Japanese clinical guidelines for juvenile orthostatic dysregulation version 1

Abstract

This clinical practice guideline provides recommendations for the assessment, diagnosis and treatment of school-aged children and juveniles with orthostatic dysregulation (OD), usually named orthostatic intolerance in USA and Europe. This guideline is intended for use by primary care clinicians working in primary care settings. The guideline contains the following recommendations for diagnosis of OD: (i) initial evaluation composed of including and excluding criteria, the assessment of no evidence of other disease including cardiac disease and so on; (ii) a new orthostatic test to determine four different subsets: instantaneous orthostatic hypotension, postural tachycardia syndrome, neurally mediated syncope and delayed orthostatic hypotension; (iii) evaluation of severity; and (iv) judgment of psychosocial background with the use of rating scales. The guideline also contains the following recommendations for treatment of OD on the basis of the result of an orthostatic test in addition to psychosocial assessment: (i) guidance and education for parents and children; (ii) non-pharmacological treatments; (iii) contact with school personnel; (iv) use of adrenoceptor stimulants and other medications; (v) strategies of psychosocial intervention; and (vi) psychotherapy. This clinical practice guideline is not intended as a sole source of guidance in the evaluation of children with OD. Rather, it is designed to assist primary care clinicians by providing a framework for decision making of diagnosis and treatments.

High Prevalence of Orthostatic Dysregulation among Circadian Rhythm Disorder Patients

“…We applied the Schellong test, i.e., the active stand ing test for the adult patients (≥ 20 years), and the new ortho static test (described below), for the adolescent patients (< 20 years). 7 We evaluated the state of sleep phase during the inves tigation using the severity level criteria for delayed sleep phase syndrome (DSPS) devised by Ohta et al 13 We also confirmed the use of medications (vitamin B 12 , GABAergic agents [such as benzodiazepines and nonbenzodiazepine hypnotics], and ramelteon). We performed the OD test when the patient came for a routine medical examination.…”

“…The protocol for the new orthostatic test established by Tanaka et al 6,7 for use in adolescents was as follows: (1) Rest for 10 min in the supine position. Put a manometer cuff on the arm.…”

“…8,9 It was reported that more than half of the Japanese children with symptoms of OD had school refusal behavior, and conversely 30% to 40% of children with school refusal behavior had OD. 7,10 In addition, approximately 50% of children with OD had disturbed sleepwake patterns and were unable to get up until noon, but they usually recovered their vigor in the evening; these symptoms could seriously impair multiple areas of functioning and quality of life. 7 Interestingly, CRSD and OD have many common clinical features.…”

“…7,10 In addition, approximately 50% of children with OD had disturbed sleepwake patterns and were unable to get up until noon, but they usually recovered their vigor in the evening; these symptoms could seriously impair multiple areas of functioning and quality of life. 7 Interestingly, CRSD and OD have many common clinical features. The sleepwake pattern is usually disrupted to vary ing degrees in children with OD, while patients with CRSD often complain of somatic symptoms such as headache, fa tigue, nausea, and abdominal pain.…”

“…4,5 It is our clinical experience that patients with CRSD often have a diagnosis of orthostatic dysregulation (OD), a functional physical disorder with an impairment of circulatory adjustment against gravitational stress because of dysregulation of the au tonomic nervous system. 6,7 OD is common in adolescents and often affected by psychosocial factors; therefore, it is regarded as a psychosomatic disorder. The characteristics of OD among adults, alternatively named as orthostatic intolerance (OI) in America and Europe, has not been as clearly defined as those of OD among children.…”