ME/CFS Primer/Education Bulletins 2010 Results of Head Upright Tilt Table Test-Full Article
IACFS/ME Bulletin


Results of Head Upright Tilt Table Test as a Predictor of Disability in a Group of Chronic Fatigue Syndrome Patients

Susan M. Levine1*, MD

Madeline Sterling2, MD/MPH candidate at Robert Wood Johnson Medical School

*Requests for reprints should be addressed to:

Susan Levine, MD
115 East 72nd Street, Suite 1A
New York, NY 10021

 

T 212 472 4816; F 212 472 9660; e-mail cfssuelev@earthlink.net

 


ABSTRACT

 

 

 

Background: Chronic Fatigue Syndrome (CFS) is a complex illness characterized by the presence of debilitating fatigue, myalgias, sore throats, headaches and cognitive disturbances. Autonomic dysfunction or orthostatic intolerance (OI) characterized by the presence of dizziness, palpitations and frank syncope has been implicated as a cause of some of the debility experienced by a subgroup of CFS patients. 

Methods: Using the results of Head Upright Tilt Table Testing (HUT), in addition to the frequency of symptoms of both CFS and OI reported by 15 subjects chosen randomly from S.L.’s private practice, we sought to determine whether the presence of autonomic dysfunction was associated with a likelihood of disability among these patients. 

Results: Of the CFS patients studied 13/15 had a positive HUT. Twelve of the thirteen patients who had a positive outcome on HUT were fully disabled and receiving disability benefits. Three of the thirteen patients who were positive had a history of syncopal episodes and demonstrated syncope on HUT.  

Conclusion: Results of this study suggest that HUT in addition to a strong history of autonomic symptoms, especially syncope, may be useful in determining disability status among CFS patients. It is important to note that methodological differences among testing sites including experience with the method in general, angle of tilt, and monitoring of ambient conditions during HUT, may affect the interpretability of the HUT data. In addition, variability among CFS patients including comorbid medical conditions, such as presence of Mitral Valve Prolapse or Asthma or the use of vasoactive medications prior to testing, may influence the outcome of this procedure.

 


INTRODUCTION

 

Chronic Fatigue Syndrome (CFS) is an illness defined by the presence of unremitting fatigue of more than 6 month’s duration. Musculoskeletal pain and weakness, swollen lymph nodes, sore throat, sleep disturbances, low grade fever, cognitive complaints, and depression are other symptoms characteristic of this condition that can affect a patient’s overall quality of life. The diagnosis is one of exclusion made by the physician in accordance with the revised CDC case definition (1). Although research has approached the elucidation of this disorder from a number of different perspectives, the cause remains unknown. Particularly difficult for patients and physicians alike is the inability to predict the duration or severity of illness.

Symptoms of dizziness with changes in posture have been reported in a number of adult and pediatric CFS patients and may play a pivotal role in the pathophysiology of this illness (2). Neurocardiogenic or vasovagal syncope is a type of response that is often documented among CFS patients who report intermittent symptoms of dizziness (5,6,7,8). The broad heading for the group of disorders that account for these symptoms is Orthostatic Intolerance (OI), which can be further characterized by the use of an orthostatic stress test, the Head Upright Tilt Table Test (HUT). After HUT some patients either have a diagnosis of Dysautonomic OI characterized by a dramatic fall in blood pressure without a change in heart rate, or Postural tachycardia syndrome (POTS) characterized by the presence of upright tachycardia and a rise in heart rate of more than 30 beats per minute within 10 minutes of HUT. Dysautonomic OI is uncommon and may be familial (9) while POTS has been found commonly in adolescents with CFS and is often accompanied by venous pooling in the extremities (10,11,12).

METHODS

 

Head Upright Tilt Table Testing (HUT) is most often carried out using a table driven by an electrical motor that is used to tilt a patient to varying angles, usually between sixty or seventy degrees during which time the patient’s hemodynamic response is recorded (4). The goal is to try to reproduce the patient’s symptoms of dizziness, flushing, nausea and headaches during the testing period.

The normal response to HUT is a 10-20 beats/minute rise in heart rate without a fall in systolic blood pressure. Usually patients will tolerate the early part of the tilt table test. However, following a period of up to 20 minutes after the start of the test, the resultant drop in heart rate and blood pressure will cause unbearable symptoms of dizziness, potentially resulting in a fainting response, a rise in body temperature, and increased sweating. In some cases HUT alone will not cause the onset of orthostatic symptoms in a given patient. In that case, isoproterenol, a Beta1 agonist, will be administered to enhance the fainting response.

To determine whether a diagnosis of OI contributed to the disability status of CFS patients, we performed a retrospective analysis of clinical data derived from HUT reports and a review of chart notes relating to patients’ symptoms suggestive of autonomic dysfunction reported prior to HUT. Patients were chosen at random from a group of patients in SL’s private practice who met the CDC criteria for CFS; who reported a range of symptoms related to possible autonomic dysfunction; who were not on medications; and who were non-smokers. Of note, Patient 3 has Mitral Valve Prolapse, and Patient 7 has gastroparesis of unknown etiology. Oral permission to use this data in a blinded fashion was obtained over the phone by M.S.


RESULTS

 

Table I provides demographic information, including age, gender, duration of illness and disability status. Out of a total of 15 subjects 3 were males. Age range was from 37 to 55 years old. Fourteen out of fifteen patients were fully disabled and receiving benefits from Social Security.

 

 

Table II provides the distribution of the major symptoms reported by the CFS patients examined in this study. Fatigue and myalgias were the most common symptoms. Fever was reported by six of the patients and three patients reported lymphadenopathy.

 

 

Table III demonstrates the range of symptoms related to possible autonomic dysfunction reported by the group of 15 CFS patients. All patients reported the episodic occurrence of dizziness and palpitations prior to HUT. A history of actual syncopal episodes was reported by three patients. Nausea and other gastrointestinal symptoms were less frequent and included Patient 7 who had a history of gastroparesis that had been documented by a gastric motility study.

 

 

Table IV provides a list of the study centers at which HUT was performed, as well as the angle at which the patient was tilted.  Other conditions of the test procedure such as whether the patient was kept still and told not to speak were not noted in the patients’ HUT reports.

 

 

Table V lists the baseline and endpoint heart rate and blood pressure recordings for the CFS patients being analyzed. Nine received isoproterenol to induce OI. Five patients experienced syncope and the test was stopped. Thirteen out of 15 CFS patients who underwent HUT had a positive test. The type of OI diagnosed is noted in the last column.


DISCUSSION

 

 

In our small sample of 15 CFS patients who reported symptoms suggestive of autonomic dysfunction prior to HUT, 13 demonstrated a positive response on HUT. Twelve of the 13 patients who demonstrated a positive response on HUT were disabled, which might suggest that autonomic dysfunction may add to the level of symptomatology experienced by this group of patients. None of the patients who underwent HUT demonstrated objective findings consistent with POTS. This pattern may be more common among adolescent patients because of their higher state of autonomic modulation (13). Resting sinus tachycardia and color changes in the distal extremities, often clues to the presence of POTS, were absent in our group of patients.

All of the study patients had symptoms that allowed them to meet the CDC case criteria for CFS in addition to reporting the intermittent occurrence of symptoms of autonomic dysfunction. The descriptive results of this report need to be considered with some limitations. Some patients in our small sample experienced episodes of syncope prior to HUT which were reproduced during the procedure. Patient 3 has MVP which confers a further degree of autonomic dysfunction. She experienced daily episodes of dizziness and near syncope up to a year prior to HUT. Similarly, Patient 5 and Patient 6 reported frequent symptoms related to autonomic dysfunction prior to HUT. Patients 3, 5, and 6 underwent HUT at different study centers whose experience with performing this type of testing likely differed (at least in the angle of the tilt) despite supposed standardization of this procedure. Patients 5 and 15 both underwent testing at the same facility with different outcomes suggesting a reasonable degree of sensitivity and specificity of the test at this study center.

Unfortunately, we were unable to ascertain in each case the severity and frequency of autonomic related symptoms, such as dizziness and palpitations. We also were not able to control for alcohol and caffeine ingestion prior to testing, the use of medications with vasoactive properties, changes in ambient temperature and humidity, and certain postural changes. Thus, we are not certain in what way these variables contributed to the patient’s disability or whether they might have been the triggering factors for the occurrence of these symptoms. Finally, a cautionary note about the generalizability of the results of this study; the data was obtained in a tertiary care setting, about 75 % of the patients in S.L,'s practice are disabled. 

 
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 Bulletin of the IACFS/ME. 2010;18(1):31-42. © 2010 IACFS/ME

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