Everything You Were Afraid To Ask About SCI Special Thanks Micah Chapman, MOTS Kayla Gaitan, MOTS Alexandra Lozada-Pelczynski, MOTS Lauren Ray, MOTS Dawndra Sechrist, OTR, PhD Audrey Attard, OTS Laura Johnson, OTS Morgan Ketchersid, OTS Kristen Shideler, OTS Heather Siewert, OTS Learning Objectives Learner will be able to select relevant intervention ideas to facilitate independence with bowel and bladder programs. Learner will be able to identify the factors that are necessary to treat clients with SCI & sexual function from a holistic perspective. Learner will be able to list and describe adaptations, strategies & resources to improve sexual relationships for clients with SCI. Learner will be able to describe the barriers and challenges in puberty, intimacy, and fertility for clients with a spinal cord injury. Topics For Discussion Bowel & Bladder Management Male & Female Puberty Male & Female Intimacy Male & Female Fertility Ice Breaker Turn To Your Neighbor and Discuss the Following Questions When was your last Bowel Movement (BM)? Bowel And Bladder Management How often do you have BM s? What was the consistency of your last BM? Have you ever been constipated? 1
How To Talk To Your Clients/Patients Bladder Management Be Compassionate and Empathetic! Use your therapeutic use of self. You will be talking about some of the most private matters with your clients/patients.. Types of Catheters: Intermittent External Indwelling Suprapubic Need to discuss disadvantages and advantages of each type. (Refer to page 2 in your handout) What population would be best suited to use a particular type? Patients should be educated on the different options available for catheters. Catheter should fit the needs of the patient. Monitor Urine Output Prevent dehydration by frequently checking the color of urine output. Hydration is a key aspect of bowel management programs. Bladder Management Tricks Of The Trade Use a bungee cord to hold pants out of the way to free up both hands for self-catheterization. Set-up a schedule that works for the client to monitor fluid intake and output. Slightly loosen the cap on the collection tube to prevent vacuum effect. Providine/Benadine UTI education! Know the signs of autonomic dysreflexia! How To Teach Self-Catheterization Intermittent Catheterization for Women: Slightly spread legs apart. Spread your vaginal lips (labia) apart, both outer and inner parts. Pick up the lubricated catheter with the other hand. Hold it like a pencil about 2-3 from its tip and insert tip straight (or upward) into urinary opening. Gently thread the catheter up into your urethra until urine starts to flow. Do not force the catheter. When the urine stops flowing, remove the catheter. (Refer to pages 2-3 in your handout)) How To Teach Self-Catheterization Intermittent Catheterization for Men: Move back the foreskin of penis, if uncircumcised. In a seated position, hold penis horizontally from body with one hand. With the other hand, gently thread the catheter through the urethral opening until urine starts to flow. Do not force it. After the urine begins to flow, thread it an additional 1-2 until a steady flow is obtained. When the urine flow stops, gently remove the catheter. (Refer to pages 2-3 in your handout) 2
Intervention Ideas For All Ages Additional Information Play Kerplunk game. String blocks/beads. Cath a banana. Open various packages to simulate opening supplies. Practice positioning. Use of mirror Dynamic sitting balance (Refer to page 5 in your handout) They look like regular jeans!! Bladder Pacemaker: Implantable system that sends electrical impulses to the sacral nerves and helps in voiding urine. USA JEANS: Heavy and light weight jeans and slacks. Designed for sitting and relieving pressure sores. Eliminates bunching in the front or back while seated. Puberty Maintenance Tampons Many prefer tampons over sanitary napkins due to less skin irritation and better protection during transfers. Be cautious of decreased sensation and correct insertion. Familiarize self with vaginal shape. Use mirror, and learn like when self-catheterizing. Use lubricated tampon (such as gel), if necessary. Change 3-4x/day or every 4 hours. Remove before catheterizing and use gel (on catheter or tampon). (Refer to page 16 in your handout) Puberty Maintenance Sanitary Napkins Position pad more posteriorly toward anus, flat, and even. Wear firm-fitting underpants. Check regularly for signs of skin irritation and pressure between legs. For wear with self-catheters: Wipe away blood in downward fashion. Add gel, if dryness is experienced. Be as clean as possible. Cut down middle of pad to fit catheter tube. (Refer to page 16 in your handout) Bowel Program What does it look like? Equipment: Place in a location where the patient can easily access all of it. Setting: Determine where the client will perform bowel program: Bed Restroom Bedside Commode Digital Stimulation Massage the abdomen to help prepare for a bowel movement. Laterally bend to the side and feel for anus with finger or Dil Stick. Use mirror to assist in locating the correct placement. (Refer to pages 6-7, 11 in your handout) (Refer to page 6 in your handout to perform program) 3
Bowel Management Tricks Of The Trade Remove feces before inserting suppositories through digital stimulation. Properly hydrate. ) Obtain adequate levels of fiber in diet. Eat foods with probiotics, such as yogurt. Stay active. (Refer to page 7 in your handout) Pressure relief while on commode: Positioning Seat cushion Get supplies out before starting program. Prepare for accidents and know how to handle the situation in a professional manner. Help your client learn from it! Intervention Ideas EDUCATION, EDUCATION, EDUCATION, EDUCATION! Gather and open supplies. Transfer to toilet/commode. Practice positioning in bed. (Refer to pages 8-9 in your handout) Perform shaving cream exercise while seated. Use mirror to locate proper placement and techniques during digital stimulation. Perform bowel program with client. They will have questions! Looking At Our Clients Holistically Male And Female Intimacy David Ok, here's my deal. I'm a 10-year C4 quad. I have sensation until about 2 inches above my elbows and about an inch above my nipples. I have zero sensation below these areas, and my shoulders are the only things I can move. Obviously, sex is a big thing on my mind. Over the last 10 years as a quad I haven't gone all the way with a woman- a lot of passion and foreplay, but no intercourse. I figured, I can't feel a damn thing down there, so what's the point? About a week ago, however, things changed, when a girl I ve been seeing for about 3 months wanted to have sex...normally a cause for celebration for most men, but I was freaking out. I just didn't know what would happen! Angela Sexy is not about sensation. It took time to recognize that what I was feeling during sex was less about physical sensation and more of a mental build-up. It s mind over matter, but there s definitely a release. It was completely frustrating at first, but I think part of the healing process was learning the ways my body works differently after my accident. Problems Faced Sexual difficulties rooted in physiological & environmental conditions: - 1 0 (Organic Impairments) Neurological Endocrinological Urological - 2 0 (Behavioral Impairments) Attitudes Anxieties interfering with sexual satisfaction Uncertainty about roles Changes in relationships Functional Capabilities & Perceptions (Refer to pages 17-18 in your handout) Males vs. Females 4
Erogenous Zones Get Creative! Areas above injury site can become hypersensitive. Dis-inhibition of spinal reflexes can, in turn, lead to stronger somatic sensations on the unaffected part of the body. Education for Clients: Phantom sensations of genital awareness by performing erotic stimulation of other erogenous zones. (Refer to page 17 in your handout) The Mind Is Our Largest Erogenous Zone Considerable research indicates that the emotional component of intimacy often grows in importance. As many as 1/3 of SCI patients report improvements in their relationships in the aftermath of injury due to less concentration on the orgasm. Better communication Longer foreplay More sensitivity to partner s needs Overall emphasis on emotional intimacy in conjunction with sexual intimacy (Donohue & Gebhard, 1995) Adaptations & Strategies Adaptation Methods & Devices Enjoying intimate time Positioning Orgasm Practicing safe sex Contraception Medication enhancements (Refer to pages 19-23 in your handout) Males Vacuum-induced erections Injected vasoactive drug Penile implants or penile prostheses Intimate Rider (Refer to pages 19-23 in your handout) ( Females Sex wedges Sex swings Sex stool Vibrators Male Fertility After SCI Male and Female Fertility Fertility is severely impaired due to impairments in erection, ejaculation, and semen quality. Erectile dysfunction will need to be addressed with the patient. Assisted Reproductive Technology: - Penile Vibratory Stimulus (PVS) - Electro-ejaculation - Prostate massage - Surgical sperm retrieval (Refer to pages 19 & 21 in your handout) 5
Insemination Options Intravaginal Insemination at home: Least invasive, least expensive. Advised for couples to be evaluated in a clinic prior to attempting. Semen is drawn into a syringe and inserted deep into the vagina, where it is then deposited. Intrauterine Insemination: Collecting semen from male to process in a lab to separate sperm from semen and to isolate motile sperm from nonmotile. 3-6 cycles tried before proceeding to In Vitro Fertilization (IVF). Insemination Options In Vitro Insemination/Intracytoplasmic Sperm Injection (IVF): Sperm is placed in a lab dish with retrieved ova. Sperm ova mixture is then placed in an incubator for up to 5 days. Embryos that develop to blastocyst stage are placed into the uterus of the female. Expensive procedure. Common Misconceptions: The only way to have a child is by adoption. Women with SCI should not have a baby because they cannot adequately take care of a child. It is too dangerous to the health of the woman and the baby. However these are WRONG! Women and SCI: Over 2,000 women in child bearing years are affected yearly. Average age of onset is 32 years. Prime childbearing years. This can disrupt current plans or crush future dreams. In one survey, only 20% of women received any education on SCI and pregnancy. All of these women stated the information was minimally helpful. Lack of knowledge is the MAIN issue keeping women from trying pregnancy. (Mayo Clinic, Retrieved 2013) Process: SCI s have neurological effects. Pregnancy is mostly hormonal changes. A woman s reproductive organs still work as they would pre-injury, despite decreased sensation. The process for getting pregnant remains the same as pre-injury. Pregnancy in SCI is possible with close monitoring and proper education of all parties involved. Pre-Natal Care Medication: Limit current medications to ONLY what is necessary. Consult with physician for information about birth defects. Pre-Natal vitamins are as necessary as for all pregnancies. Seizure medications require more Folic Acid than normal. Need to get tested for: Iron deficiency Vitamin D deficiency Anemia 6
Pre-Natal Precautions and Changes: Normal menstruation can take up to a year to return. Respiratory changes (such as with quadriplegia) increased chances of pneumonia. Neurogenic Bladder Decrease in function Deep Vein Thrombosis (DVT) Pressure ulcers Autonomic Dysreflexia (Refer to page 15 in your handout) Neurogenic Bladder: Incontinence can increase, due to changes in the body and new pressure placed on the bladder. Increasing bladder program can help prevent incontinent episodes. Occasionally women will choose to use a Foley during pregnancy, if unable to manage incontinence. Bladder complications lead to increased urinary tract infections. Decrease in Function: Occurs with progression of any pregnancy. Transfers more difficult because of increased weight. Growth of the belly can affect ADLs & IADLs: Upper body dressing Lower body dressing Toileting Bathing IADLS May need the use of adaptive equipment. Deep Vein Thrombosis (DVT): Commonly occurs in women with SCI. Chances increase with pregnancy. To reduce chances of getting a DVT: Wear stockings. Prop legs up frequently. Notify doctor of risk, and closely monitor. Pressure Ulcers: This is already a precaution for women with SCI. The normal routine MUST change. More weight means more frequent pressure release. Weight distribution is different, meaning different problem areas. If pregnancy requires bed rest, then it is pertinent to check for pressure ulcers all over the body. Labor: It is recommended at 32 weeks to begin weekly check-ups. Signs: Headache and sweating Increased spasticity Respiratory changes Most women with SCI cannot feel or do not notice labor signs. Barely feel contractions or do not feel at all. Water breaking is confused with incontinence. Vaginal birth vs. C-Section No different than other pregnancy contraindications. Assistive devices can be used to assist women without abdominal involvement for pushing. 7
Post Partum: Urinary Tract Infections (UTI) The body is still going through hormonal changes. Orthostatic Hypotension Perineal Care Episiotomy incisions are easily infected. Include this in pressure relief inspection to monitor healing. Post Partum (continued): Breastfeeding Special positioning pillows to assist holding the baby. Use of an aide. Milk production can decrease after 6 weeks. Can trigger autonomic dysreflexia. Role of Occupational Therapy: Patient Education Client-centered treatment plans Modifications for post partum Changing tables Car seats Cribs Feeding Teach advocacy Home program Checking for pressure ulcers Medication management Coping Strategies Empower the patient with knowledge. Take advantage of all therapeutic opportunities. Meet with other people and families with both old and new SCI. Be careful of internet surfing on SCI topics. Rely on reputable organizations. Check out local and state support groups: National Spinal Cord Injury Association The American Trauma Society Christopher & Dana Reeve Foundation Therapeutic Approach ALL interactions should be based on respect, equality, and support. Whether the patient grows from the experience or succumbs to the disability is directly influenced by the support received in rehabilitation. Questions??? Micah Chapman, MOTS Kayla Gaitan, MOTS CONTACT INFORMATION Micah.Dawson@ttuhsc.edu Kayla.Gaitan@ttuhsc.edu Alexandra Lozada-Pelczynski, MOTS Alexandra.lozada-pelczynski@ttuhsc.edu -Somers, 2001 Lauren Ray, MOTS Dawndra Sechrist, OTR, PhD Lauren.Ray@ttuhsc.edu Dawndra.Sechrist@ttuhsc.edu 8