Evaluation of captopril for the management of hypertension in autonomic dysreflexia: a pilot study

OBJECTIVE: To evaluate the efficacy of captopril for management of hypertensive urgencies in autonomic dysreflexia. DESIGN: A 1-year, prospective, open-label pilot study. SETTING: Rehabilitation hospital. PATIENTS: Twenty-six consecutive patients older than 15 years with spinal cord injury above T6. INTERVENTIONS: During an autonomic dysreflexia episode, captopril 25mg was administered sublingually if systolic blood pressure (SBP) was at or above 150mmHg despite the use of nondrug measures. If SBP remained elevated 30 minutes after captopril administration, 1 dose of immediate-release nifedipine 5mg was given as rescue by the bite and swallow method and repeated, if necessary, in 15 minutes. MAIN OUTCOME MEASURE: SBP 30 minutes after captopril administration at initial autonomic dysreflexia episode. RESULTS: A total of 33 autonomic dysreflexia episodes were documented, of which 18 episodes in 5 patients were treated with drug therapy. Captopril alone was effective in 4 of 5 initial episodes (80%). Mean SBPs at baseline and 30 minutes after captopril were 178+/-18mmHg and 133+/-28mmHg, respectively. There were no cases of reactive hypotension. The addition of nifedipine successfully reduced SBP in the remaining patient. Of the combined 18 initial and repeat autonomic dysreflexia episodes, 94% were successfully treated with our protocol. CONCLUSION: Captopril appears to be safe and effective for autonomic dysreflexia management.     

Blood pressure response to acupuncture in a population at risk for autonomic dysreflexia

OBJECTIVE: To determine whether acupuncture can lead to autonomic dysreflexia (AD) when used to treat chronic pain in individuals with spinal cord injury (SCI). DESIGN: Acupuncture analgesia study. SETTING: Medical rehabilitation research center. PARTICIPANTS: Fifteen participants with post-SCI chronic pain who were at risk for AD (ie, SCI at or above T8). INTERVENTIONS: Half-hour acupuncture treatment sessions twice a week for 7.5 weeks, for a total of 15 treatments. Acupuncture needles were inserted both above and below the patient's spinal lesion level. Blood pressure (BP) was measured before and after acupuncture treatments. MAIN OUTCOME MEASURES: Systolic BP (SBP) and diastolic BP (DBP). Participants monitored for signs and symptoms of AD. RESULTS: On average, SBP and DBP remained stable across all 15 treatment sessions. None of the participants experienced any symptoms of AD. However, examination of individuals' BP readings indicated acute elevations (20 mmHg or higher) in SBP for 3 of the 15 participants. CONCLUSIONS: Although none of the 15 participants who were at risk for developing AD developed symptoms consistent with this diagnosis, 3 displayed an acute elevation in SBP, suggesting a pattern of imminent AD. Comorbid hypertension appeared to contribute to the elevation in 1 patient. Therefore, careful monitoring of patients with SCI or hypertension during acupuncture treatments is advisable.     

Cardiovascular responses and postexercise hypotension after arm cycling exercise in subjects with spinal cord injury

OBJECTIVE: To examine postexercise hypotension and contributing factors in subjects with spinal cord injury (SCI). DESIGN: Prospective clinical research study. SETTING: Rehabilitation center. PARTICIPANTS: Subjects with chronic cervical-level (n=19) and thoracic-level (n=8) SCI. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Subjects underwent graded arm-cycling with electrocardiogram and oxygen uptake monitoring to exhaustion. Heart rates and blood pressures were measured before and after exercising. Injury to motor and sensory pathways was determined by American Spinal Injury Association grade, and to autonomic pathways by sympathetic skin responses (SSRs) (n=16). RESULTS: Resting blood pressures and heart rates were lower in cervical than thoracic SCI (mean arterial pressure [MAP]: cervical, 76.6+/-2 mmHg; thoracic, 93.5+/-3 mmHg; P<.001). Following exercise, heart rate responses were greater in thoracic than cervical SCI; MAP increased in thoracic SCI (8.4+/-5 mmHg) and markedly decreased in cervical SCI (-9.3+/-2 mmHg) (P<.001). No subject had significant electrocardiographic abnormalities at rest or during exercise. There were correlations between SSR and heart rate and blood pressure responses to exercise; the correlation between the SSR and blood pressure response was due to an interaction between the heart rate and blood pressure responses. CONCLUSIONS: Abnormal cardiovascular responses to exercise and transient postexercise hypotension were common in cervical, but not thoracic SCI. This may be partly related to loss of descending sympathetic nervous control of the heart and vasculature following high SCI.     

Autonomic dysreflexia: a nursing challenge in the care of the patient with a spinal cord injury

Autonomic dysreflexia is an emergency condition resulting in sudden severe hypertension that can occur in spinal cord injury (SCI) patients above the T-5-6 level. This hypertension has its proximate cause in neurologic, not cardiovascular, mechanisms. Knowledge about pathophysiology, possible consequences, and signs and symptoms will assist the nurse in identifying this syndrome, locating and removing causes, controlling symptoms, and preventing morbidity or mortality. A case study is used to illustrate a typical autonomic dysreflexia episode in a hospitalized patient at risk. Prevention of autonomic dysreflexia and patient and professional education are also addressed.     

Comparison of the efficacy and tolerability of telmisartan 40 mg vs. enalapril 10 mg in the treatment of mild-to-moderate hypertension: a multicentre, double-blind study in Taiwanese patients

The purpose of this randomised, double-blind, double-dummy, parallel-group study was to evaluate the efficacy and tolerability of telmisartan 40 mg once daily vs. enalapril 10 mg once daily in 147 Taiwanese patients with mild-to-moderate essential hypertension (diastolic blood pressure [DBP] 90-109 mmHg). After 6 weeks' treatment, telmisartan produced a significantly greater reduction from baseline in the primary endpoint of trough seated DBP compared with enalapril 10 mg (11.7 vs. 8.7 mmHg, respectively; p = 0.02). Numerically greater reductions compared with baseline in seated systolic blood pressure (SBP), standing DBP, and standing SBP were achieved with telmisartan compared with enalapril. Also, numerically greater proportions of patients achieved blood pressure control (DBP/systolic blood pressure [SBP] <90/140 mmHg) and responded to treatment (reduction from baseline in trough seated DBP > or = 10 mmHg and/or post-treatment DBP <90 mmHg; reduction from baseline in trough seated SBP > or = 10 mmHg and/or post-treatment SBP <140 mmHg) with telmisartan 40 mg compared with enalapril 10 mg. Although both treatments were well tolerated, the incidence of cough was markedly lower with telmisartan 40 mg (8.5%) than with enalapril 10 mg (18.4%) in this population of Taiwanese hypertensive patients.     

Intracerebral hemorrhage secondary to autonomic dysreflexia in a young person with incomplete C8 tetraplegia: A case report

Intracerebral hemorrhage is an unusual complication of autonomic dysreflexia and can be fatal if massive bleeding occurs with brain herniation. We report the case of a man in his midthirties with incomplete tetraplegia who suffered right putaminal hemorrhage during an episode of autonomic dysreflexia. Prompt recognition and removal of the triggering factors of autonomic dysreflexia quickly brought his blood pressure under control and the patient had a favorable functional outcome after rehabilitation. A review of the literature suggests that the location of hemorrhage in autonomic dysreflexia-induced cases is similar to that in the general population. The most common triggering factors are bladder distension in men and labor induction in women. Hemorrhagic stroke can also occur in patients with incomplete spinal cord injury (SCI) who develop autonomic dysreflexia. The role of sympathetic skin response examination is also discussed. This life-threatening complication should be kept in mind in the case of people with SCI.     

Autonomic dysreflexia during urodynamic examinations in patients with suprasacral spinal cord injury

Huang Y-H, Bih L-I, Chen G-D, Lin C-C, Chen S-L, Chen W-W. Autonomic dysreflexia during urodynamic examinations in patients with suprasacral spinal cord injury.

Objective

To investigate blood pressure (BP) and pulse rate (PR) changes during urodynamic (UD) examinations in patients with suprasacral spinal cord injury (SCI).

Design

A case control study.

Setting

Tertiary hospital affiliated with a medical university.

Patients

Control subjects (n=22) and patients with suprasacral SCI (n=120).

Interventions

Not applicable.

Main Outcome Measures

Systolic (SBP) and diastolic BP (DBP) and PR before and during UD studies.

Result

Healthy subjects had an average SBP change of 9.7±10.6mm Hg and a maximal SBP increase of 21mm Hg. Autonomic dysreflexia (AD) was defined as an SBP increase of 20mm Hg or more, and incidence rates were 36.7% overall, 42.6% in patients with injury level at or above T6, and 15.4% in patients with lesions below T6. Both SBP and DBP changes in patients with SCI showed significant negative correlations with injury levels (r=−.383 and −.315; P<.05). The BP increase was more significant in patients with SCI who had detrusor sphincter dyssynergia (DSD), especially the continuous type, or severely impaired bladder compliance than in those who did not. Most patients (75%) had no significant PR changes (within 10beats/min) during AD responses and only 22.7% had a decrease of 10beats/min or more. Patients younger than 50 years had a greater PR decrease than those 50 years or older (−7.1±9.0 vs 0.7±11.4 beats/min; P<.05).

Conclusions

AD occurred not only in patients with lesions above T6, but also in those with lower lesion levels. Patients with higher injury level, continuous DSD, or a poorly compliant bladder had greater SBP changes during UD studies. During AD reactions, younger patients tended to have a greater PR decrease than older patients.     

Cardiovascular and endocrine responses during the cold pressor test in subjects with cervical spinal cord injuries

OBJECTIVE: To investigate cardiovascular regulation and endocrine responses during the cold pressor test in patients with chronic spinal cord injury (SCI). DESIGN: Experimental and control study. SETTING: University laboratory, department of rehabilitation medicine, in Japan. PARTICIPANTS: Eight quadriplegic subjects with complete spinal cord transection at the C6 to C8 level and 6 age-matched healthy subjects. INTERVENTIONS: Cardiovascular and endocrine responses were examined during 2 minutes of control, 3 minutes of ice-water immersion of the foot, followed by a 3-minute recovery. MAIN OUTCOME MEASURES: Blood pressure, heart rate, the Borg 15-point Rating of Perceived Pain Scale, and blood samples for measurement of plasma norepinephrine, epinephrine, plasma renin activity, plasma aldosterone, and arginine vasopressin. RESULTS: The rise in the mean arterial blood pressure during the cold pressor test in patients with SCI (baseline, 81.6+/-3.7mmHg; increased by 30%+/-6.1%) was significantly (P<.05) higher than that in healthy subjects (baseline, 101.2+/-4.5mmHg; increased by 20%+/-4.5%). The SCI subjects had no change in heart rate throughout the test, in contrast to the tachycardia noted in normal subjects. Baseline plasma norepinephrine in SCI subjects (63.0+/-18.3pg/mL) was significantly lower than in normal subjects (162.3+/-19.6pg/mL) and plasma norepinephrine increased significantly during the cold pressor test in both groups. CONCLUSIONS: In the SCI subjects, a reflex sympathetic discharge through the isolated spinal cord results in a more profound rise in mean blood pressure during ice-water immersion. This response was free of inhibitory impulses from supraspinal center and baroreceptor reflexes, either of which might restrain the increase in blood pressure.     

Ovarian cyst and autonomic dysreflexia

Autonomic dysreflexia may present itself as a medical emergency in quadriplegics and paraplegics above the T6 level. Common causes are bladder/bowel dysfunction and pressure ulcers. A case study is presented in which an ovarian cyst was the cause of autonomic dysreflexia. Excision of the ovarian cyst stopped recurrence of paroxysmal hypertension and completely alleviated signs and symptoms of autonomic dysreflexia.     

Ethnic differences in physiological responses associated with the Valsalva maneuver

Ethnic differences in cardiovascular indices at rest and across the Valsalva maneuver (VM) were studied in 30 Asian, 86 Caucasian, and 12 Black healthy men and women aged 30 to 55 years. Subjects simulated the VM by blowing into an aneroid pressure-gauge meter to 40 mmHg for 10 seconds. Resting systolic blood pressure (SBP) was significantly higher in Blacks than in Asians or Caucasians. During the strain phase of the VM, the fall in SBP from baseline was significantly greater in Asians and Blacks than in Caucasians. Further, Asians had the greatest overshoot of SBP above baseline. Although resting heart rate was significantly higher in Asians compared to Caucasians, there were no differences in heart rate responses to the VM. Reduction in carotid artery blood flow velocity during strain was significantly less in Blacks. We conclude that there are ethnic differences in cardiovascular indices at rest and across the VM.     

Effect of different sympathetic stimuli-autonomic dysreflexia and head-up tilt-on leg vascular resistance in spinal cord injury

Groothuis JT, Rongen GA, Geurts AC, Smits P, Hopman MT. Effect of different sympathetic stimuli–autonomic dysreflexia and head-up tilt–on leg vascular resistance in spinal cord injury.

Objective

To compare the effect of different sympathetic stimuli, that is, exaggerated sympathetic activity and orthostatic challenges, on the increase in leg vascular resistance in persons with spinal cord injury (SCI) without and controls with supraspinal sympathetic control.

Design

Case-control intervention study.

Setting

Physiology research laboratory.

Participants

Persons with SCI (N=9; motor and sensory complete spinal cord lesion above the sixth thoracic spinal segment) and able-bodied controls (N=9).

Interventions

In persons with SCI, exaggerated sympathetic activity was evoked by autonomic dysreflexia, and in controls, by using a cold pressor test (CPT). A 30° head-up tilt (HUT) was performed in both groups.

Main Outcome Measure

Leg blood flow was measured by using venous occlusion plethysmography during the different sympathetic stimuli. Leg vascular resistance was calculated as the arterial-venous pressure gradient divided by blood flow.

Results

In persons with SCI, leg vascular resistance significantly increased during autonomic dysreflexia and 30° HUT (25±20 and 24±13 arbitrary units [AU], respectively), with no difference (P=.87) between stimuli. In controls, leg vascular resistance significantly increased during CPT and 30° HUT (15±13 and 29±12AU, respectively) with no difference (P=.03) between stimuli. There were no differences (P=.22) in increase in leg vascular resistance during the different sympathetic stimuli between persons with SCI and controls.

Conclusions

The increase in leg vascular resistance during autonomic dysreflexia in persons with SCI is not different from that during 30° HUT, which might be caused by a limited vasoconstrictor reserve. Despite the lack of supraspinal sympathetic control in persons with SCI, the increase in leg vascular resistance during exaggerated sympathetic activity was not different from controls.     

Early use of naloxone in shock--a clinical trial

Naloxone hydrochloride (N) 0.4-1.2 mg i.v. was administered during 10 episodes of shock (8 septic and 2 cardiogenic) in 9 adult patients. Shock was defined as systolic blood pressure (SBP) less than or equal to 90 mmHg and urine output less than 0.5 ml/h and signs and symptoms of hypoperfusion lasting for greater than or equal to 30 min, despite fluid loading to a CVP 5 cmH2O above baseline. N was given as early as 30 min after onset of shock and resulted in an increase of SBP from a mean of 75 +/- 10 to a mean of 130 +/- 25 mmHg maximum (P less than 0.01). Within 10-60 min urine output increased from 16 +/- 12 to 122 +/- 56 ml/h, heart rate, CVP and arterial blood gas tensions remained unchanged. No side effects were observed. Naloxone, even in small doses, may improve hemodynamic parameters in human shock, provided it is administered very early.     

Mean arterial pressure (MAP): an alternative and preferable measurement to systolic blood pressure (SBP) in patients for hypotension detection during hemapheresis

Current protocols utilize systolic blood pressure (SBP) of less than 80 mmHg as objective evidence of hypotension during hemapheresis. However, tissue hypoperfusion is the pathophysiologic endpoint of low blood pressure, and mean arterial pressure (MAP), rather than SBP, is the physiologic driving force behind blood flow to organs and tissues. It is thus hypothesized that MAP is more appropriate than SBP in the assessment of hypotension and that a threshold MAP can be utilized as a sensitive indicator of hypotension during hemapheresis. Thirty-one patients who experienced hypotension during hemapheresis over a 4.5 year period reflecting forty-four hypotensive episodes were selected. The initial phase of each hemapheresis procedure provided baseline MAP and blood pressure (BP) measurements as control values. BP and MAP were then determined at the onset of subjective hypotension and compared to one another by using regression and sensitivity analyses. Correlation coefficients between SBP and MAP were found to be 0.8097 in baseline normotensive patients and 0.7725 in hypotensive patients. Sensitivity in the detection of hypotension was 0.09% for SBP equal to 80 mmHg and 56.81% for MAP equal to 70 mmHg. An SBP of 80 mmHg or less was therefore concluded to be a less sensitive and physiologically less appropriate measurement of hypotension than MAP. As a single value less than 70 mmHg or a series of successive measurements trending downward toward 70 mmHg, MAP provides an objective assessment of hypotension that may precede hemodynamic decompensation.     

An implantable neuroprosthesis for restoring bladder and bowel control to patients with spinal cord injuries: a multicenter trial.

OBJECTIVE: To evaluate the safety and efficacy of an implanted neuroprosthesis for management of the neurogenic bladder and bowel in individuals with spinal cord injury (SCI). DESIGN: Prospective study comparing bladder and bowel control before and at 3, 6, and 12 months after implantation of the neuroprosthesis. SETTING: Six US hospitals specializing in treatment of SCI. PATIENTS: Twenty-three neurologically stable patients with complete suprasacral SCIs. INTERVENTION: Implantation of an externally controlled neuroprosthesis for stimulating the sacral nerves and posterior sacral rhizotomy. MAIN OUTCOME MEASURES: Ability to urinate more than 200mL on demand and a resulting postvoid residual volume of less than 50mL. RESULTS: At 1-year follow-up, 18 of 21 patients could urinate more than 200mL with the neuroprosthesis, and 15 of 21 had postvoid volumes less than 50mL (median, 15mL). Urinary tract infection, catheter use, reflex incontinence, anticholinergic drug use, and autonomic dysreflexia were substantially reduced. At 1-year follow-up, 15 of 17 patients reduced the time spent with bowel management. CONCLUSIONS: Neural stimulation and posterior rhizotomy is a safe and effective method of bladder and bowel management after suprasacral SCI.     

A double-blind ambulatory blood pressure monitoring study of the efficacy and tolerability of once-daily telmisartan 40 mg in comparison with losartan 50 mg in the treatment of mild-to-moderate hypertension in Taiwanese patients

Ambulatory blood pressure monitoring (ABPM) was used to compare the efficacy and tolerability of once-daily telmisartan 40 mg and once-daily losartan 50 mg in Taiwanese patients with mild-to-moderate essential hypertension in a randomised, double-blind, double-dummy, parallel-group study. The initial 2-week placebo run-in phase was followed by randomisation to treatment with telmisartan 40 mg (n = 31) or losartan 50 mg (n = 30) for 6 weeks. The reduction in 18- to 24-h mean (SE) ambulatory diastolic blood pressure (DBP) from baseline was significantly greater with telmisartan 40 mg (-12.1 +/- 1.6 mmHg, p = 0.036) than with losartan 50 mg (-7.0 +/- 1.8 mmHg). The reduction in 18- to 24-h mean (SE) ambulatory systolic blood pressure (SBP) from baseline was also greater with telmisartan 40 mg (-16.0 +/- 2.4 mmHg) than with losartan 50 mg (-11.8 +/- 2.7 mmHg), but did not achieve statistical significance. Telmisartan was well tolerated; no serious adverse events occurred.     

Valsartan vs. other angiotensin II receptor blockers in the treatment of hypertension: a meta‐analytical approach

Objective: To compare the efficacy of valsartan in systolic (SBP) and diastolic blood pressure (DBP) reduction with other angiotensin II receptor blockers (ARBs) in essential hypertension. Methods: Systematic literature search of databases between October 1997 and May 2008. Meta‐analysis of short‐term, double‐blind, parallel group, randomised controlled trials (RCTs) for treatment of adult hypertension (DBP: 90–115 mmHg). Random‐effects meta‐regression adjusting for baseline blood pressure (BP) was used to analyse the data. Mean change in SBP and DBP was estimated for each individual drug and dose combination. Results: In all, 31 RCTs (n = 13,110 patients) were included in the analysis. Six studies include trial arms with candesartan, six irbesartan, 13 losartan, two olmesartan, five telmisartan and 12 valsartan. The weighted average reduction in mean SBP and DBP for valsartan 160 mg was ?15.32 mmHg (95% CI: ?17.09, ?13.63) and ?11.3 mmHg (95% CI: ?12.15, ?10.52) and for 320 mg was ?15.85 mmHg (95% CI: ?17.60, ?14.12) and ?11.97 mmHg (95% CI: ?12.81, ?11.16); these are statistically significantly greater reductions compared with losartan 100 mg, which was ?12.01 mmHg (95% CI: ?13.78, ?10.25) and ?9.37 mmHg (95% CI: ?10.18, ?8.54) for SBP and DBP respectively. There is evidence that valsartan 160 mg reduces SBP and DBP more than irbesartan 150 mg and reduced DBP more than candesartan 16 mg. No other statistically significant difference in efficacy is demonstrated. Conclusion: Valsartan administered at 160 or 320 mg is more effective at lowering BP than losartan 100 mg and shows comparable efficacy to other ARBs in patients with essential hypertension.     

Post-traumatic hypotension: should systolic blood pressure of 90-109 mmHg be included?

It is generally accepted that patients with a systolic blood pressure (SBP)<90 mmHg are in "shock" and have a worse prognosis than patients with a higher SBP. Our objective was to determine if patients with a SBP of 90-109 mmHg have a worse outcome than patients with a higher SBP following trauma. Patients with gastric, small bowel, and/or diaphragm injuries were identified retrospectively through the trauma database from 1980-2003. All 2071 patients underwent emergent laparotomy at an urban, level one trauma center. The mortality rate of patients with a SBP of 90-109 mmHg in the ED or OR was 5% (17/354) and significantly higher than the 1% (12/1020) mortality seen in patients with a SBP of 110 mmHg or greater (P<0.001). The average length of stay of patients with a SBP of 90-109 mmHg was 15+/-14 days and was significantly longer than the 11+/-11 days seen in patients with a higher SBP. If the SBP was 90-109 mmHg, the infection rate was 39% (131/340), and this was significantly higher than the 22% (219/1016) infection rate seen in patients with higher SBP (P<0.001). Trauma patients with a systolic blood pressure of 109 mmHg or below are at increased risk for morbidity and mortality following trauma. Patients with a systolic blood pressure of 90-109 mmHg following trauma should be considered as a special group requiring aggressive resuscitation and surgery. Early operative control of hemorrhage in these patients can reduce mortality and infection.     

Response of diastolic blood pressure to long-term sodium restriction is posture related.

Eighty-five subjects, aged 31-55 years, suffering from uncomplicated essential hypertension and receiving no regular medication were randomized to sodium restriction and control groups. Systolic (SBP) and diastolic (DBP) blood pressure were measured during an orthostatic test at baseline and after 6 months sodium restriction. The mean daily sodium excretion of 43 treated subjects decreased from 193 +/- 91 mmol to 95 +/- 70 mmol (p less than 0.001). Treated patients were divided on the basis of their mean overall out-patient clinic (OC) DBP decrease in the sitting position during the 6 months (monthly measurements) into sodium-sensitive (DBP decrease greater than 10 mmHg, n = 17), indeterminate (DBP decrease 5-10 mmHg, n = 18) and sodium-resistant (DBP decrease less than 5 mmHg, n = 8) subgroups. At 6 months the level of DBP in the supine position was lower than at baseline in both sensitive and resistant subgroups, whereas in the standing position a lower DBP than at baseline was seen only in the sodium-sensitive subgroup. The magnitude of the subsequent OC DBP decrease was significantly associated with a high baseline seated OC DBP (p less than 0.001) and a high, for baseline OC DBP adjusted orthostatic DBP increase (p = 0.014). Our data suggest that posture should be included in the concept of sodium sensitivity and that an orthostatic test is useful in the prediction of seated and standing DBP decrease produced by moderate, long-term sodium restriction.     

Acute hemodynamic effects of abdominal exercise with and without breath holding

OBJECTIVES: To compare the magnitudes of change in heart rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean blood pressure, and rate-pressure product (RPP) during 3 abdominal exercises: straight partial sit-up (SPSU), oblique partial sit-up (OPSU), and the AbSculptor(R) sit-up; and to examine the effect of breath holding on these parameters. DESIGN: Prospective, repeated measures. SETTING: Autonomic research laboratory in a major medical center. PARTICIPANTS: Fourteen normal male and female volunteers (age range, 24-37y; mean, 30.4y). INTERVENTIONS: Hemodynamic parameters were recorded during each abdominal exercise performed with and without breath holding. Mean peak values were calculated for 1 minute before exercise, during exercise, and for 10 minutes after exercise.Main Outcome Measures: Statistical analysis examined for differences in the hemodynamic changes among the 3 exercises under both conditions (with and without breath holding). RESULTS: Heart rate, SBP, DBP, mean blood pressure, and RPP increased during all 3 exercises. The mean peak heart rate and RPP increases were greater for the OPSU than the AbSculptor (heart-rate increase, 21.1+/-6.6bpm vs 17.6+/-5.7bpm, P=.03; RPP increase, 36.9+/-15.5bpm.mmHg vs 29.4+/-10.1bpm.mmHg, P=.05). For all 3 exercises, breath holding significantly increased the hemodynamic parameter elevations during exercise, with the exception of heart rate (SBP, P<.001; DBP, P<.001; mean blood pressure, P<.001; RPP, P=.02). Quantitatively, breath holding during the OPSU resulted in the largest exercise-associated increases in heart rate (21.0+/-8.1bpm), mean blood pressure (22.2+/-16.4mmHg), and RPP (44.9+/-22.3bpm.mmHg). Postexercise, all hemodynamic parameters generally returned to baseline within several minutes. CONCLUSION: When performing the OPSU, SPSU, or the AbSculptor exercises as used in this investigation, normal individuals exercising at low intensities may experience peak heart rate and mean blood pressure increases of 30bpm and 50mmHg, respectively. Voluntary breath holding significantly increased the peak blood pressure elevations and RPP for all 3 exercises, but particularly for the OPSU.     

Autonomic dysreflexia after intramuscular injection in traumatic tetraplegia: a case report

Autonomic dysreflexia is a syndrome of massive imbalance of reflex sympathetic discharge occurring in patients with spinal cord lesion above the splanchnic outflow (T6). It is characterized by a sudden onset and severe increase in blood pressure and is potentially life threatening. The most common causes are bladder and rectum distention. In this case study, we report an autonomic dysreflexia case that developed after intramuscular injection in a 29-yr-old tetraplegic patient with C5 American Spinal Injury Association grade A lesion. After careful scrutiny of English literature, this clinical manifestation seems to be an unusual event.