ABSTRACT
Background: Patients with chronic refractory constipation show colon dysmotility, including impaired coordination of descending colon-sigmoid colon-rectum-anal sphincter motor functions;this may involve slow colonic transit and colo-anal dyssynergia. Impaired neuronal communication between the sacral defecation center and the distal colon may be causative. In addition, patients with lumbosacral neurological conditions (with lower back pain) may not be able to evoke an effective defecation reflex. Aims: To evaluate if a single therapeutic session of sacral low-level laser therapy (LLLT) would affect the autonomic activity in patients with chronic constipation as revealed by changes in heart rate variability, and to report a multi-session treatment case study. Methods: In 41 patients with chronic constipation, one session of LLLT was executed, using red LED light at a wavelength of 660 nm for 10 minutes and infrared LED light at wavelength of 840 nm for 10 minutes followed by infrared laser light with wavelength of 825 nm for 20 minutes, while measuring the electrocardiogram. One patient received this treatment 8x over 3 weeks. Results: The lumbar-sacral light array treatment showed a significant decrease in parasympathetic activity (RSA & RMSSD) whereas pure sacral laser light treatment showed a significant increase in parasympathetic activity (RSA & RMSSD) as well as a reduction in sympathetic activity (Baevsky's stress index: SI) (table). A single session of LLLT was also executed during HRCM in 8 patients with some but not all showing evoked colonic motility. Before COVID-19 shutdown, one patient was successfully treated. With a history of chronic constipation without ability to have spontaneous bowel movements for 5 years, symptoms improved from 13 to 8 (on a 20 scale) and quality of life improved from 1.5 to 2.5 (on a 0-4 scale) after 8 sessions. Sympathetic reactivity from supine to standing markedly reduced, from highly elevated measured as the Baevsky index from 55 to 153 s-2 it improved from 42 to 75 s-2 upon standing after 4 sessions. Parasympathetic reactivity did not change. Conclusions: A single session of sacral LLLT markedly affected autonomic nervous activity reflected in changes in HRV. The LLLT is likely affecting the sacral defecation center through peripheral nerves entering and exiting the spinal cord including the dorsal root ganglia. LLLT treatment of a patient with inability to generate spontaneous bowel movements, resulted in ability to have complete evacuations associated with marked reduction in sympathetic reactivity during the supine-standing test, after 4 LLLT sessions.
ABSTRACT
CASE: Ms.X is a 31-year-old female with an unremarkable medical history who presented to the general medicine clinic with palpitations that started 3 days after taking her second dose of Pfizer Covid vaccine. The palpitations ocurred exclusively when standing, with no associated chest pain, dizziness, or presyncope. History is negative for tobacco smoking, drug or alcohol use, and consumption of energy or caffeinated beverages. The physical examination was notable for moist mucous membranes and normal volume examination. Orthostatic vitals were remarkable for an increase in HR by 30 beats with minimal change in BP. EKG showed a normal sinus rhythm, and lab workup inclusive of a CBC, CMP, and TSH was unremarkable. As such, the patient was referred for tilt-table testing. Within 8 minutes of upright tilting, HR was137 from a baseline of 77, and BP was 144/108 from 125/71. A looprecorder was inserted which revealed presence of patient triggered episodes of sinus tachycardia upon standing. The patient was started on propranolol 10 mg every 4-6 hours while awake with almost complete resolution of palpitations. IMPACT/DISCUSSION: The incidence of POTS is 0.2-1% in developed countries, with a 5:1 female-male ratio. It presents with orthostatic symptoms like light-headedness, presyncope, and palpitations. It can occasionally present with non-orthostatic symptoms like nausea, bloating, and diarrhea. The pathophysiology is not well-understood but is postulated to be due to an autoimmune disorder, abnormally increased sympathetic activity, and/or sympathetic denervation leading to central hypovolemia and reflex tachycardia. It is a diagnosis of exclusion, but table-tilt test is used to help confirm it. The onset is typically precipitated by immunological stressors like viral infections, vaccination, and pregnancy. Recently, several case reports have been published describing POTS following infection with COVID-19 infection. This was described as long-COVID postural tachycardia syndrome by the American Autonomic Society. However, the association of POTS with COVID-19 vaccine is unclear. Only one case report was published describing the development of POTS after COVID-19 mRNA vaccine. Information relating to this remain limited, and approach to diagnosis and treatment is variable. Our understanding of this condition in relation to vaccination is mostly extrapolated from previously published reports describing it in relation to HPV vaccine. As more people continue to take the vaccine, physicians should be alert to the diagnosis. CONCLUSION: POTS is a frequently underdiagnosed or misdiagnosed disorder. It is characterized by an increase in HR by 30 within 10 minutes of standing . In rare instances, it has been described as a postvaccination adverse immune phenomena, and more recently related to mRNA COVID-19 vaccination. Increased recognition, diagnosis, and reporting will contribute to better understanding and treatment.
ABSTRACT
Introduction: The cause of tachycardia and dyspnea on exertion (DOE) in the Post Acute Sequelae CoV-2 syndrome (PASC) has yet to be identified. While endothelial invasion of the virus is well documented, how that might explain PASC is unknown. Hypothesis: Covid induced changes in vascular signaling to autonomic regulatory centers can induce sinus tachycardia and DOE. Methods: In a prospective, observational study, we enrolled 18 PASC patients who reported DOE or inappropriate tachycardia. All patients had normal left ventricular function, CXR, Hgb and thyroid studies. None had preexisting autonomic dysfunction. Vascular resistance was assessed by echocardiographic measurement of aortic-vascular impedance (Zva)=(systolic BP + mean Ao valve gradient)/stroke volume index. Ambulatory heart rate monitoring and head-up tilt table testing (HUTT) were performed. Results: Consecutively enrolled patients (18) were studied (17 females, ages 27 to 64). None had a significant aortic valve gradient. Zva was elevated in 17 of 18 patients. Ambulatory monitoring revealed episodes of symptomatic sinus tachycardia. Higher average daily heart rates correlated significantly with higher Zva levels (fig1). The 14 patients with DOE trended to higher average Zva levels than the 4 patients without dyspnea (4.13 +- 0.85 vs 3.5 +- 0.24, P=0.14). Of the 17 patients who had HUTT, 16 demonstrated patterns of orthostatic intolerance consistent with excess sympathetic tone including both postural orthostatic tachycardia and neurogenic cardiac syncope. Conclusions: PASC associated sinus tachycardia and HUTT abnormalities result from excess sympathetic tone. Covid-19 vascular injury as evidenced by abnormal Zva values may result in abnormal vascular signaling to autonomic regulatory centers. Resultant increases in sympathetic output may produce inappropriate sinus tachycardia, vasomotor dysregulation and DOE via peripheral vasoconstriction.