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SPINAL CORD INJURY: EMOTIONAL PATHS TO RECOVERY AND LIFE REVIEW
Emotional Paths to Recovery
One way of coming to grips with the “reason” for a spinal cord injury is to search for the emotional meaning of the injury. Emotional pathways to understanding are, by definition, unique to your life. The psychological impact and meaning of the injury depend on your individual characteristics and your age and stage of life. As your emotional landscape changes over time, so will your insights into the emotional meaning of your disability. Given the uniqueness of emotional experience, the emotional impact and meaning of spinal cord injury have countless personal nuances. However, several processes or tasks are common in people grappling with the emotional meaning of an injury: life review, development of emotional priorities, and resolution of past internal and interpersonal conflicts. As is evident in the examples that follow, these three tasks often occur simultaneously or overlap.
Life Review and Emotional Priorities
Life review is a process of examining our life experience, taking stock of where we’ve been, what is happening to us now, and where we might set our sights for the future. This process often happens almost automatically at certain milestones, such as a fortieth or fiftieth birthday, marriage, retirement, or becoming a parent or grandparent. We naturally try to give meaning to these events, to understand their emotional impact within the context of our own experience. This process is also useful in coping with the emotional impact of a spinal cord injury.
In developing our emotional priorities, we sort out the relationships, activities, and values that are most important to our emotional well-being and disengage ourselves from those that are less important. We all go through this process from time to time, and it can be particularly helpful when a change in life circumstances limits our energies or creates new demands.
We know about the variety of strong emotions possible soon after spinal cord injury – anger, sadness, frustration, and isolation, all common, normal reactions. Yet your particular combination of feelings is unique and depends in large part on the kind of person you have been and the experiences you had before your injury. You are still the same person after a spinal cord injury; your basic personality is not likely to change. But the injury is likely to slow you down, at least for a while. Yet at the same time it can act as a catalyst, stimulating you to review and reexamine your experiences, values, and accomplishments. This in turn can lead to important changes in your approach to life, to a new appreciation for yourself and an experience of more positive emotions.
Peter developed paraplegia in his sixties as a result of a spinal hemorrhage. He was semi-retired from his job in real estate sales, but he still served as choirmaster for his church. A lengthy hospitalization, recovery from surgery, and inpatient rehabilitation gave him plenty of time to examine his life, a process he continued after going home. As he took stock of his life, Peter felt a growing sense of pride in his past accomplishments. He had a successful career, a stable marriage, and two grown children with good jobs and families of their own. And he had a passion for singing that had been nurtured and expressed through years of leading a choir.
Although he was initially frustrated and anxious about his disability, Peter found emotional strength in assessing his life and distilling its essence – singing. On a leave from the rehabilitation hospital, he went back to his church and after that, he recalls, “Getting depressed was not an option. I had to get back to the singing.” Peter realized how much the people in his choir and his church community cared for him and depended on his leadership. He felt an increased sense of purpose and a renewed commitment to giving his time and energies to others. At the same time, he decided to quit his real estate job because it no longer seemed important to him or to reflect his values. His emotional priorities had changed.
As a result of his life review and reassessment of emotional priorities, Peter gave more energy to the activities and relationships that were truly meaningful to him and set aside those that were not. He put his disability into perspective as a practical obstacle he could generally get around with some ingenuity and adaptation. The spinal cord injury was the worst thing that had ever happened to him, but in looking to the future he felt more relaxed because he was “on the other side of tragedy” Although Peter’s injury was not something he would have wished for, in reassessing his life it became the impetus for developing his unique talents, broadening his commitment to others, and learning to set aside the things he found unfulfilling.
*62/156/5*

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Other names: Meticorten

TREATMENT OF CHRONIC CANDIDIASIS: AVOID ANTIBIOTICS AND IMMUNOSUPPRESSANTS
Antibiotics should not be taken, unless absolutely unavoidable. In particular, the ‘broad-spectrum’ drugs, that destroy the protective bacteria in the intestinal and vaginal tracts, should not be taken over a long term. When this is unavoidable, an antifungal drug, such as nystatin, should also be taken to counteract stimulation of yeast growth by the antibiotic.
Of particular danger is the long-term treatment of acne by the use of tetracycline. This is a common mistake made by skin specialists. One of their standard procedures is to prescribe a broad spectrum antibiotic for months at a time. Whilst this can help acne in the short term, it rarely works long term. The antibiotic causes further increase in the yeast infection which was often the root cause of the acne infection. In other words, like most skin disorders, acne is usually the sign of a deep-seated allergy disorder. Any long-term treatment by antibiotics will breakdown the immune system, promote candidiasis and result in further allergy illness.
Another condition arising from candidiasis, for which antibiotics ?in’ commonly prescribed, is urethritis. This is often diagnosed by doctors as the more serious and deeper-seated disease of cystitis of t lie bladder, because they do not understand candidiasis or its Symptoms. As a result, antibiotics may be prescribed for weeks or even months. They do very little good and can actually harm the patient by aggravating the yeast infection which is causing the urethritis.
A further misuse of antibiotics is in their prescription for viral infections. They are not effective for this purpose, yet doctors continue to prescribe them, knowing this to be the case. General practitioners simply cannot grasp, or do not want to grasp, the simple possibility that viruses can cause infections by gaining access to the body through mucous membranes already irritated by allergic reactions to foods and chemicals. Candidiasis is considered a prime cause of this condition and antibiotics will only serve to aggravate the situation further.
Immunosuppressant drugs, such as cortisone and steroids should be avoided as they contribute to the breakdown of the immune system. These drugs will enhance the growth of yeast by their function which is designed to suppress the immune system in order to give relief of symptoms. This is a classic example of treating the symptom and not the cause. In this case the prescription of immunosuppressant drugs is actually harmful because, although in the short term symptoms will be relieved, ultimately the increased growth of yeast caused by suppressing the normal immune mechanisms will result in the deterioration of the patient’s condition. More intolerances and more debilitating symptoms will then occur.
*24/106/2*

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MIGRAINE TREATMENT: STRESS AS PROVOCATIVE FACTOR
Stress can undoubtedly act as a provocative factor in many patients and a logical form of treatment is to lessen this, if possible.
Frustrating situations are met with in nearly all walks of life. One patient told his story as follows:
From the standpoint of migraine, the year beginning 1 July was noteworthy because of the infrequency and mildness of attacks; during this period the amount of work in which I had been engaged just filled each day, making it possible to maintain certain personal ideals of perfection. Since November the greatest amount of concentration has been directed to quantitative determinations in a large number of microscopic sections of tissues. Frequent short periods of this rather monotonous work during almost every day had not been unpleasant. On 4 February it was suggested that an attempt be made to complete this research sufficiently to present an abstract of the work to a scientific society within 16 days for consideration as a presentation at a later date. Accepting this suggestion I therefore increased my concentration on this problem by working in the evenings. It soon became evident that the amount of work accomplished was falling far short of any schedule that would produce a sufficient number of figures within this time, and furthermore, the work was for the first time becoming distasteful. In the night, after the second evening in the laboratory I was awakened by an ache over the right eye associated with nausea. After a period of semi-wakefulness, sleep was resumed and the next day the only trace of a headache was pain on the right side of the head on coughing. After the third evening of laboratory work I was awakened at 4 a.m. by an ache over the left eye associated with nausea. Unlike the symptoms of the previous night they rapidly increased in severity until it became necessary to get in a hot bath to secure some relief. When I returned to bed, the pain and nausea resumed their former severity and 1 gram of codeine finally relieved their symptoms and allowed a few hours of sleep. During the entire next day there were nausea and a constant severe generalized headache extending downward into the back of the neck, which was made worse by walking, talking or reaching. The following morning the symptoms had vanished.
This story will strike a chord with almost every migraine sufferer. Although it is possible to explain this sort of tension on a biochemical basis, too few studies have been done in chronic stress situations to pinpoint the problem but the existence of two different personality types is pertinent. Type ‘B’ people who thrive on challenges get a ‘charge or kick’ by being active and doing things and may in fact be depressed and lethargic when under-stimulated; with this personality, absence of stress may spark off headaches. The patient above is an example of a Type ‘A’ personality, who reacted badly to stress.
*43/152/5*

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WHAT TRIGGERS THE SPASM: POSTURE OR PROLONGED USE OF MUSCLES
If you hold your head and neck rigid or in an awkward position for a long period of time, muscle pain may develop. This is common in persons who become tense while driving their automobiles in bad weather or heavy traffic. Bedtime television watchers may provoke this discomfort by slouching in bed with the head propped forward by a pillow as they peer at the television set located at the foot of the bed. Looking down while reading may also lead to muscle contraction pain. This chin-on-chest posture is apt to be particularly uncomfortable for anyone who has a preexisting arthritis in the neck. Prolonged extension of the neck upward and backward, as when painting a ceiling, can, of course, also be painful.
One of our patients noted that she suffered headaches only on the evenings that she played cards with friends. The headache would usually begin late in the evening, after she had spent many hours looking down at the cards she held in her hands. Concentrating on the cards and enduring the smoke in the room cannot be entirely overlooked as contributing factors, but it eventually became clear that the woman’s chin-on-chest posture was to a large extent responsible for producing the discomfort. She was given a cervical collar to wear during her card parties. This device is worn around the neck and assists in supporting the head and limits the forward movement of the head and neck. To the patient’s delight, and to ours as well, her headaches lessened, and the pain did not interfere with her enjoyment of the game.
The chin-on-chest posture often produces discomfort in those of you whose work or other activities require this position for long periods. Typing, reading, propping a telephone receiver between the shoulder and head while talking, and similar activities can cause headaches in some people.
Facial mannerisms, such as prolonged frowning, squinting, jaw clenching, gum chewing, teeth gnashing, even holding a smile or other movements of the face requiring specific muscle activity, may also provoke muscle pain that is felt as a headache. If you have arthritis of the jaw joint, imbalances, or other abnomalities of your jaw, the muscles around your jaw and temple area may painfully contract when the jaw is used, particularly during prolonged or intense chewing activity. This is often felt as a headache in the ear area or temple region.
*43/88/2*

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Other names: Indocin Cr, Indocin SR

RATIONAL UNDERSTANDING OF SPINAL CORD INJURY
Rehabilitation, in the broadest sense, combines physical, emotional, cognitive, and spiritual changes. But hospital rehabilitation is primarily a learning process. Alterations or limitations in one’s ability to perform once mastered tasks – dressing, walking, eating and socializing – require the learning of new ways. Adopting a student’s approach to rehabilitation can help you view each “problem” or “loss” as a mystery to be worked out or a blank page to be filled with your own imagination and ingenuity. Observing, trying new approaches, and getting positive results are a rewarding process. Not only does it keep you from drowning in misery, but it focuses your attention on the creative process of rebuilding your life.
Journalist John Hockenberry’s description of his own encounter with rehabilitation emphasizes the intellectual challenge of problem-solving: “my body now presented an intriguing puzzle of great depth and texture . . . The future seemed like an adventure on some frontier of physical possibilities. Each problem – getting up, rolling over, balancing in a chair, getting from here to there – needed a new solution. I was physically an infant endowed with the mind of an adult . . . Solving each problem offered a personal authorship to experience that had never before seemed possible.”
The benefits of an individualized problem-solving model in rehabilitation have been described by physiatrists (specialists in physical medicine and rehabilitation). Through independent thinking, self-directed behavior, and experimentation, persons with spinal cord injury can regain a healthy sense of personal effectiveness and develop solutions that are tailor-made to their environment, activity preferences, and other individual needs.
A rational approach to recovery shifts your focus away from the questions of “Why?” toward the issue of “How?” It helps you to limit your handicaps by finding ways of changing the environment or making use of devices that compensate for your disabilities. When you ask yourself, first, “What do I want/need to do?” and then, “How can I get it done?” you’ll find practical solutions specific to your situation. Setting goals and inventing or discovering ways to meet them gives a sense of direction, purpose, and personal effectiveness. The ends become more important than the different means by which you achieve them. “Please don’t say that I’m . . . ‘confined to a wheelchair,’” says Ralf Hotchkiss, a designer of wheelchairs who is paraplegic. “I’ve been liberated by a wheelchair.” This sentiment applies equally well to other assistive devices, to personal care assistants, to structural or organizational, modifications at your workplace, and so on. As you gain a rational understanding of your spinal cord injury, meaning and purpose will emerge: you discover what works for you, what makes you more functional, and what lets you reach your goals.
*61/156/5*

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SPINAL CORD INJURY: WHAT DOES THE INJURY MEAN?
A spinal cord injury is almost always a life-changing event, a critical moment that forever divides a person’s history into “before” and “after.” The injury often results from disease or random accident, though it may be the consequence of violence, unusual risk-taking, or self-destructive behavior. Coming to terms with the reason (or lack of reason) for the injury can be an important part of emotional recovery. Not everyone finds it necessary or productive to grapple with the questions, “Why me? What is the meaning of the injury for my life?” But many people find that their answers to these questions shape their outlook on the future and help them live productively and meaningfully after the injury.
People make sense of their experience of spinal cord injury in many ways. Three common pathways to understanding are: the rational (cognitive), the emotional, and the spiritual. Many people tend to zero in on one of these aspects, while others draw insights from all three. Each path provides ways of interpreting the experience that can lead to guilt, bitterness, cynicism, and despair, but also to opportunities for personal growth and change, hopefulness, spiritual renewal, and joy.
Each person finds an individual path to adjustment. You may find your path through work, relationships, creativity, or simply “tincture of time” and gradual resumption of life’s daily tasks and rhythms. Our discussion of rational, emotional, and spiritual aspects of understanding spinal cord injury is offered simply as a framework to help guide your exploration. In no way is it meant to limit or define your individual experience.
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SPINAL CORD INJURY: SELF-IDENTIFICATION IN PROGRESS OF RECOVERY
A week before discharge, Vanessa’s anxiety spurred her into action. She asked her best friend to visit for an “image consultation,” and together they planned Vanessa’s makeover. She had her hair styled and her nails done in the hospital beauty parlor. She agonized with her physical therapist about color choices for her crutches, eventually choosing teal blue. She gave her friend a shopping list: brand-name athletic shoes, stretch jeans, a long skirt and some V-neck tops. She was ready to ditch the baggy sweats that had been her hospital uniform.
That night, after showering, Vanessa stood naked before the bathroom mirror – the first time she’d really looked at herself since the injury. She was surprised to see that despite the changes in her mobility and sensation, her figure was barely changed and still attractive. The physical therapy and crutch-walking had made her upper arms more muscular, and she approved of their sculpted appearance. Her legs were thinner than before, not as toned, but the changes were subtle. She considered the crutches held against her naked skin. They didn’t look too bad – as long as she was standing still. Though overall she felt more confident, Vanessa still worried how her altered mobility would affect her life outside the hospital.
Vanessa returned to her apartment just before Thanksgiving. Her sister surprised her with a welcome-home party attended by good friends and family members. Vanessa spent Thanksgiving weekend at her parents’ home surrounded by relatives. Everyone expressed delight at her progress and encouraged her to “keep working on it.” During the holiday season, she busied herself with shopping and seeing girlfriends. She went to physical therapy several times a week, working to increase her strength and improve her gait. She returned to the health club where she’d worked out before the injury, this time with a personal trainer to help her strengthen and tone her body. She registered for classes at the community college, to begin in February, and she started looking for a part-time job.
Eventually, Vanessa started going out with groups of friends, and before she knew it, she had a date. She was very excited, but also nervous about how to present her disability. In group settings she had already “passed” as able-bodied by telling people that she’d hurt her leg in an accident, implying that she’d be better soon. At other times she’d answered questions about her injury by telling the whole story from the boat trip to the ER to the details of her treatment. To her disappointment, this seemed to overwhelm and alienate people rather than create the intimacy she’d hoped for.
When the question did, inevitably, come up, Vanessa told her date what she’d been rehearsing – that she’d hurt her back in a boating accident and had some neurological damage that made it hard to walk. She thought this was an honest answer, but not overly detailed or personal. And it allowed her to be matter of fact about the disability rather than making it the central focus. Suddenly Vanessa felt weary of constantly thinking about physical therapy and her weakened legs. She wanted to focus on her strengths again – her humor, independence, and outgoing nature. The date became a symbolic turning point: she decided to be herself, not a “para,” first. She surprised herself with her ability to kid around, laugh, and talk about her interests and ideas. She had a wonderful time.
As your recovery progresses, you are likely to experience a variety of self-identifications, self-presentations, and self-labels. As people, disabled or not, mature and enter new stages of personal or professional development, they shed some aspects of their identity and take on others. Your “adjustment” to disability is an ongoing process that begins in the hospital and continues as new relationships, environments, and activities pose challenges to your physical and emotional coping skills. Self-acceptance depends not only on making peace with the physical limitations of having a spinal cord injury, but also on developing and expressing your intellect, emotions, creativity, and personality. By maintaining or redefining your unique sense of meaning and purpose, you will be better able to live successfully and keep your disability in perspective.
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IDENTITY AFTER SPINAL CORD INJURY
The development of a peer group identity is particularly important for adolescents and young adults. As teenagers struggle to differentiate themselves from parents and adult authorities, to gain self-sufficiency, and to “find” themselves, identifying with and fitting in with a peer group is of paramount concern. Defining oneself as “different” (from adults) paradoxically requires a definition as “same” (as peers). Teenagers of every generation develop styles of clothing, music, and language that distinguish them from adults – and then demand from other teens a strict adherence to these new group norms!
While teenagers may struggle at times with the pressure of having to fit in, they nevertheless gain a great deal of support and self-esteem from identifying with their peer group. Teenagers with spinal cord injury often can develop a positive self-image by interacting with other disabled teenagers. A young adult with spinal cord injury can mentor a teenager to help him or her cope with changes in appearance, self-image, and identity. Some hospitals have special support or therapy groups for younger adults and teenagers with spinal cord injuries, or they may be able to arrange peer counseling for a teenager who is getting ready to leave the hospital. After going home, teens can get acquainted with peers who also have spinal cord injuries – for example, by becoming involved in wheelchair athletics or camping trips for teenagers with disabilities.
Part of the shift in group identity after spinal cord injury, for teens and adults alike, occurs through the adoption of new language and new labels. You and your fellow patients, perhaps without thinking about it, may have begun referring to yourselves as “paras” or “quads.” Some people with spinal cord injury refer to themselves as “crips” or “gimps,” turning these previously stigmatizing labels into expressions of unique identity and pride, in much the same way that some gay people use the word “queer” or teens use “grungy” and “raunchy” as positive descriptors. You may also find yourself adopting a new slang vocabulary for the equipment that is so much a part of your life – vents, chairs, caths, TEDs, and a host of other medical abbreviations and acronyms that describe your injury and its functional consequences. Finally, you may discover from your new “in group” a language that describes non-disabled people in “out-group” terms, such as “walkies” or “a.b.’s” (able-bodied). These shifts in language are all part of the process of differentiating oneself and integrating the new variables of disability and (for some people) minority status into one’s personal identity.
Along with these changes in self-labeling or self-identification may come changes in your perception of specific aspects or consequences of your disability. In the initial period after spinal cord injury, especially if the injury was traumatic and the disability sudden, changes in bodily appearance, function, and mobility are typically seen as symptoms of illness, needing to be cured or fixed. Like a broken arm or a stomach virus, the initial effects of spinal cord injury are often viewed as alien, not part of oneself, temporary and erasable. Indeed, in many cases, some recovery of function does occur over time and some symptoms disappear totally. But for most people with spinal cord injury, some degree of disability is permanent, and many patients leave the rehabilitation hospital with significant impairments.
As you become increasingly aware that some impairments or limitations may not be fixable, you may find it harder to maintain a separation between your “real” or “normal” self and your disability. The psychological challenge at this point is to make the transition from seeing the disability as alien, not the “real me,” something to be overcome, to seeing the disability as “part of me,” an aspect or characteristic of the self, something that does not have to be eradicated.
Alicia, a young woman with quadriplegia since the age of fifteen, described the reaction when she and her boyfriend announced their engagement. Her future mother-in-law said, “We like you but we don’t like your circumstances.” Alicia replied, “I am the circumstances.” As shown by her simple but eloquent reply, she had incorporated spinal cord injury into her personal identity. In effect she was saying, “If you like me, then like my disability – because it’s part of me and I’m part of it.” This process appears to be one of incorporating or integrating the disability as a characteristic of oneself, while simultaneously relinquishing the perception of the disability as a symptom or illness. Put another way, it is the transition from being a patient (sick, damaged, broken and dependent) to being a person (with the variety of attributes, strengths, and weaknesses that all humans have).
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IMAGE CHANGES IN PEOPLE WITH SPINAL CORD INJURY
Early in your recovery, you may see the changes in yourself as invalidating, unacceptable, or repulsive – you may, in effect, stigmatize yourself. Your early social encounters may reveal social strain, physical distance, intrusiveness, or outright prejudice. Physical and social barriers will loom large in your adjustment to living with a disability. You may begin to feel that you’re on the outside looking in; you’ve become one of “them.”
You may be shocked to realize that by virtue of your injury, you’ve joined a minority group. Like any marginalized group in society, people with spinal cord injuries are often denied access to many avenues of mainstream life, including acceptance in social and personal relationships. Even your own family members may initially look at you as alien. Their emotional acceptance may not come as quickly or completely as you’d like.
Many people find it helpful, particularly in the early stages of adaptation, to associate with other people who have similar injuries. The positive side of minority or “out-group” status is joining a new group of peers with whom you can identify and from whom you’ll get support and acceptance. Identifying yourself as part of a group with unique characteristics, needs, and accomplishments can become a source of pride and strength.
The growing disability rights movement generally subscribes to a minority group model for understanding the life experiences of people with disabilities. According to this model, the social and environmental barriers to integration in society have a greater impact on adjustment and successful living than do an individual’s psychological or medical factors. While disability per se is a physical or mental characteristic, handicap (disadvantage resulting in limitations in fulfilling one’s normal role) results from the interaction between a person and the environment. The crucial point is that the attitudes of other people and the physical/environmental barriers to mobility are problems separate from the disabled person’s physical or mental adjustment. This perspective can be psychologically liberating. It makes clear that your capacity for emotional or psychological strength is not the only relevant factor in adjustment. This eases the pressure you may have put on yourself and helps you direct more of your energy to solving the problems caused by external obstacles, whether physical, attitudinal, or economic.
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SPINAL CORD INJURY: IMAGE AND IDENTITY
As the inpatient rehabilitation stay draws to a close, or perhaps in the period just after leaving the hospital, the overall changes in your image may lead to questions about personality and identity. How can you incorporate new self-perceptions, images, and feelings into the sense of yourself as a unique person? Will your past personality and identity endure, or will this experience change who you are?
For many people, psychological adjustment involves two seemingly contradictor}^ processes: on the one hand, developing an identity as disabled or having a spinal cord injury, and on the other, separating the physical consequences of injury from one’s true or core self. Put another way, adjustment requires making a distinction between the losses associated with the injury and the positive aspects of your personality. In finding a way to “repackage” yourself to incorporate both limitations and strengths, you may also discover some unexpected, positive consequences of the changes brought about by your injury.
The end of inpatient rehabilitation signals the resumption of “real life.” The future must be faced. You may wonder who you are now and who you may become. At first your identity may seem to be in limbo, and you may feel anxious and unsure about how your identity will change. You may need to focus for a time on losses, either by grieving or by simply acknowledging them. By this point it’s probably clear, at least on an intellectual level, that some functions, sensations, or images are permanently lost or changed.
Some people find it helpful to cement the reality of these changes with some sort of practical or ritual action. The sale of a previously prized bicycle that you’ll never ride again, or the move from your “dream house” that has three unmanageable flights of stairs, can become metaphors for saying goodbye to lost abilities. Well-meaning friends or family may urge you to hold onto these possessions longer, “just in case.” But selling the bike or making the move can be both an acknowledgment and a letting go of loss. This type of action can help you move on to new and different activities, to forge a new image based on what you can do rather than what you can’t. Putting your energy into discovering, reviving, or developing your individual strengths and interests will help you develop a new identity, a healthy sense of self-worth and self-esteem, and an attitude of self-acceptance.
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Other names: Emulgel, Voltaren Xr, Voltarol

A SUMMARY OF THE BASIC FEATURES OF MIGRAINE AND A MIGRAINE PERSONALITY QUIZ
Episodes of headaches lasting hours to days and sometimes hurting on one side more than another.
Often begins in childhood, teens, or early twenties.
The presence of additional symptoms, including nausea and vomiting, visual abnormalities, and sometimes weakness and numbness.
Often is inherited and other family members have similar headaches.
Attacks triggered by emotional factors, alcohol, certain foods, menstrual periods, exertion, weather changes, and sleep (attacks can awaken patients during the night).
During an attack, patients seek quiet, dark solitude.
After an attack, patients may feel “washed out” for hours or days.
A migraine personality quiz-The so-called migraine personality is characterized by
compulsive, perfectionistic, and self-critical tendencies. Often these features reflect an upbringing that placed a high premium on discipline, restraint, achievement, and respect for authority.
It is a matter of debate whether having the migraine personality really means that you are more likely to have migraine headaches. Certainly many migraine sufferers do not have these personality traits, and many people who have the migraine personality do not suffer from headaches.
The following exercise may help you determine whether or not some of the features of the migraine personality are present within you. The quiz is informal and is offered for your
entertainment. To take this quiz, read each statement carefully and decide to what extent it applies to you. If the statement reflects your personality, write the number (3) as the score. Give the statement a score of (2) if it is rather like you but not exactly. Assign a score of (1) if the statement only minimally reflects your behavior. If the statement is not at all like you, give it a score of (0).
Score
1. You put a very high premium on neatness. You feel uncomfortable when things around you are out of place. You often find yourself rearranging things so they look neat and tidy.
Score
2. Even though you don’t like to admit it, you are often angry at various people and situations.
3. Frequently your patience is quite thin. You make every effort to maintain self-control and seem calm on the surface, but you are really steaming inside.
4. Disapproval is very troubling to you. You make every effort to stand out and excel in the things you do. To you, being average at anything is almost the same as failure.
5. You become annoyed very easily at people who are not like you. Although you would like to change their ways, you become particularly incensed if they try to control you or change your manner.
6. Small irritations, such as ashes dropped on your table or people around who are messy, make you feel annoyed, hurt, or actually angry.
7. You are a pleaser. You often go out of your way to please and befriend individuals whom you either do not particularly like or who do not deserve the benefits of your efforts. Nevertheless, you choose to satisfy other people’s needs at the neglect of your own.
8. You believe that working hard is a virtue, and you have little respect for people who do not share the philosophy that hard work is the price of achievement.
9. You constantly write lists. You makes lists for shopping, trips, birthdays, daily activities, and bills. You even write lists to remember what to tell your doctor or a friend.
10. Quite often you imagine yourself “telling people off.” Nevertheless, you never seem to say these things to the right people at the right time.
11. You have a great deal of difficulty expressing your anger or disappointment. You end up smiling approvingly rather than exposing your true emotions or actually confronting anyone.
12. You tend to believe that your way is the best way. When a different approach is suggested, you are usually unwilling to change, despite the possible merits or advantages.
13. You seldom take shortcuts, even if it means reaching your goal more simply or quickly.
14. You are extraordinarily organized. When given a responsibility, you create a plan to achieve your task efficiently. You will not rest comfortably until your goal is accomplished.
15. You place a very high premium on being on time. You are punctual about everything. You avoid being late even by a few minutes. You become very uncomfortable if you are tardy, even if there is an understandable reason.
16. You are concerned about bodily cleanliness and neatness. You are concerned about cleanliness and neatness in general.
17. You worry that you have a body odor or germs and find yourself washing, brushing your teeth, showering, or bathing probably more often than truly necessary.
18. You perform many little rituals that are part of your daily routine. For example, before going to bed at night you might perform certain tasks, often in a certain sequence, like making sure the front door is locked (even if you know it is), making sure objects are in their appropriate place, seeing that every knob on the stove is checked at least once (maybe even twice), or closing the closet door tightly. If you are prevented from carrying out these little rituals, you become upset and may not be able to fall asleep.
19. You disapprove of any form of procrastination. You must do things now! You live by the adage “Don’t put off until tomorrow what you can do today.”
20. When going out for an evening, you must be dressed appropriately and in the expected manner. Not being so makes you uncomfortable and very self-conscious.
21. Dirt is definitely your enemy. If you set out to clean something, you work to get every last particle of dirt removed.
22. When you have friends over to visit, everything must be in its proper place and very clean. For example, if an ashtray has a few ashes in it, you feel inclined to empty it repeatedly, even during the visit. You worry about what people might think of you if everything is not just so.
23. Your parents were very strict with you, insisting upon discipline, early toilet training, and a heavy emphasis on neatness, withholding of emotions, and on achievement.
24. Your handwriting is very neat. For you to be comfortable, things around you must also be very neat and orderly.
25. You are very critical of yourself. If you achieve something that you know was done well, you might nevertheless be inclined to deny its merits when complimented. Although you criticize yourself readily, you shun criticism from others and become angry and hurt if people question your actions.
26. You are a perfectionist. You enjoy being told that you are a perfectionist and consider it a fine compliment.
27. You are often constipated. Not only do you hold your emotions inside, but you hold on to everything. You do not let go of anything very easily.
28. You are a collector and a saver. Throwing something out is most difficult for you. You acquire much more than you actually need.
Add up your responses to determine your total score.
63-84: If your total score is in this range, you clearly possess features of the migraine personality. It is likely that your compulsive personality brings you a good deal of discomfort. You would probably benefit from any effort that would loosen up your compulsive, rigid
life-style, but do not go about changing your life-style in a compulsive manner!
42-62: Your performance indicates that significant elements of the migraine personality are present in you. Whether or not you have migraine, you might consider loosening some of your more compulsive habits. You might feel better as a result.
21-41: Your score indicates that you have a reasonable balance between compulsive and noncompulsive elements in your personality.
0-20: Based on this quiz, you do not have much evidence of compulsiveness in your personality. If your life-style is disorganized and unstructured and if you find yourself suffering the consequences of unfulfilled ambitions, irresponsibility, and inability to achieve, you might consider becoming a bit more compulsive and organized in your ways. However, if you are happy?wonderful!
It occurs to us that if you are married or living with someone whose score on this test differs from yours by 40 or more points, you have ample reason for headaches?migraine or otherwise!
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SPINAL CORD INJURY: APPEARANCE AND SELF-IMAGE
Following spinal cord injury, the most likely physical change that is readily visible to others is in the way you move. Our image of ourselves, as well as other people’s perception of us, is shaped not only by facial features and physique but by expressions, gestures, and characteristic patterns of body movement. “The way you wear your hat, the way you sip your tea . . . they can’t take that away from me”- these old song lyrics express just how much our image of others, and even what we love or cherish about them, is related to movement. These changes in the capacity for movement or in the way of moving after the injury may affect not only how you appear to others but how you see yourself.
In some cases, such as in people with injuries high in the cervical spine, all movement below the neck is lost. Although facial expressions, voice quality, and unique speech patterns are preserved, people with high-level quadriplegia lose their characteristic hand gestures, body movements, and defining grace or clumsiness. They may feel that their head or mind is disconnected from their body, or feel trapped in their body, wanting to move but unable to do so. Or they may see their body as a burden to be dragged around. In some cases mobility may be largely restored, but uneven or awkward gait patterns look radically different from normal walking and draw attention to one’s altered function. In other cases, spasms can lead to uncontrolled shaking or jerking of the arms and legs, another highly visible alteration of normal movement.
Another physical change accompanying many spinal cord injuries is muscular atrophy. When muscles are not used, muscle mass decreases, resulting in the skinny appearance of normally large muscles such as the quadriceps (the front of the thigh). Weakened abdominal muscles can result in a flabby appearance even in a thin person. Contracted or flaccid muscles can create gnarly hands, lopsided trunks, or limp, lifeless-looking limbs.
The impact of these physical changes on overall appearance, as well as the difficulty of integrating them into one’s self-image, is compounded by the presence of “appendages,” the many assistive devices needed for living with a spinal cord injury. Braces, wheelchairs, crutches or canes, ventilators, and other adaptive devices are visible, tangible signs of disability. On the other hand, these assistive devices are essential to the injured person’s process of reintegration because they allow more varied motor activities (braces, crutches, or wheelchair) or self-care and feeding (adaptive splints or utensils). As their benefits become increasingly apparent and begin to outweigh concerns about appearance, these devices often become completely incorporated into one’s self-image, inseparable from one’s identity.
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SPINAL CORD INJURY: BODY IMAGE AND SENSATION
Body image refers to the psychological experience of the body. This includes feelings and attitudes about one’s body, its parts, and its functions, as well as awareness of bodily boundaries (what’s inside and outside the body), where the body is located in space, and the relationship of the body to the environment. Body image is a part of overall self-image, and this may be disrupted or altered by the effects of spinal cord injury on sensation.
In complete spinal cord injuries, sensory as well as motor function is lost below the level of the injury. In incomplete injuries, partial loss of sensation is common. So accompanying the changes in how the body looks are dramatic changes in how the body feels. These changes run the gamut from complete loss of all bodily sensation below the level of the injury, to diminished sensation for touch, temperature, pain, or position, to distorted or “phantom” sensations of pain, tingling, or position (that is, having the sensation that part of your body is in a position other than the position it’s actually in).
If you have diminished or distorted sensation, you have to rely on visual cues and memory to maintain a cohesive body image. Visual feedback can be essential for incorporating changes in the way your body functions. You may need to look at your leg to know whether it is properly placed on the bed or chair. Similarly, if you have a visibly altered gait or use a wheelchair, others will respond to you on the basis of these visual cues. Perhaps in part to counter these cues (still generally perceived as negative), people with spinal cord injuries often pay more attention to their personal appearance and to looking as attractive as possible than they did before the injury. This creates visual and sensory feedback that helps restore an accurate body image, and it focuses positive attention on oneself, further improving self-esteem and promoting social encounters.
Loss of tactile (touch) and kinesthetic (movement) sensation has obvious practical implications, too. Without normal pain and pressure sensations, you are more vulnerable to accidental injuries such as burns and to pressure sores (decubitus ulcers) on your skin. Instead of relying on pain sensation to tell you when your body is threatened, you need to anticipate your body’s needs. For example, doing pressure releases on a schedule will prevent pressure sores, and testing (or asking someone else to test) the temperature of water, cookware, and so forth will protect you from burns on body parts that can’t feel heat or pain. You may need to examine your skin for signs of accidental bruising, cuts, infection, and so on. Similarly, if you cannot feel pressure ? your bladder or bowel, you must schedule regular catheterization and a bowel program to avoid bladder infections or bowel impaction.
Diminished or absent pelvic and genital sensation, in addition to its effects on sexual function, can play havoc with body image and sense of self. While it is only one part of total sexuality, genital sensation is, for most adults, an important part of feeling feminine or masculine. Until you have had the opportunity to explore other aspects of sexuality or sexual experience and to discover other erogenous zones, the loss of genital sensation may be disorienting. Your sense of self as a sexual being may seem to be irreparably damaged.
The extent of permanent changes in mobility, appearance, and sensation after spinal cord injury varies widely, depending on the level of injury and degree of recovery. These changes inevitably have some effect on self-perception, body image, and self-image, but their effect on overall psychological adjustment is not necessarily devastating. The extent of the impact often depends more on attitudes, social context, and the psychological meaning of particular changes than on the extent of the actual alterations in mobility and sensation.
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SPINAL CORD INJURY: READING THE MAP. ADJUSTMENT
Vanessa worked as a waitress while attending community college part time. Her family was financially comfortable but not wealthy, and Vanessa had always known she would have to make her own way in the world and support herself after high school. She was an attractive, hard-working young woman with a good sense of humor. She had many friends and enjoyed going out to bars and parties, and liked to take boating trips near her bayside town. Although she had dated in high school, Vanessa had not had a serious romance. She hoped to get married and have a family, but not until she had finished college and found the “right” man.
Vanessa prided herself on her independence, her loyalty to her family (she lived in an apartment with her sister and visited her parents and grandparents often), and her physical fitness (she regularly went bike riding and swimming and could handle a small sailboat). Her career goals were still somewhat hazy. She enjoyed her business classes and thought about going into accounting or possibly law, then building a business or practice in her small home town.
On a beautiful sunny day in the summer she turned twenty-one, Vanessa was out on the bay in a cabin cruiser owned by the father of a friend. A group of friends had planned the outing: a picnic, some beer, and dance music on the boat. Sometime after lunch, Vanessa became aware that several of the young men had had too many beers and were becoming reckless. The man steering the boat was going much too fast and swerving dangerously close to the shoreline. Most of the group was caught up in merrymaking, many below deck, and didn’t seem to notice the danger.
Vanessa called out to the man at the helm to slow down, but he didn’t respond. She started to walk up the deck to confront him when, suddenly, the boat careened into a piling on the shore. The back of the boat jerked up and Vanessa was bounced up into the air. She landed hard on her back on the deck and felt a jolt of pain. Minutes later a friend tried to help her up, but Vanessa could not stand up. She had broken her back.
Vanessa had a spinal fracture that required fusion surgery and resulted in incomplete paraplegia. After two months in a rehabilitation hospital, she could walk with crutches for moderate distances. Although she was building strength and endurance, uneven muscle strength gave her a gait that, though functional, was clearly abnormal. She managed her bowel and bladder care. She had no “accidents” (incontinence) and had mastered the use of catheterization kits that could be stored in her purse or pocket. Her doctors expected her to get stronger and more proficient with the crutches, and even progress to the use of canes. But they thought it unlikely that Vanessa would ever walk without an assistive device.
Vanessa’s humor, independent spirit, and supportive family helped her through her initial recovery and the emotional roller coaster of early rehabilitation. Initially she had been very angry about the accident – at herself for misjudging her friends, and at the driver of the boat for his recklessness. She had been sad about her injuries, though not clinically depressed. She knew that waitressing and most sports would no longer be possible, but she was eager to get on with college and hoped to find an office job. After talking to her physical therapist about sports, she found that swimming and riding a stationary bike were still possible. She would be able to get in and out of her apartment without difficulty and drive a car with hand controls. Overall, her recovery went more smoothly than she could have imagined that first day in the Emergency Room.
Yet as Vanessa’s discharge date approached, she became increasingly anxious about facing the world. A casual comment from a friend – “I’m sure you’ll get rid of the crutches if you keep working at it” – set off an explosion of questions and concerns. Vanessa worried about her appearance and acceptability to others. As she stood before the mirror, she wasn’t sure she looked the same as before the accident. Did the crutches make her ugly? Was her unusual gait “gimpy” and repulsive? Was she working hard enough for recovery or was she wimping out? Would her friends want to be seen with her at parties? Had she changed inside because of the accident? Was she the same person as before?
She had just started to feel good about her recovery, but now the road ahead looked very scary. For the first time, Vanessa asked herself if she could manage life, especially her social life, with her disability. She knew it was not enough to be physically independent. She would have to confront her changed appearance, self-image, and identity in order to reenter the world of her peers.
After a spinal cord injury, a person’s concern with appearance can be triggered by a friend’s remark, as it was for Vanessa, but more often it arises spontaneously early in rehabilitation or soon after going home and resuming social activities. A variety of visible changes can accompany a spinal cord injury, and these changes can affect one’s self-image and identity. And, like all disabled people, individuals with spinal cord injury will encounter negative reactions to their appearance.
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SPECIALISTS TO HELP PEOPLE WITH SPINAL CORD INJURY: SOCIAL WORKERS
Hospital social workers generally have a bachelor’s degree or a master’s degree in social work (BSW or MSW). Few people with a doctorate in social work (DSW) work in hospitals. Social workers have special training in evaluating people’s needs for social and human services such as assistance with housing, welfare, medical care, or mental health services. Some social workers also have specialized training in providing clinical mental health services such as family counseling or individual psychotherapy. Some states license MSWs as licensed clinical social workers (LCSWs). These professionals work in any social service or mental health agency or maintain a private practice in psychotherapy.
Communication with family, friends, co-workers, and others close to you is essential as you integrate new limitations, needs, and emotions with old roles and relationships. You also need good rapport with your spouse or family to ensure competent and loving care or assistance “when you return home. Social workers can help with this communication by talking regularly with your spouse or family about your progress, your concerns, and your discharge plans.
All hospital-based rehabilitation programs have social workers on staff. Depending on the facility, their role may be weighted more toward patient and family counseling or more toward solving the practical problems associated with returning home – arranging for in-home therapies, transportation to work, disability payments and insurance, and so forth. The social worker is the primary person involved in securing placement in a nursing home, another hospital, an outpatient rehabilitation program, or a home care program, when necessary. He or she helps to coordinate any care or equipment needs before your discharge and makes sure that appropriate aftercare is set up with the doctor, mental health professional, or nurse practitioner.
Your social worker often acts as your advocate, helping you identify and solve practical problems, obtain assistance and training, and get information on community services. He or she also provides (or makes sure that you get) help with emotional or psychosocial problems. The social worker will, when necessary, help communicate your needs to your doctor, family, employer, or school.
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HELPERS FOR PEOPLE WITH SPINAL CORD INJURY
You may encounter a few other types of professionals in the rehabilitation hospital, depending on the type of facility. Some programs employ certified rehabilitation counselors (CRCs), who are trained to counsel people with disabilities on a variety of adjustment issues. They receive their credentials from a national board, and some are licensed or certified by their state. CRCs can play a significant role in the transition back to work. They make sure that all elements of the return to employment are in place, including the disabled client’s readiness and ability to do the job in question, the employer’s awareness of the client’s abilities and special needs, and the physical accessibility of the work site. CRCs often help prepare management and co-workers for the entry 0r return to work of a person with spinal cord injury.
Vocational rehabilitation counselors, who are sometimes also CRCs, are usually employed by state governments to help injured workers return to the work force. Their role is to help people with spinal cord injuries return to their jobs or to receive college or technical training.
A vocational rehabilitation counselor can be instrumental in finding employment opportunities for clients, by evaluating skills and aptitudes and advising them about training opportunities or new types of work for which they may be qualified.
Increasingly, case managers now plot the course and timing for successful reentry to independent living and return to work. Hired by third-party payers or hospitals, case managers assist individuals with spinal cord injury in making decisions about their medical, rehabilitation, and vocational needs. Most case managers have a background as helping professionals; they are often nurses or rehabilitation counselors. Sometimes one case manager covers both medical and vocational areas; in other cases these areas have separate case managers. A case manager often continues to work with clients after their discharge from the hospital, ensuring the coordination of outpatient care and a smooth transition to home and work life. People who have benefited from the skills of a case manager say that this relationship was crucial to their success at independent living.
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SPINAL CORD INJURY: MIDPOINT IN REHABILITATION
As you approach the midpoint in your rehabilitation, you may feel a sense of accomplishment. You’ve survived your injury and progressed in mobility, self-care, and daily living skills. While you may be more stable medically and emotionally, much physical and psychological work lies ahead.
As Jim reached the midpoint of his rehabilitation, he remained hopeful for recovery but still felt lost and confused. He had found a friend who shared his feelings and eased his loneliness, but his relationship with his wife was strained. He agonized over when and how to discuss his sexual dysfunction and fear of infertility. His self-image and identity were up for grabs. He knew he wasn’t the old macho worker he’d been before the accident, but he wasn’t sure who the “new” Jim was or could become. While throwing himself wholeheartedly into the “good patient” role, Jim knew he wouldn’t be a patient forever. He could already see his discharge date looming on the horizon.
Jim wondered how he would make sense of his injury, find a new role, and live as a different person outside the hospital. His marriage, his relationship with his family, and his career and goals would all be changed in some ways by his disability. The challenge of reshaping the future seemed daunting, and he knew that he’d have to travel a different road now. The next step in his journey would require a different road map. And despite his fear, Jim was ready to read it.
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Other names: Afeditab Er, Procardia

ANGINA AND SMOKING: WHY STOP SMOKING?
If heart patients are only told to do one thing after being diagnosed, it is to ‘give up smoking if you want to live’. This can seem harsh advice to heap on the unwelcome news of heart disease. It can seem like a further cost, even a penance. Moreover, giving up smoking is not as simple as such advice, so easily given, would have us believe. Giving up smoking usually requires more than simply giving up on a whim. It takes a certain amount of commitment and skill. This section of the book intends to provide you with both of these essential attributes. But first, why stop smoking . . .?
Smoking has been shown to be a major contributory factor to many diseases. Smoking as a risk factor for heart disease has been discussed elsewhere in this book. However, it can also result in a number of diseases of the lung and throat, particularly cancer, bronchitis and emphysema. It has also been associated with other types of cancer including bladder cancer, and cancer of the cervix in women.
Perhaps even more importantly, smoking can have a direct effect on the symptoms of angina. Sudden intake of nicotine can send the arteries providing oxygen to the heart into spasm, restricting the flow of oxygen to the heart muscle, and causing an attack of angina.
Carbon monoxide, also taken in cigarette smoke, reduces the amount of oxygen that can be taken up by the bloodstream, and muscles of the body, placing strain on the heart in getting enough oxygen to the body. This makes someone who smokes more likely to have angina while exercising.
So, while smoking may contribute in the long term to the development of disease, it also has a direct effect on the daily experience of the symptoms of angina. Smoking also increases the likelihood of the development of chest infections, causing breathlessness, which can increase the symptoms associated with angina.
More encouragingly, this means that stopping smoking can have immediate, and not just long-term, effects on health. Within a day of stopping, carbon monoxide leaves the body and as nicotine is no longer inhaled it can no longer contribute to any angina symptoms. As well as these immediate benefits, longer-term health benefits are that any disease process related to smoking immediately stops, and the body begins the process of repair. Stopping smoking has been shown to significantly lessen the risk of further heart attacks, with the risk of having a second heart attack reducing to the same as that of a non-smoker after 5 years. Think you are past the point of no return? If you cut yourself do you stop bleeding? Of course. The body never loses its ability to repair itself and even if you have smoked for many years you can reduce the risk of further heart problems.
Of course, improvements in health are not the only benefits from stopping smoking. Smoking results in a reduced sense of smell and taste, stained teeth and fingers, bad breath and costs a fortune! If you smoke twenty cigarettes a day, you are spending hundreds of pounds a year. Stopping smoking can change all this. A hidden benefit many people find is that when they have successfully stopped smoking, they feel more confident in themselves, and their self-esteem is increased.
Many people give up smoking as a result of illness: bronchitis, angina and so on. Other give up for less obvious reasons such as having just decorated a room and not wishing to stain the wallpaper and curtains with cigarette smoke, the birth of a grandchild, changing jobs and using this as an opportunity to break old habits. Some reasons are very simple: lack of money or a birthday promise.
However, these are other people’s reasons for giving up smoking, and may not apply to you. Thinking about your personal reasons for wanting to stop, and writing them down can help both as a means of motivating yourself to stop, and to remind yourself of these reasons if the going gets difficult in the future. This can be an important beginning to any attempt to stop smoking, and is worth spending a few minutes thinking about.
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SPECIALISTS FOR PEOPLE WITH SPINAL CORD INJURY: PSYCHIATRISTS
Psychiatrists are physicians (medical school graduates) who have received residency training in the diagnosis and treatment of mental illnesses. As medical doctors, they are able to prescribe medications. They admit patients to psychiatric hospitals when necessary, and they have specialized knowledge of the relationship between medical illnesses, brain function, and behavior. They may have additional training in psychotherapy or some other aspect of medicine.
Evaluation by a psychiatrist is useful when clinical depression is suspected or when a person has suicidal thoughts, and also for those with overwhelming anxiety or panic or with anger that explodes into aggression toward others. Psychiatric evaluation may also be helpful for people with a mild head injury or for those who develop confusion, disorientation, or distorted thinking for any reason.
If you were receiving psychiatric treatment before your injury or are taking psychiatric medication when you’re admitted for rehabilitation, make sure to tell your doctor. He or she can arrange for a psychiatrist to work with you so that you receive continuous care and have any necessary adjustments in your medication.
Medication can often reduce symptoms of depression or anxiety to manageable levels. This allows an injured person to continue with rehabilitation and enhances his or her ability to communicate feelings and needs to family or friends. A combination of medication with psychotherapy, or “talking therapy,” is the most effective method for treating clinical depression.
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SPECIALISTS TO HELP PEOPLE WITH SPINAL CORD INJURY: PSYCHOLOGISTS
Licensed psychologists are experts in mental health and human behavior. They usually have a doctoral degree (PhD) in psychology, with at least three years of graduate school training in psychology, at least one year of internship training in counseling or psychotherapy, and research training that culminated in an independent research or theoretical dissertation. Some psychologists have additional specialty training, for example in neuropsychology (the relation between brain function and behavior), rehabilitation psychology (psychosocial aspects of physical disability and rehabilitation), or behavioral medicine (the relation of behavior and emotions to physical illness and health). In some states, people with a master’s degree (MA or MS) in psychology are also called psychologists within the hospital setting. They may provide psychological testing, psychotherapy, or other psychological services. In some settings, they are called psychology associates or psychology technicians. They may require supervision by a PhD psychologist and may have more limited duties. Psychologists are not physicians and do not prescribe medications.
Psychologists specialize in understanding human behavior and emotions and the relationship between social and environmental factors and a person’s internal experiences and outward behaviors. In the rehabilitation setting, psychologists can help you sort through your complicated feelings and work through grief, anger, and loss of control. They can also help you change behaviors that are troubling to you or interfere with your progress. They can help with issues of pain control, sexuality, arid family relationships. Psychologists can also assess your personality style, former coping mechanisms, and learning abilities, then share this information with other staff members to assist them in teaching you new skills, motivating you, and understanding your individual needs. Psychologists may be asked to help evaluate cognitive problems related to mild head injury or past learning disabilities. They might also lead family therapy or group psychotherapy sessions for people with spinal cord injuries.
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