Many younger patients come to our office with a life-disruptive mix of random symptoms that have lasted years, sometimes with a prior diagnosis of POTS, or Postural Orthostatic Tachycardia Syndrome, and they want answers. These patients primarily complain of dizziness, palpitations, passing out, difficulty exercising, and other cardiovascular symptoms. Most also complain of seemingly vague symptoms in other body systems like fatigue, headaches, brain fog, weakness, GI issues, bladder issues, and sometimes unusual skin symptoms. They need clear answers about what is happening to them, why it is happening, and how to make it better. Functional medicine was made for these types of patients.
POTS patients do not enjoy life as they endure relentless and sometimes unpredictable symptoms which greatly limit their activities. As the name suggests, they experience symptoms primarily when they are standing upright, thus the name “Postural”. When they’re sitting or lying down, they may feel relatively fine, but ask them to stand and they begin feeling the symptoms. By definition, their standing posture triggers changes in heart rate, tachycardia. These changes in the autonomic, or the automatic, nervous system control of body functions like pulse, breathing, blood pressure, and more, trigger the characteristic symptoms of dizziness, palpitations, pre-syncope and actual syncope.
As you can imagine, experiencing such unsettling symptoms each time you try to stand or walk would hinder daily activities. School, work, exercise, or even self care activities can be problematic, especially if you pass out at times. As if these symptoms were not annoying enough by themselves, the addition of various symptoms in other body systems make even the resting life a problem as well. With the limitation of activities, deconditioning often exacerbates the fatigue and overall sense of weakness. The fluctuations in blood flow resulting from pulse changes or possibly from the underlying dysfunctional mechanisms of the disease also contribute to neurologic symptoms. These can include brain fog, headaches and migraines, sensitivity to noises and lights, and insomnia. The GI tract may be affected by the dysfunctional control of automatic functions, resulting in nausea, constipation, or diarrhea. Dysfunctional bladder control may produce excessive urination or repeated nighttime urination needs. Skin changes like rashes, but also including flushing, pallor, or petechia may occur.
While the label of POTS was not coined until 1993 in an attempt to categorize and study the condition, descriptions of these patients can be traced back to Da Costa in 1871 and possibly the 1920’s in Sweden. The article in focus below provides further information on this history and links to further reading. The Mayo Clinic’s 1993 report on the condition provided not only a name, but also diagnostic criteria by which others might categorize a patient. While we try to avoid labels in functional medicine, having a set of criteria by which to diagnose, monitor and study both individual patients and groups of patients does serve a purpose of advancing care.
In searching for patient benefiting answers, both functional medicine doctors and patients need information about the underlying mechanisms, or root causes of this condition. Research continues and provides some answers to start care with but we are waiting on more understanding. I would assert that the mix of overlapping proposed mechanisms indicates that we are dealing with more of a set of similar symptoms and root causes than one single disease process. In other words, we have a variety of POTS flavors or subtypes, each with a few possible initial root cause triggers and a few overlapping mechanisms of disease.
So far, the primary mechanisms uncovered by research include either autoimmunity or dysfunction in the sympathetic side of our autonomic nervous system. Many studies have found correlations between POTS and increased incidence of autoantibodies in these patients. While correlations do not prove causation, they do raise suspicions that these autoantibodies, antibodies directed against our own cells and tissues, are playing a part in the disease somehow. When the autoantibodies actually target parts of the autonomic nervous system as noted in the article, the suspicions seem justified.
From another perspective, there appears to be some dysfunction of the sympathetic nervous system in these patients. The sympathetic arm of the autonomic system is well known for its release of adrenaline and its role in the fight or flight response to fear or surprises. When this system activates, the body speeds up and is ready to fight or run with faster heart rate, higher blood pressure, and other hyped up feelings. Hypotheses from studies include either overactivation of parts of the system or underactivation of other parts of the sympathetic system. As is often the case, it is probably a combination of both which results in the symptoms we call POTS.
Before putting this label on a patient, both conventional and functional medicine must rule out other possible conditions that would be better explanations for the symptoms. Hormone imbalances in the thyroid or adrenal glands could contribute to the same symptoms. Chronic dehydration could explain the same symptoms. Cardiac abnormalities like arrhythmias could be the trigger. Walking through a few tests for hormones or heart conditions serves to rule out these other issues and further confirm the diagnosis.
With a good history and physical, the diagnosis can be entertained, and the further testing focused on this ruling out or ruling in process. Tilt table testing for pulse and blood pressure changes during standing are helpful. EKG monitoring offer a look at heart function. Echos of the heart may be necessary in some cases. Blood tests for dehydration or hormonal imbalances should be considered. Sometimes, specialty lab tests for other autonomic functions need to be referred to specialty centers.
Once the diagnosis is confirmed, conventional medicine and functional medicine diverge. Conventional medicine turns to symptom management with therapies to increase blood volume and control heart rate while using physical therapy to address the exercise deconditioning. This does help many, but functional medicine goes a step further.
Functional medicine searches for the causes of the sympathetic dysfunction and for means to reverse the dysfunction by removing ongoing underlying triggers. Conventional medicine acknowledges in the article that this condition often occurs after viral infections or even vaccinations but does not recognize that these root causes can be addressed. Functional Medicine searches for toxins and infections that may be causing the autoimmune reaction or sympathetic dysfunction. When we identify and treat things like mold toxicity, Lyme disease, and chronic smoldering viral infections, patients often improve. Bandaids are not bad, just not enough, so we go beyond bandaids.
With the growing number of Post COVID patients experiencing POTS symptoms on top of our already estimated 500,000 Americans with POTS (see article), a deeper understanding of root causes and root cause therapies is critical. In helping patients live healthier, more abundant lives functional MD’s like myself both look forward to further research and appreciate the root cause therapies we can already offer our patients.
Primary Article:
Fedorowski, A. “Postural orthostatic tachycardia syndrome: clinical presentation, aetiology and management.” Journal of internal medicine vol. 285,4 (2019): 352-366. doi:10.1111/joim.12852
Sanctuary Functional Medicine, under the direction of Dr Eric Potter, IFMCP MD, provides functional medicine services to Nashville, Middle Tennessee and beyond. We frequently treat patients from Kentucky, Alabama, Mississippi, Georgia, Ohio, Indiana, and more... offering the hope of healthier more abundant lives to those with chronic illness.
