Fixing Your Autonomic Function in Long Covid | With Dr Boon Lim (Film 1)

sorry for the radio silence the last month or two i have been rather busy writing a book anyway uh last week i had the great fortune to have a long chat with consultant cardiologist and electrophysiologist dr boon lim who is clinical lead for the imperial syncope units at hammersmith hospital if you've got a question about dysautonomia and tilt tests you really couldn't find anyone better to ask there's absolutely loads to talk about on the subject so i'm going to break it up into a trilogy of three films uh in this first film we're going to talk about dysautonomia which long-covered symptoms it can be responsible for how dr lim treats it in his clinic and what the hell is going on when we wake up in the middle of the night with a racing heart in the next film we dive into the fascinating world of tilt tests and how they give us a window into the physiology of dysautonomia what's actually involved in having one what can you learn from the results and do you actually need one to be able to get a handle on dysautonomia in the third film we're going to talk about hrv why it's so relevant for long haulers what we can do to improve it and what it means in terms of managing our symptoms and possibly even aiding recovery so could we just start with something really simple and that is to describe what dysautonomia is in simple terms so dysautonomia is a term that describes a disorder or dysfunction of the autonomic nervous system and i guess the two ways of thinking about it your autonomic nervous system is that bit of the nervous system that controls all the activities we don't consciously think about subconscious or unconscious control things like heart rate peristalsis blood pressure regulation temperature regulation and these things are normally automatically regulated quite finely so it generally isn't much of an issue now any one of us including those who don't have long cobait can have a dysautonomic uh profile for example uh after you've had a lot of alcohol say on a night out for your birthday you wake up the next morning you haven't had covet you haven't had a virus and you can feel a little bit rough and this is where things like the the kind of aura ring or your apple watch might tell you your readiness score or whatever that score is is a bit low and and so the autonomic numb system i don't want to imbue too much uh if you like illness or a a feeling that this is something that is an all-or-nothing phenomena i.e long-covered dysautonomia screwed for life it is something that that on a daily basis and sometimes even on a minute by minute basis will fluctuate and sometimes when it fluctuates in an exaggerated manner you can call that transient dysautonomia so my view is that dysautonomia is a is a fairly normal process that can hit any one of us even in the absence of a viral illness for some amount of time when there is a particular trigger and a susceptibility and of course what the viral illness does whether it's long corbett or glandular fever is it can then provoke a worsening earnings or an exaggerated autonomic uh dysfunction or autonomic nervous system that activates in in a way that causes a whole consolidation of symptoms and i'm sure we'll expand on that shortly um so i mean this is interesting because my feeling is that dysautonomia is or dysautonomia as a consequence of long covid is not something that we're necessarily going to be stuck with forever because my own experience of it and other other people i've seen is that it does fluctuate and there may be days where actually i'm quite tolerant and i can do all sorts of things on other days i couldn't do one of the things that david petrino uh said on twitter recently which i agreed with because that's my experience too is that there's almost this clunking that happens between okay function and then suddenly bang sympathetic nervous system activation and then suddenly clunk and it can clunk back again i don't know if that's sort of rather than a smooth transition between parasympathetic and sympathetic there does seem to be this dial that kind of does that is that something you've witnessed too is does that sort of ring a bell for you so i've witnessed on um both both states really and there are some patients who recognize to the hour or to the day that the symptoms started and started to get worse and oftentimes it is on the background of a significant stressful event and now when i say stress i don't mean mental stress it could be any challenge so for example if you think you're recovering from kobe three weeks have passed and you think you've got over it you go for a 5k run that could be the tipping point following which you trigger some kind of clunking as you say or a transition step which is quite a large step in your autonomic state and thereafter you find it very difficult to recover for a week or two after that 5k run and if you try another 5k run after two weeks you step down even greater so i think a lot of what you've discussed in your previous webinars jess including the pacing the recovery taking it nice and slow is part of um an intuitive body listening exercise that we need to learn and i think this is one aspect that we um don't do very well or people with long covered don't don't tend to have that intraceptive ability to recognize when they're at the incipient or threshold stage of clunking because the clunking doesn't happen just like that you need a few risk factors and certain preconditions to push you to the state at which you can clunk and then it happens you do something which it may not seem stupid at the time like going for a 5k run when you are typically going for 10k runs prior to corbett may not seem like such a big deal especially if you wake up fresh and alert good night sleep sunday morning well hydrated you do it and then you and then you you step down and then you kick yourself so uh so yeah yes is the answer but i also want to qualify that by saying that the other option is also possible that some people have a gradual deterioration in the autonomic nervous system function and i i particularly like what you've done previously in your previous webinars when you talked about the impact of previous trauma or the kind of personalities that may be susceptible to uh having a relapsing remitting long corvette experience because in my own view and experience this is something that comes across time and time again the likes of you jess who wants to push it skiing whilst recovering from long coven and seeing how far you can push it uh and i think he got away with it uh quite nicely but other people may not yes yeah and for me i wouldn't have got away with it had i not added a set of other behaviors to compensate for the activity i was doing and modifying the activity the way i was doing it so short you know 20 seconds skiing stop breathe ski a little bit further stop breathe and even only an hour in total in the day as opposed to what i would normally have done is just cane it from the top of the mountains to both the mountains that needs to be that needs to be repeated jess you need to tell people that you're not skiing eight hours like you used to yeah your skin for 20 seconds and just tell me about the breath again because that's phenomenally interesting so so basically what i try and do is i i mean skiing naturally for skiing with the group you would tend to ski a distance and then stop and wait ski distance top and weights and i was simply shortening those distances and in the points of time when i wasn't skiing i would very consciously slow my breath down and do coherence breathing you know five seconds in five seconds out and make sure i was doing that in every one two three four minute period i was waiting between each skiing segment and on every lift i was getting on suddenly now you're sitting down for five ten fifteen minutes on my entire lift i would just sit there and just focus on my breathing and try to not get sucked into the conversation that was happening around me but just focus on the breathing so again i was just calming things down in compensation for the fact that what i was doing was very stimulatory otherwise yeah so i i fully fully agree that this is the way that people should pace when they get back to exercise and um to your point earlier on when you ask me about clunking you don't always have to clunk in the wrong way in terms of sympathetic activation what you've demonstrated there is you can clunk the other way so you can you can you can automatically reset or actually recalibrate your parasympathetic nervous system and increase the expression of the vagus nerve by doing exactly what you've done a five second breath in and then a five second breath out um and on a continuous basis if you can breathe like this particularly through your nose and into your belly so this is belly breathing or diaphragmatic breathing i think it's a particularly useful way to activate the biggest and dial down the sympathetic nerve system so don't ever underestimate in fact it is crucial to the recovery of patients with long coverage to really focus on breath particularly nasal belly breathing and i think that's why some long covert recovery groups or exercises with either respiratory physio or even say the english national opera program ian o'brief have had some success some yoga some yoga studios have opened up rest recovery programs such as susie bowl and there are several other yoga programs and the focus for all these programs is centered around breath work i mean there are other things including pacing and important holistic strategies which i fully believe in but breath work is the central tenet by which you can reduce the expression of the parasympathetic surface nervous system so so another example of pacing where i do try and activate a clunk in the other direction is even sitting at home and working at my desk i'll do perhaps 40 minutes if i'm really lucky i might manage to stretch for about 40 minutes at my desk and i notice at that point that my cognitive is weird i start to feel that my ability to process information becomes compromised i can go and lie down i put on my alpha stim so electrical stimulation um theory of a you know slows that long wave stimulation something like that and i'll lie down on the sofa i'll close my eyes trying to remove as much as possible do the coherence breathing and what i find often happens really quickly is i will trigger a series of very strong aggressive yawns that come through and after that 10 minute period my eyes are watering the horns are attacking and that feels like it's a clunk back in the other direction back towards a parasympathetic once i've done that the heart rate's about 10 15 bpm lower and my head is clear and i can think again and i've got another 40 minutes clear and that's how i manage my working days so so can can can i can i share that um one of the things that i've always wanted to study in greater detail is the physiology of yawning because oh my goodness do we see people gone a lot during tilt particularly i mean if we have time we can talk about the tilt data which i can demonstrate your own data but the yawning that occurs in people who are not otherwise sleepy but the opposite people who are adrenergically driven or sympathetic nerve system overdrive is so marked sometimes and in the context of that of that sympathetic overdrive they start yawning and i think yawning is a very very complex physiological process and um you know the dr seuss sleep book if you've ever come across it is a great way to get your kids to sleep because i guarantee you by the time you're halfway through the book both you and your kid will have yawn at least five or a dozen times because it is that kind of looking at somebody else's yawn can trigger yawning you but in this particular case on the tilt lab and certainly what you've just described i think yawning triggers a physiological reset if you like i can't really uh prove it yet but it's something it's one of the things that i have observed as an interesting thing that's seen during tilt during synthetic there's an argument i read somewhere about how actually the process of yawning creates pressure on the vagus nerve so it's a it's a sort of an action that the body takes to try and push the body back into a parasympathetic state that was what i read and it seems to make some sort of sense right yeah so it makes sense but you know if you think about respiratory sinus arrhythmia the maximum variability in in the heart rate profile which is your respiratory sinus erythema and that's what hrv is heart rate variability is the extent that your heart rate varies between the nader the trough and the peak over a respiratory cycle so if you take a deep breath in and you take a deep breath out and you monitor your pulse either in your neck or your wrist then your audience can do that now particularly if you follow a slow cadence which is said to be a coherent breathing pattern the ideal breath as james nestor says in his book breath which is there which is there is is a phenomenal way to activate your maximum hrv training and this this we can show very clearly on tools like heart math and so this is something that actually with the bio feedback that you get and your regulation of your heart rate variability can help to activate the parasympathetic nervous system but it's often thought that it's due to the mechanisms not only pressure in the vegas but intrathoracic pressure expansion and contraction lung volume expansion and contraction and therefore the volume of blood in your heart expanding and contracting and they are very sensitive both chemoreceptors and baroreceptors but i think for yawning it's not mainly the chemoreceptor because it would take too quick for for you to change your co2 levels or oxygen levels but more like immediate stretch because the stretch receptor is quick and the stretch receptors are available for action and reaction in the lung in the aortic arch and in the bare reflex which are here and that can can be activated just like that so yawning resets those stretch receptors that then give a very complex feedback loop into the primitive brain which then alters the outputs which are vagus and sympathetic chain and depending on how much your vegas is pulsing up and down together with the sympathetic chain that dictates your hrv so it's it's complex it's wonderfully complex and i would say it's so so uh nice to see this physiology every day in in in the tilt lab uh it's just that um the too many variables when your sympathetic nervous system is yo-yoing and activating the yawn doesn't really touch it all that much so trying to demonstrate a clear delta is a bit more difficult so we need i guess more controlled conditions and it's always been one of my dreams to do a doctor sleep book tilt table test control in a normal subject to see what the physiological impact of the ion is absolutely fascinating let's say you've got two types of patients who present to you one like me who presents with this automobile but not necessarily pots and another who presents like one of those other tilt um tests you showed which have definite pots as well as dysautonomia how do you go about treating them what are the first things that you advise in terms of behavior and what do you is there anything that you go down in terms of medication so i i would suggest that there is the ability to deploy a whole lot of conservative strategies so this is my kind of website which is a moment charitably run and kind of created on a sunday morning with my co-conspirators pro bono um but uh there's one particular autonomic dysfunction sheet that you could you could download freely from from the website and um it really talks about top tips for improving autonomic dysfunction in long covet so i i don't like to start off with drugs and that much i will say i like to start off with a very clear diagnosis and i don't want to pretend that there aren't other multiple diagnosis or mechanisms for long covet that you've covered very much and very well in your other talks but if if the patient has got worsening symptoms on standing and improving on sitting and and that is a prevailing feature the palpitations and everything else we talked about then i'm going to for a moment forget about mast cell immune activation viral debris uh platelets and all this other stuff i'm gonna forget about it because if those were true then when you stand up or you sit down those mechanisms would still be at play so this is specific for the patient cohort that i'm talking about autonomic dysfunction and i recognize that this is a cohort that obviously i'm biased in my experience because when they are referred for people are suspecting it so it tends to be manifested in the tilt data but that being said that caveat being said i would say that fluid increase because most of these people have got low or low normal blood pressures uh but with the exception of the the tilts that i showed you okay yeah yeah if if you are going to be doing an activity as particularly exercising consider salt intake or consider an isotonic effervescent tablet which is the isotonic isotabs that you can put and it fizzes like a baroque dust not broken something like noon precision 1500 ors these kind of tablets consider wearing compression stockings which should be lower limb compression to the thigh or to the waist or abdomen and if you like there are consumer grade stockings sporting stockings that are pretty compressive such as skins uh but then there are there are other stockings which are medical grades such as bauerfeind sigvaris garment and these are stockings that you could wear because if you think about the physiology you're pooling blood right in your lower limbs and what you'd like to do is squeeze externally so the stockings give you some external squeeze and then the internal compression is quite helpful where you learn to perform isometric counter pressure exercises i don't know if you've ever done this js but just squeezing your glutes your quadriceps and your calves can immediately give you that boost so if you're if you're flagging a bit now jazz try and just squeeze your buttocks squeeze your halves and your and your quads you see i'm bouncing in my chair yeah and just by squeezing sometimes you see a sharpening because what you're doing is you're returning the blood parked away in the huge reservoirs which are your lower limbs back into the heart so that could work and then this is the bit that you already talked about and i'm glad you you you raised this not me slowing your breath down to five or six seconds uh in a sinusoidal pattern because then you activate or you clunk into vegas yeah um and then my view is there are two approaches one is the bottom-up approach where you engage and entrain physiology in my mind the autonomic nervous system facets of which there we said peristalsis blood pressure breathing rate temperature sweating capillary dilatation a lot of that is not under your control apart from one which is your breath so the breath i think is a very very nice shortcut or the only way in roads into the autonomic nervous system to which we can apply our own effort so physiologically we take control of our breath and we train it to the perfect breath which is five or six seconds for most people and that gives you more vagal expression but the other component that expresses higher positive autonomic balance and in particular more vegas less sympathetic is actually coupling that breath with a positive emotion or thought and the easiest to elicit would be something like gratitude but compassion love forgiveness these are also other emotions that you could you could bring into play as you're focusing on the breath and the focus on the breath without ideally any distracting thoughts about what's happening in the future or how the day is going to be or the past thoughts of anxiety is the way i think the best way to try and recenter your autonomic nervous system by yourself and this means living in the present moment and what better way as you know to be in the present moment than to just focus on the air the healing kind of nurturing air uh coming in through your nose into the deep recesses of the lungs in a six second breath and coming out so so that is my bias in terms of treatment um which is a more conservative step-wise not step-wise but a conservative lot of treatment uh there are pharmacological agents that i will use in some patients and in new jersey you hadn't if you were my patient i guess you came for a tilt but you weren't referred to me but if you were my patient i would ask you how you're getting along in day to day life and i would see you are you as a highly functioning patient when you want to be or when you're not misbehaving like going to thor park all day or skiing without a break yeah and this kind of behaviors that are necessary for enjoyment of life sometimes uh are should be forgiven by yourself yeah yeah so you you've gone to thought part don't regret a crash that you're experiencing now in fact embrace the fact that you enjoyed top part yesterday and today you'll sleep it off or rest or recover drink lots of fluids and you know what you'll be better tomorrow yeah but you have to forgive yourself and this is also part of that state that we talked about the psychological state that oh damn it i did too much and now i'm back on that is also a very autonomically uh unhelpful state of mind to be in completely agreed yeah the mindset actually affects the autonomic a lot more than we think so um that that being said jess for for you if you had done your fluid to salt your compression your mindset you didn't go to the top part every other day and you were still symptomatic then i would give you a drug to augment your blood pressure something like mediadrin which is an alpha blocker which is um something that vasoconstricts your splenic or the blood vessels in your gut or the peripheral vascular system which is your lower limbs it would constrict that return blood to your heart and improve blood volume improve blood pressure or fluid your cortisone which is a mineralocorticoid which serves to reabsorb more salt at the level of your kidney and again expanding your plasma volume and not allowing this push or this pull gravitational pull to occur so that that is what i would i would suggest um in terms of the guidance from tilt testing because the tilt testing will give me an idea whether you're low or high blood pressure if you're high blood pressure i wouldn't give you midogram if your high blood pressure is the dominant symptom and not dominant symptom but the dominant physiology together with palpitations as your dominant symptom or maybe chest pain i might give you something to slow your heart rate down so this is then guided by the tilt because i don't want to give you mediadrin your blood pressure's already high i give you propranolol which is a non-selective beta blocker in the loadout something like 10 to 20 milligrams twice a day or i give you evaporating if i'm concerned that i don't want to push your blood pressure down because propane oil can reduce your blood pressure a bit but generally propanol and ivabridine and vapordine by the way is 2.5 milligrams twice a day these are the drugs that we would give for patients predominantly suffering with tachycardia on standing but it can also have a very calming effect and then very interestingly uh well interesting for me is that those patients who have palpitations at night and i'm seeing quite a lot of them who describe pop stations in a day but also palpitations at night you might ask me why when you're lying flat do you activate the autonomic nervous system there's no reason for it right because you're not being tilted and you're not sleepwalking and the answer is not the answer but in my anecdotal experience i think there is a degree of overlap between the mast cell story so as i said i'm open to other theories yeah and in in the in the realm of mass cell degranulation or histamine intolerance what we get is a spontaneous release of histamines at night which may be triggered by a dream or may be triggered by just the ongoing insensible losses at night in sensible losses means when you produce urine you sweat under the sheets you're breathing you're not drinking anymore at night and so the blood pressure tends to fall triggers an autonomic nervous system surge whilst getting dehydrated mast cells suddenly degranulate because it's reached a critical point because one of the sensitizes of mast cells is a heightened sympathetic nervous system then you suddenly get a pooling like this is a clunk occurrence because it's not like gradually getting tax cut you wake up and your heart is racing those patients can do very well with a nocturnal antihistamine or even bd antihistamines and i don't mind a h1 in h2 blocker and i do prescribe that this in my practice as well with that specific syndrome profile but also if you get a rash and hives and all these other more typical features of mast cells i hope you found that discussion as enlightening and fascinating as i did next up is going to be the film on tilt tests where we go through my results as well as a healthy control and two other long haulers and see exactly what's going on in terms of malfunctioning physiology until next time you

Channel: Gez Medinger

Views: 75,223

Keywords: psac, pasc, corona, pots

Id: n--zjZdJuVI

Length: 26min 45sec (1605 seconds)

Published: Wed Jun 22 2022