Postural Orthostatic Tachycardia Syndrome (POTS)

by Adam Brown  BScPT  MClScPT  FCAMPT
Registered Physiotherapist
updated Dec 9, 2021

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Postural Orthostatic Tachycardia Syndrome (POTS) is a chronic health condition that impacts a persons ability to regulate heart rate and blood pressure. It can lead to difficulty tolerating prolonged standing and other upright positions. The most frequent symptoms being a sense of lightheadedness, extreme fatigue and a rapid heart rate. Dysautonomia International estimates that between 1 and 3 million Americans suffer from POTS.

 

What is POTS?

POTS is an autonomic disorder impacting a persons blood flow. This means that it impairs the coordination of the autonomic nervous system. This branch of our nervous system is not under our conscious control. One of its primary functions is to maintain blood pressure by adjusting contraction of our blood vessels and heart rate.

These two things work together to ensure adequate blood flow throughout the body despite changes in position, temperature and blood volume.

POTS results in orthostatic intolerance. This simply means that it decreases a persons ability to tolerate an upright position for prolonged periods of time.

 

Are There Different Types of POTS?

There are three main types of Postural Orthostatic Tachycardia Syndrome

Neuropathic POTS

Decreased function of the small fiber nerves that control blood vessels (vasoconstriction) causes inability for the blood vessels to constrict to maintain blood pressure.

Hyperadrenergic POTS

Increased activity in the sympathetic nervous system (a branch of the autonomic nervous system) creating dysautonomia. This type of POTS has been linked to increases in the stress hormone norepinephrine as well as mast cell abnormalities. Hyperadrenergic POTS may be associated with increases in blood pressure when moving from a lying down position to standing.

Hypovolemic POTS

Any condition that causes reduced blood volume can cause or contribute to POTS symptoms.

It is important to note that it is not always clear which type of POTS a patient has and the types may overlap considerably. For example, one patient may have some contribution of neuropathic and hyperadrenergic causes that are leading to their POTS. It is important that each patient is treated as an individual and all possible causes and risk factors are considered before beginning treatment.

 

Secondary POTS

This simply means that the diagnosis is related to another condition that is known to cause autonomic neuropathy. Some conditions associated with POTS are diabetes, Lupus, Lyme disease and more recently, Long COVID-19.

 

 

How is POTS Diagnosed

A visit to your primary care physician or pots specialist can begin the process of arriving at a POTS diagnosis. The Gold standard test is called a tilt table test. During this test the patient is strapped to a table that can change position from horizontal to vertical without requiring physical effort from the patient. Heart rate and blood pressure changes are observed with the change in position.

In an office without a tilt table available a physician may perform a lying to standing test. If heart rate increases more than 30 beats per minute for an adult or 40 beats per minute in an adolescent for the first 10 minutes of standing. This could indicate a positive test for POTS. However it is differentiated from orthostatic hypotension which occurs only in the first three minutes after standing.

 

What Causes Postural Orthostatic Tachycardia Syndrome?

Each patient may have slightly different causes that have lead to their diagnosis of POTS. A positive family history for POTS has been shown to be a risk factor. The exact causes are not well understood, but there are some conditions that are correlated with an increased likelihood that a patient will develop POTS.

Viral Illness – as mentioned above, many patients who develop POTS have a recent history of viral illness

Head Injury – POTS has been noted to develop following head trauma

Prolonged Hospitalization – or other significant medical events have been known to trigger POTS symptoms

Autoimmune conditions like Sjogren’s Syndrome or people with Celiac disease are at higher risk of developing POTS.

COVID-19 and ME/CFS– Recently it has been noted that some long haulers have symptoms consistent with POTS. Patients suffering from ME/CFS have also been noted as having a higher risk of developing POTS.

 

Can Anxiety Cause POTS?

Sometimes it is incorrectly suggested that POTS has a psychological cause. This is not true. People suffering from POTS can have anxiety and depression, just as non-POTS patients do. But it is incorrect to assume that this is the cause of their POTS.

 

POTS Symptoms

Each patient has a different collection of symptoms. The most common are lightheadedness, elevated heart rate (tachycardia) and fatigue. Any of the symptoms below can be related to Postural Orthostatic Tachycardia Syndrome.

• Abnormally fluctuating blood pressure
• Tachycardia or bradycardia (fast or slow heart rate)
• Extreme fatigue
• Chest discomfort
• Exercise intolerance
• Dizziness
• Brain Fog
• Pain
• Headaches
• Insomnia
• Blurred vision
• Difficulty with exercise
• abnormal decreased or excessive sweating
• constipation
• Diarrhea

 

How Serious is POTS?

Postural Orthostatic Tachycardia Syndrome is not life threatening. However it can have a very significant impact on a persons life. The inability to tolerate an upright position will have obvious implications for every activity and role in a persons life.

 

Treatment For POTS?

If you suspect you may be suffering from POTS the first step is a visit to your primary care physician for medical treatments. They can begin the process of eliminating other causes for your symptoms, and when necessary refer you to a POTS specialist. Once you have followed up with your medical team you can begin the process of formulating a plan to treat your POTS. Your plan may consist of some of the following;

• medications – Your primary care physician or POTS specialist may wish to try some medications depending upon the type of POTS you have.
• Diet – eating small frequent meals that are nutritious and avoiding highly processed foods may help.
• Hydration – Getting 2-2.5 liters of fluid per day.
• More Salt – between 3,000 and 10,000 mg of salt using supplements and healthy food.
• Pacing Strategies – Accommodating your cardiovascular systems need for more time to adjust to changes in position will help to reduce symptoms.
• Compression Stockings – Some patients find thigh height medical grade compression stockings can help them tolerate upright postures better.
• Physical Therapy – Exercise is an important part of POTS treatment. It should be undertaken with the guidance of a professional Physical Therapist with experience in POTS treatment. More on that later.
• Manage Stress – Increased stress can exacerbate POTS symptoms. Strategies like meditation may help.

 

Does POTS Syndrome Go Away?

Postural Orthostatic Tachycardia Syndrome has been known to improve with treatment. For some patients it will resolve for long periods of time, but may return at a later date.

There is no way to know for sure what a patients experience will be. The focus should be to manage the condition as well as possible. Autonomic disorders are difficult chronic conditions. But with persistent treatment most POTS patients improve.

 

Does Long COVID Cause POTS?

Long COVID is a relatively new condition that is being studied around the world. It has been noted that many COVID Long Haulers have a presentation that mimics POTS. At this point it is unclear whether these patients will have the same recovery trajectory as other POTS patients. Only time and research will be able to answer that question.

 

Physical Therapy for POTS

The starting point of physical therapy to treat POTS depends upon each individual patients symptoms and their severity. In severe cases it may consist mostly of education and habit development to begin to take advantage of some of the treatment strategies noted above. There may be a slow and progressive introduction of upright time strategically interspersed with rest intervals.

As things improve, patients can begin to undertake some exercise. At first, it may be advisable to exercise in a recumbent position and slowly progress toward exercise in an upright position. Patients are taught to monitor their symptoms, heart rate and blood pressure and use this information to monitor progress. The Physiotherapist should also monitor symptoms and cardiovascular response to determine when it is appropriate to progress.

Pots rehabilitation is aimed at reducing symptoms and reducing symptoms and improving function. With persistent effort, most patients are able to make significant progress toward those goals.

 

Cornerstone’s Approach to POTS Treatment

At Cornerstone Physiotherapy we have a unique treatment program delivered through telehealth. We use information from wearable technology (like apple watch) to help our Physiotherapists guide people suffering from POTS and/or Long COVID.

This approach allows us to progress patients activity levels very precisely and monitor their cardiovascular response to ensure we do not make symptoms worse. This is the first treatment program of its kind and it is open to any patients in Ontario, Canada. For more information on this program click HERE