Long term issues in spinal cord injury

Long term issues in Spinal Cord Injury

Dr. Mahima Agrawal

• Complete injury: People with no sensory or motor function below the level of spinal cord injury around the anal area (S4 and S5)• Incomplete injury:

Preservation of some function below the level of spinal cord injury

Types of injury

• Paraplegia: Injury to thoracic, lumbar or sacral segments of the spinal cord• Quadriplegia: Injury to the

cervical segments of the spinal cord i.e. between C1 and T1

Types of injury

Limitation

Mobility

Self care

Domestic activities

Education

Employment

Social relationship

Leisure

Level and Problem list

C1-C4BreathingHead and Neck movement

C4-T1Heart rate controlUpper Limb movement

T1-T12Trunk controlTemperature regulationAbdominal muscles

L1-S1Lower limb movement

S2-S4/S5Bowel, Bladder and Sexual function

Complications of SCI

Triggers - any noxious stimulus(most commonly distended / blocked bowel or bladder)

• Heavy sweating• Severe headache• Reddened skin• Blurred vision• Body hair standing • Cardiac arrhythmias

Sudden increase in blood pressureSeen in individuals with SCI at or above

T6 level

Autonomic dysreflexia

Most common in acute and sub acute phaseBut can occur any time

Most common cause –

long term immobility• Pain• Swelling• Tenderness• Skin discoloration• Warmth

Risk factors – • Age• Obesity• Lower limb fractures• Pregnancy• Previous history of DVT

Preventive measures: • Anti coagulants

• Wearing compression stockings

!!Can lead to pulmonary embolism

Deep venous thrombosis

• Fatigue• Light headedness• Dizziness• Blurred vision• Muscle weakness• Temporary loss of consciousness

!!! Sudden drop in blood pressure

When a person moves from lying to sitting/standing position

Orthostatic hypotension

Urinary tract infections

Signs and symptoms• Episodes of incontinence• Painful urination• Increase in spasticity• Neuropathic pain• Autonomic dysreflexia• Fever• Malaise• LethargyMethods of bladder emptying-

• Intermittent cathetarization• Indwelling cathetarization• Other methods

Bladder overdistention, reflux, high-pressure voiding, large postvoiding residual volume, stones, and outlet obstructionFaulty, unsterile technique

Bladder Diary

PROBLEMS• Poor colonic motility• Chronic constipation• Abdominal distension• Prolonged bowel transit time• Faecal incontinence

Gastrointestinal system

SOLUTIONS Proper nutritional and fluid intake Dietary supplements and oral

medications when needed Appropriate methods to assist

defecation (physical techniques and stimulants such as laxatives, suppositories and enema)

Surgery to form a stoma

There is increased stiffness of the limbs and it is difficult to move through the range of motion

Spasticity

Can lead to • Disabling contractures• Involuntary movements• Weakness• Fatigue• Difficulty in sleeping because of

painful spasms• Difficulty with maintaining

hygiene

Physical therapy - exercise, stretching, and joint movementsCasting or bracing Medications orally or by injection to affected muscle groups (Botox) or “intrathecally” Surgical options

Loss of bone mass immediately following SCI

Sublesional osteoporosis Can lead to fractures during trivial falls, transfersFurther morbidity

Risk factors-Old age, use of steroids, calcium and vitamin D deficiency

Management• PREVENT!!! – Drugs, care

during transfers, diet• If fracture occurs, splints,

immobilization, surgery

Heterotrophic ossification

Formation of bone in soft tissue leading to loss of range of motion of that particular joint

Most commonly affected joints: Hip, Knee, shoulder, Elbows

Management• Avoid ROM• Drugs – bisphosphonates, Anti

inflammatory drugs• Surgery

Respiratory system

• Pneumonia• Atelectasis• Aspiration• Respiratory failure

Lung capacity, ease of breathing and ability to cough and clear secretions are often compromised following a SCI

Management• Annual influenza vaccine• Five yearly pneumcoccal

vaccine• Prompt treatment of

respiratory tract infections with anti biotics

• Yearly implementation of assisted coughing for people with high level SCI

• Weight transfers• Proper bed positioning, wheelchair sitting

Pressure ulcers

Management• Regular skin checks• Pressure relieving methods• Adequate bladder and bowel care• Appropriate assistive devices• Good nutrition• Surgery

PREVENT!!!!

• Reduces the quality of life

Pain – neuropathic/musculoskeletal

Management• DrugsOthers-• Physical therapy• Working with a counselor

Problems• Decrease or loss of

sensation, difficulties in achieving orgasm• Difficulties in moving and

positioning• Lowered self esteem and

confidence• In men, partial or complete

impairment of penile erection and ejaculation • Female menstruation may

be impaired

Sexual dysfunction Respectful discussion at the appropriate time with both individual and partner

Medical care and rehabilitation relevant to the individual

Provision of education and information on positioning and preparation for sexual activity, birth control, prevention of STDs

Assistive devices for arousal or to enhance positioning

Treatment of erectile dysfunction in men( vibratory stimulation, oral medications, penile injections, vacuum devices, penile implantsAssisted fertility

Levels and Functional outcomes

C1-C4

Bathing

Weight shifts

Driving

Wheelchair propulsion

Independent with power wheelchair

Feeding Grooming UE Dressing LE Dressing

Bed MobilityTransfers

Dependent

C5

Bathing

Driving


Bed MobilityAssistanceneeded

Transfers

Weight shiftsWheelchair propulsion


C6

Bathing

Driving


Bed MobilityAssistanceneeded

Transfers

Independant

Weight shiftsWheelchair propulsion


C7

Driving



IndependantIndependant

Assistanceneeded

Bathing

C8-T1

Driving

Feeding Grooming UE Dressing


IndependantIndependant

BathingLE Dressing

Independent with adaptation

Bathing DrivingFeeding GroomingUE Dressing LE

Dressing

Bed Mobility Transfers

INDEPENDANT Bowel and Bladder

T2-T9T10-L2 L3-S5

AMBULATIONTherapeutic standing

Household ambulation

Community ambulation

Thank you

Health & Medicine

Long term issues in spinal cord injury