DOCTORS

ANS Monitoring with Physio PS

Physio PS provides unprecedented insight into the physiological responses of the autonomic nervous system.

In general, Parasympathetic and Sympathetic (P&S, respectively) Monitoring helps to diagnose and treat patients to return health and establish wellness. Once wellness is established (or if patient was well to begin with), P&S Monitoring helps to maintain wellness and prevent dysfunction, disorder, or disease.

P&S Monitoring helps to diagnose.

Most chronic diseases, such as those listed, which involve an autonomic dysfunction: high or low Parasympathetic (P), or high or low sympathetic (S); at rest or when challenged. Restoring, or establishing, P&S balance (i.e., normalizing Sympathovagal Balance (SB) at rest, or returning proper coordination upon challenge) reduces morbidity and mortality risk, as well as the number of co-morbidities. Once the P&S nervous systems are properly balanced (at rest) and coordinated (upon challenge), any remaining symptoms are due to end-organ effects, and may be more aggressively treated without interference from other medications needed to treat the co-morbidities caused by the P&S imbalance.

P&S Monitoring helps to treat.

With the additional information from P&S Monitoring, more specific and individualized therapy plans may be developed. Some diagnoses maybe either Parasympathetically-mediated or Sympathetically-mediated, yet both mediations lead to the same set of symptoms.

  • For example, hypertension may be a primary, Sympathetic excess, or may be a Sympathetic excess (SE) secondary to a (primary, co-existing) Parasympathetic excess (PE); both autonomic branches are over-active.
    • If hypertension is due to a primary SE, standard sympatholytics (e.g., antihypertensives) is indicated.
    • If hypertension is due to a SE secondary to PE, therapy should first treat the PE, and then if any SE remains, complete the therapy plan with sympatholytics. Note, this tends to be the more difficult to manage form of hypertension.
      • To treat PE without co-morbid heart disease, consider low-dose anticholinergic therapy (in the form of very, low-dose antidepressant).
      • To treat PE, with co-morbid heart disease, consider switching to or titrating Carvedilol to treat. ➢ As found with diabetic patients, Carvedilol treats both SE and PE, when autonomic dysfunction or neuropathy is indicated.

P&S Monitoring helps to maintain wellness and prevent dysfunction, disorder, or disease.

When possible, lifestyle changes and supplements are employed to help maintained wellness. Whether pharmaceutical therapy is prescribed or not, wellness is promoted by maintaining a proper balance and coordination between the P&S nervous systems. Because (1) all organs and organ systems are controlled or coordinated by the P&S systems, and (2) it is the purpose of the P&S systems to maintain normal organ function even when the P&S systems themselves are out of balance, then P&S dysfunction precedes organ dysfunction and symptoms are not demonstrated until the organs become dysfunctional. Normalizing P&S imbalance before symptoms, prevents symptoms, and maintains wellness.

Given the typical P&S characteristics associated with the disease states listed below, diagnosis and treatment, and wellness and prevention options as mentioned above are possible for all.

THE KEY FOR ALL IS BALANCE, BOTH AT REST AND DURING CHALLENGE. THIS IS A LIST OF CONDITIONS THAT PHYSIO PS MONITORING HELPS TO PREVENT AND DIAGNOSE/TREAT.

NEUROLOGY

Headache

There are numerous reasons for headache: medication mismanagement, neurologic, cardiologic, etc. P&S Monitoring provides more information to further differentiate. Whether P or S, P&S-mediated migraines are associated with improper brain perfusion (too little or too much, respectively), triggering the neurological effects that underlie migraine. P&S Monitoring specifies which and enables more specific therapy. Once P&S balance is established, any remaining symptoms are due to a brain disorder.

Tension Headache

There are numerous reasons for headache. Tension tends to indicate high SB or challenge SE.

Migraine

Like headache, there are many forms of migraine, some Parasympathetically-mediated and some Sympathetically-mediated. Whether P or S, P&S-mediated migraines are associated with improper brain perfusion (too little or too much, respectively), triggering the neurological effects that underlie migraine. P&S Monitoring specifies which and enables more specific therapy. Once P&S balance is established, any remaining symptoms are due to a brain disorder.

ADD/ADHD

Is characterized by a dynamic (challenge) PE that causes a challenge SE that is responsible for both the attention deficit and the hyperactivity. In essence, the PE induces a form of depression due to PE-induced marginal or poor brain perfusion. The secondary SE causes the “adrenaline storm” that underlies the attention deficit and the hyperactivity. We have had success switching these patients from the standard therapies (characterized by highdose, long-term) to low-dose, short-term anti-cholinergic therapy, and have relieved the disorder within 18 months. Once P&S balance is established, any remaining symptoms are due to a brain disorder.

Parkinsonism, Parkinson’s Disease

As a catecholaminergic disorder, the P&S nervous systems are involved. While P&S balance helps to maintain quality of life longer, it does not always help to slow the disease process. P&S Monitoring will identify autonomic neuropathy, including Cardiovascular Autonomic Neuropathy, to help minimize mortality risk.

Depression

Characterized by PE, either resting or challenge, or both. All antidepressants are types of anti-cholinergics. The less the BP effect of these medications, the less of a P&S effect. Depression that persists after P&S are balanced, is psychological. P&S imbalance is the physiologic component and is associated marginal or poor brain perfusion. Once P&S balance is established, any remaining symptoms are psychological issues.

Bipolar Disease

From a P&S perspective is a primary PE disorder; therefore, and primary depression disorder. Once the PE is normalized, the SE (secondary to PE) is typically relieved organically, without additional medication. With P&S imbalance, the anxiety phases of Bipolar Disease are cycled when brain perfusion becomes too low, typically after an event that is associated with increased Parasympathetic tone (after large meals, before bed-time, after emotional responses. Once P&S balance is established, any remaining symptoms are psychological issues.

Anxiety

There are two underlying P&S forms: (1) resting high SB (indicating resting SE) as the primary P&S disorder; and (2) challenge PE, causing secondary SE, releasing excess adrenaline causing anxiety secondary to the challenge PE. The latter involves depression. The commonly experienced heart palpitations, in either case, are due to the associated SE, but are typically not life threatening due to SE that is not critical. Once P&S balance is established, any remaining symptoms are psychological issues.

Post-Traumatic Stress Disorder

Is associated with what are known as “Quality of Life” (QoL) symptoms: sleep, GI, bladder and bowel dysfunction, lightheadedness upon standing, sex dysfunction, high BP, and depression. The opposing symptoms of depression and high BP help to confirm that PTSD involves both PE and SE; specifically challenge PE, leaving the SE as secondary. While P&S monitoring and guided therapy help to normalize QoL symptoms, it does not directly address the “trigger;” however, it has been found that once the QoL symptoms are normalized, patients are significantly better able to manage the trigger.

Sleep Disorders

 Disorders characterized by night-time sleeplessness are associated with SE, and disorders characterized by day-time sleepiness are associated with PE. Once P&S balance is established, any remaining symptoms may be psychological, hormonal, or neurological issues.

Shy-Drager Syndrome (Orthostatic Hypotension with Multisystem Degeneration, aka Multiple System Atrophy, or MSA)

MSA and Parkinson’s Disease are nearly identical in the early stages. Treating one with the therapy for the other, accelerates the progression of the one. Since Parkinson’s Disease preserves Sympathetic innervation to the heart, P&S Monitoring differentiates the two earlier, helping to ensure proper therapy planning. Once P&S balance is established, any remaining symptoms are due to the disorder itself.

Idiopathic Peripheral Autonomic Neuropathy

 Is one of the earliest signs of P&S dysfunction, enabling earlier and more aggressive therapy to slow or stay the progression of autonomic neuropathy by establishing and maintaining P&S balance.

Chronic Regional Pain Syndrome or Reflex Sympathetic Dystrophy (RSD)

Is characterized by pain with both SE and PE. The SE due to the “stress” of pain and the PE due to compromised blood flow (e.g., due to plexus damage) to a region of the body.

Multiple Sclerosis

While P&S balance helps to maintain quality of life longer, it does not always help to slow the disease process. P&S Monitoring will identify autonomic neuropathy, including Cardiovascular Autonomic Neuropathy, to help minimize mortality risk.

Polyneuropathy: Diabetic, Idiopathic, or other

Sensory and motor neuropathies are preceded by autonomic neuropathy causing poor circulation inducing or exacerbating the others.

Myasthenic Syndrome (Eaton-Lambert)

This disease also affects the P&S systems. While P&S balance helps to maintain quality of life longer, it does not always help to slow the disease process. P&S Monitoring will identify autonomic neuropathy, including Cardiovascular Autonomic Neuropathy, to help minimize mortality risk.

Orthostatic Hypotension

In general, Orthostatic dysfunction is associated with alphasympathetic (adrenergic) insufficiency (Sympathetic Withdrawal, or SW) causing lower extremity vascular dysfunction upon standing, which causes a drop in BP upon standing (head-up postural change). P&S Monitoring quantitatively specifies SW helping to differentiate Orthostatic dysfunction, including Orthostatic Intolerance, Orthostatic Hypotension, Orthostatic Hypertension, and Postural Orthostatic Tachycardia Syndrome (POTS) from other causes of dizziness and lightheadedness (including Syncope). Treat the SW to relieve any of the forms of Orthostatic dysfunction. Note, the majority of patients with Orthostatic dysfunction are found to simply be dehydrated. Consider proper daily hydration as the primary recommendation.

Syncope and Collapse

In general, Syncope is a (beta-) SE with standing (head-up postural change), in other words a cardiac issue. P&S Monitoring can positively identify Vasovagal Syncope (stand SE with PE), and Neurogenic Syncope (stand SE with an abnormal HR response to stand). Cardiogenic Syncope is a diagnosis by omission. While Neurocardiogenic Syncope is the most commonly diagnosed form, P&S Monitoring helps differentiate the ‘neuro’ component from the ‘cardio’. Treat PE for Vasovagal syncope. Treat the HR abnormality for Neurogenic. Consider additional cardiac testing, including tilt table, to positively diagnose and treat Cardiogenic Syncope.

Tachycardia (Postural, aka POTS)

POTS and Vasovagal Syncope are difficult to differentiate, even with tilt-table. P&S Monitoring quantitates the Sympathetic response to stand (head-up, postural change), differentiating stand SW (indicating orthostatic dysfunction, including POTS) from stand SE (indicating Syncope). This is more information that enables more individualized therapy planning; including the possibility of both Orthostatic dysfunction and Syncope concurrently.

Chronic Hypotension

Characterized by low SB or challenge PE. Once P&S balance is established, any remaining symptoms are cardiovascular issues.

Dizziness, Lightheadedness and Vertigo

As indicated above there are multiple reasons for lightheadedness and dizziness, including Vestibular dysfunction, especially in geriatrics. Consider both Vestibular testing and P&S monitoring to fully document and diagnose and determine therapy.

Chronic Fatigue Syndrome

Characterized by low SB or challenge PE.

ENDOCRINOLOGY

Thyroid Disorders

The P&S systems are intimately associated with the hormonal systems. Hyperthyroidism is characterized by SE (at least in part) causing the over-production of thyroid hormones. Hypothyroidism is characterized by PE (at least in part) shutting down the production of thyroid hormones.

(Premature) Menopausal Symptoms or Syndromes

The P&S systems are intimately associated with the hormonal systems. From a P&S perspective, menopausal abnormality is characterized by challenge PE, (at least in part) shutting down the production of estrogen and progesterone. Once P&S balance is established, any remaining symptoms are end-organ issues.

Diabetes

By the time of diagnosis, both forms of Diabetes (types I & II) are characterized by SE: (1) at first due to both an initial decline in resting Parasympathetic activity causing high SB (indicating resting SE) and a (protective) challenge PE causing a secondary challenge SE, (2) then due to the continuing effects of sugar acidosis on the more highly exposed Vagus Nerve which comprises the majority of the Parasympathetic Nervous System. In type 2 Diabetes, preDiabetes is characterized by challenge PE shutting down (at least in part) the production of insulin. Once P&S balance is established, any remaining symptoms are end-organ issues.

NEPHROLOGY

Hypertensive Renal Disease or Renal Failure

Both are typically characterized by SE: (1) at first due to both an initial decline in resting Parasympathetic activity causing high SB (indicating resting SE) and a (protective) challenge PE causing a secondary challenge SE, (2) then due to the continuing effects of uremia toxicity on the more highly exposed Vagus Nerve which comprises the majority of the Parasympathetic Nervous System. In Hypertensive Renal Disease, resting SE is exacerbated either causing, or caused by, the hypertension.

INTERNAL MEDICINE

Morbid Obesity

There are two underlying P&S forms: (1) stress induced, challenge PE (as a protective mechanism), causing secondary SE, releasing cortisol putting the body into “starvation mode;” and (2) resting low SB (indicating resting PE) keeping metabolism low. Both may involve depression. The former is typically the difficult to manage type. The latter is the type that best responds to typical diet programs, and is easier to keep off the weight.

Unspecified Immunity Deficiency

The Parasympathetic nervous system provides the immune system its memory and helps to control and coordinate immune responses. Weak Pactivity (including high SB, at rest) promotes immune deficiency.

GERD

The gastric system is uniquely controlled by the Parasympathetics. GERD as a result of PE is due to overactive gastric motility. GERD as a result of Parasympathetic insufficiency is due to forms of gastroparesis. Once P&S balance is established, any remaining symptoms may be specifically gastric (end-organ) issues (e.g., smooth muscle, excess gastric secretion, bacterial, etc.).

Gastroparesis

The gastric system is uniquely controlled by the Parasympathetics. Gastroparesis is (at least in part) a result of Parasympathetic insufficiency. Once P&S balance is established, any remaining symptoms may be specifically gastric (end-organ) issues (e.g., smooth muscle, excess gastric secretion, bacterial, etc.).

Irritable Bowel Syndrome

The intestinal system is uniquely controlled by the Parasympathetics. IBS with constipation is (at least in part) a result of Parasympathetic insufficiency, causing low motility. IBS with diarrhea is (at least in part) a result of PE, causing excess motility. Once P&S balance is established, any remaining symptoms may be specifically gastric (end-organ) issues (e.g., smooth muscle, excess gastric secretion, bacterial, etc.).

Fibromyalgia

Is now accepted as an autonomic dysfunction, typically characterized by challenge PE. The associated SE (associated with the amplified pain responses) is typically secondary to the PE and the main reason why it is difficult to control or responses, seemingly paradoxically, to anti-cholinergic therapy.

Edema

(1) lower body edema is typically associated with SW, causing pooling of blood in the lower vasculature and may result in varicose or spider veins;
(2) more generalized edema is associated with PE.

Sex Dysfunction

Requires proper coordination between the P&S systems: P for “point” responsible for erection and vaginal lubrication, and S for “shoot” responsible for ejaculation and orgasm. Once P&S balance is established, any remaining symptoms may be vascular, psychologic, or hormonal.

PULMONOLOGY

Sleep Disturbances (e.g., central or obstructive sleep apnea)

Are characterized by Parasympathetic insufficiency followed by SE. Parasympathetic insufficiency underlies the collapse of the soft palate and then the stress of not breathing while sleeping and then not sleeping causes the SE. Note, sleep apnea therapies (e.g., CPAP) are not direct sympatholytics; therefore, they only relieve the “stress” of not sleeping. They are not sufficient to reduce the SE associated with typical co-morbidities associated with sleep apnea: hypertension, diabetes, obesity, etc. Additional Sympathetic therapies are needed to normalize the mortality and morbidity risk of sleep apnea. P&S Monitoring is often necessary to properly titrate the additional sympatholytic therapy.

Asthma

Is a bronchial issue and therefore a Sympathetic dysfunction. The non-steroidal therapies may involve beta-2 adrenergic agonists to bronchodilate. However, beta-2 adrenergic agonists also affect the heart, increasing HR or BP by causing SE. The associated SE that may be induced, precedes the increase in HR or BP, and P&S Monitoring helps to titrate the asthma therapy to manage the disease without inducing heart diseases via the induced SE. Once P&S balance is established, any remaining symptoms may be pulmonary.

COPD (Asthma with Chronic Obstruction)

The non-steroidal COPD therapies may involve beta-2 adrenergic agonists to bronchodilate. However, beta-2 adrenergic agonists also affect the heart, increasing HR or BP by causing SE. The associated SE that may be induced, precedes the increase in HR or BP, and P&S Monitoring helps to titrate the COPD therapy to manage the disease without inducing heart diseases via the induced SE. Once P&S balance is established, any remaining symptoms may be pulmonary.

CARDIOLOGY

Hypertension

BP is controlled by Baroreceptor Reflex (BRR), which is controlled by the Sympathetics. Hypertension is typically characterized by SE driving up BRR and then BP. At first hypertension is due to both an initial decline in resting Parasympathetic activity causing high SB (indicating resting SE) and a (protective) challenge PE causing a secondary challenge SE, then it is due to the continuing effects of SE

Post-MI

MI causes SE; therefore, post-MI symptoms are due to SE.

Angina

The vasculature is uniquely controlled by the Sympathetic nervous system: peripheral vasoconstriction is a function of increased Sympathetic tone increasing BP and shunting blood to the core; peripheral vasodilation is a function of decreased Sympathetic tone decreasing BP and enabling blood flow to the periphery. Angina is a form of Coronary Artery Disease (CAD) and is a function of SE, either due to excess vasoconstriction or due to blockages from atherosclerotic build up.

Atherosclerosis

Induces SE. It may be induced by SE as SE may involve endothelial dysfunction.

Mitral Valve Prolapse Syndrome

Is empirically associated with PE, if not a structural cardiac issue.

Cardiomyopathy

Is characterized by SE, however, its different forms may be induced by other disorders. For example, Hypertrophic Cardiomyopathy is genetically facilitated, with the disorder turning symptomatic if and when Orthostatic dysfunction (associated with α-SW upon standing) or Syncope (associated with α-SE upon standing) is demonstrated.

Cardiac Dysrhythmias

Are varied and, in part, associated with P&S dysfunction. It is accepted that approximately 80% of atrial dysrhythms are accepted to also involve the P&S systems (only 20% are purely cardiogenic). Of the 80% that involve the P&S, approximately 20% are Sympathetically-mediated and 80% are Parasympathetically-mediated. Ventricular dysrhythms are accepted to also involve the Sympathetics, except repolarizing ventricular dysrhythms which are accepted to also involve the Parasympathetics. P&S monitoring helps to specify which branch is involved. Once P&S balance is restored, the remaining symptoms are cardiogenic.

Congestive Heart Failure

Is characterized by high SB, indicating a resting SE. Note, resting SE (high SB) precedes even the 3% weight gain indicator and which may be prevented with early intervention, including a temporary increase in diuretic, if the increase in SB is noted (up to 4 days) before the weight gain. This helps to avoid hospitalization.


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‘RFa’ is known to be a measure of Parasympathetic activity and ‘LFa’ is known to be a measure of Sympathetic activity, based on reference: Colombo J, Arora RR, DePace NL, Vinik AI, Clinical Autonomic Dysfunction: Measurement, Indications, Therapies, and Outcomes. Springer Science + Business Media, New York, NY; 2014.