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The patient had a broken arm, the result of an unexplained fall. Celia Picone, PT, a therapist on the cardiac floor at Banner Good Samaritan Medical Center in Phoenix, determined that the older woman experienced orthostatic hypotension, the root cause of her problem.

“I check for OH with most every patient, no matter what they are in for,” Picone says. “This woman had been to three hospitals with syncope episodes. But each time, someone took her blood pressure sitting down, and it was wonderful. But when she stood up, it dropped dramatically.”

OH is a fall in blood pressure of 20 mm Hg or more when changing position, usually from supine to standing, according to William Gibbs, MD, medical director, department of rehabilitation, New York Hospital Medical Center of Queens. “In layman’s terms, it’s a dizzy spell. The cause is the change in position. When someone suddenly rises, there is less blood in the head, less circulation, less venous return, and a temporary decrease in cardiac output. The symptoms are head rush, dizziness, or feeling of unease, and the person often can faint,” he explains.

There are two primary categories of risk for OH, says Michelle Brill, MPT, ATC, a therapist at Christiana Care Health System in Delaware’s Springside Rehabilitation. “The first is those with cardiovascular issues: people with low resting blood pressure, [patients] on cardiac or blood pressure medications, postsurgical patients due to loss of blood and low blood volume, and anyone following a period of immobility, particularly bed rest,” she says.

“The other is those with neurologic issues, including brain or spinal injuries, stroke, Parkinson’s disease, neuropathy from diabetes or other causes, acute postsurgical patients due to anesthesia, and those taking medication for anxiety or depression,” Brill says. Older patients in both categories have a higher risk of OH, she adds.

“An important point to get across is that neurogenic orthostatic hypotension is very much a dynamic thing,” says Phillip Low, MD, professor, Mayo Clinic, in Rochester, Minn. “It occurs under certain circumstances and not under others, so there are many things that need to be considered.”

As many as 20% to 30% of people older than 70 will have it some of the time, Low says. OH can be a serious problem for several reasons, he adds: “The person may fall or lose consciousness. Patients can have difficulty thinking clearly, so it affects function. Thirdly, because these patients often are not healthy — they may have cardiac disease, for example — a drop in blood pressure can have other consequences.”

OH Identification

A PT’s first step should be identifying whether OH is a problem. Picone checks a patient’s blood pressure in supine, sitting, and standing positions; after standing for one, two, and three minutes; and again after walking.

“You want to know what happens in real-life situations. If someone comes in with an unexplained fall or any syncopatic incident, I always check heart rate with blood pressure,” she says. For acute care patients or those in the hospital, a tilt table can be used to safely change the patients’ positions for monitoring.

Because OH can be affected by medications, Gibbs recommends that PTs always ask patients what medications they are taking. “Be aware of medical conditions a patient has that could affect this; don’t assume they do not have OH. Many of these are conditions you can’t identify just by looking,” he says.

Rehabilitation can’t be done effectively and safely if a patient can’t change positions safely, Brill points out. “If someone has dizziness, it’s the first thing we talk about. I hear older people say all the time that they feel dizzy when they get up and it’s never really been addressed. People come in who have had a fall and OH often is the cause. We check for OH routinely after surgery or if someone is on a medication that puts them at risk,” she says.

Treatment Plan

The primary take-home message is to teach patients to change positions very slowly, Gibbs says. Counter maneuvers, such as taking a deep breath before rising, tightening the muscles from the abdomen downward, or pumping the legs, help compress the veins and generate a reflex that increases blood pressure.

“Someone who stands up and squeezes their muscles might maintain a normal blood pressure. It is simple and quite effective,” Low says.

Slowly and repeatedly helping the patient change from supine to an upright position teaches the nervous and cardiovascular systems to adapt to the forces of gravity, Brill says: “In extreme cases, following bed rest for example, we use the tilt table to elevate the head of the bed to what the person can tolerate, then lower it, and try to slowly increase the angle and the amount of time the patient tolerates being in that position.”

Exercise can be an effective treatment modality. “Exercise strengthens the heart, which is related to the problem, and helps people maintain a healthy blood pressure,” Brill says. “Regular exercise may even allow the person to reduce or eliminate blood pressure medication, which may be causing the problem.”

Abdominal braces and compression stockings also are effective in treating OH, and a PT can help with proper fit and use of these tools. PTs also can educate patients on the importance of staying hydrated to maintain adequate fluid volume.

“The great thing about physical therapy is that we have the staff, skills, and tools to help people adapt in a safe environment,” Brill says. “It can be very frightening to feel dizzy or like you’re going to pass out, and being in a safe environment is a comforting feeling.”

It is important for therapists to communicate with a patient’s physicians and with family members.

“Not everyone with OH feels dizzy,” Picone says. “They may feel sleepy instead, or exhibit a behavior change. Find out what it looks like with each patient, and let everyone around that person know.”