SCI Impairments and Complications

OT Dude Academy’s Free NBCOT® Exam Prep Course Spinal Cord Injury (SCI) SCI Impairments and Complications

Respiratory

Respiratory complications may be a cause of morbidity and mortality in the acute and chronic stages for clients with SCI. The extent depends on the level and degree of motor impairment.1 2  Clients may experience insufficiency of respiratory muscles, reduced vital capacity, ineffective cough, and excess oxygen expenditure for breathing.3  Clients with respiratory complications are susceptible to atelectasis, pneumonia, and respiratory failure, and sleep-related disorders such as obstructive sleep apnea.1 4 5 

Cardiovascular

Clients with SCI may have a high risk of cardiovascular complications including orthostatic hypotension, autonomic dysreflexia, thromboembolism, impaired cardiovascular reflexes, cardiac atrophy, and reduced transmission of cardiac pain.6 7 8 

Management of orthostatic hypotension includes the application of pressure stockings and abdominal binders, promoting hydration, daily progressive head-up tilt, and pharmacological agents.9 10 

Autonomic Dysreflexia

Autonomic dysreflexia (AD) is a serious medical condition that may lead to stroke, seizure, organ damage, permanent brain injury, or even death. It is sometimes referred to as autonomic hyperreflexia.11  AD generally occurs in clients with SCI at levels T6 and above.12  A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009;90:682–695.)) AD may appear any time after SCI and has a lifetime frequency of 19%-70. It is caused by spinal reflex mechanisms from a noxious stimuli at the spinal cord below the level of injury. The stimulus causes sympathetic overactivity with vasoconstriction below the lesion and hypertension. Lack of sympathetic tone leads to vasodilation above the level of the lesion and is thought to be the cause of headaches, flushing, sweating, and nasal congestion.13 14 

Triggers of AD include the bladder being full and needing to be emptied, a blockage in catheters, bowel constipation, flatus (gas), inflamed hemorrhoids, skin ulcers or pinched skin, cuts, ingrown toenails, or extreme temperatures touching the skin, broken bone, sexual activity, and menstruation. Other symptoms of AD include a slow pulse, chills, restlessness, goosebumps, blurred vision, and cold clammy skin below the level of injury.

Management of AD includes checking and managing blood pressure (hypertension), finding the cause of AD: sitting upright, loosening constricting clothing, checking if bladder and bowel are full, checking skin for any abnormalities, and checking for broken bones. Occupational therapy practitioners should alert the team immediately at their facility or call 911 if they are unable to identify the cause or if the blood pressure is uncontrolled.15 

Prevention

  • Maintaining a consistent bladder and bowel program.
  • Daily skin checks, pressure relief, and prevention of pressure ulcers.
  • Avoiding skin injuries (cuts, bruises, sunburn).
  • Wearing loose-fitting clothing and shoes.
  • Minimizing and preventing falls and injuries.
  • Keeping a wallet card describing the risk of AD.

Urinary and Bowel Complications

Urinary and bowel complications may be due to the loss of genitourinary and gastrointestinal functions.

Bladder

Bladder complications may increase the risk of long-term complications and decrease the psychological and social well-being of the client with SCI. A common barrier is a neurogenic bladder (lacking bladder control due to a brain, spinal cord, or nerve condition). Examples of barriers include hyperreflexia of the sphincter with involuntary contractions, areflexia with stress incontinence, areflexia with overflow incontinence and urinary retention, and hyperreflexia combined with areflexia and reflex incontinence.16 

Treatment of bladder complications is based on the specific presentation of dysfunction and may include facilitating bladder emptying and therapy to facilitate the filling and storage of urine. Clean intermittent catheterization is the safest bladder emptying method for clients with SCI and requires education and support by the team including occupational therapy practitioners. The risk of urinary tract infection increases with increasing duration of catheterization. Clients with sufficient hand function are educated on how to empty the bladder regularly and reduce urinary tract infections.17 18  A permanent indwelling urethral or suprapubic catheter may be an option for some clients.8  Reflex voiding is not recommended in clients with SCI and autonomic dysreflexia.19  Other treatment options include pharmacological interventions and surgical procedures.

Bowel

Neurogenic bowel (NB) is a very common complication in clients with SCI and may affect nearly half of them.20  NB occurs when the colon lacks nervous system control.16 21  Bowel complications may include stool retention and constipation or incontinence which may also affect bladder and sexual dysfunction. Bowel complications may lead to restrictions in social activities and overall quality of life.22 

Management includes intake of high dietary fiber, abdominal massage, digital rectal stimulation, manual evacuation of stool, oral laxatives, transanal irrigation, rectal suppositories, and other pharmacological agents. Surgical treatments include sacral nerve stimulation, implantation of electrical stimulation systems, and colostomy.23 24 25 26 27 28 29 

Spasticity

Spasticity is characterized by hypertonicity, hyperreflexia, clonus, and muscle spasms.30 31 32  Spasticity affects 70% of clients with SCI. The cause of spasticity in clients with SCI is unknown. Barriers from spasticity include functional impairment, contractures, ulcers, posture disorders, and pain. OT management should start as soon as possible to address spasticity.32 

Management of spasticity includes eliminating factors that exacerbate it and the use of PAM agents and techniques. Specific interventions include addressing UTI, constipation, ingrown nails, pulmonary infection, and pressure ulcers. Medications such as baclofen and botulinum toxin may help. However, side-effects such as baclofen include sedation, fatigue, drowsiness, ataxia, and mental confusion which may interfere with therapy. OTs should work with the team to assist with the therapeutic dosing of medications.33 32 34 

Physical approaches include:

  • Stretching and ROM exercises
  • Weight-bearing or standing with support
  • Splints, braces, or progressive casting
  • Careful use of cold or heat packs. Avoid the use of hot packs over areas with decreased sensation.11 

Functional electric stimulation (FES) cycling may help to reduce lower extremity spasticity in clients with SCI at various levels. However, it is not a suitable intervention for unstable clients or those with contraindications for lower extremity movement.35  TENS applied to the nerve supplying the ankle dorsiflexors was shown to be more effective in reducing spasticity in clients with SCI at the plantar flexors.36 

Pain

Pain is one of the most frequent (up to 80%) complications for clients with SCI.37  It may lead to functional disability, emotional discomfort, depression, decreased community participation, and decreased quality of life.33 38 39 

  • Nociceptive pain: chronic musculoskeletal pain associated with abnormal posture, gait, or overuse, e.g., shoulders from wheelchair transfers and use. Muscle spasms and visceral pain also also barriers for clients with SCI.
  • Neruopathic pain: can occur above, at, or below the level of injury. May arise from CRPS, damage to nerve roots or spinal cord, and syndromes which present with burning, aching, tingling, or stabbing sensations.37 40 

Pharmacological managment includes the use of analgesics, NSAIDs, and opoids as first line as well as anticonvulsants, antidepressants, other analgesics, and antispasticity medications as alternatives.41 37 40 42 43 44 45 46 47 48 49 50 51  Exercise can provide relief from shoulder pain.52 53 54 55 

Pressure Ulcers (Pressure Injuries)

Pressure ulcers can lead to additional potentially life-threatening complications for SCI in addition to further functional disabilities, infections, and need for surgical interventions.56  Pressure ulcers are commonly classified using the National Pressure Ulcer Advisory Panel (NPUAP) system that contains 4 levels of pressure injuries from stage I (intact skin) to stage IV (full-thickness tissue loss).57 

Risk factors for pressure ulcers include immobility, reduced activity, decreased sensation, moisture from bowel and bladder incontinence, muscle atrophy, prolonged time, depression, smoking, and poor nutrition.58 

As prevention and management of pressure ulcers is a lifelong commitment for those with SCI or their caregivers, occupational therapy’s role may include education with daily skin inspection, keeping the skin clean and dry, avoiding excessive pressure or shearing, ensuring proper pressure relief techniques, prescribing appropriate equipment, a well-balanced nutrition, and early recognition and treatment.56 59  Adaptive equipment such as hand-held mirrors may help with skin checks. Further recommendations include bed positioning, using press-reducing beds and wheelchair support surfaces in addition to pressure relief strategies. Proper fitting clothes, hydration, avoiding sunburns, individualized equipment, avoiding excessive temperature, and quitting smoking may help. 60 15 

Osteoporosis and Bone Fractures

Osteoporosis can occur rapidly in the first 12-18 months after injury and continue for several years.38  Disuse may play a role in causing osteoporosis as well as poor nutrition, disordered vasoregulation, hypercortisolism, and endocrine disorders.61  As there is no standardized treatment for the management of osteoporosis in clients with SCI, pharmacological and rehab approaches have been reported.61 62  Non-pharmacological approaches include weight-bearing (standing), walking with orthotic aids, FES, and pulsed electromagnetic fields.61 62 63 64 

Heterotopic ossification (HO) is a frequent complication for clients with SCI and is characterized by the formation of new bone in soft tissue.65  The incidence ranges from 10-53%. HO is generally diagnosed 1-6 months post-injury and peaks at 2 months. Clinical findings include decreased joint ROM and swelling of soft tissues. Spasticity may increase HO development.66  Therapy goals may include maintaining proper positioning of joints such as the hips in bed and while sitting upright in the proper wheelchair. This can be achieved with passive stretching, ensuring optimal posture, and personalizing sleep.67  Maximizing range of motion, splinting, serial casting, and PNF to facilitate opposing muscle groups may be options before considering surgery.68 

Deep Vein Thrombosis and Pulmonary Embolism

Clients with SCI are at an increased risk of DVT and PE compared to the general population, with peak risk within 3 months after injury.69  Management of DVT prophylaxis include mechanical and pharmacological approaches. In one study of clients with SCI, mechanical prophylaxis, (e.g., SCDs) without anticoagulation resulted in a higher incidence of DVT compared to pharmacological methods.70  Compression devices are contraindicated for clients with severe arterial insufficiency. DVT and PE management includes visual skin inspection, e.g., twice a day for skin discoloration or breakdown. 71 

Overuse Injuries

Clients with SCI are at risk for overuse injuries. The shoulder is the most common location for overuse injuries. Occupational therapy practitioners can suggest alternatives to wheelchair pushing for exercise, practicing good body mechanics for everyday activities, stretching, strength training, aerobic exercise, and talking to a professional about new or increasing pain.11 

Temperature Regulation

Clients with SCI may be unable to regulate their body temperature. Occupational therapy practitioners can educate clients about drinking fluids before, during, and after exercise, and adjusting the amount of clothing as needed. Clients can use a cold towel or spray bottle to stay cool.11 

Sexual Dysfunction

The impact of SCI on sexual dysfunction depends on the degree and location of injury and gender.72  Women may have an impact on lubrication of the vagina, clitoral swelling, and the ability to achieve orgasm.73 74  Male libido and sexual activity frequency may decrease after a SCI.75 76  Similarly, females also have shown a decrease in sexual desire and activity after a SCI.77 78  Treatment include penile prosthesis or a vacuum erection device.79 80  Other treatments for men include injection of vasoactive drugs, the use of medications to improve erectile function, e.g., Viagra. Remediation for sexual dysfunction in women focuses on the improvement of the sexual response.

SCI has a larger impact on procreation for males than for females due to poor sperm quality and ejaculatory dysfunction.81 82 83  The ability of women to conceive after a SCI is thought to be unchanged.77  Choice of birth control is another factor as clients with SCI may have difficulty with management of contraception due to pelvic inflammatory disease or hand function and sensation, e.g., diaphragm or intrauterine device.84 

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