Dysautonomia and Hypermobility: Understanding the Connection and Managing Symptoms

By Russell Wolfe, MSc PT

As a physio, I’ve treated a large number of hypermobile patients. One in particular was a young lady who swam competitively. An excellent athlete who had recently started experiencing disabling dizziness when doing her dry-land training. She was at her wits end trying to figure it out; she would feel fine when pushing her body to the max in the pool, but the moment she needed to do a couple sit-ups or squats, she’d become overwhelmed with symptoms.

When most people think hypermobility, they probably think “flexible,” “bendy,” or “stretchy.” But hypermobility can come with a plethora of systemic symptoms that affect more than just muscles and joints.

Why is dysautonomia common in hypermobile individuals?

Dysautonomia is a broad condition characterized by dysfunction of the autonomic nervous system (ANS), the system which controls involuntary processes such as blood pressure, heart rate, perspiration and digestion. The two types of dysautonomia we’ll be discussing are:

1) Postural tachycardia syndrome (PoTS)

2) Orthostatic hypotension

As we rise from a sitting or supine position, gravity causes blood to flow downward and pool in our legs.

Before we dive into these two pathologies, it might help to first understand what the autonomic nervous system SHOULD be doing - specifically with controlling blood pressure and heart rate as our body changes positions. As we rise from a sitting or supine position, gravity causes blood to flow downward and pool in our legs. In response, our ANS kicks in by constricting the blood vessels in our lower body, which pushes blood more forcefully upward, counteracting the downward pull of gravity. If done correctly, blood will continue being adequately supplied to the vital organs such as the brain and heart. Blood pressure and heart rate may increase by a small amount, and will stabilize shortly thereafter.

PoTS is characterized by an increase in heart rate of >30bpm, that occurs when rising from a sitting or supine position, with an absence in blood pressure changes.

Orthostatic hypotension is characterized by a decrease in blood pressure (systolic >20mmHg or diastolic >10mmHg) on rising.

What role does vascular laxity play in dysautonomia symptoms?

The same phenomenon that causes ligaments and tendons to be looser also occurs in the connective tissue that makes up blood vessels.

So what’s happening here? Well, it’s not fully understood why those with hypermobility frequently experience dysautonomia, but several proposed mechanisms have been identified. A big one is related to vascular laxity. The same phenomenon that causes ligaments and tendons to be looser also occurs in the connective tissue that makes up blood vessels. As a result, they have a harder time constricting to fight against the effects of gravity.

In the case of POTS, the heart will start working overtime and pump faster as a way of compensating. This is why blood pressure is maintained while heart rate increases.

In the case of orthostatic hypotension, the heart rate will remain the same while the blood pressure will drop.

In both cases, inadequate supply of blood to the brain and other organs can result in symptoms such as dizziness, lightheadedness, fainting, sweating, cold hands/feet, and many more.

So let’s go back to the case of the swimmer. She was fine in the pool because her body remained mostly horizontal, and the buoyancy of the water reduced the effect of gravity. But when she got onto dry land, exercises that involved quick changes in body positioning exposed her autonomic dysfunction. Dysautonomia isn’t something you can cure, but there are a number of ways to manage it when it flares up. In her case, this involved focusing on horizontal exercises (e.g., planks instead of sit-ups, leg press instead of squats), ensuring adequate salt/fluid intake, and using compression garments as needed.

We’ll talk about management more in another post!

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