Non-medication approaches to orthostatic hypotension from NYU

Something like 80% of those with MSA suffer from orthostatic hypotension (OH) and about 50% of those with LBD do. Someone recently posted to one of the MSA-related Yahoo!Groups this New York University publication (written by autonomic expert Horacio Kaufmann, MD) on treating OH. The article below is copied from the Yahoo group.

Be sure not to miss the physical counter-maneuvers — making a fist, crossing your legs, clenching your buttocks — in #9!



Treating symptomatic orthostatic hypotension (OH)
by Horacio Kaufmann, MD
Director, NYU Dysautonomia Center (
(not dated)

Symptoms of OH include dizziness/lightheadedness, feeling about to faint, fatigue/tiredness, shortness of breath, changes in vision, pain in neck and shoulders or chest pain.

Symptoms of OH can be improved with time, patience and non-pharmacologic changes. It is tempting to try to control OH only with medications. However, these are not effective enough and may have adverse effects. However, treatment of OH is more successful if non-pharmacologic measurements are implemented.

Following is a series of steps to improve symptoms of OH. All steps may be implemented at the same time. If performed properly, these can lead to a dramatic improvement, even with no medications.

1. Liberalize water intake. Patients with OH need more water than healthy people. Patients with OH should be drinking 1 gallon/day (~3 liters). Ideally, it is best to drink just water. Tea and coffee might be acceptable, but they may increase urine output so, at the end, they may worsen your symptoms. Diet beverages are also acceptable. Gatorade, juices, and non-diet beverages are not recommended due to their high-sugar content. Diet (sugar free) Gatorade is fine.

2. Liberalize salt intake. Add as much salt to your meals as you can handle. Most of patients do not need to take salt tablets. In fact, salt tablets may cause abdominal discomfort. Just enjoy regular salt with your meals.

3. Wear compression stockings. Compression stockings will reduce the venous pooling that occurs when standing up and, therefore, will improve your blood pressure standing. To be useful, compression stockings should be worn up to the waist. Those up to the knee are not effective. You do not need to wear the stockings during sleep.

4. Wear an abdominal binder. The mechanism is similar to that of compression stockings. You do not need to wear it during sleep.

5. Sleep with the head of the bed raised at least 30 degrees (ideally 45-50 degrees). This is useful because patients with orthostatic hypotension frequently have supine hypertension (i.e., high blood pressure when lying down). Therefore, to avoid supine hypertension, patients should never lie flat. Sleeping with the head of your bed raised will also reduce urine output, making you wake up fewer times to urinate, and will improve your blood pressure in the morning. The best way to raise the head of the bed is to get an electric mattress. These are affordable, commercially available, and in several sizes. Other, less efficacious ways to increase the head of the bed is by using a wedge, or just by putting some books/bricks under the upper feet of the bed.

6. Drink 500 ml of cold water 30 minutes before getting out of bed in the morning. This will increase your blood pressure when you get up. Drinking 500 ml of water in any other moment of the day will also increase your blood pressure. You may use this on an as needed basis (but make sure you drink, in total, around 1 gallon/day of liquids).

7. Start a physical therapy regimen. In patients with OH, physical exercise will decrease blood pressure. But exercise is crucial to keep muscles active. Therefore, in order to avoid low blood pressure when exercising, patients should perform recumbent exercises (e.g., recumbent bicycle, elastic bands, rowing machine, etc.) The best exercise is, by far, the one performed in a swimming pool. This is because the hydrostatic pressure of the water will prevent the fall in blood pressure. Therefore your blood pressure will not fall so dramatically if you are inside the water (with the head out, of course, so that you can breathe) even in spite of the fact that you are standing. While you are inside the water you will feel much better and you will be able to exercise with no significant symptoms. The better your physical shape is, the less intense your symptoms of OH will be.

8. The following factors worsen OH (i.e., decrease blood pressure) and should be avoided (or can be used right before going to bed to lessen supine hypertension during nighttime):

a. Hot and humid temperatures
b. Physical exercise (see point #6)
c. Dehydration (see point #1)
d. Alcohol
e. High glycemic index carbohydrates. Try to reduce high-glycemic carbohydrates in your meals. Also try to have several, small meals (5-6) instead of three traditional meals.

These are high-glycemic carbohydrates that you should reduce/avoid:

Potatoes, Yams, Candy, Bagels, White bread, White pasta, Pizza, Corn, Rice, Rice cakes, Oatmeal, Wheat, Grits, Cereals (corn flakes, etc), Soft drinks, Bottled fruit juices (orange, apple, etc), Cakes, Cookies, Ice cream, Chocolate, Full fat milk, Watermelon, Bananas, Grapes, Rye, Yogurt

Try to increase low-glycemic index carbohydrates in your diet, including:

Whole wheat bread, Whole wheat pasta, Brown rice, Pearl barley, Skim milk, Reduced-fat yogurt, Apples, Grapefruits, Pears, Peaches, Just-squeezed fruit juices, Prunes, Beans, Black-eyed peas, Chickpeas, Peas, Hummus, Lentils, Soybeans, Cashews, Peanuts, Carrots, Diet soda, Almonds, Nuts, Quinoa

9. Be aware of your symptoms. If you experience symptoms of orthostatic hypotension, you will find relief by performing physical counter-maneuvers (making a fist, crossing your legs, clenching your buttocks), useful to increase standing blood pressure. If these counter-maneuvers are not enough, sit or lie down quickly to avoid passing out.

10. Finally, follow the recommendations regarding medication changes that we may recommend.