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Orthostatic Hypotension

Systematic Review

As the body of knowledge is growing in the field of OH management for SCI, it is becoming increasingly important to review the literature and ensure that the information used both in research and clinical practice is current and evidence based. The aim of this section of the OH chapter is to provide an overview of the current systematic reviews available for in areas related to OH management in SCI population.

Authors; Country
Date included in the review
Number of articles
Level of evidence
Type of study
Score
Methods
Databases
Evidence
Krassioukov et al. 2009; Canada
Reviewed published articles from 1950 to July 2008
N=26
n=251
Level of evidence:
PEDRo Scale – RCTs
(9–10: excellent; 6–8: good; 4–5: fair; 0-4: poor)
Modified Downs & Black scale – non RCTs (0 to 28)
Type of study:
2 case reports, 1 case series, 2 observational, 1 pre-post, 1 RCT
AMSTAR: 6

Methods: Key word literature search for (original) articles, previous practice guidelines, and review articles was conducted to identify literature evaluating the effectiveness of any treatment or therapy for OH in the SCI population.
Databases: PubMed/MEDLINE, CINAHL, EMBASE, PsycINFO.

  1. There is evidence that OH can be improved with the use of fludrocortisones, ergotamine, ephedrine, L-DOPS, and salt supplementation (level 4 or 5), and salt and fluid regulation, in combination with other pharmacologic interventions (level 5).
  2. Cardiovascular responses during orthostatic challenges may be improved with FES (level 2), simultaneous upper extremity exercise with paraplegia, but not tetraplegia (level 2), but not 6 months of bodyweight support treadmill training.
  3. Cardiovascular responses during exercise may be improved with midodrine (level 2) and elastic stockings and abdominal binders (level 2).
Gillis et al. 2008; Belgium
Reviewed published articles from 1966 to April 2007
N=13
n=138
Level of evidence:
Downs & Black scale
Type of study:
Parallel group, cross-over, quasi-random assignment
AMSTAR: 5

Methods: Key word literature search for non-pharmacological management of OH during early rehab in SCI.
Databases: PubMed/MEDLINE, OVID/EMBASE, CENTRAL

  1. The evidence is inconclusive whether compression/pressure, upper body exercise and biofeedback therapies are able to control OH.
  2. Upper body exercise may be more relevant to lower-level paraplegia where sympathetic outflow is intact and motor functionality is present.
  3. FES can attenuate the drop in BP by 8/4 mm Hg during an orthostatic challenge and is promising technology. However, few studies utilized patients in the acute stage.

Discussion

We found only one systematic review on OH management for individuals with SCI by Krassioukov et al. (2009). Although the authors found that the overall quality of the literature was poor and that higher quality research assessing the treatments for OH in the SCI population is needed, there is level 2 evidence that pressure from elastic stockings and abdominal binders may improve cardiovascular physiologic responses during submaximalupper-extremity exercises. In addition, FES is an important adjunct treatment to minimize cardiovascular changes during postural orthostatic stress and that simultaneous upper-extremity exercises may increase orthostatic tolerance during a progressive tilt exercise in subjects with paraplegia.

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