Body & Complications

The nervous system consists of a central, a peripheral and a vegetative part. The central nervous system consists of the brain and spinal cord. The nervous system is used for the acquisition, processing, storage and dissemination of information. Together with the hormone systems, it controls the activities of all the organ systems and is adapted and to meet environmental requirements. The spinal cord, as part of the central nervous system, plays a decisive part in the transmission of sensitive information to the brain and in the subsequent control of motor and autonomic functions.

Furthermore, the spinal cord itself is a nervous system that controls vital functions such as standing and walking, bladder, bowel and sexual functions, as well as breathing, temperature and circulation regulation.

The spinal cord is a 40 – 45 cm long, 8 – 10 mm wide and 5 – 7 mm thick rod in the vertebral canal. It emerges without any distinct boundaries from the medulla oblongata¹ and ends in a conical shape at the level of the first to second lumbar spine as the conus medullaris. The vertebral canal offers the sensory spinal cord good protection against mechanical damage. The vertebral canal generally sits directly in the axis of movement which ensures that the spinal cord is not squeezed or twisted during extreme deformations of the spinal column (when performing sports such as acrobatics or gymnastics).

The spinal cord is pushed up within the bony spinal column as a result of which the sacral region² lies in the area of the thoracic spine. There is no spinal cord in the lumbar spine, only the long roots of the lumbar and sacral segments.

The spinal cord can be structured in various sections on the basis of the associated spinal nerves emerging from it. Each of these sections can be divided into segments. A segment is a section of spinal cord from which the fibres for a pair of spinal nerves emerge on the right and left. Each section of the spinal cord is independent to a certain extent, but they are closely linked to other parts of the central nervous system.

Like the brain, the spinal cord is surrounded by a brain or spinal cord skin which is hard on the outside and soft on the inside. The cerebrospinal fluid flows between the skins of the spinal cord.

The structure of the spinal cord

The structure of the spinal cord is characterised by the butterfly-shaped, grey matter enclosing the central canal and the white matter surrounding it.

The grey matter primarily contains nerve cells, and the white matter contains the ascending and descending nerve fibres. The grey matter is the switching apparatus for the spinal cord. A distinction is to be made within the grey matter:

• The nerves which run through the anterior horn of the spinal cord supply the skeletal musculature, which contains the nerve cells that are responsible for the motor functions.
• The nerve fibres from the periphery of the spinal cord, which are responsible for sensory functions, reach into the posterior horn. In order to be perceived consciously, the sensory pulses / information must be conducted into the cerebrum. There, the pulses / information enter our consciousness as sensory perception.
• The white matter surrounds the grey matter in the centre and consists of nerve fibres containing medulla of different thicknesses. The white matter acts as the conducting connections within the spinal cord.

The autonomic nervous system

The term “autonomic” means that this part of the nervous system is not under the conscious control of an individual. The autonomic nervous system is responsible for vital functions because it controls or influences breathing, heart rate, circulation, bladder and bowel functions, metabolism, body temperature, important sexual functions, the kidneys and other organs or organ systems.

One talks about three parts: the sympathetic, parasympathetic and enteral systems. The latter regulates bowel motor responses. The sympathetic and parasympathetic nervous systems (vagus nerve und sacral parts S2 – S4) work antagonistically (against one another) in healthy people, although they are generally in a healthy balance. This balance is disrupted in people with spinal cord injuries; consequently, this imbalance may lead to many problems, some of them life-threatening.

¹ extended cord = the part of the brain at the very bottom and back

² lower-most part of the spinal cord

Injuries resulting from accidents

There are different elements in the movement segments which behave differently after an injury: bony structures and band structures. In bony spine injuries, we differentiate between three main types of fractures:

1. Compression fracture
2. Distraction injury
3. Rotation injury

The spine can be compared to two columns. The ventral¹ column consists of the body of the vertebrae and the intervertebral discs, the dorsal² column consists of the vertebral arches, the spinal or transverse processes, as well as the bands. The front column is subjected to pressure, whereas the rear column absorbs the tensile forces.

The bony structures may retain some of their original load-bearing capability following a compression injury. Once injured bones have healed, the position of the spine remains unchanged, enabling stability to be restored.

The ligament structures of the spine are less subjected to stress in a neutral position³. They serve the purpose of guaranteeing the stability of the spine at the limits of its movement potential. In the physiological range, the ligaments of the spine permit elastic movement with minimal resistance to deformation, and in the limit range they exhibit a high degree of stiffness.

The ligament structures determine the prognosis for mechanical stability in the event of a spinal fracture. The ligament structures, including the intervertebral disc, are generally involved in serious injuries. A torn ligament always leads to instability in the spinal segment. The intervertebral disc plays a decisive role here; it no longer heals due to the absence of vascular supply. Without surgery, a tear remains in the intervertebral disc, and the ligament structures are unstable throughout the person’s life.

When does paralysis occur?

Whether a spinal injury results in damage to the spinal cord depends on the extent of the injury to the spine. The spinal cord which runs along the vertebral canal is not necessarily damaged.

If the spinal cord is completely severed, irreversible paralysis sets in immediately after the injury; this is referred to as complete paralysis. If the spinal cord is only partially severed or crushed by a fracture or bleed in the spinal cord, the paralysis may regress at least in part; this is referred to as incomplete paralysis.

Difference between paraplegia and tetraplegia

The term paraplegia is used when the lower half of the body – legs, bottom, stomach and lower chest area – is affected by the spinal cord injury. In this case, the injury is located in the thoracic, lumbar or sacral region. People with paraplegia have unrestricted arm functions.

In the case of tetraplegia, the spinal cord is injured in the cervical region. In addition to the legs and the chest area, the arms are also affected by the paralysis. The extent to which the function of the arms is affected by tetraplegia depends upon the height at which the injury occurs. The lower down the spine the injury occurs, the more functional capability the arms will retain.

Respiratory musculature is also affected in the event of tetraplegia. If the injury is located above C3 at the level of the 3rd cervical vertebra, the breathing is so badly restricted that the person is dependent on mechanical support.

Spinal cord injuries do not only lead to restrictions in the functionality of the extremities, but also to other malfunctions in the organ systems because the nerves being supplied also run along the spinal cord. In the case of injuries above the 6th thoracic vertebra, the autonomic nervous system is also affected, which can lead to malfunctions in the circulation system. Depending on the level at which the injury occurs, spinal cord injuries frequently result in bladder and bowel disorders as well as sexual dysfunction because the nerves that control those functions come out of the bottom of the spine at the sacral region.

Classification according to ASIA

Nowadays, complete or incomplete paralyses are categorised from A–E according to criteria laid down by the ASIA (American Spinal Injury Association).

AIS A Complete paralysis, no motor or sensory functions.

AIS B Incomplete, sensory functions preserved but not motor functions below the level of the paralysis.

AIS C Incomplete, sensory and motor functions preserved below the level of the paralysis, but the key muscles are so weak that they cannot be used functionally.

AIS D Incomplete, sensory and motor functions preserved below the level of the paralysis; there is so much strength in the key muscles that they can be used functionally (e.g. standing up for transfers, possibly walking with mobility aids).

AIS E Normal, motor and sensory functions are normal.

Disease-related damage

In addition to traumatic injuries, a number of diseases can also lead to spinal paralysis. The most frequent are tumours, circulatory disturbances, infections and inflammations such as multiple sclerosis. In these diseases, some of the bony structures remain intact, in which case the damage only affects the spinal cord. The spine may also be affected by inflammations or tumours.

Rehabilitation is frequently made difficult by the primary disease. Consequently, the person’s health can keep changing after a tumour disease. The objectives of rehabilitation must be defined depending on the disease and the subsequent treatment must be planned well and looking ahead. In many cases, the increased susceptibility to fractures due to tumours must be taken into account.

¹ Close to the stomach

² Close to the back

³ Position in which maximum movements are possible in all directions

What is autonomic dysregulation?

Autonomic dysregulation is a regulation problem that leads to an overstimulation of the autonomic nervous system. In the case of a spinal cord injury (SCI), this may occur above the seventh thoracic vertebra. Autonomic dysregulation can be triggered through various stimuli, mostly through stimuli in the bladder or bowel area. These stimuli cause an uncontrolled spasmodic contraction of the vessels below the lesion level. As a consequence, the blood pressure increases rapidly and the symptoms described below may arise. The brain notices that the blood pressure is much too high and tries to lower the blood pressure by reducing the heart rate.

What may be the causes?

The most frequent causes are:

• Bladder congestion, bladder overstretching, spastic bladder
• Full bowel (severe constipation)
• External stimuli (pressure, bed sores, burns)

Other possible causes:

• Infections (bladder, skin, in-grown or inflamed toenails, etc.)
• Urological / gynaecological examinations
• Pregnancy / childbirth
• Intensive sports activities with a full bladder

How to react?

The most important measure is to eliminate the cause:

• Empty the bladder immediately using a disposable catheter.
• If using a permanent or suprapubic catheter, check whether it is bent or the urine bag is too full.
• If this is not the case and symptoms persist, try flushing the catheter; if this is not possible, the catheter needs to be exchanged immediately.

If the bladder is empty:

• Check whether the bowel is full and, if necessary, empty bowel.
• Change sitting or lying position to check whether there is an object hidden beneath the buttocks / body.

Definition of pain

Pain is a complex sensation similar to a feeling. Pain is always subjective; it cannot be measured or proven and also not rebutted. Since the 1970s there has been an official definition by the International Association for the Study of Pain which applies for acute and also for chronic pain:

"Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage."

The definition follows the bio-psycho-social model of disease. This model describes that disease – and therefore also pain – is not exclusively caused by physical changes but also dysfunction, emotional, mental or social problems and disruptions can cause pain and disease. The above definition of pain therefore dismisses the causal link of damage and pain. This means that pain is not necessarily caused by an objective damage of tissue but that a subjective sensation of such damage is sufficient.

Acute pain

In case of acute pain receptors – or, simplified, microphones or call buttons – are activated inside the body which forward their information via the spinal cord and many interfaces to the central nervous system, our brain. Inside the brain this information is processed in a complex way. The result of these processes may be the sensation of pain combined with a certain characteristic (burning, stabbing, pulling, throbbing etc.) and a more or less exact location within the body. Pain can, however, also be suppressed by the brain, e.g. when we are distracted, tense or concentrating on an interesting work or more important tasks (such as fleeing a danger, shock after an accident).

Acute pain has a warning function. The removal of the cause, treatment of the injuries or the underlying disease eases the pain mostly fast and sustainably. Painkillers usually work well.

Chronic pain

Acute pain can turn into chronic pain. Chronic associated with pain does not only mean "long lasting" or "existing for a long time". Chronic pain also includes the interrelatedness of various factors. Signs for pain that is becoming chronic are that the symptoms are spreading on the physical level – the area affected by pain is extending, more areas of pain develop – but also on the mental-emotional level and in social life problems can occur.

Chronic pain can best be prevented if it is treated early and appropriately. If it targeted and usually well working treatments have hardly any influence on the pain, it should be checked whether it is still an acute, simple pain and also other influences should be taken into consideration.

Frequent chronic pain problems are:

• Headache
• Back pain
• Neck pain
• Neuropathic pain (caused by damage of the nervous system such as spinal cord injury)
• Multilocular pain (i.e. at several locations) or extended (i.e. covering a larger body area) chronic pain (e.g. fibromyalgia)

In total about 16% of the persons residing in Switzerland are suffering from chronic pain, i.e. one in six. Persons with spinal cord injury suffer from chronic pain more frequently, often in combination with muscle spasticity. Most of them do not receive sufficient care and continue to suffer.

Causes and triggers

Pain can be versatile and each patient has a different perception of pain – as manifold can be the causes that trigger pain and they are often the beginning of several years of experiencing pain. Often the triggers occur at a time when the patient was in a difficult situation in life or has reached a turning point. Also previous injuries, experiences of violence or ongoing mental or social burdens may constitute weak points that may promote such a development.

Chronic pain, as generally recognized, can only be understood on the basis of a bio-psycho-social model of disease. The various parts may have a different significance from case to case. Chronic pain is often comes with a depressive mood, sometimes fear and often sleep disorders. In each case it needs to be examined whether sleep disorders has existed before (and may therefore have promoted the development of chronic pain) or whether they are co-existing without having an influence on the pain or whether they are the consequence of chronic pain. In each case they need to be treated in the context of a pain therapy.

Impact on the quality of life

Research in the field quality of life was able to show that chronic pain affects a person in his/her entirety and all areas of life.

Self-assessment of health related quality of life with the SF-36 (short form 36), results in relation to pain chronification. The red curve shows the standard values of a representative sample of the general population. The orange curve "I" shows the results for patients with low chronified pain, the green curve "I" shows the values with a medium pain chronificiation and the brown curve "III" shows a high pain chronification (Mainz Pain Staging(MPSS) by Gerbershagen) [Resource: Gerbershagen HU, Lindena G, Korb J, Kramer S. Gesundheitsbezogene Lebensqualität bei Patienten mit chronischen Schmerzen. Der Schmerz. 2002;16(4),271-84.]

The diagram clearly shows that patients with an increasing pain chronification are limited in all enquired areas because of their chronic pain. Localization of the pain does not play a significant role in this context.

Diagnosis and treatment

In order to detect and diagnose chronic pain a team of specialists is necessary. An orthopedist, for example, is not able to competently assess the mood of a patient and make a psychiatric diagnosis; a social worker is not able to assess the performance of the patient, his/her limitations and resources; and a psychiatrist or psychologist cannot evaluate the degree of physical damage and the therapeutic possibilities (e.g. through physiotherapy). Therefore to assess the complexity of a patient and his/her situation, a team of pain specialists is necessary who exchange their assessments and findings and then coordinate further treatment measures. Gold standard for the treatment of chronic pain therefore is an interdisciplinary (i.e. across the disciplines) and multimodal (i.e. in different ways) pain therapy.

The success of the therapy strongly depends on the cooperation of the patient, from the anamnesis to the motivation and participation in the treatment. Generally the pain patient does not only get a diagnosis but a list of factors that causes and maintain pain. Pain is a combination of factors and gives expression to many things such as disease, suffering, limitations, suffered injustice and much more.

If possible the therapy takes place within a group since this allows the participants to support and learn from each other. In order for the group to be harmonious and for the group treatment to be successful a thorough selection of patients is necessary.

What causes pressure sores?

Long-lasting pressure or also brief, strong pressure on one part of the skin can cause a decrease in blood flow inside the tissue. The skin presents red spots that do not turn white when pressing. Skin hardens if it is repeatedly exposed to strain at the same point.

How do we define sensitivity?

With sensitivity, we mean our fifth sense, namely feeling. Different from the other four senses, sensitivity is not perceived through a sensory organ such as vision is through the eyes. Our sensory system retrieves information from numerous nerve endings and receptors¹ that are spread all over our body. This system gives us feedback from our body through pressure, stretching, vibration, temperature or pain. This feedback comes from different places: from the mucous membranes, the inner organs or the muscular / skeletal system (position of the joints, flexion of muscles).

This sensitivity is an important warning system of our body. If there is no or only partial sensitivity, we are not receiving information that would make us aware of hazards. Due to the limited sensitivity of people with spinal cord injury, this important warning mechanism is disabled, which can lead to various complications.

Risks due to limited or non-existent sensitivity

Pressure sores

What is heterotopic ossification?

Heterotopic ossifications (synonyms: myositis ossificans, periarticular ossifications PAO) are cases where muscle tissue is rapidly transformed into bone-like, calcified tissue. They occur in 20 – 30 % of people with spinal cord injuries, typically 1 – 5 months after paralysis.

The soft tissue around the hips is most frequently affected, often on both sides. The shoulders, knees and other joints are also affected, albeit less frequently. If treatment is not started at an early phase, heterotopic ossifications may lead to considerable restrictions in the movement of a joint.

How do you identify a heterotopic ossification?

Clinical symptoms in the development of heterotopic ossifications are swelling, redness, increasing muscle spasms and local pain. Temperatures also often rise slightly in the evening. At the start of the illness, there is a muscle inflammation that calcifies over time. Conventional X-ray images only reveal the late stage of calcification. Therefore, we use magnetic resonance tomography (MRT) for the early diagnosis.

During blood tests, we detect raised inflammation values, as well as an increase in alkaline phosphatase and creatine kinase. This enables us to identify many people who can be treated in time thanks to this diagnosis. Little is known about the cause. Operations and bleeding pose risk factors. These symptoms do not only occur in people with spinal cord injuries; symptoms which are similar, albeit not identical, are observed on rare occasions in able-bodied people following hip operations or major burns.

What can be done?

Use blood thinning drugs and anti-inflammatory medications from the group of non-steroidal antirheumatics (such as Voltaren®). The treatment involves administering drugs which are otherwise used to treat osteoporosis (such as zolendronate). This can slow down the progress of the calcifications.

While people with spinal cord injuries may still be moved, excessive forced movement of the affected joint should be avoided. If the mobility of a joint is so restricted that the person is no longer able to sit properly and there is a risk of sores, the calcification must be removed surgically. As surgery itself is known to trigger heterotopic ossification, a relapse is likely to occur (recurrence).

What are contractures and how do they develop?

Contractures are shortenings of muscles, tendons or ligaments that have a limiting effect on the movements of the joints. The normal ability to move a joint is lost. Contractures are frequently attributable to the patient’s positioning. They occur when muscles and joints are not stretched or moved often enough. If, for example, the knees are permanently bent, the muscles that are responsible for extending the knee joints will shorten. As a result, the legs can no longer be fully extended.

Wheelchair users are at increased risk of infections which have to be treated with antibiotics. Taking antibiotics frequently increases the risk of harbouring multi-resistant germs.

How can you avoid multi-resistant germs becoming a health issue for you?

Multi-resistant germs – what are they?

There are numerous bacteria on everyone’s skin and mucous membranes (mouth, nose, etc.). This is completely normal and even good for you since they protect you naturally from harmful germs. Certain types of bacteria, however, have become resistant to antibiotics over time. In the case of an infection, treatment with antibiotics may show no effect or, if so, only insufficiently. Patients who carry a resistant germ are informed and instructed about the necessary precautions during a stay at the clinic. All staff at the clinic will take additional precautions (barrier nursing) to prevent the transmission of these germs to other patients, visitors and staff.

Multi-resistant germs are not generally a problem if one is healthy. However, as soon as a person’s immune system is weakened in some form, e.g. due to a wound such as a pressure ulcer, respiratory disease or regular catheterisation, it is possible that the body does not have the germs under control and this may result in a permanent colonisation or infection.

Germs are mainly transmitted via the hands

Bacteria can also survive for a relatively long time on surfaces. Through touching surfaces, they can settle on the hands and thus enter our body through the nose or the mucous membranes or via a catheter into the bladder. They can also be transmitted to other people through coughing and sneezing.

What should I remember during a hospital stay?

The main risk is posed by clinic staff / visitors / relatives

Clinic staff have to follow strict guidelines on hand sanitising. Ensure that staff sanitise their hands before:

• They begin treatment on you or
• They touch any kind of material in your surroundings.

The right behaviour towards persons carrying multi-resistant germs

Sometimes you may meet people in a clinic wearing respiratory protection. This protection mask must be used if in close contact with other persons. Especially when coughing or speaking, these germs can be transmitted through saliva specks. Keeping a minimum distance of 1.5 metres from the person you are talking to can help to protect you from germs.

If patients who are required to wear a mouth protection are moving outside of their patient room, they need to wear the nose and mouth protection permanently. The mask must cover the nose and mouth completely, otherwise protection cannot be guaranteed. They are only allowed to take off the protective mask if they are outside of the clinic and not in a group of people.

Stick to these rules and multi-resistant germs will not pose a risk to you.

Pain is a basic human experience that we are often confronted with in our lives – sometimes even on a daily basis. We hit our head, our wisdom teeth are aching or we get a headache when the weather changes.

There are different types of pain. Musculoskeletal pain can be treated with conventional measures, as well as with physical measures. But many people with spinal cord injury (SCI) suffer from pain that is much more severe, as their central nervous system is irreversibly damaged. Scientific studies have shown that 58 % of all people with SCI suffer from chronic neuropathic pain in the first year after SCI. In most cases, the symptoms exacerbate over the years and many people report that permanent pain reduces their quality of life significantly. In some cases, activities and tasks of everyday life, such as working, driving and enjoying hobbies might be affected so much that an active participation in social life is only possible from time to time.

But what is chronic neuropathic pain?

Neuropathic pain can be caused by mechanical, toxic¹, metabolic² or inflammatory damage of the central or peripheral nervous system. There are two types of pain: nociceptive and neuropathic pain. In nociceptive pain, the nervous system is intact, e.g. pain in the knee joint due to joint wear. Common examples for neuropathic pain are: pain in the leg caused by an incarceration of the nerve root due to a disc herniation or the so called “phantom limb pain” following the surgical amputation of a limb. People may perceive neuropathic pain in many different ways. It can range from tickling, dragging and electrifying to burning, stabbing or sharp pain, or it can even be a very oppressive or pressing feeling.

Neuropathic pain and paraplegia

The figure shows neuropathic pain in the case of paraplegia spinal cord injury. Due to a dysfunction of or damage to the nervous system, the pain receptors receive pain, although there is no local injury (e.g. in the legs). The message is sent through the peripheral nerve but does not reach the pain centre of the brain due to the SCI. Yet, paradoxically, the pain centre notifies a sensation of chronic pain that is in most cases perceived below the lesion level.

Diagnosis and therapies

It is sometimes not possible to give a precise diagnosis and to find out the actual cause of the pain sensation. However, it is known that stress, burden and psychological problems may exacerbate the perception of pain. But how can neuropathic pain be treated? Pain researchers have been trying to develop a comprehensive therapy for many years. There are many different approaches and a general assessment is very difficult. The causes and forms of pain are too diverse and each person reacts differently to physical stimuli.

In most cases, medication is the primary means to relieve the pain. However, it might take some time to find the right “combination” and dose of medication.

Furthermore, studies have shown that an interdisciplinary approach is often very promising. It is not only important to define the right medication, it is also crucial to show people suffering from neuropathic pain how to deal with it. Physiotherapy, art and music therapy but also sport and Feldenkrais (a special method in kinematics) therapy can help to find strategies for “shutting off” the pain and thus enabling participation in joyful activities with others. To keep the pain at a moderate level, it is also vital to create a stress-free environment.

¹ toxic, intoxication

² depending on metabolism

In people with spinal cord injuries, the paralysis affects the control of the vegetative nervous system. Orthostatic¹ dysregulation can occur in the case of paralysis at a high level, in particular.

Blood pressure is self-regulating in healthy people. There is disruption to this regulation, which is controlled by the vegetative nervous system, in people with spinal cord injuries. When changing from a lying to a sitting position, a sudden sharp drop in blood pressure can occur, orthostatic hypotonia.

Symptoms of this drop in blood pressure are dizziness, weakness, flickering vision or light-headedness. In extreme cases, the person affected loses consciousness.

What causes this reaction?

In healthy people, blood pressure is regulated by the correct control of the blood vessels and the cardiac function by the vegetative nervous system. In people with spinal cord injuries (with injuries above T6), the sympathetic nervous system loses the ability to control the blood vessels correctly. In addition, the muscular pump effect is lost in people with spinal cord injuries. This normally helps to regulate blood pressure by applying pressure to the blood vessels. If the muscles now no longer contract and the vegetative nervous system is unable to respond, the blood settles in the blood vessels of the legs, resulting in a rapid drop in blood pressure. People with tetraplegia, in particular, often pass lots of urine at night in order to counteract this disrupted circulatory function. The absence of fluid means that they frequently experience blood pressure difficulties in the mornings.

Many drugs increase orthostatic hypotonia, in particular diuretics² such as Lasix®, neuroleptics such as Haldol® or Quetiapin®, blood pressure drugs and medication to treat prostate enlargement.

What can be done about it?

A preventative effect can be achieved by wearing compression stockings. The stockings exert pressure on the blood vessels, performing some of the role of the muscular pump action in the legs. Wearing a stomach belt may be helpful in some cases, although there is no scientific proof that it helps to prevent a drop in blood pressure. However, a stomach belt can help to raise seating stability or be used as respiratory support. Functional electrical stimulation of the leg muscles, active or passive movements of the legs or sport are very effective.

As blood pressure checks in people with spinal paralysis often only works slowly, people affected should change position slowly. If orthostatic hypotonia occurs, it often helps to raise the legs briefly immediately after transferring into the wheelchair.

It may be helpful to have the top of the bed slightly raised during the night to counteract excessive micturition overnight. Drinking a half litre of water or some beef tea before moving can help to prevent dizziness. Some people with tetraplegia also experience an improvement after raising their salt intake.

Drugs which stimulate the sympathetic nervous system can also be used for treatment or prevention. Gutron® (midodrine) is the drug to choose; Effortil® (etilefrine) which is frequently administered is generally not very effective. The water balance which is disrupted in tetraplegics in particular can be corrected by administering Florinef® (fludrocortisone), which increases water retention.

¹ with the body posture upright

² drugs for expelling excessive fluid in the body

What is osteoporosis?

Osteoporosis is a disease of the skeleton which leads to a reduction in bone mineral density, as well as to a change in the micro-architecture of the bone. As a consequence of that, the strength of the bone affected is much reduced, creating the possibility of broken bones when exposed to only minimal force during your normal routine.

What may be the causes?

In addition to factors such as hormonal changes (e.g. in women during their menopause), paralysis-specific metabolic changes, increasing age or malnutrition, immobilisation is also a risk factor for developing osteoporosis. This is why people with complete motor paralysis are particularly affected by osteoporosis. These people can start to develop osteoporosis shortly after paralysis occurs. The decomposition of the bone occurs below the level of the lesion and is mainly localised in the paralysed arms and /or legs. For instance, the bone mineral density in the shin-bone can be reduced by up to 70 % in the initial years after a spinal cord injury. The longer it has been since the spinal cord injury occurred and the greater the extent of the functional restriction, the greater the extent of the osteoporosis will be. Osteoporosis also occurs in young men and women with spinal cord injuries and is not exclusively found in older people who have suffered spinal cord injuries.

What should you do?

According to current medical expertise, the development of osteoporosis can only be influenced to a limited extent. Nonetheless, the following steps should be incorporated into your daily routine as a means of treating or preventing osteoporosis.

• A balanced diet, rich in calcium
• If there is a proven vitamin D deficiency, adequate vitamin D substitution
• Physical and sporting activity, if possible outdoors (sunlight)
• Targeted support through functional electrical stimulation
• Where osteoporosis is known to be particularly serious, the person affected may need to take special medication following individual advice by a GP or by a specialist.

Spasticity develops as a result of damage to the spinal cord or to the brain. The term comes from the Greek word “spasmos”, which means muscle cramp. Spasticity and spasms frequently play a central role in the lives of people with spinal cord injuries and their caretakers.

Why does spasticity occur?

The regulation of body tension is very complex. Movements are controlled jointly by the brain and the spinal cord. The spinal cord injury causes an interruption of the ascending and descending nerve paths in the spinal cord via which regulation is controlled. The brain loses its influences over reflexes and over the development of strength in the musculature.

Reflexes are involuntary movements which are controlled directly via the reflex arc in the spinal cord. The regulation of the reflexes is disrupted by the interruption to the spinal cord; they are no longer “braked”, and they respond strongly. Therefore, many people with spinal cord injuries suffer from increased muscle tone¹ or cramp-like muscle activity.

Difference between spasticity and spasms

Spasticity means that the basic tone of the muscles in the paralysed parts of the body is increased. Spasms are unspecific responses to stimuli. As the central control via the spinal cord is lost, non-specific muscle contractions occur in response to sensory stimuli. A distinction is made here between flexor and extensor spasms, depending on whether the flexor or extensor muscles are more affected.

What this means to people affected

Spasticity means that the body works at the highest level of effort and results in very high energy consumption. The possible movements in the joints are restricted because the surrounding muscles are tensioned in such a way that any elasticity and, thus, the scope for movement are lost. As a result, movements take great effort which, among other things, can restrict independence. However, there are lots of positive effects to spasticity. It gives the body greater stability, causing those parts of the body which are affected by paralysis to follow the pulses of those which are not because the joints do not permit movement in any other direction due to the high tension of the surrounding muscles.

Shooting spasms may be used in a beneficial manner for performing some daily routines, e.g. during transfers where extensor spasms may enable the person to stand for a short time, to raise his or her legs up onto the bed or when getting dressing, where reflexor spasms may be useful.

If the spasms occur very surprisingly, they may also pose a risk because they may disrupt movements, leading to falls and injuries.

What this means to care personnel

Dealing with people with spasticity poses great challenges to care personnel. Care often takes great effort, for the muscle contraction of the patient can easily be transferred to the caretaker.

Key points in care

In spasticity

What is syringomyelia?

Syringomyelia is a slowly progressing process in which the grey matter of the spinal cord, especially in the cervical and thoracic areas of the medulla, becomes loose and a fluid-filled cavity forms. They are very rare and occur spontaneously (1–2 per 1,000,000 inhabitants) and following spinal cord injuries where they can occur months or even years after the injury.

They are generally triggered by a disturbance in the flow of the cerebrospinal fluid due to adhesions, causing a blockage of cerebrospinal fluid in the central canal of the spinal cord.

How is syringomyelia detected?

Initial symptoms are often pain radiating out above the level of paralysis, as well as headaches. Later on, the person experiences a gradual loss of muscle function above the level of paralysis; this process often takes years. Muscle twitching, vegetative symptoms, as well as swellings or redness and loss of sensitivity then come to the fore. Typical symptoms are loss of the ability to feel pain in the arms and hands, as well as weakness of the hand musculature.

Syringomyelia can be verified very simply by means of an MRI scan.

What can be done?

Syringomyelia cannot be healed. Pain therapy and physiotherapy can alleviate the symptoms. Drugs are also used, whereby conventional painkillers are often of little or no effect, and neuroleptics and antidepressants have to be combined.

Attempts are made to alleviate the cause (adhesion) through surgery. In serious cases, the fluid-filled cavity is drained by inserting a tube in the pleura or peritoneum and easing the pressure. The symptoms are generally only partially alleviated, but such draining can often prevent further progress.

As the development of the symptoms is frequently gradual, the disease often progresses for half a year before the people affected even notice it. Over a period of several years, however, the new symptoms can become so significant that surgery is advisable in most cases if there is clear evidence of progress based on a multi-year comparison (annual checks).

The loss of only one centimetre of spinal cord, especially in the cervical part of the medulla, can result in a major loss of independence, e. g. of hand functions or of the elbow extensors or flexors.

What is thrombosis and what causes it?

Thrombosis is a condition where a blood clot (thrombus) (A) forms inside a blood vessel and thus causes a restriction or blockage of the blood flow within the vessel (B).

Thromboses are dangerous as they might lead to a pulmonary embolism (see FAQs) in the event of the blood clot travelling to the lungs (C).

When is there an increased risk of thrombosis?

Common causes of thrombosis are confinement to bed, infections and injuries such as bone fractures, etc. There is also an increased risk in people who are overweight, smoke, take hormone treatment or who have already had thrombosis.

Thromboses in the case of spinal cord injuries

The risk of people with spinal cord injuries getting venous thromboses is about 250 times greater in the first few months; the risk drops to 20 times in the first few years, and then remains 3 – 10 times greater for the rest of their lives. The causes for the high risk of thromboses in people with spinal cord injuries are only partly known (lack of a muscle pump or paralysis of the autonomic nervous system are not sufficient explanation). It is unknown whether people with incomplete paralysis are at lower risk than those with complete paralysis, which is why we treat them all the same.

What are the signs and symptoms of thrombosis? Possible physical trouble:

• Sudden pain in the affected area (only with sustained sensitivity)
  • pain in the sole of the foot
  • dragging pain along the vein
• In case of no sensation of pain, symptoms may include:
  • one leg is significantly thicker than the other (by at least 2 cm), and the whole leg swells below the site of the thrombosis. Isolated swelling of the knee or thigh, for instance, would suggest it is not a thrombosis.
  • redness / blueness and overheating of the affected part of the body
• Increased frequency of spasms and spasticity
• Heavy legs / feeling of tension in the legs
• General feeling of discomfort
• Rapid pulse, slightly elevated body temperature
• Shortness of breath

What should I do if I suspect that I have a venous thrombosis?

Thromboses must be treated as quickly as possible as they may be life-threatening.

If you suspect that you have a thrombosis, consult a GP immediately and, if possible, avoid any further movement (stay still) – there is a risk of a pulmonary embolism as a result of the thrombus becoming loose. It is diagnosed through ultrasound or computerised tomography and laboratory tests.

How to prevent thrombosis:

Thromboses can be prevented through

• Sufficient fluid intake
• Injection of blood-thinning preparations in case mobilisation is restricted for a certain period of time (please consult your GP)
• Wearing of compression stockings in the case of extensive swelling of the legs
• Due to the very high risk among people who have recently become paralysed, blood thinners and compression stockings are used during the first 6 months. In the absence of any certainty as to whether incomplete paralyses pose a lower risk, we treat all patients the same way.
• After 6 months, blood thinning drugs only have to be administered in high-risk situations.

What are the high-risk situations for venous thromboses?

Particular caution is advised:

• During summer
  • warmer temperatures: sufficient fluid intake
• When travelling
  • hot climate: sufficient fluid intake
  • on journeys shorter than four hours: possibly wear compression stockings (bus, plane)
  • on journeys longer than four hours: injection of blood-thinning drugs (please consult your GP)
• In the case of leg injuries, e.g. fractures or heavy bruises as a result of a fall (please consult your GP)
• In the case of infections (please consult your GP)

Wearing compression stockings

Compression stockings lower venous pressure, prevent water retention in the legs and improve the blood supply to the legs. The risk of blood clots forming is reduced by the fact that there is an improvement in the return of blood to the heart. As a result of the pressure of the stockings, less fluid is retained in the tissue. Consequently, the stocking prevents the formation of oedemas¹.

Given the very high risk of thrombosis following the occurrence of a spinal cord injury, class II compression stockings must be worn right from the start. They can generally be taken off again in the fullness of time. In the event of bad circulation problems or swelling of the legs during movement, it is rather difficult to dispense with the stockings.

If you wear compression stockings, it is important to put them on correctly, without any creases. If stockings are rolled down, this may lead to blockages; creases encourage the development of pressure sores. In addition, support stockings must be looked after correctly. The effectiveness of the stockings is preserved by washing them regularly (every day or every other day).

In the event of changes in the circumference of the legs or if the stockings become too loose with ageing, it is important to replace them.

¹ Deposits of water in the tissue

Breathing is the most normal thing in the world for us. We hardly think about it, even though we breathe in and out about 20,000 times per day. We breathe more when we are active and exerting ourselves, and we breathe less when we are inactive.

The oxygen inhaled is delivered to every cell in our body, no matter how small. In the cells a sort of combustion takes place resulting in the production of carbon dioxide, which is then transported out of the body.

The respiratory tract

The air flows in through the mouth and nose and is then transported through the throat and larynx. These air-transporting respiratory organs are lined with a mucous membrane and with tiny hairs called ciliated epithelium. This is where the air that we breathe in is cleaned, warmed and moistened. These organs together are also called the upper airways.

The lower airways are a kind of pipe system which can be pictured as an upside-down tree. They start with the trachea, which branches into the left and right bronchi at the level of the fourth thoracic vertebra. Then the airways branch 22 more times in both lobes of the lungs while becoming smaller and smaller. Eventually, they end in tiny pulmonary alveoli which consist of extremely thin membranes. If put beside each other, the surface area of all alveoli would be 70 to 100 square meters. The oxygen exchange takes place in the alveoli: oxygen is released to the bloodstream and the carbon dioxide, which is produced during metabolism, is absorbed by the alveoli.

How does our respiration work?

While inhaling, the diaphragm flattens and the ribs are lifted. Within the created space, a vacuum exists so that lungs are expanded and air flows in.

This difference in pressure is essential for inhalation but cannot be created by the lungs as lungs have no muscles. Consequently, the diaphragm as the main respiratory muscle and the auxiliary respiratory muscles (e.g. outer intercostal and abdominal muscles) have an essential role in inhalation. Inhalation is therefore an active process.

Exhalation, on the other side, is a passive process. After inhaling, the diaphragm relaxes and goes back to its original dome-like shape. The muscles of the abdomen, chest and intercostal ribs relax. The ribs go down and the elastic lung tissue contracts – air flows out of the lungs.

Both halves of the lung are enclosed by the chest as in a cave. The lungs are covered by a visceral pleura and the parietal pleura lines the inner chest walls. The visceral and the parietal pleurae together form the pulmonary pleurae, which prevent the lungs from collapsing. Between the visceral and parietal pleurae, there are a few millilitres of liquid which prevent them from rubbing against each other during inhalation and exhalation.

Control of breathing

Breathing is controlled by the respiratory centre. This centre is located at the base of the brain stem where the brain connects to the spinal cord. It is where the number of breaths, the breathing rhythm and the depth of breath are controlled.

This control works through various mechanisms such as the diaphragm nerve, the nerves of the auxiliary respiratory muscles and chemical processes in the blood (i.e. changing of the oxygen-carbon dioxide content).

Respiration in people with spinal cord injury

The higher the level of the injury, the more serious the auxiliary respiratory muscles are affected. Therefore, people with spinal cord injury often have a partial or complete inhalation loss of abdominal muscle function, which leads to limited coughing ability.

Furthermore, the loss of these muscles changes the natural breathing mechanism. Since the abdominal muscles lack muscle tension, the abdominal organs sink, causing the diaphragm to flatten. The diaphragm becomes less flexible and can thus develop less strength which is necessary for inhaling. The paralysed part of the chest is no longer lifted but pulled down by the pulling of the diaphragm. Thus, the lungs are expanded incompletely and unevenly. As a result, less air can get into the lungs. The breathing volume is therefore smaller and the ventilation of the lungs becomes inconsistent. If this happens over a long period of time, the small airways may be completely excluded from the ventilation and they may collapse or “stick together”. This is one of the reasons why people with spinal cord injury might need breathing therapy.

Inhalation therapy is a standard treatment for acute or chronic conditions of the respiratory tract. By inhalation therapy, we mean the therapeutic inhaling of medication or the therapeutic moistening of the mucous membrane of the respiratory tract. The latter stimulates the self-cleaning mechanism of the lungs. Semi-fluid secretion can thus be liquefied and therefore mobilised more easily. Additionally, the lungs are optimally ventilated since the inhalation process supports a more conscious and deeper breathing.

It is important to apply the therapy correctly. If not, the medication may not reach the intended location where it is supposed to have an effect. Most drugs need to enter the lungs deeply in order to take effect locally in the bronchi or be absorbed through the pulmonary alveoli into the blood.

However, not only the inhalation technology but also the size of the drops plays an essential role. Inhaling only water vapour (chamomile bath, etc.) is only meant for moistening the upper airways (nasopharyngeal cavity). The lower airways, such as the trachea or bronchi, cannot however be reached.

For deep inhalation, nebulising systems and metered-dose inhalers are available. The metered-dose inhalers are used exclusively for applying medication. Nebulising systems are used to moisten the respiratory tract.

For inhaling, a nebuliser and an inhalation set with a mask or a mouthpiece are needed. In the case of a tracheal tube, the inhalation set can also be connected directly to the catheter mount¹.

What is the right way to inhale?

• If possible, inhaling should be done in a sitting position to better expand the lungs
• Concentrating on calm and deep breathing
• After inhaling, possibly taking measures for mobilising secretion (e.g. expectoration with manual support or with Cough Assist)
• Watching order and time between individual inhalations in order not to reduce their effects

Which medication to inhale

• Bronchodilators
• Anti-inflammatory drugs (cortisone)
• Expectorant drugs (secretolytic drugs)
• Antibiotics

Cleaning

After each use, the inhalation set needs to be rinsed under running water. It needs to be stored in a dry place, e.g. in a cotton bag, and is replaced once per week.

After using drugs that contain cortisone, the mouth needs to be cleaned (e.g. by rinsing your mouth and throat, eating something or brushing your teeth) in order to get rid of the drug residue and to avoid fungal infestation in the mouth / throat area.

¹ Tube extension

Coughing up secretion is very important to enable you to breathe freely. Coughing is a protective reflex for cleaning the respiratory tract since it loosens the mucous which can then be transported out of the airways.

Coughing requires abdominal and rib muscles. For people with spinal cord injury, these muscles may be impaired depending on the diagnosis, the type of paralysis and the impairment level. It is therefore possible that they will need support when coughing up secretion.

How can coughing up be supported?

• Move into a good body position.
• Breathe in deeply and deliberately.
• Increase pressure by closing the vocal folds – the counter pressure that is created expands the bronchial tubes.
• Cough strongly and briefly but without cramping.
• Breathe deeply between coughs.

It is harder to cough up thick mucus. You should therefore drink enough, especially tea (anise, fennel, thyme, ribwort, mallow and licorice).

Inhalations can help to liquefy the mucus. Best suitable are inhalations using a saline solution. Sodium chloride is atomised into tiny drops by using an ultrasonic or injector nebuliser. They go deeply into the respiratory tract when inhaling whereas with standard inhalation procedures the bronchi cannot be reached. Saline solutions and nebulisers can be bought in pharmacies.

Manual assistance by a caregiver

A powerful coughing action is needed to cough up mucous or during swallowing. If the person lacks strength in their abdominal muscles, a caregiver may help them to cough up secretions.

Sudden pressure is exerted on the abdominals and lower chest area in connection with the coughing mechanism.

Mobilising secretion with Cough Assist

If the respiratory muscles are weakened or partially paralysed, the ability to cough efficiently and to expel possible secretion is diminished. The device Cough Assist offers efficient support to release (to mobilise) the secretion. By switching fast from positive pressure during the inhalation phase to negative pressure during the exhalation phase, natural coughing up is simulated.

In order to follow an efficient therapy without complications when using Cough Assist, patients and support staff must be instructed by qualified professionals.

What is needed for the therapy?

• Cough Assist equipped with a device filter, tube and mask / mouthpiece or catheter mount (if tracheal tube present)
• Towels to absorb coughed-up secretion
• Extractor system if needed
• Possibly NaCl 0.9 % 10 ml in Mini-Plasco ampoules to better liquefy and therefore mobilise thick secretion

Preparation of the therapy

• If possible, put the patient in an upright position.
• Position the arms in such a way that there is enough space to extend the chest.
• Check the device settings before each use – the settings should be made upon consultation with a doctor or qualified nursing staff.
• Put on the mask, mouthpiece or catheter mount.

Procedures

• One cycle:
  • put toggle switch on “inhale” for 2-4 sec.
  • switch immediately to “exhale” for 3-5 sec.
  • take a short break (1-2 sec.)
• Repeat cycle 3-6 times
• Depending on how much secretion is present, suctioning and/or cleaning of the mask, mouthpiece or Mount Catheter is necessary.
• If not all secretion was mobilised, further cycles can be performed after a recovery phase (several minutes, depending on how the person feels).
• If the person using Cough Assist does not need any assistance and is able to install the mouthpiece / mask by him / herself, he or she can choose auto mode. The individually set device then performs the pressure change automatically, from inhale to exhale followed by a break.

The tubes need to be exchanged once per week. If dirty in between, they should be cleaned under flowing water and allowed to dry.

Invasive respiration

What does invasive respiration mean?

For people with spinal cord injuries with a lesion at a level of C4 or higher, breathing is inadequate, or there is a complete absence of it. As a result, people affected are dependent upon invasive respiration – invasive because the respiration takes place through a tracheostomy tube which runs through the neck directly into the airway.

Artificial respiration is the partial or complete performance of natural breathing via an external aid (respirator). A distinction is made between controlled and assisted respiration. In the case of controlled respiration, the breathing work is performed completely by the respirator. Respiratory frequency, depth and tidal volume are controlled by the machine’s settings. Depending on which parameters are defined, you may be dealing with pressure or volume-controlled respiration.

Controlled respiration

Pressure-controlled respiration

This is the most frequent form of respiration that is applied. It is easier for the person to tolerate than volume-controlled respiration because excessive pressure is unable to form. The following two pressure levels are set:

• Upper pressure = inhalation pressure
• Lower pressure = pressure remaining in the lung after exhalation

The tidal volume results from the difference between the two pressure levels. However, this reduces as the airway resistance rises, e.g. based on the presence of a secretion.

Volume-controlled respiration

In this form of respiration, a certain tidal volume is applied to the lung within a certain period of time which can be set. In this form, very high peak pressures can arise because the respirator¹ only monitors the volume being applied. Previously, this form used to be applied frequently in the intensive care unit; however, this is rarely the case now.

Assisted respiration

The natural respiratory impulse of the person affected is taken into consideration in this form. When they start to breathe, the breathing process is supported. If they experience lengthy interruptions in breathing, they undergo intermediate respiration under controlled conditions.

Non-invasive respiration

What does non-invasive respiration mean?

Non-invasive respiration means mechanical breathing support without endotracheal access, i.e. without the insertion of a tracheostomy tube in the windpipe. Respiration takes the form of excess pressure via a face mask, oronasal mask or nasal mask.

The adjustment and setting of non-invasive respiration is done by experienced personnel and require continuous monitoring at the start.

The person has to get used to wearing a respiration mask, and they must receive training in this.

When is non-invasive respiration applied?

The best known example of this is non-invasive respiration for people suffering from sleep apnoea at night; this means that they have lengthy breathing pauses while they are sleeping which reduce their supply of oxygen.

Another group for whom non-invasive respiration is suitable is people with a weakened diaphragm. Possible reasons for this include:

• High-level spinal cord injury
• ALS (amyotrophic lateral sclerosis²)
• Critical illness polyneuropathy³

When is non-invasive respiration not suitable?

Non-invasive respiration is unsuitable if the person does not have any spontaneous breathing⁴ capability. Where people have consciousness disorders such as somnolence or coma, this technique is not applied due to the absence of protective reflexes (for instance, vomiting reflex). Application is also difficult in the case of people who experience agitation or who have a lack of understanding of the measure.

Other possible reasons for not applying non-invasive respiration (and which thus necessitate invasive respiration) include:

• High level of bronchial secretion in combination with inadequate coughing
• Obstruction of the airways by tumours or foreign bodies
• Problems putting on the mask, for instance due to anatomical reasons, facial injuries or burns

What possible complications may arise during non-invasive respiration?

Risk of aspiration⁵ and gastric flatulence

• Conjunctivitis⁶ caused by the escape of air in the case of leaks in the area of the nasal root
• Pressure sores because the face mask is too tight

What are the advantages and disadvantages of non-invasive respiration?

Non-invasive respiration improves the quality of life for people who suffer from sleep apnoea. Tiredness during the day due to interrupted sleep at night caused by the lack of oxygen is reduced significantly.

One disadvantage is that it may be a nuisance having to wear the mask, especially when you turn over in bed at night. In addition, you always have to take the breathing device with you if you need it during the day.

Generally speaking, the objective of any breathing support should be that it is non-invasive in order to reduce the risk of complications.

¹ Respiration device

² Degenerative nerve disease

³ Situation after multiple organ failure

⁴ Independent breathing stimulus

⁵ Ingress of material into the airways

⁶ Inflammation of the conjunctiva

The windpipe, which is also known as the trachea, begins under the larynx and extends as far as the chest, where it is spread out into the bronchial system of the lungs. The windpipe is a stable, fixed tube through which inhaled air is conducted into the lungs. During a tracheotomy, access is created to the windpipe by bypassing the upper airways in order to guarantee unimpeded breathing or respiration or in order to shorten the airway. This is done using a tracheostomy tube, with or without a cuff¹.

Sometimes, a tracheostomy tube is also inserted if the patient has massive dysphagia with a risk of aspiration². The deep airways can be protected against aspiration with a blocked (cuffed) tube.

Tracheostomy tubes come in different shapes and sizes which can be selected individually. The tracheostomy tube is changed every four weeks by skilled personnel. The tracheostomy tube is a foreign body, and the patient may have to get used to it.

Possible complications with the tracheostomy tube

Despite taking all the necessary safety precautions, there are always certain risks of complications during any medical intervention. In particular:

• Slight bleeding around the tube – this can generally be controlled with compressions and dressings.
• Infected wounds may have to be treated with antibiotics.
• Air trapped in cutaneous tissue (= subcutaneous emphysema), which makes a crackling noise when pressure is applied to it, is generally harmless.
• Blood flows into the lungs, and this can lead to pneumonia.
• Tube blockages can be prevented by regularly clearing the tracheostomy tube.
• Displacement of the tube, which is why it must be properly fixed in place.
• Rare complications: Paralysis of the vocal cords or heavy bleeding

Tracheostomy tube with a cuff

A cuffed tracheostomy tube is used if the person is unable to swallow independently or in order to guarantee effective artificial respiration. The cuff is an inflatable balloon around the tube which seals this tracheostomy tube to the windpipe. This prevents saliva and secretions from entering the airway unhindered from the oronasal area.

It is impossible to speak with a cuffed tracheostomy tube because the respiratory air bypasses the larynx. It is also impossible to clear your throat or to cough because the air escapes without any build-up of pressure. Smelling is also greatly impaired because the person can no longer inhale through their nose.

In the case of spontaneous breathing without the support of an apparatus, the cuffed tracheostomy tube is combined with a filtre known as an “artificial nose”. It retains the warmth and moisture of air being expelled, and releases it the next time the person breathes in. Furthermore, the artificial nose cleans the air and protects the lungs against particles of dirt.

Speaking with a tracheostomy tube

Speech is very important for communication between people. To ensure that this is also possible with a tracheostomy tube, a speech valve is attached. The speech valve is a one-way valve that allows the inhaled air to flow in and which seals when the person exhales. Consequently, the entire airflow is only conducted via the upper airways during exhalation (larynx, pharynx, mouth, nose), making it possible to speak. Resistance may also build up through the one-way valve, enabling the person to cough.

If the speech valve is used all day long, there is a risk that the tracheal secretion will become very dry in the absence of an artificial nose. In the worst case scenario, the tracheostomy tube may become closed off as it is encrusted or clogged with secretion. Therefore, it is important to moisten the airways regularly by inhaling.

The speech therapist will help with practising speaking with the speech valve.

Swallowing / eating with a tracheostomy tube

With a cuffed tracheostomy tube, the secretion that runs into the airways through the larynx and that collects above the cuff cannot be coughed out actively because the airflow passes completely through the tracheostomy tube. Over time, this leads to reduced sensitivity, which means that when the person starts to consume food and liquids orally again, he or she responds too late, if at all, with reflective coughing, increasing the risk of aspiration. The first time the person attempts to swallow, intensive assistance and support will be provided by the speech therapist.

Inhalation

In order to keep the tracheal secretion liquid or to make coughing easier, regular inhalation is required. This is done using a saline solution or possibly using medication to loosen the secretion. To make inhalation more effective, it is performed with a blocked tracheostomy tube.

¹ Also called a balloon

² Ingress of material into the airways