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Postural orthostatic tachycardia syndrome (POTS) occurs in approximately 30% of people with highly symptomatic post-COVID-19 condition (PCC). It involves several symptoms that limit physical and psychological functions and cause reduced quality of life. Evidence for different treatments of POTS and PCC is limited, and this study aimed to evaluate the feasibility of individually tailored physical exercise. The secondary aim of the study was to evaluate the preliminary effectiveness of this intervention. Twenty-six participants (81% female, median age 41 years) were enrolled and performed individually tailored endurance and strength training, with progression, for twelve weeks. During the intervention period, the participants had weekly support from a physiotherapist. Feasibility was evaluated with good compliance, with 76% adherence to exercise prescription and 96% completing the study protocol. The treatment was safe, and the evaluation methods (questionnaires, physical assessments, and accelerometer monitoring) were judged to be feasible. After the intervention, improvements in symptom burden as well as in psychological and physical functions were observed. In conclusion, future randomized controlled trials can be performed with only minor adjustments and could include questionnaires, physical assessment and accelerometer monitoring, which were demonstrated as feasible by this study., (© 2024. The Author(s).)

Purpose: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia. It may occur in isolation, but frequently co-exists in individuals with hypermobile variants of Ehlers-Danlos Syndrome (EDS) and related conditions (chronic fatigue syndrome [CFS] and fibromyalgia). Exercise is recommended for non-pharmacological POTS management but needs to be individualised. This scoping review explores the current literature on use and effectiveness of exercise-based management for POTS, with specific focus on individuals with joint hypermobility and related conditions who experience hypermobility, and/or pain, and/or fatigue., Methods: A systematic search, to January 2023, of Medline, EMBASE, AMED, CINAHL and the Cochrane library was conducted. Studies that reported on adolescents and adults who had been diagnosed with POTS using standard criteria and underwent an exercise-based training intervention were included., Results: Following full-text screening, 10 articles were identified (2 randomised control trials, 4 comparative studies and 4 case reports). One comparative study reported a small subset of participants with EDS and one case report included an individual diagnosed with CFS; the remainder investigated a wider POTS population. Overall, 3 months of endurance followed by resistance exercise, graduating from the horizontal-to-upright position reduced POTS symptoms and improved quality-of-life., Conclusion: The findings highlight a paucity of higher-level studies documenting exercise for POTS management in people with joint hypermobility and related conditions. Results from the wider POTS population demonstrate exercise is safe and effective. Large, well-designed clinical studies exploring exercise for POTS management adapting to meet the complex musculoskeletal and non-musculoskeletal features of symptomatic joint hypermobility are needed., Competing Interests: Declaration of competing interest No conflicts of interest, financial or otherwise are declared by the authors., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Postural orthostatic tachycardia syndrome (POTS) is a heterogeneous disorder of orthostatic intolerance with few proven treatments., Objective: The purpose of this study was to determine the efficacy of an unsupervised at-home training regimen for the treatment of POTS., Methods: We reviewed the medical records including autonomic function testing, symptom scores, and activities of daily living in individuals with POTS who were invited to participate in a 6-month outpatient cardiovascular exercise program., Results: Seventy-seven individuals were invited (invited group), 48 of 77 (62%) participated (treated group) and 43 of 77 (56%) of those completed. Twenty-nine of 77 (38%) did not participate (control group). After 6 months, 11 of 48 (23%) individuals in the treated group met heart rate criteria for POTS compared with 27 of 29 (93%) in the control group (χ 2 test, P < .0001). Supine heart rate (68 ± 8 beats/min vs 77 ± 10 beats/min; P < .001) and standing heart rate (95 ± 11 beats/min vs 115 ± 10 beats/min; P < .001) decreased in the treated group compared with the control group. The frequency of syncope decreased in the treated group (P < .001). An improvement in the EuroQol perceived quality of life scale score was detected in the treated group (61 ± 15 vs 71 ± 12 after 6 months, P < .001) compared with the control group (64 ± 9 vs 66 ± 8 after 6 months; P = .52)., Conclusion: In this study, we report a successful pragmatic clinical trial of an outpatient exercise protocol in a tertiary care referral population that significantly improved cardiovascular function and quality of life in patients with POTS., (Copyright © 2021 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

Recent research has demonstrated that cardiovascular deconditioning (i.e., cardiac atrophy and hypovolemia) contributes significantly to the Postural Orthostatic Tachycardia Syndrome (POTS) and its functional disability. Therefore, physical reconditioning with exercise training and volume expansion via increased salt and fluid intake should be initiated early in the course of treatment for patients with POTS if possible. The use of horizontal exercise (e.g., rowing, swimming, recumbent bike, etc.) at the beginning is a critical strategy, allowing patients to exercise while avoiding the upright posture that elicits their POTS symptoms. As patients become increasingly fit, the duration and intensity of exercise should be progressively increased, and upright exercise can be gradually added as tolerated. Supervised training is preferable to maximize functional capacity. Other non-pharmacological interventions, which include: 1) chronic volume expansion via sleeping in the head-up position; 2) reduction in venous pooling during orthostasis by lower body compression garments extending at least to the xiphoid or with an abdominal binder; and 3) physical countermeasure maneuvers, such as squeezing a rubber ball, leg crossing, muscle pumping, squatting, negative-pressure breathing, etc., may also be effective in preventing orthostatic intolerance and managing acute clinical symptoms in POTS patients. However, randomized clinical trials are needed to evaluate the efficacies of these non-pharmacological treatments of POTS., (Copyright © 2018 Elsevier B.V. All rights reserved.)

The incidence of postural orthostatic tachycardia syndrome (POTS) is estimated to be at least 500,000 in the United States and is most commonly found in premenopausal females. This syndrome shares clinical features with orthostatic hypotension (OH); however, the inclusion criteria and clinical features for POTS are not well known. The purposes of this case report are to: 1) describe the common clinical features of POTS and highlight the differences to orthostatic hypotension and 2) discuss physical therapy management of patients with POTS using exercise. A 34-year-old female with a POTS exacerbation completed a 4-week physical therapy endurance and strengthening 'reconditioning' program. Initial symptoms included the following: dyspnea with mild exertion, light-headedness, fatigue, leg "heaviness," and the inability to perform normal work duties. One-mile track walk test (1-MWT) estimated VO 2max improved from the 45-50th percentile to the 65-70th percentile at 8 weeks post-discharge. She returned to work full-time and resumed all previous fitness activities. The patient demonstrated clinically meaningful improvements in estimated VO 2max after the "reconditioning" training. Physical therapists should be able to recognize the clinical features and inclusion criteria for POTS as part of a differential diagnosing process for patients complaining of orthostatic symptoms.

Background: Postural orthostatic tachycardia syndrome (POTS) affects primarily young women and impairs quality of life. We found that in a research setting, exercise training along with lifestyle intervention is effective as a nondrug therapy for POTS., Objective: To evaluate the efficacy of our exercise training/lifestyle intervention in POTS patients in a community environment., Methods: We established a POTS registry and enrolled 251 patients (86% women, aged 26 ± 11 [SD] years) through their physicians. A 3-month program involving mild- to moderate-intensity endurance training (progressing from semirecumbent to upright, 3-5 times/wk, 30-45 min/session) plus strength training was implemented along with increasing salt/water intake. The program was delivered to the physicians, who oversaw training in their patients. A 10-minute stand test was performed at the physician's office and patient quality of life was assessed using the 36-Item Short Form Health Survey., Results: One hundred and three patients completed the program. Of those that completed, 71% no longer qualified for POTS and were thus in remission. The increase in heart rate from supine to 10-minute stand was markedly lower (23 ± 14 vs. 46 ± 17 beats/min before intervention; P < .001), while patient quality of life was improved dramatically after intervention (P < .001). Of those who were followed for 6-12 months (n = 31), the effect was persistent., Conclusions: A training/lifestyle intervention program can be implemented in a community setting with physician supervision and is effective in the treatment of POTS. It remains to be determined whether exercise can be an effective long-term treatment strategy for this condition, though patients are encouraged to maintain an active lifestyle indefinitely., (Copyright © 2016 Heart Rhythm Society. Published by Elsevier Inc. All rights reserved.)

We have found recently that exercise training is effective in the treatment of the postural orthostatic tachycardia syndrome (POTS). Whether this nondrug treatment is superior to "standard" drug therapies, such as β-blockade, is unknown. We tested the hypothesis that exercise training but not β-blockade treatment improves symptoms, hemodynamics, and renal-adrenal responses in POTS patients. Nineteen patients (18 women and 1 man) completed a double-blind drug trial (propranolol or placebo) for 4 weeks, followed by 3 months of exercise training. Fifteen age-matched healthy individuals (14 women and 1 man) served as controls. A 2-hour standing test was performed before and after drug treatment and training. Hemodynamics, catecholamines, plasma renin activity, and aldosterone were measured supine and during 2-hour standing. We found that both propranolol and training significantly lowered standing heart rate. Standing cardiac output was lowered after propranolol treatment (P=0.01) but was minimally changed after training. The aldosterone:renin ratio during 2-hour standing remained unchanged after propranolol treatment (4.1±1.7 [SD] before versus 3.9±2.0 after; P=0.46) but modestly increased after training (5.2±2.9 versus 6.5±3.0; P=0.05). Plasma catecholamines were not affected by propranolol or training. Patient quality of life, assessed using the 36-item Short-Form Health Survey, was improved after training (physical functioning score 33±10 before versus 50±9 after; social functioning score 37±9 versus 48±6; both P<0.01) but not after propranolol treatment (34±10 versus 36±11, P=0.63; 39±7 versus 39±5, P=0.73). These results suggest that, for patients with POTS, exercise training is superior to propranolol at restoring upright hemodynamics, normalizing renal-adrenal responsiveness, and improving quality of life.

Purpose: Postural orthostatic tachycardia syndrome (POTS) is characterized by excessive tachycardia in the upright position. To test the hypothesis that patients with POTS have impaired arterial-cardiac baroreflex function, while exercise training normalizes the baroreflex function in these patients., Methods: Seventeen POTS patients aged 27 ± 9 (mean ± SD) years underwent an exercise training program for 3 months. Arterial-cardiac baroreflex function was assessed by spectral and transfer function analysis of beat-to-beat R-R interval (RRI) and systolic blood pressure (SBP) variability in the supine position and at 60° upright tilt during spontaneous breathing before and after training. Data were compared with 17 healthy sedentary controls., Results: Even though upright heart rate (HR) was greater in patients than controls, indexes of RRI variability did not differ between groups. Transfer function gain (SBP to RRI), used as an index of arterial-cardiac baroreflex sensitivity was similar between patients and controls in both low- (LF, P = 0.470) and high-frequency (HF, P = 0.663) ranges. Short-term exercise training decreased upright HR and increased RRI variability in POTS patients. LF baroreflex gain increased significantly in the supine position and during upright tilt [analysis of variance (ANOVA), P = 0.04 for training], while HF gain increased modestly after training (ANOVA, P = 0.105 for training) in these patients; however, the baroreflex gains remained within the normal ranges when compared with healthy controls., Conclusions: These data suggest that patients with POTS have normal arterial-cardiac baroreflex function in both supine and upright postures. Short-term exercise training increases the baroreflex sensitivity in these patients, associated with a decrease in upright heart rate.