Which tests can be used to assess the autonomic nervous system?
The main autonomic tests (tilt test, active stand, Valsalva, deep breathing, sweat tests): what each one measures and the limits of interpretation.
6sources
4min read
✓Clinical review
Verified9 November 2026
Key points
Autonomic tests answer different questions; they are selected according to the clinical question, and a battery combining several domains is more informative than a single test [1, 2].
Orthostatic measurements, the tilt-table test and the active stand test assess the cardiovascular response to being upright; continuous beat-to-beat measurements may be needed for certain rapid phenomena [3, 2].
The Valsalva maneuver and the paced deep-breathing test assess different components of autonomic cardiovascular reflexes [1, 2].
QSART (quantitative sudomotor axon reflex test), the thermoregulatory sweat test and other sweat tests do not measure exactly the same pathways [1, 2].
Age, medicines, deconditioning, hydration, testing-room conditions and technical artifacts can influence the results [1, 3, 2].
Why assess the autonomic nervous system?
Lying-to-standing measurements and the active stand test
Tilt-table test
Valsalva maneuver
Deep-breathing test
Sudomotor tests: QSART, thermoregulatory testing and other methods
Cheshire WP et al. Electrodiagnostic assessment of the autonomic nervous system: A consensus statement endorsed by the American Autonomic Society, American Academy of Neurology, and the International Federation of Clinical Neurophysiology. Clinical Neurophysiology, 132(2):666–682 2021. DOI: 10.1016/j.clinph.2020.11.024. PMID: 33419664.(guideline or consensus)
Limitations: Practice consensus; indications depend on the clinical context. Population: consensus on autonomic testing. Read: full text.
Declared conflicts of interest: No conflicts of interest declared. Corrigendum published (Clin Neurophysiol 2021;132(5):1194) concerning an author's name
Cortez MM, Cook G, Miglis MG, Raj SR, Robbins NM, Singer W, Sletten DM, Stino AM, Vernino S. Utility and best practices for clinical diagnostic testing of the autonomic nervous system: A Consensus Statement Endorsed by the American Autonomic Society and the American Association of Neuromuscular & Electrodiagnostic Medicine. Clinical Autonomic Research 2026. DOI: 10.1007/s10286-026-01238-9. PMID: 42766240.(guideline or consensus)
Limitations: Expert consensus; not a comparative trial of all strategies. Population: specialist consensus on autonomic testing. Read: full text (open access, Springer).
Declared conflicts of interest: Several authors declare consulting activities or industry funding (notably Argenx, CSL Behring, Takeda); others declare none
Thijs RD et al. Recommendations for tilt table testing and other provocative cardiovascular autonomic tests in conditions that may cause transient loss of consciousness: Consensus statement of the European Federation of Autonomic Societies (EFAS) endorsed by the American Autonomic Society (AAS) and the European Academy of Neurology (EAN). Clinical Autonomic Research, 31(3):369–384 2021. DOI: 10.1007/s10286-020-00738-6. PMID: 33740206.(guideline or consensus)
Limitations: The authors state that this is not a formal evidence-based guideline. Technical recommendations; does not replace the overall clinical evaluation. Population: provocation tests for syncope, OH and related presentations. Read: full text (Leiden University repository).
Declared conflicts of interest: Several authors declare fees or industry funding outside the submitted work (Medtronic, UCB, Novo Nordisk, Boston Scientific…)
Joint Task Force of the EFNS and the PNS. European Federation of Neurological Societies/Peripheral Nerve Society Guideline on the use of skin biopsy in the diagnosis of small fiber neuropathy. Journal of the Peripheral Nervous System, 15(2):79–92 2010. DOI: 10.1111/j.1529-8027.2010.00269.x. PMID: 20626771.(guideline or consensus)
Limitations: Guideline focused on skin biopsy; older, and to be read alongside recent criteria. Population: guideline on the use of skin biopsy. Read: full text (co-publication in Eur J Neurol).
Declared conflicts of interest: No declaration in the text read (co-publication Eur J Neurol 2010;17:903-912)
Devigili G et al. Diagnostic criteria for small fibre neuropathy in clinical practice and research. Brain, 142(12):3728–3736 2019. DOI: 10.1093/brain/awz333. PMID: 31665231.(observational study)
Limitations: Clinical cohorts; criteria depend on the examination and the methods available. Population: reassessment and validation of diagnostic criteria. Read: full text.
Declared conflicts of interest: The authors declare no conflicts of interest; funding: Italian Ministry of Health (Ricerca Corrente)
Hovaguimian A. Dysautonomia: Diagnosis and Management. Neurologic Clinics, 41(1):193–213 2023. DOI: 10.1016/j.ncl.2022.08.002. PMID: 36400555.(expert opinion)
Limitations: Narrative review; not a formal guideline. Population: general clinical review of dysautonomias. Read: abstract.
Declared conflicts of interest: Not reviewed in the part of the source that was read
Written by
AI-assisted literature research (ChatGPT) and AI-assisted writing (Claude)
Editor
Jean Viry-Babel
Review status
Clinical review: Dr Françoise Charmoillaux (anesthesiologist)
Approved on
9 November 2026
Literature search
8 November 2026
Last verified
9 November 2026
Geographic scope
international, United States, France
Audience
everyone
Conflicts of interest
No known financial ties. Separately, the publisher is developing a personal approach to these conditions under the name Connected Conditions, which is not cited here (see the legal notice).
Limitations of this page
General overview of the tests: it does not replace the testing laboratory's instructions or medical interpretation. No instructions on test preparation or on stopping medicines are given.