Assistant Professor Medical College of Wisconsin Milwaukee, Wisconsin, United States
Case Diagnosis: A 41 year-old male veteran with C8 AIS C quadriplegia presented with chronic orthostatic hypotension, neurogenic in nature and refractory to several blood pressure medications.
Case Description: A 41 year-old male with C8 AIS C quadriplegia originally presented with orthostatic hypotension that has been occurring since his original injury. Multiple medications were trialed with several adjustments, including midodrine, fludrocortisone, and pseudoephedrine. Other modalities, such as compression stockings and abdominal binder, were also used. He was started on droxidopa, which gave him some improvement, but the veteran was having elevated blood pressures at night and low blood pressures during the day, complicating his medication administration options. Coordination with PT resulted in changing to a power wheelchair to allow for tilt function to help management of his hypotension. Transcutaneous spinal cord stimulation, along with an electro-stimulation vest and thigh cuffs, were eventually trialed, which helped him increase tolerance to sitting with at least a 30 degree tilt for over 20 minutes and improve his blood pressures.
Discussions: Neuromuscular electrical stimulation has been shown to promote improved body composition changes and have an effect on cardiovascular parameters. It has been shown to affect autonomic responses in regards to blood pressure regulation and improve cognitive function during an orthostatic episode. A complete spinal cord injury patient can benefit from electrical stimulation, which in the above case was transcutaneous and with the use of a stimulation vest. E-stim has also been shown to improve spasticity, leading to less usage of spasticity medications that cause or exacerbate hypotension, such as tizanidine.
Conclusions: Medication-resistant hypotension can be difficult to treat in a patient with spinal cord injury who has constant autonomic dysregulation. Using electrical stimulation in adjunct with physical therapy can help such patients tolerate their orthostatic episodes and improve their blood pressure goals and function.
