Autonomic Dysrelexia (Hyperreflexia)
Heterotopic Ossification (HO)/CYST
Postural (Orthostatic) Hypotension
Autonomic dysreflexia, also known as hyperreflexia, is a state that is unique to patients after spinal cord injury at a T-5 level and above. Patients with spinal cord injuries at Thoracic 5 (T-5) level and above are very susceptible. Patients with spinal cord injuries at Thoracic 6 - Thoracic 10 (T6-T10) may be susceptible. Patients with Thoracic 10 (T-10) and below are usually not susceptible. Also, the older the injury the less likely the person will experience autonomic dysreflexia. Autonomic dysreflexia can develop suddenly, and is a possible emergency situation. If not treated promptly and correctly, it may lead to seizures, stroke, and even death. Autonomic dysreflexia means an over-activity of the Autonomic Nervous System. It can occur when an irritating stimulus is introduced to the body below the level of spinal cord injury, such as an overfull bladder. The stimulus sends nerve impulses to the spinal cord, where they travel upward until they are blocked by the lesion at the level of injury. Since the impulses cannot reach the brain, a reflex is activated that increases activity of the sympathetic portion of autonomic nervous system. This results in spasms and a narrowing of the blood vessels, which causes a rise in the blood pressure. Nerve receptors in the heart and blood vessels detect this rise in blood pressure and send a message to the brain. The brain sends a message to the heart, causing the heartbeat to slow down and the blood vessels above the level of injury to dilate. However, the brain cannot send messages below the level of injury, due to the spinal cord lesion, and therefore the blood pressure cannot be regulated.
A pounding headache (caused by the elevation in blood pressure), goose pimples, sweating above the level of injury, nasal congestion, slow pulse, and blotching of the skin and restlessness are all symptoms of dysreflexia. There can be many stimuli that cause autonomic dysreflexia. Anything that would have been painful, uncomfortable, or physically irritating before the injury may cause autonomic dysreflexia after the injury. The most common cause seems to be overfilling of the bladder. This could be due to a blockage in the urinary drainage device, bladder infection (cystitis), inadequate bladder emptying, bladder spasms, or possibly stones in the bladder. The second most common cause is a bowel that is full of stool or gas. Any stimulus to the rectum, such as digital stimulation, can trigger a reaction, leading to autonomic dysreflexia. Other causes include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications.
Treatment of autonomic dysreflexia must be initiated quickly to prevent complications. Remain in a sitting position, but do a pressure release immediately. You may transfer yourself to bed, but always keep your head elevated. Since a full bladder is the most common cause, check the urinary drainage system. If you have a Foley or suprapubic catheter, check the following: Is your drainage full? Is there a kink in the tubing? Is the drainage bag at a higher level than your bladder? Is the catheter plugged? After correcting an obvious problem, and if your catheter is not draining within 2-3 minutes, your catheter must be changed immediately. If you do not have a Foley or suprapubic catheter, perform a catheterization and empty your bladder. If your bladder has not triggered the episode of autonomic dysreflexia, the cause may be your Bowel. Perform a digital stimulation and empty your bowel. If you are performing a digital stimulation when the symptoms first appear, stop the procedure and resume after the symptoms subside. If your bladder or bowel are not the cause, check to see if you have a pressure sore, an ingrown toenail or a fractured bone. If you are unable to find the stimulus causing autonomic dysreflexia, or your attempts to receive the stimulus fail, you need to obtain emergency medical treatment. Since not all physicians are familiar with autonomic dysreflexia (hyperreflexia) and its treatment, you should carry a card in your wallet that describes the condition and the treatment required.
Prevention of autonomic dysreflexia is very important. The following are precautions you can take which may prevent episodes: If you have an indwelling catheter, keep the tubing free of kinks, keep the drainage bags empty and check daily for grits (deposits) inside of the catheter. If you are on an intermittent catheterization program, catheterize yourself as often as necessary to prevent overfilling. If you have spontaneous voiding, make sure you have an adequate output. Also, maintain a regular bowel program and perform daily skin assessments.
Heterotopic ossification (HO) is the development of abnormal bone in soft (non-skeletal) tissue, primarily in the region of the hip and knee joints. It occurs in many spinal cord injured individuals and may develop within days following the injury or several months later. Heterotopic ossification occurs below the level of injury. The cause of HO is unknown. Most cases of heterotopic ossification cause no significant additional physical limitations, but in a minority of patients, HO may result in a major limitation of joint motion. The first symptom you may notice is difficulty or limitation in your ability to perform activities of daily living, especially activities that require you to bend at the hips. However, sometimes the onset of HO is more rapid, and symptoms at that time may be swelling of one hip and warmth and redness overlying the swelling. In addition to decreased range of motion and swelling in the area of the HO, other symptoms may include increased spasticity, swelling of the entire leg, and/or elevated temperature. If you suspect you have HO, contact your physician. He or she will do an X-ray of your hips and knees, a special isotope bone scan, and blood tests. A medication called Didronel is available and can slow down or arrest the process if started early. If you have HO, watch your skin closely. The HO can increase the amount of pressure applied to the tissue under certain bony prominences. A significant loss of motor function could strongly suggest a cyst. The changes in sensation or motor function may develop gradually. You may notice that it is more difficult to do some of your functional activities, such as holding a cup or putting on your clothes, or you may notice a change in your balance or find that you are burning yourself in places where you previously had sensation. Be aware of your sensory level and muscle strength. If you notice significant changes, contact your physician, and give him or her specific information about the changes you have notices. A muscle and sensory test will be conducted and if you have neurologic deterioration due to a cyst, it may be corrected with surgery. The earlier HO is detected, the easier the treatment, so if you have any signs or symptoms contact your doctor immediately.
Due to your spinal cord injury, the temperature of your body has an increased tendency to fluctuate according to the temperature of the environment. If you are in a hot room your temperature may increase (hyperthermia); if you are in a cold room, your temperature may decrease (hypothermia). This occurs because of the altered function of the autonomic nervous system. The higher the level of injury, the greater the tendency for fluctuations in your body temperature. Hyperthermia refers to an elevation in body temperature. For example, it may occur on a hot day if you are out-of-doors, sitting in a hot car, or covered with too many blankets. One or more of the following symptoms may indicate hyperthermia: Skin feels hot and dry and appears flushed, feeling of weakness, dizziness and visual disturbances, headache, nausea and elevated temperature. Your pulse is generally rapid and may be irregular or weak. It is important that you attempt to prevent hyperthermia when exposed to an overheated environment. Be familiar with how long you can be in an overheated environment without symptoms. Drink lots of fluids, wear protective, light-weight clothing (cotton and light colors) and also try wearing a hat.
Some patients with SCI develop deep venous thrombosis (DVT), or clots in the veins that sometimes give rise to clots in the lungs. Possible signs and symptoms of DVT include swelling of the leg, dilation of the veins, increased skin temperature, pain and tenderness, and, rarely, a bluish discoloration of the lower leg. Sometimes, there are no signs and symptoms of DVT. There are also no characteristic signs or symptoms of lung clots, meaning the signs and symptoms are very nonspecific, such as fever, chest pain, cough, or changes in heart beat. Although other measures are sometimes used, the most common form of treatment for DVT is the use of anticoagulants, such as heparin and warfarin.
On the average, pain occurs in between one third and one half of patients with SCI as a complication of the injury. Only a minority of people with SCI experience pain that is severe or persistent, and pain is relatively rare following discharge from the hospital. However, abnormal phantom sensations (not necessarily pain) in the body and limbs, below the level of the injury, occur in almost all people with SCI.
TYPES OF PAIN: In general, there are four categories of pain that occurs as a complication of SCI: central, muscle tension, visceral, and psychogenic. Central pain, also called dysesthetic pain, is typically a burning, tingling, shooting, stinging, or “pins and needles” sensation. Some people also complain of a stabbing, piercing, cutting, and drilling pain. This type of pain usually occurs within days, weeks, or months of the injury and tends to decrease with time in both frequency and intensity. Central pain is diffuse and occurs most often in the legs, back, feet, thighs, and toes, although it can also occur in the buttocks, hips, upper back, arms, fingers, abdomen, and neck. Central pain occurs more frequently in older, more anxious people. It often results from noxious stimuli, such as smoking, bladder and bowel distention, infections, and skin sores, and from heterotopic ossification, deep venous thrombosis, fractures of the arms and legs, prolonged inactivity, spasticity, fatigue, and depression. Muscle tension, also known as mechanical pain or musculoskeletal pain, is a dull, aching sensation that occurs in people with or without SCI. Muscle tension, that is a complication of SCI, occurs with increased frequency in the shoulder, hip, and hand, although it also occurs in the lower back and buttocks. Muscle tension is probably caused by a combination of factors, such as abnormalities that may have always been there, inflammation, repetitive trauma, excessive activity, vigorous stretching, and contractions due to paralysis, spasticity, flabbiness, disuse and misuse. Generally speaking, muscle tension is usually aggravated by activity and relieved by rest. Visceral pain is a vague and dull or diffuse sensation, or feeling of discomfort or bloating, in the area of the abdomen, or referred pain felt elsewhere, such as the shoulder. Visceral pain is caused by problems with internal organs, such as the stomach, kidney, gallbladder, urinary bladder, and intestines. These problems include distension, perforation, inflammation, and impaction or constipation, which can cause associated symptoms, such as nausea, fever, and malaise, and pain. Visceral pain is also caused by problems with abdominal muscles and the abdominal wall, such as spasm. Psychogenic pain is also known as phantom limb sensations. Its symptoms and causes are extremely variable and can diagnosed best by the patients description of the pain.
PAIN TREATMENT MEASURES There are numerous methods of managing SCI pain. Perhaps the most important method involves the commonsense techniques that you can perform to prevent complications and maintain general good health. Other methods include psychological and physical measures, medication, electrostimulation, and surgery.
As you have seen in the above section on the types and causes of pain in SCI, pain can be caused or made worse by infections, skin sores, bladder and bowel distention, smoking, emotional stress, spasticity, excessive use, misuse, or disuse, and other noxious stimuli to the body. Avoiding these problems in the first place and treating them promptly and completely if they do occur are the most important way of preventing and managing pain. In general, this is done by proper nutrition, positioning, exercising, and the methods explained elsewhere in this handbook to care for your skin, urinary tract, bowel, and respiratory system.
Pain can also be caused by stress, anxiety, and depression, as well as by improper or excessive activity and inactivity. Therefore, psychological support, recreational and vocational therapy, emphasizing positive or favorable attributes, rather than negative attributes and limitations, training in relaxation techniques, biofeedback, hypnosis, and other ways of achieving your maximum psychosocial adaptation to your injury are also important in the prevention and management of pain in SCI. So too, are physical measures, such as therapeutic exercise to improve your range of motion (ROM), muscle tone, strength, and movement, massage, hydrotherapy, acupuncture, biofeedback, and other physical measures.
Medications are used to treat pain in SCI if the benefits of the drug are greater than possible side effects. Common drugs, such as aspirin, often provide the necessary relief with a minimum of side effects. Narcotics are prescribed only if the pain is extreme and disabling, such as interfering with the sleep-wake cycle or preventing participation in therapeutic exercise activities. Depending on the type and cause of the pain, other drugs that may be prescribed include antidepressants, tranquilizers, anticonvulsants, and nerve blocks.
Electrostimulation, or the electrical stimulation of nerves in a variety of locations on different parts of the nervous system are sometimes used to treat specific types of severe, persistent, and disabling pain in SCI individuals.
Postural hypotension, also known as orthostatic hypotension, is a condition which results in a decrease in blood pressure when you sit or stand. This can cause “light-headedness” or “fainting”. It occurs more commonly when you are first injured, when you are fatigued, or after any illness. You will have an increased tendency for postural hypotension if your level of injury is at T-6 or above, but it can occur in all spinal cord injured individuals. After your spinal cord injury, the blood vessels do not decrease in size, in response to lowered blood pressure, due to the altered function of the autonomic nervous system. Because of this, blood pools in the pelvic region or legs while you are sitting or sanding. Postural hypotension usually occurs when you are initially placed in your wheelchair or on the tilt table. To prevent this, wear elastic hose and an abdominal support. It is also helpful to come to a sitting or standing position gradually. If postural hypotension occurs while you are in a wheelchair, your attendant should firmly grab the handles of the wheelchair and tilt you backward, until your head and neck are nearly horizontal to the floor. This will increase your blood pressure and the “fainting” will quickly disappear. You should then be gradually returned to a sitting position. Another problem that may occur as a result of the lowered blood pressure is a decrease in the amount of urine produced by the kidneys. You may notice that there is little or no urine in your urine bag. After you recline, your leg bag may fill quickly. This is a result of the increase in your blood pressure that occurs when you lie down. Watch your drainage bag closely after changing positions to make sure it does not get too full. Taking deep breaths in through your nose and out through your mouth will help elevate your blood pressure as well.