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SPINAL CORD INJURY: BALANCING PHYSICAL AND EMOTIONAL NEEDS
As rehabilitation begins (and especially in the current climate of shortened hospital stays and pressure to get patients home as quickly as possible), tension often exists between the goals of the rehabilitation program and the psychological needs of the injured person. Both you and the hospital staff share the same ultimate goal of maximizing your health and physical abilities, but you may be on a different psychological timetable.
Enthusiastic staff will present you with an array of therapeutic methods and technological supports to help you learn new ways of caring for yourself, performing daily living activities, and getting around (mobility is the technical term). They won’t hesitate to point out the areas in which you are permanently impaired (or at least for the foreseeable future) and to show you different ways of compensating for your lost abilities. You’ll be expected to take part in a rigorous program of exercise and self-care training (such as dressing or bathing), as well as planning for economic assistance, vocational retraining, and perhaps home modifications or personal assistance after you return home. You may be told to learn to rely on a wheelchair for mobility and not to count on walking again.
Yet at the same time, you are experiencing an emotionally traumatic event. You may be so overwhelmed by your feelings about the injury that you have difficulty participating in any activity. While the rehabilitation professionals urge you on to success in using your wheelchair, you may still be reeling from the loss of your ability to walk. While they are promoting compensatory measures, you may be hoping for a return to fully normal function. And while they are demanding action and learning, you may feel too depressed to get out of bed or too anxious and scared to face another day of therapy.
Your ability to make the best use of the inpatient rehabilitation period depends on at least a partial resolution of these tensions. Although everyone with a spinal cord injury experiences some emotional upheaval and loss, the effects of emotions on ability to function are not necessarily disastrous. Many people can focus on progress and the excitement of meeting new goals. Some view their disability as an opportunity for changing their direction in life or strengthening their character. Some people initially feel depressed and defeated in rehabilitation, whereas others see it as a battle they have just begun to fight. With some understanding of the range of feelings you can expect, how to talk them through, and how to get emotional support, you’ll be better equipped to begin your emotional adjustment and healing while you are going through physical adjustments and therapies.
*30/156/5*

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Other names: Meticorten

CHILDHOOD ASTHMA: HOLIDAYS AND STAYING AWAY FROM HOME
In my surgery and in the asthma clinic one of the factors that causes great concern to parents is whether it is safe to go on holiday. My answer is invariably ‘yes’, as it is important for a child with asthma to lead as normal a life as possible. I have a young teenage patient who is going to Kenya on her third safari this year! The only time I would recommend staying at home is if the asthma is in an unstable condition. If attacks are coming very frequently it is wise to have the treatment reviewed and appropriate action taken in the stable environment of your own home. Usually this does not take long and hopefully only means a postponement of the holiday rather than a total cancellation. For the vast majority of asthmatics it is perfectly safe to go away but as a precaution you must ensure that you have the means to deal with an attack if one should occur.
Most vital is to remember to take the medication with you! This may sound silly but for three years I worked in a hospital in Blackpool and we once calculated that over half our admissions in summer were people who had forgotten to bring their medicine with them. Inhalers are usually the last to be packed so they can be easily reached and it is amazing how often they are left behind on the bedroom table. Also make sure you have one or two spare inhalers with you as they do have an irritating habit of running out or being lost just when needed most. If you are staying in this country then an attack can almost be as easy to treat as at home. It is well worth remembering to check when you arrive at your destination as to where the local doctor is based and how to make contact in an emergency. Everyone in the United Kingdom is entitled to medical treatment wherever they are staying free on the N.H.S. If you are staying in a hotel – and this applies particularly in London – the staff will often call a doctor privately for you, and the visit plus treatment can take up most of your holiday spending money. You are within your rights to ask for an N.H.S. visit and you should always insist on this. A useful tip is to take your own doctor’s phone number away with you and give him or her a ring first for advice. It is not very often necessary to call a doctor out, especially if you follow the treatment plan.
The first night of a holiday is the one when your child is most likely to suffer an asthma attack as the change of environment throws up different kinds of allergens and also there is all the excitement. So be organized and unpack the medication before you retire to bed.
If you are travelling abroad the situation is slightly more complicated, though if you are well prepared you should have little trouble. First, before you go, make sure you have adequate medical insurance just in case you need it. If you are going to the United States also ensure you have a credit card with sufficient reserve funds on it, as often the hospitals over there want the money before they will give the treatment. The last thing you want at that time is to have the stress of ringing insurance companies to obtain a cash advance.
*64/211/5*

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CAUSES OF CHRONIC BACK PAIN: LUMBAR STENOSIS
Another cause of chronic back pain is lumbar stenosis, a narrowing of the spinal canal that contains nerve roots coming from the spinal cord. It causes pressure on the nerves and, in many cases, pain is felt in both legs when the patient walks or engages in other mobile activity.
For people with lumbar stenosis, the pain often stops when their walking stops. Over time, the distance they can walk before they feel pain becomes shorter and shorter. This problem commonly happens in people with arthritis in the lower back, especially those with osteoarthritis.
We recently saw a 67-year-old woman who had felt pain in the lower back over the past year. She felt pain when she walked, and it traveled down the back of both legs. She found that when she walked a few blocks the pain started, but it stopped quickly when she rested. She was bothered by the fact that during the past year she had become able to walk only shorter and shorter distances. She had been very active and the problem was limiting her travel and volunteer work.
Magnetic resonance imaging (MRI) showed that she had] lumbar stenosis. After surgery to remove the bone and other tissue causing pressure on the nerves, her pain was relieved and she is now walking without limitations.
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LIPID OR CHOLESTEROL-LOWERING DRUGS TO TREAT AFTER CORONARY ARTERY BYPASS SURGERY
Reductase Inhibitors – Statins
Probably the most commonly used drugs to lower lipids (cholesterol) are the so-called reductase inhibitors (such as simvastatin or pravastatin). These drugs inhibit the synthesis of cholesterol and lead to significant lowering of total cholesterol and LDL cholesterol. They are always used in combination with a low-fat, low-cholesterol diet and they may be prescribed in combination with other drugs. Their adverse effects include occasional abdominal discomfort and (rarely) liver damage and muscle damage which may produce a variety of symptoms and may also be detected by blood tests.
There have now been a number of large studies which have demonstrated the great effectiveness of reductase inhibitors in lowering total cholesterol and LDL cholesterol, also in raising HDL cholesterol, reducing need for further interventions and further operations, reducing hospital admissions, reducing later heart attacks and improving life expectancy. It appears that these very considerable benefits can be achieved with a very small risk of adverse effects and hence with very considerable safety.
Bile Sequestrants
The other major group of lipid-lowering drugs, which are not absorbed into the body, are the so-called bile sequestrants (Cholestyramine, Colestipol and others). They absorb bile salts which are then passed in the motions. The deficiency of bile salts which they cause leads the liver to produce larger amounts of bile salt. These are produced by using up cholesterol. Thus, indirectly, cholesterol is excreted. The liver absorbs more cholesterol from the blood to achieve this end, thereby lowering the blood cholesterol level. The adverse effects of these drugs are very troublesome to some patients. They may cause abdominal distention, a sense of bloating and constipation. Other people, however, can take them without any problems.
Other Lipid-lowering Drugs
There are several other drugs which are used for particular lipid problems. Examples include treatment for both high LDL cholesterol and triglycerides or for both low HDL cholesterol and high triglyceride.
*15/160/5*

Indocin (Indomethacin)

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Other names: Indocin Cr, Indocin SR

SPINAL CORD INJURY: PHYSICAL CHANGES AND LIMITATIONS
At this stage in your recovery, awareness of physical changes and limitations is a primary concern. You may not be able to walk to the bathroom, tie your shoes, or eat your food without assistance from another person. Like Jim, you may not be able to walk at all. If your cervical spine is damaged, your arms and hands may be weak or paralyzed. You may not be able to turn over in bed, feed yourself, or hug your child.
For many people with spinal cord injury, being unable to walk is the most frustrating part of their disability. Persons with paraplegia can sometimes learn to walk with crutches and metal braces, but this is not for everyone. “Brace-walking” may require weeks and weeks of intensive physical therapy, because it is quite different from “normal” walking. It requires a whole gamut of new physical skills, and it can be slow and extremely strenuous. Even with sophisticated braces, lightweight crutches, and extensive physical therapy, some individuals with paraplegia find that walking with crutches and braces is simply too difficult, too strenuous, and too slow for use in the real world.
Individuals with injury at a very high level of the spinal cord may need to use a mechanical ventilator (respirator), because the muscles that control breathing are partially paralyzed. Some need special help to cough or clear fluids from the throat and chest. Some people have difficulty communicating because the ventilator and tracheostomy tube interfere with speech, and paralysis of the arms prevents them from writing. Weeks of speech therapy and specialized tubing and air valves may be needed to learn to talk again.
Depending on the type of spinal cord damage, you may have mild or profound changes in sensation. If you are quadriplegic, you may be unable to regulate your body temperature, perhaps experiencing fluctuations from hot to cold (even developing a fever in hot weather) and having to rely more on air conditioners, heaters, blankets, and so forth. You may experience bowel or bladder incontinence, inability to empty your bowel or bladder spontaneously, or a combination of these, requiring bladder catheterization or a bowel program to maintain healthy elimination. And your sexual function and sensation may be affected. Men may have changes in their ability to have an erection, experience sexual pleasure, or ejaculate. Women’s menstrual cycles may be temporarily interrupted, although menses and fertility generally return after some months, and they may have changes in genital sensation and the ability to lubricate or have an orgasm.
Rehabilitation is the period in which you confront and come to understand the full range of your limitations, disabilities, and complications. This is one of the most physically difficult tasks a person can undertake. It is also emotionally disruptive, intellectually demanding, and a challenge to your personality, social skills, and spiritual beliefs. One of the keys to success is being able to cope with a variety of emotional responses while simultaneously focusing your energy on physical recovery.
*29/156/5*

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SPINAL CORD INJURY: EMOTIONAL REACTIONS FOR YOU AND YOUR FAMILY
When the extent and consequences of your spinal cord injury are explained to you and your family, individual reactions will vary greatly. Some will react with tears, others with profanity, frozen shock, a feeling of emptiness, saintly acceptance, humor, stoic resolve, complete denial, anger, confusion, or a feeling that life is unfair. Many other feelings and consequent behaviors, some seemingly bizarre, can also be experienced. Don’t be concerned if you and your family are “all over the map” in your reactions to your spinal cord injury. Whatever feeling erupts or seeps through is a normal reaction to one of life’s abnormal events. You and each family member are entitled to feel however you do. This is to be expected, because each of you has different expectations, coping experiences, and relationships. Expressing your feelings may help to unload that big bag you feel is weighing you down. Paradoxically, you sometimes need to give yourself permission to lose control in order to maintain control.
At this early stage, family members need to accept and support each other wherever they are emotionally. You are experiencing one of life’s unplanned wilderness experiences; you are a frontiersman. You have no map for this new phase of life. You and those around you need to express all your feelings, including feelings of uncertainty. Doing so will bring much relief, and then you can concentrate your energy on the next difficult steps toward your recovery.
*26/156/5*

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SPINAL CORD INJURY: REHABILITATION
Jim was feeling on top of the world as he drove down the highway to a new job site. He was twenty-eight, married a few years, and enjoying success in his job as foreman in a large construction company. He loved working outside, using his physical strength and mental abilities at the same time, and being around people. He had dreams of owning his own company, starting a family, vacationing in the Rocky Mountains.
Jim was almost at his exit when he noticed a truck behind him coming close a little too fast. He figured it was just a case of tailgating intimidation, but before he could change lanes, the truck smashed into his car. Jim lost consciousness. When he came to, he heard ambulance sirens and felt pain in his neck. His legs wouldn’t work. He was trapped in a crushed car and had to be extracted by the Jaws of Life machine.
At the hospital Jim was found to have an incomplete cervical spinal cord injury causing significant weakness in both legs. After his neck was stabilized surgically, he was transferred to an inpatient rehabilitation facility. He couldn’t walk and had to use a wheelchair to get around. He couldn’t urinate normally and had to be catheterized periodically. His neck hurt, and he couldn’t lift anything heavy. He noticed that he didn’t have “morning erections” any more, and he wondered if his sex life was over. He was pretty sure he could never return to his construction job.
Jim’s friends were working and didn’t have much time to visit. His wife came every day, but she couldn’t sleep at the rehabilitation facility. They had no privacy, and Jim couldn’t share his fears and frustrations with her. He was humiliated by his dependence on others, but at the same time he was lonely and felt isolated from people. He wanted more than anything to get well, to walk again, but at times he was so overwhelmed by anger, grief, embarrassment, and fear that he had to force himself to do his physical therapy.
Jim felt his dreams were dashed. It would be easy just to give up. Who would care anyway, when he was so useless to everyone?
After emergency treatment and acute hospitalization, most people with severe spinal cord injury spend some time in an inpatient rehabilitation program. During this period, further assessment is done to determine the effects of the injury on physical function. Doctors, nurses, physical and occupational therapists, and other staff members work with the injured person to prevent complications, maximize remaining physical abilities, develop techniques to compensate for lost abilities, and develop proficiency in the use of assistive devices (such as wheelchairs, braces, and splints). At the same time, family and other caregivers are taught how to assist the injured person in areas where he or she cannot become completely self-sufficient.
The inpatient stay generally ends when the injured person has learned the skills and obtained the equipment needed for living at home. After discharge, outpatient physical therapy and other types of treatment may continue for a brief time or an extended period, depending on individual needs.
*27/156/5*

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SPINAL CORD INJURY: PARTICIPATING IN YOUR OWN CARE
In many ways you may feel like a passive bystander during your acute hospitalization, and in some ways you are. There you are, immobilized cared for, having things done to you and for you. Now it is time to begin investigating what medical choices you and your family can make.
Although you may seem to have few choices, in reality you are always the arbiter of your treatment. Remember that you, the patient, are also the consumer of services and have the obligation to understand the treatment and to determine whether the service is satisfactory. Don’t hesitate to ask questions about your care, and ask again and again if you don’t understand the answers. You are very dependent on your doctors and nurses at the beginning of your recovery, but you’ll gradually become a partner in the management of your own care. Again, remember that the hospital staff is working for you and it is their job to take care of you both emotionally and physically. You have the final say about what tests you undergo and what procedures are performed. If you do not understand why a test is necessary, ask for an explanation.
*24/156/5*

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SPINAL CORD INJURY: HOW CAN MY FAMILY HELP DURING THE ACUTE HOSPITAL PHASE?
In the initial stages of your hospitalization, how can you and your family take some control of the situation? Here are some suggestions for how family members can assume responsibility for supporting you (and each other) and for seeing that you get the best care.
1. Form your own family team, with each member responsible for information and input about a certain aspect of your care. For instance, one member could be with you each morning to talk with the doctors on their rounds. Another member could talk with rehabilitation centers about the second stage of your recovery, to get the information necessary for making the best decision.
2. Ask questions until you really understand procedures, medications, and any side effects of treatments and medications. This is how you’ll become an informed consumer and a partner in the decision-making for your care.
3. Ask family members to accompany you to therapies to observe, assist, and give you feedback. They can reinforce your progress and will also be better prepared to help you with exercises when you return home.
4. Advocate for your own care. If your voice is not heard, ask family members to speak up for you.
5. Ask family members to listen to you and understand your observations and needs. And listen to your family. This will keep you attuned to one another’s emotional states so that you can support each other when needed.
6. If you have questions or concerns that are not being answered or addressed to your satisfaction, request a meeting with the physician. In a rehabilitation hospital or in an acute care setting that uses a team approach to patient care, you can request a Case Conference. This is a meeting that pulls together all the medical personnel involved in your care. You and your family will be included in the conference so that you can hear the different strategies being integrated to form the core of your care. Carefully consider every aspect of your care or prognosis so that you can ask just the right questions.
*25/156/5*

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PEOPLE WITH SPINAL CORD INJURY IN HOSPITALS: SCHEDULES AND TIME MANAGEMENT
Now that you have some grounding in the medical and physical realities of spinal cord injury, what can you expect as a patient in a hospital? How do you deal with medical personnel? What are their roles?
As a patient in a hospital, you have entered a new world. It consists of predetermined schedules for visitors, therapies, meals, and waking and sleeping. It has a defined hierarchy of authority. It gives you more (or less) personal care than you probably expect, and minimal privacy.
Schedules and Time Management
First, let’s consider the hospital timetable. Hospitals have their own schedules. You’re awakened early and have your meals early. You usually order your meals from a limited number of offerings. Technicians may come into your room at any time to give you a variety of tests, or you may be removed from your room for tests or therapies. Visiting hours may be set, and at some hospitals, phone service is cut off early in the evening. Just when you get the schedule under your belt, a weekend arrives and the whole itinerary changes!
You may find the disruption of some routines and the rigidity of others disorienting during your first weeks in the hospital. You may also experience time as compressed or slowed down, because many tasks will take much longer to accomplish soon after your injury. Yet your situation may seem to change every day, as early recovery unfolds.
*22/156/5*

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PEOPLE WITH SPINAL CORD INJURY IN HOSPITALS: DOCTORS AND NURSES
Doctors make their rounds at fairly specific times. Because doctors are not mind readers, make sure you have your questions or concerns at hand when they visit. Some patients are reluctant to ask questions or present problems. Remember that your concerns help the doctors to focus on your specific issues and to have a more informed view so that they can make more educated decisions.
You’ll interact with and receive care from a number of doctors, including orthopedists (specialists in the muscular and skeletal systems), neurosurgeons (surgeons who operate on the nervous system), and physiatrists (specialists in physical rehabilitation, who usually lead the rehabilitation team). You’ll encounter doctors at various levels of training and experience, especially if you are in a teaching hospital. After graduating from medical school, doctors do a residency for several years. During this time they learn to practice a specialty and are called residents. First-year residents are sometimes called interns. Residents are on call in the hospital at all times, especially at night!
Nursing care is an especially important consideration for people with spinal cord injury, because the care required is usually more intense and frequent than for other patients. The nursing staff includes individuals with differing levels of training and experience. Registered nurses (RNs) usually have the equivalent of a bachelor’s degree and carry management responsibility for the floor or ward. Licensed practical nurses (LPNs) have graduated from shorter courses and do much of the hands-on work. Other members of the nursing staff (such as aides, assistants, and technicians) have less training and carry out most of the bathing, toileting, and feeding duties.
Nursing care has changed over time, partly as the result of cost-cutting in this era of managed care. You can no longer expect the comforting extras, such as a back rub at night. However, your relationship with your nurse is still likely to be one of your closest connections with hospital staff, because he or she will provide so much of your personal care. Your nurse can be a good source of information about various aspects of spinal cord injury.
*23/156/5*

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Other names: Emulgel, Voltaren Xr, Voltarol

CORONARY BYPASS SURGERY: DOUBT AND INSECURITY
While you are in hospital, doctors and other team members will explain to you what has happened. They will discuss coronary heart disease and its causes with you and you will learn about the processes of mobilization and physiotherapy. However, when you are in hospital recovering from a big operation, it may be difficult to take in all this information. Your mind is probably on other things. You may be anxious and insecure about your recovery, about possible disability, about the operation failing or heart problems recurring, about what the future may or may not hold. We all know that death associated with surgery is always a possibility, no matter how remote. Even if you have been told that only one patient in 100 dies, you may worry that you could be that one.
The possibility of unsuccessful surgery
We know that the operation may occasionally fail. This may be because the grafts or the coronary arteries themselves are unsuitable for the operation to be successful. Your surgeon can only find this out once the chest is opened and the vessels are inspected. It is also reasonable to think that something may go wrong during the operation. A patient could suffer from a heart attack while undergoing surgery but this is very rare. In some cases, the operation is successful in relieving angina but leaves you partly disabled by shortness of breath or some other problem.
Although these chances are small, it is not unreasonable to think about the possibility that you may not be able to work in future, or support yourself or your family, or lead a normal life. Indeed, it would be a strange person who does not have such thoughts. These thoughts may linger and concern you for some time after the operation, until your recovery is complete.
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COMMON COMPLICATIONS OF SPINAL CORD INJURY: URINARY TRACT INFECTION, LOSS OF MUSCLE TONE
Urinary Tract Infection
Some individuals with spinal cord injury are prone to developing urinary tract infections (UTIs), for two reasons. First, the nerves that signal when the bladder is full and those that control the sphincter muscles between the bladder and the urethra can be damaged by the injury. When the bladder does not empty completely, there is a greater risk of infection. Second, the use of a urinary catheter can introduce bacteria into the bladder. Infections can be minimized by proper bladder care and the use of sterile catheters, but may occur despite your best efforts. A UTI requires treatment with antibiotics, usually for about a week. A mild UTI involves only the bladder and typically responds to oral antibiotics. A severe UTI with fever may involve the kidneys and can cause serious kidney damage if not treated aggressively. It usually requires IV antibiotics and a short stay in the hospital.
Loss of Muscle Tone
Damage to the spinal cord itself usually causes spasticity, an increase in muscle tone, as noted above. Damage to the cauda equina (the bundles of nerve roots located below the spinal cord but inside the lower vertebral column), however, usually causes decreased muscle tone. (Muscle tone can also decrease in some cases of true spinal cord injury.) When tone is reduced, the muscles become flaccid and may atrophy (lose bulk). Flaccid legs can become very thin and bony. Loss of the cushioning normally provided by muscle increases the risk of developing pressure sores on the skin.
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COMPLICATIONS OF SPINAL CORD INJURY: MILD HEAD INJURY
Traumatic injuries to the spinal cord are sometimes accompanied by other injuries, such as broken bones, damage to internal organs, or mild head injury. The same jerking or compressing force that damaged the spine may also cause trauma to the head. For severe brain injury, resulting in a coma or significant impairment of mental function, the course of treatment and subsequent rehabilitation are quite different from those for spinal cord injury alone.
Sometimes, because the primary focus of treatment is on the spinal cord injury, a mild injury to the head may be undiagnosed. It is useful to be aware of symptoms that can result, from a mild head injury, so that you can report them to your doctor and get appropriate treatment.
Symptoms of mild head injury include dizziness, headache, difficulty remembering recent events, and poor concentration. Mood swings and increased irritability or emotionality (for example, crying, laughing, or becoming angry more readily than usual) can also occur. Most symptoms get better spontaneously over time, but if your injury is diagnosed early your rehabilitation program can be better tailored to help you learn and to avoid unnecessary frustration. Medications may be helpful to lessen emotional swings and irritability and to improve concentration.
*21/156/5*

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COMMON COMPLICATIONS OF SPINAL CORD INJURY: SPASTICITY
Spasticity, or abnormally increased muscle tone, affects most individuals with spinal cord injury at the T12 level or higher. It can cause a variety of problems, including muscle stiffness, sudden involuntary contraction of muscles (spasms), or rhythmic repetitive muscle jerks. These uncontrolled movements may be jarring, annoying, and painful, and may interfere with positioning and transfers (from wheelchair to bed, wheelchair to car, and so forth) or cause falls from the wheelchair.
Several drugs are effective in treating spasticity. Baclofen (Lioresal), diazepam (Valium), tizanidine (Zanaflex), and dantrolene sodium (Dantrium) are the most common. However, some of these drugs can cause drowsiness or a “spacey” feeling and can interfere with driving or work tasks. For this reason, and because spasms are not necessarily dangerous, some people with spinal cord injury choose not to use medicine for spasms. Some learn to control spasms by changing position, applying pressure to a limb, or other physical means. A few people can learn to harness spasms for useful purposes, intentionally eliciting particular spastic movements that help with pressure releases, transfers, or other functional activities.
*16/156/5*

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COMMON COMPLICATIONS OF SPINAL CORD INJURY: PNEUMONIA AND PAIN
Pneumonia
In people with spinal cord injury, difficulty coughing (and thus clearing the lungs), prolonged bed rest, and decreased mobility all contribute to an increased risk of developing pneumonia. Several treatments are used for patients who contract pneumonia. A combination of antibiotics and vigorous respiratory therapy is the first choice. The respiratory therapist pounds with both hands on your chest or back while you are tilted at an angle to help drain the affected lobe of the lung. This is called postural drainage. Inhalants are also used to help dilate and clear airway passages.
People with quadriplegia usually need assistance with coughing to prevent or treat pneumonia. In a technique known as quad coughing, the caregiver pushes on your upper abdomen while you cough, and this helps to expel air forcefully from the lungs.
Pain
Most individuals with spinal cord injury have to deal with pain at some point during the recovery process. For most, the pain is transient and is associated with the initial trauma (for example, the pain caused by a vertebral fracture or an associated injury). This pain may persist for weeks, but it generally is responsive to traditional analgesic medications (painkillers) and resolves over time. However, many individuals have chronic pain after spinal cord injury that is disabling and difficult to treat. This dysesthesia, or neurogenic pain, is caused by abnormal processes inside the spinal cord, not by a pain-inducing stimulus outside the body. Neurogenic pain is particularly frustrating because it commonly affects an area of the body that is anesthetic?that is, a region that has no sensation whatsoever for external stimuli. Individuals with neurogenic pain describe it as feeling like burning, tingling, or an electric shock, sometimes very intense. They often say that it’s unlike any sensation they have experienced before.
Neurogenic pain is difficult to treat. It sometimes responds to traditional analgesic medications, but it may be resistant to these. Narcotic painkillers are sometimes necessary but are not always effective. Several medications not usually classified as painkillers may help with this sort of pain. Certain antidepressant drugs, particularly tricylic antidepressants (such as amitriptyline), have been used successfully in treating neurogenic pain. The other medications with proven efficacy for neurogenic pain are certain antiepileptic drugs, especially Neurontin (gabapentin). Psychological approaches, such as relaxation and imagery training, can also be useful for dealing with chronic pain.
*17/156/5*

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COMMON COMPLICATIONS OF SPINAL CORD INJURY: TEMPERATURE REGULATION
Internal body temperature regulation is another major concern for people who are quadriplegic. Spinal cord injury affects the two mechanisms for maintaining body temperature: shivering, which generates heat, and sweating, which cools the body. (You can still sweat above the level of the injury, because the spinal cord can communicate with the skin above this level.) Having lost these mechanisms of temperature control, people with quadriplegia cannot regulate their internal body temperature. They are dependent on external temperature control, a condition called poikilothermia.
If you have quadriplegia you will need to be vigilant in monitoring your body temperature and will need to rely more on clothing, covers, and heaters to stay warm. When the environment is hot, you’ll develop a high temperature. Fever does not necessarily indicate infection for a person with quadriplegia. It may mean that a blanket needs to be removed or the body cooled down. Body temperature must always be carefully monitored when out in the sun. Similarly, exposure to cold may cause a drop in body temperature. Without the ability to shiver, the body can’t warm itself. You will need to anticipate clothing needs carefully when going outside in cold weather. If you lack sensation in your feet, they must be adequately protected by warm boots to prevent frostbite.
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COMMON COMPLICATIONS OF SPINAL CORD INJURY: AUTONOMIC DYSREFLEXIA
In people who are quadriplegic, autonomic dysreflexia (also called hyperrefiexia) indicates that the sympathetic nervous system, and thus blood pressure regulation, is out of control. It occurs only when the level of spinal cord injury is above T5 and the sympathetic nervous system – primarily responsible for controlling blood flow and blood pressure – loses important connections to the brain.
An attack of autonomic dysreflexia typically causes a severe headache coupled with very high blood pressure. Other symptoms can include blurred vision and sweating, flushing of the skin and goose bumps above the level of the spinal cord injury. It can result from almost any noxious stimulus to the body below the level of the injury.
Autonomic dysreflexia can be a medical emergency, sometimes resulting in a stroke if the blood pressure is not brought under control. Once it starts, an attack of autonomic dysreflexia is best treated by finding and removing the cause. When the cause is eliminated, the attack usually resolves almost immediately. The cause of an attack is usually one of the following:
1. Over-distention of the bladder, caused by an accumulation of too much urine. This is treated by draining the bladder.
2. Stool retained in the lower bowel. This is treated by eliminating the fecal material, which may require use of a suppository.
3. Pressure on the skin. Intermittent pressure releases will alleviate this problem. Choosing looser clothing that does not exert pressure is also recommended.
Other causes include trauma (for example, a broken bone), infection, severe menstrual cramps or contractions during labor, and temperature changes. Maintaining a reliable bowel and bladder program and protecting the skin can help prevent episodes of autonomic dysreflexia. If the cause of the dysreflexia cannot be found or eliminated, medications are required to lower the blood pressure.
*19/156/5*

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COMMON COMPLICATIONS OF SPINAL CORD INJURY: LOW BLOOD PRESSURE AND DECUBITUS ULCERS
Low blood pressure
Normal methods of maintaining blood pressure are sometimes damaged by spinal cord injury. Blood pressure may drop suddenly when moving from a lying to a sitting position, especially during the first few weeks after the injury. This phenomenon, called orthostatic hypotension, is what Franklin experienced when he got dizzy the first few times he tried to sit up.
To prevent a substantial drop in blood pressure when sitting up, you may need to wrap your legs or use an elastic belt around your abdomen in order to eliminate pooling of blood. Rising slowly also helps. At first you may feel faint and may even pass out, but this will improve with practice. Often, as in Franklin’s case, the problem is eliminated spontaneously with regular sitting and activity. For those with severe problems sitting up, a tilt table is sometimes useful. Faintness and dizziness on sitting up can recur whenever you’ve had prolonged bed rest.
Decubitus Ulcers
Pressure sores, or decubitus ulcers (also known as bed sores), develop on the skin in areas subjected to prolonged pressure that temporarily decreases the blood flow to that area. The skin can easily recover if the pressure is relieved, but when pressure persists, pain and eventually irreversible damage can result.
Decubitus ulcers are a potential problem in the absence of normal sensation in the skin, because the individual does not feel discomfort after putting pressure on one area for too long. The first approach to preventing decubitus ulcers when you are confined to bed is to change position every two hours, turning onto the side or onto your back. Once you begin sitting up in a chair, regular pressure releases will get pressure off the sensitive areas. These will become part of your daily routine for the rest of your life. The several kinds of pressure releases relieve the pressure of body weight from particular areas of skin.
A common type of pressure release for those who can use their arms is a wheelchair pushup, using both arms to lift your body above the seat for about a minute to relieve pressure on the buttocks. If you cannot use your arms, pressure can be relieved by using an electric wheelchair that automatically tilts back your upper body and thus shifts your weight. To prevent decubitus ulcers from forming while you sleep, you may need to change position every few hours. This may require assistance from another person.
*15/156/5*

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Other names: Afeditab Er, Procardia

LDL CHOLESTEROL
LDL cholesterol is the component of the body?s cholesterol management system that has earned the description of “bad cholesterol”. It is LDL cholesterol that comes from animal fats, crystallizing into artery walls to attract calcium and cause hardening of the arteries.
To lower LDL cholesterol and decrease chances of heart disease and strokes it is necessary to avoid milk and fatty cuts of meat and poultry. The old adage that says if it lives, walks on land and ends up in the diet it should be largely avoided, still holds true.
It is possible to have a low animal fat diet and still eat meat if such meats are lean and poultry is eaten without its skin. Wisdom dictates that all offal be avoided including sausages, brain, liver, kidneys and mince meat. Tea bone steaks are rich in fat and are not missed if excluded from the diet. Dairy products can be consumed via skim milk plus cheese, yoghurt and even ice cream come in reduced fat varieties. Prawns and avocadoes are back on the list of foods that can be eaten without fear of promoting cardiovascular disease.
Home Remedies
A very senior cholesterol authority in the form of the Framingham studies, Dr. Castelli says that the average family has a staple menu that consists of only 11 recipes. All a family needs to do for its members to live an extra ten years is to change those ten recipes. Cuisines that are low in LDL cholesterol and relate to a lower incidence of heart disease in their home countries are Chinese, Japanese, Italian, Greek and seafood. The change of one recipe a month selected from these cuisines after due deliberation is worth an extra ten years of healthy lifespan.
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