Dysautonomia: Emerging Strategies To Identify and Manage

On Thursday 2/23/23 in the afternoon at a national physical therapy conference (CSM) in San Diego, I attended a fantastic presentation about Dysautonomia that included differential diagnosis, examination, appropriate referrals, treatment options, and exercise progressions called:

Emerging Strategies for the Physical Therapist to Identify and Manage Dysautonomia Presented by Lauren Jamie Ziaks, PT, DPT, ATC, and Thomas Koc, PT, DPT, PhD

Dysautonomia includes at least 15 diagnoses, such as orthostatic intolerance (OI), orthostatic hypotension (OH), and postural orthostatic tachycardic syndrome (POTS).

Dysautonomia may be a cause of dizziness with standing, due to dysregulation of heart rate or blood pressure by the autonomic nervous system.

Orthostatic Intolerance (OI)

Orthostatic intolerance is defined as inability to tolerate upright standing due to uncomfortable symptoms. These symptoms are typically relieved by lying down.

Symptoms of OI include lightheadedness, mental confusion, cognitive impairment, headaches, fatigue, weakness, intolerance of exercise, nausea, abdominal pain, visual symptoms, presyncope, and even loss of consciousness.

In OI, the blood pressure may increase or decrease while upright.

For a more technical discussion of OI, click here.

Three diagnoses that fall under the category of OI include orthostatic hypotension, POTS, and vasovagal syncope (VVS).

Orthostatic intolerance may also be used to describe a patient who has symptoms while upright, but does not meet the diagnostic criteria for a specific diagnosis like OH or POTS.

Orthostatic Hypotension (OH)

OH is a type of OI.

Orthostatic hypotension (OH) is defined as a drop in systolic blood pressure at least 20 mm Hg (top number) or a drop in diastolic blood pressure at least 10 mm Hg (bottom number) within three minutes of standing upright.

OH can occur while getting up from bed, a chair, the toilet, off the ground, etc.

In patients who are hospitalized or have recently returned home from the hospital, OH can occur within seven minutes of standing.

I discuss cardiovascular issues that may contribute to vertigo in this blog.

For tips on how to manage dizziness with standing due to OH, click here.

POTS

POTS is another type of OI.

Patients with POTS typically have symptoms with standing on a day-to-day basis for at least six months.

The diagnostic criteria for POTS includes heart rate increase of at least 30 beats per minute (bpm) with standing or heart rate is greater than 120bpm within the first ten minutes after standing. This criteria must be met without orthostatic hypotension occurring.

This type of elevated heart rate response to standing can occur in people without POTS if they are dehydrated or have recently lost a lot of blood.

With standing, patients with POTS may feel lightheadedness, brain fog, blurry vision, headache, nausea, fatigue, tremor, and palpitations. They typically have an intolerance to exercise.

The presenters at CSM shared some interesting information about the experience of patients with POTS.

They stated that the average patient with POTS took more than 5 years and saw more than 7 doctors to receive a proper diagnosis.

The gold standard for diagnosing POTS is a tilt table test, but many times the wait is 3-6 months for this type of test.

Typically there is a triggering event for someone with POTS such as:

• Infection
• Pregnancy
• Surgery
• Accident
• Concussion
• Long COVID
• Onset of Autoimmune condition

The onset of POTS is common in adolescents, but most are not diagnosed until 19 years old or older.

Presenters Take Home Points

This presentation was so important for patients with dizziness after a concussion! 

Dysautonomia can also affect patients with other neurological disorders, whiplash-associated dizziness, and autoimmune conditions, to name a few.

A typical treatment plan usually follows a protocol that progresses in stages and may include medications along with a graded aerobic exercise progression.

Compression therapy and daily intake of salt, electrolytes, and water are also important aspects of minimizing symptoms day to day. These are usually included as part of a comprehensive treatment approach for patients with dysautonomia. 

Dysautonomia needs to be managed long term for the patients to have the best quality of life.

Many patients learn to use a heart rate monitor to measure their tolerance to exercise.

The speakers shared the protocols they use for the wellness and graded aerobic exercise progression for people with dysautonomia.

The presenters explained that the most important treatment for dysautonomia is exercise. Many patients eventually learn the exercise protocols and progression as well.

Thank you Dr. Koc and Dr. Ziaks for an excellent talk!