression 

  • Feelings of Anger / Frustration 

  • Concerns about Family Members 

  • Managing Relationships Better 

  • Managing Stress 

  • Persistent Worries 

  • Difficulty Coping with Hospital and Treatment Routines 
 

Physician

The physician role and type of physicians involved will vary hugely depending on the timeframe post injury, the level and type of injury and phase of management i.e. acute, rehabilitation or post discharge. Types of physicians involved include Emergency Medicine, Anaesthesiologist, Orthopedist, Neurologist, Neurosurgeon, Respiratory, Urologist, Physiatrist or Rehabilitation Medicine. Diagnosis and management of underlying pathology and impairments through medical assessment, treatment whether conservative or surgical, including prescribing pharmacological and non-pharmacological, and rehabilitation planning are key roles of the physician. They have an important role in ensuring that the patient is well enough to attend their therapy sessions and in setting limits or restrictions if there are ongoing health issues including fracture instability, soft tissue injury, pressure injuries or illnesses such as urosepsis and clearing a patient to return to or increase their therapy load. [3][4][6] 

Nurse

Nurses have a broad role covering a range of rehabilitation issues including personal care, activities of daily living, short and long term health, social, independence issues and emotional support. They also facilitate other discipline rehabilitation activities outside therapy time as they are present “24-7,” thus allowing and even encouraging the patient to practice what they have been learning in their therapy sessions. The range of tasks or routines undertaken specifically by nurses as part of the team environment includes: [3][6]

  • Management of personal care and activities of daily living 

  • Management of continence 

  • Prevention and Management of Tissue Viability
  • Practice of mobility skills in the ward setting 

  • Education: Information and practical teaching of nursing procedures or related 
routines to be learned before going home, which also includes teaching carers or family 
members to be proficient in tasks that you require assistance with. 
 

The scope of practice of nurses often crosses the boundaries and overlaps into the area of expertise of most other disciplines and may include: 


  • Encouragement to use strategies that will improve self-sufficiency and control over 
activities of daily living 
 
  • Working in conjunction with other disciplines to assist with practice and 
maintenance of skills or function developed during therapy. These may include techniques for practicing showering, dressing, feeding yourself, transfers, or mobility skills 

  • Advocacy and negotiation of daily needs with other disciplines, including medical staff 

  • Assisting other disciplines with assessment of requirements for equipment

Peer Mentors

Peer mentoring is described as a relationship between two individuals who share some common characteristic or experience and in which one provides needed assistance or support to the other. Peer mentoring programmes for individuals with a spinal cord injury have been implemented throughout the world with the purpose of assisting individuals who have a new spinal cord injury with community integration and independent living tasks both during inpatient stay and on hospital discharge and is now becoming recognized as an important component of rehabilitation. Peer support ultimately meets a critical rehabilitation goal, to promote optimal health and social reintegration of individuals with a spinal cord injury and represent a critical interface between the professional hospital-based care system and the community.In the case of spinal cord injury, peer mentors are individuals who have a spinal cord injury and have the skills, training, and understanding, which allow them to use their lived experience to help others who have sustained a spinal cord injury more recently. They can offer emotional, social and practical support assist individuals to overcome obstacles and identify problems, strengthening beliefs of self-efficacy, community integration and prevention and management of secondary conditions. [21][22][23]

Peer Mentorship Can Make A Difference.jpg
SCI Peer Mentorship - Quality of Life and Participation.jpg
"There is no greater support than that of your peers"

Individual with an SCI

Individuals with a spinal cord injury are a key member of the team throughout each phase of treatment. They are key in the development of goals and should have the opportunity to question the process and / or the goals, and direct their rehabilitation.

Family

The family members / caregivers play an essential role and provide emotional support to the individual with a spinal crod injury throughout all phases of treatment. Family and Caregiver education is an important and integral part of any rehabilitation program.

Conclusion

Team-based care begins during the acute phase and carries through to rehabilitation and later transition back in to the community, with recognition that the patient is an integral part of the team. It is widely accepted that no single medical discipline can provide complete care for people’s health and as such team-based care is considered a key element in the provision of high quality patient care. Best practices call for a team-based care approach involving a group of professionals with complementary clinical knowledge, roles, and skills that can formulate and provide timely and effective interventions i.e. the physiotherapist may assist individual in developing good balance in “long sitting”; then the occupational therapist works with the them so that they can utilize this newly (re)acquired skill to dress themselves; while the nursing staff then assist by encouraging them to practice these new activities in the ward situation by watching them and assisting only where needed rather than doing the tasks for the patient. [3][6][8]

Good team dynamics, communication, consultation and collaboration are the key for a successful team. Members of the team should complement each other’s roles to facilitate improved care. The best teams are also creative and think outside the square, challenging each other to do better for the team and for the patients they serve and try to ensure that communications are open and clear. An environment of mutual respect and support, shared responsibilities, and a problem-solving attitude are key elements in building a well-defined team around a common goal. [9][11][27]

References

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