Orthostatic dysregulation in childhood with special reference to the standing electrocardiogram

Temporal virtual reality-guided, dual-task, trunk balance training in a sitting position improves persistent postural-perceptual dizziness: proof of concept

Background

Persistent postural-perceptual dizziness (PPPD) is a newly defined disorder characterized by functional dizziness. Due to its recent discovery, definitive treatment for PPPD has not been established; therefore, this study aimed to assess the effectiveness of virtual reality (VR)-guided, dual-task, trunk balance training for the management of PPPD using the mediVR KAGURA system.

Methods

We analyzed data of patients who presented with PPPD from January 1, 2021, to February 28, 2021. The VR group included patients who underwent mediVR KAGURA-guided training for 100 tasks (10 min). Patients with PPPD who received standard treatment and rehabilitation were assigned to the control group. Equilibrium tests were performed at baseline and immediately after mediVR KAGURA-guided training to examine its effectiveness in improving static and dynamic balance. Additionally, clinical questionnaires related to balance disorders were administered at baseline and 1 week after mediVR KAGURA-guided training to examine its effects on balance-related symptoms. The primary outcome was improvements in static and dynamic balance and Niigata PPPD Questionnaire (NPQ) scores.

Results

VR-guided training using mediVR KAGURA improved objective outcomes, including static and dynamic postural stability, after a single 10-min training session. Additionally, mediVR KAGURA-guided training improved scores on the Hospital Anxiety and Depression Scale and NPQ 1 week after the 10-min training session.

Conclusion

VR-guided training using mediVR KAGURA represents a viable method for managing balancing ability, anxiety, and symptoms in patients with PPPD. Such training provides a safe and cost-effective solution for PPPD management. Further studies are required to evaluate the clinical efficacy of this strategy.

Trial registration: Institutional Ethics Committee of Kitano Hospital, approval number: 1911003. Registered 18 December 2019, https://kitano.bvits.com/rinri/publish_document.aspx?ID=426.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01068-6.

Effects of Kampo medicine hangebyakujutsutemmato on persistent postural-perceptual dizziness: A retrospective pilot study

BACKGROUND

Persistent postural-perceptual dizziness (PPPD) is a functional disorder, typically preceded by acute vestibular disorders. It is characterized by a shift in processing spatial orientation information, to favor visual over vestibular and somatosensory inputs, and a failure of higher cortical mechanisms. To date, no therapies for PPPD have been approved. Kampo medicine hangebyakujutsutemmato (HBT) has been reported to alleviate disturbances of equilibrium. We hypothesized that HBT would be a beneficial treatment for PPPD.

AIM

To examine the efficacy of HBT for the treatment of PPPD.

METHODS

Patients with PPPD were enrolled and divided into two groups: The HBT group (n = 24) and the non-HBT group (n = 14). The participants completed questionnaire surveys [Niigata PPPD questionnaire (NPQ), dizziness handicap inventory, hospital anxiety and depression scale (HADS), orthostatic dysregulation questionnaire, pittsburg sleep quality index (PSQI), and motion sickness scores] before and after HBT treatment. Additionally, to identify HBT responders, multivariate regression analysis was performed using the results of the questionnaire surveys and equilibrium tests; including stabilometry, and caloric, vestibular evoked myogenic response, and head-up tilt tests.

RESULTS

Thirty-eight outpatients were included in this study, of which 14 patients (3 men, 11 women; mean age, 63.5 ± 15.9 years) received treatment without HBT, and 24 (1 man, 23 women; mean age, 58.2 ± 18.7 years) received combination treatment with HBT. Following HBT treatment, NPQ scores decreased significantly (baseline 40.1 ± 10.0 vs 2 mo 24.6 ± 17.7, P < 0.001). No statistically significant changes were observed in the NPQ scores in the non-HBT group (baseline 38.6 ± 12.2 vs 2 mo 39.4 ± 14.4, P = 0.92). Multivariable regression analysis revealed that the results of stabilometry (P = 0.02) and the caloric (P = 0.03), and head-up tilt tests (P < 0.001), HADS (P = 0.003), and PSQI (P = 0.01) were associated with HBT responsiveness in PPPD patients.

CONCLUSION

HBT may be an effective adjunct therapy for PPPD. Patients with autonomic dysfunction, unstable balance, semicircular canal paresis, anxiety, and poor sleep quality may be high responders to HBT.

Vestibular Function After the 2016 Kumamoto Earthquakes: A Retrospective Chart Review

This retrospective chart review aimed to examine both the vestibular function and causes of dizziness experienced by individuals following a series of major earthquakes and repetitive aftershocks. All patients with balance disorders who experienced the 2016 Kumamoto earthquakes and their aftershocks completed questionnaires relevant to balance disorders and were enrolled in this study after providing informed consent. There were 2.8 times more patients with balance disorders post the earthquake. Anxiety (P = 0.02), orthostatic dysregulation (P = 0.005), and motion sickness scores (P = 0.03) were all significantly higher after the earthquakes. A subset of participants underwent clinical equilibrium testing, showing significant deteriorations in the equilibrium test results (stabilometry: P = 0.01), cervical vestibular-evoked myogenic potentials (P = 0.04), and head-up tilt (P = 0.03) after the earthquake. The findings of this study also suggest that earthquake-induced disequilibrium may be further influenced by physical stressors, including sensory disruptions induced by earthquake vibrations, changes in the living conditions, and autonomic stress. This study increases our understanding of human equilibrium in response to natural disasters. Moreover, these findings will facilitate the management of dizziness experienced during or after such disasters. Future studies should identify strategies for mitigating autonomic dysfunction to prevent post-earthquake dizziness.

Changes in cerebral blood oxygenation induced by active standing test in children with POTS and NMS

Orthostatic dysregulation (OD) has been classified into subtypes by heart rate and blood pressure; however, the hemodynamics of brains have not yet been revealed. Therefore, we investigated changes in cerebral blood flow and oxygenation during an active standing test to clarify the pathophysiology of two subtypes: postural tachycardia syndrome (POTS) and neurally mediated syncope (NMS). We studied 31 children (15 boys, 16 girls; mean age, 14.0 ± 1.7 years) who presented with OD at the Department of Pediatrics and Child Health, Nihon University School of Medicine between 2009 and 2011. OD was diagnosed using the Japanese clinical guidelines for juvenile orthostatic dysregulation. After a 10-min resting period in the supine position, patients were asked to quickly stand up and keep upright for 10 min. Cerebral blood flow and cerebral oxygenation were measured using transcranial Doppler sonography and near-infrared spectroscopy. POTS showed a significant decrease of oxy-Hb and resistance index (RI), suggesting transient ischemia with maintainable cerebral autoregulation. NMS showed a decrease of oxy-Hb and an increase of RI, suggesting ischemia and impairment of autoregulation.

Two types of orthostatic dysregulation assessed by diameter of inferior vena cava

AIMS

Orthostatic dysregulation (OD) is common in adolescents. This study was conducted to evaluate the usefulness of the measurement of the diameter of the inferior vena cava (IVC) for objective assessment of patients with OD.

METHODS

Twenty children with OD (median 14 years, range 9-15 years) and 23 age-matched healthy children (median 12 years, range 10-15 years) were enrolled. A diameter of IVC was measured by an abdominal echogram before and after a head-up tilt table testing (HUT). Changes in IVC was assessed by an arbitrary parameter, collapse index (CI) as the following equation: [(maximal IVC diameter in the supine position - maximal IVC diameter in the standing position)/(maximal IVC diameter in the supine position)]× 100. CI was evaluated 4 weeks after treatment with an adrenergic agent.

RESULTS

Children with OD demonstrated either higher CI or lower CI compared to that in control children: CI was more than 50 (range 50-71) in 12 patients with OD while that was equal to or less than 0 (range -225 to 0) in eight out of 20 patients. In contrast, CI was between 0 and 50 (range 1-26) in 23 healthy children. Pharmacological treatment induced the normalization in the CI in both higher and lower CI group.

CONCLUSION

OD can be classified into two subtypes: by HUT, one is characterized by an increase of IVC diameter while another is characterized by its decrease. Measurement of IVC diameter by HUT is useful to understand the pathophysiology and to assess the efficacy of treatment.

Japanese clinical guidelines for juvenile orthostatic dysregulation version 1

This clinical practice guideline provides recommendations for the assessment, diagnosis and treatment of school-aged children and juveniles with orthostatic dysregulation (OD), usually named orthostatic intolerance in USA and Europe. This guideline is intended for use by primary care clinicians working in primary care settings. The guideline contains the following recommendations for diagnosis of OD: (i) initial evaluation composed of including and excluding criteria, the assessment of no evidence of other disease including cardiac disease and so on; (ii) a new orthostatic test to determine four different subsets: instantaneous orthostatic hypotension, postural tachycardia syndrome, neurally mediated syncope and delayed orthostatic hypotension; (iii) evaluation of severity; and (iv) judgment of psychosocial background with the use of rating scales. The guideline also contains the following recommendations for treatment of OD on the basis of the result of an orthostatic test in addition to psychosocial assessment: (i) guidance and education for parents and children; (ii) non-pharmacological treatments; (iii) contact with school personnel; (iv) use of adrenoceptor stimulants and other medications; (v) strategies of psychosocial intervention; and (vi) psychotherapy. This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OD. Rather, it is designed to assist primary care clinicians by providing a framework for decision making of diagnosis and treatments.

Psychiatric, somatic, and gastrointestinal disorders, and Helicobacter pylori infection in children with recurrent abdominal pain

AIMS

To examine the utility of the Rome II criteria in children with recurrent abdominal pain (RAP) and compare them to those who met Apley's criteria and those who met neither criteria.

METHODS

Prospective study in general paediatric clinics in Komagane, Japan. Children with abdominal pain were classified into those who met Rome II criteria, those who met Apley's criteria, and those who met neither.

RESULTS

A total of 182 children with RAP participated; 45 children met Rome II criteria, 55 met Apley's criteria, and 82 met neither. Children who met Rome II criteria had a significantly higher prevalence of psychiatric and somatic disorders compared to the group met neither (36% v 6%, 22% v 10%, respectively). The overall prevalence of H pylori was 7%; prevalence increased with age from 3% at age < or = 10 to 10% for children >10 years. Children who met Rome II criteria had a significantly higher prevalence of H pylori infection than the reference group (18% v 4%). In a logistic regression model, all the study variables were included in the model specifying first the Rome II criteria group as the independent variable; psychiatric disorders, H pylori infection, and older age group were independent risk factors.

CONCLUSIONS

More than half the children suffering from recurrent abdominal pain met neither Apley's nor Rome II criteria. Children who meet Rome II criteria should be evaluated for psychiatric disorders and should be tested for H pylori infection. Despite the overall trend for a fall in the prevalence of H pylori infection among children in Japan, there are subpopulations of sick children where the prevalence of the infection is relatively high.

Contingent negative variation in children with orthostatic dysregulation

BACKGROUND

Children with orthostatic dysregulation (OD) appear to have hypodynamia, as well as the symptoms described in the OD criteira. Hypodynamia, which is greatly influenced by motivation, volition and concentration, is unexceptionally recognized in their everyday life. It has been suggested that the symptoms and hypodynamia aggravate considerably the quality of life (QOL) of children with OD. The purpose of this study was to distinguish the characteristics of contingent negative variation (CNV) and post imperative negative variation, which may reflect the level of attention and motivation in children with OD.

METHODS

Twelve patients with OD aged 10-15 years and 23 age-matched healthy children were included. The CNV was recorded from Fz, Cz and Pz linked to earlobes during 30 trials consisting of a warning stimulus and an imperative stimulus with an interstimulus interval (ISI) of 2 s and an intertrial interval (ITI) of 10 s. The imperative stimulus of each trial required a button to be pressed.

RESULTS

The untreated children with OD did not have a significantly smaller CNV amplitude than healthy children. Children with OD treated with midodrine and autonomic training had a significantly larger CNV amplitude than the untreated children, in the area of early, late and total CNV at the three sites.

CONCLUSION

The present study confirms that children with OD have diminished motivation and deterioration of concentration, which cause hypodynamia in everyday life. Treatment for OD improves the symptoms, diminished motivation and deterioration of concentration, consequently restoring dynamia. Treatment for OD should be recommended to ameliorate QOL of children with OD.

Instantaneous orthostatic hypotension in children and adolescents: a new entity of orthostatic intolerance

We are the first to report clinical characteristics and circulatory and catecholamine responses to postural change in 44 children with instantaneous orthostatic hypotension (INOH). The symptoms include chronic fatigue, orthostatic dizziness, weakness, sleep disturbance, syncope or near syncope, headache, and loss of appetite. We divided the patients into two groups: group I (30 patients) had either a recovery time for mean arterial pressure of >25 s or a recovery time of >20 s with a 60% or greater decrease in mean arterial pressure at the initial decrease; group II (14 patients) had a prolonged reduction in systolic arterial pressure of > 15% during the later stage of standing (3-7 min) in addition to the criteria for group I. INOH was characterized by a marked reduction in blood pressure at the initial decrease (mean, -55/-27 mm Hg systolic/diastolic). Delayed recovery time of >60 s was found in 21 of 44 patients and orthostatic tachycardia (>35 beats per minute) in 20 of 44. Plasma noradrenaline responses were significantly lower in group I and II than in controls at 1 min of standing and were lower in group II at 5 min of standing. These results suggest that mechanisms responsible for INOH may depend on insufficient sympathetic activation during standing, possibly due to centrally mediated sympathetic inhibition, thus causing impairment of quality of life including school absenteeism. INOH is an important pathologic condition in children with complaints of orthostatic intolerance and can be an unrecognized cause of chronic fatigue. This condition can be identified by using a noninvasive beat-to-beat continuous blood pressure monitoring system.

The effects of the noradrenaline precursor, L-threo-3,4-dihydroxyphenylserine, in children with orthostatic intolerance

To evaluate the usefulness of L-threo-3,4-dihydroxyphenylserine (L-DOPS), a precursor of noradrenaline, in the treatment of orthostatic intolerance in children, we examined the circulatory responses to orthostatic stress and clinical symptoms before and after medication. Seven children with orthostatic intolerance, two boys and five girls, aged 11-15 years (mean age 13.3 years), were studied. L-DOPS (100-200 mg) was administered orally once or twice a day for 4 weeks. Blood pressure (BP) and heart rate (HR) were measured with a non-invasive beat-to-beat method (Finapres). All had a marked reduction in BP (delta SBP/DBP = -50 +/- 9/-27 +/- 6 mmHg) with prolonged recovery time in the initial phase during standing. After L-DOPS for 4 weeks, BP reduction in the initial phase was significantly attenuated (delta SBP/DBP = -37 +/- 9/-17 +/- 7 mmHg, p < 0.05) and recovery time was normalized in all, although supine BP and HR were unchanged. Two reported relief of all symptoms, while in five symptoms were markedly improved. There were no adverse effects reported. These preliminary studies have indicated that L-DOPS may be an effective drug for the treatment of orthostatic intolerance in children.

Circulatory responses in children with unexplained syncope evaluated by continuous non-invasive finger blood pressure monitoring

Cardiovascular responses on active standing in children with unexplained syncope were investigated with continuous non-invasive finger artery pressure monitoring (Finapres). We examined 34 symptomatic patients (13 boys and 21 girls), aged 8-16 years, and 24 age-matched controls. Finger blood pressure and heart rate were monitored continuously for 5 min in the supine position and for 10 min while standing. Ten of 34 patients developed fainting symptoms with hypotension during upright posture (fainters). In the initial standing phase (0-30 s), two prominent abnormal blood pressure responses were found in patients: a marked decrease 45 +/- 18/23 +/- 8 mmHg and a prolonged recovery time (16.5 +/- 2.9 versus 27.7 +/- 13.6 s), which appeared to be based on impaired vasoconstriction. Either or both abnormalities were observed in 21 (62%) of the 34 patients and in 2 (8%) of the controls. In addition, fainters also had a more marked increase in heart rate during standing compared with non-fainters. Our findings suggested that more than half of children with syncope had abnormal cardiovascular reflexes in the initial phase which appeared to be associated with vasodepressor syncope. The active standing test with a continuous beat-to-beat blood pressure recording has a high sensitivity in detecting abnormalities of autonomic function in patients with unexplained syncope.

Decreased plasma catecholamine and renin activity in children with difficulty waking up in the morning

Plasma catecholamine concentration (CAT: adrenalin and noradrenalin) and plasma renin activity (PRA) were measured in 26 children, aged 10 to 15 years, who had difficulty waking up in the morning. CAT, which was examined only in the supine position in control children, and PRA, which was examined before and after standing for 15 min, were significantly lower than in age-matched control children. These results suggest that low CAT and PRA may contribute to difficulty waking up in the morning in childhood.

Urinary electrolyte excretion and orthostatic response of blood pressure and plasma renin activity in children with postural hypotension before and after treatment with Dihydergot

Na and K metabolism, and orthostatic response of blood pressure and plasma renin activity (PRA) were studied in six children, aged 10 to 15 years, with postural hypotension before and after treatment with Dihydergot (DHE). All abnormal findings which we had already observed in children with postural hypotension (i.e. low fractional excretion of filtered Na in spite of low PRA, extremely high PRA on fainting, great postural fall in blood pressure, and so on) improved on treatment with DHE. This suggests that these abnormal physiological findings found in children with postural hypotension may result from increased venous pooling which can be reduced by DHE. Consequently, DHE seems an excellent drug to treat postural hypotension from the physiological point of view.