I recently had an evaluation of a 14 y/o male who was referred for generalized hypermobility. One unique co-morbidity that the patient was recently diagnosed with the head tilt table test was Postural Orthostatic Tachycardia Syndrome (POTS). This might be more common in the general orthopedic patient but my first in the sports medicine arena working with athletes. When the patient sits or lies for any period and quickly moves to standing he gets light headed and experiences headaches. (This isn't uncommon in the general public with orthostatic hypotension) What has been abnormal is that after running or jumping for even a short period of time he has to lay flat to manage symptoms of POTS or he reports near fainting. I didn't know much about the diagnosis prior to this patient so I thought I would share some of the research artciles for fun.

Postural orthostatic tachycardia syndrome
A K Agarwal, R Garg, A Ritch, P Sarkar

Background

POTS was first described 1940. Low et al from the
Mayo clinic did the pioneering work on this
condition.3 Robertson of the Vanderbilt autonomic
laboratories stated it was one of the most common
conditions in young females. Frolich et al reported
patients who developed symptomatic postural
tachycardia without any change in blood pressure.5
The condition is common in the age group 12–50
years with a female to male ratio of 5:1. It is
common after stress such as sepsis, pregnancy,
fever, surgery or trauma. In some of the variants
of POTS there is a functional mutation in the gene
encoding for norepinephrine (noradrenaline)
transportation. Ala 457pro mutation renders the
transfers non-functional leading to altered heart
rate as well as epinephrine (adrenaline) metabolites. 

(taken from the above article)

Symptoms of orthostatic intolerance

* Headache
* Fatigue
* Sleep disorder
* Weakness
* Hyperventilation/dyspnea
* Tremulousness
* Sweating
* Anxiety/palpitation
* Dizziness/vertigo
* Pre-syncope/syncope

Diagnosis

The 70˚ head up tilt table study has become the standard
stress test for orthostatic integrity and thus of neurovascular
competence. Patterns of heart rate as well as blood pressure
response will be the key to identifying which type of orthostatic
intolerance is present and thus for planning treatment for
further management. In a control population there is an
increase of only 15 bpm in heart rate in the first minute of
standing and a further increase for 9 min. In POTS supine heart
rate is greater than the normal control population and an
increase of more than 30 bpm takes place between 1–5 min on
70˚head uplift.

What Can Physical Therapy Do?

Taken from the Levine Protocol from: http://www.dizziness-and-balance.com/treatment/rehab/pots%20training.html

  • All patients first undergo tilt-table testing to measure their starting performance. It would be unreasonable to use this protocol if one does not "fail" the tilt table test. This is also used to determine the target heart rate.
  • Changes to behavior
    • Salt/water loading
      • The goal is up to 3 liters of water/day and 7000-10,000 mg of sodium/day. This might not always be possible in persons with heart disease (for example), so this needs to be monitored. 1 tsp of ordinary table salt= about 2300 mg of sodium, and the ordinary diet contains about 4000 mg of sodium. So as a rough estimate, you might be aiming for 1.5 to 2 more tsp of salt/day. Start slow and work up. There are online tools (such as myfitnesspal.com) that can help you track your sodium intake.
    • Elevate the head of the bed -- raise the head of the bed by 4-6 inches. The goal is to tilt the entire body, not the head. Two pillows is not enough. Bed risers are a way to do this (such as are used by college students. Just under the top of the bed.
    • Stay upright during the day. Do not lie down all day long because you feel better. Get up and walk around a little bit every hour.
  • A home program consisting of twice a day regime for up to 30 minutes each session, and conditioning (Cardio and weight training).
    • Usually medications for POTS are "held" during this exercise program. These may need to be weaned off. Examples of these are fludrocortisone and mitodrine.
    • You should have a heart rate monitor, so that you know when to quit exercises (i.e. when your heart rate gets too high if you have POTS). The goals are shown below.
    • This program is supervised. You should see your provider (perhaps physician or physical therapist), who assigns progressively harder exercises, and monitors your progress. The provider should provide you with a calendar for activities for each week.
    • "Cardio" exercises are done to improve lower extremity tone and strength (these are from the Levine protocol). These exercises are to be done every day, and are for both patients with orthostatic hypotension and POTS. You should not take off more than 2 days from training. Weight training is in addition to this, but it is required less frequently (see below). There should be a 10 minute warm up and cool down prior and following the cardio exercises.
      • month 1 (pick one of these) -- target heart rate should be 75-85% of maximum.
        • recumbant biking
        • rowing
        • swimming laps or kicking laps with a kickboard
      • month 2
        • upright bike instead of recumbant
        • Try to add treadmill (no incline at first)
        • Try to add ellipitical
      • month 3
        • elliptical
        • treadmill
      • months 4-6.
        • If you are doing fine up to now, ask your health care provider (PT or physician) what you can do next -- jogging perhaps.
    • Weight training. These are started once weekly (15 to 20 min/session), and gradually increased to twice weekly (30 to 40 min/session).
      • Goal is two sets of 10 repetitions of
        • seated leg press
        • seated leg curl
        • leg extension
        • calf raise
        • chest press
        • seated row.
      • If seated weight training equipment is no available, alternatives are
        • floor exercises (such as Pilates)
        • resistance bands
        • Physioball
  • After the training is completed (i.e. 3 months) a follow up tilt-table test is performed at the same time of day as the initial training.
  • Conditioning should be continued as a life-long activity.

Other Resources and Articles on POTS

GENERAL INFORMATION BROCHURE ON
ORTHOSTATIC INTOLERANCE AND ITS TREATMENT - http://www.dysautonomiainternational.org/pdf/RoweOIsummary.pdf

The Postural Tachycardia Syndrome (POTS):Pathophysiology, Diagnosis & Management
Satish R Raj MD MSCI -
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1501099/pdf/ipej060084-00.pdf

Postural Tachycardia Syndrome and Reflex Syncope:
Similarities and Differences - Julian M. Stewart, MD, PhD
Center for Hypotension, Department of Pediatrics, Physiology, and Medicine, New York Medical College, Valhalla, NY

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3810291/pdf/nihms-491666.pdf

 

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