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Tajima Y, Komiyama M, Mimura N, Yamamoto M, Fukuie M, Suzuki R, Matsushima S, Hirasawa A, Shibata S. Acute effects of bolus water intake on post-exercise orthostatic hypotension and cardiovascular hemodynamics. Clin Auton Res 2025; 35:231-241. [PMID: 39476217 DOI: 10.1007/s10286-024-01077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 10/02/2024] [Indexed: 04/16/2025]
Abstract
INTRODUCTION Water intake is known to be effective in preventing orthostatic hypotension (OH). However, it is unknown whether water intake would be effective in acutely preventing exercise-induced OH. METHODS Fourteen adults (men/women: 7/7, age: 20 ± 8 years) were recruited. Each subject underwent two protocols with and without 500 ml water intake using a randomized crossover design (Water vs. Control). Participants underwent 30 min of cycle ergometry at the 60-70% predicted VO2 max. OH and hemodynamics were assessed before and after exercise, and immediately (Water 1) and 20 min (Water 2) after the water intake. OH was evaluated with a 1-min standing test as the criteria for systolic blood pressure (SBP) < 90 mmHg. A cross-spectral analysis for RR and SBP variability was used to evaluate the cardiac autonomic activity and baroreflex sensitivity. RESULTS In both protocols, the incidence of OH increased after the exercise. The incidence of OH was lower in Water than in Control at Water 1 (OR: 0.093, 95% CI: 0.015-0.591). Heart rate was lower and SBP was higher in Water than in Control at Water 1 and 2 (P < 0.05). High-frequency power of RR variability and transfer function gains in Water were normalized and higher than in Control at Water 1 and 2 (P < 0.05). The ratio of low- to high-frequency power of RR variability in Water was normalized and lower in Water than in Control at Water 1 (P < 0.05). CONCLUSION Our findings indicate that water intake may prevent acute exercise-induced OH, accompanied by normalized cardiac autonomic activity and baroreflex sensitivity.
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Affiliation(s)
- Yuki Tajima
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Mayu Komiyama
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Naoya Mimura
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Maika Yamamoto
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Marina Fukuie
- Japan Society for the Promotion of Science, Tokyo, Japan
| | - Rina Suzuki
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Shinya Matsushima
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan
| | - Ai Hirasawa
- Faculty of Health Sciences, Department of Health and Welfare, Kyorin University, Tokyo, Japan
| | - Shigeki Shibata
- Faculty of Health Sciences, Department of Physical Therapy, Kyorin University, Tokyo, Japan.
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Lijo M, Hamilton A, Russell ME, Wren N. Acute inpatient rehabilitation for COVID-19 survivors: A retrospective case series. Physiother Theory Pract 2024; 40:1898-1907. [PMID: 37184416 DOI: 10.1080/09593985.2023.2213773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Patients with Coronavirus Disease 2019 (COVID-19) who required mechanical ventilation and had prolonged hospital stay present with medical instability and functional impairments after the acute hospitalization. OBJECTIVE To present the rehabilitation outcome of three patients with COVID-19 admitted to an inpatient rehabilitation unit using a case series method. METHODS Subjects included three consecutive male patients admitted to the rehabilitation unit with a diagnosis of deconditioning and critical illness myopathy. On admission, patients were evaluated by a multidisciplinary team using outcome measures such as 6-min walk test (6 MWT), 10-m walk test (10 MWT), berg balance scale (BBS), and dynamometry. Each patient received daily therapy with a minimum of 900 min per week during their rehabilitation stay. Treatment strategies included fatigue management, training of mobility and activities for daily living tasks, muscle strengthening, and cognitive retraining. RESULTS All patients showed significant improvements across all the outcome measures, specifically, the 6MWT (minimal clinically identifiable difference (MCID) range: 14-30.5 m) and the 10MWT (MCID range: 0.10-0.20 m/s) which exceeded the MCID for all three patients. The BBS also demonstrated significant improvement, surpassing the minimum detectable change of 5-7 points. Of the three patients, two were able to be discharged at an independent level, while one required supervision for safety. CONCLUSION Patients with COVID-19, who experienced prolonged hospital stay present with severe impairments in muscle strength, functional mobility, and participation in daily living tasks. Inpatient rehabilitation may have the potential to reduce impairments and accelerate the recovery process while managing ongoing medical issues.
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Affiliation(s)
- Mithu Lijo
- Rehabilitation Services, John H. Stroger Jr. Hospital of Cook County, Chicago, IL, USA
| | - Ashley Hamilton
- Rehabilitation Services, TIRR Inpatient Rehabilitation, The Woodlands, TX, USA
| | - Mary E Russell
- Rehabilitation Services, TIRR Inpatient Rehabilitation, The Woodlands, TX, USA
| | - Nicole Wren
- Rehabilitation Services, TIRR Inpatient Rehabilitation, The Woodlands, TX, USA
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3
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Vidal-Petiot E, Pathak A, Azulay JP, Pavy-Le Traon A, Hanon O. Orthostatic hypotension: Review and expert position statement. Rev Neurol (Paris) 2024; 180:53-64. [PMID: 38123372 DOI: 10.1016/j.neurol.2023.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 11/19/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023]
Abstract
Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20mmHg or a drop in diastolic blood pressure of at least 10mmHg within 3minutes of standing. It is a common disorder, especially in high-risk populations such as elderly subjects and patients with neurological diseases, and is associated with markedly increased morbidity and mortality. Its management can be challenging, particularly in cases where supine hypertension is associated with severe orthostatic hypotension. Education of the patient, non-pharmacological measures, and drug adaptation are the cornerstones of treatment. Pharmacological treatment should be individualized according to the severity, underlying cause, 24-hour blood pressure profile, and associated coexisting conditions. First-line therapies are midodrine and fludrocortisone, which may need to be combined for optimal care of severe cases.
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Affiliation(s)
- E Vidal-Petiot
- Service de physiologie, ESH Excellence Center, hôpital Bichat, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; INSERM U1148, Université Paris-Cité and Université Sorbonne Paris Nord, LVTS, 75018 Paris, France.
| | - A Pathak
- Service de cardiologie, ESH Excellence Center, centre hospitalier Princesse Grace, 1, avenue Pasteur, 98000 Monaco, France
| | - J-P Azulay
- Service de neurologie et pathologie du mouvement, hôpital de la Timone, 13385 Marseille cedex 05, France
| | - A Pavy-Le Traon
- Service de neurologie, CHU de Toulouse, 31059 Toulouse cedex, France; UMR 1297, institut des maladies métaboliques et cardiovasculaires, Toulouse, France
| | - O Hanon
- Service de gériatrie, université Paris-Cité, EA4468, hôpital Broca, AP-HP, 75013 Paris, France
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Hoxhaj P, Shah S, Muyolema Arce VE, Khan W, Sadeghzadegan A, Singh S, Collado GF, Goyal A, Khawaja I, Botlaguduru D, Razzaq W, Abdin ZU, Gupta I. Ampreloxetine Versus Droxidopa in Neurogenic Orthostatic Hypotension: A Comparative Review. Cureus 2023; 15:e38907. [PMID: 37303338 PMCID: PMC10257554 DOI: 10.7759/cureus.38907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Neurogenic orthostatic hypotension (nOH) is a disabling problem of autonomic dysfunction in patients with Parkinson's disease, which is associated with poor quality of life and higher mortality rates. The purpose of this literature review was to explore and compare the efficacy and safety of droxidopa (an existing treatment) and ampreloxetine (a newer medication) in the treatment of nOH. We used a mixed-method literature review that addresses the epidemiology, pathophysiology, and pharmacological and non-pharmacological management of nOH in Parkinson's disease in a general way, with a more exploratory approach to droxidopa- and ampreloxetine-controlled trial studies. We included a total of 10 studies of randomized controlled trials with eight studies focused on droxidopa and two studies focused on ampreloxetine. These two drugs were analyzed and compared based on the collected individual study results. Treatment of nOH in Parkinson's disease patients with droxidopa or ampreloxetine showed clinically meaningful and statistically significant improvements relative to placebo on the components of the OHSA (Orthostatic Hypotension Symptom Assessment) composite score and OHDAS (Orthostatic Hypotension Daily Activity Scale composite scores) composite score. Droxidopa had an improved effect on daily activities, with an associated increase in standing systolic blood pressure (BP), but the long-term efficacy of droxidopa has not been documented. Standing systolic BP was maintained by ampreloxetine and worsened after the withdrawal phase. This highlights the importance of conducting further research which will help us to improve the therapeutic approach for patients with nOH and Parkinson's disease.
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Affiliation(s)
| | - Shruti Shah
- Internal Medicine, Byramjee Jeejeeboy (BJ) Medical College, Pune, IND
| | | | | | | | - Saumya Singh
- Internal Medicine, Gujarat Medical Education & Research Society (GMERS) Medical College and Hospital, Gujarat, IND
| | - Gaudy F Collado
- Internal Medicine, Fleet Medical Unit, Philippine Fleet, Philippine Navy, Cavite City, PHL
| | - Abhishek Goyal
- Internal Medicine, Kasturba Medical College, Manipal, Manipal, IND
| | - Imran Khawaja
- Internal Medicine, Ayub Medical Institute, Abbottabad, PAK
| | | | - Waleed Razzaq
- Internal Medicine, Services Hospital Lahore, Lahore, PAK
| | - Zain U Abdin
- Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Ishita Gupta
- Medicine, Dr. Rajendra Prasad Government Medical College, Tanda, IND
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Shackleton C, Hodgkiss D, Samejima S, Miller T, Perez MA, Nightingale TE, Sachdeva R, Krassioukov AV. When the whole is greater than the sum of its parts: a scoping review of activity-based therapy paired with spinal cord stimulation following spinal cord injury. J Neurophysiol 2022; 128:1292-1306. [PMID: 36222423 DOI: 10.1152/jn.00367.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 10/06/2022] [Indexed: 11/22/2022] Open
Abstract
Spinal cord injury (SCI) results in both motor and autonomic impairments, which can negatively affect independence and quality of life and increase morbidity and mortality. Despite emerging evidence supporting the benefits of activity-based training and spinal cord stimulation as two distinct interventions for sensorimotor and autonomic recovery, the combined effects of these modalities are currently uncertain. This scoping review evaluated the effectiveness of paired interventions (exercise + spinal neuromodulation) for improving sensorimotor and autonomic functions in individuals with SCI. Four electronic databases were searched for peer-reviewed manuscripts (Medline, Embase, CINAHL, and EI-compedex Engineering Village) and data were independently extracted by two reviewers using pre-established extraction tables. A total of 15 studies representing 79 participants were included in the review, of which 73% were conducted within the past 5 years. Only two of the studies were randomized controlled studies, while the other 13 studies were case or case-series designs. Compared with activity-based training alone, spinal cord stimulation combined with activity-based training improved walking and voluntary muscle activation, and augmented improvements in lower urinary tract, bowel, resting metabolic rate, peak oxygen consumption, and thermoregulatory function. Spinal neuromodulation in combination with use-dependent therapies may provide greater neurorecovery and induce long-term benefits for both motor and autonomic function beyond the capacity of traditional activity-based therapies. However, evidence for combinational approaches is limited and there is no consensus for outcome measures or optimal protocol parameters, including stimulation settings. Future large-scale randomized trials into paired interventions are warranted to further investigate these preliminary findings.
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Affiliation(s)
- Claire Shackleton
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Hodgkiss
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Soshi Samejima
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tiev Miller
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Monica A Perez
- Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Shirley Ryan Ability Laboratory, Chicago, Illinois
- Edward Hines Jr. VA Hospital, Chicago, Illinois
| | - Thomas E Nightingale
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, United Kingdom
| | - Rahul Sachdeva
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Spinal Cord Program, GF Strong Rehabilitation Centre, University of British Columbia, Vancouver, British Columbia, Canada
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Menezes EC, da Silva Pereira F, Porto RM, Fank F, Mazo GZ. Effect of exercise on female pelvic floor morphology and muscle function: a systematic review. Int Urogynecol J 2022; 34:963-977. [PMID: 36205725 DOI: 10.1007/s00192-022-05375-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/20/2022] [Indexed: 10/10/2022]
Abstract
INTRODUCTION AND HYPOTHESIS The objective was to synthesize the scientific evidence on the relationship of exercise with morphology and muscle function parameters of the female pelvic floor. The design was a systematic review. METHODS Searches were performed in MEDLINE, PubMed, CINAHL, Web of Science, SCOPUS, SportDiscuss, and Google Scholar up to April 2021. Observational and experimental studies evaluating the morphology and/or function of the pelvic floor muscles (PFMs) in women were eligible. Studies reporting exercise or sports disciplines as exposure/intervention were included. RESULTS Twenty-five studies were included. Compared with the control group, women performing vigorous and high-impact exercises exhibited lower maximum voluntary contraction of the PFM and those performing moderate exercise had better maximum voluntary contraction. Exercise practitioners had a larger hiatal area at rest, during contraction, and during Valsalva, and greater bladder neck descent than the control group. CONCLUSIONS The results of this review demonstrate an inverse relationship of PFM maximum voluntary contraction with exercise intensity. Qualitative synthesis showed that the studies found favorable outcomes for the control group in terms of hiatal area during contraction and Valsalva and bladder neck displacement.
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Affiliation(s)
| | - Franciele da Silva Pereira
- Gerontology Laboratory, State University of Santa Catarina, Street Pascoal Simone, 358, Coqueiros, Florianopolis, SC, CEP: 88080-350, Brazil.
| | - Rafaela Maria Porto
- Gerontology Laboratory, State University of Santa Catarina, Street Pascoal Simone, 358, Coqueiros, Florianopolis, SC, CEP: 88080-350, Brazil
| | - Felipe Fank
- Gerontology Laboratory, State University of Santa Catarina, Street Pascoal Simone, 358, Coqueiros, Florianopolis, SC, CEP: 88080-350, Brazil
| | - Giovana Zarpellon Mazo
- Gerontology Laboratory, State University of Santa Catarina, Street Pascoal Simone, 358, Coqueiros, Florianopolis, SC, CEP: 88080-350, Brazil
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Fedorowski A, Ricci F, Hamrefors V, Sandau KE, Chung TH, Muldowney JAS, Gopinathannair R, Olshansky B. Orthostatic Hypotension: Management of a Complex, But Common, Medical Problem. Circ Arrhythm Electrophysiol 2022; 15:e010573. [PMID: 35212554 PMCID: PMC9049902 DOI: 10.1161/circep.121.010573] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Orthostatic hypotension (OH), a common, often overlooked, disorder with many causes, is associated with debilitating symptoms, falls, syncope, cognitive impairment, and risk of death. Chronic OH, a cardinal sign of autonomic dysfunction, increases with advancing age and is commonly associated with neurodegenerative and autoimmune diseases, diabetes, hypertension, heart failure, and kidney failure. Management typically involves a multidisciplinary, patient-centered, approach to arrive at an appropriate underlying diagnosis that is causing OH, treating accompanying conditions, and providing individually tailored pharmacological and nonpharmacological treatment. We propose a novel streamlined pathophysiological classification of OH; review the relationship between the cardiovascular disease continuum and OH; discuss OH-mediated end-organ damage; provide diagnostic and therapeutic algorithms to guide clinical decision making and patient care; identify current gaps in knowledge and try to define future research directions. Using a case-based learning approach, specific clinical scenarios are presented highlighting various presentations of OH to provide a practical guide to evaluate and manage patients who have OH.
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Affiliation(s)
- Artur Fedorowski
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fabrizio Ricci
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Neuroscience, Imaging & Clinical Sciences, “G.d’Annunzio” University, Chieti-Pescara
- Casa di Cura Villa Serena, Città Sant’Angelo, Italy
| | - Viktor Hamrefors
- Dept of Clinical Sciences, Lund University, Malmö
- Dept of Internal Medicine, Skåne University Hospital, Malmö, Sweden
| | | | - Tae Hwan Chung
- Dept of Physical Medicine & Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD
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Tanzer TD, Brouard T, Pra SD, Warren N, Barras M, Kisely S, Brooks E, Siskind D. Treatment strategies for clozapine-induced hypotension: a systematic review. Ther Adv Psychopharmacol 2022; 12:20451253221092931. [PMID: 35633931 PMCID: PMC9136453 DOI: 10.1177/20451253221092931] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/22/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Clozapine is the most effective medication for treatment-refractory schizophrenia but is associated with significant adverse drug effects, including hypotension and dizziness, which have a negative impact on quality of life and treatment compliance. Available evidence for the management of clozapine-induced hypotension is scant. OBJECTIVES Due to limited guidance on the safety and efficacy of pharmacological treatments for clozapine-induced hypotension, we set out to systematically review and assess the evidence for the management of clozapine-induced hypotension and provide guidance to clinicians, patients, and carers. DESIGN We undertook a systematic review of the safety and efficacy of interventions for clozapine-induced hypotension given the limited available evidence. DATA SOURCES AND METHODS PubMed, Embase, PsycINFO, CINAHL, and the Cochrane trial Registry were searched from inception to November 2021 for literature on the treatment strategies for clozapine-induced hypotension and dizziness using a PROSPERO pre-registered search strategy. For orthostatic hypotension, we developed a management framework to assist in the choice of intervention. RESULTS We identified nine case studies and four case series describing interventions in 15 patients. Hypotension interventions included temporary clozapine dose reduction, non-pharmacological treatments, and pharmacological treatments. Midodrine, fludrocortisone, moclobemide and Bovril® combination, and etilefrine were associated with improvement in symptoms or reduction in orthostatic hypotension. Angiotensin II, arginine vasopressin, and noradrenaline successfully restored and maintained mean arterial pressure in critical care situations. A paradoxical reaction of severe hypotension was reported with adrenaline use. CONCLUSION Orthostatic hypotension is a common side effect during clozapine titration. Following an assessment of the titration schedule, salt and fluid intake, and review of hypertensive and nonselective α1-adrenergic agents, first-line treatment should be a temporary reduction in clozapine dose or non-pharmacological interventions. If orthostatic hypotension persists, fludrocortisone should be trialled with monitoring of potassium levels and sodium and fluid intake. Midodrine may be considered second-line or where fludrocortisone is contraindicated or poorly tolerated. For patients on clozapine with hypotension in critical care settings, the use of adrenaline to maintain mean arterial pressure should be avoided. REGISTRATION PROSPERO (Registration No. CRD42020191530).
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Affiliation(s)
| | - Thomas Brouard
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Samuel Dal Pra
- Metro South Addiction and Mental Health Services, Brisbane, QLD, Australia
| | - Nicola Warren
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Michael Barras
- Department of Pharmacy, Princess Alexandra Hospital, Brisbane, QLD, Australia School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia
| | - Steve Kisely
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Emily Brooks
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Dan Siskind
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
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Oud TAM, Lazzari E, Gijsbers HJH, Gobbo M, Nollet F, Brehm MA. Effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions: A scoping review. PLoS One 2021; 16:e0260271. [PMID: 34793566 PMCID: PMC8601455 DOI: 10.1371/journal.pone.0260271] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 11/06/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the field of orthotics, the use of three-dimensional (3D) technology as an alternative to the conventional production process of orthoses is growing. PURPOSE This scoping review aimed to systematically map and summarize studies assessing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions, and to identify knowledge gaps. METHODS The Cochrane Library, PubMed, EMBASE, CINAHL, Web of Science, IEEE, and PEDro were searched for studies of any type of 3D-printed orthoses for traumatic and chronic hand conditions. Any outcome related to the effectiveness of 3D-printed orthoses was considered. Two reviewers selected eligible studies, charted data on study characteristics by impairment type, and critically appraised the studies, except for case reports/series. RESULTS Seventeen studies were included: four randomized controlled trials, four uncontrolled trials, four case series and five case reports. Only three studies had a sample size >20. Impairments described were forearm fractures (n = 5), spasticity (n = 5), muscle weakness (n = 4), joint contractures (n = 2) and pain (n = 1). Four poor to fair quality studies on forearm fractures supported the effectiveness of 3D-printed orthoses on hand function, functionality, and satisfaction. One good quality study on spasticity demonstrated the effectiveness of 3D-printed orthoses on hand function. One poor quality pain study reported limited positive effects on satisfaction. Studies on muscle weakness and joint contractures showed no benefits. CONCLUSION Current literature addressing the effectiveness of 3D-printed orthoses for traumatic and chronic hand conditions consists primarily of small and poor methodological quality studies. There is a need for well-designed controlled trials including patient-related outcomes, production time and cost analyses.
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Affiliation(s)
- T. A. M. Oud
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - E. Lazzari
- Laboratory of Clinical Integrative Physiology, University of Brescia, Brescia, Italy
| | - H. J. H. Gijsbers
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - M. Gobbo
- Laboratory of Clinical Integrative Physiology, University of Brescia, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - F. Nollet
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - M. A. Brehm
- Amsterdam UMC, University of Amsterdam, Rehabilitation Medicine, Amsterdam Movement Sciences, Amsterdam, The Netherlands
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10
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Nagumo M, Tashiro S, Hijikata N, Ishikawa A, Akiyama T, Tsuji T. Conservative rehabilitation for a patient presenting with severe orthostatic hypotension after surgical management of brainstem tumor: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2136. [PMID: 35855083 PMCID: PMC9245778 DOI: 10.3171/case2136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Blood pressure (BP) dysregulation is frequently observed in patients after surgical management of brainstem lesions; however, there has been no standard rehabilitation. Considering the conflicting risks for hypoperfusion and disuse syndrome in these patients, a safe and effective rehabilitative strategy is warranted. OBSERVATIONS A 50-year-old man who had undergone craniotomy for resection of a recurrent dorsal medullary epidermoid cyst developed persistent orthostatic hypotension. It was resistant to physical exercise, pharmacological therapy, abdominal binders, and compression stockings; therefore, it inhibited postoperative rehabilitation. Although the responsible lesion was not clearly visible on the postoperative image, accompanying symptoms, including segmental sensory impairment, implied an improvement in BP control. Although there was a trade-off between the risk of developing disuse syndrome and a delay in functional recovery, the authors decided to continue a conservative rehabilitation strategy rather than increasing the workload. The patient’s BP control was gradually restored by the seventh postoperative week, and the authors proceeded with basic activity training. LESSONS A conservative prognostic prediction-based rehabilitation strategy was applied in this case. The precise evaluation of the accompanying neurological symptoms was helpful in deciding the treatment regimen. The conflicting risks for hypoperfusion and disuse syndrome in such cases must be considered.
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Affiliation(s)
| | - Syoichi Tashiro
- Departments of Rehabilitation Medicine and
- Neurosurgery, Keio University School of Medicine, Tokyo, Japan; and
| | | | | | - Takenori Akiyama
- Department of Rehabilitation Medicine, Kyorin University School of Medicine, Tokyo, Japan
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11
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Rocha EA, Mehta N, Távora-Mehta MZP, Roncari CF, Cidrão AADL, Elias Neto J. Dysautonomia: A Forgotten Condition - Part II. Arq Bras Cardiol 2021; 116:981-998. [PMID: 34008826 PMCID: PMC8121459 DOI: 10.36660/abc.20200422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Affiliation(s)
- Eduardo Arrais Rocha
- Hospital Universitário Walter Cantídio da Universidade Federal do Ceará (UFC) - Programa de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | - Niraj Mehta
- Universidade Federal do Paraná, Curitiba, PR - Brasil.,Clínica de Eletrofisiologia do Paraná, Curitiba, PR - Brasil
| | | | - Camila Ferreira Roncari
- Departamento de Fisiologia e Farmacologia - Faculdade de Medicina da Universidade Federal do Ceará (UFC), Fortaleza, CE - Brasil
| | - Alan Alves de Lima Cidrão
- Programa de Pós-graduação em Ciências Cardiovasculares da Faculdade de Medicina da UFC, Fortaleza, CE - Brasil
| | - Jorge Elias Neto
- Serviço de Eletrofisiologia do Vitória Apart Hospital, Vitória, ES - Brasil
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12
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Affiliation(s)
- Artaza Gilani
- UCL Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Hospital Campus), London NW3 2PF, UK
| | - Stephen P Juraschek
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA 02215, USA
| | - Matthew J Belanger
- Harvard Medical School, Beth Israel Deaconess Medical Center, Division of General Medicine, Section for Research, Boston, MA 02215, USA
| | - Julie E Vowles
- Hillingdon Hospitals NHS Foundation Trust, Uxbridge UB8 3NN, UK
| | - S Goya Wannamethee
- UCL Research Department of Primary Care and Population Health, University College London Medical School (Royal Free Hospital Campus), London NW3 2PF, UK
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Logan A, Freeman J, Pooler J, Kent B, Gunn H, Billings S, Cork E, Marsden J. Effectiveness of non-pharmacological interventions to treat orthostatic hypotension in elderly people and people with a neurological condition: a systematic review. JBI Evid Synth 2021; 18:2556-2617. [PMID: 32773495 DOI: 10.11124/jbisrir-d-18-00005] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
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.
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Affiliation(s)
- Angela Logan
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,Stroke and Neurology Therapy Team, Cornwall Partnership Foundation NHS Trust, Camborne Redruth Community Hospital, Cornwall, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
| | - Jennifer Freeman
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
| | - Jillian Pooler
- Faculty of Health, Peninsula Medical and Dentistry Schools, Plymouth, UK
| | - Bridie Kent
- The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence.,School of Nursing and Midwifery, Faculty of Health, Plymouth University, Plymouth, UK
| | - Hilary Gunn
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK
| | - Sarah Billings
- Stroke Rehabilitation Unit, Livewell Southwest, Mount Gould Hospital, Plymouth, UK
| | - Emma Cork
- Stroke Rehabilitation Department, Northern Devon Healthcare Trust, Northern Devon District Hospital, Barnstaple, UK
| | - Jonathan Marsden
- School of Health Professions, Faculty of Health, Peninsula Allied Health Centre, Plymouth University, Plymouth, UK.,The University of Plymouth Centre for Innovations in Health and Social Care: A JBI Centre of Excellence
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14
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Donovan J, Forrest G, Linsenmeyer T, Kirshblum S. Spinal Cord Stimulation After Spinal Cord Injury: Promising Multisystem Effects. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2021. [DOI: 10.1007/s40141-020-00304-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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15
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McDougall J, Jutzeler CR, Scott A, Crocker PRE, Kramer JLK. Conditioned pain modulation in elite athletes: a systematic review and meta-analysis. Scand J Pain 2020; 20:429-438. [PMID: 32755103 DOI: 10.1515/sjpain-2019-0153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/15/2020] [Indexed: 12/12/2022]
Abstract
Background and aims Elite athletes reportedly have superior pain tolerances, but it is unclear if results extend to conditioned pain modulation (CPM). The aim of our study was to synthesize existing literature in order to determine whether CPM is increased in elite athletes compared to healthy controls. Methods A systematic review and random-effects meta-analysis was conducted. Cochrane Central Register of Controlled Trials, SPORTDiscus, PsycINFO, CINAHL, Web of Science, and PubMed were searched for English-language studies that examined CPM in adult elite athlete populations. Results Seven studies were identified; all were of poor to fair methodological quality. There was no overall difference in CPM between elite athletes and controls (Hedges g = 0.37, CI95 -0.03-0.76; p = 0.07). There was heterogeneity between studies, including one that reported significantly less CPM in elite athletes compared to controls. An exploratory meta-regression indicated that a greater number of hours trained per week was associated with higher CPM. Conclusions The overall number and quality of studies was low. Despite nominally favoring higher CPM in elite athletes, aggregate results indicate no significant difference compared to healthy controls. A possible factor explaining the high degree of variability between studies is the number of hours elite athletes spent training. Implications Based on available evidence, athletes do not have remarkable endogenous pain modulation compared to controls. High quality experimental studies are needed to address the effect of hours trained per week on CPM in athletes.
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Affiliation(s)
- Jessica McDougall
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,Department of Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Catherine R Jutzeler
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada
| | - Alex Scott
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, Vancouver, British Columbia, Canada.,Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter R E Crocker
- School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - John L K Kramer
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, British Columbia, Canada.,School of Kinesiology, University of British Columbia, Vancouver, British Columbia, Canada
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16
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McDougall J, Chow E, Harris RL, Mills PB. Near-infrared spectroscopy as a quantitative spasticity assessment tool: A systematic review. J Neurol Sci 2020; 412:116729. [PMID: 32120130 DOI: 10.1016/j.jns.2020.116729] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 02/05/2020] [Accepted: 02/09/2020] [Indexed: 11/24/2022]
Abstract
The purpose of this paper is to systematically review the literature on the use of near-infrared spectroscopy (NIRS) for assessing spasticity. MEDLINE, CINAHL, and EMBASE were searched for human and/or animal studies written in the English language published until November 2018. that used NIRS to examine the hemodynamics and/or metabolism of spastic musculature were included. Of the 35 articles identified, five met the inclusion criteria. Two reviewers independently extracted spasticity outcomes, NIRS instrumentation specifications, and NIRS hemodynamic and metabolic measures from each article. Risk of bias was assessed using the Downs & Black tool for non-randomized studies. Three different models of NIRS devices were used in the five studies. Four studies examined the effects of passive limb movements and one examined active hand movements on NIRS parameters in spastic and non-spastic muscle. Owing to the small number and diverse nature of the studies, statistical comparison was deemed inappropriate. Rather, descriptive comparisons were drawn and levels of evidence were assigned based on the modified Sackett Scale. There is level 4 evidence that NIRS can non-invasively detect and measure differences between spastic and non-spastic muscles in blood volume and oxidative capacity changes over time or in response to interventions, and may correlate with other, established measures of spasticity, such as the Modified Ashworth Scale (MAS) and electromyography (EMG). Future research studies should use a validated definition of spasticity for inclusion criteria, a control group, and standardized NIRS variables.
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Affiliation(s)
- Jessica McDougall
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, 818 W 10th Ave, Vancouver, BC V5Z 1M9, Canada; Department of Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, 6081 University Blvd, Vancouver, BC V6T 1Z1, Canada.
| | - Eric Chow
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, 818 W 10th Ave, Vancouver, BC V5Z 1M9, Canada; Centre for Molecular Medicine and Therapeutics, University of British Columbia, 950 West 28th Avenue, Vancouver, BC V5Z 4H4, Canada
| | - R Luke Harris
- School of Health Sciences, T&L #10-3590, University of Northern British Columbia, 3333 University Way, Prince George, BC V2N 4Z9, Canada
| | - Patricia Branco Mills
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, 818 W 10th Ave, Vancouver, BC V5Z 1M9, Canada; GF Strong Rehabilitation Centre, 4255 Laurel St, Vancouver, BC V5Z 2G9, Canada; Division of Physical Medicine and Rehabilitation, University of British Columbia, 4255 Laurel St, Vancouver, BC V5Z 2G9, Canada; Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Coastal Health, 2635 Laurel St, Vancouver, BC V5Z 1M9, Canada
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17
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Legg Ditterline BE, Aslan SC, Wang S, Ugiliweneza B, Hirsch GA, Wecht JM, Harkema S. Restoration of autonomic cardiovascular regulation in spinal cord injury with epidural stimulation: a case series. Clin Auton Res 2020; 31:317-320. [PMID: 32405661 DOI: 10.1007/s10286-020-00693-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 05/06/2020] [Indexed: 12/24/2022]
Affiliation(s)
- Bonnie E Legg Ditterline
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Sevda C Aslan
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Siqi Wang
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Beatrice Ugiliweneza
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA.,Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Glenn A Hirsch
- Division of Cardiology, Department of Medicine, National Jewish Health, Denver, CO, USA.,Division of Cardiovascular Medicine, Department of Medicine, University of Louisville, Louisville, KY, USA
| | - Jill M Wecht
- James J. Peters VA Medical Center, Bronx, NY, USA.,VA RR&D Service Center for the Medical Consequences of Spinal Cord Injury, Bronx, NY, USA.,Departments of Medicine and Rehabilitation Medicine, Icahn School of Medicine, New York, NY, USA
| | - Susan Harkema
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, USA. .,Department of Neurosurgery, University of Louisville, Louisville, KY, USA. .,Frazier Rehabilitation Institute, 220 Abraham Flexner Way, Louisville, KY, 40202, USA.
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18
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LeWitt PA, Kymes S, Hauser RA. Parkinson Disease and Orthostatic Hypotension in the Elderly: Recognition and Management of Risk Factors for Falls. Aging Dis 2020; 11:679-691. [PMID: 32489712 PMCID: PMC7220277 DOI: 10.14336/ad.2019.0805] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 08/05/2019] [Indexed: 12/11/2022] Open
Abstract
Parkinson disease (PD) is often associated with postural instability and gait dysfunction that can increase the risk for falls and associated consequences, including injuries, increased burden on healthcare resources, and reduced quality of life. Patients with PD have nearly twice the risk for falls and associated bone fractures compared with their general population counterparts of similar age. Although the cause of falls in patients with PD may be multifactorial, an often under-recognized factor is neurogenic orthostatic hypotension (nOH). nOH is a sustained decrease in blood pressure upon standing whose symptomology can include dizziness/lightheadedness, weakness, fatigue, and syncope. nOH is due to dysfunction of the autonomic nervous system compensatory response to standing and is a consequence of the neurodegenerative processes of PD. The symptoms associated with orthostatic hypotension (OH)/nOH can increase the risk of falls, and healthcare professionals may not be aware of the real-world clinical effect of nOH, the need for routine screening, or the value of early diagnosis of nOH when treating elderly patients with PD. nOH is easily missed and, importantly, healthcare providers may not realize that there are effective treatments for nOH symptoms that could help lessen the fall risk resulting from the condition. This review discusses the burden of, and key risk factors for, falls among patients with PD, with a focus on practical approaches for the recognition, assessment, and successful management of OH/nOH. In addition, insights are provided as to how fall patterns can suggest fall etiology, thereby influencing the choice of intervention.
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Affiliation(s)
- Peter A LeWitt
- 1Henry Ford Hospital and Wayne State University School of Medicine, West Bloomfield, MI 48322, USA
| | | | - Robert A Hauser
- 3University of South Florida Parkinson's Disease and Movement Disorders Center, Parkinson Foundation Center of Excellence, Tampa, FL 33613, USA
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19
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Orthostatic and Exertional Hypotension: Review and Implications for Physical Therapy. JOURNAL OF ACUTE CARE PHYSICAL THERAPY 2020. [DOI: 10.1097/jat.0000000000000112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
OBJECTIVE To examine differences in heart rate (HR) responses during international wheelchair rugby competition between athletes with and without a cervical spinal cord injury (SCI) and across standardized sport classifications. DESIGN Observational study. SETTING The 2015 Parapan American Games wheelchair rugby competition. PARTICIPANTS Forty-three male athletes (31 ± 8 years) with a cervical SCI (n = 32) or tetraequivalent impairment (non-SCI, n = 11). MAIN OUTCOME MEASURES Average and peak HR (HRavg and HRpeak, respectively). To characterize HR responses in accordance with an athletes' International Wheelchair Rugby Federation (IWRF) classification, we separated athletes into 3 groups: group I (IWRF classification 0.5-1.5, n = 15); group II (IWRF classification 2.0, n = 15); and group III (IWRF classification 2.5-3.5, n = 13). RESULTS Athletes with SCI had lower HRavg (111 ± 14 bpm vs 155 ± 13 bpm) and HRpeak (133 ± 12 bpm vs 178 ± 13 bpm) compared with non-SCI (both P < 0.001). Average HR was higher in group III than in I (136 ± 25 bpm vs 115 ± 20 bpm, P = 0.045); however, SCI athletes showed no difference in HRavg or HRpeak between groups. Within group III, SCI athletes had lower HRavg (115 ± 6 bpm vs 160 ± 8 bpm) and HRpeak (135 ± 11 bpm vs 183 ± 11 bpm) than non-SCI athletes (both P < 0.001). CONCLUSIONS This study is the first to demonstrate attenuated HR responses during competition in SCI compared with non-SCI athletes, likely due to injury to spinal autonomic pathways. Among athletes with SCI, IWRF classification was not related to differences in HR. Specific assessment of autonomic function after SCI may be able to predict HR during competition and consideration of autonomic impairments may improve the classification process.
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21
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Abstract
Parkinson disease (PD) is associated with a variety of motor and non-motor clinical manifestations, including cardiovascular autonomic dysfunction. Neurogenic orthostatic hypotension (nOH) is a potentially serious manifestation of cardiovascular sympathetic failure that occurs in approximately 30% of patients with PD. Here we review the pathophysiology and effects of the condition as well as treatment considerations for patients with PD and nOH. Screening for nOH using orthostatic symptom questionnaires, orthostatic blood pressure measurements, and specialized autonomic testing is beneficial for the identification of symptomatic and asymptomatic cases because cardiac sympathetic denervation and nOH can occur even at early (premotor) stages of PD. Symptoms of nOH, such as orthostatic lightheadedness, in patients with PD, have been shown to adversely affect patient safety (with increased risk of falls) and quality of life and should prompt treatment with non-pharmacologic and, occasionally, pharmacologic measures. Patients with nOH are also at increased risk of supine hypertension, which requires balancing various management strategies. FUNDING: Lundbeck (Deerfield, IL).
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Affiliation(s)
| | - Phillip A Low
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
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22
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Abstract
PURPOSE OF REVIEW Autonomic dysfunction is common in dementia, particularly in the Lewy body dementias. This review considers the evidence for autonomic dysfunction in dementia, common symptoms and potential management options. RECENT FINDINGS Autonomic dysfunction has been shown in Alzheimer's disease and Lewy body dementias. Common symptoms include orthostatic dizziness, syncope, falls, urinary tract symptoms and constipation. Non-pharmacological management of orthostatic hypotension should include bolus water drinking. Pharmacological management may include the use of midodrine or droxidopa although the latter is not available in Europe. Atomoxetine is a noradrenaline reuptake inhibitor which may be useful if further clinical trials become available. Management of constipation may include the use o f probiotics, osmotic laxatives such as macrogol and chloride type 2 channel activators such as lubiprostone. Management of urinary tract symptoms may include the use of mirabegron. There is a dearth of clinical trials for autonomic dysfunction in dementia and most of the evidence is imputed from trials in Parkinson's disease. However, pragmatic recommendations may be made. There is a need for controlled clinical trials in people with dementia.
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Affiliation(s)
- Louise M Allan
- Institute of Health Research, College of Medicine and Health, University of Exeter, South Cloisters Building, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
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Sachdeva R, Nightingale TE, Krassioukov AV. The Blood Pressure Pendulum following Spinal Cord Injury: Implications for Vascular Cognitive Impairment. Int J Mol Sci 2019; 20:ijms20102464. [PMID: 31109053 PMCID: PMC6567094 DOI: 10.3390/ijms20102464] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 12/15/2022] Open
Abstract
Cognitive impairment following spinal cord injury (SCI) has received considerable attention in recent years. Among the various systemic effects of SCI that contribute towards cognitive decline in this population, cardiovascular dysfunction is arguably one of the most significant. The majority of individuals with a cervical or upper-thoracic SCI commonly experience conditions called orthostatic hypotension and autonomic dysreflexia, which are characterized by dangerous fluctuations in systemic blood pressure (BP). Herein, we review the potential impact of extreme BP lability on vascular cognitive impairment (VCI) in individuals with SCI. Albeit preliminary in the SCI population, there is convincing evidence that chronic hypotension and hypertension in able-bodied individuals results in devastating impairments in cerebrovascular health, leading to VCI. We discuss the pertinent literature, and while drawing mechanistic comparisons between able-bodied cohorts and individuals with SCI, we emphasize the need for additional research to elucidate the mechanisms of cognitive impairment specific to the SCI population. Lastly, we highlight the current and potential future therapies to manage and treat BP instability, thereby possibly mitigating VCI in the SCI population.
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Affiliation(s)
- Rahul Sachdeva
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
| | - Tom E Nightingale
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
| | - Andrei V Krassioukov
- International Collaboration on Repair Discoveries (ICORD), University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
- Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
- GF Strong Rehabilitation Center, Vancouver Coastal Health, Vancouver, BC V5Z 2G9, Canada.
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24
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Subbarayan S, Myint PK, Martin KR, Abraha I, Devkota S, O'Mahony D, Cruz-Jentoft AJ, Cherubini A, Soiza RL. Nonpharmacologic Management of Orthostatic Hypotension in Older People: A Systematic Review. The SENATOR ONTOP Series. J Am Med Dir Assoc 2019; 20:1065-1073.e3. [PMID: 31109911 DOI: 10.1016/j.jamda.2019.03.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 03/25/2019] [Accepted: 03/26/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Nonpharmacologic therapies are often recommended as a first-line treatment for orthostatic hypotension (OH). However, the true effect of nonpharmacologic therapy remains unclear, particularly in the older population. We undertook a systematic review evaluating the efficacy of nonpharmacologic interventions in older people with OH to provide evidence-based recommendations. DESIGN Systematic review of systematic reviews. SETTING AND PARTICIPANTS MEDLINE, PubMed, EMBASE, and Cochrane Database of Systematic Reviews, CINHAL, and PsycINFO were searched up to June 2018. Two reviewers identified eligible systematic reviews from which primary studies were selected. We included both randomized and nonrandomized studies that evaluated any type of nonpharmacologic intervention and reported outcomes of change in postural drop in systolic blood pressure (SBP) and/or orthostatic symptoms measured using any validated instrument. The Cochrane risk of bias tool was used, with recommendations based on the GRADE approach. RESULTS Eleven trials were included. Meta-analysis of lower limb compression showed a reduction in the postural drop in SBP of 9.83 mmHg [95% confidence interval (CI) -12.56, -7.11], whereas abdominal compression showed a larger reduction in postural drop in SBP of 12.30 mmHg (95% CI -18.20, -6.39). Compression therapy was also beneficial in reducing OH symptoms. However, the quality of the evidence for compression therapy was very poor. One study each was identified for sleeping with head-up (SHU), home-based resistance training (HBRT), and multicomponent intervention but did not significantly reduce postural SBP drop. Bolus water drinking was effective in 1 study but the study was of low quality. CONCLUSIONS/IMPLICATIONS There is no high-quality evidence to recommend any of the nonpharmacologic therapies for the management of OH in older people. Yet, we make a weak recommendation for lower limb and abdominal compression therapy based on very low quality evidence. Large-scale trials are warranted in older people to substantiate the efficacy of nonpharmacologic therapies in OH.
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Affiliation(s)
- Selvarani Subbarayan
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom; Aberdeen Royal Infirmary, Aberdeen, United Kingdom.
| | - Phyo K Myint
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom; Aberdeen Royal Infirmary, Aberdeen, United Kingdom
| | - Kathryn R Martin
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom
| | - Iosief Abraha
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | | | - Denis O'Mahony
- Department of Medicine (Geriatrics), University College Cork, Cork, Ireland
| | | | - Antonio Cherubini
- Geriatria, Accettazione geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy
| | - Roy L Soiza
- School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, United Kingdom; Aberdeen Royal Infirmary, Aberdeen, United Kingdom
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25
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Magny E, Donadio C, Maronnat F, Nghiem D, Berthelot E, Belmin J, Lafuente-Lafuente C. [Hypotensions in the elderly: Clinical and therapeutic features]. Presse Med 2019; 48:134-142. [PMID: 30728099 DOI: 10.1016/j.lpm.2018.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 10/01/2018] [Accepted: 11/07/2018] [Indexed: 12/28/2022] Open
Abstract
Hypotension and especially very low diastolic blood pressure could be an at-risk situation in very old and frail patients and in those with coronary heart disease. Chronic hypotension in people with heart failure is an indicator of poor prognosis and hinders the management of therapy. Orthostatic hypotension is a decrease in blood pressure>20mmHg for systolic and/or>10mmHg for diastolic within 3minutes after transition from supine to upright. Orthostatic hypotension may be symptomatic or not. The search for orthostatic hypotension is part of the clinical examination of elderly patients with hypertension, falling, diabetes and or polymedication. First intention treatment aims to correct modifiable modifying factors and to limit the circulatory consequences of orthostatism by elastic venous compression.
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Affiliation(s)
- Emmanuelle Magny
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France
| | - Cristiano Donadio
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France
| | - Florian Maronnat
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France
| | - Duy Nghiem
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France
| | | | - Joël Belmin
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France; Université Sorbonne, faculté de médecine Sorbonne Médecine, 75013 Paris, France.
| | - Carmelo Lafuente-Lafuente
- Hôpitaux universitaires Pitié-Salpêtrière Charles-Foix, hôpital Charles-Foix, service de gériatrie, 94200 Ivry-sur-Seine, France; Université Sorbonne, faculté de médecine Sorbonne Médecine, 75013 Paris, France
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26
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Yadav R, Rukmani M, Pal P, Sathyaprabha T. Clinical management of neurogenic orthostatic hypotension. ANNALS OF MOVEMENT DISORDERS 2019. [DOI: 10.4103/aomd.aomd_24_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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27
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Robinson LJ, Pearce RM, Frith J. Acceptability of non-drug therapies in older people with orthostatic hypotension: a qualitative study. BMC Geriatr 2018; 18:315. [PMID: 30558552 PMCID: PMC6296017 DOI: 10.1186/s12877-018-0999-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/28/2018] [Indexed: 11/23/2022] Open
Abstract
Background Orthostatic hypotension (OH) is highly prevalent in older populations. It is associated with a reduced quality of life and an increased risk of dementia, stroke and death. Non-pharmalogical therapies are the recommended first-line therapy and are preferred to drug treatments by older people. However, uptake and adherence is low and evidence for their use is lacking. Objective: Determine the acceptability of non-pharmalogical interventions for OH in older people. Methods This qualitative study, nested within a phase II efficacy study, recruited 25 people aged over 60 years from a Falls and Syncope Clinic. All participants had experienced the following non-pharmalogical therapies within a phase II study: bolus water drinking, compression stockings, abdominal compression, physical counter-manoeuvres. Individual semi-structured qualitative interviews were recorded and transcribed verbatim. Emergent themes were identified through framework analysis of transcripts. Results Physical counter-manoeuvres were considered the most acceptable therapy as no equipment is required, they can be performed discreetly and are only required during postural change. Bolus water drinking was mostly considered as an acceptable therapy, although there were significant concerns around urinary frequency. The idea of bolus water drinking was a barrier to its uptake, but once experienced it was easier than anticipated. Participants had mixed views on acceptability of abdominal compression whereas compression stockings were considered unacceptable by the majority of participants. This was due to the practicalities of applying/removing the compression and the stigma attached to their appearance. Conclusions Current first-line treatment with compression stockings is largely unacceptable to older people with OH, challenging current guidelines. In order to promote uptake and adherence, first line therapy should focus on bolus-water drinking and physical counter-manoeuvres.
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Affiliation(s)
- Lisa J Robinson
- The Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK
| | - Ruth M Pearce
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - James Frith
- The Falls and Syncope Service, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE1 4LP, UK. .,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK. .,The NIHR Newcastle Biomedical Research Centre, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK.
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Newton JL, Frith J. The efficacy of nonpharmacologic intervention for orthostatic hypotension associated with aging. Neurology 2018; 91:e652-e656. [PMID: 30006412 PMCID: PMC6105042 DOI: 10.1212/wnl.0000000000005994] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 05/11/2018] [Indexed: 11/15/2022] Open
Abstract
Objective To determine the efficacy and safety of nonpharmacologic interventions for orthostatic hypotension (OH) secondary to aging. Methods A total of 150 orthostatic challenges were performed in 25 older people (age 60–92 years) to determine cardiovascular responses to bolus water drinking, compression stockings, abdominal compression, and physical countermaneuvers. Primary outcome was response rate as assessed by proportion of participants whose systolic blood pressure (SBP) drop improved by ≥10 mm Hg. Results The response rate to bolus water drinking was 56% (95% confidence interval [CI] 36.7–74.2), with standing SBP increasing by 12 mm Hg (95% CI 4–20). Physical countermaneuvers were efficacious in 44% (95% CI 25.8–63.3) but had little effect on standing SBP (+7.5 mm Hg [95% CI −1 to 16]). Abdominal compression was efficacious in 52% (95% CI 32.9–70.7) and improved standing SBP (+10 mm Hg [95% CI 2–18]). Compression stockings were the least efficacious therapy (32% [95% CI 16.1–51.4]) and had little effect on standing SBP (+6 mm Hg [95% CI −1, 13]). No intervention improved symptoms during standing. There were no adverse events. Conclusions Bolus water drinking should become the standard first-line nonpharmacologic intervention, whereas compression stockings should be disregarded in this population. Classification of evidence This study provides Class III evidence that for older people with OH, bolus water drinking is superior to other nonpharmacologic interventions in decreasing SBP drop.
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Affiliation(s)
- Julia L Newton
- From the Institute of Cellular Medicine (J.L.N.), Newcastle University; Falls and Syncope Service (J.L.N., J.F.), Newcastle Upon Tyne Hospitals NHS Foundation Trust; and NIHR Newcastle Biomedical Research Centre (J.F.), Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, UK
| | - James Frith
- From the Institute of Cellular Medicine (J.L.N.), Newcastle University; Falls and Syncope Service (J.L.N., J.F.), Newcastle Upon Tyne Hospitals NHS Foundation Trust; and NIHR Newcastle Biomedical Research Centre (J.F.), Newcastle Upon Tyne Hospitals NHS Trust and Newcastle University, UK.
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Menant JC, Migliaccio AA, Sturnieks DL, Hicks C, Lo J, Ratanapongleka M, Turner J, Delbaere K, Titov N, Meinrath D, McVeigh C, Close JCT, Lord SR. Reducing the burden of dizziness in middle-aged and older people: A multifactorial, tailored, single-blind randomized controlled trial. PLoS Med 2018; 15:e1002620. [PMID: 30040818 PMCID: PMC6057644 DOI: 10.1371/journal.pmed.1002620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Accepted: 06/21/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dizziness is common among older people and is associated with a cascade of debilitating symptoms, such as reduced quality of life, depression, and falls. The multifactorial aetiology of dizziness is a major barrier to establishing a clear diagnosis and offering effective therapeutic interventions. Only a few multidisciplinary interventions of dizziness have been conducted to date, all of a pilot nature and none tailoring the intervention to the specific causes of dizziness. Here, we aimed to test the hypothesis that a multidisciplinary dizziness assessment followed by a tailored multifaceted intervention would reduce dizziness handicap and self-reported dizziness as well as enhance balance and gait in people aged 50 years and over with dizziness symptoms. METHODS AND FINDINGS We conducted a 6-month, single-blind, parallel-group randomized controlled trial in community-living people aged 50 years and over who reported dizziness in the past year. We excluded individuals currently receiving treatment for their dizziness, those with degenerative neurological conditions including cognitive impairment, those unable to walk 20 meters, and those identified at baseline assessment with conditions that required urgent treatment. Our team of geriatrician, vestibular neuroscientist, psychologist, exercise physiologist, study coordinator, and baseline assessor held case conferences fortnightly to discuss and recommend appropriate therapy (or therapies) for each participant, based on their multidisciplinary baseline assessments. A total of 305 men and women aged 50 to 92 years (mean [SD] age: 67.8 [8.3] years; 62% women) were randomly assigned to either usual care (control; n = 151) or to a tailored, multifaceted intervention (n = 154) comprising one or more of the following: a physiotherapist-led vestibular rehabilitation programme (35% [n = 54]), an 8-week internet-based cognitive-behavioural therapy (CBT) (19% [n = 29]), a 6-month Otago home-based exercise programme (24% [n = 37]), and/or medical management (40% [n = 62]). We were unable to identify a cause of dizziness in 71 participants (23% of total sample). Primary outcome measures comprised dizziness burden measured with the Dizziness Handicap Inventory (DHI) score, frequency of dizziness episodes recorded with monthly calendars over the 6-month follow-up, choice-stepping reaction time (CSRT), and gait variability. Data from 274 participants (90%; 137 per group) were included in the intention-to-treat analysis. At trial completion, the DHI scores in the intervention group (pre and post mean [SD]: 25.9 [19.2] and 20.4 [17.7], respectively) were significantly reduced compared with the control group (pre and post mean [SD]: 23.0 [15.8] and 21.8 [16.4]), when controlling for baseline scores (mean [95% CI] difference between groups [baseline adjusted]: -3.7 [-6.2 to -1.2]; p = 0.003). There were no significant between-group differences in dizziness episodes (relative risk [RR] [95% CI]: 0.87 [0.65 to 1.17]; p = 0.360), CSRT performance (mean [95% CI] difference between groups [baseline adjusted]: -15 [-40 to 10]; p = 0.246), and step-time variability during gait (mean [95% CI] difference between groups [baseline adjusted]: -0.001 [-0.002 to 0.001]; p = 0.497). No serious intervention-related adverse events occurred. Study limitations included the low initial dizziness severity of the participants and the only fair uptake of the falls clinic (medical management) and the CBT interventions. CONCLUSIONS A multifactorial tailored approach for treating dizziness was effective in reducing dizziness handicap in community-living people aged 50 years and older. No difference was seen on the other primary outcomes. Our findings therefore support the implementation of individualized, multifaceted evidence-based therapies to reduce self-perceived disability associated with dizziness in middle-aged and older people. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612000379819.
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Affiliation(s)
- Jasmine C. Menant
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Americo A. Migliaccio
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- Graduate School of Biomedical Engineering, University of New South Wales, Sydney, New South Wales, Australia
| | - Daina L. Sturnieks
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Cameron Hicks
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Joanne Lo
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | | | - Jessica Turner
- Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Kim Delbaere
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Nickolai Titov
- Department of Psychology, Macquarie University, Sydney, New South Wales, Australia
| | - Daniela Meinrath
- Department of Physiotherapy, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Catherine McVeigh
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Jacqueline C. T. Close
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Stephen R. Lord
- Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Public Health and Community Medicine, University of New South Wales, Sydney, New South Wales, Australia
- * E-mail:
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Rapidi CA, Tederko P, Moslavac S, Popa D, Branco CA, Kiekens C, Varela Donoso E, Christodoulou N. Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section). Eur J Phys Rehabil Med 2018; 54:797-807. [PMID: 29952157 DOI: 10.23736/s1973-9087.18.05374-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions. EVIDENCE ACQUISITION A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section. EVIDENCE SYNTHESIS The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure. CONCLUSIONS The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.
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Affiliation(s)
| | - Piotr Tederko
- Department of Rehabilitation, Medical University of Warsaw, Warsaw, Poland
| | - Sasa Moslavac
- Department of Physical and Rehabilitation Medicine, Special Hospital for Medical Rehabilitation, Varaždinske Toplice, Croatia
| | - Daiana Popa
- Clinical Rehabilitation Hospital Felix-Spa Bihor County, Oradea, Romania
| | - Catarina A Branco
- Department of Physical and Rehabilitation Medicine, Centro Hospitalar de Entre o Douro e Vouga E.P.E, Porto, Portugal
| | - Carlotte Kiekens
- Department of Physical and Rehabilitation Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Enrique Varela Donoso
- Physical and Rehabilitation Medicine Department, Complutense University School of Medicine, Madrid, Spain
| | - Nicolas Christodoulou
- Medical School, European University Cyprus, Nicosia, Cyprus.,UEMS PRM Section, Brussels, Belgium
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Aslan SC, Legg Ditterline BE, Park MC, Angeli CA, Rejc E, Chen Y, Ovechkin AV, Krassioukov A, Harkema SJ. Epidural Spinal Cord Stimulation of Lumbosacral Networks Modulates Arterial Blood Pressure in Individuals With Spinal Cord Injury-Induced Cardiovascular Deficits. Front Physiol 2018; 9:565. [PMID: 29867586 PMCID: PMC5968099 DOI: 10.3389/fphys.2018.00565] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 04/30/2018] [Indexed: 12/23/2022] Open
Abstract
Disruption of motor and autonomic pathways induced by spinal cord injury (SCI) often leads to persistent low arterial blood pressure and orthostatic intolerance. Spinal cord epidural stimulation (scES) has been shown to enable independent standing and voluntary movement in individuals with clinically motor complete SCI. In this study, we addressed whether scES configured to activate motor lumbosacral networks can also modulate arterial blood pressure by assessing continuous, beat-by-beat blood pressure and lower extremity electromyography during supine and standing in seven individuals with C5-T4 SCI. In three research participants with arterial hypotension, orthostatic intolerance, and low levels of circulating catecholamines (group 1), scES applied while supine and standing resulted in increased arterial blood pressure. In four research participants without evidence of arterial hypotension or orthostatic intolerance and normative circulating catecholamines (group 2), scES did not induce significant increases in arterial blood pressure. During scES, there were no significant differences in electromyographic (EMG) activity between group 1 and group 2. In group 1, during standing assisted by scES, blood pressure was maintained at 119/72 ± 7/14 mmHg (mean ± SD) compared with 70/45 ± 5/7 mmHg without scES. In group 2 there were no arterial blood pressure changes during standing with or without scES. These findings demonstrate that scES configured to facilitate motor function can acutely increase arterial blood pressure in individuals with SCI-induced cardiovascular deficits.
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Affiliation(s)
- Sevda C Aslan
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Bonnie E Legg Ditterline
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Michael C Park
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Department of Neurosurgery and Neurology, University of Minnesota School of Medicine, Minneapolis, MN, United States
| | - Claudia A Angeli
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Frazier Rehab Institute, Louisville, KY, United States
| | - Enrico Rejc
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Yangsheng Chen
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Alexander V Ovechkin
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States
| | - Andrei Krassioukov
- Experimental Medicine Program, University of British Columbia, Vancouver, BC, Canada.,International Collaboration on Repair Discoveries, Division of Physical Medicine and Rehabilitation, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.,GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, BC, Canada
| | - Susan J Harkema
- Department of Neurological Surgery, University of Louisville, Louisville, KY, United States.,Kentucky Spinal Cord Injury Research Center, University of Louisville, Louisville, KY, United States.,Frazier Rehab Institute, Louisville, KY, United States
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Gradalski T. Diuretics Combined With Compression in Resistant Limb Edema of Advanced Disease-A Case Series Report. J Pain Symptom Manage 2018; 55:1179-1183. [PMID: 29288880 DOI: 10.1016/j.jpainsymman.2017.12.481] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 12/15/2017] [Accepted: 12/18/2017] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The extremity edema of advanced disease is a common, multifactorial feature, which impairs patients' activities and quality of life. The most frequently chosen management is based on combined decongestive physiotherapy or pharmacotherapy (with diuretics or steroids). Subcutaneous lymphatic drainage in refractory edema may decrease the swelling, prevent spontaneous lymphorrhea, but also increase the risk of infection. Safe and effective conservative management in diuretics-resistant edemas is lacking. The objective of this prospective, observational study was to assess the effectiveness and tolerability of combined physiotherapeutic and diuretic therapy in edemas refractory to parenteral diuretics. METHODS A group of 19 patients with advanced disease and severe bilateral leg edema resistant to parenteral diuretic therapy were treated for three days with a combination of multilayer short-stretch compression bandaging and furosemide in hypersaline intravenous infusion. RESULTS A clinically meaningful decrease in mean limb volume (of 1.52 L; 20.6%; P < 0.0001)-strongly correlating with patients' weight loss (ρ = 0.71; P = 0.0001), with a lowering of the intensity of complaints-was achieved. The treatment was well tolerated, without decreasing the performance status in any patient. Stable levels of blood pressure, laboratory kidney profile (potassium, sodium, creatinine clearance), and serum albumin were observed. Maintenance of the achieved results with a good compliance was seen during an informal follow-up at the hospice. CONCLUSION The combination of compression therapy with hypersaline diuretics could be considered as a valuable option for refractory cases of limb edema in advanced disease.
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Legg Ditterline BE, Aslan SC, Randall DC, Harkema SJ, Castillo C, Ovechkin AV. Effects of Respiratory Training on Heart Rate Variability and Baroreflex Sensitivity in Individuals With Chronic Spinal Cord Injury. Arch Phys Med Rehabil 2017; 99:423-432. [PMID: 28802811 DOI: 10.1016/j.apmr.2017.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 06/13/2017] [Accepted: 06/27/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To evaluate the effects of pressure threshold respiratory training (RT) on heart rate variability and baroreflex sensitivity in persons with chronic spinal cord injury (SCI). DESIGN Before-after intervention case-controlled clinical study. SETTING SCI research center and outpatient rehabilitation unit. PARTICIPANTS Participants (N=44) consisted of persons with chronic SCI ranging from C2 to T11 who participated in RT (n=24), and untrained control subjects with chronic SCI ranging from C2 to T9 (n=20). INTERVENTIONS A total of 21±2 RT sessions performed 5 days a week during a 4-week period using a combination of pressure threshold inspiratory and expiratory devices. MAIN OUTCOME MEASURES Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and beat-to-beat arterial blood pressure and heart rate changes during the 5-second-long maximum expiratory pressure maneuver (5s MEP) and the sit-up orthostatic stress test, acquired before and after the RT program. RESULTS In contrast to the untrained controls, individuals in the RT group experienced significantly increased FVC and FEV1 (both P<.01) in association with improved quality of sleep, cough, and speech. Sympathetically (phase II) and parasympathetically (phase IV) mediated baroreflex sensitivity both significantly (P<.05) increased during the 5s MEP. During the orthostatic stress test, improved autonomic control over heart rate was associated with significantly increased sympathetic and parasympathetic modulation (low- and high-frequency change: P<.01 and P<.05, respectively). CONCLUSIONS Inspiratory-expiratory pressure threshold RT is a promising technique to positively affect both respiratory and cardiovascular dysregulation observed in persons with chronic SCI.
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Affiliation(s)
- Bonnie E Legg Ditterline
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Sevda C Aslan
- Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - David C Randall
- Department of Physiology, University of Kentucky, Lexington, KY
| | - Susan J Harkema
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Camilo Castillo
- Department of Neurological Surgery, University of Louisville, Louisville, KY
| | - Alexander V Ovechkin
- Department of Physiology, University of Louisville, Louisville, KY; Department of Neurological Surgery, University of Louisville, Louisville, KY.
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Chan AK, Finlayson H, Mills PB. Does the method of botulinum neurotoxin injection for limb spasticity affect outcomes? A systematic review. Clin Rehabil 2017; 31:713-721. [PMID: 27370102 DOI: 10.1177/0269215516655589] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
OBJECTIVE To systematically review randomized controlled trials of botulinum neurotoxin for limb spasticity to determine whether different injection techniques affect spasticity outcomes. METHODS MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials electronic databases were searched for English language human randomized controlled trials from 1990 to 13 May 2016. Studies were assessed in duplicate for data extraction and risk of bias using the Physiotherapy Evidence Database scale and graded according to Sackett's levels of evidence. RESULTS Nine of 347 studies screened met selection criteria. Four categories of botulinum neurotoxin injection techniques were identified: (1) injection localization technique; (2) injection site selection; (3) injectate volume; (4) injection volume and site selection. There is level 1 evidence that: ultrasound, electromyography, and electrostimulation are superior to manual needle placement; endplate injections improve outcomes vs. multisite quadrant injections; motor point injections are equivalent to multisite injections; high volume injections are similar to low volume injections; and high volume injections distant from the endplate are more efficacious than low volumes closer to the endplate. CONCLUSION Level 1 evidence exists for differences in treatment outcomes using specific botulinum neurotoxin injection techniques. Findings are based on single studies that require independent replication and further study.
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Affiliation(s)
- Aaron K Chan
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
| | - Heather Finlayson
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
- 3 Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Patricia B Mills
- 1 Department of Medicine, Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, Canada
- 2 G.F. Strong Rehabilitation Centre, Vancouver, Canada
- 3 Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
- 4 ICORD (International Collaboration on Repair Discoveries), Vancouver, Canada
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Logan A, Marsden J, Freeman J, Kent B. Effectiveness of non-pharmacological interventions in treating orthostatic hypotension in the elderly and people with a neurological condition: a systematic review protocol. ACTA ACUST UNITED AC 2017; 15:948-960. [DOI: 10.11124/jbisrir-2016-003027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Abstract
Background orthostatic hypotension (OH) is a common disabling condition associated with increased morbidity and mortality. Much of the evidence available is derived from younger populations with chronic neurological disease leading to uncertainty for the diagnosis and management of older people. Objective to provide an overview of recent and emerging evidence for the diagnosis, management and prognosis of OH in older persons. Methods a narrative review of recent studies, emerging therapies and relevant regulatory updates. Findings revisions to the diagnostic criteria for OH include the duration of the blood pressure drop, specific criteria for initial and delayed OH and OH with hypertension. Non-drug therapies remain the first-line treatment option and Comprehensive Geriatric Assessment appears to result in lower rates of OH. Recent evidence concerning withdrawal of causative medication is inconsistent. Midodrine has recently become the only licenced medication for OH in the UK. Other emerging treatments include atomoxetine and droxidopa but these require further evaluation. Many other agents may be used but are not supported by high-quality evidence. The increase in mortality associated with OH is less apparent in older people. Summary OH remains common in older people, the new diagnostic criteria address some of the previous uncertainty but evidence concerning withdrawal of antihypertensives is conflicting. Midodrine is now the only licenced medication for OH in the UK, but non-drug therapies remain first line and fludrocortisone may be considered before midodrine. We may see other agents such as droxidopa becoming increasingly used over the coming years.
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Affiliation(s)
- James Frith
- Newcastle University-Institute of Cellular Medicine, Newcastle upon Tyne NE1 7RU, United Kingdom of Great Britain and Northern Ireland
- The Newcastle upon Tyne Hospitals NHS Foundation Trust-Falls and Syncope Service, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
| | - Steve W Parry
- Newcastle University-Institute of Cellular Medicine, Newcastle upon Tyne NE1 7RU, United Kingdom of Great Britain and Northern Ireland
- The Newcastle upon Tyne Hospitals NHS Foundation Trust-Falls and Syncope Service, Newcastle upon Tyne, United Kingdom of Great Britain and Northern Ireland
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Lozano T, Ena J. Cardiovascular autonomic neuropathy in patients with diabetes mellitus. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Velilla-Zancada SM, Prieto-Díaz MA, Escobar-Cervantes C, Manzano-Espinosa L. [Orthostatic hypotension; that great unknown]. Semergen 2016; 43:501-510. [PMID: 27865581 DOI: 10.1016/j.semerg.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 09/14/2016] [Accepted: 09/20/2016] [Indexed: 12/01/2022]
Abstract
Orthostatic hypotension is an anomaly of growing interest in scientific research. Although certain neurogenic diseases are associated with this phenomenon, it can also be associated with non-neurological causes. Although orthostatic hypotension is defined by consensus as a decrease in the systolic blood pressure of at least 20mmHg, or a decrease in diastolic blood pressure of at least 10mmHg, within 3min of standing, the studies differ on how to diagnose it. Orthostatic hypotension is associated with certain cardiovascular risk factors and with drug treatment, but the results are contradictory. The purpose of this review is to update the knowledge about orthostatic hypotension and its treatment, as well as to propose a method to standardise its diagnosis.
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Affiliation(s)
- S M Velilla-Zancada
- Centro de Salud Espartero, Logroño, La Rioja, España; Grupo de trabajo de Hipertensión Arterial y Enfermedad Cardiovascular de SEMERGEN, España.
| | - M A Prieto-Díaz
- Grupo de trabajo de Hipertensión Arterial y Enfermedad Cardiovascular de SEMERGEN, España; Centro de Salud Vallobín-La Florida, Oviedo, Asturias, España
| | - C Escobar-Cervantes
- Grupo de trabajo de Hipertensión Arterial y Enfermedad Cardiovascular de SEMERGEN, España; Departamento de Cardiología, Hospital La Paz, Madrid, España
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Gutkin M, Stewart JM. Orthostatic Circulatory Disorders: From Nosology to Nuts and Bolts. Am J Hypertens 2016; 29:1009-19. [PMID: 27037712 PMCID: PMC4978226 DOI: 10.1093/ajh/hpw023] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 11/27/2015] [Accepted: 02/12/2016] [Indexed: 12/17/2022] Open
Abstract
When patients complain of altered consciousness or discomfort in the upright posture, either relieved by recumbency or culminating in syncope, physicians may find themselves baffled. There is a wide variety of disorders that cause abnormal regulation of blood pressure and pulse rate in the upright posture. The aim of this focused review is 3-fold. First, to offer a classification (nosology) of these disorders; second, to illuminate the mechanisms that underlie them; and third, to assist the physician in the practical aspects of diagnosis of adult orthostatic hypotension, by extending clinical skills with readily available office technology.
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Affiliation(s)
- Michael Gutkin
- Hypertension Section, Saint Barnabas Medical Center, Livingston, New Jersey, USA;
| | - Julian M Stewart
- Center for Hypotension, New York Medical College, Valhalla, New Jersey, USA
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Cardiovascular autonomic neuropathy in patients with diabetes mellitus. Rev Clin Esp 2016; 217:46-54. [PMID: 27544842 DOI: 10.1016/j.rce.2016.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/28/2016] [Accepted: 07/18/2016] [Indexed: 01/13/2023]
Abstract
Cardiovascular autonomic neuropathy associated with diabetes mellitus is caused by an impairment of the autonomic system. The prevalence of this condition ranges from 20% to 65%, depending on the duration of the diabetes mellitus. Clinically, the autonomic function disorder is associated with resting tachycardia, exercise intolerance, orthostatic hypotension, intraoperative cardiovascular instability, silent myocardial ischemia and increased mortality. For the diagnosis, the integrity of the parasympathetic and sympathetic nervous system is assessed. Parasympathetic activity is examined by measuring heart rate variability in response to deep breathing, standing and the Valsalva manoeuvre. Sympathetic integrity is examined by measuring blood pressure in response to standing and isometric exercise. The treatment includes the metabolic control of diabetes mellitus and of the cardiovascular risk factors. Treating symptoms such as orthostatic hypotension requires special attention.
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Menant JC, Wong AKW, Trollor JN, Close JCT, Lord SR. Depressive Symptoms and Orthostatic Hypotension Are Risk Factors for Unexplained Falls in Community-Living Older People. J Am Geriatr Soc 2016; 64:1073-8. [DOI: 10.1111/jgs.14104] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 09/03/2015] [Accepted: 09/05/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Jasmine C. Menant
- Neuroscience Research Australia; University of New South Wales; Sydney Australia
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
| | - Alfred K. W. Wong
- Neuroscience Research Australia; University of New South Wales; Sydney Australia
| | - Julian N. Trollor
- Department of Developmental Disability Neuropsychiatry; University of New South Wales; Sydney Australia
- Centre for Healthy Brain Ageing; School of Psychiatry; University of New South Wales; Sydney Australia
| | - Jacqueline C. T. Close
- Neuroscience Research Australia; University of New South Wales; Sydney Australia
- Prince of Wales Clinical School; University of New South Wales; Sydney Australia
| | - Stephen R. Lord
- Neuroscience Research Australia; University of New South Wales; Sydney Australia
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
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Transcutaneous Electrical Nerve Stimulation for Management of Limb Spasticity. Am J Phys Med Rehabil 2016; 95:309-18. [DOI: 10.1097/phm.0000000000000437] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Krypciak S, Liuu E, Minard A, Obraztsova A, Paillaud E. [Orthostatic hypotension in elderly: a case-control study]. SOINS. GERONTOLOGIE 2016; 21:37-43. [PMID: 26805647 DOI: 10.1016/j.sger.2015.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Orthostatic hypotension is common in the elderly and is often associated with increased morbidity and mortality. Compression bandages are recommended as a first-line treatment but there is little evidence of their efficacy in literature. A case-control study involving 52 patients was carried out to test the efficacy of the bandages. In the group with orthostatic hypotension, compression improved the symptoms without correcting the blood pressure readings.
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Affiliation(s)
- Sébastien Krypciak
- Département de médecine interne et de gériatrie, université Paris Est-Créteil, groupe hospitalier Henri-Mondor, AP-HP, 51 avenue du Maréchal-de-Lattre de Tassigny, 94010 Créteil, France.
| | - Evelyne Liuu
- Département de médecine interne et de gériatrie, université Paris Est-Créteil, groupe hospitalier Henri-Mondor, AP-HP, 51 avenue du Maréchal-de-Lattre de Tassigny, 94010 Créteil, France
| | - Aurélien Minard
- Département de médecine interne et de gériatrie, université Paris Est-Créteil, groupe hospitalier Henri-Mondor, AP-HP, 51 avenue du Maréchal-de-Lattre de Tassigny, 94010 Créteil, France; Service de gériatrie, groupe hospitalier Paris Saint-Joseph, 185 rue Raymond-Losserand, 75014 Paris, France
| | - Anastasia Obraztsova
- Département de médecine interne et de gériatrie, université Paris Est-Créteil, groupe hospitalier Henri-Mondor, AP-HP, 51 avenue du Maréchal-de-Lattre de Tassigny, 94010 Créteil, France
| | - Elena Paillaud
- Département de médecine interne et de gériatrie, université Paris Est-Créteil, groupe hospitalier Henri-Mondor, AP-HP, 51 avenue du Maréchal-de-Lattre de Tassigny, 94010 Créteil, France
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Currie KD, Krassioukov AV. A walking disaster: a case of incomplete spinal cord injury with symptomatic orthostatic hypotension. Clin Auton Res 2015; 25:335-7. [DOI: 10.1007/s10286-015-0309-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 07/14/2015] [Indexed: 10/23/2022]
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