The Spinal Unit

Guttmann's model for success

By Professor Wagih El-Masri, Hon. Clinical Professor of Spinal Injuries, Keele University

 I first came to Stoke Mandeville in 1971, a young graduate from Cairo Medical School. I had heard a great deal about Sir Ludwig Guttmann’s pioneering work with spinal injuries and I came specifically to find out whether his approaches were credible. Back in Cairo in the late 1960s no one knew how to treat such patients, yet there were these rumours about this extraordinary man at Stoke Mandeville Hospital who not only enabled tetraplegic and paraplegic patients to survive their acute episodes but who was also able to get even the most paralysed of patients into the standing position and who would even get such patients back into work and with a decent quality of life. Back in Cairo no one could believe that, so I decided I had to come and see for myself. 

Specialist solutions

Photo:Dr. Guttmann with a patient

Dr. Guttmann with a patient

Photo IWAS

Guttmann was very clear in his own mind that because of the complexity of spinal injuries and the multiple ways in which they affected patients and because of the need for simultaneous adequate management of both the medical and the non-medical effects, then the only appropriate system of service provision for patients was in specialist centres that could provide a team with the knowledge and skills specific for each patient. This enables specialists within such centres to have the ability to understand each other’s professional language and capabilities. “In my opinion that core presumption is still correct today, forty years on and has not been challenged by evidence of added value when delivery of care is fragmented” 

A spinal injury is a very frightening condition; it becomes even more frightening if you are the only patient in a hospital with that condition.

One argument for the specialist centre model is statistical. In the UK there are only 10-15 spinal cord injuries per 1 million of population per year (considerably less than in the US or the Middle East); extrapolated across the UK that meant that the average district general hospital serving a population of quarter of a million might expect no more than two or three patients a year. So, considering the different types of spinal cord injuries it was just not going to be possible for each of these local hospitals to cater for the very wide-ranging injuries and effects for such a small number of patients or indeed to develop any expertise in their care.

Photo:"Patient in traction on a turning bed, which relieved pressure and changed position. Traction was used to reduce dislocation from movement; it has now largely been replaced by the surgical use of plates and pins so now everything happens much more quickly; previously you had to wait for the patient to heal in position."

"Patient in traction on a turning bed, which relieved pressure and changed position. Traction was used to reduce dislocation from movement; it has now largely been replaced by the surgical use of plates and pins so now everything happens much more quickly; previously you had to wait for the patient to heal in position."

Photo NSIC

The other argument Guttmann put forward was one of humanity of care. A spinal injury is a very frightening condition; it becomes even more frightening if you are the only patient in a hospital with that condition. Whereas at specialist spinal injuries centres everyone is in the same boat psychologically and can learn from and derive comfort and knowledge from the experiences of patients with similar problems.

Holistic approach

He demonstrated that the problem was not just that of the damage or injury to the spinal cord or vertebrae but that this initial injury went on to create a multi-system physiological impairment and malfunction causing a wide range of disabilities and being a potential source of many complications. In the early days of treatment these included bed sores and genito-urinary infections, muscle contractures, excess spasticity, deep vein thrombosis, stress ulcers and very many other.

He further demonstrated that almost all of these conditions are preventable or their effects can be minimised. Among the techniques that that he established arguably the most important was his multi-disciplinary approach that recognised that  a combination of all disciplines – medical, nursing, physiotherapy, OT, social worker  - was needed to simultaneously address a patient’s needs. Further he promoted the idea that the physician treating the patient should (apart from the most specialised of treatments) be capable of covering both the medical and the surgical aspects of the patient’s treatment. Such a holistic merger of medical and surgical disciplines had rarely been practised before.

Professor El-Masri

Wagih El-Masri came to Stoke Mandeville in 1971 and trained under Sir Ludwig Guttmann - even though he had officially retired. He went on to become Director of the Midlands Centre for Spinal Injuries. Read the full interview with Profesor El-Masri below.

This page was added on 15/03/2011.

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