Postural orthostatic tachycardia syndrome (POTS) was once considered a relatively uncommon condition – one that even seasoned practitioners might encounter only occasionally in clinical practice. That reality has changed dramatically. Over the past several years, and particularly since the COVID-19 pandemic, POTS has moved from the periphery of clinical awareness into the mainstream of both conventional and integrative medicine.
This heightened attention is due in large part to the effects of SARS-CoV-2 infection on the autonomic nervous system (ANS). As a result, clinicians across disciplines are now encountering increasing numbers of patients presenting with symptoms of orthostatic intolerance, exercise intolerance, tachycardia, dizziness, fatigue, and cognitive dysfunction. Many of these patients ultimately meet diagnostic criteria for POTS.
POTS falls under the broader category of dysautonomia, a term used to describe dysfunction of the autonomic nervous system. The ANS governs a vast range of involuntary physiological processes, including heart rate, blood pressure regulation, digestion, thermoregulation, pupillary reflexes, and aspects of immune and inflammatory control. Given the breadth of these functions, dysautonomia can manifest in a wide variety of clinical presentations – often involving multiple organ systems and fluctuating symptom patterns.
Dysautonomia vs. Autonomic Dysregulation
It is essential to delineate an important clinical distinction: Not all autonomic symptoms constitute dysautonomia in the medical sense. Many individuals experience milder forms of autonomic dysregulation during periods of high stress, anxiety, depression, trauma exposure, or post-traumatic stress. In these cases, symptoms such as palpitations, lightheadedness, gastrointestinal upset, headaches or dizziness may arise from heightened sympathetic tone or impaired parasympathetic regulation. While these presentations can be clinically significant and deserve thoughtful treatment, they do not necessarily meet criteria for a diagnosable autonomic disorder.
In contrast, dysautonomia as a medical diagnosis refers to a persistent, pathological failure of autonomic regulation, often measurable through objective testing and associated with predictable physiological abnormalities. POTS represents one such subtype, characterized by a reproducible abnormal cardiovascular response to upright posture.
Understanding this distinction is critical for acupuncturists. Patients with POTS are often misdiagnosed – or dismissed entirely – as having anxiety, deconditioning or psychosomatic illness. A clear grasp of diagnostic criteria and pathophysiology allows clinicians to validate patients’ experiences and design more effective, individualized treatment strategies.
Understanding POTS: Current Diagnostic Criteria
Postural orthostatic tachycardia syndrome is defined by an excessive increase in heart rate upon assuming an upright posture, in the absence of significant orthostatic hypotension. Current diagnostic criteria generally include:
Importantly, POTS is not a single disease entity, but rather a clinical syndrome with multiple underlying mechanisms. This heterogeneity explains why patients with the same diagnosis may present very differently; and why a one-size-fits-all treatment approach is rarely effective.
Common Clinical Features
Patients with POTS may report a wide constellation of symptoms, including:
Many patients also report symptom onset following a triggering event, such as viral illness, traumatic brain injury, surgery, pregnancy, or prolonged immobilization. In clinical practice, it is not uncommon to see POTS emerge as part of a broader post-viral or post-concussive syndrome.
Overlap With Autoimmune and Connective-Tissue Disorders
Another clinically significant – and often underappreciated – aspect of POTS is its frequent overlap with autoimmune and connective-tissue disorders, particularly Ehlers-Danlos syndrome (EDS) and related hypermobility spectrum disorders. A substantial subset of POTS patients demonstrate joint hypermobility, tissue fragility, or a history of frequent sprains, dislocations, and chronic pain.
In these individuals, impaired connective-tissue integrity may contribute to excessive venous pooling in the lower extremities when upright, placing greater demand on autonomic reflexes to maintain cerebral perfusion. Over time, this increased compensatory burden may exacerbate or unmask autonomic dysfunction.
Additionally, immune dysregulation, whether autoimmune or mast cell-mediated, appears to play a contributory role in many patients, further complicating the clinical picture.
For acupuncturists, recognizing these overlaps is critical. Patients with POTS and comorbid hypermobility or autoimmune features often present with heightened sensitivity to treatment, slower recovery timelines, and complex mixed-pattern presentations. A narrow or overly aggressive approach may fail to address the underlying terrain contributing to autonomic instability.
Why This Matters for Acupuncturists
From a traditional East Asian medicine perspective, POTS patients often present with complex, overlapping patterns that do not fit neatly into a single diagnostic category. Symptoms may fluctuate day to day, worsen with exertion, heat, or stress, and involve both excess and deficiency presentations. Without a clear understanding of the biomedical framework of POTS, clinicians risk undertreating the condition – or inadvertently exacerbating symptoms by applying strategies better suited for stress-induced autonomic imbalance rather than true dysautonomia.
Author’s Note: Part 2 of this article will explore distinct phenotypes of POTS based on underlying mechanisms, and translate these patterns into traditional Chinese medicine differential diagnoses, allowing practitioners to select more precise and supportive herbal strategies.
Resource
Fertility acupuncture sometimes gets presented as a narrow protocol: a handful of reproductive points applied uniformly across patients. What this case reinforced for me: The most powerful work happens when we read the whole picture. The hormone data, the constitutional tendency, the sleep, the digestion, and the menstrual pattern, so we can treat the environment the ovaries live inside.
Mast cell activation syndrome (MCAS) affects more than 15% of the U.S. population but evades most practitioners’ radar. Just five years ago, it wasn’t even on my radar, despite already having 20 years of experience as a clinician at that time. The more I dug (similar to leaky gut and post-COVID syndrome), the more I found my patients were suffering from this disorder.
The motivation behind our practice of medicine is important, impacting not just our experience but also the experiences of those we treat. It is perhaps for this reason that the aspiration to help not just some, but all beings heal, has historically been an important part of the medical tradition. To explain this, we need to consider how medicine is interwoven with other social domains.