Postural Orthostatic Tachycardia Syndrome (POTS), the Vagus Nerve and Cervical Spine instability

Ross Hauser, MD

In this article and explanatory video, I will discuss how cervical instability affects the function of the heart including blood pressure variations and rapid heartbeat by way of disruption of normal vagus nerve function.

One of the scariest effects of cervical instability is how it affects the heart. I’ve had patients who have made emergency room visits on numerous occasions because they thought they were having a heart attack or a heart arrhythmia. They describe their heart as fluttering or they are getting palpitations. Once they got to the emergency room, cardiac tests revealed “nothing,” they are in fact told, “everything is normal.” In a less than reassuring way, some are told to relax, it must be anxiety, stress, or a panic attack and it is not their heart that should be looked at but rather their head.

Does this sound like your story?  Your doctors have found nothing

This is what we hear and it may be similar to a story you have to tell.

My doctors have not found anything wrong with my heart. They tell me that they cannot give me a diagnosis for something they cannot find. On numerous occasions, I have suffered from chest pain. 

I notice my chest pains sharpen when I get up from bed, chair, or any reclining or seated position. Out of nowhere, my heart rate will rapidly increase and my heart will be pounding. Sometimes my heart is pounding so hard it scares me. When I get scared I go to the emergency room. I have been to the emergency room on several occasions.  Typically I will get a CAT scan of my abdomen and chest, EKG, all the blood workups, and almost as predictable as to when I know my heart will race a doctor will come to tell me that the team can not find any issues that would cause my heart to “behave” like this.

I even wore a heart monitor that showed my heart rate will race and my blood pressure will rise. Without any evidence to support that this is my heart causing this, it has been suggested to me that I have “head” problems. I need counseling to control the cause of my heart problems which must be, for lack of anything else, panic attacks. Further, I should consult with a nutritionist in case it is something in my diet. 

While you may have found familiarity with these stories, you may also find the same difficulties in dealing with a problem that seems “invisible” to many. The Invisibility of POTS is something we will explore below as well.

Article outline:

  • My doctors don’t know. “POTS is underdiagnosed.” “POTS is understudied.”
    • There is limited research in the published medical data on POTS and no one really knows how good that research is.
  • The Adolescent and POTS.
  • I am interested in finding more treatment options for my condition rather than being told to drink more water and increase my intake of salty foods.
  • “I have severe symptoms that seem to match Dysautonomia and Postural Orthostatic Tachycardia Syndrome (POTS), but my spine specialist/neurologist and neurosurgeon are claiming not to understand my symptoms – say they are unrelated to my spine injury. Please help!”
  • Ehlers-Danlos Syndrome? Do I have it or not?
  • Whiplash injury and POTS.
  • The Vagus Nerve and POTS.
  • Cervical degenerative dysstructure (broken neck syndrome in cervical instability) a cause of POTS.
  • Cervicovagopathy and heart function – nobody can tell me why I have tachycardia.
  • Cervicovagopathy and heart function – nobody can tell me why I have tachycardia – Determining vagus nerve malfunction or disruption.
  • The Heart Rate Variability is low:
  • What are we seeing in this image? A chart demonstrating cervical instability induced heart arrhythmias.
  • Structural high blood pressure: hypertension due to atlantoaxial (C1-C2) instability.
  • Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?

Postural Orthostatic Tachycardia Syndrome

One of the more common problems we see as it relates to these cardiovascular-like attacks, heart palpitations and blood pressure problems is Postural Orthostatic Tachycardia Syndrome or POTS. POTS is the most common form of dysautonomia –  problems of or dysfunction of the autonomic nervous system. Its symptoms such as lightheadedness, palpitations, and tremulousness and are characterized by orthostatic intolerance (this is the development of many of the symptoms just described when a person stands up. These same symptoms are also relieved when a person lays down.) These symptoms can be present without with or without associated orthostatic hypotension (your blood pressure drops drastically when you stand up), and excessive autonomic system stress. One observation can be typically given in these people with these symptoms, their body is not correctly responding to a change from laying down to standing up straight. This incorrect response may be seen as:

  • Excessive heart rate upon standing is the defining symptom of POTS and is characterized by a marked rise of 30 beats per minute or greater within 10 minutes of standing from supine, or greater than 120 bpm while upright.
  • Tachycardia (a heart rate over 100 beats per minute) is often accompanied by a mild decrease in blood pressure. Sympathetic overactivity causes tachycardia, mild hypotension, with brain and other organ hypoperfusion (a reduction of blood flow) causing a host of other symptoms.

It is a mystery to me

Sometimes we will be contacted by someone who has done a lot of research into the origins of their problems. As may be the case for you, this aggressive need to understand what is going on stems from the fact that their doctors do not know what is wrong with them or worse, have become dismissive. Here is another story that you may find has a familiar tone to it.

It started with a concussion

I suffered a concussion, as a result, I had severe muscle spasms and tightness at the base of my skull, at the back of my neck. After physical therapy and massage, the muscles stopped spasming and the tightness went away. Then I started to have symptoms related to autonomic nervous system dysfunction. This included a high heart rate when I stood up. I was diagnosed with POTS. My neck muscles have begun spasming again and will not calm down. I am believing now that I have cervical ligament damage and cervical instability. I think it is affecting my vagus nerve and is the reason I have POTS.

My doctors don’t know. “POTS is underdiagnosed.” “POTS is understudied.”

In the sample stories that we just shared we find that people are doing a lot of research on their own trying to figure out the cause of their heart problems despite the fact that their health care professionals are telling them that they do not have a heart problem.

A July 2021 paper in the Journal of Autonomic Neuroscience: Basic & Clinical (1) comes to us from doctors at the University Hospitals Coventry & Warwickshire NHS Trust, United Kingdom of Great Britain, and Northern Ireland. The theme of this paper? “POTS is underdiagnosed.” Further, not only is POTS underdiagnosed it is understudied. Here is what these examiners noted:

“POTS is underdiagnosed with an estimated prevalence of 0.2% (Two in 1000 people). North American and Australian researchers, as well as patient groups, have called for more research into POTS. However, there has been no comprehensive appraisal of the current POTS evidence base.”

In other words, there is limited research in the published medical data and no one really knows how good that research is. It is on that research however that doctors base their treatment and diagnosis guidelines on.

There is limited research in the published medical data on POTS and no one really knows how good that research is.

To take this one step further the July 2021 special edition of the Journal of Autonomic Neuroscience (2) highlights the gaps in POTS knowledge. Specifically, the five major needs identified by doctors towards improving future care of POTS:

1) Improved understanding of POTS pathophysiology;

2) Improved data on POTS prevalence and its impact on sufferers;

3) Improved physician awareness for POTS diagnosis and access to care;

4) Improved studies on effective treatments for POTS;

5) Improved research funding for POTS. The editors add: “Indeed, there is an urgent need for well-conducted collaborative research to address the many gaps identified surrounding management of this complex condition.”

The Adolescent and POTS

Adolescent, POTS syndrome

The same holds true for the adolescent patient. A December 2022 study published in Clinical pediatrics (3) from Johns Hopkins All Children’s Hospital suggested that doctors should better understand the adolescent and their parents feelings towards the disease, the treatments and their doctors to help the young patient cope and recover. In this paper the researchers found four common themes among a small group of adolescent POTS patients and their parents.

  • Concern 1: There was expressed concern about the reduced or negative changes in adolescents’ functioning,
  • Concern 2: The feeling that the patient was not believed, their condition could not be validated and the accompanying “difficulties living with an invisible condition.”
  • Concern 3: Patients and parents had difficulties with medical trust and advocacy, and
  • Concern 4: The patients and parents felt there was a need for increased resources and understanding.

The conclusion of course is that these concerns greatly impacted the well being of the family. Doctors should explore providing POTS Specific treatment recommendations and possibly consider mental health counseling.

POTS is different for Adolescents

A November 2022 paper in the journal Medicine (4) found adolescents with POTS demonstrated several unique characteristics compared to adults with POTS and adolescents without POTS. POTS may be underrecognized among syncope and presyncope patients, among which 22.4% of these adolescent patients were diagnosed with the syndrome.

  • The researchers write: Adolescent postural orthostatic tachycardia syndrome has distinguishing features, with significantly lower resting diastolic blood pressure and heart rate, and more rapid conversion to maximum heart rate than adolescents without the syndrome.

In August 2000, Julian Stewart, M.D., Ph.D. of the Department of Pediatrics, The Center for Pediatric Hypotension, New York Medical College wrote in the journal Pediatric research (5) of his work to determine the nature of autonomic and vasomotor changes in adolescent patients with orthostatic tachycardia associated with the chronic fatigue syndrome (CFS) and the postural orthostatic tachycardia syndrome (POTS). These are the summary findings:

Heart rate and blood pressure responses before and 3-5 min after head-up tilt in 22 adolescents with POTS and 14 adolescents with CFS, compared with control subjects comprising 10 healthy adolescents and 20 patients with simple faint.

  •  Two of 10 healthy controls and 14 of 20 simple faint patients experienced vasovagal syncope during head-up tilt.
  • By design, all CFS and POTS patients experienced orthostatic tachycardia, often associated with hypotension.
  • R-R interval and heart rate variability were decreased in CFS and POTS patients compared with control subjects and remained decreased with head-up tilt. (Heart rate variability (HRV) refers to the variability between successive heart beats, specifically the R-R intervals on an EKG recording. If a person has a heart rate of 60 beats per minute, the average R-R interval would be 1 second but some R-R intervals may be 0.8 seconds and others 1.2 seconds. The variability between successful beats determines the HRV level, as well as its subcomponents.)
  • Low-frequency blood pressure variability reflecting vasomotion was increased in CFS and POTS patients compared with control subjects and increased further with head-up tilt. This was associated with depressed baroreflex transfer indicating baroreceptor attenuation through defective vagal efferent response.
  • Loss of beat-to-beat heart rate control may contribute to a destabilized blood pressure resulting in orthostatic intolerance. The dysautonomia of orthostatic intolerance in POTS and in chronic fatigue are similar.

I am interested in finding more treatment options for my condition rather than being told to drink more water and increase my intake of salty foods.

This is something we hear more and more. The person will write to us that up until recently they were a very healthy individual. Suddenly they would begin to experience multiple near-fainting incidents, heart palpitations, and breathlessness. Finally, they were diagnosed with POTS. After the diagnosis and countless exams, scans, and testing, no one has been able to direct them to a course of treatments that could “fix” them. They have common daily symptoms including fatigue, brain fog, and tunnel vision. They have a common treatment recommendation of drinking more water and eating more salt. Some people who contact us have far more symptoms and far less successful treatments.

In a January 2023 paper from doctors at King’s College London, United Kingdom, published in the journal Autonomic neuroscience (6), a possible list of treatments for POTS is given. “(POTS) is currently poorly understood with no approved licensed treatments. . .” One of the challenges in treatment is that doctors are looking to treat symptoms. The POTS symptoms that they are treating appear in other disorders and, using the outcomes in those treatments as they relate to other disorders, may not be an effective guide in providing the best treatment path. The paper explains: “Orthostatic symptom burden was higher in POTS than other long term conditions such as cardiovascular problems, Thyroid conditions, Addison’s disease, Diabetes, Parkinson’s disease among many).”

Many of the common symptoms the doctors explore were “Serum activity against adrenergic α1 receptors (disruption in the sympathetic nervous system causing heart rate problems), physical functioning, depression, catastrophizing, prolonged cognitive stress testing (chronic long-term stress) and anxiety were significantly associated with symptom burden in medium-high quality studies examining POTS.  . .”

The treatments that this paper recommends? Those that have been suggested to provide some alleviation of POTS symptoms. There are:

  • Compression garments, propranolol (beta blocker for heart problems), pyridostigmine (typically used for Myasthenia gravis, it is used to treat problems of signaling between muscles and nerves that can result in muscle atrophy), desmopressin (to treat diabetes and dehydration) and bisoprolol (high blood pressure medication). These, the researchers suggest, may hold promise in reducing symptom burden.

“I have severe symptoms that seem to match Dysautonomia and Postural Orthostatic Tachycardia Syndrome (POTS), but my spine specialist/neurologist and neurosurgeon are claiming not to understand my symptoms – say they are unrelated to my spine injury. Please help!”

As you can see, a recurring theme in this article is how poorly understood POTS is. Most people that contact our office do not contact us just for POTS or problems with a racing heart rate or dizziness and fainting sensation. Their cardio-like symptoms are often just one problem bundled among many issues that they are facing. However, we do see the patient whose symptomology is mostly focused on cardiac-like events. Let’s read some of their stories.

Panic attack or heart attack? Neither?

I have been dealing with many new, exotic, and mysterious symptoms over the last year. It all started when while walking I thought I was having a heart attack or a stroke. I went to the emergency room where all the cardio and vascular tests came back normal. Nothing was wrong with me “I only had a panic attack” brought on by anxiety. I should monitor for tachycardia symptoms moving forward.

My POTS test came back normal

My heart rate continued to bounce around. I noticed racing or variations in heart rate, especially when walking upstairs, getting up from bed or a chair, or simply turning my head one way or another. Finally, I had a POTS test. But that came back normal. So I was sent for more tests including stress tests, more lab work, more EKGs, other tests.

I am told it must be panic attacks

I experience lightheadedness, POTS symptoms, chest pain, neck pain and back pain, headaches, ear pressure, fatigue, difficulty swallowing, and more. Nothing can be pinpointed and my doctors refer back to the ER diagnosis, panic attacks brought on by anxiety.

Primary hypertension

I got diagnosed with POTS. Since then I have been bedridden. I believe I have cervical instability. I was a healthy person who had a diagnosis of primary hypertension. Now  I get random bouts of dizziness and vision disturbances when standing and when I move my neck. I have now developed headaches, digestive problems, and the feeling of fullness after even eating small meals. Heart rate has been all over the place. I have had so many tests all my doctors can tell me is primary hypertension. I get medications now for that too.

No one knows 

I have always struggled with neck pain and discomfort, in the last few years, my pain got worse. I was told that I have pinched nerves in my neck and I started seeing a chiropractor. The chiropractor helped but only for so long. I then had these strange episodes where people thought I was having a stroke, I went into a seizure-like state. I had a workup and my doctors thought I had POTS. Every time I go to the emergency room with a racing heart of seizures they treat me for a migraine. But one thing that has always been consistent is the neck pain a lot of it starts in my neck and then will move to my hair down my back down my arms sometimes I have weakness in my legs and then in my arms. I was then given blood pressure medication but I felt like that really wasn’t the issue, my blood pressure does drop low when I go from standing and sitting. Because of the heart palpitations, I was sent to the cardiologist. One of the nurses on one of my ER visits told me it was tachycardia.

Because of my continued neck pain, I had an MRI of my neck. My doctor noticed I have a couple of herniated discs pushing against my spinal cord. I asked if this could be the problem for me, nobody really has the right answers.

Your doctors found something and it requires brain surgery

Often I will be contacted by someone who has been diagnosed with Chiari Malformation Type 1 and a list of medical “anomalies” no one can figure out. These people will tell me that they can’t hold their head up, they have upper cervical instability, they blackout when they stand up and after a long series of tests, they were e ultimately told they had Hyperadrenergic dysautonomia Positional orthostatic tachycardia (POTS). (This is POTS associated with higher levels of norepinephrine. Norepinephrine is a stress hormone that can show in higher levels symptoms of “roller-coaster emotions from happy to sad,” panic attacks, and elevated blood pressure.) In their own research, they found familiar symptoms that were related to damage of the vagus nerve. They get tachycardia when they eat, sit up, get too hot. Depending on the position of their neck they have trouble breathing. But because they had a Chiari Malformation and eventually they will need brain surgery. Please see my article Chiari malformation: Non-surgical alternatives to Chiari decompression surgery

Ehlers-Danlos Syndrome? Do I have it or not?

I want to briefly discuss a very complex problem. This does not affect all POTS patients but may impact more than doctors think. Some patients do get a POTS diagnosis, especially after their doctors now suspect a diagnosis of Ehlers-Danlos Syndrome. Let’s point out that some people, specifically those with a history of joint dislocation, or double-jointed characteristics may be thought of as having Ehlers-Danlos Syndrome. Not all people with suspected POTS have Ehlers-Danlos Syndrome. The focus is on whether the hypermobile-type of Ehlers-Danlos Syndrome is causing the cervical spine to become unstable and allowing for the bones of the neck to compress on the vagus nerves. This then can be seen as a possible cause of the cardiac-like problems that are characteristic of POTS.

This is something we will discuss further below. Whether cervical instability causes pressure on the vagus nerves and in fact is the underlying cause for POTS.

Here is what we hear from the people with suspected Ehlers-Danlos Syndrome.

  • I have a POTS diagnosis confirmed by a tilt-table test and chronic migraine. My doctors now believe that the underlying cause of my POTS is EDS but I am waiting for genetic testing to confirm.
  • I have POTS and EDS. I see an excellent hEDS doctor who has given me something new to think about. He believes my symptoms are being caused by craniocervical instability, possibly from a Cerebrospinal Fluid leak. This may be also the cause of my bad headaches and neck pain.
  • My doctors are now suspecting that I have issues with my vagus nerve. I have EDS, POTS, nausea, severe leaky gut, and dizziness.
  • I have had a past cervical fusion. I continue to have severe and constant back pain and POTS heart episodes. I have migraines all the time nausea, vomiting, and now endometriosis.

POTS, hypermobility spectrum disorders (HSD) and Pregnancy

A December 2022 paper in the International journal of women’s health (7) offers guidelines on POTS in pregnant women. The authors write: “Studies on POTS and pregnancy are limited, and there is a lack of clinical guidelines regarding assessment and management of pregnant women with POTS. . .” More reassuring is their suggestion that “pregnancy appears to be safe for women with POTS and is best managed by a multi-disciplinary team with knowledge of POTS and its various comorbidities. . .Clinicians should be aware of the clinical presentation, diagnostic criteria, and treatment options in pregnant women with POTS to optimize outcomes and improve medical care during pregnancy and post-partum period.”

An interesting point offered is the consequence of hypermobility spectrum disorders (HSD). THe researchers note: “hypermobility spectrum disorders (HSD) that encompass patients who do not qualify for a diagnosis of hEDS are also common among patients with POTS. The prevalence of hEDS/hypermobility spectrum disorders (HSD) in POTS is high, with reports of 31% of POTS patients meeting the criteria for hEDS and a further 24% for non-hEDS generalized joint hypermobility.”

It’s my neck

People with and without an hEDS diagnosis can have their POTS come from neck instability. Such as the people that write us about their situation that goes something like this:

One day I woke up and I knew something was off. I went to work but I caused concern among my co-workers because I was having breathing problems and weird heart palpitations. These were things I have never felt before. When I tried to stand up it felt like I was going to pass out. This went on for months when, because of neck pain I went to a chiropractor. An x-ray showed that I had a straight neck or a “military neck.” I found that the chiropractor was giving me short-term relief from my neck pain and my problems with fainting and a racing heart. It was the chiropractor who told me about POTS.

A description of cervical scoliosis and neck pain

For the last year and a half, I have suffered from autonomic health issues specifically POTS syndrome. I also have cervical scoliosis. I have a lot of neck pain and one of the back pain specialists thought that my problems may be related to my vague nerves being compressed. I also have twitches and involuntary movements, brain fog, ear ringing.

Whiplash injury and POTS

There is medical evidence and research, as we have been discussing, that connects whiplash injury to cardiovascular problems, let’s look at some stories shared with us by people seeking more information from our center. These emails have been edited for clarity.

I was rear-ended while sitting at a red light by a truck traveling at 45 MPH. I have developed Postural Orthostatic Tachycardia Syndrome (POTS), problems with low blood pressure, my EKG reading are off. I suffer from Fatigue, dizziness, and palpitations. I need to gasp for air, I suffer from fainting, digestion symptoms, stomach pain, severe nausea, blurred vision, and headaches. I want my life back this is miserable. All my doctors suspect I’m faking my symptoms or it’s just stress/ anxiety. It all began since the car accident.

Post-Concussion and POTS symptoms after a whiplash head injury

I am a young athletic, adult male who developed Post-Concussion and POTS symptoms after a whiplash head injury from a fall during basketball. For over a year symptoms were managed and improved until another recent neck injury that brought back the symptoms.

I’m now experiencing episodes of extreme vasodilation (decreases blood pressure) and also episodes of extreme vasoconstriction (narrowing of blood vessels) . . .heart palpitations when I straighten my posture.

In this video Ross Hauser, MD highlights some of the most common reasons why cervical instability or cervical dysstructure (broken neck syndrome) can be the underlying structural cause of low vagal tone and associated poor heart function, leading to POTS, or dysautonomia.

  • POTS symptoms may range from mild and occasional complaints to severely incapacitating disease. Sufferers are commonly misdiagnosed as having chronic anxiety or panic disorder or chronic fatigue syndrome.
  • There is a multitude of other symptoms that often accompany this syndrome including pre-syncope, syncope, dizziness, palpitations, headache, fatigue, bladder, and gastrointestinal (GI) symptoms.

Vagal tone and the ability to regulate heart function. What are we seeing in this image? A flowchart from standing up to rapid heartbeat.

The purpose of this illustration is to give a snapshot of POTS and how upper cervical instability can cause its symptoms.

  1. It starts with a person standing up and their blood pressure dropping.
  2. As we discussed above, the body’s natural response to standing is to provide a seamless transition and an interrupted blood flow response. In a disrupted response, the blood pressure regulators and the blood flow monitors are not sending or receiving the right messages. Rapid heart rate increases to try to raise and regulate blood pressure.
  3. In a situation where there is cervical instability and there is compression on the vagus nerve, the messages from the vagus nerve are distorted, unreadable, or blocked. We call this phenomenon a problem of cervical dysstructure – or “broken neck syndrome.”
  4. Uninhibited sympathetic nerves discharging in the neck is a fancy way of saying “short-circuited” or “misfiring”.
  5. Because of this message misfiring or short-circuiting, the heart rate stays elevated. The cerebral blood flow is impeded.
  6. What happens next is symptomology:
    1. Tachycardia
    2. Panic attacks and anxiety
    3. Shortness of breath
    4. Fatigue, some to the point of exhaustion
    5. General body weakness
    6. Dizziness

What are we seeing in this image? Cervical degenerative dysstructure (broken neck syndrome).

The progressive nature of cervical instability is demonstrated. In the normal position, the cervical spine supports the head in its natural position and the blood vessels and nerves that travel from body to brain and back through the neck, go about their routine business.

As cervical instability develops through the breakdown of the cervical ligaments, the bones of the neck start to wander out of their natural positions. The normal neck posture is replaced by MILD loss of natural curvature. This can progress to complete loss of curvature as displayed by a MILTARY neck or straight up and down position. Finally, progression can reach the KYPHOTIC state, the curve of the neck reverses and faces the wrong way. When the neck is bent the wrong way, destructive forces are placed on the neurovascular structures including the cervical spine and vagus nerves.

Cervicovagopathy and heart function – nobody can tell me why I have tachycardia

In the video below, Ross Hauser, MD gives a brief answer to a frequently asked question about heart symptoms and vagus nerve input. We hear from many people who have intermittent heart symptoms that no one can figure out because their traditional tests for major heart problems come back as normal, yet they regularly experience tachycardia or other heart issues.

Cervical instability-induced vagus nerve injury is called cervical vagopathy. Vagopathy means degeneration or injury to the vagus nerve. We determine the extent of this injury through testing and measuring the vagus nerve. We generally find that people who suffer from POTS or tachycardia have diminished size vagus nerves. Their vagus nerves are small than those who do not suffer from POTS or tachycardia and then their heart rave variable of HRV is low.

For more information and research please see my companion article Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?

In this article, I continue with discussions on:

  • lesser-known diagnoses of a racing heart and the problem of heart rate messaging miscommunication in the autonomic nervous system.
  • baroreflex hyposensitivity
  • Afferent baroreflex failure
  • unexplainable heart attack-like, panic attack-like symptoms.

Cervicovagopathy and heart function – nobody can tell me why I have tachycardia – Determining vagus nerve malfunction or disruption

The Heart Rate Variability is low:

The clinical importance of Heart Rate Variability (HRV) cannot be overestimated. A low HRV has been confirmed in numerous studies to be a strong, independent predictor of future health problems and as a correlate of all-cause mortality.

Understanding

  • Heart rate variability (HRV) refers to the variability between successive heartbeats, specifically the R-R intervals on an EKG recording. If a person has a heart rate of 60 beats per minute, the average R-R interval would be 1 second but some R-R intervals may be 0.8 seconds and others 1.2 seconds. The variability between successful beats determines the HRV level, as well as its subcomponents. The vagus nerve has the greatest impact on heart function, as the cardiovascular afferents (nerve fibers)  go through the nodose ganglion (a sensory ganglion of the peripheral nervous system – the nervous system not in the brain or spinal cord) which sits in front of the atlas (C1), thus giving a structural reason why upper cervical instability can affect HRV. Fluctuations in parasympathetic (vagus) nerve activity are a major source of HRV, particularly under resting conditions.

At our center, we put an HRV monitor on you, and then we have you move into various neck positions and see if the heart rate variability goes down. Low HRV can indicate that you are in constant stress, meaning that your fight-or-flight response is constant or near-constant and not allowing your body to slow down or relax. In a constant state of stress, there are fewer variations between heartbeats.

What are we seeing in this image? A chart demonstrating cervical instability induced heart arrhythmias

A description is below:

Ross Hauser, MD gives a brief answer to a frequently asked question about heart symptoms and vagus nerve input. We hear from many people who have intermittent heart symptoms that no one can figure out because their traditional tests for major heart problems come back as normal, yet they regularly experience tachycardia or other heart issues.

The video opens with Dr. Hauser talking in front of this slide:

The caption reads Cervicovagopathy-induced heart arrhythmias. Vagus nerve injury, primarily of the craniocervical junction can be the underlying cause of many heart arrhythmias.

A brief explanation of this slide:

Here we see the varying conditions that can be caused by Cervicovagopathy-induced vagus nerve injury. The autonomic nervous system (ANS) is made up of nerves that control the automatic functions throughout the body. It regulates and controls heart rate, blood pressure, temperature, respiration, sweating, digestion, and other vital functions. In my opinion, the structural instability that devastates patients the most is cervical instability involving the autonomic nervous system. Most of the time the part of the autonomic nervous system that is affected is the parasympathetic nervous system, specifically the vagus nerve.

One of the main effects of the vagus nerve is to slow heart rate by increasing the time between heartbeats. Heart rate is controlled by action potentials transmitted via the vagus nerve to the sinoatrial node of the heart, where vagus nerve-dependent acetylcholine release essentially prolongs the time to the next heartbeat, thus slowing the pulse.

  • Excessive SA Node Activity and AV node pacemaker dysfunction.
    • The vagus nerve innervates the sinoatrial node (SA Node) and the atrioventricular node (AV node) of the heart. This comes from the online publication Pacemaker Malfunction in the US National Library of Medicine’s STATPEARLS Updated May 2021. (8) “The sinoatrial node acts as the natural pacemaker of the heart. The cells present in the sinus node have innate automaticity (a natural ability to control the heartbeat or the pace of the heart), which starts the electrical activity in the heart. This innate electrical potential moves from the sinoatrial node to the atrioventricular node and finally into the His-Purkinje system (the His-Purkinje system is in charge of the rapid electric conduction in the ventricles (the muscle contraction of the chambers of the heart)). It relays electrical impulses or messages from the atrioventricular node to the heart muscle cells that coordinate the contraction of ventricles. (In other words the contraction of the heart muscle that makes your heart pump.)” Excessive SA Node Activity or AV node pacemaker dysfunction would then obviously cause a disruption of the heart’s pacemaking abilities.

  • Lowered ventricular threshold – creating the electricity to make a heartbeat
    • Lowered ventricular threshold – is a loss in the minimum amount of electrical energy required to make the heartbeat. Updated information in the National Center for Biotechnology Information publication STAT PEARLS (9) offers this explanation. “The heart carries out the vital function of pumping oxygenated blood around the body, for which it has to contract and relax in a coordinated fashion. This contraction process is preceded by electrical excitation, which under normal conditions is initiated by the SA node (the natural pacemaker of the heart) as an action potential. An action potential is the rapid sequence of changes in the membrane potential, resulting in an electrical impulse. This electrical impulse then travels down through the heart’s electrical conduction system to cause myocardial contraction followed by relaxation in an orderly fashion.” When this lowered the ventricular threshold – the heart loses its pace.

  • Lowered ventricular nitric oxide
    • Nitric oxide is a neurotransmitter (something that facilitates messages between the nerves (neurons) and muscle. Nitric oxide helps blood vessels relax and makes for better circulation.

  • Paroxysmal atrial tachycardia is an irregular heartbeat.
    • The term Paroxysmal atrial tachycardia means the irregular heartbeat (arrhythmia) starts and ends abruptly in the atria (the upper heart chambers). Tachycardia is the heart beating abnormally fast.

  • Atrial flutter and fibrillation
    • Both atrial flutter and atrial fibrillation are abnormal heart rhythms caused by disruption or distortion of the electrical signals and pathways in your heart. The atrial portion of your heart, the upper chambers, or atria push blood into the lower chambers of the heart, the ventricles. In atrial flutter, the atria beat at a regular but faster than usual rhythm and at a rate more often than the ventricles. The heart is out of rhythm.
    • In atrial fibrillation, the atria beat irregularly and rapidly and can lead to clots in the heart. A French study as early as 1978 (10) made a connection between atrial fibrillation and vagus nerve dysregulation when the researchers questioned why there was a usual resistance of atrial arrhythmias of vagal origin to well-known medications to slow down the heart rate including digitalis, beta-blockers, and quinidine.
    • A 2012 study suggested that in the atria, simultaneous sympathovagal discharges are common triggers of paroxysmal atrial tachycardia and paroxysmal atrial fibrillation. (11)  What is being suggested is that disruption and distortion of the sympathetic and parasympathetic messages’ “sympathovagal balance” are causing heartbeat issues. The concept of “sympathovagal balance” reflects the autonomic state resulting from the sympathetic and parasympathetic influences. (12)

  • Bradycardia
    • Bradycardia is a slower than normal heartbeat. Bradycardia can be the result of an overactive vagus nerve.

  • Supraventricular tachycardias
    • Supraventricular tachycardias or paroxysmal supraventricular tachycardia is a grouping of abnormally fast heart heartbeats (Typically a heart rate between 100 to 150 beats per minute.). This is considered an “electrical problem” centered in the upper chambers of the heart. These erratic heartbeats can come on suddenly and leave just as suddenly. This is a difficult problem to treat “electrically.” A December 2021 study in the journal Expert Review of Medical Devices (13) wrote: “Patients with brief arrhythmias is a challenging group to treat effectively with catheter ablation. Current standard approaches in the localization and treatment of brief arrhythmias suffer from several limitations, including the lack of spatiotemporal stability and adequate resolution.”

Structural high blood pressure: hypertension due to atlantoaxial (C1-C2) instability -Wearing a neck compression collar would attenuate orthostatic symptoms

In an April 2020 study in the Journal of applied physiology (14)  researchers suggested that wearing a neck compression collar would attenuate orthostatic symptoms, increase brain blood flow, and influence autonomic reflexes including the Arterial Baroreceptor Reflexes. (This will be highlighted below).

  • Ten participants with POTS (9 women average age 36) underwent two trials of supine rest, paced deep breathing (6 breaths/min), Valsalva maneuver (40 mmHg for 15 seconds – this means a standard scale pressure strain), and 70° upright tilt.
  • For one trial, participants wore a neck compression device
    • Blood pressure, heart rate (HR), brain blood flow velocity, stroke volume, respiratory rate, and end-tidal gases (an ability to measure C02 gas pressure in the arteries) were continuously measured.
    • The researchers found that “using a neck compression collar alleviated orthostatic symptoms in upright posture in participants with postural orthostatic tachycardia syndrome (POTS). This could be due to compression of the baroreceptors and subsequent changes in autonomic function. (Baroreflex Dysfunction can be caused by any compression on the nerves, arteries, and veins that pass through the neck, such as compression or injury on the carotid sinus nerve, a branch of the glossopharyngeal nerve. In this scenario, high blood pressure may be caused by simply turning your head one way or the other and creating compression or pressure on the glossopharyngeal nerve. The neck collar may prevent that.)

Baroreflex Dysfunction can be caused by any compression on the nerves, arteries, and veins that pass through the neck, such as compression or injury on the carotid sinus nerve, a branch of the glossopharyngeal nerve. In this scenario, high blood pressure may be caused by simply turning your head one way or the other and creating compression or pressure on the glossopharyngeal nerve. The neck collar may prevent that.

More reading and information – Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?

Cervical instability created autonomic myopathy or autonomic neuropathy, that is nerve damage that blocks or interferes with the messages sent between the brain and the heart and blood vessels, can lead to a variety of serious symptoms including postural orthostatic tachycardia syndrome (POTS).

In my companion article “Can cervical spine instability cause cardiovascular-like attacks, heart palpitations, and blood pressure problems?” I describe how chest pain, a racing heartbeat, panic attacks, and anxiety may be coming from a cervical spine and neck instability pressing on the vagus nerve. It is important to realize that this may only be one possible explanation as to why seemingly healthy individuals, having been checked out by their cardiologist, have cardiovascular-type symptoms with seemingly no explanation.

Cervical and thoracic spinal manipulation

A July 2022 paper presented a case study in the Journal of family medicine and primary care (15) of a 50-year-old woman suffering with lightheadedness, palpitation, and neck pain for 3 years. Here is the story her doctors presented: “(For the patient,) the lightheadedness and palpitation occurred when shifting from a prolonged seated or lying position. Standing radiographs showed spinal misalignment with cervical kyphosis and thoracic scoliosis. Continuous static stress on these minor variants could aggravate biomechanical and autonomic disorder like POTS. After ruling out cardiovascular, neurological, or vestibular pathophysiology, a multicomponent treatment approach was adopted including the use of thermal ultrasound therapy, cervical and thoracic spinal manipulation, and intermittent motorized cervicothoracic traction to manage her neck pain complaints. Following 3 months of regular treatment, the patient reported a full resolution of neck pain, dizziness, and POTS.”

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

One of the things that you can do at home or we do at our center is to use an HRV monitor on you and then we have you move into the various neck and head positions. We look to see if this motion causes the heart rate variability to go down (meaning vagus nerve compromise). If so, we would suspect that vagal nerve impulses are getting blocked or interrupted with neck motion. That is a sign that the person’s heart condition is being generated by cervical spine instability.

We hope you found this article informative and it helped answer many of the questions you may have surrounding cervical spine instability causing POTS, heart palpitations, and blood pressure problems. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

Similar articles:

Inappropriate sinus tachycardia

This article discusses very similar problems that cause an elevated heart rate – Inappropriate sinus tachycardia and postural tachycardia syndrome (POTS). While they share common cardiovascular-like symptoms, there is the main difference that separates their diagnosis.  POTS and its cardiovascular-type symptoms are triggered by a change in body position or orthostatic stress. Inappropriate sinus tachycardia is a condition where the heart races and there is no understandable reason for it other than it is “inappropriate.”

Part of this confusion is revealed in a March 2022 paper in the journal Cardiology in the young (16) Here doctors from the Children’s National Hospital in Washington, DC, and The George Washington University School of Medicine suggested that a “a substantial proportion of postural tachycardia syndrome/orthostatic intolerance patients may have concomitant underlying cardiac arrhythmias, at a frequency similar to what is seen in patients undergoing primary evaluation for cardiac symptoms such as chest pain, palpitations, and syncope. In the appropriate clinical context, physicians caring for postural tachycardia syndrome/orthostatic intolerance patients should consider additional evaluation for arrhythmias beyond sinus tachycardia.”

Summary and contact us. Can we help you? How do I know if I’m a good candidate?

Please see related articles:

We hope you found this article informative and it helped answer many of the questions you may have surrounding Postural Orthostatic Tachycardia Syndrome (POTS), the Vagus Nerve and Cervical Spine instability. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.

Please reach out to the Hauser Neck Center Patient Team here

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References

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This article was updated January 7, 2023

 

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