Miwa, Kunihisa · Journal of clinical medicine · 2026 · DOI
Many long COVID patients experience dizziness and difficulty standing (orthostatic intolerance), but researchers found this is not usually caused by the heart racing when standing up (POTS). Instead, balance problems detected by simple standing tests were the main cause in these patients. When treated with an antibiotic or brain stimulation therapy, most patients with balance-related standing problems improved.
This study challenges the widely-held assumption that POTS is the primary cause of standing intolerance in long COVID, suggesting instead that balance dysfunction is the key driver. This finding could redirect treatment approaches toward vestibular and neurological rehabilitation rather than cardiovascular interventions alone, potentially improving outcomes for patients with orthostatic symptoms.
This study does not establish causation between disequilibrium and orthostatic intolerance—the cross-sectional design only shows association. The small sample size (n=32, with only 7 OI cases) limits generalizability to the broader long COVID population. The treatment response in a subset of patients suggests potential therapeutic options but does not prove the underlying mechanism of how disequilibrium causes OI.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Miwa, Kunihisa (2026). Disequilibrium, Rather than Postural Orthostatic Tachycardia Syndrome, Is the Primary Determinant of Orthostatic Intolerance in Patients with Long COVID.. Journal of clinical medicine. https://doi.org/10.3390/jcm15062263
BibTeX
@article{mecfsatlas-miwa-2026-disequilibrium-rather,
author = {Miwa, Kunihisa},
title = {Disequilibrium, Rather than Postural Orthostatic Tachycardia Syndrome, Is the Primary Determinant of Orthostatic Intolerance in Patients with Long COVID.},
journal = {Journal of clinical medicine},
year = {2026},
doi = {10.3390/jcm15062263},
note = {PubMed: 41899187},
url = {https://www.mecfsatlas.com/evidence/miwa-2026-disequilibrium-rather},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-30. https://www.mecfsatlas.com/evidence/miwa-2026-disequilibrium-rather
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