Physical therapy for POTS

This page is primarily intended to be a reference for patients who have been referred for therapy. 

Timothy C. Hain, MD

Click here for the main vestibular rehabilitation page. • Page last modified: July 21, 2020

POTS, positional orthostatic tachycardia syndrome, can sometimes be treated with physical conditioning. This document discusses a conditioning program for POTS. This is sometimes called the "Levine" protocol, after one of the authors on several recent papers (Fu et al, 2010; Shibata et al, 2012). This protocol is largely based on physical conditioning, adapted to start in a safe sitting or lying down position.

The idea of this protocol is to improve cardiac function. This presumes that the "problem" in POTS is poor cardiac function. However, there are many other suggested causes for POTs including autonomic neuropathy, changes in autonomic responsiveness, and venous pooling.

According to Low(1995), about half of patients with POTS have impaired autonomic function. In this substantial group, where blood vessels do not constrict on standing, the heart could be fine. In other words, some common sense is needed regarding patient selection, and where there is dysautonomia, the rationale for this protocol is somewhat tenuous. One might argue -- if someone is lying around for a year, won't they be deconditioned ? Yes this is true, but if they are both deconditioned and have dysautonomia, this protocol might not work.

The rationale for salt-loading (as noted below) can also be reasonably questioned. If the problem in POTS is poor cardiac output, salt loading will not make any difference. If the problem is dysautonomia however, this makes some sense.

Method of physical therapy approach to positional orthostatic tachycardia.

We will describe the "Levine protocol" (e.g. Shibata et al, 2012). The Levine protocol adds conditioning (i.e. you go to the gym), as well as salt/water loading (i.e. same treatment as for orthostatic hypotension). The Levine program is a long supervised program -- 3 months or more.