As vestibular physical therapists, we regularly treat the most challenging cases of dizziness, imbalance, and gait dysfunction. We observe the subtle, often profound, struggle patients experience when their primary Sensory Organization systems fail to achieve homeostatic balance. The presence of dysautonomia—autonomic dysfunction—in a patient significantly complicates this picture, frequently driving symptoms like the VVM (Visual-Vestibular Mismatch) and SVVM (Somatosensory>Visual-Vestibular Mismatch) strategies we work to unwind. We must recognize this common yet under-recognized comorbidity to deliver comprehensive, effective care.
Dysautonomia challenges the very foundation of postural control, as the Vestibulo-Sympathetic Reflex (VSR) works in tandem with the baroreflex to maintain blood flow to the brain against gravity. When the autonomic system falters, patients experience orthostatic intolerance, which causes dizziness and unsteadiness, prompting compensatory avoidance behaviors that lead to mismatch strategies. We owe it to our patients to understand these specific autonomic disorders.
Postural Orthostatic Tachycardia Syndrome (POTS)
POTS presents as a critical form of orthostatic intolerance. Upon transitioning to an upright posture, the patient’s heart rate increases excessively and consistently, yet they avoid a significant drop in blood pressure. This pathological response triggers pre-syncopal symptoms, compelling the patient to experience dizziness, lightheadedness, and profound fatigue, all of which directly interfere with their ability to perform functional activities.
POTS patients often develop a chronic deconditioning that severely limits their exercise capacity. Vestibular professionals actively treat this patient population by initiating a graded exercise program. This program initially limits orthostatic stress by using supine or semi-recumbent activities, meticulously progressing the patient to more upright and dynamic exercise over time. This approach improves cardiovascular regulation and increases their overall tolerance for standing and daily mobility, ultimately helping normalize their input systems.
Orthostatic Hypotension (OH)
Orthostatic Hypotension (OH) is a distinct challenge where the patient experiences a significant and immediate drop in blood pressure upon standing. We define this drop as a fall in systolic blood pressure of $20$ mmHg or more, or diastolic blood pressure of $10$ mmHg or more, within three minutes of standing up. This rapid drop in perfusion causes transient cerebral hypoperfusion, making the patient feel dizzy, lightheaded, and potentially causing them to faint.
The vestibular specialist must actively screen for this disorder by using the 10-minute in-office stand test, meticulously recording heart rate and blood pressure at baseline and at regular intervals upon standing. Identifying OH is crucial because it often indicates a failure of the sympathetic nervous system to adequately vasoconstrict peripheral vessels, a problem common in patients with neurodegenerative diseases such as Multiple System Atrophy (MSA) or Diabetic Autonomic Neuropathy (DAN). We design interventions that teach slow, controlled postural transitions and often advocate non-pharmacological methods, such as increasing fluid/sodium intake and wearing compression garments.
Neurocardiogenic Syncope (NCS)
Vestibular professionals must also identify Neurocardiogenic Syncope (NCS), also known as Vasovagal Syncope. NCS involves a sudden, reflexive drop in both heart rate and blood pressure, resulting in a temporary loss of consciousness. The vagal nerve over-responds to a trigger—which may include pain, emotional stress, or prolonged standing—causing the patient to crash.
While the primary treatment for NCS involves cardiac management, we play a vital role in recognizing pre-syncopal signs and symptoms, such as nausea, pallor, sweating, and rapid-onset dizziness. We empower the patient to recognize these triggers and immediately employ counter-maneuvers, such as tensing their lower body and abdominal muscles, to abort syncope. By educating the patient on these self-management strategies, we provide them with a crucial tool to maintain their safety and functional independence.
Brian Werner, PT, MPT, is a physical therapist who has been specializing in vestibular and balance disorders for over a quarter of a century. He is the founder of the FYZICAL Balance Paradigm and one of the co-founders of FYZICAL, LLC, Balance Center Division with Dr. Daniel Deems, MD, PhD, where he served as the National Director of Vestibular Education & Training for 14 years.
This video provides an overview of Physical Therapy strategies, including a graded exercise program, for patients with dysautonomia. Physical Therapy Strategies for People with Dysautonomia