There are over ½ a million POTS syndrome sufferers in the US alone, the majority young women. In POTS syndrome, being unable to stand for periods of time can result in severe functional impairment. Unfortunately, the exact underlying causes of POTS syndrome are poorly understood and treatment options are often limited. The good news is that ongoing research efforts are increasing our understanding of POTS syndrome. Exercise training is currently a key strategy. In this article, we will review the role of exercise in improving quality of life in POTS syndrome patients.
To find experts in POTS around the United States check out XpertDox.
Physical Deconditioning
Evidence suggests that physical deconditioning is an important aspect of POTS syndrome and can worsen symptoms. POTS syndrome patients have low exercise tolerance in addition to the difficulty sustaining an upright position. Studies have shown that POTS syndrome patients have lower peak oxygen uptake during exercise as compared to healthy individuals that is a strong marker of physical deconditioning. Importantly, studies have also shown that endurance exercise training is an effective therapy in POTS. In many patients exercise training results in substantial improvement in symptoms and exercise performance.
POTS syndrome patients generally have higher heart rates for a given level of exercise compared to healthy individuals. This is thought to be due to POTS syndrome patients having smaller heart chamber sizes and lower heart muscle mass, related to the fact they do less activity because of the symptoms. Due to this, the heart has to pump more times to deliver the same amount of blood to the body and therefore the heart rate is higher.
Studies Have Shown Exercise Works
Although some therapies have been tried with limited success, there is no uniformly effective drug treatment for POTS syndrome. Exercise training has been proven to expand blood volume and plasma volume and increase cardiac muscle mass and heart size. These in turn have been associated with improvement in symptoms, and therefore exercise training is often suggested as a therapy for POTS syndrome.
One study looked at 3 months of exercise training, 20-30 minutes 3 times per week, starting with exercises performed in a sitting position and gradually progressing to higher intensity exercises and those performed in an upright position. It was found that VO2peak increased by 8% in POTS patients, a significant increase in physical conditioning. Heart size and blood volume were also found to increase. Around half the patients improved to such a degree that they no longer fulfilled the criteria for a diagnosis of POTS syndrome. Several studies have confirmed these effects. It is likely that for those patients with a more severe form of POTS, a longer duration of training would be required to see results. It is likely that patients would need to keep exercising in order to keep seeing the benefits. Although it may be tough initially given the symptoms, POTS syndrome patients should be encouraged to pursue an exercise program, start slowly and build up, and stick with it with the goal of significantly improving quality of life.
Would you be able to recommend exercises that one could do?
Terry, I’ve read that cycling and the rowing machine is very good for POTS sufferers. Swimming is good too. Something to do with gravity and how low impact it is.
I have POTS and for me recumbent biking induces the fewest symptoms, followed by rowing, then swimming. I am working my way up to longer and longer workouts on the upright bike, which does induce symptoms. I do 7-10 minute warm up, then 15 minutes on the recumbent bike, then 15 minutes on the regular bike, then 10 min on recumbent, then cool down. I also do lots of strength training to build muscle, especially in my legs. I am loosly following this work-out plan, except for titrating up to longer periods of more upright activity: http://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
Wow! How long have you been training before you could do a sitter upright bike. My daughter was diagnosed in January and she does 20 minutes of the recumbent bike every other day and off days she does yoga. She mostly sits on the couch binge watching Netflix on her laptop. I think she’s doing more harm then good, but every time I say anything my wife gives me a hard time and my daughter seems like gets more depressed because I ask her to try harder. I would like her to do a little more cardio or something. She does just enough. She’s a typical teenager attitude with pots. So you don’t know if it’s actually the symptoms of pots or it’s her attitude or her using pots as an excuse not to do anything. Any suggestions about her stepping up her game I would really appreciate it. Thank you,
Dad with a pots daughter ?
Hey I thought I would reach out. I am a 15 year old male and was recently diagnosed with pots. I went from being able to exercise for 1 hour to only 5 minutes. Although I will give you some hope. I became sick and tired and sitting around not being able to exercise and I just got up went outside and began to walk. I can now do 30-40 minutes of walking outside and hopefully will reach an hour soon. I am not encouraging your daughter to do that but I have found that if you have a mindset to just get up and get moving you can really overcome this.
Hello Dad with a pots daughter. I have a daughter with Pots as well. She has suffered many years. Recently just walking is helping quite a bit and we plan to move up to using weights, maybe jogging and following the Levine Protocol. Unfortunately, for kids with pots, exercise is the last thing they feel like doing. I recommend a good Pots Specialist, tons of salt and water, start with some light exercise, compression leggings help too (spanx or Nike leggings even).
My understanding is that the exercise not only increases the hearts blood volume capability but also the added muscle to the body helps with blood flow.
Don’t give up and keep trying. I know it is hard. God bless.
Personally, from experience, I think cardio is unhelpful in the early stages of recovery. Muscle building such as strength training, recumbent cycling focussing on harder to push the pedals than straight out cardio was much more helpful for me. I recovered to a point where I could do more cardio based exercise but only after I built up some muscle. Hope that helps. I know your comment is older
I wouldn’t put too much pressure on someone with PoTs as it’s invisible and only someone with it can know their limits. Even that level of exercise you’ve described can leave patients exhausted. It takes a mental health toll too, so making someone with PoTS feel like they aren’t doing enough is something to be cautious of. You wouldn’t pressure someone in a wheelchair to get up and walk.
I finally was diagnosed after Seven long Horrible Years of suffering every symptom ! I also was diagnosed with SFSN a couple months later. My story started at age 30 getting Diagnosed with Lupus…. Nothing about my body works correctly. Auto immune diseases for every part !
This Article is absolutely the most informative I have read. It’s very scary to live with , and Alone.
I hope more people learn as much as did.
POTS affects everyone differently because We all uniquely put together. Unfortunately this changed my Life for the worst.
If Your Suffering and No one is listening to You .. get a Fitbit. Smart watch .. Amazon has Great prices. Get one that shows BP , Heart rate, Miles ( steps)and sleep . It affects POTS This is what helped show just how high my rates were getting.
Please Don’t Let Anyone tell YOU what YOUR BODY is Feeling . We have to be our own Self advocates. I wish I had the strength years ago to tell this Cardiologist I wasn’t being Paranoid. !!! I don’t think i would be in this weakened state if Someone ( Dr.) would have listened.
I can’t do housework, take my rescue dogs for a walk , and I’ve just been diagnosed with Gastroparesis.
My son has many symptoms of POTS. Can anyone recommend an expert in this field in the Kansas City area? We have called KU med but have to wait several months to see anyone. He began having these symptoms after being involved in a chemical spill of chlorine. But doctors say that is not associated with his symptoms. Any advice welcome.
Has your son seen a cardiologist? That is the specialist that normally diagnose POTS and also who diagnosed mine.
I also live in Kansas City and I’m experiencing these symptoms for 2 years. Were you able to find a POTS specialist at KU?
My son was diagnosed with by the Teen Clinic at Children’s Mercy in KC. They prescribed some medication and he started seeing a physical therapist and it has made a huge difference.
Dr. Rush at Children’s Mercy or KU – he sees patients at both hospitals.
What kind of exercise is recommended for patients with Pots and Chronic Fatigue Syndrome?
This exercise program has helped me a ton! (Also see comment above — where I’ve altered it is I am titrating up to more upright exercise because the upright exercises like upright biking are more triggering for my symptoms.) http://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
Does anyone know of any POTS Syndrome support group meetings in Florida?
I LIVE IN FL DID YOU GET ANY ANSWERS?
I live in Florida, too. Trying to find some good doctors to help but, right now, my 2 cardiologists and my electrophysiologist don’t seem to know how to treat pots. This illness sucks. I’d totally be open to starting a support group if anyone wants to. I know there’s one on Facebook but I don’t have a FB account anymore and don’t want another one. Please reach out with any info or questions 🙂
Im so frustrated, I am a competitive swimmmer. I just started my freshman year of college. My pot was diagnosed when I was a freshman in HS all 4 years of HS I fough through this frustrating disease, salt tabs, compression garments,water, rest limited swim time bla bla bla… by the end of HS thigs actually were improving and by neurologist said ok your better you have grown out of it just like I said you would. and this summer I had a geat long couse season. However now that I am at college. BAM all of my smyptoms are back and some much worse than before?! so…Back to neurology… and, oh yeah, you still have pots probably just a flare up, and oh by the way you also have ehlers danlos. (wait ehlers danlos, isn’t that genetic and a contributing factor for pots so will I “grow out of it?”) I feel like my doctor doesnt know how to treat me. he just tells me he doesnt know how I can do what I can because his other patients with pots dont go to school or exercise. so I should be happy. Really!?, happy I cant do what I love (swimming) happy that when I’m in class I loose my vision in lectures because by brain doesn’t have enough blood to serve by vision centers, happy that im starving all the time but dont feel like eating because I’m nauseous 24/7, happy that aparently nobody has any answers for me on how to fix this!!! Sorry every body I needed to vent for a minute. I have been doing alot of research on pots but I have not found very much information for patient in my situation where they were an elite athlete before being diagnosed with pots I have only found two others a tennis player and one other swimmer. I want more than anything to continue my swimming career but I worry, especially when Im having a paticularly bad pots day that I might be hurting myself by trying to push thru and my doctors have not been helpfull in answering those questions. Also not seeing any end to the struggle is very daunting.
I am an ex competitive swimmer and though I have not been diagnosed with POTS, I have Chronic Lyme Disease and am currently wearing a heart monitor to try and diagnose heart palpitations that are very concerning. I am thankful for my competitive swimming because no human without a death wish could “push through it” like a we can. But every minute of every day is a struggle.?
I push sooo hard. I don’t think my XNP for the neurologist believes me. He has no idea how miserable I am existing and then making myself exercise
What are your coaches, AD, and team doctors telling you about POTS and sports? My son was just diagnosed with POTS and he was told that he is not cleared to play lacrosse because they are feared he is a liability. He is feeling fine. He had some issues last semester but has been better this semester. but because of the diagnosis they will not sign off.
I am a PT and have POTS along with autoimmune diagnoses. I have found that swimming is an activity that I can tolerate, as it keeps me cool, and my body is horizontal. The trick is to start slow, and work on the breathing first, standing up as needed to rest. (I swim in the ocean, and so floating is easy in the salt water). I keep track of my heart rate constantly, with a GARMIN to ensure that a significant heart rate increase does not occur. I needed to change my mindset to swimming being for “movement”, and not for traditional stroke, or racing purposes. With this mindset, I have slowly been able to build my cardiac capacity over the last year, and have started adding in walks in the last month, with a cooling vest.
I have been trying for years to get a handle on this with little help from physicians…this article has helped reassure me and offer more help than any other avenue. No one ever even mentioned POTS…thank you!! I will be discussing this with my PCP.
I am in year 7 of POTS. it has gotten better over the years on its own. I have gone from wheel chair to walking to driving as the years went along. This past year was the first time I was able to work full time in seven years and it was a struggle almost every day. Excercise still remains a huge challenge but it does make me feel better overall. It is very easy to push too far and make myself feel worse for days so I have to take great care When doing it. . And I still have a week or two now and then when I just can’t excercise at all because symptoms are too strong and I know I’ll make them worse. Can’t make myself too sick to work or raise my child alone. I started with lying on floor and just moving legs and arms as much as I could then onto recumbent bike then onto swimming and now walking 3/4 of a mile 3-4 times a week. It can get better so please don’t give up. I’ve been on one long terrible journey just like most of you but I celebrate every little improvement Just know that you can keep going as long as you drop the expectation of being just like you were before and stop mourning the loss of what you think you “should” be like right now. Best wishes.
Everyone’s comments are so very appreciated. I’ve been struggling for almost a decade with no answers from doctors and no mention of POTS. Even got incorrect pacemaker surgery. I felt all alone in my experiences. But because of your advice and your personal successes, I feel like there’s a light at the end of the tunnel. Thank you.
LOOK UP THE DNRS PROGRAM, IT WORKS FOR A LOT OF PEOPLE, GOT ME TO WALK, BUT STANDING IS STILL THE WORST.
This is awesome! I have POTS and working out is the ONLY thing that has helped. It doesn’t even seem like the increased salt helps much. I went from barely walking a few feet to now doing the row machine for 25 solid minutes and lifting weights. I do this 5-6 times a week depending on how I feel that day. Still have a lot of symptoms but I fight through it. Maybe this DNRS program can get me to the next level.
I have pots less than 2 years now. It was a big change in my life. I can’t do barely any exercise without raising my heart rate too much that I feel like i am gonna pass out. I can do like 3 to 5 sit ups and I am done. Before this I use to do 50 sit ups and 30 push ups and be fine. I can’t dance, run, ride a bike, play any sports and etc anymore. I use to all of those things before this. I miss playing sports. I also can’t drink any coffee, tea, energy drinks and alchole. I miss having poweraid during really hot weather or playing sport. I work in retail, which i had to change how much i did there. I use to love going outside for free air and a break from inside getting trolleys. It was nice getting 20+ trolleys back inside. Now i can’t even bring in 3 without raising my heart rate too much. I have to limit myself on the amount I can lift and how much a day i do heavy lifting. Before it was like nothing. So much more has changed in my life from tHis condition.
I have POTS and love working out. It keeps me relatively symptom free if I keep up with it and if I don’t, I decline quickly. But I notice my heart rate gets INSANELY high (160-170) if I’m left to my own judgement and it worries me when I see it so I force myself to go slower, but even a slow walk after hitting those rates leaves me at 140-150 for the rest of my work out. I heard it’s good for POTS patients to work hard for short periods of time but what exactly is the cut off for where my heart rate should be and how short is ‘short’? I love working out for 30-45 minutes without having to worry about it, but I don’t want to harm my body. I do get dizzy after too hard or too long of a workout, but only when I’m getting back into it after a while (like catching a cold). Anyone know what I should do? (Sorry this is long)
Did you ever find an answer to this? I take propranolol (beta blocker) for POTS and my heart rate can get up to 180’s with very light jogging for 90 seconds. I’ve been working my way up to this for six months and stop when I have chest pain or pre-syncope. I can’t find anything online about target heart rate and Max heart rate for POTS patients, let alone patients who take beta blockers.
Well done on your exercise journey!
My doctor has me walk first week for 10 min increase next week to 15 min every week increase five minutes in your walk!
My son is 22 and was diagnosed with POTS 5yrs ago after several years of symptoms. He used to love long jump and would love to get back to it but is very deconditioned. Does anyone have experience of this and know anyone who has managed to get back to athletics from POTS? Thank you for any advice.
Hello,
I’ve been recently diagnosed with POTS (5 months ago).
My heart rate rate will zoom to 208 with small exertion or hill climbing. Once I stop it will return to normal. I am 62 years old. All of my cardio/neuro testing was normal. I’ve had slight improvement on Metropolol. My question is whether or not these spikes in heart rate do any long term damage?
You might need another holter monitor. Did your doctor rule out SVT? While pots will not kill you, your heart is very seriously being stressed with that high of a heart rate, especially if it lasts for an extended period of time. I currently take propranolol and alprazolam to control my symptoms. You might just be on the wrong beta blocker or you would be a good candidate for ivabradine. Ivabradine can be used along with a beta blocker. Alprazolam helps with the norepinephrine dumps that go along with mine. It’s not recommended for everybody but it does help people with dysautonomia. It just has a stigma though. Benzodiazepines always do. I know it definitely keeps me out of the ER most times. I hope you are doing better. My POTS comes and goes but when it comes boy does it ever!
Swimming, recumbent cycling or rowing
While this is an affective treatment for some, it is important to remember it does not work for all POTS patients. And this doesn’t mean that those POTS patients are “lazier” or “not trying as hard.” For those whose POTS causing loss of consciousness, excerises like cardio and walking can be very dangerous. I personally fall into that category, and find medications to be the most helpful treatment so far. I do participate in some land and water physical therapy for other issues I have,but I am very limited on what I can do and that is the reality for some POTS patients. Please listen to your doctor if they tell you to avoid excerise or certain types of excerise at the moment, loss of conciousness while excerising can cause serious injuries and negative health effects. Discuss with your medical team what treatment plan works best for you, and know your own limitations and don’t push it. And to those without POTS, please don’t automatically assume excerise treatment will work for a POTS patient you know.
“POTS syndrome patients generally have higher heart rates for a given level of exercise compared to healthy individuals. This is thought to be due to POTS syndrome patients having smaller heart chamber sizes and lower heart muscle mass, related to the fact they do less activity because of the symptoms. Due to this, the heart has to pump more times to deliver the same amount of blood to the body and therefore the heart rate is higher.“
This was disproven ages ago. In 2021, Jeopardy issued an apology for using this incorrect information on their show. Most of us have structurally normal hearts. Please update with correct information. Dysautonomia International is a fantastic resource with the most current information about POTS.
I can only do seated workouts for now. I search seated workouts on YouTube and do 20-30 minutes 5x a week. I will day that getting started is hard with the fatigue but it gets easier. I will also say do not push yourself to do standing cardio because it can make it worse. If you do too much you will go into a flare and make things worse.