Spinal Cord Injury: Treatments and Rehabilitation (cont.)
How Does a Spinal Cord Injury Affect the Rest of the Body?
People who survive a spinal cord injury will most likely have medical
complications such as chronic pain and bladder and bowel dysfunction, along with
an increased susceptibility to respiratory and heart problems. Successful
recovery depends upon how well these chronic conditions are handled day to day.
Any injury to the spinal cord at or above the C3, C4, and C5 segments, which
supply the phrenic nerves leading to the diaphragm, can stop breathing. People
with these injuries need immediate ventilatory support. When injuries are at the
C5 level and below, diaphragm function is preserved, but breathing tends to be
rapid and shallow and people have trouble coughing and clearing secretions from
their lungs because of weak thoracic muscles. Once pulmonary function improves,
a large percentage of those with C4 injuries can be weaned from mechanical
ventilation in the weeks following the injury.
Respiratory complications, primarily as a result of
pneumonia, are a leading
cause of death in people with spinal cord injury. In fact, intubation increases
the risk of developing ventilator-associated pneumonia (VAP) by 1 to 3 percent
per day of intubation. More than a quarter of the deaths caused by spinal cord
injury are the result of VAP. Spinal cord injury patients who are intubated have
to be carefully monitored for VAP and treated with antibiotics if symptoms
appear.
- Irregular heart beat and low blood pressure
Spinal cord injuries in the cervical region are often accompanied by
blood
pressure instability and heart arrhythmias. Because of interruptions to the
cardiac accelerator nerves, the heart can beat at a dangerously slow pace, or it
can pound rapidly and irregularly. Arrhythmias usually appear in the first 2
weeks after injury and are more common and severe in the most serious injuries.
Low blood pressure also often occurs due to loss of tone in blood vessels,
which widen and cause blood to pool in the small arteries far away from the
heart. This is usually treated with an intravenous infusion to build up blood
volume.
People with spinal cord injuries are at triple the usual risk for
blood
clots. The risk for clots is low in the first 72 hours, but afterwards
anticoagulation drug therapy can be used as a preventive measure.
Many of our reflex movements are controlled by the spinal cord but regulated
by the brain. When the spinal cord is damaged, information from the brain can no
longer regulate reflex activity. Reflexes may become exaggerated over time,
causing spasticity. If spasms become severe enough, they may require medical
treatment. For some, spasms can be as much of a help as they are a hindrance,
since spasms can tone muscles that would otherwise waste away. Some people can
even learn to use the increased tone in their legs to help them turn over in
bed, propel them into and out of a wheelchair, or stand.
Autonomic dysreflexia is a life-threatening reflex action that primarily
affects those with injuries to the neck or upper back. It happens when there is
an irritation, pain, or stimulus to the nervous system below the level of
injury. The irritated area tries to send a signal to the brain, but since the
signal isn't able to get through, a reflex action occurs without the brain's
regulation. Unlike spasms that affect muscles, autonomic dysreflexia affects
vascular and organ systems controlled by the sympathetic nervous system.
Anything that causes pain or irritation can set off autonomic dysreflexia:
the urge to urinate or defecate, pressure sores, cuts, burns, bruises,
sunburn,
pressure of any kind on the body,
ingrown toenails, or tight clothing. For
example, the impulse to urinate can set off high blood pressure or rapid heart
beat that, if uncontrolled, can cause
stroke,
seizures, or death. Symptoms such
as flushing or sweating, a pounding headache, anxiety, sudden high blood
pressure, vision changes, or goosebumps on the arms and legs can signal the
onset of autonomic dysreflexia. Treatment should be swift. Changing position,
emptying the bladder or bowels, and removing or loosening tight clothing are
just a few of the possibilities that should be tried to relieve whatever is
causing the irritation.
- Pressure sores (or pressure ulcers)
Pressure sores are areas of skin tissue that have broken down because of
continuous pressure on the skin. People with paraplegia and quadriplegia are
susceptible to pressure sores because they can't move easily on their own.
Places that support weight when someone is seated or recumbent are vulnerable
areas. When these areas press against a surface for a long period of time, the
skin compresses and reduces the flow of blood to the area. When the blood supply
is blocked for too long, the skin will begin to break down.
Since spinal cord injury reduces or eliminates sensation below the level of
injury, people may not be aware of the normal signals to change position, and
must be shifted periodically by a caregiver. Good nutrition and hygiene can also
help prevent pressure sores by encouraging healthy skin.
People who are paralyzed often have what is called neurogenic pain resulting
from damage to nerves in the spinal cord. For some survivors of spinal cord
injury, pain or an intense burning or stinging sensation is unremitting due to
hypersensitivity in some parts of the body. Others are prone to normal
musculoskeletal pain as well, such as
shoulder pain due to overuse of the
shoulder joint from pushing a wheelchair and using the arms for transfers.
Treatments for chronic pain include medications, acupuncture, spinal or brain
electrical stimulation, and surgery.
- Bladder and bowel problems
Most spinal cord injuries affect bladder and bowel functions because the
nerves that control the involved organs originate in the segments near the lower
termination of the spinal cord and are cut off from brain input. Without
coordination from the brain, the muscles of the bladder and urethra can't work
together effectively, and urination becomes abnormal. The bladder can empty
suddenly without warning, or become over-full without releasing. In some cases
the bladder releases, but urine backs up into the kidneys because it isn't able
to get past the urethral sphincter. Most people with spinal cord injuries use
either intermittent catheterization or an indwelling catheter to empty their
bladders.
Bowel function is similarly affected. The anal sphincter muscle can remain
tight, so that bowel movements happen on a reflex basis whenever the bowel is
full. Or the muscle can be permanently relaxed, which is called a "flaccid
bowel," and result in an inability to have a bowel movement. This requires more
frequent attempts to empty the bowel and manual removal of stool to prevent
fecal impaction. People with spinal cord injuries are usually put on a regularly
scheduled bowel program to prevent accidents.
- Reproductive and sexual function
Spinal cord injury has a greater impact on sexual and reproductive function
in men than it does in women. Most spinal cord injured women remain fertile and
can conceive and bear children. Even those with severe injury may well retain
orgasmic function, although many lose some if not all of their ability to reach
satisfaction.
Depending on the level of injury, men may have problems with erections and
ejaculation, and most will have compromised fertility due to decreased motility
of their sperm. Treatments for men include vibratory or electrical stimulation
and drugs such as sildenafil (Viagra). Many couples may also need assisted
fertility treatments to allow a spinal cord injured man to father children.
Once someone has survived the injury and begun to psychologically and
emotionally cope with the nature of his or her situation, the next concern will
be how to live with disabilities. Doctors are now able to predict with
reasonable accuracy the likely long-term outcome of spinal cord injuries. This
helps patients set achievable goals for themselves, and gives families and loved
ones a realistic set of expectations for the future.
Next: How Does Rehabilitation Help People Recover From Spinal Cord Injuries? »
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