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    Jane Simmonds Rehab Sept 17

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    Mendeleus Xiii
    This document provides an overview of Dr. Jane Simmonds' approach to rehabilitating patients with Postural Orthostatic Tachycardia Syndrome (PoTS). The summary includes: 1) Education, pacing, anxiety management, sleep management, and monitoring medications are key principles of rehabilitation. 2) A graded exercise program aims to improve cardiovascular fitness and lower body strength over 3-6 months starting from reclined positions and progressing to upright exercises. 3) Case studies demonstrate functional restoration programs including diet, fluids, graduated exercise, and goals can help patients complete activities of daily living and education.

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    Jane Simmonds Rehab Sept 17

    Uploaded by

    Mendeleus Xiii
    13 views23 pages
    This document provides an overview of Dr. Jane Simmonds' approach to rehabilitating patients with Postural Orthostatic Tachycardia Syndrome (PoTS). The summary includes: 1) Education, pacing, anxiety management, sleep management, and monitoring medications are key principles of rehabilitation. 2) A graded exercise program aims to improve cardiovascular fitness and lower body strength over 3-6 months starting from reclined positions and progressing to upright exercises. 3) Case studies demonstrate functional restoration programs including diet, fluids, graduated exercise, and goals can help patients complete activities of daily living and education.

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    This document provides an overview of Dr. Jane Simmonds' approach to rehabilitating patients with Postural Orthostatic Tachycardia Syndrome (PoTS). The summary includes: 1) Education, pacing, anxiety management, sleep management, and monitoring medications are key principles of rehabilitation. 2) A graded exercise program aims to improve cardiovascular fitness and lower body strength over 3-6 months starting from reclined positions and progressing to upright exercises. 3) Case studies demonstrate functional restoration programs including diet, fluids, graduated exercise, and goals can help patients complete activities of daily living and education.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    13 views23 pages

    Jane Simmonds Rehab Sept 17

    Uploaded by

    Mendeleus Xiii
    This document provides an overview of Dr. Jane Simmonds' approach to rehabilitating patients with Postural Orthostatic Tachycardia Syndrome (PoTS). The summary includes: 1) Education, pacing, anxiety management, sleep management, and monitoring medications are key principles of rehabilitation. 2) A graded exercise program aims to improve cardiovascular fitness and lower body strength over 3-6 months starting from reclined positions and progressing to upright exercises. 3) Case studies demonstrate functional restoration programs including diet, fluids, graduated exercise, and goals can help patients complete activities of daily living and education.

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    of 23

    Rehabilitation for PoTS

    PoTS UK Masterclass

    Dr Jane Simmonds MCSP MACP SFHEA


    D Prof, MA, PGDip, B App(Sc), BPE
    Programme Lead: MSc Paediatric Physiotherapy
    Physiotherapy Lead Hypermobility Unit, Hospital of St John and St Elizabeth
    Plan

    •  Share an approach to rehabilitating people with PoTS


    •  Integrating key PoTS exercise related research
    •  Anecdotal experience
    •  Case studies
    .
    Acknowledgments
    Patients
    Dr Nelly Ninis
    Professor Christopher Mathias
    Professor Rodney Grahame
    Dr Alan Hakim
    Dr Hanadi Kazkaz
    Dr Inge de Wandele
    Dr David Low
    Professor Peter Rowe
    .
    Interest started with complex referrals
    •  Joint laxity/ hypermobility / joint instability (hEDS/ HSD)
    •  Persistent widespread pain
    •  Persistent fatigue
    •  Pre syncope and sometimes fainting
    •  Temperature dysregulation
    •  Gastrointestinal symptoms - reflux, slow transit
    •  Bladder symptoms – irritable bladder, incontinence
    •  Allergies - rashes
    Onset
    Musculoskeletal
    Pain
    Cardiac Dysautonomia

    Fa,gue
    Mental Health

    Bladder GI manifesta,ons

    Allergy/MAC systemic severity scale


    Ninis, de Wandele & Simmonds 2013
    Musculoskeletal
    Pain
    Cardiac Dysautonomia

    Fa,gue
    Mental Health

    Bladder GI manifesta,ons

    Allergy/MAC systemic severity scale


    Ninis, de Wandele & Simmonds 2013
    Musculoskeletal
    Pain
    Cardiac Dysautonomia

    Fa,gue
    Mental Health

    Bladder GI manifesta,ons

    Allergy/MAC systemic severity scale


    Ninis, de Wandele & Simmonds 2015
    Musculoskeletal
    Pain
    Cardiac Dysautonomia

    Fa,gue
    Mental Health

    Bladder GI manifesta,ons

    Allergy/MAC systemic severity scale


    Ninis, de Wandele & Simmonds 2013
    Problem based approach - Explore expecta7ons - Choice
    Rehabilitation Principles
    Education:
    Reassurance
    Pacing – fatigue and pain management
    Agree and set realistic goals
    Anxiety management
    •  Cognitive Behavioural Therapy, Relaxation, Mindfulness, Hypnosis
    •  Hyperventilation - Breathing Exercises
    Sleep management
    •  Sleep routine
    •  Timing of food and exercise
    •  Screen time
    •  Sleepio App
    Monitor medications: often complex cocktail
    Advise on non pharmacological treatments
    •  Compression garments – aid venous return
    •  Fluids and salt – maintain blood volume
    •  Dietary advice – small meals, low carbohydrate, FODMAPS
    Design and implement exercise reconditioning programme*
    Evidence suggests that orthostatic intolerance and PoTS
    are related to deconditioning (Fu et al., 2010; Parsaik et al., 2012; Sheldon et al., 2016)

    Cause or Effect?
    Monitor medications: often complex cocktail
    Advise on non pharmacological treatments
    •  Compression garments – aid venous return
    •  Fluids and salt – maintain blood volume
    •  Dietary advice – small meals, low carbohydrate, FODMAPS
    Design and implement exercise reconditioning programme*
    Evidence suggests that orthostatic intolerance and PoTS
    are related to deconditioning (Fu et al., 2010; Parsaik et al., 2012; Sheldon et al., 2016)

    Cause or Effect?
    Regardless of the relationship – deconditioning negatively
    influences cardiovascular function
    Premise: Long term benefits of improved physical fitness
    counteract orthostatic intolerance
    •  Increased blood volume
    •  Increased cardiac output
    •  Enhanced vascular compression due to increased muscle
    mass and tone
    •  Improved endothelial function
    •  Improved baro-reflex function
    Case Control Study: 19 cases of PoTS and 16 healthy controls
    3 month graduated exercise interven7on
    Results
    •  10/19 cases no longer met the diagnosis of PoTS
    •  Significant reduc,on in upright heart rate
    •  All improved quality of life (SF36)
    Growing evidence for exercise as alternative to medication

    Side effects of medication – lead to cessation


    •  Beta blockers – fatigue
    •  Fludrocortizone – hypokalemia
    •  Alpha adrenergic agonists - hypertension
    Galbreath et al., 2016 Clin Auton Res, 21, 73-80
    Exercise Reconditioning Programme
    Aims : improve cardiovascular fitness and lower limb strength

    Cardiovascular exercise
    Start with chair peddles, reclining bicycle, rowing and swimming
    Progress to upright position

    During exercise, people with PoTS have a low stroke volume response to
    exercise – leads to light headedness, dizziness, dyspnoea and weakness
    Resistance / Strength Training
    •  Body weight
    •  Weights
    •  Elastic bands

    Resistance training is more demanding on the circulatory system. Lead to


    changes in blood pressure. Avoid Static exercise and Valsalva hold breath
    – increase in BP, followed by a fall in BP
    How Often and How Hard? Rate of Perceived Exer7ons
    Frequency and Intensity of Exercise
    First month
    3-4 per week: Reclining exercise CV training (20 - 40 min)
    1 x per week: Resistance training per week (15 – 20 mins)
    RPE 6 - 16
    Second month
    3-4 per week: Upright bike CV training (25 -34 mins)
    2 x per week: Resistance training per week (20-25 mins)
    RPE 6 - 18
    Third month
    3-4 per week: Upright CV training (35-40 mins)
    Cross trainer/ walking
    2 x per week: Resistance training (30 mins)
    RPE 8 - 18
    George et al., 2016 Heart Rhythm, 13, 943 - 50
    My Reality - Frequency and Intensity of Exercise

    First Month
    4-5 per week: Reclining exercise CV training (2-10 mins)
    4-5 x per week: Resistance & propriocep,on training per week
    (2-10 mins)
    RPE 6 – 9: Graduate by 10% per week
    Second – Third Month
    4-5 per week: Upright bike / Walking CV training (10 – 30 mins)
    4-5 per week: Resistance & func,onal training per week (10 –
    20 mins)
    RPE 6-13
    Fourth – Six Month
    3-4 per week: Upright bike, Walking, Cross trainer (30-40 mins)
    2 - 3 x per week: Resistance & func,onal training (20 mins)
    RPE 9 - 18

    George et al., 2016 Heart Rhythm, 13, 943 - 50


    Musculoskeletal
    Pain
    Cardiac Dysautonomia

    Fa,gue
    Mental Health

    Bladder GI manifesta,ons

    Allergy/MAC systemic severity scale


    Ninis, de Wandele & Simmonds 2015
    Case Two
    Management
    Complex pharmacological management for PoTS and Mast Cell Ac,va,on
    •  Fluids and salt
    •  Dietary advice
    •  Schooling plan

    Func7onal restora7on programme
    Normalise movement
    Gait re educa,on
    Hydrotherapy
    Graduated cardiovascular and resistance training
    Bike, cross trainer, squats, weights arms and legs, leg press

    Goals
    Complete GCSE’s
    Be able to go shopping on the high street
    Stay over with friends and holiday

    Tips for Rehabilitation

    Give hope
    Holis,c view
    Problem solving
    Find the base line
    Progress steady pace
    Drink before, during and aber
    Psychology
    Graduate slowly
    Underlying HSD – likely to be very weak and decondi,oned with porr
    propriocep,on. Need to incorporate stability training.

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