L6 Autonomic Dysfunction Flashcards
Dysautonomia
- 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
Sympathetic ganglia
distribute throughout throacic spine, have long post ganglionic neurons closely located near ganglia
NORE is used as hormone
Parasympathetic ganglia
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
Preganglionic Neurons in Sympathetic
- 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
Postganglionic Neurons in Sympathetic
- long distance to travel to reach effector organs
- predominantly releases NE onto end organs
Parasympathetic preganglionic neurons
- 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
Parasympathetic post ganglionic neurons
- release acetylcholine, activating muscarinic cholinergic receptors on end organs
Dysautonomia is an
umbrella term
Primary vs secondary dysautonomia
- primary = result of primary disease process
- secondary = occurs as consequence of non-autonomic disease process
POTS Prevalence
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
Common comorbidities of POTS
- EHD
- migraines (up to 40% of pts)
- mast cell activation syndrome
- autoimmune disorders
Possible triggers of POTS
- viral infection
- physical injury/trauma like mTBI
Long COVID
describes heterogeneous s/s experienced after acute COVID-19 infection that perssit more than 12 weeks after infection
Common s/s of Long COVID
- fatigue
- dyspnea
- cardiac abnormalities
- cognitive and attention impairments
- sleep disturbances
- muscle pain
- headache
- GI impairments
Long COVID RF
- older age
- female
- pre-exisiting comorbidities like autoimmune conditions
- severity of infection
- number of covid infections
Orthostatic s/s of POTS
- high heart rate with positional changes
- low BP
- dizziness
- increased sweating
- SOB
- chest pain
- heart palpitations
- syncope
Non-orthostatic S/S POTS
- GI s/s
- urinary urgency
- fatigue
- anxiety
- poor sleep
- brain fog
- raynaud’s
- hives
- headache
Why do people develop POTS
- 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
Neuropathic POTS
- partial autonomic neuropathy
- decreased sympathetic activity in LE venous systems, leads to blood pooling
- decreased NORE, leading to decreased constriction
Pathophys of POTS
- 3 different types
- neuropathic
- hyperadrenergic
- hypovolemic
Hyperadrenergic POTS
- increased sympathetic acitivty
- leads to excessive catecholamines in blood
Hypovolemic POTS
- 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
Pathophys of Long COVID
- 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
Long term cardiac changes due to POTS
- 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
Vestibular Impairments in POTS
- 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
Vestibulosympathetic Reflex
- 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
Tilt Table Test
- 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
QSART Sweat Test
- 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
Positional Change Test
- 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)
Ages 12-18 diagnostic criteria for POTS
- 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
Age 19+ diagnostic criteria for POTS
- 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
Orthostatic Intolerance Characteristics
- 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
Inappropriate Sinus Tachycardia Characteristics
- resting HR > 100
- avg HR > 90 bpm on 24 hr monitor
- not associated with positional changes
- associated with emotional response or stress
Neurocardiogenic Syncope Characteristics
- 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
PT diagnosis of POTS
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
Lifestyle interventions for POTS
- 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
Medical Management for POTS
- beta blockers
- pressors like midodrine/alpha-adrenergic agnoists
- stimulants for brain fog
COMPASS-31 Outcome Measure
- 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
Fatigue Severity Scale
- 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
Patient Specific Functional Scale
- 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
Exercise for POTS
- 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
CHOPS Protocol
intensive strength and aerobic training for POTS individuals, last for three months
Principles of CHOPS
- 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
For pts who are too deconditioned for month 1 of CHOPS
- 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
For patients for whom month 1 is too easy in CHOPS:
- 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
Strength Training in CHOPS
- 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
Effectiveness of Exercise for POTS
- 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
Education for POTS
- lifestyle management
- medical management with PCP
- energy conservation
- self-advocacy for accommodations
- adaptive equipment
- fall risk
