How do you help patients with a spinal cord injury overcome resistance to rehabilitation?

Most folks are resistant to rehab for a reason, there’s something that they’re afraid of. And I think some of what we try to do is ground it back to -- what are your current goals? I have no idea whether that individual will recover fully as they wish, but we say we know what you have now, we know what you need to deal with. So if we can tie into something they really like and enjoy, and then address the fear the individual has, we might make baby steps. And it is important to really conceptualize rehab in a broad way. There are many things that we do that are rehab orientated that don’t involve going down to the gym and working on a mat. That can be self-care activities, well that’s rehab, that’s helping you, look how you’re gaining control. So it probably does circle back to trying to understand what are the factors of the resistance. Are there some fears or maybe some avoidance things that are going on? And being honest to deal with them, those are very genuine concerns. I remind folks that rehab is something we do with you and not to you; we can’t do it without you and subsequently you’re a partner, you’re a collaborator. If you can do it better, then we can do it better with your participation.

We first join with the patient, that is we reach out to the patient, let them know we know this is tough. We don’t try to deny the fact that it is a challenge, but let them know that there is a big light at the end of the tunnel, that they will actually benefit from this and become one of the team members that will determine what rehab goals will be set. They will be a part of that process, so they don’t feel like they’re resisting external forces but that they’re actually joining those individuals to become a better person.

Understanding the nature of the resistance. Is it a system issue? Is it a family issue? Is it a personal issue? Is it a spiritual issue? To me, that’s too broad a term and if someone is reluctant, the only way to help people is to first see the world through their eyes. I need to understand the nature of that resistance to understand the best way to help.

The readiness really speaks to -- readiness for what? Are you ready for an emergency? Are you ready to have your life taken away from you? Resistance is sometimes a factor in terms of, “I’m not really ready to deal with that.” We’re all under the drive that there are a certain number of days; your functioning improves and you’re out, and that’s that. Then there’s this other part of readiness in being able to accept, and being able to get back, and being able to be seen and being able to say, “Where can I be seen? I can been seen in a hospital and you all are making me feel good, when I get home they’ll make me feel good. But when I’m out in the community, when somebody doesn’t make me feel good, how does that affect me?” That’s a normal resistance, so a part of that is to say “Let’s do it in increments, let’s do it little by little, let’s do it with somebody you know is on your side.”

It helps to figure out where the resistance is coming from. Some people just don’t have trust, and so we need to slow down and teach them that we’re trustworthy by example. Some people can’t accept what happened to them, they’re very angry and they feel if they collaborate that that’s kind of giving in. Those people may need a harder hand to force them to work because there’s a window of peak opportunity, and they’ll never get that again, even though they can continue to progress through their life.  Some extreme cases, since we’re dealing with active-duty service people, we’ll have their commanding officer order them into rehab. But, that’s really not the best way; that’s kind of the last resort way. Usually by helping them identify small measures of progress, people will then begin to collaborate. They’re looking at the big picture, “I want to walk by Tuesday,” is not going to happen. But, can we help them see in order to get there, first they need to sit up and not have their blood pressure drop, and then they need to be able to stand a little bit in a standing frame, and to anticipate these milestones of progress.

When people are having difficulty with rehab, there’s often a reason why. We don’t want to assume that it’s some behavioral problem, or that somebody might be difficult to work with because underneath that there’s typically some sort of fear or worry, and I think it’s important to have good rapport with the patients. So you’ll need to discuss any barriers to care. It might be something very simple as the time of day, or it could be based upon fear of moving. It’s important that we openly talk about these aspects so that we can modify them or address them as needed. I think it’s important that we have a team approach, so that we understand why the patient isn’t ready, as much as they're willing to engage in that conversation at that point in time, and having the different disciplines come in and maybe have a team meeting—hear from the patient where they’re at, and then use what’s called “motivational interviewing”. So it’s a form of communication where we’re eliciting from the person their own reasons to change, or move in a direction of healthy behavior at their own speed. And making sure that we’re all at the same place, and we understand any concerns that might be going on, so that we can pace with the individual. Making sure that they understand that window of care—that some things, especially with nerves, are very time oriented—so that we can continue to make gains. As long as we're providing that information and the patient is able to make their own decisions, I feel like we’re at a good point.

It varies tremendously but a lot of beliefs and myths about rehab, about doctors and all of that. And so a lot of times we’ll have individuals who think, “Oh, I can get better on my own, I don’t need this,” and that’s very, very challenging as well. But it’s very common for individuals to not want to be there, to think, “If I was just went home, if I were just back in my environment everything would be fine, and I would walk again or I’d be functioning again just as I was before, I could get back to work.” And it’s a huge, huge process to realize that’s not going to happen, or not in the same and it can happen differently, but it’s just a huge process. We know what can work and we’ve seen improvement, we know that rehab makes a tremendous benefit and ultimately our goal is to improve quality of life.

When you’re thinking about resistance, I think we have to look back on ourselves as the team to say “We’re somehow missing who this person is. We’re trying to engage them in something that doesn’t fit within their world view, or that is foreign to them, and we need to retrace our steps and try and figure out who is this person and what are their goals?”