w
Symptoms of Orthostatic Intolerance

Delayed & Autonomic Symptoms

Not all of the symptoms start right away. It is these other symptoms that can interfere the most with daily life.
    •  Delayed symptoms - The third set of symptoms comes after standing up and getting the first round of OI symptoms. A person can continue with other symptoms that last for days or weeks.
    •  Other symptoms - There are also symptoms that can develop that are associated with failure of the autonomic nervous system.


  • Delayed Symptoms
  • Other Symptoms - Autonomic Nervous System Dysfunction

After Fainting:    If a person has fainted, the faint is usually short. It comes on quickly. The person faints and then regains consciousness within 1-2 minutes5. They are often tired afterward. The fatigue can last an hour or a day.

After an Orthostatic Event with other types of orthostatic problems (NMH or POTS):    The "event" with these conditions is as simple as standing up for a long time. The change in blood pressure (BP) or pulse change can last much longer than a couple of minutes. For example, with POTS, the person starts to develop symptoms over 3-10 minutes. The orthostatic-type symptoms could last as long as the person stands and the pulse continues to be high.

Afterward standing for longer periods, the person may have a different type of symptoms. The delayed symptoms can last for hours and even days. The challenge in understanding the delayed symptoms is the fact that if a person's not on medication or stable with other management, every time a person stands up, they are releasing Epi/Norepinephrine and stressing the body. This starts a new set of delayed symptoms or makes them worse.


The delayed symptoms after a faint or orthostatic event or symptoms a person might experience on a daily or cyclical basis:

  • Fatigue - This could be mild to 'tired to the bone' fatigue. It can last hours or days.
  • Mental fog - This might be confusion, problem with finding words, word-letter substitution,doing simple math, & memory.
  • Exercise Intolerance - This usually means the person cannot exercise like before getting sick. There is usually more fatigue after exercising. There might be orthostatic symptoms with exercising such as headache/neck pain, shortness of breath (hard to breath), or just feel "yucky". Just going up a flight of steps can bring symptoms.
  • Post-Exertional Malaise (PEM) - This is the fatigue and other symptoms including a general "yucky" feeling that comes after doing too much. It could come after climbing stairs, doing exercise, being in the heat for a long time or doing mental activities like reading, concentrating on paperwork, focusing on a computer screen. This relationship is especially obvious in people who have both POTS and CFS.16
  • Sleep disturbance
  • Migraine headaches

The most common things that trigger symptoms or make them worse:1-8, 10-13  heat, exercise, menstrual cycle, eating

Severity of symptoms and effect on daily life: These symptoms can be severe enough that they interfere with being able to be up standing to do daily care, like washing your face, showering, cooking, or doing laundry etc. or sitting up in a chair for long periods of time.

Trying to do things standing up when the orthostatic problem has not been corrected or treated will make the problem worse.

You can learn more about all these on the different sections and pages. For example: check out Symptoms of OI, Common Triggers, Managing OI and Recovering from OI.

There are a number of other symptoms that people with orthostatic intolerance (OI) can have that are due to autonomic nerve failure. .

 

Symptoms Comments
Vasomotor
Symptoms

This refers to the blood vessels and whether they constrict or dilate (get narrower or wider).

Constricted Blood Vessels - in the arms and legs, they can result in cold hands and arms and cold feet.

Dilated vessels - this would be wider vessels that hold more blood. It can cause 'acrocyanosis' or blue legs (see the entry at the bottom of the table)

Sweating
Sudomotor

Too much sweating - hyerhidrosis. If it is local, it is usually the palms and soles (bottoms of the feet).

No sweating. This can cause a problem with dry skin, increase heat (hyperthermia and even vasomotor collapse in hot weather. It's important to keep cool, avoid exposure to heat.

It can happen everywhere or only in regions of the body, like the feet or hands or forehead. (Sudomotor means something that stimulates the sweat glands.)

GI Symptoms

Bloating, nausea, vomiting, pain, constipation, diarrhea

However, in one study, patients with POTS, neurally-mediated hypotension (NMH) or both POTS and NMH had upper GI symptoms. On follow-up, they found that the GI symptoms had improved with improvement in the orthostatic condition.13

Xerostomia - dry mouth.

Other autonomic symptoms not reported as being strongly associated with POTS or NMH: Delayed emptying of the stomach (gastroparesis) - sense of fullness after eating a little bit; problem with swallowing (dysphagia)

Temperature changes

With autonomic dysfunction, there is often a change in the ability to regulate body temperature. A person will overheat when exercising or in hot weather or hot rooms. They can switch and be cold. The person may feel hot inside but the skin on their arms/hands can be cool or cold to the touch. Body temperature or their sense of temperature may be inconsistent with the room temperature. On the other hand, they can be more sensitive to cold and heat. (This is 'peripheral vasomotor dysfunction'14)

Pupil dysfunction (eyes)

Changes in the pupil muscle and accommodation may be present and create symptoms of sensitivity to excessive glare or bright lights or poor night vision.14

Blood pressure fluctuations

The blood pressure is more variable, going up and down, more than it does it in people without POTS.10 There may also be difficulty palpating a pulse at the wrist when a person continues to stand or with the Valsalva maneuver.

Changes in sensation on skin

There may be changes in how the skins feels things.14 There could be areas of increase sensitivity to repeated stimulation of skin. There can a sense of pain from things that do not normally cause pain (allodynia). There could be hyperpathia - which means there is an abnormal increase sense of pain from a stimulus that would be painful, like a pinprick. (autonomic nerve dysfunction)14

Dry eyes, dry mouth, dry skin

These are symptoms of autonomic dysfunction.14

Blue legs

People with POTs or CFS often have a condition called "acrocyanosis" - which means blueness.5,8,10,11, 15  The legs turn colors with standing. These are "acral vasomotor" vasomotor changes due to the failure of the autonomic nervous system (ANS).14  (Changes in the skin due to the blood vessel changes).

They can turn blue (cyanotic) or be pale. They can be pink/red with standing for awhile. But when it is most extreme, they turn blue and the legs swell with standing up for a longer period of time. The blueness or redness could be solid or it might be blotchy (mottled).

The hands can also turn blue with standing up for a while. In some people, when they lie down, the color returns to normal and there is tingling or abnormal sensation until they return to "normal".




References
  1. Moya, Guidelines for the diagnosis and management of syncope (version 2009). European Heart Journal (2009); 30: 2631-2671.*Abstract. Article PDF.
  2. Jacob G, Costa F, Shannon JR, Robertson RM et al. The Neuropathic Postural Tachycardia Syndrome. N Engl J Med 2000;343: 1008-14.*   Abstract.   Article PDF.
  3. Freeman, Roy. Neurogenic orthostatic hypotension.NEJM 2008;358(6):615-624.* Abstract
  4. Brignole, M. The syndromes of orthostatic intolerance. E-journal of Cardiology Practice. 2007: 6(5).* Access.http://www.escardio.org/communities/councils/ccp/e-journal/volume6/Pages/vol6n5.aspx
  5. Medow MS, Stewart JM, Sanyal S, Mumtaz A, Stca D and Frishman WH. Pathophysiology, Diagnosis, and Treatment of Orthostatic Hypotension and Vasovagal Syncope. Cardiology in Review 2008;16(1):4-20.* Abstract
  6. Soliman, K., Sturman, S., Sarkar, PK, Michael, M. Postural Orthostatic tachycardia Syndrome (POTS): A Diagnostic Dilemma. Br J Cardiol.2010: 17(1);36-39.*
  7. Low PA and Singer W.  Update on Management of Neurogenic Orthostatic Hypotension. Lancet Neurol. 2008 May ; 7(5): 451–458.* Abstract. Article PDF.
  8. Rowe, Pete. General Information Brochure on Orthostatic Intolerance and Its Treatment. June 2010. Accessed from http://www.cfids.org/webinar/cfsinfo2010.pdf. Accessed May 28.2012.*
  9. Robertson D, Kincaid DW, Haile V, Roberston RM.The head and neck discomfort of autonomic failure: an unrecognized aetiology of headache. Clin Autonom Res. 1994: 4; 99-103
  10. Low PA, Sandroni P, Joyner M, Shen WK. Postural Tachycardia Syndrome (POTS). J Cardiovasc Electrophysiol. March 2009: 20; 352-358.
  11. Grubb BP. Postural tachycardia syndrome. Circulation. 2008;117:2814–2817. Abstract. Article PDF.
  12. Thieben MJ, Sandroni P, Sletten DM, et al. Postural orthostatic tachycardia syndrome: The Mayo Clinic experience. Mayo Clin Proc. 2007;82:308–313. Abstract. Article PDF.
  13. Sullivan SD, Hanauer J, Rowe PC, Barron DF, Darbari A, Oliva-Hemker M. Gastrointestinal symptoms associated with orthostatic intolerance. J Pediatr Gastroenterol Nutr. 2005 Apr;40(4):425-8. Abstract.
  14. Gordon, Victor. Assessment of the Autonomic Nervous System in Patients with Neuropathies. Presentation. Faculty of Pain Medicine. Autonomic laboratory, Melbourne Victoria. Assessed July 6, 2012.
  15. Johnson JN, Mack KJ, Kuntz NL, Brands CK, Porter CJ and Fischer PR. Postural Orthostatic Tachycardia Syndrome: A Clinical Review. Pediatr Neuro 2010; 42:77-85. Abstract.
  16. Capuron L, Welberg L, Heim C, Wagner D, Solomon L, Papanicolaou DA, Craddock RC, Miller AH, Reeves WC. Cognitive dysfunction relates to subjective report of mental fatigue in patients with chronic fatigue syndrome. Psychosom Med. 2008 Sep;70(7):829-36. Epub 2008 Jul 7.Abstract.  Article PDF.

Author: Kay E. Jewell, MD
Page Last Updated: June 22, 2012