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 present latest basic science and clinical data on 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 (e.g., acute life-threatening episodes of AD), it would be unethical to have a ‘no treatment’ control group, when a well-established protocol for the management of AD has been proposed by the Consortium for Spinal Cord Medicine
based upon physiological evidence and clinical consensus. Education on the causes of AD, appropriate bladder and bowel routines, and pressure sore prevention, appear to be the most effective measures for prevention of AD in individuals with SCI. However, for each individual, the identification and elimination of specific triggers for AD also should be employed to manage and prevent this condition.2, 3, 90
Based upon the physiological mechanisms of AD, it is assumed that a multi-modal protocol to reduce triggers of AD would be most effective and there is a need to formally evaluate a combined approach. The most effective approach to AD seems to be preventing it.92
This includes careful evaluation of individuals with SCI and early recognition of possible triggers that could result in AD. Improved clinician awareness of AD and greater attention to eliminating noxious stimuli in individuals with SCI is a priority. Clinicians, family members, and caregivers should be aware that increased afferent stimulation (e.g., via surgery, invasive investigational procedures, and labour) in persons with SCI will increase their risk for AD; and that a variety of procedures can be used to prevent AD episodes.
When conservative management of AD with an established bladder program is not sufficient, detrusor hyperreflexia can be treated pharmacologically and in more difficult cases, with surgery. However, note that all the pharmacological interventions (except for intra-vesical resiniferatoxin) and surgical interventions were lacking in controlled trials. The lack of controlled trials (even those involving other deemed therapeutic interventions) seriously undermines the strength of this evidence. On the positive side, several of these studies have established effects over long periods (e.g., the positive effect of botulinum toxin on detrusor hyperreflexia over nine months, and the positive effect of augmentation enterocystoplasy on detrusor hyperreflexia over one year).
We emphazis that AD is often not recognized outside of specialized SCI rehabilitation facilities. Despite appropriate medical care and advances in our understanding of the possible pathophysiology of AD, the majority of individuals susceptible to AD (those with cervical and high thoracic SCI) experience numerous episodes of AD during their acute and sub-acute rehabilitation period.14, 15
Unfortunately, the level of awareness of AD among family physicians, and medical personal in ER or ambulance services appears to be low, especially as it pertains to SCI patients (unpublished observations). This reinforces the need to educate and empower individuals with SCI and their families, so that they can direct their own treatment. This reinforces the need to educate and empower individuals with SCI and their families, so that they can direct their own treatment. Furthermore, all individuals with SCI should carry a Medical Emergency Card for Autonomic Dysreflexia.86
This card provides a short description of AD as a medical emergency, and gives brief details on its causes, presentation and management. The ultimate goal in the management of AD in individuals with SCI is protecting them from its development and ensuring appropriate and timely intervention. However when non-pharmacological measures fail and systolic blood pressure remains elevated, pharmacological agents should be initiated. Nifedipine, nitrates, and captopril are the most commonly used and recommended agents for the management of acute AD episodes,86, 90, 92
and are supported by Level 2, 5 and 4 evidence, respectively. To date, no RCTs have been conducted to determine which of these agents is best, however.
In some instances, individuals with SCI should be supplied with short-acting antihypertensive agents, like nifedipine or nitrates, which they can take themselves, prior to seeking medical attention. However, if their symptoms continue and/or their blood pressure does not stabilize, they must proceed or be brought to the nearest emergency department for further management.