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Simple Way to Assess Orthostatic Intolerance

NASA 10 Minute Lean Test*

Orthostatic intolerance (OI) is an umbrella term used to describe abnormal autonomic nervous system response to orthostatic challenge.  Orthostatic hypotension (OH), neurally mediated hypotension (NMH) [or neurogenic hypotension] and postural orthostatic tachycardia syndrome (PoTS) are terms used to describe variants of this response.  The new evidence-based IOM clinical criteria for ME/CFS establish that orthostatic intolerance is a common and often overlooked feature of illness that is objectively measurable. OI may contribute to dizziness, fatigue, cognitive dysfunction, chest and abdominal discomfort, and pain manifestations.

We recommend that all ME/CFS and Fibromyalgia patients have a NASA 10-minute Lean Test to assess for orthostatic intolerance. In order to help facilitate the adoption of this test, the Bateman Horne Center has put together these simple instructions for healthcare providers in order to educate them on the process and encourage them to utilize it with their patients.

We encourage ME/CFS and FM patients to share a link to this post, or download the instructions below in order to share this information with their healthcare team.

The test will be most revealing if measures that reduce orthostatic intolerance are withheld before testing. For example: limit extra fluid and sodium intake, do not wear compression socks and alter the intake of medications that might influence the test (see below). These treatments can be resumed after the test. Use continuous monitoring devices when possible.

Ask the patient to remove shoes and socks and lie down on a bed or exam table in supine position. After patient has been lying quietly 5-10 minutes, record blood pressure and pulse. Repeat a minute later. If repeat vitals are not similar, retake until two consecutive vital readings are relatively consistent. The goal is to determine the average resting supine blood pressure and pulse.

Next, ask the patient to arise, stand straight and lean against the wall, with only shoulder blades contacting the wall, and heels approximately 6″ from the wall. Coach patient to relax as much as possible. Once the patient is leaning against the wall, start the timer and record the first standing blood pressure and pulse. Repeat blood pressure and pulse every minute for the next 10 minutes. Instruct patient not to talk and chat, except to report symptoms, and to resist moving feet or shifting weight. Observe patient for lightheadedness or signs of pre-syncope and stop the test if the patient is about to faint. Observe skin and extremities for swelling or changes in color and temperature. Assess cognition. Include any comments as applicable. A template that can be used to record blood pressure and pulse follows on page 2.

General test preparation instructions, directed by provider, adjusted as appropriate for each patient.

  • Limit water/fluid intake to 500-1000 mL for 24 hours before the test
  • Limit sodium intake for 48 hours before the test
  • Do not wear compression socks or clothing on the day of the test
  • Withhold medications, supplements, or substances that might affect blood pressure or heart rate, with timing based on the drug half-life and patient safety. Examples:
    • midodrine or Northera
    • fludrocortisone
    • beta blockers such as propranolol,  metoprolol or atenolol
    • stimulants such as methylphenidate, dexadrine or caffeine
    • tricyclic antidepressants (TCA)– amitriptyline, doxepin or cyclobenzaprine
    • Serotonin Norepinephrine Reuptake Inhibitors (SNRI) e.g. Cymbalta or duloxetine
    • tizanidine

10 Minute Lean Test

 

10minuteleantesttracking

 

*The NASA 10-minute Lean Test is a variant of a test used by NASA researchers to test for orthostatic intolerance1; it reduces muscular influences on venous return, a major cause of variability in orthostatic testing. Passive stand testing has been validated as an equivalent or superior measure of orthostatic intolerance as compared to head-up Tilt Table tests2,3.

[1] Bungo, M. W., Charles, J. B., & Johnson Jr, P. C. (1985). Cardiovascular deconditioning during space flight and the use of saline as a countermeasure to orthostatic intolerance. Aviation, space, and environmental medicine, 56(10), 985-990.

[2] Shvartz, E., Meroz, A., Magazanik, A., Shoenfeld, Y., & Shapiro, Y. (1977). Exercise and heat orthostatism and the effect of heat acclimation and physical fitness. Aviation, Space, and Environmental Medicine, 48(9), 836-842.

[3] Hyatt, K. H., Jacobson, L. B., & Schneider, V. S. (1975). Comparison of 70 degrees tilt, LBNP, and passive standing as measures of orthostatic tolerance. Aviation, Space, and Environmental Medicine, 46(6), 801-808.

 

7 Comments

  1. Katharine Spann on September 29, 2016 at 12:47 am

    Several years ago, I began having POTS symptoms. There were times they were so severe I would pass out. I.e sitting in Church for a long time (which is difficult since I typically am bed bound). Then we would be asked to stand to sing 2-3 hymns. I couldn’t move around at all since we were shoulder to shoulder and the next pew in front was so close-you couldn’t turn around). I thought I was getting panic attacks, but it also felt as if I was going to have a heart attack. I went to several docs and told them I had severe CFS (they had never heard of Myalgia Encephomyalitis ) as well as Fybro. I was put on Klonapin ! After years of my own research, and my home health care workers concerned about my rapid pulse when I got back in bed after doing my standing in 1place exercises; I looked for a doctor that would treat POTS. I have now seen 16 physicians who do not know what POTS is. They refuse to find out. And they refuse to give me the Beta blockers instead of the addictive Klonipin ! WHERE do I find a doctor who either knows something about POTS- or is willing to learn? Help!!!



    • Shy on October 9, 2016 at 2:18 am

      Note: not the doctor/ just a fellow ME/CFSer.

      Your first step would be to find a neurologist with a good relationship with cardiologist so that you can properly be refered for tests. With complete syncope the willingness of a cardiologist and neuro to help should be greater than just partial syncope. The tests performed for POTS are not actually that specific from what I have read.

      You can try the dysautonomia international map of doctors, but that is pretty limited. If lucky there are dysautonomia/syncope centers in a few places- I know of one in NY state for example, however a lot focus on children. You or a caretaker could probaby call and ask for a recomendation from one if all that is near you is focused on children or the fatal dysautonomia subtype. You may in the end have to travel for appropriate treatment and it may be costly (time and money), but it sounds like your symptoms are severely limiting.



    • Toni Campbell on October 9, 2016 at 6:55 pm

      I have Fibromyalgia and OI / POTS, Web groups like Dysautonomia International, and Dinet.org are very good sites for those of us with autonomic dysfunction and they have list of doctors in various states who treat us. I personally see a Neurologist for it, but even he was not well versed in it when I first went to him. There are specialist out there you just have to search and advocate for yourself.



  2. Freda on October 8, 2016 at 11:12 pm

    I found it useful to log my heart rate on an app at the same time (eg Elite HRV, Me/CFS Assistant, polarflow…) and to take photos of my feet before the test while supine and just before I have to quit standing.
    Cardiologists and doctors not familiar with orthostatic intolerance appear to be ,Pte swayed by the photos and a screen shot of the heart rate changes demonstrates that the numbers are real and not made up.
    Medical professionals that I’ve seen have thought that postural orthostatic tachycardia syndrome occurs as soon as you stand up and have refused to allow me to stand still for anytime to “test” for POTS. Even at a specialist ME clinic.



  3. leelaplay on October 8, 2016 at 11:36 pm

    This looks useful for POTS. Seems the same as Dr Rowe, who was also on the IOM committee, and an orthostatic intolerance expert from Johns Hopkins. recommends. But he says that it can take at least 45 minutes to diagnose neurally-mediated hypotension.
    http://www.dysautonomiainternational.org/pdf/RoweOIsummary.pdf



  4. Pat Kumar on October 9, 2016 at 12:09 am

    My daughter has neurocardiogenic syncope. The ER watched her bp drop from reclining to sitting to standing, and referred her to a cardiologist who did the tilt table test. They put her on the fludrocortisone and it helped. Now, 18 years later, her bones are dissolving, osteopenia at 37. Now they are in the process of changing her meds to midodrine. The Dr. Has to know your history before prescribing these meds. She will be hooked up to a continuous heart monitor form2 weeks as she transitions. If you are standing, do heel to toe rocking to contract the calf muscles. My daughter also has a variant of Elers Danlos. Her blood vessels are elastic and blood can pool in her legs. Learning to pump the leg muscles helps her. She now is a lead singer at her church, and she moves on the stage and has her water bottle with her.



  5. Matthew on October 9, 2016 at 9:37 am

    Just having this article up is incredible… I dont see any other CFS clinic even trying like this… thank you..



  6. Jacob Teitelbaum MD on October 9, 2016 at 5:53 pm

    Another excellent article by Dr Bateman! Here is another excellent tool to detect OI– a simple quiz from the Mayo Clinic Journal

    Self report Orthostatlc Grading Scale
    Mayo Clin Proc. 2005;80(3):330-334
    (“Orthostatic symptoms” include worsening dizziness, fatigue,
    Racing heart or brain fog when standing)

    Circle 0-4 below as best applies to you

    A. Frequency of orthostatic symptoms
    0 I never or rarely experience orthostatic symptoms when I stand up
    1 I sometimes experience orthostatic symptoms when I stand up
    2 I often experience orthostatic symptoms when I stand up
    3 I usually experience orthostatic symptoms when I stand up
    4 I always experience orthostatic symptoms when I stand up

    B. Severity of orthostatic symptoms
    0 I do not experience orthostatic symptoms when I stand up
    1 I experience mild orthostatic symptoms when I stand up
    2 I experience moderate orthostatic symptoms when I stand up and
    sometimes have to sit back down for relief
    3 I experience severe orthostatic symptoms when I stand up and
    frequently have to sit back down for relief
    4 I experience severe orthostatic symptoms when I stand up and
    regularly faint if I do not sit back down

    C. Conditions under which orthostatic symptoms occur
    0 I never or rarely experience orthostatic symptoms under any
    circumstances
    1 I sometimes experience orthostatic symptoms under certain
    conditions, such as prolonged standing, a meal, exertion
    (eg, walking), or when exposed to heat (eg, hot day, hot bath,
    hot shower)
    2 I often experience orthostatic symptoms under certain conditions,
    such as prolonged standing, a meal, exertion (eg, walking), or
    when exposed to heat (eg, hot day, hot bath, hot shower)
    3 I usually experience orthostatic symptoms under certain
    conditions, such as prolonged standing, a meal, exertion
    (eg, walking), or when exposed to heat (eg, hot day, hot bath,
    hot shower)
    4 I always experience orthostatic symptoms when I stand up; the
    specific conditions do not matter

    D. Activities of daily living
    0 My orthostatic symptoms do not interfere with activities of daily
    living (eg, work, chores, dressing, bathing)
    1 My orthostatic symptoms mildly interfere with activities of daily
    living (eg, work, chores, dressing, bathing)
    2 My orthostatic symptoms moderately interfere with activities of
    daily living (eg, work, chores, dressing, bathing)
    3 My orthostatic symptoms severely interfere with activities of
    daily living (eg, work, chores, dressing, bathing)
    4 My orthostatic symptoms severely interfere with activities of
    daily living (eg, work, chores, dressing, bathing). / am bed or
    wheelchair bound because of my symptoms

    5. Standing time
    0 On most occasions, I can stand as long as necessary without
    experiencing orthostatic symptoms
    1 On most occasions, I can stand more than 15 minutes before
    experiencing orthostatic symptoms
    2 On most occasions, I can stand 5-14 minutes before experiencing
    orthostatic symptoms
    3 On most occasions, I can stand 1-4 minutes before experiencing
    orthostatic symptoms
    4 On most occasions, I can stand less than I minute before
    experiencing orthostatic symptoms
    _____Total Score
    Scores of 9 or higher suggest Orthostatic Intolerance