Clinical Update

doi: 10.1111/joim.12249

Physical countermeasures to increase orthostatic tolerance

W. Wieling1, N. van Dijk2, R. D. Thijs3,4, F. J. de Lange5, C. T. Paul Krediet1 & J. R. Halliwill6
From the 1Department of Internal Medicine, Academic Medical Centre University of Amsterdam, Amsterdam, the Netherlands; 2Family
Medicine, Academic Medical Centre University of Amsterdam, Amsterdam, the Netherlands; 3SEIN – Stichting Epilepsie Instellingen
Nederland, Heemstede, the Netherlands; 4Department of Neurology, Leiden University Medical Centre, Leiden, the Netherlands; 5Cardiology,
Academic Medical Centre University of Amsterdam, Amsterdam, the Netherlands; and 6Department of Human Physiology, University of
Oregon, Eugene, OR, USA

Keywords: blood pressure, cardiac output, muscle pump, orthostatic hypotension, syncope, venous return.

oppose orthostasis. Existing external devices,

Introduction
Standing upright challenges the cardiovascular
system as the pull of gravity displaces about 70%
of the circulating blood volume to below heart level,
much of it to the compliant veins of the dependent
limbs and the pelvic organs. In patients with
autonomic failure due to neurodegenerative dis-
eases, the normal cardiovascular adjustments to
this challenge are impaired, and symptomatic
orthostatic hypotension becomes a common risk
on standing or even sitting quietly. These patients
learn to sway and shift, so that the pumping action
of the muscles can be utilized to counter gravita-
tional displacement of blood by squeezing venous
blood from the legs upward. Augmentation of
venous return in the upright posture can also be
achieved by deliberate tensing of lower limb and
abdominal muscles [1, 2], as depicted in Fig. 1.
These clinical observations were the basis for
physical countermeasures, which are taught to
patients with autonomic failure to combat symp-
tomatic orthostatic hypotension [3–5]. Physical
counterpressure manoeuvres specifically generate
a counterpressure to oppose gravitational venous
pooling (e.g. a single bout of lower-body muscle
contraction to translocate blood centrally and
sustained tensing of the same muscles to prevent
subsequent peripheral pooling in the legs and
abdomen). More recently, it has been shown that
physical counterpressure manoeuvres are also
effective interventions in otherwise healthy sub-
jects with episodic orthostatic syncope due to
neurally mediated (i.e. vasovagal reactions) [6, 7]
or postexercise syncope [8].
In this narrative review, we will primarily consider
these physical counterpressure manoeuvres. Sec-
ondarily, we will describe the broader category of
physical countermeasures that include breathing
manoeuvres and other physical methods, to
which operate through some of the same physio-
logical principles as these manoeuvres, will only be
discussed for proof of principle.
The defining characteristic of the manoeuvres
described in this review is the fact that they can
be employed by patients when a faint is imminent.
This is in contrast to devices such as bandages and
abdominal belts, which require ongoing use to be
effective. We will discuss both early studies in
patient with primary autonomic failure due to
neurodegenerative diseases, as well as more recent
experience obtained in patients with neurally med-
iated syncope. The physiology and pathophysiology
of orthostatic blood pressure control and perfusion
of the brain are key factors in understanding how
physical countermeasures work. These topics have
been reviewed extensively [2, 9–12] and will only be
discussed here briefly.
Physical counterpressure manoeuvres
Muscle tensing
It has been reported that intramuscular pressure is
related to orthostatic tolerance [2]. Henderson
et al. demonstrated that intramuscular pressure
measured in the relaxed biceps muscle was
decreased after prolonged bed rest (38%), following
surgery (35%), during voluntary hyperventilation
(28%) and in the absence of air movement over the
skin (31%) [13, 14]. These conditions are strongly
associated with decreased orthostatic tolerance
and a tendency to faint [2, 15]. In addition,
intramuscular calf pressure has been shown to
be 15–24 and 6–9 mmHg, respectively, in those
without and with a tendency to faint during the
head-up tilt test using a tilt table with a saddle and
suspended legs (Fig. 1) [16].
Although these interesting results from studies
performed in the 1930s and early 1940s have

ª 2014 The Association for the Publication of the Journal of Internal Medicine 69
 W. Wieling et al.
Fig. 1 Effect of whole-body muscle tensing on central
blood volume and increased venous pooling in patients
with decreased intramuscular pressure. Left, mechanical
factors play an important role in promoting venous return
in the upright posture. Whole-body muscle tensing
increases central blood volume, i.e. the amount of blood
available for the heart to pump. Right, intramuscular
pressure in normal ‘non-fainters’ during quite standing
(left) and in patients with tendency to faint (right). From [2];
reproduced with permission.
never been confirmed, it is highly likely that any
increase in muscle tension will function to aug-
ment intramuscular pressure. Intramuscular
pressure can be thought of as a pressure opposing
that within the veins. As such, venous distension
is determined by the difference in the opposing
pressures on each side of the venous wall (i.e. the
venous transmural pressure). Increasing pressure
outside the vein will therefore reduce venous
distension, displacing blood back towards the
heart [2].
During quiet standing, the body behaves more or
less as an inverted pendulum that sways about the
ankles. The static increase in tone of the antigrav-
ity muscles that are involved in maintaining
upright posture also function to oppose venous
pooling in lower limb veins, thereby protecting
central blood volume, i.e. the amount of blood
available for the heart to pump [13, 14, 17–19].
It is considered that postural sway during quiet
standing is able to compensate for otherwise poor
orthostatic tolerance [20, 21]. Along these lines,
Amberson [22] suggested the possibility of a
connection between arterial baroreceptors and
skeletal muscle tone, which could serve to increase
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Clinical Update: Manoeuvres improving orthostatic tolerance
muscle tensing during orthostasis. Although the
precise neural pathway has not been established
[2], recent work by Bernardi et al. demonstrated
that carotid baroreflex modulation influences pos-
tural sway [23].
The first reports of the application of skeletal
muscle tensing to prevent fainting reactions were
from psychologists interested in the prevention of
fainting reactions due to haemophobia. In the
1980s Ost € and Sterness reported that ‘applied
tension’ could be used as a behavioural method
for treatment of this phobia [24], but the physio-
logical mechanisms underlying its effect remained
poorly understood due to the lack of haemodynamic
measurements. However, the development in the
early 1990s of the Penaz-Wesseling volume-clamp
method, combined with the computation of stroke
volume by pulse wave analysis, commercially avail-
able as the Finapres device, enabled clinical
researchers to combine the experiences of individ-
ual patients with continuous noninvasive measure-
ments of beat-by-beat changes in arterial pressure
[25, 26]. As a result, the underlying haemodynam-
ics of a wide range of movements that simulated
every day activities could be investigated, first in
patients with symptomatic orthostatic hypotension
due to autonomic failure [1, 3] and in recent years
as a countermeasure to avert an impending vaso-
vagal faint. Single case reports were published at
first [1, 27–31]. Figure 2 shows an example of such
work, in which the combination of leg crossing and
leg muscle tensing is effective in counteracting an
impending vasovagal syncope [32].
Further evidence came from a study by Krediet
et al., which included 20 patients [6]. This work
confirmed that the combination of leg crossing and
leg muscle tensing depicted in Fig. 2 is highly
effective. A rise in blood pressure was observed in
all 20 subjects, and the vasovagal reaction was
averted in five of these individuals. The remaining
15 subjects were able to postpone the faint by an
average of 2.5 min. Patients who could completely
abort the faint started the manoeuvre at a signif-
icantly higher blood pressure level than those
patients who could not (79/51 vs. 61/41 mmHg).
In a study focusing on the underlying haemody-
namic mechanism, Krediet et al. [33] demonstrated
that physical counterpressure manoeuvres such as
leg crossing, muscle tensing, squatting and the
crash position are effective against vasovagal reac-
tions solely through increases in cardiac output as
shown in Fig. 3.
 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance
Fig. 2 Aborting a vasovagal faint by the combination of
leg crossing and muscle tensing. Typical vasovagal syn-
cope in a 24-year-old male subject with recurrent syncope
during orthostatic stress testing on a tilt table. After
crossing of the legs and tensing of leg and abdominal
muscles (+) with the patient remaining in the standing
position, blood pressure and heart rate quickly recover.
The delay in the increase in blood pressure of about five
beats is explained by the transit delay of the venous return
through the pulmonary circulation. HR, heart rate; BP,
blood pressure; bpm, beats/min. From [32]; reproduced
with permission.
During the manoeuvres involving muscle tensing,
cardiac output increased by a factor of 1.3–1.7
from the low levels during presyncope and was
restored to 95–104% of the stable values recorded
in the head-up position in the first few minutes of
tilt [33]. Systemic vascular resistance responses
varied, but remained largely unchanged. Because
lower-body muscle tensing is accompanied by a
threefold increase in leg blood flow [34], a counter-
acting presumably reflex-mediated vasoconstric-
tion must occur in other parts of the circulation,
such as the nonworking muscle, kidney and
splanchnic vascular beds.
The rise in cardiac output during muscle tensing is
largely attributed to mechanical and not to auto-
nomic effects. The change in cardiac output as
produced by leg crossing with muscle tensing is
strikingly similar to that which is produced by
inflation of an antigravity suit, which is similarly
effective at aborting an impending vasovagal faint
(see Fig. 4) [35]. This reinforces the notion that the
physiological effects of muscle tensing are mainly
mechanical.
However, an instantaneous increase in heart rate
(see Figs 2 and 3) was also observed during muscle
tensing. This indicates that autonomic effects are
present as well. The instantaneous increase in
heart rate at the onset of muscle tensing is a reflex
effect produced by a combination of the muscle
mechanoreflexes and central command with inhi-
bition of cardiac vagal tone [26]. Such chronotropic
changes at the onset of exercise are generally
associated with concurrent increases in cardiac
contractility, which may contribute to the
increased cardiac output [33].
It is worth noting that forceful arm tensing
manoeuvres, i.e. hand gripping at maximal volun-
tary force using a rubber ball and arm tensing by
gripping one hand with the other and abducting
both the arms at the same time [7, 36, 37], are also
effective if they are accompanied by whole-body
muscle tensing and thereby by an increase in
cardiac output. Isometric arm exercises without
tensing of large lower-body muscle groups are far
less effective and cannot prevent an impending
vasovagal faint [6, 38].
Muscle pumping
Activation of the muscle venous pump of the legs
during tiptoeing or walking, in the presence of
competent venous valves, pumps blood back to
the heart and partially restores cardiac filling
pressure. The leg muscle pump can be considered
as a ‘second heart’ [2] and is capable of translo-
cating blood against a substantial pressure
gradient (e.g. >90 mmHg). Manoeuvres that use
skeletal muscle pumping are heel raises (i.e.
plantar flexion; rising on the toes using calf
muscles to raise heels off the floor) and repeated
knee flexion (i.e. marching in place) [4, 16, 39].
However, their effects on standing blood pressure
in patients with autonomic failure vary. The
variable responses may stem from differences in
the degree of sympathetic vasomotor failure in
these patients [40, 41].
Bending
Knowledge that bending forward can mitigate
orthostatic hypotension dates back to the 1930s
[42] i.e. to the time of the first description
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 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance

Fig. 3 Haemodynamics underlying blood pressure rise induced by muscle tensing. Typical vasovagal syncope in a 21-
year-old female subject with recurrent vasovagal syncope during tilt-table testing [head-down tilt (HDT), i.e. supine; head-up
tilt (HUT), i.e during orthostatic stress]. Leg crossing combined with muscle tensing (first grey bar) and lower-body muscle
tensing without leg crossing (second grey bar) are very effective in aborting vasovagal faints. The haemodynamic effect is
mediated by an increase in cardiac output (CO), as systemic vascular resistance (SVR) remains largely unchanged. BP,
blood pressure; HR, heart rate; SV, stroke volume. SV,CO and SVR are represented as percentage (%) from baseline i.e.
mean values over 2.5–3 min after HUT. From [33]; reproduced with permission.

It is a useful manoeuvre for patients with auto-

ECG
nomic failure to increase blood pressure in the
160 mmHg
RESP.
upright posture, as has been reported by many
investigators [1, 41, 43] and is shown in Fig. 5.

BRACHIAL The beneficial effect of bending forward in patients

ARTERY with autonomic failure can be ascribed to pro-
CARDIAC nounced abdominal compression and to lowering
OUTPUT

O
CVP 5 cmH O
2
Fig. 4 Aborting a vasovagal faint following inflation of
antigravity suit to 60 mmHg. Note the progressive fall in
intra-arterial pressure (trace labelled ‘Brachial artery’).
Blue highlighting indicates the period of inflation. Central
venous pressure (CVP) increases immediately after infla-
tion. The increase in blood pressure is delayed by about
3 s due to the transit time from the right to the left ventricle
(as in Fig. 3). The increase in blood pressure was solely
explained by the increase in cardiac output (increase by a
factor of 1.4). ECG, electrocardiogram; Resp., respiration.
From [35]; reproduced with permission.
of patients with idiopathic orthostatic hypoten-
sion in the English literature by Bradbury and
Eggleson.
the head to heart level. Abdominal compression
squeezes blood from the compliant splanchnic
venous pool towards the heart, resulting in an
increase in cardiac output and thereby in arterial
pressure [44, 45]. Additionally, lowering the head
to heart level shortens the hydrostatic column
between the heart and the brain instantaneously
by 25–30 cm corresponding to a hydrostatic pres-
sure increase of 15–20 mmHg in mean blood
pressure [11].
In patients prone to vasovagal syncope, bending
forward is also reported to be a useful manoeuvre
to increase orthostatic tolerance. Treatment of
fainting patients traditionally consists of lowering
the head between the knees whilst sitting (Fig. 6)
[46–49]. Likewise, bending forward with hands on
knees appears to be a preferred position for many

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 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance

Fig. 5 Effects of bending forward on blood pressure. Tracing obtained in a 24-year-old female patient with autonomic
failure and debilitating orthostatic hypotension. Orthostatic blood pressure response without (upper panel) and with
abdominal compression and bending the head (lower panel). Line marked ‘standing’ indicates the duration of the period of
standing. Note in the lower panel the increases both in mean arterial pressure and in pulse pressure during abdominal
compression and bending the head. From [1]; reproduced with written informed consent of the patient and permission from
the publisher.

athletes during recover from vigorous physical
activity.
Leg crossing
The beneficial effect of leg crossing in patients with
autonomic failure (Fig. 7) [1, 43, 50, 51] has been
attributed to mechanical compression of the veins
in the legs, buttocks and abdomen, which dis-
places gravitationally pooled blood towards the
heart and increases thoracic blood volume [39, 52,
53]. This results in an increase in cardiac filling
pressure, stroke volume and cardiac output, effec-
tively correcting the symptom-causing reductions
in systemic arterial pressure and cerebral blood
flow.
When leg crossing is practiced routinely, standing
systolic/diastolic blood pressure can be increased
by ~20/10 mmHg in patients with autonomic fail-
ure [3, 4, 9, 39, 43]. Even such a small rise in
upright blood pressure may be clinically impor-
tant, as it may shift mean arterial pressure from
just below to just above the critical level of perfu-
sion of the brain [10]. Larger increases of ~30/
15 mmHg can be seen when leg crossing is com-
bined with the additional tensing of the leg mus-
culature, thighs and buttocks.
Leg crossing improves orthostatic tolerance in
healthy subjects as well as in patients with vaso-
vagal fainting [27, 54–56]. When standing for
prolonged periods, healthy humans who have a
tendency to faint often unknowingly utilize this leg
crossing countermeasure (i.e. the ‘cocktail party
posture’ serves a physiological purpose).
Sitting
By sitting down, the orthostatic load due to grav-
itational displacement of blood is decreased,
resulting in increases in venous return, stroke
volume and cardiac output and thereby blood
pressure is increased [57, 58]. Portable chairs have
been shown to be quite useful for patients who are
severely incapacitated by their orthostatic symp-
toms [59]. We have shown that the beneficial effect
of sitting is greater, i.e. blood pressure increases
more, when using lower portable chairs [60]. A
chair height of about 40 cm may be optimal for

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 W. Wieling et al.
Fig. 6 Manoeuvres to combat vasovagal syncope. A 32-
year-old female patient underwent cardiovascular reflex
assessment for recurrent syncope and presyncope of
vasovagal origin. A vasovagal reaction with prodromal
pallor and sweating occurred whilst the patient was
standing in the cardiovascular laboratory. The patient
sat down with her head between her knees (crash
position) (upper panel). After standing up, the hypotension
returned and the patient squatted (middle panel). After
standing up from squatting, when hypotension returned
again, she was instructed to cross her legs and tense leg,
buttock and abdominal muscles (lower panel), which
successfully aborted the presyncope. BP, blood pressure.
From [49]; reproduced with permission.
many patients, being effective in raising blood
pressure and yet not so low as to cause difficulty
in rising, although this may be more of a concern
for patients with neurodegenerative diseases with
motor disability [9, 59]. Leg crossing can increase
seated systolic blood pressure considerably in
patients with autonomic failure (Fig. 7) [5, 60,
61], whereas the effects in healthy normotensive
subjects (on average <2 mmHg) and patients with
hypertension (on average <7 mmHg) are small [62].
Cheshire has reported an interesting phenomenon,
observed in six patients with autonomic failure, of
an urge to produce leg movements in the sitting
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Clinical Update: Manoeuvres improving orthostatic tolerance
position; these movements were effective at
increasing seated blood pressure. This ‘hypoten-
sive akathisia’ appeared to be habitual and could
be transiently suppressed, yet felt irresistible to the
patients [5].
Squatting
Squatting, which is a combination of sitting,
bending and increased muscle tone, expresses
blood out of the leg venous vessels, thereby rapidly
restoring venous return, cardiac filling pressure
and cardiac output (Fig. 6) [33, 63, 64]. The
temporary hindrance to blood flow to the legs
caused by physical compression or kinking of
blood vessels is thought to increase systemic
vascular resistance mechanically as well, but this
issue is debated [65]. There are two varieties of the
squatting posture. In the first, the body is vertical,
with the weight resting on the balls of the feet and/
or the toes and with the calves strongly pressed
against the back surface of the thighs. In the
second, the body is inclined forward, with the feet
flat on the floor. The latter is reported to have a
stronger effect in most subjects [46], but might be
considered difficult by the less athletic. It is worth
noting that the greater the amount of blood pooled
in the lower limbs, the more robust the effect of
squatting [46]. In patients with autonomic failure,
squatting is a useful manoeuvre when syncope is
imminent [18] as it increases blood pressure and
cerebral blood flow almost instantaneously (Fig. 7).
It can produce an increase in systolic and diastolic
blood pressure of about 60 mmHg and 35 mmHg,
respectively, in these patients [1, 4, 9].
Squatting is also very effective for aborting an
imminent vasovagal faint (Fig. 6). Suspension with
a double-strop device imitating squatting is used
as a position that secures venous return during
helicopter rescue transportation [66]. A drawback
of squatting is that patients may have difficulty in
returning to standing from this position. They may
experience orthostatic lightheadedness due to a
rapid fall in pressure during the transition [67–70].
This fall in pressure occurs primarily because of
the sudden increase in blood flow to the legs due to
vasodilatation of resistance vessels as the result of
the brief large muscular effort to stand up from
squatting, with widening of the local arterial–
venous pressure gradient and removal of the
physical hindrance of blood flow to the legs (reac-
tive hyperaemia) as additional factors [69]. The
accelerative force during standing up from squat-
 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance
FINAP (mmHg)

FINAP (mmHg)
200 200

100 100

0 0
0 60 120 0 60 120
Time (s) Time (s)

FINAP (mmHg)
200
FINAP (mmHg)

200

100 100

0 0
0 60 120
0 60
Time (s) Time (s)

Fig. 7 Physical countermanoeuvres using isometric contractions of the lower limbs and abdominal compression in a patient
with autonomic failure. The effects on finger arterial blood pressure (FINAP) of leg crossing in standing and sitting positions,
placing a foot on a chair and squatting in a 54-year-old male patient with pure autonomic failure and debilitating orthostatic
hypotension. The patient was standing (or sitting) quietly prior to the manoeuvres. Bars indicate the duration of the
manoeuvres. Note the increase in blood pressure and pulse pressure during the manoeuvres. From [32]; reproduced with
written informed consent from the patient and permission from the publisher.

ting may play an additional role [71]. The fall in

Effects of breathing manoeuvres
pressure upon arising from squatting can be exac-
erbated if the patient strains during the transition Although the main focus of this review is the
thereby decreasing venous return and further physical counterpressure manoeuvres that directly
reducing stroke volume and cardiac output [11]. oppose gravitational venous pooling, it is worth
Muscle tensing, such as clenching the buttocks or discussing several breathing-related physical
immediately walking upon standing, may reduce countermeasures that appear to indirectly benefit
this problem (Fig. 8) [68, 69]. cardiovascular stability in the upright individual
via action on the respiratory pump.
Other postures
Intrathoracic and intra-abdominal pressures dem-
The beneficial effects of sitting in a knee-chest onstrate counterpoised oscillations with breath-
position [46, 49, 72] or placing one foot on a ing, such that intrathoracic pressure decreases
chair whilst standing [46, 73] are comparable to during inspiration whilst intra-abdominal pres-
squatting (Fig. 7). It is clear that lying down sure increases. This pumps blood towards the
(preferably with raised legs) is also a very effective heart through the abdominal region during inspi-
intervention in case of an impending orthostatic ration, as veins in the iliac and femoral veins
faint [74]. prevent retrograde flow out of the abdomen when

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Journal of Internal Medicine, 2015, 277; 69–82
 W. Wieling et al.
Fig. 8 Effects of lower-body muscle tensing on the fall in
blood pressure on standing from squatting after vasovagal
fainting. Six consecutive squatting and standing manoeu-
vres are depicted in a patient with recurrent vasovagal
syncope. The patient was studied directly after a tilt-table-
induced vasovagal faint. White bars indicate squatting,
grey bars indicate standing without lower-body tensing
and black bars indicate standing with lower-body muscle
tensing. BP, blood pressure. From [68]; reproduced with
permission.
this region is compressed by inspiratory efforts.
The negative intrathoracic pressure further facili-
tates venous return from the abdomen, as well as
augmenting return from the upper limbs and head
[2]. The large oscillations in peripheral venous
return to the heart that are generated by this
respiratory pump are buffered during normal
breathing by the splanchnic circulation, as the
hepatic vein is compressed to the point of occlu-
sion by the diaphragm during inspiration, but in
turn will release pooled blood during expiration
when the vein is decompressed [75]. The net result
is that preload on the heart is somewhat enhanced
during inspiration, but still maintained during
expiration with normal breathing. With rib-cage-
only breathing, intra-abdominal pressure no
longer rises with inspiration, and the primary
effect is augmented venous flow into the thorax
during inspiration [76].
It appears that humans are ‘wired’ to take advan-
tage of this respiratory pump during orthostatic
challenge, as deep inspirations and sighs are
common precedents to faints and may serve to
augment venous return. Such sighs and gasps may
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Journal of Internal Medicine, 2015, 277; 69–82
Clinical Update: Manoeuvres improving orthostatic tolerance
also promote vasoconstriction and venoconstric-
tion in the skin [77]. Indeed, recent findings by
Lucas et al. suggest that slow deep breathing in the
absence of hyperventilation may improve ortho-
static tolerance [78].
Negative-pressure breathing and inspiratory resistance
Manipulation of intrathoracic pressure, designed
to take advantage of the action of the endogenous
respiratory pump, can be affected by changing
breathing patterns and breathing resistances.
Early work by Weissler et al. demonstrated that
negative-pressure breathing (inspiring and expir-
ing against a slight vacuum of 16–19 mmHg) was
an effective means to reverse or protect against
experimentally induced orthostatic vasovagal syn-
cope [35]. More recent refinement of this concept
has been the development of an impedance thresh-
old device (ITD) for treatment of severe haemor-
rhage and as an adjunct to cardiopulmonary
resuscitation, CPR. In spontaneously breathing
subjects, this commercially available device pre-
vents inspiration until a negative pressure of 7
cmH2O (~5 mmHg) has been generated at the
mouth by greater inspiratory effort, and thus
creates a more negative intrathoracic pressure
during the inspiratory phase, but with minimal
effect on expiration.
In healthy subjects, use of an ITD has been shown
to increase tolerance to simulated haemorrhage
(lower-body negative pressure) [79], increase ortho-
static tolerance during free standing [80], reduce
orthostatic hypotension during a squat/stand test
[81] and increase tolerance to upright tilt following
1 min of all-out sprinting on a cycle ergometer
against a high resistance [82], as illustrated in
Fig. 9. The use of an ITD also has been shown to be
beneficial in subjects with a tendency towards
vasovagal syncope) [80]. In patients with auto-
nomic failure, use of an ITD augments standing
blood pressure by ~8 mmHg [83]. The notion that
this additional circulatory pump is under volitional
control prompted the study of other manoeuvres,
without the use of a device, including inspiratory
sniffing and inspiration through pursed lips. How-
ever, responses across patients were more variable
than with the ITD, as the voluntary breathing
manoeuvres sometimes resulted in concomitant
hypocapnia and hypotension, due to inadvertent
hyperventilation. Hypocapnia causes vasodilata-
tion in skeletal muscle and vasoconstriction in the
brain and can induce syncope in patients with
 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance

Fig. 9 Effects of inspiratory resistance on recovery from vigorous exercise. Inspiratory resistance generated by an
impedence threshold device (right panel) versus control (left panel) during upright recovery from 1 min of vigorous sprinting
on a cycle ergometer against a high resistance in a healthy subject. The subject became symptomatic during control
breathing but not when using the device. Note the increase in arterial and pulse pressures as well as cerebral tissue
oxygenation index when inspiring against the resistance, and the oscillations in both arterial pressure and stroke volume
generated by the enhanced respiratory pump (Lacewell et al. 2013, unpublished data).

autonomic failure [84, 85]. Thus, voluntary inspi-
ratory sniffing and inspiration through pursed lips
can also reduce orthostatic hypotension with the
important caveat that hyperventilation must be
avoided [83]. This highlights the importance of
training and feedback in the use of many counter-
measures.
It is worth noting that use of inspiratory resis-
tance, either by means of a device or by breathing
through pursed lips, may generate additional
benefits beyond the primary effects on venous
return. Along these lines, it appears that inspiring
against resistance resets the operating point of
the arterial baroreflex towards higher pressures,
akin to what happens during exercise. This may
provide an advantage for defending against hypo-
tension. It has also been suggested that inspira-
tory resistance may increase cerebral blood flow
independent of changes in arterial pressure. From
animal studies, it is clear that breathing against
an inspiratory resistance will lower intracranial
pressure [86], which is inversely related to cere-
bral vascular resistance owing to the Starling
resistor effect. In addition, negative intrathoracic
pressures may augment cerebral blood flow via a
siphon effect, although the presence of a func-
tional cerebral siphon in upright humans remains
controversial (as discussed by Lacewell et al.
[82]). Further refinements related to purposeful
slow deep breathing [78] or use of rib-cage-only
versus diaphragmatic breathing need to be
explored [76].
Physical countermanoeuvres: from single observations and small
series to clinical trials
When physical countermanoeuvres were applied in
the early small, open-design patient series (n = 19–
29) under conditions of daily living, excellent
outcomes were reported during long-term follow-
up (6–21 months) [6, 7, 36]. Next, the multicentre
PC trial was performed [87], in which patients were
recruited in 15 medical centres worldwide. The PC
trial included 223 patients, aged 16–70 years, with
recurrent vasovagal syncope (at least three epi-
sodes in the past 2 years, or at least one syncopal
spell and at least three presyncopal episodes in the
past year, and recognizable symptoms). The trial
assessed the effect of adding physical counterpres-
sure manoeuvres (either arm tensing or leg cross-
ing) to conventional therapy (explanation of
underlying mechanisms of vasovagal syncope, life-
style modification advice using an information
leaflet). There was a 36% relative risk reduction
for syncope in the physical counterpressure group
versus conventional therapy (Fig. 10). It should be
noted that 35% of the patients did not have
sufficiently long prodromes to benefit from the
manoeuvres. The relative risk reduction of 36% is
amongst the largest seen in a randomised con-
trolled trial of any therapy for vasovagal syncope.

ª 2014 The Association for the Publication of the Journal of Internal Medicine 77
Journal of Internal Medicine, 2015, 277; 69–82
 W. Wieling et al.
Log rank statistic P = 0.018
Hazard ratio 0.59 (0.38–0.92).
Fig. 10 Difference in syncope-free survival between
patients treated with physical counterpressure manoeu-
vres (PCM) compared to treatment as usual (conventional)
in the PC trial. The Kaplan–Meier curve shows that the 106
patients treated with PCM were significantly less likely to
experience a recurrent syncopal episode than the 117
patients treated as usual (32% vs. 51%). From [87];
reproduced with permission.
In the study by Croci et al., counterpressure
manoeuvres were not effective in patients
>65 years of age [36]; however, the number of
patients involved was small and, under laboratory
conditions, the pressor effect of muscle tensing in
fit elderly subjects is at least as great as in young
subjects [54]. Squatting was not part of the count-
erpressure manoeuvres in the PC trial, but its great
effectiveness under laboratory conditions is clear.
Thus, an additional large prospective randomized
controlled trial is not needed [88].
Teaching physical countermanoeuvres
The subtle but significant effects of physical count-
erpressure manoeuvres, such as leg crossing or
squatting, on a low standing blood pressure are
difficult to monitor by sphygmomanometer. A con-
tinuous (ambulatory) noninvasive blood pressure
device, such as Finapres [25, 26], enables quanti-
fication of their effects in detail. The changes in
blood pressure can be demonstrated immediately
to a patient by showing the finger blood pressure
tracing on a video screen in the doctor’s surgery.
78 ª 2014 The Association for the Publication of the Journal of Internal Medicine
Journal of Internal Medicine, 2015, 277; 69–82
Clinical Update: Manoeuvres improving orthostatic tolerance
This biofeedback will demonstrate to patients the
effectiveness of their manoeuvres and will also help
to select effective manoeuvres and to relate symp-
toms to actual blood pressure readings. Patients
can thereby practise applying the manoeuvre effec-
tively whilst being coached, possibly by a specialist
nurse practioner [4, 32].
Physical countermanoeuvres often need to be
modified specifically for individual patients
depending on their abilities. They may be hard to
perform in patients with multiple system atrophy.
In the elderly, crossing the legs and pressing them
together may lead to destabilisation, causing them
to fall over. However, the buttock-clenching
manoeuvre is often possible in the elderly [3]. In
our experience, this manoeuvre is effective to
combat initial orthostatic hypotension.
Patients should be instructed in how to perform
muscle tensing without raising intrathoracic pres-
sure, as raising intrathoracic pressure impedes
venous return to the heart and may cause blood
pressure to drop and lead to lightheadedness in
patients with neurogenic orthostatic hypotension
[11]. Patients should also be advised to avoid deep
breathing and consequent hypocapnia during
physical manoeuvres, because hypocapnia causes
vasodilatation in skeletal muscle and vasoconstric-
tion in the cerebral vessels both in patients with
autonomic failure and in those with a tendency to
vasovagal fainting [84, 85, 89]. Close observation
whilst practising the manoeuvres may be useful to
alert patients to this habit.
A great advantage of physical countermanoeuvres
is that they can be applied instantaneously at the
moment of symptomatic low upright pressure.
They thereby give the patient the opportunity to
regain self-confidence in provocative situations.
Gradual exposure to specific provocative condi-
tions may be of use to regain self-confidence.
Patients may benefit from practising leg and
lower-body muscle tensing whilst standing motion-
less each morning as part of their daily routine
[32]. A video demonstrating useful counterpres-
sure manoeuvres and illustrating the direct effect
they have on blood pressure is available on the
patient website www.stars.org.uk.
We have found the following practical patient
recommendations to be helpful (Table 1). First,
apply leg crossing or skeletal muscle pumping
using heel raises or marching in place as a
 W. Wieling et al. Clinical Update: Manoeuvres improving orthostatic tolerance
Table 1 Practical patient recommendations for manoeuvres
to increase low blood pressure on standing
Preventive measures
Leg crossing
Skeletal muscle pumping using heel raises or marching
in place
Combatting symptomatic orthostatic hypotension
Bending forward
Leg muscle or buttock clenching
Whole-body muscle tensing, e.g. with arm tensing
Skeletal muscle pumping using heel raises or marching
in place
Slow deep breathing
Combatting initial orthostatic hypotension
Buttock clenching
Emergency countermeasure in case of an impending faint
Squatting
Bending over as if to tie shoe laces
Sitting with head between the knees (crash position)
Lying down with raised legs
A video with instructions for patients and additional
lifestyle measures for patients with orthostatic intoler-
ance can be found at www.syncopedia.org and www.
stars.org.uk, respectively.
preventive measure. Leg crossing has the advan-
tage that it can be performed casually without
much effort and without drawing attention to
oneself. With proper instruction and practice,
many patients will begin to automatically apply
leg crossing in daily life to prevent the feeling of
lightheadedness or faints during quiet standing.
Leg crossing can also be used to prevent these
symptoms in the sitting position in patients with
reflex syncope (Wieling and Krediet, unpublished
observations).
Secondly, when leg crossing is insufficient to
prevent symptoms, patients can try adding leg
muscle tensing and buttock clenching. Whole-body
muscle tensing, for example with arm tensing by
gripping one hand with the other and abducting
both the arms at the same time, can also be used.
Buttock clenching is also very effective to combat
orthostatic hypotension upon standing (initial
orthostatic hypotension).
Finally, squatting, which is the most effective
physical manoeuvre to increase blood pressure,
can be used as an emergency measure to prevent
losing consciousness when fainting symptoms
develop rapidly. Likewise, bending over as if to tie
shoe laces has similar effects to squatting and is
simpler to perform by elderly patients [1, 18]. When
arising again from the squatted position, patients
should immediately sit down or begin lower-body
muscle tensing to prevent the return of symptoms
(Fig. 8 [68]).
Conclusion
The beneficial effect of physical countermeasures,
based on the keen observations of astute clinicians
in the first half of the 20th century, is an excellent
example of how therapies that help many patients
may be based on clinical observations in small
groups or even individual patients [90, 91]. In
summary, physical countermeasures are simple,
inexpensive techniques that have a strong biolog-
ical rationale based on experiments conducted in
the physiology laboratory. These techniques can be
applied instantaneously at the moment of symp-
tomatic low upright pressure. Furthermore, they
are clinically effective evidence-based interventions
without side effects that improve quality of life in
patients with orthostatic intolerance.
Conflict of interest statement
There are no conflicts of interest.
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Correspondence: Wouter Wieling, Academic Medical Center at the
University of Amsterdam, Department of Medicine, Room F4-221;
Meibergdreef 9, PO Box: 22700, 1100 DE Amsterdam, the
Netherlands.
(fax: +31-20-6919658; e-mail W.Wieling@amc.uva.nl).
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