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: November 8, 2009

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).

• All patients first undergo tilt-table testing to measure their starting performance.
• A home program consisting of twice a day regime for up to 30 minutes each session
  • 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.
  • Exercises are also done to improve lower extremity tone and strength
• After the training is completed (4 weeks), a follow up tilt-table test is performed at the same time of day as the initial training.
• If syncope is not induced by the repeat tilt-table test, the training is reduced to once/day.

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).

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

Comment:

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

References:

• 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.
• 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.
• 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.
  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.