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Orthostatic intolerance
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'''Orthostatic intolerance''' (OI) is the inability to correctly regulate blood pressure, cerebral blood flow and consciousness when upright, usually when standing, but it can also occur when sitting. If irregular blood pressure and heart rate initiate while in a supine position (lying down, faceup), then officially it is not orthostatic intolerance.<ref name="Stewart2015" /> == Prevalence == Orthostatic intolerance is a common dysfunction in [[ME/CFS]].<ref>{{Cite news | url=http://solvecfs.org/guest-blog-dr-peter-rowe-is-the-physical-examination-normal-in-cfs-part-1/| title = Guest Blog: Dr. Peter Rowe β Is The Physical Examination Normal in CFS? Part 1 - Solve ME/CFS Initiative | last = Rowe | first = Peter | date = 2014-09-05|work=Solve ME/CFS Initiative|access-date=2018-08-27|archive-url=|archive-date=|url-status=|language=en-US}}</ref><ref>{{Cite web|url=https://ammes.org/overlapping-conditions/| title = Overlapping Conditions | website = [[American ME and CFS Society]]|language=en-US|access-date=2018-08-12}}</ref> Estimates of the rate of orthostatic intolerance in [[chronic fatigue syndrome]] and [[myalgic encephalomyelitis]] patients vary widely, with estimates as low as 50% to as high as 97% of patients.<ref name="Miwa2015" /> Orthostatic intolerance is also commonly associated with [[fibromyalgia]].<ref>{{Cite web|url=http://drlapp.com/wp-content/uploads/TTT_symptoms.pdf| title = Symptoms Predict the Outcome of Tilt Table Testing in CFS/ME/FM | last = Lapp | first = Charles | last2 = Black | first2 = Laura | date = |website=drlapp.com|archive-url=|archive-date=|url-status=|access-date= | last3 = Smith | first3 = Rebekah S.}}</ref> ==Testing== <embedvideo service="youtube" dimensions="400" alignment="right" container="frame" description="This interactive video explains what you can expect during the tilt table test. By eMedTV">https://www.youtube.com/watch?v=5H5FZTAic7c</embedvideo> Orthostatic intolerance can be diagnosed by a [[tilt table test]], although a tilt table test isn't required. It is part of the [[Institute of Medicine report]]'s proposed diagnostic criteria for [[Systemic Exertion Intolerance Disease]].<ref name="SEID2015" /> The [[NASA 10-minute lean test|NASA 10-minute Lean Test]] is a variant of a test used by NASA researchers to test for orthostatic intolerance following space flight. The adaption for [[ME/CFS]] patients was developed by Dr. [[Lucinda Bateman]], which she recommends all [[ME/CFS]] and [[fibromyalgia]] patients undergo to assess for orthostatic intolerance. The NASA 10-minute Lean Test is less taxing on the patient and can be done in any physician's office. Instructions are available for printout for both [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Test-Instructions-1.pdf healthcare providers] and [https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Patient-Preparation-Instructions-1.pdf patients].<ref name="Bateman2016-NASA">{{Cite web|url=https://batemanhornecenter.org/assess-orthostatic-intolerance/| title = Simple Way to Assess Orthostatic Intolerance - Bateman Horne Center | last = Bateman | first = Lucinda | date = 2016-09-27 | website = [[Bateman Horne Center]]|access-date=2018-08-27|archive-url=|archive-date=|url-status=|language=en-US}}</ref> ==Symptom recognition== Orthostatic intolerance (OI) is an optional symptom for diagnosis in [[Systemic Exertion Intolerance Disease]] (SEID), the [[Canadian Consensus Criteria]] (CCC) which diagnoses ME/CFS and the [[International Consensus Criteria]] (ICC)<ref name="ICC2011primer" /> which can be used to diagnose Myalgic encephalomyelitis (ME).<ref name="SEID2015">{{Citation | last = Institute of Medicine | authorlink = Institute of Medicine| title = Beyond Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Redefining an Illness|location=Washington, DC|publisher=The National Academies Press | date = 2015 | url=https://www.ncbi.nlm.nih.gov/books/NBK284902/}}</ref><ref name="canadianconsensus-CCC">{{Citation | last1 = Carruthers | first1 = Bruce M. | authorlink1 = Bruce Carruthers | last2 = Jain | first2 = Anil Kumar | authorlink2 = Anil Kumar Jain | last3 = De Meirleir | first3 = Kenny L. | authorlink3 = Kenny De Meirleir | last4 = Peterson | first4 = Daniel L. | authorlink4 = Daniel Peterson | last5 = Klimas | first5 = Nancy G. | authorlink5 = Nancy Klimas | last6 = Lerner | first6 = A. Martin | authorlink6 = Martin Lerner | last7 = Bested | first7 = Alison C. | authorlink7 = Alison Bested | last8 = Flor-Henry | first8 = Pierre | authorlink8 = Pierre Flor-Henry | last9 =Joshi | first9 = Pradip | authorlink9 = Pradip Joshi | last10 = Powles | first10 = AC Peter | authorlink10 = A C Peter Powles | last11 = Sherkey | first11 = Jeffrey A. | authorlink11 = Jeffrey Sherkey | last12 = van de Sande | first12 = Marjorie I. | authorlink12 = Marjorie van de Sande | title = Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical Working Case Definition, Diagnostic and Treatment Protocols | journal = Journal of Chronic Fatigue Syndrome | volume = 11 | issue = 2 | pages = 7-115 | date = 2003 | pmid = | doi = 10.1300/J092v11n01_02 | url = http://www.investinme.org/Documents/PDFdocuments/CanadianDefinitionME-CFS.pdf }}</ref><ref name="ICC2011primer">{{citation | last1 = Carruthers | first1 = BM | authorlink1 = Bruce Carruthers | last2 = van de Sande | first2 = MI | authorlink2 = Marjorie van de Sande | last3 = De Meirleir | first3 = KL | authorlink3 = Kenny de Meirleir | last4 = Klimas | first4 = NG | authorlink4 = Nancy Klimas | last5 = Broderick | first5 = G | authorlink5 = Gordon Broderick | last6 = Mitchell | first6 = T | authorlink6 = Terry Mitchell | last7 = Staines | first7 = D | authorlink7 = Donald Staines | last8 = Powles | first8 = ACP | authorlink8 = A C Peter Powles | last9 = Speight | first9 = N | authorlink9 = Nigel Speight | last10 = Vallings | first10 = R | authorlink10 = Rosamund Vallings | last11 = Bateman | first11 = L | authorlink11 = Lucinda Bateman | last12 = Bell | first12 = DS | authorlink12 = David Bell | last13 = Carlo-Stella | first13 = N | authorlink13 = Nicoletta Carlo-Stella | last14 = Chia | first14 = J | authorlink14= John Chia | last15 = Darragh | first15 = A | authorlink15 = Austin Darragh | last16 = Gerken | first16 = A | authorlink16 = Anne Gerken | last17 = Jo | first17 = D | authorlink17 = Daehyun Jo | last18 = Lewis | first18 = DP | authorlink18 = Donald Lewis | last19 = Light | first19 = AR | authorlink19 = Alan Light | last20 = Light | first20 = KC | authorlink20 = Kathleen Light | last21 = Marshall-Gradisnik | first21 = S | authorlink21 = Sonya Marshall-Gradisnik | last22 = McLaren-Howard | first22 = J | authorlink22 = John McLaren-Howard | last23 = Mena | first23 = I | authorlink23 = Ismael Mena | last24 = Miwa | first24 = K | authorlink24 = Kunihisa Miwa | last25 = Murovska | first25 = M | authorlink25= Modra Murovska | last26 = Stevens | first26 = SR | authorlink26 = Staci Stevens | title = Myalgic encephalomyelitis: Adult & Paediatric: International Consensus Primer for Medical Practitioners | date = 2012 | isbn = 978-0-9739335-3-6 | url = http://www.investinme.org/Documents/Guidelines/Myalgic%20Encephalomyelitis%20International%20Consensus%20Primer%20-2012-11-26.pdf }}</ref> In the [[London criteria]] which diagnoses ME, OI is mentioned under the criteria of ''periods of impaired circulation compatible with autonomic dysfunction''.<ref name="Londoncriteria2013">{{Citation | url =http://www.axfordsabode.org.uk/me/mecrit2014.htm|archive-url=http://web.archive.org/web/20150923181011/http://www.axfordsabode.org.uk/me/mecrit2014.htm|archive-date=2015-09-23|url-status=dead| title = Myalgic Encephalomyelitis (ME). Criteria and clinical guidelines. 2014 | date = Oct 15, 2014 | last = Howes | first = Sandra | authorlink = Sandra Howes | last2 = Goudsmit | first2 = Ellen M.|author2-link=Ellen Goudsmit | last3 = Shepherd | first3 = Charles | author3-link=Charles Shepherd}}</ref> == Types of orthostatic intolerance == === Postural orthostatic tachycardia syndrome === {{Main article|page_name=Postural orthostatic tachychardia}} [[Postural orthostatic tachycardia syndrome]] (POTS) is one of a group of disorders that have orthostatic intolerance (OI) as their primary symptom. The primary symptom of OI is lightheadedness or fainting. In POTS, the lightheadedness or fainting is also accompanied by a rapid increase in heartbeat of more than 30 beats per minute, or a heart rate that exceeds 120 beats per minute, within 10 minutes of rising.<ref>{{Cite web|url=https://www.ninds.nih.gov/Disorders/All-Disorders/Postural-Tachycardia-Syndrome-Information-Page| title = Postural Tachycardia Syndrome Information Page | website = [[National Institute of Neurological Disorders and Stroke]]|access-date=2018-08-27}}</ref> === Orthostatic hypotension === {{Main article|page_name=Orthostatic hypotension}} [[Orthostatic hypotension]], also called postural hypotension, it is a form of sudden low blood pressure that occurs upon standing. It can often cause dizziness. it is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position.<ref>{{Cite news | url=http://www.potsuk.org/living_with_low_blood_pressure| title = PoTS - Living with low blood pressure | last = | first = |work=PoTS UK|access-date=2018-08-27|language=en}}</ref> === Neurally mediated hypotension === {{Main article|page_name=Neurally mediated hypotension}} [[Neurally mediated hypotension]] (NMH), also called neurally mediate syncope, peripheral vasodilation causes blood to pool in the extremities. It is associated with a decrease in blood pressure, and a slow or lowered heart rate upon standing.<ref>{{Cite web|url=http://www.dysautonomiainternational.org/page.php?ID=31 | website = Dysautonomia International| title = Summary of Syncope and Neurally Mediated Syncope|language=en|access-date=2018-08-27}}</ref> === Vasovagal syncope === {{Main article|Syncope}} Syncope means fainting, and near-syncope is when a person almost faints.{{citation needed | date = 2022}} == Potential treatments == ===Drugs=== * beta-blockers (Metopropol) *[[Fludrocortisone]] (Florinef) *[[Mestinon|Pyridostigmine]]<ref>{{Cite news | url=https://www.prohealth.com/library/evergreen_pages/pharmaceutical-medications-for-chronic-fatigue-syndrome-myalgic-encephalomyelitis| title = Pharmaceutical Medications for Chronic Fatigue Syndrome & Myalgic Encephalomyelitis - Prohealth|work=Prohealth|access-date=2018-08-28|language=en-US}}</ref> ===Management=== *[[increase fluids]] and [[increased salt intake|increase dietary salt]]<ref name=":0">{{Cite web|url=https://www.cdc.gov/me-cfs/treatment/index.html| title = Treatment {{!}} Myalgic Encephalomyelitis/Chronic Fatigue Syndrome | date = 2018-05-18 | website = [[Centers for Disease Control and Prevention]]|language=en-us|access-date=2018-08-28}}</ref> *taking [[oral rehydration salts]]<ref name=":1">{{Cite journal | last = Medow | first = Marvin S. | last2 = Guber | first2 = Kenneth | last3 = Chokshi | first3 = Shilpan | last4 = Terilli | first4 = Courtney | last5 = Visintainer | first5 = Paul | last6 = Stewart | first6 = Julian M. | date = Nov 2019| title = The Benefits of Oral Rehydration on Orthostatic Intolerance in Children with Postural Tachycardia Syndrome|url=https://pubmed.ncbi.nlm.nih.gov/31405524/|journal=The Journal of Pediatrics|volume=214 | pages = 96β102|doi=10.1016/j.jpeds.2019.07.041|issn=1097-6833|pmc=6815702|pmid=31405524}}</ref> *monitoring heart rate<ref>{{Cite news | url=https://www.prohealth.com/library/orthostatic-intolerance-part-2-treating-oi-82949| title = Orthostatic Intolerance, Part 2: Treating OI - Prohealth | date = 2018-06-15|work=Prohealth|access-date=2018-08-28|language=en-US}}</ref>{{citation needed | date = 2022 | reason=Better citation needed}} *raising head of bed<ref>{{Cite web|url=http://www.theoicenter.com/Taking-Care/Head-Up.html| title = Head of Bed Up|website=theoicenter.com|access-date=2018-08-28}}</ref><ref>{{Cite journal | last = Fan | first = C. W. | last2 = Walsh | first2 = C. | last3 = Cunningham | first3 = C.J. | date = 2011-01-13| title = The effect of sleeping with the head of the bed elevated six inches on elderly patients with orthostatic hypotension: an open randomised controlled trial|url=https://academic.oup.com/ageing/article/40/2/187/47278|journal=Age and Ageing|language=en|volume=40|issue=2|pages=187β192|doi=10.1093/ageing/afq176|issn=0002-0729}}</ref> *shower chair, handheld shower head, cooler water<ref>{{Cite web|url=http://www.theoicenter.com/Taking-Care/Showers-and-Stuff.html| title = Cleaning Up - Shower, Hair, Skin|website=theoicenter.com|access-date=2018-08-28}}</ref> *support stockings/[[compression stocking]]s<ref name=":0" /><ref name="vanCampen2022"/> *abdominal compression<ref>{{Cite journal|title=Abdominal Compression as a Treatment for Postural Tachycardia Syndrome|date=2020-07-21|url=https://www.ahajournals.org/doi/10.1161/JAHA.120.017610|journal=Journal of the American Heart Association|volume=9|issue=14|pages=e017610|last=Miller|first=Amanda J.|last2=Bourne|first2=Kate M.|language=en|doi=10.1161/JAHA.120.017610|pmc=PMC7660708|pmid=32673524|issn=2047-9980}}</ref> ==Research studies== *1999, [https://www.researchgate.net/publication/13372595_Orthostatic_Intolerance_in_Adolescent_Chronic_Fatigue_Syndrome Orthostatic intolerance in the chronic fatigue syndrome]<ref>{{Cite web|url=https://www.researchgate.net/profile/Julian_Stewart2/publication/13372595_Orthostatic_Intolerance_in_Adolescent_Chronic_Fatigue_Syndrome/links/5747411808aef66a78b079bf.pdf| title = Orthostatic Intolerance in Adolescent Chronic Fatigue Syndrome | last = Stewart | first = Julian Mark | last2 = Gewitz | first2 = Michael | date = Feb 1999 | website = researchgate.net|publisher=PubMed|via=Research Gate|archive-url=|archive-date=|url-status=|access-date= | last3 = Weldon | first3 = A | last4 = Munoz | first4 = J}}</ref> *2000, [http://www.ncbi.nlm.nih.gov/pubmed/10910366 The Roles of Orthostatic Hypotension, Orthostatic Tachycardia, and Subnormal Erythrocyte Volume in the Pathogenesis of the Chronic Fatigue Syndrome]<ref>{{Cite journal | last = Streeten | first = D. H. | last2 = Thomas | first2 = D. | last3 = Bell | first3 = D.S. | date = 2000| title = The roles of orthostatic hypotension, orthostatic tachycardia, and subnormal erythrocyte volume in the pathogenesis of the chronic fatigue syndrome|url=https://www.ncbi.nlm.nih.gov/pubmed/10910366|journal=The American Journal of the Medical Sciences|volume=320|issue=1|pages=1β8|issn=0002-9629|pmid=10910366|via=}}</ref> *2000, [https://www.tandfonline.com/doi/abs/10.1300/J092v08n02_05 Orthostatic Intolerance: A Review with Application to the Chronic Fatigue Syndrome]<ref>{{Cite journal | last = Stewart | first = Julian M. | date = 2000| title = Orthostatic Intolerance|url=http://dx.doi.org/10.1300/J092v08n02_05|journal=Journal of Chronic Fatigue Syndrome|language=en|volume=8|issue=2 | pages = 45β64|doi=10.1300/j092v08n02_05|issn=1057-3321|via=}}</ref> *2015, [http://link.springer.com/article/10.1007/s00246-015-1274-6 Intravenous Hydration for Management of Medication-Resistant Orthostatic Intolerance in Adolescents and Young Adults]<ref name="Moak2015" /> *2016, [http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460014/ Orthostatic Changes in Hemodynamics and Cardiovascular Biomarkers in Dysautonomic Patients]<ref name="Nilsson2015" /> *2019, Orthostatic intolerance in chronic fatigue syndrome<ref>{{Cite journal | last = Garner | first = Richard | authorlink = | last2 = Baraniuk | first2 = James N. | authorlink2 = James Baraniuk | date = Dec 2019| title = Orthostatic intolerance in chronic fatigue syndrome|url=https://translational-medicine.biomedcentral.com/articles/10.1186/s12967-019-1935-y|journal=Journal of Translational Medicine|language=en|volume=17|issue=1|pages=|doi=10.1186/s12967-019-1935-y|issn=1479-5876|quote=|via=}}</ref> *2019, The Benefits of Oral Rehydration on Orthostatic Intolerance in Children with Postural Tachycardia Syndrome<ref name=":1" /> *2022, Compression Stockings Improve Cardiac Output and Cerebral Blood Flow during Tilt Testing in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Patients: A Randomized Crossover Trial<ref name="vanCampen2022">{{Cite journal| title = Compression Stockings Improve Cardiac Output and Cerebral Blood Flow during Tilt Testing in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Patients: A Randomized Crossover Trial | date = Jan 2022|url=https://www.mdpi.com/1648-9144/58/1/51/htm|journal=Medicina|volume=58|issue=1 | pages = 51 | last = van Campen | first = C. (Linda) M.C. | authorlink = Linda van Campen | last2 = Rowe | first2 = Peter C. | authorlink2 = Peter Rowe | last3 = Visser | first3 = Frans C. | authorlink3 = Frans Visser|language=en|doi=10.3390/medicina58010051|pmc=PMC8781100|pmid=35056360|access-date=|issn=1648-9144|quote=|via=}}</ref> - [https://www.mdpi.com/1648-9144/58/1/51/htm (Full text)] ==Talks and interviews== *2010, [https://www.youtube.com/watch?v=5iF30TVLaRE Mangaging Orthostatic Intolerance]<ref>{{Cite web|url=https://link.springer.com/article/10.1007%2Fs00246-015-1274-6| title = Managing Orthostatic Intolerance | last = Rowe | first = Peter | date = Sep 1, 2010 | website = YouTube|publisher=SolveCFS|archive-url=|archive-date=|url-status=|access-date=}}</ref> *2016, [https://www.youtube.com/watch?v=_eydfpVtb0c Remaining Upright: Approach to Orthostatic Intolerance]<ref>{{Cite web|url=https://www.youtube.com/watch?v=_eydfpVtb0c| title = Remaining Upright: Approach to Orthostatic Intolerance - Melissa Cortes | last = Cortes | first = Melissa | date = Apr 7, 2016 | website = YouTube|publisher=Bateman Horne Center|archive-url=|archive-date=|url-status=|access-date=}}</ref> ==See also== *[[Tilt table test]] *[[Dizziness]] *[[Neurally mediated hypotension]] *[[Postural orthostatic tachycardia]] ==Learn more== *2015, [http://emedicine.medscape.com/article/902155-overview#showall Orthostatic Intolerance]<ref>{{Cite journal | last = Stewart | first = Julian | date = 2018-01-04| title = Orthostatic Intolerance: Background, Pathophysiology, Etiology|url=https://emedicine.medscape.com/article/902155-overview|journal=MedScape|volume=|pages=|via=}}</ref> *2016, [https://batemanhornecenter.org/remaining-upright-approach-to-orthostatic-intolerance/ Remaining Upright: Approach to Orthostatic Intolerance]<ref>{{Cite news | url=https://batemanhornecenter.org/remaining-upright-approach-to-orthostatic-intolerance/| title = Remaining Upright: Approach to Orthostatic Intolerance - Bateman Horne Center | last = Reynolds | first = Leigh | date = 2016-04-08|work=Bateman Horne Center|access-date=2018-08-28|archive-url=|archive-date=|url-status=|language=en-US}}</ref> *2016, [http://www.meaction.net/2016/02/21/nih-gives-246000-for-study-of-oral-rehydration-in-mecfs-patients-with-orthostatic-intolerance/ NIH gives $246,000 for study of oral rehydration in ME/CFS patients with orthostatic intolerance]<ref>{{Cite news | url=https://www.meaction.net/2016/02/21/nih-gives-246000-for-study-of-oral-rehydration-in-mecfs-patients-with-orthostatic-intolerance/| title = NIH gives $246,000 for study of oral rehydration in ME/CFS patients with orthostatic intolerance - #MEAction | last = Anderssen | first = Alex | date = 2016-02-21|work=#MEAction|access-date=2018-08-28|archive-url=|archive-date=|url-status=|language=en-US}}</ref> *[http://www.theoicenter.com/Index.html The Orthostatic Intolerance (OI) Center]<ref>{{Cite web|url=http://www.theoicenter.com/Index.html| title = Orthostatic Intolerance (OI) Center|website=theoicenter.com|access-date=2018-08-28}}</ref> ==References== <references> <ref name="Miwa2015">{{Citation | last = Miwa | first = Kunihisa | title = Cardiac dysfunction and orthostatic intolerance in patients with myalgic encephalomyelitis and a small left ventricle | journal = Heart and Vessels | volume = 30 | issue = 4| pages = 484β489 | date = Jul 2015 | pmid = 24736946 | doi = 10.1007/s00380-014-0510-y | url = http://www.ncbi.nlm.nih.gov/pubmed/24736946 }}</ref> <ref name="Stewart2015">{{Citation | last = Stewart | first = Julian M | authorlink1 = Julian Stewart | last2 = Medow | first2 = Marvin S | authorlink2 = Marvin Medow | title = Orthostatic Intolerance | journal = Medscape | date = 2 Feb 2015 | url = http://emedicine.medscape.com/article/902155-overview#showall }}</ref> <ref name="Moak2015">{{Cite journal | last = Moak | first = Jeffrey P. | last2 = Leong | first2 = Derek | last3 = Fabian | first3 = Robin | last4 = Freedenberg | first4 = Vicki | last5 = Jarosz | first5 = Elizabeth | last6 = Toney | first6 = Carol | last7 = Hanumanthaiah | first7 = Sridhar | last8 = Darbari | first8 = Anil | date = 2015-10-07| title = Intravenous Hydration for Management of Medication-Resistant Orthostatic Intolerance in the Adolescent and Young Adult|url=https://link.springer.com/article/10.1007/s00246-015-1274-6|journal=Pediatric Cardiology|language=en|volume=37|issue=2|pages=278β282|doi=10.1007/s00246-015-1274-6|issn=0172-0643}}</ref> <ref name="Nilsson2015">{{citation | last1 = Nilsson | first1 = David | last2 = Sutton | first2 = Richard | last3 = Tas | first3 = Widet | last4 = Burri | first4 = Philippe | last5 = Melander | first5 = Olle | last6 =Fedorowski | first6 = Artur | title = Orthostatic Changes in Hemodynamics and Cardiovascular Biomarkers in Dysautonomic Patients | journal = PLoS ONE | volume = 10 | issue = 6 | date = 6 Aug 2015 | pmid = 26053073 | doi = 10.1371/journal.pone.0128962 | url = http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4460014/ }}</ref> </references> [[Category:Signs and symptoms]] [[Category:Cardiac signs and symptoms]] [[Category:Potential comorbidities]] [[Category:Neurological signs and symptoms]] [[Category:Autonomic nervous system disorders]] [[Category:Diagnoses]] [[Category:Disease]] [[Category:Energy production or transportation symptoms]]
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