Physiotherapy Neurological Rehabilitation

1. ORTHOSTATIC HYPOTENSION IN PATIENTS
WITH SPINAL CORD INJURY
A CASE PRESENTATION
BY
ADEYEMO. A.O BMR(PT) M.SC PT

2. DEFINITION
 Orthostatic hypotension is a physical finding defined
by the American Autonomic Society and the American
Academy of Neurology as a systolic blood pressure
decrease of at least 20 mm Hg or a diastolic blood
pressure decrease of at least 10 mm Hg within three
minutes of standing.

3. PHYSIOLOGY
 When a normal adult changes from lying to standing
position between (300-800)ml of blood pools in the
blood vessel of the trunk and legs.
 Immediate reduction in filling pressure of the right
atrium, fall in cardiac output and arterial pressure.
 The baroreceptors reflex in the aortic arch and
carotid bodies blood sensed the fall in blood pressure,
activate a vasoconstriction of vascular smooth muscle
to restore arterial pressure so that the mean arterial
blood pressure is not reduced by more than a few
mmHg when a person is standing up compared to
lying down.

4. PATHOPHYSIOLOGY
The mechanism underlying OTH:
 Cardiovascular deconditioning as a result of
prolonged bed rest
 Excessive pooling of blood in the organs and viscera
due to reduced efferent sympathetic nervous activity
and loss of reflex vasoconstrictor effect of arterial
baroreceptors caudal to the level of injury
 Lack of the counteracting muscular effects of the lower
extremities to venous pooling
 Reduced plasma volumes as a consequence of
hyponatremia

5. CAUSES
 Hypovoleamia
e.g. bleeding, diuretic, vasodilators, dehydration, prolonged bed
rest, anaemia
 Diseases
e.g. diabetes, Parkinson disease, Addison's disease,
pheochromocytoma,spinal cord injury (quadriplegic &
paraplegic)
 Medication side effects
e.g. antidepressant(such as tryclics), alpha blockers(inhibit
vasoconstriction initiated by baroreceptor reflex upon postural
change)
 other risk factor
e.g. elderly, postpartum mother, alcoholics etc.

6. SIGNS AND SYMPTOMS OF OTH
 Blurred vision,
 light-headedness,
 dizziness,
 fatigue,
 restlessness,
 and dyspnoea

7. ORTHOSTATIC HYPOTENSION & SPINAL
CORD INJURY
In addition to the motor and sensory deficit associated with
SCI, coincident autonomic nervous system impairment are
common.
 individuals with SCI face the challenges of managing the
unstable blood pressure which results in persistent hypotension
and/or episodes of uncontrolled hypertension.

8. Cases of SCI patients with orthostatic hypotension
ASCI PT WITH
OTH
AK AM PQ ST
EPISODES OF OTH
(DURING
AMBULATORY
PHASE)
4 6 5 4
PROPPING UP IN
BED
2 2 3 3
SITTING IN
WHEEL CHAIR
2 4 2 1
Out of the 9 acute SCI patients seen these 4 experienced orthostatic
hypotension

9. SCHEMATIC DIAGRAM OF AUTONOMIC
CARDIOVASCULAR CONTROL

10. CARDIOVASCULAR COMPLICATION OF SCI
 Acutely
 Bradycardia
 orthostatic hypotension
 thermoregulation difficulty
 autonomic dysreflexia
 chronically
 increased risk of coronary artery disease

11. CASE STUDY
 Name: AK
 Age: 65years
 Sex: Male
 Occupation: Trader
 Religion: Christianity
Pc: Inability to move all limbs

12. CASE STUDY cont’d

 PcHx: A case of a 65 year old involved in a MB-RTA on the 6th
of March 2011 somewhere in Ondo state. He was standing by
a road side and was hit from behind by a motor bike. There was
no history of convulsion, no craniofacial efflux from any of the
orifices although there was immediate transient LOC which was
fully regained minutes after but there was history of bleeding
from the forehead. Patient was moved from scene on the back
of a rescuer to a private hospital in the vicinity. He spent a day
at the private hospital, transferred to general hospital (Akure)
then to FMC (Owo) where he was referred to OAUTHC and
later referred to UCH. Patients was reported to be unable to
move both LL but could still move the UL at the shoulders.
However, there was associated bisphincteric incontinence.

13. CASE STUDY cont’d
 PmHx: Not a known hypertensive nor diabetic, not asthmatic, no
previous surgery but had been hospitalised before on account
of typhoid fever 28years ago
 FsHx: A 65year old man married in polygamous settings with
2 children, practise Christianity, smokes (2-4sticks/wk) and
drinks alcohol(1-4bottles/wk)
 O/e: An elderly man , met in supine lying, rigid cervical collar
insitu, afebrile , ajaundiced, acyanotic, not dehydrated and
has scar on his fore head.
 Investigations: x-ray of the c-spine shows spondylotic changes
with osteopaenia.
MRI reports spinal stenosis, multiple disc contusion
C3-C5 with Ant. and post. compression

14. CASE STUDY cont’d
 Examination:
 CNS: Conscious , alert and oriented in TPP
 Sensations: pain, light and deep touch absent
globally below the neurological level
 ReflexesREFLEXES RT LT
BICEPS Hypo Hypo
TRICEPS Hypo Hypo
KNEE JERK Hypo Hypo
CLONUS Absent Absent
BABINSKI SIGN Absent Absent

15. CASE STUDY cont’d
 Tone
 Head and neck: sutured 4cm mid-frontal scalp laceration
 Chest and abdomen: vesicular breathe sound, chest moves
with abdomen and R.R is 23cpm
 CVS: B.P- 100/70 mmHg
P.R- 80 B/min
 UGS: Associated bisphincteric incontinence (urinary
catheter in situ)
TONE (Rt) UL (Lt) UL (Rt) LL (Lt) LL
Reduced Reduced Reduced Reduced

16. CASE STUDY cont’d
 MSS:
UPPERLIMBS RT LT
SWELLINGS NIL NIL
MUSCLE BULK PRESERVED PRESERVED
PROM FULL FULL
MUSCLE STRENGTH
Shoulder abductors 1 1
Shoulder adductors 0 0
Shoulder flexors 0 0
Shoulder extensors 0 0
Elbow flexors 0 0
Elbow extensors 0 0
Wrist flexors 0 0
Wrist extensors 0 0
Grip strength 0 0

17. CASE STUDY cont’d
LOWERLIMBS RT LT
SWELLINGS Nil Nil
MUSCLE BULK Reduced Reduced
PROM Full Full
MUSCLE STRENGTH
Hip abductors 0 0
Hip adductors 0 0
Hip flexors 0 0
Hip extensors 0 0
Knee extensors 0 0
Knee flexors 0 0
Dorsiflexors 0 0
Planterflexors 0 0

18. CASE STUDY cont’d
 Analysis of findings:
- Loss of muscle power and weakness in all limbs
- Loss of sensation
 Clinical impression: C4 Traumatic Quadriplegia (Frankel
A)
 Goals
-To prevent further musculoskeletal and cardiopulmonary
complication
-To strengthening weak muscle of the extremity
-To restore patient back to function as much as possible

19. CASE STUDY cont’d
 Means
-PM and PNF techniques to the Bil. UL and LL
-Chest physiotherapy
 Rx
-PM and PNF to all joints of the UL and LL
-Chest physiotherapy(incentive spirometry)

20. INTERVENTION
After FES study (the 6th week) and patient is deemed fit
for ambulation
 Patient is instructed to tell the feeling as ambulation
progresses
 Relevant questions are asked as to determine the signs &
symptoms(Blurred vision, light-headedness, dizziness,
fatigue, restlessness, dyspnoea)
 The patient is placed back into horizontal /lying position
each time any of the signs & symptoms is reported.
 And when it occurs during wheel chair ambulation, the
wheel chair is tilted backward

21. PROGRESSION OF MANAGEMENT
TIME PERIOD(WKS) DEGREE OF BED
INCLINATION
NO OF EPISODES
1-6TH O˚
7TH 45˚(on bed) 1
8TH 6O˚(on bed) -
9TH 90˚(On bed) 1
10th 90˚ (on wheel chair) 2
11th 90˚ (on wheel chair) Tolerates wheel chair
ambulation

22. PREVENTION OF OTH
 Check vital signs
 Watch for signs and symptoms
 Timing
 Progressive ambulation
NB: The simple technique of exercising caution and
progressive changing position can allow the body to
adjust to the new position

23. MANAGEMENT OF OTH
Medical
 Drugs
e.g. Fludrocortisone and erythropoietin to aid fluid
retention and vasoconstrictors like midodrine ,
pyridostigmine bromide etc.

24. MANAGEMENT OF OTH
Physiotherapy
•Tilt Table Testing can be used to
confirm postural hypotension. Tilt
table testing involves placing a
patient on table with foot support.
The table is tilted upward and
blood pressure and pulse is
measured while symptoms are
recorded in various position.

25. MANAGEMENT OF OTH
Physiotherapy cont’d
 Progressive ambulation
 Breathing deeply and flexing the abdominal muscles
while rising helps maintain blood oxygen flow to the
brain
 Dangling
 compression stocking to aid venous return
 and physiotherapy to improve tone(active exercises
& resisted active exercises)

26. CONCLUSION
 Spinal injury is a multi- faceted clinical problem that
demands sound knowledge and skilful handling
from health care workers right from the acute
phase to the recovery phase in order to achieve
best possible outcome.

27. REFERENCES
 Cleophas TJ, Kauw FH, Bijl C, et al: Effects of beta adrenergic
receptor agonists and antagonists in diabetics with symptoms of
postural hypotension: a double-blind, placebo-controlled study.
Angiology 37:855-862, 1986
 Frisbie JH, Steele DJ: Postural hypotension and abnormalities of salt
and water metabolism in myelopathy patients. Spinal Cord 35:303-
307, 1997
 Sclater A, Alagiakrishnan K: Orthostatic hypotension. A primary care
primer for assessment and treatment. Geriatrics 59:22-27, 2004
 Illman A, Stiller K, Williams M: The prevalence of orthostatic
hypotension during physiotherapy treatment in patients with an acute
spinal cord injury. Spinal Cord 38:741-747, 2000

28. Thank you for listening