Pediatric Pelvic Floor Case Study: Relationship Between POTS And APD

In the complicated realm of pediatric pelvic health, every case presents a unique puzzle to solve. Today, we’ll explore an interesting case study that examines the interplay between two seemingly unrelated conditions: Postural Orthostatic Tachycardia Syndrome and Abdomino-Phrenic Dyssynergia.

First, we’ll briefly review what each of these two diagnoses clinically look like. Second, we’ll delve into the case study of a teenager who struggled with both of these diagnoses and how I helped treat her.

Complex cases such as this one can be difficult to navigate, so building your clinical reasoning will help you piece together the difficult puzzles.

Postural Orthostatic Tachycardia Syndrome (POTS) presents unique challenges in the pediatric population. Characterized by an abnormal increase in heart rate upon standing, POTS is often accompanied by many symptoms affecting multiple body systems.

I commonly first notice this by measuring the change in my patient’s heart rate when they transition from supine or sitting to standing. Diagnostic criterion includes a sustained heart rate increase of 40+ bpm or above 120 bpm within 10 minutes of active standing or with a table tilt test.

This supine-to-stand monitoring is a simple test that you can do in the clinic if you suspect a patient may have POTS.

Although POTS is widely recognized for its cardiovascular irregularities, kids may also present with:

• Neurological impairments, such as headaches, brain fog, cognitive impairments, and anxiety
• Musculoskeletal weakness and pain
• Respiratory issues, such as asthma or shortness of breath
• Bladder dysfunction, including nocturia and polyuria
• Gastrointestinal symptoms, including nausea, gastroparesis, constipation, diarrhea

Your patients may present to your clinic with one or more of these signs & symptoms. In the case study, we’ll look at shortly, my patient was simply referred to me with abdominal pain.

When working with pediatric patients with POTS, integrating lifestyle modifications into your treatment plan is paramount. Here are key strategies to consider:

1. Patient and Family Education:
   • Educate patients and families on gradual changes in posture to mitigate symptoms.
   • Advise against prolonged standing and include physical counter-maneuvers during standing.
   • Encourage small, frequent meals to prevent exacerbation of symptoms.
2. Exercise Therapy:
   • Implement supervised exercise programs, such as the Dallas Program, emphasizing gradual aerobic conditioning and resistance training.
   • Start exercises in a semi-recumbent position and progress cautiously.
   • Time exercise appropriately. Exercise should not be performed in the morning or after meals. Give time for meals to digest before exercising.
3. Dietary Recommendations:
   • Advocate for increased salt and fluid intake to expand blood volume and alleviate symptoms.
   • Discuss the importance of dietary modifications with patients and families.
4. Compression Therapy:
   • Consider the use of compression stockings or garments to reduce peripheral pooling and improve symptoms.
5. Collaboration with Healthcare Providers:
   • Work closely with other healthcare professionals, including cardiologists and gastroenterologists, to ensure a multidisciplinary approach to patient care.

Now that you have an understanding of how POTS can affect your kids, let’s look at the second diagnosis. Then we’ll pull them both together and examine the case study!

Abdomino-phrenic dyssynergia (APD) is characterized by the paradoxical contraction of the diaphragm and abdominal wall. This condition not only affects respiratory function in children but also influences digestion and musculoskeletal function.

With APD, you will observe diaphragmatic contraction and relaxation of the abdominals during exhalation. This pattern pushes the abdominal contents in a ventral-caudal direction. This dysregulation leads to the redistribution of abdominal contents and may contribute to gastrointestinal dysmotility.

Consequently, children may experience symptoms such as shortness of breath, rumination, and aerophagia. Additionally, APD can contribute to musculoskeletal issues, potentially including back pain as their breathing mechanics and movement patterns are affected.

When treating a child with APD, you should always assess defecation dynamics, postural control, and musculoskeletal function and compensations. Therapeutic interventions may focus on respiratory retraining, optimizing postural alignment, and implementing pain management strategies.

You can learn more about APD in my online Peds Level 1 course. In the meantime, let’s delve into the case study!

Meet Katrina, a 16-year-old girl who was referred to my clinic with debilitating abdominal pain. Her symptoms began 2 months prior after a 48-hour bug with a bout of diarrhea. Despite multiple medical work-ups, including vaginal ultrasound, gynecological examinations, and abdominal CT scan, no one could give her answers.

Katrina was referred to physical therapy for her abdominal pain, but with further questioning, she began to divulge a slew of multiple system symptoms. She missed 3 days of school each week due to pain, dizziness, nausea, a low-grade fever, and chronic fatigue.

She also reported feeling bloated, which led me to suspect that she was constipated. However, Katrina reported that she had been cleaned out at the hospital, and addressing the constipation hadn’t helped improve her symptoms.

Based on her history, I considered POTS as a differential diagnosis. We tested her heart rate with supine to stand transitioning. After lying supine for 15 minutes, her resting heart rate was 68 bpm. Upon standing for 1 minute, her heart rate spiked to 125 bpm! Remember, 40 bpm is the differential indicative of POTS.

When assessing her breathing mechanics, she demonstrated shallow, apical breaths. I found that during inhalation, her diaphragm did not descend and her external obliques contracted instead of relaxing. This is a classic sign of APD!

With further assessment of her external pelvic floor, she demonstrated perfect contraction but she was unable to relax and descend her pelvic floor.

Katrina really just wanted to know what was wrong with her. With all her mysterious symptoms, she was searching for answers. I spent time educating Katrina about how her body’s sympathetic “fight or flight” state was causing spikes in her heart rate, contributing to her gastrointestinal disruptions and motility issues.

I referred her to a cardiologist, who she was fortunately able to see 2 weeks later. The cardiologist increased her water and salt intake to help her body retain fluid. She also was given instructions to elevate her feet and wear waist high compression garments.

At Katrina’s second physical therapy visit, I used ultrasound to give biofeedback so she could learn how to coordinate the descent of her pelvic floor with her breath. We put the ultrasound at her 10th rib, where the liver should descend to and come into view with inhalation. Because she had no descent of her diaphragm, we were not able to visualize the liver.

Additionally, we examined the bladder with ultrasound to visualize the elevation of her pelvic floor because Katrina couldn’t feel if she was squeezing or letting go. She demonstrated poor endurance with only 3 contractions.

To assist in stimulating the diaphragm, I gave her a 10-pound weight to put on her belly during inhalation. This helped minimally, so we used the weight and compression of my hands on the rib cage. Then we wrapped a TheraBand around her ribcage to mimic this at home.

After 3 minutes of practicing diaphragmatic breathing into the compression, we used ultrasound to confirm her liver was now descending with inhalation. Katrina was so excited to feel like she could breathe again!

Katrina had become very deconditioned secondary to her digestive issues and fatigue. So, I wanted to start her out with simple cardiovascular conditioning to retrain her autonomic nervous system (ANS).

I introduced her to high-intensity interval training (HIIT) with walking. For 5 cycles, she walked fast 30 seconds and slow 90 seconds. HIIT stimulates the vagus nerve and teaches the ANS how to rev up and calm down appropriately. Vagus nerve stimulation also helps to alleviate anxiety, which is very common in POTS and APD.

With diligent adherence to her treatment plan, Katrina experienced significant improvements in her symptoms and quality of life. Her ability to regulate her breathing, coupled with targeted exercises, enabled her to manage her anxiety and regain control of her health. Gradually, she returned to school with renewed energy and enthusiasm, eager to reclaim the time lost to illness.

Katrina’s case highlights the importance of a comprehensive and collaborative approach in diagnosing and treating complicated pelvic floor conditions. Many kids often have multiple conditions that affect each other and increase the complexity of their cases.

By sharing Katrina’s story, I aim to call your attention to these involved cases and give you guidance. Your patients’ conditions and cases can often be overwhelming. My online bowel & bladder course offers you invaluable insights and tools, designed to empower you to better understand and manage pediatric pelvic health issues.

In my Peds Level 1 course, you can learn more about POTS and ADP!