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7 Neuro Dysfunction > L6 Autonomic Dysfunction > Flashcards

L6 Autonomic Dysfunction Flashcards

1
Q

Dysautonomia

A
  • medical condition in which there are dysfunction of any of the body systems under control of ANS
  • PT can be the first one to see them and recognize the patterns
  • exercise based care is critical part ot tx
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2
Q

Sympathetic ganglia

A

distribute throughout throacic spine, have long post ganglionic neurons closely located near ganglia

NORE is used as hormone

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3
Q

Parasympathetic ganglia

A

distributed in cranial and sacral nerve ganglia and have short post ganglionic neurons traveling to effector organs

ACH hormone is used, acting on muscarininc receptors

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4
Q

Preganglionic Neurons in Sympathetic

A
  • located in intermediolateral cell column in lamina 7 of spinal cord levels T1-L3. Short length
  • two sets of ganglia, paired paravertebral. form a chain called sympathetic trunk running from cervical to sacral. allows efferents to reach different parts of body besides exiting points
  • Unpaired prevertebral ganglia located in celiac plexus surrounding aorta
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5
Q

Postganglionic Neurons in Sympathetic

A
  • long distance to travel to reach effector organs
  • predominantly releases NE onto end organs
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6
Q

Parasympathetic preganglionic neurons

A
  • travel a long distance to reach terminal ganglia located within or near effector organs
  • arise from cranial nerve parasympathetic nuclei and from sacral parasympathetic nuclei located in gray matter of S2-S4
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7
Q

Parasympathetic post ganglionic neurons

A
  • release acetylcholine, activating muscarinic cholinergic receptors on end organs
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8
Q

Dysautonomia is an

A

umbrella term

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9
Q

Primary vs secondary dysautonomia

A
  • primary = result of primary disease process
  • secondary = occurs as consequence of non-autonomic disease process
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10
Q

POTS Prevalence

A

Prior to COVID = 1-3 million people in US, more females (4:1), avg onset was 14 yo. Most reported a viral infection beforehand

After COVID = men are reporting POTS as consequence of long COVID. 2-14% of long covid will develop POTS

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11
Q

Common comorbidities of POTS

A
  • EHD
  • migraines (up to 40% of pts)
  • mast cell activation syndrome
  • autoimmune disorders
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12
Q

Possible triggers of POTS

A
  • viral infection
  • physical injury/trauma like mTBI
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13
Q

Long COVID

A

describes heterogeneous s/s experienced after acute COVID-19 infection that perssit more than 12 weeks after infection

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14
Q

Common s/s of Long COVID

A
  • fatigue
  • dyspnea
  • cardiac abnormalities
  • cognitive and attention impairments
  • sleep disturbances
  • muscle pain
  • headache
  • GI impairments
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15
Q

Long COVID RF

A
  • older age
  • female
  • pre-exisiting comorbidities like autoimmune conditions
  • severity of infection
  • number of covid infections
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16
Q

Orthostatic s/s of POTS

A
  • high heart rate with positional changes
  • low BP
  • dizziness
  • increased sweating
  • SOB
  • chest pain
  • heart palpitations
  • syncope
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17
Q

Non-orthostatic S/S POTS

A
  • GI s/s
  • urinary urgency
  • fatigue
  • anxiety
  • poor sleep
  • brain fog
  • raynaud’s
  • hives
  • headache
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18
Q

Why do people develop POTS

A
  • abnormal hypovolemia
  • cardiovascular deconditioning and low stroke volume
  • ecxcessive central sympathetic activation
  • increased inflammation
  • impacted peripheral vasculature, blood pooling
  • prevention of normal constriction of peripheral capi beds
  • hypermobility of peripheral blood vessels
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18
Q

Neuropathic POTS

A
  • partial autonomic neuropathy
  • decreased sympathetic activity in LE venous systems, leads to blood pooling
  • decreased NORE, leading to decreased constriction
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18
Q

Pathophys of POTS

A
  • 3 different types
  • neuropathic
  • hyperadrenergic
  • hypovolemic
19
Q

Hyperadrenergic POTS

A
  • increased sympathetic acitivty
  • leads to excessive catecholamines in blood
20
Q

Hypovolemic POTS

A
  • decreased blood volume, about 70% of pts
  • MOI unknown, possibly impaired RAAS, lacks levels of aldosterone, lack of water reabsorption
  • decreased venous return, lack of water and salt retention, low blood pressure
21
Q

Pathophys of Long COVID

A
  • inflammatory process of RAAS
  • dysfunction of peripheral autonomic pathways due to presence of inflammatory cytokines
  • development of autoantibodies for muscarinic and adrenoreceptors
  • binding of COVID to ACE2 receptors in multiple ACE2 receptor rich areas of brain

overall increases inflammation in the body, because the modulator system is blocked

22
Q

Long term cardiac changes due to POTS

A
  • decreased stroke volume/volume of blood ejected
  • decreased cardiac output/volume of blood ejected from heart
  • decreased left ventricular mass/amount of o2 blood
  • decreased blood volume
23
Q

Vestibular Impairments in POTS

A
  • vertigo, gait unsteadiness (almost all), swimming sensation, rocking sensation
  • altered vestibulosympathetic reflex
  • altered oVEMP and cVEMP responses, decrease in ocular and cervical responses to vestibular changes
24
Q

Vestibulosympathetic Reflex

A
  • reflex arc incorporating input from utricle and saccule about head position and positional changes
  • helps to regulate sympathetic nervous system response to positional changes to increase alertness
25
Q

Tilt Table Test

A
  • Gold standard for POTS
  • pt is supine for 5-10 min to allow s/s to be at baseline
  • table is raised from 0 to 70° over 1-2 minutes
  • monitoring of EKG and BP for 10 min total
26
Q

QSART Sweat Test

A
  • assesses for different types of dysautonomia
  • helps determine how sympathetic system responds to stimuli
  • small sensor is placed on arm and leg
  • cholinergic agent is passed across the skin
  • sensors detect sweat response

neuropathic will present with decreased sweat response

27
Q

Positional Change Test

A
  • inexpensive and can be done in PT clinic
  • pt is supine for 5-10 min, with bp/hr measured
  • pt immediately transitions to standing
  • monitor HR and BP (minutes 1,3,5,10)
28
Q

Ages 12-18 diagnostic criteria for POTS

A
  • sustained increase in hr of ≥ 40 bpm in absence of orthostatic hypotension within first 10 min of standing
  • sustained hr of 120 bpm + in standing
29
Q

Age 19+ diagnostic criteria for POTS

A
  • sustained increased in HR ≥30 bpm in absence of orthostatic hypotension within first 10 min of standing
  • sustained HR of 120 bpm or more in standing
30
Q

Orthostatic Intolerance Characteristics

A
  • decrease in systolic BP of 20 mmHg or more within 3 minutes of positional change
  • decrease in diastolic BP of 10 mmHg or more within 3 min of positional change
  • no significant increase in HR
31
Q

Inappropriate Sinus Tachycardia Characteristics

A
  • resting HR > 100
  • avg HR > 90 bpm on 24 hr monitor
  • not associated with positional changes
  • associated with emotional response or stress
32
Q

Neurocardiogenic Syncope Characteristics

A
  • decrease in blood pressure upon standing equal to orthostatic hypotension
  • decrease in HR
  • dizziness, nausea, syncope in response to triggers
  • triggers can include positional changes
33
Q

PT diagnosis of POTS

A

impaired activity tolerance in upright position due to signs and symptoms consistent with POTS, leading to limitations in functional ability to complete ADLs and IADLs

34
Q

Lifestyle interventions for POTS

A
  • compression garments
  • increased fluid intake/bolus drinking (3L of water)
  • increased electrolyte intake (8-10 grams)
  • small meals
  • avoiding hot/humid environments
  • sitting to shower
  • energy conservation technique
35
Q

Medical Management for POTS

A
  • beta blockers
  • pressors like midodrine/alpha-adrenergic agnoists
  • stimulants for brain fog
36
Q

COMPASS-31 Outcome Measure

A
  • 31 self reported questionnaire that covers 6 domains of autonomic function (orthostatic intolerance, vasomotor, secretomotor, GI, bladder, pupillomotor)
  • useful for tracking overall function and severtiy
  • not sensitive to change over short period of time
37
Q

Fatigue Severity Scale

A
  • 9 item self reported questionnaire that uses likert scale (1 to 7)
  • higher score means greater impact of fatigue on daily life
  • report total item socre out of 63
  • > 36 = severe fatgiue
  • MDC = 1.2 points
  • avg person = total of 2.3
38
Q

Patient Specific Functional Scale

A
  • pt selects 3-5 activities that are difficult
  • rates on scale of 0 to 10 on how well they can perform the activity
  • helpful for pts who have specific goals in mind
  • promotes pt autonomy and motivation
39
Q

Exercise for POTS

A
  • aerobic and strength for LE and core
  • exercise can help individuals go into “remission”/not present with symptoms
  • semi-supervised aerobic can be more effective than indepedent
40
Q

CHOPS Protocol

A

intensive strength and aerobic training for POTS individuals, last for three months

41
Q

Principles of CHOPS

A
  • start with recumbent
  • rowing machine is highly recommended in first 3 months ( can help with heart impairments)
  • keep workouts evenly distributed throughout week
  • try not to take off more than 2 days of exercsie in a week
  • repeat weeks if not completed
42
Q

For pts who are too deconditioned for month 1 of CHOPS

A
  • pts who have a hard time completing buffalo
  • start with “month 0”, which is exercises in seated or supine position with 1 minute rests and short bouts of exercise
  • HR is about 40-50% of HRmax
  • should not have excessive fatigue
43
Q

For patients for whom month 1 is too easy in CHOPS:

A
  • pts who were active and received quick dx
  • may tolerate buffalo without severe fatigue
  • can start with walking intervals
  • should still not have rpe go above 6, hr > 50-60%, > 30 min
  • can progress all restrictions after 4 weeks
44
Q

Strength Training in CHOPS

A
  • strengthen large LE and core to help with vascular pumping
  • start with supine, such as bridges
  • avoid standing until month 2-3
  • avoid standing lifts and overhead lifts until cleared
45
Q

Effectiveness of Exercise for POTS

A
  • increased left ventricular mass
  • increased plasma volume
  • improved stroke volume and cardiac output
  • improved VO2 peak
  • decreased HR in upright position
  • delayed symptom onset during exercise
  • improved QOL
46
Q

Education for POTS

A
  • lifestyle management
  • medical management with PCP
  • energy conservation
  • self-advocacy for accommodations
  • adaptive equipment
  • fall risk

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