Exercise guide
Postural tachycardia syndrome (PoTS, or POTS in the US) makes your heart race and can leave you dizzy or light-headed when you stand up. Exercise is one of the main treatments, but how you start matters: upright exercise often sets off symptoms, so the programmes that help begin seated or lying down, on a recumbent bike, a rowing machine or in a pool, and move upright over weeks to months.
The honest picture: in small studies, most without a proper comparison group, these programmes improved fitness and symptoms, and many people who finished no longer met the criteria for PoTS. But many people found them too hard to finish, and no trial checked whether people had post-exertional malaise (PEM), a crash a day or more after effort.
This guide explains the Levine and Children's Hospital of Philadelphia (CHOP) programmes and what the studies found, how much to do and how to build up, the fluids, salt and compression advice that goes alongside, what to do if you feel faint, and the links with hypermobility, long COVID and myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS). It includes a 30-minute lying and seated starter session with 3D demos.
The Heart Rhythm Society's expert statement says a regular, structured and progressive exercise programme "can be effective", starting with exercise that isn't upright, such as rowing machines, recumbent bikes and swimming. The NHS suggests gentle exercise such as walking, Pilates and swimming, stopping if you get symptoms. PoTS UK's rule is to start low and go slow: a starting point can be as little as 60 seconds.
The Levine and CHOP programmes run for 3 to 8 months: seated or lying exercise first, upright exercise from about month 3 to 5, and leg strength twice a week. In the studies, many people who finished no longer met the criteria for PoTS, but the studies were small, most had no comparison group, and in the largest, 59% didn't finish.
Drink plenty of fluids until your pee is pale, as the NHS puts it; PoTS UK suggests 2 to 3 litres a day for adults. Extra salt helps some people but isn't safe for everyone, so only add it if your doctor agrees. Waist-high compression tights help some people.
Lie down and raise your legs until you feel better. If you can't, cross your legs and squeeze your buttock and tummy muscles, rock up and down on your toes, or clench your fists. If you faint while exercising, call 999 (911 in the US).
That pattern can be PEM, which PoTS UK says people with ME/CFS are especially prone to. No trial of the reconditioning programmes screened for it, so it's our inference, not a tested finding, that they may not suit you: pace as our ME/CFS guide describes, and talk to your specialist.
The NHS says PoTS is more likely with long COVID, ME/CFS or joint hypermobility syndrome. In one study of 91 people with PoTS, about 3 in 10 had hypermobile Ehlers-Danlos syndrome. Each of these changes how you exercise.
In PoTS, your heart rate rises when you get up from sitting or lying down, often making you dizzy or light-headed. PoTS UK describes it as an abnormality of the autonomic nervous system, the part that runs the body's automatic functions. The NHS says there's no cure, but it can be managed with changes to your lifestyle or with medicines.
The criteria: your heart rate rises by more than 30 beats a minute within 10 minutes of standing (at least 40 in 12 to 19 year olds), usually without a fall in blood pressure, and the symptoms mostly happen when you're upright, ease when you lie down and have lasted at least 3 months. Standing heart rate is often 120 beats a minute or more.
On standing, you may get dizziness, palpitations, chest pain, breathlessness, shaking and sweating, or faint or nearly faint. Other symptoms include tummy problems, headaches and blurred vision, purple hands and feet, extreme tiredness, not being able to do much exercise, poor sleep and brain fog. Symptoms are often worse in the morning and change from day to day.
The NHS lists getting too hot, standing or sitting upright for long, eating (especially carbohydrates), not drinking enough, alcohol, resting too much, exercise and periods as things that can make it worse. PoTS UK adds moving quickly from lying or sitting to standing, prolonged bed rest or losing fitness, stimulants such as tea, coffee and nicotine, and infections.
A GP may check your heart rate and blood pressure before and after you stand up, several times (an active stand test), with blood tests and an electrocardiogram (ECG) to check for other causes. A specialist may do a tilt table test. PoTS UK says the stand test should bring on symptoms and some people faint, so it's done under supervision. The Heart Rhythm Society says everyone being assessed should have a full history, an examination, lying and standing measurements and an ECG.
The Heart Rhythm Society puts it at about 0.2% of people; a 2019 US National Institutes of Health (NIH) expert meeting said estimates, based largely on clinical experience, range from 0.2% to 1%. More than 3 in 4 people with PoTS are women, and most first have symptoms between 15 and 25. In a survey of over 4,800 people, the most common age at onset was 14, and 20% to 50% of people report a viral infection before it started. A Canadian position statement warns that many people are given the diagnosis without meeting the criteria.
Up to 70% of people with PoTS have less blood circulating than usual, and in some, blood pools in the legs and gut when they stand. In one study, people with PoTS had smaller hearts and less blood than healthy people, and 3 months of training grew both. Whether losing fitness causes PoTS or results from it is unclear. The heart rate rise "is not caused by anxiety", the Heart Rhythm Society says, though anxiety is common with PoTS.
The NHS says PoTS is more likely with long COVID, ME/CFS or joint hypermobility syndrome. In 91 people with PoTS, 31% met the criteria for hypermobile Ehlers-Danlos syndrome (hEDS) and another 24% had hypermobile joints, and PoTS UK calls the link common. The NIH meeting estimated that about 40% have migraine and about 15% an autoimmune disease. In 467 people with severe long COVID at one Swedish clinic, 31% had PoTS.
Most people with PoTS are young women, and the studies were mostly in women: 18 of 19 in the first training trial. Some people are very disabled by it, and PoTS UK says a wheelchair or mobility scooter can help with severe symptoms, while keeping as mobile as possible. Many people improve with lifestyle changes, PoTS UK says, though some need medicines and some have significant symptoms for many years; the NIH meeting said most people report long-term symptoms with flare-ups.
See a GP if you have symptoms of PoTS: other conditions can cause them. Before you start a structured programme, make sure a doctor has diagnosed PoTS and checked your heart (our suggestion, based on the Heart Rhythm Society's advice that everyone being assessed has a history, an examination and an ECG).
If effort is followed by a crash a day or more later, out of proportion to what you did, that can be PEM: use the 5-question check in our ME/CFS guide. PoTS UK notes that people with ME/CFS are especially prone to it. No trial of the reconditioning programmes screened for PEM, so it's our inference, not a tested finding, that they may not suit you; if this sounds like you, pace as our ME/CFS guide describes and talk to your specialist. A Swedish trial that stops building up the exercise if PEM appears hasn't reported its results yet.
The NHS lists fludrocortisone, and heart and blood pressure medicines such as beta blockers, and says you may need to try several. The Heart Rhythm Society says some other medicines may be considered, and that medicines that block the reuptake of noradrenaline can make PoTS worse. No medicine is specifically approved for PoTS in the US. Exercise works alongside medicines: never stop or change one yourself. On a beta blocker, judge your effort rather than your heart rate, as CHOP advises.
The Heart Rhythm Society's 2015 statement says "A regular, structured, and progressive exercise program for patients with POTS can be effective", starting with exercise that isn't upright. The NIH meeting said exercise training "should be a component of any POTS treatment plan". The NHS and PoTS UK both recommend gentle exercise built up gradually, and PoTS UK says supervised programmes have been shown to work best. The grade reflects how consistent this advice is: the studies behind it are small.
In the first Levine study, 25 people started 3 months of training and 19 finished. Their heart muscle grew by about 12% and their blood volume by about 7%, upright heart rate fell by 9 beats a minute, 10 of the 19 no longer met the criteria for PoTS, and quality of life improved in all of them; there was no comparison group, and a person with Ehlers-Danlos syndrome was left out. In reports from the same group of people, training raised physical functioning from 33 to 50 out of 100 and peak fitness by 11%, while 4 weeks of the beta blocker propranolol didn't improve quality of life; the exercise part wasn't randomised.
In a registry of 251 people training in the community, 71% of the 103 who finished no longer met the criteria, and the heart rate rise on standing halved, from 46 to 23 beats a minute; it held in the 31 people followed for 6 to 12 months. But 59% didn't finish. CHOP's own version of the programme hasn't been tested in a published trial.
In 60 people with PoTS (49 analysed), 12 weeks of semi-supervised training (an exercise consultation and 8 sessions, with 3 interval sessions a week starting with 3-minute bouts, mostly semi-recumbent at first) raised peak fitness by about 12% of the expected value, against a 1% fall with usual care. Exercise tolerance and symptoms on standing improved more, but overall symptom scores and the heart rate rise on standing didn't differ between the groups. People with hEDS were included, and 13% of the exercise group stopped because of illness or worse symptoms.
In 31 military recruits with symptoms on standing, 3 months of jogging left 6 of 16 still affected, against 10 of 11 who didn't train. They were young men, and not all had PoTS as it's defined now.
Of 77 people offered a 6-month home programme (recumbent to upright, 6 days a week, sessions building from 10 to 45 minutes), 48 took part. At 6 months, 23% of them still met the heart rate criteria for PoTS, against 93% of those who didn't take part, and quality of life improved. People chose whether to take part, and 10 of the 29 comparison group had no follow-up, so their first results were carried forward.
A review found 7 studies, four of them different analyses of the same group of people, and rated five at high risk of bias. Heart rate improvements were the most consistent finding, but often modest; between 10% and 59% of people dropped out, and most studies analysed only those who finished. None recorded people's past experience of exercise, and the authors note that people who feel worse after exercise, such as those with significant PEM, may be less likely to volunteer.
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A review of 10 reports found very little research in people with PoTS and hypermobile joints, though in the wider PoTS population, endurance then strength training, moving from lying to upright, reduced symptoms. The one randomised trial that included hEDS still found benefits. CHOP advises seeing a physiotherapist first if you're hypermobile.
In 14 people with PoTS, 6 days of a very high-salt diet, compared with a very low-salt one, raised the amount of blood plasma and reduced the heart rate rise on standing, though it stayed higher than in healthy people. It was a tiny, short study.
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In 30 people tilted upright, heart rate averaged 109 beats a minute without compression, 103 with lower-leg compression, 97 with tummy and thigh compression and 92 with full tummy and leg compression, and symptoms improved in the same order. This tested a short session in a lab, not daily life.
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In 223 people with repeated fainting and warning signs beforehand, learning muscle-tensing manoeuvres cut the share who fainted again over about 14 months from 51% to 32%, with no harms. In a lab, crossing the legs and tensing the muscles raised blood pressure within 3 to 5 seconds. These studies were in fainting in general, not PoTS, and the Heart Rhythm Society notes the manoeuvres don't work if you get little or no warning.
A Swedish trial is testing 16 weeks of individually tailored exercise, starting lying down and supervised weekly by a physiotherapist, in 60 people with PoTS after COVID-19, and stops building up the exercise if PEM appears. It hasn't reported results yet.
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A treadmill test set each person's heart rate zones. For the first months, training was mostly at a steady base pace, 2 to 4 times a week for 30 to 45 minutes, on a recumbent bike, a rowing machine or in a pool: the researchers called the seated start "a critical strategy". Upright exercise came "usually not until the second or third month", and by the end people trained 5 to 6 hours a week, with weights once and then twice a week. People were also encouraged to have 6 to 8 g of salt and 3 to 4 litres of water a day and to raise the head of the bed, so not all the benefit can be put down to exercise.
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CHOP turned the programme into 8 monthly calendars. Months 1 to 3 or 4 are seated or lying only: a recumbent bike, a rowing machine, swimming or kicking with a float, or a seated stepper. An upright bike can start in month 4, and a cross-trainer (without the arm handles at first) or a treadmill (with no incline at first) in month 5. Months 6 to 8 get harder, with 1-minute hard intervals. Jogging comes only once harder upright exercise brings no extra symptoms, and "You do not ever have to jog".
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Week 1 has 3 cardio sessions of a 5 to 10 minute warm-up, 3 minutes at base pace, 2 minutes of easy recovery, 3 minutes at base pace and a 5 to 10 minute cool-down, with strength training on 2 of those days. Each week the base-pace blocks get longer (4, then 5, then 6 to 7 minutes). In month 2 they become three blocks of 5 to 8 minutes, then two of 10 to 15, and the month ends with 20 to 28 minutes at a steady base pace.
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CHOP's clinic sets heart rate zones for each person. Base pace matches an effort of 2 to 4 out of 10 (very easy to easy), and recovery 0 to 2. On a beta blocker, CHOP says to go by effort, not heart rate. It doesn't recommend exercise in the heat.
Source 5
Miss more than 2 cardio sessions and CHOP repeats the week; miss a week and you go back a week; miss more than 2 weeks and you restart the month, and you may need to go back to seated or lying exercise for a while.
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CHOP's strength sessions take 20 to 30 minutes, using your body weight or seated machines, with a day off between them. At a gym it's 3 sets of 8 to 10 of the leg press, leg curl, leg extension, calf raise, chest press and seated row, adding weight when you can do more than 10 on the third set. At home it's bridges held 10 seconds, seated marches and leg kicks, straight-leg raises, side-lying leg raises, inner-thigh squeezes into a pillow held 5 seconds, clamshells, planks and wall sits. Free weights wait until your form is good. PoTS UK's examples are similar, from lying knee folds to seated cycling.
"The first month may be very difficult, and you may feel increased fatigue", CHOP warns, and it asks people to give the programme 3 to 5 full months: "Push forward when you can, or repeat a week if you feel you need to." That advice is for PoTS without PEM. If a session is followed by a crash a day or more later, stop building up and talk to your specialist (our caution: none of the studies screened for PEM).
"Introducing a baseline of 60 seconds of exercise and then progressing this over time" is fine, PoTS UK says. Build up to 3 to 4 sessions a week, with the option of 5 to 6 after at least 3 months of successful training. Most should be aerobic, with 1 to 2 strength sessions.
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Week 1: our lying and seated starter session 3 times, with the strength block on 2 of those days. If that's too much, do the cardio only, or start with a few minutes. Each week, if your symptoms are no worse, lengthen the easy-pace blocks by about a minute, as CHOP's calendar does. Stay seated or lying for about the first 3 months; then try an upright bike, and later a cross-trainer or treadmill. If an upright session brings your symptoms back, return to the recumbent bike for a few weeks, as CHOP advises.
The NIH meeting warned that people "Will initially feel poorly/worse for up to 6 weeks" on a programme, and PoTS UK says it can take 6 to 12 weeks to notice a change. Repeat a week rather than pushing on if you need to.
The Heart Rhythm Society recommends some strength training for the thighs. PoTS UK favours lower-body exercises, because stronger leg muscles help push blood back from the legs, and notes that heavier weights challenge the blood pressure system more. Start lying down or on seated machines.
PoTS UK suggests two glasses of water before you start, waiting an hour after a meal, wearing compression if you use it, asking about the timing of your medicines, and choosing a cool time and place. Cool down gradually rather than stopping suddenly or standing still, then lie or sit with your legs raised above your hips. Swim with others or somewhere supervised.
For about the first 3 months, as in both programmes; CHOP's week 1 is two 3-minute blocks at an easy pace with a warm-up and cool-down, 3 times a week.
An upright bike from about month 4, then a cross-trainer or treadmill from month 5 (CHOP); go back to seated exercise for a few weeks if your symptoms return.
Twice a week, on days apart. CHOP's dose is 3 sets of 8 to 10 (bridges held 10 seconds, inner-thigh squeezes 5 seconds, planks 15 to 30 seconds); start with 1 set.
3D demoGlute bridgeBeginner · No equipment
3D demoStraight-leg raiseBeginner · No equipment
3D demoSide-lying leg raiseBeginner · No equipment
3D demoLying adductor ball squeezeBeginner · Other / check instructions
3D demoClamshellBeginner · No equipment
3D demoKnee foldBeginner · No equipment
3D demoDead bugBeginner · No equipment
3D demoKnee plankBeginner · No equipmentCHOP's gym list: 3 sets of 8 to 10, adding weight when you can do more than 10 on the third set, with seated machines before free weights.
3D demoLeg pressBeginner · Strength machine
3D demoMachine leg curlBeginner · Strength machine
3D demoLeg extensionBeginner · Strength machine
3D demoMachine calf pressBeginner · Strength machine
3D demoChest press machineBeginner · Strength machine
3D demoSeated cable rowBeginner · A cable machine
3D demoSeated knee extension (chair)Beginner · A bench or box + Something with weight
3D demoSeated bent-knee calf raise (soleus raise)Beginner · A bench or boxCool down gradually, stretch for 3 holds of 30 seconds each side (CHOP), then lie with your legs raised for a few minutes.
PoTS UK says fainting can often be avoided by acting on early warning signs such as light-headedness, dizziness, feeling sick and sweating. The NHS adds changes to your vision and feeling hot.
Lie down and raise your legs until you feel better. If you can't lie down, sit, if possible with your head lowered between your knees, and drink some water.
Cross one leg in front of the other while standing, then tense your leg muscles and clench your buttock and tummy muscles. You can also rock up and down on your toes, or clench your fists. Keep breathing while you hold the squeeze, sit or lie down as soon as you can, and practise when you're well so the moves come quickly (our suggestions).
In people who faint repeatedly, learning these moves cut the share who fainted again by about a third, and crossing the legs while tensing the muscles raised blood pressure within seconds. The studies weren't in PoTS, and the moves only help if you get some warning.
Get up slowly, sitting for a while first. Avoid standing or sitting still for long: "fidgeting is the key", PoTS UK says. Avoid holding your hands above your head for long. If you faint while exercising, call 999 (911 in the US).
Start with our lying and seated session, which follows week 1 of the CHOP programme. The chair workouts suit dizzy days; with hypermobility, add the strength and control routine; if your PoTS came with long COVID, check for PEM first. The starter and easy cardio workouts are upright: leave them until about month 4 or 5.
A 30-minute PoTS session that never asks you to exercise standing: easy intervals on a bike and rowing machine, lying leg strength, then legs up the wall.
30 minBeginner8 movesCardio machine, Other / check instructionsA 20-minute chair Pilates workout for beginners and older adults: breathing, sitting tall, gentle spine and leg moves, and a standing finish at the chair.
20 minBeginner14 movesA bench or box, Something with weightA 20-minute seated workout for older adults who cannot stand for long: marching, leg and arm strength, posture, and sit-to-stands that lead back to standing.
20 minBeginner11 movesA bench or box, Something with weightA 25-minute workout done sitting, in a chair or wheelchair: seated cardio intervals, light strength work, posture and stretches, with pacing and cooling built in.
25 minBeginner14 movesA bench or box, A dumbbellA 20-minute mat Pilates workout for complete beginners. It covers breathing, spine position and the foundation moves, each with an easier option.
20 minBeginner13 movesNo equipmentA 25-minute low-load routine for hypermobile joints: hip, trunk and shoulder control plus balance, done slowly in the middle of your range.
25 minBeginner15 movesA bench or box, A wallA 12-minute routine for long COVID that starts lying down and stays mostly seated: breathing, gentle leg and arm moves, and legs up to finish.
12 minBeginner13 movesA bench or box, Something with weightA 10-minute session for low-energy days: marching, sit-to-stands, wall push-ups, step-ups and bridges, then a short walk. Doing a little counts.
10 minBeginner7 movesA bench or box, A wallA steady 30 to 45 minute cardio session at talk-but-not-sing pace: walk, cycle, row or cross-train, counting toward weekly activity guidelines.
40 minBeginner3 movesCardio machine, A wall"Drink plenty of fluids until your pee is pale", the NHS says. PoTS UK suggests 2 to 3 litres a day for adults, more on hot days or when you exercise, with a drink before you get up in the morning; if you feel faint, two glasses of cool fluid drunk quickly may help. The Heart Rhythm Society says up to 2 to 3 litres of water a day may be considered.
PoTS UK advises 6 to 10 g of extra salt a day for most adults (6 g is about a level teaspoon), but says to ask your doctor first if you have heart or kidney disease or high blood pressure, and that children need a paediatrician's advice. Electrolyte drinks and tablets typically contain 0.3 to 0.8 g of salt a serving. The Heart Rhythm Society says 10 to 12 g of salt a day may be considered, and the NIH meeting listed high blood pressure and swelling as side effects. The NHS page doesn't mention salt.
The NHS suggests small meals with fewer carbohydrates, and PoTS UK lists large, heavy meals high in refined carbohydrates such as sugar and white flour as a trigger. Keep exercise for an hour or more after a meal.
The NHS suggests support tights to improve blood flow. PoTS UK recommends waist-high tights at European class 2 (23 to 32 millimetres of mercury, mmHg, at the ankle), put on in the morning before you get out of bed and replaced every 3 to 6 months, and notes that compressing the tummy as well as the legs worked better. The NIH meeting says they "Can be hot, tight, and itchy".
PoTS UK says compression can be harmful with conditions that reduce the blood supply to the legs, such as peripheral vascular disease, diabetes, or a leg injury or infection, and that your doctor should check your circulation first. See our guide to peripheral arterial disease.
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The NHS suggests raising the head of your bed so you're not lying completely flat, not standing for too long, sitting for a while after lying down before you stand up, and not drinking too much caffeine or alcohol.
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About 3 in 10 people with PoTS have hEDS. Few exercise studies include hypermobile people, and the first Levine study left them out, though the one randomised trial that included hEDS still found benefits. Protect your joints, keep movements controlled and in the middle of your range, and see a physiotherapist first, as CHOP advises. Our hypermobility guide has a strength and control routine.
The NHS says PoTS is more likely with long COVID, and in one Swedish clinic 31% of people with severe long COVID had it. Check for PEM first: our long COVID guide has the check and a gentle routine that also starts lying down.
PoTS UK says it isn't unusual to have ME/CFS as well as PoTS, and that people with ME/CFS are especially prone to PEM. It points them to the advice of the National Institute for Health and Care Excellence (NICE): activity overseen by a specialist in an ME/CFS team, and no graded exercise therapy. Because no trial of the reconditioning programmes screened for PEM, we can only infer they may not suit you; the Swedish trial built around PEM hasn't reported yet.
PoTS UK says being in water can help by squeezing the blood vessels and reducing pooling, that walking in a pool takes weight off your joints, and that floats help when you're starting. The Heart Rhythm Society lists swimming among the first exercises to try. Heated pools can make symptoms worse, so limit your time in the heat, have a cool shower afterwards, and swim with others or somewhere supervised.
Pilates can be done lying down, and the NHS lists it among gentle options. Types of yoga vary a lot, so choose slow, floor-based classes (our suggestion). Avoid hot yoga: CHOP doesn't recommend any exercise in the heat.
CHOP prefers the rowing machine to strengthen your heart, and PoTS UK notes that rowing and cycling are seated, so may be easier to tolerate; a recumbent bike reduces the effect of gravity further.
CHOP adds jogging late in its programme, only once harder upright exercise causes no extra symptoms, and you never have to jog. In the gym, seated machines and supervision help, PoTS UK says, and heavier weights are more of a challenge.
The criteria for 12 to 19 year olds use a heart rate rise of at least 40 beats a minute. Salt and fluid advice for children needs a paediatrician, PoTS UK says. CHOP's programme was written for a children's hospital's patients. The Heart Rhythm Society says there's little evidence that any treatment helps children with PoTS, but that it's reasonable to reassure them, encourage salt and fluids, and teach the counter-manoeuvres. See our guide to exercise for children.
Call 999 if someone has any of these, and don't drive yourself to A&E:
If you feel faint, stop, lie down and raise your legs. Use the counter-manoeuvres if you can't lie down.
If exercise is followed by a crash a day or more later that's out of proportion to what you did, stop increasing and talk to your specialist: it may be PEM.
Exercise is recommended by the Heart Rhythm Society, the NHS and PoTS UK, built up gradually from seated or lying exercise. The NHS lists resting too much as something that can make PoTS worse.
Upright exercise often sets off symptoms. The programmes start on a recumbent bike, a rowing machine or in a pool and move upright over months, and the researchers called the seated start a critical part of the plan.
The Heart Rhythm Society says that although anxiety is common with PoTS, the heart rate rise on standing "is not caused by anxiety" but by an underlying physical problem.
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In the community registry, 71% of people who finished no longer met the criteria, but 59% didn't finish. In the one randomised trial in PoTS, fitness and some symptoms improved but the heart rate rise on standing didn't change more than with usual care. Long-term results are limited.
PoTS UK says to ask your doctor first if you have high blood pressure or heart or kidney disease, and that children need a paediatrician's advice. High blood pressure and swelling are known side effects.
That pattern can be PEM, and PoTS UK notes that people with ME/CFS are especially prone to it. No trial of the reconditioning programmes screened for PEM, so pushing through isn't supported: pace instead, as NICE advises for ME/CFS, and talk to your specialist.
For many people, yes: expert guidelines recommend a regular, structured exercise programme that builds up gradually. In the first studies, about half the people who finished 3 months of training no longer met the criteria for PoTS. But the studies were small, most had no comparison group, and many people found the programmes too hard to finish.
Start with exercise lying down or seated, such as a recumbent bike, a rowing machine or swimming, because standing up makes symptoms worse. Most of it should be aerobic, with 1 to 2 strength sessions a week focused on the legs. Move to upright exercise gradually, over months.
A 3-month training programme from a research team in Dallas: seated or lying exercise first, at heart rate zones set from an exercise test, building to 5 to 6 hours a week, with upright exercise added from about the second or third month and weights twice a week. In its first study, 10 of the 19 people who finished no longer met the criteria for PoTS. It hasn't been compared with no exercise in a randomised trial.
The Children's Hospital of Philadelphia turned the Levine programme into 8 monthly calendars: seated or lying training for the first 3 to 4 months, an upright bike from month 4, a cross-trainer or treadmill from month 5, and leg and core strength twice a week. Week 1 is two 3-minute blocks at an easy pace, with a warm-up and cool-down. This version hasn't itself been tested in a published trial.
Start low and go slow: PoTS UK says a starting point can be as little as 60 seconds, building to 3 to 4 sessions a week. Drink two glasses of water first, wait an hour after a meal, keep cool, cool down gradually, and lie with your legs raised afterwards. It can take 6 to 12 weeks to notice a difference.
Exercise can set off PoTS symptoms, and experts say you may feel worse for up to 6 weeks when you start a programme. If a session is followed by a crash a day or two later that's out of proportion to what you did, that can be post-exertional malaise. The programmes weren't tested in people with it, so stop building up, pace as our ME/CFS guide describes and talk to your specialist.
The NHS says to drink plenty of fluids until your pee is pale, and PoTS UK suggests 2 to 3 litres a day for adults. PoTS UK also suggests 6 to 10 g of extra salt a day for most adults, but only after asking your doctor if you have high blood pressure or heart or kidney disease, and children need a paediatrician's advice. Extra salt isn't safe for everyone, so don't add it without checking.
They help some people. PoTS UK recommends waist-high class 2 tights, and in a small study, compressing the tummy and legs together lowered the heart rate when upright more than compressing the legs alone. Don't use them if you have poor blood supply to your legs.
Lie down and raise your legs until you feel better. If you can't lie down, cross your legs and squeeze your buttock and tummy muscles, rock up and down on your toes, or clench your fists. If you faint while exercising, call 999 (911 in the US).
Yes: Pilates and some yoga can be done lying down, and being in water can help by reducing blood pooling in your legs. Avoid hot yoga and very warm pools, because heat makes PoTS worse, and swim with others or somewhere supervised.
Later, yes. CHOP's programme adds jogging only once harder upright exercise causes no extra symptoms, usually after several months, and says you never have to jog. Start strength training with lying exercises or seated machines, and leave heavy free weights until your form is good.
Yes: the NHS says PoTS is more likely with long COVID, ME/CFS or joint hypermobility syndrome. In one study, about 3 in 10 people with PoTS met the criteria for hypermobile Ehlers-Danlos syndrome. If you also have ME/CFS, or get a crash a day or two after effort, pace rather than following a reconditioning programme.
Exercise education, not a diagnosis or treatment plan, and clinical review of these guides is pending. Stop and get advice for chest pain, unusual breathlessness, dizziness or fainting, or new pain, and check with your doctor or midwife first if they have told you to limit activity. Health disclaimer.
