**5. Cardiovascular rehabilitation**

Cardiovascular rehabilitation is critical because daily life activities are not enough to preserve cardiovascular health. It is estimated that the prevalence of cardiovascular diseases in patients with SCI is 60–70% and these represent, just as in able population, the main cause of death [48]. Besides, if the level of injury is higher, so will be the sedentarism and risk [49]. Another detail to consider is that SCI patients have a higher risk of complications such as thromboembolism, autonomic dysreflexia (AD), orthostatic hypotension, pain, and cardiac atrophy [34].

#### **5.1 Cardiovascular health**

For cardiovascular status enhancement in the SCI patient, it is suggested to: (1) do body weight-supported training for it has advantageous effects on cardiac rhythm and blood pressure; (2) do upper limb exercise with moderate to strenuous intensity 3 days a week for at least 6 weeks; and (3) train with functional electrical stimulation 3 days a week for at least 2 months. This kind of training improves the patient lipid profile because it reduces triglycerides and LDL cholesterol [48].

#### **5.2 Orthostatic hypotension**

After a long resting period, patients may suffer orthostatic hypotension. Training with a tilt table can be useful to get patients used to a vertical position, with a gradual beginning until tolerance of position is achieved. Afterward, patients should sit on the border of the bed by their own 3 or 4 times a day to keep balance. This is important because the position is needed for wheelchair use [19].

#### **5.3 Glycemic control**

For optimal glycemic control, aerobic exercise and EES 30 min a day for at least 3 times a week for 8 weeks is recommended [48].

#### **5.4 Autonomic dysreflexia**

Autonomic dysreflexia consists of a sudden blood pressure elevation caused by stimuli such as bladder overdistension or lack of bowel voiding, tight clothes, or pressure ulcers.

AD is considered when systolic blood pressure increases to 20–40 mmHg over the baseline. This usually occurs in patients with injuries in or over T6 level. AD happens because the previously mentioned stimuli start an uncontrolled adrenergic response due to an abnormal supraspinal regulatory signal, causing blood pressure elevation and bradycardia as a compensatory response.

AD is an emergency since it can cause serious complications such as hypertensive encephalopathy, seizures, cardiac arrest, or even death. To prevent patients from

AD, stimuli should be avoided. Some pharmacological treatments used are nitrates, nifedipine, prazosin, capsaicin, and botulinum toxin for refractory cases [50, 51].
