This type of dysfunction tends to be seen in those with injuries of the spinal cord affecting the upper motor neurons. In these cases, the lack of coordination of the sphincter and the detrusor is caused by lack of coordination from the pontine micuturition centre due to the spinal cord injury. Both the detrusor and the sphincter are overactive due to lack of control and descending inhibition from the pons and cortex, and both sphincter and detrusor contract reflexively when stretched. The detrusor becomes overactive, reflexively contracting at small volumes against an overactive sphincter, resulting in high bladder pressures. This leads to incontinence (when the detrusor contracts hard enough to overcome the sphincter contraction), incomplete emptying (due to sphincter co-contraction), and reflux (due to high bladder pressures) with resultant recurrent bladder infections, stones, hydronephrosis, pyelonephritis, and renal failure. In the case of a flaccid bladder, loss of detrusor muscle tone prevents bladder emptying and leads to bladder wall damage from over-filling, urine reflux and an increase in infection risk due to stasis. The sphincter tone also tends to be flaccid (at least the external sphincter) causing incontinence, especially with maneuvers that increase intraabdominal pressure (so-called "Valsalva" maneuvers) including straining during transfers, coughing and sneezing. Internal sphincter tone may be intact due to the higher origin of sympathetic innervation, thus complete emptying, even with externally applied suprapubic pressure, may be difficult.
Compared to DESD, patients with detrusor areflexia comprise a much smaller proportion of the SCI population and there is very little literature examining the effectiveness of interventions for this patient subpopulation (patients with detrusor areflexia).
Detrusor areflexia is seen most commonly in cauda equina lesions where the sacral reflex is disrupted. It can occasionally occur at other levels of spinal lesions. The clinical manifestation of this results in an inability for the bladder to empty completely or at all, leading to overdistension and stasis. Additionally, there is frequently incontinence due to lack of external sphincter tone, most often due to increased abdominal pressure on the bladder (i.e. stress incontinence). This can be especially problematic in persons with paraplegia that may require high valsalva forces for activities such as transferring from wheelchairs.
In general, the goal is either: 1) stopping leakage and improving storage with medications and intermittent catheterization, or 2) improving emptying, either voluntarily in the incomplete injury, and/or into condom drainage in the person with more severe neurogenic bladder impairments.
Urinary tract infections (UTIs) are a common secondary health condition following SCI and a major cause of morbidity
These designate a UTI as indicative of significant bacteriuria with tissue invasion and resultant tissue response with some or all of the following signs and / or symptoms:
•Leukocytes in the urine generated by the mucosal lining,
•Discomfort or pain over the kidneys or bladder, or during urination,
•Onset of urinary incontinence,
•Cloudy urine with increased odor,
•Malaise, lethargy, or sense of unease.
The mechanism underlying heterotopic ossification following spinal cord injury is not fully understood but it appears to be initiated by mesenchymal cells into bone precursor cells (Schuetz et al. 2005). Pape et al. (2004) has noted that mesenchymal stem cells can differentiate into osteogenic cells given the right stimuli within the right environment, even soft tissues (Chalmers et al. 1975). These mesenchymal stem cells can generate cartilage, bone, muscles, tendons, ligaments or fat (Williams et al. 1999) and are thought to play a pivotal role in the development of HO (Pape et al. 2004). HO then forms through a typical process beginning with the formation of a protein mixture created by bone cells (osteoid) that eventually calcifies within a matter of weeks (Pape et al. 2001). Over the next few months, the calcified osteoid remodels and matures into well-organized trabecular bone (Pape et al. 2001). Months following the initial trauma patients develop bone formation in muscle and soft tissues adjacent to a joint (paraarticular) with resultant restriction in range of motion, pain and ankylosis (Banovac & Gonzalez 1997, Garland et al. 1980). The bony lesion has a high metabolic rate, adding new bone at more than three times the rate of normal bone. Osteoclastic (bone removal cell) density is more than twice that found in healthy bone (Puzas et al. 1987). It is suspected there may be a neurogenic factor contributing to HO but the mechanism is poorly understood (Hurvitz et al. 1992, Pape et al. 2001, Pape et al. 2004). In many cases, discharge from hospital is delayed for SCI patients due to lack of accessible housing, which leads to unnecessary increase of cost of care.
Independent Living Centres (ILCs) that have relationships with hospital Medical Rehabilitation Programs (MRPs) serve more clients than those without, and the most frequently serviced individuals are those with SCI who attend for peer counseling, skills training, and discharge planning.
Living with a spouse and/or children, living alone, or living with unrelated persons are more desirable arrangements than living with parents and spouse/children together, living with distant family (i.e., grandparents), or living with parents and siblings.
Marital status, transportation barriers, education level, medical supervision requirements, economic disincentives, services received, and severity of disability are predictors of independent living.
Choice and control are important when planning living situations and setting goals with clients with SCI because they are directly related to residential and life satisfaction.
Individuals with SCI have lower perceived life satisfaction, locus of control, and satisfaction with certain aspects of housing than normative samples.
Accommodation options for a person with a disability are limited. The preferred accommodation is a private house or apartment.
Living with someone prior to SCI, having insurance or private funding for equipment, and being younger decrease the risk of being discharged to an extended care facility following SCI rehabilitation.
Individuals with SCI have a need for assistance with fire safety to increase their perception of home safety.
Individuals with SCI move multiple times after injury. In most cases they start living with their parents and/or in an institution before moving into their own homes.
The transition process from rehabilitation setting to community is difficult because of the lack of resources mainly in terms of adaptation, accommodation and equipment.
A majority of caregivers indicated to be overwhelmed with their caregiving responsibilities.
Most informal caregivers are female spouses of individuals with SCI who require assistance in fulfilling and maintaining services.
There is general satisfaction with informal attendant services.
The most significant predictors of Personal Care Assistance (PCA) use are motor function, days spent in rehabilitation, and length of stay in a nursing home.
Personal attendant turnover is positively correlated with higher injury level and increased need for assistance in exercise and transfers.
Goal-directed occupational therapy can achieve gains in role performance and improvements in life satisfaction.
Re-hospitalization might be reduced after participation in an educational intervention involving a workshop, a collaborative home visit, and access to follow-up.
Counselling on proper technique and hygiene for at least one session might reduce the risk of urinary tract infections (UTIs) to below-threshold for individuals at risk for UTIs.
Workshops for attendants and consumers can increase knowledge about SCI.
Directing, training, and financing oneâ€™s personal attendant care may lead to financial savings, better health outcomes, and increased life satisfaction.
Individuals with complete tetraplegia have higher rates of altered glucose metabolism.
Impaired gallbladder emptying is seen in diabetic and obese SCI individuals.
A combined diet and exercise program can help patients reduce weight following SCI without compromising total lean mass and overall health.
Participation in a holistic wellness program is positively associated with improved eating and weight-related behaviours in persons with SCI.
A combined nutrition, exercise and behaviour modification program can help persons with SCI increase metabolically active lean tissue, work efficiency, resting oxygen uptake and strength.
Dietary counseling results in improved lipid profile; consultation with a registered dietitian should be obtained, because individualized diets may enhance compliance.
Blood concentrations of DHA and EPA increased as the result of n-3 fatty acid supplementation; however, no significant changes in lipid profile were identified.Â
Omega-3 fatty acid supplementation increases upper body strength and endurance in persons with SCI.
Individuals with SCI should be screened for vitamin D deficiency and, if needed, replacement therapy should be initiated.
Clinicians should conduct early screening for and treatment of vitamin B12 deficiency.
Creatine supplementation does not result in improvements in muscle strength, endurance or function in weak upper limb muscles.
Creatine supplementation enhances exercise capacity in persons with complete tetraplegia and may promote greater exercise training benefits.
Consumption of a standard liquid meal does not change blood pressure, heart rate or noradrenalin levels in tetraplegics with postural hypotension.
The consumption of a whey protein plus carbohydrate supplement following fatiguing ambulation improves subsequent ambulation by increasing distance, time to fatigue and caloric expenditure in persons with incomplete SCI.
Meal-induced thermogenesis is not decreased in tetraplegic individuals with low sympathoadrenal activity and efferent sympathoadrenal stimulation from the brain is not necessary for nutrient-induced thermogenesis.
Impairment of sympathetic control of the kidney secondary to SCI resulting in tetraplegia does not impact renal sodium conservation in response to dietary salt restriction.
More research is needed to evaluate the role of nutrition in the management of post-acute SCI to provide the evidence base required for optimal clinical decisions.
Risk factors that have been identified most often include: limitation in activity and mobility, injury completeness, moisture from bowel and bladder incontinence, lack of sensation, muscle atrophy, poor nutritional status and being underweight. Studies have also found that those most likely to develop pressure ulcers are male, have lower levels of education, are unemployed and do not practice standing. Other risk factorsinclude: smoking, number of comorbidities especially renal, cardiovascular, pulmonary disease and diabetes; residing in a nursing home/hospital; autonomic dysreflexia, anemia and hypoalbuminemia; spasticity and a history of previous ulcers; and an increase in tissue temperature; race and ethnicity. *Deep Tissue Injury (Suspected) Stage
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Intact skin with non-blanchable redness of a localized area usually over a bony prominence.Â Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area.Â
Partial-thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Full-thickness tissue loss.Â Subcutaneous fat may be visible but bone, tendon, or muscles are not exposed.Â Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling.
Full-thickness tissue loss with exposed bone, tendon, or muscle.Â Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling
Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Sometimes, increased spasticity is beneficial for transfers and mobility, and the reduction of tone may negatively impact those activities of daily living. The goal should not be to modify the excitability and rigorousness of reflexes, but to overcome functional impairments related to "spasticity" (Dietz 2000). Therefore, the decision to treat "spasticity" should not only be based on the findings gained by the examination in passive (lying bed, sitting in the wheelchair) but also in active conditions (like walking, doing transfer etc.). As well, spasticity can be protective against skeletal muscle atrophy that in turn could indirectly affect functional independence, ambulation and incidence of fracture (Gorgey & Dudley 2008). Spasticity has also been reported to increase glucose uptake and thereby reduce the risk of diabetes in SCI (Bennegard & Karlsson 2008). Furthermore, recent reports identifying spasticity related enhancement/detraction of sexual activity in males/females respectively (Anderson et al. 2007a&b), again exemplifies the importance of individualized treatment choices. Post-traumatic syringomyelia is a term used to describe the formation of an intramedullary cyst filled with cerebrospinal fluid (CSF) within the spinal cord (Brodbelt & Stoodley, 2003). Though uncommon, its impact can be devastating following spinal cord injury (SCI). It can be seen as early as two months after injury, or may occur years later.
The classical symptoms of syringomyelia with suspended sensory loss, segmental weakness and burning are often not present in SCI patients. Many individuals may lack symptoms in general or present with nonspecific symptoms that may be attributed to other complications of spinal cord injury such as spasticity, autonomic dysreflexia or neuropathic pain. Most common symptoms include radicular pain, gait ataxia, sensory disturbance, dysesthesias and motor weakness (Brodbelt & Stoodley, 2003; Klekamp & Samii, 2002; Lyons, Brown, Calvert, Woodward, & Wriedt, 1987; Kramer & Levine, 1997). As syringomyelia progresses, reduction in sensation and increased spasticity may be seen (Carroll & Brackenridge, 2005). Progression is usually slow in most patients, with the clinical picture remaining static for many years (Mariani et al., 1991).
Non-modifiable personal characteristics such as being male and Caucasian, younger at injury, with a longer duration of injury (20-30 years) with a higher pre-injury education, less severely injured, and being employed at injury in a low-intensity job increase the likelihood of employment post-SCI.
Modifiable personal characteristics such as being married, highly educated, limiting the occurrence of health complications with a higher level of independence (including wheelchair skills), valuing work increase the likelihood of employment post-SCI.
Environmental barriers to employment are social or physical and include financial disincentives, discrimination associated with negative attitudes toward people with disabilities and difficulties with physical access to workplace.
Environmental facilitators include having access to various assistive devices, using transportation independently and having the possibilities of work adaptation including reduced work hours.
A single environmental factor can be perceived either as a barrier or a facilitator to employment based on its presence/absence in oneâ€™s environment and its impact on effective returning to work.
People with SCI may benefit from vocational rehabilitation in the process of job placement and work reintegration.
There is a dearth of high quality research in vocational (re) training. Consequently, conclusions are based on evidence from observational studies or case studies.
Continuous support to the employee and employer before and after vocational placement might lead to a successful return to work and job retention.
Individuals with complete C1-C4 (high) tetraplegia have little or no movement of upper and lower extremity muscles. They have movement of the head and neck, as well as, possibly, shoulder elevation (shrug). Persons with an injury at the C4 level have innervation of the diaphragm (the primary muscle for respiratory inspiration). They should not need long-term ventilatory assistance, although it is not uncommon to receive ventilation initially after injury.
Patients with C1-C3 injuries are likely to require long-term mechanical ventilatory support because of the loss of innervation to the diaphragm. These individuals may be candidates for FES of the phrenic nerve (or diaphragm) to reduce their need for mechanical ventilation, if their lower motor innervation to the diaphragm remains intact. Swallowing and phonation functions are preserved.
Individuals with injuries at the C1-C4 level will likely depend on others for help with almost all of their mobility and self-care needs, although they may be able to use a power wheelchair with chin or pneumatic (sip and puff) controls. If their elbow flexion and shoulder movement are suboptimal (muscle grade 2 or 3), a balanced forearm orthosis (BFO) or mobile arm support (MAS) may assist them with feeding and grooming activities. The use of a long bottle or straw can allow these individuals to drink independently.
Patients should be able to communicate with caregivers (and provide direction) about their mobility needs, as well as about self-care and bladder and/or bowel care. Assistive technologies, such as electronic aids to daily activities (EADLs, previously referred to as environmental control units), may be accessed by using a mouth stick or switch or by employing voice activation. Assistive devices transmit signals by means of radio waves, infrared light, or ultrasonographic waves to facilitate an individual's control of his/her environment. In this way, the person can accomplish such tasks as answering phones, adjusting bed height, and controlling computers, lights, and televisions.
Brain Control Interface (BCI) methods, using noninvasive electroencephalography (EEG), is being trialed in order to bridge the disconnection between the brain and muscle.[11, 12] With BCI, it is necessary to interpret brain activity and interface brain signals with a computer, and this may enable a person with tetraplegia to control a computer, operate devices such as an EADL, or control a power wheelchair. Individuals using BCI systems indicate it gives them an increased sense of independence and improves their quality of life. This technology needs further refinement before it can be clinically implemented.
Individuals with C5 tetraplegia have functional use of elbow flexion. With the help of specialized assistive devices (such as wrist or hand orthotics to allow them to hold objects), these persons can achieve independence in feeding and grooming. It is important to prevent contractures of elbow flexion and forearm supination caused by unopposed biceps activity. Patients with a C5 injury can assist with upper extremity dressing and bed mobility.
For persons with C5 tetraplegia, a power wheelchair with hand controls will probably be required for most of their mobility needs, although a manual wheelchair with grip enhancements (rim projections) may be used for short-distance mobility on level surfaces. Patients require assistance for most other self-care (eg, lower extremity dressing, bathing), for transfer mobility, and for bladder and/or bowel tasks.
As with persons who have sustained injuries at higher cervical levels than this one, assistive technology (eg, EADLs) can play an important role in maximizing the individual's control of his/her environment, helping the patient to adjust bed height, answer phones, and use computers, lights, and televisions. Driving a specially modified or adapted van is possible
Individuals with C6 tetraplegia have the added function of wrist extension. This permits tenodesis, or passive thumb adduction on the index finger during active wrist extension, which assists with grasp and release. A wrist-hand orthosis (tenodesis splint) can be used to facilitate these abilities. The patient should avoid overstretching the finger flexors, which limits the tenodesis action.
C6 is the highest level at which patients can have a complete injury and still function independently without the aid of an attendant, although this situation is not common. Individuals with injuries at this level can achieve functional independence in terms of feeding, grooming, bathing, and bed mobility by using assistive devices. They can dress their upper body and assist with lower-body dressing, as well as with the bladder and bowel program. With the use of a slide board, persons with C6 tetraplegia may become independent in performing transfers from a bed to a chair, although they usually require assistance with these. Intermittent catheterization for bladder care may be possible with set-up and assistive devices, although this is not common and is technically more difficult for women than for men.
Manual wheelchairs with enhancement for gripping the wheel rims may be used for community mobility, although patients may prefer a power chair. Driving a vehicle with adaptations, such as a custom lift and hand controls, is an option. Patients with C6 injuries can be independent in using a phone, turning pages, and writing and typing (with assistive devices).
Individuals with C7 tetraplegia have the functional ability to extend their elbow, which greatly enhances their mobility and self-care skills. C7 is usually the highest level at which patients can have an injury and still be able to live independently. They may achieve independence in feeding, upper extremity dressing, bathing, bed mobility, transfers (although they may require assistance with moving over uneven surfaces), and manual wheelchair propulsion in the community (with the exception of going over curbs).
With the use of assistive devices, patients may also become independent with regard to grooming, lower extremity dressing, and bowel care. Individuals with a C7 injury, especially women, may need help with bladder care (eg, intermittent catheterization). Patients may be able to independently drive an adapted van or a car that has been adapted with hand controls. Patients with C7 tetraplegia can be independent, with or without assistive devices, in writing, typing, turning pages, answering phones, and using computers.
Individuals with C8 tetraplegia have functional finger flexion, which improves their independence in terms of hand grasp and release. They can achieve independence in feeding, grooming, upper and lower extremity dressing, bathing, bed-mobility transfers, manual wheelchair propulsion, and bladder and bowel care, as well as in typing, writing, answering phones, and using computers. These persons can also drive independently using an adapted van or a car that has been adapted with hand controls. Individuals with T1-T12 paraplegia have innervation and function of all upper extremity muscles, including those for hand function. They can achieve functional independence in self-care (including light housekeeping and meal preparation), in bladder and bowel skills, and, at the wheelchair level, in all mobility needs. Individuals should receive advanced wheelchair training so that they can move over uneven surfaces, rough terrain, and ramps and curbs, as well as do "wheelies" and make transfers from the floor to the wheelchair. Like patients with an injury to the low cervical levels, persons with thoracic paraplegia can drive independently by using an adapted van or a car adapted with hand controls.
Individuals with a T2-T9 injury have variable trunk control (of the paraspinal and abdominal muscles), and they may be able to stand by using bilateral knee-ankle-foot orthoses (KAFOs) along with a walker or crutches. Persons with a T10-T12 injury have better trunk control than do patients with a higher injury, and they may be able to walk household distances independently with KAFOs and assistive devices; they may even attempt to walk up and down stairs. Unfortunately, these maneuvers can require extreme energy expenditure, and many individuals may prefer wheelchair mobility.