214
edits
Physical manoeuvres that reduce postural hypotension in autonomic failure: Difference between revisions
Physical manoeuvres that reduce postural hypotension in autonomic failure (view source)
Revision as of 10:50, 15 July 2014
, 15 July 2014no edit summary
No edit summary |
No edit summary |
||
| Line 18: | Line 18: | ||
After discharge she reported that she felt reasonably well and was not seriously restrained in daily life duties. At that time she started a laborious part-time job as a social worker in an institution for battered women. She regularly went for bicycle rides, initially with her friend as the rear rider on a tandem covering distances of up to 60 km a day, but in due course on her own as well. This faced her with a new problem: light-headedness during and immediately following cycling. She prevented fainting by short intermittent resting periods with her knees pulled-up on the frame. A further difficulty was to stop at red traffic-lights as stopping cycling almost instantaneously caused dizziness; she discovered that by bending over de handle bar of her bicycle prevented fainting. On investigation of her ‘bicycle manoeuvres’ in the laboratory (Fig. 2, positions 1 to 4), her blood pressure fell progressively when she was sitting motionless on the bicycle. By pulling up her legs blood pressure increased; bending over the handle bar resulted in an additional increase in pulse pressure. On returning her feet from the frame to the pedals blood pressure again dropped. | After discharge she reported that she felt reasonably well and was not seriously restrained in daily life duties. At that time she started a laborious part-time job as a social worker in an institution for battered women. She regularly went for bicycle rides, initially with her friend as the rear rider on a tandem covering distances of up to 60 km a day, but in due course on her own as well. This faced her with a new problem: light-headedness during and immediately following cycling. She prevented fainting by short intermittent resting periods with her knees pulled-up on the frame. A further difficulty was to stop at red traffic-lights as stopping cycling almost instantaneously caused dizziness; she discovered that by bending over de handle bar of her bicycle prevented fainting. On investigation of her ‘bicycle manoeuvres’ in the laboratory (Fig. 2, positions 1 to 4), her blood pressure fell progressively when she was sitting motionless on the bicycle. By pulling up her legs blood pressure increased; bending over the handle bar resulted in an additional increase in pulse pressure. On returning her feet from the frame to the pedals blood pressure again dropped. | ||
[[File:PhysicalManoeuvresAutonomic_Fig2.jpg | right | 300px | thumb | Figure 2. Blood pressure and heart rate tracings of “bicycle manoeuvres” prior to onset of cycling are shown. The blood pressure is low when sitting quietly with their feet on the pedals (1). Pulling up the legs and putting them on the frame induces an increase in blood pressure (2) with an additional increase in pulse pressure by bending over the handle bar (3). There is a rapid fall in blood pressure when the feet are lowered (4).]] | |||
During later visits to our laboratory she was instructed to use other manoeuvres to improve orthostatic tolerance like leg crossing and putting a foot on a chair as demonstrated in Figure 3. | |||
[[File:PhysicalManoeuvresAutonomic_Fig3.jpg | thumb | 300px | left | Figure 3. Patient is demonstrating legcrossing, bending forward, placing a foot on a chair and squatting. The effects of the manoeuvres on orthostatic blood pressure are indicated. The patient was standing quietly prior to the manoeuvres. Bars indicate duration of the manoeuvres.]] | |||
During long-term follow up our patient has been using a combination of these manoeuvres almost automatically i.e. before warning systems occurred in daily life. She never lost consciousness again. However, she still was definitely restricted in her activities and social life activities. Running or doing things in a hurry were avoided. Cycling uphill or against a strong wind were problematic. She went to bed tired and stood up tired. Sleeping with the head elevated every night was mandatory. | |||
In the next few years, 3 children were born. During the pregnancies, she felt extremely well. There were no moments of lightheadedness, she felt less tired and the volume expansion by fludrocortisone was not needed. At age 46 years she had to retire from her job, feeling not only tired, but exhausted by the combination of her demanding job and taking care of a household with 3 children. In this period she experienced chest pain during relative heavy exercises like cycling with a child on the carrier and walking up 2 flights of stairs to the attic. Myocardial ischemia was diagnosed during exercise testing. | |||
After retirement her condition has stabilised. However, her activity level has slowed down considerably. She now uses an electric bike and when she visit the attic she crawl up the 2nd flight of stairs. | |||
In a video made about 1 decade after the onset of her illness, the patient describes her own experience. She later made an instruction video for patients was made demonstrating how our patient applied physical counterpressure manoeuvres to increase low standing blood pressures. | |||
[[File:PhysicalManoeuvresAutonomic_Fig4.png]] | |||
}} | }} | ||
== Editor's comments == | == Editor's comments == | ||
This is a unique case of acute dysautonomia associated with Hodgkin’s disease with almost complete regression of the symptoms of parasympathetic involvement of several organ systems, namely pupillary abnormalities, a dry mouth and disturbed bladder and bowel function after the acute phase. The sympathetic involvement, indicated by incapacitating orthostatic hypotension remained. | |||
During a 30 year follow up the complaints of orthostatic hypotension have been counteracted by volume expansion and the use of physical counterpressure manoeuvres. Details will be dealt with in the Tutorials dealing with countermeasures and chronic volume expansion. Pregnancies in patients with autonomic failure have to the best of our knowledge not been described. | |||
{{clr}} | {{clr}} | ||