by David S. Bell, MD, FAAP
The Lyndonville Journal
Orthostatic intolerance is a term used for illnesses, which are characterized by inability to maintain the upright posture. It is a group of illnesses that overlaps with CFS [Chronic Fatigue Syndrome] just as fibromyalgia does, and it may give up leads as to the underlying pathology of the illness. The most exciting new leads are happening in the world of orthostatic intolerance.
Because much of the literature on OI may be unfamiliar to the reader, I will try to summarize it. For those interested in more in-depth reading, I would start with the February 1999 issue of the American Journal of the Medical Sciences, (Am J Med Sci 1999;317(2). This issue is devoted to a review of OI, and much of what I will say here is taken from that issue. The parallels with CFS are tremendous, starting with the title of the first article by David Robertson, "The epidemic of orthostatic tachycardia and orthostatic intolerance".
Defined simply, OI is the presence of symptoms due to inadequate cerebral perfusion on assuming the upright posture. The usual symptoms include fatigue, nausea, lightheadedness, heart palpitations, sweating, and sometimes passing out. Many persons with medically proven OI have been assumed to have emotional problems when they don't. Like CFS, there have been many terms in the past to describe this group of disorders, including "asthenia." Sound familiar? It is not known what is the exact relationship between OI and CFS, and up until recently studies in the two areas have followed separate tracts. The one very nice advantage OI has over CFS is that it can be proven and there are well defined subgroups.
Over the past year in our office we have been testing patients with CFS for OI by two methods. One has been a circulating blood volume study, described in the last section of this series, and the second is a test for orthostatic intolerance. This test is easily done in the office and requires only a blood pressure cuff and a good nurse to catch the patient before passing out.
The test is relatively simple. The patient lies comfortably for ten minutes and BP [blood pressure] and pulse are taken several times. Then the patient stands quietly (no moving around) with the blood pressure cuff on, and BP and pulse are taken every few minutes. This is a poor man's tilt test, and I would argue that it is more accurate because it reproduces exactly what happens to a patient waiting in the check out line at the supermarket.
A person with CFS nearly always has orthostatic intolerance. They describe the symptom of fatigue (which is not fatigue at all) which is characterized by being relatively OK while walking down the aisle of the supermarket, but being unable to stand in the checkout line. The orthostatic testing describes physiologically why this occurs.
There are five separate abnormalities than can occur during quiet standing:
As an aside, everyone thought he was a fruitcake - a healthy looking man who said he felt poorly and couldn't work. He was denied disability as usual. Yet when we did the test, he was so determined to stand up I was afraid he was going to stroke out and croak. But he was standing with a BP of 210/140 and a pulse of 140 bpm. He is definitely not a wimp.
After the test, we gave him a liter of saline in the office because he didn't look too good and his blood pressure fell to 90/60 after an hour or so. It is important to note that we had measured his volume the day before so we knew he was hypovolemic. Normally you would never give saline to someone with high blood pressure, it just makes it go higher. In the future, orthostatic testing will require being done in an intensive care unit because these numbers are so scary. Now it is ignored, and patients with CFS called fruitcakes!
Below is a listing of the abnormalities and the normal values taken from Dr. David Streeten's book Orthostatic Disorders of the Circulation. In the next segment I will describe the results in the first twenty new patients I have tested and how it documents disability. This is important as it will directly measure treatment responses with something other than symptom improvement.
Normal sBP: recumbent: 100-142; Standing (4 min) : 94-141; Orthostatic change: -19 to +11
Orthostatic systolic hypotension: fall in systolic blood pressure of 20 mmHg or more
Reference [of "Results"]: Streeten DHP. Orthostatic disorders of the circulation. New York: Plenum, 1987:116.
In reply to Dr. Bell's writings a reader shares: Without blood in your head, bad things happen!
[Abbreviations used above:
Information in brackets has been added.
Lyndonville News written by:
David S. Bell, MD FAAP
Lyndonville News - DISCLAIMER: The views in this newsletter are the feelings and opinions of the individual authors and do not necessarily reflect all of the current theories that are being explored and published relating to CFS. If you have specific questions and concerns you should consult your personal physician for the answers.
Lyndonville News - COPYRIGHT NOTICE: The entire contents of this newsletter are copyrighted to Bell, Pollard & Robinson, 2000. For permission to reprint sections of this newsletter please direct your request to the above authors.
Copyright © Bell, Pollard, Robinson, 2000
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