Treatment of Orthostatic Hypotension During Acute Inpatient Rehabilitation After Spinal Cord Injury: Usual Care vs. Anti-hypotensive Therapy.

BACKGROUND: To compare the pharmacological treatment of hypotension and orthostatic hypotension (OH) initiated based upon a blood pressure (BP) threshold, regardless of symptoms (TXT), to usual care pharmacological treatment of symptomatic hypotension (UC), during acute inpatient rehabilitation (AIR) following spinal cord injury (SCI). METHODS: Block randomization, based on the neurological level of injury as: cervical lesions (C1-C8); high thoracic lesions (T1-T5), and low thoracic lesions (T6-T12), was used to determine responses to the primary question "was the therapy session affected by low BP or concern for low BP development?" Study participants and therapists were unaware of the group assignment. RESULTS: A total of 66 participants enrolled; 25 (38%) in the TXT group, 29 (44%) in the UC group, and 12 (18%) withdrew. Responses to the primary question were recorded for 32 participants, 15 in the TXT, and 17 in the UC group. There was an average of 81 ±â€…51 therapy sessions/participant in the TXT and 60 ±â€…27 sessions/participant in the UC group. Of those therapy sessions, low BP or concerns for low BP affected an average of 9 ±â€…8 sessions/participant in the TXT group and 10 ±â€…12 sessions/participant in the UC group. Neither the total number of therapy sessions (P = 0.16) nor group assignment (P = 0.83) significantly predicted the number of sessions affected by low BP. CONCLUSIONS: These data are not conclusive but indicate that the treatment of asymptomatic hypotension and OH does not increase time spent in therapy compared to UC treatment of symptomatic hypotension and OH in newly injured patients with SCI. CLINICAL TRIALS REGISTRATION: #NCT02919917.

Effectiveness of non-pharmacological interventions to treat orthostatic hypotension in elderly people and people with a neurological condition: a systematic review.

OBJECTIVE: The objective of this review was to summarize the best available evidence regarding the effectiveness of non-pharmacological interventions to treat orthostatic hypotension (OH) in elderly people and people with a neurological condition. INTRODUCTION: Orthostatic hypotension is common in elderly people and people with a neurological condition and can interfere with or limit rehabilitation. Non-pharmacological interventions to treat OH could allow for longer and earlier mobilization, which is recommended in national clinical guidelines for rehabilitation in the acute or sub-acute phase following stroke or other neurological conditions. INCLUSION CRITERIA: The review considered people aged 50 years and older, and people aged 18 years and elderly people with a neurological condition. Non-pharmacological interventions to treat OH included compression garments, neuromuscular stimulation, physical counter-maneuvers, aerobic or resistance exercises, sleeping with head tilted up, increasing fluid and salt intake, and timing and size of meals. The comparator was usual care, no intervention, pharmacological interventions, or other non-pharmacological interventions. Outcome measures included systolic blood pressure, diastolic blood pressure, heart rate, cerebral blood flow, observed/perceived symptoms, duration of standing or sitting in minutes, tolerance of therapy, functional ability, and adverse events/effects. METHODS: Databases for published and unpublished studies available in English up to April 2018 with no lower date limit were searched. Critical appraisal was conducted using standardized instruments from JBI. Data were extracted using standardized tools designed for quantitative studies. Where appropriate, studies were included in a meta-analysis; otherwise, data were presented in a narrative form due to heterogeneity. RESULTS: Forty-three studies - a combination of randomized controlled trials (n = 13), quasi-experimental studies (n = 28), a case control study (n = 1), and a case report (n = 1) - with 1069 participants were included. Meta-analyses of three interventions (resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions. Results from individual studies indicated physical maneuvers such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH. Sleeping with head up in combination with pharmacological treatment was more effective than sleeping with head up alone. Eating smaller, more frequent meals was effective. Drinking 480 mL of water increased blood pressure. CONCLUSIONS: The review found mixed results for the effectiveness of non-pharmacological interventions to treat OH in people aged 50 years and older, and people with a neurological condition. There are several non-pharmacological interventions that may be effective in treating OH, but not all have resulted in clinically meaningful changes in outcome. Some may not be suitable for people with moderate to severe disability; therefore, it is important for clinicians to consider the patient's abilities and impairments when considering which non-pharmacological interventions to implement.

A case of highly disabling orthostatic hypotension: when an integrated cardiac rehabilitation approach makes the difference.

SUMMARY: Orthostatic hypotension (OH) is a disabling condition accompanying several diseases. It has increased morbidity and mortality, and limited chances of treatment. We report a case of a patient with stable ischemic heart disease and severe OH unresponsive to usual care. A baseline 75° head-up tilt test (HUT) was positive for symptomatic OH, i.e. pre-syncope with a systolic arterial pressure drop of 35 mmHg. On top of optimal treatment, ivabradine was started. Symptoms improved within 24 hours. At a repeated HUT, the patient could tolerate the up-right position up to 25 minutes. He was able to undergo an individualized training program with further amelioration of quality of life. Thereafter, titration of ACE inhibitors became possible. Lasting benefits were present at a 6-month follow-up. To our knowledge, this is the first reported case of successful use of ivabradine to integrate cardiac rehabilitation for management of a highly disabling OH.

Is Technology for Orthostatic Hypotension Ready for Primetime?

Spinal cord injury (SCI) often results in the devastating loss of motor, sensory, and autonomic function. After SCI, the interruption of descending sympathoexcitatory pathways disrupts supraspinal control of blood pressure (BP). A common clinical consequence of cardiovascular dysfunction after SCI is orthostatic hypotension (OH), a debilitating condition characterized by rapid profound decreases in BP when assuming an upright posture. OH can result in a diverse array of insidious and pernicious health consequences. Acute effects of OH include decreased cardiac filling, cerebral hypoperfusion, and associated presyncopal symptoms such as lightheadedness and dizziness. Over the long term, repetitive exposure to OH is associated with a drastically increased prevalence of heart attack and stroke, which are leading causes of death in those with SCI. Current recommendations for managing BP after SCI primarily include pharmacologic interventions with prolonged time to effect. Because most episodes of OH occur in less than 3 minutes, this delay in action often renders most pharmacologic interventions ineffective. New innovative technologies such as epidural and transcutaneous spinal cord stimulation are being explored to solve this problem. It might be possible to electrically stimulate sympathetic circuitry caudal to the injury and elicit rapid modulation of BP to manage OH. This review describes autonomic control of the cardiovascular system before injury, resulting cardiovascular consequences after SCI such as OH, and the clinical assessment tools for evaluating autonomic dysfunction after SCI. In addition, current approaches for clinically managing OH are outlined, and new promising interventions are described for managing this condition.

Hemodynamic Mechanisms Underlying Initial Orthostatic Hypotension, Delayed Recovery and Orthostatic Hypotension.

OBJECTIVES: Continuous noninvasive blood pressure (BP) measurement enables us to observe rapid changes in BP and to study underlying hemodynamic mechanisms. This study aimed to gain insight into the pathophysiological mechanisms underlying short-term orthostatic BP recovery patterns in a real-world clinical setting with (pre)syncope patients. SETTING AND PARTICIPANTS: In a prospective cohort study, the active lying-to-standing test was performed in suspected (pre)syncope patients in the emergency department with continuous noninvasive finger arterial BP measurement. MEASURES: Changes in systolic BP, cardiac output (CO), and systemic vascular resistance (SVR) were studied in normal BP recovery, initial orthostatic hypotension, delayed BP recovery, and sustained orthostatic hypotension. RESULTS: In normal recovery (n = 47), ΔBP at nadir was -24 (23) mmHg, with a CO change of +10 (21%) and SVR of -23 (21%). In initial orthostatic hypotension (n = 7) ΔBP at nadir was -49 (17) mmHg and CO and SVR change was -5 (46%) and -29 (58%), respectively. Delayed recovery (n = 12) differed significantly from normal recovery 30 seconds after standing, with a ΔBP of -32 (19) vs 1 (16) mmHg, respectively. Delayed recovery was associated with a significant difference in SVR changes compared to normal recovery, -17 (26%) vs +4 (20%), respectively. There was no difference in CO changes. In sustained orthostatic hypotension (n = 16), ΔBP at 180 seconds after standing was -39 (21) mmHg, with changes in CO of -16 (31%) and SVR of -9 (20%). CONCLUSIONS/IMPLICATIONS: Hemodynamic patterns following active standing are heterogeneous and differ across orthostatic BP recovery patterns, suggesting that volume status, medication use, and autonomic dysfunction should all be taken into account when evaluating these patients. Moreover, results suggest that a delayed BP recovery is associated with an impaired increase in SVR in a significant proportion of individuals, implying that physicians treating older adults with hypertension should consider the possible negative effect of intensive hypertension treatment on initial orthostatic blood pressure control.

Respiratory Training Improves Blood Pressure Regulation in Individuals With Chronic Spinal Cord Injury.

OBJECTIVE: To investigate the effects of respiratory motor training (RMT) on pulmonary function and orthostatic stress-mediated cardiovascular and autonomic responses in individuals with chronic spinal cord injury (SCI). DESIGN: Before-after intervention case-controlled clinical study. SETTING: SCI research center and outpatient rehabilitation unit. PARTICIPANTS: A sample of (N=21) individuals with chronic SCI ranging from C3 to T2 diagnosed with orthostatic hypotension (OH) (n=11) and healthy, noninjured controls (n=10). INTERVENTIONS: A total of 21±2 sessions of pressure threshold inspiratory-expiratory RMT performed 5d/wk during a 1-month period. MAIN OUTCOME MEASURES: Standard pulmonary function test: forced vital capacity, forced expiratory volume in one second, maximal inspiratory pressure, maximal expiratory pressure, beat-to-beat arterial blood pressure, heart rate, and respiratory rate were acquired during the orthostatic sit-up stress test before and after the RMT program. RESULTS: Completion of RMT intervention abolished OH in 7 of 11 individuals. Forced vital capacity, low-frequency component of power spectral density of blood pressure and heart rate oscillations, baroreflex effectiveness, and cross-correlations between blood pressure, heart rate, and respiratory rate during the orthostatic challenge were significantly improved, approaching levels observed in noninjured individuals. These findings indicate increased sympathetic activation and baroreflex effectiveness in association with improved respiratory-cardiovascular interactions in response to the sudden decrease in blood pressure. CONCLUSIONS: Respiratory training increases respiratory capacity and improves orthostatic stress-mediated respiratory, cardiovascular, and autonomic responses, suggesting that this intervention can be an efficacious therapy for managing OH after SCI.

The association between orthostatic hypotension, falling and successful rehabilitation in a nursing home population.

PURPOSE OF THE STUDY: Our objectives were to identify the prevalence of orthostatic hypotension (OH) in frail, elderly nursing home residents, and assess its possible association with falling and chances of successful rehabilitation. MATERIALS AND METHODS: A prospective observational cohort study. A total of 290 patients participated in this study, of which 128 were admitted to the rehabilitation department. OH was defined as a drop in systolic blood pressure of >20mmHg and diastolic blood pressure of >10mmHg after postural change within 3min. The analyses regarding falling and successful rehabilitation were only performed in the rehabilitation group. Multivariate binary logistic regression analyses were used to describe risk factors related with falling. Cox proportional hazard modeling was used to investigate the relation between OH and the time to successful rehabilitation. RESULTS: The prevalence of OH in the studied nursing home population was 36.6% (95% CI (confidence interval): 31.1-42.1%). The prevalence varied from 28.6% (95% CI: 16.8-40.4%) in somatic patients, 36.7% (95% CI: 28.4-45.1%) in rehabilitation patients, to 40.6% (95% CI: 31.3-50.0%) in psychogeriatric patients. The association between orthostatic hypotension and previous falling was not significant; Odds ratio 0.66 (95% CI: 0.30-1.48). The Hazard ratio of the relationship between OH and successful rehabilitation was 2.88 (95% CI:1.77-4.69). CONCLUSIONS: OH is highly prevalent in nursing home residents. Surprisingly, patients with OH were found to have a higher chance of successful rehabilitation compared to patients without OH. If confirmed in other studies, these results may change our view of the implications of OH.

Effects of patient-controlled abdominal compression on standing systolic blood pressure in adults with orthostatic hypotension.

OBJECTIVE: To assess the effects of patient-controlled abdominal compression on postural changes in systolic blood pressure (SBP) associated with orthostatic hypotension (OH). Secondary variables included subject assessments of their preferences and the ease-of-use. DESIGN: Randomized crossover trial. SETTING: Clinical research laboratory. PARTICIPANTS: Adults with neurogenic OH (N=13). INTERVENTIONS: Four maneuvers were performed: moving from supine to standing without abdominal compression; moving from supine to standing with either a conventional or an adjustable abdominal binder in place; application of subject-determined maximal tolerable abdominal compression while standing; and while still erect, subsequent reduction of abdominal compression to a level the subject believed would be tolerable for a prolonged period. MAIN OUTCOME MEASURES: The primary outcome variable included postural changes in SBP. Secondary outcome variables included subject assessments of their preferences and ease of use. RESULTS: Baseline median SBP in the supine position was not affected by mild (10mmHg) abdominal compression prior to rising (without abdominal compression: 146mmHg; interquartile range, 124-164mmHg; with the conventional binder: 145mmHg; interquartile range, 129-167mmHg; with the adjustable binder: 153mmHg, interquartile range, 129-160mmHg; P=.85). Standing without a binder was associated with an -57mmHg (interquartile range, -40 to -76mmHg) SBP decrease. Levels of compression of 10mmHg applied prior to rising with the conventional and adjustable binders blunted these drops to -50mmHg (interquartile range, -33 to -70mmHg; P=.03) and -46mmHg (interquartile range, -34 to -75mmHg; P=.01), respectively. Increasing compression to subject-selected maximal tolerance while standing did not provide additional benefit and was associated with drops of -53mmHg (interquartile range, -26 to -71mmHg; P=.64) and -59mmHg (interquartile range, -49 to -76mmHg; P=.52) for the conventional and adjustable binders, respectively. Subsequent reduction of compression to more tolerable levels tended to worsen OH with both the conventional (-61mmHg; interquartile range, -33 to -80mmHg; P=.64) and adjustable (-67mmHg; interquartile range, -61 to -84mmHg; P=.79) binders. Subjects reported no differences in preferences between the binders in terms of preference or ease of use. CONCLUSIONS: These results suggest that mild (10mmHg) abdominal compression prior to rising can ameliorate OH, but further compression once standing does not result in additional benefit.

Clinical treatment of orthostatic hypotension after spinal cord injury with training based on electric uprise bed coupled with remote ECG and BP monitor.

BACKGROUND: The treatment for orthostatic hypotension (OH) after spinal cord injury (SCI) is an important part of rehabilitation in late-stage SCI. Electric uprise bed training is a relatively commonly used method in treating OH, and how to carry out uprise bed training safely and effectively is an urgent problem. In the early stage of SCI, we used a remote monitoring system to monitor the whole process of uprise bed training, and we explored a safe and efficient method of electric uprise bed training. MATERIAL AND METHODS: The experimental group consisted of 36 patients diagnosed with orthostatic hypotension (OH) after SCI and who received training with an electric uprise bed coupled with remote monitoring system, and the control group of 18 subjects who used a traditional training method. RESULTS: There were no differences in baseline data between the 2 groups. There were no severe symptoms during training in the experimental group, but 3 patients had severe symptoms in the control group. Among the 32 enrolled subjects reaching upright training status within 30 days (17 subjects in the experimental group and 15 subjects in the control group), time interval of training from horizontal position to erect position in the experimental group was 18.00±3.12 days and 21.40±4.95 days in the control group. Time interval in the experimental group was significantly less than in the control group. However, among all 36 subjects, by combining results of follow-up, there was no significant difference of time interval of training from horizontal position to erect position between the experimental group and the control group. In the experimental group 90.52% of patients finished training compared to 78.19% in the control group (P<0.01). After training, values of OCs and OCd of the experimental group were lower than in the control group. There was no significant difference between groups in number of re-diagnosed OH. CONCLUSIONS: Implementation of training with electric uprise bed coupled with remote monitoring system is generally safe for patients with OH after SCI. For patients who could reach standing training status within 30 days, implementation can improve efficiency of training by shortening time interval of training from horizontal position to erect position. It can increase orthostatic blood pressure change during position change.

Acute physiological effects of whole body vibration (WBV) on central hemodynamics, muscle oxygenation and oxygen consumption in individuals with chronic spinal cord injury.

PURPOSE: (1) Investigate the acute effects of whole body vibration (WBV) on central hemodynamic responses, muscle oxygenation and oxygen consumption (VO2) in individuals with spinal cord injury (SCI) versus sex, age and activity-matched able-bodied (AB) individuals. (2) Assess the effects of three WBV frequencies on all outcome measures. METHODS: Eleven males with SCI and 10 AB individuals were recruited. Subjects completed three WBV exercise sessions at 30, 40 and 50 Hz. Heart rate (HR), mean arterial blood pressure (MAP), stroke volume (SV), cardiac output (CO), VO2 and relative changes in oxygenated (Δ[HbMbO2]), deoxygenated (Δ[HHbMb]) and total (Δ[HbMbtot]) heme groups were obtained when VO2 steady state was achieved for: pre-WBV sitting, pre-WBV standing, WBV and post-WBV standing. RESULTS: Both groups demonstrated small but significant increases in VO2, Δ[HbMbO2] and Δ[HbMbtot]; but the increases were larger in the SCI group. A significant decrease Δ[HHbMb] was observed in the SCI group. No frequency effect was observed. CONCLUSION: The WBV responses do not appear sufficient to induce cardiovascular benefits in the SCI population. WBV may be helpful for individuals with SCI in improving lower limb peripheral blood flow and coping with orthostatic hypotension symptoms earlier in their rehabilitation programs.

[Organization and methodology of early rehabilitation of the patients with cardioembolic stroke complicated by cardiac insufficiency].

The present work was focused on the safety and effectiveness of the combined rehabilitative treatment in the case of pre-acute and acute cardioembolic stroke in 45 patients with varying degree of cardiac decompensation. The study showed that the use of "passive" remediation, such as the postural treatment, breathing exercises, selective massage, neuromuscular electrical stimulation, is safe and can be recommended to the patients with stroke and cardiac decompensation of different severity (II and III FC of chronic cardiac insufficiency). The introduction of such active measures as verticalization into the program of comprehensive rehabilitation may cause decompensation of cardiac insufficiency. The rehabilitation strategy used in the present study improved performance and exercise tolerance in the majority of the patients. Moreover, it resulted in the significant reduction of the severity of stroke, improved the motor function, and increased functional independence of the patients.

Combined counter-maneuvers accelerate recovery from orthostatic hypotension in familial dysautonomia.

BACKGROUND: In patients with familial dysautonomia (FD), prominent orthostatic hypotension (OH) endangers cerebral perfusion. Supine repositioning or abdominal compression improves systolic and diastolic blood pressure (BPsys and BPdia). OBJECTIVE: To determine whether OH recovers faster with combined supine repositioning and abdominal compression than with supine repositioning alone. METHODS: In 9 patients with FD (17.8 ± 3.9 years) and 10 healthy controls (18.8 ± 5 years), we assessed 2-min averages of BPsys, BPdia, and heart rate (HR) during supine rest, standing, supine repositioning, another supine rest, second standing, and supine repositioning with abdominal compression by leg elevation and flexion. We determined BPsys- and BPdia-recovery-times as intervals from return to supine until BP reached values equivalent to each participant's 2-min average at supine rest minus two standard deviations. Differences in signal values and BP-recovery-times between groups and positions were assessed by ANOVA and post hoc testing (significance: P < 0.05). RESULTS: Patients with FD had pronounced OH that improved with supine repositioning. However, BP only reached supine rest values with additional abdominal compression. In controls, BP was stable during positional changes. Without abdominal compression, BP-recovery-times were longer in patients with FD than those in controls, but similar to control values with compression (BPsys: 83.7 ± 64.1 vs 36.6 ± 49.5 s; P = 0.013; BPdia: 84.6 ± 65.2 vs 35.3 ± 48.9 s; P = 0.009). CONCLUSION: Combining supine repositioning with abdominal compression significantly accelerates recovery from OH and thus lowers the risk of hypotension-induced cerebral hypoperfusion.

Differences in motor and cognitive function in patients with Parkinson's disease with and without orthostatic hypotension.

Patients with Parkinson's disease (PD) often present with orthostatic hypotension (OH) as a result of the dysautonomia associated with the disease or as a side effect of the dopaminergic medications used to treat the disease. The purpose of this study was to investigate differences in motor and cognitive function in patients with PD with and without OH. Forty-four patients with a diagnosis of PD were evaluated and stratified by the presence of OH based on orthostatic blood pressure recordings. Both groups underwent assessments of motor and cognitive function. OH was present in 17 of 44 patients (39%) with PD. These patients with OH had significantly lower scores in gross motor, balance, and cognitive function (p < .05). No significant difference between groups was found in the finger tapping scores. These results suggest that patients with PD should be routinely screened for OH as it commonly occurs and may negatively impact gross motor, balance, and cognitive function.

Treating orthostatic hypotension in patients with Parkinson's disease and atypical Parkinsonism improves function.

BACKGROUND: Patients with idiopathic Parkinson's disease (PD) or atypical Parkinsonism (AP) often present with orthostatic hypotension (OH) as a result of the dysautonomia associated with the disease or as a side effect of the dopaminergic medications used to treat it. Our recent study suggested that OH negatively impacts gross motor, balance, and cognitive functions in patients with PD. OBJECTIVE: To determine if correcting the orthostatic hypotension (OH) of patients with PD or AP improves their gross motor, balance, and cognitive functions. METHODS: Forty patients with PD or AP were assessed before and after correcting their OH using a staged approach with a goal of SBP >80 when standing and SBP <180 when laying. Step 1 of treatment included reducing antihypertensive medications, as possible, maintaining hydration with 1500cc/day, decreasing dietary salt, wearing high compression stockings, and keeping the head of bed elevated at 30 degrees when supine. If SBP <80 with standing after step 1, then treatment was started with fludrocortisone and/or midodrine. RESULTS: Patients' OH was managed as part of a rehabilitation program. Tests such as the Motor and Cognitive Functional Independence Measures, Berg Balance Scale, Two Minute Walking test, and the Finger Tapping test showed significant improvements (p < 0.05) in their gross motor, walking, balance and cognitive function with our OH management plan. No significant differences between admission and discharge were found in the Timed Up and Go test. CONCLUSION: Our data suggest that monitoring and correcting the OH of patients with PD or AP improves their gross motor, balance, and cognitive function.

Validación de la clasificación funcional de la bipedestación del Hospital de Sagunto / Validation of the functional ambulation classification of the Hospital of Sagunto

Introducción: La bipedestación es una de las facultades más importantes y características del ser humano, imprescindible para la mayoría de las tareas funcionales. Por eso es una de las funciones habitualmente exploradas en Rehabilitación. Existen varios test de valoración funcional, pero ninguno es rápido y sencillo ni valora exclusivamente la bipedestación; es por ello que se desarrolló la clasificación funcional de la bipedestación del Hospital de Sagunto (BipHS). El objetivo del presente trabajo es demostrar la fiabilidad y la validez de esta escala utilizando para ello, como patrón de referencia, la posturografía. Material y métodos: Utilizando la escala BipHS, que cuenta con 6 niveles de función autoexcluyentes y autoexplicativos (nivel 0: imposible, 1: completamente dependiente, 2: mano dependiente, 3: libre, 4: prolongada, 5: normal), se evaluó la bipedestación en 36 pacientes con ictus y 10 sujetos sanos por parte de dos observadores independientes, efectuando un análisis de la concordancia entre observadores. Registramos diversos parámetros del equilibrio con un equipo de posturografía y efectuamos un análisis de comparación y correlación entre el nivel de bipedestación de nuestra escala y los valores de la posturografía. Resultados: La concordancia entre observadores fue muy buena, con un índice kappa de Cohen de 0,83 (IC: 0,69–0,97). Obtuvimos una asociación significativa entre las medidas del desplazamiento del centro de presiones (cdp) y la escala BipHS, con una buena correlación lineal. A mejor nivel funcional, mejor equilibrio y menores desplazamientos del cdp. Conclusiones: La escala de BipHS es una escala fiable y válida para valorar el equilibrio en bipedestación (AU)

Introduction: Standing is one of the most important and characteristic features of human beings, indispensable for most functional tasks. Therefore, it is one of the functions usually explored in rehabilitation. There are several tests of functional valuation but none of them are quick and easy neither do they evaluate exclusively standing, fact due to which the Standing scale of the "Hospital de Sagunto" (BipHS) was developed. The aim of this work is to demonstrate the reliability and validity of this scale using, as a standard the posturography analysis. Material and methods: Using BipHS Scale, which takes into account 6 levels of function which are self-excluding and self-explanatory (level 0: imposible, 1: completely dependent, 2: hand-dependent, 3: free, 4: prolonged, 5: normal), we evaluated standing in 36 patients which had suffered a vascular stroke and 10 healthy individuals, using two independent observers making a analysis of agreement between both. We then registered different parameters of equilibrium using posturography and made a comparison and correlation analysis between the level of standing of our scale and the values of posturography. Results: The resulting kappa index was 0,83 (CI: 0,69-0,97), proving a good concordance between observers. We achieved a significant association between the measures of movement of the center of pressure (cp) and the BipHS Scale, with a good linear correlation. The better the functional level, the better the balance and smaller displacement of the cp. Conclusion: BipHS is a trustworthy and valid scale to evaluate standing (AU)

Orthostatic hypotension following spinal cord injury: impact on the use of standing apparatus.

INTRODUCTION: Upright posture confers numerous medical and social benefits to a spinal cord injured (SCI) patient. Doing so is limited by symptoms of orthostatic hypotension. This is a common secondary impairment among tetraplegic sufferers. OBJECTIVE: Establish the proportion of SCI patients who are restricted from using standing apparatus, such as standing frames and standing wheelchairs, because of inducing symptomatic orthostatic hypotension or the fear of developing these disabling symptoms. STUDY DESIGN: Survey conducted by Internet-accessible electronic questionnaire. Questionnaire validated for reliability and accuracy. RESULTS: 293 respondents. Mean age 44.6; 76% male. Median time from injury: 7 years. 38% suffered with orthostatic hypotension; majority were complete injuries and all (except one - T12) were T5 or above level. 52% replied that they were using standing wheelchairs or frames. Of these, 59 (20% of total) stated that orthostatic hypotension symptoms were limiting the use of their upright apparatus. Of those who did not use standing wheelchairs or frames, 16 (5.5% of total) reported that this was because of the fear of worsening their orthostatic hypotension. CONCLUSION: Orthostatic hypotension restricts standing apparatus use in a large proportion (a total of 25.5% of respondents in this survey) of SCI patients.

POTS versus deconditioning: the same or different?

The 2007 Streeten Lecture focused on the idea that physical deconditioning plays a key role in the symptomology and pathophysiology of POTS. Parallels were drawn between the physiological responses to orthostatic stress seen in POTS patients and the physiological responses seen in "normal" humans after prolonged periods of bedrest, deconditioning, or space flight. Additionally, the idea that endurance exercise training might ameliorate some of these symptoms was also advanced. Finally, potential parallels between POTS, chronic fatigue syndrome, and fibromyalgia were also drawn and the potential role of exercise training as a "therapeutic intervention" in all three conditions was raised. The conceptual model for the lecture was that after some "initiating event" chronic deconditioning plays a significant role in the pathophysiology of these conditions, and these physiological changes in conjunction with "somatic hypervigilence" explain many of the complaints that this diverse group of patients have. Additionally, the idea that systematic endurance exercise training might be helpful was advanced, and data supportive of this idea was reviewed. The main conclusion is that the medical community must retain their empathy for patients with unusual conditions but at the same time send a firm but empowering message about physical activity. As always, we must also ask what do the ideas about physical activity and inactivity and the conditions mentioned above not explain?

Development of a biofeedback tilt-table for investigating orthostatic syncope in patients with spinal cord injury.

The purpose of this study was to develop a biofeedback tilt-table for automatic tilt-table training, helping patients with spinal cord injury (SCI) to recover more rapidly from orthostatic hypotension, and increasing safety to avoid syncope during training. This biofeedback tilt-table implemented automatic training maneuvers and included three closed feedback loops to monitor the acquisition of physiological signals from patients and the feedback of presyncope symptoms (PS) to regulate the angle of tilt. The results of clinical testing revealed that the mean blood pressure and oxygen saturation represented the most useful physiological signals for determining PS feedback and the quantitative criteria adopted were practicable and useful in describing the level of PS. This novel biofeedback tilt-table system offered higher patient throughput, faster training and safety in training of SCI patients to overcome their orthostatic hypotension than traditional tilt-table training, and could provide quantitative information of PS to assist medical staff in studying the mechanism of orthostatic syncope.

Orthostatic circulatory disorders in early neurorehabilitation: a case report and management overview.

Orthostatic circulatory disorders are a common problem in the mobilization of patients with severe neurological diseases such as paraplegia, the vegetative state or the minimally conscious state. They create difficulties when mobilizing the patient out of bed. Although their incidence has not been clearly established and the severity and length of symptoms differ greatly, a relevant number of the patients in a rehabilitation unit is affected. Rehabilitation specialists should therefore be aware of these disorders and the therapeutic alternatives available. This case study reports on a 45-year-old patient who repeatedly suffered from orthostatic hypotension after a severe traumatic brain injury. The pathogenesis and predisposing factors of orthostatic dysfunction in severely disabled neurological patients as well as therapeutic efforts are subsequently reviewed.