Why POTS Changes Your PT Session
Updated: Sep 11
A patient can tolerate bridges, leg strengthening, and several minutes on a recumbent bike without a problem. Then she stands up to finish the session and suddenly feels lightheaded, nauseated, shaky, and exhausted.
If you are only watching the exercises, that response may not make sense.
If you understand postural orthostatic tachycardia syndrome, it does.
POTS changes more than which cardiovascular exercise you choose. It changes how you position the patient, how quickly you move between activities, what you monitor, how you interpret fatigue, and what counts as a successful session.
In other words, it changes the dose of gravity.
What POTS Actually Means
Postural orthostatic tachycardia syndrome is a chronic disorder of orthostatic intolerance. Current diagnostic criteria include a sustained heart-rate increase of at least 30 beats per minute in adults—or 40 beats per minute in adolescents ages 12 to 19—within 10 minutes of standing, without significant orthostatic hypotension. Symptoms must also be present for at least three months and cannot be better explained by another condition.[1]
Patients may experience lightheadedness, palpitations, tremulousness, nausea, brain fog, blurred vision, presyncope, exercise intolerance, and profound fatigue. Symptoms can vary considerably from one day to the next.
That last point matters in physical therapy.
A patient may tolerate an activity on Tuesday and struggle with it on Friday without losing strength or motivation in between. Sleep, hydration, illness, medication changes, menstrual cycles, heat, prolonged standing, and everything the patient did before arriving can influence what their autonomic system can manage that day.
A rigid progression based only on what happened during the previous appointment will miss that.
POTS and Hypermobility Frequently Overlap
If you regularly treat patients with hypermobile Ehlers-Danlos syndrome or hypermobility spectrum disorder, POTS needs to be part of your clinical awareness.
In one study of 91 people with POTS, 31% met the 2017 diagnostic criteria for hEDS and another 24% had generalized joint hypermobility without hEDS.[2] That does not mean every hypermobile patient has POTS or that every episode of dizziness is autonomic dysfunction. It does mean the overlap is common enough that unexplained lightheadedness, tachycardia, fatigue, nausea, or exercise intolerance deserves more attention than “you are probably deconditioned.”
POTS is a heterogeneous condition. Deconditioning may be part of the clinical picture for some patients, but it does not fully explain the syndrome. Current research describes multiple possible contributors, including low circulating blood volume, altered autonomic regulation, peripheral neuropathy, excessive sympathetic activation, and increased dependent blood pooling.[3]
When hypermobility is also present, tissue laxity may further affect the vascular system’s ability to manage blood distribution in an upright position.[3]
The result is a patient whose musculoskeletal and autonomic limitations cannot be treated as two completely separate problems.
Your Standard Warmup May Be the Hardest Part of the Session
Many physical therapy sessions begin with five or ten minutes of walking, cycling, or standing movement.
For a patient with POTS, an upright warmup may require more cardiovascular compensation than the strengthening exercises you planned afterward. Starting there can consume a large portion of the patient’s available capacity before you reach the treatment that brought them into the clinic.
When a patient becomes symptomatic during an upright warmup, the answer is not automatically to stop exercise. It is to reconsider the position, duration, intensity, and timing.
Recumbent cycling, rowing, swimming, and other horizontal or semi-recumbent activities are frequently used during the early stages of POTS rehabilitation because they reduce the immediate orthostatic demand.[4,5] Upright exercise can then be introduced as the patient builds tolerance.
The patient is not avoiding standing forever. You are giving the cardiovascular system a position in which it can begin adapting without being overwhelmed.
Monitor the Patient, Not Just the Heart Rate
Heart rate gives you useful information, but it cannot tell you the entire story.
I want to know what the patient feels, how quickly symptoms appear, what position triggered them, how long recovery takes, and whether the effects follow them home. A technically completed exercise is not a successful dose if it causes a prolonged flare that makes the rest of the patient’s day—or week—less functional.
During a session, that may mean monitoring:
Heart-rate response
Blood pressure when clinically appropriate
Dizziness or lightheadedness
Nausea
Tremulousness
Headache or cognitive fog
Perceived exertion
Symptom recovery after changing positions
Delayed fatigue following previous sessions
This also means asking better questions before you begin.
What has the patient already done today? How long have they been upright? Have they eaten and hydrated according to their medical plan? Are their symptoms already elevated? Did the previous session produce a delayed flare?
That information may change the session more than a predetermined set and repetition scheme.
Transitions Are Part of the Exercise Dose
Moving from supine to sitting and immediately into standing may look like a break between exercises. For a patient with POTS, it is an intervention.
Transitions should be deliberate. The patient may need time in sitting before standing, a brief period of lower-extremity muscle activation, or a different sequence that groups activities by position instead of repeatedly moving up and down.
For example, I may complete the supine interventions together, transition to sitting once, perform the seated work, and save standing activities for the end. That reduces unnecessary orthostatic transitions without removing the patient’s opportunity to practice upright tolerance.
This is a small programming decision that can make the entire appointment more tolerable.
Strength Training Still Matters
POTS does not mean the patient should only perform cardiovascular exercise.
Published rehabilitation approaches often combine aerobic reconditioning with lower-extremity and core strengthening.[4,5] The lower-extremity muscle pump helps move blood back toward the heart during upright activity, while improved strength supports the patient’s ability to tolerate daily tasks.
When the patient is also hypermobile, strength work has another job: improving active joint stability.
However, the usual hypermobility rules still apply. The patient needs appropriate muscle recruitment, midrange control, and a load they can recover from. Adding weight to a compensation pattern does not create stability, and pushing a patient through autonomic symptoms does not build tolerance efficiently.
The cardiovascular and musculoskeletal plans must support each other.
Progression Should Be Based on Recovery, Not Compliance
One of the most damaging assumptions we make about patients with POTS is that inconsistent performance means inconsistent effort.
A patient who cannot reproduce last week’s session may still be following the plan exactly. Their available capacity changed.
Recent literature has questioned whether rigid, high-volume protocols are appropriate for every person with POTS, particularly patients with severe orthostatic intolerance, post-exertional symptom exacerbation, or substantial fatigue.[4] Individualized programs may be more sustainable because they account for the patient’s starting function, comorbidities, symptom variability, and recovery response.
Progress may mean:
Tolerating the same activity with fewer symptoms
Recovering more quickly after standing
Completing more of the session upright
Performing a functional task without needing the rest of the day to recover
Increasing duration before increasing resistance
Having fewer delayed flares between appointments
Those changes may look slow on paper. They can still represent meaningful physiological and functional progress.
Know the Boundary Between Screening and Diagnosis
A heart-rate increase during one physical therapy session does not diagnose POTS.
Pain, dehydration, illness, medication effects, anemia, anxiety, prolonged bed rest, and other medical conditions can also produce tachycardia or orthostatic symptoms.[1] A physical therapist can recognize the pattern, document objective findings, modify the session appropriately, and refer the patient for medical evaluation.
That distinction protects the patient from both extremes: having their symptoms dismissed and having a diagnosis assumed without an appropriate workup.
The Takeaway
POTS should not remove exercise from the plan of care. It should make the exercise prescription more thoughtful.
Start in a position the patient can tolerate. Treat transitions as part of the workload. Monitor symptoms and recovery alongside heart rate. Build strength without ignoring joint instability. Progress upright activity gradually, and do not confuse symptom variability with a lack of effort.
Most importantly, listen when the patient tells you that a seemingly simple activity affects their body differently than you expected.
They are giving you information about the system you are treating.
Treat patients with POTS, hypermobility, or both?
EDS Essentials is a practical clinical framework for physical therapists who want to recognize these patterns earlier, understand how common comorbidities change rehabilitation, and build plans of care that work with a hypermobile patient’s body instead of repeatedly overwhelming it.
References
Raj SR, Fedorowski A, Sheldon RS. Diagnosis and management of postural orthostatic tachycardia syndrome. CMAJ. 2022;194(10):E378-E385. doi:10.1503/cmaj.211373
Miller AJ, Stiles LE, Sheehan T, et al. Prevalence of hypermobile Ehlers-Danlos syndrome in postural orthostatic tachycardia syndrome. Auton Neurosci. 2020;224:102637. doi:10.1016/j.autneu.2020.102637
Vernino S, Bourne KM, Stiles LE, et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting—Part 1. Auton Neurosci. 2021;235:102828. doi:10.1016/j.autneu.2021.102828
Trimble KZ, Switzer JN, Blitshteyn S. Exercise in postural orthostatic tachycardia syndrome: Focus on individualized exercise approach. J Clin Med. 2024;13(22):6747. doi:10.3390/jcm13226747
Ziaks L, Johnson K, Schiltz K, et al. Adaptive approaches to exercise rehabilitation for postural tachycardia syndrome and related autonomic disorders. Arch Rehabil Res Clin Transl. 2024;6(4):100366. doi:10.1016/j.arrct.2024.100366
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