Protecting Spinal Cord Injured Patients from Autonomic Dysreflexia, Research Paper Example

Abstract

Autonomic dysreflexia (AD) is a potentially life-threatening condition associated most commonly with spinal cord injuries. While the signs of AD are subtle, the complications can result in seizures, strokes, or even death. The best cure for AD is simple prevention. Patients in a home environment need  to be educated on the importance of watching for the subtle signs and stimuli that can cause AD. They also need to be taught the straightforward home and self-care techniques that can prevent occurrences of AD. This paper proposes a project that will educate patients on the importance of watching for AD.  It will include educating professional nursing staff in the project medical institutions on the signs and symptoms of AD. The  proposed project will track the progress of the patients receiving this training to determine if the additional education  has been beneficial in averting AD events.

Introduction

Autonomic dysreflexia, or hyperreflexia (AD) is most commonly linked to traumatic physical injuries to the spinal cord. It is caused by spinal reflexes that are not damaged by the spinal injury. When a negative stimulus such as minor damage or injury impacts the body below the damaged area of the spine, it can cause spasms in the cardiovascular system, which in turn can raise blood pressure, and generate effects ranging up to and  including  stroke to seizures to death. (Blackmer, 2003).  Blackmer reports that AD is remarkably common with it occurring during the lifetime of between 19% to 70% of all patients with spinal damage at or above the T6 level. (Ibid., p. 931). The types of events that can stimulate an AD event include urinary catheter kinks, urinary infections, appendicitis, esophageal reflux, and, most commonly, fecal impactions; even pressure sores and ingrown toenails can stimulate AD, as can menstruation and  labor in women, and such medications as nasal decongestants. (Ibid., p. 932).

A single such negative stimulus or injury may not seem serious or threatening, but AD can cause seizures, strokes, or death. Furthermore, as the following literature review will demonstrate, the research and care of patients with AD or other spinal traumas have been based upon long-standing medical misconceptions and a lack of education. Frequent telecommunications have opened new doors which worry the professionals who personally know the difficulties of working with spinal cord injuries (SCI) and AD and know the challenges of overlapping care in a patient with AD. This generally applies to both self-administered and professional health care, because, as the following literature review will demonstrate, the professional research and care of patients with AD or other spinal traumas have been based upon long-standing medical misconceptions and a lack of education.

In this paper, the challenges which AD presents to both the patient and the health care professionals are reviewed, focusing on identification of stimuli and the signs and symptoms of AD. The research question of interest is whether patients with spinal cord injuries can be taught to recognize the stimuli, signs, and symptoms of AD and thus prevent AD occurrences.

Search Strategy

These resources were located by performing an internet search of Google’s academic documents and the EBSCO Academic Database. The search phrases were “autonomic dysreflexia”, “spinal cord injuries”, and “autonomic dysreflexia health care”. The results were narrowed according to their reliability, validity, and the modernity of the results. The chosen articles were selected because of their relation to the thesis statement, but research agreement within the articles was not considered during the selection process.  This was crucial to the objectivity of the academic discourse of the clinical research.

Literature Review

Health Challenges

Parker (2005) opens her editorial on AD patients’ bowel care by relating the dangers of ignorance. In particular, the need for manual removal of feces, if  unmet, can cause the symptoms to rapidly escalate, manifest as hypertension and become life-threatening. The disruption of the neurologic functioning results in a chemical and mechanical non-responsiveness to the gastrointestinal and digestive needs (Walker, 2009). AD is not always readily apparent, because its emergence may occur more as an attack very similar to an epileptic spasm. AD is “unmistakable to the experienced clinician…can be poorly diagnosed… perhaps for lack of differentiation from other diagnoses, such as essential hypertension, migraines, cluster headaches or toxemia of pregnancy” (Lapierre et al., 2006, p.20). Although a high incidence of AD is linked to spinal injury, it is not commonly known that a variety of common causes are not related to spinal trauma. These triggers can occur due to a number of natural causes, and the likelihood of developing AD increases with age (Walker, 2009). However, since the majority of cases are related to spinal trauma, we will focus mainly on these incidents (Krassioukov et al., 2007).

Following a spinal cord injury, the body is less able- or unable- to identify and regulate changes in the pressure within the body. The body’s reaction to the development of AD is highly unique. Immediately after SCI, some symptoms can already be found if a very close examination is made. Silver (2000) states that the first month following the injury will include spinal shock, which disables the patient’s ability to sense the negative effects. Significantly, this study highlights the importance of research methodology by examining the findings’ differences for natural contractions of the bladder and those which employed artificial methods, such as a cystometrogram (Silver, 2000).

Walker’s article provides vivid illustrations of the interrelationship of the nervous system and the abdominal, urinary, and rectal functioning and lists the effects which spinal injuries have on neurological activity, breathing, cardiovascular and gastrointestinal function, continence, ulcers, and (in AD specifically) headaches, sweating, and vision (Walker, 2009). In addition, other symptoms include paresthesias, shivering, flushing, nasal obstruction, and nausea (Karlsson 1999). This is especially devastating to the digestive system, which frequently swells. Shergill, Arya, Hamid et al. begin their study of the urological challenges by providing a very brief but intriguing medical history of AD. The authors describe the problem in great and accessible detail and isolate knowledge which a urologist is likely to encounter (Shergill, et al., 2004, p.923).

Recent research has discounted  the early assumptions that hypotension existed only during the acute phase of spinal injury. Among the scarce other causes is sexual stimulation, which is frequently overlooked, but can also cause blood pressure to skyrocket and require the regulation which AD prevents. Forsythe and Horsewell present a survey of sexual rehabilitation of women with SCI and conclude that recovery depends upon the injury and the quality of the rehabilitation (Forsythe and Horsewell, 2006). Reproductive risk factors are among the least-recognized triggers which can be responsible for these sudden attacks of AD. The release of adrenaline during intercourse and other sexual stimulation compounds the risks of the drastically increased blood flow (Krassioukov, 2006). Physically, this increased blood flow does little to heighten sexual stimulation in both male and female SCI patients, because the limitations presented by incontinence, spasticity, and sexual response distract from the bodily response (Forsythe & Horsewell, 2006; Soler, Previnaire, Plante et al., 2008). Even with the aid of effective prescriptions, cognitive barriers to confidence abound (Soler, Previnaire, Plante et al., 2008). Pregnancy and childbirth increase the risk of developing AD (Krassioukov, 2006). For patients with spinal injuries at or above the sixth thoracic vertebra, there is an 85-90% likelihood of developing AD (Blackmer, 2003).

The list of possible causes is alarmingly great and inclusive, and AD itself can be a symptom of other health complications, making it a ‘blessing in disguise’ (Shergill, Arya, Hamid et al., 2004). Functional Electrical Stimulation (FES) is a common tool for assessing sensation and responsiveness in patients with AD. However, double-blind studies suggest that FES tends to elevate blood pressure, perhaps triggering the development of AD in patients with spinal cord injuries above the sixth thoracic vertebra (Matthews, Wheeler, Burnham et al., 1997, pp. 647-648). The authors’ results support taking simple precautionary methods, such as monitoring blood pressure and applying lower intensities of FES. When these precautions are taken, local anesthesia is more effective in reducing the pain felt during FES (Matthews, Wheeler, Burnham et al., 1997).

These electrical currents were intended to stimulate musculature affected- or even paralyzed- by SCI. This stimulation increases the blood pressure and decreases heart rate without regulation, simultaneously producing a rush of adrenaline. The reduced heart rate and reduced neurosensitivity do not notify the brain of the dangers of overexertion, and, according to Bhambhani, “athletes with spinal cord injury have unique changes in cardiorespiratory, metabolic, neuromuscular, and thermoregulatory systems that reduce their overall physiological capacity” (Bhambhani, 2002, p. 26). Patients with AD experience high risk of overexertion during athletic activity.

Surprisingly, some patients deliberately seek to provoke an attack of AD to participate in athletic competitions. Athletic performances can be improved by as much as 9.7 percent through the provocation of AD (Mokha, 2005). Short-term and long-term reliability were consistent in paraplegic male patients (Bhambani, 2002). Some methods are comparatively innocent, such as holding their urine, but the majority of methods are invasive and perilous, such as sitting on a sharp object or pinching or punching themselves (Mokha, 2005). The provocation of AD can also be unintentionally achieved by athletes who do not anaerobically train or are ill, do not get adequate sleep, avoid extreme heat, do not wear loose clothes, and stay appropriately hydrated (Bhambani, 2002, pp. 44-45).

The literature demonstrates that even the younger athletes with AD are likely to realize the extreme risks of exploiting their condition to “boost” their competitive performance (Schottler, Vogel, Chafetz et al., 2009). The severity of the SCI is directly related to the likelihood of awareness of the symptoms, so patients who are unfamiliar with the medical and challenges of AD experience increased risk when FES or boosting go awry.  Symptomatic knowledge aside, the implications of personal differences in ethics generate a new cause for concern, and the challenges of attacks of AD present a new picture of health care: It is no longer a question of if a patient can manage the majority of their own care with the proper education but if a patient should be given that license (Schottler, Vogel, Chafetz et al., 2009). Thus, the foundational guidelines of medical professionals provide a firm ethical premise which is lacking in the average patient.

Prevention of Autonomic Dysreflexia

Shergill, Arya, Hamid et al. (2004) emphasize prevention and early identification. Because such a large portion of the swelling which may trigger spasms is caused by complications of distension in the digestive system, the authors suggest regular catheter sanitation and urinary monitoring for patients with spinal cord injuries to the upper thoracic vertebra (e). If these preventive measures are not taken, the authors convey the impression that it is not a matter of if AD develops, but when. When the syndrome does begin to escalate, the risks to the patient increase dramatically. Time can be the enemy of AD care, because this condition can escalate rapidly without proper medical attention and monitoring (Blackmer, 2003). In 2004, the National Patient Safety Agency released a notice concerning the care of these patients. It recommended that hospitals have established procedures for manual bowel evacuation, training and information sessions for treating patients with AD, ensure the availability of seasoned personnel, and recognize that the patients are knowledgeable about their own care and prompted the United Kingdom to develop a new patient card system which organized the essential elements of patient care. These guidelines are readily available online (Parker, 2005). These are short-term strategies for use in the general health domain and do not eliminate the need for assessments conducted by a specialist. Spinal injuries are unique to the patient, and thus generalizations about the seriousness of their condition are not valid (Walker, 2009). Anton and Townson’s editorial criticizes the anecdotal and limited nature of the majority of AD research and blames this shortsighted approach for the adverse reactions caused by using the drug nifedipine in place of the safer prescription, captopril (2004).

The very nature of this syndrome often prevents patients from seeking care for what they perceive as minor symptoms. Consequently, many AD patients have turned to telehealth, the “use of communications and information technology to deliver health-care services and information over large and small distances” (Lapierre et al., 2006, p. 21). Lapierre et al. (2006) expresses fears that these telehealth lines are not properly monitored or supported by the same level of information that is available at health conferences and other professional development initiatives. This is especially important in life-threatening conditions, such as AD, which present such ambiguous symptoms. As we have previously discussed, even experienced doctors can mistake the common symptoms following spinal cord injuries with harmless sickness. These may occur frequently and asymptomatically. Only recently has the medical community even begun to learn the truths of AD. Krassioukov wrote:

This means that the phenomenon of AD is part of a continuum from  no symptoms to full-blown AD. Presently, neither a common classification for characterizing this continuum nor a system for grading this reaction exist that could lead to classification of different severities of AD. (Krassioukov, 2007, p. 103).

Lapierre et al. (2006) proposed an algorithm for responding to these calls in a manner consistent with the uncertainty of telehealth and of the AD complications. The first question in the algorithm questions the patient with a spinal cord injury as to the location and severity of the injury, a detail which is central to the identification of AD. This algorithm also simplifies the decision-making process and creates a guideline for seeking the help of a specialist (Lapierre et al., 2006). Only licensed medical professionals can provide the prescriptions for glyceryl trinitrate, which is used to control hypertension and reduce the risk of escalation (Walker, 2009). However, there are many actions that laymen can perform. Sparing hydration, monitoring blood pressure and other symptoms, elevating the head of the bed, careful manual stool removal (with gloves), and decreasing anxiety are all measures which do not require specialist knowledge or action (Keely, 1998).  Nonetheless, the risk is increased in self-care. As Karlsson (1999) wrote: “If more than one peripheral stimuli is present simultaneously… the reaction is more severe and more readily activated” (Karlsson, p. 385).

Because injuries in different areas of the spine can produce similar symptoms, it can often be difficult to properly diagnose a patient, especially when they are asymptomatic or describing their symptoms on a telephone line. Spinal injuries were not studied extensively until World War I, after excessive sweating and bladder distension were linked to patients who had experienced spinal trauma. Even now, the cataloguing and understanding of symptoms can be problematic. Shergill, Arya, Hamid et al. report that ‘gooseflesh’ is a symptom of AD. The lack of a common, specialist vocabulary has complicated the sharing of medical information (Shergill, Arya, Hamid, et al., 2004).  This spurs on the telehealth movement and lends support to the non-pharmacological methods of self-treatment. Forsythe and Horsewell (2006) also suggest peer counseling as a positive self-treatment option.

Proposed Clinical Project

The goal of the proposed project is to determine if training patients with SCI  on the signs and stimuli of AD and proper self-care can reduce the number of AD events.  To this end, specialized training materials, either printed or available on computer files, will be prepared, and patients given special instruction on self-care that can help them avoid AD events. These patients will be compared to similar patients who do not receive the specialized training but who otherwise receive best practices care, to determine if the training and information available to the patient helps avoid AD events in SCI patients.

The first phase of this project consists of research into the current state of best practices for SCI patients, with particular attention to the self-care steps that will best avoid AD events. Second, this will be followed by the production of a carefully prepared instructional pamphlet intended to teach patients the importance of following such self-care procedures and being alert for stimuli that might generate an AD event. Then a cohort of CSI patients will be recruited, and split into two groups, one of which receives standard CSI care and the other of which additionally receives extra training and a copy of the pamphlet (printed and/or electronic, depending on patient needs and preferences) on self-care techniques. These two cohorts will be followed to determine if AD events are reduced in the group with the additional training.  In conjunction with this effort, nursing staff will receive in-service training on AD prevention and self-care.

As noted above, this project will include preparation of appropriate training materials to be used by trained nursing staff to educate patients and family members on the stimuli, signs, and symptoms of AD. It is important that this documentation make clear the vital importance of preventing AD. While the initial signs may seem minor, the impact can be life-threatening, and that point would be stressed.  The goal is to keep the patients alert for AD signs and to teach them simple self-care procedures to avoid AD, and, should AD arise, the importance of promptly seeking professional medical care.

In addition, a training class for nursing staff who deal with SCI patients will be prepared to teach them how to teach patients how to understand and use the information in the brochure.

Needs Assessment

After reviewing the literature concerning patient education for health promotion, maintenance, and rehabilitation and after identifying the gaps therein, many important questions remain; the research  is full of contradictions and unclear information. Added to the natural complexity of the syndrome, there is cause for concern and a need to clarify and standardize the use of medical terminology, the recommended practices for care, and the future of care for patients with AD and similar syndromes. The lack of consistency, clarity, and informational availability are the greatest challenges facing the treatment of AD.

In 1998, there were approximately 250,000 survivors with severe spinal injuries (Keely, 1998). These multitudes are falling through the cracks due to easily preventable miscommunications. For this reason, the education of medical professionals working with patients exhibiting AD and of the patients themselves is vital to the development of conscientious preventive treatment.  Since AD is potentially life-threatening, the urgency of training CSI patients to avoid vulnerabilities and provide proper self-care is evident.

Planning for this project will require identifying and obtaining appropriate funding to support the project. In addition, it will be necessary to obtain the consent of the institution’s ethics board regarding obtaining appropriate informed consent from all patients who will be participating in the clinical project. It will be important to get the cooperation of doctors who will be reviewing the proposed educational materials. This will be a project that requires group coordination and cooperation.

Implementation

The project will be implemented in stages. In the first stage, a review of the latest literature on AD care, signs, and symptoms will be conducted to be sure the information to go into the patient training will contain best practices. Then a preliminary version of the material in pamphlet form will be produced, using simple desktop publishing techniques. This will be sent to three to five AD care experts for review, with at least two of those experts physicians familiar with AD, and the remainder with nurses who have substantial AD experience. Once those corrections and suggestions have been incorporated, the pamphlet will be ready for a preliminary roll-out.

This initial roll-out will consist of using the pamphlet (printed and/or electronic) with a group of AD patients. This group will consist patients, newly diagnosed with SCI, who agree to participate in this project. The patients participating will be split into two approximately equal groups, matched as closely as possible for age, severity of SCI, and other medical factors. One group will receive the same instructions and information as patients currently receive. The second group will additionally receive special instruction and a copy of the proposed  pamphlet to take home with them for referral. These two groups will then be followed to determine if there is any significant difference in the rate of AD events. The groups will be surveyed at regular intervals about their symptoms, as well as how confident they are in their understanding of how to prevent AD. Those who receive the AD patient training materials will be also asked for suggestions on how to improve that training.

Their suggestions regarding clarity and completeness and ease of understanding will be collected to further refine the pamphlet. In addition, the nurses who explain the pamphlet to these patients will be queried regarding questions and problems the patients expressed.

In preparation for the education rollout, the information should begin with professional development. In these smaller sessions, the focus can be intensified. However, there are often so many potential foci for professional development that competition for a spot may be intense. Practically, offering patient and professional information sessions at pre-scheduled times reaches the widest range of interested persons. These sessions should be scheduled to optimize attendance. In addition, interested professionals should be provided with information (and, if necessary, additional funding) to attend relevant conferences in the area. It is especially important to be aware of the differences which age presents in the manifestation of symptoms and in recovery. Schottler, Vogel, Chafetz et al. (2009) present evidence that younger SCI patients recover quicker from traumatic injuries of comparable severity. This means that the concerns of the patient will differ greatly according to the age and the location and severity of the injury sustained.

In the initial phases, a reward system for the professional staff will be beneficial. Offering positive and negative incentives for upholding the new initiatives is central to the success of the staff education program. Thus, implementation of the program requires a high level of coordination between patients and between professionals at varying levels of authority and expertise. In addition, one of the primary concerns will be the funding and the execution of the work to be done. Thus, the very first step in this project is to secure grants or other funding to support this work. In addition,  the assignment of passionate, capable professional staff  is paramount to making a judgment on the worthiness of the program. This should not be hastily done and should integrate patient feedback and support and perhaps seek additional funding.

Evaluation

Evaluation of the success of the project will be determined in several ways. First, the two patient cohorts (one of which received the special training on avoiding AD with self-care), will be followed and quantitative measures will determine if the incidences of AD are reduced. The second evaluation will derive from patient surveys taken throughout the study. These surveys will attempt to determine how confident the patients are that they understand how to avoid AD events, and whether they understand the self-care techniques to deal with the signs and symptoms associated with potential AD events. The evaluation of these data will determine the effectiveness of the training material and the “educated self-care” approach to avoiding AD..

Dissemination of Information

The project’s results will be disseminated in various ways to share the discovered best practices with others. First, a report will be prepared and submitted to an appropriate journal, including the detailed description of the patient cohorts, the results data, and a detailed evaluation of the success or failure of these efforts in averting AD events. Second, talks will be proposed for various appropriate professional conferences to provide the results to other professionals. Finally, if the patient educational materials are successful in averting AD events, the patient training information will be made available on a website designed to allow SCI patients and their families to access this information as they need it. As new information on how best to avoid AD events is encountered, this website will continue to be updated, thus providing all patients with SCI who have access to the Internet with the critical self-care information to prevent AD events.

Summary

Despite the considerable knowledge which patients often exhibit regarding their condition, Schottler, Vogel, Chafetz et al. discover that even patients who are twenty-one years old typically do not possess the information available to their caregiver and that knowledge of AD corresponds to the severity of their symptoms (Schottler, Vogel, Chafetz, et al., 2009). Because AD can escalate if unchecked, it is crucial that information about prevention, stimuli, and warning signs be made available at every juncture of treatment within the SCI health care network. This project is intended to determine if providing special self-care and AD awareness training can reduce the incidence of AD events in patients with SCI.

Will another medical professional be able to identify gooseflesh from the use of that term, or will it produce another patient casualty of miscommunication (Shergill, Arya, Hamid et al., 2004)?  Miscommunication is obviously a large part of the challenge of treating a patient with spinal cord injuries or AD. Miscommunication within hospitals has put the lives of these patients at risk, and miscommunication of the subtle symptoms has hindered the effort to unify the research in this area. In the end, as the National Patient Safety Agency asserted, the patient typically becomes second only to well-read specialists in the knowledge of their condition, and even medical research contradicts itself frequently (Anton & Townson, 2004).

It is the intention of this project to cull the best practices from current medical research and provide patients with the information they need to stay self-aware of their conditions, to maintain their health at home using self-care techniques and, most importantly, to know when apparently minor symptoms are sufficiently urgent as to require professional medical attention. Such knowledge may well reduce the incidence of AD, and improve the quality of life for SCI patients.

References

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Bhambhani, Y. Y. (2002). Physiology of wheelchair racing in athletes with spinal cord injury. Sports Medicine, 32(1), 23-51.

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Forsythe, E. E., & Horsewell, J. E. (2006). Sexual rehabilitation of women with a spinal cord injury. Spinal Cord, 44(4), 234-241.

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Shergill, I.S., Arya, M., Hamid, R., Khastgir, J., Patel, H.R.H., & Shah, P.J.R. (2004). The Importance of Autonomic Dysreflexia to the Urologist. BJU International (93): 923-926. doi:10.1111/j.1464-410X.2004.04756.x.

Silver, J. (2000). Early autonomic dysreflexia. Spinal Cord, 38(4), 229.

Soler, J., Previnaire, J., Plante, P., Denys, P., & Chartier-Kastler, E. (2008). Midodrine Improves Orgasm in Spinal Cord-Injured Men: The Effects of Autonomic Stimulation. Journal of Sexual Medicine, 5(12), 2935-2941.

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