ORTHOSTATIC HYPOTENSION IN PATIENTS

WITH SPINAL CORD INJURY

A CASE PRESENTATION

BY

ADEYEMO. A.O BMR(PT) M.SC PT

DEFINITION

Orthostatic hypotension is a physical finding defined

by the American Autonomic Society and the American

Academy of Neurology as a systolic blood pressure

decrease of at least 20 mm Hg or a diastolic blood

pressure decrease of at least 10 mm Hg within three

minutes of standing.

PHYSIOLOGY

When a normal adult changes from lying to standingposition between (300-800)ml of blood pools in theblood vessel of the trunk and legs.

Immediate reduction in filling pressure of the rightatrium, fall in cardiac output and arterial pressure.

The baroreceptors reflex in the aortic arch andcarotid bodies blood sensed the fall in blood pressure,activate a vasoconstriction of vascular smooth muscleto restore arterial pressure so that the mean arterialblood pressure is not reduced by more than a fewmmHg when a person is standing up compared tolying down.

PATHOPHYSIOLOGY

The mechanism underlying OTH:

Cardiovascular deconditioning as a result of

prolonged bed rest

Excessive pooling of blood in the organs and viscera

due to reduced efferent sympathetic nervous activity

and loss of reflex vasoconstrictor effect of arterial

baroreceptors caudal to the level of injury

Lack of the counteracting muscular effects of the lower

extremities to venous pooling

Reduced plasma volumes as a consequence of

hyponatremia

CAUSES

Hypovoleamia

e.g. bleeding, diuretic, vasodilators, dehydration, prolonged bedrest, anaemia

Diseases

e.g. diabetes, Parkinson disease, Addison's disease,pheochromocytoma,spinal cord injury (quadriplegic &paraplegic)

Medication side effects

e.g. antidepressant(such as tryclics), alpha blockers(inhibitvasoconstriction initiated by baroreceptor reflex upon posturalchange)

other risk factor

e.g. elderly, postpartum mother, alcoholics etc.

SIGNS AND SYMPTOMS OF OTH

Blurred vision,

light-headedness,

dizziness,

fatigue,

restlessness,

and dyspnoea

ORTHOSTATIC HYPOTENSION & SPINAL

CORD INJURY

In addition to the motor and sensory deficit associated with

SCI, coincident autonomic nervous system impairment are

common.

individuals with SCI face the challenges of managing the

unstable blood pressure which results in persistent hypotension

and/or episodes of uncontrolled hypertension.

Cases of SCI patients with orthostatic hypotension

ASCI PT WITH

OTH

AK AM PQ ST

EPISODES OF OTH

(DURING

AMBULATORY

PHASE)

4 6 5 4

PROPPING UP IN

BED

2 2 3 3

SITTING IN

WHEEL CHAIR

2 4 2 1

Out of the 9 acute SCI patients seen these 4 experienced orthostatic

hypotension

SCHEMATIC DIAGRAM OF AUTONOMIC

CARDIOVASCULAR CONTROL

CARDIOVASCULAR COMPLICATION OF SCI

Acutely

Bradycardia

orthostatic hypotension

thermoregulation difficulty

autonomic dysreflexia

chronically

increased risk of coronary artery disease

CASE STUDY

Name: AK

Age: 65years

Sex: Male

Occupation: Trader

Religion: Christianity

Pc: Inability to move all limbs

CASE STUDY cont’d

PcHx: A case of a 65 year old involved in a MB-RTA on the 6th

of March 2011 somewhere in Ondo state. He was standing bya road side and was hit from behind by a motor bike. There wasno history of convulsion, no craniofacial efflux from any of theorifices although there was immediate transient LOC which wasfully regained minutes after but there was history of bleedingfrom the forehead. Patient was moved from scene on the backof a rescuer to a private hospital in the vicinity. He spent a dayat the private hospital, transferred to general hospital (Akure)then to FMC (Owo) where he was referred to OAUTHC andlater referred to UCH. Patients was reported to be unable tomove both LL but could still move the UL at the shoulders.However, there was associated bisphincteric incontinence.

CASE STUDY cont’d

PmHx: Not a known hypertensive nor diabetic, not asthmatic, no previous surgery but had been hospitalised before on account of typhoid fever 28years ago

FsHx: A 65year old man married in polygamous settings with 2 children, practise Christianity, smokes (2-4sticks/wk) and drinks alcohol(1-4bottles/wk)

O/e: An elderly man , met in supine lying, rigid cervical collar insitu, afebrile , ajaundiced, acyanotic, not dehydrated and has scar on his fore head.

Investigations: x-ray of the c-spine shows spondylotic changes with osteopaenia.

MRI reports spinal stenosis, multiple disc contusion C3-C5 with Ant. and post. compression

CASE STUDY cont’d

Examination:

CNS: Conscious , alert and oriented in TPP

Sensations: pain, light and deep touch absent

globally below the neurological level

ReflexesREFLEXES RT LT

BICEPS Hypo Hypo

TRICEPS Hypo Hypo

KNEE JERK Hypo Hypo

CLONUS Absent Absent

BABINSKI SIGN Absent Absent

CASE STUDY cont’d

Tone

Head and neck: sutured 4cm mid-frontal scalp laceration

Chest and abdomen: vesicular breathe sound, chest moves with abdomen and R.R is 23cpm

CVS: B.P- 100/70 mmHg

P.R- 80 B/min

UGS: Associated bisphincteric incontinence (urinary catheter in situ)

TONE (Rt) UL (Lt) UL (Rt) LL (Lt) LL

Reduced Reduced Reduced Reduced

CASE STUDY cont’d

MSS:

UPPERLIMBS RT LT

SWELLINGS NIL NIL

MUSCLE BULK PRESERVED PRESERVED

PROM FULL FULL

MUSCLE STRENGTH

Shoulder abductors 1 1

Shoulder adductors 0 0

Shoulder flexors 0 0

Shoulder extensors 0 0

Elbow flexors 0 0

Elbow extensors 0 0

Wrist flexors 0 0

Wrist extensors 0 0

Grip strength 0 0

CASE STUDY cont’d

LOWERLIMBS RT LT

SWELLINGS Nil Nil

MUSCLE BULK Reduced Reduced

PROM Full Full

MUSCLE STRENGTH

Hip abductors 0 0

Hip adductors 0 0

Hip flexors 0 0

Hip extensors 0 0

Knee extensors 0 0

Knee flexors 0 0

Dorsiflexors 0 0

Planterflexors 0 0

CASE STUDY cont’d

Analysis of findings:

- Loss of muscle power and weakness in all limbs

- Loss of sensation

Clinical impression: C4 Traumatic Quadriplegia (Frankel A)

Goals

-To prevent further musculoskeletal and cardiopulmonary complication

-To strengthening weak muscle of the extremity

-To restore patient back to function as much as possible

CASE STUDY cont’d

Means

-PM and PNF techniques to the Bil. UL and LL

-Chest physiotherapy

Rx

-PM and PNF to all joints of the UL and LL

-Chest physiotherapy(incentive spirometry)

INTERVENTION

After FES study (the 6th week) and patient is deemed fit

for ambulation

Patient is instructed to tell the feeling as ambulation

progresses

Relevant questions are asked as to determine the signs &

symptoms(Blurred vision, light-headedness, dizziness,

fatigue, restlessness, dyspnoea)

The patient is placed back into horizontal /lying position

each time any of the signs & symptoms is reported.

And when it occurs during wheel chair ambulation, the

wheel chair is tilted backward

PROGRESSION OF MANAGEMENT

TIME PERIOD(WKS) DEGREE OF BED

INCLINATION

NO OF EPISODES

1-6TH O˚

7TH 45˚(on bed) 1

8TH 6O˚(on bed) -

9TH 90˚(On bed) 1

10th 90˚ (on wheel chair) 2

11th 90˚ (on wheel chair) Tolerates wheel chair

ambulation

PREVENTION OF OTH

Check vital signs

Watch for signs and symptoms

Timing

Progressive ambulation

NB: The simple technique of exercising caution and

progressive changing position can allow the body to

adjust to the new position

MANAGEMENT OF OTH

Medical

Drugs

e.g. Fludrocortisone and erythropoietin to aid fluid

retention and vasoconstrictors like midodrine ,

pyridostigmine bromide etc.

MANAGEMENT OF OTH

Physiotherapy

•Tilt Table Testing can be used to

confirm postural hypotension. Tilt

table testing involves placing a

patient on table with foot support.

The table is tilted upward and

blood pressure and pulse is

measured while symptoms are

recorded in various position.

MANAGEMENT OF OTH

Physiotherapy cont’d

Progressive ambulation

Breathing deeply and flexing the abdominal muscles

while rising helps maintain blood oxygen flow to the

brain

Dangling

compression stocking to aid venous return

and physiotherapy to improve tone(active exercises

& resisted active exercises)

CONCLUSION

Spinal injury is a multi- faceted clinical problem that

demands sound knowledge and skilful handling

from health care workers right from the acute

phase to the recovery phase in order to achieve

best possible outcome.

REFERENCES

Cleophas TJ, Kauw FH, Bijl C, et al: Effects of beta adrenergic receptor agonists and antagonists in diabetics with symptoms of postural hypotension: a double-blind, placebo-controlled study. Angiology 37:855-862, 1986

Frisbie JH, Steele DJ: Postural hypotension and abnormalities of salt and water metabolism in myelopathy patients. Spinal Cord 35:303-307, 1997

Sclater A, Alagiakrishnan K: Orthostatic hypotension. A primary care primer for assessment and treatment. Geriatrics 59:22-27, 2004

Illman A, Stiller K, Williams M: The prevalence of orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury. Spinal Cord 38:741-747, 2000

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