Spinal cord injury rehabilitation and pressure ulcer prevention after the 2005 South Asian Earthquake: a CBR case study from Pakistan.

BACKGROUND: The 2005 South Asian earthquake led to large-scale injuries and disabilities in northern Pakistan, which were dealt with using various approaches. In this regard, a community-based rehabilitation approach was initiated in the Muzaffarabad district of Pakistan in early 2006, focused on preventing complications among persons with Spinal Cord Injury. This case study briefly describes its development, aims and service provision components, in addition to the distribution of injuries from the disaster. Pressure ulcer prevention education, its recall and decrease in prevalence over a year are presented as key outcomes and illuminate the process of implementing rehabilitation in this context.

METHODS: This case study presents findings from a larger internal program evaluation in 2010-11. The study design was cross-sectional, to elicit recall of education components and the resulting prevalence of pressure ulcers over the year, in 33 randomly selected persons with Spinal Cord Injury. Outcomes included retention of knowledge about pressure ulcer prevention, practices and reduction in the prevalence of pressure ulcers over the last year. We also conducted a narrative literature review on the types of injuries and complications in the Spinal Cord population from Northern Pakistan.

RESULTS: Hospital cohort studies reported "spine" injuries at 5%, while persons with spinal cord injury were identified as the most underserved needing rehabilitation services after the quake. Results from the evaluation of prevention education revealed that all 33 respondents were trained in detection of pressure ulcers, while 32 recalled "danger signs" for which they would seek immediate help. All correctly recalled postural change timings, however, their actual practices differed. Twenty-seven respondents (82%) reported no pressure ulcers over the last year.

CONCLUSION: The decrease in pressure ulcer prevalence over the last year in persons with spinal cord injury highlights the strengths of the community-based rehabilitation approach, particularly preventive education in geographically challenging and highly resource constrained settings. The research also begins to fill a critical gap in the present literature as most research is limited to hospital based interventions from the first year of the 2005 earthquake. Implications for Rehabilitation Prevention education for targeting pressure ulcers can be effective in reducing incidence of this important complication in persons with spinal cord injury. Community-based rehabilitation approaches can prove beneficial in post-disaster settings, especially in resource constrained settings and difficult hilly terrain. Rehabilitation programs should consider nutrition interventions to reduce multiple pressure ulcers, especially in lower middle income countries.