Counter pressure maneuvers for syncope prevention: A semi-systematic review and meta-analysis

Abstract

Physical counter pressure maneuvers (CPM) are movements that are recommended to delay or prevent syncope (fainting) by recruiting the skeletal muscle pump to augment cardiovascular control. However, these recommendations are largely based on theoretical benefit, with limited data evaluating the efficacy of CPM to prevent syncope in the real-world setting. We conducted a semi-systematic literature review and meta-analysis to assess CPM efficacy, identify literature gaps, and highlight future research needs. Articles were identified through a literature search (PubMed, April 2022) of peer-reviewed publications evaluating the use of counter pressure or other lower body maneuvers to prevent syncope. Two team members independently screened records for inclusion and extracted data. From 476 unique records identified by the search, 45 met inclusion criteria. Articles considered various syncopal conditions (vasovagal = 12, orthostatic hypotension = 8, postural orthostatic tachycardia syndrome = 1, familial dysautonomia = 2, spinal cord injury = 1, blood donation = 10, healthy controls = 11). Maneuvers assessed included hand gripping, leg fidgeting, stepping, tiptoeing, marching, calf raises, postural sway, tensing (upper, lower, whole body), leg crossing, squatting, “crash” position, and bending foreword. CPM were assessed in laboratory-based studies (N = 28), the community setting (N = 4), both laboratory and community settings (N = 3), and during blood donation (N = 10). CPM improved standing systolic blood pressure (+ 14.8 ± 0.6 mmHg, p < 0.001) and heart rate (+ 1.4 ± 0.5 bpm, p = 0.006), however, responses of total peripheral resistance, stroke volume, or cerebral blood flow were not widely documented. Most patients experienced symptom improvement following CPM use (laboratory: 60 ± 4%, community: 72 ± 9%). The most prominent barrier to employing CPM in daily living was the inability to recognize an impending faint. Patterns of postural sway may also recruit the skeletal muscle pump to enhance cardiovascular control, and its potential as a discrete, proactive CPM needs further evaluation. Physical CPM were successful in improving syncopal symptoms and producing cardiovascular responses that may bolster against syncope; however, practical limitations may restrict applicability for use in daily living.

The Impact of Self-Care Recommendations with and without Tilt-Training on Quality of Life in Children and Adolescents with Vasovagal Syncope: A Randomized Clinical Trial

“…Consistent with the present study, the results of a systematic review and meta-analysis by Williams et al . [ 24 ] show that physical counter-pressure maneuvers are a risk-free, cost-effective, and first-line management strategy for syncope prevention.…”

Exaggerated postural sway improves orthostatic cardiovascular and cerebrovascular control

“…According to current guidelines ( 1 ), CPM are a class IIa recommendation for patients with syncope. While community trials show that these CPM can be beneficial ( 18 , 36 , 37 ), practical barriers are reported that limit their effective use in daily living ( 45 ). For example, during a squat, one must lower their center of mass, which requires mobility and strength about the hip, knee, and ankle joints.…”

“…This could be utilised in individuals who do not have sufficient prodrome, or are unable to effectively perform CPM. Indeed, one of the most highly reported barriers to employing CPM is the inability to identify an impending faint ( 45 ), and this has been noted by patients with and without a history of prodrome prior to their syncopal episodes ( 14 , 18 , 25 , 35 – 37 ). Similarly, there are distinct advantages of the subtlety of postural sway; CPM may not always be socially acceptable or desirable, and can be impractical in certain situations or occupations that require prolonged motionless standing.…”

“…Accordingly, enhanced postural sway may reflect a subconscious adaptive response to poor orthostatic control ( 23 , 43 , 44 ); it may be that enhanced postural sway could serve as an effective CPM to augment orthostatic cardiovascular control. However, it is unclear whether the small muscle contractions associated with postural sway are sufficient to produce meaningful enhancements in cardiovascular control ( 45 ). Given that the direction of postural sway can be manipulated to target specific muscle groups ( 38 , 39 ), there may be particular sway patterns that optimally bolster cardiovascular control and could be exploited by individuals at risk of syncope.…”

Haemodynamic Parameters Underlying the Relationship between Sarcopenia and Blood Pressure Recovery on Standing

“…Pressor agents such as fludrocortisone and midodrine are routinely prescribed for OH and delayed BP recovery [ 60 ] despite their off-label use and potential side effects [ 61 ]. Perhaps increasing use of multicomponent intervention as well as training in physical counterpressure manoeuvres [ 62 ] would lessen the use of these medications and also benefit cases of combined supine hypertension and OH [ 63 ], where physical interventions can help both.…”