Review article (meta-analysis)
A Systematic Review of the Management of Autonomic Dysreflexia After Spinal Cord Injury

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Abstract

Krassioukov A, Warburton DE, Teasell R, Eng JJ, Spinal Cord Injury Rehabilitation Evidence Research Team. A systematic review of the management of autonomic dysreflexia after spinal cord injury.

Objective

To review systematically the clinical evidence on strategies to prevent and manage autonomic dysreflexia (AD).

Data Sources

A key word search of several databases (Medline, CINAHL, EMBASE, and PsycINFO), in addition to manual searches of retrieved articles, was undertaken to identify all English-language literature evaluating the efficacy of interventions for AD.

Study Selection

Studies selected for review included randomized controlled trials (RCTs), prospective cohort studies, and cross-sectional studies. Treatments reviewed included pharmacologic and nonpharmacologic interventions for the management of AD in subjects with spinal cord injury. Studies that failed to assess AD outcomes (eg, blood pressure) or symptoms (eg, headaches, sweating) were excluded.

Data Extraction

Studies were critically reviewed and assessed for their methodologic quality by 2 independent reviewers.

Data Synthesis

Thirty-one studies were assessed, including 6 RCTs. Preventative strategies to reduce the episodes of AD caused by common triggers (eg, urogenital system, surgery) primarily were supported by level 4 (pre-post studies) and level 5 (observational studies) evidence. The initial acute nonpharmacologic management of an episode of AD (ie, positioning the patient upright, loosening tight clothing, eliminating any precipitating stimulus) is supported by clinical consensus and physiologic data (level 5 evidence). The use of antihypertensive drugs in the presence of sustained elevated blood pressure is supported by level 1 (prazosin) and level 2 evidence (nifedipine and prostaglandin E2).

Conclusions

A variety of options are available to prevent AD (eg, surgical, pharmacologic) and manage the acute episode (elimination of triggers, pharmacologic); however, these options are predominantly supported by evidence from noncontrolled trials, and more rigorous trials are required.

Section snippets

Methods

A keyword literature search of original articles, previous practice guidelines, and review articles was conducted to identify all English-language literature, published from 1950 to 2007, evaluating the efficacy of any intervention related to AD in the SCI population. Population key words—spinal cord injury, paraplegia, tetraplegia, and quadriplegia—were individually paired with autonomic dysreflexia, autonomic, dysreflexia, blood pressure, nifedipine, phenazopyridine, beta-blockers, detrusor

Results

The 31 selected articles were categorized according to (1) preventative strategies to reduce episodes and symptoms of AD from common triggers (eg, from the urogenital system, gastrointestinal system, general surgery, exercise)31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48; and (2) therapeutic management strategies, either acute or chronic, for AD.45, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61 The management of AD included both nonpharmacologic and pharmacologic

Discussion

The objective of this review was to evaluate the latest evidence from clinical literature on present strategies in the management and prevention of AD, as well as to present latest basic science and clinical data on the mechanisms and pathophysiology of this condition. The very small number of RCTs (n=6)33, 40, 41, 48, 58, 61 demonstrates the difficulty of applying this type of review to assessing AD. In many instances (eg, acute life-threatening episodes of AD), it would be unethical to have a

Conclusions

There is a severe lack of controlled trials in the management and prevention of AD. A variety of options are available to prevent AD (eg, surgical, pharmacologic), but only intersphincteric anal block with lidocaine when undergoing anorectal procedures had evidence using a control group (level 1). The identification and elimination of specific triggers for AD (eg, distended bladder) are considered the first line of treatment based on physiologic rationale and expert consensus, but there are

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  • Cited by (0)

    Supported by the Rick Hansen Man in Motion Foundation and the Ontario Neurotrauma Fund, the Michael Smith Foundation for Health Research, and the Canadian Institutes of Health Research.

    No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or on any organization with which the authors are associated.

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