Orthostatic intolerance in chronic fatigue syndrome

Richard Garner, James N Baraniuk, Richard Garner, James N Baraniuk

Abstract

Background: Orthostatic intolerance (OI) is a significant problem for those with chronic fatigue syndrome (CFS). We aimed to characterize orthostatic intolerance in CFS and to study the effects of exercise on OI.

Methods: CFS (n = 39) and control (n = 25) subjects had recumbent and standing symptoms assessed using the 20-point, anchored, ordinal Gracely Box Scale before and after submaximal exercise. The change in heart rate (ΔHR ≥ 30 bpm) identified Postural Orthostatic Tachycardia Syndrome (POTS) before and after exercise, and the transient, exercise-induced postural tachycardia Stress Test Activated Reversible Tachycardia (START) phenotype only after exercise.

Results: Dizziness and lightheadedness were found in 41% of recumbent CFS subjects and in 72% of standing CFS subjects. Orthostatic tachycardia did not account for OI symptoms in CFS. ROC analysis with a threshold ≥ 2/20 on the Gracely Box Scale stratified CFS subjects into three groups: No OI (symptoms < 2), Postural OI (only standing symptoms ≥ 2), and Persistent OI (recumbent and standing symptoms ≥ 2).

Conclusions: Dizziness and Lightheadedness symptoms while recumbent are an underreported finding in CFS and should be measured when doing a clinical evaluation to diagnose orthostatic intolerance. POTS was found in 6 and START was found in 10 CFS subjects. Persistent OI had symptoms while recumbent and standing, highest symptom severity, and lability in symptoms after exercise. Trial registration The trial was registered at the following: https://ichgcp.net/clinical-trials-registry/NCT03567811.

Keywords: Chronic fatigue syndrome; Orthostatic intolerance; POTS; Tachycardia.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Pre-exercise Dizziness and Lightheadedness Scores. CFS subjects reported significantly more Dizziness and Lightheadedness than controls while supine and standing. Absence of symptoms was reported in 14/25 controls and 6/39 CFS subjects (FET, p < 0.0001). The connected dots indicate trends for Dizziness and Lightheadedness to increase in controls and CFS when standing up. Black bars indicate p < 0.05 by Mann–Whitney U test between CFS and controls for supine and standing symptoms
Fig. 2
Fig. 2
Average Recumbent and Standing Dizziness and Lightheadedness Scores in POTS, STOPP, and START. Each pair of symbols shows the average scores while recumbent (left) and standing (right). CFS POTS (blue), STOPP (red), and START (green) had significantly higher symptoms between recumbent Dizziness and Lightheadedness after 5 min of standing. In contrast, controls had no significant changes in symptoms between the average of all recumbent and standing measurements even if they had postural tachycardia before and after (POTS, blue) or only after exercise (START, green). Black bars indicate P < 0.05, Wilcoxon Signed-Rank test between recumbent and standing symptoms
Fig. 3
Fig. 3
Recumbent and Standing Dizziness and Lightheaded Symptoms in Stratified Groups. Controls and CFS were stratified based on ROC thresholds of 2. Four controls had Dizziness and Lightheadedness symptoms only when standing. The other 21 controls were asymptomatic. Eleven CFS subjects reported scores p < 0.05 Mann–Whitney U test Postural OI controls vs. No OI controls. Black bars indicate p < 0.05, Mann–Whitney U test vs. CFS No OI and CFS Persistent OI CFS group for recumbent and standing symptoms

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