Reducing Symptoms During Upright Posture

By Peter C. Rowe, MD

Originally published in Youth Allied By CFIDS, Spring 1997

Most individuals with chronic fatigue syndrome (CFS) develop worse symptoms when they are in positions which involve prolonged upright posture, including sitting quietly for long periods, standing in line or taking a shower. The formal term used to describe symptoms that occur with upright (or orthostatic) stress is orthostatic intolerance, and medical conditions in which orthostatic intolerance is common include orthostatic hypotension (in which blood pressure drops substantially within the first three minutes of standing), neurally mediated hypotension (in which the drop in blood pressure is more delayed and with a slightly different heart rate response) and postural orthostatic tachycardia syndrome (in which heart rate increases excessively during upright positioning, with or without a drop in blood pressure).

Although the available pharmacologic treatments for orthostatic intolerance are not beneficial for all with CFS, almost everyone can use non-pharmacologic physical maneuvers when they have to be in an upright position for more than a few minutes. All the maneuvers seem to help by shifting blood from the legs and abdomen towards the heart, either by increasing the amount of muscle contraction in the legs (thereby causing a mechanical pressure on the veins to return blood to the heart) or by increasing the amount of compression against the abdomen (thereby reducing the amount of blood that pools in the intestinal circulation).

Dr. Wouter Wieling in Amsterdam and his colleagues have popularized the postural methods, and they emphasize that even small changes in blood pressure can help maintain an adequate blood flow to the brain.^1-3

The helpful maneuvers include:

• standing with one’s legs straight, but crossed
• squatting
• standing with one leg resting on a chair
• bending forward from the waist (such as leaning over a shopping cart)
• sitting in the knees-to-chest position
• sitting in a low chair to keep the legs flexed at the hips
• leaning forward with hands on the knees when sitting

Some of these are less conspicuous than others. Many patients have adopted these postures because they know they feel better when they sit or stand this way, without perhaps knowing the scientific rationale. Sitting with the legs tucked up is a posture commonly adopted by our adolescent patients long before they understand why it has become their habit. Sitting in a low chair is helpful because it causes the legs to be brought up toward the abdomen, and probably reduces the amount of blood pooling in the intestinal circulation. Conversely, sitting in a high chair with the legs dangling freely should be avoided, as there is no resistance to blood pooling unless the leg muscles are actively contracting. One young woman we know found she could sit longer without symptoms if she put her feet on a low foot rest (this probably required more leg muscle contraction than regular sitting, and may have also compressed the abdomen better).

Other researchers have recently suggested that an inflatable belt around the abdomen may also help to reduce the blood pooling in the abdominal circulation. The patients in this recent report were all adolescents with orthostatic hypotension or neurally mediated hypotension.⁴ The application of an inflatable abdominal band led to greater comfort in the upright position, and eight of nine patients in this study had less dizziness, blurred vision and fatigue while standing. We are not sure whether this belt is commercially available at this time, perhaps to the chagrin of those rushing to lead the CFS fashion parade in their neighborhoods.

1. van Lieshout JJ, ten Harkel ADJ, Wieling W: Physical manoeuvres for combating orthostatic dizziness in autonomic failure. Lancet 1992;339:897-8.

2. Wieling W, van Lieshout JJ, van Leeuwe AM: Physical manoeuvres that reduce postural hypotension in autonomic failure. Clin Autonom Res 1993;3:57-65.

3. Weiling W: Nonpharmacologic management of autonomic disorders. In: Robertson D, Low PA, Polinsky RJ, eds. Primer on the Autonomic Nervous System. San Diego: Academic Press, 1996:319-324.

4. Tanaka H, Yamaguchi H, Tamai H: Treatment of orthostatic intolerance with inflatable abdominal band. Lancet 1997;349:175.