Postural Orthostatic Tachycardia Syndrome: What Occupational Therapy Practitioners Should Know

Editor's note: This text-based course is a transcript of the webinar, Postural Orthostatic Tachycardia Syndrome: What Occupational Therapy Practitioners Should Know, presented by Scott Cheatham, PhD, DPT, OCS, ATC, CSCS.

*Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, the participant will be able to:

• Differentiate the clinical presentation and symptoms of postural orthostatic tachycardia syndrome (POTS).
• Differentiate evidence-based diagnostic and assessment strategies for POTS for different patient populations.
• Analyze the current research evidence on common management strategies for POTS for different patient populations.

Introduction

Thank you, everybody, and thank you to the OccupationalTherapy.com team for hosting me. I know we have a lot of professionals joining from the East Coast, the Midwest, the West Coast, and possibly some international participants as well — welcome to all of you.

Before we get into the modules, I want to say a few words about my perspective. I am a professor in the Division of Kinesiology at California State University, Dominguez Hills, and I also own a concierge physical therapy organization. I have been treating patients with POTS for about 15 years now, and I also teach within our occupational therapy program at the university. I regularly work alongside OT experts, and I am consistently reminded that OTs bring something that PTs like me simply do not have. We PTs, I like to say, are hammerheads — all we know is exercise. Occupational therapists bring a finesse to patient management, ADL support, lifestyle organization, and whole-person care that is genuinely irreplaceable when working with a condition as complex as POTS. I want to acknowledge that upfront because the PT-OT team approach, in my view, is the most powerful model we have for these patients.

Today, I have organized this presentation into five modules. Module I defines POTS and establishes a foundational understanding that sets the tone for everything that follows. Module II covers the diagnostic classification of POTS and its subtypes. Module III addresses POTS symptoms and differential diagnosis. Module IV — our longest and most applied module — covers interprofessional management, from what the medical team does through OT and PT assessment and exercise programming. Module V closes with patient monitoring, self-care programming, and documentation. My goal is that everyone leaves with a solid, evidence-based update and some practical tools to bring directly to their patients.

Module I: Defining Postural Orthostatic Tachycardia Syndrome (POTS)

What Is POTS?

I want you to write this down if you are taking notes, because it is the most important thing I will say in this module: POTS is a condition of the autonomic nervous system. That foundational definition should anchor everything we discuss today. When we understand POTS through that lens — as a syndrome rooted in autonomic dysregulation — our entire clinical approach changes. We stop just chasing symptoms and start asking: what is causing the autonomic nervous system to go out of whack? And how can we help it regulate?

POTS is formally characterized by orthostatic intolerance with changes in body position, most notably from supine to standing. This autonomic dysregulation — also referred to as dysautonomia or autonomic dysfunction — results in tachycardia and a cluster of symptoms. The syndrome was formally characterized in 1993 by Dr. Phillip Low and his colleagues at the Mayo Clinic, although, as we will see in a moment, the condition has been observed and named for over 150 years under various labels.

One of the most important shifts I have seen in the research over the last ten years is the move away from treating POTS as just a label. I see this in my clinic all the time. Patients come in and say, "I have POTS," as though that is the end of the story. And I redirect them: you have a cluster of symptoms we call POTS, but that cluster is itself a manifestation — a sequela — of something affecting your autonomic nervous system. Our job is to figure out what that is and how we can help your nervous system regulate more effectively. Every patient will have their own unique clinical presentation. POTS is heterogeneous by nature, with many potential etiological causes. We cannot apply a one-size-fits-all approach. The key — and this is where I believe the most progress has been made — is understanding what is causing the ANS to go out of balance, not just managing the downstream cluster of symptoms.

Think about what that means for intervention. Everything from exercise to diet to sleep to stress management is, at its core, an attempt to help the autonomic nervous system recalibrate. If you can help a patient shift more toward parasympathetic — reduce that cortisol, calm the sympathetic overdrive, give the ANS a chance to reset — you are making a real difference. And as a team, the OT has powerful tools for this that PTs simply do not have the scope or training to provide.

A Brief History of POTS

Looking at how long this syndrome has been recognized puts the current research moment in context. POTS has been described under various names for over 150 years. It was first noted as Da Costa's Syndrome and called "soldier's heart" because of its prevalence in military populations. From there, the terminology evolved through labels such as mitral valve prolapse syndrome and neural circulatory asthenia, progressing to orthostatic tachycardia and orthostatic intolerance, before the current term was formally coined by Dr. Low's group at the Mayo Clinic in 1993.

This history tells us that clinicians have been observing these autonomic symptoms for a long time. The diagnostic sophistication has grown dramatically over the past decade. We are in an exciting research period right now — we have some concrete evidence I can share with you today, but I want to be honest: we are still learning a lot. I anticipate that as the research continues to grow, expert consensus panels will issue further updates in the coming years.

POTS Statistics

Let me share the epidemiology, because it underscores why every one of us needs to understand this syndrome.

Population estimates suggest POTS affects approximately 500,000 to 3 million people in the United States. Worldwide estimates are not yet available, but occurrences have been documented in the UK and Australia. POTS impacts approximately 1 in 100 teenagers — a statistic I find striking and that I am seeing reflected in my own practice. I am getting more and more patients in their teen years, or patients who trace their symptoms back to adolescence but were not formally diagnosed until their twenties.

Both men and women are affected, but approximately 80 to 85% of POTS patients are women between the ages of 12 and 50, with the most commonly affected age range being 15 to 25 years. Caucasian women are the most affected demographic. Approximately 40% of individuals with POTS have a family member with POTS or dysautonomia, indicating a meaningful genetic component. From a quality of life standpoint, approximately 25% of POTS patients are disabled and/or unable to work (Dysautonomia International; Mayo Clinic). These are not patients with a minor inconvenience — these are individuals whose daily participation has been substantially compromised.

I always ask new patients: When did your symptoms start? Many trace it back to their teen years — feeling dizzy after gym class, struggling to get up in the morning, fatigue that did not make sense. But they were not diagnosed until years later because they did not seek answers until adulthood. That intake question can tell you a great deal about the history of the ANS dysregulation you are working with.

POTS Phenotypes and Related Conditions

There are several important statistics about POTS phenotypes and related conditions that I want you to have on record.

Approximately 30 to 60% of individuals with POTS have the hyperadrenergic subtype, characterized by elevated sympathetic stress hormone norepinephrine upon standing. This is the most prevalent phenotype and is relevant to examination question one in this course — please note it.

Approximately 50% of individuals with POTS have a loss of autonomic nerve fibers in the skin, which is associated with skin manifestations and is closely linked to the overlap between POTS and connective tissue disorders.

There are also several related conditions that co-occur with POTS at clinically significant rates. Long COVID is one of the most prominent recent examples: POTS occurs in approximately 2 to 14% of individuals who have had COVID-19, and POTS-like symptoms appear in 9 to 61% of individuals six to eight months after COVID-19 infection (Ormiston et al., 2022; Vernino et al., 2021). Ehlers-Danlos Syndrome (EDS) is another critical co-occurring condition: POTS occurs in 12 to 31% of individuals with hypermobile EDS (Miller et al., 2020). And Mast Cell Activation Syndrome (MCAS)completes what is referred to as the triad — POTS, EDS, and MCAS — with one study finding MCAS in approximately 31% of a group of EDS/POTS individuals (Wang et al., 2021).

I treat patients with EDS every week, and I have seen in the chat that many of you are seeing the same. The POTS symptoms that accompany connective tissue disorders are among the most challenging presentations in this population. Understanding these overlaps matters not just for assessment but for setting realistic expectations about exercise tolerance and the pace of rehabilitation.

Module II: POTS Classification

Medical Diagnosis of POTS

Understanding how the medical community diagnoses POTS is important context for us as rehabilitation professionals, because by the time a patient arrives in our clinic, this process should have already occurred. The physician begins with a comprehensive patient history and physical examination. In my area in Southern California, I work with rheumatologists who perform the Beighton test and EDS screening criteria as part of their standard evaluation to rule out connective tissue involvement. From there, the physician performs a differential diagnosis, refers to specialists as needed — such as rheumatology, cardiology, and others — and may prescribe medications while ordering further testing.

From there, the physician may order a tilt-table test, which is the gold standard for diagnosing POTS. Sometimes, a modified version using a blood pressure cuff with supine, sitting, and standing measurements is used instead. Adjunct testing can include a 24-hour ECG, echocardiogram, and blood and urine tests. I have also seen private-pay patients pursuing genetic testing, though this is generally not covered by insurance.

This process leads to a formal POTS diagnosis, and — and I say this from experience — usually what amounts to a fairly limited, cookie-cutter treatment plan. The burden of substantive rehabilitation falls squarely on us as a team. I want to prepare you for that reality.

Diagnostic Criteria for POTS

The formal diagnostic criteria, based on the Heart Rhythm Society and Canadian Cardiovascular Society guidelines, consist of three components.

First, chronic orthostatic intolerance of three to six months or more in duration. Symptoms must be persistent, not episodic.

Second, orthostatic intolerance with a heart rate increase of 30 or more beats per minute within the first 10 minutes of standing, without significant hypotension — meaning no systolic blood pressure drop of 20 mmHg or more. This is an important clinical distinction: we are talking about a jump in heart rate, not a drop in blood pressure. POTS is not the same as orthostatic hypotension. The hallmark is tachycardia upon standing — racing pulse, palpitations, lightheadedness — without the significant blood pressure drop. For adolescents ages 12 to 19, the required heart rate increment is 40 beats per minute rather than 30, accounting for physiological differences in younger patients.

Third, frequent symptoms of orthostatic intolerance during standing, with rapid improvement upon return to a supine position. This positional relief pattern is characteristic and clinically important. Many of my patients describe lying on the floor or returning to bed not because they are tired, but because it is the position that gives them the most symptom relief.

POTS Subtypes

The classification of POTS has evolved significantly. The diagnostic timeline reflects refinement from early descriptions in the 1800s through the formal 1993 definition and subsequent consensus updates in 2011, 2015, and 2019 — the most evidence-supported update currently available.

The two most frequently diagnosed subtypes are hyperadrenergic POTS and neuropathic POTS. Hyperadrenergic POTS is driven by excessive sympathetic nervous system activation. Neuropathic POTS is the second most common. Beyond these, we see subtypes including hypovolemic POTS — which is particularly relevant in athletes and active individuals — autoimmune POTS, and secondary POTS, which arises as a consequence of another medical condition.

There is also a broader clinical classification: primary POTS refers to cases with no identifiable underlying medical condition — essentially idiopathic. Secondary POTS is POTS occurring alongside another medical condition. Common secondary conditions in the literature include COVID-19, EDS, chronic fatigue syndrome, post-concussion syndrome, migraines, diabetes, lupus, alcoholism, and chemotherapy. In my own practice, I tend to think in these primary versus secondary terms because it is a practical organizing framework. Most of my referred patients present with primary POTS, but patients with connective tissue disorders — particularly EDS — consistently present with secondary POTS as a significant comorbidity.

The bottom line for Module II: POTS has an established diagnostic classification, with hyperadrenergic and neuropathic as the most frequently diagnosed subtypes. The classification has gained significant respect in the research and clinical community, which matters. I think about POTS in some ways like fibromyalgia — it started as something that was dismissed, and now it is recognized as a real, measurable, treatable medical condition with its own ICD-10 code. POTS is real. The patients who have it do not feel good. And they deserve our best clinical thinking.

Module III: POTS Symptoms and Differential Diagnosis

Hallmark Symptoms

The hallmark symptoms are what we rely on most clinically, and I want to be specific about what the research tells us. Based on two large studies — Shaw et al. (2019) with 4,835 subjects and Angeli et al. (2024) with 378 subjects — the three primary hallmark symptoms are lightheadedness, dizziness, and tachycardia/palpitations. In my practice and from our discussion today, most of us agree that these three are the most consistently reported and the most reliably associated with positional change. When a patient moves from sitting to standing, those are the symptoms that emerge.

Additional hallmark symptoms moving around the full clinical picture include vision changes, headaches, excessive sweating, reduced sweating, and cognitive difficulty — the brain fog that so many POTS patients describe. On the other side of the cluster: fatigue, shaking, anxiety, exercise intolerance, chest pain, dyspnea, presyncope, and syncope.

Migraine headaches have come up in our discussion today, and there is a growing body of research linking migraines with POTS. Gastrointestinal issues are also increasingly prominent in the literature — gastroparesis, nausea, bloating, constipation, and vomiting — and I have been in conversations with medical colleagues who are now recommending pre- and probiotics because the gut biome appears to be significantly disrupted in POTS patients. This is a hot area of emerging research. And what I will say on this point from a practical standpoint is: when you are asking questions during intake, definitely discuss GI issues. They may be a primary manifestation tied to autonomic dysregulation.

One clinical practice point I want to give you right now: ask your patients not just what symptoms they have, but when they feel best. What time of day? After eating? After lying down? Those answers should guide when you schedule exercise and interventions. In my practice, I always ask: What time of day do you feel best? And then I schedule accordingly. If they feel best in the early afternoon, that is when we work out.

POTS Symptom Categories

When we organize the symptoms into categories — and I know some of you process information more easily this way — we can see clusters of neurological, cardiorespiratory, musculoskeletal, gastrointestinal, genitourinary, psychiatric, and endocrine symptoms (Steinberg et al., 2023). The neurological category contains the primary hallmark symptoms. The cardiorespiratory category includes tachycardia, chest pain, dyspnea, and exercise intolerance. Musculoskeletal symptoms include joint pain and myalgia — something I hear from my patients regularly, particularly as they begin exercise programs. The GI category is growing in clinical significance, as discussed. Psychiatric and endocrine manifestations reflect the reality that these patients simply do not feel good, and we should expect to address those dimensions as part of our care.

The key clinical takeaway: POTS is not just an orthostatic problem. It is a whole-person syndrome that affects nearly every body system by disrupting the autonomic nervous system.

Differential Diagnosis

The differential diagnosis of POTS is complex, and having a working knowledge of it helps us ask better questions, document more carefully, and communicate more effectively with the medical team.

The most common etiological categories include connective tissue disorders (particularly hypermobile EDS), diabetes, deconditioning, and chronic fatigue syndrome. On deconditioning specifically, the evidence is mixed. We know that severe deconditioning — including in athletic populations that overtrain and then abruptly reduce activity — can be associated with POTS-like symptoms. But I want to caution against assuming deconditioning is the primary driver, particularly with patients who already struggle with exercise intolerance. We have to be careful there. We have to understand that there are specific etiological causes affecting the ANS that are manifesting in this cluster of symptoms — it is not just someone being out of shape.

Additional differential diagnoses documented in the research include infections such as mononucleosis, Epstein-Barr virus, Lyme disease, extra-pulmonary Mycoplasma pneumonia, and Hepatitis C. Mitochondrial disease, mast cell activation disorder, neoplastic syndromes, post-concussion syndrome, migraines, vaccinations, vitamin deficiencies, and anemia are also in the literature (Dysautonomia International; Steinberg et al., 2023).

One participant in our discussion today raised mold toxicity as a consideration — particularly in older housing environments — and I think that is a valuable point. Environmental factors affecting the immune and nervous systems can absolutely be part of the clinical picture and are worth exploring when standard etiologies do not explain the presentation.

Regarding the geriatric population, there was a question today about whether we see differences in geriatric patients compared to younger populations. There was a study I believe from around 2023 that noted sarcopenia and deconditioning in geriatric patients was associated with POTS symptoms in some individuals. This is an area that needs more research. It is something to consider as we look at the aging population and the link between ANS dysregulation and age-related functional decline.

The bottom line for Module III: POTS hallmark symptoms are the most reported in the research, but individuals will present with their own unique cluster. The differential diagnosis of POTS can be difficult due to unknown or competing etiologies. We should approach it with the understanding that POTS is most accurately conceptualized as a consequence of ANS dysregulation, driven by an underlying condition, known or unknown.

The POTS-EDS-MCAS Triad

I want to specifically address the relationship between POTS, hypermobile Ehlers-Danlos Syndrome, and Mast Cell Activation Syndrome, because this triad is something I see regularly in my clinic, and the symptom overlap is extensive (Kohn & Chang, 2020).

Across all three conditions, shared symptoms include exercise intolerance, palpitations, abdominal pain, impaired cognition, diarrhea, hypotension, nausea, bloating and constipation, vomiting, fatigue, weakness, and headaches. POTS-specific symptoms within this overlap include visual blurring, vertigo, lightheadedness, dizziness, sleep disturbance, orthostatic intolerance, and chest pain. Hypermobile EDS is characterized by pain, skin hyperextensibility, joint hypermobility, tissue fragility, hernias, easy bruising, GERD, and heartburn. MCAS contributes to ocular itching, nasal pruritus, wheezing, nasal congestion, throat swelling, pruritus, angioedema, urticaria, flushing, dermographism, chest pain, heartburn, and GERD.

When working with a POTS patient, ask yourself whether a broader connective tissue or immune picture is present. These conditions share underlying physiological mechanisms, and patients with the full triad require a more individualized approach to exercise and ADL programming than patients with primary POTS alone.

Module IV: POTS Interprofessional Management

The Interprofessional Team

POTS requires a team. I say that directly because the reality of what patients receive from the medical system after diagnosis is often not enough. The effective interprofessional team for POTS includes the medical doctor or specialist for diagnosis and pharmacological management, the physical therapist for exercise rehabilitation, the occupational therapist for ADL management and lifestyle support, and, depending on the presentation, a registered dietitian and other specialists.

When I look at the triad of professional management, the first line is always the medical doctor — they own the diagnosis. From there, OT and PT work together. And then there is self-care, because if a patient is only seeing us two or three times a week, what are they doing the rest of the time? That is where the self-care program comes in, which we will address in Module V.

POTS Medical Management

Initial Non-Pharmacological Treatment.

After the diagnostic process, patients arrive in our clinics with a standard non-pharmacological treatment recommendation sheet. This is directly related to examination question four in this course, so I want to walk through it. The medical team's initial recommendations typically fall into three categories.

First, diet: increase fluid intake to 2 to 3 liters per day to increase blood volume, and increase sodium intake to 8,000 to 10,000 mg per day. Second, clothing: wear compression garments — compression stockings, shorts, or an abdominal binder — to help maintain blood volume in the trunk and reduce pooling in the lower extremities. Third, body positioning: raise the head of the bed when sleeping, exercise in reclined positions when possible, and lie in a comfortable position.

Additional standard recommendations include avoiding triggers, such as standing up quickly from a lying position and stressful situations; prioritizing approximately 7 to 9 hours of sleep per day; regular exercise; and stress-reduction practices such as meditation.

I want to be honest with you about the reality of this. I have patients who come in after their diagnosis, and they have this sheet of paper. The doctor told them: eat more salt, don't get up too fast, and don't be stressed. One patient was a young mom with two small children. She asked me how she was supposed to avoid getting up quickly to get to the restroom. Right. These are well-meaning recommendations, but they do not account for the real complexity of living with this condition. The burden of making these recommendations meaningful and actionable falls on us. And that is an opportunity.

Pharmacological Treatment.

Some patients will arrive on pharmacological treatment. An important note: there is currently no FDA-approved medication specifically for POTS. All pharmacological treatments are prescribed off-label (Fedowski, 2018). Commonly used medications include heart rate-controlling agents and vasoactive volume-expanding agents, among others. I have also seen antidepressants and anti-anxiety medications prescribed, which can concern me when they are issued primarily because the patient does not feel good, rather than because a formal psychiatric diagnosis has been carefully established. If a psychiatrist or psychologist has made that assessment and medication is warranted, that is a different and appropriate scenario. But I am seeing GPs hand these out fairly quickly, and that can create downstream complications for us because the medications have side effects that affect exercise tolerance, heart rate response, and motivation. When a patient is not progressing as expected in your program, medication changes are always worth exploring with the prescribing physician.

Nutrition Consultation.

Patients may be referred to a registered dietitian. The dietary component of POTS management is more nuanced than "eat more salt," particularly given the emerging evidence on GI complications. Recommended considerations include adequate fluid and sodium intake, foods rich in probiotics and prebiotics to support gut health, and attention to micronutrients and dietary supplements (Do et al., 2021).

I also want to flag a cultural competency point that comes up in our clinic. Generic dietary recommendation sheets are often not culturally sensitive. A recommendation to eat a high-sodium diet may conflict with a patient's cultural practices, religious beliefs, or family food norms. When we are talking with patients about diet and we are honoring who they are, we have to include their cultural context. Food is a representation of culture. I have had patients explain that the doctor's sheet did not account for their customs at all, and that it felt dismissive. Something for all of us to hold as we work with diverse populations.

POTS Occupational and Physical Therapy Management

Assessment Framework.

When the patient arrives in our care, assessment is the foundation. The general assessment framework we use in our clinic covers healthcare assessment, including health risks and vitals; cardiorespiratory evaluation; movement assessment; muscle strength and endurance; flexibility and mobility; balance and proprioception; and performance field tests. Blood pressure in three positions — supine, sitting, and standing — is a standard part of every POTS patient intake.

Data collection from this assessment yields a patient's physiological profile: training age and exercise history, body composition (if relevant), estimated cardiovascular fitness, muscle performance, flexibility and mobility findings, and functional performance measures. The psychosocial dimension — exercise readiness, social support, and goals — is equally important and should be integrated throughout rather than treated as an add-on.

I use the transtheoretical model of behavior change as an organizing framework for understanding where patients are in their readiness to engage. If a patient is in precontemplation or contemplation, they need a different kind of engagement before we layer on an exercise protocol. And someone in the chat raised motivational interviewing, which I want to echo strongly: it's huge with this population. We have to be positive and empowering. If we are not genuinely invested in their progress, if we approach them with impatience or skepticism, we will lose them. These patients do not feel good. They need us to love them for who they are and meet them where they are. So if we are not in that headspace, these may not be the right patients for us.

One recommendation I want to emphasize, drawn from Huynh et al. (2024): integrate education throughout the assessment, not after it. When a patient comes in with that sheet of paper from the doctor, they are nervous. They just received a complex, unfamiliar diagnosis. While you are going through your assessment, walk them through it. Talk about body positions as you test them. Explain the compression garment recommendation as you note it in your chart. Explain what their blood pressure readings in different positions mean. Education delivered in context — during the assessment itself — produces much better downstream effects than a separate education session bolted on at the end.

Specific Questionnaires for POTS Assessment.

There are several validated questionnaires relevant to this population. The Malmö POTS Symptom Survey (MAPS) is the one I use most regularly. It is an ordinal scale with 12 questions scored 0 to 10, for a total possible score of 0 to 120. A cut-off score of 42 or higher is consistent with POTS. It is available for free on the Standing Up to POTS website, and supporting research by Spahic et al. (2023) appears in the Journal of Internal Medicine.

Other questionnaires gaining research support include the Orthostatic Hypotension Questionnaire (OHQ) (Kaufmann et al., 2012), the Vanderbilt Orthostatic Symptom Score (VOSS), and the Composite Autonomic Symptom Score (COMPASS). Links to all of these are available in the course resources. These questionnaires are not perfect, but they provide an objective, repeatable measure of symptom burden that complements clinical findings and supports documentation and billing.

POTS Exercise Program Design.

This is where I want to spend the most time, because exercise is the foundational intervention for POTS and the area where the PT-OT team can do the most good together. The most important thing to write in your notes from this entire module is that cardiorespiratory exercise is the foundation of the POTS exercise program. All other exercise types are built on top of it. I want to make that point clearly and repeat it, because it is the most consistent finding in the research evidence.

There are five key principles shaping how we design POTS exercise programs.

Individualized program design. POTS is heterogeneous, and exercise tolerance varies enormously between patients. What works for one patient may be poorly tolerated by another. Start with a thorough assessment and truly listen to what the patient tells you about their tolerances, their best times of day, and their triggers. Individualization is not optional — it is the mechanism by which POTS exercise actually works.

Rate of Perceived Exertion (RPE) for monitoring. The Borg CR-10 scale (0 to 10) is our primary monitoring tool throughout the POTS exercise program. Rather than relying on heart rate targets — which can be unreliable given the dysregulated heart rate response in POTS — I set RPE targets. I tell the patient upfront: today I do not want you to go above an RPE of 4. Please tell me if you get there. This gives the patient agency, gives you clinical data, and reduces the risk of triggering a symptom flare.

Linear periodization. This is simply the principle of progressively increasing training load and difficulty over time (Lorenz & Morris, 2015). For POTS, I apply it both to intensity — moving through RPE zones as tolerance improves — and to position, which leads me to the most important design principle of all.

U.S. Physical Activity Guidelines as a benchmark. The Physical Activity Guidelines for Americans — 150 to 300 minutes per week of moderate-intensity aerobic activity — represent a long-term target for POTS patients, not a starting point. But having this benchmark informs our progression milestones and gives patients a meaningful goal to work toward.

Positional progression. This is the most important and most distinctive aspect of POTS exercise programming, and I cannot overstate it. We always start exercise in positions that minimize orthostatic stress — supine or reclined — and progressively advance toward upright positions as the ANS adapts. The progression moves from supine to reclined, to sitting, to semi-upright, to standing. I have tried accelerating this progression over 15 years of clinical experience, and it consistently produces worse outcomes. The slow, methodical positional approach is not just conservative caution — it is how we allow the autonomic nervous system to adapt (Trimble et al., 2024).

POTS Exercise Programming: The Components.

Cardiorespiratory Exercise. Cardiorespiratory exercise is the foundation. The research consistently demonstrates that aerobic exercise significantly improves symptoms of orthostatic intolerance, reduces the frequency of syncope, enhances quality of life, and improves autonomic balance as assessed by heart rate variability analysis and cardiorespiratory endurance (Cortez et al., 2025; Gonçalves Leite Rocco et al., 2024; Trimble et al., 2024; Huynh et al., 2024; Li et al., 2024; Svensson et al., 2024).

The target is Zone 2 training — moderate intensity, corresponding to an RPE of approximately 5 to 6. Zone 2 is where we see the most consistent ANS adaptation — sustained but not overwhelming cardiorespiratory stress. The goal, progressed over time, is 150 or more minutes per week of this kind of activity.

Recommended cardiorespiratory exercises begin in positions that minimize orthostatic demand and progress to higher positions. Water aerobics is one of the best starting options for patients with low exercise tolerance — warm water, horizontal or semi-horizontal positioning, and cardiorespiratory work without the orthostatic challenges of land-based exercise. From there, patients can progress to a recumbent bike, swimming, rowing when tolerated, and eventually upright cycling and walking.

In terms of zone training for your reference: Zone 1 is light activity, Zone 2 is moderate, Zone 3 is vigorous, Zone 4 is near-maximal. The RPE correlations I use map Zone 1 to an RPE of approximately 3 to 4, and Zone 2 to an RPE of 5 to 6. Getting patients to sustained Zone 2 exercise is our cardiorespiratory goal, and I typically use Zone 1 warm-up intervals transitioning into brief Zone 2 pushes as an early-stage strategy.

A practical approach that works well: instead of asking a patient to sustain 30 minutes of brisk walking on day one, have them walk at a comfortable pace, pick a landmark down the block, walk briskly to that landmark (Zone 2), then slow back down. Brief ANS stress followed by recovery. This trains the nervous system to tolerate and recover from cardiorespiratory demands without overwhelming it. Many of the OTs I work with use this same principle with patients during ADL planning — build in movement through the day, not all at once. Park at the far end of the lot. Walk to the store if you can. Movement throughout the day is medicine for these patients.

The general exercise progression for cardiorespiratory work in POTS moves through three phases: an initial phase focused on supine or reclined low-intensity work progressed over time in duration; an intermediate phase with seated and semi-upright cardio at increasing duration and Zone 2 intensity; and an advanced phase with upright cardiorespiratory work progressing toward U.S. Physical Activity Guideline targets.

Resistance Exercise. Once cardiorespiratory stability is established — meaning the patient tolerates aerobic sessions with manageable symptom responses — we introduce resistance training. The same foundational principle applies: positional progression first.

Resistance exercise for POTS follows this sequence: isometric exercises first, with strong emphasis on core activation; then isotonic exercises in supine and seated positions; then isotonic exercises in all positions, including standing, with concentric and eccentric phases. Core activation should be integrated across all phases and all exercise types — note that core can be included in all types of exercise at all stages of the program (Trimble et al., 2024).

The RPE scale also applies to resistance training. I set RPE targets for resistance work just as I do for cardio. I tell patients: I don't want you to feel this exercise above a 4 to 5 today. Let me know if you get there (Helms et al., 2016).

Practical exercise progressions include moving from a supine chest press to a seated press to a standing press variation, and from a supine leg press or bridge to a seated leg exercise to a body-weight squat. Pilates is a particularly useful modality for POTS because it is primarily supine, it emphasizes core, and it integrates breathing with movement — all well-aligned with POTS rehabilitation priorities. I say to any clinician new to Pilates: it is really supine positional resistance training with a breathing and core emphasis. People forget that because it has taken on a life of its own, but that is what it is.

Equipment options include resistance bands, machines, body weight, free weights, and cables. A safety note on free weights: I have had patients experience sudden lightheadedness while holding dumbbells in a supine press. Please be present and spotting during any free-weight exercise until you are confident in the patient's symptom stability.

For patients with secondary POTS related to hypermobile EDS or other connective tissue disorders, resistance training requires additional care. Joint laxity and tissue fragility change the risk profile, and these patients generally need a more conservative load progression and closer medical collaboration.

Flexibility and Mobility. Flexibility and mobility work should not be neglected, even with our emphasis on cardiorespiratory and resistance training. Using the FITTE principle as a framework: frequency of 2 to 5 sessions per week, intensity as tolerated and pain-free, time and type determined by the patient's ability to assume different positions. Self-myofascial rolling for 30 to 60 seconds per muscle group, static stretching for 10 to 30 seconds for 1 to 3 sets, and active stretching with 1 to 2 second holds for 5 to 10 repetitions are the general recommendations. An important clinical caveat: flexibility and mobility strategies may be precautionary or contraindicated for some individuals with POTS and connective tissue disorders, so clinical judgment is essential.

Nerve mobilization is a component that I want to highlight specifically for this population. We consistently achieve good results with neural mobilization techniques — sliders, gliders, tensioners — particularly for patients presenting with myalgia, limb tightness, and adverse mechanical tension. This is especially relevant for OTs working in upper extremity and hand therapy roles with this population. Regarding contraindications in connective tissue disorders, I have not found well-referenced contraindications specific to POTS in the literature, but I do treat each EDS patient on a clinical, individual basis. I have had some patients with abnormal responses to nerve glides, so proceed carefully, screen your patients thoroughly, and monitor responses closely.

Balance Exercise. POTS significantly affects balance by disrupting the three primary balance systems — visual, vestibular, and proprioceptive — which converge on the brainstem (Cheatham et al., 2020). Balance training is therefore an important and often underemphasized component of POTS rehabilitation.

Balance training should be purpose-driven and task-specific, challenging the body statically and dynamically. Training variables to progressively manipulate include: surface stability (stable to unstable), environment (anticipated to unanticipated), exercise type (simple to complex, single-joint to multi-joint), tempo (slow to fast), base of support (double leg to single leg), balance systems (eyes open to eyes closed to head turns), planes of motion (sagittal to multi-plane), load (light to moderate), and mental focus (single task to dual task).

I typically introduce formal balance training after establishing stability with cardiorespiratory and resistance exercise, though proprioceptive challenges can be woven in earlier through resistance exercise progressions. A practical progression from our clinic: begin with a static tandem stance on a stable surface, progress to single-leg balance with head turns, reach tasks, unstable-surface challenges, and eventually dual-task scenarios. The sit-stand test is another useful tool both for assessment and as an exercise in its own right.

Integrating the Full Exercise Program. The complete integrated program can be summarized in three phases:

Initial phase — Core stability, low-intensity aerobic work in supine or reclined positions, pacing, and education. Introduce nerve mobilization early if appropriate.

Intermediate phase — Dynamic stabilization, introduce diaphragmatic breathing patterns, increase aerobic activity time and intensity in seated positions, begin seated resistance exercise.

Advanced phase — Progress toward upright functional exercise, introduce standing resistance training, advance balance challenges, and work toward U.S. Physical Activity Guideline targets.

The evidence base supports this integrated approach (Cortez et al., 2025; Trimble et al., 2024; Huynh et al., 2024; Li et al., 2024). A 2025 survey of 284 individuals with POTS found that patients believe exercise is important but that significant barriers exist — including symptom burden and insufficient support from healthcare providers — and identified important facilitating factors that could support exercise engagement (Walsh et al., 2025). Our job as a team is to reduce those barriers and make exercise sustainable for these patients.

Module V: Patient Monitoring, Self-Care, and Documentation

Patient Monitoring

Biometric Tracking. Routine biometric monitoring for POTS patients includes blood pressure in supine, sitting, and standing positions, heart rate, and pulse oximetry. These should be taken at the start of every session and tracked longitudinally for trends.

Heart rate variability (HRV). This is an emerging and increasingly important metric. HRV measures the variability in the intervals between heartbeats — when the ANS is well-regulated, the balance between sympathetic and parasympathetic activity produces natural variability in the heart rhythm. In the rehabilitation context, tracking a patient's HRV over the course of a treatment program can provide objective data on how their autonomic regulation is responding to your interventions. I did some HRV research in exercise physiology nearly 10 years ago, and during the pandemic, HRV was used to monitor autonomic stress responses in COVID-19 patients. I believe HRV is going to be one of the most important metrics coming out over the next ten years for ANS-related diagnostics and rehabilitation, and I encourage you to begin familiarizing yourself with it. Wearable devices — Fitbit, Whoop band, and tracking watches — are now continuously collecting this data and making it accessible to our patients.

Overtraining Syndrome. POTS patients are at real risk for overtraining syndrome, and the risk is elevated compared to the general population because their ANS is already dysregulated. Overtraining can present as a worsening of their baseline POTS symptoms, which makes it challenging to distinguish from a normal symptom day.

I tell my team to be a forensic psychologist with these patients. Ask detailed, specific questions. Many POTS patients are not forthcoming about their symptom burden because they do not want to appear as though they cannot handle the program. Regular open-ended check-ins yield more accurate information than a simple "how are you feeling?" The two most important questions I ask every POTS patient at the start of each session are: what is the optimal time of day for you to exercise right now, and which positions or activities trigger your symptoms most? Those answers change over time, and staying current with them allows you to adjust programming proactively rather than reactively.

Progressions and regressions in the exercise program should be driven by both objective data — vitals, RPE, HRV when available — and the patient's subjective report. Both matter equally.

Self-Care Programming: The CHOP Program 

The most widely used and evidence-supported self-care and home exercise program for POTS is the Children's Hospital of Philadelphia (CHOP) POTS Exercise Program, also known as the Levine Protocol after its developer, Dr. Benjamin Levine. This program is freely available online through Dysautonomia International, and I encourage every clinician working with POTS patients to download and familiarize themselves with it.

The CHOP program is an 8-month structured protocol. The first four months focus primarily on cardiovascular conditioning, with progressive advancement through the remaining months. The program provides month-by-month goals and weekly exercise targets. It is comprehensive — approximately 20 pages — but organized in a clear algorithm that patients can follow month by month with appropriate clinical oversight.

I use the CHOP program in two ways. First, as a reference framework that aligns my own clinical programming with the best available evidence. Second, as a patient homework tool, I highlight the relevant month's targets, give it to the patient, and send them home with a clear, structured plan. You just chop it, as I say — give them the program, walk them through month one, and let them follow the algorithm. It significantly reduces the education burden during sessions and gives patients agency and direction in their own self-management.

The OTP's role within this framework is to complement the exercise program with what the CHOP protocol does not address: lifestyle integration, ADL coaching, energy conservation strategies, home environment setup, and psychological support that allow the patient to sustain the program in the first place. The exercise program cannot function if the patient cannot organize their day to make space for it or if they do not have the psychological resources to maintain engagement. That is where OT is indispensable.

Documentation

From a documentation standpoint, POTS now has an ICD-10 code: G90.A. This is significant because it formally legitimizes POTS as a billable diagnosis within the healthcare system. For those of you who bill for your services, use this code.

For interprofessional teams working with POTS patients, I recommend establishing a shared assessment template. Having standardized documentation for the baseline metrics everyone collects — vitals in three positions, RPE-based exercise tolerance, functional tests — ensures seamless transitions between providers and reduces redundancy for the patient. OT-specific documentation can then include specialized ADL findings, a home environment assessment, an occupational profile, and client-centered goals, which are the hallmarks of OT practice.

POTS Resources

The following organizations and resources are recommended for ongoing clinical reference:

• POTS Awareness Day — October 25th annually.
• CHOP POTS Exercise Program: https://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
• Dysautonomia International: https://www.dysautonomiainternational.org/page.php?ID=30
• Standing Up to POTS: https://www.standinguptopots.org
• The Dysautonomia Project: https://thedysautonomiaproject.org/resources/
• POTS UK: https://www.potsuk.org

Final Thoughts

Let me bring this together. POTS is a syndrome rooted in autonomic nervous system dysregulation. It is not just a label, not just a diagnosis code, and not just a sheet of paper with three recommendations. It is a complex, heterogeneous condition affecting a growing number of individuals — disproportionately young women, though not exclusively — that touches nearly every body system through the disruption of the ANS. It is being diagnosed at younger ages than previously recognized, it is associated with long COVID and connective tissue disorders, and it is getting the research attention it deserves.

The interprofessional management is evidence-based and increasingly refined. The medical team establishes the diagnosis and provides initial management. The rehabilitation team — OT, PT, dietitian, and others as indicated — provides the substance of long-term care. And at the center of that rehabilitative work is exercise, with cardiorespiratory conditioning as the absolute foundation.

The OT's role is not supplementary — it is foundational. Helping patients manage their daily lives around this condition, supporting their ADLs, coaching their caregivers, organizing their home environment, sustaining their psychological well-being, and integrating the CHOP program and exercise principles from this course into a functional, livable daily plan—that is OT at its finest. And it is exactly what these patients need.

The research is still emerging. New studies are being published every year, and I anticipate meaningful updates to the evidence in the coming years. I hope to come back with an update as the field continues to grow. In the meantime, the tools we discussed today represent our current best evidence, and they will serve your patients well.

Thank you so much for attending. The interaction throughout has been fantastic, making it genuinely fun to present. Please feel free to reach out with questions that come up in practice.

References

See additional handout.