SCHIZOPHRENIA PERCEPTION PROBLEMS: DEFINITION... Schizophrenia ( /sktsfrni/ or /skts frini/) is a mental disorder !ara teri"ed #$ a disinte%ration of t!o&%!

!t 'ro esses and of emotional res'onsi(eness)It most ommonl$ manifests itself as a&ditor$ !all& inations* 'aranoid or #i"arre del&sions* or disor%ani"ed s'ee ! and t!inkin%* and it is a om'anied #$ si%nifi ant so ial or o &'ational d$sf&n tion) T!e onset of s$m'toms t$'i all$ o &rs in $o&n% ad&lt!ood* +it! a %lo#al lifetime 're(alen e of a#o&t ,)-. ,)/0) 1ia%nosis is #ased on o#ser(ed #e!a(ior and t!e 'atient2s re'orted e3'erien es) BACKGROUND... 4eneti s* earl$ en(ironment* ne&ro#iolo%$* and 's$ !olo%i al and so ial 'ro esses a''ear to #e im'ortant ontri#&tor$ fa tors5 some re reational and 'res ri'tion dr&%s a''ear to a&se or +orsen s$m'toms) C&rrent resear ! is fo &sed on t!e role of ne&ro#iolo%$* alt!o&%! no sin%le isolated or%ani a&se !as #een fo&nd) T!e man$ 'ossi#le om#inations of s$m'toms !a(e tri%%ered de#ate a#o&t +!et!er t!e dia%nosis re'resents a sin%le disorder or a n&m#er of dis rete s$ndromes) 1es'ite t!e et$molo%$ of t!e term from t!e 4reek roots skhizein (* 6to s'lit6) and phrn, phren- (, -5 6mind6)* s !i"o'!renia does not im'l$ a 6s'lit mind6 and it is not t!e same as disso iati(e identit$ disorder7also kno+n as 6m&lti'le 'ersonalit$ disorder6 or 6s'lit 'ersonalit$67a ondition +it! +!i ! it is often onf&sed in '&#li 'er e'tion) T!e mainsta$ of treatment is anti's$ !oti medi ation* +!i ! 'rimaril$ s&''resses do'amine (and sometimes serotonin) re e'tor a ti(it$) Ps$ !ot!era'$ and (o ational and so ial re!a#ilitation are also im'ortant in treatment) In more serio&s ases7+!ere t!ere is risk to self and ot!ers7in(ol&ntar$ !os'itali"ation ma$ #e ne essar$* alt!o&%! !os'ital sta$s are no+ s!orter and less fre8&ent t!an t!e$ on e +ere) T!e disorder is t!o&%!t mainl$ to affe t o%nition* #&t it also &s&all$ ontri#&tes to !roni 'ro#lems +it! #e!a(ior and emotion) Peo'le +it! s !i"o'!renia are

likel$ to !a(e additional ( omor#id) onditions* in l&din% ma9or de'ression and an3iet$ disorders5 t!e lifetime o &rren e of s&#stan e a#&se is almost :,0) So ial 'ro#lems* s& ! as lon%;term &nem'lo$ment* 'o(ert$ and !omelessness* are ommon) T!e a(era%e life e3'e tan $ of 'eo'le +it! t!e disorder is <= to <: $ears less t!an t!ose +it!o&t* t!e res&lt of in reased '!$si al !ealt! 'ro#lems and a !i%!er s&i ide rate (a#o&t :0)) SY PTO S... A per!on "ia#no!e" $i%h !chizophrenia &a' e(perience ha))*cina%ion! +&o!% repor%e" are hearin# ,oice!-. "e)*!ion! +o/%en 0izarre or per!ec*%or' in na%*re-. an" "i!or#anize" %hin1in# an" !peech. The )a%%er &a' ran#e /ro& )o!! o/ %rain o/ %ho*#h%. %o !en%ence! on)' )oo!e)' connec%e" in &eanin#. %o incoherence 1no$n a! $or" !a)a" in !e,ere ca!e!. Socia) $i%h"ra$a). !)oppine!! o/ "re!! an" h'#iene. an" )o!! o/ &o%i,a%ion an" 2*"#&en% are a)) co&&on in !chizophrenia. There i! o/%en an o0!er,a0)e pa%%ern o/ e&o%iona) "i//ic*)%'. /or e(a&p)e )ac1 o/ re!pon!i,ene!!. I&pair&en% in !ocia) co#ni%ion i! a!!ocia%e" $i%h !chizophrenia. a! are !'&p%o&! o/ paranoia3 !ocia) i!o)a%ion co&&on)' occ*r!. In one *nco&&on !*0%'pe. %he per!on &a' 0e )ar#e)' &*%e. re&ain &o%ion)e!! in 0izarre po!%*re!. or e(hi0i% p*rpo!e)e!! a#i%a%ion. a)) !i#n! o/ ca%a%onia. POSITI4E 4S. NEGATI4E SY PTO S S !i"o'!renia is often des ri#ed in terms of 'ositi(e and ne%ati(e (or defi it) s$m'toms) Positi(e s$m'toms are t!ose t!at most indi(id&als do not normall$ e3'erien e #&t are 'resent in 'eo'le +it! s !i"o'!renia) T!e$ an in l&de del&sions* disordered t!o&%!ts and s'ee !* and ta tile* a&ditor$* (is&al* olfa tor$ and %&stator$ !all& inations* t$'i all$ re%arded as manifestations of 's$ !osis) >all& inations are also t$'i all$ related to t!e ontent of t!e del&sional t!eme) Positi(e s$m'toms %enerall$ res'ond +ell to medi ation) Ne%ati(e s$m'toms are defi its of normal emotional res'onses or of ot!er t!o&%!t 'ro esses* and res'ond less +ell to medi ation) T!e$ ommonl$ in l&de flat or #l&nted affe t and emotion* 'o(ert$ of s'ee ! (alo%ia)* ina#ilit$ to e3'erien e

'leas&re (an!edonia)* la k of desire to form relations!i's (aso ialit$)* and la k of moti(ation (a(olition)) Resear ! s&%%ests t!at ne%ati(e s$m'toms ontri#&te more to 'oor 8&alit$ of life* f&n tional disa#ilit$* and t!e #&rden on ot!ers t!an do 'ositi(e s$m'toms) Peo'le +it! 'rominent ne%ati(e s$m'toms often !a(e a !istor$ of 'oor ad9&stment #efore t!e onset of illness* and res'onse to medi ation is often limited) CAUSES... GENETICS EN4IRON ENT SUBSTANCE ABUSE PRE5NATA6 TRE?TMENTS))) EDICATIONS

re8&irin% in reasin% t!e dosa%e d&e to ells 'rod& in% more ne&ro !emi als to om'ensate for t!e dr&%s (tardi(e 's$ !osis)* and a 'otential for 'ermanent !emi al de'enden e leadin% to 's$ !osis m& ! +orse t!an #efore treatment #e%an* if t!e dr&% dosa%e is e(er lo+ered or sto''ed (tardi(e d$s'!renia)) Tem'orar$ +it!dra+al s$m'toms in l&din% insomnia* a%itation* 's$ !osis* and motor disorders ma$ o &r d&rin% dosa%e red& tion of anti's$ !oti s* and an #e mistaken for a ret&rn of t!e &nderl$in% ondition) FIRST GENERATION... B*%'rophenone! ain ar%ic)e7 B*%'rophenone!

Ha)operi"o) +Ha)"o). Serenace Droperi"o) +Dro)ep%an Pheno%hiazine! ain ar%ic)e7 Pheno%hiazine!

PSYCHOSOCIA6 THERAPIES ANTIPSYCHOTICS... ?n an%ip!'cho%ic (or ne*ro)ep%ic) is a tran8&ili"in% 's$ !iatri medi ation 'rimaril$ &sed to mana%e 's$ !osis (in l&din% del&sions or !all& inations* as +ell as disordered t!o&%!t)* 'arti &larl$ in s !i"o'!renia and #i'olar disorder) ? first %eneration of anti's$ !oti s* kno+n as t$'i al anti's$ !oti s* +as dis o(ered in t!e <@:,s) Most of t!e dr&%s in t!e se ond %eneration* kno+n as at$'i al anti's$ !oti s* !a(e #een de(elo'ed more re entl$* alt!o&%! t!e first at$'i al anti's$ !oti * lo"a'ine* +as dis o(ered in t!e <@:,s and introd& ed lini all$ in t!e <@/,s) Bot! %enerations of medi ation tend to #lo k re e'tors in t!e #rain2s do'amine 'at!+a$s* #&t anti's$ !oti dr&%s en om'ass a +ide ran%e of re e'tor tar%ets) EFFECTS... ? n&m#er of !armf&l and &ndesired (ad(erse) effe ts !a(e #een o#ser(ed* in l&din% lo+ered life e3'e tan $* +ei%!t %ain* de rease in #rain (ol&me* enlar%ed #reasts and milk dis !ar%e in men and +omen (!$'er'rola tinaemia)* lo+ered +!ite #lood ell o&nt (a%ran&lo $tosis)* in(ol&ntar$ re'etiti(e #od$ mo(ements (tardi(e d$skinesia)* dia#etes* an ina#ilit$ to sit still or remain motionless (akat!isia)* se3&al d$sf&n tion* a ret&rn of 's$ !osis

Ch)orpro&azine +Thorazine. 6ar#ac%i) F)*phenazine +Pro)i(in- 5 A,ai)a0)e in "ecanoa%e +)on#5ac%in#- /or& Perphenazine +Tri)a/on Proch)orperazine +Co&pazine Thiori"azine + e))ari). e))eri)-

Tri/)*operazine +S%e)azine e!ori"azine

Periciazine Pro&azine Tri/)*pro&azine +4e!prin 6e,o&epro&azine +Nozinan Pro&e%hazine +Phener#an Pi&ozi"e +Orap C'a&e&azine +Tercian Thio(an%hene! ain ar%ic)e7 Thio(an%hene!

Ch)orpro%hi(ene +C)o(an. Tarac%an. Tr*(a)-

 C)open%hi(o) +Sor"ino) F)*pen%hi(o) +Depi(o). F)*an(o) Thio%hi(ene +Na,ane Z*c)open%hi(o) +Ci!or"ino). C)opi(o). Ac*pha!eSECOND GENERATION... Clo"a'ine (Clo"aril) ; Re8&ires +eekl$ to #i+eekl$ om'lete #lood o&nt d&e to risk of a%ran&lo $tosis) Olan"a'ine (A$'re3a) ; Bsed to treat 's$ !oti disorders in l&din% s !i"o'!renia* a &te mani e'isodes* and maintenan e of #i'olar disorder) 1osin% =): to =, m% 'er da$) Ris'eridone (Ris'erdal) ; 1osin% ,)=: to C m% 'er da$ and is titrated &'+ard5 di(ided dosin% is re ommended &ntil initial titration is om'leted* at +!i ! time t!e dr&% an #e administered on e dail$) Bsed off;la#el to treat To&rette s$ndrome and an3iet$ disorder) D&etia'ine (Sero8&el) ; Bsed 'rimaril$ to treat #i'olar disorder and s !i"o'!renia* and 6off;la#el6 to treat !roni insomnia and restless le%s s$ndrome5 it is a 'o+erf&l sedati(e) 1osin% starts at =: m% and ontin&es &' to E,, m% ma3im&m 'er da$* de'endin% on t!e se(erit$ of t!e s$m'tom(s) #ein% treated) Ai'rasidone (4eodon) ; ?''ro(ed in =,,FG/FH to treat #i'olar disorder) 1osin% =, m% t+i e dail$ initiall$ &' to E, m% t+i e dail$) Side; effe ts in l&de a 'rolon%ed DT inter(al in t!e !eart* +!i ! an #e dan%ero&s for 'atients +it! !eart disease or t!ose takin% ot!er dr&%s t!at 'rolon% t!e DT inter(al) ?mis&l'ride (Solian) ; Sele ti(e do'amine anta%onist) >i%!er doses (%reater t!an F,, m%) a t &'on 'ost;s$na'ti do'amine re e'tors res&ltin% in a red& tion in t!e 'ositi(e s$m'toms of s !i"o'!renia* s& ! as 's$ !osis) Lo+er doses* !o+e(er* a t &'on do'amine a&tore e'tors* res&ltin% in in reased do'amine transmission* im'ro(in% t!e ne%ati(e s$m'toms of s !i"o'!renia) Lo+er doses of amis&l'ride !a(e also #een s!o+n to !a(e antide'ressant and an3iol$ti effe ts in non; s !i"o'!reni 'atients* leadin% to its &se in d$st!$mia and so ial '!o#ias) ?mis&l'ride !as not #een a''ro(ed for &se #$ t!e Iood

and 1r&% ?dministration in t!e Bnited States) ?sena'ine (Sa'!ris) is a :;>T=?; and 1=; re e'tor anta%onist &nder de(elo'ment for t!e treatment of s !i"o'!renia and a &te mania asso iated +it! #i'olar disorder) Pali'eridone (In(e%a) ; 1eri(ati(e of ris'eridone t!at +as a''ro(ed in =,,C) Ilo'eridone (Iana't) ; ?''ro(ed #$ t!e I1? on Ma$ C* =,,@) Aote'ine (Ni'ole't* Losi"o'ilon* Lodo'in* Seto&s); ?n at$'i al anti's$ !oti indi ated for a &te and !roni s !i"o'!renia) It +as a''ro(ed in Ja'an ir a <@E= and 4erman$ in <@@,* res'e ti(el$) Sertindole (Serdole t* and Serle t in Me3i o)) Sertindole +as de(elo'ed #$ t!e 1anis! '!arma e&ti al om'an$ >) L&nd#e k) Like t!e ot!er at$'i al anti's$ !oti s* it is #elie(ed to !a(e anta%onist a ti(it$ at do'amine and serotonin re e'tors in t!e #rain) T>IR1 4ENER?TION))) ?ri'i'ra"ole (?#ilif$) ; 1osin% < m% &' to ma3im&m of -, m% !as #een &sed) Me !anism of a tion is t!o&%!t to red& e s&s e'ti#ilit$ to meta#oli s$m'toms seen in some ot!er at$'i al anti's$ !oti s) T!e e3tent to +!i ! t!ese effe ts differ from ot!er at$'i al anti's$ !oti s is de#ated) Partial a%onists of do'amine)

PERCEPTION AND COORDINATION: SPINAL CORD INJURY Risk Factors for SCI Each year, 11,000 people experience a SCI. 200,000 more people are living "pinal cor# in$%ry re"%l!" i!h CASE STUDY ONE C.+. i" a 22 yo male pa!ien! >ell 00>! >rom a chairli>! hile ",iing an# lan#e# on har# "no . 6e a" >o%n# !o have a C10D11 >rac!%re i!h paraplegia. 6e a" a#mi!!e# !o !he ICE an# place on high #o"e" o> "!eroi#" >or 2/hr". 6e a" !a,en !o "%rgery >or ex!ernal "pinal "!a&iliFa!ion. 6e "pen! ! o #ay" &ac, in !he ICE, 0 #ay" on S!ep 7o n, an# i" no rea#y !o &e !ran">erre# !o yo%r reha& %ni!. 6e con!in%e" !o have no movemen! !o !he lo er ex!remi!ie". %& : 'oal of Tr atm !t i! Ac#t P(as

S!a!i"!ic" "ho !ha! male" are highe"! n%m&er. 'ge" 1( ) *0 y.o. +hy #o yo% !hin, !ha! i" "oExampl s of I!"#r$ 'cci#en!" ./012 Car, van, coach 1(.01 3o!orcycle 201 4icycle 0.01 5e#e"!rian 1.01 6elicop!er 1.01

5a!hophy"iologyG imme#ia!e mechanical #i"r%p!ion o> axon" a" a re"%l! o> a lacera!ion, "!re!ch, !ear, or "ever Primar$ I!"#r$ ) S co!*ar$ O!+oi!+ I!"#r$ @ormal &loo# >lo !o area i" #i"r%p!e#

7ome"!ic 8 In#%"!rial 'cci#en!" .*/12 Spor! In$%ry 101 7iving /1 9ver!ical compre""ion": ;%g&y 11 6or"e ;i#ing *1 <!her =1

Spinal cor# #eprive# o> <2 H.i"chemia an# cell #ea!h H +i!hin >o%r ho%r" Aree ;a#ical" relea"e# 6emorrhage in area ca%"e" e#ema an# compre""ion H >%r!her #amage !o axon" H &lee#ing appear" i!hin one ho%r H !hi" can "prea# !he area o> in$%ry an# #amage Che longer !hi" proce"", !he more permanen! #amage H C@S #oe" no! regenera!eI ) 'oals

'""a%l! (1 Sel> 6arm 01 '""a%l!e# 11 5ro>o%n# 6eal!h Care E>>ec!"

%&: Critical N#rsi!+ Car

?i>elong @ee#" o> SCI 5hy"ical 5"ycho"ocial Ainancial Boca!ional Social A%nc!ioning

Imme#ia!e S!a&iliFa!ion !o preven! >%r!her in$%ry, !ra%ma, an# ca"ca#e o> "econ#ary in$%ry 6o #o e #o !hi"-

S#r,i,

t(

I!"#r$

3ain!ain phy"iological "!a&ili!y !hro%gh "pinal "hoc, ACUTE SPINAL FACTS Che ex!en! o> #amage re"%l!" >rom !he primary an# "econ#ary in$%ry an# can

&e #eva"!a!ing i> "!a&iliFa!ion an# early !rea!men! ere no! "!ar!e# 5rogno"i" 8 ;ecovery mo"! acc%ra!ely #e!ermine# =2hr" or more a>!er in$%ry %-: St roi* T( rap$ . ! fits 6igh #o"e IB "!eroi#" .Sol%me#rol2 given i!hin >ri"! Jhr" o> in$%ry ;e#%ce #amage !o cell mem&rane" an# #ecrea"e in>lamma!ion. Ao%n# in !he early J0" !o &e highly e>>ec!ive !o re#%ce !he leng!h o> !ime >or "pinal "hoc, an# !o re#%ce #egree o> in$%ry

Cemporary 5acema,er 6ypo!en"ionG Al%i#" 7opamine Care>%l moni!or o> '4C". 'ny increa"e o> vagal re"pon"e can >%r!her increa"e &ra#ycar#ia an# ca%"e car#iac arre"!. %5 Post Ac#t P(as

S!a&iliFing !he "pine an# re"olving "pinal "hoc, ill allo >or early mo&iliFa!ion. Early mo&iliFa!ion preven!" >%r!her complica!ion". +ha! "y"!em &y "y"!em complica!ion" are e concerne# i!h Car#iova"c%lar ;e"pira!ory Ka"!roin!e"!inal 8 @%!ri!ion Elimina!ion 3%"c%lo",ele!al In!eg%men!ary R spirator$ Complicatio!s 3a$or ca%"e o> #ea!h in !he ac%!e pha"eI 5%lmonary "%ppor! S%c!ioning 8 5o"!%ral 7rainage 8 C%rning Coor#ina!e i!h ;C

Si#e E>>ec!"G #ecrea"e# imm%ne re"pon"e, ri", >or in>ec!ion, increa"e "er%m gl%co"e, in#%ce #epre""ion, p"ycho"i", ri", >or KI &lee# %/: 0(at is Spi!al S(ock1 2A3A N #ro+ !ic S(ock4 Cemporary Con#i!ion 8 'c%!e 5ha"e Sympa!he!ic >%nc!ion 8 comm%nica!ion i" impaire# &elo !he level o> in$%ry ) Sympa!he!ic nerve" leave !he "pine a! !horacic an# l%m&ar area" 5ara"ympa!he!ic >%nc!ion !a,e" over Ba"o#ila!ion , Beno%" 5ooling, 7ecrea"e# Car#iac <%!p%! BS Change"G 6ypo!en"ion, 4ra#ycar#ia, Cempera!%re >l%c!%a!ion", Al%"he# ex!remi!ie", 6ypoxia ?o"" o> Spinal ;e>lexe" ?o"" o> Sen"a!ion Alacci# 5araly"i" &elo in$%ry

66@ <2 "%ppor! Ben!ila!or- 'm&% a! &e#"i#e Crach nee#e# 3oni!or '4K" ) ga" exchange 4rea!h "o%n#" 8 &rea!hing pa!!ern" 8 "p%!%m pro#%c!ion 5oor co%gh e>>or! '!elec!a"i" 8 5ne%monia

Cime Arame ) one

ee, !o "ix mon!h"

3a"," !he ex!en! o> in$%ry Spinal Shoc, ;e"olve"G ;e>lexe" re!%rn L*G @%r"ing S%ppor! 4ra#ycar#iaG 'n!icholinergic 9'!ropine:

 6igher !he level in$%ry, !he higher !he ri",I '&ove C/ 8 4elo C/ .5hrenic nerve a! #iaphragm. In!erco"!al m%"cle impaire#2 Car*io,asc#lar Complicatio!s 6ypo!en"ion 4ra#ycar#ia 7ecrea"e# Car#iac <%!p%! Beno%" 5ooling Impaire# Ci""%e 5er>%"ion ;i", >or 7eep Bein Chrom&o"i" ) 7BC 5rophylaxi"I 'astroi!t sti!al ) N#tritio! Complicatio!s 5araly!ic Ile%" Sep!ic 4o el @ecro!ic 4o el S!re"" Elcer" KI4 3alno%ri"hmen! 0(at *o s t( t( !#rs !#rs ass ss1 0(at *o s

S,in Complica!ion" Patients who do not have an ulcer state that nurses in the ICU turned them every 2 hours after injury ;e"earch "ho " !ha! pa!ien!" go !o reha& i!h %lcer" alrea#y >orme# ) 7ISKESCI@K n%r"ing careI ;i", >ac!or" >or ",in &rea,#o n In!erven!ion"- S,in In"pec!ion"%7 S lf Car A6iliti s of T&89&&

?evel o> C2 ) C12 "ho%l# &e in#epen#en! i!h !he heelchair 3ay even al, "hor! #i"!ance" i!h or!ho!ic" an# cr%!che"

3anage !heir o n '7?" 3anage !heir 48 4 ro%!ine :LE;ELS OF INJURY< Symptoms, degree of paralysis, e tent of injury, and disa!ility depends on the level of cord that is injured Cervical 8 Choracic 8 ?%m&ar Cervical .C1 ) C12 D Ce!raplegia .arm" are rarely comple!ely paralyFe#2 Choracic 8 ?%m&ar ) .C2 ) l%m&ar2 5araplegia .>%ll %" o> arm"2 Comple!e v". Incomple!e Comple!e G Co!al lo"" o> "en"ory an# mo!or >%nc!ion &elo !he level o> in$%ry Incomple!eG 3ixe# lo"" o> vol%n!ary an# invol%n!ary ac!ivi!y an# "en"a!ion Cervical In$%rie" C1D2 G limi!e# hea# an# !r%n, con!rol , reM%ire" 8c i!h &rea!h con!rol"

mo!itor1 A6*omi!al ass ssm !t1 N'T to s#ctio!1 Elimina!ion Complica!ion" ?o"" o> 4la##er an# 4o el con!rol @e%rogenic 484 ;i", >or Impac!ion 8 ;e!en!ion 8 Incon!inence 8 Erinary Crac! In>ec!ion" 3%"c%lo",ele!al Complica!ion" ;i", >or Con!rac!%re" 3%"cle "pa"!ici!y Con!rac!%re" H.. ?o"" o> >%nc!ion

4one lo"" 3%"cle '!rophy

C*D/G 7epen#en! i!h '7?", may "!ill nee# ven!ila!or "%ppor! C/ an# a&oveG "ome "or! o> li>elong ven!ila!ory "%ppor! C0G el&o C(G >lexion

Che &o el ha" i!" o n ne%ral con!rol !ha! re"pon#" !o #i"!en!ion. Chi" i" ha! help" SCI pa!ien!" regain con!rol o> emp!ying. Crain !he &o el a pre#ic!a&le pa!!ern o> emp!ying @ *s: Di t: Ai&er, >l%i#" S!ool So>!ener" S!im%lan! ?axa!ive"

ri"! ex!en"ion

C=G >inger con!rol In#epen#ence increa"e" >rom C( #o n

%= .la** r F#!ctio! SCI a&ove C12 ) Spa"!ic or ;e>lexic 4la##er Charac!eriFe# &y invol%n!ary &la##er con!rac!ion" i!h %ncon!rolle# voi#ing an# incon!inence. ?1 ) 're>lexic or Alacci#

7igi!al "!im%la!ion .avoi# enema"2 5o"i!ioning '&#ominal 3a""age Bal"alva CASE STUDY %/* yo male p! en!ere# !he ho"pi!al i"chial i!h a le>!

SCI &elo 4la##er

'&"en! &la##er con!rac!ion" re"%l!ing in high vol%me" o> re"i#%al %rine an# %rinary re!en!ion ;i","G ;enal Calc%li , ECI"

pre""%re "ore "!age IB. 6e i" a Incomple!e C0 ) C( level o> in$%ry >or 20 year" a>!er "%>>ering a SCI a>!er a #iving acci#en!. 6e ha" a hi"!ory o> pre""%re %lcer". Bi!al Sign"G C N(.0, 45 JJ8/2, 502, ;;20 6e al"o ha" a hi"!ory o> '%!onomic 7y"re>lexia Ca,e a loo, a! hi" me#ica!ion regiman. %&: INCO@PLETE1 SELF CARE A.ILITIES1 A%ll hea#, nec,, an# "ho%l#er con!rol 7iaphragm con!rol Sho%l# no! nee# re"pira!ory "%ppor! El&o >lexion ex!en"ion i!h "ome ri"!

Koal"G 'voi# &la##er in>ec!ion". Increa"e >l%i#". 4la##er program 5! CeachingG "8 "x o> in>ec!ion In!ermi!!en! ca!h program 3e#ica!ion" !o help &la##er i!h !one S!im%la!e %rine >lo Increa"e >l%i#" In# elling ca!he!er ) irriga!ion" Cran&erry $%ice 3e#"G 'n!icholinergic" !o "%ppre"" con!rac!ion 'n!i"pa"mo!ic" !o #ecrea"e "pa"!ici!y

'""i"!ive #evice" >or >ine mo!or ",ill" In#epen#en!G >ee#ing, grooming, &a!hing, heelchair on even "%r>ace", #rive i!h han# con!rol"

%> .o? l Trai!i!+

 '""i"!anceG Cran">er", #re""ing %- ;S C(a!+ s i! SCI '%!onomic @ervo%" Sy"!em e>>ec!e# i!h in$%rie" a&ove !he C( level. Chere can &e a lo"" o> comm%nica!ion i!hin !he &o#y i!h !he '@S. Ina&ili!y !o a%!oreg%la!e ) par!ic%larly BS ?o 45, ?o 5%l"e, 5oi,lo!hermia .!a,ing on !he !emp o> !he room i!h perio#" o> >l%"hing an# ina&ili!y !o " ea!2 %5 @ *icatio! R +im ! 3%"cle Spa"!ici!yG 4aclo>en Alexeril Bali%m

3e#ic 'ler!I '7 i" %"%ally &ro%gh! on &y 4 8 4 #i"!en!ion, ECI, "pa"m", pre""%re "ore", in>ec!ion, ingro n !oenail, in"ec! &i!e, #y"mennorhea, "%rgery "i!e, con"!ric!ive clo!hing Ass ss fastB 6ea#ache Al%"hing S ea!ing 6igh 45 4l%rre# vi"ion @a%"ea 'c! >a"!I Eleva!e 6<4, con!ac! 37, moni!or BS, i#en!i>y noxio%" "!im%li, !rea! ca%"e L( ?e!O" Cal, '&o%! Sex 4a&yI i!h %pper

Bi!amin" 5ain an# 3%"cle ;elaxa!ionG @e%ron!in

;e>lex erec!ion i" po""i&le mo!or ne%ron le"ion"

4la##er Care 7e!rol 7i!ropan

<rga"m an# e$ac%la!ion i" no! %"%ally po""i&le 7r%g" or "%rgery >or erec!ile #y>%nc!ion op!ion 5oor "perm M%ali!y E"%ally remain >er!ile an# can have chil#ren E!erine con!rac!ion no! >el! 'llo ven!ing o> >eeling", o>>er "%ppor!, "%gge"! co%n"eling, e#%ca!e 5SPC6<S<CI'? C<@CE;@S-+ha! can yo% come %p Colla&ora!ive Koal" i!h---

4o el Care Colace S%ppo"i!ory

%A A#to!omic D$sr fl xia '&normal '@S re"pon"e in SCI p!" a C( or higher i!h

5a!hoG '@S canno! #ecipher "!im%l%" re"pon"e" rapi#ly coming %p !he "pinal !rac! ca%"ing an a&normal '@S re"pon"e flight and flight 5recipi!a!e# &y noxio%" "!im%li &elo !he level o> in$%ry 9Conge"!e# comm%nica!ion: in "pinal !rac! Can &e ?i>e Chrea!ening ) ca%"e increa"e# IC5, hemorrhage, SeiF%re, S!ro,e

i!h SCI ellne""

3ain!ain op!imal level o>

3ain!ain op!imal >%nc!ioning 3inimal or no complica!ion" o> immo&ili!y ?earn ne ",ill", "el> care

;e!%rn !o home

 In!egra!e &ac, in!o comm%ni!y