Autonomic Dysreflexia

Autonomic dysreflexia, also known as hyperreflexia, means an over-activity of the Autonomic Nervous System causing an abrupt onset of excessively high blood pressure. Persons at risk for this problem generally have injury levels above T-5. Autonomic dysreflexia can develop suddenly and is potentially life threatening and is considered a medical emergency. If not treated promptly and correctly, it may lead to seizures, stroke, and even death.

AD occurs 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.

What Cause Autonomic 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.

In general, noxious stimuli (irritants, things which would ordinarily cause pain) to areas of body below the level of spinal injury. Things to consider include

Bladder (most common)

Urinary tract infection
Urinary retention
Blocked catheter
Overfilled collection bag
Non-compliance with intermittent catheterization program

Bowel

over distention or irritation

Constipation / impaction
Distention during bowel program (digital stimulation)
Hemorrhoids or anal fissures
Infection or irritation (eg. appendicitis

Brand strategy

Heterotopic ossification (“Myositis ossificans”, “Heterotopic bone”)
Acute abdominal conditions (gastric ulcer, colitis, peritonitis)
Skeletal fractures

Sexual Activity

Over stimulation during sexual activity [stimuli to the pelvic region which would ordinarily be painful if sensation were present]

Skin-related Disorder

Any direct irritant below the level of injury (eg. – prolonged pressure by object in shoe or chair, cut, bruise, abrasion)
Pressure sores (decubitus ulcer)
Ingrown toenails
Burns (eg. – sunburn, burns from using hot water)
Tight or restrictive clothing or pressure to skin from sitting on wrinkled clothing

Treatment

Treatment 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?

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 fractured bone.

You have an ingrown toenail

You have a pressure sore

Identify and remove the offending stimulus whenever possible. Often, this alone is successful in allowing the syndrome to subside without need for pharmacological intervention. It is also good for the person with the symptoms to be sitting up with frequent blood pressure checks until the episode has resolved. [In hospital-based settings or in high-risk individuals / persons who have recurrent episodes, consideration should be given having atropine at the bedside]

Suspected Cause

Bladder?

Check catheter – remove kinks if found, empty urinary collection bag, irrigate catheter. If catheter is not draining, replace it immediately. If an intermittent catheterization program is in place, a straight catheterization should be performed immediately with (slow drainage to prevent bladder spasms).

Bowel

If episode happens during digital stimulation, stop stimulation until symptoms and signs subside. Consider use of a prescribed anesthetic ointment to suppress the noxious stimulus. If the issue is impacted stool, disimpact. If it occurs while doing a bowel program in bed, try commode-based bowel evacuation. Consider use of abdominal massage instead of digital stimulation.

Skin

Loosen clothing. Check for source of potential offending stimulus – check for pressure sores, toenail problems, soles of the feet.

If symptoms persist despite interventions such as the foregoing, notify a physician.

Prevention

The following are precautions you can take which may prevent episodes:

Frequent pressure relief in bed/chair
Avoidance of sun burn/scalds (avoid overexposure, use sunscreen, watch water temperatures)
Maintain a regular bowel program.
Well balanced diet and adequate fluid intake
Compliance with medications
Persons at risk and those close to them should be educated in the causes, signs and symptoms, first aid, and prevention of autonomic dysreflexia.
If you have an indwelling catheter:

Keep the tubing free of kinks
Keep the drainage bags empty
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.
Carry an intermittent catheter kit when you are away from home.
Perform routine skin assessments.

My Journal

My name is Kofi Prince, On November 2008 as a result of a spinal cord injury, I became a quadriplegic. This is how I sustained my injury.

It all began at the tender and promising age of 21, with the unfortunate passing of my mother on November 18, 2007, back home in Ghana. Upon hearing of my mother’s passing, my eldest sister and I wanted to attend the funeral, but unfortunately our travel documents would not be ready in time. As a result, we postponed our trip until the following year, for the one year anniversary ceremony.

One year later, with our travel documents in order, my sister, her infant son and I decided to make the trip to Ghana. At that time, I was employed at a company, where I received insurance coverage and so prior to the trip, I contacted my insurance provider to verify the international travel assistance number. With this information in hand, I was all set for our flight, on Saturday November 8, 2008.
We arrived in Accra, Ghana, on Sunday November 9, 2008 at approximately 7 p.m., but unfortunately, our luggage did not arrive with us, nor would it arrive that same day. As a result, an airline representative suggested that we return the following day to retrieve our luggage. My sister, my nephew and I then left the airport for my uncle’s residence where we would stay overnight.

At seven o’clock that evening, a taxi arrived to take us to the airport. I sat in the front passenger seat and my sister sat in the back seat, between my two uncles. Once situated in the car, we set out on our journey through the busy streets of Accra. After several minutes, we emerged through the traffic and the last thing that I remember was seeing a bridge ahead of us.

That night, it rained throughout the entire night. It rained so much that the following morning my uncle’s driver could not get the car to start, and so they took the car to the mechanic. With the car out of commission, we had to make alternate arrangements to retrieve our luggage from the airport.

Usually, when someone is involved in a high impact car accident, the person loses the memory of the accident itself, but they can recall the events leading up to the accident. I am no different. I have no memory of how the accident occurred or, how I arrived at the Ghana military hospital, but from what I was told and from the details in the police report, the accident was as resolves of careless driving by the taxi driver causing him to lose control of the car on the overhead bridge, the vehicle then went airborne and crashed onto the road below. The lowest point of the car was at the roof on the passenger side, where I was sitting. It is also my understanding that before being taken to the hospital, we were robbed of our belongings.

Upon arrival at the military hospital, all I remember is asking someone to retrieve my travel insurance card from my luggage and contact the number on the card. I have since been told that I spent the next three days at the hospital in Ghana, before being taken by air ambulance to Marseilles, France, for surgery. (Ideally, spinal cord surgery is performed within an 18 hour period in order to reduce the amount of damage to the spine caused by swelling.)

When I woke up after surgery, I had no idea where I was or how got there. I was wearing a neck brace, I had a tube going through my nose and my mouth, and to my left there was a machine monitoring my vital signs. This was the first time that I realized that I may have gotten into an accident. The next thing I did was try to wipe my eyes, but when I tried to lift up my right hand, it felt like I was trying to lift a building. Then I tried to lift my left hand and it was just as difficult. Next, I tried to move my legs to sit up and I realized that I couldn’t do that either. Realizing I couldn’t move, I tried to call for help, but no sound came out of my mouth. I tried yelling, still no sound. I realized this couldn’t be good so I closed my eyes and said a prayer to thank God for my life because from all indications of the situation, I could have died and I also asked him to deliver me from this condition.

Ten minutes after I opened my eyes again, I started experiencing strange sensations throughout my body. First, it felt like I was burning alive. Thirty minutes later, I felt extremely cold, as if I was freezing alive. What felt like a few minutes later, the vital sign monitor began making noise and two nurses came in to my room. As they attended to me, they spoke to each other in a foreign language (which I later realized was French). I tried to ask them about my sister and nephew, but we were unable to communicate in the same language

The following day, an English speaking doctor came in to my room to speak with me. He told me that I was injured in a car accident in Ghana and that because of my insurance coverage I had been transported to Marseilles, France for surgery. He explained that I was in the intensive care unit of the hospital because I sustained a very serious injury to my spinal cord (C-4) complete. He also explained that because of the injury, I am a quadriplegic, which mean that I am completely paralyzed from the neck down, which is why I could not move my body, or feel below my neck. Finally, he remarked that given that I was in the early stage of recovery, the level of the injury may change depending on how quickly the swelling in the surrounding tissue is reduced. After he finished speaking, I asked him about my family’s condition, but unfortunately, the only thing that he was able to tell me was that my family was still in Ghana, but that he was unsure of their condition. He did however reassure me that my father was on his way to France from Canada.

When my father got to France he mention to me that my sister and nephew was okay and they did not get injured but one of my uncle’s did as the results of that he was paralyzed from the waist down. We spent the remainder of the month of November in France until I was stable enough to travel with the air ambulance. When we got to Canada I spent additional two more months in intensive care unit before I was able to start my rehab.

C1-4 Quadriplegia

Patients with C-1 and C-2 lesions may have functional phrenic nerves. In these cases, implanted phrenic nerve pacemakers can be used, and pacing of the diaphragms may be simultaneous or alternating. If secretions are not a problem, tracheostomies may be plugged or discontinued. Less equipment may be needed for C-1 and C-2 patients than for C-3 and C-4 patients.

Patients with C-3 lesions have impaired breathing and may be ventilator-dependent. They can shrug their shoulders and they have neck motion, which permits the operation of specially adapted power wheelchairs and equipment, such as tape recorders, computers, telephones, page turners, automatic door openers, and other environmental control units with mouth control (sip and puff), voice activation, chin control, head control, eyebrow control, or eye blink. Patients with C-4 lesions may be free of respiratory equipment beyond the initial acute care stage, but may have the same functional equipment needs as ventilator-dependent patients.

In addition to powered wheelchairs, C1-4 t Quadriplegics require assistance for all personal care, turning, and transfer functions. Head rests, troughs or a lapboard, for the upper extremities, and lifts may be necessary. Bed surfaces with two or more segments that are alternately inflated and deflated may be indicated for patients who do not have assistance for turning. Functional electrical stimulation (FES) may restore elbow flexor function in patients with C-4 lesions. Complete assistance required during mealtimes. For patients with lesions at C-5 or higher, power recliners to achieve pressure relief while sitting are recommended. Patients with partial C-4 lesions and inadequate elbow flexors and patients with C-5 lesions may initially require a balanced forearm orthosis, for enhanced arm placement, or a long opponens orthosis with utensil slots and pen holders, for wrist stability, during activities such as feeding, writing, and typing. Complete domestic care is required, such as household cleaning, washing of clothes and kitchen duties, preparation of meals and general household duties.

C7-8 Quadriplegia

C-7 patients have functional triceps, they can bend and straighten their elbows, and they may also have enhanced finger extension and wrist flexion. As a result, they have enhanced grasp strength which permits enhanced transfer, mobility, and activity skills. They can turn and perform most transfers independently. They can propel a manual wheelchair on rough terrain and slopes, and may therefore not need a powered wheelchair. They may drive with a van and specialized equipment. They can perform most daily activities, they can cook and do light housework, and therefore they may live independently. They may, however, require assistance for bowel care and bathing.

C-8 patients have flexor digitorum profundus function which permits all arm movement, with some hand weakness. They can propel a manual wheelchair community distances, including in and out of a car and over curbs, and may even become wheelchair independent. They can drive with a van or car and special equipment. They can perform all personal care and daily activities, except heavy housework.

C-6 Quadriplegia

C-6 patients have musculature that permits most shoulder motion, elbow bending, but not straightening, and active wrist extension which permits tenodesis, opposition of thumb to index finger, and finger flexion. Wrist extensor recovery is common in C-6 patients, but its return can be delayed. Tenodesis orthoses support tenodesis training early in recovery. Wrist-driven flexor hinge splints permit pinching strength, needed for catheterization and work skills. Short opponens orthoses with utensil slots, writing splints, Velcro handles, and cuffs permit feeding, writing, and oral facial hygiene.

C-6 patients can perform upper body dressing without assistance and may also perform lower body dressing without assistance. They can catheterize themselves and perform their bowel program with assistive devices. They can perform some transfers independently with a transfer board, turn independently with the use of side rails, and relieve pressure by leaning forward, alternating sides, or possibly by push-ups. Water mattresses can lower pressure sufficiently to eliminate the need for turning during the night. They can propel a manual wheelchair short distances on level terrain, operate power wheelchairs, and may drive with a van and special equipment. They can cook, perform light housework, and live independently with limited attendant care.

Upper extremity reconstructive surgery, or functional neuromuscular stimulation of the upper extremity, or surgery and stimulation in the same patient can improve function in C-6 patients. Surgery is recommended only for patients who are neurologically stable and without spasticity. Stimulation can be provided by external, percutaneous, or implanted electrodes, by shoulder motion utilizing an external system, or by key and palmar grip and release, or by a bionic glove, an electrical stimulator garment that provides controlled grasp and hand opening.

C-5 Quadriplegia

C-5 Quadriplegics have functional deltoid and/or biceps musculature. They can internally rotate and abduct the shoulder, which causes forearm pronation by gravity. Wrist flexion is similarly produced. They can externally rotate the shoulder and cause supination and wrist extension. They can bend the elbow, but elbow extension can only be produced by gravity, or by forceful horizontal abduction of the shoulder and inertia or shoulder external rotation.

C-5 patients require assistance to perform bathing and lower body dressing functions, for bowel and bladder care, and for transfers. With the use of balanced forearm orthoses, long opponens orthoses, or universal cuffs and adaptive equipment, C-5 patients can feed themselves, perform oral facial hygienic and upper body dressing activities, operate computers, tape recorders, telephone, etc. and participate in leisure activities. They can propel manual wheelchairs short distances on level surfaces, although the hand-hand rim interface should be modified with vertical or horizontal lugs (or plastic tubing can be wrapped around the rims), and gloves should be worn to protect the hands. Powered wheelchairs, propelled with a hand control, are needed for community distances and outdoor terrain.

Spinal Cord Injury Fact Canada

A spinal cord injury can happen to anyone at any time, is one of the most traumatic events to occur in an individual’s life. It affects family, friends, employers, community and the health care system. An individual can make a positive adjustment to life with a spinal cord injury given the right supports at the right time. On average, it can takes 2 to 3 years to gain sufficient independence following a spinal cord injury. Intensive psycho-social support is a critical component to rehabilitation from the onset of injury, through acute hospitalization, rehabilitation and transition to community living.

In Canada there are over 100,000 people living in with spinal cord injuries. current estimates indicate that there are more than 4,300 new spinal cord injuries per year. (based on research by the Urban Futures Institute). Approximately 51 % of SCI’s are due to a traumatic injury or accident. The remaining 49 % are due to illness or diseases

Slips and falls
Sports-related injuries,
motor vehicle collisions
Trampoline accidents
The other leading cause is diseases such as ALS and cancer Transverse Myelitis, Spina Bifida, or Polio.

In Ontario alone there are approximately 35,140 Ontarians living with spinal cord injury, an average of 600 new case per year (more then one per a day). Males represent 68.4% of traumatic spinal cord injuries. Women represent 31.6%. The highest incidence of traumatic injury is to individuals in the age range of 16-30 and to also, those over 70 years of age.The top causes for traumatic spinal cord injuries in Ontario are:

unintentional falls – 43.2%
motor vehicle accidents – 42.8

A manual wheelchair costs between $4000 and $5000. A power chair can cost between $10,000 and $15,000.

Rehab

After nearly a month of intense care after my surgery in Marseilles, France. I had finally arrived back home in Canada on December 2, 2008 where I was admitted to Brampton Civic Hospital and accompanied by my family. My girlfriend that I was with at the time had already been informed when I was in France. At this time I didn’t know how she would receive me, mainly because I did not want to become a burden to her going forward if she was to stick around, but she gave me her full support and her understanding. That gave me additional motivation knowing that everything was going to be alright with her and with my family’s support. Being in the Hospital was not necessarily an easy stay, because before I would be able to transfer from there to start my rehab, I would have to be able to get rid of my tracheotomy tube and then be able to communicate again. After nearly 2 and a half months of not being able to talk I was so blessed and happy to get my voice back. It made me really appreciate how privileged we are to have a voice to communicate with one another.

Toronto Rehab Lyndhurst

On February 2, 2009 I was transferred from Brampton to Toronto Rehab at Lyndhurst so I could start my rehabilitation. I didn’t know what my rehab would consist of but I was so excited to get started and give it my all. When I got to rehab I was given an assessment to determine the level of my injury, as they reconfirmed what I had originally been told, which was a C4 complete. My first goal, was for them to help me become as independent as possible so I could get around the facility. When I first arrived the only movement that I had was being able to move my head from side to side. I was then given a power wheelchair where I would be able to control it with my head. It wasn’t an easy task at the beginning given the fact that I didn’t have strong neck muscles. After 30 minutes of using it I began to feel intense fatigue and dizziness, then I started perspiring heavily and feeling sharp pins and needles all over the parts of my body that I have sensation, which was mainly from my neck up. This was my first sign of what you would call Autonomic Dysreflexia. Dysreflexia can be caused by many things, like an over-activity of the Autonomic Nervous System causing an abrupt onset of excessively high blood pressure. Headaches, restlessness, slow pulse are some of the main symptoms. Given the level of my injury, any pain or discomfort can cause Dysreflexia.

The next day I was assigned to two wonderful ladies who were to be my occupational and physio therapists. We started our sessions by them performing an assessment on me to figure out what type of movement that I had and what my ranges were. This would give them an idea of where to start in terms of my therapy and as well as knowing my starting point they could then be able to determine my progress over time. Before we could start I had to set long and short term goals that I wanted to accomplish while I was there. At first the only two things that I could come up with was to walk and to get back the sensation in the parts of my body that I could not feel. I was determined to do anything and whatever was necessary to do to get to that point. My therapist said that we would have to start with short term goals and work towards my long term goal of walking. Rehabilitation does not only consist of getting your mobility back but it goes far beyond that. Following a spinal cord injury rehabilitation helps to determine what functional level you are at and how to train your body to perform some of the functions that came naturally to your body prior to your injury. Some main areas are bladder and bowel control, being independent, managing your personal care and learning how to live with your disability

Short Term Goals

To be able to lift my hands
To get some sensation
To be able to feed myself
To drive my chair with my hands
To get movements in my legs
To get comfortable in my own skin
To control bladder and bowel
To learn how to direct my care

Long Term Goals

To fully feel
To be able to stand
To be able to take a step
To be able to walk again

After these goals were set, I was able to start my rehab. I was shown the equipment that was available to me and at first I was disappointed because out of all the equipment in the room, I could only use a very few, but later on it would make more sense to me. Toronto Rehab has many types of equipment for rehabilitation, so a person with a disability can really benefit from them to restore some strength and movement in their body but unfortunately due to the level of my injury and lack of movement that I had, I was limited to using just a few. In the beginning I was only able to use certain pieces of equipment and then in order for me to be able to have full access to the others, I would need to gain some strength and mobility to be able to use them. We started by doing some Range of Motion exercises on the mattress to loosen up some of the muscles and although I could not move any limbs in my body, my job was to imitate every movement as I was being stretched. Mentally it was not easy from the beginning, so I would close my eyes and try to move part of my limbs and it would feel like I was actually moving them, but when I’d open my eyes I would come to the sad realization that I couldn’t even move an inch. I would look at my body and feel like I was not a part of it, feeling like I was just a head on a lifeless dummy body. Later we would move on to the electrical motor bike for my legs and arms, this would also help me to loosen up any stiffness I may have had in my legs or arms. Generally if a person has a little bit of movement in either their legs or arms they can help to propel and work the pedals on the bike, if they don’t have movement or strength they can imitate the movements as the bike does the work for you. During my O.T. sessions I would use the electrical stem to see if I could pick up any movement in the active muscles that I may have in my arms.

For the first month I would come out of rehab feeling disappointed in myself, mainly because I felt like everyone around me was making progress except for me. For me I have always been the type of person who doesn’t complain and appreciates life so I always kept it to myself and would hope the next day would be better. After rehab I would leave my problems in the gym and go on with the rest of my day with a smile on my face and not let it get to me, because being depressed was the last thing that I needed if I was going to go through this, and not have any other setbacks. At the end of the day I would be excited to talk to my girlfriend and family members and although my girl was quite a distance away in a different city for school, we spoke very often and talking to her helped me to take my mind off the situation that I was in. She was one of a few people that I could really count on when I needed to. After a life-changing event like this you may lose some friends and also meet some new friends along the way. Simply because your condition or your lifestyle doesn’t coexist in the same way as it used to with theirs, many relationships with friends and marriages often fall apart over time. Although it is unintended, no matter what you do to try to avoid it you will in some way eventually become a burden to a loved one. They automatically feel the need to adopt your problems as their own. For instance, the physical things that you unable to do, they take it upon themselves to do it for you, to assist in relieving your body, as well as your stress. Some people might feel like your responsibilities automatically becomes theirs, these things are done because of the love and care that they have for you and over time it can become overwhelming for them, feeling responsible for you. These are some of the things that you are constantly reminded of during your rehab. There is no one to blame in this situation. That is why learning to be independent is quite important for the person who is disabled.

After nearly 3 months of being in rehab I had not yet seen any dramatic changes, aside from being able to flip the palm of my left hand. I was not disappointed but motivated, I was growing as a person and becoming more comfortable and understanding of my injury. Every Wednesday I would attend the spiritual meeting where we would read the Bible and also reflect on it and how we could apply it to our day-to-day lives. This would be a very helpful time for me as we learned about each other and how far we had come, the importance of staying positive and that having any doubts would become a setback to your journey. I learned to be more patient than ever, and was reminded that everything works through God, and his time has and will always be the best time. Being closer to God not only helped me through my process but allowed me to leave my worries to him, because at the end of the day he will always have the final say. If my time is not now it is sure to come, where there’s a will there is a way, as long as you believe and have the faith. I would later be discharged and I continued my rehab as an outpatient at Lyndhurst and continued moving forward.