Optimize Vagal Tone to Optimize Health

Ekta Lund PT, MSPT, CFMT, CKTP and Fiona McMahon PT, DPT

Vagus, Baby! The nerve, not the City. The vagus nerve is the 10th cranial nerve and plays a critical role in the body, specifically in the regulation of digestion, breathing, heart rate, and healing. When there are issues with the vagus nerve, you may experience brain fog, heart rate and blood pressure issues, digestive symptoms, chronic pain, fibromyalgia-like symptoms, and low stomach acid. The aforementioned symptoms are what we like to call, nonspecific, meaning there are many things that could be influencing them. It is important to visit your primary care provider (PCP) first to rule out any more serious conditions, but if you don’t find answers and your symptoms remain it might be a good time to investigate your vagus nerve.

To understand the Vagus nerve and the first few layers of Polyvagal Theory, we must first understand the autonomic nervous system. I promise I will make this as absolutely pain-free as possible to understand. The autonomic nervous system is the part of the nervous system responsible for regulating all of the things our body does to keep us alive without us even having to think about it. Need your heart rate to slow down or speed up? Want to digest that burger you had for dinner? Need to dilate your pupils so you can see better in a dark room? Thank your autonomic nervous system.

Traditionally, experts further divide your autonomic nervous system into two opposing but complementary systems. The sympathetic and parasympathetic nervous system. You can think of them rest and digest (parasympathetic) and fight, flight (sympathetic). I like to think of the parasympathetic nervous system as the care taker or office manager. The parasympathetic works during times of rest and peace to ensure long term survival objectives like reproduction, digestion, and healing are done and done well. The sympathetic nervous system makes me think of the security guard, mobilizing energy and directing folks (or your organs) in states of threats or emergency. In the body, the sympathetic nervous system provides you with a rush of adrenaline, freshly mobilized glycogen stores for energy, and generally revs you up to take on whatever perceived threat is out there.

Neither of these systems is good or bad. They perform two very different duties. In folks with a healthy autonomic nervous system, we will access both systems throughout the day. You need both to work in order to get up and go for a workout, to have a bowel movement, and even to get aroused and complete the sexual cycle to orgasm. You. Need. Both.

Let’s go back to the office manager and security guard metaphor. One could imagine that an office would run very poorly if the security guard was on high alert, high threat detection mode. Perhaps, in this scenario, the security guard would garner so much attention and bandwidth from the employees at this office that meetings would not get scheduled, supplies would not be restocked, and Brenda’s highly anticipated surprise retirement party would not go on as planned. Total bummer.

Having an over vigilant and dare I say it, reactionary, security guard is kind of like having an overworked sympathetic nervous system. You can function, for a time, but not optimally. The fact is the state of fight or flight is a costly place to be for all animals, (we too, are animals). Being in fight or flight moves energy away from digestion, reproduction, and healing to systems designed to neutralize threat. Your muscles will have increased blood flow, your heart rate will speed up, etc.,. In the short term it is so adaptive, but if left unchecked it can take away from your ability to just be a happy, well functioning animal.

Here’s where Polyvagal Theory comes in. Polyvagal Theory gets its name from the 10th cranial nerve, the vagus nerve. The vagus nerve forms the primary component of Parasympathetic nervous system (the office manager in our metaphor). The theory actually subdivides the parasympathetic ( rest and digest system) into two branches; the dorsal vagal complex and the ventral vagal complex. Now in this metaphor we have 2 office managers and a security guard. The first office manager is the ventral vagal complex. This office manager is really good at communicating with the security guard (the sympathetic nervous system) and is effective at letting the guard know that the threat is no longer there, and can help the office return to its happy, social everyday functioning. When the ventral vagal complex is active, we feel safe an happy, motivated to engage and social with others. The dorsal vagal complex, represents an office manager who is perhaps burnt out and disengaged. The dorsal vagal complex is activated when the threat is prolonged and represents shutdown and immobility. As an office manager it is lousy at getting it’s employees back on track and well, is just kind of exhausted from the security guard being revved up all the time.

In a perfectly functioning body the sympathetic nervous system is activated when a particular threat is detected, and when it is safe to do so the ventral vagal complex, calms the sympathetic nervous system so it can get back to healing and digestion.

To summarize the above, our body exist in a balance between dealing with threats and tending to homeostasis (things like digestion/reproduction) in times of peace. In a person with a well functioning ventral vagal system (the very capable office manager), they can efficiently move from a state of increased sympathetic tone to increased ventral vagal tone appropriately. Sometimes, when a perceived threat remains present folks can experience increased dorsal vagal tone, which leads to social withdrawal isolation, and despair. But what does that have to do with physical therapy? Let’s read on.

Applying Polyvagal Theory to Physical Therapy

In order to reap the full benefits of physical therapy treatment, we need to be respectful of the autonomic nervous system at the very least, and cognizant of Polyvagal Theory to further optimize results.

Especially in pelvic floor physical therapy, but I would argue that with ANY type of physical therapy we need healthy parasympathetic tone. This is because, the work of healing, laying down new synapses, digestion, and restoration all require us to have some sort of parasympathetic tone. We simply do not heal as well when stressed. It is the body’s primary objective to survive, if it feels under threat, it will not allocate resources to healing. It will allocate resources to extinguishing the threat.

The Autonomic Nervous System and Pelvic Health

Healthy autonomic tone is imperative to pelvic and abdominal health. Like I said before, we need both systems to function optimally in order to be healthy and happy. Sympathetic tone has many useful outputs. Increased sympathetic tone helps to keep the bladder squeezer muscle from working, allowing you to delay peeing until a socially appropriate time. It also stimulates orgasm in all genders. Parasympathetic tone allows us to digest and absorb our food, have good pee and poo voids, and is also responsible for erection. You can imagine how difficulty switching from sympathetic tone to parasympthetic tone could be extremely disruptive and upsetting.

How to Optimize Polyvagal Tone on Your Own

You may be deep into PT and perhaps this article has piqued your interest. Who doesn’t want to optimize healing? Just relax. I’m totally kidding. When in the history of “relax” has that ever worked? Life is stressful, especially now. What we need is habits to reassure our bodies that the threat it is perceiving is not imminent and does not need to be resolved straight away. No one will tell you to eliminate stress, but improving your ability to access your ventral vagal system can go a really long way.

The ventral vagal complex is activated with social engagement. It is activated in infants by their caretaker’s warm voice and soothing gestures. Employing activities that sooth you, like deep breathing, meditation, and mindful movement strategies have all been posited to help increase ventral vagal tone. Other activities like humming, rubbing behind your jaw, laughing, singing, sun, and smiling can all increase your ventral vagal tone. Basically, while you are in the hard work of rehabbing and healing, it really is important to give yourself a rest day or two and do something enjoyable. It does the body a world of good! That said, I would caution you, that if stress is a constant disruptor in your life, to utilize a trained mental health professional. These techniques are certainly not meant to replace qualified mental healthcare, rather they are meant to help optimize physical healing.

Treating the Vagus Nerve Directly

Trained physical therapists can directly affect vagal tone directly. Because ventral vagal tone increases with pleasant socialization, getting along with your physical therapist can go a long way. It may sound silly, but taking time to find a PT who you trust and enjoy being around can really help therapy.

More directly your physical therapist can work on improving the alignment of the top 2 bones in the neck (c1-c2) to improve blood flow from the vertebral artery, which supplies the brainstem containing the 5 cranial nerves involved in social engagement (hearing, phonation, facial expression), which improves ventral vagal tone.

Your vagus nerve inclined therapist may also use techniques such as taping, vibration ear taping, ear pull technique to stimulate the vagus nerve, improve lymph flow.

Final Thoughts

The autonomic is a powerful and vital part of your physiology. When approaching challenges to our health, infection, injury and stress, it is important to be aware of how your body’s ability to respond to stress and return to rest and digest affects your healing. In pelvic floor physical therapy, an over active sympathetic or dorsal vagal nervous system tone can hamper healing, digestion, urinary, and sexual function. Awareness of how your nervous system works, as well as ways to optimize it can go a long way to optimizing healing.


Porges S, Polyvagal theory: A science of safety. Front Integr NeuroSci. 2022 May 10;16:871227. 2018 Mar;17(1):5-15. doi: 10.1177/1534735416682087.

Lucas A, Klepin H, Rejeski J. Mindfulness-based movement: A polyvgal perspective. Integrative Cancer Therapies. 2018 Mar;17(1):5-15. doi: 10.1177/1534735416682087.

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