FAQ’s

Urinary tract refers to the system that is concerned with formation storage and excretion of urine. It consists of two kidneys that lie at the back of upper part of abdomen, one on each side

Urine formed in the kidneys is drained by two hollow tubular structures, called the ureters into the bladder.

Bladder is a hollow muscular bag that lies in the lower part of abdomen. Bladder serves to hold urine tail it is full and then contracts to empty itself through another hollow tube called urethra, to the outside A muscular valve, called the sphincter, located in the urethra, keeps the urethra closed & opens when a person wishes to pass urine.

Depending upon the type and level of your injury, some functions of the bladder will be affected either temporarily or permanently. Some of the common changes that you may observe are

• Lack of sensation of
  bladder fullness and/or
  bladder fullness recognised by excessive sweating. flushing, tremors headache
• Inability to judge urine leakage that occurs without one’s knowledge
• Inability to control passage of urine 4 Inability to pass urine at all or fully.
• Inability to pass urine at all or fully.

Depending upon neurological status, each person will observe ether one or various combinations of above mentioned symptoms. Neurological recovery takes a long time and this period may vary from few weeks to months to years. Therefore, the final behaviour pattern of bladder function will also take time to emerge

Immediately after SCI, the spinal is in a shock phase During this phase, there is complete inactivity of the bladder and its muscles are not capable of contraction Therefore, the bladder will continue to store large volumes of urine, becoming over distended. This state of over distention is detrimental for eventual bladder muscle recovery and imparts over stretching and thinning of its muscle Over distension prevented by an indwelling catheter placed in the bladder to keep it empty This n catheter is passed via the urethra and connected to a collection bag Between, ? 4 weeks when the spinal shock begins to wear, the indwelling catheter is removed and you will start doing intermittent catheterisation scheduled every 445 hours

Urine is stored in the bladder. As the bladder becomes full this information is passed via your spinal cord centres to your brain. If you wish to empty your bladder, then the bladder muscle contracts to empty the bladder.

Normally the desire can be modified. One can suppress the desire to pass urine until an appropriate time or place is available. Usually, the bladder empties completely leaving behind insignificant residue. Presence of large volume of urine at the end of voiding happens either because of weak muscles or some obstruction along the outlet

enerally there are two ways the bladder works after a spinal cord injury.

Spastic or Reflex Bladder means that when your bladder fills with urine, a reflex automatically triggers the bladder to empty. The problem in a reflex bladder is you do not know when the bladder will empty. Reflex or spastic bladder usually occurs when the injury is above the T12 level. The choice of bladder management methods for an individual with a spastic/reflex bladder include intermittent catheterisation, indwelling catheter and condon drainage.

Flaccid or non-reflex bladder means ones reflexes may be sluggish or absent. You may not feel when the bladder is full. It then becomes over distended and stretched. This can cause the urine to back-up through the ureters to the kidneys. Individuals with injuries below T12/L1 usually have a flaccid bladder. The bladder management system most commonly used is intermittent catheterisation. To avoid problem do not allow more than 400 cc of urine to fill in your bladder.

A bladder management programme allows you to plan for bladder emptying in an acceptable manner when it is convenient for you. This helps you to avoid accidents and prevent infections. Your level and type of injury will affect the choice you and your doctor make for your bladder programme. Because each person’s injury is different, your doctor will probably conduct some tests to see how your bladder functions. You also need to consider your hand function. How easy is it for you to do your own bladder programme? Can you manage alone or will you need help? During your rehabilitation you learn different ways to empty your bladder. The methods most frequently used are intermittent catheterisation; indwelling catheter; and the condon external catheter for male. You may use just one programme or a combination of methods. You will decide the method that works best for you. You can prevent leaking and have a pleasant outing by regulating your water intake Maintaining a voiding diary may help you plan A voiding diary is a statement of water intake Vs urine output in relation to time By analysing the diary, one can find out that by regulating the water intake at these trines, one can reduce my urine output a specified times to be comfortable.

Individuals with SCI are more likely to have urinary infection or other urinary problems with the urinary system. To avoid problems and keep you’re urinary system healthy.

Empty your bladder completely

After Your SCI your bladder often does not empty completely l?he residual ur ine becomes a breeding medium from bacteria and germs that may cause infection

Use a “clean technique” catheterisation

Always wash your hands before arid after doing catheterisation Be sure your catheter and equipment are clean Read the chapter on Clean Intermittent Catheterisation.

Keep skin clean and dry

Change your wet or soiled clothes immediately to avoid any bacterial growth n the genital area. Clean the area around the genitals with soap and water everyday.

Drink plenty of liquids

A steady intake of fluids helps “wash?out” bacteria and waste materials. Drinking the recommended amount of liquids helps avoid problems. How much fluid you need to drink each day depends on your bladder management. Water is the best fluid to drink.

Keep bladder pressures low

While you need to drink the recommended amount of fluid, you also need to empty your bladder on a regular schedule. Do not let more than 400cc of urine collect in your bladder anytime.

Loss of normal bladder function after spinal cord injury places you at a increased risk for urinary tract infection (UTI), regardless of the bladder management system you follow. Urinary tract infection can occur in the bladder, kidneys or other parts of the urinary tract.

The most common symptoms of bladder infection include going to the bathroom more frequently, passing blood in the urine. cloudy and odorous urine, increased spasticity in the lower extremities fever and chills Depending on your level of injury, you nay feel a burning with urination, or discomfort in the lower pelvis; area, abdomen or lower back.

If you notice any of these symptoms see the doctor for laboratory tests to determine the need for treatment. Research shows that UTIs that do not have symptoms usually do not need treatment with antibiotics. Use antibiotics only when symptoms (fever, chills and pain) are present. Your doctor based on your Urine Culture Report will prescribe antibiotics.

Losing bowel control with bowel accidents is probably the most embarrassing and frustrating experience that you have faced, as a result of your SCI. Proper bowel management is the answer to your problem. A bowel training program that aims at establishing a routine for emptying your bowels is the safest, most convenient and dependable for you. There is no single unfailing method that would suit everyone. Experimentation is needed in each case to find a method that suits one’s own needs and lifestyle Over a period of time the bowel can be ‘reeducated’ to empty regularly, adequately and at predictable times. The baseline for your program will be similar to the bowel pattern that you had before your injury. Even if you had an irregular bowel habit before your injury it is better to establish a more regular habit now as this will enable you to participate in a fuller social life without the fear of embarrassment of accidents.

• Make sure you eat a well balanced diet.
• Eat foods that provide roughage like raw vegetables, fruits, whole fruits with skin, green vegetables, whole grain cereals etc. This would increase the bulk that would make bowel movement easier
• Drink plenty of fluids. Most fluids help to soften stools. Drink more if you are constipated.
• Stick to a scheduled bowel program.
• Keep active.

Yes. Food and proper fluid intake play a vital role in establishing a good routine. Stool consistency is directly related to food eaten. It determines the success or failure of your program. It is also important to have a right diet to avoid obesity. A person who is overweight may put excessive pressure on a small area of the body, causing a pressure sore and in addition their is the difficulty of having to lift the excess weight, whether the SIP lifts independently or is lifted by others

• Eat a great variety of food
• Eat more fibre rich foods
• Eat plenty of fruit and vegetables
• Cut down on fat and sugar, especially if you are overweight

A daily diet should include servings of:

Non vegetarian

Meat, fish, chicken, egg

Vegetarian

paneer, lentils, dal, soyabean and yogurt.

Eggetarian

eggs, plus the vegetarian diet These are protein foods needed for muscle repairs and maintenance and they also aid the healing of pressure sores. Remember these products do not have any fibre, therefore it is essential to compliment this with items from the other categories

Chapatti

(Wheat, maize, bajra etc.), rice or daliya.

Fruits and Vegetables

Fresh fruits and vegetables are the sources of vitamins They help the body to fight infections and also for the formation of various body tissues. It is important in wound healing. e.g. pressures sores.

Fibre is found in cereals, fruits and vegetables but not in meat and animal products like milk. Your fibre intake will increase by taking:

• Breakfast cereals: Porridge (Daliya), sprouted black gram or pulses, corn flakes
• Wholemeal flour and brown rice: It is recommended not to sieve the flour before making chapatti, purl etc. Brown rice can be used in place of ordinary rice.
• Vegetables: Have generous helpings, especially, peas, spinach, potatoes m their jackets and eat the skins too if possible. Eat more salads.
• Fruits: Try to eat one portion of fresh fruits each day including skins when possible like apples, guavas, pears etc. Papaya is a highly recommended fruit,
• Pulses and lentils: black channa, rajma, whole dais.

Try avoiding:

• Excess of spices.
• Cold carbonated beverages and alcohol
• Gas forming foods such as onions, Arbi etc.
• Too much fat and sugar
• Excessive amount of oils and Ghee

A bowel program will work better If you:

• Do the program everyday and at the same hour
• Do it even if you have had an accidental bowel movement shortly before or 11 yin; have diarrhea
• Try the bowel movement at the same time of the day that you had bowel movements before your injury. But chose a time for your bowel routine that is convenient and which allows you sufficient time so you will not be rushed
• If possible take advantage of the colic reflex’ This is the reflex stimulation of the bowels that occurs 20?30 minutes after meats. Moving the bowels is thereby easier immediately following a meal.
• Do the program on a toilet seat or pot The bowels work batter sitting than lying Keep as physically active as possible even when in bed for long periods Do exercises to maintain range of motion exercises m paralysed limbs and make frequent position changes. Exercise increases muscle tone and stimulates bowel movement.

Be patient! The bowels sometimes take days or weeks to change their pattern

The program that you should follow will depend on your level of injury that in turn will determine whether your bowel is ‘AUTOMATIC’ or ‘FLACCID / LIMP

AUTOMATIC BOWEL

If your level of injury is above L1, you will have an Automatic Bowel

• In this case the sphincter in the anus stays shut until there is stimulation m the bowel to make it open so that the stool can come out
• An automatic bowel will move in response to a suppository or stimulation try a finger.

FLACCID OR LIMP BOWEL

This occurs if your level of injury is L1 or below.

• In this case sphincter of the anus is limp and the person with this kind of bowel has incontinence.
• A flaccid bowel does not respond to finger stimulation.

• Start with a suppository
• Insert the prescribed suppository at your scheduled time.
• If a suppository works quickly for you insert it while sitting on a toilet or commode when this is possible. If it takes over 15 minutes insert it while lying on your left side

Steps for inserting a Suppository

• With the gloved finger lubricated with KY jelly push the suppository about 2 cms Gently push it to the right or left side to make sure it is in direct contact with the bowel wall.
• Drink a cup of tea or coffee or do anything that generally helps to bring on a bowel movement for you, go back to your pre-injury habit



• If not on a toilet or commode transfer after 15?20 minutes Sitting time should not exceed 30 minutes
• After being seated put your feet on the footstool to get into as much of a “squatting” position as possible Massage the upper abdomen from right to left and down several times.
• If you are unable to sit then lie on your left side If a bedpan is to be used do so with care
• If on the second day there has still been no bowel movement repeat the suppository. If there are no results within the expected time, do a digital finger stimulation.

How to calculate the time a suppository would take for action?

In the beginning it will be helpful to keep a careful record of your bowel pattern transfer to the toilet seat, insert the suppository and wait. Note the time that it takes for the bowel movement to occur. This time varies from person to person and you have to find out for yourself how much time you need. You should also observe how different kinds of food affect your bowel movements and use them accordingly to influence your, bowel movement favourably.

• Gently insert a gloved lubricated forefinger beyond the anal sphincter and gently move it in stimulating circular motion several times. If still unsuccessful end the bowel routine for the day.
• Repeat the same routine on the third day. If still unsuccessful:
  (a) with gloved lubricated forefinger gently remove pieces of stool
  (b) resort to an enema as prescribed by your doctor.

In such cases your bowel will not push the stool and the stool will have to be taken out with a finger at least once a day to begin with. If possible do it sitting on your toilet seat if not on your left side. With a gloved and lubricated finger remove as much stool as you can. Since this type of bowel tends to be incontinent i.e. it leaks, eat food that makes the stool firm.

Intermittent catheterisation means inserting a narrow tube (catheter) along the usual passage (urethra) into the bladder. The urine flows out through the tube into the lavatory or a container until the bladder is completely empty and the tube is then removed. This procedure is called catheterisation and is done several times in a day

The advantages of CIC is as follows

• You will have better control of your bladder ? and your life
• You will have a healthier bladder and healthier kidneys
• You possibly will not need any other appliances such as pads, catheters and urine bags, sheaths etc.
• The risk of urinary infections will be reduced.
• Normal sexual relations.
• Less anxiety ? improved social relationship.

• You can catheterise 4-6 times in a day.
• Regulate the amount of fluids that you drink to the timing of cathaterisation. Measure the quantities drunk and obtained on catheteisation. (< 500 cc)
• Between catheterisations drink no more than your bladder will hold.
• Prevent the bladder from filling above 300-350 ml. (pressure < 40 cc) between each catheterisation.
• Avoid drinking at bedtime unless you are prepared to catheterise during the night
• A daily intake of 1-1.5 liters of fluid is sufficient.

CIC is a safe gentle technique that is being used by thousands of people all over the world.

However, if NOT used properly, using a larger size catheter, use of excessive force, stiffer catheters, inadequate lubrication can cause trauma to the urethra. Therefore you should learn it properly under supervision of your doctor or nurse before self practicing at home.

• Always bathe, shower, or wash each day.
• Always wash your genitals immediately before CIC, i.e. after adjusting clothes, and after dealing with your catheter.
• Wash the area around the catheter from front to back as this prevents spread of bacteria from the anal area thus reducing the risk of infection
• Always expel all the urine from the bladder;
• Wash catheter in running water after use, dry it and replace it in its container
• Change catheter after one week. Silicon coated catheter can be used for 2 weeks

Dry your catheter and stored it in a clean cotton cloth bag or a wooden container. Take care the either of these should be cleaned once a day. You could change you cloth bag daily.

There is no method of bladder drainage that is absolutely free of infection. CIC however if done properly is quite safe as has been the experience of users over nearly last 30 years.

• Collect the equipment needed: Catheter, clean cottons swab clean tissue or gauge pieces, dish for urine collection, lubricant, clean water and soap to wash hands, waterproofing and towel.
• Get into the position you find comfortable. sitting on the toilet, wheelchair or bed.
• Get the clothing out of the way. Spread the waterproof protection.
• Wash hands and the end of the penis drawing back the foreskin if possible.
• Squeeze out two blobs of Xylocaine jelly on clean tissue or gauge pieces; discard the first blob. For anyone with a sensitive urethra it may also be advisable to squeeze some lignocaine gel directly into the urethra.Allow 4 minutes for the local anesthetic to take effect before passing the catheter. Once you are good at catheterisation, the anesthetic effect of lignocaine may not be needed.

• Place the dish between the legs to collect the urine.
• With your left hand (if you are right handed) hold the penis out straight, away from the body to help straighten the urethra. Do not grip the penis too tightly as this may prevent the catheter passing.
• Take the catheter out of its container, dip the tip into the second blob of lubricant, taking care not to let the jelly block the holes in the catheter
• Insert the catheter slowly into the opening of the urethra and continue pushing gently until the urine flows into a dish. If the catheter sticks just before it enters the bladder, wait a minute for the sphincter muscle to relax and then gently push it in a little further.
• When the urine stops flowing strain to try to push out any remaining urine and insert the catheter one or two cm, further.
• Remove the catheter slowly. If at any stage more urine starts to flow, wait until it finishes.
• Rinse through the catheter with running water and return it to its container.

• Collect the equipment needed: Catheter, clean cottons swab clean tissue or gauge pieces, dish for urine collection, lubricant, mirror if required, clean water and soap to wash hands, mackintosh and towel.
• Get into the position you find comfortable: sitting on the toilet, wheelchair or reclining on bed. (lie on back or sit with legs apart and knees bent.)
• Get the clothing out of the way.
• Spread the waterproof protection.
• Wash hands
• Squeeze out two blobs of Xylocaine/KY jelly on clean tissue or gauge pieces, discard the first blob. For anyone with a sensitive urethra it may also be advisable to squeeze some jelly directly into the urethra.
• Separate and clean the lips (labia) using tissue or cotton swab, with a mild antiseptic solution. (In case you have a heavy menstrual flow, it might be a good idea to use a tampon or tissue to control the flow.
• Place the dish between the legs ready to catch the urine.
• Adjust the mirror.
• Take the catheter out of its container, wash in running water and flick dry. Dip the tip into the second blob of lubricant jelly, taking care that the jelly does not block the holes in the catheter.
• If you need to let go of the catheter while finding the opening to the urethra, lay it on a clean tissue or return it to its container.
• Without a mirror by sliding the finger back along the ridge from the clitoris in front to the vagina behind. For anyone who has not lost sensation in this area, the urethral opening is a very sensitive spot so that you soon learn to recognise the feel when the catheter touches the opening.
• Having located the opening hold the catheter about 2 cms from its tip and insert it about 5 cms or so until the urine flows. If the catheter has slipped into the vagina no harm is done, just try again to find the hole in front of the vagina.
• When urine stops flowing make sure that the bladder has completely emptied by bearing down, inserting the catheter a little further and twisting it gently.
• Take out the catheter slowly and if more urine starts to flow, stop and wait until it has finished before removing the catheter.
• Rinse through the catheter with running water, flick dry and return it to its container.

A full list of clinical departments within the Trust is available in the Our Services section of this website.

Just call the Trust’s switchboard number – 011 4225 5225 – and ask for the name of the service or person you want.

Information on travelling to and between the hospitals can be found in the Visiting Us section of this website.

These are available on our Maps and Leaflets page.

You should have received a letter with your admission date and details about where to go. If you are uncertain about when to come in or where to go, please telephone the contact number on your letter.

If you cannot keep your appointment, or you need to change the time and date, please telephone the number on your appointment letter as soon as possible. This will allow us to rearrange your appointment and to give your appointment to someone else.

If you are unable to make your admission date, please call the number on your letter immediately so that we can rearrange your appointment and give your bed to someone else. If you fail to contact us, it may affect your position on the Trust’s waiting list.

No. Smoking is not permitted in any of the Trust’s premises.

Information is provided in the Your inpatient stay and Your outpatient stay pages in the Patient Care section.

Visiting hours vary from ward to ward. A nurse will be able to tell you the visiting times on your ward when you arrive.

ISIC Corporate / TPA help desk is manned by hospital itself, open on all working days & holidays. The Insurance / TPA help desk staff entertains only insured & policyholders having medical insurance from empanelled TPA / Insurance Co. & different corporates to help them avail cashless approval & Credit letters from TPA / Corporates.

Today, most health Insurance policies do offer cashless hospitalization facility and route your policy through a Third Party Administrator (TPA). However you should be familiar with the terms Network Hospital and Non-network Hospital. Network hospital are those hospitals that your TPA has an agreement with, if you get admitted to a Network hospital you will be eligible for cashless hospitalization, subject to the other terms & conditions mentioned in your policy being fulfilled. In case you are admitted to a Non-network Hospital, you will have to settle the bills directly to the hospital and the seek reimbursement through your TPA.

No, cashless hospitalization does not means the free of cost treatment. The assigned TPA will mediate between the hospital and the insurance company and settle the bills on behalf of the of the insured customer. The hospital is only a facilitator and has no authority to approve or disapprove any request for cashless hospitalization. Certain protocols lay down by the Insurance Regulatory and Development Authority (IRDA) with respect to cashless hospitalization will need to be adhered to strictly.

Hospitalization occur under two conditions: Planned & Emergency.

Planned Hospitalization:

If doctor advised you on the probable date of hospitalization in such case, you must have applied for an approval of the estimated hospital expenses directly with your TPA at least 4-5 days prior to the date of hospitalization

Emergency Hospitalization:

For cashless treatment it is mandatory for the hospital to have an approval from TPA or Credit letter from Corporate. In case of emergency hospitalization, you can undertake the treatment by paying the necessary advance cash deposit. If you get approval from your TPA / Corporate after paying cash deposit, you are entitled for refund at the time of discharge.

Pre- Authorization of the estimated hospital expenses is a must to avail cashless facility.

The pre-authorization procedure is detailed below:

Step 1 : Established contact with the corporate / TPA help desk at the hospital.

Step 2 : Collect the Pre-Authorization of your respective TPA.

Step 3 : Your Pre-Authorization will have two sections –

• General details on the health Insurance policy to be filled in by you (the Corporate / TPA desk will assist you in case you have any difficulty)
• Pertains to the treatment recommended for you needs to be filled in and duly signed by treating doctor

Step 4 : Return the completed form to the Corporate / TPA help desk with respective TPA ID card, relevant prescriptions & reports. The Corporate clients submit original copy of your Credit letter with ID & Address proof.

Step 5 : Once the form & related formality is complete in all respect, the Corporate / TPA help desk will fax the form to TPA office & after receiving the approval the help desk will revert on the approval status.

4. What will I do if approval from TPA not received till the time of discharge?

Cashless hospitalization is linked to the approval of the estimated expenditure on proposed treatment. In case you not received approval you need to pay the entire bill incurred on the treatment.

In case hospitalization expenses exceed the pre-approved amount; you can approach the Corporate / TPA Help Desk to apply for an enhancement of the pre-approved amount. In case you have not exhausted your medical insurance limit, it is most likely that your TPA will approve the application for the enhancement either for the requested enhanced amount or up to your insured limit after deducting the value already utilized by you during the year whichever is less. If the TPA turns down the request for enhancement you will need to pay the amount incurred in excess of your approved amount directly to the hospital before the discharge.

For complete details on the medical expenses which are covered & not covered, you need to go through your health insurance policy. However, in general, the expenses listed below are not reimbursable under cashless hospitalization like:

This needs to be settled by you directly with the hospital at the time of discharge.

Do’s

• Obtain Pre-Authorization request form from TPA help desk at least 4-5 days prior to planned hospitalization.
• Inquire the status about the approval from Insurance help desk in the next 24 hrs.
• Bring all relevant past treatment records while coming to Insurance help desk to seek cashless benefit from TPA.
• Bring your TPA ID Card, previous year policy copies, ID proof, residence proof.
• Always confirm your final bill with approval from your respective TPA to avoid hassles in discharge procedure. If your policy amount limit is exhausted please make the payments on your daily bill outstanding.
• Confirm with your respective TPA regarding exclusion which is not covered & directly payable by patient to the hospital.
• Co-operate with the Insurance / TPA help desk staff to help them in getting cashless approval from TPA.

Don’ts

• Don’t insist upon admission at the hospital merely for diagnostic / evaluation / investigation purposes, as it it is not payable by TPA.
• Don’t insist upon admission on cashless basis before getting approval for the same from TPA.
• Don’t ask the Doctor / TPA staff to put any fraudulent / misleading information in request form / any other documents.

In case of any query related to TPA / Corporate please Contact:

Coordinator Corporate Affairs

Contact No. : 011-4225 5394
Fax No. : 26899147, 26898810
Email : coordinator@test1.isiconline.org
Timings : 8.00 am to 08.00 pm (Mon to Sat), 9.00 am to 5.30pm (Sundays & Holidays)

Home modification will help you in a number of ways. Enter and exit your home easily and whenever you like Follow the routine of going to the bathroom as you may have been in the spinal unit Do cooking in the kitchen if you wish to. Be more independent on the whole in your activities of daily living. Most importantly it will give you control your own life.

The points to be considered are:

• The accessibility of different rooms and facilities in the home.
• The mobility permitted by size, furnishing and arrangement of rooms.
• safety in the house.
• The need for modification or assistance to ensure safe to the entrance of the house from outside is evaluated as in case for emergency. With that Source, cost end description of equipment that is needed are specified.

The main points to be considered before thinking of modification are.

• Whether you live in a ground floor house.
• Whether you or your family owns it.
• Whether the house is rented and if so is it possible to make changes in the house?

Ideal Ramp

• Ramp installed should be 1″ of rise to every 12″ of length.
• Maximum width should be 36″ (inside rails) ? (48″ is ideal)
• Slip resistant surfaces ? strips, rough concrete are acceptable surfaces.
• Door should have at least have 2′ 8″ opening at 90 degree position

• All electrical switches should be at a height that you can reach (3 feet from the ground). The light switch, fan regulator could be next to your bedside so that yon need not get out of bed to switch it off
• The height of the bed should be same as your wheelchair for easy transfer and at least one side of bed should be wheelchair.
• One clear area (best in front of closet) measuring at least 5 sq feet should exist for wheelchair maneuvering.
• Try to make almirah and drawers accessible otherwise a stick with a hook is provided to take off the hangers
• Stacking shelves with rollers can be used.
• Avoid any heavy furniture.

• A minimum of 5 sq. feet space is required for wheelchair maneuvering Bathroom controls including taps, flush etc. should not be higher than 3 feet.
• All electrical fittings should be at the height you can reach (3 feet from the ground)
• Horizontal grab bars of 1.5 inches diameter and capable of bearing most of your weight should be installed at a height of approximately 3 feet
• The sink should be about 3 to 3 5 feet from the ground with the area under it free for the wheelchair
• All exposed edges should be rounded.
• The looking mirror should not be placed higher that 3 to 3.5 feet from the ground

• A western type commode wilt be ideal for you. Alternatively you could build a wooden stool with a hole that could be placed over the Indian commode
• Fixture or seat should be raised to wheelchair height.
• Place a horizontal grab bar adjacent to the toilet at a height of about 2.9 feet from the ground

• Counter area should be continuous. Cooking and eating surfaces could be combined
• A movable worktable may be made in place of lowering the existent cabinet place
• Work counter installed (minimum 3′ wide x maximum height of 2′-10″) Leg clearance minimum of 2′-3″.
• Tile, Pyrex or marble slabs to be installed for working with hot things and for sliding
• The shelf with cooking stove should have a maximum height 34″
• Knee Space beneath should be at least 3′ wide and 27″ high
• Self-defrosting and Frost Free are easier for cleaning

• Carpeting should be low pile, close knit.
• Mirrors should be 48″ from floor
• Light switches should be 42″ from floor.
• Hallways should be at least 36″ and ideally should be 42″.
• Parking place should have at least 5′ wide clear area on one side of the car space.

Medical Emergencies are a few conditions affecting spinal cord injured people that, require urgent treatment. They can happen anytime irrespective of the numbers of years that have passed after your injury. You should be aware of them and the first aid that is required just incase you are faced with them at home. They are as follows

• Autonomic Dysreflexia
• Pressure sore
• Bladder blockage or infection
• Kidney infection
• Chest infection
• Sudden lowering of Blood Pressure

This is a warning system to let you know that something is wrong; and that your body is experiencing pain or discomfort. This is an acute emergency and if not treated quickly may lead to bleeding in the brain with serious consequences. It consists of a rapid increase in blood pressure caused by pain, irritation or over-stimulation in a paralyzed part of the body. Only if you have a spinal cord lesion above T6 are you prone to autonomic dysreflexia or hyper-reflexia. Your family members should also be aware of Autonomic Dysreflexia so that they can help you when needed.

The Symptoms for autonomic dysreflexia are

• Pounding headache
• Goose pimples
• Profuse sweatingFlushed and blotched skin on face and upper trunk Those with a spinal cord lesion above T6 must be aware of autonomic dysreflexia or hyper-reflexia and so should their family and carers.
• High blood pressure

Note: You may already have a lower normal blood pressure (e.g. 90/160) after injury, therefore 120/180 may represent a rise.

The symptoms of autonomic dysreflexia can be any one of the following or combination of the follows over-full bladder caused by a blocked catheter bladder stones. Urinary tract infection constipation anal fissure wind ingrown toenail burns or scalds pressure sore labor pain ejaculation during sexual intercourse menstrual cramps

• Remove the cause (if possible) you may have to contact your doctor to help you remove the cause.
• Sit up either yourself or with help
• If symptoms persist, give drugs to lower the blood pressure and contact your doctor
• Autonomic Dysreflexia is a serious condition and if immediate relief is not achieved you must call a doctor.

Other emergencies that can arise are Pressure sores and problems related to the Bladder like Kidney infection and kidney stones. These are discussed at length in chapters given before. Apart from these you may be prone to Chest infections and low blood pressure.

If your spinal lesion is above T6 you have to, take extra care to avoid chest infections The potential problems that may occur in the are

• Decreased Lung Volume
• Congestion and/or Pneumonia

Decreased lung volume is caused be either change in the function of the respiratory muscles or thick secretions in the lungs. You can identify this by shortness of breath.

Decreased lung volume can be prevented by regularly

• Doing deep breathing regularly
• Sitting in wheelchair daily
• Maintaining regular turning schedule in bed
• Doing regular assisted coughing as needed to bring up secretions
• Do respiratory treatment as prescribed by the doctor

Assisted coughing is when someone else assists you in coughing out your secretions which you may be unable to do yourself. Coughing assists in cleaning thickened secretions from the respiratory system. If your spinal lesion is T6 and above then ask your physiotherapist to teach assisted coughing procedure to your family members, who can assist you at home.

Pressure sores or bed sores are sores that form over bony parts of the body when a person lies or sits on that particular part of the body for too long without moving

Where the skin is pressed against the bed or chair, the pressure causes a decrease in the blood flow. If too much time passes without moving or rolling over, the skin and flesh in that area can be injured or die. First a red or dark patch appears, and if pressure continues the skin breaks down creating an open sore

• More than 2 hours when you are lying down with turning
• More than 10 minutes when you are sitting, without doing a push-up

When a normal, healthy person lies or sits in one position for a long time he begins to feel uncomfortable, which makes him/her move or roll over to let another part of his body bear his weight. A person with a spinal injury :

• fails to respond to warnings of pain or discomfort due to loss of sensation and
• secondly is unable to move or roll over to relieve pressure,

These two points that make them at a very high risk of developing pressure sores.

Pressure sores are very common in persons who are bed ridden and those who have lost sensation in parts of their body such as persons with spinal cord injuries or aged persons.

Parts of the body where skin and subcutaneous tissues that overlie bony prominence are likely sites for pressure sore formation. The parts where they form most often are shown in the picture. The points colored are the points of highest risk.

Points most prone to pressure sores while sitting and bed sores while lying.

The most important factor is unrelieved Pressure.

The other critical factors are:

• decreased mobility
• decreased sensations
• friction/ shearing during transfers or turning
• moisture, e.g., sweat, urine soaked clothes
• poor nutrition can cause thus, there is loss of padding over the bony prominence

YES. Pressure sores can be prevented completely provided you turn w bed every 2 hours day and night and change position every 10 minutes when sitting.

A PRESSURE SORE TAKES ONLY HOURS TO DEVELOP BUT IT TAKES MONTHS OR AT TIMES YEARS TO HEAL.

AS FAR AS POSSIBLE, YOU SHOULD TAKE RESPONSIBILITY FOR YOUR SKIN CARE YOURSELF.

• Avoid staying in the same position for very long. When lying down, turn from side to side and front to back every 2 hours. When sitting lift body up arid change position every 10?15 minutes.
• Do not rub or scrape skin across bed or wheelchair when transferring or changing position.
• Use soft, clean, dry bed sheets. Keep all clothing & bed linen free of wrinkles
• Keep dry! Change wet clothing and/ or bed linen promptly. a person who stays wet gets pressure sores especially if it is from URINE
• Bathe daily and dry thoroughly by patting, not rubbing.
• Examine the whole body carefully everyday, checking especially those areas where sores are most likely to occur.
  • Look for the danger signs: –
  • Pinkness / Redness
  • Paleness
  • Darkness
  • Unnatural wrinkles
  • Warmth
  • If any of the danger signs are present, take care to prevent pressure over this area until skin returns to normal.
• Good Food is important for preventing pressure sores Be sure that you eat well, but do not become fat. Eat plenty of fruits, vegetables, pulses, beans, eggs, meat, fish, and milk products. Ghee & Oil are to be avoided.

To prevent pressure sores it is essential that you lie & sit on a soft surface, that reduces pressure on bony areas

It is best to lie an a flat surface with a thick spongy mattress. A thick foam rubber mattress often works well. However some foam are so spongy that it sinks completely down under weight. Then the bony areas are no longer protected from pressure Therefore, the right mattress should be firm, thick and smooth.

Careful placement of pillows, cushions or soft folded blankets can also help prevent pressure sores. Correct positioning not only prevents pressure sore but also prevent contractures. In a wheelchair also always use a firm cushion, sitting directly on a canvas or metal seat can cause sores.

Proper lying position is very important to prevent bed sores.

Care of Pressure Sores

Watch for the first sign of a pressure sore by examining the whole body every day. You can do this yourself by using a long handled mirror

If you can notice any of the danger signs, e.g. , redness, paleness, darkness, warmth or unnatural wrinkles over any susceptible points, then avoid pressure on that area until the warning signs disappear. This means not lying or sitting on that particular part.

• Keep pressure off the affected area completely.
• Keep the area clean, you can wash it with boiled water (do not use strong antiseptics)
• Eat well. If lot of liquid comes out of the sore, a lot of protein is lost with it This must be replaced to promote healing. Eat food rich in proteins, i.e., milk, curd, pulses, eggs, meat, fish, beans, etc. Also take iron pills, if there are signs of anemia.
• If a sore is deep and has dead flesh, consult your doctor and follow his instructions.

In addition to the disability and the limits it imposes, the problem is of getting through to the minds of the able-bodies that SIP are people with the same kind of human desires and impulses. The disabled are people, and people are sexual. Much of our sense of personhood comes from our ability to play a sexual role. The person with disability first obstacle is self de-programming – rejecting the idea that he or she is not a potentially sexual person. The second is effective militancy – doing something about it. The ideal strategy is open discussion with other individuals or couples who share the same problem and counsel each other. In institutions SIP should demand that the matter be talked out. Almost all SIP can be made sexually functional with special counseling and a minimum of physical help. Virtually nobody is too disabled to derive some satisfaction and personal reinforcement from sex.

When a SIP is unable to enjoy sex, the greatest obstacle to enjoyment usually is not the difficulty or impossibility of making particular movements, but the social convention that sex consists of putting the penis in the vagina and that all the rest of the rich range of human sexual responses oral, manual and skin stimulations are abnormal. That is the reason a SIP begin to think of himself as an invalid and distrust on his own personhood makes him suspect other peoples affection as pity. Once you overcome that, try and explore your sexuality. Learn the techniques and procedures for sexual exploration and fulfillment. Sexual expression has to be tailor-made for the individual and one has to try hard to achieve it. This is a challenge same as learning other skills of management of spinal cord injury. But sexual challenge is probably the one best worth accepting as one discovers that one is loving, lovable, interacting human being – a participant rather than an onlooker.

The perception of the sexual act in male comprises of erection, orgasm and ejaculation, and in the females the corresponding responses. This is called Penetrative Sex. In sexuality and disability, we redefined it as Participative Sex.

The best way to put yourself and people at ease is communication. The partner with a disability needs to educate the other person about the ways in which his or her body is different, both the partners need to communicate about what they like, what seems to be working for them and any problems they might be having.

Practical Advice: Empty your bladder and bowel before having sex. Be careful in positioning yourself in a way that avoids too much friction or pressure, Use humor to help you cope unexpected situations, Negative thoughts and worries can prevent an erection from occurring. Avoid thinking of performance anxiety.

The mechanism of erection are complex. When sexually aroused, a man’s brain signals the muscles in the penis to relax and the blood vessels to expand. As more blood flows into the penis, the veins that normally allow blood to flow out of the organ become tightly compressed. The result of all this blood trapped blood is an erection. The consistent inability to maintain erection firm enough for satisfactory sexual intercourse is a common feature in case of SCI. This is because for a man to get erection, his brain must send signals along the spinal cord to tell the nerves in his penis that he is sexually aroused so that the mechanism of erection sets in.

There are two types of erections

Psychogenic-Transmitted by cortical (brain) stimulation and regulated by sympathetic nerves. It is poorly sustained and lasts briefly in case of SIP

Reflexic- It is well sustained and more powerful. Transmitted and integrated – by spinal centers.

Loss of erection may be temporary, often lasting for only first few months after injury, although in men with a lesion below T12 the ability to achieve even a reflex erection may be permanently abolished.

Suprasacral lesions : Reflex erection is possible. It is activated by stimulation procedure Squeezing of penis, Suprapubic tapping, Pulling of pubic hair etc.

Sacral lesion : Weak and ill sustained erection. This requires additional maneuvers through the use of

Vacuum erection aids : A cylinder fits on penis and with a gadget vacuum is created by pumping all the air out of the cylinder. This stimulates blood flow to the area within few minutes and that results in erection. A rubber band is slipped on to the base of penis to maintain erection. A rubber band is slipped on to the base of penis to maintain erection. After intercourse, the rubber band can be removed and the penis becomes flaccid.

Intracavonosal injection of papavrine : 7.5 – l 10mg good erection for 30 minutes. But one has to learn injection under the guidance of a urologist. One should know the right area (Corpocavinosum) and be very particular about the dose. A little extra dose can be very dangerous as the erection does not subside for hours and the blood in the penis gets clotted and there would be no more erections in future by any method. In such a situation one must straight away rush to a doctor specially Urologist.

Energizing Ring : Is made of ebonite and fits behind the man’s penis and testicles. The snug fit sets up a tiny charge of static electricity, which cannot be felt, but has the effect of enlarging the minute blood vessels on which an erection depends. It can nearly always improve an erection which is otherwise incomplete. A cheaper alternative to the energizing ring could be a small loop or tube of latex rubber which fits around the base of the penis. It helps to improve a rather limp erection or helps to maintain an erection which would otherwise be rapidly lost.

MUSE : It is a tiny pellet which is to be inserted into the urethera with the help of an applicator available along with it. The applicator is inserted about one inch into the penis and then the plunger is being pressed to release the Muse. The pellet quickly melts by the body temperature allowing the medication to be absorbed into the penile tissue. It results in erection in 5-10 minutes. Muse must be stored in fridge.

Mini Press or Hypovase : It is a tablet prescribed to relax the internal sphincter. The main constituent of it being the chemical Prazosin. This medicine gives a proper erection along with it’s normal effect of helping in evacuation of bladder due to relaxing of sphincter. The erection is more pronounced in the case of cervical injury cases. The factor that might inhibit erection is presence of Urinary tract infection (UTI). One should put an elastic band once the erection comes, for better results.

Penile Prosthesis : These implants come in two varieties. A surgeon may insert either an inflatable device that can be pumped up to cause an erection or semirigid rods that you can bend yourself either outward or close to your body.

If your partner is non-disabled, she can straddle you, open the lips of her vagina and stuff your soft penis in, using her vaginal muscles to hold it in position. This may stimulate erection, but still if it does not, it may still be very pleasurable for both of you.

Beside these devices & methods posture is very important. Male acts as a passive partner and female as an active partner and on top of the male. Legs can be supported by pillows.

If it is not possible to get the maintain an erection there are a range of artificial penises for use when penetration is desired.

This imitation penis, which straps on the man’s body with a elastic harness, may be solid or hollow so that flaccid penis can fit inside. The more sophisticated models can even squirt a warm fluid to stimulate ejaculation. Some even have a built-in vibrator.

Those who do not have a partner or for whom sexual intercourse is not possible may need a device to assist masturbation. A vibrator can be used in these instances or to improve love-making

Many a spinal cord injured people not only enjoy sex, but also experience orgasm. Although the orgasm may be and feel different from those they had before injury, but they are not necessarily less satisfying or intense. Some people say that other parts of their bodies appear to compensate with greater sensitivity for the lack of feeling in their paralyzed parts. It has been found that women with SCI have an alternative sensory path for orgasms coming through the vagus nerve, the I0th cranial nerve and which should not be affected by SCI. It is also likely that hormones released during intercourse play a major role in orgasm.

The brain plays a large part in the ability of ejaculate, and in SCI the brain – penis connection is lost. Thus ability to ejaculate return less frequently, although some men experience a `phantom orgasm’, without ejaculation, when their partner reaches orgasm. However, many do have an orgasm with ejaculation through the use of vibrator. Finally, as everybody knows, ejaculation is only one reflex part of the orgasm and the rest is in the mind. A number of SIPS are capable of fathering children. Sperms can be obtained, if ejaculation can’t be produced by normal masturbation, by the use of a powerful vibrator applied to the gland penis, or by electro-ejaculation, involving the introduction of electrodes into the rectum under anesthesia. The semen may then be introduced into the partner’s vagina using AID/AIH equipments or a simple rubber tube – a technique which couples may learn to carry out for themselves without difficulty.

There is a considerable amount of research at present being conducted in the field of fertility of SCI.

For women however the essential sexual functions are unaltered, though there may be a decrease in lubrication of the vagina and they may have little or no sensation on the clitoris. In case of women the fertility is not affected by spinal injury, the periods may cease for a while after the injury but they would resume as earlier. They are fertile and thus women should think about contraception if in a sexual relationship.

Autonomic Dysreflexia If one has a high lesion, sexual activity and especially ejaculation may bring on autonomic dysreflexia. If this happens, one should stop immediately, check all possible causes, sit upright if you have been laying down, and do not hesitate to call the doctor if any symptoms persist. Sublingual Nifadipine in emergency.

The backbone is the number one support for your body. The bones stacked on top of each other are called vertebrae and the spinal cord runs through them. The bones help protect the spinal cord. The vertebral column is made up of 33 bones called vertebrae. Seven vertebrae are in the neck region called Cervical Vertebrae denoted as C1, C2,C7, twelve in the thorax also called thoracic vertebrae and denoted as T1- T12 or D1-D12 and five in the lumbar region, L1- L5. There are five vertebrae in the sacral region (S1-S5) and remaining four are fused together as a vestigial organ, to remind us that our ancestors had tails. The spinal cord is a part of your nervous system. It is like a telephone wire that goes from your brain to the middle of your back, to your hips.

It divides into many nerves as it moves down, like wires of a telephone cable and carries messages from the brain to the various parts of the body and back

With a spinal cord injury (SCI) your spinal cord can be hurt any place from neck to the hips. Just like a telephone wire will stop relaying messages beyond the point it is damaged, in the same way messages from the brain stop passing beyond the injured part.

The area below the injured part of the spinal cord becomes paralyzed with probable loss of sensation and movements. Depending upon the level of injury you could be either a paraplegic or a tetraplegic.

• The main cause of a spinal injury in our country is fall from height. May it be from a tree, scaffolding, top of a building, into a well etc.
• Fall of weight over you
• Road traffic accidents
• Injuries due to violence
• Sports injuries
• Tuberculosis of the spine
• Medical and surgical accidents

If you cannot move your legs but came move your arms like before, your spinal cord is hurt in your back (T1 and below) and you would be termed in medical language as a paraplegic.

If you cannot move your legs and arms both then your spinal cord is injured in your neck area (C1 to C8) and you would be termed as a tetraplegic. The closer the injury of the spinal cord to the brain fewer parts and systems of the body work normally.

This would depend entirely on how hurt or damaged the nerves of your spinal cord are The prognosis differs from patient to patient. Depending upon the extent of injury, some people are able to walk normally, some use calipers to get about and some also would have to use a wheelchair. The progress is extremely stow, therefore, you need to be patient and have a lot of hope. Ask your doctor to give you a clearer picture in your case.

The doctors would be able to give you the prognosis only after 6 weeks. !t is difficult to be sure of anything before that as your spine is in a spinal shock. Only after the spinal shock wears out can a more appropriate judgment be made.

This movement is called spasms. This is an unexplainable symptom normally seen in the case of incomplete spinal cord injury. This is an involuntary movement so let it not confuse you. It need not mean that you would soon be walking, though it is a good sign.

More or less all the systems below the level of injury are affected may it be the digestive, circulatory or respiratory systems etc. But again the extent of damage depends on the level of injury and the severity of the injury. In the initial phase loss of control over bladder, bowel and pressure ulcers are the main cause of worry, anger and depressions. Later they may also come to realise about loss of sensation, erection and thus inability to perform sex. It too becomes a major worry in addition to bladder and bowel management. At the hospital you would be re-trained in how to perform these vital functions, may it be bladder, bowel, sexuality or keeping free from pressure sores Ask you doctor for more information.

Yes, you would be able to go out as often as you like. Though travelling after a SCI can becomes a matter of great fear and anxiety for you that might make you confine yourself to your home. There might be many questions in you mind like what if I have a bladder or a bowel accidents or a simple worry of how you would manage yourself. This could result in your feeling lonely and depressed. SCI is not a disease whereby you can or should not go out. Just by taking care of a certain points you can have successful outings.

GIVE YOURSELF A CHANCE

Care needs to be taken of preventing any pressure and be careful of the following points:

• Scraping and knocking hips and bottom when transferring in and out of the car can easily cause a sore.
• Make sure the car upholstery is not to hot before shifting as this can cause hip burns
• Most car seats are welt contoured and quite soft and should not cause pressure
• Beware from burns in the car if you can

Again care needs to be taken about:

• Empty your bladder before starting the journey. Incase you are going for a long journey make sure you regulate your fluid intake by not taking much fluid one hour before from when you start your journey.
• In case of a long journey check your bowel movement by being sure in your mind that you would have no accident. In case of doubt, have your bowel movement before you start your journey, as there is no point in having an accident.

As far as possible auto rickshaws should be avoided as they are very bumpy and can have a detrimental effect on the already damaged spine. Whenever one has to then be careful of the following.

• Persons with cervical injuries must wear a collar while traveling.
• While transferring take care not to scrape and knock your hips and bottom.
• Make sure the upholstery is not to hot before shifting as this can cause hip burns.
• Beware from burns in the auto rickshaw on hot days if you can.
• Empty your bladder before starting your journey
• Take care of your bowel movements.

• While transferring take care not to scrape and knock your hips.
• Make sure the upholstery is not too hot before shifting as this can cause hip burns
• Beware from burns in the auto rickshaw on hot days if you can
• Empty your bladder before starting your journey
• Take care of your bowel movements

There is a train concession given by the government upto 25% for the disabled person and 25% for the carer.

Pre Preparations

• Make sure that your tickets are booked
• Must have a bowel movement before you start your journey
• For women who are either tapping or using intermittent catheterisation it may be advisable to switch to indwelling catheterisation for the journey for ease and hygiene
• Make sure you carry your medicines and also other common medicines you might need like lomotil etc.
• Carry some eatables preferably salty that you may need in case of sudden lowering of blood pressure

As the door and the passage in the train are very narrow you may need to be carried by two people tilt your seat.

• Must have a bowel movement before you start your journey
• For women who are either tapping or using intermittent catheterisation it may be advisable to switch to indwelling catheterisation for the journey for ease and hygiene.

A proper wheelchair is very important, as it will help you to do all the activities you decide to do. It needs to fit your body, your abilities and your lifestyle Once you have procured the right wheelchair, keeping it well maintained is equally important

A broad category as following:

• Spinal cord injuries
• Cerebral palsy
• Multiple sclerosis
• Muscular dystrophy
• Brain injuries
• Stroke
• Autism
• Developmental delays
• Macular degeneration
• Amputation
• Elderly persons

The different kinds of wheelchairs available are:

Manual Wheelchair

Large rear wheel / small front caster.

Propulsion by concentric hand-rims attached to rear wheels Good upper body strength is a must. These chairs may or may not be folding. May be attendant or self propelled

Powered Wheelchair

For patients with inadequate muscle function, or those with insufficient pulmonary or cardiac reserves. Control systems can vary depending upon the user’s residual function e.g. chin control. tongue control, puff and sip control, sonic control, light control etc These are very expensive and not available in India.

Before deciding the wheelchair you plan to purchase you need to know your energy level and abilities based on your level of your injury and the level of your independence, daily activities you can do for yourself. Other points to consider are:

• whether the wheelchair is for indoor/ outdoor use or both?
• Your ability to transfer and the amount of assistance required for getting in or out of the chair.
• What features will make the wheelchair more comfortable
• What type of transport do you use or plan to use to get about
• Funds available to purchase the wheelchair
• Architectural barriers at home & workplace.

If you are either a paraplegic or a tetraplegic your wheelchair should be:

• Folding With detachable armrests
• Swinging and/or detachable footrests
• Good braking system

Other features you can consider having are:

• Detachable rear wheels
• Desk type arm rest

Be sure of the color of the wheelchair you want. A heavy wheelchair is difficult to use

• If you can propel it without undue exertion.
• Are efficient.
• If the footrests and armrests can be easily detached, stored and replaced
• Easy maneuverability at home/work environment.
• If you can transfer yourself (independently/ with assistance) in and out of the chair safely.

A folding wheelchair will give you greater maneuverability to travel. This option will give you a lot of freedom and confidence to do more.

It is important to keep your wheelchair in the best condition so as to avoid an accident or inconvenience at the wrong time. Oiling is important for easy maneuvering. Folding and detachable parts if not oiled can give a problem when you are all dressed to go out. Try and stick to a fortnightly oiling schedule. A detailed maintenance chart is given below.

• Wheelchair Part : Maintenance Required
• Casters : Oiling fortnightly and replacement when required
• Brakes : Tightening once a month
• Rear Wheels : Change when required. Pneumatic tyres will require air filling fortnightly and puncture repair when required
• Seat cover and back cover : Regular washing and changing when they begin to tear from the sides
• Arm rests : Oiling of locking pin fortnightly. Keep checking the springs of the locking pins
• Foot rests : Oiling of detachable parts fortnightly
• Hand rims : Tighten the screws of the propelling knobs once a Month
• Axle : Oiling fortnightly and replacement of ball bearings once a ear
• Cross brace : Oiling of folding rods fortnightly.

Minor maintenance jobs like oiling, and tightening of different parts can be done by someone in your family or friend. Otherwise you can make use of a local cycle repair person. This person would have to be guided the first few times. He will also be able to take care of replacing the ball bearing. For any replacement like the castors, wheelchair seat and back, tyres, you will have to get in touch with the manufactures.

No ! Primary goals of AT is enhancement of capabilities and removal of barriers to performance. The least complex intervention should be considered first. For example, a person having difficulty in feeding, brushing or writing, a low-tech universal cuff could be adapted according to the user’s need. A head pointer or mouth stick is other low-tech device to negotiate computer-aided tasks. A tow cost and low tech wheelchair could be modified as per the individuals needs. Those who are able to afford there are high tech and cost effective wheelchair are available only after doing proper assessment of the individual.