By Sharon Hall, DPT, MS, NCS, M.Ed.
“I think my head is going to explode!”
“I have a migraine, my head hurts, I’m sweating, and I feel anxious.”
These are all signs that an individual with a spinal cord injury may be experiencing autonomic dysreflexia (AD).
John, a friend who has a spinal cord injury (SCI), told me about the time he went to his friend’s house for a Super Bowl party. Before halftime he started feeling weird, anxious and got a headache to beat all headaches. He went to the restroom at halftime, and within a few minutes he felt fine. I asked John how much he had to drink, and he said a couple of sodas before halftime. He also told me he has not had but one soda since his accident. I suspected John was experiencing autonomic dysreflexia related to an overly full bladder from drinking more than the amount in which he was accustomed.
What is Autonomic Dysreflexia?
Autonomic dysreflexia is an EMERGENCY! It is a condition where the brain is unable to receive signals of distress from the nervous system, requiring the body to utilize other methods to convey information. Individuals with a spinal cord injury at T6 (the sixth thoracic vertebrae of the spine located just below the level of the shoulder blades) and above, and in some cases, injuries at T7 and T8, are most commonly at risk. Those with complete/incomplete spinal cord injuries are also at risk. If not treated, autonomic dysreflexia can lead to dangerously high blood pressure that can lead to seizures, stroke, organ damage, permanent brain injury or even death.
What happens during Autonomic Dysreflexia?
Normally noxious stimuli would be perceived as pain. However, due to the injury to the spinal cord, the normal signals that alert the body about pain are not available. The autonomic nervous system alerts the body through autonomic functions like raising blood pressure.
What causes Autonomic Dysreflexia?
In John’s case, his bladder got overly full, and the stretch receptors in his bladder sent out the pain signal. However there are other conditions that can put someone into AD.
The bladder is the number one cause of dysreflexia and may occur for the following reasons:
- A clogged or kinked catheter
- The catheter bag is full, defective or not connected correctly
- A urinary tract infection or bladder infection
- If a person has kidney or bladder stones
- The bladder is too full because of incomplete emptying or not emptying often enough
- Someone is experiencing bladder spasms because of bladder spasticity
The bowels can also cause AD from:
- Impaction or constipation
- Infection of the bowels
- Pain from digital stimulation
- Having anal sex
- Gas or bloating
Problems with a person’s skin can also put someone into AD because of:
- Pressure sores
- Burns—sunburn, stove burn, coffee in lap burn, hot pan on lap burn, motorcycle exhaust pipe burn
- Blisters, especially on an individual’s feet
- Bug bites
- Wrinkles in clothes, sheets, wheelchair cushion cover, pants scrunched around the genitalia
- A flat wheelchair cushion or the person is bottoming out
- Anything sharp pressing the individual from a pocket or seated surface
- Ingrown toenails
Other causes that could put someone into AD:
- Gallbladder attack, infection, stomach ulcers, gastritis, appendicitis
- Menstruation, endometriosis, pregnancy, child birth • Blood clots or deep vein thrombosis
- Heterotopic ossification—joints with too many bone deposits
- Broken bones, strained or sprained muscles, ligaments and tendons
- A sudden change in temperature or prolonged unrelieved temperature that is either too high or too low
- Anything that would cause pain to the body before the injury—and still does—but it just can’t be felt in your brain. The body uses its default system to raise blood pressure
There are several symptoms when someone with a spinal cord injury is in AD:
- A severe, pounding headache
- Having goose bumps or the chills
- Sweating below the level of the injury
- Blurry vision, seeing spots, or a complete loss of vision
- Feeling anxious
- Developing splotchy skin above the level of the injury
- Having nasal congestion
- The person’s heart rate gets slower than normal because the heart is trying to compensate for blood pressure going too high
- Having blood pressure that is greater than 20 points above normal after an injury. For example, if the person’s normal blood pressure is 90/50 then having blood pressure of 120/80 is AD. This may be lower than an ablebodied person’s blood pressures, but it is an EMERGENCY for individuals with a spinal cord injury.
How does one get out of Autonomic Dysreflexia?
If the person is lying down, have them sit up. Their head should be higher than their feet. Once sitting up, the cause of the AD needs to be found. The individual or care giver should start with the bladder. Check everything: the catheter tubing for kinks, or if it’s pulling, etc. The care giver should consider the bowels and potential painful stimulus from there. Check the skin for burns or bites, etc. Make sure the person’s clothing isn’t bunched or there are no unusual folds in the material. Check shoes, wheelchair seat cushions, and the feet for any blisters or ingrown toenails. In essence, the source of the irritation or pain must be removed. If the source of pain can’t be removed or found, the person should take blood pressure medication or call 911.
Because of the small population at risk for AD, some people in the health care industry may not be familiar with the condition and may need to be educated. Individuals with a SCI who are susceptible to going into AD should carry an information card or have information on their phone about AD to share with others. The Paralyzed Veterans Administration (PVA) has free informational cards that can be carried in a wallet or purse. Additionally, the PVA has a poster that can be printed and hung in a prominent place for others who are not experienced with AD.
Remember autonomic dysreflexia can be triggered from simple, little things, but it can cause great big problems. Be detailed when looking for potential causes.