FISIATRA KINESIÓLOGO TERAPEUTA FONOAUDIÓLOGO

OCUPACIONAL
- Evaluación del - Evaluación del - Evaluación del - Evaluación de la
paciente. paciente. paciente. deglución, riesgo
- Determinación del - Ejercicios de de aspiración y
nivel neurológico mantención de - Aplicación de consistencia
de la lesión. ROM pasivos, escalas de alimentaria.
- Detección de activo-asistido o funcionalidad. - Técnica de
complicaciones activos en respiración
médicas y extremidades - Entrenamiento en glosofaríngea.
quirúrgicas. superiores e actividades de la - Técnicas de
- Manejo inferiores. vida diaria. vocalización en
farmacológico de - Ejercicios de paciente con VM o
las estiramiento. - Ejercicios de Válvula de
complicaciones fortalecimiento de fonación.
(espasticidad, - Ejercicios de extremidades
osificación propiocepción. superiores.
heterotópica,
hipercalcemia, - Ejercicios de - Ejercicios de control
infecciones fortalecimiento de motor fino y
urinarias, etc.) extremidades. coordinación.
- Coordinación de
terapias con el - Técnicas - Reeducación
ERH. reductoras de neuromuscular.
- Coordinación con tono.
el resto del equipo
médico (cirujanos, - Técnicas reductoras
- Actividades en de tono.
psiquiatras).
colchoneta.
- Detección de
necesidades de - Ferulaje de EESS:
- Entrenamiento en palmetas de reposo,
AAT.
transferencias férula para
- Control en la
funcionales. tenodesis.
etapa aguda,
subaguda y
crónica. - Entrenamiento del - Ferulaje de EEII:
equilibrio en topes antiequino,
sedente y bípedo. cuñas antiedema.

- Entrenamiento - Adaptaciones: cuff

progresivo de la universal,
marcha con AATT. adaptaciones en el
vestuario, etc.
- Programa de
ejercicios - Técnicas de
domiciliarios. simplificación del
trabajo y
- Fisioterapia con conservación de
TENS, Compresas energía.
frías.
- Evaluación de
- Educación del uso equipamento
médico durable.
 de AATT. - Evaluación de
hogar: acceso,
necesidad de
equipamento
especial.

- Técnicas de
propulsión de la
SDR.

TRABAJADOR PSICÓLOGO NUTRICIÓN ENFERMERA

SOCIAL
- Evaluación del - Evaluación de - Evaluación del - Cuidados de
contexto social. trastornos del estado nutricional. enfermería,
- Evaluación de ánimo. - Establemiento de cambios
redes de apoyo - Técnicas de dieta adecuada posicionales.
familiar y enfrentamiento al según - Curación de UPP.
comunitarias. estrés y requerimientos. - Realización de
- Evaluación del frustración. - Implementación de cateterismo.
estado laboral – - Psicoterapia. nutrición enteral. - Educación manejo
financiero. - Consejería - Implementación de vesical.
- Identificar familiar. nutrición parenteral
servicios - Incrementar fibra en
ambulatorios de la dieta.
reintegración - Aportar
comunitaria suplementos
laboral o grupos alimenticios orales.
de apoyo.
- Gestión de AATT.
 84
Table2.9 Bladder medications
Medication Mechanism Dosing Side effects Notes
Bethanecol Muscarinic agonist (M2 and M3) Start 10 mg po tid Hypotension, headache, GI Contraindicated in
® increases detrusor contractility Increase 10 mg/dose cramping, lacrimation, patients with asthma,
Max 100 mg/dose sweating CAD, gastric ulcers
Tamsulosin a 1A adrenergic antagonist ® relaxes Start 0.4 mg po qhs Orthostasis Do not use with nitro
smooth muscle of prostate and May increase to 0.8 mg agents
bladder neck Contains sulfa
Doxazosin a1 adrenergic antagonist ® relaxes Start 1 mg po qhs Orthostasis, hypotension
smooth muscle of prostate and Max dose 8 mg/day
bladder neck
Tolterodine Muscarinic antagonist (M1–M5) ® Start 1–2 mg po bid Dizziness, dry mouth, Available in LA
relaxation of detrusor Max 4 mg/day constipation, confusion, formulation
drowsiness
Oxybutynin Muscarinic antagonist (M1, M3) ® Start 5 mg po bid–tid Dizziness, dry mouth, Available in XL and patch
relaxation of detrusor Increase 5 mg/dose constipation, confusion, formulations
Max 30 mg/day drowsiness
Pseudoephedrine Norepinephrine release from Start 30 mg po bid Tachycardia, palpitations,
J.W.

presynaptic neurons ® Max 120 mg/day blur y vision, anorexia,

Siefferman

contraction of internal urethral vertigo

sphincter and relaxation of
detrusor
et
al.
 nal
Cord
Table2.8 Bowel medications

Injury
Medication Mechanism Dosing Side ef ects Onset
Docusate Emol ient (increases sto l fat content) 10 mg po TID Soft sto l PO: 12–72 h
Ir itates rectal mucosa Mini enema PR Discomfort PR: 10–20 min
Sen a Activates Auerbach’s plexus—increases 2–4 tabs (8.6 mg) po 8 h Catatonic colon 8 h
peristalsis prior to bowel routine (with chronic use)
Bisacodyl Ir itates colonic mucosa ® peristalsis and 10 mg po or pr daily Discomfort PO: 8 h
electrolyte secretion or
20 mg po q8h ×3 for severe PR: 15–30 min
constipation
Lactulose Osmotic ef ect ® colonic distention ® 15–30 ml po q6h prn (60 ml Gas and bloating, 2–6 h
peristalsis and H2O secretion daily max) ac idents
Polyethylene glycol Osmotic diuresis increases sto l H2O 17 g po daily-bid Accidents £24 h
Magnesium citrate Osmotic ef ect ® colonic distention ® 150–30 ml po ×1 Increased serum Mg, 2–6 h
peristalsis and H2O secretion ac idents
Milk of magnesia Osmotic diuresis 30–60 ml po q6h prn Increased serum Mg, 2–6 h
ac idents
79
Table2.10 Spasticity medications
Medication Mechanism Dosing Side effects Notes
Baclofen GABAB agonist ® pre- and Start 10 mg po tid, increase by Sedation, confusion, Abrupt discontinuation may
post-synaptic inhibition 5–10 mg/dose every 3–5 days constipation precipitate seizures
Dantrolene Decrease release of calcium from Start 25 mg daily, increase to Weakness, fatigue, Follow LFT’s weekly
sarcoplasmic reticulum TID, then increase dose by drowsiness, diar hea,
25 mg every 3–5 days liver toxicity
Max 400 mg/day
Diazepam GABAA agonist ® pre-synaptic Start 2 mg po bid or qhs, may Drowsiness, fatigue, Tachyphylaxis with
inhibition increase to 5 or 10 mg confusion tolerance and
dependence
Clonazepam GABAA agonist ® pre-synaptic Start 0.5 mg po tid or qhs, may Drowsiness, fatigue, Tachyphylaxis with
inhibition increase to 1 mg confusion tolerance and
dependence
Tizanidine a 2 agonist ® inhibits spinal Start 2 mg tid–qid and titrate by Orthostasis, hallucination, Follow LFT’s
interneurons 2 mg as needed sedation, dizziness,
Max 36 mg/day elevated LFTs Tab and Cap are not
bioequivalent
OnabotulinumtoxinA Cleaves SNAP-25, preventing 25–50 units/muscle Dysphagia, dyspnea, Approved for elbow,
exocytosis of presynaptic ACh Max 12–14 units/kg or 400 units weakness, upper wrist, and finger flexor
vesicles at the neuromuscular in 3 months respiratory infection spasticity only
junction
RimabotulinumtoxinB Cleaves synaptobrevin preventing Start 2,500 units total Dysphagia, dyspnea,
exocytosis of presynaptic Increase per muscle up to 50% weakness, upper
ACh vesicles respiratory infection
Table2.13 Pain medications

2
Spinal Cord Injury
Medication Mechanism Dose Side effects
Amitriptyline Acts on 5HT2A receptors increasing Start 25 mg po qhs Drowsiness, dry mouth, dizziness, N/V,
serotonin and norepinephrine Max: 150 mg/day constipation, confusion,
concentrations in the central nervous anxiety, insomnia, urinary retention,
system, inhibiting afferent pain signals paresthesias, tremor, vision
[18, 19] changes, QT prolongation, SIADH
Baclofen GABAB agonist 5 mg po TID increase: 15 mg/day Drowsiness, dizziness, weakness,
q3 days confusion, hypotension, respiratory
Max: 80 mg/day depression, withdrawal seizures
Duloxetine Serotonin and norepinephrine reuptake Start 30 mg po daily Headache, somnolence, fatigue, nausea,
inhibition ® descending inhibition of Increase after 1 week dizziness, hyperhydrosis
pain Max: 60 mg
Gabapentin Interacts with a 2d subunit of voltage-gated Start 100–300 mg po qhs Dizziness, drowsiness, ataxia, n/v,
N-type Ca2+ channels and indirectly Increase frequency to tid–qid peripheral edema
with the NMDA receptor ® inhibition Titrate by 200–300 mg/dose
of nociceptive signals [109, 110] Max: 3,600 mg/day
Levetiracetam Inhibits N-type voltage gated Ca2+ channels 500 mg po q12h Headache, N/V, diar hea, anorexia,
and acts as a GABAA agonist [111] Increase by 1,000 mg/day q2 week fatigue, dizziness, agitation, ataxia,
Max: 3000 mg/day withdrawal seizures
Not effective for SCI pain [111]
Lidocaine Inhibits Na+ channels, stabilizing neuronal 5% patch, 12 h on, 12 h off Erythema, edema, burning, urticaria,
topical cell membranes and inhibiting nerve Max: 3 patches arrhythmia
impulse initiation and conduction [112] 5% ointment QID
(continued)
107

Table2.13 (continued)
Medication Mechanism Dose
Methadone m-opioid agonist and NMDA antagonist Start 1–2.5 mg po q8h–q12h
Increase dose q10–14 days
Milnacipran Norepinephrine and serotonin (3:1) Day 1: 12.5 mg
reuptake inhibition ® descending Day 2–3: 12.5 mg bid
inhibition of pain Day 4–7: 25 mg bid
Day 8: 50 mg bid
Max: 100 mg bid
Morphine m-opioid agonist [112] Start 7.5 mg po or 2 mg IV
Monitor for sedation, respiratory
depression
PO dose = 3× IV dose
Pregabalin Interacts with a 2d subunit of voltage-gated Start 50 mg po TID
N-type Ca2+ channels and indirectly Increase to 300 mg/day over
with the NMDA receptor ® inhibition 7 days
of nociceptive signals Max: 600 mg/day
Tramadol A low-affinity m-opioid agonist and weak 50 mg po q6h prn
monoamine reuptake inhibitor [112] Max: 400 mg/day
108
Side effects
Repiratory depression, hypotension,
dizziness, sedation, N/V, constipation,
QT prolongation
Nausea, constipation, headache, insomnia,
hot flashes
Repiratory depression, hypotension,
drowsiness, constipation, pruritus, dry
mouth, urinary retention
Dizziness, drowsiness, ataxia, tremor, n/v,
peripheral edema, headache, blurry
vision, weight gain
Dizziness, orthostatic hypotension, n/v,
constipation, headache, pruritus,
J.W. Siefferman et al.

serotonin syndrome
Valproic acid Blocks voltage-gated Na+ channels Start 250 mg po TID Headache, N/V, diarrhea,
suppressing high-frequency firing of Increase by250 mg/dose thrombocytopenia, dizziness, appetite
neurons Monitor serum levels (goal: changes, depression, insomnia,
Indirect ↑GABA concentrations in CNS 50–100 mg/L) elevated AST/ALT, SIADH, vision
[113] changes