Hypermobile Ehlers-Danlos Syndrome, POTS, and Dysautonomia: How Physical Therapy and Pilates Can Help

by Lisa Lenhart, PT

Edited by Brittany Schroeder, PT, DPT, NCPT, WCS

A Whole-Body Approach to Managing Complex Conditions

Ehlers-Danlos Syndrome (EDS) is a group of inherited connective tissue disorders that affect the body's collagen, a protein that provides strength and support to skin, joints, blood vessels, and other tissues. Individuals with EDS commonly experience joint hypermobility, chronic pain, frequent sprains or dislocations, fatigue, and skin fragility.

Living with Ehlers-Danlos Syndrome (EDS) often means navigating a complex array of symptoms that extend far beyond joint hypermobility. Many individuals with EDS also experience Postural Orthostatic Tachycardia Syndrome (POTS) and other forms of dysautonomia, creating challenges that affect mobility, endurance, pain levels, and overall quality of life.

While there is currently no cure for EDS, POTS, or dysautonomia, evidence supports the use of targeted exercise, physical therapy, and movement-based interventions such as Pilates to improve function, enhance body awareness, and help individuals safely return to meaningful activities.

Understanding Ehlers-Danlos Syndrome

In people with EDS, connective tissues often provide less stability than normal. As a result, muscles must work harder to support and protect joints. Over time, this can contribute to pain, fatigue, muscle tension, and recurrent injuries.

The most common subtype, hypermobile Ehlers-Danlos Syndrome (hEDS), is characterized by:

• Joint hypermobility

• Frequent sprains, subluxations, and dislocations

• Chronic musculoskeletal pain

• Fatigue

• Poor balance and coordination

• Soft tissue injuries

• Impaired proprioception (awareness of body position)

EDS is often misunderstood as simply a condition of "being flexible." In reality, hypermobility exists on a spectrum, and many individuals with EDS experience significant symptoms despite appearing healthy from the outside. Joint instability, pain, fatigue, autonomic dysfunction, gastrointestinal symptoms, pelvic floor dysfunction, headaches, and exercise intolerance can all affect daily life.

Importantly, symptoms are not solely the result of joint laxity. Living with chronic pain, recurrent injuries, and unpredictable symptoms can place additional demands on the nervous system, contributing to increased sensitivity, fatigue, and reduced tolerance for physical and emotional stress. Effective treatment often requires addressing both the musculoskeletal system and the nervous system.

The Link Between EDS, POTS, and Dysautonomia

Because connective tissue exists throughout the body, EDS can affect multiple systems, including the cardiovascular, gastrointestinal, and autonomic nervous systems. Research has shown that autonomic dysfunction is common among individuals with hypermobile EDS.

Researchers continue to investigate why POTS and dysautonomia are so common in individuals with hypermobile EDS. Several factors may contribute, including increased venous pooling due to connective tissue laxity, altered blood vessel function, reduced blood volume, deconditioning, and changes in autonomic nervous system regulation.

While the exact relationship varies from person to person, recognizing the overlap between these conditions is essential because symptoms such as fatigue, dizziness, exercise intolerance, gastrointestinal dysfunction, and brain fog may not improve through joint-focused treatment alone.

What is POTS?

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia in which the heart rate increases excessively when a person moves from lying down to standing. Common symptoms include:

• Dizziness

• Lightheadedness

• Rapid heartbeat

• Palpitations

• Fatigue

• Brain fog

• Exercise intolerance

• Shortness of breath

• Fainting or near-fainting episodes

What is Dysautonomia?

Dysautonomia refers to dysfunction of the autonomic nervous system, which regulates many automatic bodily functions, including:

• Heart rate

• Blood pressure

• Digestion

• Temperature regulation

• Breathing

• Sweating

For many individuals with EDS, dysautonomia contributes significantly to daily symptoms and can make physical activity feel overwhelming.

The Challenges of Managing Multiple Conditions

When EDS, POTS, and dysautonomia occur together, symptoms often reinforce one another. Joint instability may lead to reduced physical activity due to pain, fatigue, or fear of injury. Reduced activity can contribute to deconditioning, which may worsen orthostatic intolerance and cardiovascular symptoms. Increased dizziness and fatigue can then make exercise feel overwhelming, creating a cycle that can be difficult to break.

Many individuals also develop understandable fear and uncertainty around movement after years of injuries, flare-ups, or being told that exercise is harmful. As a result, treatment is not simply about getting stronger. It is about helping individuals rebuild trust in their bodies through appropriately dosed movement, symptom education, and gradual exposure to activity.

Physical therapy and Pilates can help interrupt this cycle by improving physical capacity while supporting nervous system regulation, body awareness, and movement confidence.

The Role of Physical Therapy

Physical therapy is considered one of the most important conservative treatments for EDS. A skilled physical therapist develops an individualized program designed to improve movement while minimizing symptom flare-ups.

Goals of Physical Therapy

Physical therapy interventions often focus on:

• Improving joint stability

• Building muscular strength

• Enhancing balance and coordination

• Increasing cardiovascular tolerance

• Reducing pain

• Improving posture

• Preventing injury

• Supporting long-term self-management

Joint Stabilization Training

Since connective tissues may provide less support in EDS, muscles must compensate to help stabilize joints.

Treatment may include:

• Core strengthening

• Hip stabilization exercises

• Shoulder and scapular strengthening

• Functional movement training

• Neuromuscular re-education

The focus is on controlled movement, proper alignment, and movement efficiency rather than maximizing flexibility.

Proprioceptive Training

Many individuals with EDS have difficulty sensing joint position accurately, increasing their risk of falls and injuries.

Physical therapists often incorporate:

• Balance exercises

• Single-leg activities

• Dynamic stability drills

• Coordination training

Improved proprioception can help patients feel more secure and confident during daily activities.

Education and Symptom Management

A key component of physical therapy is helping individuals understand how to work with their bodies rather than against them.

This may include education on:

• Activity pacing

• Energy conservation strategies

• Managing symptom flare-ups

• Hydration and exercise considerations

• Breathing mechanics

• Sleep and recovery habits

• Nervous system regulation

Learning how to appropriately balance activity and recovery often allows individuals to remain more active without triggering significant symptom exacerbation.

Exercise for POTS and Dysautonomia

For individuals with POTS, therapy often begins in positions that minimize orthostatic stress.

Examples include:

• Recumbent cycling

• Rowing

• Swimming

• Aquatic therapy

• Supine strengthening exercises

As tolerance improves, exercise progresses gradually toward upright activities.

Current evidence supports graded cardiovascular exercise as one of the most effective non-pharmacological interventions for POTS. Early phases often emphasize recumbent or semi-recumbent exercise to build cardiovascular capacity while minimizing orthostatic symptoms.

Consistency is often more important than intensity. Small, sustainable increases in exercise volume typically produce better long-term outcomes than repeatedly pushing through symptoms and experiencing setbacks.

The Unique Benefits of Pilates

Pilates is increasingly recognized as a valuable complement to physical therapy for individuals with EDS, POTS, and dysautonomia when appropriately modified and supervised.

At Core Moves, we view Pilates as a movement education system rather than simply a workout. The Pilates environment allows individuals to explore movement with precision, curiosity, and appropriate challenge. This can be particularly valuable for those who have spent years feeling disconnected from or frustrated by their bodies.

Pilates focuses on controlled movement, core stability, breathing, alignment, and body awareness—all areas that can benefit individuals with hypermobility disorders.

Why Pilates Works for EDS

Unlike many traditional fitness programs that emphasize flexibility, Pilates emphasizes stability and control.

Potential benefits include:

• Improved core strength

• Enhanced postural control

• Better body awareness

• Increased muscular endurance

• Improved movement efficiency

• Reduced joint strain

• Better breathing mechanics

For individuals with hypermobile joints, learning how to control movement within a safe range can be more beneficial than increasing flexibility.

Pilates and Proprioception

Pilates exercises require focused attention to alignment and movement quality.

This mindful approach may help individuals with EDS improve:

• Joint position awareness

• Coordination

• Movement confidence

• Neuromuscular control

These improvements can translate into better functional movement and fewer episodes of joint instability.

Pilates for POTS and Dysautonomia

Many Pilates exercises can be performed in supine, side-lying, seated, or reclined positions, making them particularly helpful for individuals who struggle with upright exercise.

Benefits may include:

• Gradual cardiovascular conditioning

• Improved breathing patterns

• Enhanced circulation

• Increased exercise tolerance

• Reduced symptom provocation

Exercises can be modified to accommodate dizziness, fatigue, and fluctuating symptoms.

Breathing, Core Function, and the Pelvic Floor

Many individuals with EDS and dysautonomia experience altered breathing patterns, pelvic floor dysfunction, abdominal pressure management challenges, and feelings of core instability. These issues may contribute to symptoms such as pelvic pain, urinary urgency or frequency, constipation, low back pain, and reduced exercise tolerance.

Physical therapy and Pilates can help improve coordination between the diaphragm, abdominal wall, pelvic floor, and deep stabilizing muscles of the trunk. Rather than focusing on "tightening" or bracing, treatment emphasizes efficient pressure management, breathing mechanics, and movement strategies that support both stability and function.

For many individuals, improving these foundational systems can have meaningful effects on comfort, endurance, and quality of life.

Important Precautions

Although Pilates can be highly beneficial, not all Pilates classes are appropriate for individuals with EDS.

Certain movement approaches may require modification, particularly during periods of symptom flare-up or significant joint instability. These may include:

• Sustained end-range stretching

• Repeated hyperextension of joints

• High-impact activities introduced too quickly

• Exercise programs that prioritize flexibility over stability

• Rapid progression without adequate recovery

Many individuals with EDS can safely participate in a wide variety of activities—including strength training, Pilates, yoga, running, and recreational sports—when movement is appropriately modified and progressed.

The physical therapists and Pilates instructors at Core Moves are familiar with hypermobility disorders.

Our goal is to help clients find a safe, effective, and sustainable movement practice that supports strength, resilience, and long-term health.

The emphasis should always be on stability, control, movement quality, and building capacity over time rather than achieving greater range of motion.

A Team-Based Approach to Success

When physical therapy and Pilates are integrated thoughtfully, individuals can develop the strength, endurance, movement confidence, and self-management skills needed to participate more fully in work, recreation, exercise, and everyday life.

Because EDS, POTS, and dysautonomia affect multiple body systems, the most effective care is often collaborative. Physical therapists, Pilates instructors, physicians, mental health providers, nutrition professionals, and other healthcare providers may all play an important role in helping individuals achieve their goals.

Moving Forward with Confidence

Although Ehlers-Danlos Syndrome, POTS, and dysautonomia can present significant challenges, a diagnosis does not mean giving up the activities that matter most. With the right support, many individuals are able to build strength, improve endurance, reduce symptoms, and return to meaningful movement.

At Core Moves, we believe treatment should address the whole person—not just individual symptoms. Through individualized physical therapy, Pilates-based movement training, nervous system-informed care, and collaborative goal setting, we help clients develop the skills and confidence needed to move through life with greater stability, resilience, and ease.

Progress is rarely linear, but meaningful change is possible. Better begins today.

If you are interested in learning more about our physical therapy and Pilates programs, we would be happy to help you explore the best approach for your unique needs.