Teaching counter pressure maneouvres

N. van Dijk, C.T.P. Krediet and W. Wieling
N. van Dijk, C.T.P. Krediet and W. Wieling Department of Medicine. Academic Medical Centre, University of Amsterdam. Amsterdam (The Netherlands)

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. Then he was asked to stop the countermanoeuvre and step off the tilt table, upon which vasovagal symptoms returned. Standing next to the tilt table he was educated on the application of physical countermanoeuvres in front of a computer video screen. Leg crossing with muscle tensing (+); squatting and sitting down with legs crossed were practiced to combat vasovagal hypotension. During this training session the continuous blood pressure tracing on the computer video screen was used as feedback to instruct the patient to perform the manoeuvres effectively.

Fig 1. Continuous blood pressure recordings during manoeuvres (see text).

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 ). .

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)[1][2]. 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.

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.

References

1. 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.

2. Wieling W, van Dijk N, Thijs RD, de Lange FJ, Krediet CT, and Halliwill JR. Physical countermeasures to increase orthostatic tolerance. J Intern Med. 2015 Jan;277(1):69-82. DOI:10.1111/joim.12249 |
3. Bouvette CM, McPhee BR, Opfer-Gehrking TL, and Low PA. Role of physical countermaneuvers in the management of orthostatic hypotension: efficacy and biofeedback augmentation. Mayo Clin Proc. 1996 Sep;71(9):847-53. DOI:10.4065/71.9.847 |