How are reflexes managed in patients with paraplegia?

Management of Reflexes in Paraplegia

The management of reflexes in paraplegia should focus on treating spasticity and contractures with antispastic positioning, range of motion exercises, stretching, splinting, serial casting, or surgical correction as first-line approaches, followed by pharmacological interventions when necessary. 1

Pathophysiology of Reflexes in Paraplegia

Reflexes in paraplegia are characterized by:

• Hyperreflexia due to loss of supraspinal inhibitory control
• Segmental reflexes interacting with and controlled by distant segments and brainstem influence 2
• Reflexes classified as:
  1. Simple segmental stretch and withdrawal reflexes
  2. Plurisegmental gross reflex movement of paralyzed muscles
  3. Propriospinal processes with partial brain influence 2

Assessment of Reflexes

Assessment should include:

• Evaluation of muscle tone using standardized scales
• Testing of deep tendon reflexes
• Assessment for clonus
• Evaluation of flexor and extensor spasms
• Monitoring for signs of autonomic dysreflexia, a life-threatening complication in injuries at T6 or above 3

Management Approaches

Non-pharmacological Management

1. Physical Interventions:

   • Antispastic positioning
   • Range of motion exercises (several times daily)
   • Stretching
   • Splinting
   • Serial casting 1

2. Rehabilitation Strategies:

   • Physical therapy focusing on:
     • Teaching patients to avoid rapid multijoint movements
     • Encouraging slower movements limited to single joints
     • Reducing movement complexity
     • Stabilizing against inertial effects of limb movement 4

3. Circuit Class Therapy:

   • Should be used to increase scheduled therapy time 1

4. Aerobic Training:

   • Individually tailored aerobic training involving large muscle groups
   • At least 3 times weekly for a minimum of 8 weeks
   • Progressing to 20 minutes or more per session 1

Pharmacological Management

When non-pharmacological approaches are insufficient, consider:

1. First-line Medications:

   • Tizanidine: Effective for chronic stroke patients with improvement in spasticity and pain without loss of motor strength 1
   • Dantrolene: Benefits include no cognitive side effects 1
   • Oral baclofen: Inhibits both monosynaptic and polysynaptic reflexes at the spinal level by hyperpolarization of afferent terminals 5

2. Medications to Avoid:

   • Diazepam and other benzodiazepines: Relatively contraindicated during recovery period due to possible deleterious effects on recovery and sedation side effects 1

3. Advanced Interventions for Refractory Cases:

   • Botulinum toxin or phenol/alcohol injections: For selected patients with disabling or painful spasticity 1
   • Intrathecal baclofen: For chronic patients with spasticity resulting in pain, poor skin hygiene, or decreased function 1

Surgical Interventions

Consider for severe, refractory spasticity:

• Selective dorsal rhizotomy
• Dorsal root entry zone lesion 1

Management of Complications

Autonomic Dysreflexia

A life-threatening complication in SCI at T6 or above characterized by:

• Uncontrolled sympathetic discharge in response to noxious stimuli
• Dangerous rise in blood pressure
• Often triggered by urological, gastrointestinal, or gynecological problems 3

Management:

• Prevention is primary
• Prompt recognition and treatment is vital
• Remove noxious stimuli (check for bladder distension, bowel impaction)
• Position patient upright to induce orthostatic pooling
• Monitor blood pressure frequently 3

Contractures

• Early treatment is key to preventing this disabling complication
• Patients with muscle spasticity are at high risk 1
• Regular positioning and range of motion exercises are essential

Monitoring and Follow-up

• Regular assessment of spasticity and reflexes
• Evaluation of medication efficacy and side effects
• Monitoring for complications such as contractures, pressure ulcers
• Assessment of functional status and quality of life

Common Pitfalls to Avoid

1. Overlooking autonomic dysreflexia: This can be life-threatening and requires immediate intervention
2. Excessive medication: Can cause weakness, sedation, and impair rehabilitation efforts
3. Inadequate non-pharmacological management: Physical interventions should be the foundation of management
4. Neglecting underlying causes: Addressing triggers such as urinary tract infections, pressure sores, or constipation is essential
5. Delayed treatment of spasticity: Can lead to contractures and permanent disability

By implementing this comprehensive approach to reflex management in paraplegia, clinicians can help minimize complications and optimize functional outcomes for patients.