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Case Study – Ms. M2

Ms. M2 is a 26-year-old female who began having dysautonomia symptoms in early 2018 after having two infections. She spent 2-3 months in and out of the hospital and was on antibiotics. She had a Tilt Table Test done, during which her heart rate increased only 20 beats. She reported her most problematic symptoms were brain fog, fatigue, and gastrointestinal issues such as nausea and stomach aches. She recognized that stress, having a lot to do, going places alone, and increased activity all made her symptoms worse. She reported her symptoms were present about 2 weeks per month and lasted all day. She rated the overall severity of her symptoms at 7/10 (see symptom checklist below for specific symptom ratings). She felt that resting helped reduce her symptoms. She also reported great difficulty sleeping, taking 1-3 hours to fall asleep and waking during the night. Her appetite was also decreased. She stated she lost 30 pounds in less than a year. She was unable to take her 2-year-old daughter out of the house without help from someone else. She reports having to crawl to make it up stairs. She also stated that showers made her heartrate increase to 150 bpm. She felt she had no energy to talk or socialize.

Ms. M2 came to the POTS Treatment Center in Dallas, Texas in January 2019 for an intensive 8-day treatment program. Sessions were approximately 3 plus hours in length. Her treatment concentrated on rebalancing the autonomic nervous system through relaxation and biofeedback training, cognitive behavioral therapy techniques, nutrition, supplement recommendations, sleep optimization, standing and exercise techniques.

Ms. M2 reported the following improvements:

  • After the first day of treatment she noticed her body felt relaxed and rested.
  • On day four, she noted she could look back and see “the small changes that were HUGE.”
  • After the first week of treatment, she says she walked out of the building and everything was clear. She had a phone call and was able to understand and pay attention to every detail. She was able to joke and use words she had not used in a year.
  • She felt energized, and finally felt she was home.
  • By the end of treatment, she reported her symptoms were lighter and more manageable. She stated that she had energy to walk and could climb 3 flights of stairs without needing a break.
  • She also reported her brain fog was clearing. She was aware of her surroundings and felt she had awoken from a dream.
  • She also rated her symptoms as much lower at the end of treatment (see symptom rating chart below). She reported 90% improvement by the end of treatment.

Ms. M2 also indicated a decrease in symptoms of depression and anxiety. At the beginning of treatment, her Beck Depression Inventory-II (BDI-II) score was 13, indicating mild to moderate symptoms of depression. By the end of treatment, her BDI-II score was 4, which is in the normal range. Her Beck Anxiety Inventory score at the beginning of treatment was 18, indicating moderate levels of anxiety. By the end of treatment, it was 7, which is in the normal range.

Five months after treatment, Ms. M2 has completed her home program protocols and is maintaining her progress. She is more active and able to enjoy time outdoors with her family.

 

Symptom

Pre-Treatment Rating 1-28-19

Post-Treatment Rating 2-6-19

Post- Treatment Rating 07-16-19

Tachycardia

7

0

0

Fatigue

9

0

1

Dizziness/lightheadedness/

spinning

8

1

1

Brain Fog

10

0

0

Tension headache

8

0

2

Nausea

7

0

0

Anxiety/adrenaline

7

0

0

Chest tightness

8

0

0

Gastrointestinal issues

9

3

3

Blurry vision/light and sound sensitivity

7

0

0

Insomnia

7

2

0

Thermoregulation

8

0

0