Medical Complications, Long-term medical mgmt, and prevention of secondary impairments

Question 1

Autonomic Dysreflexia

Answer 1

Massive reflex sympathetic discharge that occurs after SCI of T6 or above in response to noxious stimuli below the level of injury causing a sudden increased in BP ( >15 mmHG over baseline systolic)

Untreated = stroke, seizures or death

Clinical features = headache, flushing, sweating, pilomotor activity (goosebumps), brady or tachycardia, HTN
– infants or children may be more sleeping or crying–check vitals

Causes: overdistended bladder, kinked catheter, overdistended bowel, excessive pressure on skin below level of injury (wrinkle, compression hose, shoes), cervical collar that is too tight

Treatment: monitor vitals every 5 minutes, elevate HOB, remove items resulting in excessive pressure, BB mgmt

If pt does not respond to treatment– may need meds from MD or nurse

Question 2

Respiratory Dysfunction

Answer 2

May occur cervical and thoracic lesions–prominent cause of mortality/morbidity

Dysfunction ranges from complete diaphragm paralysis requiring vent (C1-3 and occasionally C4), decreased vital capacity, weakened forced expiration during coughing d/t weak/absent accessory mm (lower cervical and thoracic level injuries)

Need to instruct pt in respiratory/breathing exercises

• exercises can occur during any part of rx (i.e mat mobility, sitting balance activities)
• Quad coughing- forced compression of abdomen with hands in an inward and upward fashion

Question 3

DVT

Answer 3

Can develop in paralyzed and dependent extremities

DVT occurs less frequently in children vs adults (seen more in teens than young children)

Use prophylactic protocol

Question 4

Hypercalcemia/Bone density/MM Atrophy

Answer 4

Common in children- immobilization hypercalcemia
In first 12-18 months post SCI = 40% loss of bone mineral density with calcium excreted in urine
Children are more likely to have rapid bone turnover = larger load of calcium the kidneys can excrete = hypercalcemia
Symptoms: lethargy, nausea, altered mood, anorexia
Treated through IV hydration for improved release of calcium

Pathologic Fractures: occur at increased rate in people with bone mineral density less than 40% of normal—complication of osteopenia

Heterotrophic ossification- can be asymptomatic or interfere with ROM
– mc seen in hips, knees, shoulders, elbows

Atrophy begins early and occurs at rapid rate during acute immobilization through 24 wks post injury
– 15% loss of lean mm mass below level of injury

Question 5

Orthostatic Hypotension

Answer 5

position related drop in BP
- decrease in venous return from LE as a result of mm paralysis = decreased cardiac output and arterial pressure = quick drop in BP

Common with SCI

Treatment: compression stockings, abdominal binder, tilt table, pharmacologic intervention

Question 6

Thermoregulatory Dysfunction

Answer 6

Impaired ability to regulate body temp d/t loss of hypothalmic thermoregulatory control and interruption of afferent pathways of peripheral temp receptors below level of injuries

Above T6 = complete loss of shivering and sweating and no peripheral circulatory adjustment below level of injury

Education important

Question 7

Syringomyelia

Answer 7

fluid filled cyst of cavity in area of injury
occurs in patients with complete/incomplete
common and may progressively enlarge = further loss of neurological function months to years after SCI

S/S: loss of motor function, ascending sensory level, increased spasticity or sweating, new onset of pain or dysesthesia

Question 8

Spasticity and Pain

Answer 8

Spasticity = common in SCI, usually evolves over period of 1-2 yrs

Initially pt appears flaccid, but hypertonus gradually appears, in first 3-6 mo after SCI develop hyperreflexia, clonus, and flexor spasms– later extensor spasms predominate

Can control spasticity pharmacologically (baclofen, botox)

PT: ROM, FES cycling, static standing—some patients use spasticity to their advanceate

Neurogenic pain- can occur after SCI at/above/below level of injury

• described as burning pn which anecdotally precedes return on function or sensation at dermal levels where pn is experiences
• treated/managed with pharma (gabapentin, lyrica)

Question 9

Skin Breakdown/PU

Answer 9

Children often completely disregard areas that are insensate

Education regarding pressure relief and awareness of insensate areas

Frequency of pressure relief 15-30 minutes and should last for 1 minute to allow blood flow to affected area

Question 10

Ortho Mgmt

Answer 10

Contractures due to static positioning, spasticity, or HO
PROM, stretching. stander
Tightness m/c seen in hip flexors, hams, adductors, PF
Pseudo hip flexor tightness—IT band is actually causing tightness

Hip Sublux/Dislocation is common in children with SCI onset before age 10, with increased incidence under age 4
Most important intervention is prevention (stretching, positioning, seating)—want to treat to prevent pelvic obliquity which can cause scoliosis

Pathologic fractures d/t osteopenia

Neuromuscular scoliosis- occurs in 98% of SCI, especially when SCI occurs in children injured before adolescent growth spurt

Prophylactic Bracing–controversial as may interfere with independence in activities