POTS and Concussion: The Overlooked Neurological Link Behind Chronic Dizziness and Fatigue

Still dizzy, foggy, exhausted—or dealing with racing heart symptoms—despite “normal” tests? 

In this Q&A episode, Dr. Zimmerman explains why concussions and POTS are often misunderstood, why MRI/CT scans are usually normal in concussion, and what most evaluations miss (objective balance + eye-movement testing). He also breaks down POTS as a nervous system/autonomic issue, why patients get bounced between cardiology and neurology, and how immune/metabolic factors like histamine patterns and low ferritin can worsen symptoms.

https://peakbrainandbody.com/concussion-symptoms-and-treatment/

Transcript

Hey everyone. We are going to do a question and answer. Feel free to ask me any question that you have. especially if it's related to concussion or POTS, postural orthostatic tachycardia syndrome. Now, realistically, you can go beyond that realm. And if it's something that I can answer, I absolutely will. Friendly reminder, this is for educational purposes only. I'm not allowed to provide medical advice without an evaluation. But once again, type in a comment. Let me know what questions you have. and I will answer them. And during the times when there's not questions, I'm just going to go through different things on what I think people should know about concussion and POTS. Hey, good evening as well to you. First, when we look at these things, the reason why I picked both concussion and POTS to do together is these are two very, very frustrating diagnoses that people get. And they're both very misunderstood in the general public and even in the medical community. So for example, we look at concussions. For an example, we go back to our childhood. Concussions were brushed off as this little thing. It didn't really matter. You were back playing sports in a day or two. And it was believed that no one had ongoing issues. And unfortunately, that mentality has carried forward. into the medical community and the broader society, despite there being an abundance of research showing that's not true. But then on the other side, when we look at POTS, POTS has been only recently in official diagnosis, really in the past, you know, since about twenty twenty one. Before then, people were given the diagnosis, but there wasn't an official ICD-TEN code. And as a result, this is something that most providers have never received training on while they were in school, residency or anything else like that. And those who are currently really good at treating it, it's through really just looking at the research and through gaining the experience. And because people don't have the training on it, unfortunately, when people just don't know, you then get the diagnosis of you must have anxiety. So First though, we're going to go to concussions, talk about all things concussions. Once again, if you have questions on anything, whether it's concussion related, POTS, or really anything else with brain and body health, because the reality is the body works as a whole unit and the better we understand how it works as a whole unit, the better off you ultimately are going to be. So I'm going to share my screen and we are going to dive right into some of that research. So very first thing, right? There's a lot of confusion out there when we look at concussions. Like, did somebody even suffer a concussion or not, right? Or is it something else? Because you get people who think they've had concussions and they get told, well, no, you didn't. And then you get people who concussions kind of blame for everything. And so... What do we even look for when we're diagnosing a concussion? Because if this isn't done right from the beginning, we can lead people down paths that are not going to really help them with their health. Now, this is currently, in my opinion, one of the best articles we have. So this is the American Congress of Physical Medicine and Rehab Diagnostic Criteria for Myotraumatic Brain Injury. And concussion is the most common form of myotraumatic brain injury. Now, they've got some great graphics here and it's important to understand that one, you must have a plausible mechanism of injury. Now, what is not required is you to have a direct blow to your head. That is not the only plausible mechanism of injury, okay? A whiplash injury is sufficient, falling, landing on your butt and having a big jolt. Once again, that can cause a whiplash injury, very common. also falling and hitting your shoulder right we see this a lot when people have a shoulder injury or they broke their clavicle which is your collarbone that can do it because you get you know the head jolts it slams the brain rattles inside now you need to have that and then you don't have to have this clinical sign part so what are these clinical signs of a concussion and the Our pool does a good job going through all the clinical signs so you really know, hey, what's needed, what's not needed. But for example, amnesia of the event, just not remembering what's happened. What else? Well, you know, losing consciousness, definitely going to get you there. Vomiting is going to get you there. So like I said, loss of consciousness, altered mental status, just really slow, gross motor impairment. That's one of the big ones, especially if we look back a few years ago with Tua Tagovailoa with one of the severe concussions he took in a game. Forgetfulness of the event, right? Those are the things we're looking for. Now, reminder, you do not have to have that to have sustained a concussion now that's a thing unfortunately people will still stick with it like oh but you didn't lose consciousness so therefore you didn't have a concussion please there's zero research that shows that's what needs to be done um and then you know as i'm doing this i'll read some of the comments Yep, and we're going to talk about the imaging that comes back normal, you know, and why that's frustrating for so many people. And honestly, when we look at things with this, there are those who lose consciousness and don't know it. And then there's those where they're like, we don't really know because... especially in like car accidents, sometimes there's such a stress response that you have amnesia of the event and unless someone was there and witnessed it, maybe you lost consciousness, maybe you didn't. Now, losing consciousness is only going to happen in about ten percent of all concussions. So while it can happen, it's not required and they actually did a follow-up to this article that we are reviewing. because they just want to make sure from a medical legal perspective, this is used to make a diagnosis. It's not to say how severe an injury was, how long recovery was going to be, or anything else like that. Next, we're looking for symptoms, okay? So these are going to be symptoms that people develop within typically, forty-eight hours of the injury. Now, I'm going to highlight this part. because there's a lot of different symptoms that we are going to review here. But when you look at this, the part of this highlighted, physical disruption of brain function is manifested by two or more new or worsened symptoms from the list below. You don't need five of these. You don't need ten. They don't even all need to be new. Someone who already had headaches who now gets headaches at a greater frequency, That would count someone with depression or pre-existing brain fog. That is now worse. That would count because that would be two things that are worsened compared to the injury. And once again, if you do have questions, feel free, put them in the comments. I will answer them when I see them. So what are the different things? Well, feeling confused, disoriented, a little fuzzy, physical symptoms, headaches, nausea, dizziness, balance issues, visual problems. You know, like it's like, oh, my vision's blurry. I think I need to go and see an eye doctor. And then you often do and they're like, well, your prescription's fine. It's because the brain can't coordinate it. Light sensitivity, noise sensitivity, cognitive issues such as feeling slowed down, brain fog, memory issues, and so forth. And then you just can get emotional issues. It's not uncommon for people to get depression or anxiety following a concussion. That's very common as well. And this is where people are really done a disservice is they have the appropriate mechanism of injury. They've got the symptoms, but if they're seeing someone that's not used to really working with concussions or they're not in the research and they come in specifically, this happens to females a lot. They come in doc. I've got brain fog. I've got dizziness. I've got a headache, you know, and they're like, Oh, this person's kind of on the edge. And they're like, you've had anxiety. the fact is you can have anxiety worsened from a concussion or anxiety that starts after a concussion it doesn't mean your anxiety is driving all the issues now for some people they really do need their anxiety treated at the same time to get better but there's a difference between saying this is worsening your symptoms versus this is the sole cause of your symptoms now When we continue looking at this graphic, right? You need this. You don't need part two. And then it's the clinical examination is gold. And unfortunately I rarely see this is done. So what are they really talking about when they say clinical examination? Now they do say lab findings. That is more of a placeholder because currently we don't have labs for concussions. They're still researching things that may or may not be beneficial. So they're working on it, right? But clinical examination, specifically, these examination findings, including measured cognitive impairment, okay, so like a computerized cognitive test, okay, impact has the market cornered on that in most sports, but there's CNS vital signs, there's many others out there. Now, oftentimes cognitive testing will return to normal before the other things. And so for me, it's kind of lowest down on the list because of that. Balance impairment is massive and this is not just, oh, well, I run into walls, I'm tripping. No, if I only tested people's balance because they told me they have an issue, I would skip eighty percent of those that are actually going to struggle on that testing. And when we look at balance impairment, that's vestibular system as well. Vestibular system impairment is one of the greatest predictors of how long it takes someone to recover. So there was a study I read and they were looking at school. Don't quote me exactly, but I mean, it was like six months. You know, when people have vestibular issues, like how long they were going to be significantly impacted. I mean, it lasted a bit. It was not a short little thing. And then when we're looking at this ocular motor impairment, you know, I don't know on. know i've got someone commenting and they said their eyes were checked recently and they said they were fine and yes if you go to an eye doctor they're looking at a prescription they're not looking at do your eyes track do they focus appropriately can you shift your attention to targets at the speed you should and the accuracy you should that should be done using preferably in my opinion computerized testing where you have objective data it's not someone just like hey follow my finger let's see how you do um because honestly no one documents that appropriately like it's just impossible even the best person in the world cannot adequately document it in a way that matches what a recording can do so that is super important and when we look at this okay And then you can actually technically ace your eye movement testing or your balance testing. So it says symptom provocation in response to a vestibular or oculomotor challenge. So even doing your eye movement testing and saying that gave me a headache, that made me dizzy would be a positive finding. And it's important to realize that you do not need to have all of these. You know, you don't. You just need to have one of these that has been a struggle for you. Down here at the bottom, in patients who do not report acute symptoms, the presence of two or more clinical examinatory or lab findings should raise suspicion for MTBI. I kind of agree with that. I do treat a lot of people who come in with concussions from ten years ago that were not ever evaluated or treated that we still have to treat. So I agree with it there. But there are many different things that can also impact your eye movements and your balance. And so we don't necessarily need to say just because that happens, therefore you have suffer a concussion, right? We should always be looking for is that potential mechanism of injury? Right? Maybe you had a car accident five years ago, you've had ongoing neck pain and headache sense and you were told you had a whiplash. Well, we could then consider that a missed concussion diagnosis. See that all the time. But if there's not anything that could possibly happen, then we shouldn't go there because we don't have the information to support it. Now, someone asked, do you have to have an MRI done in order to get functional neurology physical therapy? unfortunately you know insurance in general just not cover the functional neurology approach you may be able to get some generic physical therapy through your insurance but it's going to be generic but as far as an mri no i don't usually even recommend mris to people because When we look here, neuroimaging is not required to diagnose a mild traumatic brain injury. Because actually it's going to be normal. Okay, it is going to be normal when we look at a concussion. If you have positive findings on an MRI, you've left concussion and you're now fully in the criteria of a mild traumatic brain injury. Or if it's worse, it may just be considered a full blown traumatic brain injury. So you do not need this. And there's times where it's beneficial based upon your symptoms and everything. And there's other times, honestly, people are wasting money and I know why they do it because I have these patients come into my office all the time. They're like, hey, I begged and begged and begged my provider to do a CT scan or an MRI on me because I still have symptoms nine months down the road. Maybe there's something that was missed. And then they get the imaging and they said, hey, your imaging is normal. And that's frustrating because no one likes hearing that their imaging is normal. But know that your imaging will be normal. Ninety nine percent of the time, roughly, it's just going to be normal. Now, that does not mean you don't have an issue. So let's step back and look and say, well, why could you have some of these things? Right. Let's go here first. So first, one of the things we talked about was, well, concussions don't give people any long-term issues. Everyone recovers, blah, blah, blah, blah, blah, right? And we said that is not true, okay? That is categorically not true. This is from Journal of the American Medical Association, okay, JAMA. And this was done a few years ago, back in, and here is when we look at the abstract and we go to conclusions. those with a negative ct scan right so that's going to be a normal ct scan reported incomplete recovery at two weeks and six months after their injury okay most participants so let's go up here at six months only forty four percent had functional recovery fifty six percent did not they had an incomplete recovery so this Myth. I'm going to call it a myth now because this is one of many research articles that shows people a significant portion of people, fifty plus percent struggling six months there's other research that shows twelve months following an injury and as long as providers are still holding on to outdated information people aren't getting taken as seriously as they should and then it gets gaslighted into well you're just anxious you're just depressed so up to this point i hope people really understand concussions are a big issue There's a way to make sure these are diagnosed appropriately. There's some strengths, there's some weaknesses to the diagnoses and the way current exams are being done. Even a lot of the testing that should be done for concussions, you will never find a neurologist that actually does the eye movement testing or imbalance testing. It's insanely rare. Physical therapists may be the ones doing it actually. Now there's other providers like myself that also do it. But once again, it's not done at the neurologist usually, which is very frustrating. So yeah, someone commented, So it really is best to reach out to my team and just go to peak brain and body. You can submit your information. My team will reach out to you because I don't have a, here's my one exam for everyone. It depends on how much information that we need to work through to get the answers for people. And I'll go into that in a moment about, and you'll start understanding why depending on what someone has, they may need, sixty minutes they may need an hour and forty five and so forth next question is there a difference between chiropractic neurology and functional neurology my understanding is that functional neurology encompasses a wide range of practitioners including osteopaths So this is confusing for people. So there's chiropractic neurology, which has been around for decades. And it was more about chiropractors that really had a passion for the nervous system and understanding brain anatomy, brain function, and then using that brain function to evaluate and treat people. Then that same group right so if we look at this at the high level um dr karek dr robert malilo dr brock and others okay i know there's other people out there as well but there were more people interested in than just chiropractors and so functional neurology is really just a mindset of how we're going to evaluate and treat a patient and even functional neurology has continued to evolve i mean their providers who used to crap and say it didn't matter what you eat supplements are garbage go and eat you know mickey d's all you want it's not going to impact your brain and now it's like oh huh you know what now a lot of those people are now suggesting labs they're now suggesting supplements which they weren't doing before and so i hope that explains the difference on that now within the world of functional neurology or chiropractic neurology there is a big difference in what people treat there are those who do purely concussions tbi dizziness migraines and stuff like that which is where i focus neurodegeneration but then there are those who do it but all they do is like neuropathy and other stuff and then there is a confusing aspect you have those who are like um they will call themselves neurologically centered chiropractic and they're using different systems to try to measure nerve impulses. I really don't know how accurate that stuff is, honestly. But that's what they are doing. Okay. And so that unfortunately does create a lot of confusion because you don't necessarily know where someone's at because are they truly trained? Are they using it as a marketing tool? Right? And so it's, unfortunately it's all over the place. It's not like traditional medicine where you see a primary care doc, ten out of ten are going to give you the same medication for strep throat, right? Or they'd be within one or two meds. This world is going to be very different. All right. Feel free to keep these questions coming. You know, we'll get back to concussions and then work our way to POTS. Someone, you know, TBI, spine injury. Ended up surgery. dizzy um okay so real quick when we look at dizziness dizziness post-traumatic brain injury post-concussion there's different reasons you get it when your brain receives information and your brain supported appropriately you've taken the information and you feel stable Now there's primary places your brain gets information from with dizziness, right? Or if it's done right, you don't have dizziness. It's gonna be your visual input. It's going to be your vestibular system input, which is way more than just your inner ears. And it's going to be your cervical spine. So the joints and the neck muscles. All three of those feed into the brain and the brain uses it to be stable. If the information is good, people are stable. If not, people can become dizzy. Now, there are ways in which we do evaluations that allows us to evaluate, is it a cervical spine issue greater than a vestibular issue greater than a visual issue so for example let's say i've got someone i've got them wearing my goggles they're tracking left and right and they're like that made me dizzy or i get dizzy when i'm driving in a car and i'm not moving my head that's what we call visually induced dizziness so that's the visual system now there are those who let's say you're sitting in a chair and they just rotate right um you just rotate like this there is no head movement at all That makes him dizzy. That could either be vestibular or visual. It's important to understand that we're not necessarily looking for one thing. It's usually a combination, okay? But it can let us know what gets the most attention, right? And then there's what we call... And then the other thing, right? So we can spin someone, right? So we don't have any head or neck movement. And then we can do something where we actually hold your head still and we rotate your body, right? with your head being still but you are getting neck stretch so you're getting activation and if that makes you dizzy then cervical spine can definitely be a player in that um fusions some of those people do really really well others because of the fusions it does mess up a lot of the feedback into the brain and gives people issues so i hope that kind of explains it because it's not It's not about one thing. And I know many providers try to reduce it down to one thing, right? You've got, someone's like, Ooh, I adjust this. It's this one thing. Then there's people like, Oh, but it's always acupuncture, right? You've got people who are trying to reduce things down and call it the reductionist approach. The more we reduce things down to one thing, the worst people are actually going to do because we can not predict it because we don't have the information and that's where we go here and you're gonna understand why that reductionist approach is in my opinion silly and why it fails so many people it doesn't mean it doesn't help anyone it just means it's not predictable so let's go here right so this is the impact so once you have a concussion right you have the impact you then get issues within your brainstem. Now the brainstem being impacted, that's where your relay centers are for your balance. That's where things are for your eye movements. And that's why it is so, so common that we see issues with eye movements, balance, vestibular function, post a concussion, whether it's a whiplash concussion or a direct blow to the head. But that's not the only thing that happens. It's not that you have impact and there's only physical things. We get a lot of things happening in the brain chemically. We had a lot of things happening from a inflammation standpoint. We had a lot of things happening from a cellular energy mitochondrial issues. We get some issues with cerebral blood flow and perfusion, so oxygenation. You get all of these things that are added together that then disrupts the networks in the brain and then that leads to the wide variety of symptoms people have from sleep, to physical fatigue, to light sound sensitivity, to emotional regulation, to I'm overloaded, I just not think and work the way I used to, to dizziness, to balance issues, to visual impairment, right? There's a lot of things. And yeah, the easiest concussions to treat are those who only have one of these. And this is why even though I do really, really well with most concussions, there's some that just are not responding at the rate I'd really like them to respond. And it's because they have more going on in here. And the frustrating part as a provider is i can't really measure your neuroinflammation post concussion i can't really measure your cellular energy imbalance mitochondrial dysfunction post a concussion even your blood brain barrier i can't predictably measure like we've got some labs we can kind of do that one but it's still not overly predictable um we can measure some of the stuff here in the green dizziness eye movements But it's figuring out where in this whole arena are people stuck? And that's why I try to do the best I can to address energy production and utilization, immune system, blood flow and oxygenation, as well as all of the objective findings that are present. Um, thanks. Thanks for sharing this with your CT group. I really appreciate it. And I hope people find benefit from this. Um, if you have questions, let me know, you know, we're going through a little bit more, probably another five or so minutes on concussion, and then we're going to switch focus and go to pots. Um, because there's a lot of people who have concussions who develop pots, or there's people who have pots because of their symptoms end up having concussions. Oh, hey, yes. Hey, Chris. Thanks for sharing. And I will definitely let you know. Right? But you see how complex this is. And this is why people are so frustrated. And it's why I'm anti the magic bullet because it's, it's just highly unpredictable. It's hard enough when you can address multiple of these. But if you try to make one of these everything, you're just literally going in there with your fingers crossed. Now, here's something else that we must consider. So your health before you walk into a concussion absolutely matters. And I love this title, hiding in plain sight. Providers that understand the inflammatory and immune system issues with concussions do really, really well here. Because they understand your pre-existing issues and how those play a role in your likelihood of recovering from a concussion. Because sometimes you will have a concussion, right? They get it, they bounce back and they have their life. There's other times people have concussions and it devastates them. They're never ever the same. And this is why we have to look beyond the injury. Factors influencing the neuroinflammatory response to sport-related concussion. And yes, there's more research on that. But when we look at this, right? Let's just look at that. Medications can impact it. There's different medications people are on that impacts mitochondrial function. There's different medications people are on that impacts their immune system, right? Blood sugar response, all sorts of things that can do it. age just simply as we get older the immune system and our resting inflammatory level changes gender differences male versus female impacts it pre-existing fitness levels impact it people's nutrition and what that does to their gut health and ultimately what the gut produces that's supporting or hurting the brain The amount of daily stress people have in their life from relationships to work and many other things. Sleep. People who don't sleep well before concussion are set up for a nightmare recovery more often than not. And then post concussion, those who don't sleep well, honestly, they're some of my hardest patients to fix. especially if they're only getting three hours or so. The brain becomes a toxic soup and it's so hard to get their inflammation levels down. And then ongoing immune system issues, right? This may be related to the gut. This may be due to mold. There are people who get reactivation of Lyme. There are people who had COVID. There's people who have the flu before it happens, right? There's any number of things that impact your immune system. You could be an even rheumatoid arthritis flare, but these change everything. And so now when you're trying to get better from your concussion, if you have some of this stuff off, specifically your diet, your stress, your sleep and immune challenges before you walk into a concussion, It's no longer sufficient to say, Hey, can we ignore my health before the concussion? The more you try to ignore someone's health before the concussion, the less likely they're going to get the results they want. Especially whenever I get people who are pre-diabetic or diabetic or guys who have no testosterone. females who are menopausal and their hormones are non-existent. I mean, there's a lot of things working against people. But if you try to rehab the brain without making sure the environment's good, it's just not as predictable. So if people have more questions on concussions, you can absolutely keep them coming in. But now we are going to switch our attention because we have spent a solid thirty or so minutes on concussion. and now we're gonna go to one of the other things that I really do well with but is highly frustrating with people and that's postural orthostatic tachycardia syndrome otherwise known as POTS and once again feel free to ask questions I'm here I understand not everyone who's watching this would ever be able to fly in and get treatment But the better the education people have, and we understand that there is research for this stuff and there's a different approach that maybe it'll be beneficial. If one person gets their life back, whether it's by seeing me or being able to get help from someone else that makes the hour that we're doing this completely worth it. So when we're looking at this, so this is from, you know, narrative, um, us cardiology review. which is interesting because cardiologists really do not like trading POTS. I've talked to many. But let's look at this really quick. First thing, when we look at POTS, there's a wide variety of symptoms throughout the entire body. So POTS normally is going to have systemic symptoms from cardiovascular-based symptoms respiratory symptoms gastrointestinal genital urinary musculoskeletal neurological endocrine and even psychiatric now the reason why it's important that we call these symptoms is this is not the cause and it can lead to a lot of chasing things that maybe don't make sense um so that's really important to know so when we look at pots there's what's considered primary pots and then there's subtypes of pots okay um let's see i'm gonna read this question really quick and then we'll keep going yeah i mean some people right they do have adrenal dysfunction or they have hypothalamic pituitary dysfunction where people basically, you know, can go into an adrenal crisis or adrenal insufficiency. And sometimes there's autoimmunity. Sometimes it's just immune system dysfunction. That's really throwing it off. And I think there may be some of that here in this article where they review it. Let's see if, All right, so we'll come back to this in a second, but we'll hop between the two. But you can have hyperadrenergic, okay? So this is going to be through plasma norepinephrine concentration. So you can actually get this measured to see if it happens. I know different research suggests varying degrees of how much this occurs. It's not something I really see a lot. You can also have impact of a receptor. You can have volume dysregulation due to different things. Now, I don't really know how true that one is, honestly. For me, if that's true, then it's not even POTS. It's a cardiovascular issue because POTS is a syndrome. So you give the diagnosis of POTS when people meet certain criteria. Ultimately, Diagnosis of POTS, it's you've had symptoms for at least three months, oftentimes six months, okay, without a better explanation. So if there's a better explanation, such as you have an echocardiogram that shows you have a valvular defect, that's not POTS. Next, you need to have orthostatic changes. Specifically, your heart rate should go up greater than thirty beats per minute if you're an adult, or greater than forty beats per minute if you are a kid or a teenager. And then you can not have hypotension or orthostatic hypotension. So your blood pressure should not drop greater than twenty for the high number and ten for the low. Now I get it. There are plenty of providers diagnosing people with POTS plus orthostatic hypotension. Honestly, I don't overly care. That's more of a medication management. Are they just going to give someone a beta blocker and mitodrine or not? That's what that determines. And then there are people who do have autoimmunity to basically receptors, you know, acetylcholine receptors, alpha adrenergic receptors. Okay. Now you have secondary POTS due to a variety of things. Okay. You can have small fiber neuropathy, you can have mast cell activation syndrome or histamine related issues, which we are going to get into. And then it puts, you know, post viral illness. And that's once again, what got POTS all the attention was everything that happened post COVID. even though before it did happen with other infections, mold, stuff like that, heavy metals, right? Alcohol, diabetes. And then there's these associated disorders. Now, a lot of people, POTS are all being diagnosed with not only mast cell activation syndrome, but they're coming in with Ehlers-Danlos syndrome. Ehlers-Danlos syndrome is a genetic thing. Most people I see though, they've never even been to a geneticist. You know, how much do they have it? Yeah, some people do, others, you know, People are just going for the trifecta. POTS, MCAS, EDS. Chronic fatigue syndrome, if you pull up the symptoms of chronic fatigue, you're literally going to be like, this mirrors POTS pretty much. And chronic fatigue syndrome is another one of those where the criteria is kind of similar to POTS. And it's a, we don't really know. sinus tachycardia, right? Heart rate goes up a ton. And then you even see associated disorders with traumatic brain injuries or migraines that can play a role. And once again, there's plenty of people who are having concussions that do get POTS due to autonomic dysfunction. And then you do get people who have POTS who are getting weak, falling, passing out, hitting their head and do develop a concussion plus POTS and they're often like well you know which one is doing it it's like well honestly it can be both like you don't have to have one or the other and then when we look at pots traditionally medical treatment it really is around increased fluids do a ton of salt a lot of people are doing all sorts of different electrolytes to try to help But that doesn't really get people significantly better in my experience. Maybe they improve to varying degrees, but it's usually not significant. Compression garments, people are doing, right, to try to help. And then from a medication standpoint, you have people, if they think it's more MCAS related, they're giving some histamine blockers, sending them to allergists, you know, address contributing factors. So that's going to be excessive blood loss with menses. And we're going to look at iron and what iron does from both a histamine related issue. Okay. and what's happening there because there is research that shows if you do have iron deficiency, you do have an increased likelihood of developing POTS and this is not just purely your CBC shows your red blood cells are low and then your size of your blood cells, your MCV and MCH are low. The amount of people I see where that's normal, but then their ferritin in the toilet is very high. And it's very sad that people are not routinely getting their ferritin evaluated because it's not that expensive of a test. Cash pay, right? Full iron panels, like not even twenty bucks. So it's not that that's out of reach. It's just something not being looked at. And then even outside of that, you still can have the inflammation from the menstrual cycle even without iron deficiency that can flare up pots issues because you get a big inflammatory release as your body is shedding the lining also nutritional deficiencies like says iron vitamin d b-twelve get those there i would actually like that they put this here trial gluten-free diet and remove any possible triggers such as corn and dairy Now, I'm not saying you remove that and you're magically better, but the amount of people who notice benefits, especially those who thought they were MCAS and had histamine issues, it's pretty surprising. And there's no trade-offs. I mean, yeah, the trade-off is no brownies and stuff like that, but there's no trade-offs that you have to have. A lot of the medications come with trade-offs and it doesn't cost like supplements or other things that may help. And don't worry, we're going to go more, but I do like going over just kind of what's the standard treatment and then the way we do it a little bit differently. Many people are getting mitodrine if they've got more of the orthostatic hypotension passing out. If you're just blood, you know, tachycardia, people are getting beta blockers. Usually some people are getting calcium, but I don't see that a lot. It's usually beta. And then iver bradeen is used for some and then once again you know people are often being co-treated and like well you know we think you're it's just your anxiety let's give you an ssri let's give you something to help with anxiety um now there's a wide variety of stuff some people are pushing for iv fluids you know which is a band-aid at best unless you're just going to do that forever but even then they still don't feel great and like i've said you know if you have questions feel free to put them in here i'll address them as i can um so omnitrope um clomiphene citrate seems to help a bit so i mean yeah you know there's different things that people can take to help right um So clomid citrate is also known as clomid. I mean, maybe, you know, I mean, for guys, some people use it to get their testosterone levels up. So maybe if someone's testosterone is really low, that could be a benefit. Is it a medication that I use routinely in pots? No, it's not. So, and then Omnitrope, it's not really something that, i use you know so this is a growth hormone now some people do wealth growth hormones but i don't do a lot with it because prolonged growth hormone use does increase the risk you know of different things and so but once again it's not something i've experienced with and i like staying in where i've got over a decade of experience Now, once again, right, when we look at this, right, mast cell, and so when people come in, here's how I go through it. I'm like, okay, POTS is always a neurological issue, period. It is a neurological issue if it's POTS, because if your EKG, shows issues if your echo shows issues then that's a cardiovascular issue and it's not pots you found the issue you treat it you're doing well pots is under the family of dysautonomia okay so that the autonomic nervous system dysfunction so that is nervous system so i look at it from this how's your nervous system functioning realizing that your mri and ct scan is going to be normal and so very much in the same way with a concussion We look at balance and eye movements because it's very, very common. I see in probably seventy five percent of my POTS patients where they struggle mightily with both the eye movement testing and balance testing. It makes them feel horrible. Their test results aren't good. And that's why when we were looking at the criteria for concussions and they said, well, if people struggle on these, you should consider the fact that they've had concussions. And I didn't fully agree with it because there's many things that can cause it. So that part, looking at nervous system, matters. Next, I say, what impacts the nervous system, specifically immunology, the immune system? This would be mast cell-related issues, autoimmune issues. There's research that shows increased ANA levels at a higher prevalence in those with POTS compared to those without POTS. but there's a lot of different things, but that's the way I break it down as a neuro or neuroimmunology. What's impacting it? So under the mast cell thing, right? Mast cells cause histamine related issues. And we'll just go through this for a little bit. Once again, feel free to ask questions. I'll address them as I can. And if you're watching replay, the more questions that I get in certain areas that lets me know what to do for future lives and also just when I make videos in general, even if it's not life. Histamine intolerance originates in the gut is the title of this one. Now, while that may be true for some things, neurological issues concussions other things can impact your gut and can be the driver of it so just because it makes kind of be there and that's its home it doesn't mean there's not things that mess up its home but histamine intolerance is assumed due to the deficiency of an enzyme known as diamine oxidase that ultimately helps break down histamine there are supplements out there for diamine oxidase that people are doing okay But once again, get your food well, don't use supplements to make up for the food and the lifestyle you have. Use it to support what you're not able to accomplish on your own. Now, when we look at histamine though, is it's, Important to understand the link between iron issues. So iron, right? Low iron storage, mild anemia associated with POTS suggesting that low iron storage is a issue. Now, why does that matter? I want you to look at this. Compensating functional iron deficiency in patients with allergies, with targeted micronutrition. Okay. Um, this is really, really interesting. Okay. You don't need to understand this, but providers do providers do. And a lot of people don't understand what iron deficiency does to histamine. So iron deficiency is associated with a topic. Okay. Um, now this would be eczema, rashes, allergic issues, right? So Iron deficiency during pregnancy increases the risk of atopic diseases in children. So if your mom was anemic, while you were being developed and grown, you now have a higher likelihood of allergies and skin-related issues. While both allergic children and adults are more likely to have iron deficiency as well. It's like, huh. So even as an adult, you could have iron deficiency contributing to your allergies. Most people don't think about iron-related issues and allergies. Now, here's what it does. So from an immune system perspective, your iron deficiency, which you can see by using a ferritin level, leads to activation of a part of your immune system, your Th-II cells. Th-II cells is for allergies. And so... that is going to mess with people. Let's scroll down a little bit. So here, right? So you have, it ultimately switches, okay? THU cells, crucial for allergy development, have a survival advantage over TH-one under iron deficient conditions. Now, whenever I work with my mast cell activation patients, histamine intolerance patients who also have POTS, It's kind of split into those who have no immune system issues from what we can truly tell. There are those who have allergy skin prick tests or go nuts, right? Food allergies. And then there's those same criteria. And then they're getting sick all the time. They're getting sick once a month, once every two months. Every time they're sick, they're sick for a week or two. And when they get sick, everything flares up and they just do worse. Now, why are these people prone to getting sick? Well, these have survival advantage over Th one cells under iron deficient conditions. Now these are T helper one cells. So these job it's to identify the bad guys and to kill them. And so if you're iron deficient and your th-one cells, the people that should be surveying and killing the bad guys goes down, now all of a sudden you're more likely to get sick. And this is why we have to rebuild many people's immune systems who have POTS and associated conditions. Now, this takes a bit of time to do it. It's not as fast as fixing the neurological side. It can be done, but that is something to really know. And so people will be like, well, my iron is getting better. I'm not necessarily feeling better. Just know that you may not feel better just because your iron goes up. There are plenty of people who do, but there's others who won't. But it's part of the puzzle. So that absolutely should be addressed. Once again, if people have questions, feel free to let me know. I'm going to look through the questions, go through the ones I've missed. And because that was the last research article I wanted to go through. And like I said, I'll double check, make sure I've got it. Everyone's question answered, trying to do the best I can. to really provide value and hopefully I am providing that value for people. Is there a way to differentiate between POTS and paroxysmal sympathetic hyperactivity? Okay. One of the big things, so whenever we look at the definition of proxismal sympathetic hyperactivity, we are getting not just an increased heart rate, but we are also getting high blood pressure, sweating, fever, and things like that. Typically with POTS, you're not just going to get the fever out of nowhere. You're not going to get the sweating out of nowhere, and you're definitely not going to have the hypertension. So normally with POTS, when you make those positional changes, your heart rate goes up, but your blood pressure usually stays about the same or goes down minimally. And it's always important to remember that with POTS, we're really looking at positional changes. So these are the people who come in and like, yeah, if I'm laying down, you know, I'm at sixty or seventy beats per minute, but then I stand up and it just goes nuts. Proximal sympathetic hyperactivity don't treat many who've actually come in with that diagnosis. But you know, I believe that's kind of no matter the position, that's where it is. And then when you look at it, this is also very common to get post-traumatic brain injury. So you'd be in the acute phase most likely and I don't think it's something that people are getting months and years down the road. And that is important when we look at POTS. POTS is something people have had for at least three months, if not six months, that has just been ongoing. And so we're really looking for the consistency of it with pots, not just say, well, like, you know, it happens once when I stand up every month or so. It's like, no, it's pretty consistent. So, you know, so hopefully that made some sense on that. And I'm trying to answer all the questions. that people have. If people have other questions, feel free to let me know and then I do plan on doing more of these. I'll probably try to keep it pretty consistently to Wednesdays in the future. And then in general, if you haven't, follow me on YouTube. I have lots of in-depth videos on a variety of topics and the more comments I get on them, the more questions people have. If I see a lot of questions for certain things, I will make specific videos for them. I'll make blog posts for my website. as well because knowledge that you can act upon becomes power. But I also, once again, we've got to act on it, right? Things that people just hear and don't know anything with, it's kind of a waste of time, right? Because you've got to get experience. Yeah, and just kind of address this last comment. Getting sent back and forth between neurologists and cardiologists. This is very common in the POTS world. It's very common when you have hypertension, tachycardia, orthostatic hypotension, but you also have neurological issues like headaches, migraines, dizziness. No one really wants to treat it and it's just because they don't know how. So imagine you're a cardiologist and people are coming in with tachycardia and you're like, look, I've got beta blockers. I've got calcium channel blockers. And if you're not getting better, they don't have anything else they can really offer you. And they're like, well, let's send you to neuro. And the neuro is like, what are you doing here? Like your heart rate's doing this, you know? And it is frustrating. Because it does take someone who, and it's why I tell everyone, we're not reductionists. We need to understand how the body operates as a whole unit. Being a reductionist is amazing for surgeries, right? I want the heart doctor who understands every little thing about the heart surgeries they're doing. But when we leave surgeries and we look at these things that become chronic illnesses that so much of the population is dealing with, We can't pretend that the gut doesn't impact the brain or that the thyroid impacts the brain or that hormones impact the brain or that anemia impacts the brain. And that list can go on and on and on. So we have to get back to realizing the body does connect as a whole unit. The more specialized we've become, the sicker people, become i don't want to say it's just because we're people are so specialized but there's it's very disjointed because no one knows what the other one's doing and why they're doing it well you do your thing i'll do my thing um but if we look at sports like football teams would lose without a great head coach that's why the head coach is paid way more than anyone else and it's because they understand how all the different units of that team must work together effectively to have the outcome they want. And the same thing is true with our health. Providers that seek to understand how to get everything to work together optimally are going to have the best results with chronic illness compared to anyone else. know thank you everyone for joining we're going to wrap this up as i believe i've been able to answer all the questions i hope everyone has a good night and like i said in the future we will do more of these and we'll cover a variety of different topics you know from conditions to different symptoms people have the way i work through it the way i think about it um because there's far too many people out there who are stuck with what they believe to be chronic things that really if they can get the right help it's not chronic it's a speed bump but it's all about being able to get the right help. So until next time, I am Dr. Z. I've got a clinic in Tampa, Florida. I'm dual licensed as a nurse practitioner, doctor of chiropractic. And my focus really is on connecting the body as a whole unit, not the brain or the body, but both. And so, yes, I love the brain, but part of loving the brain is understanding what's going to make the brain thrive or die. So, so next time. Thanks.