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Recorded Tuesday, October 6, 2026
This article is based on the CHKD Provider Relations CME Lunch & Learn presentation, “Autonomic Dysregulation in the Hypermobile Child,” presented by Dr. Katrina Lesher and Amber Stewart, PA-C.
Autonomic Dysregulation in Children With Hypermobility
Dizziness, fatigue, headaches, gastrointestinal complaints, and chronic pain can be difficult to connect when they appear together in a child or adolescent. For some patients, these seemingly unrelated concerns may be part of a broader pattern of autonomic nervous system dysregulation, particularly when joint hypermobility is also present.
During a recent CHKD Provider Relations CME Lunch & Learn, Dr. Katrina Lesher, director of CHKD’s Physical Medicine and Rehabilitation program, and Amber Stewart, PA, discussed how providers can recognize autonomic dysregulation, help patients and families better understand their symptoms, begin supportive management, and determine when specialty care may be appropriate.
Recognizing the Clinical Picture
Children with autonomic dysregulation may present with symptoms affecting multiple organ systems and, in some cases, may have already been evaluated by several specialists. Symptoms often become more prominent during adolescence and may worsen around puberty or following viral illnesses.
Common symptoms discussed during the session included:
Dizziness, lightheadedness, presyncope, or syncope
Chronic fatigue and nonrestorative sleep
Headaches and brain fog
Palpitations or changes in heart rate
Nausea, abdominal pain, bloating, and gastrointestinal motility concerns
Chronic musculoskeletal pain
Joint hypermobility or instability
Changes in sweating
Bladder symptoms
Dizziness, lightheadedness, and syncope, along with persistent pain that cannot be explained by an acute injury, are common reasons patients are referred to CHKD’s Physical Medicine and Rehabilitation team.
Looking Beyond Diagnostic Labels
Autonomic symptoms can be challenging for patients and families, particularly when symptoms affect several areas of daily life. Dr. Katrina Lesher emphasized using descriptive terminology to help patients understand what they are experiencing rather than focusing exclusively on diagnostic labels or acronyms.
For example, orthostatic symptoms do not necessarily indicate postural orthostatic tachycardia syndrome, or POTS. The CHKD team often uses the broader term orthostatic intolerance when discussing difficulty tolerating positional changes and focuses treatment on the patient's symptoms and functional needs.
This approach can be especially helpful when patients arrive with terminology or diagnoses they have encountered through social media or other nonclinical sources.
Understanding the Role of Hypermobility
Joint hypermobility is frequently seen among the patients treated by the team for autonomic symptoms. Its presentation can vary, and patients may develop muscular tightness as their bodies compensate to stabilize hypermobile joints. Some experience chronic musculoskeletal pain, while others remain active without significant pain.
When pain, instability, or deconditioning affects function, physical therapy may focus on muscle strengthening, joint stabilization, pain management, and a gradual return to movement.
Building Treatment Around Function
Management begins with education and a strong foundation of healthy daily habits. During the session, Amber Stewart, PA, described several areas the team addresses with patients, including hydration and nutrition, sleep, movement, and mental health. Recommendations are individualized according to the patient's symptoms and needs.
Hydration and nutrition: The team evaluates fluid intake, sodium, protein, and overall nutrition. Regular meals, including breakfast, are encouraged, particularly for patients whose morning nausea or other symptoms interfere with eating.
Sleep: Consistent sleep schedules and healthy sleep habits are emphasized because patients may experience nonrestorative sleep, fatigue, and excessive daytime sleepiness.
Movement: Regular activity is encouraged based on each patient's abilities. For patients who have become deconditioned because of pain or other symptoms, gradually returning to movement can be an important part of restoring function.
Mental health: Stress and anxiety do not cause autonomic symptoms, but they can amplify them. The team discusses the mind-body connection and the value of healthy coping strategies, with behavioral health support considered when appropriate.
When to Consider Referral
For patients with mild positional dizziness, primary care providers may begin with basic supportive strategies and monitor response. Referral to Physical Medicine and Rehabilitation may be appropriate when symptoms are persistent, complex, or significantly affecting function.
The CHKD team also recommends considering referral for patients with significant joint hypermobility accompanied by persistent pain, diffuse instability, frequent subluxations or dislocations, unusual stretch marks, significant scarring, or a personal or family history of concerning wound-healing or connective tissue issues.
Because symptoms may involve several organ systems, care may also require collaboration with specialties including cardiology, gastroenterology, allergy, sleep medicine, adolescent gynecology, nutrition, behavioral health, and physical or occupational therapy.
Education Is Part of the Treatment
One of the most important takeaways from the session was the value of helping patients and families understand their symptoms.
Providing a clear explanation of what may be happening, ruling out other concerning causes when appropriate, and establishing a practical management plan can help families better navigate symptoms. Rather than focusing solely on diagnostic labels, the CHKD Physical Medicine and Rehabilitation team emphasizes improving function and giving patients strategies to manage their symptoms.
For providers caring for children and adolescents with complex, multisystem complaints, recognizing patterns of autonomic dysregulation and hypermobility can help guide evaluation, initial management, and appropriate specialty referral.
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