Tilt Training for Orthostatic Hypotension and Syncope

This page is primarily intended to be a reference for patients who have been referred for therapy. 

Timothy C. Hain, MD

Click here for the main vestibular rehabilitation page. • Page last modified: March 2, 2021

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).

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.

Physical Countermeasures

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).

squat leg cross tense hands
Squa maneuver (from Benditt and Nguyen, 2009). Leg cross maneuver (from Benditt and Nguyen, 2009). Hand tense maneuver (from Benditt and Nguyen, 2009).