Managing Orthostatic Hypotension in Acute Spinal Cord Injury: A Systematic Review

Orthostatic hypotension (OH) is a common complication after spinal cord injury (SCI), causing dizziness, presyncope, cognitive slowing, and reduced functional participation. In acute rehabilitation, these symptoms limit upright tolerance, delay progress, and affect psychological wellbeing. Effective OH management is essential for early mobilisation and engagement in daily and therapeutic activities, but evidence on optimal interventions remains limited and heterogeneous. The aim of this study is to systematically review and critically appraise the existing literature on the management of orthostatic hypotension in individuals with spinal cord injury during the acute in-patient rehabilitation phase, to identify effective interventions and inform clinical practice. A comprehensive literature search was conducted using PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials to identify relevant human studies published between January 1950 and May 2024. Prospective experimental studies investigating pharmacological and non-pharmacological interventions for the management of orthostatic hypotension (OH) and orthostatic intolerance in individuals with acute spinal cord injury (SCI) were included. Titles and abstracts were screened, followed by full-text review, independently by two reviewers. Of 440 records identified, 13 studies met the inclusion criteria. Methodological quality and risk of bias were assessed using the PEDro Scale for randomised controlled trials and the Downs and Black checklist for non-randomised studies. Two pharmacological studies evaluated midodrine and demonstrated consistent improvements in blood pressure, alongside reductions in orthostatic symptoms. Eleven non-pharmacological studies examined a range of interventions, including exercise, compression garments, functional electrical stimulation (FES), and biofeedback. Findings across these interventions were variable, although compression garments emerged as the most consistently effective non-pharmacological strategy. Due to substantial clinical diversity and methodological heterogeneity among the included studies, a meta-analysis was not feasible; consequently, the findings were synthesised narratively. To conclude, Midodrine is shown to be effective in improving blood pressure and alleviating symptoms of orthostatic hypotension in individuals with acute spinal cord injury. In comparison, non-pharmacological interventions demonstrate inconsistent outcomes, although compression garments appear to offer the most reliable benefit. Overall, the available evidence is limited and heterogeneous, emphasising the need for high-quality, standardised research to better determine treatment effectiveness and support clinical decision-making.