Non-pharmacological management of orthostatic hypotension after spinal cord injury: a critical review

Objectives: Identify and describe the body of literature pertaining to nonpharmacological management of orthostatic hypotension (OH) during the rehabilitation of persons with a spinal cord injury (SCI). Setting: Sunnaas Rehabilitation Hospital, Oslo, Norway. Methods: Search strategy: A comprehensive search of electronic databases and cited references was undertaken. Selection criteria: Case studies, parallel group trials and crossover designs using random or quasi-random assignments were considered. Participants with any level or degree of completeness of SCI and any time elapsed since injury were included. Interventions must have measured at least systolic blood pressure (BP), have induce orthostatic stress in a controlled manner and have attempted to control OH during an orthostatic challenge. Data collection and analysis: Studies were selected, assessed and described qualitatively. Meta analysis was deemed inappropriate. Results: Four distinct non-pharmacological interventions for OH were identified: application of compression and pressure to the abdominal region and/or legs, upper body exercise, functional electrical stimulation (FES) applied to the legs, and biofeedback. Methodological quality varied dramatically between studies. Conclusions: Compression/pressure, upper body exercise and biofeedback therapies have proven inconclusive in their ability to control OH in persons with SCI due to a limited number of studies on the topic, and large variation in methodological quality. Functional electrical stimulation consistently attenuates the fall in BP during an orthostatic challenge; however its clinical application is less well established due to an under-reporting of patient perception during orthostatic challenge and a limited number of randomized control trials conducted in representative population samples.