Physical therapy for POTS
This page is primarily intended to be a reference for patients
who have been referred for therapy.
Timothy C. Hain,
MD Frank DiLiberto, PT, Ph.D.
Click here for the main vestibular rehabilitation page. Page last modified:
July 21, 2020
POTS, positional orthostatic tachycardia syndrome, can sometimes be treated with physical conditioning. This document discusses a conditioning program for POTS. This is sometimes called the "Levine" protocol, after one of the authors on several recent papers (Fu et al, 2010; Shibata et al, 2012). This protocol is largely based on physical conditioning, adapted to start in a safe sitting or lying down position.
The idea of this protocol is to improve cardiac function. This presumes that the "problem" in POTS is poor cardiac function. However, there are many other suggested causes for POTs including autonomic neuropathy, changes in autonomic responsiveness, and venous pooling.
- Some quibbles about conditioning programs in POTS:
According to Low(1995), about half of patients with POTS have impaired autonomic function. In this substantial group, where blood vessels do not constrict on standing, the heart could be fine. In other words, some common sense is needed regarding patient selection, and where there is dysautonomia, the rationale for this protocol is somewhat tenuous. One might argue -- if someone is lying around for a year, won't they be deconditioned ? Yes this is true, but if they are both deconditioned and have dysautonomia, this protocol might not work.
The rationale for salt-loading (as noted below) can also be reasonably questioned. If the problem in POTS is poor cardiac output, salt loading will not make any difference. If the problem is dysautonomia however, this makes some sense.
Method of physical therapy approach to positional orthostatic tachycardia.
We will describe the "Levine protocol" (e.g. Shibata et al, 2012). The Levine protocol adds conditioning (i.e. you go to the gym), as well as salt/water loading (i.e. same treatment as for orthostatic hypotension). The Levine program is a long supervised program -- 3 months or more.
- All patients first undergo tilt-table testing to measure their starting performance. It would be unreasonable to use this protocol if one does not "fail" the tilt table test. This is also used to determine the target heart rate.
- Changes to behavior
- Salt/water loading
- The goal is up to 3 liters of water/day and 7000-10,000 mg of sodium/day. This might not always be possible in persons with heart disease (for example), so this needs to be monitored. 1 tsp of ordinary table salt= about 2300 mg of sodium, and the ordinary diet contains about 4000 mg of sodium. So as a rough estimate, you might be aiming for 1.5 to 2 more tsp of salt/day. Start slow and work up. There are online tools (such as myfitnesspal.com) that can help you track your sodium intake.
- Elevate the head of the bed -- raise the head of the bed by 4-6 inches. The goal is to tilt the entire body, not the head. Two pillows is not enough. Bed risers are a way to do this (such as are used by college students. Just under the top of the bed.
- Stay upright during the day. Do not lie down all day long because you feel better. Get up and walk around a little bit every hour.
- A home program consisting of twice a day regime for up to 30 minutes each session, and conditioning (Cardio and weight training).
- Usually medications for POTS are "held" during this exercise program. These may need to be weaned off.
Examples of these are fludrocortisone and mitodrine.
- You should have a heart rate monitor, so that you know when to quit exercises (i.e. when your heart rate gets too high if you have POTS). The goals are shown below.
- This program is supervised. You should see your provider (perhaps physician or physical therapist), who assigns progressively harder exercises, and monitors your progress. The provider should provide you with a calendar for activities for each week.
- "Cardio" exercises are done to improve lower extremity tone and strength (these are from the Levine protocol). These exercises are to be done every day, and are for both patients with orthostatic hypotension and POTS. You should not take off more than 2 days from training. Weight training is in addition to this, but it is required less frequently (see below). There should be a 10 minute warm up and cool down prior and following the cardio exercises.
- month 1 (pick one of these) -- target heart rate should be 75-85% of maximum.
- recumbant biking
- swimming laps or kicking laps with a kickboard
- month 2
- upright bike instead of recumbant
- Try to add treadmill (no incline at first)
- Try to add ellipitical
- month 3
- months 4-6.
- If you are doing fine up to now, ask your health care provider (PT or physician) what you can do next -- jogging perhaps.
- Weight training. These are started once weekly (15 to 20 min/session), and gradually increased to twice weekly (30 to 40 min/session).
- Goal is two sets of 10 repetitions of
- seated leg press
- seated leg curl
- leg extension
- calf raise
- chest press
- seated row.
- If seated weight training equipment is no available, alternatives are
- floor exercises (such as Pilates)
- resistance bands
- After the training is completed (i.e. 3 months) a follow up tilt-table test is performed at the same time of day as the initial training.
- Conditioning should be continued as a life-long activity.
- Benditt DG, Nguyen JT. Syncope Therapeutic approaches. Journal of the American College of Cardiology, 53(19), 2009, 1741-1751
- Fu, Q., T. B. Vangundy, M. M. Galbreath, S. Shibata, M. Jain, J. L. Hastings, P. S. Bhella and B. D. Levine (2010). "Cardiac origins of the postural orthostatic tachycardia syndrome." J Am Coll Cardiol 55(25): 2858-2868.
- Howden, R., J. T. Lightfoot, et al. (2002). "The effects of isometric exercise training on resting blood pressure and orthostatic tolerance in humans." Exp Physiol 87(4): 507-15.
- Low, P. A., T. L. Opfer-Gehrking, S. C. Textor, E. E. Benarroch, W. K. Shen, R. Schondorf, G. A. Suarez and T. A. Rummans (1995). "Postural tachycardia syndrome (POTS)." Neurology 45(4 Suppl 5): S19-25.
- Nazar, K., A. Gasiorowska, et al. (2006). "Effect of 6-week endurance training on hemodynamic and neurohormonal responses to lower body negative pressure (LBNP) in healthy young men." J Physiol Pharmacol 57(2): 177-88.
- Parsaik, A., et al. (2012). "Deconditioning in patients with orthostatic intolerance." Neurology 79(14): 1435-1439.
- Shibata, S., Q. Fu, T. B. Bivens, J. L. Hastings, W. Wang and B. D. Levine (2012). "Short-term exercise training improves the cardiovascular response to exercise in the postural orthostatic tachycardia syndrome." J Physiol 590(Pt 15): 3495-3505.
- Ueno, L. M. and T. Moritani (2003). "Effects of long-term exercise training on cardiac autonomic nervous activities and baroreflex sensitivity." Eur J Appl Physiol 89(2): 109-14.
- Zion, A. S., R. De Meersman, et al. (2003). "A home-based resistance-training program using elastic bands for elderly patients with orthostatic hypotension." Clin Auton Res 13(4): 286-92.