Applied Tension Treatment of Vasovagal Syncope during Pregnancy

Military Medicine, Sep 2004 by Peterson, Alan L, Isler, William C III

Because the patient was pregnant, her obstetrician was consulted regarding possible complications of using the applied tension technique. It was recommended that the patient not tense any of her abdominal muscles during the applied tension treatment, to limit any possibility of inducing premature labor. The behavioral treatment was seen as posing minimal risk to the patient and being greatly preferable to medical or surgical interventions for the syncope.

The treatment included the use of applied muscle tension combined with graduated exposure to increasingly stressful stimuli.10 Before the initiation of the applied tension treatment, a 1-hour clinic appointment was spent in preparation for the behavioral treatment session. A hierarchy of stimuli likely to induce a syncopal episode, including verbal descriptions of needles, injections, and blood draws, watching others undergo subcutaneous injection or venipuncture, and actually experiencing an injection or blood drawing, was developed. The patient was asked to use a rating scale of O to 10 (O = no fainting symptoms and 10 = being passed out) subjective units of distress (SUDs) and decided that she would initiate the applied tension at a level of 5 or greater.

A detailed description of the applied tension treatment was also provided during this session, and the patient practiced the applied tension technique without exposure to any stressful stimuli. The applied muscle tension consisted of tensing the muscles in the arms, torso, and legs until a feeling of warmth was noticed in her face (10-20 seconds). The patient was encouraged to practice the applied tension exercise at home, in a similar manner, five times per day in the upcoming week.

The treatment was initiated during the third clinic appointment. This session was scheduled for an extended 3-hour period and included exposure to the hierarchy of stressful stimuli and use of the applied tension technique. The session began with a discussion of needles and a verbal description of the procedures involved in giving an injection. The patient was instructed to use the applied tension technique at the earliest signs of a possible syncopal episode (e.g., feelings of intense warmth in her face and sweating). During the initial exposure to the verbal description of needles and injections, the patient's presyncopal symptoms increased to a SUDs level of 6 and she initiated the applied tension. The patient was instructed to gradually reduce the muscle tension as the sensory symptoms related to fainting subsided but not to fully relax, because this might lead to syncope. Repeated cycles of tensing and gradually reducing the muscle tension, until the patient was able to decrease the muscle tension without fainting, were sometimes required. Subsequently, continued verbal discussions and descriptions of needies, injections, and blood draws failed to elevate the patient's SUDs levels above a 4 rating. Exposure to each of the stressful stimuli in the hierarchy was not initiated until the patient was ready to proceed voluntarily.