Postural tachycardia syndrome (POTS). Not everyone could have the same studies done because of insurance issues, COVID-19 restrictions and determinants-of-health issues, Dr. Wilson explains. Amber M.S. Once their exercise tolerance improves, "they no longer need to rely on the drug," she says. Ask for help if you need it. People with a confirmed case of Covid had not been vaccinated. I can be so out of it at times that when I talk it sounds like Im drunk. Unfortunately, there's nothing you can do to prevent developing POTS. A small double-blinded, placebo-controlled study published this year in the Journal of the American College of Cardiology found ivabradine significantly lowered the heart rate of patients, including 22 people with POTS. "Vaccines continue to be an important strategy to fight against Covid and its effects," he said. For an optimal experience visit our site on another browser. The elevated heart rate isn't necessary.". In those with POTS, this function typically performed by the ANS doesnt work as well, so blood tends to pool in their lower extremities upon standing. Cleveland Clinic 1995-2023. Finally, post-COVID POTS may result from activity of the immune system. Sleep difficulties - 26 percent. | But drinking extra fluids alone isn't enough. Her approach fits with some preliminary research from Vanderbilt University that found POTS symptoms get worse after meals rich in carbohydrates. Chung at Johns Hopkins agrees that the onset of POTS following COVID-19 is likely "autoimmune" in nature. Another diagnostic test is a cutaneous nerve biopsy to look at the small fiber nerve in the skin which makes up the autonomic nervous system to look for nerve damage. Ormiston CK, et al. They cant sleep., While usual POTS treatments include hydration, salt, compression stockings and exercise, patients with COVID-19-associated POTS often also require a beta-blocker. Parker WH, et al. 6. In addition, she continued to feel a tightness in her chest, and the brain fog was so intense at times, she says, she couldn't remember a four-digit code for her phone. This happens when your bodys autonomic nervous system, which should work automatically, fails to control your blood pressure and heart rate to make up for your change in posture. Your primary care provider can help you manage POTS, but so can cardiologists, neurologists, post-COVID clinics and more. We do not endorse non-Cleveland Clinic products or services Policy. Research on POTS conducted before the COVID-19 pandemic further indicates that the syndrome can be associated with various chronic conditions, including diabetes, sarcoidosis, and lupus, as. Now though, when he wakes. It moisturizes the nose while flushing out allergens and mucus, says John Craig, M.D., an ear, nose and throat (ENT) surgeon who specializes in nasal . It can be difficult to talk openly about these more embarrassing symptoms, but in doing so, were both raising awareness of these symptoms are reminding other POTS warriors that theyre not alone. After having COVID-19, 2% to 14% of people are diagnosed with POTS. Hannah W. My friends make a joke about how I always have to have the entryway to a bathroom anywhere we go but its tough too because I am always having to leave to pee. All rights reserved. Hair loss - 22 percent. Heres what our community shared with us: Since temperature regulation is controlled by the autonomic nervous system, autonomic dysfunction (including POTS) can make it difficult for the body to maintain an even temperature. After an initial positive COVID-19 . The PT regimen emphasizes floor exercises and strength training to avoid sudden positional changes that may exacerbate her symptoms. A normal heartbeat for an adult ranges between 60 and 100 beats per minute. "The risk of this happening is much greater with Covid than it is with the vaccine. he extreme body temperature drops I experience. fatigue. Talk to your doctor if you notice any of the above symptoms. Still, the myocarditis risk is significantly higher after a Covid infection than after vaccination. We avoid using tertiary references. It can be hurtful if others make assumptions or judgments simply based on looks. You can get up and sit down without a thought. You do you! (2022). Passing out in the middle of a crowd or waking up to a group of concerned onlookers can be uncomfortable, but it can also be scary to lose consciousness, whether youre alone at home or out and about. Nausea/Vomiting. Just know you are beautiful, no matter what shade your cheeks may be. Their bodies are much more revved up, in fight-or-flight mode, he explains. When the Doctor Is a Covid 'Long Hauler'. "Normally I'm very active. All Rights Reserved. POTS has overlapping features with chronic fatigue syndrome, including fatigue and brain fog, and experts who treat it say POTS has had some of the same challenges as CFS in gaining recognition. "Some patients with brain fog benefit from stimulant medication, for instance," he says. Isolation. All but one of the 39 patients with POTS following COVID-19 had mild COVID-19 cases, and 32 (82%) were women. Yesenia R. Orthostatic intolerance the defining characteristic of POTS means that the blood pressure does not remain stable when a person goes from lying down or sitting to standing. A larger number of people, 9% to 61%, may have POTS-like symptoms that usually occur when moving to an upright position. No. POTS isnt well-known. "The immune system is confused," he says, causing the misdirected attacks. Tae Chung, M.D., is a neuromuscular specialist and rehabilitation physician, and director of the Johns Hopkins POTS Program. Jessica Bortz Schaap developed a rash on her neck months after her COVID . Our Mighty community is always here for you as well. Thats because some people who recovered from COVID-19 seem to have POTS-like symptoms like: It appears that anyone who has had COVID-19 can get POTS, whether the virus initially caused serious symptoms or mild ones. After a POTS diagnosis, there are a few treatment routes. Privacy COVID-19 vaccination might induce postural orthostatic tachycardia syndrome: A case report. A small number of children who received the Pfizer-BioNTech vaccine have reported swelling in the heart. Sometimes the symptoms can even go away or come back again. "Just standing up to make a sandwich, my heart rate would be 120," recalls Minhas, a 54-year-old nurse who lives in San Diego. Although Im glad we can find some humor in this wild chronic illness life. It doesnt happen often, but when it does its frustrating! POTS happens when your heart rate increases by at least 30 beats per minute within 5 to 10 minutes of moving to an upright posture. But the COVID-19 pandemic has brought new attention and many new diagnosed cases. What to do if your COVID-19 fatigue lasts a long time or gets worse: "I would definitely recommend that anyone experience post-COVID fatigue talk to their primary care physician," says Dr. Lago. You May Be at Less Risk if Youve Had Omicron Variant, How to Work with Your Doctor to Prevent Heart Disease, 3 Best Heart Health Tests to Take at Home. According to Stuart Berger, M.D., the executive director of the heart center and interim division head of cardiology at Ann & Robert H. Lurie Childrens Hospital in Chicago, POTS is most likely a syndrome in the realm of autonomic dysfunction. Johns Hopkins Medicine: Diagnosing Postural Orthostatic Tachycardia Syndrome, COVID-19 and POTS: Is There a Link?, Kaiser Family Foundation: Little-Known Illnesses Turning Up in Covid Long-Haulers., Stanford Health Care: Postural Orthostatic Tachycardia Syndrome (POTS)., Immunologic Research: Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: a case series of 20 patients.. While it may feel a bit awkward at times to run at a different temperature than your friends, know theres no reason to feel ashamed for doing whatever you need to do for your health. For some, it makes everyday life challenging. Third, it reaffirms that POTS occurs at a high rate after. "Some may feel consistently tired and fatigued. I avoid talking to new people at all costs and sometimes even limit speaking to those close to me to save myself the embarrassment. Pandemic research may provide treatment clues for both. Post COVID-19 care: Here are 6 things you need to after having recovered from coronavirus infection 1. Around 2.5% of people are still coughing a year after being infected with COVID. Some patients are so disabled by POTS that it's hard for them even to stand up. Gall NP, et al. POTS can be treated with at-home strategies and, if necessary, medications. In the short-term, if you feel lightheaded or dizzy, sit or lie down right away. Current research shows that its still possible to have lingering POTS symptoms several months after COVID-19. She spends much of the day in bed or on the sofa, because the fatigue, headaches and lightheadedness have been so intense. ", Minhas, with her 8-month-old puppy Murphy, says she felt relief after getting diagnosed with POTS, a blood circulation disorder, and her health is improving slowly with treatment. After COVID-19, 9% to 61% of people have POTS symptoms. Doctors are studying an unexpected coronavirus complication that can appear a few weeks or even months after the initial COVID-19 infection. Eventually, physical therapy is key, but it often takes months before patients respond to treatment sufficiently to be ready for a physical therapy regimen. When you move to an upright position, gravity causes blood to travel to your lower body. But she persevered, determined to "dig in and look for answers.". It's not clear yet whether patients are developing POTS after COVID-19 for some reason above and beyond why any other infections trigger POTS, or whether it's just that we're seeing a lot. Many researchers suspect that POTS may be an autoimmune disorder, caused by the body's immune system becoming overzealous. Dr. Anderson has seen POTS go away on its own for some people. To evaluate the effects of physical training in patients with POTS after Covid-19 a single subject design will be used (the patient is their own control). In addition to blood tests to assess overall health, this can include heart diagnostics such as: If POTS is suspected, tests can be done to assess how heart rate and blood pressure change when you move into an upright position. "I am up to drinking a gallon of water a day," says Michaelene Carlton, 47, who was recently diagnosed with POTS by Chung. Whatever symptoms or side effects of POTS you may be struggling with, know youre not alone. If you have a problem with the autonomic function it can affect each and every organ.. Sometimes I can look like Im under the influence. What you need to know from Johns Hopkins Medicine. Some patients may only have mild symptoms, whereas others may have severe symptoms that affect their quality of life. After 2-3 weeks I was starting to feel better, but then this constant dizziness, not vertigo, came on me and hasn't left. The predominance of women aligns with that for POTS in general. 16 December 2021 | Q&A Most people who develop COVID-19 fully recover, but current evidence suggests approximately 10%-20% of people experience a variety of mid- and long-term effects after they recover from their initial illness. Berkeley Lovelace Jr. is a health and medical reporter for NBC News. Its embarrassing to all of a sudden look like you dont know how to walk and your hands go limp or curl in due to nerve malfunction/spasticity. Tara Pixley for NPR have been linked to a small risk of myocarditis. The autonomic nervous system regulates functions we dont consciously control, such as heart rate, blood pressure, sweating and body temperature. The good news with this condition, however, is that more recent studies have shown that it might not be as common . Key Takeaways Reports show that long COVID may be linked with an autonomic disorder called postural orthostatic tachycardia syndrome (POTS). "Some people switch from two glasses of water a day to eight or more glasses of water, and POTS goes away," says Dr. Anderson. "I would wake up in the middle of the night with burning hands and feet, and I would look down and my feet would be bright red," Minhas says. And as she slowly improves, she has become involved in efforts to raise awareness about the condition, and the need for research to understand better all of the post-COVID-19 illnesses. It can be a response to an emotional state, or a sign of an underlying medical issue if its recurring. Its still unclear. Getting regular checkups is key when it comes to reducing your risk of heart disease and catching issues early before they cause serious complications. Onset of postural orthostatic tachycardia syndrome (POTS) following COVID-19 infection: A pediatric case report. Others may experience GI issues in conjunction with other symptoms, such as fainting. The link between an infection including Covid and POTS, however, is more well-established. Though the exact mechanisms behind POTS-related fatigue are not well understood, some believe people with POTS tend to be more exhausted because the heart has to work harder to pump blood throughout the body. "Millions of long-haulers and people living with other forms of post-viral dysautonomia are counting on the research community to figure this out so they can get back to living their lives," Stiles says. Posts: 1. The symptoms of POTS include but are not limited to lightheadedness (occasionally with fainting), difficulty thinking and concentrating (brain fog), fatigue, intolerance of exercise, headache, blurry vision, palpitations, tremor and nausea. "We're seeing a spectrum of symptoms after acute. Author: Office of Public Affairs Informacin en espaol. A series of recent studies identified COVID-19 side effects that might never go away, as well as one annoying coronavirus symptom that can linger for weeks after an infection is cleared. Malfunction in any of these areas can produce symptoms that can be shared by numerous conditions. Obtain psychological support and join support groups to help manage. Postural orthostatic tachycardia syndrome (POTS) and other autonomic disorders after COVID-19 infection: A case series of 20 patients. But some people experience it for longer and with a rapid and persistent rise in heart rate.This is called "postural orthostatic tachycardia syndrome" (POTS). Currently, researchers may define post-acute COVID-19 as symptoms extending beyond 3 weeks since onset and chronic COVID-19. Browse through our medical image collection to see illustrations of human anatomy and physiology, Rohini Radhakrishnan, ENT, Head and Neck Surgeon, Postural orthostatic tachycardia syndrome, Dysfunction of the heart or blood vessels, Genetic predisposition (positive family history), Increased heart rate of over 100 beats per minute within the first 10 minutes of standing. Jennifer Minhas had been a nurse for years when she contracted COVID-19 in 2020. 1996-2023 MedicineNet, Inc. All rights reserved. People with post-COVID conditions can have a wide range of symptoms that can last weeks, months, or even years after infection. POTS can be triggered by a number of things like infection or surgery. Here are our three favorite test kit options, how to take. Plus 5 more hypertension questions. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. The ideal situation would be if everybody got the same uniform testing. Its unclear how exactly COVID-19 can lead to POTS. hen you have a systemic issue such as an autonomic issue, it can manifest in so many different ways, and every patients a bit different, Berger said. Now, POTS is being diagnosed among long COVID patients. In contrast to the predominant orthostatic hypotension seen in other people with POTS, those with COVID-19-related POTS typically swing from highs to lows in blood pressure and heart rate. You should talk to your doctor if you have had COVID-19 and are experiencing ongoing symptoms, including: Your doctor will first try to rule out other complications. Having to sit or lie down in the middle of a store when the presyncope or extreme fatigue and weakness hits. The findings from some of the case series suggest that treating the condition can be challenging. Not because theyre crazy, but because theyre in a hypersympathetic state., He and his colleagues plan to publish their findings after longer follow-up, focusing on the patients whose POTS was diagnosed using a tilt table. Alyssa A.A. To learn more about POTS, check out the following stories from our community: Whats an embarrassing symptom of POTS you experience? It's where you lay on a special table, and then the table slowly rotates up to where you'd be standing. Some studies have also found that vestibular symptoms, including dizziness, vertigo and gait unsteadiness, are common in those with POTS. These patients need sleep hygiene, mindfulness work, wellness modalities, Dr. Wilson says. Taking a heart health test at home is a convenient way to conduct a much-needed checkup. I am a physician who . Treatment of POTS will vary for each patient, depending on the type, severity and cause of the condition. Jennifer Minhas had been a nurse for years when she contracted COVID-19 in 2020. POTS has been associated with COVID-19. She's also pedaling on a recumbent bike to regain some aerobic capacity. Short of that, we thought the best we could do was identify patterns." Indeed, several patterns emerged. Sometimes, POTS can be managed at home by doing the following: If the above strategies arent effective at improving your symptoms, a doctor may suggest trying a medication. A leading theory for why COVID-19 long-haulers develop the syndrome is that "the antibodies produced after COVID may attack the autonomic nervous system," says Taub, the UC San Diego cardiologist. Anecdotally, Dr. Wilson sees differences between POTS that is and isnt related to COVID-19. Anxiety/depression - 23 percent. Coping with the more visible symptoms of your condition can sometimes be tough, but know its OK to sit down and take time to rest and recover if you need to. If you test positive for COVID-19, stay home for at least 5 days and isolate from others in your home. Have you ever felt dizzy after standing up too fast? "It was disconcerting," Minhas says, and "lingering way too long without a proper answer." If you have persistent symptoms after being ill with COVID-19, make an appointment with a doctor. He said POTS cases may be developing in patients with long-COVID because of hypoxia or the low oxygen that patients with virus experience or due to chronic dehydration or immune disorders. Ashley V. Since every POTS patient is different, some may primarily experience gastrointestinal symptoms, such as nausea, vomiting or poor feeding, Berger explained. Flushing very noticeably and easily! "Little by little" is her motto, she says. Many of the early patients were healthcare workers, he notes. Micca H.B. In many situations, POTS slowly improves as time passes. Insider's takeaway Long COVID may contribute to POTS, a condition where your body has trouble regulating its own heart rate and blood pressure when you change posture. There are some medications that your doctor can prescribe to control heart rate. Many long COVID symptoms overlap with those of POTS. The drug has helped Minhas, the nurse in San Diego, although she pays for it out of pocket because her insurance company denied coverage. Once other lingering conditions are ruled out, you may be referred to a specialist to start the process of getting diagnosed with POTS.. Other reported cardiac complications from COVID-19 include myocarditis, an inflammation of the heart muscle that can weaken it and lead to heart failure and, in some cases, sudden death. According to the CDC, these effects can include severe weakness, problems with thinking and judgment, and post-traumatic stress disorder (PTSD). NIH Director Francis Collins says the goal is to "identify the causes of long COVID, to develop ways of treating individuals who don't fully recover, and, ultimately, to prevent the disorder.". There, youll also find thoughts and questions by our community. Chung at Johns Hopkins agrees that the onset of POTS following COVID-19 is likely "autoimmune" in nature. Some researchers believe that coronavirus can be a trigger for POTS, as an increased number of people who recovered from COVID-19 are now experiencing POTS-like symptoms, such as brain fog, tachycardia (increased heart rate) and severe chronic fatigue. Another recommended treatment for POTS patients is to drink lots of fluids. POTS can cause a variety of symptoms, from fainting to fatigue, and it can seriously interfere with day-to-day functioning. None of these individuals had been hospitalized while they were ill with COVID-19. Either way, you can get help from an experienced physician to manage your symptoms. It's also known as postural orthostatic tachycardia syndrome. At this point, there is no one standard approach to post-COVID patients with POTS-like symptoms, and treatment should be personalized, based on the diagnosis. Check if it's postural tachycardia syndrome (PoTS) If you live with POTS, youre likely familiar with the wide range of frustrating symptoms the condition can cause. Until recovery takes place, treatment can be helpful. POTS is a debilitating condition that causes your heart to speed up by at least 30 beats per minute after you move from sitting or lying down to standing. Doctors hope continued research into long-haul COVID-19 could demystify a symptomatically similar disorder. Blood pooling/swelling. Experts say a small slice of people with long-haul COVID-19 have symptoms of dysautonomia, though its prevalence is unknown. POTS can be triggered by a variety of conditions, including viral or bacterial infections. 1996-2023 MedicineNet, Inc. All rights reserved. A debilitating chronic condition is being linked to COVID-19. Wear a high-quality mask if you must be around others at home and in public. For months, she and her doctors struggled to understand what was behind her fatigue and rapid heartbeat, among other symptoms. There is some evidence that the coronavirus that causes COVID-19 may also trigger a condition called postural orthostatic tachycardia syndrome (POTS) in people with long-haul COVID-19 (people who have recovered from the initial illness but still have lingering symptoms). Masks are required inside all of our care facilities, COVID-19 testing locations on Maryland.gov, Coronavirus Symptoms: Frequently Asked Questions, Spiking pulse rate with minimal or mild physical activity. I think dont give up is probably one of the most important principles of the treatment, Chung explains. Be sure to tell your doctor if youve had (or suspect youve had) COVID-19. This puts them at risk for severe conditions like stroke or heart attack. "Within a couple of days, I started feeling better," she says. Experts speculate that COVID-19 antibodies may be targeting the autonomic nervous system, which can cause POTS after an infection. It's been 2 1/2 weeks, but seems like an eternity. This allows the upper part of your body to get enough blood. "I had profound fatigue," she says, along with brain fog, headaches and a rapid heartbeat, especially when she changed positions from lying down to standing up. And exercise is tough, too, because "exercise requires a lot of blood flow to the muscle," he explains. joint or muscle pain. (2022). Therefore if there is an abnormality in this system it can affect any and all systems and can manifest in a multitude of ways.. Kacee A.W. Many colleges were shifting away from requiring ACT or SAT scores long before COVID, arguing in part that exam scores can contribute to inequities . As with any viral infection, COVID-19 can temporarily worsen POTS symptoms, which could make recovery harder. Ansley D.M. Their most common symptoms were the following: These patients most frequent pre-existing comorbidities were chronic migraine (in 38%), inflammatory bowel syndrome (IBS) (23%), Raynauds phenomenon (18%) and fibromyalgia (13%). (2022). I cant keep my head turned in that position because Ill pass out. "Young women complaining about multiple symptoms are often told 'it's all in your head' before an autonomic nerve disorder like POTS would even be considered," Stiles says. Chung uses a combination of tests and symptom history to diagnose POTS, including a tilt-table test. Its unclear what exactly causes POTS to occur. Bryarly M, et al. Is Heart Disease More Common in African Americans? Carlie L.W. Schaffner agreed, saying the event following vaccination is "rare.". And the average patient saw over seven doctors before they were diagnosed with POTS. Physicians often fail to recognize the condition, experts say, because it can be confused with a myriad of other health problems, including anxiety and dehydration. Research published Monday has confirmed a link between a Covid infection and a debilitating heart condition called POTS, or postural orthostatic tachycardia syndrome, that has been diagnosed in. stomach upset. It's not just COVID toes: Coronavirus long-haulers are also getting red, scaly rashes a sign of lingering inflammation. Brain fog. Last medically reviewed on November 1, 2022. COVID-19 and postural tachycardia syndrome: A case series. Blitshteyn S, et al. Presyncope/syncope standing up and never knowing if I will pass out, fall backwards, fall into things, plus grabbing the walls or door frames to hold myself up. Terms. Cholesterol is one of those buzz words that has always seemed to carry a negative connotation when it comes to your health. Its also possible for POTS to develop after a traumatic event. However, many felt as if their symptoms had improved with treatment, which included at-home care, medications, or both. Lesley Kavi GP and chair of PoTS UK says: Postural tachycardia syndrome, also known as postural orthostatic tachycardia syndrome (PoTS), is a condition that causes an abnormal increase in your heart rate after sitting up or standing up. At first, her primary care doctor thought it was anxiety. Postural orthostatic tachycardia syndrome (POTS) appears to be a component of long COVID in some people following even mild SARS-CoV-2 infection, a large case series suggests. Kokorelis C, et al. The extreme body temperature drops I experience. Sep 26, 2022 1:00 PM. The POTS program at Johns Hopkins brings together specialists in rehabilitation, cardiology, neurology, physical therapy and other fields to provide well-rounded care for POTS patients. Before her COVID-19 infection about a year ago, Carlton, who lives in Magnolia, Del., was active. Be patient with yourself Joined: 2 years ago. At the same time, POTS can be very debilitating and requires specific treatment, so an accurate diagnosis is vital. You asked, we answered: Should I take a baby aspirin to prevent heart attack or stroke? Lifestyle has a big impact on brain health. Blood pooling can cause your lower legs and feet to change color, turning shades or red or purple. According to Berger, every POTS patient is different and may experience different manifestations of autonomic issues. However, fainting at the wrong time can be dangerous. IE 11 is not supported. Cleveland Clinic is a non-profit academic medical center. Medication, physical therapy, diet can all bring relief. Since every POTS patient is different, some may primarily experience gastrointestinal symptoms, such as nausea, vomiting or poor feeding, Berger explained. Others may experience GI issues in conjunction with other symptoms, such as fainting. Postural orthostatic tachycardiasyndrome: Chadda KR, et al. Still, even before COVID-19, there were often long delays between the onset of symptoms and getting a diagnosis. Elizabeth M. Sweating is one of the bodily processes controlled by the autonomic nervous system, so those who have POTS or other autonomic disorders may experience either excessive sweating (hyperhidrosis) or a lack of sweating (anhidrosis). Dr. Daniel Dudenkov, a physician at the Mayo Clinic, said that although Covid vaccines may be associated with POTS, it is important to keep in mind that Covid infection itself is much more likely to lead to POTS. Berger explained: [POTS] is typically treated with supportive care but some of the mainstays of therapy include assuring adequate hydration status and promoting aerobic exercise. POTS can occur in both sexes and at any age, but it is more common in women between 15 and 50 years of age. A 2022 review notes that an estimated 2% to 14% of people who've had COVID-19 may experience POTS in the months after their illness. You may get dizzy and even faint. One of the signs of COVID-19 disease is a loss of taste and smell. For months, she and her doctors struggled to understand what was behind her fatigue and rapid heartbeat, among other symptoms. Whats the connection between POTS and COVID-19? Some who get hit hard by the initial illness or by the initial long Covid bout have a slow, gradual recovery. And while theres no reason to feel ashamed of any symptoms or side effects you experience, the reality is that it can still feel embarrassing sometimes when autonomic dysfunction causes you to suddenly faint in public or sweat uncontrollably during an important work meeting. Post-COVID conditions may not affect everyone the same way. POTS predates the pandemic. "It's slow going," Carlton says. The symptoms can be vague, he says. Prior to the COVID-19 pandemic, POTS was estimated to affect about 500,000 people in the United States. We knew when the pandemic started in March 2020 that we would see more POTS cases, although I dont think we anticipated this level of magnitude, says senior investigator Robert Wilson, DO, a neurologist in Cleveland Clinics Neuromuscular Center. A growing number of people are facing mountains of frustration over health problems that linger after COVID-19 with no clear path to improvement.