Dysautonomia Program Objectives

MODULE 1

This 3-day program is part one of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part one of this series will cover the following topics:

1. Current knowledge base of modern autonomic theory ○ Looking back to move forward.
2. Autonomic Neurotransmission
3. Gross anatomy of the peripheral sympathetic and parasympathetic nervous system
4. Visceral afferent neurons and autonomic regulations
5. The final autonomic pathway and its analysis
6. The peripheral sympathetic and parasympathetic pathways
7. Sympathetic non-vasoconstrictor neurons innervating pelvic viscera and colon
8. “Other” types of sympathetic neurons
9. Adrenal Medulla
10. Sympathetic neurons innervating immune tissue
11. Parasympathetic systems
12. The enteric nervous system
13. Autonomic dysreflexia

Outline:

• Current knowledge base of modern autonomic theory ○ Looking back to move forward.
• Autonomic Neurotransmission
  • Neurochemical substrate underlying autonomic activity
  • Hexamethonium Man
  • Case Study
• Gross anatomy of the peripheral sympathetic and parasympathetic nervous system
  • Peripheral Sympathetic System
  • Sympathetic preganglionic neurons
  • Parasympathetic nervous system
  • Reactions of autonomic target organs to activation of sympathetic and parasympathetic axons
  • Case Studies
• Visceral afferent neurons and autonomic regulations
  • Visceral Afferents
  • Vagal and spinal visceral afferent neurons
  • Visceral primary afferent neurons as interface between visceral organs and brain
  • Case Study
  • Vagal afferent neurons
  • Receptive properties and organ regulation
  • Vagal afferent neurons and body protection
  • Spinal visceral afferent neurons
  • Role of visceral afferent neurons in visceral nociception and pain
  • Central ascending pathways associated with autonomic regulations and visceral sensations
  • Functions and projections of deep dorsal horn neurons
  • Projection to the parabrachial nuclei
  • Projection to the thalamo-cortical system
  • Vagal afferents and the thalamocortical system
• The final autonomic pathway and its analysis
• The peripheral sympathetic and parasympathetic pathways
  • Autonomic Specialization in PNS
  • Muscle Vasoconstrictors
  • Cutaneous Vasoconstrictors
  • Skin Vasoconstriction and Vasodilation
  • Case Study
  • Skin Vasoconstriction and Vasodilation
  • Sudomotor Neurons
  • Pilomotor Neurons 
  • Skin Vasodilators
  • Muscle Vasodilators
• Sympathetic non-vasoconstrictor neurons innervating pelvic viscera and colon
• “Other” types of sympathetic neurons
• Adrenal Medulla
• Sympathetic neurons innervating immune tissue
• Parasympathetic systems
  • Parasympathetic pathways to pelvic organs.
  • Parasympathetic neurons innervating the hindgut
  • Parasympathetic neurons innervating the lower urinary tract
  • Parasympathetic neurons innervating the reproductive organs (male).
  • Parasympathetic pathways from the brainstem: Heart
  • Parasympathetic pathways from the brainstem: Airway
  • Parasympathetic pathways from the brainstem: Gastrointestinal tract
  • Parasympathetic pathways from the brainstem: Salivary glands
  • Parasympathetic pathways from the brainstem: Eyes
  • Case study & Summary 
• The enteric nervous system
  • The enteric nervous system: General anatomy
  • Enteric neurons
  • Enteric motility patterns
  • The interstitial cells of Cajal (ICC) and slow waves
  • The rhythmoneuromuscular apparatus to generate gastrointestinal motility.
  • Regulation of secretion and transmural transport
  • GALT: GI & enteric defense system
• Autonomic dysreflexia
  • Spinal reflex examples
  • Sacral parasympathetic systems
  • Urinary bladder and colon
  • Regulation of organ systems by the lower brain stem
  • Ventrolateral Medulla (VLM)
  • RVLM: sympathetic premotor nucleus
  • Arterial baroreceptor reflexes

MODULE 2

This 3-day program is part two of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part two of this series will cover the following topics:

1. Central control of autonomic function.
2. Synucleopathies
3. Autonomic Reflex Integration
4. Cardio-respiratory control
5. Cardiorespiratory control at rest
6. Integration of autonomic regulation in upper brain stem and limbichypothalamic centers
7. Defense reactions integrated in the mesencephalon
8. Central representation of emotional states and patterns of autonomic reactions
9. Autoimmune Autonomic Disorders
10. POTS
11. Syncope
12. Autonomic Hyperactivity

Outline: 

• Central control of autonomic function.
  • Insular Cortex
  • Asymmetric homeostatic afferent activation of the anterior insula
  • Anterior Cingulate Cortex
  • Amygdala
  • Hypothalamus
  • Periaqueductal Gray
  • Extended Parabrachial Complex
  • RVLM
  • CVLM
  • RVMM and Caudal raphe
  • Medullary respiratory groups
  • Vagal input and output
• Synucleopathies
  • Involvement of the central autonomic network and peripheral neurons controlling autonomic function may manifest as: 
    • orthostatic hypotension  
    • urogenital dysfunction  
    • gastrointestinal dysmotility 
    • thermoregulatory dysfunction
  • PURE AUTONOMIC FAILURE 
    • Diagnosis
    • Treatment
    • Pathophysiology 
    • Case study
  • MULTIPLE SYSTEMS ATROPHY (MSA)
    • Case Studies
  • Vagal efferent pathways and regulation of gastrointestinal functions
  • DEMENTIA WITH LEWY BODIES
  • Parkinson’s Disease (PD)
    • Diagnosis
    • Treatment
    • Pathophysiology 
    • Case study
• Autonomic Reflex Integration
  • Regulation of organ systems by the lower brain stem
  • Regulation of lower brainstem
  • Ventrolateral Medulla (VLM)
  • RVLM: sympathetic premotor nucleus
  • Arterial baroreceptor reflexes
• Cardio-respiratory control
  • Central Mechanisms Regulating Coordinated Cardiovascular and Respiratory 
  • Respiration
  • Respiration and oropharyngeal control
• Cardiorespiratory control at rest
  • Resting Conditions
• Integration of autonomic regulation in upper brain stem and limbichypothalamic centers
  • Homeostasis
  • Allostasis
  • Behavior patterns and autonomic responses
  • Autonomic changes during centrally generated muscle effort
• Defense reactions integrated in the mesencephalon
  • Types of defense reaction elicited from the PAG
  • Efferent projections of the PAG cell columns to the medulla oblongata
  • Afferent projections to the PAG cell columns from the body 
  • Autonomic responses during conditioned emotional responses
  • Tonic immobility, freezing and vigilance
• Central representation of emotional states and patterns of autonomic reactions
  • Basic emotions and autonomic response patterns
  • Central representation of emotional states and patterns of autonomic reactions
  • Integrative responses and the hypothalamus
  • Anatomy and functions of the hypothalamus
  • Autonomic nervous system and behavior 
  • Defensive behavior
  • Resetting of the Baroreflex Control 
  • Role of Midbrain Colliculi in Integrating Stress-Evoked Responses
  • Perspectives and Significance 
• Autoimmune Autonomic Disorders
  • Autoimmune Encephalitis
  • Rheumatological diseases and Sjogrens
  • Diabetic Autonomic Neuropathy
  • Treatment Induced Diabetic Autonomic Neuropathy
  • Hereditary Autonomic Neuropathy
  • Toxic Neuropathies
  • Case Studies
• POTS
  • Clinical features
  • NEUROPATHIC POSTURAL TACHYCARDIA SYNDROME
  • HYPERADRENERGIC POSTURAL TACHYCARDIA SYNDROME
  • VOLUME DYSREGULATION
  • DECONDITIONING
  • POTS 2019 NIH Consensus 
  • Case Studies
• Syncope
• Autonomic Hyperactivity
  • PATHOPHYSIOLOGY OF AUTONOMIC HYPERACTIVITY 
  • GENERAL FEATURES OF AUTONOMIC HYPERACTIVITY IN ACUTE BRAIN DISEASE
  • Paroxysmal Sympathetic Hyperactivity in Traumatic Brain Injury 
  • Paroxysmal Sympathetic Hyperactivity Pathophysiology 

MODULE 3

This 3-day program is part three of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part three of this series will cover the following topics:

1. REVIEW- Module 1
2. Pathological conditions
3. Cerebral vascular anatomy
4. Cerebral Blood Flow
5. Cardiac Examination
6. Fundoscopy
7. Autonomic Testing
8. Head Up Tilt Test

Outline:

• REVIEW- Module 1
  • The autonomic nervous system and the regulation of body functions
  • Gross anatomy of the peripheral sympathetic and parasympathetic nervous system
  • Reactions of autonomic target organs to activation of sympathetic and parasympathetic axons
  • Visceral Afferents
  • Vagal and spinal visceral afferent neurons
  • Receptive properties and organ regulation
  • Vagal afferent neurons and body protection
  • Muscle Vasoconstrictors & Cutaneous Vasoconstrictors
  • Skin Vasodilators
  • Central control of autonomic function
• Pathological conditions
  • Diabetic Autonomic Neuropathy
  • Synucleopathies
  • POTS
  • Syncope PATHOPHYSIOLOGY
  • Autonomic Hyperactivity
• Cerebral vascular anatomy
  • Circle of Willis
  • Brain arterial vascular territories
  • Midbrain Vascular Territories
  • PCA involvement
  • SCA involvement: Dorsal midbrain syndrome
  • Medial Pontine Involvement: Basilar Artery 
  • Lateral Pontine Involvement: AICA/Basilar
  • AICA Involvement
  • PICA Involvement
• Cerebral Blood Flow
  • Cerebral blood flow- Neurovascular Coupling
  • Cerebral blood flow-Vasoreactivity
  • Cerebral blood flow- Autoregulation
  • Cerebral blood flow- Static vs Dynamic Autoregulation
  • Autonomic regulation of CBF
  • Failures in vasoreactivity
  • Cerebral vasoreactivity via BHT in COVID
• Cardiac Examination
  • Cardiac Exam
  • Cardiac Exam- Abnormal Heart Sounds
  • Cardiac Exam- Murmurs
• Fundoscopy
  • Fundoscopy- Technique
  • Fundoscopy- Exudates
  • Fundoscopy-Retinal hemorrhages
  • Papilledema
• Autonomic Testing
• Head Up Tilt Test
  • Physiological Basis of Tilt Testing
  • Normal Response to Tilt Table Test
  • Tilt Table Test Protocol
  • Tilt Table Test Interpretation
  • Tilt Table Test Safety

MODULE 4

This 3-day program is part four of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part four of this series will cover the following topics:

1. Cerebral Blood Flow
2. Resting sinus arrythmia
3. Valsalva
4. Head up Tilt Test
5. Hand Grip
6. Amaurosis Fougax
7. Peripheral Nerve Exam
8. Neurovisceral Integration Hypothesis
9. Pupillometry
10. Heart Rate Variability
11. The Cerebellum and Baroreflex
12. Brainstem Reflexes

Outline:

• Cerebral Blood Flow
  • Case Study
• Resting sinus arrythmia
  • Methods of Measuring HRV
  • Factors that affect HRVdb
  • Clinical Applications
  • Physiology
  • Technique
  • Interpretation of Deep Breathing Test
  • Cardiovagal function and Atherosclerosis
  • Case Study
• Valsalva
  • Valsalva Maneuver
  • Analysis of Valsalva Waveform
  • Valsalva Maneuver Technique
  • Valsalva Ratio
  • Cerebral blood flow monitoring in Valsalva Maneuver
  • Valsalva Maneuver Interpretation
  • Valsalva Maneuver Recap
  • Valsalva Maneuver Limitations
  • Bedside Valsalva Maneuver
• Head up Tilt Test
• Hand Grip
  • Isometric Hand-Grip Test
• Amaurosis Fougax
• Peripheral Nerve Exam
  • The components of the modified Toronto Clinical Neuropathy Score (mTCNS)
  • The Components of the Utah Early Neuropathy Scale
  • “Pain & Temp Test”
  • Spoon Test
  • Central Pathways of Thermoregulation
  • Quantitative Sudomotor Axon Reflex Test (QSART)
  • Normative Data for QSWEAT device
  • Electrochemical skin conductance
• Neurovisceral Integration Hypothesis
  • Neurovisceral Integration Hypothesis
  • Cortical Control of Cardiac Activity
  • Inhibition as a function of the prefrontal cortex
  • Summary
• Pupillometry
  • Pupil Size as a Window on Neural Substrates of Cognition
  • Pupil size as a function of the PON
  • Pupil size as a function of the LC
  • Pupil size as a function of the SC
  • Case Study
• Heart Rate Variability
  • What is heart rate variability (HRV)?
  • HRV Metrics
  • Frequency Domain Measurements
  • ULF Band
  • VLF Band
  • LF Band-“Baroreflex Band”
  • HF Band-“Respiratory Band”
  • LF/HF Ratio not an index of “sympatho-vagal balance”
  • Time-Domain Measurements
  • Context is crucial when interpreting HRV measurements
  • RMSSD
• The Cerebellum and Baroreflex
  • Basic principles
  • The Vestibulo-sympathetic Reflex
  • Cerebellar-cerebral Connectivity
  • NTS revisited
• Brainstem Reflexes
  • Motor Innervation of the Soft Palate

MODULE 5

This 3-day program is part five of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part five of this series will cover the following topics:

1. Consensus Management
2. Jugular Venous Pressure
3. Passive leg raise
4. Blood flow, breathing and blood gases
5. Heistad’s Dogs
6. Neurovascular coupling in humans: Physiology, methodological advances and clinical implications
7. Vestibular interactions
8. Cervical spine interactions
9. Trigeminal stimulation
10. Vagal Stimulation
11. Water immersion
12. Exertion

Outline:

• Consensus Management
  • Consensus Management POTS
  • Consensus Management Syncope
  • Consensus Management OH
• Jugular Venous Pressure
• Passive leg raise
• Blood flow, breathing and blood gases
• Heistad’s Dogs
• Neurovascular coupling in humans: Physiology, methodological advances and clinical implications
• Vestibular interactions
  • Effects of Postural Alterations on the Cardiovascular System 
  • Detection of Postural Alterations that Affect the Cardiovascular System 
  • Detection of Postural Alterations
  • Vestibulo-Sympathetic Reflexes in Animal Models 
  • Recovery of Posturally-Related Cardiovascular Responses Following Vestibular System Lesions 
  • Neural Pathways that Mediate Vestibulosympathetic Responses 
  • Responses Elicited by Natural Stimulation of Vestibular Afferents 
  • Influences of Vestibular Stimulation on Cardiovascular Regulation in Healthy Individuals: Activation of Otolith Organs
• Cervical spine interactions
  • Cervical integrity and vagal function.
  • Cervical integrity and vertebral artery function.
  • Cervical Myelopathy and Autonomic Function
  • Clinical examination of Cervical Myelopathy
  • Jugular Venous Compression
• Trigeminal stimulation
  • Trigeminal Nerve Control of Cerebral Blood Flow
  • MECHANISMS BEHIND TRIGEMINAL NERVE CONTROL OF CEREBRAL BLOOD FLOW 
  • Antidromic Pathway 
  • Trigeminal Parasympathetic Pathway 
  • Central Trigeminal Pathway 
  • NEUROANATOMICAL BASIS OF TRIGEMINAL NERVE CONTROL OF CEREBRAL BLOOD FLOW 
  • Ophthalmic Division (V1) 
  • Maxillary Division (V2) 
  • Mandibular Division (V3) 
  • THE EFFECT OF TRIGEMINAL NERVE STIMULATION ON DISORDERED CEREBRAL PERFUSION 
  • Hypoglossal stimulation
  • Case Study
• Vagal Stimulation
  • Vagus Nerve Stimulation
  • VNS:Anatomical Considerations 
  • VNS:Stimulation sites
  • VNS:Brain Activation
  • Case Study
• Water immersion
  • HOWI and Matched Hypercapnia 
  • Cerebral Blood Flow During In-Water Exercise 
• Exertion
  • Exertion therapies
  • Case Studies

MODULE 6

This 3-day program is part six of six for clinicians developing an expertise in the diagnosis, management and clinical decision-making in autonomic syndromes.

Part six of this series will cover the following topics:

1. Clinical Rounds as it relates to topics covered in the entire series. 

Outline:

• Clinical rounding
  • Intake procedures
  • History
  • Physical examination
  • Neurological examination
  • Special testing
  • Differential diagnosis
  • Procedures
  • Application of neurorehabilitation
  • Treatment plan and execution
  • Follow-up procedures
  • Referral and co-management