Autonomic Dysreflexia Case Studies

Aside from the motor and sensory impairments as well as independent breathing difficulty (if higher level injury), numerous complications can arise after an individual sustains a SCI. Initially after injury, spinal shock occurs resulting in a phase of areflexia, a disruption of the autonomic nervous system causing irregularities in blood pressure and temperature control, and flaccidity. The initial phase may last approximately 24 to 48 hours with a gradual return of reflexes over time. Ultimate reflex return can range from one to six months.5,6

Autonomic dysreflexia (AD), also known as autonomic hyperreflexia, is a serious life-threatening condition occurring in individuals with injuries at T5 and above and is characterized by a sudden

increase in blood pressure when exposed to noxious stimuli below the level of the spinal cord lesion. If not treated, AD could lead to seizures, renal failure, subarachnoid hemorrhage, stroke, or possibly death. Signs and symptoms other than severe hypertension may be a throbbing headache, bradycardia, flushing and sweating above the level of the lesion, goose bumps, blurred vision, and constricted pupils.5 The most common cause of AD is bladder distention. If the individual has an indwelling catheter, examine the drainage tubes for any kinks in the system; if they void via intermittent catheterization, place the catheter in the bladder so that draining can occur. Other common causes of AD are bowel impactions, restrictive clothing, tight catheter straps, abdominal binders, or anything else that may cause painful stimuli to the body. If an individual presents with these symptoms, the most immediate action to take is to sit them up in an upright position to assist with decreasing blood pressure and assess what is causing the response, being sure to monitor blood pressure and pulse rate. Addressing this condition as soon as symptoms arise is vital, and all primary care providers should be notified as soon as possible to address the situation; if the symptoms cannot be resolved further medical interventions may be required.6
Spasticity is common with SCIs and is typically seen more with quadriplegia.

It usually appears after spinal shock has subsided and is part of an upper motor neuron (UMN) syndrome. Other symptoms related to spasticity are muscle spasms, an abnormal increase in muscle tone, overactive stretch reflex, and clonus. Multiple causes can contribute to an increase in spasticity including but not limited to: changes in positions, the temperature of the environment, tightness of clothing, urinary/digestive complications, emotional stress, pressure ulcers, or a quick passive stretch to the spastic muscle. The severity of spasticity varies, and SCIs who have been diagnosed with spasticity reports it as being problematic; however, if those with mild to moderate involvement are taught how to control the onset of spasticity or spasms at specific times, this could be used to the individual’s advantage in helping with functional tasks such as transfers. On the other hand, if the spasticity is severe it can cause major problems with functional tasks. Treatment of spasticity typically includes slow-controlled stretching exercises, modalities, and medications. Common medications are muscle relaxants and spasmolytic agents such as baclofen, diazepam, tizanidine, and dantrolene sodium. Botulinum neurotoxin (botox) may also be given intramuscularly to manage focal spasticity. Surgical intervention may be required if all other treatments have failed. Surgical procedures that may be

performed are a myotomy, tenotomy, or a dorsal rhizotomy.6
Pressure ulcers, also known as decubitus ulcers or pressure sores, are one of the most common complications after SCI and is a major factor in increased medical costs and length of hospital stays. Areas with bony prominences become susceptible to breakdown due to the individual not being able to relieve pressure from the area; sheering forces can also cause trauma leading to breakdown. Some other elements that may play a role in the development of a pressure ulcers are bowel and bladder incontinence, nutritional deficiencies, smoking, prolonged immobilization, and poor skin hygiene. Common areas of vulnerability are the sacrum, scapula, elbows, heels, greater trochanter, knees, ischium and anterior iliac spines. Pressure relief is one of the most important interventions to include in their daily routine and should be performed habitually. Protocols for pressure relief schedules may vary for each facility, but generally the individual should perform one minute of pressure relief for every 15 to 20 minutes of sitting. It is important to incorporate the individual and caregivers in performing pressure relief because they will assume this responsibility when returning home, and implementing the relief schedule will be the main key in preventing pressure ulcers from occurring.5,6
Bowel and bladder dysfunction are another common complication associated with individuals with quadriplegia. For bladder dysfunction, typically the individual will present with what is called a hyperreflexic or spastic bladder, meaning the bladder will empty automatically when the pressure within reaches a certain level. Urinary tract infections (UTIs) are one of the major causes that lead to death in persons with SCIs and careful monitoring of residual volumes and bladder-training programs will help with prevention of these infections. Bladder-training programs include intermittent catheterization, manual stimulation, and timed voiding, all of which are used for emptying the bladder and can be performed catheter-free.5
For bowel dysfunction, the individual is typically said to have a spastic or reflexive bowel, meaning when the rectum is full, elimination will occur reflexively.

Bowel dysfunction can interfere with their social involvement and a bowel program should be implemented to help the individual maintain a schedule. Establishment of a diet high in fiber with adequate fluid intake along with medications and manual stimulation will assist in promoting a proper bowel program. It is important for the therapy team to know the bladder and bowel schedule of the individual so that they will be able to construct therapy around these schedules, being sure not to

interfere.5
Temperature control is another complication seen, and occurs due to the hypothalamus not being able to control sweating or blood flow to the skin below the level of the lesion; this results in an inability to shiver below the level of injury. Injuries to the cervical level and complete injuries usually have more involvement and complications related to temperature control. Peripheral vasodilation is an issue initially after injury and hypothermia may result; however, hyperthermia becomes an issue later on due to the inability to control sweat glands. In individuals with quadriplegia, longstanding impairments with body temperature regulation are noted, especially in extreme climate change.6
Sexual dysfunction is one of the major concerns for the individual. For males, there are two types of erections: reflex and psychogenic. Reflex erections occur by external stimulation and are possible if the sacral reflex arc is intact; psychogenic erections occurs by cognitive activity by way of the cerebral cortex. Erection quality is typically greater in those with UMN lesions and incomplete injuries compared to LMN lesions and complete injuries; oral, topical, and injectable medications as well as mechanical devices are used to help with the improvement of erectile function. Ejaculation complications are common among both UMN and LMN lesions, making fertility an issue. Fertilization for women with quadriplegia due to SCI remains unchanged compared to persons without a SCI; however, close monitoring is required if the individual becomes pregnant. Problems such as venous thrombosis, UTIs, and anemia may arise during pregnancy causing complications. Also, AD may become an issue during labor and delivery. Hospitalization is usually required around the due date for observation as a precaution due to the fact that the woman may not be able to feel contractions indicating labor has begun. When dealing with sexual health and dysfunction, the individual will have questions to ask, and the therapy team must be knowledgeable and comfortable in helping address their needs.5,6
Respiratory compromise affects injuries from the cervical region on into the thoracic region until T11 causing complications for individuals with quadriplegia at any level of injury with varying degrees of impairment. As discussed previously, the higher the level of injury, the more respiratory difficulty is involved with the lack of innervation of the diaphragm; these individuals will require mechanical ventilation for respiratory support. In lower level quadriplegia injuries, typically C5 through C8, the diaphragm is fully innervated but the lack of innervation of the abdominal muscles results in the individual having trouble with forceful coughs and secretion clearance. Because of this inability, these individuals have an increased risk of developing respiratory illnesses such as pneumonia and atelectasis.6 These illnesses are commonly seen in the acute stage of injury, but remain a risk throughout the lifespan with pneumonia being a leading cause of death in SCI. Interventions to assist with coughing and secretion clearance include suctioning, positioning, postural drainage, abdominal corsets/binders to help with abdominal content positioning, assisted cough techniques, strengthening of the diaphragm, and incentive spirometry.5,10

Other common complications that may arise in an individual with quadriplegia are contractures, heterotropic ossification (HO), deep vein thrombosis (DVT), and osteoporosis; these conditions are a result of long-term immobilization. HO is a condition in which there is an abnormal growth of bone in the soft tissues, usually occurring in the hip and knee joints.6 Postural hypotension and pain are also common complications seen in individuals with quadriplegia. Postural hypotension occurs when the blood pressure drops when the individual is coming to a more upright position. Symptoms include dizziness, headache, sweating, pallor, fatigue, and possibly syncope. Management of postural hypotension may include pressure stockings, abdominal binders, and slow progression to an upright position.10 Pain can be divided into two categories: nociceptive and neuropathic. With nociceptive pain, the musculoskeletal system is typically involved and usually effects the upper extremities. The pain can be a result of the initial injury or can stem from an overuse injury. Neuropathic pain is a result of injury to the central nervous system and/or peripheral nervous system; the pain may be felt above, below, or at the level of the lesion. Medications, transcutaneous electrical nerve stimulation (TENS), acupuncture, and mental imagery may all be used for treatment of chronic pain in these individuals.