Intrinsic Physical Therapy

Chronic Illness Persistent Pain

The Trifecta: hEDS, POTS & MCAS

Have you been diagnosed with one or more of these conditions? Wondering how they all fit together?

The trifecta describes the triad of chronic conditions including hypermobile Ehlers-Danlos syndrome (hEDS), Postural Orthostatic Tachycardia Syndrome (POTS) and Mast Cell Activation Syndrome (MCAS).

Why do these three conditions like to show up together?Research indicates that there may be a genetic mutation that when triggered, could flip the switch, triggering all 3 conditions to occur together. Each persons presentation may be different depending on epigenetic expression. 

Let’s review the three conditions.

Mast cells are a type of white blood cell found in connective tissues throughout the entire body including just beneath the skin, near blood and lymph vessels, in nerves, lungs and the intestines. They are present in high numbers anywhere the outside environment interacts with our body so think mouth, sinuses, esophagus, lungs, GI tract, and bowel/bladder. They are intended to warn us of danger, but sometimes they become overreactive and send false danger signals.

Hypermobile Ehlers-Danlos Syndrome is a connective tissue disorder where there is increased laxity in the connective tissue, including ligaments. This results in joint hypermobility and instability. 

Postural Orthostatic Tachycardia Syndrome is a dysfunction of the autonomic nervous system, resulting in autonomic dysregulation with the cardinal sign being increased heart rate upon standing.

How do they all relate? Let’s dive into the connections between the pairs of conditions.

One theory that connects MCAS and hEDS is that MCAS creates an immune response to pathogens, which releases mediators (such as histamine or tryptase) and this can affect the collagen in the connective tissue. This can lead to ligamentous laxity and joint hypermobility. 

Another theory is that collagen, which plays a role in the connective tissues of the body, is located inside the extracellular matrix (ECM) and mast cells stick to this ECM. EDS could cause a change in the ECM enough to alter the behavior of the mast cells, leading to over activation.

hEDS contributes to laxity of the connective tissue, which includes blood vessels. This makes blood vessels “floppy” and more likely to vasodilate. POTS occurs when blood vessels remain dilated and blood pools, causing the heart to beat faster. There is disrupted communication between the autonomic nervous system and the vascular system.

hEDS can also lead to cranial cervical instability along with brainstem compression that could compromise the vagus nerve. The vagus nerve is involved in autonomic nervous system function and may cause dysautonomia or POTS.

Mast cell over activation can act on the blood vessels and cause vasodilation, which causes pooling of blood in the legs and abdomen as seen in POTS. Mast cells can interact with neurons, including autonomic nerve fibers, which can lead to POTS.

Increased norepinephrine, which is secreted in response to standing (and in higher levels with POTS) may cause mast cell degranulation, releasing mediators and causing symptoms.

More research is needed, but this is why it is important to view the body from a holistic lens because treating the one part of the trifecta may improve the others. 

Wondering about holistic treatment of the trifecta and where to start?

Schedule a free discovery call!


Chronic Illness Persistent Pain

Concussion and dysautonomia: vision changes, exercise intolerance and POTS

As we talked about in the last blog post, a concussion is a mild traumatic brain injury (mTBI) which can have an impact on so many systems in the body. One of those is the autonomic nervous system, the same area that we see dysfunction in POTS! As a result of a traumatic brain injury, autonomic dysregulation, or dysautonomia, can occur. This results in high sympathetic tone in the body, which can cause anything from exercise intolerance to dizziness to vision impairments.

Let’s review. The autonomic nervous system controls our automatic body processes such as heart rate, blood pressure, body temperature, and digestion to name a few. There are two branches of the autonomic nervous system, the sympathetic nervous system and the parasympathetic nervous system. The sympathetic nervous system (SNS) we can think of as the fight or flight system and the parasympathetic (PNS) is the rest and digest system.  We need balance between these two systems to live optimally. 

After a mTBI, the brain shifts into an increased sympathetic state. Symptoms of high sympathetic tone include increased heart rate, increased respiratory rate, blood pressure dysregulation, sweating, anxiety, headaches, nausea and GI issues. Exercise intolerance may be one of the first clues that autonomic dysfunction is occurring post concussion, but even vision issues can be a result of dysautonomia.

Let’s dive into the specifics a bit more.  Vision changes are one of the most common findings post concussion. Our eyes require a balance between the sympathetic and parasympathetic systems to shift from near, focal vision to a faraway gaze. We need the PNS to activate the near triad response, which is responsible for accommodation, convergence, and pupillary constriction. This is why issues with focus on one object can be difficult post concussion and people may experience double vision or blurred vision. This may also account for light sensitivity experienced post concussion, because the pupils are not able to properly constrict to accommodate for the brighter light. 

Also, when we are in the sympathetic state, our vision becomes more like tunnel vision because our brain is only concerned with what is right in front of us and is not worried about things in our periphery or far away. Following a concussion, you may notice increased symptoms when you sense movement in your periphery because your brain is not accommodating to this movement and doesn’t know how to interpret that information since it is stuck in fight or flight. One simple, calming technique for your eyes involves looking at the horizon and noticing things in your periphery.  If you are wondering about vision impairments post concussion, make sure you get assessed by an occupational therapist or vision therapist.

Exercise intolerance may be another symptom that pops up post concussion. You may find that your heart rate increases or you become sweaty or dizzy with minimal activity, or even just with standing. If this is the case, getting assessed for postural orthostatic tachycardia syndrome (POTS) may be beneficial. A physical therapist should be able to screen for this and a cardiologist or neurologist may diagnose you with this condition. Physical therapists might perform the Buffalo Concussion Treadmill Test (BCTT), which can screen for autonomic dysfunction. Monitoring heart rate or heart rate variability with change in positions can identify autonomic dysfunction and this may warrant a more formal assessment using the gold standard Tilt Table Test for diagnosis. 

Treatment for autonomic dysfunction can come in a variety of forms and is best guided by your practitioner. Lifestyle modifications including increasing fluid and salt intake, wearing compression stockings, eating small, frequent meals, and learning pacing strategies can help manage symptoms. Working with a practitioner familiar with dysautonomia is key to a successful recovery. 

Intrinsic Physical Therapy now offers Wellness Coaching to assist you in management of POTS. Schedule a free phone consultation today!


Chronic Illness Persistent Pain

Concussion Awareness Month

March is Brain Injury Awareness Month so let’s talk about concussions! A concussion is classified as a mild traumatic brain injury or mTBI. A concussion is a brain injury induced by biomechanical forces, such as a blow or trauma to the head, but can also occur from a high velocity movement where the brain moves inside the skull, such as during a whiplash injury.  You do not have to lose consciousness to have a concussion, and in fact, most concussions do not result in a loss of consciousness. 80-90% of concussions resolve within 7-10 days. If symptoms persist, a diagnosis of post concussion syndrome aka prolonged concussion symptoms may be warranted to help guide your treatment plan. 

In the initial phases of concussion management, it is important to be evaluated by a medical professional in order to monitor symptoms and guide treatment intervention. Treatment recommendations no longer consist of rest in a dark room. Instead, activity should be resumed as tolerated as long as symptoms are not exacerbated. 

Concussions are complex injuries since they affect the brain and the brain interacts with every system in the body.  There are seven phenotypes of concussion, including: cognitive, oculomotor, emotional, cervical, headache, cardiovascular, and vestibular, with sensorimotor being another potential category, but not a true phenotype. It is common to have several phenotypes present when experiencing symptoms of a concussion and this is why it is so important to work with a rehab team that can help to address all aspects of concussion. 

Connecting with a rehab team that understands the full scope of concussion treatment is imperative to a successful recovery. Members of a concussion rehab team may include: neurology, physical therapy, occupational therapy, speech therapy, psychology, neuro optometry, and functional medicine practitioners, among others. Treatment interventions may include vestibular rehab, vision therapy, cognitive behavioral therapy, cardiovascular rehab, manual therapy for headaches and neck pain, nutrition and hormone balancing and medications as needed. 

It can feel overwhelming to navigate the recovery process when your brain is not operating at full capacity. Continue to advocate for help to meet your needs. Although recovery from a concussion can be complex and slow, healing is absolutely possible!  

My favorite resource for all things concussion is Concussion Compass or follow @mollyparkerpt on instagram.



Chronic Illness Persistent Pain

What is Joint Hypermobility?

Are you highly flexible? Do your joints often pop or crack? Were you the kid who could put their legs behind their head as a party trick? 

Typically, we think of flexibility as a good thing, but it is possible to have too much of a good thing! Too much flexibility or joint hypermobility can also lead to pain and dysfunction within the body. Joint hypermobility means that your joints are moving beyond their normal limits due to increased ligament laxity.

Joint hypermobility can span a continuum from someone who has increased flexibility, but is asymptomatic, to someone who may dislocate their joints often and have a lot of pain and decreased function because of the hypermobility. Someone may have localized hypermobility, where fewer than five of their joints are hypermobile, or generalized hypermobility, where five or greater joints are hypermobile. Joint hypermobility is a hallmark in two different diagnoses, Hypermobility Spectrum Disorder (HSD) and Ehlers-Danlos Syndrome (EDS).  For more information on the difference between the two, check out this article.

It can be difficult to diagnose joint hypermobility because people may report tight and stiff muscles and mistakenly believe they are not flexible enough. They may seek massages or try to stretch and stretch with no benefit and quite possibly may feel worse. In this case, the muscles are doing their job and are trying to protect the unstable joint and highly elastic ligaments and therefore tighten up to provide as much stability as possible. When a person stretches or gets a massage, the joint loses the stability that the tight muscle was providing and pain increases. When this occurs, it can be beneficial to work with a PT skilled in treating joint hypermobility to allow the body to gain stability while decreasing muscle tension and improving overall posture and alignment. 

Are you wondering if you may have joint hypermobility? There is a simple 9 point scale called the Beighton Scoring System that can assess hypermobility. Check it out here! But remember, this alone does not diagnose anything; it only tells us if you have hypermobile joints or not. 

At Intrinsic PT, we are passionate about helping people manage their joint hypermobility. Feel free to reach out with any questions that you may have about it!



Chronic Illness General Pelvic Heatlh Persistent Pain

How Is Your Breathing?

We all do it, but are you aware of HOW you’re breathing? 


Breathing occurs automatically, thanks to the autonomic nervous system, but the magic of breathing is that we are able to exert conscious control over it as well! Research has shown that we can change our physiology and therefore our health, by changing how we breathe. 


I assess breathing with just about every single client. It can tell me so much information, such as their ability to coordinate muscles through contraction and relaxation, ribcage and spine mobility, compensation patterns, and breathing patterns. It is a foundational tool that I like to start with for almost everyone because it is vital to movement and mind/body connection.


On average we take 20,000 breaths a day. That’s a lot of opportunity for improved health just by changing the way we breathe!  Ideally, we want to be breathing through the nose. This is especially important at night and affects everything from oxygen saturation, fatigue levels, deep sleep, and dental health. We should also breathe with our diaphragm by expanding the lower ribcage and belly, letting it rise on every inhale and sink on every exhale. By focusing on extending the exhalation, it will activate the parasympathetic nervous system, which is the rest/digest/heal system and will aid in relaxation. 


Stress can contribute to shallow chest breathing, poor posture can contribute to mouth breathing, and lack of coordination or tight muscles can decrease your ability to breathe with your diaphragm. Do you want to learn to be a better breather? Physical therapy can help! 


Schedule a free consult with Intrinsic PT today.



Chronic Illness

What is POTS?

October is dysautonomia awareness month. What is dysautonomia? It is simply a dysfunction of the autonomic nervous system, which controls the automatic functions of the body such as heart rate, blood pressure, breathing rate, temperature control and digestion. People who experience dysautonomia have difficulty regulating these symptoms and experience lightheadedness, fainting, nausea, malnutrition, chronic fatigue, and abnormal heart rates. Postural Orthostatic Tachycardia Syndrome (POTS) is one form of dysautonomia.


POTS is a constellation of symptoms, ranging from mild to severe, with the common link being autonomic nervous system dysfunction. It is estimated that POTS affects 1-3 million Americans and many more worldwide. It is most common in young females, who are often high achievers. Despite increased recognition and improved diagnostics, it often takes years to get a diagnosis. Part of this can be because the person often looks “healthy” on the outside, while internally their body is desperating fighting to regulate a dysfunctional system. POTS also presents with vague symptoms that can easily be misdiagnosed.


Common symptoms of POTS include: lightheadedness, fatigue, headache, fainting, nausea, poor digestion, temperature dysregulation, blood pooling, allergies, brain fog, light and sound sensitivity, tightness in the chest, heart palpitations, exercise intolerance, tingling, and pain.


POTS is most commonly diagnosed using a tilt table test where the patient is strapped onto a table and the head is elevated to 70 degrees.  The patient is left there for up to 10 minutes while heart rate, blood pressure, and symptoms are monitored. POTS is diagnosed if the heart rate increased by 30 beats per minute in adults or 40 beats per minute in children/adolescents.


POTS is a syndrome and not a disease in itself and therefore treatment will need to be tailored to the individual to address underlying causes and conditions. Common treatment for POTS includes: increasing fluid and salt intake, wearing compression garments, participating in a customized exercise program, diet changes, and medications when necessary.


Working with a physical therapist familiar with POTS can be helpful to create a customized treatment approach that takes into account the complexities of orthostatic intolerance in order to improve your endurance and decrease your fatigue. At Intrinsic PT, we believe in a holistic approach to treating POTS and will address nervous system dysregulation, exercise intolerance, diet, and lifestyle modifications to help you successfully manage this condition.

Interested in learning more about how Intrinsic PT can help you manage your POTS? Schedule a free phone consult with us!


Chronic Illness Persistent Pain

Understanding Fear to Improve our Health

Let’s talk about fear. Fear often comes from doubt or the unknown. It’s a normal human emotion that has helped us survive for years. However, living in a constant state of fear can be harmful to our health.

I often notice that our bodies respond to fear in two ways: we overreact and stress ourselves out or we ignore. Prepare or avoid. I see this in my practice as a physical therapist in relation to injury or illness. People are constantly seeking answers, diagnoses, trying to figure out how they can fix their issue or people ignore it because they don’t know what to do. Both of these responses are our bodies reaction to fear which activates our sympathetic nervous system –  the fight, flight or freeze response. These responses are extremely beneficial to us for short term survival, like if you were out running a bear. But long term, we need balance with our parasympathetic nervous system, which allows for resting, digesting and healing. If we aren’t able to decrease fear, our stress response will stay elevated and our healing response will not become activated.  

Education can help combat fear. My purpose is to share my expertise with you to improve your understanding of your condition, decrease your fear and ultimately give you back the power to take control of your health.

Learn more about how physical therapy can help you with your persistent pain and chronic illness.