Individuals with Spinal Cord injuries and the importance of a bowel and bladder program for prevention of autonomic dysreflexia.
Autonomic dysreflexia (AD) can be a serious condition in individuals with spinal cord injuries (SCI) typically above T6 level. This condition is a response that is triggered by the autonomic nervous system when the body senses pain or discomfort even if the individual does not have sensation below the injury (2). In normal, healthy individuals a noxious stimuli from the skin or organs produce a response that increases vasoconstriction leading to an increase in blood pressure (1). With an increased blood pressure the heart will respond by decreasing its rate of contractions and systemic vasodilation will take place in order to regain homeostasis. In patients with a SCI this systemic vasodilation does not travel below the level of injury (LOI) so in general blood pressure remains high. The combination of high blood pressure (BP) and cerebral vasodilation increases the risk a patient may have a hemorrhagic stroke (1).
When working with a patient with a SCI a baseline blood pressure should be identified since these individuals typically have a resting systolic pressure around 90mmHG. If a patient has a systolic reading of 120mmHg this increase may indicate an abnormal response and AD should be considered (1,3).
Signs a patient may be experiencing AD include reports of a severe throbbing headache, increased BP, profuse sweating and/or flushing of the skin above the LOI, visual changes, anxiety, nausea/vomiting and dry pale skin below the LOI (1). As healthcare workers it is important to know these signs and how to appropriately respond. One of the first things to do is sit the patient upright and remove any tight clothing, abdominal binders or tedhose in an attempt to lower blood pressure (1,2). Once upright check other causes of noxious stimuli like a kink in a catheter, wounds or distended abdomen which may indicate constipation or a full bladder (1,3).
In approximately 85% of individuals who experience autonomic dysreflexia the cause is from a urinary tract infection, distended bladder or a kink in a catheter (1). Other sources report that constipation, pressure injury, a cut or ingrown toe nail can cause AD(2,3). With the majority of causes relating to bladder or bowel it is very important for individuals with SCI at or above T6 to have a routine bowel and bladder program in an attempt to prevent AD. With the loss of sensation due to a SCI a patient may not be aware that they need to empty their bowel and/or bladder so it is important to get on a regular voiding schedule.
As a physical therapist in an acute setting, it is very important to work with the nursing staff on scheduling therapy sessions around daily bowel and bladder schedules to avoid overfilling of these organs. It is also very important to educate the patient on the signs of AD and their participation in a bowel and bladder schedule, even though it is sometimes inconvenient. In general individuals are most likely to experience AD 1 month to 1 year after initial injury which typically corresponds to the time when a patient is transitioning home and will be managing their own care (1).
References
1-Allen KJ, Leslie SW (2021). Autonomic Dysreflexia. StatPearls [Internet]. Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK482434/
2-Chiodo, A. et al (2015) . Autonomic Dysrefelxia. MSKTC. Retrieved from: https://msktc.org/lib/docs/Factsheets/SCI_AutonomicDysreflexia.pdf
3-Morgan, S. (2020). Management of autonomic dysreflexia in the community. British Journal of Community Nursing, 25(10), 496-501. https://doi-org.proxy.kumc.edu/10.12968/bjcn.2020.25.10.496