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How Shepherd Center Works
by Marshall Brain

Although it is not a lot of fun to think about, imagine the following scenes.
  • You are driving your car down a freeway and you run into another car.
  • You are swooshing down your favorite ski slope and you hit a tree.
  • You are walking down the steps and you slip and fall.
When you regain consciousness, you find you are in the hospital. You have broken the bones in your back or neck, and they have damaged your spinal cord. Suddenly you realize that you can't feel or move your arms or legs.

Accidents like these can happen to anyone at any time, and they are actually fairly common. Eighty-two percent of these kinds of accidents happen to males between the ages of 16 and 30.

It is not a pleasant thought, but thousands of people find themselves in this situation every year. If this were to happen to you, how would your life change? What would you do? Where would you go for help? What tools does modern technology offer to people who become paralyzed today?

Shepherd Center is a catastrophic care hospital specializing in the treatment of spinal cord injury and disease, acquired brain injury, multiple sclerosis and other neuromuscular disorders and urological problems.

In this edition of HowStuffWorks, we will visit and explore one of America's leading catastrophic care hospitals, Shepherd Center, based in Atlanta, Georgia. Shepherd Center helps people with spinal cord injuries (as well as acquired brain injuries, multiple sclerosis and other neuromuscular illnesses) to rebuild their lives after an accident or illness. It is a fascinating and distinctly humanistic process that allows people -- people just like you and me -- to make the most of a life-threatening situation.

How the Spinal Cord Works
The muscles in your body get their commands from the brain. For example, when you decide to walk, your brain tells your leg muscles to start moving. When you want to lift something, your brain sends signals to your arm muscles. Between your brain and your muscles are "wires" -- nerve cells -- that carry the commands. Every nerve pathway that controls your arms, hands, torso, legs and feet passes through your spinal cord to get to its destination. Your brain + your spinal cord = your central nervous system.

The bones -- vertebrae -- in your spine protect your spinal cord. Between the vertebrae, spinal nerves branch off and head toward different muscle groups. Nerves also collect signals for touch, pain, heat, cold, joint position and so on, and send this information back to the brain through the spinal cord.

Dr. David Apple, Shepherd Center's medical director, checks an MRI (magnetic resonance image) to determine where a patient's spinal cord was injured.

But if the spinal cord gets injured, this communication system is interrupted, leaving parts of the body disconnected from the brain. Depending on the severity of the injury, a person may experience partial or complete paralysis, which can be temporary or permanent.

The spinal cord (purple) runs down the spine and is protected by bone. Between the vertebrae, spinal nerves branch off and head toward different muscle groups.

If the damage to the cord is located below chest level, then the stomach and legs may be affected. This is called paraplegia. Injuries above the chest may result in tetraplegia (also known as quadriplegia), meaning all four limbs and the trunk have a loss of feeling or movement. Higher-level injuries can even make breathing difficult or stop altogether.

Injuries to the spinal cord can be caused by traumatic injuries like an auto or diving accident, but they can also occur because of an illness that causes nerve degeneration.

According to the spinal cord injury resource center:

    Approximately 450,000 people live with spinal cord injuries in the US. There are about 10,000 new SCIs every year; the majority of them (82%) involve males between the ages of 16-30. These injuries result from motor vehicle accidents (36%), violence (28.9%), or falls (21.2%). Tetraplegia is slightly more common than paraplegia.

Shepherd Center
Since most spinal cord injuries start with an accident, chances are the person will end up in an emergency room, where his or her condition is stabilized. In many situations, the patient can move straight from the emergency room to Shepherd Center, a 100-bed catastrophic care hospital in Atlanta, Georgia, to begin treatment. This was not the case in the past, and is one of the big advantages to having specialized facilities like Shepherd available today. At Shepherd, people who specialize in treating spinal cord injuries help the patient recover as much movement and sensation in his or her body as possible.

At Shepherd Center, patients with paralysis in their arms and hands can still operate TVs, telephones and nurse-call buttons by sipping or puffing into a straw that controls the equipment. Ceiling lifts also help nurses and therapists easily transfer a patient from wheelchair to bed or from bed to wheelchair.

A spinal cord injury can be a life-changing event, and without the proper care, things can look hopeless. One of the most important things that Shepherd Center does from the start is to show patients that life is not over -- there is hope. Every step of the way, from intensive care and rehabilitation to returning to the community, Shepherd helps patients realize their independence.

Therapists at Shepherd Center often supplement a patient's rehabilitation program with aquatic therapy, because warm water has been shown to help increase flexibility, decrease pain, relieve muscle spasms and improve circulation.

Most people who leave Shepherd resume the activities they were doing before their injury, whether it means going back to work or school, participating in hobbies or sports or getting involved in the community. Their lives may be very different, and things may have to be adapted to accommodate the changes, but they have been given the tools and learned the skills necessary to get back into living. Today, a big factor in leading a productive life is technology, as we will discuss later in this article.

Treatment at Shepherd Center
As a patient arrives at Shepherd Center, these things may happen:

  • He/she is placed in the Center's intensive care unit.
  • He/she is assigned a rehabilitation team made up of a physician or physiatrist, physical therapist, occupational therapist, speech therapist, respiratory therapist, recreation therapist, nurse (primary care coordinator), dietician, case manager, counselor, and therapy technician.
  • If necessary, he/she will undergo surgery to stabilize the spine and any other broken bones.

Every year in the United States, 11,000 people are diagnosed with spinal cord injury. It's important to get medical treatment and rehabilitation from experts who specialize in this type of catastrophic injury in order to achieve the best possible outcome.

Once the person is stabilized, he or she may move out of the intensive care unit and into a patient room in the hospital. Even during a stay in the ICU, the patient may start a limited therapy program to help him/her get out of bed, increase range of motion in the arms and legs, maintain muscle tone and flexibility and prevent joints from stiffening.

For someone who no longer has feeling or movement below the waist, learning to transfer from a wheelchair to another surface, or even sitting for any length of time, can be very difficult. Therapists help patients with spinal cord injuries rebuild their strength and flexibility and practice the techniques that will allow them to become as independent as possible.

After moving to a patient room, a more intensive rehabilitation regimen begins.

The goal of spinal cord injury rehabilitation is to help patients regain function and sensation in the body so that they can begin to rebuild their lives with hope, dignity and independence.

The actual course of rehabilitation is unique to each patient, but here are some of the common features:

  • Regaining mobility - Some people with spinal cord injuries regain partial mobility. If the patient has the potential to regain some function, then rehabilitation therapists will work to accelerate that process and help return as much function as possible.

Daily therapeutic sessions are often intense and tiring, but data from Shepherd Center's Outcomes Research System indicates that beginning a rehabilitation regimen within two weeks of injury can lead to increases in functional improvement.

  • Learning new skills - Using a wheelchair for mobility is definitely different. Everyday functions from cooking to driving to using the restroom change. A combination of skill-based and occupational rehabilitation helps the patient learn how to do all of these things in new ways.

Shepherd Center's Activities of Daily Living Kitchen is a model that demonstrates how a few simple adaptations can make a kitchen wheelchair-accessible. Patients are encouraged to cook a meal or dessert here so they can begin to feel comfortable about working in their kitchens at home.

  • Gaining a new perspective - A big part of the recovery process is mental. The patient begins to understand that life has changed, and then learns adjustments that can make it nonetheless fulfilling. One big advantage of Shepherd Center is peer support. Because there are dozens of patients working through the program at the same time, at varying stages along the way, they can offer each other encouragement and support.

Having a spinal cord injury doesn't necessarily mean you have to stop driving. Adapted hand-controls on the steering wheel allow the driver to accelerate and brake. Certified driver rehabilitation specialists and occupational therapists can conduct evaluations and provide driving lessons to both new and experienced drivers with a wide range of disabilities.

  • Taking care - Because paralysis is normally combined with loss of feeling and decreased mobility, there are a number of new exercises to learn. Even the simplest day-to-day tasks may require retraining. For example, simply sitting in a wheelchair for too long can cause a problem. Why? Because people naturally shift their position while sitting to eliminate pressure points, but for a person without feeling and sensation this natural process stops. A person who sits too long in one position can cut off circulation to the skin, causing it to die and leaving pressure sores. Part of the rehabilitation process is learning to avoid problems like this.

Therapists often use standing frames to help patients stretch and strengthen their hips and legs and for general weight bearing.

  • Enjoying life - Although things change after a catastrophic injury, enjoying life doesn't have to stop. One of the best ways to adjust to lifestyle changes caused by a disability is to participate in meaningful recreational activities. In fact, studies show that participating in therapeutic recreation helps patients get better and reduces their risk of later medical complications. This is why Shepherd Center introduces recreational therapy to every newly injured patient. The Center has its own indoor pool, basketball court, weight room, arts-and-crafts room and greenhouse, so patients can swim, learn to play a variety of sports, paint, take photographs, or work in the garden as part of their therapy.

Rehabilitation can involve everything from an intense session with a physical therapist to a driving lesson to an hour of swimming. There is so much to learn that a typical patient's day is filled with activity.

The Role of Technology
People with paraplegia and tetraplegia return to the community in very high numbers, and one of the things that makes that possible is today's technology. Technology can't repair a damaged spinal cord, but it allows for many other possibilities.

Technology is especially important for people with tetraplegia. Think about what it would be like to be in this situation, and you can begin to understand why -- without the ability to move your arms or legs, it can be nearly impossible to do anything without help. Here are some of the ways that technology can make a difference:

  • Speech-recognition software has gotten much better in recent years. It is now possible to use a piece of software like Dragon Naturally Speaking to control nearly every aspect of a computer. A person can type, browse the Web, create spreadsheets and so on without ever touching a keyboard.

Astounding technological strides have helped people who have limited mobility or neurological deficits take greater control of their lives and their environment. By customizing wheelchairs, seating systems, electronic equipment and computer-assisted technology, assistive technology professionals help individuals achieve maximum independence. These technological solutions can range from off-the-shelf universal remote controls and voice-recognition software to specially equipped computers, wheelchairs or vans.

  • Battery-powered wheelchairs with incredibly sensitive joysticks make it possible to move around independently. There are even wheelchairs that lift the user into a near-standing position, as well as the iBot balancing wheelchair, which increases mobility tremendously.

Wheelchairs are not a "one size fits all" piece of equipment. They must be customized to fit each person's lifestyle and functional ability. To determine which wheelchair works best, seating experts perform medical evaluations, clinical assessments and fitting services.

  • Lifts in cars and buildings make it possible to get in and out easily.

  • Ventilators help people with high-level spinal cord injuries, who no longer have the ability to control the muscles in their diaphragm, to breathe. A portable ventilator provides air in that situation.

  • Sip and puff straws, which are activated by blowing and sucking air, can help control everything from the phone to the TV.

People with high tetraplegia can drive their wheelchairs independently using a sip-and-puff control device.

Wheelchairs give people with spinal cord injuries their mobility. The first two images show today's most common wheelchair designs, and the third and fourth images show the wheelchair of the future.

A standard wheelchair is commonly used by paraplegics.

A powered wheelchair is commonly used by tetraplegics. In many cases, there is very subtle control left in one or both hands -- combine that with an extremely sensitive joystick, and wheelchair control is possible.

The iBot wheelchair, created by Dean Kamen and being manufactured by Johnson & Johnson, has the ability to handle a wide variety of terrain types, including sand, gravel and 8-inch curbs.

The iBot wheelchair also has the ability to "stand up" and balance on two wheels, putting the passenger at eye level with standing adults and making it possible to reach much higher objects and controls.

Acquired Brain Injuries
Another area of specialty for Shepherd Center is acquired brain injury (ABI). A stroke is a classic ABI. In a stroke, a clot blocks a blood vessel leading to the brain, causing the death of brain cells in the affected area. A brain tumor and the damage it causes is another form of acquired brain injury.

A traumatic brain injury (TBI) is a specialized form of ABI. TBIs are caused by an external force or by a rapid movement of the head, in which the brain is whipped back and forth and bounces off the inside of the skull. People frequently receive TBIs in automobile accidents or sports accidents.

Brain injury may result in physical, intellectual, emotional, social and vocational difficulties, so it is important to receive the appropriate care and therapy at the earliest stages of recovery. Rehabilitation involves learning new ways to compensate for abilities that have permanently changed due to brain injury. Regardless of how the patient acquires the injury, Shepherd Center's goal is to intervene as quickly as possible and provide the best care available. As the patient recovers, the staff at Shepherd Center also works with the family, the employer and the community to make the transition as smooth as possible.

ABIs are surprisingly common in the United States, with an estimated 1.5 million to 2 million Americans sustaining brain injuries each year. An estimated 50,000 people die each year of traumatic brain injuries in the United States.

The first stage of recovery may begin in the intensive care unit, where doctors and nurses help control the brain’s natural swelling process that follows such an injury. The patient may even be in a coma, which means he or she does not respond to stimulation. Later, the patient may move to a hospital room and begin a daily therapy program to re-learn basic skills such as memory, speech, balance, walking, writing or problem solving. Some people need continued therapy and may move to a post-acute setting that prepares them for more independent living.

People who sustain a severe brain injury can make significant improvements in the first year after injury, and can continue to improve at a slower pace for many years. Brain injury does not mean the end of a fulfilling and productive life; in fact, 95 percent of Shepherd’s patients return to their community having achieved a higher level of functioning.

Multiple Sclerosis
Multiple sclerosis (MS) affects the central nervous system, which includes the brain and the spinal cord. In MS, the immune system attacks myelin -- the protective coating on nerve cells.

Multiple sclerosis attacks the myelin sheath that protects the nerve fiber.

Without the protective coating, nerve cells have difficulty doing their job and sending signals. The damage that MS causes can affect:

  • the eyes, which have thousands of nerve fibers to carry visual information from the retina to the brain, as well as nerve cells controlling the eye's muscles
  • muscle coordination and strength, because nerve fibers have direct control of all muscles
  • speech, which is controlled by muscles in the throat, mouth and tongue
  • bladder and bowel control
MS is a disease that treats each patient differently. Approximately 15 percent of patients experience severe problems that can totally disable them. MS generally is not fatal, and most MS patients live a normal life span. MS affects as many as 300,000 Americans.

There is no cure for MS, but it is treatable. In a state-of-the-art facility, Shepherd Center offers comprehensive evaluation, diagnostic and rehabilitation services for people with MS.

MS Center professionals at Shepherd Center work to slow the ongoing process of the disease, focus on rehabilitation that emphasizes realistic goals for maximum independence, promote family involvement, and empower people with MS to make decisions and take responsibility for their own health care.

Shepherd MS services include:

  • Medical treatment to slow the disease process and relieve symptoms
  • Physical rehabilitation, including strength and energy conservation training
  • A range of supportive services, including psychological counseling, educational programs, vocational services, nutritional counseling, and therapeutic recreation programs
Patients at Shepherd Center are treated by an interdisciplinary team that may include neurologists, urologists, MS nurses, physical and occupational therapists, case managers, nutritionists, speech therapists, vocational counselors, recreational therapists, and neuropsychologists.

What I Learned
I was distinctly changed by the experience of visiting Shepherd Center. Here are some of the things I learned:

  • After my visit, the thing that left the most powerful impression on me is the incredible resilience of human beings. A spinal cord injury changes life significantly, but both the patients and the staff work toward making the most of it. The general attitude is that a person who becomes paralyzed can still return to work, school or volunteer opportunities and live their lives as members of the community.

Recreation doesn't have to stop after a spinal cord or brain injury. From basketball to water sports, competitive and non-competitive recreational activities are one of the best ways to adjust to lifestyle changes caused by a disability.

  • We see wheelchair-accessible features around us all the time, but after visiting Shepherd Center I understand how important they are to people who need them. Simple things like parking spaces, cuts in a curb so that a wheelchair can roll up easily, wider doors and accessible restrooms don't add much to the cost of a building as it is being constructed, but they make a huge difference to a person who uses a wheelchair.

  • The insurance industry needs to be modified to reimburse services like those offered by Shepherd Center. In the grand scheme of things, a very small number of people need the care that Shepherd Center provides, but if they need it, they need it. A place like Shepherd Center makes a huge difference in the rate of recovery, as well as the overall outcome of spinal cord injuries. Unfortunately, many insurance programs do not provide full coverage for this kind of care. As a result, Shepherd Center relies on donations and government grants to make up the difference.

  • There is a lot of value in a specialized facility like this. The doctors, nurses and staff deal with hundreds of catastrophically injured patients every year and have intensive, daily experience with them. This makes the staff better prepared and more flexible. It also benefits the patients, because everyone in the hospital is on a similar track and so can offer each other support.

A specialized medical facility like Shepherd Center is certainly one of the pinnacles of modern society. It takes a bad situation -- what could be a life-ending spinal cord injury -- and applies the highest levels of care, experience and technology to turn the situation around. For the individual patients who experience the process, the benefits are immeasurable.

As I found out, and as you hopefully have discovered in the course of this article, a place like Shepherd Center is a remarkable asset for society as a whole. The skill and expertise housed there makes a huge difference in the lives of its patients, and offers the best care possible for people in life-changing situations.

Not surprisingly, the latest developments in medical science and technology are often expensive. Insurance and government funding do not cover the whole cost of the Shepherd Center process. A big part of the operating budget for Shepherd comes from the generosity of individuals.

If you would like to contribute to Shepherd Center, you can do so either online, by mail or by phone. This page offers complete information:

Your support is greatly appreciated by both the patients and staff at Shepherd Center.

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