Pilates guide
Pilates is one of the gentle activities the NHS suggests for postural tachycardia syndrome (PoTS; in the US, POTS, postural orthostatic tachycardia syndrome), and it fits the way PoTS exercise is meant to start: lying down first, then seated, then upright over months. But no study has tested Pilates in PoTS, so it works best as the strength part of a plan that also has seated or lying cardio.
The Pilates advice comes from the people behind the main PoTS training programmes: the Dallas team recommends "anything Pilates based that they can do on the floor" for core strength, and the Children's Hospital of Philadelphia (CHOP) programme includes a held chest lift it calls the "Pilates hold".
This guide covers what PoTS is, what the exercise trials found (including a 2026 Swedish trial), how to order a class so you change position as little as possible, fluids, salt and compression, hot classes, PoTS with Ehlers-Danlos syndromes (EDS) or hypermobility, PoTS with post-exertional malaise (PEM), the moves to change, a 20-minute class that never asks you to stand, and what to do if you feel faint.
The NHS suggests "gentle exercise, such as walking, pilates and swimming", and PoTS UK says Pilates exercises "can be done laying down". Expert guidance starts PoTS exercise lying or seated, and moves upright over months.
The Pilates advice is expert opinion from the main training programmes, not a trial result. The exercise studies in PoTS used mostly cycling, rowing and swimming.
PoTS UK suggests mostly aerobic exercise with 1 to 2 strength sessions a week. Strong legs and buttocks matter most, because those muscles help pump blood back to the heart. A floor Pilates class can be one of the strength sessions, with seated or lying cardio on other days.
In small studies without proper comparison groups, many people who finished 3 months of training no longer met the criteria for PoTS. In the randomised trials, fitness improved but overall symptoms didn't differ from usual care, and a 2026 Swedish trial in PoTS after COVID-19 found exercise added nothing to standard care.
Do all the lying moves, then the side-lying ones, then seated, then standing. Sit for a minute before you stand, keep the room cool, don't hold your arms above your head for long, and keep breathing in holds.
That can be post-exertional malaise. Talk to your specialist, and pace as our Pilates for chronic fatigue guide describes, rather than pushing on.
In PoTS, "your heart rate increases after getting up from sitting or lying down, often making you feel dizzy or lightheaded", the NHS says. Doctors look for a rise of 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, with symptoms for at least 3 months.
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. PoTS UK adds moving quickly from lying or sitting to standing.
A 2026 review puts it at 0.1% to 1% of people in the US, about 90% of them female, mostly starting between the ages of 13 and 29. In a survey of 4,835 people, about 70% had substantial limits on daily life.
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Up to 70% of people with PoTS have less blood circulating than usual, and blood can pool in the legs and gut on standing. Whether losing fitness causes PoTS or follows it is unclear: in a review of 17 studies, fitness was lower in 80% of them, but in only 30% when the comparison group was matched for fitness. The heart rate rise "is not caused by anxiety", the Heart Rhythm Society says.
The NHS says PoTS is more likely with long COVID, myalgic encephalomyelitis or chronic fatigue syndrome (ME/CFS), or joint hypermobility syndrome. In 91 people with PoTS, 31% had hypermobile Ehlers-Danlos syndrome (hEDS). In 467 people with severe long COVID at a Swedish clinic, 31% had PoTS. Our PoTS exercise guide has the full picture.
No study has tested Pilates in PoTS. The evidence below is for exercise programmes in general, mostly cycling, rowing and swimming.
The Heart Rhythm Society says "A regular, structured, and progressive exercise program for patients with POTS can be effective", and that at first exercise should be "restricted to non-upright exercises" such as rowing machines, recumbent bikes and swimming. A 2019 US National Institutes of Health (NIH) expert meeting says exercise training "should be a component of any POTS treatment plan". The trials behind this are small.
Our searches found no trial of Pilates in PoTS or orthostatic intolerance (October 2026). The Dallas team's review recommends core work "such as abdominal crunches, back extensions, side planks or anything Pilates based that they can do on the floor". CHOP's programme has a "Pilates hold", and PoTS UK says Pilates "Can provide full body strengthening due to the variability in movements". That is expert opinion, not a tested finding.
In the Dallas study, 25 people started and 19 finished 3 months of training, mostly lying or seated at first; their heart muscle grew by about 12%, and 10 of the 19 no longer met the criteria for PoTS. In a community registry, 103 of 251 people (41%) finished, and 71% of those no longer met the criteria. Neither had a proper comparison group, and many people dropped out.
In the one randomised trial in PoTS in general (60 randomised, 49 analysed), 12 weeks of semi-supervised training improved fitness and symptoms on standing, but the total symptom score didn't differ from usual care. In the exercise group, 13% stopped for illness or worse symptoms.
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The trial randomised 60 adults with PoTS after COVID-19, nearly all of whom also had post-exertional malaise, to standard care with or without 16 weeks of tailored exercise done mostly lying or semi-reclined, supervised weekly by a physiotherapist. Quality of life didn't differ, both groups improved, and the authors concluded that "the intervention did not confer additional benefits beyond standard care". It's one trial in one group of people, so it doesn't settle the question for PoTS in general.
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A 2025 review found 7 studies, rated 5 at high risk of bias, and found dropout ranged from 10% to 59%. A 2026 review of all PoTS treatments found only 1 randomised exercise trial and warned that "physical training might increase the risk of PEM".
In 13 people with PoTS and 13 without, 6 minutes of cycling lying down produced similar responses in both groups, while upright cycling sent the heart rate in PoTS too high. It was a small, single-session lab study.
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In 30 people with PoTS, slow, deep tummy breathing at 6 breaths a minute during a 10-minute tilt test lowered the heart rate rise by about 7 beats a minute, and eased symptoms, compared with normal breathing. It was one session in a lab, not a treatment trial.
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In an online survey of about 270 people with PoTS, 78% had been advised to exercise and 52% said exercise makes them feel worse. It was a self-selected survey.
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Standing up is what sets off PoTS, so the programmes start with exercise lying or seated: CHOP keeps the first 3 to 4 months seated or lying. Most mat Pilates is done lying on your back, on your side or face down, which keeps your heart and head at about the same level while your legs work.
Do all the lying moves, then all the side-lying ones, then any seated ones, then standing. The NHS says "do not get up too quickly after lying down". The risky moments in a class are the changes: rolling up to sitting or standing, and getting up and down between moves.
PoTS UK says to avoid holding your hands above your head for long, so bring your arms down between reps. Count out loud in holds so you keep breathing (our suggestion).
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Word for word from our Pilates for hypermobility guide, which took them from the NHS PoTS and fainting pages, PoTS UK and a Pilates teacher's case report; rolling onto your side to sit up is our suggestion.
See the movement on the 3D figure: Sit to stand from a chair
PoTS UK says "a baseline of 60 seconds of exercise and then progressing this over time" is fine. It suggests building up to 3 to 4 sessions a week, and 5 to 6 after at least 3 months that have gone well. It can take 6 to 12 weeks to notice a change.
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PoTS UK suggests mostly aerobic exercise with 1 to 2 strength sessions a week. CHOP's strength sessions take 20 to 30 minutes, twice a week with a day between, at 3 sets of 8 to 10. Our PoTS starter session does the cardio on a bike and rowing machine.
Use the floor class below as one of your strength sessions. Start with 1 set of each move, as our PoTS starter session does, and add a second, then a third set only after a week with no worse symptoms (our suggestion, building towards CHOP's 3 sets).
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The NIH meeting warns that people "Will initially feel poorly/worse for up to 6 weeks". Feeling more tired in the first weeks is common, CHOP says: repeat a week rather than pushing on.
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.
The 2026 Swedish trial paused progression when symptoms, including post-exertional malaise, lasted beyond 24 hours.
PoTS UK's advice around exercise:
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PoTS UK suggests 2 to 3 litres of fluid a day for adults.
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PoTS UK 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. In 14 people with PoTS, 6 days of a high-salt diet lowered the heart rate rise on standing; it was a tiny, short study.
PoTS UK recommends waist-high class 2 tights, put on before you get out of bed. In 30 people tilted upright, heart rate averaged 109 beats a minute with no compression, 103 with the legs compressed, and 92 with the tummy and legs compressed. Don't use them with poor blood supply to your legs, diabetes, or a leg injury or infection unless a doctor has checked.
Our PoTS exercise guide covers fluids, salt and compression in full.
Lateral breathing: 5 breaths, slow and easy (adapted from the move page's dose); its page says to stop and breathe normally if you feel dizzy or light-headed. Slow breathing: 2 to 3 minutes at the start (adapted from the move page's dose).
Bridge: 8 to 10, holding each up to 10 seconds. Straight-leg raise: 8 to 10 each leg. Inner-thigh squeeze: 8 to 10, holding each 5 seconds, a pillow between your thighs. (Those three are our PoTS starter session's doses, from CHOP, at 1 set.) Knee folds: 6 each side, and heel slides: 8 each side (each adapted from the move page's dose). Single-leg circles: "5 circles each direction, each leg (the classical sequence uses 5)." (the move page's dose).
3D demoGlute bridgeBeginner · No equipment
3D demoStraight-leg raiseBeginner · No equipment
3D demoLying adductor ball squeezeBeginner · Other / check instructions
3D demoKnee foldBeginner · No equipment
3D demoSupine heel slideBeginner · No equipment
3D demoSingle-leg circle (Pilates one leg circle)Beginner · No equipmentChest lift, done as CHOP's "Pilates hold": 8 to 10 lifts, each held up to 10 seconds while you count out loud, with an apple-sized space under your chin (CHOP; adapted from the move page's dose). Dead bug heel taps: 6 each side (our editorial starting point). Kneeling plank, optional: 1 to 3 holds of 15 to 30 seconds (CHOP's plank, started at 1 set); leave it out if being face down makes you light-headed (our suggestion).
Side-lying leg raise and clamshell: 8 to 10 each side (our PoTS starter session, from CHOP; PoTS UK's examples call the clamshell the "Oyster"). Side kicks: 8 each side (adapted from the move page's dose).
Seated march: "1 to 2 minutes as a warm-up (the Otago-based Later Life Training booklet), or 5 lifts each leg (the NHS sitting exercises)." (the move page's dose). Seated knee extension: 1 to 3 sets of 15 (CHOP's seated knee extensions are 3 sets of 15; adapted from the move page's dose). Thoracic rotation: "6 rotations per side, moving with the breath" (the move page's dose).
Sit to stand: 8, slowly, a hand on a counter. Slow calf raises: 10 to 15 (both our editorial starting points). Wall side leg lift: "10 to 12 each side." (the move page's dose), a hand on the wall.
Legs up the wall: 2 to 3 minutes, or legs raised on cushions, then sit for a minute before you stand (our PoTS starter session's dose). PoTS UK advises lying or sitting with your legs raised above your hips after exercise.
Roll-downs and roll-ups to standing, standing footwork, and getting up between moves. The wall roll-down's page says "Come up slowly if you feel dizzy." Keep the class in order: lying, side-lying, seated, standing.
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The standing series, standing reformer work and standing still for long. CHOP keeps the first months seated or lying, and the NHS lists standing upright for long periods as a trigger.
Bring your arms down between reps in the hundred, the roll-up and the mermaid, as PoTS UK says to avoid holding your hands above your head for long.
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The roll-over, jack knife and corkscrew take your head below your heart and are followed by a quick return to sitting; leave them out until you're well (our suggestion). The roll-over and jack knife also put weight on your neck: their pages say to leave them out with a neck problem, and with hypermobility unless a physiotherapist who knows your neck has cleared it.
Count out loud in holds, as our PoTS starter session cues (our suggestion).
PoTS UK mentions the reformer as a way to exercise lying down. Leave standing and kneeling reformer work until upright exercise is comfortable, and get off the carriage slowly, sitting for a minute first (our suggestion). No study has compared mat and reformer in PoTS.
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Getting too hot is the first trigger on the NHS list, and CHOP says "we do not recommend any exercise in the heat". Choose a cool room and have water with you.
In 91 people with PoTS, 31% had hEDS and another 24% had hypermobile joints. PoTS UK cites a 2020 worldwide survey in which 31% had hEDS and 55% were hypermobile. The other way round, at a UK fainting clinic, 82% of 218 hypermobile patients had an abnormal tilt-table test, but only 9.9% met the criteria for PoTS.
A 2024 review found a "paucity" of exercise research in people with PoTS and joint hypermobility. The randomised trial included people with hEDS, but 4 of the 11 withdrew.
CHOP advises hypermobile patients to see a physiotherapist first, and the Dallas team suggests starting without weight-bearing and building up slowly. On the mat, work in the middle of your range, keep your elbows and knees soft, use fists if your wrists bend back too far, and keep weight off your neck (from the move pages' cautions).
Our Pilates for hypermobility guide covers EDS and hypermobility spectrum disorder in full, with its own class.
PoTS UK says people with ME/CFS are especially prone to post-exertional malaise and points them to the National Institute for Health and Care Excellence (NICE) guideline. A 2026 review says training "might increase the risk of PEM". With PEM, pace as our Pilates for chronic fatigue and ME/CFS exercise guides describe, not with a reconditioning plan.
For orthostatic intolerance or PoTS in long COVID, World Physiotherapy suggests "utilisation of non-upright exercises, use of isometric exercises, compression garments", while watching for symptoms that get worse after exertion.
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).
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If you feel faint, stop, lie down and raise your legs. Use the counter-manoeuvres if you can't lie down.
If you faint while exercising, call 999 (911 in the US).
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Our floor Pilates class for PoTS keeps you lying down from start to finish; it follows CHOP's home strength list in the order the hypermobility steps give, and no trial has tested it. The PoTS starter session is the cardio day, on a bike and rowing machine. Chair Pilates suits dizzy days. The beginner class is all on the floor, for later.
A 20-minute floor Pilates class for PoTS (POTS): breathing, leg strength and core work lying down and on your side, then legs up the wall, with no standing.
20 minBeginner14 movesOther / check instructions, A wallA 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 Pilates class for hypermobile joints, HSD and hEDS: supported positions first, mid-range control, slow changes and steady breathing.
20 minBeginner17 movesOther / check instructions, A bandA 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 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 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 equipmentThe 999 list, the GP list and the line on when to stop building up are from our PoTS exercise guide, word for word; the breathlessness, stop and before-you-start lines are the ones our other Pilates guides use. This is general information, not a diagnosis. A&E means accident and emergency; in the US, call 911 for 999, and use your doctor's urgent line or urgent care for NHS 111.
Call 999 if someone has any of these, and don't drive yourself to A&E:
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.
Call 999 or go to A&E (accident and emergency) straight away for severe difficulty breathing (gasping, choking or not able to get words out), a chest that feels tight or heavy, pain that spreads to your arms, back, neck and jaw, lips or skin turning very pale, blue or grey, or sudden confusion. If you're more short of breath than usual, or your heart is racing, fluttering or skipping beats, contact NHS 111.
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You feel any pain or become unwell, as the NHS advises for its Pilates videos, and especially for chest pain or pressure, unusual breathlessness, dizziness or fainting. If you have a health problem, an injury or any symptoms, get advice from a healthcare professional, such as a GP, before you start.
The NHS advises getting advice from a healthcare professional first if you have a health problem, an injury or symptoms, or have recently had a heart attack or an operation.
See a GP before you start if your symptoms haven't been diagnosed: the NHS says PoTS symptoms can be similar to those of other conditions. If you take a beta blocker, go by effort rather than heart rate, as CHOP does. Ask before adding salt if you have high blood pressure, heart or kidney disease, and before compression with poor blood supply to your legs or diabetes. Teenagers need a paediatrician's advice on salt and fluids. (Our suggestion, from the sources here.)
Guidance starts with exercise that isn't upright, CHOP keeps the first months seated or lying, and upright exercise sent heart rates too high in a lab study.
There's no trial, but the Dallas team recommends floor Pilates for core strength and CHOP includes a Pilates hold. It's the strength part of a plan that also needs cardio.
No trial has tested it. Exercise programmes helped many people who finished them in small studies, but the randomised trials found modest or no extra benefit on overall symptoms.
Nobody has tested it. Compressing the tummy as well as the legs lowered the upright heart rate in a lab trial, and leg muscles pump blood back, so train your legs and buttocks as well as your core.
Getting too hot is a trigger, and CHOP doesn't recommend exercise in the heat.
That pattern can be post-exertional malaise. Newer trials pause progression when symptoms last beyond 24 hours, and a 2026 review says training may raise the risk of PEM.
The Heart Rhythm Society says the heart rate rise "is not caused by anxiety".
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It can be a good fit. Much of it is done lying down, which is how PoTS exercise should start, and it builds the leg and core strength that helps push blood back to your heart. The NHS lists Pilates among gentle options, and PoTS UK says it can be done lying down. No study has tested Pilates in PoTS itself.
No trial yet. The Pilates advice comes from the team behind the main PoTS training programme, which recommends "anything Pilates based" on the floor for core strength, and from a children's hospital programme that includes a "Pilates hold". The exercise studies in PoTS used mostly cycling, rowing and swimming.
Standing up is what sets off PoTS, so exercising lying down lets you train without the heart rate surge. Expert guidance starts with exercise that isn't upright, and one programme keeps the first 3 to 4 months seated or lying. In a small lab study, heart rate during lying exercise in PoTS was like that of healthy people.
PoTS UK suggests building up to 3 to 4 exercise sessions a week, mostly aerobic, with 1 to 2 strength sessions. Pilates fits as a strength session, with seated or lying cardio, such as a recumbent bike, on other days. Start with one set of each move and add more only after a week with no worse symptoms (our suggestion).
Yes, lying down: PoTS UK mentions the reformer as a way to exercise lying down. Leave standing and kneeling reformer work until upright exercise is comfortable, and get off the carriage slowly, sitting for a minute first. No study has compared mat and reformer in PoTS.
We'd avoid it. Getting too hot is the first trigger on the NHS list, and one PoTS programme says it doesn't recommend any exercise in the heat. Choose a cool room and have water with you.
Early on, avoid standing work, rolling up to standing, and getting up and down between moves. Keep your arms overhead only briefly, and keep breathing rather than holding your breath in holds. Leave out legs-over-the-head moves such as the roll-over, which also put weight on your neck.
Stop, 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, or clench your fists. If you faint while exercising, call 999 (911 in the US).
If you use compression, PoTS UK suggests wearing it to exercise. Waist-high tights that squeeze your tummy as well as your legs worked best in a lab study. Don't use them with poor blood supply to your legs, diabetes, or a leg injury or infection, unless a doctor has checked.
It can be, with care: hypermobility and EDS are common with PoTS, and few exercise studies include hypermobile people. Keep movements controlled and in the middle of your range, and see a physiotherapist first, as one PoTS programme advises. Our Pilates for hypermobility guide covers the joint side.
Feeling more tired in the first weeks is common, and experts say it can last up to 6 weeks. But a crash a day or two later, out of proportion to what you did, can be post-exertional malaise. Stop building up, pace, and talk to your specialist.
Not on its own. The programmes that help are mostly aerobic, starting on a recumbent bike, a rowing machine or in a pool, with strength work twice a week. Pilates is a good way to do the strength part lying down.
Exercise education, not a personal prescription, and clinical review of these guides is pending. If you are pregnant, have a health condition or have had recent surgery, check with a doctor, midwife or physiotherapist before starting, and stop for sharp or increasing pain. Health disclaimer.
