Respiratory Management Following Spinal Cord Injury - 24

RESPIRATORY MANAGEMENT FOLLOWING SPINAL CORD INJURY

It is well recognized within the spinal cord injury literature that there exists a high incidence of comorbid substance abuse (Bombardier, 2000; Heinemann, 1993; Heinemann et al., 1989). As a result, it is clinically imperative that these potential comorbidities be assessed and treated, commencing within the acute rehabilitation setting. In the assessment, the clinician should determine the degree of substance abuse or dependence, the potential need for medical detoxification, and the existence of possible comorbid psychiatric disorders; explore physical and/or sexual abuse; examine family dynamics; evaluate the person’s motivation for constructive change; and develop a treatment plan, including relapse prevention. The treatment plan should link the patient with a skilled substance abuse provider. Commonly used screening and assessment measures include the Michigan Alcoholism Screening Test (MAST), the Alcohol Use Inventory (AUI), and the Addiction Severity Index (ASI) (Cushman and Scherer, 1995). Without this type of assessment and intervention, undesirable outcomes, such as relapse subsequent to acute rehabilitation, a higher incidence of secondary physical and psychological complications, additional hospitalizations, and a compromised quality of life become more likely.

presence of occult, secondary mild head injury (MHI). The presence of MHI, although typically resolving 3–6 months post injury, nevertheless requires clinical sensitivity and attention, especially in the acute rehabilitative setting. The Head Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine defined this diagnosis as possessing at least one of the following: 1. Any loss of consciousness up to approximately 30 minutes in duration; within 30 minutes after the injury, the person must have progressed to a GCS score of 13–15. 2. Any alteration of mental state at the time of the accident (dazed, disoriented, or confused). 3. Any loss of memory for events immediately before or after the accident (retrograde or anterograde amnesia). 4. Posttraumatic amnesia not greater than 24 hours. 5. Focal neurological deficit that may or may not be transient. It should be noted that the absence of a loss of consciousness does not exclude the possibility of a comorbid mild head injury. Prototypically, there are negative CT and/or traditional MRI findings. Nevertheless, MHI symptoms can occur in the physical, cognitive, and emotional domains. Primary physical symptoms include headaches, dizziness, sleep architecture alterations, and fatigue. Central cognitive issues include, but are not limited to, compromises in short-term memory, simultaneous processing, reaction time, attention, ability to multitask and organize, and executive functions. Affective difficulties typically involve depression, anxiety, irritability, and reduced selfesteem. As a result, a careful differential diagnostic process is essential to minimize clinical misunderstanding. Assuredly, these physical, cognitive, and affective issues can have a deleterious impact on the rehabilitation process (Davidoff et al., 1992; Black and Desantis, 1999; Ricker and Regan, 1999).

Pain
30. Assess the patient’s level of pain, if any, and establish the type of pain to determine the most appropriate physical and psychological treatment modalities.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Pain can be one of the most problematic consequences of spinal cord injury. Clinicians must accurately assess the type and location of pain (e.g., myofascial, radicular, and/or central deafferentation) and explore which physical and psychological treatment modalities are likely to be effective. If unattended, pain can have an omnipresent and deleterious impact upon rehabilitation and perceived quality of life (Britell and Mariano, 1991; Siddall et al., 1997; Putzke et al., 2000).

Secondary Mild Brain Injury
31. Assess for possible comorbid brain trauma as indicated by the clinical situation.
(Scientific evidence–NA; Grade of recommendation–NA; Strength of panel opinion–Strong)

Decision-Making Capacity
32. Determine the individual’s capacity to make decisions and give informed consent on medicalrelated issues by examining the following: Organicity. Medications.

A body of empirical work addresses the issue of SCI comorbidities, specifically the potential

Respiratory Management Following Spinal Cord Injury

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