The Polyvagal Theory was developed by the neuroscientist Stephen Porges in 1994. It provides a new perspective on understanding how the nervous system shapes our emotions and relationships. As well as how it may help us cope with pain and stress. This theory explains that the autonomic nervous system works in different states, influenced by the vagus nerve, and can have an effect on how safe or threatened we feel (Porges, 2025).
3 states of the nervous system
According to Polyvagal Theory, the nervous system is seeking to understand if we are safe or under threat. Depending on the answer, the body shifts into different states:
- Safety and connection (ventral state or rest and digest). The body feels calmer, pain is easier to manage, and daily activities feel more manageable.
- High alert (fight or flight). Pain sensitivity increases, muscles tense, and the body feels on edge.
- Shutdown or crash (dorsal vagal). Freeze, disconnect, energy drops, fatigue deepens (Missimer, 2020). This is often described as driving a car with feet on break and acceleration at the same time. Which leads people feeling exhausted.
These responses are your body’s automatic way of keeping you safe. They are not a flaw or a shortcoming.
According to Porges (2025,) when the ventral vagal system (feeling safe) is activated, we are better able to connect with others, stay emotionally balanced, and are able to respond better to challenges. Some of the main ideas in the theory include:
- Neuroception (which is our body’s automatic sense of safety or danger)
- Co-regulation (how we calm each other through connection),
- Dissolution (the nervous system’s ability to shift from defensive states and return to safety).
Heart rate variability (HRV)
The link between vagus nerve and the high-frequency component of HRV has been well established by research (Capilupi, Kerath and Becker, 2020). Why is this important in this context? Heart rate variability refers to the time between each heartbeat. It is a key indicator of autonomic nervous system balance. A 2019 study showed that higher HRV was more strongly associated with lower pain reports (Adler-Neal et al., 2019). And lower stress levels, better health and disease outcomes (Gerritsen and Band, 2018). Negative affect (low mood, distress, emotional strain) is consistently associated with decreased parasympathetic (ventral vagal/calmer state) activity and decreased HRV (Gullett et al., 2023). Basically, cardiac variability reflects the balance of ‘fight or flight’ and ’safety and connection‘ influence in autonomic function. As evident in cardiac activity (Chapman, Tuckett & Song, 2008).
Polyvagal Theory, EDS and Pain: Why Safety Matters
Living with Ehlers-Danlos Syndrome (EDS) often means living with pain, fatigue, and a body that feels unpredictable. People with EDS often notice that pushing through symptoms can lead to flare-ups and crashes (Boom Burst Cycle). This is happening because EDS affects not only joints and connective tissue, but also the autonomic nervous system (Ehlers Danlos Society, 2026).
The Ehlers Danlos Society (2026) explain that many people with EDS experience autonomic nervous system dysregulation. Including POTS, dizziness, gut issues, and extreme fatigue. Living with all these symptoms can keep the nervous system stuck in survival mode. This can amplify pain and slow recovery. When the body does not feel safe, pain becomes harder to regulate. At the same time, chronic pain can keep the nervous system in a fight-or-flight state, which may increase discomfort. Becoming aware of this cycle and using gentle strategies to stimulate the vagus nerve may help calm the nervous system. Which can make pain a bit more manageable.
Why Feeling Safe Matters
The Polyvagal Theory perspective is that regulation comes before’ doing’. This approach would suggest asking yourself: ‘How am I feeling?’ before engaging in an activity. Depending on the answer people could either use some strategies to shift their nervous system into a calmer state or engage in the activity straight away. By checking in with our bodies before engaging into an activity makes us more attuned and confident. When the nervous system feels safer, the body is better able to tolerate movement, recover from activity, and engage in daily life without triggering too many flare-ups.
This does not imply that activities should be avoided. It means approaching activity in ways that reduce threat rather than increase it.
How Occupational Therapy Can Help (this in not a exhaustive list)
Occupational therapy supports people with EDS to participate in daily life more safely and sustainably. A Polyvagal-informed OT approach may include:
- Pacing and energy conservation – helps to reduce nervous system overload and minimise flare-ups
- Joint protection and task adaptation – reduce strain and pain, facilitating occupational engagement
- Sensory- based strategies – such as warmth or compression to enhance body awareness and nervous system regulation
- Building routines that support regulation – promote safety, regulation and consistency in daily life
Current medical applications and trials
The Polyvagal Theory is not a cure for EDS, but it offers a compassionate way to understand pain and fatigue. By prioritising safety and regulation, people with EDS may begin to rebuild trust in their bodies and engage more fully in daily life.
Whitin the NHS, stimulation of the vagus nerve (VNS implant) has been used as an approach to different medical conditions. Including treatment resistant depression, epilepsy and stroke recovery trials (MIND, 2022; Epilepsy Society, 2023; Mills, 2024). The NHS doesn’t yet provide vagus nerve implant stimulators for people with EDS. But there is emerging research into the effectiveness of VNS for this group population. The Medical University of South Carolina has been among the firsts to use stimulation on the vagus nerve in people with EDS, trough implantable vagal nerve stimulators (MUSC, 2023).
Moving Toward Safety, Not Perfection
Stimulation of the vagus nerve can be done in many ways, not only by VNS implant. It’s recommended for people to choose the option that is more aligned with their natural preferences, as this will not add extra pressure or stress to their daily life.
Some of the options like VNS implants and auricular stimulators may not be accessible for everyone due to medical or financial circumstances. Auricular stimulators may be useful, but it would be recommended to try different approaches – to trial if this is something that might work for you -before committing to such an investment.
The list below is not arranged in order of efficacy of the options, as different options could work differently for people
Mindfulness and Meditation
Encourages present moment awareness which can stimulate the vagus nerve (Keer, 2024). Mindfulness meditation has been shown to improve cognitive flexibility, and emotional resilience. It lowers stress and pain levels, both of which are linked to healthier heart rate variability (Adler-Neal et al., 2019). Meditation can be done in the comfort of your home with multiple guided meditation options available on Youtube. You could join a meditation group, or why not create your own meditation group with family or friends (face to face or by video calls).
Yoga
Mind–body therapies, such as yoga, can support people to atune into their body by noticing internal sensations and body position. They combine this awareness with mindfulness skills like acceptance, curiosity, and being gentle with yourself. In time, yoga practice can help the brain interpret sensations differently, making them feel less threatening or overwhelming. (Sullivan et al., 2018). There are numerous yoga groups that can accessed, and the yoga practitioner can adapt the yoga possess to your medical condition. There are yoga videos available on Youtube for people with EDS, POTS or other medical conditions. I will attach a list at the end.
Neuronal exercise
Activities such as sing, play music, hum, cold water, laughing, belly breathing are associated with the increase of neurotransmitters such as endorphins, serotonin and dopamine that can support the nervous system to shift towards a calmer, regulated state (Kang, Scholp and Jiang, 2018; Van der Wal and Kok, 2019). You can use music, singing and humming while doing some chores or use belly breathing while watching TV.
Vagus nerve massage
One of the easier ways to stimulate the vagus nerve is massage. This can be done by gently massaging specific points of the outer ear (NHS, 2024). People with CCI (cranio-cervical instability) need to use caution with this type of massage. It is recommended to be carried out by a professional or to try different alternative ways of vagal stimulation. With this in mind, this link provides more information on the technique.
Auricular stimulation
If you are interested about auricular VNS there ScienceInHealrg.com offers with information on different devices, with prices and specifications.
Useful Links
Yoga for POTS and EDS videos
Meditation and Mindfulness videos
Tapping
About the author
I’m Mariana, Occupational Therapy student. I am interested in learning ways to manage out occupation through things we can easily include in day to day life. My own past experiences along with OT training inspired this post. We don’t often talk about mental health openly and that needs to change. Learning to manage our emotions, nervous systems and health can help with a lot of different challenges.
