Autonomic dysfunction is a common, debilitating feature of IACIs, including Long
COVID, POTS, ME/CFS, and tick-borne disease. Symptoms like dizziness,
palpitations, blood pooling, and exercise intolerance reflect impaired regulation of
vascular tone and cardiac output—not simple deconditioning. Traditional exercise
protocols often fail these patients, and in some cases, worsen symptoms through
PEM.
Our approach to autonomic rehabilitation emphasizes symptom-guided pacing,
upright tolerance retraining, and gradual cardiovascular reconditioning. Patients
begin at their current level of positional tolerance (often supine) and progress
through phases that reintroduce upright positions, aerobic movement, and
neuromuscular control—always below the patient’s crash threshold.
Moving Beyond Graded Exercise Therapy (GET)
Rigid GET programs can cause harm in patients with PEM or dysautonomia.
Instead, we promote pacing and recovery-based progression using symptom-guided
thresholds (modified Borg RPE scale, VAS symptom tracking), positionally modified
exercises (e.g., supine to upright transition), adaptive breathwork to regulate
arousal and stabilize autonomic tone and therapist comfortability with small, even
active assisted movements when needed and progressing based on symptom
tolerance.
Foundation Protocols & Adaptations
Our team draws from established protocols (Dallas, CHOP-Modified Dallas, Levine)
and adapts them for infection-associated presentations. Early rehab often includes
recumbent cardio (e.g., spin bike with reclining chair in supine and progressing
through semi-reclined positions, recumbent and then upright bike and
standing on pedals), compression and fluid loading, low-load neuromuscular control in
gravity-minimized positions and vagal-supportive breathwork.
Breathwork as a Cornerstone
Breathing techniques improve parasympathetic tone, reduce orthostatic
symptoms, and support safe movement. Patients are trained in diaphragmatic,
pursed-lip, box, and VNS-based breathwork as part of every phase. These
tools not only stabilize physiology but also provide real-time feedback on readiness to
engage in activity. Progress isn’t linear. Patients may fluctuate between phase
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Supporting Success
Autonomic rehabilitation is most effective when integrated with gentle
neuromuscular training for core and scapular stabilization, energy conservation
and pacing education, structured breathwork for readiness and recovery
(see more information in appendix), careful symptom tracking (e.g., RPE/VAS scales)
and flexible program design and language that honors each patient’s path.
Patients with connective tissue disorders (e.g., hEDS/HSD) require additional
stabilization strategies to protect joints and manage subluxation risk throughout
positional rehab.
We encourage providers to reference the Pacing and Hypermobile Rehabilitation
sections for additional considerations when treating these patients.
