Lecture # 414:
Care of Spinal Cord Injuries

copyright 2008 Cheryl K. Hosken, BSN, MS Psych.

The spinal cord is part of the nervous system and measures approximately 18 inches long, extending from the base of the brain to about the waist. The nerves that branch out from the spinal cord to the other parts of the body are called lower motor neurons (LMNs). These spinal nerves exit and enter at each vertebral level and communicate with specific areas of the body.

Spinal cord injury (SCI) is damage to the nerves within the spinal canal. Most SCI's are caused by trauma to the spinal column and affect the spinal cord's ability to send and receive messages from the brain to the body's systems that control sensory, motor and autonomic function below the level of injury. Usually, the part of the spinal cord that has the largest degree of curvature is the site of injury. These are the cervical and lumbar area.

There are two classifications for spinal cord injuries -- complete and incomplete. In a complete injury, nerve damage obstructs every signal coming from the brain to the body parts below the injury. In an incomplete injury, only some of the signals are obstructed.

Meditate Word By Word On These Verses:
Acts 20:7-12.

The rings of bone that make up the spinal column are known as vertebrae. The vertebrae are named according to their location and are called the Cervical, Thoracic, Lumbar and Sacral vertebrae.

Cervical Vertebrae are the seven vertebrae in the neck. Spinal cord injury to these vertebrae usually causes a loss of function to the arms and legs, thereby resulting in quadriplegia.
Thoracic Vertebrae are the twelve vertebrae in the chest. Injuries in the thoracic region usually affect the chest and the legs and result in paraplegia.
Lumbar Vertebrae are in the lower back. Damage to one of these five vertebrae will result in loss of control of the legs, bladder, bowel and sexual functions.
Sacral Vertebrae are the five vertebrae that run from the pelvis to the end of the spinal column. Injury to this region generally results in some loss of functioning in the legs and difficulty with bowel, bladder and sexual control.

The leading cause of SCI are motor vehicle accidents (44 percent), followed by acts of violence (24 percent), falls (22 percent), sports injuries (8 percent), and other causes (2 percent). Males account for 82 percent of all SCI's and females for 18 percent.

Question 1: Why is an injury to the spinal cord serious and physically devastating?

 

 

What are the signs of a spinal cord injury?

Overall, 85 percent of SCI patients who survive the first 24 hours following injury are alive 10 years later.

What treatments are available for spinal cord injuries?
Currently, there is no cure for spinal cord injuries. However, ongoing research to test surgical and drug therapies are progressing more rapidly than ever before. Therapeutic techniques, nerve cell transplantation, nerve regeneration, decompression surgery, and complex drug therapies are all being examined as a means to overcome the effects of spinal cord injury. This information is taken from http://www.spinalcord.org/, Edward C. Benzel, M.D. http://www.spineuniverse.com/, http://www.spinalcord.uab.edu/show.asp?durki=29178

Effects of Spinal Cord Injury
Loss of spinal cord function can affect activities that are autonomous (e.g. breathing) as well as thought-driven actions (e.g. driving). Both motor and sensory functions may be lost. Occasionally other diseases such as polio cause spinal cord injury. Spinal cord injuries are described using the following terms:

Question 2: What particular information is important to know before you begin working with a spinal injury patient?
(Only one of the following answers is correct.)
Where does it hurt, and how bad does it hurt?
What are the symptoms, and what type of SCI does the patient have?
How did the injury happen, and why did it happen?

 

 

Other terms used to describe neural dysfunction include:

The spinal cord does not have to be severed for function to be lost. Most people with spinal cord dysfunction have an intact spinal cord. Cord injuries usually fall into one of the following categories:

When injury occurs and for a time period following, the spinal cord swells. Loss of function occurs below the level of the injury and may be permanent or temporary. Much depends on the severity of the injury.

Symptoms may include loss of motor function, sensation or proprioception. The nerves responsible for these functions transmit their messages through the muscles, tendons, joints and other organs. Destruction of sensory nerve fibers may lead to loss of sensation such as touch, pressure, and temperature. Reflexes may become exaggerated, bladder and bowel control may be lost, even the ability to breath normally may be endangered.

Diagnosis
When spinal cord injury is suspected (e.g., spinal fracture) immediate medical attention is required. Spinal cord injury (SCI) is usually first diagnosed when the patient presents with a loss of function below the level of injury. The initial evaluation includes x-rays, a CT scan, and possibly a MRI. Fractures are demonstrated on plain radiographs. CT scanning and MRI studies are used to evaluate the soft tissues in the spinal column. In addition, a myelogram may be performed to identify and evaluate spinal cord injuries caused by trauma or disease. The neurologic evaluation includes assessment of the patient's symptoms, which might include loss of motor or sensory function. Other neurologic symptoms may include pain, numbness, paresthesias (e.g., tingling), muscle spasm, weakness, and bowel/bladder changes.

Question 3: Why do the muscles not work when there is a spinal cord injury?

 

 

URINE AND BLADDER CONTROL
Before spinal injury, a person does not pay much attention to the urinary system because the nerve control was automatic. However, with SCI, the bladder does not work automatically. Through several types of tests, the rehabilitation doctor determines what type of management is best for the person.

The kidneys remove wastes and excess water from the blood stream and process them into urine. The urinary bladder is a muscular sack that stretches to hold urine until a person is ready to urinate. When urinating, the bladder contracts and the circular sphincter muscle opens to let urine out of the body. Urination is a finely balanced coordination of bladder and sphincter muscles. This coordination involves voluntary and involuntary control by the nervous system. Messages are sent from the bladder to the brain to alert a person that his bladder is full and needs emptying. Then a person decides whether or not he can urinate. This is the part of the urination process that is under voluntary control. The involuntary part involves opening the sphincter muscle.

Bladder function is changed in spinal cord injury because the nerve impulses from the bladder can no longer get to and from the brain to let you know that you need to urinate. There are two general kinds of bladder dysfunction depending on the level of the spinal cord injury. There are also individual variations of these dysfunctions.

Question 4: Why doesn't the urinary bladder work normally after spinal cord injury?
(Only one of the following answers is correct.)
Because the patient doesn't know how to control it.
Because the patient doesn't feel when it is full.
Because the spinal cord is injured, so the bladder nerves don't function correctly.

 

 

Type I is the upper motor neuron bladder (reflex or spastic bladder). In this condition, the bladder tends to hold smaller volumes of urine than before the SCI. Just like your other muscles may have spasms and contract on their own, the bladder muscle does as well. The result is that there is frequent, small urination without control. The bladder type is common in most spinal cord injuries above the sacral level.

Type II is the lower motor neuron bladder (flaccid bladder). In this condition, the bladder muscle has lost its ability to contract and can be easily stretched. Therefore, the bladder holds large volumes of urine. Because the muscle cannot contract, urine leaves the bladder only when it is overfilled. The urine spills out like a glass that is too full of water. This type of bladder is common when SCI affects the sacral area of the spinal cord.

Question 5: What are the two types of bladder dysfunction?

 

 

How is the Bladder Emptied After Spinal Cord Injury?
If there is an incomplete injury, the person may regain all or some voluntary control of the bladder. If the injury is complete, one or a combination of the following bladder empying techniques will become part of the bladder management program.

Catherization
A catheter is inserted in the bladder to drain urine. If this is done several times a day, it is called intermittent catherization. In the first stages after injury, the medical staff does this procedure. This may also be done at home and is the preferred method of emptying the bladder.

A catheter that is left in the in the bladder is called an indwelling catheter. This type of emptying the bladder is not preferred because it can cause numerous infections and damage the sphincter. Another, less common type of catheter, is the suprapubic catheter. This type is placed through the abdominal wall into the bladder.

Stimulated voiding
Some bladders can be mechanically stimulated to empty. Just as a spastic muscle may move when tapped or brushed, so may an upper motor neuron bladder. This is simply called "tapping". The tapping by the hand is done on the abdomen over the bladder. A lower motor neuron bladder may empty with firm pressure over the bladder called crede and/or by bending forward.

Spontaneous Voiding
Some upper motor neuron bladder muscles spontaneously contract. For those who have bladders that empty on their own, wearing and external collecting device will keep the person dry. There are many types of collection devices and the person can chose what is best for him.

What are the Goals of Bladder Management? They are:

Bladder volumes are kept low by watching fluid intake and routinely emptying the bladder. If an intermittent catheterization program is used, the amount of urine that collects in the bladder needs to be 400cc or less. The fluid intake should be 400cc with meals and 200cc between meals and after supper. With 4-6 catheterizations throughout the day, the bladder will not get too full. More than 500cc of urine in the bladder will overstretch the bladder muscle and may cause infection.

A catheter or suprapubic catheter always drains urine so that the bladder does not fill at all. It is good for the person to drink as much fluid as possible to flush mineral deposits out of his system. These catheters should always be taped in place. If they are not, they may be pulled out by normal activity and injure the urethra.

Question 6: By what means is urine released from the bladder?

 

 

If there is spontaneous or stimulated voiding, the person will need to balance his fluid intake. Since a certain volume of urine will make the bladder empty, the person needs to know what that volume is in order to get to a toilet on time. Usually, the intake for this type of bladder per hour is 125 cc.

Avoidance of Infections
If the person has a regulated fluid intake to wash out bacteria this is the first step to prevention of infections. Drinking enough fluid will also limit kidney stone formation (the SCI person cannot move about and maybe subject to kidney stones) and keep the urine clear.

The bladder needs to be emptied when it contains 400 cc of urine. More than 400cc can weaken the bladder muscles cells since it cannot fight off infection. Secondly, the muscle cannot contract as tightly as necessary to empty the bladder. This leaves a pool of urine in the bladder in which bacteria can grow. While in a hospital situation, sterile technique is necessary for catheterizations. Use "clean" technique (wash the catheter in hot, soapy water with a little bleach and reuse it).

Bowel Control
With a spinal cord injury, damage can occur to the nerves that allow a person to control bowel movements. If the spinal cord injury is above the T-12 level, the ability to feel when the rectum is full may be lost. The anal sphincter muscle remains tight, however, and bowel movements will occur on a reflex basis. This means that when the rectum is full, the defecation reflex will occur, emptying the bowel. This type of bowel problem is called an upper motor neuron or reflex bowel. It can be managed by causing the defecation reflex to occur at a socially appropriate time and place. A spinal cord injury below the T-12 level may damage the defecation reflex and relax the anal sphincter muscle. This is known as a lower motor neuron or flaccid bowel. Management of this type of bowel problem may require more frequent attempts to empty the bowel and bearing down or manual removal of stool.

Both types of neurogenic bowel can be managed successfully to prevent unplanned bowel movements and other bowel problems such as constipation, diarrhea and impaction.

Question 7: What two types of reaction do the bowel nerves have in spinal cord injury?

 

 

Methods for Emptying the Bowel
Each person's bowel program should be individualized to fit his/her own needs. The type of disease or nerve damage (for example, upper or lower motor neuron) should be taken into account as well as other factors (see What Factors can Affect the Success of the Bowel Program, below). Components of a bowel program can include any combination of the following:

What is a Bowel Program?
Most people perform their bowel program at a time of day that fits in with their prior bowel habits and current lifestyle. The program usually begins with insertion of either a suppository or a mini-enema, followed by a waiting period of approximately 15-20 minutes to allow the stimulant to work. This part of the program should, preferably, be done on the commode or toilet seat.
After the waiting period, digital stimulation is done every 10-15 minutes until the rectum is empty. In order to avoid damage to the delicate rectal tissue, no more than four digital stimulations should be performed in any one session. Those with a flaccid bowel frequently omit the suppository or mini-enema and start their bowel programs with digital stimulation or manual removal. Most bowel programs require 30-60 minutes to complete.

Question 8: What is a bowel program?
(Only one of the following answers is correct.)
It is a program on TV about how to train the bowel.
It is a plan for when and how to empty the bowel.
It is the Super Bowel football game on TV.

 

 

Bowel programs vary from person to person according to their individual preferences and needs. Some people use only half of a suppository, some require two suppositories, and some use no suppository or mini-enema at all. Some choose to do the entire program in bed, while others sit on the toilet from the beginning. Some find that the program works better if they can eat or drink a warm beverage while it is in progress, others find that this is not helpful. What is most important is that you discover what works best for you.

Factors that affect the success of a Bowel Program
Any one of the factors listed below, or a combination of factors, can affect the success of a bowel program. Changing one factor may produce results almost immediately, or it may take several days to see the results. Changing more than one factor at a time makes it difficult to determine the effects of individual factors, and may increase the time it takes to develop a stable bowel program.

Autonomic Dysreflexia
Autonomic dysreflexia is a massive cardiovascular reaction of the sympathetic division of the autonomic nervous system to visceral stimulation. It occurs in SCI persons that have spinal cord lesions above T6. The autonomic nervous system is the part of the nervous system that is concerned with control of involuntary body functions. It regulates the functions of glands (especially the salivary, gastric and sweat glands), the adrenal medulla, smooth muscle tissue, and the heart. The autonomic nervous system may act on these tissues to reduce or slow activity or to make them start functioning. It is divided into the sympathetic and parasympathetic divisions.

If the sympathetic fibers are stimulated, there is constriction of the blood vessels, rise in blood pressure, erection of body hair, goose flesh, pupillary dilation, depression of gastric activity, and acceleration of the heart. In general this reaction happens to our bodies when we have a flight-fight-fright experience. Norepinephrine is the transmitter that sets this system in motion.

The condition of autonomic dysreflexia can be life threatening and needs immediate resolution. The manifestations of autonomic hyperreflexia include hypertension (up to 300mm. systolic blood pressure), throbbing headache, blurred vision, marked sweating above the level of the spinal cord injury, decreased heart rate, erection of body hair, nasal congestion, and nausea.

The most common precipitating cause is a distended bladder or rectum. Contraction of the bladder or rectum can also cause this condition. To stop this process, elevate the head of the bed and search for the cause. Immediate catheterization may be necessary. Skin stimuli such as tight clothes or shoes should be removed. If the symptoms persist, a doctor will have to give Regitine or Apresoline to decrease symptoms.

Question 9: Why is autonomic dysreflexia dangerous?

 

 

This information was taken from http://www.trilobyeproductionsii/sci_pg.html

Skin Care
We have discussed skin care previously, and for the spinal cord injured person, good skin care is important. The SCI person cannot feel his skin nor can he move about to inspect it. Therefore, his caregivers must watch his skin for abrasions or other pressure-related breakdown.

When he is in bed, he needs to be turned every two or three hours. A foam cushion is a good preventive measure against skin sores. When he sits in a chair, he also needs a cushion. He should lift himself up off the seat of the chair every hour to relieve pressure on the skin covering the coccyx and hipbones.

Care of Extremities
Even though his extremities may be flaccid, range of motion exercises are necessary. They are done for two reasons: 1) to stretch the muscles and give muscles tone manually, 2) to relieve the muscles from assuming one position only. If the extremities are moved, they also can relax and the SCI person sleeps better.

Question 10: What is the goal of good skin care?

 

 

Adjustment to Spinal Cord Injury
Adjustment is defined as adapting to a new condition. Everyone makes adjustments during their lifetime. Some of the conditions that you adjust to may be planned, and you have time to think about how you are going to react to the situation. For example, you may have to make adjustments in your work hours when you start a new job. Other events may be a surprise, and you are forced to adjust to an unplanned event.

After Spinal Cord Injury: Everyone agrees that a spinal cord injury (SCI) is one of the most devastating of all traumatic events. It is common for individuals who are newly injured to have health problems. Plus, it takes time to build enough strength to be able to fully participate in daily activities.

Grieving individuals who are newly injured and their families will likely experience grief. This is a period of mourning that is similar to that following the death of a loved one. The difference is that a person may be grieving the loss of ability to walk or use his hands. People experience many different thoughts and feelings after injury. Some may seem extreme and others mild. There is no step-by-step grieving process, but some thoughts and feelings are common after injury.

Denial
SCI persons may first react to your injury as if nothing happened. They may refuse to accept their loss of feeling and movement is permanent. Instead, they may see the injury as an illness similar to a cold or flu that will soon pass with time.

Sadness
Obviously, no one is happy to be injured. It does not matter what the level of injury, extreme sadness is common after injury because they have experienced a great personal loss. Sadness is that down, or blue feeling that we feel when something bad happens. However, it is important to not confuse sadness with depression. Depression is a condition that requires professional treatment. A person may be depressed if he has 3 or more symptoms such as extreme sadness, inactivity, difficulty in thinking and concentrating, a significant increase or decrease in your appetite and/or time spent sleeping, and feelings of dejection, hopelessness or worthlessness. He may even have thoughts about suicide if he has depression.

Anger
Some people react to their injury with strong feelings of displeasure. He might lash out verbally or want to become physically violent towards others. He may feel angry toward himself if his actions resulted in his own injury. He may even feel anger toward God or someone else for causing his injury.

Bargaining
At some time following your injury, he may begin to admit to himself that he has a serious condition. However, he may still want to hold onto the belief that his injury is not permanent. He may act as if he accepts his injury as (the way things are, but his acceptance may come with the belief that he will be rewarded for your prayers and hard work in therapy and eventually recover from his injury at some point in the future.

Acceptance
Grieving usually ends with acceptance. He comes to accept a realistic view of his current condition and find meaning in your life. He begins to think about his future and set goals to pursue in life.

Adjustment
Individuals who adjust well to unexpected events generally lead healthy, active, and happy lives after their injury. Individuals who do not adapt well to unexpected events tend to be less healthy, less active, and unhappier after their injury. A person experiences two primary areas of adjustment to spinal cord injury. When he is newly injured, it takes time to get used to his life after injury. Some people grieve longer than others, so the adjustment period is different for everyone. It may take as much as a year for him to accept the realities of your injury. He will also experience a continued process of adjusting to the unique issues that occur in his every day life as a person with SCI.

Question 11: Can these reactions to SCI also happen to others who do not have SCI?
yes / no.

 

 

Problems Adjusting to SCI
If he has been injured for a year or more and has not come to accept his injury, it is a good idea to look into other areas to find out whether or not he is having problems adjusting to SCI. Although he may find it hard to believe upon first thought, what happens to himself is not as important as what he thinks about when something happens to himself. His thinking directly influences how he feels and reacts to events that occur in his life.

This idea is the basis for Rational Emotive Behavior Therapy (REBT). Many counselors and psychologists teach REBT as a way to help people with and without SCI improve their ways of living. There are events in your life that trigger a chain reaction causing a negative attitude on your overall well being.

Event
An event is something that happens to you. It can be something as small as misplacing the keys to your car or something as devastating as a spinal cord injury. Anytime an event occurs in your life, you start to talk to yourself about that event. This self-talk is based on what you know or what you believe to be true. For example, a person who gets a promotion at work might think, I earned it!

Irrational Beliefs
There are times when this self-talk is based on completely false or partially false assumptions about an event. If you do not know all the facts involved in the event, your self-talk may be based on wrong information or a series of unrealistic ideas, or irrational beliefs, about the event. This is often true for individuals with SCI. If he is a person who is newly injured, he probably does not know all of the facts about living with an injury. His self-talk will likely reflect his lack of knowledge.

Examples of early self-talk based on irrational beliefs are:

Question 12: Why is it good for a person to talk about his irrational beliefs?
(Select the best answer.)
Because then it helps him feel better.
Because then he learns how to deal with them.
Because then he understands they are not rational, and he lets go of those beliefs.

 

 

Although these irrational beliefs are common for individuals who are newly injured, many persons with SCI continue to hold onto these types of unrealistic, irrational beliefs long after their injury. The longer he holds onto such beliefs, the more likely it is that he is not adjusting well to his injury. He may have even adopted other false assumptions that are limiting his adjustment.

Some other examples of self-talk based on irrational beliefs are:

Question 13: In your country, are those irrational beliefs listed above really irrational? Explain.

 

 

Emotion
What a person feels, or his emotional response, depends on his self-talk. For example, individuals who are newly injured may think that their life is over because they cannot live with a spinal cord injury. This unrealistic self-talk may lead to extreme feelings such as anger, fear, and/or other emotional responses. If he has been injured for a year or more, he may feel sad, lonely, hopeless or worthless if he continues to hold onto irrational beliefs such as (no one can possibly accept, respect, or love a person with SCI. It is also important to know that feelings are neither good nor bad. It is normal to feel excited at times and sad at other times. He may feel both sad and excited at the same time. Because his self-talk might be different from another person, you may feel differently than others about the same event.

Question 14: What is self-talk?

 

 

Unhealthy Behavior
If his feelings are based on irrational beliefs, his reactions to his feelings may result in behavior that is bad for his overall health and happiness. For example, he may not see the need to take proper care of his bladder or skin if he feels worthless. He may isolate himself from others and avoid spending time with family and participating in other enjoyable activities. Individuals with a history of alcohol and/or substance abuse may return to their old pattern of self-destructive behavior. Others may start drinking or taking drugs. Either way, substance abuse is unhealthy behavior.

Unhealthy Results
Unhealthy behavior almost always leads to unhealthy results. When he neglects his personal care, he puts himself at greater risk for developing a wide range of health problems such as respiratory complications, urinary tract infection, and pressure sores. These problems can limit his ability to participate in activities. In some extreme cases, he may die. Substance abuse can complicate existing medical problems or lead to other health problems. Substance abuse can also lead to other injuries and a loss of personal relationships.

Healthy Adjustment to SCI
No matter what the event, it triggers self-talk. These ideas, thoughts, and/or beliefs lead a person to feel the way he feels. His behavior and the results of his behavior are guided by his feelings. The biggest key to adjustment to spinal cord injury is personal motivation. Individuals who are newly injured are often motivated to attend therapy sessions out of a desire to gain strength and function. A healthy approach to this reality is to move forward with your life after injury with the continued hope that advances in medicine will one day lead to a cure. Do not wait on a cure.

People who adjust well to life after injury are usually motivated to meet personal goals. These goals are different for everyone and may change throughout life. For example, your goal today may be to get a job, and you may want to have children in the future. Research shows that people who set personal goals report greater acceptance and life satisfaction, and they feel less shameful about their condition. It is up to you to find purpose in your life and the motivation to achieve your goals. It may help to think about what you wanted out of your life before you were injured. You may have once strived for good health, an enjoyable job, and a loving family. There is no reason that you cannot continue to strive for the same things now that you have a spinal cord injury.

Replacing Irrational Beliefs with Rational Beliefs
Once you set your personal goals and have motivation for change, you may find it easier to identify unrealistic, unfounded information and false assumptions. You can help yourself avoid irrational beliefs:

It does not matter what his level of injury, he can challenge his irrational beliefs and replace his false assumptions with information that is based on fact. Take time to learn the facts about living with SCI. An individual who is newly injured may want information on bladder or bowel management. An individual who has been injured for a year or more may want information on employment or sexuality. When he is looking for educational information, only rely on information that comes from a knowledgeable source on issues of SCI. For example, he can usually learn about SCI in patient education classes when you are first injured. In fact, he may have been given an informational booklet to take home with him from the rehabilitation center.

Question 15: What is the best way to reduce irrational beliefs?
(Select the best answer.)
Reduce or eliminate negative, rigid and exaggerated self-talk.
Try to understand that they are foolish.
Enable the patient to live better with these beliefs.

 

 

It is also important to ask yourself what evidence he has to support his beliefs. Is there evidence to disprove his belief? He can then learn to recognize those beliefs that are based on false assumptions. For example: My life is over because I can never live or be happy after a spinal cord injury. Individuals who are newly injured often use this irrational belief as a way to deny the possibility that their injury is permanent. Individuals who have been injured for over a year may use this statement as a reason to do nothing. To dispute this assumption, he focuses on the word never. By using these words he is not allowing himself to believe that there are other possibilities. He is ignoring the fact that you cannot predict the future. "Although I hope that my injury is not permanent and I fully recover, I know that many people are happy and living many years with all levels of injury."

Question 16: How did David help Mephibosheth to turn his irrational belief about himself into rational belief?

 

 

This type of rational self-talk is supporting his hope for recovery, but it also supports the fact that he can be happy and live with or without an injury. He is recognizing the fact that other people with the same level of injury are alive and happy. He is also recognizing the fact that he cannot predict the future: "Because of my injury, it is now impossible for me to ever work or have a family." This is a false assumption that many people hold onto long after their injury. There are some individuals with SCI, family members, friends and others in the community that wrongly believe that no one with SCI can work, especially those individuals with high levels of injury. He may even find it hard to imagine that he can work.

In reality he may have physical limitations that prevent him from doing some jobs. He may not have the physical ability to do the same job that he did before your injury. For example, if he was a construction worker before his injury, it is not likely that he can return to that job if he had a high level injury. However, this fact does not mean that he cannot work. With job retraining and support from his family, friends and employer, he may find there are a number of jobs that he can do. The above rational statement also supports the fact that he has choices in his life.

Once he challenges his irrational beliefs and replace them with beliefs that are based on facts, he will likely feel differently about himself. Instead of feeling sad, he might feel hopeful about his future. Instead of feeling worthless, he might begin to feel worthy.

Healthy Behavior
When he begins thinking more rationally and experiences a change in his feelings, he will usually act differently. He uses problem-solving steps:

Information from:
University of Alabama,
Birmingham, AL 35249-7330,
(205) 934-3283 or (205) 934-4642 (TTD only),
Email: rtc@uab.edu

Question 17: What feelings would you have if you needed to care for a spinal cord injured person?