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The PVA Guideline for management of AD is well established, and utilized by some programs, some of the time (Figure 4.0). Equally important is that healthcare providers, outside rehabilitation sites, recognize and have an approach for management of AD, when individuals with SCI present in emergency departments (or other medical care environments), where health professionals may be less familiar with AD. Individuals with SCI, who have received rehabilitation from some of the E-Scan sites, carry wallet cards. Again, this is not a universal practice and more attention to this approach, and other related knowledge translation efforts, would go a long way to ensure best practice, and to minimize adverse outcomes of untreated AD. Approaches to Management of Orthostatic Hypotension The Toronto Lyndhurst Centre tilt table protocol, a postural retraining method, is done at most sites (ten of the 12), either as appropriate (seven sites) or sometimes (three sites). Other OH-related assessments are done as appropriate (four sites), and sometimes (one site). In addition, the TLC tilt table protocol is used in an on-going research study, at one site. Use of the postural retraining protocol (Figure 6.0), in most sites, demonstrates how development of a specific protocol can lead to uptake of the approach, for the betterment of individuals and the field. Figure 6.0 Toronto Lyndhurst Site Postural Retraining Protocol Reproduced from Craven BC, Bugaresti JM, McGilivray CF, Adachi RJ, Nantais TC, Peper I. The development and evaluation of a postural retraining protocol for persons with spinal cord injury. J Spinal Cord Med. 2002;25(1):S38b. © 2002 W.S. Maney & Son Ltd. Reprinted with permision. 0° supine Stage I 30° x 5 min HR, BP, PPS at 3 min intervals SBP < 70 mmHg DBP < 40 mmHg HR < 50 bpm PPS ≥ 3, or subject request yes yes PPS = 2 no no yes PPS = 2 no no tilt terminated Stage II 50° x 5 min HR, BP, PPS at 3 min intervals SBP < 70 mmHg DBP < 40 mmHg HR < 50 bpm PPS ≥ 3, or subject request yes tilt terminated Perceived Pre-Syncope Score (PPS) Sampson et al.6 Symptoms of syncope include lightheadedness, dizziness, vision changes, nausea and fainting. 0 = no symptoms 1 = mild symptoms 2 = moderate symptoms 3 = severe symptoms 4 = syncope yes PPS = 2 no no Stage III 70° x 5 min HR, BP, PPS at 3 min intervals SBP < 70 mmHg DBP < 40 mmHg HR < 50 bpm PPS ≥ 3, or subject request yes test terminated Maintain Stage IV until clinical endpoint is achieved (30 minutes at 85° without signs/symptoms of postural hypotension) no or total time is 45 minutes test terminated Stage IV 85° x 30 min HR, BP, PPS at 5 min intervals SBP < 70 mmHg DBP < 40 mmHg HR < 50 bpm PPS ≥ 3, or subject request yes Note: First training session begins at Stage I. If successive training sessions are needed, begin at the last completed stage (i.e., stage maintained for 15 minutes and PPS < 2). The maximum number of training sessions is five. 132 CAPTURING CAPACITY IN CANADIAN SCI REHABILITATION


M - Cardiovascular Integrity
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