A Comprehensive Guide to Exercising with Postural Orthostatic Tachycardia Syndrome (POTS)
What We Know About POTS
Postural Orthostatic Tachycardia Syndrome (POTS) is a form of Dysautonomia predominantly affecting pre-menopausal women. POTS is characterized by orthostatic intolerance, a condition in which an excessively reduced volume of blood returns to the heart after an individual stands up from a lying down position.
Per the National Institute of Health (NIH), POTS patients commonly experience “lightheadedness or fainting [which is] accompanied by a rapid increase in heartbeat of more than 30 beats per minute, or a heart rate that exceeds 120 beats per minute, within 10 minutes of rising. The faintness or lightheadedness of POTS is relieved by lying down again. Other common symptoms include:
fatigue
brain fog
nausea and vomiting
headaches
excessive sweating
shakiness
exercise intolerance
These symptoms may be exacerbated by warm environments, long periods of standing, inadequate salt or fluid intake, skipping a meal, or suffering a cold or infection.
What we Don’t Seem to Know About POTS: How to Effectively Treat and Manage Symptoms
Current treatment options aim to relieve low blood volume and/or regulate circulatory problems, and unfortunately, when it comes to pharmaceutical treatment options, there doesn’t seem to be a universally effective solution. Beta-Blockers are perhaps the most common pharmaceutical treatment option, although not all patients respond well to them and for some patients, it may even exacerbate their symptoms. Given that the pharmaceutical treatment options available for the treatment of POTS are not consistently effective, it is worth considering non-pharmaceutical options, such as increasing fluid intake, increasing salt intake, compression stockings, exercise programs, lifestyle changes, and more.
The Role of Exercise as a Promising Non-Pharmaceutical Treatment
As it turns out, one very promising non-pharmaceutical treatment option for POTS is exercise. Exercise programs can be used as a treatment for POTS by addressing the issue of cardiac de-conditioning through gradual progression.
“Recent research has demonstrated that cardiovascular de-conditioning (i.e., cardiac atrophy and hypovolemia) contributes significantly to the Postural Orthostatic Tachycardia Syndrome (POTS) and its functional disability”
Given this information, it’s important to consider prioritizing exercise and its potential therapeutic effects on POTS.
How POTS Earned the Nickname of The Grinch Syndrome, and How It Relates to Exercise
Additionally, research has found that POTS patients tend to have on average a smaller heart with reduced blood volume compared to healthy controls, earning POTS the amusing nickname of “The Grinch Syndrome” which draws a parallel to the well-known Christmas movie character who had a heart that was two sizes too small.
In the context of exercise, it was determined that short-term exercise training increased cardiac size/mass and expanded blood/plasma volume, thereby improving and potentially even curing POTS for some patients. These results further draw on the importance of treating the de-conditioning aspect of POTS and the effectiveness of prescribing exercise training as a non-pharmaceutical therapy. (Fu et al., 2010)
Exercise Therapy May Even be a More Effective Treatment Than Beta-Blockers
We’ve established that exercise programs are an important option for the treatment of POTS, especially given the fact that pharmaceutical options are inconsistently effective and sometimes even detrimental to treatment outcomes. To further drive this point home, I want to discuss a study done by Fu et al. (2010) which investigated the effectiveness of Propranolol (a Beta Blocker) treatment vs. exercise therapy, which found that:
“exercise training, but not propranolol treatment, improved adrenal function, POTS symptoms, and, most importantly, patient quality of life…Because there are no effective pharmacological therapies for POTS patients so far, and many patients have disabling adverse effects with standard drug treatments, exercise training would appear to be the best initial therapy for this condition.”
Given these promising results and what we know about the role of cardiac de-conditioning in POTS patients, it is important to encourage POTS patients to participate in exercise even though they may feel discouraged from exercise due to their symptoms.
Now that we’ve established the crucial role that an exercise routine plays in the management of symptoms and improvement in quality of life in POTS patients, let’s discuss how to go about designing and structuring a program. We’ll discuss designing an endurance program first.
Designing an Endurance Training Program for a POTS Patient
Endurance training plays a key role in cardiac re-conditioning but will need to be designed and integrated carefully so as not to exacerbate symptoms. Here are some general guidelines as outlined by Fu and Levine (2018) for beginning POTS patients on an endurance training program:
Begin with horizontal modes of training such as rowing and recumbent biking
Spread the workouts out over the week as opposed to stacking workouts back-to-back
Avoid taking more than 2 days off from exercising
If you are unable to complete all of the scheduled sessions for the week, repeat the entire week again before continuing
if more than two consecutive weeks of training are missed, consider starting the training program from the beginning
Expect that symptoms will be exacerbated when beginning the exercise program. It may feel uncomfortable, but assure them that it will not harm them and once their body adapts, they will have a much higher baseline.
Only consider more vertical forms of cardiovascular exercise once they are able to complete horizontal modes of training completely symptom-free. Once they reach that point, the switch is actually encouraged for more functional training purposes.
If they are able to complete workouts on the elliptical and/or fast walking on the treadmill completely symptom-free, they may consider advancing to jogging and stair-stepping, but only if they want to.
The final thought that I will leave you with on cardiovascular training for POTS is to ensure that the endurance program is conservative and gradual, both to avoid overly provoking symptoms and to ensure a steady improvement.
Designing a Resistance Training Program for a POTS Patient
Resistance training also plays an important role in exercise training for POTS patients, and similarly to endurance training, should be incorporated and progressed carefully. Here are some established guidelines for resistance training for POTS patients from Fu and Levine (2018):
Focus on training the lower body and core to encourage increased venous return to the heart through contraction of lower body muscles (This means using higher reps at a steady tempo).
Begin resistance training sessions once a week, 15-20 minutes per session, then gradually increase to twice a week, 30-40 minutes per session
Perform resistance training movements on seated equipment and avoid free weights until they are strong and fit enough to do so
Employ a personal trainer if they are unfamiliar with resistance training
Start with 2 sets of 10 reps of the following sample exercises, then increase the weight once they can complete more than 10 reps on the second set:
seated leg press
leg curl
leg extension
calf raise
chest press
seated row
abdominal crunches
back extensions
side planks
other Pilates-based exercises that can be done on the floor
Additional exercises may be slowly added in after a month of consistent training and after the POTS patient has consulted with their physical therapist and/or provider. Some additional sample exercises can be found here.
Important Considerations: Accurately Monitoring and Gauging Exertion During Exercise
Prior to beginning an exercise program with a POTS patient, it is important to understand that using heart rate to gauge exercise intensity may not be an accurate measure.
Using measures of heart rate in patients who are taking Beta-Blockers or other medications, or with underlying autonomic disorders, may result in an inaccurate reflection of exercise intensity. If patients are to continue taking Beta-Blockers during their exercise program, exercise intensity should be gauged by Rating of Perceived Exertion (RPE), although most healthcare providers will opt to wean patients off of Beta-Blockers prior to beginning an exercise program (Fu and Levine 2018).
Non-Pharmaceutical Options Beyond Exercise
In addition to understanding how to design, progress, and monitor an exercise program for POTS patients, it is helpful to be aware of other non-pharmaceutical interventions that POTS patients may utilize to improve their symptoms. Below are a list of some non-pharmacological treatment options to be aware of:
sleeping in the head-up position (done usually by elevating the head of the bed on boards or blocks to achieve a slight incline)
use of lower body compression garments which ideally extend to the xiphoid to reduce venous pooling
physical countermeasure maneuvers, such as squeezing a rubber ball, crossing legs, muscle pumping, squatting, and negative pressure breathing
increasing dietary salt intake by up to 10 grams per day combined with increasing water intake by up to 3 liters per day
In Summary…
Given that the existing pharmaceutical options for POTS patients are inconsistently effective and even sometimes detrimental, it is undebatable that exercise and other non-pharmaceutical treatments play an important role in symptom management and quality of life for those affected by POTS. Incorporating both endurance and resistance training is recommended, but must be done carefully and intentionally so as to progress patients at a speed that does not exacerbate symptoms to an unmanageable extent. It is worth noting here that depending on the severity of symptoms, POTS patients may suffer from extreme fatigue, dizziness, nausea, exercise intolerance, and other symptoms which will likely make exercise undesirable, however, it is important for those working with POTS patients to encourage exercise and emphasize the importance of it despite how uncomfortable it may be.
