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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: October 12, 2014

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. .

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 this methodology is useful in treating syncope.

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.

Method of Tilt Training:

We will describe the protocol of Abe et al (2003).

Physical Countermeasures

There are also physical countermeasures for an impending faint. 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).

Physical conditioning.

Nearly all patients with orthostatic intolerance are deconditioned (Parsaik et al, 2014). This provides a strong rationale for conditioning -- i.e. building up muscle strength, in orthostatic intolerance. This might be productively combined with tilt training. There are many exercise regimens that can be accomplished safely in pateints at risk of falling (i.e. mainly sitting or lying down) that can build strength.


Tilt training is a useful method of treating recurrent fainting spells.


Copyright April 21, 2015 , Timothy C. Hain, M.D. All rights reserved. Last saved on April 21, 2015