Common Medical Issues in Pediatric Rehabilitation-Part II

Posted by Nurse Linda in Life After Paralysis on January 27, 2021 # Health

girl in classLast month, was a presentation of issues common in pediatric spinal cord injury that included issues and treatments for mental health, bladder, bowel, skin and respiratory issues. This month is a continuation of the issues and treatments in cardiovascular, metabolic, nervous and infection. These are some of the more common issues, not an inclusive set of concerns.

Cardiovascular There are several issues for the cardio (heart) and vascular (blood vessels) system. The autonomic system controls the automatic functioning of the body. Anything that occurs in the body without our thinking about it is controlled by the autonomic nervous system. Therefore, several issues can occur.

Last month, noted was the autonomic nervous system's effect of slowing the bowel and bladder sphincter coordination. Slowing of the heartbeat, called bradycardia, is another example of how the autonomic nervous system is affected by SCI. These are examples of the many disruptions that can occur in the autonomic nervous system. Problems in the autonomic nervous system are called dysautonomia or autonomic dysfunction.

Orthostatic hypotension is an issue with the autonomic nervous system. When a person sits up, the autonomic nervous system will signal for blood vessels in the lower body to constrict or become smaller; the heart will pump a bit harder, all in an effort to send increased blood to the brain, so you do not pass out.

In spinal cord injury, this message is not processed, and these functions do not occur. The drop in blood pressure to the brain when the upper body is being elevated is called orthostatic hypertension, which is a sudden and profound lowering of blood pressure. Lowering the head can relieve symptoms. It can be treated by increasing fluids as allowed by the bladder program, by wearing compression clothing such as an abdominal binder and compression stockings. Getting up slowly to allow more time for the body to compensate is also a strategy. Over time, the body accommodates this disruption, but as your child has a growth spurt, you may encounter it returning at different times.

Sudden or quickly lowered blood pressure can also occur with suctioning and during the bowel program. In these cases, the compensation of blood flow regulation becomes an issue. Strategies to treat these forms of autonomic dysfunction in the respiratory system include lower level suctioning, changes in suctioning equipment and more frequent breathing treatments. For the bowel program, rectal analgesic ointments can be used, or changing to a less irritating suppository may benefit the situation. Sometimes, the suppository used can be cut in half or quarters. Be sure to cut the long way of the suppository so the maximum benefit of the suppository can be gained as it is placed on the wall of the bowel. Also, remember digital stimulation in the bowel program should be performed with generous lubricant and in a slow, gentle manner. The goal of digital stimulation is to relax the rectal sphincters, not a sharp action that tends to close them.

Veins can be traumatized easily with movement or spasms. Clots in the veins are called deep vein thrombosis (DVT). Clots prevent blood from passing through a vein, which slows blood flow. The entire clot or a part of the clot can break off and travel to other parts of the body, including the brain resulting in stroke or the lungs resulting in pulmonary embolism. Both are dangerous and can be life-threatening. Being careful with limbs during movement is the best prevention. Avoid compression of the limb from crossing legs, 'hooking' an arm around the back of the chair, wearing too tight clothes or too tight of a leg bag. Remember, the leg bag may start out loose when empty but will tighten when filled. Inspect your child's limbs for swelling (usually on one limb), a red streak, warmth, pain, or an increase in spasms or autonomic dysreflexia symptoms. Call your healthcare provider if you suspect a DVT.

Metabolic One of the big issues for metabolism after SCI is the loss of bone minerals. It occurs in children with mobility issues. This is often due to lack of standing or putting pressure through the bones of the body. Typically, calcium is the mineral most affected. Using a standing frame, which is allowed by most payors, is one way to have your child put weight through their bones, especially the long bones of the legs.

A bone mineral density test will provide information about the strength of your child's bones. Having this simple test (no needles, just lay on a table) done early will help you keep ahead of problems. Bone demineralization is much easier to correct if caught early. Too little calcium in the bones can lead to easy fractures (broken bones). Medication can help if there is an issue. Maintaining a healthy diet will help as well, but it is not a complete treatment without the use of standing. Calcium supplements may be needed but only with a healthcare provider's direction. It is very easy to overdose a child with calcium, so professional advice must be followed. Calcium supplements should not be provided unless the child has a calcium issue. Most children will obtain enough calcium from their diet.

After spinal cord injury, maintenance of a healthy weight can be a challenge. Some children have a slow bowel, which causes them to not be hungry. Other children might have spasticity, which causes them to use extra calories than in a healthy diet for their age. Lack of movement may lead to weight gain. Extra movement from spasms can quickly burn calories. A dietician's consultation will benefit your child to get the right number of calories needed for their metabolism. Most payors allow a yearly update as your child grows.

Nervous System After SCI, children with higher-level injuries in the cervical or thoracic areas might develop tone or spasticity. Many do, some do not. Tone does not develop until the spinal shock has resolved, typically about six weeks after injury, some shorter and some longer times. Often, I see parents who will see the tone and think voluntary movement. Knowing that tone or spasticity in children with cervical or thoracic injury is possible is important in differentiation between tone and voluntary movement.

The benefit of tone is that it can help with transfers. The downside is that it can impede functioning. There is a treatment for tone starting with activity to the body below the level of injury. Additional therapies can be used as needed, including medication, injections, and implants to help control tone if it advances.

Remember this old nursing adage, if you see it on the outside, it is probably the same on the inside. Tone might be easily seen outside of the body but if it is there, it is probably at work on the inside of the body as well. For example, tone can play havoc with the bowels and sphincters of the bowel and bladder. If higher, it can affect breathing or any internal organ of the body.

Children with SCI in the lumbar or sacral levels generally do not have tone (although mixed injuries occur). Lower-level SCI results in flaccid lower limbs, not arms, as they are not affected at the lower level of injury. Because the muscles are not stimulated, they become smaller over a short amount of time. You still need to provide input to the body below the level of injury by doing range of motion exercises and other movement exercises as tolerated.

After spinal cord injury, the autonomic nervous system can be affected by a crisis disruption called autonomic dysreflexia (AD). This is an extremely serious condition.

In AD, blood pressure becomes elevated higher than the child's normal due to a stimulus below the level of injury. Most often, this is a full bladder due to overdistention, a catheter kink, a fully distended bowel, pressure, or tightness from clothing, or wrinkled sheets. But any stimulus can trigger an episode. AD happens because the autonomic nervous system is unable to regulate nerve impulses in the body. AD is a medical emergency. Take corrective action but if the blood pressure does not return to the child's normal after correction of the stimulus, call 911. Do not hesitate.

More detailed information about AD can be found on the Christopher & Dana Reeve Foundation website.

Pain is one of the most difficult issues after spinal cord injury. Everyone's perception of pain is different. Children are not often able to talk much about it if they are younger and not developmentally able to discuss it. You will note pain in your young child by withdrawing, lack of participation or behavior or mood changes.

Muscular pain is familiar to most people. It is the result of overworked muscles. In SCI, it is often seen as the zone of transition from sensation/function to reduced sensation/function because the muscles above are overcompensating for the muscles below. Over the counter medication can usually help. Visceral pain is internal body pain. You might see this after surgery. Medication helps this type of pain as well.

Neuropathic pain is specific to the nerves. It is elusive for treatment. Neuropathic pain changes and evolves over time. Sometimes, it even resolves. When it is present, it can be relentless. There are two medications that have been developed specifically for neuropathic pain, pregabalin and gabapentin. Some antiseizure or antidepressant medications, in very low doses, help with neuropathic pain. When in pain, people generally do not want to move. However, a gentle movement will help with neuropathic pain. There are also nerve blocks, implants, and surgeries that can help extreme forms of this type of pain.

Infection Pathogens surround us and are within us. Pathogens include bacteria, viruses, fungi, protozoa, and parasitic worms. Some bacteria can be useful, such as those that are found within the bowel that help us digest food. Other types cause inflammation in the body. Infections can include anything from a red, swollen, warm area like a cut on the skin or more serious types of infections in the organs, lungs, bladder, or skin as in a pressure injury.

Symptoms of an infection might not be immediately noticed with sensory issues until it has built up in the body. Signs of an infection are fever, chills, sweating, cough, sore throat, mouth sores, shortness of breath, nasal congestion, burning sensation, stiff neck, or pain with urination. One symptom or multiple symptoms can be present. Your child might not feel some of these symptoms, but infection can be reflected in fever, changes that you can see like redness and swelling, changes that you can hear such as breathing sounds or increased tone (spasms), or episodes of AD.

It is critically important to get treatment for infections quickly as delay only allows the infection to continue to develop. Generally, for bacterial infections, antibiotics are provided. The sooner the infection is treated, the lower levels of antibiotics can be used. This is important as higher level; broad-spectrum antibiotics can lead to more antibiotic resistance. With infection, the sooner treatment begins, the easier the infection is to treat. The prescription antibiotic should be given in its entirety as even though symptoms subside, the pathogen is not destroyed until the antibiotic has been used in its full course.

If infections are left untreated or are particularly strong infections, sepsis can occur. Sepsis is an infection that takes over the major organs of the body. It is extremely serious and can lead to death. A wallet card for treatment of sepsis can be found for free on the Foundations website.

There are many issues that affect children with SCI or diseases that affect the spinal cord. Parents and guardians know a child best as you spend the most time with them. It is very helpful for your healthcare provider that you actively participate in the care of the child by expressing concerns as well as successes. Nurse Linda

Linda Schultz, Ph.D., CRRN, a leader and provider of rehabilitation nursing for over 30 years, and a friend of the Christopher & Dana Reeve Foundation for close to two decades. Within our online community, she writes about and answers your SCI-related healthcare questions in our Heath & Wellness discussion.

This project was supported, in part, by grant number 90PRRC0002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.