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Non-pharmacological Interventions for Orthostatic Hypotension

To date, studies addressing the non-pharmacological management of OH in acute SCI are limited. There have been several more non-pharmacological modalities of treatment studied in the chronic SCI population, including fluid intake and salt loading, use of elastic stockings and abdominal binders, harness application, whole-body vibration, exercise, and standing training (refer to SCIRE Orthostatic Hypotension rehabilitation evidence chapter).

Table 3. Non-pharmacological Management of Orthostatic Hypotension during Acute SCI

Author Year

Country

Research Design

PEDro

Sample Size

MethodsOutcomes
Tesini et al., (2013)

Switzerland

RCT Crossover

PEDro=4

N=9

 

Population: Median age=30.1yr; Gender: males=6, females=3; Level of injury: C4-T4; Severity of injury: AIS A-C.

Intervention: Patients were positioned on a tilt-table at 0°, 15°, 30°, 45°, 60°, and 70° with individual electrical stimulation intensities depending on each patient; Patients underwent this tilting procedure for each of the following randomly assigned stimulation sites: A) abdominal muscles, B) lower limb muscles (Mm. gastrocnemii, hamstrings, Mm. quadriceps) C) combination of A and B, D) control (diagnostic) session.

Outcome Measures: Systolic BP, diastolic BP, Mean Arterial Pressure (MAP), and Perceived Presyncope Score (PPS).

Chronicity: Patients were 20-135 days (median=34 days) post injury.

1.     BP did not differ significantly between the interventions (A, B, C, D) at any degree of incline (p>0.05).

2.     BP was more stable up to 30° for A, B, and C interventions compared to D.

 

Elokda et al., (2000)

USA

RCT

PEDro=3

N=5

Population: Mean age=29yr; Gender: males=5, females=0; Level of injury: C6-T8.

Intervention: Acute SCI patients were examined during tilting (0°, 15°, 30°, 45°, 60°), with or without Functional Neuromuscular Stimulation (FNS) of the knee extensors and foot plantar flexors in a randomized treatment order.

Outcome Measures: HR, systolic BP, diastolic BP.

Chronicity: Patients were 1-6wk post injury (mean=3wk).

1.     At 15°, 30°, 45°, and 60° tilt test positions, systolic BP without FNS was significantly lower than with FNS (p=0.05, p=0.0001, p=0.04, p=0.007, respectively).

2.     At 30° and 45° tilt test positions, diastolic BP without FNS was lower than that with FNS (p=0.02, p=0.01, respectively).

3.     HR progressively increased with tilt angle.

4.     At the 60° tilt test position; HR was significantly higher with FNS than without FNS (p<0.05).

 

Sampson et al., (2000)

Canada

Pre-Post

NIntial=6

NFinal=3

Population: Mean age=30.3yr; Gender: males=6, females=0; Level of injury: C4-T4; Severity of injury: AIS A-B.

Intervention: Patients were tilted by 10° increments from 0° to 90° at four Functional Electrical Stimulation (FES) intensities (0, 48, 96, and 160 mA); this tilting procedure was conducted for 2 separate stimulation sites: 1) quadriceps and pretibial muscles, and 2) patellae and malleoli. The order of stimulation intensities was randomized for each testing session.

Outcome Measures: HR, systolic BP, diastolic BP, Perceived Presyncope Score (PPS).

Chronicity: 3 patients had acute SCI (8-10wk post injury), 3 patients had chronic SCI (10-14yr post injury).

1.     Mean systolic BP increased significantly with increasing stimulation intensities (p=0.001).

2.     Mean diastolic BP increased significantly with increasing stimulation intensities (p=0.0019).

3.     Mean systolic BP and diastolic BP decreased with increasing levels of incline angle (p<0.001).

4.     Site of stimulation did not affect systolic BP or diastolic BP.

5.     HR increased significantly with angle of incline (p<0.001).

6.     Presyncopal symptoms were significantly greater with increased degrees of incline (p<0.001).

Daunoraviciene et al., (2018)

Lithuania

Pre-Post

N=6

Population: Combined SCI and Stroke population: Mean age: 58.83yr; Gender: males=5, females=1; Severity of injury: AIS: C=3.

Interventions: Verticalization training occurred with the use of a robotic tilt table, there were 10 sessions in total. Verticalization started at 20° and finished at 80°. During each 20-40 min session patients also experienced passive leg movement exercises if they remained stable throughout verticalization.

Outcome Measures: Heart Rate (HR), Blood Pressure (BP), Berg Balance Scale (BBS) score, lower limb range of motion, (PASS), patient opinion of treatment. *Results reported for SCI only.

Chronicity: Post-acute rehabilitation (2-4wk)

1.     Compared to before treatment SCI patient’s heart rate and systolic BP significantly decreased post treatment (p<0.05). BBS scores significantly increased post treatment (p<0.05).

2.     Lower limb range of motion did not significantly change over the course of treatment.

3.     PASS scores significantly increased post treatment in SCI patients (p<0.05).

4.     SCI patients subjectively felt less confident in their training compared to stroke patients.

Three studies have examined the non-pharmacological management of OH during acute SCI with electrical stimulation and tilt table verticalization. In a RCT by Elokda et al. (2000), five patients who were, on average, 3 weeks post SCI were examined during a tilting procedure with or without functional neuromuscular stimulation (FNS) of the knee extensors and foot plantar flexors. The effect of FNS on postural-related orthostatic stress was measured at 0°, 15°, 30°, 45°, 60° tilt angles. Measures of systolic BP at 15° (p=0.05), 30° (p<0.001), 45° (p=0.04), and 60° (p=0.07) positions without FNS were significantly lower than with stimulation, while measures of diastolic BP at 30° (p=0.02) and 45° (p=0.01) without stimulation were lower than with FNS. Sampson et al. (2000) studied six patients in a RCT who underwent a tilting procedure at four functional electrical stimulation (FES) intensities (0, 48, 96, and 160 mA). Half of the participating subjects recruited for this study had an acute/subacute SCI as they were studied at 8-10 weeks post injury, while the other half were 10-14 years post injury (chronic phase of SCI). Patients were tilted by 10° increments from 0° to 90° during separate stimulation of the quadriceps and pretibial muscles, and at the patellae and malleoli. The authors observed a dose-dependent increase in BP, regardless of stimulation site. The mean systolic (p=0.001) and diastolic BP (p=0.0019) increased significantly with increasing stimulation intensities. Tesini et al. (2013) recruited nine patients who were a median of 34 days after injury. Participants were positioned on a tilt-table at increasing angles (0°, 15°, 30°, 45°, 60°, and 70°) with varying electrical stimulation intensities being used according to each patient. The tilting procedure was conducted for three sites of stimulation, which included the abdominal muscles, lower limb muscles, and a combination of abdominal and lower limb muscles, as well as a baseline measure without stimulation. Although a tendency towards the beneficial use of ES for OH was seen, BP was not observed to differ significantly between the interventions at any degree of incline (p>0.05 for all); however, the numbers were small.

In a more recent pre-post study, Daunoraviciene et al. (2018), found that tilt table verticalization was effective at significantly decreasing heart rate and systolic BP in SCI populations. Although this study aimed to assess motor function, there were significant effects on cardiovascular parameters which have implications for the management of OH.

Conclusion

There is level 2 evidence (from one RCT, one PCT and one pre-post; Tesini et al., 2013; Elokda et al., 2000; Sampson et al., 2000) that tilt tables in combination with functional electrical stimulation can effectively raise blood pressure in an SCI population, but not with tilt tables alone.

There is level 4 evidence (from one pre-post study; Daunoraviciene et al., 2018) that tilt table verticalization can significantly lower cardiovascular parameters in SCI patients.

The use of functional electrical stimulation in combination with tilt tables may be effective for the management of orthostatic hypotension during the acute and subacute phase post SCI.

Tilt table verticalization may be effective for lowering heart rate in patients post SCI.