Reviewed by Tyler Tice, PT, DPT, OCS, ATC
Article:
Exercise and Non-Pharmacological Treatment of Positional orthostatic tachycardia syndrome (POTS)
Introduction:
Positional orthostatic tachycardia syndrome (POTS) is a condition where the heart rate increases to a tachycardic rate following positional changes. Previous studies have demonstrated that patients suffering from POTS tend to have smaller hearts as well as lower blood volume. These factors contribute to a large decrease in stroke volume during orthostasis which in turn leads to an increase in heart rate via the baroreflex. Patients with POTS often have low exercise tolerance and poor cardiovascular conditioning. Patients with POTS are commonly treated with exercise training along with volume repletion therapy. This article proposes a structured, non-pharmacological treatment approach designed to treat patients with POTS.
Methods:
The article divides its treatment approach into exercise, volume expansion, reduction in venous pooling and physical countermeasures. The article draws on many other studies to pull its advice from but it is not an organized meta-analysis or systematic review.
Results:
The article gives the following advice regarding the treatment of POTS:
A combination of endurance training and lower body strength training are the primary components in the treatment of POTS. A structured exercise program is known to correlate with increased cardiac size, peak oxygen uptake, blood volume and improvement in functional capacity and patient mood.
In the early stages of treatment for POTS, patients should begin endurance training at about 75% of their predicted max heart rate or at an RPE of 13-15 which may be described as somewhat hard. Sessions should take place for 25-30 minutes 3 times per week using a recumbent bike. The use of the recumbent bike is critical in the early stages of treatment because it allows the patient to exercise without experiencing POTS symptoms. Patients with POTS and Ehlers-Danlos Syndrome (EDS) are recommended to exercise either by swimming or by using a rowing machine at moderate intensity to avoid putting excess stress on ligaments that are inherently less stable than average. These patients may also benefit from wearing knee or elbow sleeves depending on the severity of their condition.
As treatment continues, the goal is to gradually progress the patient over a 3-month period to doing more upright exercise such as an upright bike or elliptical. Once the patient is confident with upright endurance training, they may progress to jogging or stair climbing if they want to and are encouraged to continue exercising for endurance 3 times per week.
Resistance training is also recommended for this patient population with an emphasis on lower body muscles since these muscles act as pumps to encourage more efficient venous return. The author suggests that seated, machine-based lifts are preferable to free weight lifts at least in the early stages of treatment. This is to lower the risk of injury and to allow the patient to exercise in a seated or recumbent position to avoid increasing POTS symptoms. The routine suggested includes leg press, knee extension, hamstring curls, seated calf raises, chest press, seated rows and some form of floor-based core exercises such as planks and abdominal crunches. The author suggests that weight training begin once a week for 15 to 20 minutes and gradually progress to twice a week for 30-40 minutes as the patient’s tolerance improves.
Since many patients with POTS are known to have low blood volume which may contribute to their symptoms, the author recommends a diet that includes high levels of salt as well as increased water intake. Patients may also try to sleep in a head-up position to encourage an increase in blood plasma volume. The author cautions that although effective anecdotally, there have not been large clinical controlled trials to assess the efficacy of this treatment approach.
Patients with POTS have been shown to have increased venous pooling while in upright positions. To counteract this, the author recommends compression garments. Compression of all lower body compartments is ideal so the author suggests using compression garments that cover the entire lower extremity even into the lower abdomen. The author cautions that compliance with this treatment is often low because the garments are difficult to don and doff, even with assistance. Custom compression garments have been developed by NASA that may be easier for patients to use.
The author also provides several physical countermeasures that patients can utilize while experiencing POTS symptoms acutely. Rhythmically squeezing a rubber ball with the hands while engaging the core and lower body muscles has been shown to increase mean arterial pressure. Crossing the legs and squeezing the glute and quadricep muscles has been shown to quickly return blood from the venous system to the heart, this is mainly mechanical effect but there is some evidence that it may also reflexively cause an increase in cardiac output. Engaging the leg muscles in rhythmic contractions has been shown to effectively pump blood centrally from the lower legs.
Squatting, sitting and lying down have all been shown to reduce the symptoms of POTS acutely. Forceful coughing can increase intrabdominal pressure which increases cardiac output and mean arterial pressure, assisting the heart. Using a device to increase inspiratory resistance is effective in increasing cardiac output. Cooling the surface of the skin can also be effective in increasing orthostatic tolerance by encouraging blood flow toward the center of the body.
Discussion and clinical utility:
This paper does an excellent job not only of putting forth a structured, evidence-based approach for non-pharmacological treatment of POTS, it also explains the rationale behind each recommendation. The suggested treatment approach may not be practical to use on all patients with POTS, but it gives a useful framework from which to draw, so clinicians can modify treatment to better suit their patient’s specific needs.
References:
Fu Q, Levine BD. Exercise and non-pharmacological treatment of POTS. Auton Neurosci. 2018 Dec;215:20-27. doi: 10.1016/j.autneu.2018.07.001. Epub 2018 Jul 4. PMID: 30001836; PMCID: PMC6289756.