The effectiveness of non-pharmacological interventions to treat orthostatic hypotension in people with stroke.

Purpose

The prevalence of Orthostatic Hypotension (OH) post-stroke is high. OH can be a barrier to stroke rehabilitation, where mobilisation (out-of-bed activities such as sitting, standing and walking) is recommended at the earliest opportunity. The potential risk of harm with OH must be acknowledged and addressed since, in acute and sub-acute stroke, OH has the potential to cause further brain damage due to cerebral hypo-perfusion. This may result in increased disability and mortality. However, current guidelines for the management of people with stroke do not provide guidance on assessing and treating OH.

People with stroke are more likely to have multi-morbidity, thus are at greater risk of polypharmacy. Therefore, identifying non-pharmacological interventions to treat OH is of importance both to minimise polypharmacy, and optimise safe participation in early rehabilitation.

The aim of this systematic review was to summarise the best available evidence regarding the effectiveness of non-pharmacological interventions to treat OH in people with stroke.

Meta-analyses of three interventions
(resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions.
Results from individual studies
indicated physical manoeuvres such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH.

Approach

The review considered people aged 50 years and older, and people aged 18 years and elderly people with a neurological condition. Non-pharmacological interventions to treat OH included compression garments, neuromuscular stimulation, physical counter-manoeuvres, aerobic or resistance exercises, sleeping with head tilted up, increasing fluid and salt intake, and timing and size of meals. The comparator was usual care, no intervention, pharmacological interventions, or other non-pharmacological interventions. Outcome measures included systolic blood pressure, diastolic blood pressure, heart rate, cerebral blood flow, observed/perceived symptoms, duration of standing or sitting in minutes, tolerance of therapy, functional ability, and adverse events/effects.

Databases for published (MEDLINE, AMED, Cochrane, CINAHL, PEDro and Embase) and unpublished (Google Scholar, Conference Papers Index and clinical trials registers) studies of any quantitative design, available in English up to 27 April 2018 were searched. Critical appraisal was conducted by two independent researchers, using standardized instruments from the Joanna Briggs Institute. Any disagreements were resolved through discussion. Data were extracted using standardized tools from the Joanna Briggs Institute. Where appropriate, studies were included in a meta-analysis, but otherwise data were presented in a narrative form due to heterogeneity.

Outcomes

Forty-three studies—a combination of randomized controlled trials (n=13), quasi-experimental studies (n=28), a case control study (n=1), and a case report (n=1)—with 1069 participants were included. Studies in this systematic review included participants with OH, stroke, spinal cord injury, Parkinson’s disease, brain injury, brain haemorrhage, syncope, familial dysautonomia and primary autonomic/autonomic failure.

Meta-analyses of three interventions (resistance exercise, electrical stimulation, and lower limb compression bandaging) showed no significant effect of these interventions. Results from individual studies indicated physical manoeuvres such as leg crossing, leg muscle pumping/contractions, and bending forward improved orthostatic hypotension. Abdominal compression improved OH. Sleeping with head up in combination with pharmacological treatment was more effective than sleeping with head up alone. Eating smaller, more frequent meals was effective. Drinking 480mL of water increased blood pressure. 

Cost and savings

The systematic review did not include an economic analysis. However, the review suggests a range of non-pharmacological interventions may be effective in managing OH, most do not require specialist equipment and training.

Implications

Although meta-analyses were not statistically significant and the GRADE certainty of evidence was very low, on a practical level physical modalities such as electrical stimulation, lower limb compression, and resistance exercise training could be implemented into and outside of rehabilitation sessions for people with stroke, people with neurological conditions, and elderly people with relatively minimal effort. However, the patient’s physical abilities and impairments (e.g. cognitive impairment, severity of disability, swallow impairment) should be considered when selecting a non-pharmacological intervention.

Top three learning points

  1. This review found mixed results for the effectiveness of non-pharmacological interventions to treat OH in people 50 years and older and people with a neurological condition. The settings, participants, outcomes, study designs, and intervention types were heterogeneous, resulting in an inability to include all studies in a meta-analysis. For those interventions that underwent meta-analysis (resistance exercise, electrical stimulation and compression bandaging), all produced statistically non-significant results.
  2. Many neuro-rehabilitation units have cycle ergometers (e.g. MOTOmed, Thera Trainers), which patients could use while sitting out, even in specialist wheelchairs. However, depending on the severity of disability, some patients may need supervision to optimize safety. Additionally, many neuro-rehabilitation units also have access to functional electrical stimulation (e.g. Microstim), which could be incorporated into standing practice to increase the duration of standing and optimize physical activity during rehabilitation sessions.
  3. Several non-pharmacological interventions may be effective in treating OH but have not resulted in clinically meaningful changes in outcome. Some interventions may not be suitable for people with moderate to severe disability (e.g., they may be unable to stand to perform physical manoeuvres or perform resistance training due to weakness). Thus, it is important for clinicians to consider a patient’s abilities and impairments when choosing which non-pharmacological interventions to implement.

Fund acknowledgements

This systematic review presents independent research funded by the National Institute for Health Research (NIHR) (Integrated Clinical Academic, Clinical Doctoral Research Fellowship- 2015-01-044).

The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

Additional notes

This work was presented at Physiotherapy UK 2019. The systematic review is being published in Joanna Briggs Institute Evidence Synthesis and the proofs are available via: 

https://journals.lww.com/jbisrir/Abstract/9000/Effectiveness_of_non_pharmacological_interventions.99830.aspx

JBI Evidence Synthesis: August 06, 2020 - Volume Online First - Issue - doi: 10.11124/JBISRIR-D-18-00005. 

 

Please see the attached Innovations poster below. 

 

For further information about this work please contact Angie Logan