Differentiating POTS from Other Conditions

Picking up on the symptom of small-fiber neuropathy, one audience member asked about the use of intravenous immunoglobulin in patients with POTS. Dr. Adler said that the question reflected a broader curiosity among rheumatologists about the role of immune dysregulation in POTS and postinfectious chronic illness and what that may mean for treatment. “The possibility that a subset of patients may have an autoimmune etiology raises important questions about when immunotherapy might be appropriate,” she said.

Dr. Adler urged rheumatologists to consider dysautonomia when making a differential diagnosis of a patient, saying that not doing so risks misinterpreting symptoms and managing patients in ways that don’t address their underlying physiology. “By recognizing POTS, we can provide more accurate diagnoses, guide appropriate referrals and improve quality of life for patients who feel misunderstood,” she said.

Management of POTS

Mr. Albert Mears

As a physical therapist, Mr. Mears has been treating POTS for about a decade, and he reinforced the need for an interdisciplinary approach to treatment that includes physical therapy, occupational therapy and speech language pathology therapy. All of these treatment approaches, he said, overlap but each provides specific rehabilitation needs that drives the main goal of management: improving functional capacity.

As a physical therapist, Mr. Mear’s first aim is to narrow the scope of the myriad symptoms with which patients with POTS present, such as whether the patient has heart palpitations, dizziness, fatigue, brain fog or unrestful sleep. Any or all of these symptoms can decrease functional capacity due to poor activity tolerance, emphasizing that poor activity tolerance is the real issue underlying patients with POTS.

He said that therapy starts with understanding the limits of what a patient can do: how much stress can they tolerate while still allowing a timely recovery. To assess this, he uses both subjective and objective measures.

Subjective measures include assessing what a patient’s daily demands are and how well they are tolerated, such as sleep hygiene and how long it takes for them to get up and get going. Mr. Mears uses two subjective scales, the Brief Questionnaire of Exertional Malaise and the Malmo POTS score. He said he gets a pretty good idea of how a patient’s daily living functioning is once he gets the scores from these tests.

He then makes an objective assessment that includes a Static Standing Tolerance Test at every visit. In the test, patients stand for 10 minutes and are asked how they feel while their vital signs are also measured. Other measures include gait speed, a six-minute walk test and an exercise tolerance test. For higher functioning patients, he uses the Functional Index Tool, which is good for measuring endurance.