This page is primarily intended to be a reference for patients
who have been referred for therapy.
Timothy C. Hain,
MD Frank Dilberto, PT, Ph.D.
Click here for the main vestibular rehabilitation page. Page last modified:
July 8, 2015
Syncope and orthostatic hypotension can be treated with medications as well as non-drug methods. This document discusses use of tilt-training, which is a recently developed non-drug treatment. If you actually have POTS, then you should see the POTS training page.
In recent years a very large literature has developed concerning use of "tilt training" to prevent fainting. (see reference list at the end).
- Tilt training was first described by Ector and associates in 1998. They reported that 13 patients were successfully treated, and showed no recurrence of syncope during a mean follow-up period of 7.2 months. The suggested that the reason of the effect was repeated exposure. Di Girolamo et al(1999) undertook a controlled study of adolescents. In their study, tilt-induced syncope occurred in only 4.2% of 24 participants after 1 month training, in contrast to syncope in 74% of 23 control subjects.
- From these studies, it appears that tilt training methodology is useful in treating syncope.
- Recently, a similar protocol has been developed to treat POTS (positional orthostatic tachycardia). This is sometimes called the "Levine" protocol, after one of the authors on several recent papers (Fu et al, 2010; Shibata et al, 2012). This protocol is largely based on physical conditioning, adapted to start in a safe sitting or lying down position.
Accompaning the tilt-training literature is also evidence that simple physical countermeasures can ward off syncope. We think that these techniques should be taught at the same time as tilt training. So
Method of physical therapy approach to syncope and positional lightheadness:
We will describe the tilt training protocol of Abe et al (2003) combined with physical countermeasures. The Levine protocol adds conditioning (i.e. you go to the gym), as well as salt/water loading. The Levine program is a longer program -- 3 months+, compared to the 1 month protocol of Abe et al.
- All patients first undergo tilt-table testing to measure their starting performance. It would be unreasonable to use this protocol if one does not "fail" the tilt table test. This is also used to determine the target heart rate.
- Changes to behavior
- Salt/water loading
- The goal is up to 3 liters of water/day and 7000-10,000 mg of sodium/day. This might not always be possible in persons with heart disease (for example), so this needs to be monitored. 1 tsp of ordinary table salt= about 2300 mg of sodium, and the ordinary diet contains about 4000 mg of sodium. So as a rough estimate, you might be aiming for 1.5 to 2 more tsp of salt/day. Start slow and work up. There are online tools (such as myfitnesspal.com) that can help you track your sodium intake. Generally one should not salt load to this extent if one is taking medications to cause salt retention (such as fludrocortisone).
- Elevate the head of the bed -- raise the head of the bed by 4-6 inches. The goal is to tilt the entire body, not the head. Two pillows is not enough. Bed risers are a way to do this (such as are used by college students. Just under the top of the bed.
- Stay upright during the day. Do not lie down all day long because you feel better. Get up and walk around a little bit every hour.
- A home program consisting of twice a day regime for up to 30 minutes each session, and conditioning (Cardio and weight training).
- Medications need to be decided upon by the supervising doctor. For neurally generated syncope, such as dysautonomia, stopping working medications could be counterproductive. For individuals with non-neurally generated syncope, it might be cleaner to stop. That being said, there is not much difference between salt loading and taking fludrocortisone.
- You should have a heart rate monitor, so that you know when to quit exercises (i.e. when your heart rate gets too high if you have POTS). The goals are shown below.
- This program is supervised. You should see your provider (perhaps physician or physical therapist), who assigns progressively harder exercises, and monitors your progress. The provider should provide you with a calendar for activities for each week.
- Tilt training -- this is mainly for orthostatic hypotension, and can be skipped in persons where POTS is the main problem.
- The patient stands and leans with their upper back up against a wall with their feet planted 15 cm away from the wall, without moving.
- Sessions are performed in a safe environment
- Sessions are stopped if syncope is eminent
- Patient records daily symptoms during the self-training, the reason for ending the training, and the self-training duration.
- "Cardio" exercises are done to improve lower extremity tone and strength (these are from the Levine protocol). These exercises are to be done every day, and are for both patients with orthostatic hypotension and POTS. You should not take off more than 2 days from training. See the "POTS training" protocol for much more detail. Conditioning should be continued as a life-long activity.
- After the training is completed (i.e. 3 months) a follow up tilt-table test is performed at the same time of day as the initial training.
There are also physical countermeasures for an impending faint. These are probably most useful when one cannot just sit down. These include leg-crossing with lower body tensing, squating, and hand/arm-tensing (Benditt and Nguyen, 2009). These maneuvers have been shown to be effective in preventing fainting (van Dijk et al, 2006). Rapid drinking of 16 oz of water has also been shown to be an effective method of avoiding a faint (Lu et al, 2003).
|Squa maneuver (from Benditt and Nguyen, 2009).
||Leg cross maneuver (from Benditt and Nguyen, 2009).
||Hand tense maneuver (from Benditt and Nguyen, 2009).
- Abe, H., K. Kohshi, et al. (2003). "Effects of orthostatic self-training on head-up tilt testing and autonomic balance in patients with neurocardiogenic syncope." J Cardiovasc Pharmacol 41 Suppl 1: S73-6.
- Abe, H., K. Kohshi, et al. (2003). "Efficacy of orthostatic self-training in medically refractory neurocardiogenic syncope." Clin Exp Hypertens 25(8): 487-93.
- Abe, H., K. Kohshi, et al. (2005). "Home orthostatic self-training in neurocardiogenic syncope." Pacing Clin Electrophysiol 28 Suppl 1: S246-8.
- Abe, H., S. Kondo, et al. (2002). "Usefulness of orthostatic self-training for the prevention of neurocardiogenic syncope." Pacing Clin Electrophysiol 25(10): 1454-8.
- Abe, H., M. Sumiyoshi, et al. (2003). "Effects of orthostatic self-training on head-up tilt testing for the prevention of tilt-induced neurocardiogenic syncope: comparison of pharmacological therapy." Clin Exp Hypertens 25(3): 191-8.
- Benditt DG, Nguyen JT. Syncope Therapeutic approaches. Journal of the American College of Cardiology, 53(19), 2009, 1741-1751
- Di Girolamo, E., C. Di Iorio, et al. (1999). "Usefulness of a tilt training program for the prevention of refractory neurocardiogenic syncope in adolescents: A controlled study." Circulation 100(17): 1798-801.
- Duygu, H., M. Zoghi, et al. (2008). "The role of tilt training in preventing recurrent syncope in patients with vasovagal syncope: a prospective and randomized study." Pacing Clin Electrophysiol 31(5): 592-6.
- Ector, H., T. Reybrouck, et al. (1998). "Tilt training: a new treatment for recurrent neurocardiogenic syncope and severe orthostatic intolerance." Pacing Clin Electrophysiol 21(1 Pt 2): 193-6.
- Franke, W. D., K. K. Mills, et al. (2003). "Training mode does not affect orthostatic tolerance in chronically exercising subjects." Eur J Appl Physiol 89(3-4): 263-70.
- Fu, Q., T. B. Vangundy, M. M. Galbreath, S. Shibata, M. Jain, J. L. Hastings, P. S. Bhella and B. D. Levine (2010). "Cardiac origins of the postural orthostatic tachycardia syndrome." J Am Coll Cardiol 55(25): 2858-2868.
- Gabbett, T. J., G. C. Gass, et al. (2001). "Does endurance training affect orthostatic responses in healthy elderly men?" Med Sci Sports Exerc 33(8): 1279-86.
- Gajek, J., D. Zysko, et al. (2006). "Influence of tilt training on activation of the autonomic nervous system in patients with vasovagal syncope." Acta Cardiol 61(2): 123-8.
- Gajek, J., D. Zysko, et al. (2006). "Efficacy of tilt training in patients with vasovagal syncope." Kardiol Pol 64(6): 602-8; discussion 609-10.
- Howden, R., J. T. Lightfoot, et al. (2002). "The effects of isometric exercise training on resting blood pressure and orthostatic tolerance in humans." Exp Physiol 87(4): 507-15.
- Lu CC and others. Water ingestion as prophylaxis against syncope. Circulation 2003; 108;2660-2665
- Nazar, K., A. Gasiorowska, et al. (2006). "Effect of 6-week endurance training on hemodynamic and neurohormonal responses to lower body negative pressure (LBNP) in healthy young men." J Physiol Pharmacol 57(2): 177-88.
- On, Y. K., J. Park, et al. (2007). "Is home orthostatic self-training effective in preventing neurally mediated syncope?" Pacing Clin Electrophysiol 30(5): 638-43.
- Parsaik, A., et al. (2012). "Deconditioning in patients with orthostatic intolerance." Neurology 79(14): 1435-1439.
- Reybrouck, T. and H. Ector (2006). "Tilt training: a new challenge in the treatment of neurally mediated syncope." Acta Cardiol 61(2): 183-9.
- Reybrouck, T., H. Heidbuchel, et al. (2000). "Tilt training: a treatment for malignant and recurrent neurocardiogenic syncope." Pacing Clin Electrophysiol 23(4 Pt 1): 493-8.
- Shibata, S., Q. Fu, T. B. Bivens, J. L. Hastings, W. Wang and B. D. Levine (2012). "Short-term exercise training improves the cardiovascular response to exercise in the postural orthostatic tachycardia syndrome." J Physiol 590(Pt 15): 3495-3505.
- Ueno, L. M. and T. Moritani (2003). "Effects of long-term exercise training on cardiac autonomic nervous activities and baroreflex sensitivity." Eur J Appl Physiol 89(2): 109-14.
Verheyden, B., H. Ector, et al. (2008). "Tilt training increases the vasoconstrictor reserve in patients with neurally mediated syncope evoked by head-up tilt testing." Eur Heart J 29(12): 1523-30.
- Van Dijk NV, and others. Effectiveness of physical counterpressure maneuvers in preventing vasovagal syncope: the physical counterpressure manoevres trial (PC-trial). J. Am Coll Cardiol 2006; 48: 1652-1657
Wieling, W., N. Colman, et al. (2004). "Nonpharmacological treatment of reflex syncope." Clin Auton Res 14 Suppl 1: 62-70.
Zion, A. S., R. De Meersman, et al. (2003). "A home-based resistance-training program using elastic bands for elderly patients with orthostatic hypotension." Clin Auton Res 13(4): 286-92.
August 3, 2016
, Timothy C. Hain, M.D.
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August 3, 2016