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==Patient education of physical countermanoeuvres using continuous on-screen blood pressure monitoring==
''N. van Dijk, C.T.P. Krediet and W. Wieling''<br/>
''N. van Dijk, C.T.P. Krediet and W. Wieling''<br/>
''Department of Medicine. Academic Medical Centre, University of Amsterdam. Amsterdam (The Netherlands)''<br/>
''N. van Dijk, C.T.P. Krediet and W. Wieling Department of Medicine. Academic Medical Centre, University of Amsterdam. Amsterdam (The Netherlands)''<br/>


A 49-year old male with a clinical history of recurrent vasovagal syncope underwent tilt table testing. Blood pressure was measured continuously and its tracing was shown on a 15 inch computer monitor placed next to the tilt table. The provoked vasovagal reaction was counteracted by leg crossing and tensing of leg, abdominal and buttock muscles (+) while in head-up tilt position. The effect was reproducible.  
A 49-year old male with a clinical history of recurrent vasovagal syncope underwent tilt table testing. Blood pressure was measured continuously and its tracing was shown on a 15 inch computer monitor placed next to the tilt table. The provoked vasovagal reaction was counteracted by leg crossing and tensing of leg, abdominal and buttock muscles (+) while in head-up tilt position. The effect was reproducible.  
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===Editor’s Comment===
===Editor’s Comment===
Patients with recurrent posture related vasovagal syncope have found leg crossing with lower body muscle tensing, isometric arm counter-pressure and squatting to be simple manoeuvres to combat orthostatic symptoms, i.e. hypotension [1, 2]. Instruction in these physical countermanoeuvres is part of the therapeutic program for our patients (See Tutorial Countermeasures ).
Patients with recurrent posture related vasovagal syncope have found leg crossing with lower body muscle tensing, isometric arm counter-pressure and squatting to be simple manoeuvres to combat orthostatic symptoms, i.e. hypotension <cite>Wieling</cite><cite>Wieling2</cite>. Instruction in these physical countermanoeuvres is part of the therapeutic program for our patients (See Tutorial ). .


Training enhances the effectiveness of leg crossing and muscle tensing 3]. Biofeedback on the performance of the physical countermanoeuvres can be obtained using continuous blood pressure recordings displayed on a computer screen [1,2]. During such sessions patients can directly observe the effects of the manoeuvres on their blood pressure.  
Training enhances the effectiveness of leg crossing and muscle tensing [9]. Biofeedback on the performance of the physical countermanoeuvres can be obtained using continuous blood pressure recordings displayed on a computer screen (e.g. FinapresTM, Finometer)<cite>Wieling</cite><cite>Wieling2</cite>. During such sessions patients can directly observe the effects of the manoeuvres on their blood pressure.  


Training of physical countermanoeuvres can also be performed during tilt-table testing. When vasovagal syncope is induced for diagnostic purposes, patients can apply manoeuvres to postpone or even abort the episode. The laboratory circumstances provide them with maximal confidence in the possibilities of the manoeuvres to abort a faint (Figure).  It is advisable to instruct patient on the manoeuvres and let them practice before starting the tilt-table test.
Training of physical countermanoeuvres can also be performed during tilt-table testing. When vasovagal syncope is induced for diagnostic purposes, patients can apply manoeuvres to postpone or even abort the episode. The laboratory circumstances provide them with maximal confidence in the possibilities of the manoeuvres to abort a faint (Figure).  It is advisable to instruct patient on the manoeuvres and let them practice before starting the tilt-table test.
We suggested earlier that patients may benefit from practicing legcrossing and lower body muscle tensing while standing motionless each morning as part of their daily routine [ 1] (i.e. when brushing their teeth) to prevent delay because of problems remembering them when they are needed.


We suggested earlier that patients may benefit from practicing legcrossing and lower body muscle tensing while standing motionless each morning as part of their daily routine<cite>Wieling</cite> (i.e. when brushing their teeth) to prevent delay because of problems remembering them when they are needed.
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==References==
==References==
<biblio>
<biblio>
#Wieling Parts of this case were published earlier: Wieling W, Colman N, Krediet CT, Freeman R. Nonpharmacological treatment of reflex syncope. Clin Auton Res. 2004; 14 Suppl 1: 162-170. We thank Springer Verlag (Darmstadt, Germany) for permitting this reproduction.  
#Wieling Parts of this case were published earlier: Wieling W, Colman N, Krediet CT, Freeman R. Nonpharmacological treatment of reflex syncope. Clin Auton Res. 2004; 14 Suppl 1: 162-170. We thank Springer Verlag (Darmstadt, Germany) for permitting this reproduction.  
#Wieling2 pmid=24697914
#Wieling2 pmid=24697914  
#Bouvette pmid=8790259
#Bouvette pmid=8790259
</biblio>
</biblio>
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