Chapter 27
Staying Healthy... and a Bedtime Story
People with spinal cord injuries face the same challenges to maintaining their health that their uninjured friends and neighbors do. Some areas of health that need your attention include vaccinations, colon cancer screening, male and female health issues, and satisfying sleep.
VACCINATIONS
It sometimes seems that the world is swarming with bacteria and viruses that are out to get us. For many of the common bacterial and viral infections, we have a great defense: vaccination.
Diphtheria/Tetanus
Everybody needs to stay current with diphtheria/tetanus vaccinations. The bacteria that causes tetanus (named Clostridium tetani) is everywhere in our environment. Our first line of defense against this bacteria is our skin. If our skin gets broken by a scrape, a cut, a puncture wound, or a tear, then this dangerous bacteria may get into our bodies and cause a severe disease, tetanus, that is often fatal.
Diphtheria is a disease that has virtually disappeared in the United States and Western Europe as a result of vaccination programs. In unvaccinated individuals, diphtheria occurs as a severe upper respiratory infection with extremely sore throat and can progress to closing the airway, severe cardiac infection, and death. The disease is starting to occur more frequently in Eastern Europe where vaccination programs have broken down in the last few years.
The best defense against these diseases is vaccination. After being immunized as children, adults should have a booster vaccination every 10 years. It’s common in medical practice for people with traumatic injuries to be vaccinated if they haven’t been vaccinated in the last 5 years.
Influenza
Influenza (flu) virus has built-in defenses that confound the effort to control it. The virus changes various characteristics on a frequent basis, so we need to be vaccinated every year against the flu. We tend to think of the flu as a trivial disease, but the worst epidemic in American history was the influenza epidemic of 1918. More people died in this epidemic than all of the combat deaths in that century combined.
People with respiratory diseases, elderly people, and people who work in health care are encouraged to get immunized every year. Since many people with spinal cord injury, especially quadriplegics, have respiratory impairments, you should be vaccinated every year.
There are also new drugs available to treat the flu if you get it, but they are most effective in the early stages of the illness. Therefore, if you get the flu, or think you might be getting the flu, it’s best to call your doctor right away, so you can get the medicine you may need to prevent a severe case.
Pneumococcus
Pneumonia is the sixth leading cause of death in the United States. The most common cause of bacterial pneumonia is a bacteria named Streptococcus Pneumoniae. There are more than 90 strains of these bacteria, but medicine is available to help prevent pneumonia from about 95 percent of them. Authorities recommend that people with chronic illnesses, especially respiratory diseases, and elderly people receive the vaccine. People with SCI, especially people with quadriplegia, often have respiratory impairments, so it is recommended that they receive this vaccine as well. People who receive the vaccine should have repeat vaccinations about every six years.
COLON CANCER SCREENING
Colon cancer is a common form of cancer in the United States. Fifteen percent of all cancer deaths are caused by colon cancer. The disease affects 2 out of every 1,000 people. There is no definitive way of preventing colon cancer. Factors that contribute to prevention are low fat, high fiber diet and regular bowel movements. Factors associated with an increased risk of colon cancer are colorectal polyps, cancer elsewhere in the body, a family history of colon cancer, ulcerative colitis, granulomatous colitis, and immune deficiency disorders.
If you have a family history of colon cancer, you should have your stool tested for hidden blood every year after you are 40 years old. If you don’t have a family history, you should be checked every year after you are 50 years old. The test involves taking a small amount of stool and smearing it on a special card that you will be given (or receive in the mail) from your health-care providers. You return this card to them and they can then test to see if there is any blood present in your stool.
Factors that can cause this test to be less accurate include:
- Bleeding gums following a dental procedure
- Eating of red meat within 3 days
- Eating of fish, turnips, or horseradish
Drugs that can cause false positive results due to bleeding in the stomach and intestines include blood thinners, aspirin, colchicine, iron supplements in large doses, anti-inflammatory drugs, and corticosteroids. Other drugs that can cause false positive measurements include oxidizing drugs (such as iodine, bromides, and boric acid) and reserpine.
Large amounts of vitamin C can cause false negative results.
Bleeding hemorrhoids can cause false positive readings on this test and for people with SCI, if their bowel care is very vigorous or they are constipated and have hard stool, this may cause some minor bleeding in the rectum that can give a false positive reading.
To control for the possibility of false positive results, the test is normally repeated on three consecutive days.
If it is discovered that you have blood hidden in your stool, you should be referred to doctors who specialize in stomach and intestinal diseases (gastroenterologists) to have a colonoscopy or some other study performed. A colonoscopy is a test where a fiber optic tube is threaded up into your colon so the doctors can see the lining and identify any abnormalities by examination.
Colon cancer that is identified early is easily treatable with surgery and the chances of being cured of the disease are very good. If you are within the age guidelines given above (after you are 40 or 50) and your doctor does not offer you this test, ASK FOR IT!
GENDER-SPECIFIC HEALTH ISSUES
There are health issues that are specific to men and to women. People with SCI need to be aware of these problems and take the same steps that able-bodied people take to prevent them or at least to recognize them early.
Female Health Issues
Breast Cancer
It is estimated that one out of eight or nine women will develop breast cancer in the course of her life. The occurrence of breast cancer increases dramatically over the age of 30.
Some studies have indicated that diet may have an impact on the occurrence of the disease. Breast cancer appears to be more likely to develop in women whose diet is very high in fat. Older women who are overweight also seem to have a greater risk. Some scientists believe that a low-fat diet, eating well-balanced meals with plenty of fruits and vegetables, and maintaining ideal weight can lower the risk of breast cancer.
Other risk factors include having a family history of breast cancer, particularly in mother or sisters; a past medical history of breast cancer, ovarian cancer, uterine cancer, or colon cancer; early menarche (start of menstruation before age 12) or late menopause (after age 55); no pregnancies or a first pregnancy after age 30; and radiation exposure. Post-menopausal estrogen therapy and oral contraceptive use (such as estrogens and progestin oral contraceptives) were considered positive risk factors, but the majority of recent studies do not confirm such risk.
As with colon cancer and most other forms of cancer, the chances of successful treatment of breast cancer are best if the disease is detected early. The best practices for early detection include monthly breast self-exam after the age of 20 and yearly mammograms for women over 40.
Breast Self Exam (BSE)
Women should examine their breasts for lumps every month, at the same time after their period (menstruation). Just before menstruation and during pregnancy, a woman’s breasts may be somewhat lumpy and more tender. If you are taking hormones, ask your doctor about when to perform BSE.
For women with SCI, there may be a problem with sufficient hand function to complete this examination. Where this is the case, an attendant or family member should perform this examination for them. It would be important to have the same person performing this examination from month to month so that he or she may easily recognize any changes in the breast tissue.
To do BSE perform the following steps:
- Lie down; flatten your right breast by placing a pillow under your right shoulder. Place your right arm behind your back. You can also examine your breast when you are upright in the shower, using soap for lubrication.
- Use the fingertips (the most sensitive part of your hand for touch) of your middle three fingers. Feel for lumps using a circular, rubbing motion in small dime-sized circles without lifting your fingers. You can use powder, oil, or lotion to lubricate your hands to make this easier.
- Start with light pressure, move to medium pressure, and then use firm pressure to examine different levels of breast tissue.
- Completely examine all of the breast and chest area up under your armpit and up to the collarbone and all the way over to your shoulder.
- Use a pattern to insure that you examine the whole breast. This pattern could be parallel lines running from your shoulder toward your legs, concentric circles starting at the outside of your breast and moving inward toward the nipple, or you can use wedges, starting at the edges and moving toward the nipple in small wedge-shaped sections all around your breast. Whatever pattern you use, be sure to check the "tail" of the breast that runs up under your armpit.
- After you have completely examined your right breast, then examine your left breast using the same method.
- You should also examine your breasts in a mirror when you are upright looking for any changes in size or contour, dimpling of the skin, or spontaneous nipple discharge.
If you identify any changes in your breast tissue, in size or contour, any dimpling, or nipple discharge you need to be seen by your doctor soon.
Cervical Cancer
The third most common form of cancer in women is cervical cancer. Two to three percent of women over 40 will develop some form of cervical cancer. The cause of cervical cancer is unknown but factors that contribute to the development of cervical cancer include multiple sexual partners, early onset of sexual activity (less than 18 years), or early childbearing (less than 16 years). Sexually transmitted diseases, specifically Human papilloma virus (genital warts), HIV infection, and genital herpes, also appear to increase the risk of cervical cancer.
It is now known that women who were exposed to the drug DES (Diethylstilbestrol) in utero are at risk for developing certain rare vaginal and cervical cancers along with many other abnormalities of the uterine, cervical, and vaginal tissues. DES is a drug that was once thought to prevent miscarriages. Unfortunately, the risks of taking DES were not known and between 1940 and the early 1970s, many pregnant women received the drug in hopes of preventing any suspected miscarriages. Clinical studies have shown the risk of cancer among the daughters born to women who were taking the drug to be around 4 in 1,000.
Cervical cancer may take years to develop. Initially, subtle changes develop in superficial cells of the cervix. Then the condition progresses to "dysplasia", which is the presence of pre-cancerous cells. These can then progress to superficial cancer (noninvasive) and then to invasive cancer that can spread to other abdominal organs.
Strategies to prevent cervical cancer include deferring sex until a person is 18 years old, monogamy, and safer sexual behaviors.
A routine pelvic examination, including a Pap smear, should be performed yearly beginning at the onset of sexual activity, or by the age of 20 in non-sexually active women. Pap smears detect abnormalities in the cells of the cervix, thus alerting the physician that further tests may need to be done. Early detection allows treatment to begin before cancer has actually developed.
Male Health Issues
Testicular Cancer
Cancer of the testicles accounts for only about 1 percent of all cancers in men. It is, however, the most common form of cancer in men between 18 and 25 years of age. Usually only one testicle is affected.
The cause of testicular cancer is not known but the known risk factors include:
- Uncorrected undescended testicles in infants and young boys
- A family history of testicular cancer
- Having an identical twin with testicular cancer
- Viral infections
- Injury to the scrotum
In the very early stages, testicular cancer may have no symptoms but when there are symptoms, they include:
- Small painless lump in testicle
- Enlarged testicle
- Feeling of heaviness in the testicle or groin
- Pain in the testicle
- A change in the way the testicle feels
- Enlarged male breasts and nipples
- Blood or fluid suddenly accumulating in the scrotum
Testicular cancer is almost always curable if it is found and treated early. The testicle is removed surgically. One testicle is sufficient for fully normal sexual functioning.
The American Academy of Family Physicians Subcommittee for Male Patients recommends learning testicular self-examination (TSE) between the ages on 13 and 18.
To perform TSE, examine each testicle gently with both hands. The index and middle fingers should be placed underneath the testicle while the thumbs are placed on top. Roll the testicle gently between the thumbs and fingers. It should feel smooth and have no bumps.
On the backside of the testicle you will feel a soft, ropy, tube-like structure. This is called the epididymis and should not be confused with a lump. Follow the epididymis up with your fingers until it enters the body. It should have the same consistency along its whole length.
If you have severe testicular pain, you should seek medical care urgently (this is more likely to be an infection or a physical problem rather than cancer, but it can be dangerous).
If there are any lumps, enlargements, swelling, or change in consistency or any sense of heaviness or pain, you should talk to your doctor. If there is an enlargement of the breasts and nipples or a sudden feeling of puffiness in the scrotum, you should also see a doctor.
You should practice TSE at least monthly or as directed by your doctor. Men with quadriplegia may need to have a family member or an attendant perform TSE for them. It is best if the same person performs the test from month to month in order to identify changes.
Prostate Health
We are hearing more and more about the dangers of prostate gland problems in men. Enlargement of the prostate gland, called benign prostatic hyperplasia (BPH), occurs in most men. Eighty percent of men over 40 and 95 percent of men over 80 have some degree of BPH. Eunuchs (men who have lost their testicles) do not develop BPH. This is the only known strategy for prevention of BPH and is, obviously, not recommended.
The biggest problems associated with BPH are changes in urination:
- Urgency (feeling a sudden strong urge to urinate)
- Frequency (having to urinate more often than normal)
- Urinary retention (not emptying the bladder completely)
In men with SCI, there can be increasing difficulty inserting a catheter and increased occurrence of bleeding and trauma from inserting a catheter. A special kind of catheter called a coude tipped catheter often helps to go into the bladder through an enlarged prostate gland.
There are surgical procedures that can be done to help with prostate problems and there are medicines that you can take to help with this as well. Be sure to discuss this with your doctor if you suspect that you are having problems with an enlarged prostate gland.
Prostate cancer is a more serious problem. It is the third most common cause of death from cancer in all men and the most common cause of death from cancer in men over the age of 75. The incidence is greatest in African American men over 60 years old. Increased incidence is also associated with farmers, tire workers, painters, and men exposed to cadmium. The lowest incidence occurs in Japanese men and vegetarians.
The precise cause of prostate cancer and how to prevent it are not known. Adopting a vegetarian, low-fat diet or one that mimics the traditional Japanese diet may lower risk.
The key to survival is early detection. It is recommended by some healthcare organizations that men over 40 or 50 have a yearly rectal exam and a yearly laboratory test for the level of prostate specific antigen (PSA) in the blood stream. A normal level of PSA is 4 nanograms per milliliter. A PSA greater than 10 nanograms per milliliter requires further diagnostic testing. Values between 4 and 10 can be the result of BPH or prostatitis (an infection of the prostate gland).
Many men find rectal exams unpleasant and distasteful, but it is in their best interest to tough it out and have it done. Ninety-five percent of the changes in the prostate gland can be felt by the examiner during a rectal exam and this exam, coupled with PSA levels, can identify prostate cancer at the earliest (and treatable) stages.
Breast Cancer
Both men and women can develop breast cancer. About 10 percent of cases of breast cancer each year occur in men. Consequently, men need to be aware of strategies for early detection as well as women.
AND A BEDTIME STORY
Satisfactory sleep time is an important element of a quality lifestyle. Human beings cycle through five different stages of sleep in the course of a typical night. There is the sleep pattern associated with dreaming, called rapid eye movement (REM) sleep because the eyes move through alternating cycles of slow and rapid movement during this stage. There are also four increasingly deepening sleep rhythms known as non-REM stage 1 through stage 4 sleep. In a normal night, the first half of the night is marked by long periods in deep non-REM sleep and the last half by long periods of REM sleep.
One interesting fact about sleep is that people’s cycles tend to run in 25-hour cycles (not 24 hours to match a single day); that’s why we sometimes feel the need to catch up on sleep on the weekends and why Mondays are so bleak for some people--because they have to get up much earlier than their internal clock would indicate.
Spinal cord injury may have subtle impacts on sleep patterns. Able-bodied people have a decrease in urine output during the hours of sleep, whereas people with SCI have a steady or even an increased level of urine output at night. This means that people who use intermittent catheterization for their bladder program need to be careful to reduce the amount of fluid they take in after dinner and may need to get up once during the night to catheterize themselves. One study that compared the time use patterns of men with SCI to able-bodied men found that men with SCI spent a little more time each day sleeping than the other people in the study.
Two factors that can cause difficulty sleeping are disrupted daily rhythms and aging. As we age, our sleep patterns change. We spend less time each night in deep non-REM sleep and we also have less REM sleep. Total sleep time may stay the same or even increase a little with aging, but our sense of feeling rested and refreshed after sleep diminishes with age. Also, changes in our daily rhythms--when we eat, when we try to sleep, and when we get up--can change our sense of rest and refreshment and even lead to difficulties falling or staying asleep.
Drugs aren’t much help. Although some drugs may initially make falling asleep easier, they have a bad effect on the depth and quality of sleep. If they are used over a long period of time, they may make falling asleep even more difficult than it would have been otherwise. Many people try using alcoholic drinks to help with sleep, but although alcohol may initially make people feel sleepy, it has a very disruptive effect on the quality and quantity of sleep.
So, in order to have the best quality of sleep, it’s important to set and keep to a reasonably stable schedule. Get ready for bed at the same time at night. Develop and follow routines for getting ready for bed. Make sure that your bedroom can be darkened during your sleep periods. If there are problems with noises waking you, try using some form of "white noise" like table fans or recordings of wind and water sounds.
There are two medical conditions that can have an effect on your sleep. If you suspect that you have either of these, it’s important to see your doctor. The first of these conditions is depression. With serious depression, people actually may sleep much more than eight hours a day, but they don’t feel refreshed or energized after sleep. They may fall asleep easily enough at night but wake up in the early morning hours and have difficulty falling asleep again. If you experience sleep problems like this or a general absence of joy and pleasure in life, you should consult with your doctor. The drugs to treat depression have increased in quality and there is real hope of improved mood and improved sleep patterns.
Another disease that affects sleep is called sleep apnea. In sleep apnea, people actually stop breathing for brief periods when they are asleep at night. Their blood oxygen levels drop until they startle awake feeling anxious about insufficient air. These people most often snore loudly and their bed partners often are troubled by the uneven pattern of their breathing. People with sleep apnea are deprived of adequate rest and are often sleepy during the day. They fall into a doze readily during the day.
In the able-bodied population and probably among people with paraplegia, the risk factors for this condition are being male, getting older, and being overweight. Many people with quadriplegia have this condition without the normal risk factors. We don’t really know why quads have this problem but a number of them do.
Risks associated with sleep apnea include high blood pressure, heart problems, and stroke. Another big problem is automobile accidents, since people with sleep apnea often fall asleep at the wheel. If you think you might have sleep apnea, there are some treatments that your doctor can use to try and help you. If you suspect you have this problem, exercise extreme caution when you are driving.
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Staying Healthy