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Nonpharmacologic Management of Orthostatic Hypotension: A Systematic Review

  • Patricia Branco Mills
    Correspondence
    Corresponding author Patricia Branco Mills, MD, MHSc, FRCPC, GF Strong Rehabilitation Centre, 4255 Laurel St, Vancouver, BC V5Z 2G9, Canada.
    Affiliations
    Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada

    Department of Medicine, International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada

    GF Strong Rehabilitation Center, Vancouver, British Columbia, Canada

    Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Coastal Health, Vancouver, British Columbia, Canada
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  • Carlen K. Fung
    Affiliations
    Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada

    Department of Medicine, International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada
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  • Angelique Travlos
    Affiliations
    Faculty of Arts and Science, Queens University, Vancouver, British Columbia, Canada
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  • Andrei Krassioukov
    Affiliations
    Division of Physical Medicine and Rehabilitation, University of British Columbia, Vancouver, British Columbia, Canada

    Department of Medicine, International Collaboration on Repair Discoveries, University of British Columbia, Vancouver, British Columbia, Canada

    GF Strong Rehabilitation Center, Vancouver, British Columbia, Canada

    Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver Coastal Health, Vancouver, British Columbia, Canada
    Search for articles by this author
Published:October 13, 2014DOI:https://doi.org/10.1016/j.apmr.2014.09.028

      Abstract

      Objective

      To systematically review the literature on nonpharmacologic treatment of orthostatic hypotension.

      Data Sources

      MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane Central Register of Controlled Trials, and SPORTDiscus were searched for human studies written in the English language between January 1980 and April 2013. Reference lists of relevant articles were reviewed for citations to expand the data set.

      Study Selection

      Prospective experimental studies assessing nonpharmacologic interventions for management of orthostatic drop in blood pressure in various patient populations were included. All studies identified through the literature search were reviewed independently in duplicate. Of the 642 studies, 23 met the selection criteria.

      Data Extraction

      Two reviewers independently extracted data for analysis, including systolic and diastolic blood pressure and orthostatic symptoms in response to postural challenge before and after the intervention. All 23 studies were assessed in duplicate for risk of bias using the Physiotherapy Evidence Database scale for randomized controlled trials and the Downs and Black tool for nonrandomized trials.

      Data Synthesis

      There were 8 identified nonpharmacologic interventions for management of orthostatic hypotension under 2 general categories: physical modalities (exercise, functional electrical stimulation, compression, physical countermaneuvers, compression with physical countermaneuvers, sleeping with head up) and dietary measures (water intake, meals). Owing to the clinically diverse nature of the studies, statistical comparison (meta-analysis) was deemed inappropriate. Instead, descriptive comparisons were drawn. Levels of evidence were assigned.

      Conclusions

      Strong levels of evidence were found for 4 of the 8 interventions: functional electrical stimulation in spinal cord injury, compression of the legs and/or abdomen, physical countermaneuvers in various patient populations, and eating smaller and more frequent meals in chronic autonomic failure. However, this conclusion is based on a limited number of studies with small sample sizes. Further research into all interventions is warranted.

      Keywords

      List of abbreviations:

      DBP (diastolic blood pressure), FES (functional electrical stimulation), HUT (head-up tilt), MSA (multiple system atrophy), OH (orthostatic hypotension), PEDro (Physiotherapy Evidence Database), RCT (randomized controlled trial), SBP (systolic blood pressure)
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      References

        • Freeman R.
        • Wieling W.
        • Axelrod F.B.
        • et al.
        Consensus statement on the definition of orthostatic hypotension, neurally mediated syncope and the postural tachycardia syndrome.
        Clin Auton Res. 2011; 21: 69-72
        • Jordan J.
        New trends in the treatment of orthostatic hypotension.
        Curr Hypertens Rep. 2001; 3: 216-226
        • Lagi A.
        • Bacalli S.
        • Cencetti S.
        • Paggetti C.
        • Colzi L.
        Cerebral autoregulation in orthostatic hypotension. A transcranial Doppler study.
        Stroke. 1994; 25: 1771-1775
        • Perlmuter L.C.
        • Sarda G.
        • Casavant V.
        • Mosnaim A.D.
        A review of the etiology, asssociated comorbidities, and treatment of orthostatic hypotension.
        Am J Ther. 2012; 20: 279-291
        • Mehrabian S.
        • Duron E.
        • Labouree F.
        • et al.
        Relationship between orthostatic hypotension and cognitive impairment in the elderly.
        J Neurol Sci. 2010; 299: 45-48
        • Ooi W.L.
        • Hossain M.
        • Lipsitz L.A.
        The association between orthostatic hypotension and recurrent falls in nursing home residents.
        Am J Med. 2000; 108: 106-111
        • Perlmuter L.C.
        • Sarda G.
        • Casavant V.
        • et al.
        A review of orthostatic blood pressure regulation and its association with mood and cognition.
        Clin Auton Res. 2012; 22: 99-107
        • Fedorowski A.
        • Stavenow L.
        • Hedblad B.
        • Berglund G.
        • Nilsson P.M.
        • Melander O.
        Orthostatic hypotension predicts all-cause mortality and coronary events in middle-aged individuals (The Malmo Preventive Project).
        Eur Heart J. 2010; 31: 85-91
        • Illman A.
        • Stiller K.
        • Williams M.
        The prevalence of orthostatic hypotension during physiotherapy treatment in patients with an acute spinal cord injury.
        Spinal Cord. 2000; 38: 741-747
        • Desboeuf K.
        • Grau M.
        • Riche F.
        • et al.
        Prevalence and costs of parkinsonian syndromes associated with orthostatic hypotension.
        Therapie. 2006; 61: 93-99
        • The Consensus Committee of the American Autonomic Society and the American Academy of Neurology
        Consensus statement on the definition of orthostatic hypotension, pure autonomic failure, and multiple system atrophy.
        Neurology. 1996; 46: 1470
        • Lanier J.B.
        • Mote M.B.
        • Clay E.C.
        Evaluation and management of orthostatic hypotension.
        Am Fam Physician. 2011; 84: 527-536
        • Lahrmann H.
        • Cortelli P.
        • Hilz M.
        • Mathias C.J.
        • Struhal W.
        • Tassinari M.
        EFNS guidelines on the diagnosis and management of orthostatic hypotension.
        Eur J Neurol. 2006; 13: 930-936
        • Higgins J.P.T.
        • Green S.
        Cochrane handbook for systematic reviews of interventions version 5.1.0.
        The Cochrane Collaboration, 2011 (Available at:) (Accessed March 26, 2011)
        • Moseley A.M.
        • Herbert R.D.
        • Sherrington C.
        • Maher C.G.
        Evidence for physiotherapy practice: a survey of the Physiotherapy Evidence Database (PEDro).
        Aust J Physiother. 2002; 48: 43-49
        • Downs S.H.
        • Black N.
        The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions.
        J Epidemiol Community Health. 1998; 52: 377-384
      1. Centre for Evidence-Based Medicine. Available at: www.cebm.net/. Accessed June 25, 2014.

        • Krassioukov A.
        • Warburton D.E.
        • Teasell R.
        • Eng J.J.
        A systematic review of the management of autonomic dysreflexia after spinal cord injury.
        Arch Phys Med Rehabil. 2009; 90: 682-695
        • Smith G.D.
        • Mathias C.J.
        Postural hypotension enhanced by exercise in patients with chronic autonomic failure.
        QJM. 1995; 88: 251-256
        • Zion A.S.
        • De Meersman R.
        • Diamond B.E.
        • Bloomfield D.M.
        A home-based resistance-training program using elastic bands for elderly patients with orthostatic hypotension.
        Clin Auton Res. 2003; 13: 286-292
        • Cheing G.L.
        • Chao C.Y.
        Effects of lower-extremity functional electric stimulation on the orthostatic responses for people with tetraplegia.
        New Zealand Journal of Physiotherapy. 2006; 34: 1427-1433
        • Elokda A.S.
        • Nielsen D.H.
        • Shields R.K.
        Effect of functional neuromuscular stimulation on postural related orthostatic stress in individuals with acute spinal cord injury.
        J Rehabil Res Dev. 2000; 37: 535-542
        • Sampson E.E.
        • Burnham R.S.
        • Andrews B.J.
        Functional electrical stimulation effect on orthostatic hypotension after spinal cord injury.
        Arch Phys Med Rehabil. 2000; 81: 139-143
        • Henry R.
        • Rowe J.
        • O'Mahony D.
        Haemodynamic analysis of efficacy of compression hosiery in elderly fallers with orthostatic hypotension.
        Lancet. 1999; 354: 45-46
        • Podoleanu C.
        • Maggi R.
        • Brignole M.
        • et al.
        Lower limb and abdominal compression bandages prevent progressive orthostatic hypotension in elderly persons a randomized single-blind controlled study.
        J Am Coll Cardiol. 2006; 48: 1425-1432
        • Gorelik O.
        • Fishlev G.
        • Almoznino-Sarafian D.
        • et al.
        Lower limb compression bandaging is effective in preventing signs and symptoms of seating-induced postural hypotension.
        Cardiology. 2004; 102: 177-183
        • Denq J.C.
        • Opfer-Gehrking T.L.
        • Giuliani M.
        • Felten J.
        • Convertino V.A.
        • Low P.A.
        Efficacy of compression of different capacitance beds in the amelioration of orthostatic hypotension.
        Clin Auton Res. 1997; 7: 321-326
        • Huang C.T.
        • Kuhlemeier K.V.
        • Ratanaubol U.
        • McEachran A.B.
        • DeVivo M.J.
        • Fine P.R.
        Cardiopulmonary response in spinal cord injury patients: effect of pneumatic compressive devices.
        Arch Phys Med Rehabil. 1983; 64: 101-106
        • Wadsworth B.M.
        • Haines T.P.
        • Cornwell P.L.
        • Rodwell L.T.
        • Paratz J.D.
        Abdominal binder improves lung volumes and voice in people with tetraplegic spinal cord injury.
        Arch Phys Med Rehabil. 2012; 93: 2189-2197
        • Tutaj M.
        • Marthol H.
        • Berlin D.
        • Brown C.M.
        • Axelrod F.B.
        • Hilz M.J.
        Effect of physical countermaneuvers on orthostatic hypotension in familial dysautonomia.
        J Neurol. 2006; 253: 65-72
        • Brignole M.
        • Croci F.
        • Menozzi C.
        • et al.
        Isometric arm counter-pressure maneuvers to abort impending vasovagal syncope.
        J Am Coll Cardiol. 2002; 40: 2053-2059
        • Krediet C.T.
        • Go-Schon I.K.
        • Kim Y.S.
        • Linzer M.
        • Van Lieshout J.J.
        • Wieling W.
        Management of initial orthostatic hypotension: lower body muscle tensing attenuates the transient arterial blood pressure decrease upon standing from squatting.
        Clin Sci. 2007; 113: 401-407
        • Krediet C.T.
        • van Dijk N.
        • Linzer M.
        • van Lieshout J.J.
        • Wieling W.
        Management of vasovagal syncope: controlling or aborting faints by leg crossing and muscle tensing.
        Circulation. 2002; 106: 1684-1689
        • Krediet C.T.
        • de Bruin I.G.
        • Ganzeboom K.S.
        • Linzer M.
        • van Lieshout J.J.
        • Wieling W.
        Leg crossing, muscle tensing, squatting, and the crash position are effective against vasovagal reactions solely through increases in cardiac output.
        J Appl Physiol. 2005; 99: 1697-1703
        • Ten Harkel A.D.
        • Van Lieshout J.J.
        • Wieling W.
        Effects of leg muscle pumping and tensing on orthostatic arterial pressure: a study in normal subjects and patients with autonomic failure.
        Clin Sci. 1994; 87: 553-558
        • Smit A.A.
        • Wieling W.
        • Fujimura J.
        • et al.
        Use of lower abdominal compression to combat orthostatic hypotension in patients with autonomic dysfunction.
        Clin Auton Res. 2004; 14: 167-175
        • Fan C.W.
        • Walsh C.
        • Cunningham C.J.
        The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial.
        Age Ageing. 2011; 40: 187-192
        • Ten Harkel A.D.
        • Van Lieshout J.J.
        • Wieling W.
        Treatment of orthostatic hypotension with sleeping in the head-up tilt position, alone and in combination with fludrocortisone.
        J Intern Med. 1992; 232: 139-145
        • Mathias C.J.
        • Holly E.
        • Armstrong E.
        • Shareef M.
        • Bannister R.
        The influence of food on postural hypotension in three groups with chronic autonomic failure–clinical and therapeutic implications.
        J Neurol Neurosurg Psychiatry. 1991; 54: 726-730
        • Shannon J.R.
        • Diedrich A.
        • Biaggioni I.
        • et al.
        Water drinking as a treatment for orthostatic syndromes.
        Am J Med. 2002; 112: 355-360
        • Puvi-Rajasingham S.
        • Mathias C.J.
        Effect of meal size on post-prandial blood pressure and on postural hypotension in primary autonomic failure.
        Clin Auton Res. 1996; 6: 111-114
        • Hilz M.J.
        • Ehmann E.C.
        • Pauli E.
        • et al.
        Combined counter-maneuvers accelerate recovery from orthostatic hypotension in familial dysautonomia.
        Acta Neurol Scand. 2012; 126: 162-170
        • Karas B.
        • Grubb B.P.
        • Boehm K.
        • Kip K.
        The postural orthostatic tachycardia syndrome: a potentially treatable cause of chronic fatigue, exercise intolerance, and cognitive impairment in adolescents.
        Pacing Clin Electrophysiol. 2000; 23: 344-351
        • Bradshaw M.J.
        • Edwards R.T.
        Postural hypotension–pathophysiology and management.
        Q J Med. 1986; 60: 643-657
        • Jordan J.
        • Shannon J.R.
        • Black B.K.
        • Paranjape S.Y.
        • Barwise J.
        • Robertson D.
        Raised cerebrovascular resistance in idiopathic orthostatic intolerance: evidence for sympathetic vasoconstriction.
        Hypertension. 1998; 32: 699-704