Adaptive Approaches to Exercise Rehabilitation for Postural Tachycardia Syndrome and Related Autonomic Disorders 2024 Cortez et al

Abstract

Exercise is a well-documented, nonpharmacologic treatment for individuals with autonomic dysfunction and associated orthostatic intolerance, such as postural tachycardia syndrome and related disorders. Exercise has been shown to increase blood volume, reverse cardiovascular deconditioning, and improve quality of life.

Current first-line standard of care treatment for autonomic dysfunction combines graded approaches to exercise with medications and lifestyle modifications. However, current exercise rehabilitation protocols for postural orthostatic tachycardia syndrome contain rigid timelines and progression paradigms that often threaten tolerability and adherence. In addition, they fail to account for clinical variables potentially critical to care and lack guidance for individualization, limiting accessibility to patients with co-morbidities that affect exercise appropriateness and safety.

Therefore, we introduce an adaptive approach to exercise prescription for orthostatic intolerance that allows patient-specific modifications to meet functional goals for a wider spectrum of patients, thus improving adherence. The proposed approach integrates iterative physiological and symptomatic assessments to provide flexible, yet structured, exposure to aerobic exercise and strength training to improve functional capacity and tolerance of daily activities for patients with postural tachycardia syndrome and related autonomic disorders.

Open access

 

"Screening for tolerability
The graded exercise program concepts reviewed here, including previously published exercise protocols for POTS,6,14,16,17 focus on the treatment of patients with chronic orthostatic intolerance who can presumably tolerate low to moderate steady state exercise without significant symptom increases. However, certain types of exercise may not be appropriate for all patients with autonomic symptoms. One such factor that must be considered is PEM, often associated with myalgic encephalomyelitis/chronic fatigue syndrome. The PEM is an exacerbation of symptoms after minimal cognitive, emotional, or physical activity,75 and can occur in conjunction with chronic activity intolerance and symptoms of dysautonomia. Although exercise therapies are relatively well-studied for patients with POTS, optimal dosing and progression parameters for therapeutic exercise for patients with orthostatic intolerance associated with significant PEM requires further investigation.27,76-78 Concerns regarding the potential for long-term consequences resulting from exacerbating activities (such as cardiopulmonary exercise) for individuals with myalgic encephalomyelitis/chronic fatigue syndrome has been introduced;79,80,81 however, these assertions require further investigation to better understand the underlying mechanisms, and to what extent exercise with a pacing approach can be safely used. In our experience, many patients may be able to effectively minimize the effect of mild to moderate symptom exacerbation related to exercise by entering an exercise program at a very low dose, both in intensity and duration, though those with significant postexercise related symptoms may be best served by focusing on principles of energy conservation82,83 (described further below).

With these considerations in mind, we recommend symptom screening tools to screen for PEM and alert the therapist to use caution when prescribing cardiopulmonary exercise. Based on our experience and established myalgic encephalomyelitis/chronic fatigue syndrome literature, we suggest a preconditioning state (see fig 1) for patients with marked symptom exacerbation who are working toward building tolerance to a 20-minute bout of supine or recumbent exercise.55 Techniques such as pacing or fatigue management, functionally-driven range of motion and strengthening, vision or vestibular therapies (as indicated by examination), manual therapy for pain mitigation, and down regulatory strategies (breathing, meditation, and counterpressure maneuvers) should be considered in the formulation of a comprehensive treatment plan.84 A detailed overview of these principles is beyond the scope of this article, though expert reviews can be found elsewhere.83,85"

 

So is taking in more salt, and I'm equally skeptical of its success as a treatment.

Not sure what this has to do with POTS.

 

Further investigation? I think it’s pretty clear it at best doesn’t do anything much, if you go by the trials, or at worst worsens peoples conditions permanently, if you go by longer term surveys.

If exercise is making people worse, it only making them a little worse is not a valid reason to present it as a treatment. “Your experience” as doctors is almost meaningless unless there are biological markers that change. Someone’s perception of their illness is going to change based on how much you as a doctor believe in the treatment.

 

Same clueless drivel as usual, presented as new. They use words they don't even understand, trying to achieve outcomes that don't even make sense of the actual problems involved, which they choose to ignore in favor of alternative made-up problems.

They don't even know what they're trying to achieve here. They just follow the usual script that if you rehabilitate people, they will be rehabilitated. It's so completely mindless. This discipline is like a lake of mediocrity in a sea of confusion that stands out in very sharp contrast to all the other professions, where being stuck mindlessly going around doing the same loop for decades isn't even possible, you'd be fire 500 times before you could get there.