Table 15.2 Head Posture for the Acute Management of Intracranial Pressure Post ABI
|
Author Year Country Research Design PEDro Sample Size |
Methods | Outcomes |
|
(2010) USA RCT Crossover PEDro=5 N=33 |
Population: ABI; Mean Age=48.3 yr; Gender: Male=22, Female=11; GCS Range<8. Intervention: Participants were placed in 12 different head and body positions, each for 2 hr, in random order. Body positions included the supine, supine with knee bent, left lateral position and right lateral position. In each position, the head of bed (HOB) was elevated to 15, 30° or 45°. Outcomes were assessed before and 15 min after each position change. Outcome Measures: Brain Tissue Oxygen Pressure (PbtO2), Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. PbtO2 decreased in 4 of the positions: supine with HOB 30° (p=0.006), supine with HOB 45° (p=0.004), left lateral with HOB 30° (p=0.046) and right lateral with HOB 30° (p=0.028). 2. ICP was significantly reduced when individuals were placed in the supine with HOB 45° (p=0.002), left lateral with HOB 15° (p=0.026), right lateral with HOB 15° (p=0.002) and the knee elevation with HOB 30° (p=0.039). 3. Only left lateral with HOB 30o had a significant effect on CPP (p<0.05). |
|
Winkelman (2000) USA RCT Crossover PEDro=4 N=8 |
Population: TBI; Mean Age=28.0 yr; Gender: Male=6, Female=2; GCS Range ≤8. Intervention: Participants were placed with the backrest elevated at 30° and at 0° for 65-75 min in a random order. Outcomes were assessed 5, 15, 30 and 60 min after each position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. Significant improvements in both ICP and CPP occurred immediately after changes in backrest position from 0° to 30°. (p=0.001) and during equilibrium at the 30° position (p=0.003). |
|
March et al. (1990) USA RCT Crossover PEDro=3 N=4 |
Population: TBI; Mean Age=23.0 yr; Gender: Male=2, Female=2; Mean GCS=6.5. Intervention: Participants received backrest manipulation in 3 different positions: 30° head elevation, 30° head elevation with knee gatch raised, and flat to reverse Trendelenburg position. Subjects were initially placed in the flat position for 15 min, followed by 15 min in one of the three randomly assigned alternate backrest positions. Outcomes were assessed at each position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Cerebral Blood Flow (CBF). |
1. No significant changes were noted on any of the measures among the 4 backrest positions (p>0.05). |
|
Mahfoud et al. (2010) Germany Pre-Post N=40 |
Population: ABI; Mean Age=54 yr; Gender: Male=18, Female=15. Intervention: Participants had their heads elevated to 30° and 60° from a flat position. Outcomes were assessed at each position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Mean Arterial Pressure (MAP). |
1. Mean ICP was significantly reduced (p<0.001) from 0° to 30° (-6.9 mmHg) and from 0° to 60° (-8.5 mmHg). 2. Mean CPP was significantly reduced (p<0.05) from 0° to 30° (-5.3 mmHg) and from 0° to 60° (-10.2 mmHg). 3. Mean MAP was significantly reduced (p<0.05) from 0° to 30° (-12.1 mmHg) and from 0° to 60° (-18.6 mmHg). 4. There was a significant correlation between ICP and CPP (r=-0.5, p=0.003), and between CPP and MAP (r=0.81, p<0.001). |
|
Schulz-Stiibner & Thiex (2006) Germany Case Series N=10 |
Population: ABI; GCS Range<8. Intervention: Participants were put in the flat position with a positive end expiratory pressure (PEEP) of 5, 10 and 15 cm H20. Participants had their head elevated to 30° with a positive end expiratory pressure (PEEP) of 5 cm H20. PEEP was then increased to 10 and 15 cm H20. Outcomes were assessed beforehand after each position change. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. When participants had their heads lowered to a flat position, ICP was significantly increased and CPP was significantly reduced (p<0.05). 2. In the flat position, an increase in PEEP from 5 to 10 cm H20 increased ICP without dropping CPP significantly (p>0.05). 3. In the flat position an increase in PEEP from 5 to 15 cm H20 increased ICP with a significant drop in CPP (p<0.05). 4. When the head was elevated to 30° and PEEP changed from 5 to 10 cm H20, ICP and CPP did not change significantly (p>0.05). 5. When the head was elevated to 30° and PEEP was increased to 15 cmH20, ICP significantly increased (p<0.05) and CPP did not change significantly (p>0.05). |
|
Ng et al. (2004) Singapore Pre-Post N=38 |
Population: TBI; Mean Age=34.05 yr; Median GCS=7.0. Intervention: Participants were elevated to a 30° head-up position then subsequently lowered to a 0° position. Outcomes were assessed before and 15 min after each position change. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Mean Arterial Pressure (MAP), Global Cerebral Oxygenation (GCO), Regional Cerebral Oxygenation (RCO). |
1. ICP was significantly lower at 30o than at 0o of head elevation (p<0.0005). 2. CPP was slightly but not significantly higher at 30o than at 0o (p=0.412). 3. Those who had lower ICP at baseline were found to have the greatest decrease in ICP when the head was elevated 30°. 4. MAP, GCO and RCO were not affected significantly by head elevation. |
|
Moraine et al. (2000) Belgium Pre-Post N=37 |
Population: TBI=13, SAH=9, ICH=7, Tumor=3, Other=5; Mean Age=52 yr; Gender: Male=22, Female=15; Mean GCS=6. Intervention: Participants were placed into 4 positions of head elevation: 0o, 15o, 30o and 45o. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. Mean ICP significant decreased from 25 mmHg at 0° to 20 mmHg at 15°, 14 mmHg at 30°, and 16 mmHg at 45° (all p<0.01). 2. Mean CPP significantly decreased from 62mmHg at 0° to 57 mmHg at 45° (p<0.01), but not at 15° or 30°. |
|
Meixensberger et al. (1997) Germany Case Series N=22 |
Population: ABI; Mean Age=36.8 yr; Gender: Male=11, Female=11; GCS: 3-5=9, 6-8=8, 9-12=5. Intervention: Participants were placed in a 30° and then 0° body position each for 10-15 min. Outcomes were assessed before and after each position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Brain Tissue Oxygen Pressure (PbtO2), Mean Arterial Pressure (MAP). |
1. Compared with 30°, ICP was significantly higher (p<0.001) and CPP was significantly lower (p<0.01) at the 0°. 2. PbtO2 and MAP pressure were unaffected by head position. |
|
Schneider et al. (1993) Germany Pre-Post N=25 |
Population: TBI=17, SAH=5, ICH=3; Mean Age=48y r; Mean GCS=6. Intervention: Participants were placed into 4 positions of head elevation: 0o, 15o, 30o and 45o. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Mean Arterial Pressure (MAP), Jugular Venous Oxygen Saturation (SjvO2). |
1. Mean ICP significantly decreased from 19.8 mmHg at 0° to 14.3 mmHg at 15°, 11.0 mmHg at 30°, and 10.2 mmHg at 45° (all p<0.001). 2. Mean MAP significantly decreased from 79.9 mmHg at 0° to 75.7 mmHg at 15° (p<0.01), 72.3 mmHg at 30° (p<0.001), and 68.9 mmHg at 45° (p<0.001). 3. There was no significant change in CPP or SjvO2 associated with any elevation. |
|
Feldman et al. (1992) USA Case Series N=22 |
Population: TBI=22; Mean Age=35 yr; Gender: Male=19, Female=3; Mean Time Post Injury=72 hr; GCS: 3-5=3, 6-8=14, 9-12=5. Intervention: Participants had their heads initially elevated to 30° (n=13) or 0° (n=9). Head elevation was changed to the alternate position after 45 min. Outcomes were assessed at each position. Outcome Measures: Intracranial Pressure (ICP), Mean Carotid Pressure (MCP), Cerebral Perfusion Pressure (CPP), Cerebral Blood Flow (CBF), Cerebrovascular Resistance (CR), Cerebral Metabolic Rate of Oxygen (CMRO2), Arteriovenous Oxygen Difference (AOD). |
1. ICP and MCP were significantly lower at 30° than at 0° (p=0.0062 and p=0.001). 2. All of the other physiological parameters were not significantly affected by the change in head elevation. |
|
Park & Ha (1992) South Korea Pre-Post N=34 |
Population: TBI; Gender: Male=9, Female=25; GCS Range=5-8. Intervention: Participants had their heads elevated to 30° from a flat position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. There was a significant decrease in mean ICP from 23 mmHg at 0° to 18.6 mmHg at 30° (t=4.22, p<0.001). 2. There was no significant change in CPP after elevation. |
|
Rosner & Coley (1986) USA Pre-Post N=18 |
Population: ABI; Mean Age=36 yr; Gender: Male=9, Female=9; Mean GCS=7.7. Intervention: Participants were progressively subjected to 6 different positions of head elevation: 0°, 10°, 20°, 30°, 40°, and 50°. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Central Venous Pressure (CVP), Systemic Arterial Pressure (SAP). |
1. For every 10° increase in head elevation, mean ICP decreased by 1 mmHg (p<0.1) and CPP decreased by 2-3 mmHg (p<0.05). 2. There were significant reductions in SAP (p<0.001) and CVP (p<0.01) with head elevation. |
|
Parsons & Wilson (1984) USA Pre-Post N=18 |
Population: TBI; Age Range=5-67 yr; Gender: Male=13, Female=5; Mean GCS=6.5. Intervention: Participants had their heads elevated to 35° from a flat position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Mean Arterial Pressure (MAP). |
1. ICP and MAP significantly decreased at 35° (p<0.05), but increased when returned to 0°. 2. There was no significant change in CPP after elevation. |
|
Durward et al. (1983) Canada Case Series N=11 |
Population: TBI=11; GCS Range<8. Intervention: Participants were placed into 4 positions of head elevation: 0o, 15o, 30o and 60o. Each position was maintained for 5-10 min. Outcomes were assessed at each position. Outcome Measures: Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP). |
1. ICP decreased significantly from 0o to 15o (p<0.001). 2. This decrease in ICP was maintained at 30o (p<0.001) but was not significantly different from the ICP at 15o. 3. ICP at 60o was not significantly different from 0o of elevation. 4. CPP was not significantly affected by 15o or 30o of head elevation. 5. Elevation of 60o caused a significant reduction of CPP compared with 0o (p<0.02). |
|
Ropper et al. (1982) USA Case Series N=19 |
Population: TBI=13, ICH=5, Stroke=1; Age Range=15-77 yr. Intervention: Participants had their heads elevated to 60° from a flat position. Outcome Measure: Intracranial Pressure (ICP). |
1. ICP was significantly lower at 60° in 10 participants (p<0.05). 2. ICP was lower at 0° in 2 participants (p>0.05). 3. ICP did not change in 7 participants. |
|
Kenning et al. (1981) USA Case Series N=24 |
Population: TBI=15, Other=9; Mean Age=36 yr; Mean GCS=8.2. Intervention: Participants had their heads elevated to 45° and 90° from a flat position. Outcome Measure: Intracranial Pressure (ICP). |
1. At baseline, 13 participants had elevated levels and 11 had normal levels. 2. ICP was reduced at 45° and/or 90° in all participants. 3. ICP was lower at 90° than at 45° in most participants. 4. In those with initial elevated ICP, reductions were maintained for 24-48 hr. |