What is Postural Orthostatic Tachycardia Syndrome (POTS)?

Jul 28

Postural Orthostatic Tachycardia Syndrome, or POTS, is a form of dysautonomia.

Dysautonomia refers to a class of disorders that involve dysfunction of the autonomic nervous system, or ANS. The autonomic system regulates critical involuntary bodily functions including heart rate, blood pressure, breathing, digestion, and a number of other reflexes that are critical to survival.

POTS is a particular type of dysautonomia in which an individual cannot regulate the autonomic responses needed to compensate for a postural change. When someone goes from lying to standing, gravity pulls blood down towards their feet. The autonomic system needs to tell blood vessels to constrict, so that blood can be pumped back up to the brain. These reflexes work poorly in POTS, and blood flow to the brain subsequently decreases.

The brain will normally increase the heart rate to compensate for this drop in blood pressure. However, in POTS the increase in heart rate is extreme, and thus the heart will beat before it has a chance to properly fill with blood. This leads to even less blood flow to the brain. POTS sufferers will experience dizziness, often will faint, and frequently are injured as a result of these falls.

How Common is Postural Orthostatic Tachycardia Syndrome?

POTS affects approximately 1-3 million Americans. POTS is most common among females ages 15-50, but is also known to affect men and in a few cases, children (4).

What Causes Postural Orthostatic Tachycardia Syndrome?

POTS is caused as a result of the body's diminished ability to regulate proper blood volume through the body through the changing of positions. What causes this lack of regulation is different in each case (1), and some people have multiple contributing factors. Most commonly, POTS has either a neuropathic cause (from damaged small-fiber nerves that regulate these functions), a hyperadrenergic cause (associated with elevated levels of stress hormone), a hypovolemic cause (associated with abnormally low blood volume), or a secondary cause (meaning it becomes present following the onset of another condition such as an autoimmune disease (16).

Postural orthostatic tachycardia syndrome is extremely common following concussions and traumatic brain injuries. POTS is a common feature of post-concussion syndrome (15).

It is important that each individual living with POTS receives a thorough neurological assessment, as the correct treatment differs depending on the cause.

What are the Symptoms of Postural Orthostatic Tachycardia Syndrome?

Symptoms of POTS differ from person to person. They may include any of the following symptoms: severe and long-lasting fatigue, lightheadedness or dizziness when changing posture, fainting, nausea, vomiting, headaches, “brain-fog” (thought and focus difficulties), excessive sweating, sensation of powerful or irregular heartbeats, and pale face/discolored hands and feet. Not all patients will have all symptoms, and not all symptoms listed are the only symptoms of POTS. However, often POTS patients will have increased symptoms present when they are in warm environments, when they have decreased water intake, or they have been standing for an extended period of time (1).

How is Postural Orthostatic Tachycardia Syndrome Diagnosed?

POTS is generally diagnosed with tilt table testing, in which heart rate and blood pressure are tested in both supine and standing positions (10).

The accepted criteria for a diagnosis of POTS are:

a sustained increase in HR of at least 30 bpm within 10 minutes of assuming the upright posture (often with absolute upright HR ≥120 bpm);

in the absence of sustained orthostatic hypotension (drop in BP >20/10 mmHg);

with symptoms of orthostatic intolerance for at least 6 months that are relieved by recumbence; and

excluding other causes of sinus tachycardia including acute physiological stimuli (e.g. panic attacks, pain, exercise), dietary influences (e.g. caffeine, alcohol), medications (e.g. sympathomimetics, anticholinergics, rebound effects of β-blocker withdrawal), and other medical conditions (e.g. anemia, dehydration, hyperthyroidism, inappropriate sinus tachycardia) (11).

What Happens in the Brain with Postural Orthostatic Tachycardia Syndrome?

When the brain does not receive sufficient blood flow, myriad symptoms may present. You brain requires a great deal of energy to function properly, and when this is disrupted, a host of brain functions are disrupted (12). Simple cognitive tasks become profound challenges simple physical tasks become exhausting. Emotional regulation can become extremely difficult. Everything your brain does depends on the ability to properly regulate blood flow. When this fails, virtually everything your brain attempts to do can become a struggle (3).

How is Postural Orthostatic Tachycardia Syndrome Usually Treated?

There is no known established cure for POTS. Most cases are treated through lifestyle changes, diet, and physical exercise. For some patients, medications are deemed appropriate (13). While these can help mitigate some of the symptoms of POTS, they generally do little to affect the impaired autonomic reflexes that are the underlying cause of the disorder.

How is the NeuroRescue Program Different?

One of the main things your brain does, and maybe even the primary thing, is help you determine where you are in the world. Your brain uses inputs from your inner ear to figure out where your head is in relation to gravity and how it is moving. It uses inputs from your muscles and joints to figure out where your body is in relation to your head and what your body is doing. It uses inputs from your eyes to figure out where your body is in relation to the visual environment.

Your brain needs to put all of that together to make sense of where the world is, and where you are in relation to the world. It needs to be able to localize you effectively in the environment, in order for you to be able to respond to the environment properly.

Your brain organizes all of this information in terms of maps. There is a vestibular map from the inner ear, a proprioceptive map from muscles and joints, a vascular map of your blood flow, a visual map of the world from your eyes, and several others. Your brain needs these maps to be saying largely the same thing about where you are in the world at all times.

One often overlooked feature of POTS is that these maps usually fail to match. Your eyes, inner ear, and muscles are creating maps that say different things about where your head is in relation to gravity. When you go from lying down to sitting up or standing, problems in these maps can make it difficult for the brain to compensate for the postural shift. If the brain does not understand the position of the head in relation to gravity, it cannot properly control the vascular system to send the appropriate amount of blood to the head (3). We utilize eye movements and associated therapies to activate the various cortical, subcortical and brainstem regions involved in autonomic regulation to improve function and connectivity (14).

This is why many patients fail to fully resolve their POTS with most forms of treatment. Without addressing the problems in these maps, it will remain impossible for the brain to properly control blood flow, and the best they can hope for is to gain some control over their symptoms. We would much rather try to address the underlying cause.

How Does the NeuroRescue Program Work?

We design your unique NeuroRescue Program to be among the most comprehensive diagnostic and therapeutic protocols available today. We create individual NeuroRescue Programs based on a comprehensive analysis of every relevant neurological system and pathway, using gold-standard, cutting edge neurodiagnostic technologies and examination procedures and state-of-the-art therapies.

We begin with your Discovery Day, wherein we perform a comprehensive history of not only your condition, but your life on a timeline. This allows us to dive deeply into your case and see all of the factors that led to where you are now. It helps us uncover hidden problems and associated conditions that may be making it difficult for you to move your recovery forward.

Our examination allows us to identify the areas and pathways of your brain involved in your POTS. We begin by precisely quantifying the function of your visual, vestibular, and proprioceptive systems through computerized analysis of your eye movements, your inner ear reflexes, and your balance in a host of different sensory conditions.

We employ technologies including Videooculography and Saccadometry to measure several classes of eye movements. We use Video Head Impulse Testing to measure the function of your inner ear, and Computerized Dynamic Posturography to assess your balance in different sensory conditions.

We use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and perception of vertical in a virtual reality environment.

We combine all of this with a comprehensive physical and neurological examination of your sensory, motor, autonomic, and cognitive systems. We review any relevant laboratory testing, radiological imaging, and prior neurodiagnostic testing, and integrate that information with our findings.

We use this information to identify which parts of your brain are working properly, which systems are struggling, and the precise point at which your systems fatigue.

We can then design a NeuroRescue Program that is unique and specific to your brain, and yours alone. Your NeuroRescue Program works to rejuvenate and reintegrate the damaged neurons and pathways in your brain. It works to improve energy, endurance, and functional capacity within your fragile systems.

Our therapies may range from specific eye exercises (5), to specific types of vestibular therapy (6), to unique forms of electrical stimulation (7). We may employ laser and LED photobiomodulation (8), or even exercises in a virtual reality environment (9). All of our therapies will be specific to your unique case, based purely on your neurodiagnostic testing data and examination findings.

We use our technologies and procedures to not only see what we need to address, but also when it is time to stop and let you rest. We address your impaired neurological function from multiple angles of therapy, and provide metabolic support to improve neurological recovery.

While we cannot bring back neurons that have been lost, your NeuroRescue Program allows us to take the pathways that remain and maximize their efficiency and endurance. And by focusing on the integration of systems, we can do more than just get pathways working better, we can get them working together again. This gives us our best opportunity to return you to living a healthy, vibrant, and fulfilling life.

Your Next Best Step:

Living with postural orthostatic tachycardia syndrome can be challenging, but there is hope for recovery. To see if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.

And remember, it’s never too late to start getting better.