PoTS Archives - Unity Physiotherapy and Wellbeing

The Window of Tolerance and Chronic Illness

Ann Parkinson — Fri, 05 Sep 2025 09:59:29 +0000

What is The Window of Tolerance

The Window of Tolerance is a model of nervous system regulation developed by Dr. Dan Siegel. It describes the optimal zone of arousal – the state where our physiology is balanced, we feel settled enough to connect with others, we can explore, learn and grow. Inside the window emotions and challenges are tolerable, and we can respond rather than react – we can cope with life stressors.

Either side of the window are two dysregulated states — hyperarousal and hypoarousal.

Hyperarousal is the fight or flight response, driven by the sympathetic nervous system. Here we may feel, for example, anxious or agitated, or on high alert – our physiology is dialled up
Hypoarousal happens when something is too much for too long, it’s the parasympathetic nervous system without the “vagal brake”, and we lack the enough mobilisation of the sympathetic nervous system that we need to function effectively day to day (this is not the same as the fight or flight response which of course we need too!).

Each of the three zones is associated with different emotions, thoughts, feelings, behaviours and physiology. The window isn’t only about our emotions, it’s about the body and behaviour too – it’s about the whole person and being able to function in a balanced, or efficient, way aS much as possible.

The aim isn’t to stay in our window all of the time – that’s not realistic. Instead, we can over time learn to spend more time there, gently expand the window and recognise its edges (a place of growth). These edges are sometimes called our stretch zone: where we are challenged but not overwhelmed. I’ve created an infographic below which illustrates these states.

(You’re welcome to use & share this infographic – please keep the copyright & logo visible so the work is credited)

What is Nervous System Regulation

Nervous system regulation is a term used to refer to the state of the autonomic nervous system (ANS). The ANS controls bodily functions like heart rate, breathing, digestion and our stress responses, and of these, the breath is unique because can also influence it consciously.

I often describe efficient nervous system regulation as having the ability to move flexibly between different states, in response to life’s demands and stressors. It means the level of arousal is matched to what’s needed in the moment – and being able to return to a more regulated state with some degree of ease when dysregulation happens. This supports a sense of safeness, connection, optimal functioning, growth, and healing. A regulated state is where we and learn and grow, and feel grounded, settled/safe, able to connect with others, restore, recover and heal.

It’s important to remember when we talk about nervous system regulation, it’s broader than the ANS alone – everything in the body is deeply interconnected. You can read more about nervous system regulation in my blog: https://unityphysio.co.uk/nervous-system-regulation-a-path-home-to-your-body/

Window of Tolerance and Chronic Illness

What Happens to The Window

When living with chronic illness, and struggling with symptoms, the window shrinks. Other things shrink our window too including trauma, chronic stress, not taking care of ourselves and over working.

With a narrower window we are more easily moved into survival responses by everyday stressors — dysregulating too quickly, too often, or too much. This isn’t a sign of weakness or doing anything wrong; these are survival strategies and there is wisdom here if we listen. We know people struggling with chronic illness easily move out of the window in chronic illness, and some people get stuck swinging between hyperarousal and hyperarousal.

“There’s wisdom in survival strategies if we listen”

Fear is one of the most common triggers for dysregulation and increasing the dysregulation, for example: fear of flare-ups, of not getting better, of being negatively judged, or fear about an activity. Sometimes fear shows up as hyperarousal (worry, tension, hypervigilance) and if it becomes too much, it can tip us into hypoarousal (numbness, disconnection, withdrawal, collapse).

“Fear often pulls us out of our window, compassionate awareness helps us return”

The Feedback Loop: Symptoms & Threat Responses

When we are dysregulated the symptom dial often turns up – which can in turn dysregulate us further. For example, worrying about doing an activity because of the expected impact can pull us outside of our window before we even begin. Then during the activity, hypervigilance and tension increase pain, fatigue and other symptoms. Afterwards, self-criticism or frustration may arise, further dysregulating systems and turning the symptom dial up more.

Different parts of us can take the wheel in these moments. In hyperarousal, a part might push us to keep going – until symptoms flare more (boom-bust pattern). Then the critical part of us may jump in, getting hooked into critical thought loops can push us into hypoarousal, where another part that may want to hide away and give up gets into the driving seat. Each part is trying to protect us, even if it’s using a strategy that is causing distress.

Learning to listen with compassion to these different parts helps us understand their wisdom and gradually expand our window – with awareness and practice we can understand the wisdom here, meet what’s needed and can gently expand our window over time. Also, the more time that we spend in the window, the easier it is to access our compassionate self, which supports healing and making helpful changes.

(You’re welcome to use & share this infographic – please keep the copyright and logo visible so the work is credited)

The angry self, anxious self, and sad self are recognised as common parts in Compassion Focused Therapy that increase threat system activation. Recognising them with awareness and compassion helps us return to balance.

Returning to Regulation

To return to regulation we first need to notice:

What’s present and what the nervous system state is (hyperarousal, hypoarousal or in our window)
The signs that we are moving beyond the edge of our window into dysregulation.

From there, we can explore practices that either downregulate hyperarousal or upregulate hypoarousal to move us back into or more towards our window. It’s important to remember: just because something is described as calming or energising doesn’t mean it will have that affect for you – notice how you feel before and after and let your body teach you what is supportive for you and in what context.

There are some suggested practices for hyperarousal and hypoarousal below:

Practices for Hyperarousal

Compassionate awareness of what’s present
Somatic tracking (either with a sense of safety noticing and tracking an unpleasant sensation, or leaning into a pleasant of neutral sensation)
Breath practices, for example diaphragmatic soft slow nose breathing (normal breathing), Buteyko recovery breathing, extended exhale, coherent breathing, bee breath
Grounding practices, for example the 5-4-3-2-1 practice, or noticing your feet on the floor and gently swaying if gentle movement feels accessible
Connection with others
Time in nature in a way that feels soothing or settling
Soothing self-touch
Soothing music or nature sounds
Rhythmic movement, for example somatic shaking, walking, dancing, jogging, or swimming. Other movement for example stretching
Humming
Sensory stimulation, for example a soothing essential oil, listening to soothing music or nature sounds, touching objects with a soothing texture or temperature, looking around and naming objects
Self compassion practices
Let be, let go let in (I’ve written more about this here: https://unityphysio.co.uk/the-mindful-compassion-based-5-steps-stress-awareness-management-model

Practices for Hypoarousal

Mindfulness and somatic techniques, for example tapping, squeezing, or self-massage
Energising movement, for example walking, stretching, jumping, somatic shaking, swimming, anything to energise the body that feels accessible and within tolerance levels
Sensory stimulation, for example the smell of coffee, an essential oil, or another strong scent, touching objects with different textures or temperatures, looking around and naming objects, uplifting sounds, eating something salty/cold/crunchy, drinking a cold drink with a straw
Cold shower or splashing cold water on face
Stimulating breath practices
Time in nature, gently connecting with energising elements
Walking barefoot on a safe surface (grass is one option)
Grounding practices. for example the 5-4-3-2-1 practice
Self-compassion practices

Many practices, like breathwork, yoga, mindfulness and compassion practices, as well as time in nature, support both states in different ways depending on the person and how they are approached and engaged with. They can upregulate or downregulate and bring more balance depending on different factors and the individual. It’s really an exploration and noticing how your body responds to different practices in different states and contexts. Sometimes downregulating in hyperarousal needs more up-regulation to mobilise the energy and other times starting to downregulate with slower movements is possible as the starting point, for example needing a run or brisk walk in hyperarousal before a slow walking or sitting outdoors is accessible. Doing a somatic check in before and after is helpful – see if you feel you’ve moved more towards or away from your window.

Expanding the Window

We can expand our window by understanding and noticing the early signs from our body of being at the edge of our window and gently working here in a way that feels safe enough. I often describe it as having one foot (or even a toe) outside the window and the other in regulation. This supports nudging the window in a way that feels possible.

“Expanding the window isn’t about staying regulated all the time – it’s about awareness and finding enough safety at the edges, and returning from dysregulation with more ease”

Some ways I support people in expanding their window includes:

Awareness of the edge of the window
Somatic and embodiment practices (e.g. somatic tracking, somatic check-in)
Meditationand mindfulness-based practices
Compassion practices
Mindful language and reframing
Downregulation practices to support regulation after nudging hyperarousal
Learning to trust the body
Holding outcomes lightly
Supporting connection with others
Lifestyle changes, such as pacing of activities, including some restorative rest each day, good quality sleep and a healthy balanced diet.

In Summary

There are many things that support regulation — awareness, compassion, and regular practice are key. Expanding the window also takes gentleness, patience and time: finding what’s best for you, listening to your body’s signals, and trusting the wisdom within. Remember, the aim isn’t to stay in the window all of the time – over time, we want to be able to return to it with greater ease, and to gently expand it.

Nervous System Regulation: A Gentle Path to Coming Home to Your Body

Ann Parkinson — Sat, 24 May 2025 13:39:18 +0000

Introduction to This Nervous System Regulation Blog

This blog offers a compassionate trauma-informed introduction to nervous system regulation – what it is, why it matters, and how trauma and chronic stress can impact it. We explore protective responses like fight, flight, freeze, and fawn, and share trauma-informed nervous system regulation frameworks such as Polyvagal Theory and the Window of Tolerance. You’ll also be introduced to my own Compassionate Nervous System Regulation Framework, Polyvagal Theory infographics, and further resources that can support the journey back to balance, safety, and connection.

What Is Nervous System Regulation?

Nervous system regulation often refers to the state and balance of the autonomic nervous system (ANS). This system controls automatic bodily functions like heart rate, breathing, digestion, and our stress responses. Of these, breath is unique, as we can also influence it consciously.

The ANS is a network of nerves that extend throughout the body, with neurons originating in both the brain and spinal cord. Two key brain regions involved in its function are the hypothalamus and the brainstem. The ANS has two main branches: the sympathetic nervous system (SNS), which activates the fight-or-flight response, and the parasympathetic nervous system (PNS), which supports rest, digestion and restoration.

There’s also a third division: the enteric nervous system (ENS). While it’s technically part of the ANS, it can also function independently and is often referred to as our “second brain.” It governs digestion and communicates with the rest of the ANS, especially via the vagus nerve – the main part of the PNS, making up about 75% of it’s nerve fibres. Like the rest of the nervous system, the ANS communicates through a complex network of electrical signals and chemical messengers.

The ANS is a functional division of the peripheral nervous system, which connects to the central nervous system (the brain and spinal cord). When we talk about nervous system regulation, it’s broader than the ANS alone – everything in the body is deeply interconnected.

It’s important to understand: it’s normal to move in and out of regulation throughout the day. No one lives in a perfectly regulated state all the time, and that’s not the goal. Life includes challenges, and our nervous system is designed to respond. Sometimes it may over-respond, but that’s still it doing its job based on previous experiences. With time and support, the system can learn when we are safe, helping the threat response settle more easily, when the environment is actually safe. The aim isn’t to avoid dysregulation, but to notice when it happens and gently support ourselves in returning to balance, again and again. This helps build nervous system efficiency, capacity, and resilience.

Understanding our nervous system, gently coming home to a regulated place, and befriending the body can support many things including healing & thriving.

My Working Definition of Nervous System Regulation

When I talk about nervous system regulation, I’m not referring to being calm all of the time or never getting dysregulated – this is normal and part of being human (though when we are dsyregulated too often/too much, and struggle to return to regulation, is when it’s problematic). Regulation isn’t a fixed state – it’s a dynamic process.

To me, helpful nervous system regulation means having the ability to move flexibly between different states, in response to life’s demands and stressors. It’s about matching the level of arousal to what’s needed in the moment – and being able to return to a more regulated state with some degree of ease when dysregulation happens. This supports a sense of safeness, connection, optimal functioning, growth, and healing.

Understanding Dysregulation: The 5 F’s

When we experience threat/stress in general, chronic stress or trauma our nervous system shifts into protective states that help us survive. These protective states are referred in different ways, one is the 5 F’s:

Fight – activation of the SNS (mobilised)
Flight – activation of the SNS (mobilised)
Freeze –blends SNS activation (mobilised) with the PNS (immobilised), initially this is state is SNS driven – we are mobilised with physiological changes that are needed to flee or fight e.g. an increased heart rate and muscle tension. It’s a brief pause whilst the options to get to safety are assessed automatically and quickly, if there is no escape we begin to shift into a state of dysregulated immobility (flop). Freeze can be understood as part of a spectrum – with a more activated freeze at one end and flop (shutdown) at the other
Flop – this is a shutdown state, it is the body’s last resort for protection when there is perceived to be no escape
Fawn – this is also referred to as appeasing, the protection response is to please and pacify the threat for safety. It’s a complex blended state of fight/flight and freeze

At its core, nervous system regulation is about returning to a place of balanced physiology and a sense of safeness after being in one of the dysregulated states. It’s important for us all to be able to re-regulate quickly and efficiently, with some level of ease. This can be challenging for people who have experienced chronic stress or trauma, and/or are struggling with chronic health conditions such as ME/CFS, PoTS, fibromyalgia, or Long Covid – dysregulating more easily, taking longer to return to regulation and getting stuck in dysregualtion, over time this can be changed.

Why Regulation Matters

The good news is that your body knows how to come back to regulation – it knows the way home. Sometimes, it simply needs compassionate, trauma-informed support, this is part of my role in my work – to walk alongside people in the journey to remembering the innate state of regulation and connection.

Nervous system regulation is a foundational aspect of how we feel, think, move, and relate to others. For example, when we are in a fight or flight state (SNS) our experience may include anxiety, restlessness, difficult concentrating and a racing mind, we may be impatient, there may be insomnia, stillness may be difficult and movements are likely to be quick. When your nervous system is dysregulated, it can affect everything, including:

Sleep and rest
Pain and fatigue management
Emotional resilience
Concentration and memory
Your ability to connect with others

Nervous system dysregulation is not a sign of weakness—these responses are wise protective responses, however, when they persist beyond the original threat, they affect our health and wellbeing and limit our ability to thrive – we can move from surviving to thriving.

What Regulation Isn’t

Nervous system regulation isn’t about pushing through, ignoring or fixing symptoms. It’s about learning to:

Feel safer in your body
Gently restoring balance
Expanding capacity to be present and grounded even when life is challenging

Various things support nervous system regulation including understanding it, along with trauma-informed, compassionate, and somatic approaches – to support shifting out of survival mode and into a state where healing, connection, and thriving become possible.

We are social beings, nervous system regulation enables us to co-regulate—to be present, steady and attuned with others, both in our work and with the children and loved ones in our lives. It’s especially important with children as initially they can’t regulate themselves initially and then they learn to self-regulate from co-regulation.

The Nervous System Regulation Tools and Models I Use

The tools I use are grounded in compassionate trauma-informed care, compassion and mindfulness-based practices, somatic and embodiment practices, and clear frameworks that help to understand and support the nervous system with compassion and clarity in sustainable ways. The main frameworks I use are:

Window of Tolerance

This was developed by Dr. Dan Siegel, this model describes the optimal nervous system state (the Window of Tolerance) which is sometimes referred to as the optimal zone of arousal, where we are settled/safe, alert and engaged, and the two dysregulated states either side of it (hyperarousal and hypoarousal). Hyperarousal is the fight or flight response and hypoarousal is dorsal vagal in Polyvagal Theory – the parasympatehtic nervous system without the vagal brake and without the mobilisation of the SNS that we need to function day to day (this is not the same as the fight or flight responses of the SNS, which of course we also need!). The aim isn’t to be within our window all of the time, instead to know how to stay there as much as possible and keep gently expanding the window over time. The edges of the optimal zone are our stretch zone, here we can learn and grow.

There is a Window of Tolerance infographic I created below and a few links to more information on this model.

A helpful short video about the Window of Tolerance by Lewis Psychology https://m.youtube.com/watch?v=TNVlppGz0zM

A helpful Window of Tolerance blog by Dr Sarah Davies https://www.drsarahdavies.com/post/what-is-window-of-tolerance-emotional-regulation-model-explained

Polyvagal Theory

Developed by Dr. Stephen Porges, this theory explains how the autonomic nervous system moves between:

Ventral vagal (safety, connection & social engagement)
Sympathetic (fight/flight, mobilisation)
Dorsal vagal (shutdown, immobilisation)

Understanding and mapping these states helps us better understand our nervous system and gently support return to regulation. The three main states are shown in the first infographic below and the two blended ventral vagal ones are shown in the second infographic (please feel free to share these infographics, kindly ensure the credit is visible).

A helpful blog about what Polyvagal theory is by the Polyvagal Theory institute https://www.polyvagalinstitute.org/whatispolyvagaltheory

A useful video on Polyvagal Theory by Lewis Psychology https://m.youtube.com/watch?v=SlhFrBoEnxU

The Three Circles Model (The Three Emotional Systems Model)

This is part of Compassion Focused Therapy and was developed by Professor Paul Gilbert. The three emotional systems in this model are:

- Threat (protection and safety seeking system, activating/inhibiting)
- Drive (incentive/resourced focused system, pursuing and achieving, activating)
- Soothing (connection, safeness & care, non-wanting/affiliative)

No one of these systems is good or bad, we need them all, the aim is for them to be in balance. Many people I work with have overactive threat systems and underactive soothing systems, which is a very common pattern partly due to the way our society is in general. One of the ways I use this model is to support people in growing the green (the soothing system) with practices and strategies that feel safe, nourishing and sustainable.

Trauma-Sensitive Mindfulness (TSM)

TSM was developed by David Treleaven, and I have completed his Advanced Trauma-Sensitive Practitioner training. It’s grounded in the 4R’s of trauma informed practice:

Realising the widespread impact of trauma
Recognising the signs and symptoms of trauma
Responding with informed, supportive practices
Resisting (or avoiding) Retraumatisation

You can read more about the 4 R’s on my Trauma Informed Practice page: https://unityphysio.co.uk/services/trauma-informed-practice/

Mindfulness can be a powerful tool for nervous system regulation—when it’s offered safely. I use mindfulness in a trauma-sensitive way: the practices are choice-based, gentle, and paced to meet each person’s needs. Regulation, choice, and empowerment are central to this approach.

My Framework: A Compassionate Path to Regulation

In both my workshops and 1:1 sessions, I use a visual framework that I developed to support regulation through compassionate awareness and curiosity. It’s non-linear – each element is interconnected, and many experiences may sit in more than one circle at a time.

The process usually begins with noticing your internal state through compassionate awareness with a gentle curiosity. From there, you might explore settling, grounding, letting go, or receiving what feels nurturing and supportive. Each part of the framework reinforces the others, helping you reconnect with safety, presence, compassion and self-trust at your own pace. Over time, this helps build your capacity for regulation, connection, and thriving.

There’s no one right way to move through this—it’s a path of compassionate awareness and curiosity that you can return to again and again.

Summary

Nervous system regulation is a vital, ongoing process of gently returning balance for us all, and is especially important with chronic health conditions, or healing from chronic stress or trauma. It isn’t about fixing ourselves (we are all already whole)—it’s about gently understanding our bodies, restoring balance, and reconnecting with a felt sense of safety and compassion towards ourselves, others, and the world around us.

Understanding protective responses and using compassionate, trauma-informed frameworks, supports us in reconnecting with safety, regulating and building nervous system capacity, and moving from surviving towards thriving. This journey is unique for each of us, and it’s important that it’s grounded in curiosity, patience, compassion and kindness toward ourselves and others.

Would You Like to Explore More?

If you would like to explore nervous system regulation more take a look at:

Nervous System Regulation https://unityphysio.co.uk/services/nervous-system-regulation/

You can also book a free 15 minute discovery call to see if this work feels like a good fit for you 1:1, alternatively you are invited to take a look at my 4-week nervous system regulation workshop series on:

The Awakening The Body’s Wisdom: A Somatic Workshop Series https://unityphysio.co.uk/services/awakening-the-bodys-wisdom-somatic-workshops/

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Managing Pain and Fatigue Over the Festive Period

Ann Parkinson — Sat, 30 Nov 2024 11:16:25 +0000

The festive period can be a wonderful time and a difficult one too for a variety of reasons for some people, including for people managing health conditions associated with persistent pain and fatigue. These health conditions include: persistent pain, fibromyalgia, ME/CFS, long covid and PoTS. If you live with one of these conditions, or another, you may find Christmas challenging or you may sail though it, many don’t. I’m hoping there will be some information and tips in this blog that will help make the festive period easier to manage for people who are living with pain & fatigue. As we move into the blog remember even a little change can make a big difference.

The festive period commonly brings with it a lot of stress, a variety of feelings and emotions, decreased routine and lack of sleep and other things. These are are things that can turn up the dial on pain and fatigue. Strategies/tools/practices that help to manage pain & fatigue in general, to manage stress and regulate our nervous system can be helpful. Practices/tools that can support stress management and nervous system regulation include:

Breath practices
Mindfulness & Meditation
Self-compassion practices
Being mindful of our language & reframing it (watch out for the ‘shoulds’, more on this a little later)
Gentle yoga or other mindful movement practices
Somatic practices
Time connecting with nature

Commonly over the festive periods routines get thrown out of the window, people try and fit way more in than usual and more than they have capacity for, this is another reason symptoms increase. There are different contributors to this including feeling pressure to do things a certain way, to do more & make everything ‘perfect ‘ at Christmas. There’s no such thing as a perfect Christmas or a perfect anything for that matter, one of my wise sisters once said to me ‘it’s the imperfections that make us perfect.’ Christmas has become very over commercialised and there is quite a lot of unhelpful messaging that can make people feel they aren’t good enough unless the Christmas they have matches all the adverts and social media posts. It can be helpful to remember that it’s only one day of the year and we can choose what we want to do on that day, it doesn’t have to be a certain way.

When managing any condition associated with pain and fatigue there needs to be flexible routine and pacing of activities. By flexible routine I mean doing the things that support us each day though not in a fixed or prescriptive way. For example, maintaining a sleep routine, eating food that supports health & wellbeing, pacing activities, using breath practices and other practices to support nervous system regulation, maintaining our boundaries, connecting with others and nature, and used in a way that meets what’s needed each day.

Sticking to your daily routine as best you can in terms of using the resources/practices that support you in managing the condition you’re living with is important, as well as setting some compassionate boundaries over the festive period. Creating a flexible plan each day, prioritising and planning what you need and want to do, considering what’s realistic, what supports you, what’s meaningful to you, and consideration of what’s in the week ahead can all help with pain and fatigue management at anytime of year and is especially important with events like Christmas.

It can be helpful to explore our beliefs, expectations & our language, for example, noticing when we are we telling ourselves that we must do something, that we have to do something, that we should do more/should do something a certain way. It’s quite likely that if you tend to overdo things that this language is appearing quite a bit, commonly there are a lot of shoulds (this comes from our threat system). When you catch this language ask yourself where these come from & explore reframing the language. For example, maybe reframing something from I have to do ‘x’ to I get to do ‘x’ and I’m going to ask for some help to make it easier. Are your beliefs about Christmas supportive of your wellbeing & values? It’s not always easy to reframe unsupportive beliefs, expectations and language sometimes support is needed to do this, especially when there is a history of trauma.

It’s important to know your toolbox of resources, knowing your resources and nervous system well can help you to choose which tools/practices are supportive each day, as well as bringing in additional practices to support you over the festive period as needed. It’s helpful to know what your energy nurturers are, what is restful for you and what regulates your nervous system so that these things can be included each day. We all need rest and when living with a long-term health condition we need extra rest and more so if experiencing an increase in symptoms (often referred to as a flare-up). The winter time is also the time we need more rest and the busyness that has now become a ‘norm’ of Christmas pulls us out of our natural rhythm with nature and our time for rest and restoration.

Things I see as foundational, are using mindfulness, self-compassion & listening to your body’s wisdom to guide management of pain & fatigue. Mindfulness simply means being aware of the present moment, or being aware of our experience as we our experiencing it. If we aren’t aware of what’s happening and how we are then how can we take helpful action? The way in which we pay attention matters too, it is important that we are aiming to be compassionate and non-judgemental. Turning a loving awareness towards ourselves is most supportive and it takes ongoing practice. Being mindful of what’s present in our body in a compassionate way means that we can hear our body’s wisdom and we can use this to guide our choices.

Here is a summary of tips (there are more than I have written about above, the blog would have got rather long if I wrote a bit about each tip!):

Have a flexible daily plan
Have a flare up plan (what supports settling systems down)
Pace things in a way that supports you (5P’s to remember planning, prioritising, play & purpose, problems solving. My blog on pacing for pain is linked at the end of this blog)
Take regular rest breaks
Check-in with your body regularly
Listen to your body’s wisdom
Practice self-compassion
Be kind to yourself
Remind yourself what you can do is enough
Include what’s meaningful each day
Connect to a sense of playfulness
Set compassionate boundaries (it’s ok to say no)
Communicate what’s possible
Ask for help when needed (asking for help is a strength not a weakness)
Use daily practices that support you
Use nervous system regulation practices (for example breath practices, meditation, mindfulness, yoga, somatic & embodiment practices, self-compassion practices, singing/humming)
Prioritise sleep, rest & restoration
Manage stress
Communicate with family & friends
Reach out for support
Connect with others & nature
Spend a little time outdoors each day if you can, or look out of the window & see what you can notice
Remind yourself Christmas doesn’t have to look or be a certain way
Explore beliefs & expectations, reframe them if it’s helpful & possible
Watch out for ‘I should…’, ‘I have to…’, ‘I must…’
Connect to a sense of joy, wonder, vitality and other nurturing feelings each day

The tips with this post can be helpful for us all and are especially important when living with persistent pain & other conditions. You don’t need to do them all, trying to change too much at once often has the opposite impact, instead pick one or a few things that feel helpful for you and take action on them. Maybe you have some tips you would add, I would love to hear them if you do.

It’s important for us all to remember there is no such things as a perfect Christmas & whatever we choose to do is ok and whatever we can do is enough.

Here’s the link to the pacing for persistent pain blog mentioned in this blog (a lot of what is in the blog applies to ME/CFS and long covid too, though pacing for these is slightly different): https://unityphysio.co.uk/what-is-pacing-how-can-it-help-with-persistent-chronic-pain/

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How Can Physiotherapy Help With PoTS?

Ann Parkinson — Sat, 15 Jul 2023 10:19:48 +0000

Physiotherapy can be helpful for people with PoTS (postural orthostatic tachycardia syndrome), it is recommended to be with a physiotherapist that has a specialism or special interest in PoTS. Before we look at how physiotherapy can help let’s look at what PoTS is.

What is PoTS?

Postural orthostatic tachycardia syndrome (PoTS) is a form of dysautonomia (autonomic dysfunction) and is characterised by an abnormal increase in heart rate within 10 minutes of sitting from laying down or with standing, this is referred to as orthostatic intolerance. For people with PoTS upright posture (sitting or standing) is limited to varying degrees. Alongside the main diagnosis of PoTS, which we could call classic PoTS, there are different subtypes: neuropathic PoTS, hypovolaemic PoTS & hyperadrenergic PoTS.

PoTS diagnostic criteria is a sustained increased in heart rate (HR) for over 3 months of 30bpm within 10 minutes of standing in adults, or reaches 120bpm or more in this time, and in children an increase of at least 40bpm. A tilt table test is used for diagnosis and/or the active stand test or NASA lean test. It is also important that other conditions are ruled out and tests should include blood tests and an ECG. If people don’t meet the diagnostic criteria and other things have been ruled out they most likely have orthostatic intolerance (which is one end of the PoTS spectrum before it reaches a level classed as PoTS).

There are a whole range of associated symptoms including:

Increased heart rate
Alteration in blood pressure
Palpitations
Light headedness/dizziness
Shortness of breath
Chest pain
Fatigue
Brain fog
Sweating
Shakiness or tremulousness
Fainting/blackouts (in a fairly low percentage of people)
Sleep issues
Headaches/migraines
Anxiety
Nausea
Gut & bladder issues (IBS is common)
Visual problems
Purple hands and feet (pooling of blood in extremities due to sitting and standing for varying amounts of time)

I would like to highlight that people are often misdiagnosed with anxiety when it’s actually PoTS, PoTS itself creates feelings associated with anxiety & increased sympathetic nervous system (SNS) activation. Living with PoTS can of course also cause anxiety, or anxiety may be pre-exisiting as well.

Many things can make symptoms worse including excess heat, a big meal or certain foods, decreased fluids or dehydration, hormones, stress, standing up too quickly, not getting enough rest, exercise (doing too much or certain types like HITT – HITT is never a place to start but may be possible with rehab), time of day (generally worse in the morning) and alcohol.

PoTS can occur as a primary problem or secondary (associated with another condition), including: fibromyalgia, ME/CFS, Elhers-Danlos syndrome (EDS), Parkinsons disease, lupus, rheumatoid arthritis, lyme disease & others. Mast cell activation syndrome (MCAS) can be present as well, it is not clear if this is a primary or secondary issue, there is also a triad of EDS, PoTS & MCAS. PoTS is also associated with long covid/post covid syndrome and is fairly common with this. In my experience PoTS rarely exists in isolation.

PoTS is something I screen for as part of an autonomic screen with all the people I work with including those with persistent pain & fibromyalgia. It’s not widely enough known about and screened for so is not always picked up and can be misdiagnosed as anxiety. Some level of autonomic dysfunction is common in all the conditions I work with.

There are many things that can cause PoTS or contribute to it, which I am not going to cover in this blog. You can find more information on PoTS here:

PoTS U.K website: https://www.potsuk.org

Information on the Long Covid Physio: https://longcovid.physio/dysautonomia-pots

How Can Physiotherapy Help With PoTS?

PoTS often needs to be managed by a multidisciplinary team (with a specialism or good experience in managing the condition). Ideally a cardiologist with an a specialism or special interest in PoTS, a specialist physiotherapist, an occupational therapist when needed, a psychologist when needed, and a dietician may be needed with dietary adjustments especially if there is MCAS. Psychological therapy can help in a number of ways, including with managing the distress of living with PoTS and some treatments, like EMDR, can help to regulate the ANS. Other specialists may need to be involved, for example a sleep specialist.

A specialist physiotherapist can help to reduce symptoms and improve function, this needs to be alongside other factors like medication (when needed), hydration, increased salt (when not contraindicated), diet, compression stockings/garments, stress management & pacing of activities. Some of the ways in which a physio can help are mentioned below.

Education & lifestyle modification: A physio can help people understand the condition and give advice on the lifestyle changes that help with management, along with supporting exploration of these. There are a variety of lifestyle factors that can help, some of the main ones are mentioned above.

A tailored exercise programme: A specialist physiotherapist can tailor an exercise programme, although this isn’t a place to start when PoTS is severe and great care is needed when there is PEM. It is crucial that PEM is screened for as it completely changes how things are done. Depending on severity of PoTS and other factors, including other conditions and exercise tolerance, recumbent exercises may be the starting point. Exercise has been shown to be helpful in the management of PoTS, any exercise programme needs to bear in mind many factors. To begin with it needs to be of a low intensity and progressed very slowly and it needs to be combined with other factors, including regulating & retraining of the ANS.

Pacing: A physiotherapist can help people explore pacing of activities and different strategies that help with managing functional activities. Pacing is not a set or fixed way of doing things, there isn’t a right or wrong, it needs to be individualised and it’s something we need to hold lightly otherwise we step into over control which ramps up the threat system and impacts our flexibility in interacting with life. Pacing needs to be flexible and come from a foundation of compassionate awareness and understanding in my opinion. People understanding their baselines for activities and what rest is for them is part of pacing, for people with PoTS rest may need to be laying down.

Breathing exercises: Some people have a breathing pattern disorder alongside PoTS due to the prolonged over activation of the sympathetic nervous system, increased heart rate & shortness of breath (a breathing pattern disorder also contributes to these symptoms, and other reasons, it becomes a bit of a vicious cycle). A physio can assess for this and give exercises to help retrain normal breathing and regulate the ANS, if needed people can be referred onto a respiratory specialist physiotherapist.

Management of multiple conditions: People may well have other issues alongside PoTS including persistent/chronic pain, a specialist physiotherapist can tailor things bearing in mind the other conditions someone is living with as well as PoTS. People may also have ME/CFS or long covid, I have an interest in both of these conditions along with PoTS, a graded exercise programme is not recommended with ME/CFS and this would also apply to long covid when PEM is present. I have worked many years as a persistent pain specialist physio & so am well placed to help with this.

Regulating & retraining the autonomic nervous system: This is important with PoTS, a physiotherapist can help people explore what helps them with nervous system regulation and retraining. This like other aspects of care needs to be individualised, there is not a set guide and instead more of a flexible framework. Part of this includes using measures like monitoring heart rate and heart rate variability (HRV), these are also helpful as part of guiding exercise progression.

Self-Compassion: This isn’t something that is part of physiotherapy as such, it is however part of my approach to whole person care. Self-compassion can help to regulate the nervous system and the research shows us it helps in many ways (not specific PoTS research) including with decreasing self-criticism, increasing resilience and overall wellbeing.

About Me

I work as a Pain & Fatigue Specialist Physiotherapist & Integrative Somatic Therapist. Alongside working in the specialist area of persistent/chronic pain I also have a special interest in ME/CFS, long covid & PoTS, chronic stress & anxiety. I also have lived experience of PoTS, ME/CFS, persistent pain & anxiety. All of my offerings are trauma informed and I have a compassionate, integrative, person-centred approach to care. You can find out more about me by clicking the link below

https://unityphysio.co.uk/about-ann-physiotherapist-in-lincoln/

I can work with anyone in the UK virtually and locally can offer in person appointments or a combination of remote and in person. I offer a free 15 minute call for anyone before they decide if they would like to book an appointment.

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