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  • Writer's pictureKenneth Civello, MD

"Lifestyle Changes to help Manage and Cure POTS Syndrome"

Updated: May 6

If you're someone who has been diagnosed with Postural Orthostatic Tachycardia Syndrome (POTS), it's essential to have an exercise protocol (a structured plan for your exercise routine) in place that suits your specific needs. Recent research has demonstrated that cardiovascular deconditioning) contributes significantly to the Postural Orthostatic Tachycardia Syndrome (POTS) and its functional disability. Therefore, physical reconditioning with exercise training and volume expansion via increased salt and fluid intake should be initiated early in the course of treatment for patients with POTS if possible. In this document, we will outline some tips and guidelines to help you develop a safe and effective exercise routine that can assist you in managing your POTS symptoms.


POTS is a condition that affects the autonomic nervous system and can cause symptoms such as heart palpitations, dizziness, and fatigue upon standing. Regular exercise has been shown to improve POTS symptoms and increase exercise tolerance. To help manage POTS symptoms and improve exercise tolerance, we designed an exercise protocol emphasizing safety and comfort at every step. Before beginning the exercise program, it's essential to note that it should be carried out at a carefully paced and controlled rate to prevent any adverse effects.


Exercise Guidelines:

1. Preparation:

To prepare your body for exercise, it is recommended that you begin with a 5-minute warm-up consisting of light stretching and gentle movements. This will help prevent injury and prepare your muscles and joints for the workout.


2. Baseline Assessment:

Before embarking on the exercise program, it's crucial to establish your baseline heart rate (HR) and blood pressure (BP) while lying down and after standing for 5 minutes. This initial assessment is vital to understanding your orthostatic intolerance and will be a reference point for tracking your progress. Additionally, it's essential to document any symptoms you experience, such as dizziness, lightheadedness, and fatigue, as this will help tailor your exercise routine. See Table 1


3. Starting the exercise program:

When embarking on the exercise sessions, starting with three sessions per week is essential, gradually increasing to 5 sessions per week as your body becomes more accustomed to the exercise and you feel comfortable doing so.


Each session should initially last 10 minutes, gradually increasing by 5 minutes weekly as your body adapts and you feel comfortable with the increased duration. This gradual progression ensures your safety and comfort throughout the program, providing a sense of security in your exercise routine.


4. Exercise types and intensity:

The use of horizontal exercise (e.g., rowing, swimming, recumbent bike, etc.) at the beginning is a critical strategy, allowing patients to exercise while avoiding the upright posture that elicits their POTS symptoms. As patients become increasingly fit, the duration and intensity of exercise should be progressively increased, and upright exercise can be gradually added as tolerated. You should start with low-intensity exercises that allows for comfortable conversation (50-60% of your maximum heart rate, which can be calculated by subtracting your age from 220). It is essential to monitor your heart rate and symptoms throughout the session so that you can make any necessary adjustments to your exercise routine. If symptoms worsen significantly, it is okay to stop. Document your progression in Table 2.


5. Cooldown:

Once you have completed the exercise session, it is essential to cool down with 5 minutes of gentle stretching and relaxation exercises.


6. Progression:

To advance your exercise routine, increasing the exercise duration by 5 minutes per week is recommended until you reach a target duration of 45 minutes per session. Additionally, you can gradually increase exercise intensity by incorporating intervals of higher intensity (e.g., brief periods of faster walking or cycling) as tolerated. This gradual progression is crucial for your safety, preventing overexertion and ensuring a comfortable exercise experience.


7. Benefits of Exercise:

It's important to remember that exercise is not just beneficial for managing POTS symptoms, but it's also the key to potentially curing POTS. Regular exercise can improve blood circulation, increase heart function, and strengthen muscles. It can also help reduce the severity and frequency of POTS symptoms like dizziness, lightheadedness, and fatigue. This knowledge should inspire hope and motivate you to incorporate exercise into your routine, knowing that it can make a significant positive impact on your health. See Figure 1.


8. Safety Precautions:

Lastly, it's crucial to reiterate the importance of safety precautions during your exercise routine. This includes staying hydrated before, during, and after exercise, avoiding exercising in extreme temperatures, and being mindful of symptoms. If you start feeling unwell, it's vital to stop exercising immediately. These precautions are in place to ensure your safety and protect you from any potential harm.


9. Non-pharmacological interventions outside of Exercise

Include 1) chronic volume expansion via sleeping in the head-up position; 2) reduction in venous pooling during orthostasis by lower body compression garments extending at least to the xiphoid or with an abdominal binder; and 3) physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, negative-pressure breathing, etc., may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients.


9a. Salt Loading

Salt loading in patients with posturally related syncope has been shown to increase plasma volume and orthostatic tolerance. Thus, if tolerated, POTS patients with normal cardiac and renal-adrenal function should gradually increase their daily salt intake by using dietary salt up to 10 grams per day. A slow, progressive increase in daily sodium intake in/on the food and eating salty snacks are recommended. However, salt tablets should be avoided because they are very concentrated and can induce an osmotic load into the stomach, which may cause nausea, vomiting, and dehydration, leading to reduced rather than expanded plasma and blood volume. Patients are also encouraged to increase water intake up to 3 liters per day. Increasing salt and water intake throughout the day and consuming them together are recommended, as water alone is ineffective in long-term volume expansion. 

To help increase the amount of salt consider using sodium supplements such as Liquid IV, LMNT, or Nuun supplements.


9b. Sleeping in the head-up position

Another non-pharmacological intervention is sleeping in the head-up position. This involves elevating the head of the bed off the ground 4 to 6 inches. The best way to achieve this is by placing large phone books, blocks of wood, or bed risers under the feet at the top of the bed. This positioning helps to increase circulating plasma and blood volume. It's important to note that this approach is different from simply using a few extra pillows under the head.

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