Counter-Pressure Maneuvers

In order to decrease orthostatic symptoms due to low blood pressure, positions to increase or maintain blood pressure, otherwise called counter-pressure maneuvers, may be helpful. ¹ ² ³ ⁴.

Below are examples and descriptions of the three types of counter-pressure maneuvers.

Isometric counter-pressure maneuvers ⁵ (holding a position by tensing large muscles)	Description
Leg crossing with muscle tensing	Crossing of legs combined with tensing, or tightening, of the leg, abdominal, and buttock muscles
whole-body tensing	Tensing, or tightening, of the arm, leg, abdominal, and buttock muscles
Buttocks clenching	Tensing, or tightening, of the buttocks muscles

Positional counter-pressure maneuvers ⁶	Description
Bending over as if to tie shoelaces	While sitting, bend over at the hips and reach for toes
Squatting	Bending the knees and hips in a squatting position

Dynamic Muscle Pumping counter-pressure maneuvers ⁷ (moving the body in a way that uses muscles to pump the blood)	Description
Heel raises/ toe extension	While sitting or standing, lift up heels and/or toes
Marching in place	While sitting or standing, march in place by lifting feet off the ground
Postural swaying	While standing, shift weight back and forth from one leg to the other

While these maneuvers can be helpful in decreasing symptoms of orthostatic intolerance in some individuals, they might not be able to completely prevent a syncopal event, especially if not initiated early enough.

If symptoms persist and worsen to the point where you feel like you are going to faint, it is best to try and sit, lie down, or get into a safe position to prevent injury in the event of passing out.

Reviewed by Medical Content Experts, 2021

REFERENCES

Bryarly, M., Philips, L. T., Fu, Q., Vernino, S., & Levine, B.D. (2019). Postural orthostatic tachycardia syndrome: JACC focus seminar. Journal of the American College of Cardiology, 73(10). 1207-1222. {1}

Fedorowski, A. (2019). Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management. Journal of Internal Medicine, 285(4), 352–366. {2}

Mitro, P., Muller, E., & Lazurova, Z. (2019). Hemodynamic differences in isometric counter-pressure maneuvers and their efficacy in vasovagal syncope. International Journal of Arrhythmia, 20(4), 1-10. {5}

Raj, S.R., Guzman, J.C., Harvey, P., Richer, L., Schondorf, R., Seifer, C., Thibodeau-Jerry, N., & Sheldon, R.S. (2020). Canadian cardiovascular society position statement on postural orthostatic tachycardia syndrome (POTS) and related disorders of chronic orthostatic intolerance. Canadian Journal of Cardiology, 36(3), 357-372. {4}

Shen, W. K., Sheldon, R. S., Benditt, D. G., Cohen, M. I., Forman, D. E., Goldberger, Z. D., Grubb, B.P., Hamdan, M.H., Krahn, A.C., Link, M.S., Olshansky, B., Raj, S.R., Dandhu, R.K., Sorajja, D., Sun, B.C., & Yancy, C. W. (2017). 2017 ACC/AHA/HRS guideline for the evaluation and management of patients with syncope: A report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines and the Heart Rhythm Society. Journal of the American College of Cardiology, 70(5), e39-e110. {3}

Wieling, W., van Dijk, N. Thijs, R. D., de Lange, F. J., Krediet, C.T. Paul, & Hallwill, J., R. (2015). Physical countermeasures to increase orthostatic tolerance. Journal of Internal Medicine, 277 (1), 69-82. {6, 7}