Tag Archive for: POTS

Post-Concussion POTS

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A recent study published in 𝘊𝘩𝘪𝘭𝘥 𝘕𝘦𝘶𝘳𝘰𝘭𝘰𝘨𝘺 𝘖𝘱𝘦𝘯 sought to understand autonomic dysfunction in kids after concussion.⁣
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In recent years, more clinicians have become aware of autonomic dysfunction in patients after concussion, with many showing positive diagnostic findings resembling orthostatic hypotension and Postural orthostatic tachycardia syndrome.⁣
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While some of the symptoms of concussion and POTS overlap, there are likely important differences that make treatment for each unique.⁣


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Post concussion autonomic dysfunction tends to be very responsive to neurologic rehabilitation techniques, and can often be self-resolving as the brain heals.⁣
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More traditional POTS tends to have elements of autoimmune and/or neurometabolic causes that may make treatment more complicated and less likely to self-resolve.⁣


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Knowing the background behind these cases can dictate effective treatments for these challenging conditions. ⁣
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Keystone Brain Bytes Episode 3 – Our Approach to Dysautonomia

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Keystone Brain Bytes Episode 3 – Our Approach to Dysautonomia

Dysautonomia is becoming a more common complaint in our office and one that we have had a good amount of success in treating. It will likely become a more prevalent issue in the coming years. In this episode of Brain Bytes, Dr. Chung explains our approach to dysautonomia and the neurological reasons why we use the cervical spine and vestibular system as our window into the autonomic nervous system.

 

 

 

Cracking the Code on Lightheaded Dizziness

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When people say that they feel dizzy, most people, even healthcare providers usually think that you’re talking about the room spinning sensation of vertigo. However, there are thousands of people around the country describe themselves as having dizziness but don’t have the characteristic sensation of vertigo. Many patients may describe their dizziness as a rocking, swaying, floating, or disoriented feeling. More than anything, people with dizziness have a feeling of being out of sorts if it’s not specifically related to vertigo.

In this article, we are going to breakdown a specific and very common feeling that people associate with dizziness. We are going to talk about lightheaded dizziness.

Orthostatic Intolerance – a blood flow issue

Most people have had a feeling of light headedness at some point in their life. It’s most commonly felt when people go from laying down to standing too quickly. Your head feels funny and you might feel your vision get dark for a moment. After a few seconds, the feeling passes and you probably won’t even think twice about it.

This sensation of feeling light headed on standing is called orthostatic hypotension or orthostatic intolerance.These are terms used to describe the fact that when you change positions, your blood pressure didn’t meet the brain’s demand for blood in that moment in time.

Your brain is a greedy organ when it comes to blood flow. Although it only makes up about 2-3% of the body’s total mass, the brain hogs about 20% of the body’s blood flow. Your blood pressure is not just a marker for the health of your heart, but the purpose of a tightly regulated blood pressure is to make sure that your brain is getting that 20% blood flow at all times. 

While people generally think of their heart as the main controller of blood pressure, it is actually your nervous system that keeps it tightly regulated. It’s so regulated, that in the moments right before you stand (when the idea of standing was just a thought), your brain is sending messages to your muscles and arteries to tighten up so it can keep your blood pressure constant when you are changing postures.

Pretty neat right?

While most people can have moments of lightheadedness like this from time to time, it usually goes away on its own. However, some people feel this sensation on a regular basis. It’s been estimated that anywhere between 4% young adults and 30% of older adults experience orthostatic intolerance. About 42% of people with a complaint of dizziness have a complaint of light headed dizziness related to standing. [Source]

Whether you feel like you’re  spinning, rocking, or light headed, a persistent feeling of dizziness can lead to feelings of anxiety and depression because of the impact on your daily life activities. Orthostatic hypotension is also associated with increased incidence of cardiovascular events and overall mortality, especially in the aging population where feinting and dizziness can lead to falls

Why Does Orthostatic Intolerance Happen?

So far, research has shown that the light headed feeling from orthostatic intolerance is a blood flow issue in the brain. We also know that the autonomic nervous system is a major role player in this problem as many patients with this form of dizziness will have abnormal findings on head upright table tilt testing as well as abnormal blood pressure findings when using a valsava maneuver. [Source]

For many of these cases, there is a problem in the regulation of the sympathetic or parasympathetic nervous system. This gets further complicated by the fact that people who experience orthostatic hypotension may have the same symptoms, but the neurological mechanism that is causing the symptoms are different. [Source]. In general terms, the sympathetic nervous system may have problems constricting your arteries on standing, or the parasympathetic system may have difficulties in regulating your cardiac output. That’s why many patients with orthostatic issues may get evidence-based treatment for the condition.

How Is It Treated?

This part is difficult, because unless you’re in an area that does specialized autonomic laboratories, many people don’t even know this condition exists. Many people get misdiagnosed with vertigo. Many others will just have their condition brushed off.

If you’re lucky enough to have someone that understands orthostatic issues, then you will likely be managed with a regiment of blood pressure medication and IV’s to help keep your blood pressure from tanking. This gets complicated if a patient has HYPERtension when they lie down which is obviously problematic to give therapies that will non-specifically increase your blood pressure.

A Neurological Approach

While many doctors are concerned with blood pressure numbers in of themselves, from a chiropractic perspective we ask why the body is having an abnormal autonomic response to changes in posture. This is particularly important when we are thinking about the head.

When the head and neck shift, it can disrupt normal proprioception into the brainstem and have wide ranging effects of the autonomic nervous system. Excessive twisting or rotation of the Atlas vertebrae may also affect the jugular vein and how blood flow returns to the heart leading to problems with the vagus nerve and cardiac output.

We have also seen patients with dysautonomia have small disturbances in the function of their vestibular system. In some cases patients with orthostatic hypotension can experience vertigo, but in many cases it simply makes head and eye movement far less efficient.

When we put this all together, we have found that a cervical-vestibular approach has the potential to create important improvements in the autonomic nervous system which can help patients overcome their poor relationship with gravity.

Tell us about your dizziness

What Happens in Vagus: Chronic Pain and Dysautonomia

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I’ve been doing a lot of reading lately about the vagus nerve and the autonomic nervous system. We’ve been super fortunate to work with a handful of patients with POTS in the past 6 months with some really great and surprising results from taking a cervical and vestibular approach to care, and it’s driven me to learn more about this unconscious super system in the body.

While dysautonomia is considered a rare problem, there are actually certain types of patients that have a higher risk of having dysautonomia as a co-morbid condition. This includes neurodegenerative disorders like multiple sclerosis and Parkinson’s Disease, but the ground I want to cover is something that affects people as an invisible illness.

Today we’re going to breakdown the relationship between chronic pain and the vagus nerve.

Fibromyalgia, Chronic Fatigue, and Dysautonomia

Fibromyalgia and chronic fatigue syndrome (aka myalgic encephalomyelitis) are 2 conditions that are frequently associated with each other. Estimates as high as 75% of of fibromyalgia patients report fatigue as a major symptom and 20% of chronic fatigue patients also report having widespread body pain [source].

What’s unique about these disorders is that they both show an unusually high amount of dysautonomia compared to the general population. A review in the Journal of Clinical Rheumatology showed that patients with fibromyalgia frequently show scores reflecting autonomic dysfunction along with non-pain symptoms like light-headedness on standing (orthostatic intolerance), digestive complaints, excess sweating, and fatigue.

It’s also been reported in the Journal of Internal Medicine that patients with chronic fatigue syndrome frequently have postural orthostatic tachycardia syndrome (POTS) enough to classify the POTS patients as a distinct subgroup of chronic fatigue.

So why is chronic pain associated with this breakdown of the autonomic nervous system?

What Happens in Vagus….

The nervous system is classified into different branches. For ease of understanding, you have one branch that controls all of your muscles like your biceps, triceps, and quads called the somatic nervous system. You also have another branch that controls your organ systems called the autonomic nervous system.

The autonomic nervous system is further divided into the sympathetic nervous system and the parasympathetic nervous system. The sympathetic system is the one that causes the things you feel when you get stressed out. Rapid heart beat, sweating, high blood pressure, along with increased blood flow to your muscles. It helps you prepare to fight or escape danger. The sympathetic system is primarily driven by a bundle of nerves called the sympathetic chain.

The parasympathetic does the opposite. It forces you to breathe slowly, digest, breathe slowly, and think about reproducing. The parasympathetic system is mainly driven by your vagus nerve.

The Vagus Nerve has a direct connection to most of your body’s internal organ systems

These systems generally work in opposition to each other to set the tone for how your body is going to operate.

The vagus nerve is an special and unique nerve that travels from your brainstem into the bulk of your internal organ systems. It gives the brain a direct line of communication with your organ systems because your body generally wants to spend most of it’s time being parasympathetic. 

Why?

Because when your body is more parasympathetic it is able to breath easier, digest better, engage in sexual intercourse, sleep, and heal from injury.

The sympathetic system is designed to help you survive from an imminent threat, but your parasympathetic system is there to ensure that you can adequately heal and recover from that threat.

The more active the Vagus nerve is, the more likely your body is able to heal and recover. This isn’t just some pleasant billboard sticker either. Research has shown that increased parasympathetic activity is associated with higher survival heart disease and cancer. It’s also associated with improved recovery and decreased injury in athletes.

Most importantly for the patient in chronic pain, lower vagus nerve activity was associated with chronic pain compared to healthy controls. [Source] It’s also been shown that lower vagus activity can be associated with intensity of symptoms in patients with fibromyalgia. [Source]

Weak Vagus and Chronic Stress

Vagal activity is measured using something called heart rate variability (HRV). Many years ago, you could only measure heart rate variability from electrocardiograms (EKG) and measuring the distance between each heart beat. Today, there is no shortage of computer and even smart phone applications that have brought HRV to a wide audience.

In general terms, the higher your HRV is over time, the higher your vagal or parasympathetic activity. The lower your HRV is over time, the higher your stress or sympathetic activity.

If your body is in a chronically high state of stress, then it is going to:

  • Decrease blood flow to your organs
  • Increase exposure to your stress hormones (adrenaline and noradrenaline)
  • Decrease your stores of serotonin (feel good neurotransmitter)
  • Increase your blood sugar (diabetes)
  • Increase your blood pressure
  • Decrease your immune system
  • Decrease tissue healing

Why? Because if your brain thinks that it is in danger from attack, then it does not care about healing and immune function. It is strictly concerned about getting you out of danger.

When you have low HRV and high sympathetic activity, your body is at a distinct disadvantage when it comes to healing and resilience. While low HRV isn’t necessarily the cause of heart disease, cancer, fibromyalgia, or chronic fatigue, but if you have a low HRV then your body’s ability to adapt and overcome these conditions is compromised.

I’ll put that in bold text because that’s an important distinction:

When you have low HRV and high sympathetic activity, your body is at a distinct disadvantage when it comes to healing and resilience. While low HRV isn’t necessarily the cause of heart disease, cancer, fibromyalgia, or chronic fatigue, but if you have a low HRV then your body’s ability to adapt and overcome these conditions is compromised.

Bringing Vagus Back

There was an interesting study published in 2014 that used strength exercise as a treatment for patients with fibromyalgia. The study showed that patients with Fibromyalgia had significant improvements in pain and quality of life through a regiment of strength training, but no significant changes in HRV. The study was surprising, because exercise is one of the best, easiest, and cheapest ways you can improve your HRV, but the biggest surprise was in the conclusion. The study concluded that strength training was an effective therapy for patients with fibromyalgia, which is absolutely true, but also said that changing the autonomic nervous system is not a goal worth achieving in patients with fibromyalgia.

Knowing what you know now about the autonomic nervous system, it seems like a rational and reasonable goal for any patient because improving the autonomic nervous system improves the health and survival of patients regardless of what condition they have.

The best part is that vagal tone can be improved using non-invasive methods that include cardiovascular exercise, resistance exercise, breathing exercise, mindfulness training, non-invasive vagal nerve stimulation, and yes even upper cervical chiropractic.

By taking the focus away from just addressing the pain, and making the focus of care on the autonomic nervous system, it gives us the ability to affect the person as a whole, instead of just addressing a symptom. By taking people away from their condition, and returning them to their bodies.

 

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