Psychosocial Dimensions and Functioning in Youth With Postural Orthostatic Tachycardia Syndrome

Outcomes of Pediatric Patients with Excessive Postural Tachycardia After Attending an Intensive Interdisciplinary Pain Program: A Pilot Study

BACKGROUND/OBJECTIVES

Adolescents with autonomic disorders who attend Intensive Interdisciplinary Pain Treatment (IIPT) programs report improvements in functioning. However, it is unclear whether they experience corresponding improvements in physiological measures. As such, the aim of this pilot study was to examine changes in physiological measures in youth attending an IIPT program who demonstrated excessive postural tachycardia on an active stand test. The secondary goal was to examine associations between physiological measurements and self-reported measures of chronic orthostatic intolerance (cOI) and functioning.

METHODS

At admission and discharge, eighteen adolescents and young adults (AYAs) attending IIPT (M age = 17.39 years; SD = 2.15 years) completed an active stand test, measures of breathing rate and muscle tension, as well as self-reported measures of cOI symptoms and functioning.

RESULTS

AYAs showed significant reduction in active stand test heart rate increase (p < 0.001; d = 1.07) and maximum heart rate (p = 0.002, d = 0.76) from admission to discharge. Improvements were also observed in resting respiration rate (p = 0.001, d = 89) and resting trapezoid tension (p = 0.03, d = 0.49). Although patients showed significant improvements on self-report measures of functioning (p < 0.001, d = 1.78), changes on subjective report of cOI symptoms did not reach significance. Exploratory analyses that only included patients with a POTS diagnosis were consistent with the overall results.

CONCLUSIONS

Youth who demonstrated excessive postural tachycardia on active stand test at admission to an IIPT showed significant improvements from admission to discharge in their active stand maximum heart rate and heart rate increase, as well as respiration rate, muscle tension, and reports of their functioning. Future research is necessary to examine the mechanisms of change that contribute to symptom improvement.

Exploring quality of life in postural orthostatic tachycardia syndrome: A conceptual analysis

Postural Orthostatic Tachycardia Syndrome (POTS) is a complex autonomic disorder characterized by an abnormal increase in heart rate upon orthostatic change. While primarily described in its effect on the autonomic and cardiovascular system, it can cause significant functional impairment, leading to a diminished quality of life (QoL). This review paper aims to delve into the multifaceted dimensions of QoL in individuals with POTS by providing a conceptual model to discuss factors influencing QoL. Current QoL assessments used in the POTS population and their findings are described for each domain in this conceptual model. Limitations to this body of research include the literature having no consensus in the most appropriate measure of QoL to use for individuals with POTS, the absence of a POTS-specific measure of QoL, and current measures not assessing concerns germane to this population. The authors emphasize the necessity of a POTS-specific measure to be developed to improve our assessment and understanding of how living with POTS impacts QoL.

"You Look Perfectly Healthy to Me": Living With Postural Orthostatic Tachycardia Syndrome Through Adolescents' and Parents' Eyes

Postural orthostatic tachycardia syndrome (POTS) is an autonomic dysfunction that impairs quality of life (QoL). Increased familiarity with the lived experiences of youth with POTS better informs our understanding of this condition and its impact on QoL, provides context and depth to existing research, and improves patient-centered care. Thus, this qualitative study seeks to develop a more robust understanding of QoL in this understudied population. Youth with POTS (N = 6) and their parents (N = 8) participated in semi-structured interviews. Following saturation, data were analyzed via conventional content analysis, including code/theme identification and member-checking. Four themes were identified (1) negative changes in functioning, (2) invalidation and difficulties living with an invisible condition, (3) trust and advocacy, and (4) need for increased resources and understanding. Findings suggest POTS negatively impacts adolescents' QoL across domains. Based on participants' responses, developing POTS-specific resources and integrating mental health services into interdisciplinary POTS treatment may improve youth's QoL.

Sinus Tachycardia: a Multidisciplinary Expert Focused Review

Sinus tachycardia (ST) is ubiquitous, but its presence outside of normal physiological triggers in otherwise healthy individuals remains a commonly encountered phenomenon in medical practice. In many cases, ST can be readily explained by a current medical condition that precipitates an increase in the sinus rate, but ST at rest without physiological triggers may also represent a spectrum of normal. In other cases, ST may not have an easily explainable cause but may represent serious underlying pathology and can be associated with intolerable symptoms. The classification of ST, consideration of possible etiologies, as well as the decisions of when and how to intervene can be difficult. ST can be classified as secondary to a specific, usually treatable, medical condition (eg, pulmonary embolism, anemia, infection, or hyperthyroidism) or be related to several incompletely defined conditions (eg, inappropriate ST, postural tachycardia syndrome, mast cell disorder, or post-COVID syndrome). While cardiologists and cardiac electrophysiologists often evaluate patients with symptoms associated with persistent or paroxysmal ST, an optimal approach remains uncertain. Due to the many possible conditions associated with ST, and an overlap in medical specialists who see these patients, the inclusion of experts in different fields is essential for a more comprehensive understanding. This article is unique in that it was composed by international experts in Neurology, Psychology, Autonomic Medicine, Allergy and Immunology, Exercise Physiology, Pulmonology and Critical Care Medicine, Endocrinology, Cardiology, and Cardiac Electrophysiology in the hope that it will facilitate a more complete understanding and thereby result in the better care of patients with ST.

Physical Symptoms, Distress, and Functional Disability in Youth With Chronic Orthostatic Intolerance

OBJECTIVE

Youth with chronic orthostatic intolerance (OI) can experience significant physical, social, and academic functional debilitation. Previous studies have indicated associations among symptom severity, psychosocial factors, and functional disability. However, empirically tested models explaining how different medical and psychosocial factors may contribute to functional disability are lacking. The current cross-sectional study aimed to evaluate mediation, moderation, and additive models of the effect of physical symptoms and psychological distress on functional disability.

METHODS

One hundred and sixty-five youth (13-22 years old) undergoing medical evaluation of chronic OI symptoms completed measures of autonomic dysfunction symptom severity, depressive and anxiety symptoms, and functional disability. Models were evaluated using tests of indirect effects and linear and logistic regression analyses.

RESULTS

Results supported the mediation and additive effects models for depressive symptoms. Mediation, moderation, and additive models for hypothesized effects of anxiety symptoms were not supported.

CONCLUSIONS

Results provide preliminary support for models in which OI symptoms affect functional debility via their effects on mood and in which depressive symptoms have unique and additive effects on functioning. Findings lay the foundation for longitudinal and experimental evaluation of biopsychosocial models of functional disability in youth with chronic OI and related conditions. Implications include the importance of a biopsychosocial conceptualization of OI symptoms and debility as a complex interplay of factors rather than as a purely physiological or psychological process.

Excessive Postural Tachycardia and Postural Orthostatic Tachycardia Syndrome in Youth: Associations With Distress, Impairment, Health Behaviors, and Medication Recommendations

Among adolescents with fatigue and postural dizziness, it is unclear how health behaviors and emotional distress relate to the presence of excessive postural tachycardia. We prospectively evaluated adolescents aged 13-22 years presenting with symptoms suggestive of autonomic dysfunction between September 2017 and December 2018. Patients underwent standard 10-minute, 70-degree head-up tilt testing. Clinician diagnoses and recommendations were recorded from the medical record. Patients completed validated self-report measures of lifestyle factors, autonomic symptoms, depression, anxiety, and functional disability. Of 179 patients, 58 were diagnosed with postural orthostatic tachycardia syndrome and 59 had excessive postural tachycardia, with 90.5% concordance between the 2 groups. Presence of excessive postural tachycardia was associated with greater baseline fluid intake and likelihood of medication prescription in their treatment plan. Medication findings were replicated for postural orthostatic tachycardia syndrome diagnosis. Presence of excessive postural tachycardia or postural orthostatic tachycardia syndrome did not differentiate patients on perceived symptom severity, emotional distress, disability, or health behaviors but did appear to determine treatment recommendations.

Impact of Comorbidities on the Prognosis of Pediatric Postural Tachycardia Syndrome

OBJECTIVE

To investigate the influence of comorbidities on the prognosis of pediatric postural tachycardia syndrome (POTS).

METHODS

In this retrospective cohort study, 275 children with POTS admitted to the Department of Pediatrics at Peking University First Hospital were recruited from 2016 to 2019 and followed up. The participants were divided into simple POTS (S-POTS, n=156 cases) and POTS with comorbidities (Co-POTS, n=119 cases) groups according to whether they were complicated with comorbidities. A Cox regression analysis was used to identify the prognostic risk factors for children with POTS, while Kaplan-Meier curves were applied to compare the cumulative symptom remission rate (CSRR) between the two groups. The rehospitalization of the children between the two groups was also compared to explore the influence of comorbidities.

RESULTS

Twenty-one participants (7.6%) were lost during a median follow-up of 24 months. The Cox regression model showed that comorbidities and body mass index (BMI) were associated with the CSRR of the children with POTS. The CSRR of pediatric POTS alone was 1.748 times higher than that of patients with comorbidities, and the CSRR was decreased by 5.1% for each 1 kg/m2 increase in BMI. The most common comorbidity in children with POTS in this study was allergic disorders, followed by the psychological diseases. The patients in the Co-POTS group had a lower CSRR than those in the S-POTS group (log rank P=0.0001). In addition, compared with those of the S-POTS group, the total number of rehospitalizations was high (P=0.001), and the total hospital stays were long in the Co-POTS group (P<0.001).

CONCLUSION

Complicating with comorbidities, pediatric patients with POTS had lower CSRR and more rehospitalizations than those without comorbidities. More attention should be given to comorbidities when managing pediatric POTS.

Salt supplementation in the management of orthostatic intolerance: Vasovagal syncope and postural orthostatic tachycardia syndrome

Salt supplementation is a common non-pharmacological approach to the management of recurrent orthostatic syncope or presyncope, particularly for patients with vasovagal syncope (VVS) or postural orthostatic tachycardia syndrome (POTS), although there is limited consensus on the optimal dosage, formulation and duration of treatment. Accordingly, we reviewed the evidence for the use of salt supplementation to reduce susceptibility to syncope or presyncope in patients with VVS and POTS. We found that short-term (~3 months) salt supplementation improves susceptibility to VVS and associated symptoms, with little effect on supine blood pressure. In patients with VVS, salt supplementation is associated with increases in plasma volume, and an increase in the time taken to provoke a syncopal event during orthostatic tolerance testing, with smaller orthostatic heart rate increases, enhanced peripheral vascular responses to orthostatic stress, and improved cerebral autoregulation. Responses were most pronounced in those with a baseline sodium excretion <170 mmol/day. Salt supplementation also improved symptoms, plasma volume, and orthostatic responses in patients with POTS. Salt supplementation should be considered for individuals with recurrent and troublesome episodes of VVS or POTS without cardiovascular comorbidities, particularly if their typical urinary sodium excretion is low, and their supine blood pressure is not elevated. The efficacy of the response, in terms of the improvement in subjective and objective markers of orthostatic intolerance, and any potential deleterious effect on supine blood pressure, should be routinely monitored in individuals on high salt regimes.

Daily Functionality in Adults with POTS: Predictive Factors

Symptoms associated with postural orthostatic tachycardia syndrome (POTS) hinder overall functionality. This study examined factors that impacted daily life and contributed to overall daily functionality in adults with POTS (n = 958, ages 18-60). Descriptive and multiple linear regression analyses indicated that participants with fewer challenges in ADLs, IADLs, work, school, leisure, and socializing had overall better functionality. Furthermore, 'younger age with exercise tolerance', 'having a job', and 'no falls in the last year' were predictors of better functionality. A comprehensive approach to addressing physical, environmental, and psychological factors could help improve overall functionality and enhance quality of life in individuals with POTS.

Using the PEOP Model to Understand Barriers to Functioning in Postural Orthostatic Tachycardia Syndrome

Individuals with postural orthostatic tachycardia syndrome (POTS) experience many barriers that lead to decreased functioning and quality of life. At this time, there are limited resources regarding the functional impact of POTS on occupational performance. Therefore, this narrative review demonstrates how occupational therapy practitioners can conceptualize, categorize, and systematically organize their thinking around barriers individuals with POTS experience using the Person-Environment-Occupation-Performance (PEOP) model of practice.

Understanding How Perfectionism Impacts Intensive Interdisciplinary Pain Treatment Outcomes: A Nonrandomized Trial

OBJECTIVE

Several factors are known to impact response to the intensive interdisciplinary pain treatment (IIPT) program described in this study, yet no research has explored the role of perfectionism. This secondary data analysis explored direct and indirect relations between perfectionism and functional disability (primary outcome) and pain severity (secondary outcome) after IIPT, with pain catastrophizing and fear of pain as mediators.

METHODS

Youth (N = 253) aged 8-21 with chronic pain and associated disability completed pre- and post-IIPT measures of self-oriented perfectionism (SOP), socially prescribed perfectionism (SPP), pain catastrophizing, fear of pain, functional disability, and pain characteristics for routine clinical care and this nonrandomized trial. Eight mediated models were run for the two predictors, two mediators, and two outcomes.

RESULTS

Pretreatment perfectionism (SOP and SPP) led to greater reductions in pain catastrophizing over the course of IIPT, which resulted in lower pain severity (β = -.02 [CI = -0.07, -0.01] for SOP and β = -.02 [CI = -0.06, -0.003] for SPP) and less functional disability (β = -.06 [CI = -0.13, -0.01] for SOP and β = -.06 [CI = -0.14, -0.01] for SPP). Independent of pain catastrophizing, pretreatment SPP was directly associated with more posttreatment functional disability (β = .16 [CI = 0.05, 0.27]). Fear of pain was not a mediator.

CONCLUSIONS

Findings suggest perfectionism has the potential to negatively impact IIPT outcomes. However, when perfectionistic youth with chronic pain learn to manage pain-related distress, they benefit. Results highlight the importance of assessing for and treating perfectionism and pain-related distress in youth with chronic pain.

Pain Management In Pediatric Patients With Postural Orthostatic Tachycardia Syndrome: Current Insights

Pediatric patients with postural orthostatic tachycardia syndrome (POTS) often present with co-occurring struggles with chronic pain (POTS+pain) that may limit daily activities. POTS is a clinical syndrome characterized by orthostatic symptoms and excessive postural tachycardia without orthostatic hypotension. Active research from the medical and scientific community has led to controversy over POTS diagnosis and treatment, yet patients continue to present with symptoms associated with POTS+pain, making treatment recommendations critical. This topical review examines the literature on diagnosing and treating pediatric POTS+pain and the challenges clinicians face. Most importantly, clinicians must employ an interdisciplinary team approach to determine the ideal combination of pharmacologic (e.g., fludrocortisone), non-pharmacologic (e.g., physical therapy, integrative medicine), and psychological (e.g., cognitive behavioral therapy, psychoeducation) treatment approaches that acknowledge the complexity of the child's condition, while simultaneously tailoring these approaches to the child's personal needs. We provide recommendations for treatment for youth with POTS+pain based on the current literature.

Youth with Chronic Pain and Postural Orthostatic Tachycardia Syndrome (POTS): Treatment Mediators of Improvement in Functional Disability

Intensive pain rehabilitation programs are effective in increasing functioning for youth with chronic pain (CP). However, the utility of such programs for youth with CP and co-morbid postural orthostatic tachycardia syndrome (POTS) is rarely examined. In addition, studies examining mediators of treatment for CP are sparse. This paper compares treatment outcomes for youth with CP (n = 117) and youth with CP + POTS (n = 118). Additionally, depression and pain catastrophizing were tested as potential mediators of treatment effects. Significant treatment improvements were found for functional disability, depression, pain catastrophizing, and perceived pain intensity but with no differences between groups. Improvements in depressed mood, pain catastrophizing (helplessness subscale), and pain severity partially mediated functioning improvement. Pain severity was not a significant mediator in the CP + POTS group. We concluded that depression and pain catastrophizing, especially the helplessness domain, can impact functioning improvement in adolescents with CP and POTS and are particularly important to target in treatment.

Pediatric Disorders of Orthostatic Intolerance

Orthostatic intolerance (OI), having difficulty tolerating an upright posture because of symptoms or signs that abate when returned to supine, is common in pediatrics. For example, ∼40% of people faint during their lives, half of whom faint during adolescence, and the peak age for first faint is 15 years. Because of this, we describe the most common forms of OI in pediatrics and distinguish between chronic and acute OI. These common forms of OI include initial orthostatic hypotension (which is a frequently seen benign condition in youngsters), true orthostatic hypotension (both neurogenic and nonneurogenic), vasovagal syncope, and postural tachycardia syndrome. We also describe the influences of chronic bed rest and rapid weight loss as aggravating factors and causes of OI. Presenting signs and symptoms are discussed as well as patient evaluation and testing modalities. Putative causes of OI, such as gravitational and exercise deconditioning, immune-mediated disease, mast cell activation, and central hypovolemia, are described as well as frequent comorbidities, such as joint hypermobility, anxiety, and gastrointestinal issues. The medical management of OI is considered, which includes both nonpharmacologic and pharmacologic approaches. Finally, we discuss the prognosis and long-term implications of OI and indicate future directions for research and patient management.