Dr. Bell’s Simple Test for Orthostatic Intolerance

From Lyndonville News September 2000 Volume 2 Issue 5. 

(Dr. Bell was one of the earliest physicians to recognize the importance of orthostatic intolerance and low blood volume in chronic fatigue syndrome -ed.)

A number of people have requested the procedure for orthostatic testing that we perform in the office. It takes about 45 minutes and requires a nurse to be constantly present. It is important to note that this test is difficult for some persons with CFS [Chronic Fatigue Syndrome] and an opportunity to rest for an hour after the testing is offered. Intravenous saline is helpful to aid recovery.

  1. Patients should be tested late morning or early afternoon with no unusual activity prior to testing. Large meals and large volumes of fluid prior to testing should be avoided
  2. Normal medications should be taken the day of the test. Medications, which affect circulating volume, should be stopped at least two weeks prior to testing, as they will affect the results. Examples are Florinef, diuretics, blood pressure medications, large salt loads. Tricyclics [antidepressants] and SSRI [selective serotonin reuptake inhibitor] medications are acceptable if not for research studies.
  3. Blood pressure should be taken with manual blood pressure cuff every three to five minutes, along with pulse. If available, a dynamap or other accurate BP [blood pressure] device can be used.
  4. Step 1. Patient lying down comfortably for 10 minutes. Pulse and BP are recorded at onset, 5 min and 10 min, along with recording of observations of spontaneously reported symptoms.
  5. Step 2. Patient stands without moving or leaning on any object for 30 min or as long as tolerated. If patient pre-syncopal, the test is terminated. Right arm is resting on table at mid chest (heart) level with BP cuff in place. Pulse and BP are taken every 5 minutes, and spontaneous symptoms recorded as well as observations (ie, yawning, feet mottled or bluish, etc). If symptoms become more severe, pulse and BP are taken every 3 minutes.

Results

Below is a listing of the abnormalities observed and the normal values taken from Dr. David Streeten’s book Orthostatic Disorders of the Circulation.

Normal Test Results

  • Systolic Blood Pressure (top number): recumbent: 100-142; Standing (4 min): 94-141; Orthostatic change: -19 to +11
  • Diastolic Blood Pressure (bottom number): recumbent: 55-90; Standing: 61-97; Orthostatic change: -9 to +22
  • Pulse: recumbent: 54-96; Standing: 62-108; Orthostatic change: -6 to +27

Indications of orthostatic intolerance

  • Orthostatic systolic hypotension (low blood pressure): fall in systolic blood pressure of 20 mmHg or more
  • Orthostatic diastolic hypotension (low blood pressure): fall in diastolic BP of 10 mm Hg or more.
  • Orthostatic diastolic hypertension (high blood pressure): rise in diastolic BP to 98 mm Hg or higher
  • Orthostatic narrowing of pulse pressure: reduction in pulse pressure to 18 mm Hg or lower.
  • Orthostatic postural tachycardia (increased heart rate): increase in heart rate of 28 bpm or to greater than 110 b/min.
16 comments

{ 16 comments… read them below or add one }

Maria April 15, 2013 at 8:55 pm

My b/p supine was 137/73. Standing was 147/95..What does that indicate? I have lots of syncope and mitochondrial myopathy…

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taniaaust1 May 16, 2013 at 4:28 pm

Maria, your BP result indicates your systolic is normal but your diastolic increased by 22 so you are sitting right on the border of having orthostatic dystolic hypertension with it only just within normal range. From my memory, some studies have used a lesser difference then 22 to diagnose orthostatic diastolic hypertension I think if Im remembering correctly . Check out “orthostatic hypertension” on wikipedia.

ive found with my orthostatic hypertension ..that my BP can suddenly shoot up to crazy heights eg (170/138.. when its low BP when Im laying) if after being on feet for a while… it was only after having this happening for a few years did it then start to show up on the standard standing test recommended here. My very high BP readings when standing got picked up by a 24 hr BP monitoring, so I then knew to check it randomly when standing, if it wasnt for that I wouldnt have know I had a orthostatic hypertension.

best luck

“Normal Test Results

Systolic Blood Pressure (top number): recumbent: 100-142; Standing (4 min): 94-141; Orthostatic change: -19 to +11
Diastolic Blood Pressure (bottom number): recumbent: 55-90; Standing: 61-97; Orthostatic change: -9 to +22 ‘

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Rebecca Stuart May 16, 2013 at 3:52 am

Hi,

I have had Fibromyalgia and chronic fatigue for the last 3 years – suffer greatly from light head/ dizziness, thumping in my ears, and overall muffled sensation in head on standing from sitting, car seat/ of sofa or getting into and out of bed. I am really struggling to cope with fatigue, weight gain as exercise is very limited every other day I spend 14 plus hours sleeping. This is crippling my life.
Who and where can this test be carried out in Northern Ireland.

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Angela July 23, 2013 at 8:04 pm

Hi there . My best advice is to do your own tilt test. Buy a wrist by monitor from amazon-moron basic bp monitor is a good reliable buy and reasonable at £15. Take readings lying down and standing. It will also record pulse. Take the readings to your GP.they cannot deny actual facts-don’t rely on giving them a history alone,they will simply look baffled as a I have found out after several years. I am now awaiting a formal tilt test but in essence a I have done my own.I don’t know where investigations are done in Ireland but a cardiology referral is a good place to start. I live in Glasgow and got so fed up with the blank faces that I paid for a private referral and slotted in to the NHL that way. I have been disabled for years with this with low bp lying down and readings of 240/146 when staning. This is associated with full body drenching sweats and palpitations. My skin is cold and clammy all over. Clonidine has been a godsend for me. I no longer feel the intense heat I have had for years and I can finally stand without sweating. Insist on a cardiology referral and don’t take no for an answer ! I wish you well and I sympathise with all you are going through .best wishes Angela

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fay September 21, 2013 at 10:19 pm

Do you mean Amazon’s Omron and not Moron? Thank you for making me laugh in i don’t know how long.

Rino August 31, 2014 at 7:08 am

Angela what therapy of clonidine you took for years that has helped you. The dosage and how many times per day. Does it makes more fatigue sensation?

Thanks
Rino

carly September 8, 2013 at 8:07 am

Hi,

I was diagnosed with orthostatic intolerance in 2008. I was sick for 2yrs previous, I know what you mean by blank faces! With eating every 2 hours or less, increasing salt and drinking plenty of fluids the dizzy spells, nausea and fainting subsided/improved but the fatigue was an ongoing issue. This year due to stomach upset I went gluten free and that has actually helped reduce the fatigue more than anything else thus far, bonus is its much easier to keep weight off on a GF diet! Worth a try:)

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Karen Ayres September 19, 2013 at 3:09 pm

I had the pleasure of having Dr. David Streeten diagnose me in 1992. Because of a heart problem I cannot take diuretics so I keep watching my weight go up, up, up. Any advice.

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Tatum Johnson November 6, 2013 at 7:52 pm

I went to the doctor because I was having all of these symptoms, but I was passing out and fainting. The symptoms have not gone away, I just stand up slower and try and pretend that I can see when my eyes go fuzzie. When I was passing out I went to the doctor and they were monitoring my heart, which was normal when I was lying down, but sky rocketed up when I stood up, the doctor and nurse wanted me to wear a heart monitor for a weekend, but no one around had one…I gave up and went home. The symptoms come and go, and now they are getting worse, to the point where my heart hurts from pounding so fast and hard when I stand up. I don’t want to say anything because the doctors really had no answers last time, they gave me a bunch of different medicines for the pain in my legs that were for restless leg syndrome, and a bunch of other nervous system disorders, none even touched the pain, so I guess I don’t know what to do anymore :( I just want to know if it can be deadly? I know I almost hit my head one of the times I passed out, and it makes my life miserable.

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Lorna June 20, 2014 at 1:41 am

Hi I have Me/Cfs I have been having this problem with my bp for a few years now.
It is always worse in the mornings.
What can you do to help is there any medication?
My morning bp is 115/65 sitting standing 166/98
I even get this if I have to get up in the middle of the night. These readings are not the highest by any means.

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Vee July 29, 2014 at 9:29 am

Hi Lorna,

I also have ME and mine is worse in the morning not being able to stand for long and very breathless and fatigued. By about 12pm it eases. How do you measure your bp?

Best,

Vee

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kevinj August 22, 2014 at 6:49 pm

I am always shocking in the morning too
I’m gonna try this test Now until my doctor about it

He didn’t have a clue frankly

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mary September 1, 2014 at 11:55 pm

Hi, hope you can help. I’ve been to a lot of Doctors, my bp flucuates bad from sitting to standing. It rises when standing. At times I notice vision changes due to dialation of pupils. I will have bad attacks with severe chest pain, can’t breath, feels like chest is being squeezed. Sometimes I vomit, then pass out. The Docs say I have vasovagle sycope. Sometimes my bp rises instantly without standing. I’ve also been told that it is an electrical problem with my heart. But none of the doctors don’t know what to do for me. Plz help. Don’t want my heart to just quit like they are saying will eventually happen. Only meds I take are omeprazole 20mg. 1x per day. They are afraid to put me on anything because my bp drops so bad. What could this be??

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denise thomson September 29, 2014 at 6:44 pm

Hello everyone
Please tell me who to see
What kind of Dr for this condition
Orthostatic. Intolerance.
Regards Denise Thomson
I live in Mississauga , Ontario Canada

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Shari Watson November 25, 2014 at 2:19 pm

I thought I was the only one with this problem. My BP Skyrockets to 140-150/95-107 as soon as I stand up. When I lie down, it generally goes down to normal limits. I am trying Clonidine and xanax right now but it doesn’t seem to be making a difference with the high BP when I’m standing or walking. It shoot right up. If I lie down, it comes right down. I’ve tried higher doses of the Clonidine but it made me dizzy and my BP was 85/57 standing then and when I slept my pulse drops to the mid 40′s. Can anyone please help?

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Joy Boyd Colhoun November 29, 2014 at 6:07 pm

I have been diagnosed with FMS by a Rheumatologist in 1997 and CFS by my GP shortly afterwards. However, no tests were carried out! I was given early retirement on the grounds of ill health the following year (1998) by a Civil Service Dr. Two years ago I was diagnosed with 2 bulging discs. My chronic fatigue was always very severe and I always had difficulty standing but over the past years it has become intolerable and find I only have ease when lying! This has exacerbated my previous very limited quality of life to being housebound! I am also having severe to chronic ‘crashes’ with only three or four days between! If I exert myself another flares up! My BP that always tended err on the low side suddenly became very high probably at the time my fatigue standing ability and fatigue worsened! I have been on BP medication for approximately 2/3 yes and there has been no sign of it lowering it! I should advise that my Rheumatologist traced my FMS back to childhood and this reminded me that I always needed to sit even when growing up although I was able to live a normal childhood otherwise! I perhaps should also advise that I’d my legs are not elevated my toes become blue/red/black and numbish! Thankyou

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