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

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

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

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

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

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

Space flight rehabilitation

The weightless environment of space imposes specific physiologic adaptations on healthy astronauts. On return to Earth, these adaptations manifest as physical impairments that necessitate a period of rehabilitation. Physiologic changes result from unloading in microgravity and highly correlate with those seen in relatively immobile terrestrial patient populations such as spinal cord, geriatric, or deconditioned bed-rest patients. Major postflight impairments requiring rehabilitation intervention include orthostatic intolerance, bone demineralization, muscular atrophy, and neurovestibular symptoms. Space agencies are preparing for extended-duration missions, including colonization of the moon and interplanetary exploration of Mars. These longer-duration flights will result in more severe and more prolonged disability, potentially beyond the point of safe return to Earth. This paper will review and discuss existing space rehabilitation plans for major postflight impairments. Evidence-based rehabilitation interventions are imperative not only to facilitate return to Earth but also to extend the safe duration of exposure to a physiologically hostile microgravity environment.

Effect of physical countermaneuvers on orthostatic hypotension in familial dysautonomia

Familial dysautonomia (FD) patients frequently experience debilitating orthostatic hypotension. Since physical countermaneuvers can increase blood pressure (BP) in other groups of patients with orthostatic hypotension, we evaluated the effectiveness of countermaneuvers in FD patients. In 17 FD patients (26.4 +/- 12.4 years, eight female), we monitored heart rate (HR), blood pressure (BP), cardiac output (CO), total peripheral resistance (TPR) and calf volume while supine, during standing and during application of four countermaneuvers: bending forward, squatting, leg crossing, and abdominal compression using an inflatable belt. Countermaneuvers were initiated after standing up,when systolic BP had fallen by 40mmHg or diastolic BP by 30mmHg or presyncope had occurred. During active standing, blood pressure and TPR decreased, calf volume increased but CO remained stable. Mean BP increased significantly during bending forward (by 20.0 (17 - 28.5) mmHg; P = 0.005) (median (25(th) - 75(th) quartile)), squatting (by 50.8 (33.5 - 56) mmHg; P = 0.002), and abdominal compression (by 5.8 (-1 - 34.7) mmHg; P = 0.04) - but not during leg-crossing. Squatting and abdominal compression also induced a significant increase in CO (by 18.1 (-1.3 - 47.9) % during squatting (P = 0.02) and by 7.6 (0.4 - 19.6) % during abdominal compression (P=0.014)). HR did not change significantly during the countermaneuvers. TPR increased significantly only during squatting (by 37.2 (11.8 - 48.2) %; P = 0.01). However, orthopedic problems or ataxia prevented several patients from performing some of the countermaneuvers. Additionally, many patients required assistance with the maneuvers. Squatting, bending forward and abdominal compression can improve orthostatic BP in FD patients, which is achieved mainly by an increased cardiac output. Squatting has the greatest effect on orthostatic blood pressure in FD patients. Suitability and effectiveness of a specific countermaneuver depends on the orthopedic or neurological complications of each FD patient and must be individually tested before a therapeutic recommendation can be given.

Effects of orthostatic self-training on head-up tilt testing for the prevention of tilt-induced neurocardiogenic syncope: comparison of pharmacological therapy

Although a wide variety of medical treatments for neurocardiogenic syncope have been proposed, therapy has largely been emperic based on the mechanisms commonly believed to lead to neurocardiogenic fainting. To determine the utility and efficacy of drug therapy and an orthostatic self-training program in the prevention of tilt-induced neurocardiogenic syncope, we investigated 43 consecutive patients who had shown syncope and were induced by head-up tilt test reproducibly, with either traditional medical treatments or orthostatic self-training at home. The initial 19 of 43 patients were treated with either oral propranolol or disopyramide therapies. The remaining 24 patients were treated with an orthostatic self-training program alone. Effects of these therapies on head-up tilt test were reevaluated in all patients. Propranolol prevented syncope in only six (32%) and disopyramide in five (26%) of the 19 patients. There was no significant difference in the effectiveness between them. Syncope was prevented in nine (47%) patients with either propanolol or disopyramide therapy alone, while in the remaining 10 patients it was not. On the other hand, orthostatic self-training program prevented syncope in 22 (92%) of 24 patients. We concluded that orthostatic self-training program is far more effective than traditional drug therapies. Orthostatic self-training is an effective, safe and well accepted therapy in the prevention of tilt-induced neurocardiogenic syncope.

Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury

The purpose of the study was to evaluate the cardiovascular responses of functional neuromuscular stimulation (FNS) on postural-related orthostatic stress in individuals with acute spinal cord injury. Two tetraplegics and three paraplegics participated in this study. A repeated measure design was used in which subjects underwent two graded-tilt table (0 degrees, 15 degrees, 30 degrees, 45 degrees, 60 degrees) orthostatic stress tests with and without FNS (randomized treatment order) of the knee extensors and foot plantar flexors. Successive one-minute digital readings of heart rate (HR) and blood pressure were obtained with an electronic pulse oximeter and automated blood pressure monitor, respectively. Analysis of covariance (ANCOVA) revealed significant test position (tilt angle) and treatment condition (with or without FNS) main effects, but no significant interactions. Between-treatment pairwise contrasts showed that systolic blood pressure was lower without FNS for 15 degrees, 30 degrees, 45 degrees g, and 60 degrees of tilt, while diastolic blood pressure was lower without FNS at 30 degrees and 45 degrees of tilt. In contrast, HR showed a progressive rise with increasing tilt angle. Functional neuromuscular stimulation may be an important treatment adjunct to minimize cardiovascular changes during postural orthostatic stress in individuals with acute spinal cord injury.

[Effect of antiorthostatic pre-training on transcapillary turnover of fluids in extra- and intracranial vessels of rats in antiorthostatic hypokinesia]

Dynamics of the transcapillary turnover of liquids in the brain and soft tissues of the head was studied in pre-trained small laboratory animals (rats) during antiorthostasis, and their controls. Training for antiorthostasis consisted of tail-suspension for 2 hours in the period of two weeks. The transcapillary turnover of liquids was determined based on the arteriovenous difference in blood density (AVBD). Blood density was measured with the equipment of Anton Paar K.G. (Austria). Rats in the horizontal position did not exhibit any apparent trend in the dynamics of blood transcapillary turnover. Blood drain from the interstitial space at the time of return of the antiorthostatic rats into the horizontal position was dependent on the length of antiorthostatis. Beginning from the fifth hour of tail suspension, changed AVBD sign was an indication of edema of the muzzle soft tissue. This phenomenon was not observed in the pre-trained rats. Similar results were obtained in the investigation of cerebral vessels AVBD. Hence, changes in the transcapillary turnover of liquids in cranium during antiorthostatic hypokinesia point to the dominance of liquid filtration into the extravascular space. Antiorthostatic pre-training precludes liquid deposition in the interstitial space of the brain and the cerebral soft tissue.

Effect of strength training on orthostatic hypotension in older adults

PURPOSE

This preliminary study attempted to identify the frequency of orthostatic hypotension (OH) in community dwelling older adults who volunteered to participate in an 8-week, heavy-resistance, strength-training program. It also assessed the effect of the strength-training program on OH.

METHODS

From a larger study (n = 53) on high-resistance strength training in older adults (mean age 71.4 +/- 6.6 years), a subset of subjects (n = 24), mean age 71.0 +/- 5.8 years, was evaluated who met at least one criterion for OH. All subjects were tested for resting blood pressures (BP) and heart rates (HR) in the supine, sitting, and standing positions. Also noted was their response to orthostatism in rising from a cot after 10 minutes and rising from a chair after 5 minutes. The subset was not different from the overall group in gender ratio, age, or effect of medication on BP. The treatment was an 8-week strength-training program at 80% of their one repetition maximum.

RESULTS

Significant changes (P < 0.05) were shown in supine diastolic BP (+3.2 mm Hg), sitting systolic BP (-3.9), and standing HR (+4.9 beats per minute). In response to the orthostatic challenge, significant (P < 0.05) improvements were shown in systolic BP (+9.7 mm Hg), diastolic BP (+4.7), and HR (+3.2 beats per minute) for the rise from chair, and in diastolic BP (+6.7 mm Hg) rise from the cot.

CONCLUSIONS

These data show that OH is not uncommon (45%) in community dwelling older adults. A strength training program in older adults has little effect on resting BP, but elicits a positive adaptation to an orthostatic challenge.

Treating postural hypotension

Postural hypotension (PH) is a relatively common condition that particularly affects older people. As a symptom it is associated with a variety of conditions and may be a transient or long-term feature, depending on the underlying cause. This article aims to raise awareness of the condition and give practical advice for its treatment.

Tilt training: a new treatment for recurrent neurocardiogenic syncope and severe orthostatic intolerance

Medical treatment of neurocardiogenic syncope is insufficient in many cases. We have observed a therapeutic effect of repeated head-up tilt testing. Therefore, we have started a program of tilt training for heavily symptomatic patients. After hospital admission, they were tilted daily (60 degrees inclination) until syncope, or until a duration of 45-90 minutes (90 sessions in 13 patients). The mean tilt tolerance, at the first diagnostic head-up tilt table test, was 22.3 minutes (st. dev. 10.9). Before hospital discharge, 12/13 patients could sustain the full duration of tilt table testing without any symptom. In one patient syncope persisted. The patients were instructed to continue a program of daily tilt training at home, by standing against a wall for 30 minutes, one or two times per day. This resulted in a complete disappearance of syncope in all 13 patients. Orthostatic intolerance and the excessive autonomic reflex activity of neurocardiogenic syncope can be remedied by a program of continued tilt training, without the administration of drugs.

Orthostatic hypotension in spinal cord injured patients

Treatment of orthostatic hypotension is an important consideration for many patients with spinal cord injuries, especially those with an injury to the cervical cord. Delay in attainment of an upright sitting posture can cause a delay in the completion of rehabilitation. Although most trials of medications used in the treatment of orthostatic hypotension have been performed on non-spinal cord injured patients, this paper provides a review of both pharmacological and non-pharmacologic means of therapy. Normally, regulation of mean arterial pressure occurs through several different mechanisms; long-term control is via the renal system and short-term control is via the nervous system. These mechanisms will be discussed, as well as causes of orthostatic hypotension in spinal cord injured patients, and the normalization of blood pressure control which generally occurs to some degree following a spinal cord injury.

Awareness of blood pressure: interoception or contextual judgement?

Most patients with mild to moderate hypertension are asymptomatic but some patients report symptoms and seem to be aware of their blood pressure. The research question is whether the estimation of blood pressure is primarily derived from interoception or is inferred by contextual judgement. A psychophysiological ambulatory assessment was conducted with 51 male hypertensive patients and 30 either normotensive or hypotensive student subjects employing (1) a multichannel recording system for blood pressure, heart rate and physical activity; and (2) a pocket computer for assessing estimated BP, setting variables and self-ratings of subjective state. Within-subject correlations revealed that there was no significant relationship between estimated BP and concurrently recorded systolic BP. Estimated BP is, however, related to self-ratings of feeling physically tense and self-ratings of physical activity. Blood pressure awareness appears to be a rather inconsistent and subjective phenomenon, based on contextual judgements and inferences instead of "perception", but it is a relevant methodological issue (and possible bias) in hypertension research.

[Physical therapy in cardiology]

With different part the physiotherapy is of importance in the general therapy plan of the patient with heart disease. In long-term preventive and therapy programmes, respectively, of the coronary heart disease as well as of the essential arterial hypertension physiotherapy is a real alternative or a complementary element to pharmacotherapy. In the hospital therapy means of physiotherapy often form the basis for nursing. The further spreading of functional cardio-circulatory syndromes and the burdening of the outpatient medical sector connected with this as well as a consumption of medicaments more and more characterized by polypragmasia demands an increased application of effective means of physiotherapy. Apart from this in social-medical respect important task in future the long-term care of patients with chronic coronary heart disease and essential arterial hypertension will set organisational and scientific methodological tasks to physiotherapy.

Biofeedback as an experimental treatment for postural hypotension in a patient with a spinal cord lesion

A man having severe postural hypotension resulting from a spinal cord lesion at level T3, was trained to raise and lower his blood pressure with the use of biofeedback. The procedure consisted of 11 learning sessions during which the subject's task was to effect specific changes of his blood pressure without skeletal muscle or respiratory involvement. Blood pressure was continuously monitored and reported to the subject, and positive verbal reinforcement for correct changes was also supplied. Analysis of the results revealed that the subject had learned to produce large voluntary changes in pressure. This learned ability was then applied in a standing position resulting in counteracting the postural hypotension. Suggestions for further research and implications for clinical applications are discussed.