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What causes pressure sores? Pressure What happens after longer periods of pressure? Long lasting pressure or also brief strong pressure on one part of the skin causes a decreased blood flow inside the tissue. The skin shows locally visible reddening that does not show white when pressing. This reddening of the skin is caused by dead cells and requires decompression. This happens specifically to body parts that are paralyzed and have no sensibility. Buttocks with reddened skin Shearforces What are shearforces? tissue movement in opposite directions Slow pushing or pulling of the various tissue layers causes micro injuries. Where do shearforces occur? Shearforces are caused through sitting in bed, when transferring (sliding) into the wheelchair or shower wheelchair. Shearforces Frequent spots for pressure sores pressure spots in a lying position (Source: Berufsfachschule für Sozialpflege Bayreuth) Frequent spots for pressure sores in a sitting position When should the skin be checked? At least twice per day in the morning during your personal hygiene at night when going to bed Additional skin checks are important: after sitting or lying on a new or unaccustomed surface new mattress or bedding material at home foreign mattress in a hotel, at friends, in hospital, etc. new wheelchair or cushion sports devices such as monoski, handbike, speed wheelchair, etc. seat in an airplane, transfer seat for airplane, etc. dentist's chair, examination stretcher, x-ray stretcher, etc. after wearing new clothes and shoes thick seams of pants, tight shoes, etc. during a health condition or after an accident fever, flue Attention: fever makes the skin much more sensitive! diarrhea increased spasticity after falls when the skin changes swellings dry skin – cracked skin, very scaly skin increased callus hard skin in a hot climate when perspiring profusely Important The most important prophylaxis against pressure sores is a frequent checking through visual examination and palpating of the skin: Press the reddened part of the skin with the finger. If the spot disappears (whitish color for 1-2 seconds), further damage can be avoided by relieving this part of the skin. If this part stays red, the skin is damaged and the condition is called decubitus. It is necessary to consistently relieve this part of the skin for a longer period. If hard skin, scab or blisters have formed, the decubitus reaches deeply and needs urgent treatment by a doctor. What do I need to do in case of pressure sores? If a reddening occurs, immediate relief of the affected skin part is necessary until the skin has recovered. The further the pressure ulcer has progressed, the longer it will take to recover. If an erythema can no longer be pressed away, more time is needed until the skin will have recovered. If the pressure ulcer occurs at a spot that is not affected when using the wheelchair, it is possible to use the wheelchair during the day. However, more frequent periods of relief should be adhered to. If there is pressure on the affected part, it is necessary to lie in bed with frequent repositioning. The longer a pressure ulcer remains without treatment, the deeper will be the decubitus and the longer the recovery period. It is not recommended to treat the wound by oneself over a longer period. Having it checked and treated by a GP or an out-patient care service helps to avoid complications. How can I avoid pressure ulcers? through regular relief or movement of the weight when sitting in the wheelchair – lifting, leaning to the side or ahead, tilting the wheelchair (roughly every 20 minutes) decompression in bed through shifting into various positions – to the side, prone position avoid sitting or lying by mistake on objects that can cause pressure ulcers – buttons, cell phones, etc. wrinkle free bed sheets, suitable clothes without rivets, buttons or thick seams at the buttocks or back FAQs If I notice a reddening at the buttocks using a mirror and cannot check myself if it can be pressed away, what can I do? Family or a care service can hold the mirror for you or check your skin. What do I do if I am unsure about my assessment of the reddened part? Don't hesitate to see your GP or ask an out-patient care service for help. What can I do if I notice that my mattress is causing pressure ulcers repeatedly? Contact an out-patient care service or care counselor. Staff can help you to choose a suitable mattress. About the author: Karin Gläsche is an expert in wound care and stomata in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1999. She is co-author of the key publication in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
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Spinal cord injury is a highly complex injury. From one moment to the next, the body does not function like it did before. Everyday activities require a high level of attention, energy and patience. Within the initial period after the occurrence of spinal cord injury, it is extremely hard to imagine what is actually going on and what this means for the future. In order to be able to actively influence the rehabilitation process as well as life after the initial rehabilitation period, detailed information and knowledge are crucial. This chapter explains what happens to the body in case of a spinal cord injury and what the consequences are. It needs to be mentioned, however, that the consequences of a spinal cord injury are different for every person, depending on the cause and severity of the injury as well as the location of the injury within the spinal cord. What is spinal cord injury? Spinal cord injury is an injury of the spinal cord. The spinal cord is located in the spinal canal of the spine. The spine reaches from the nape of the neck to the sacral bone and forms the framework of our body. It consists of 33 single overlapping bones, the vertebrae. These are held together by disks, tendons and ligaments. The spine can be divided into five sections: the cervical spine (cervical, abbr. C) the thoracic spine (thoracic, abbr. Th) the lumbar spine (lumbar, abbr. L) the sacral spine (sacral, abbr. S) the coccyx (coccygeal) The spinal cord, in principle, is a cord of nerves and can, strongly simplified, be compared with a telephone cable that transports signals back and forth between the brain and the body. Similarly to the spine, the spinal cord can be divided into four sections which, again, can be subdivided into individual segments (neurotoms). In between the vertebrae, the nerves of the spinal cord branch off on each side to the respective body regions. There are 8 cervical segments (C1 to C8) 12 thoracic segments (Th1 to Th12) 5 lumbar segments (L1 to L5) 5 sacral segments (S1 to S5) In case of a spinal cord injury, the spinal cord has been damaged or even severed at a specific spot through and accident or a health condition. Therefore, the communication is disrupted between the body parts below the damage and the brain. The damage of the spinal cord is called lesion. Important functions such as mobility (motor functions) or sensation (sensory functions) fail below the lesion. Spinal cord injury can be described as a horizontal paralysis where a lesion height can be defined that runs through the body on a horizontal line, unlike a vertical lesion, that can occur in case of a stroke. What is the difference between traumatic and non-traumatic SCI? Traumatic SCI is the result of trauma where the spine, conjointly the spinal cord, have experienced direct external force. In most cases, these are associated with luxations (dislocations) or fractures of the spine as well as injuries of adjacent structures. The spinal cord becomes pinched, crushed or sometimes even torn. However, paraplegia may also result from a simple contusion of the spinal cord, when it hits against the wall of the spinal canal. The most common causes for traumatic paraplegia are falls, sports, motor vehicle accidents and work accidents. Men are more frequently affected by traumatic paraplegia than women. In non-traumatic paraplegia, the nervous tissue of the spinal cord is either damaged by a disease, perishes due to lack of blood supply, or is displaced and incarcerated by tumours and metastases until paralysis eventuates. Non-traumatic paraplegia is caused by diseases of the spinal cord or the surrounding structures: Inflammation, infection, bleeding, circulatory disorders, tumours and metastases as well as degenerative nervous system disorders. Paraplegia induced by medical treatment, is also considered non-traumatic. With over 70%, traumatic paraplegia is far more common than non-traumatic paraplegia. What is the difference between paraplegia and tetraplegia? The characteristics of paraplegia is a paralysis starting in the thoracic (Th1-Th12), lumbar (L1-L5) or sacral (S1-S5) area, while tetraplegia is caused by damages in the cervical area (C1-C8). Paraplegics possess good functions of arms and hands. The lesion occurs primarily in the trunk and legs. Tetraplegics, in comparison, also suffer from paralysis of the hands and partially of the arms. In a first clinical examination, the physician can locate the injury exactly. With the help of technology, such as x-rays or computer tomography (CT), the damages of the vertebrae can be made visible and magnetic resonance imaging (MRI) shows damages of the spinal cord. The lesion height is defined by the last fully functioning segment of the spinal cord. Tetraplegia "sub C6", for example, means that the spinal cord segments C1 to C6 are fully functioning and the segments C7 and below affected. What does "complete" and "incomplete" mean? Depending on the damage of neural pathways within the spinal cord, the result is a complete or incomplete lesion. Paraplegia is considered complete if no motor or sensory functions can be determined below the lesion level (exception: zone of partial preservation (ZPP)). If sensitivity can be observed in the neurological segments S4/S5 (skin area surrounding the anus), it is considered an incomplete SCI. Neurologic examinations enable the physician to locate the damage quite precisely and to determine its extent. The physician uses three international scales: With the survey sheet ISNCSCI (International Standards for Neurological Classification of SCI; see http://www.asia-spinalinjury.org/elearning/ASIA_ISCOS_high.pdf) the SCI induced motor and sensory function deficiencies are documented. The AIS scale (ASIA Impairment Scale, here ASIA stands for American Spinal Injury Association, the American society for spinal cord injuries; see page 2 of the above ISNCSCI sheet) helps to determine the various levels of incomplete paralysis. The Autonomic Standards Assessment Form (see http://www.asia-spinalinjury.org/elearning/ASIA_Auto_Stan_Worksheet_2012.pdf) complements the examination by covering the dysfunctional attributes of the autonomic nervous system. The examinations illustrate all remaining sensory and motor functions. These remaining functions, the level of injury, and the degree of paralysis enable prognosis and allow for inferences about the future possibilities regarding daily activities and routines. What are the most important consequences of spinal cord injury? Initially, most people will think in terms of mobility of legs and hands when it comes to paralysis. However, damages of the spinal cord have more extensive consequences, namely on three levels: the motor level, where mobility is decreased, the sensory level, where sensitivity of e.g., the skin is decreased, the autonomic level, where the activity of the inner organs (bladder, bowel, cardiovascular activities, respiration, etc.) or sexual functions are controlled involuntarily. Therefore, also the functions of the inner organs are strongly limited. If bladder and bowel do not work automatically, the people affected have to manage them consciously. This is important to avoid complications and permanent damage such as bladder or kidney infections. Until 60 years ago, life expectancy for people with spinal cord injury was low due to these kinds of complications for which there were no long term treatment possibilities. Today, life expectancy is almost the same as in people without spinal cord injury due to efficient bladder and bowel management. Recently injured people are confronted with these topics from the beginning; challenges can be overcome, however, due to professional care and support as well as technological and medical aids. Specific attention should be paid to the sensitivity (ability to feel) of the skin since it can be decreased. Since the people affected can no longer react to warning signs such as pain from insect bites or pressure sores, they have to predict and ultimately prevent possible damages. Furthermore, in tetraplegics and paraplegics with high lesion levels, body temperature regulation is affected. People with spinal cord injury sometimes experience inconsistent respiratory difficulties. It is the task of the rehabilitation team to teach the person concerned as well as his/her family how to overcome such possible complications. This forms the basis for a maximum independence within the given possibilities when living with spinal cord injury. updated: January 2015
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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. 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 already in the first year after SCI. In most cases, the symptoms exacerbate over the years and many people report that permanent pain reduces the 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, toxic (intoxication), metabolic 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 might be from tickling, dragging, and electrifying over burning to stabbing or a sharp pain, or it can even be a very oppressive or pressing feeling. Paraplegia is caused by an injury of the spinal cord. The spinal cord runs through the vertebral canal and is part of the central nervous system (together with our brain). Neuropathic Pain The figure shows neuropathic pain in case of paraplegia spinal cord injury. Due to a dysfunction or damage of 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 mental 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. Sometimes an in-patient therapy in a specialized pain clinic might be advisable – it just takes some time and expert advice to assess the different options. 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 sports, Feldenkrais (a special method in kinematics) and hippo therapy (therapeutic horseback riding) can help to find strategies for “shutting off” the pain and thus enable participation in joyful activities with others. To keep the pain at a moderate level, it is also vital to create a stress-free environment. For more detailed information and expert advice on pain please contact a Pain Society or a Centre for Pain Medicine. Further Information on the Internet: Swiss Association of Pain Studies: http://www.pain.ch/ Centre for Pain Medicine Nottwil, Switzerland: http://www.paraplegie.ch/de/pub/zsm.htm Austrian Pain Society: http://www.oesg.at/index.php?id=225 German Pain Society: http://www.dgss.org/ German Neuropathic Pain Research Association: http://www.neuro.med.tu-muenchen.de/dfns/index.html French Pain Society: http://www.sfetd-douleur.org/accueil/index.phtml?mapViewDataId=9b9637d6-7ec3-4185-8d64-9affa6897b90 American Pain Society: http://www.americanpainsociety.org/ References: Budh C, Kowalski J, Lundeberg T. A comprehensive pain management programme comprising educational, cognitive and behavioral interventions for neuropathic pain following spinal cord injury. J Rehabil Med. 2006;38:172-80. Cardenas DD, Rosenbluth J. At-and Below-Level Pain in Spinal Cord Injury: Mechanisms and Diagnosis. Top Spinal Cord Inj Rehabil. 2001;7(2):30-40. Richards J, Siddall P, Bryce T, Dijkers M, Cardenas DD. Spinal Cord Injury Pain Classification: History, Current Trends, and Commentary. Top Spinal Cord Inj Rehabil. 2007;13(2):1-19. Störmer S, Gerner HJ, Grüninger W, Metzmacher K, Föllinger S, Wienke Ch, Aldinger W, Walker N, Zimmermann M, Paeslack V. Chronic pain/dysaesthesiae in spinal cord injury patients: results of a multicentre study. Spinal Cord. 1997;(35):446-55. updated: December 2013
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Why is compression therapy necessary? In people with spinal cord injury, the blood cannot flow back to the heart as easily. When sitting in a wheelchair, the blood needs to flow “uphill" in the veins. The calf muscles, that pump the blood towards the heart when walking, are missing completely or partially. As a result of the paralysis, the blood collects in the legs and these become swollen. The blood pressure is lower than in people without spinal cord injury. How do compression stockings work? Compression stockings accelerate the blood flow, decrease the venous pressure, avoid water retention and improve the blood supply in the legs. Through better transportation of the blood to the heart, the danger of edema decreases. The pressure of the stockings keeps liquid from collecting in the tissue. Therefore the stockings prevent the development of oedema. Wheelchair users wear compression stockings class II. Compression stockings (Source: MedicalExpo) What do you absolutely need to watch out for? It is important to put on the compression stockings correctly. They must not be worn rolled down since a rolled seam may lead to dangerous congestion and therefore may cause thrombosis. After putting them on, you should watch out carefully for creases (especially in the hollow of the knee). After taking them off, the skin needs to be checked for pressure sores. Important Always use gloves when putting on compression stockings to avoid damage through finger nails. If the compression stockings are open at the toes, we recommend using a foot slip since this makes it easier to put on the compression stockings. Remove foot slip afterwards. Dressing of stockings with gloves (Source: SIGVARIS) Care instructions for compression stockings The stockings should be washed every 1-2 days at around 40°C using the laundry machine. Washing them keeps the stockings in shape. Use detergents for delicates but not fabric softener. If you wash them by hand, rinse them well and don't wring them but fold them into a towel and squeeze the water out. Most stockings can be put in the dryer using a gentle program. We do not recommend putting them on the radiator or in direct sunlight. Holes and tears should only be mended by professionals. Do not remove threads that are sticking out. If the stockings are damaged, we recommend looking for the reasons (roughened callus, long toe nails, damaged lining of the shoe inside, wrong handling, etc.). If you have the impression that the volume of your legs is increasing, please contact your physician immediately. If your legs are decreasing in volume and the stockings are too loose, you should also contact your physician. Where can you get new compression stockings? In Switzerland you can get a prescription from your physician for 2 pairs of stockings per year and the costs are reimbursed by the health insurance. In other countries, you need to contact your health insurance regarding the costs. The stockings can be bought from a retail healthcare supplier. What can be done additionally? Do not wear tight clothes and shoes since this can obstruct blood flow in the veins. Do not expose yourself to heat (sunbathing, hot baths, etc.) since the veins are expanding even more in the heat and the blood collects in the feet. Do not cross your legs since this can obstruct the veins in the knee hollows. Watch your body weight. Being overweight strains the heart, arteries and veins. FAQs Do I need to wear the stockings permanently due to my spinal cord injury? Whether the wearing of compression stockings is necessary permanently depends on various factors; mostly, however, it is not. If your legs become heavily swollen, we recommend wearing the stockings. This often happens in case of a climate change. Also for trips on the airplane we recommend wearing them. Wearing compression stockings helps to stabilize the blood pressure. If you have circulation problems when mobilizing, you will find it difficult without the stockings. For how long can I use a pair of compression stockings? Medical compression stockings can be used for 6 months before the fabric loses its firmness and the medical effect decreases. What do I do if my compression stockings cause pressure sores? Check whether the stockings have been put on the wrong way and whether the pressure marks disappear overnight. If this is not the case, don't put on the stockings again. Contact the supplier – he will check whether they fit properly or not. Can I order new compression stockings via phone? We do not recommend doing so. Your legs may change and therefore need to be measured every time again before getting the right stockings. About the author: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). updated: December 2013
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What are contractures and how do they develop? Contractures are shortening of muscles, tendons or ligaments that have a limiting effect on movements of the joints. 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 cannot be fully extended any more. The cause for contractures may also be previously existing restrictions on movement of the joints that are necessary for recovery (e.g. a plaster cast) or other health conditions (e.g. arthritis). Where can restrictions in movement caused by contractures be seen most frequently? Hip joints Knee joints Ankles (equinus foot deformity) Toes (claw foot) also on the arms of tetraplegics: - Shoulder joints - Elbow joints - Wrists How can contractures be avoided? Contractures can be avoided by moving (if possible autonomously) arms and legs actively and by changing the body position frequently: - lying - sitting - bent - extended Why is it important to avoid contractures? Movement restrictions in arms and legs make everyday life more difficult and decrease autonomy considerably, e.g. eating, personal hygiene, dressing oneself, transferring oneself, etc. Contractures can lead to pressure sores. Important If positioning measures are not performed consistently and correctly, contractures may develop quickly and treating them might take a long time. FAQs After being released from the hospital, do I need to go on with the equinus foot deformity prophylaxis? Normally not. If the feet are in the right position (min. 90° angle of the ankle) during mobilization (more than 6 hours) and upright training is done (30 min per day), no drop foot prophylaxis is necessary in bed. However, should the situation change, e.g. through increased spasticity, it needs to be reassessed whether prophylaxis against foot drop becomes necessary. What happens if I rarely wear shoes in the wheelchair or not at all? The footrests on the wheelchair are normally too narrow for the toes to be supported so that they are hanging down if you are not wearing shoes. This may cause the development of claw feet which may cause problems when wearing shoes (pressure sores). Moreover, shoes offer protection against injuries, e.g. when striking the walls. What is the best position in bed in order to avoid contractures in the hip and knee joints? The best position is the prone position since this stretches the joints. About the author: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). updated: December 2013
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What are hemorrhoids? The hemorrhoid veins are part of the locking mechanism of the rectum and are responsible for sealing the anus. The sealing works through different levels of filling of the blood vessels. If these vessels do not inflate and deflate properly and cause problems, it is called hemorrhoids. What are the symptoms of hemorrhoids? Anal bleeding Mild fecal soiling In case of existing sensitivity: anal itching anal burning What is an anal fissure? An anal fissure is a crack in the anal canal. Most anal fissures are caused by stretching the anal mucosa beyond its capability. Pain causes additional tenseness of the anal opening which reduces its opening volume even more. Scars may develop and further decrease the elasticity of the anus. What are the symptoms of anal fissures? Weeping and fresh blood on the toilet paper In case of existing sensitivity: pain when defecating, potentially long lasting anal itching Important Hemorrhoids and anal fissures cannot always be avoided; however, if some simple rules are followed, their occurrence can be reduced: regular defecation, every 1-2 days preventing constipation or hard stool only as many digital manipulations of the rectum as necessary; carry out carefully and use sufficient Vaseline What do I do if I suffer from problems due to hemorrhoids or anal fissures? Regulation of stool consistency – it should be soft and depends on: eating food rich in dietary fiber avoiding flatulence-causing foods drinking enough adjusting of laxative medication Hemorrhoids local treatment using hemorrhoid paste or suppositories Anal fissures if painful, a local anesthetic paste may be used good personal hygiene, possibly warm hip-baths If hemorrhoids are too big or cause too much discomfort, surgery becomes necessary. The enlarged vessels are normally ligatured with an elastic band or atrophied. FAQs Is blood in the stool generally caused by hemorrhoids or anal fissures? Is this always harmless? No, a change in the bowel can also be the reason for it. You should consult your GP when a bleeding occurs for the first time. Is it dangerous if it is bleeding strongly? Usually not – hemorrhoids can bleed severely. However, if the bleeding continues , you should inform your GP. About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". The article is the result of a collaboration with the panel of experts in bowel management of the Swiss Paraplegic Centre. updated: December 2013
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What is thrombosis and what causes it? Thrombosis is a condition where a blood clot (thrombus) forms inside a blood vessel and thus causes a restriction or blockage of the blood flow within the vessel. Thromboses are dangerous as they might lead to a pulmonary embolism (see FAQs) in case the blood clot travels to the lungs. Causes of thrombosis (Source: Kliniken des Main-Taunus-Kreises GmbH) What causes thrombosis? Blood flows slowly when sitting for long periods of time, lack of muscle activity in the legs, confinement to bed, injuries such as bone fractures etc. – therefore increased risk in people with spinal cord injury Increased risk in people who: are overweight, smoke, have already had thrombosis or use certain medication (e.g. birth control pill) What are the signs and symptoms of thrombosis? Possible physical trouble: Sudden pain in the affected area plantar pain dragging pain along the vein In case of no sensation of pain, symptoms may include: one leg is significantly thicker than the other redness of skin and warm skin in the affected area 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 Legs with and without thrombosis (Source: Kliniken des Main-Taunus-Kreises GmbH) How to prevent thrombosis: sufficient fluid intake (see FAQs) wearing of compression stockings in case of extensive swelling of the legs injection of blood-thinning preparations in case mobilisation is restricted for a certain period of time => please contact physician When do I have to be especially careful? during summer warmer temperatures: sufficient fluid intake when traveling hot climate: sufficient fluid intake on journeys shorter than four hours: possibly wear compression stockings on journeys longer than four hours: injection of blood-thinning preparations => please contact physician in case of leg injuries, e.g. fractures or heavy bruises as a result of a fall => please contact physician in case of infections => please contact physician Important Thrombosis has to be treated as soon as possible as the results can be life threatening. In case a thrombosis is suspected, the GP must be contacted immediately. It is important to move as little as possible (e.g. mobilisation) – the thrombus might be released and cause a pulmonary embolism. FAQs What kind of compression stockings do I need? Compression class 2. To be effective, the compression stockings must fit well. In case you already have older stockings at home, make sure they still fit and are effective. What is a pulmonary embolism? A pulmonary embolism is a life threatening condition caused by a sudden blockage of a blood vessel in the lungs. E.g. the vessel might be blocked by a blood clot that originated in the leg. Symptoms of a pulmonary embolism include: shortness of breath, anxiety, irritation of the throat, rapid pulse. What does sufficient fluid intake mean? It is recommended to drink 2.5 liters each day – on hot days correspondingly more. 1.5 liters of urine have to be excreted through the bladder each day. Suitable fluids are water and fluids that are rich in minerals (mineral water). About the author: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). updated: December 2013
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What is autonomic dysreflexia? Autonomic dysreflexia, also called „Gutmann-Reflex“, is a regulation problem that leads to an over-stimulation of the autonomic nervous system. In case of a spinal cord injury (SCI), this may occur above the seventh, rarely also the eighth thoracic vertebra. Autonomic dysreflexia can be triggered through various stimuli, mostly through stimuli in the bladder or bowel area. These stimuli are causing 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 way too high and tries to lower the blood pressure by reducing the heart rate. Signs of an autonomic dysreflexia pulsating or hammering headache vertigo sweating facial flushing low pulse rate massive and very sudden increase of blood pressure What may be the causes? The most frequent causes are: bladder congestion, or overstretching, spastic bladder full bowel (severe constipation) external stimuli (pressure, decubitus, burns) Other possible causes: infection urological/gynecological examinations pregnancy/childbirth sexual activity intensive sports activities with a full bladder Important Do not ignore the symptoms! If not treated properly, they may lead to seizures, unconsciousness or stroke. How to react? The most important measure is to eliminate the cause: Empty 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 under the buttocks/body. Important If the reason cannot be identified, contact your GP immediately! FAQs Can the bladder be emptied normally through triggering if I have an autonomic dysreflexia? Normally not. The bladder has to be emptied as soon as possible using a disposable catheter. What do I need to consider if I am pregnant? Women with spinal cord injury (SCI) may suffer from autonomic dysreflexia when giving birth. Not all gynecologists are confident with this condition and it is therefore important to discuss it with the physician. About the authors: Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1997. She is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" and "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch). updated: December 2013
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1) Invasive ventilation What is invasive ventilation? For people having tetraplegia with a lesion level at C4 or higher, their breathing is insufficient or fails completely. They are therefore dependent on invasive ventilation – invasive because breathing takes place through a tracheal tube which goes through the throat directly into the trachea. Ventilation means that the physiological breathing is taken over partially or completely by external assistance (ventilator). A distinction is made between controlled and assisted ventilation. When ventilation is controlled, breathing is taken over completely by the ventilator. The breathing rate, depth and volume of breathing are controlled by the device settings. Depending on the defined parameters, one calls it a pressure- or volume-controlled ventilation. Ventilator Vivo 50 Controlled ventilation Pressure-controlled breathing This is the most commonly used type of ventilation. In opposite to the volume-controlled ventilation, this type of ventilation is gentler since no high pressure can occur. The following two pressure levels can be adjusted: Upper pressure = inhalation pressure Lower pressure = pressure which remains in the lungs after exhaling The breathing volume results from the difference of both pressure levels. It decreases, however, with an increasing breathing resistance, e.g. due to existing secretion. Volume controlled breathing With this type of ventilation, a certain breathing volume is applied into the lungs within a specific adjustable time. During this type of ventilation, very high peak pressures might occur since the respirator (ventilator) only monitors the volume that is applied. In the past, this type of ventilation was often used in intensive care but is now hardly used any more. Assisted ventilation The natural respiratory drive of the patient is taken into consideration for this type of ventilation. When the patient starts to breathe, the breathing process is supported. If the patient has longer breathing interruptions, a controlled inter-ventilation will take place. 2) Non-invasive ventilation What is non-invasive ventilation? Non-invasive ventilation is a mechanical support of respiration without endotracheal access (i.e. without tracheal tube through the trachea). The ventilation is applied through overpressure via full-face, mouth-nose or nasal masks. Various types of masks The setting and adjustment of non-invasive ventilation is carried out by experienced staff and will initially require continuous monitoring. It is necessary to get accustomed to wearing a ventilation mask and needs to be trained. Adjusting the nasal mask When is non-invasive ventilation applied? Best known is the non-invasive ventilation for persons who are suffering from nocturnal sleep apnoea, i.e. they have long breathing breaks while sleeping and therefore suffer from a reduced oxygen supply. Another group for which non-invasive ventilation may be applied is people with a weakened diaphragm. Reasons therefore may be: Spinal cord injury with a high lesion level ALS (Amyotrophic Lateral Sclerosis, a degenerative neurological disease) Critical illness polyneuropathy (condition after multiple organ dysfunction) Further possible needs of non-invasive ventilation may be: Patients who exhaust themselves due to a high respiration rate Oxygenation impairment (dysfunction of absorption of oxygen in the blood) Mild respiratory acidosis (dysfunction of the acid-base balance) When is non-invasive ventilation inappropriate? If no spontaneous respiration (respiratory reflex) is present, the non-invasive ventilation will be inappropriate. For people with disturbances of consciousness such as somnolence or coma, this type of ventilation is also not applied due to the absence of protective reflexes (e.g. nausea). Likewise for people with agitation (restlessness) or a lack of understanding for the measure, the ventilation is hardly applicable. Further possible reasons that speak against the application of non-invasive ventilation (and therefore require invasive ventilation): A lot of bronchial secretion in combination with insufficient coughing-up Relocation of the respiratory tract due to tumors or foreign objects Problems with putting the mask on, e.g. due to anatomy, facial injuries or burns What are the possible complications of non-invasive ventilation? Hazard of aspiration (penetration of material in the respiratory tract) and gastric insufflations Conjunctivitis (inflammation of the conjunctiva), caused by escaping air results from leakage in the area around the nasal root Pressure marks due to a facial mask that is too tight Which (dis-)advantages does non-invasive ventilation have? For people who suffer from sleep apnoea, non-invasive ventilation improves the quality of life. The daytime fatigue due to many sleep interruptions during the night, caused by the lack of oxygen, is reduced significantly. A disadvantage may be that the mask is disturbing, especially when turning around in bed at night. Furthermore it is necessary to always bring the ventilation device along if it is also used during daytime. In general the goal of respiratory assistance should always be a non-invasive type so as to reduce the risks of complications such as infections. FAQs What do I do if the breathing mask does not fit properly? There are many different types and sizes of masks. Finding the ideal mask requires time. It is also possible that a problem occurs only after a longer period of time. Contact a specialist, e.g. the RespiCare-Team. Possibly a new mask needs to be fitted. Can I travel with my ventilation device? Yes, this is possible. Don't forget to inform yourself whether you will need an adapter for the plug, e.g. for connecting it to a car battery. About the authors: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Jens Katzer is graduate nurse specialized in respiration and ventilation. He heads the panel of experts in respiration management of the Swiss Paraplegic Centre. updated: January 2017
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In some cases, support is needed for cleaning the nasopharyngeal space and keeping it free from secretion. For this purpose, suctioning is performed through the nose and, if necessary, through the mouth. This is particularly necessary if the nose cannot be blown properly by the patient him-/herself or if the mouth cannot be rinsed. Suctioning is also performed through the tracheostomy (trach) tubes at least 2-3 times per day to check that the tubes are secretion-free and more frequently, in case of secretion which cannot be coughed up. Suctioning is necessary if the coughing is insufficient to mobilize secretion from the lungs; to ensure that the trach tube is clear; for decuffing in order to remove the secretion that has cumulated above the cuff; in case of a suspected aspiration (penetration of material into the respiratory tract) through swallowing/vomiting; if you can hear that there is a secretion. Suctioning is an unpleasant procedure. Persons who carry out this intervention must be well trained so that no lack of oxygen (if suctioning is too long), mucosa injuries and bleeding (if suctioning is too strong) or germ migration (due to lack of hygiene) can occur. They also need to be familiar with the symptoms of vagus stimulation (slowing down of the heart rate or even life-threatening heart rhythm disturbances) which can occur through suctioning. Depending on the localization of the suctioning, different materials are needed. Other than the suction device these are: for nose suctioning a bent catheter Fr 10 or 12, lubricant or anesthetic gel, nasal ointment if necessary; for mouth suctioning Yankauer (a specific suction catheter), bent or atraumatic catheter (with a specifically-shaped end to avoid injuries); for cannula/trachea suctioning atraumatic catheter Fr 12 or 14 (ProFlo), pulse oximeter (device for measuring the heart rate and oxygen saturation), if necessary, sterile gloves, face mask, and safety goggles if necessary. Bent and atraumatic catheter Procedures Suctioning in the nose: apply gel in the nose; allow 1-2 minutes absorption if using anesthetic gel (Xylocaine gel); apply gel on catheter; insert catheter into the nose without suction; suction with 200 mbar suction pressure. Suctioning in the cannula/trachea: insert catheter during suction (suction pressure 400 mbar); possibly liquefy the secretion. Replacing the catheter A suction catheter must be used up to three times only for the same suction procedure. The same catheter must never be used for both trachea and nose/mouth suctioning. Tubes, Yankauer and Fingertip are replaced weekly or when visibly dirty. Water bottles (for rinsing the suction tube after the suctioning) are also replaced once per week or earlier if dirty. The water needs to be changed daily. An adaptation of hygiene measures within the domestic environment may be evaluated individually. In clinics or institutions, however, all work should always be done aseptically (use of sterile materials, protective gloves, etc.). About the authors: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Jens Katzer is graduate nurse specialized in respiration and ventilation. He heads the panel of experts in respiration management of the Swiss Paraplegic Centre. updated: October 2016
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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 mucus which can then be transported out of the airways. Coughing requires abdominal and rib muscles. In persons 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 coughing. It is harder to cough up thick mucus. You should therefore drink enough, especially tea (anis, fennel, thyme, ribwort, mallow and licorice). Inhalations can help to liquefy the mucus. Best suitable are inhalations using a saline solution. Sodium chloride is atomized by using an ultrasonic or injector nebulizer. Tiny drops go deeply into the respiratory tract when inhaling whereas with standard inhalation procedures the bronchi cannot be reached. Saline solutions and nebulizers can be bought at pharmacies. Mobilizing secretion with Cough Assist If the respiratory muscles are weakened or partially paralyzed, the ability to cough efficiently and to expel possible secretion is diminished. The device Cough Assist offers efficient support to release (to mobilize) the secretion. By switching fast from positive pressure during the inhalation (inspiration) phase to negative pressure during the exhalation (expiration) phase, natural coughing up is simulated. In order to follow an efficient therapy without complications by using Cough Assist, patients and support persons need to be instructed by qualified staff. What is needed for the therapy? Cough Assist equipped with device filter, tube and mask/mouthpiece or Mount Catheter (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 mobilize thick secretion Cough Assist and Cough Assist E 70 Preparation of the therapy If possible put the patient in an upright position. Position the arms in a way that there is enough space to extend the chest. Check settings of the device before each use – the settings should be made upon consultation with a doctor or qualified nursing staff. Put on mask, mouthpiece or Mount Catheter. Applying Cough Assist 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 there is, suctioning and/or cleaning of the mask, mouthpiece or Mount Catheter is necessary. If not all secretion was mobilized, 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 the 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 then let dry. About the authors: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Jens Katzer is graduate nurse specialized in respiration and ventilation. He heads the panel of experts in respiration management of the Swiss Paraplegic Centre. updated: March 2016
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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. (Source: © fotolia) 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. Swiss Paraplegic Centre in Nottwil, Switzerland, has the Centre for Pain Medicine, a specialist department for the treatment of acute and chronic pain. This is where outpatients and inpatients receive the best-possible examination of their pain problem and an accordingly designed treatment – see www.schmerz-nottwil.ch/en/pub/zsm.htm. Useful links: An instructive video about how to deal with pain can be found here: www.youtube.com/watch?v=5KrUL8tOaQs. As a recently founded organization "Schmerzliga Schweiz" offers information and capacity building: www.schmerzliga.ch (in German). A list of pain specialists with the certification "Pain specialist SASP" can be found on the website of the "Swiss Association for the Study of Pain" (SASP): www.pain.ch (in German and French). About the author: Dr. med. André Ljutow, MSc, is leading the Centre for Pain Medicine, one of the biggest interdisciplinary specialist units for pain of the German-speaking countries. As "Pain specialist SASP" with numerous other international qualifications, Dr. med. Ljutow is currently also president of the Swiss Association for the Study of Pain. Furthermore, in his role on the scientific advisory board, he is working on the creation of a self-help organization for pain patients of "Schmerzliga Schweiz". updated: February 2016
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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 mobilized 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 to 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 vapor (chamomile bath, etc.) is only meant for moistening the upper airways (nasopharyngeal cavity). The lower airways such as trachea or bronchi cannot be reached. For a deep inhalation, nebulizing systems and metered-dose inhalers are available. The metered-dose inhalers are exclusively used for applying medication. Nebulizing systems are additionally moistening the respiratory tract. For inhaling, a nebulizer and an inhalation set with a mask or a mouthpiece are needed. In case of a tracheal tube, the inhalation set can also be connected directly to the catheter mount (tube extension). Inhalation set Important When using a mask for inhaling, it is important that it fits well since this can otherwise cause eye irritation or improper inhalation of the medication. How to inhale properly If possible, inhaling should be done in a sitting position to better expand the lungs Concentrating on a calm and deep breathing After inhaling, possibly taking measures for mobilizing 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 Patient during inhalation 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 renewed once per week. After using drugs that contain cortisone, the mouth needs to be cleaned (e.g. rinsing mouth and throat, eating something, brushing teeth) in order to get rid of the drug residue and to avoid fungal infestation in the mouth/throat area. About the authors: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Jens Katzer is graduate nurse specialized in respiration and ventilation. He heads the panel of experts in respiration management of the Swiss Paraplegic Centre. updated: January 2016
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Breathing is the most normal thing for us in the world. 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, even to the smallest ones. In the cells a sort of combustion takes place and results in the production of carbon dioxide, which would then be 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. Anatomy of the respiratory tract (source: eesom) 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 a very 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. Lower airways with profile of the lungs (source: MOVINCOACH.COM) How does our respiration work? Physiology of inhalation and exhalation (source: MOVINCOACH.COM) While inhaling, the diaphragm flattens and the ribs are lifted. Within the created space exists a vacuum so that lungs are expanded and air flows in. This difference in pressure is essential for inhalation but cannot be created by 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 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 like 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 pleura together form the pulmonary pleurae which prevent the lungs from collapsing. Between the visceral and parietal pleura there are a few millimeters of liquid which protects both from rubbing each other while inhaling and exhaling. Control of breathing The breathing is controlled by the respiratory center. This center 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 the chemical processes in the blood (i.e. changing of the oxygen-carbon dioxide content). Respiration in persons with spinal cord injury The higher the level of injury, the more serious the auxiliary respiratory muscles are affected. Therefore, persons with spinal cord injury often have a partial or complete function loss of abdominal muscles which leads to limited coughing ability. Furthermore, the loss of these muscles changes the physiological 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 would be 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 persons with spinal cord injury might need a breathing therapy. FAQs At which level of injury does the breathing stop completely? The diaphragm, which is the main muscle for inhaling, is controlled by nerves between C3 and C5. If the diaphragm does not work, autonomous breathing becomes impossible and a respiratory aid would be needed. About the authors: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Jens Katzer is graduate nurse specialized in respiration and ventilation. He heads the panel of experts in respiration management of the Swiss Paraplegic Centre. updated: December 2015
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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 the sense of seeing through the eye. Our sensitive system retrieves the information from numerous nerve endings and receptors (sort of a specialized cell that transmits stimuli) 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 persons with spinal cord injury, this important warning mechanism is disabled, which can lead to various complications. Risks due to a limited or nonexistent sensitivity Pressure sores Due to a limited or nonexistent sensitivity, persons with spinal cord injury are especially at risk of pressure sores. More detailed information on this topic can be found in a separate text in the Library. Burnings through heat therapy and touching of hot objects or surfaces Heat therapy is one of the oldest medical treatments and is used in conventional western medicine as well as in natural medicine. Since it is used in the home environment, nearly everybody knows it: it includes a number of different applications such as hot-water bottles, cherry pit cushions, heating cushions and blankets, red light, hot compresses and packs. Usually heat applications are perceived as comfortable, relaxing or revitalizing. However, using heat applications can be dangerous if the perception of heat is limited because this can cause burnings and scalding. (Source: © fotolia) Furthermore there are many everyday situations in which we come in contact with hot objects and surfaces. If the person's ability to sense the heat is eliminated or limited, one has to be especially careful with: carrying hot objects on the legs use protection between objects and legs! taking a shower or a bath watch out for changing water temperatures! sink drainage mostly made of metal – very hot! heat cushions or hot-water bottles surfaces that transport heat deck chair, sand, etc. Sun The perception of heat and cold is impaired if the sensitivity is limited. This may lead to hyperthermia or hypothermia of the body. Persons with spinal cord injury, above all tetraplegics, often feel cold and therefore dress overly warm and enjoy the warmth of the sun. However, the sun also has its drawbacks. UV radiation can damage the skin (sunburn) and heat can lead to an overheating of the body (sunstroke). Excessive sunbathing speeds up the ageing process of our skin and promotes several other skin changes – it may even cause skin cancer. Check your skin for alterations after spending time outside. A good sun protection (hat, sunglasses and sun screen) is recommended. (Source: © fotolia) Regulation of body temperature Humans regulate their body temperature also through sweating. People usually start to sweat at air temperatures just over 30°C. Persons with spinal cord injury are only able to sweat as regulating measure in those areas of the body that are not paralyzed. This means that especially tetraplegics have a strongly limited ability to regulate their body temperature, which is insufficient to keep it within a normal range when they expose themselves to high temperatures. Due to the spinal cord injury, the autonomous nervous system can no longer control the mechanisms responsible for our temperature regulation (heat production and heat loss), these are: blood circulation in the skin, sweating, shivering and directing the blood from the abdominal organs towards the muscles. This may result in a decrease in body temperature (hypothermia) or an excessive elevation (hyperthermia). These issues may be caused by high room temperatures, intense sun radiation or wrong clothing. People with tetraplegia therefore have to pay special attention to ambient temperatures. They need to be especially careful when travelling to very hot countries but also during the summer time in Switzerland. The following points are important for tetraplegics but also for persons with paraplegia: fluid loss Increased sweating requires an increased fluid intake. As a general rule, the bladder should excrete at least 1.5 litres urine per day. This helps to prevent thromboses and urinary tract infections. thromboses The risk of thrombosis is increased during the hot season. An adequate fluid intake and compression stockings are the best possible prophylaxis. It is therefore important to check the legs for rash, overheating, swelling and oedemas on a daily basis, because these are first signs of a thrombosis. pressure sores Sweating causes damp skin and thus increases the risk of pressure sores. Decompression in the wheelchair is therefore important in order to prevent pressure sores. Damp clothes need to be changed and the skin check should never be forgotten. medication People who are taking anticholinergics such as Ditropan (for the treatment of an overactive bladder) or Buscopan (against stomach cramps and spastic constipation) do only perspire to a limited extent and therefore need to be particularly careful when being exposed to the sun. It is also important to check the package information leaflet to see if the taking these drug increases photosensitivity. Compression stockings (source: © MedicalExpo) Important What to do on hot summer days: take a spray bottle filled with water with you in order to spray it on your body in case of hyperthermia – this makes up for the limited perspiration. make sure you always wear a hat drink plenty of water avoid heat wear light clothing use a mobile fan Also hypothermia may have severe physical consequences and can even lead to unconsciousness. It is therefore very important to be especially careful when staying outside for a longer period of time also during the winter time, for instance when going for a stroll or skiing. FAQs What can I do when I notice that I am overheating? Spraying yourself with cold water (e.g. with a spray bottle) may be very efficient. Also make sure you drink enough. In general you should avoid strong and direct sunlight. Are electrical heat cushions better than hot-water bottles? Also electric heating cushions can become very hot and therefore you need to be very careful in which body area you are using them. Generally, you should apply them only in those body areas that show sensitivity. Is it still possible for people with tetraplegia to travel to countries with a hot climate? Yes, if you follow the above-mentioned recommendations, it should be possible. However, some people with tetraplegia might not be able to withstand intense heat. In case the heat causes blood pressure problems, isotonic drinks might help. Reference: Abteilung Arbeitsmedizin (2006). Factsheet Sonnenschutz bei der Arbeit. Lucerne: SUVA. URL: http://www.suva.ch/factsheet_sonne.pdf (retrieved November 4, 2014) (in German) About the authors: Christa Schwager is a specialist in movement science in the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where she has worked since 1994. She is co-author of the key publications in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation" (eds. Guido A. Zäch & Hans Georg Koch) and "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). Karin Roth is advanced practice nurse in the Department for Nursing Development and Education at the Swiss Paraplegic Centre, where she has worked since 1997. She is also co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung". updated: June 2015
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A previous article here in the Library described the development of spasticity as well as the positive and negative aspects associated with spasticity. This article now deals with the treatment. When treating spasticity, it is important that practitioner and patient agree on clear aims. Important aims are: reducing spasticity avoiding pain improving functioning and thus mobility avoiding contractures improving care and hygiene possibly enabling rehabilitation. Not every spasticity needs to be treated. Often the consequences of the side effects of the treatments (such as restricted roadworthiness) are more severe than the spasticity itself. It would also be wrong to expect the spasticity to disappear completely when treating it. It is always important to balance the benefits for the patient against impairment due to side effects. Step scheme of spasticity treatment Step 1: Avoiding stimuli that trigger spasticity Often spasticity is triggered by sensory stimuli. These stimuli range from physical contact to pain sensation to optical stimuli, e.g. if somebody slams the door. Spasticity is also often an indicator for a full bladder, an overstretched intestine, a pain stimulus in the paralyzed part of the body that is not perceived (e.g. decubitus ulcers), or an infection (bladder, epididymides etc.). The easiest treatment is therefore avoiding these situations and events. This does not cause any costs or side effects and can be applied by the patients themselves. Before starting spasticity treatment, it is important to eliminate possible causes. Step 2: Anti-spastic positioning and other methods There are various anti-spastic positioning methods (e.g. sitting cross-legged) and also other methods such as sauna, swimming or hippotherapy that can help to reduce spasticity. Often the effect lasts for several hours and improves the well-being of the affected person. Standing exercises can also have a positive impact on spasticity. It is reported that Transcutaneous electrical nerve stimulation (TENS) has positive effects on spasticity; however research in this field is still in progress. It can also be helpful to change the sitting position in the wheelchair. The ideal position is with hip and knees at right angles and the seat slightly tilted backwards. Finally also new forms of treatment, such as walking in a Lokomat or Exoskeleton seem to help reducing spasticity momentarily. Step 3: Physiotherapy Special physiotherapy exercises can reduce spasticity significantly (e.g. physiotherapy according to Vojta). The aim is to inhibit pathological movement patterns caused by spasticity, to reduce flexion of the arms as well as stretching of the legs. Stretching the muscles prevents structural contraction; regular mobilization helps to preserve the passive mobility of the joints. Ideally the state achieved this way should be maintained afterwards by going to physiotherapy once or twice a week and doing exercises independently on a daily basis. Step 4: Oral Medication For patients with pronounced spasticity and significant impairments in everyday life, it is advisable to think about oral medication. One of the following objective reasons needs to be given: The spasticity makes intimate hygiene of the patient impossible. causes pressure sores. represents an injury risk. prevents participation in everyday life. causes intense pain that needs to be treated using painkillers. Most drugs reduce the activity of brain and spinal cord, which has positive effects on the spasticity. On the other hand, this also causes fatigue, lack of concentration, sleepiness, and a drop in blood pressure, as well as muscle weakness that also affects the non-paralyzed muscles. Patients with incomplete paraplegia might experience impairments with regard to their ability to stand and walk. Another possible consequence is an unfavorable sitting position in the wheelchair that might cause secondary damages and a restriction of mobility and autonomy. One needs to be aware of the fact that no substance prescribed by any practitioner will completely eliminate the spasticity or make the affected muscles stronger. The spasticity can be controlled using medication but at the same time the drugs weaken the muscles in the non-paralyzed part of the body. It is therefore extremely important to choose the right substance and dosage because all effective drugs can also cause severe side effects. Step 5: Invasive methods (Botox) Today botulinum toxin (e.g. Botox) is better known from the cosmetics industry than from the medical sector. However when it comes to the treatment of local spasticities of individual muscles or muscle groups it can improve functioning significantly. Botulinum toxin is a strong poison that blocks the transmission of nerve impulses to the muscle. This weakens the muscle – depending on the dosage this can also result in a complete paralysis of the muscle. After the local injection it takes a few days until the effect occurs. The effect usually lasts for three to four months. Short-term nerve blocks can also be induced using local anesthetics. Step 6: Intrathecal therapy The intrathecal therapy uses surgically implanted medication pumps to inject various substances (baclofen, morphine etc.) directly into the cerebrospinal fluid, where the spinal cord "swims". In contrast with what happens when taking oral medication, with this kind of administration the drug gets directly to the nervous tissue and losses of effectiveness due to the absorption in the stomach, the filtration process performed by the liver and at the blood-brain barrier can be avoided. Therefore the same or an even better effect can be achieved using only a fractional amount of the dosage needed otherwise. With lower dosages the side effects can be reduced accordingly. Before opting for this form of therapy, it is recommended to test the effects over a couple of days, using a temporarily implanted intrathecal catheter (CoSPAN catheter) and an external pump. The right dosage for a positive effect can thus be determined – with "acceptable" side effects for the patient. Frequent symptoms of overdoses are sleepiness, drowsiness, limp muscles, sickness and vertigo. Depending on the dosage, the pump needs to be refilled after the implantation every 3 to 12 weeks. This can be done by inserting a cannula through the patients' skin down to the reservoir of the pump. The battery of the pump lasts for 4 to 5 years – afterwards the whole unit needs to be replaced surgically. Possible causes for underdoses are malfunctioning of the pump as well as bending, leakage or incorrect positioning of the catheter. Step 7: Orthopedic treatment Orthopedic surgeries usually aim at correcting muscle contractures to enable the patient to sit in the wheelchair again. To make intimate hygiene easier, various tenolysis (cutting of tendons) of muscles of the adductor group can be performed. In the long run, spasticity also results in a deformation of the spinal column (scoliosis). If the physiotherapy is no longer effective and the positioning in the wheelchair (seat shell) fails, corrective surgeries performed by spinal column surgeons are inevitable in order to allow the patient to sit without experiencing pain. Step 8: Neurosurgical treatment Neurosurgical treatment of spasticity involves cutting some of the nerve fibers that come from the muscles affected by spasticity and enter the spinal cord. Today, however, such a treatment is very rare. Due to improved medication, these destructive and usually irreversible surgeries can generally be avoided. Exception: urologists intercept the sacral spinal nerves during the implantation of a bladder stimulator, in order to treat spasticity. During all steps of spasticity treatment it is important that practitioner and patient find the right balance between desired effects and undesirable side effects and thus improve the patient's quality of life. About the author: Dr. med. Hans Georg Koch was head physician for 19 years at the Swiss Paraplegic Centre in Nottwil/Switzerland. Together with Guido A. Zäch, founder of the Centre, he published a book that has become a key textbook in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation". Hans Georg Koch is a member of the paraforum team. updated: February 2015
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Spinal cord injury (SCI) and many other neurological conditions often include spasticity. An examination by Maynard (1990) of 96 patients has shown that, at the end of the rehabilitation phase after a traumatic spinal cord injury, 67% of the patients had developed symptoms of spasticity. 37% of the patients showed symptoms that were so severe that they needed to be treated medically. During a follow-up examination about one year after the spinal cord injury, even 78% of the patients suffered from spasticity and 49% required medical treatment. Patients with spinal cord injury in the cervical area or in the upper thoracic spine developed spasticity significantly more often than patients with a lower spinal cord injury. This examination shows that a large number of persons with SCI are suffering from spasticity. In an examination by Walter (2002), 99 persons with SCI were asked with which common complications they were currently having problems. With 53% the most commonly named complication was spasticity. Second was pain (44%) and third pressure sores and pressure ulcers (38%). 14% were very satisfied with their treatment of spasticity (physiotherapy, medication) and 76% were quite satisfied. But why do persons with SCI suffer from spasticity? This question is often asked, however, it is extremely difficult to give an easy to understand answer. Despite the fact, I will attempt to do so in this article. The word “spasticity” can be derived from the Greek word “spasmos” and means cramp of the musculature. This cramp is almost always caused by a damage of the spinal cord (e.g. in case of spinal cord injury) or of the brain (e.g. in case of a cerebral palsy). From a medical point of view, spasticity is an increased resistance to the stretching of the muscles. This resistance appears during a passive movement and is dependent on the speed of the movement. Beside muscle lesions, spasticity also shows in a deceleration of motion sequence, in increased proprioceptive reflexes of the muscles and a continuously increased muscle tone (muscle tension). The spasticity is increased through pain, infections, a full bladder or a full colon, fractures, thrombosis, pressure ulcers as well as pain below the lesion level and even through emotional excitement. Persons who have only recently suffered a spinal cord injury do not show any signs of spasticity since these patients are in a state of spinal shock. Spasticity occurs only after days or weeks. Why can spasticity develop? From a neurological perspective, spasticity is the consequence of an injury of the upper motor neuron (pyramidal tract) as well as the control system of muscle tension and reflexes (extra-pyramidal system). The following simplified representation of the muscle's innervation shows the mechanisms and processes that lead to spasticity. Muscle's innervation and mechanisms that lead to spasticity in spinal cord injury Due to interception of the ascending and descending pathways in the spinal cord, the inhibiting effect of the extra-pyramidal system, which would normally make the musculature relax, is missing. The brain loses the absorbing influence on the reflexes and the strength development of the musculature. Thus the reflex arcs below the lesion level are no longer “slowed down" and are highly reactive if triggered. Many patients with spinal cord injury are therefore suffering from an increased muscle tone or cramp-like sudden muscle activity which is called spasm. The repetitive twitches of a clonus-like spasm (shaking of the knee and/or feet) can be explained by an excitation that has been circling on the reflex arc for a longer period: a banal exterior influence (e.g. crossing a threshold) triggers stretching of neuromuscular spindles in a muscle. The stretching is communicated via an afferent (i.e. leading to the spinal cord) nerve to the still intact spinal cord below the lesion level. The spinal cord then reacts reflexively, through a motor stimulus, and tries to avoid the stretching of the muscle. The stimulus is transported via the efferent (i.e. leading away from the spinal cord) nerve to the muscle which consequently twitches. The twitching, in turn, leads to a stretching of the neuromuscular spindle and thus the cycle of this stimulus starts over and over again since the absorption as described above is missing. Positive and negative aspects of spasticity Spasticity does not only have negative effects – in many situations there are also positive aspects: the musculature is automatically trained which can prevent muscle atrophy (as e.g. in a flaccid paralysis). The musculature of the legs is conserved which does not only have an aesthetic effect. The buttock muscles are preserved and thus form a natural cushion – this serves as protection from pressure ulcers and provides for a better balance when sitting. The joints of the paralyzed extremities are being moved through spasms from time to time without any physiotherapy. Furthermore the muscle contractions support the venous blood circulation. Swellings of the lower extremities are less frequent and the risk of thromboses is reduced. In tetraplegics the spasms can even support the coughing. Many patients can trigger targeted spasms and use them skillfully for transfers and other activities of daily life. A negative effect of spasticity is the inactivity of the affected person with all its consequences. The impairment of body functions through spasticity has varied effects on the participation in life and society. Over a longer period of time, spasticity can also lead to contractures (muscle shortening), impairments in mobility and pressure sores, and even impairments in breathing; all these are additional impairments for paraplegics. Persons affected often indicate having pain which is triggered by spasticity and which requires additional diagnostics and major therapies. Soon there will be a second article published here in the library which informs about therapeutic options of spasticity and their effects and side effects as well as about the phase model of spasticity treatment. About the author: Dr. med. Hans Georg Koch was head physician for 19 years at the Swiss Paraplegic Centre in Nottwil/Switzerland. Together with Guido A. Zäch, founder of the Centre, he published a book that has become a key textbook in the field of spinal cord injury "Paraplegie. Ganzheitliche Rehabilitation". Hans Georg Koch is a member of the paraforum team. updated: October 2014
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Studies have shown that wheelchair users are at a higher risk to carry multi-resistant germs. They visit the hospital for regular follow-up examinations or in case of complications, where they can encounter persons who carry harmful germs. How can you avoid that multi-resistant germs become a health issue for you? Here are some hints and tips: Multi-resistant germs – what is that? Multi-resistant germs are bacteria that are resistant against many antibiotics. Hence infections caused by these bacteria are very difficult to treat. On every person's skin and mucous membranes there are numerous bacteria. This is completely normal and even good for you since they protect you naturally from harmful germs. Certain types of bacteria have, however, become resistant to antibiotics over the course of time. Thus, in case of an infection, treatment with antibiotics may show no effect or only insufficiently. In this case one speaks of MRSA, ESBL, MDRO or VRE. Patients that carry one of these germs are being informed and instructed by the clinic about the necessary protective measures. Medical staff will take additional specific protective measures (isolation) in order to prevent the transmission of these germs to other patients.    The multi-resistant bacteria may settle on the skin or inside the nose. From there they can be transmitted to other persons via the hands, when sneezing or coughing. In order to prevent this mode of transmission it is important to comply with the protective measures. 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 due to regular catheterization – it is possible that the body does not have the germs under control and this may result in a permanent colonization. Germs are mainly transmitted via the hands Bacteria can survive for a relatively long time also on non-organic surfaces. Through touching surfaces, they can settle on the hands and thus enter our body through the nose or the mucous membranes or via catheter into the bladder. Hand sanitizing is  the most important measure in order to prevent multi-resistant germs from spreading. You should therefore wash and possibly also sanitize your hands frequently. Also clean the grab points on your wheelchair frequently. Primary hazard is the clinic staff Clinic staff has to follow strict policies with respect to hand sanitization. Pay attention that clinic staff sanitizes their hands before they begin treatment on you they touch any kind of material in your surroundings before examining you. Help to make sure that these rules are followed by addressing staff members in case of non-compliance. Feel free to also encourage family members, acquaintances and friends to use hand sanitizer. It is to protect yourself! Hygienic Hand Sanitization (Source: © B. Braun Melsungen AG) The right behavior towards persons carrying multi-resistant germs Sometimes you can meet patients that are wearing a mouth and nose 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 you protecting 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 nose and mouth completely since otherwise protection cannot be guaranteed. Only if they are outside of the clinic area and not within a group of persons, they are allowed to take off the protective mask. Encourage other patients to behave correctly in order to protect everybody. Stick to these rules and multi-resistant germs will not create a hazard for you. About the author: Adrian Wyss is head of the Department for Nursing Development and Education at the Swiss Paraplegic Centre in Nottwil/Switzerland, where he has worked since 2006. He is co-author of the key publication in the field of spinal cord injury "Pflege von Menschen mit Querschnittlähmung" (ed. Ute Haas). updated: August 2014
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