I picked this article to read to today, because 1) I was thinking I might have a case of this on my case load and I didn’t know anything on the topic (now having read the article, I’ve ruled it out of the differential), 2) there was some recent discussion in the Neurocollaborative Professionals Facebook page a few weeks ago on POTS, 3) I saw a case of it on one of those medical mystery tv shows eons ago and thought it sounded interesting. So come along and we’ll learn together!
First, these folk have to have a concussion leading to post-concussion syndrome, which is defined by WHO as “3 or more symptoms of headache, dizziness, fatigue, irritability, difficulty with concentration and mental tasks, memory impairment, sleep disturbances, heightened emotional responses and poor stress intolerance… interfering with the ability to participate in life activities.” Some of the lesser known symptoms of concussion involved the autonomic nervous system– those “flight or fight” responses to stress– like body temperature regulation, sleep cycles, digestion and cardiac function to name a few. These are due to “altered cerebral blood flow, inflammatory processes and disrupted axonal communication.”
If these alterations effect the cardiovascular system (which one study showed occurred in 11.4% of concussions), you can get an variable array of symptoms which are termed postural orthostatic tachycardia syndrome or POTS. Not everyone experiences every one of the symptoms. Some people just have a couple. The main characteristic symptom is a sustained (10 minutes or more) of tachycardia (irregularly fast heart rate) in standing. Other symptoms could include dizziness, lightheadedness, headache, nausea, stomach area pains, heaviness in the arms or legs, fatigue, mental fog, disturbed sleep patterns, being too hot or too cold, bloating, being full all the time or getting full faster than normal, swelling in the arms or legs, losing control of the bladder and skin discolorations like these:
Or like these
Acrocyanosis (blusish discoloration of hands or feet).
To diagnosis, a physician may use a questionnaire called the Compass Autonomic Symptom Score (COMPASS) (which I couldn’t find for free on the internet), and/or tilt table testing. A therapist could look at the following table to determine if someone should get checked out by a physician for possible POTS. These are heart rates when the person has been standing for 10 minutes.
There are 3 subtypes of POTS.
- Hypovolemia— low plasma, red cell and total blood volume
- Neuropathic— “partial sympathetic denervation of blood vessels in the lower extremities, resulting in reduced vasoconstriction response during upright posture” (meaning that the blood vessels in the legs aren’t working properly
- Hyperadrenergic— “excessive plasma [norepinephrine, a neurotransmitter] greater than 600 pg/mL upon standing and profound sympathetic activity that often results in anxiety, [heart] palpitations, tachycardia [fast heart beat], tremulousness, and sometimes postural hypertension [high blood pressure] with greater than 10-mm Hg systolic BP increase upon standing.”
Medical management starts with some dietary changes: drinking more fluids (to combat the hypovolemia) and wearing compression stockings (to force some constriction in the legs where the body’s natural vasoconstriction is absent).
That was more than enough for me to take in this evening. We’ll look at how this effects their concussion rehabilitation next time!