AUTONOMIC

FUNCTION TEST

~ Nihidha S

Reference:

AIIMS Autonomic Function Testing

Manual
Clinical Neurophysiology UK Misra And J
Kalita

Autonomic Nervous System

Tests Done At Neurobionics Lab,

Jipmer:
Head up tilt-table testing
Deep breathing
Valsalva maneuver and Valsalva ratio
cardiovascular response to standing
Miscellaneous tests :
BP response to sustained handgrip
BP response to mental stress
Cold pressor test
Sympathetic skin response

Preprocedure

No fasting.
have food before two hours
of the test
will avoid food for
preceding two hours before
the test.
remain relaxed throughout
the test
Stethograph should be
placed around the chest in
the fourth intercostals
space where respiratory
excursion is highest
Both ECG and respiratory
recording should be taken
throughout the test
Baseline recording of least
30sec before each test is

ECG electrodes are applied

on the subject after proper
cleaning of the skin.
Black left upper limb
White- right upper limb
Green earth

Parts of the machine

3 ECG electrodes + 2
electrodes (SSR)
Finometer
Tilt table
Sphygmomanometer
Handgrip
dyanamometer
Ice pack

The Finometer MIDI can be connected to a

PowerLab (using a standard BNC cable) to
record, display and analyze the brachial arterial
pressure and beat-to-beat values of systolic,
diastolic and mean blood pressure using
LabChart software. As only one PowerLab input
channel is used to acquire the finger pressure
waveform, other instruments, such as
amplifiers and transducers, can be used to
record additional signals using the
remaining PowerLab inputs.
The optional Blood Pressure Module can be
used to automatically extract blood pressure
parameters, after recording data or in real time.
Included with the Finometer MIDI:
Front-end unit featuring an
infrared plethysmograph, air pressure control
valve and pressure transducer.
Small and Medium Finger Cuffs
Height Correction Unit

Head up tilting
STIMULUS

BP upright posture

AFFERENTS

Baroreceptors CN IX, X

EFFERENT

sympathetic

NORMAL RESPONSE

BP maintained

PROTOCOL:
Baseline ECG and BP are recorded in
supine position for 5 mins.
The patient is positioned at an incline of
60 from horizontal on a tilt table with a
footboard for weight bearing.
Monitored for 10mins


o
o

RECORDING:
Baseline ECG and BP for 5mins
Continuous monitoring for 10mins
PHYSIOLOGY OF THE TEST:
testing the integrity of autonomic cardiovascular and
neurocardiogenic reflexes.
Orthostatic hypotension
recumbent to upright position on a tilt table - 25-30%
shift of venous blood from the central to the peripheral
compartment - occurs within seconds.- decreased
cardiac filling pressure, stroke volume by 40%
This decreased afferent activity from the sensory
baroreceptors and the heart rate rise are due to
withdrawal of parasympathetic activity and later due
to increasing sympathetic activity.
The sympathetic activity increases the vascular tone
and total peripheral vascular resistance
BP and HR are generally maintained.

Heart Rate Variation With Respiration

(Deep Breathing Test)
STIMULUS

Deep and regular breathing at the rate of 6 cycles per

minute

AFFERENTS

central

EFFERENT

Parasympathetic (cardiovagal, cholinergic)

NORMAL
RESPONSE

Inspiration - increase in HR
Expiration decrease in HR

PROTOCOL:
Instruction
Breathing should be smooth, slow and deep
Hand signal is given to maintain the rate and timing of the
breathing.
6 cycles per min, inspiration 5 sec, expiration 5 sec.
. If cycles are not appropriately done, it is repeated to get
compete 6 cycles

RECORDING:
o Baseline ECG and respiration taken for 30 sec.
o Then deep breathing test is started
o Respiration and ECG is recorded continuously
CALCULATIONS:
Delta HR: difference between the maximal and
minimal HR during inspiration and expiration
respectively, averaged for 6 cycles.
E:I ratio: ratio of the longest R-R interval and
shortest R-R interval averaged over 6 cycles.
NORMAL VALUES:

Delta HR

E:I ratio

Normal

15 bpm

1.04

Border line

11-14 bpm

Abnormal

10 bpm

PHYSIOLOGY OF THE TEST:

The variation of HR with respiration sinus
arrhythmia mediated by vagus. The neuronal
output from the respiratory centre - afferent and
nucleus tractus solitarius - efferent outputs.
Pulmonary stretch receptors, cardiac
mechanoreceptors, baroreceptors contribute in the
regulation of HR variation.
FACTORS KNOWN TO AFFECT DBT:
- age, hyperventilation, hypocapnia, increasing
resting HR, cardiac failure, pulmonary disease, CNS
depression
In patients with autonomic failure syndromes such
as multiple system atrophy and progressive
autonomic failure, abnormalities are detected in 8085% of patients.

Valsalva Maneuver And Valsalva Ratio

STIMULUS

Forced expiration through open glottis

AFFERENTS

Baroreceptors and cranial nerves IX and X

EFFERENT

Parasympathetic (cardiovagal, cholinergic)

sympathetic (adrenergic)

NORMAL RESPONSE

PHASE I - BP, HR
PHASE II - BP, HR
PHASE III - BP
PHASE IV - BP, HR

PROTOCOL:
sitting position
Patient blows into a mouth piece attached to
sphygmomanometer
Expiratory pressure is kept at 40mm Hg for 15 seconds
At the end of 15 seconds the pressure is released
Forceful blow to maintain the level
Patient should Avoid deep breath before and just after
Due care is taken to prevent deep breathing before and


o
o
o

o
o

RECORDING:
Baseline values ECG, HR, BP 1 min
Then continuously recorded during the maneuver
30-45 seconds following release of respiratory
strain.
CALCULATIONS:
Valsalva Ratio: longest RR interval during phase
IV/shortest RR interval during phase II
Tachycardia Ratio: shortest RR interval during the
maneuver/longest RR interval before the
maneuver.
Bradycardia ratio: longest RR interval during the
maneuver/longest RR interval before the
maneuver
NORMAL VALUES:
VR > 1.21

PHYSIOLOGY OF THE TEST:

Test involves forced expiration through open glottis.

Phase I: When forced expiration is started the BP rises for a
few beats along with decrease in HR increase in RR interval.
Phase II: with continued strain at 40 mmHg - venous return
becomes very low - drop in the BP- baroreceptor reflex is
initiated - vagal withdrawal and sympathetic stimulation- HR
increases (RR interval decreases).
Phase III: On the release of the respiratory strain, the blood
pressure drops suddenly for few beats
Phase IV: there is rise in BP due to sudden increase in the
venous return leading to overshoot above the baseline values.
Due to baroreflex, this rise is associated with the decrease in
HR (increase in the RR interval)
Changes in BP during phase I and III purely mechanical events
Rise in HR during II mediated initially with vagal withdrawal and
subsequently by increase in sympathetic outflow.
The decrease in HR in response to overshoot in phase IV is
mediated by baroreflex(vagal).

FACTORS

KNOWN TO AFFECT VALSALVA RATIO:

Age

: VR
Position of the patient
Expiratory pressure: VR
Duration of the strain: duration lesser than 15 sec
decreases VR
Medications
CONTRAINDICATIONS:
Diabetic

retinopathy
Proliferative degenerative retinopathy
papilloedema

Cardiovascular Response To Standing

And 30:15 R-r Ratio
STIMULUS

Change of posture from lying to standing

AFFERENTS

Baroreceptors and cranial nerve IX & X

EFFERENT

Sympathetic (adrenergic), parasympathetic

(cardiovagal, cholinergic)

NORMAL
RESPONSE

Initially, increase in heart rate followed by decrease in

heart rate. Fall in blood pressure.

PROTOCOL:
Instruction
Conducted after 10 min of supine test
Standing posture for 5mins
Not hold anything during standing

RECORDING:
o BP
o HR
recorded at baseline and serially at 0.5th , 1st,
2nd, 2.5th and 5th min.
CALCULATIONS:
30:15 ratio: the ratio between the longest R-R
interval at or around the 30th beat and the
shortest R-R interval at or around the 15th best.
NORMAL VALUES:

fall of systolic
BP

30:15 ratio

Normal

10 mm Hg

1.04

Border line

11-29 mm Hg

1.01-1.03

Abnormal

30mm Hg

1.0

PHYSIOLOGY OF THE TEST:

Change of posture puts hydrostatic
stress on the venous return.
venous decrease due to pooling of
blood in lower limb decrease BP
baroreflex increase HR (between
10-20sec) increase BP
The recovery of BP results in
decrease in HR later (25-35sec)
CONTRAINDICATIONS:
Severe orthostatic hypotension (fall
in SBP > 35-40 mm Hg), unstable
cardiovascular disease, pregnancy

BP Response To Mental Stress

STIMULUS

Arithmetic

AFFERENTS

None

EFFERENT

sympathetic (adrenergic)

NORMAL RESPONSE

BP

PROTOCOL:
The patient is asked to do arithmetic calculations.
Such as 100-7 or 20-3
The BP values are noted

BP Response To Sustained Handgrip

STIMULUS

Isometric exercise

AFFERSTS

Muscle afferent

EFFERENT

sympathetic (adrenergic)

NORMAL RESPONSE

BP, HR

PROTOCOL:
proper instruction and demonstration to use handgrip dynamometer
Asked to grip using maximum force with their dominant hands for few
seconds.
Three times its repeated and values are noted.
Maximum value is considered as their maximal voluntary contraction
(MVC)
Patient is asked to maintain 30% of MVC of sustained grip for 4 minutes.

RECORDING:
BP is measured on the contra lateral arm during
and after the test.
CALCULATIONS:
Highest DBP during the test- baseline DBP
NORMAL VALUES:
increase DBP
Normal

16mm Hg

Borderline

11-14mmHg

abnormal

10mm Hg

Rise is relatively independent of age and

decreased in diabetic and uremic neuropathy.

PHYSIOLOGY OF THE TEST:

voluntary muscle activity is associated with
sympathetic outflow to the cardiovascular system to
increase the HR and blood pressure.
The rise in HR is also due to parasympathetic
withdrawal and excitation of other central
command.
The accumulation of metabolites during the
isometric contraction initiates the exercise reflex
resulting in sustained sympathetic activity,
isometric exercise is associated with rise in diastolic
pressure.

Cold Pressor Test

STIMULUS

Immersion of hand in ice cold water

AFFERENTS

Nociceptive and cold receptor, pain and temperature

pathways

EFFERENT

sympathetic (adrenergic)

NORMAL RESPONSE

BP

PROTOCOL:
immersion of hand in ice cold water for 1 min.
Proper instruction is required


o
o

RECORDING:
Baseline ECG and BP taken for 30 sec.
BP is recorded
CALCULATIONS:
highest DBP during the test baseline DBP
NORMAL VALUES:
increase in DBP 10 mm Hg
PHYSIOLOGY OF THE TEST:
The cold water causes stimulation of cold receptors and
pain receptors in the hand. The information is carried to the
brain through spinothalamic pathways. The reflex involves,
rise in sympathetic outflow to the vasculature and heart
resulting in rise in blood pressure.

In patients with afferent small-fibre neuropathy or

spinothalamic tract dysfunction or with central or efferent
sympathetic lesions, such as in diabetic or alcoholic
autonomic neuropathies, the responses to CPT are
diminished or even absent.

PRECAUTIONS:
Do not touch the bottom of the cold water bath
Monitored properly for 1 min
Time interval for the BP measurement during the
test and after the test should be appropriately
followed
If subject feels severe pain after immersion of
hand in cold water hand should be taken out
before 1 min
Subjects hand should be properly covered with a
towel after he takes his hand out from cold water.
CONTRAINDICATIONS:
coronary artery disease, severe hypertension

Sympathetic Skin Response

STIMULUS

Electric stimulation or clap

AFFERENTS

Somatosensory and others

EFFERENT

sympathetic (adrenergic)

NORMAL RESPONSE

Skin potential

PROTOCOL:
Method 1: electric stimulation:
Electrode placement: active electrode: brown
palm mid aspect
Reference electrode: Red dorsum middle
Stimulation : contra lateral limb
Method 2: clap and note the response

RECORDING:
o BP and HR
o Skin temperature
o Monophasic, biphasic or
triphasic
and varies from stimulus to
stimulus
o Symmetric in homologous body
regions
o Have higher amplitude and
shorter latency in hands
compared to feet

Upper limb
latency
NORMAL

Amplitude

1.6 0.1 s
VALUES:
1.3 0.2mV

Lower limb
2.1 0.1 s
0.8 0.1mV

PHYSIOLOGY OF THE TEST:

Useful in studying the integrity of peripheral
sympathetic cholinergic (sudomotor) function by
evaluating the changes in resistance of skin to
electric conduction. The changes are regulated by
the sweat gland of dermis and may be generated by
presecretory rather than secretory activity, SSR may
be elicited either directly or reflexly.
On direct response, obtained by stimulating a
peripheral nerve but is not used in clinical practice
because of high threshold of sympathetic trunk for
activation of unmyelinated C fibers and simultaneous
activation of pain fibers.

In patients with multisystem atrophy and

progressive autonomic failure, abnormalities in
SSR have been reported.

Thank You!!