Autonomic Dysreflexia

What is autonomic dysreflexia?

Autonomic dysreflexia is a condition that crops up due to a spinal injury. AD shoots up the blood pressure to a treacherously high level and if left unattended, it can lead to stroke, seizure or cardiac arrest or death. The occurrence of AD happens if the injury is above the T6 level and unexpectedly occurs if the level is below T10. The severity depends on the injury level. Higher the injury level, more severe will be the cardiovascular dysfunction.

The normal systolic blood pressure will be of the range of 90 – 110mm Hg for people with spinal cord injuries (SCI) above T6.

• In adults with AD, the blood pressure will be range about 20mm to 40mm Hg above the baseline.
• In children with AD, the blood pressure will be 15mm above the baseline.
• Adolescents with AD, the blood pressure will be 15mm to 20mm above the baseline.
• Patients with AD have a pulse rate of lower than 60 beats per minute.

What is an autonomic nervous system?

The autonomic nervous system of the spinal cord usually works on the regulation of blood pressure, body temperature, heart rate, breathing rate, defecation, sexual response, metabolism, digestion, and water-electrolyte balance.

The ANS has two branches:

• Sympathetic autonomic nervous system (SANS)
• Parasympathetic autonomic nervous system (PANS)

The SANS and PANS function in opposite ways to maintain the balance of the involuntary functions in your body (the SANS overreacts, the PANS can compensate for it). Some of the functions of the SANS include a rise in the blood pressure, enabling they blood vessels to pump more blood and on the other hand, the PANS normalize the heartbeat and blood pressure.

What happens to the ANS in case of autonomic dysreflexia?

In the case of AD, there is impairment of the ANS. There is an intervention in the functioning of both the sympathetic and the parasympathetic nervous systems. In other words, the body’s SANS overreacts to the stimuli and on the other hand, this overreaction is not effectively stabilized by the PANS.

Due to the spinal injury, the signals from the lower body produces can’t get past the spinal injury and reach the brain for a further response. Even though the SANS and PANS continue to operate and generate signals at regions below the spinal injury, the brain will be unable to respond. It is like intervention/barricades on the roads where vehicles cannot get past the road to reach a certain destination. Finally, the SANS and PANS become unmanageable.

Common Causes

Anything that is painful or uncomfortable can give rise to autonomic dysreflexia. It can result in spasms or blood vessel constriction thereby increasing the blood pressure. The normal systolic blood pressure for an individual with spinal cord injury above T6 would range from 90 – 110 mm Hg. If the blood pressure increases to 20 – 40 mm Hg above the reference range, such patients are more prone to autonomic dysreflexia.

Some of the common causes of AD rising from the bladder, bowel and the skin are listed here:

• Bladder:
  • Hyperactive bladder
  • Urinary tract infection
  • Kidney stones
  • Urological procedures
  • Inserting a catheter (a thin tube of medical grade material)
• Bowel
  • Constipation
  • Fecal impaction (hardened stool that’s stuck in the rectum or lower colon due to chronic constipation)
  • Rectosigmoid gaseous distension (expansion of the abdomen due to the accumulation of substances such as gas or air and fluid)
  • Rectal irritation (for example, enema, etc.)
  • Hemorrhoids (or piles – a condition of painful swellings in the rectum)
• Skin
  • Ingrown toenail (side of the toenail grows into the flesh of the toe)
  • Burns
  • Pressure areas
  • Tight clothing
• Others
• Fracture (complete or partial break in the bone)
• Epididymoorchitis (a painful swelling of the tubes in the testis)
• Distended stomach (a swollen belly)
• Sexual intercourse
• Childbirth
• Severe menstrual cramps

Immediate measures

• Find out about the patient’s medical history and call for help.
• Elevate the patient’s head by making him/her sit upright and lower the legs.
• Avoid pressing on the bladder.
• Loosen all the tight clothing and apparel accessories.
• Monitor the blood pressure every 2 to 5 minutes.
• With some help, remove all the unpleasant stimuli (bowel, bladder, skin, clogged catheters, and other symptoms).

Diagnosis

There is no specific diagnostic test for AD but the functioning of the autonomic nervous system is monitored. The doctor will carefully observe the autonomic functioning patterns to conclude on whether or not a patient has AD or not. Common tests involve monitoring the heart rate, monitoring of the blood pressure, monitoring of the sweat pattern, ultrasounds, urine analysis, and bladder function tests. A low sympathetic activity does not result in AD but a high sympathetic activity can result in AD.

Treatment

The treatment differs from the kind of symptoms exhibited by the patient. Medications are used to treat blood pressure problems, stomach and esophageal problems, urinary assistance, bladder emptying medications, and medications to treat sexual dysfunction are used to treat AD.

Can it be prevented?

AD can be prevented and cured if we maintain a certain regime with respect to our diet, clothing and skin care. You can follow the plan given below.

• Follow a good bowel and bladder management program strictly.

• Consume fiber based foods and fluids.

• Maintain a thorough skin check on a daily basis to check for any symptoms. Avoid skin sores and also check for ingrown toenails.

• Avoid wearing tight clothes. Ensure that your apparel and accessories fit you comfortably.
• Monitor body temperature regularly.

• Improve the management of the urinary catheters.

Dietary and lifestyle changes

Diet plan must be tailored to take care of all the triggers to bring down AD to a manageable level. It must be modified in such a manner that it meets the basic body needs, especially for those associated with the trigger of AD.

• For good skin care, enroll in a diet plan that is rich in vitamins (vitamins A and C) and minerals such as zinc and iron, along with ample calories, protein.
• Constipation can be treated with the use of laxatives or stool softeners. The inclusion of dietary fibers can also aid better bowel movements.
• Conditions such as obesity must also be treated.
• Consumption of high-fat foods, caffeine-containing beverages, mint, drinks, and citrus or tomato products must be limited.
• It is advisable to eat small, frequent meals instead of a few large ones.
• Maintaining a good posture while eating, sitting upright, and avoiding crouching forward is advisable.
• Elevating the head of the bed while sleeping is helpful.
• Smoking, indulging in late-night snacks and regular consumption of fatty foods must not be consumed.

Beware of osteoporosis 

Calcium aids in muscle flexibility, nerve reaction, heart function, and blood clotting. Osteoporosis mostly occurs due to a reduction in bone strength. The bone density decreases and they tend to break.

How to prevent spinal injuries and conditions?

Physical activities are restricted in patients suffering from spinal injuries. In such cases, maintaining good bone health becomes a little difficult.

• You can include the food sources such as milk, cheese, yogurt, broccoli, kale, spinach, egg yolks, collard greens, dried figs, blackstrap molasses, legumes, dried beans, peas, tofu (if calcium is added in processing), salmon and sardines with soft bones included and calcium-fortified juices and cereals.
• Some of these foods also contain vitamin D to enable calcium absorption. You can also get your share of vitamin D from exposure to the sun.
• Care must be taken to monitor the calcium levels as the calcium can get resorbed from the bones in the paralyzed part of the body. The calcium resorption can shoot up the calcium levels in the bloodstream eventually resulting in nausea, kidney stones, and bone formation disorders. Use calcium and vitamin D pills only with the approval of the doctor.

References