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According to ASIA, when assessing autonomic function, we assess three things:
- 1. General autonomic function
- 2. Low urinary tract, bowel and sexual function
- 3. Urodynamic evaluation
Patients w/ SCI do not always retain accurate autonomic control of the heart. Professionals note problems with autonomic control of:
- Other dysrhythmias
HR less than 60bpm
HR more than 100bpm
What general autonomic functions occur after SCI?
- resting systolic BP below 90
- orthostatic hypotension (decrease in BP exceeding 20 mm HG systolic or 10 mm HG diastolic when moving from supine to upright)
- autonomic dysreflexia (pts above T6)
Patients w/ SCI do not always retain control of the ability to sweat. Therapists note problems w/:
- hyperhydrosis above the lesion
- hyperhydrosis below the lesion
- hypohydrosis below the lesion
Hyperhydrosis above the lesion:
non-physiologic sweating that occurs in response to noxious or non-noxious stimuli in the absence of fever, exercise, or high temperature in the environment
Hyperhydrosis below the lesion:
non-physiologic sweating that occurs in respones to noxious or non-noxious stimuli in the absence of fever, exercise, or high temperature in the environment
Hypohydrosis below the lesion:
no sweating is present at any time
therapists note normal or abnormal
Abnormal temperature regulation:
body temp (rectal) above 38.5 degrees C or 101.3 degrees F, w/o signs of infection
body temperature below 35.0 degrees C or 95.0 degrees F
General autonomic and somatic control of the Bronchopulmonary System:
- therapist not either normal or
- -inability to voluntarily breathe
- -impaired voluntary breathing
- -voluntary respiration impaired but not requiring ventilator support
- -remember respiration is usually impaired until T12
- Is the pt aware of the need to empty the bladder?
- Is the patient able to prevent leakage (continent)?
- Method of emptying bladder
- occurs when sacral reflex arc is disrupted
- parasympathetic control is altered
- results in urinary retention
- can cause back-up into ureters w/ resulting renal failure over time
How to manage areflexive bladder?
- indwelling catheter
- intermittent catheter
- suprapubic catheter
- intact reflex arch
- lack of connection to cortex
- occurs in complete injuries below the level of injury
In a reflexive bladder, the bladder empties reflexively when there is...
sufficient stretch to the wall of the bladder
You can trigger a reflexive bladder by:
stroking, pressing, or hitting the abdomen above the symphysis or stroking the inner thigh
Do people with a reflexive bladder need to cath?
may need to self-cath, have an indwelling cath, or learn to hold urine b/w reflexive voidings
Bowel control -- therapists assess pt's:
- ability to sense the need for a bowel movement
- ability to prevent stool leakage
- voluntary sphincter contraction
SCI disrupts the autonomic and somatic input to the GI tract. Thus, movement through the bowels is _____.
- if S2-4 have an intact reflex arch, the bowel functions reflexively
- the anal sphincter remains taut and relaxes reflexively when rectum is distended
- pts can get into bowel routine
- the defecation reflex remains intact, but the stronger parasympathetic defecation reflex is lost so the bowel will not empty reflexively
- this can lead to impaction
- a regular routine, suppositories, anal stimulation, and massage can aid in regular bowel training
Assessment of Sexual Function (self report)
- genital arousal (erection or lubrication) that is psychogenic or reflex in nature
- sensation of menses
- most likely intact function after SCI
- psychogenic (thoughts and stimulation) erections are possible in 25% of incomplete lesions and reflexogenic in more than 90%
present in about 1% of complete, and 25% of incomplete lesions
Female function: child bearing-
Female function: ability to enjoy sexual function-
specialized testing that requires urodynamic technology to test
What are the top ten complications for people w/ spinal cord injury?
- Respiratory Complications
- Skin Problems
- Orthostatic Hypotension
- Deep venous thrombosis
- urinary tract infections
- heterotopic ossification
- GI complications
- Autonomic Dysreflexia
Respirator Complications: Inspiratory Muscle Paralysis
- diaphragm (involved at C3 and above)
- external intercostals from T1-T12
- expiratory muscle paralysis
- abdomials innervated through T12
- internal intercostals innervated through T12
- important for forceful expiration and coughing
All pts have some level of respiratory involvement unless the lesion is a _____ lesion.
Pulmonary complications particularly pneumonia and pulmonary embolism are primary causes of death in individuals w/ SCI, particularly during the ______ stages of SCI.
Respiratory Complication Management:
- upright position as soon as possible aides in breathing and coughing -- always use a cushion
- pts w/ SCI can re-train breathing patterns and allow for cardio-vascular endurance
- teach alternate methods of coughing
- encourage deep breathing
From C5-C8 vital capacity is ___% of normal.
Paradoxical methods of breathing:
when ribs go in when pt breaths in (opposite of typical)
What causes skin problems?
- shearing forces
- inadequate hygiene
Pressure relief while in bed every __ hours.
Pressure relief in WC every ____ minutes for ____ seconds.
Tissue requires __ minutes for tissue perfusion to an uncompressed level.
- combined frequently w/ LE edema (bld pooling/venous stasis)
- pts will feel dizzy or about to pass out
How to manage orthostatic hypotension:
- over time, the cardiovascular system reestablishes enough vasomotor tone to allow resumption of normal upright positions
- initially, a gradual resumption of upright helps individuals accommodate to upright
- abdominal binders and long hose also prevent blood pooling
- ephedrine may assist to increase bld pressure, as do low-dose diuretics
Deep venous thrombosis:
- notable swelling -- asymmetrical legs
- warm and possibly reddened LE
Treatment for DVT:
bed rest w/ no passive or active ROM and medications including heparin or coumadin
Thermoregulation is controlled by:
the autonomic nervous system
- no temperature control is available below the level of the lesion
- lack of vasoconstriction adds to the problem
- people have inability to shiver in cold and to sweat in warm
- bacoflen pumps
Urinary tract infections:
- affect 80.4% of people in the acute phase of SCI
- continue to be problematic in most pts
- occurs in 5-20% of pts
- signs: decreased ROM, swelling, heat, redness, fever
- occur frequently in people w/ mid-thoracic and cervical lesions
List the joints in order that are involved in Heterotopic Ossification:
What can you do for heterotopic ossification?
- eat fiber!
- bowel routines w/ suppositories
What is another name for autonomic dysreflexia?
- autonomic hyperreflexia
What is autonomic dysreflexia?
massive uncompensated cardiovascular reaciton of the sympathetic nervous system to noxious stimuli below the level of the lesion (usually sacral tracts)
What does it mean to have autonomic dysreflexia?
the sympathetic nervous system overreacts to a stimuli. The parasympathetic system can't respond (w/ vasodilation) so blood pressure rises
What is the cause of autonomic dysreflexia?
- distended bladder or bladder infections
- bowel impactions or other problems
- decubitis ulcers
- ingrown toenails
- stretching hamstrings s
- stimulation of genitals
- exposure to high temperatures
What are the signs and symptoms of autonmic dysreflexia?
- severe, sudden, pounding headache
- chills w/o fever
- sweating and flushed skin above the level of the lesion
- decrease in heart rate
- **This is a medical emergency!
What to do during autonomic dysreflexia:
- immediately elevate the person's head (sitting position)
- causes hypotension and an immediate drop in blood pressure
- check for causes and alleviate if possible
- call medical personnel for assistance