© Roland Defrancesco

“The Smallest Improvement is a Success”

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As we follow Richard Altenberger to his office in the rehabilitation clinic of Bad Häring in Austria, it seems as if we are in the company of a celebrity. Everyone here knows the clinic’s head of physiotherapy. After 37 years, the specialist from Tyrol is about to retire. He looks back at his innumerable patients, speaks about tests of patience, and impressive progress.

Mister Altenberger, you decided to specialise in physiotherapy for patients with spinal cord injuries. Why?
Following my training as a physiotherapist in Innsbruck, I managed to secure an internship here in Bad Häring. My entire life revolved around sports at the time. I simply couldn’t imagine assisting a rehabilitation process that confines people to wheelchairs… However, my view changed completely through direct contact with spinal cord injury patients. I quickly understood that values in life change after such a trauma. Materialism, metres and seconds, etc, are sidelined in favour of other purposes in life, such as independence. I have witnessed what an impaired body is capable of doing via trick movements. Ever since, my task has been to improve the quality of life of patients with spinal cord injuries and to enable them to make the best of their situation.

Why are patients with spinal cord injuries so interesting to you?
We have approximately 120 spinal cord injury patients in our rehab department every year. The interesting thing is that these injuries are hardly ever according to the book. If you look at three patients with the same lesion height, all three will turn out to be quite different cases.
There are a lot of factors to take into consideration: the body itself, the leverage ratios, and even the intelligence level of the patient. One has to determine how receptive a patient is and how the structure of the body evolves. As a therapist, one has to find individual ways to make the patient self-sufficient and capable of coping with everyday life.

 (Roland Defrancesco)
© Roland Defrancesco

At which point do you have contact with the patients after an accident?
The patients are transferred to us from the acute care hospital six to eight weeks after the accident. Once a doctor has conducted a medical interview, the respective patient has an initial interview with a therapist. During this interview, we ask patients what they expect and which goals they have defined for themselves. This allows us to gauge to which extent an accident victim is aware of the situation. 

What does awareness mean in this context?
Some patients come here with a complete spinal cord injury and are under the impression that they will be able to walk again. In these cases, it is my task to sensitively explain what the injury is and what it means. Naturally, I cannot give patients back bodily functions that are beyond repair. However, I can highlight how the situation can be improved and I can react immediately as soon as certain bodily functions return.

You often experience the first phase of processing the injury. How does that feel?
We describe that phase as the mourning for the patient. This is when the accident victim understands – for the first time – what has happened and what it means for the future. It would, however, be a mistake to believe that all patients despair. On the contrary, they are motivated, crave a perspective, and are eager to learn. They encounter other accident victims who are in a more advanced stage of their respective rehabilitation processes. Then comes the day when they can eat in a seated position or prop themselves up for the first time. This progress triggers confidence and hope. The situation often worsens after the dismissal. The accident victims have to find their own way in everyday life. Doors that prove difficult to open, doorsteps, and a limited space in the home environment are barriers that the patients didn’t have to deal with in the rehabilitation centre.

Do you remember many of your patients?
I remember almost all of them. I even remember the accidents of people who haven’t visited the clinic for 20 or 30 years. In the course of the therapy sessions, one accompanies people for weeks – or even months during an exceptional situation. One discusses the most intimate aspects of life and develops something akin to a friendship. I am among the people who are afforded the opportunity to lead the patients into a different life.

Seeing that you have such a close relationship with the patients, can you switch off when you are at home?
I can now, but I had to learn how to distance myself. I rarely talk about my work. Things that are distressing remain here within the walls of the clinic.

Are you affected by individual cases? Or do you also create a certain distance in this respect?
I am the father of two daughters and, of course, you sometimes think: “That could be my child.” It can become quite gruelling if you allow yourself to think about it too much, especially as one can tell quite early on what a patient will have to go through. If a patient suffers a C4 lesion, I know that this individual will have to navigate through life with a chincontrol system before he or she knows.

Have you found a special way to deal with patients?
I want my patients to listen to their bodies and to see that they are still powerful. Many people didn’t even know their bodies and their limits prior to their accident. That’s where I come into play with strength and endurance training. Some are quite overwhelmed by it. I often apply the “carrot and stick” principle. I am motivating, but also demanding. I want my patients to stay fit in the long term without additional therapy.

Have you experienced moments of disillusion in the process?
I have experienced some. Right now, I have a patient who is finding it very difficult to prop herself up. She has the required strength, but she is scared of falling forwards. This psychological barrier makes her despair. I despair with her, mainly because I can’t find the key to unlock the situation. I am both cautious and impatient. It can be very difficult to find the right balance.

Which progresses within the field have made you particularly happy?
All of them! Even the smallest improvement is a success. However, the real milestones are when patients with incomplete spinal cord injuries manage to stand up after an intensive strength workout and then make their first unsupported steps in the walking school. One experiences how someone learns how to walk again; that is unique. This is when we applaud, animate, and celebrate. The entire house needs to know what just happened here.

 (Roland Defrancesco)
© Roland Defrancesco

Has the situation for spinal cord injury patients changed over the years?
When I started working here, I had a lot more completely paralysed patients. Today, we see many more patients with incomplete spinal cord injuries than before. The reasons for this are advanced initial care and new surgical techniques. The problems pertaining to bowel movements and bladder control are easier to address due to improved techniques and medication. And let’s not forget that mobility and participation have become easier due to light and agile wheelchairs.

What are your thoughts in terms of healing spinal cord injuries?
I am absolutely convinced that there will be a cure in the future. Researchers are, after all, working very hard on finding such a cure. I believe that the key lies in the field of genetics. Something in terms of primary care will happen at the source of the injury.

What do you believe in?
I am not deeply religious. I remember a father who had a severe accident and suffered a C6 spinal cord injury. A year later, his son suffered exactly the same fate. Two people within one family, who had done nothing out of the ordinary, suffered the same devastating injury. That’s when you start asking yourself whether there actually is some mysterious power up there or how everything is controlled.

You are about to retire. How do you feel about that?
I loved my work, but this phase of my life is over. I will definitely continue to monitor certain projects and remain interested in the field. I am very active and will focus on sports again. Also, my wife is already threatening me with housework. 

In conclusion, has one particular moment etched itself in your mind more than others?
I have experienced so much here. I remember a group of young boys with spinal cord injuries. In terms of wheelchair technique, they were almost perfect. They managed to navigate kerbstones, slopes, and all other obstacles. I really didn’t know how to handle their energy. Then I invented the wheelchair long jump. The boys buried the front wheels of their wheelchairs into the sand of a long jump pit. Whoever was propelled out of the wheelchair the furthest was the winner. Today, that would be unthinkable, but it felt like a little piece of joie de vivre to us.

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