Orthostatic intolerance

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.

Prevalence
Orthostatic intolerance is a common dysfunction in ME/CFS. 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.

Orthostatic intolerance is also commonly associated with fibromyalgia.

Testing
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.

The 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 in less taxing on the patient and can be done in any physician's office. Instructions are available for printout for both healthcare providers and patients.

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) which diagnoses Myalgic encephalomyelitis (ME). In the London criteria which diagnoses ME, OI is mentioned under the criteria of periods of impaired circulation compatible with autonomic dysfunction.

Postural orthostatic tachycardia syndrome
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.

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.

Neurally mediated hypotension
Also called neurally mediate syncope, in NMH, 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.

Potential treatments
These recommendations, although for POTS, may be helpful for patients experiencing various orthostatic intolerance conditions and low blood pressure.
 * Fludrocortisone
 * Lifestyle Adaptations for POTS
 * increase fluid and salt intake


 * smaller meals


 * lower carbs/lean protein


 * examine dietary reactions


 * gluten


 * dairy


 * caffeine


 * avoid alcohol


 * elevate head during sleep


 * compression garments


 * exercise


 * counter-maneuvers (tensing leg muscles, crossing legs while standing)


 * scheduling (mornings difficult, flexible schedule)


 * morning routine (hydration, standing in stages)


 * avoid prolonged standing


 * showering routine (shower chair, lukewarm water)


 * disability parking


 * mobility scooter or wheelchair


 * maintaining an even temperature


 * find your triggers


 * have a go bag (large purse/knapsack with items you always need)


 * keep a list of medications (current medications/dosages with you all the time)

Notable studies

 * 1999, Orthostatic intolerance in the chronic fatigue syndrome
 * 2000, The Roles of Orthostatic Hypotension, Orthostatic Tachycardia, and Subnormal Erythrocyte Volume in the Pathogenesis of the Chronic Fatigue Syndrome
 * 2000, Orthostatic Intolerance: A Review with Application to the Chronic Fatigue Syndrome
 * 2015, Intravenous Hydration for Management of Medication-Resistant Orthostatic Intolerance in Adolescents and Young Adults
 * 2016, Orthostatic Changes in Hemodynamics and Cardiovascular Biomarkers in Dysautonomic Patients

Talks & interviews

 * 2010, Mangaging Orthostatic Intolerance
 * 2016, Remaining Upright: Approach to Orthostatic Intolerance

Learn more

 * 2015, Orthostatic Intolerance
 * 2016, Remaining Upright: Approach to Orthostatic Intolerance
 * 2016, NIH gives $246,000 for study of oral rehydration in ME/CFS patients with orthostatic intolerance