Inpatient-Phase I Rehabilitation

1. General and Modified Tehniques
   • Maintain circulatory blood volume
   • Prevent autonomic dysreflexia and orthostatic hypotension
   • Reduce complications of bedrest and inactivity
   • Identify and quantify risk factors for CAD, and begin medication and patient/family education to modify risk factors
   • Alleviate anxiety, prevent depression, and initiate changes in lifestyle, such as giving up smoking
   • Evaluate position changes and functional activity and monitor heart rates and blood pressure during different activities following a recent MI

2. Stress Management-Since mental stress has confirmed cardiovascular efects and can be caused by a reduced quality of life and low self-esteem, interventions to manage stress are necessary following SCI.  Stress management begins with a review of diagnostic findings, an explanation of the current care program, plans for rehabilitation, and realistic encouragement and education to successfully achieve rehabilitation goals, with both the patient and his/her family and friends.

3. Medications-The following management of cardiac disease differs for SCI pateints only in the following ways:
   • Antihypertensive agents, such as angiotensin converting enzyme inhibitors, beta blockers, and diuretics, should be administered at the lowest possible effective dose (due to low baseline blood presure being common in SCI patients), and blood pressure should be carefully monitored in both supine and upright positions
   • Agents that affect renal function, such as angiotensin converting enzyme inhibitors, should be use cautiously (due to underlying renal insufficiency being common in SCI patients, as a result of urologic problems), and frequent checks of the patient's electrolytes, blood urea nitrogen, creatinine levels, and creatinine clearance should be done
   • Drugs that disrupt glucose or lipid homeostasis, such as thiazide diuretics and beta blockers, should be avoided, if possible (due to baseline glucose intolerance and low HDL levels being common in SCI patients)
   • Medications requiring less frequent dosing and available in other than pill form are preferred, to promote patient compliance by overcoming dexterity problems (common in SCI patients)

4. Treatment of Hypercholesterolemia and Low HDL-The management of hypercholesterolemia and low HDL differs for SCI patients only in the medications prescribed, if other than dietary therapy, aerobic exercise, and elimination of secondary causes, such as untreated diabetes mellitus or thyroid dysfunction, is indicated.
   • Bile acid sequestrants, such as cholestyramine and colestipol, should be avoided (due to neurogenic bowels and either diarrhea or constipation being common in SCI patients)
   • Nicotonic acid should be avoided (due to glucose intolerance being common in SCI patients)

5. Nutritional Intervention-Due to exercise limitations, conventional nutritional interventions for CAD are inadequate to reduce or reverse the disease process in SCI patients.  A high protein (20% of total calories) low fat content (less than 15% of calories), diet, rich in insoluble fiber, maximally reduces the risk of CAD in SCI.  The hospital diet should reflect the practical diet goal for home and be integrated with occupational and recreational therapy.
   • Calories
     • The standard Harris Benedict Formulae to determine basal energy expenditure (BEE) should be reduced by up to 25% for high quadripeligic patients, 20% for low quadriplegic patients, 15% for high paraplegic patients, and 10% for low paraplegic patients, before calories activity requirements are added to the BEE, to account for lower caloric needs, based on lower basal metabolic rates, which can fall by as much as 21% 6 months to 1 year following the injury.
     • The Metropolitan Life Insurance ideal body weight values should be reduced by 10 to 20 pounds, depending on the level of injury, to account for reduced bone and muscle mass in SCI patients
   • Proteins-Adequate protein supplementation is needed to address and prevent protein deficiency, common in SCI patients.  Low fat, high protein sources should constitute 20% of the diet to prevent excess catabolism, which can significantly affect hemodynamic stability.
   • Fiber-A high fiber diet, rich in complex carbohydrates, guards against serum glucose fluctuations, decreases gut transit time which reduces fat absorption, and is consistent with the regimen for neurogenic bowel dysfunction in SCI patients.
   • Vitamins-Although vitamin supplementation during the acute phase may reduce the risk for vitamin deficiency, most vitamin deficiencies improve over a period of months with good nutrition that includes albumin, carotene, transferrin, ascorbate, thiamine, folate, copper, and chromium.
   • Creatine-Supplementation with creatine enhances exercise capacity in persons with complete cervical - level SCI and may promote greater exercise training benefits (Jacobs, et al 2002).

6. Mobility and Exercise-Interventions to enhance functional mobility, circulatory volume, and endurance should be initiated the day after the MI, unless there are complications that prevent movement:
   • Frequent position changes, on a bed surface that distributes forces widely and uniformly, protect the skin, promote blood pressure stabilization, and help prevent autonomic dysreflexia and coronary vasopasm
   • Thigh-high compression stockings, sequential pneumatic compression devices, and abdominal binders help maintain adequate venous return, cardiac output, and blood pressure
   • Frequent elevation of the head and dangling of the legs over the bedside can begin on day 2 tohelp maintain dynamic circulatory responses to changes in position
   • Aerobic conditioning with sustained isotonic repetitive extremity movement, i.e. arm ergometry, should begin in the recumbent position
   • Out of bed transfers, with ECG monitoring, should begin when the patient is hemodynamically stable, to help stabilize sitting blood pressure, and bed-to-wheelchair transfers to increase cardiac stress, at first gradually by using a slide board and keeping the patient's center of gravity in the same horizontal plane, help assess the patient's response to the physical demands of the home
   • Wheelchair ambulance progresses based on the patient's ability to sustain aerobic exercise, with a goal of 20 minutes of sustained exercise at least once daily
   • Heart problem support groups and supervised exercise groups, with individual program prescription, should be attended by patients, spouses, children, and significant others

7. Coronary Artery Bypass Surgery can be performed to treat angina in SCI, but the special needs of SCI patients must be addressed, such as bowel and bladder care, wrappin goperating beds to protect the back, pharmacologic support for low vascular resistance during surgery, and ventilation support, if needed (Walker, et al 1996)