Have you ever stood up and felt your heart race, your vision blur, and your legs suddenly feel as though they might give way—despite being young, fit, or otherwise ‘healthy’? For many people living with Postural Orthostatic Tachycardia Syndrome (POTS), this is not an occasional inconvenience but a daily reality that quietly reshapes work, study, relationships, and self‑confidence.
As a physiotherapist who has worked with individuals struggling to reconcile persistent symptoms with normal test results, I have seen first‑hand how POTS is often misunderstood—even within healthcare. Yet, when managed correctly, physiotherapy can become one of the most powerful, evidence‑backed tools for regaining function, independence, and quality of life. This article brings together clinical evidence, real‑world practice, and patient‑centred insights to explain how physiotherapy supports POTS recovery, what actually works, and how you can start safely.
Understanding POTS: Why Movement Feels So Hard
Postural Orthostatic Tachycardia Syndrome is a form of dysautonomia characterised by an excessive increase in heart rate (≥30 beats per minute in adults, ≥40 in adolescents) within 10 minutes of standing, without a corresponding drop in blood pressure. Symptoms may include dizziness, palpitations, fatigue, brain fog, exercise intolerance, gastrointestinal discomfort, and near‑syncope.
What makes POTS particularly challenging is that symptoms worsen precisely when patients try to be active—the very thing traditionally prescribed for health. Many patients are therefore told to “just exercise more”, only to experience flare‑ups that reinforce fear of movement and inactivity.
Why physiotherapy matters in POTS
Research increasingly shows that physical deconditioning is not the cause of POTS—but it can become a powerful perpetuating factor. Reduced blood volume, impaired skeletal muscle pump function, and autonomic imbalance mean that upright posture becomes physiologically expensive. Physiotherapy addresses these mechanisms in a structured, graded, and safe manner rather than through generic fitness advice.
The Evidence Base: What Research Actually Shows
One of the most influential bodies of work on POTS rehabilitation comes from cardiovascular physiologist Dr Benjamin Levine and colleagues. Their studies demonstrate that structured, recumbent‑based exercise programmes can significantly reduce POTS symptoms and, in some cases, lead to remission.
A landmark study published in Circulation reported that after a 3‑month supervised exercise programme, over 50% of participants no longer met diagnostic criteria for POTS, alongside improvements in cardiac size, blood volume, and autonomic regulation.
Crucially, these benefits were achieved without starting with upright exercise—a mistake that often leads patients to abandon rehabilitation prematurely.
How Physiotherapy Works in POTS (Beyond “Just Exercise”)
Physiotherapy for POTS is not about pushing through symptoms. It is about re‑educating the autonomic nervous system while respecting physiological limits.
1. Rebuilding the skeletal muscle pump
Lower‑limb and core muscles play a central role in returning blood to the heart. In POTS, prolonged inactivity weakens this system. Physiotherapy focuses on progressive strengthening of calves, thighs, gluteals, and trunk, initially in positions that minimise orthostatic stress.
2. Improving cardiovascular efficiency safely
Rather than upright treadmill walking, early‑stage programmes rely on recumbent cycling, rowing, or swimming, which allow cardiac conditioning without excessive heart rate spikes. Over time, the cardiovascular system becomes more efficient, reducing symptom burden during daily activities.
3. Autonomic retraining through graded exposure
Avoidance of standing can unintentionally sensitise the autonomic system. Physiotherapists use carefully graded postural challenges, such as semi‑recumbent to seated transitions, before progressing to supported standing tasks.
4. Breathing and vagal modulation
Many patients with POTS demonstrate dysfunctional breathing patterns. Diaphragmatic breathing and paced respiration are used to enhance parasympathetic activity, reduce tachycardia, and improve perceived exertion.
A Clinician’s Perspective: What I See in Practice
In clinical practice, one of the most common turning points occurs when patients realise that feeling worse initially does not mean the programme is failing. One young university student I worked with described it perfectly: “For the first time, someone explained why my body reacts like this—and gave me a plan that didn’t make me feel broken.”
Progress in POTS rehabilitation is rarely linear. Symptom fluctuations are expected. Physiotherapy works when patients are supported to interpret these fluctuations without fear, using objective markers such as recovery heart rate, exercise tolerance, and functional capacity rather than symptom intensity alone.
Practical Structure of a POTS‑Specific Physiotherapy Programme
Phase 1: Foundation (Weeks 1–4)
- Fully recumbent or semi‑recumbent exercise only
- Short, frequent sessions (10–20 minutes)
- Focus on consistency rather than intensity
- Gentle resistance training for lower limbs
Phase 2: Conditioning (Weeks 5–8)
- Increased duration of recumbent cardiovascular work
- Introduction of seated strength exercises
- Controlled transitions between positions
Phase 3: Upright Tolerance (Weeks 9–12)
- Supported upright exercise
- Functional tasks such as sit‑to‑stand training
- Gradual reintroduction of walking
This phased approach mirrors protocols used in published trials and reduces dropout caused by symptom exacerbation.
Supporting Strategies That Enhance Physiotherapy Outcomes
Physiotherapy is most effective when integrated into a broader management plan.
Compression garments
Graduated compression stockings (30–40 mmHg) reduce venous pooling and can significantly improve tolerance to upright activities during rehabilitation.
Fluid and salt optimisation
Increased plasma volume supports exercise tolerance. Many patients benefit from clinician‑guided increases in fluid and sodium intake, though this should always be medically supervised.
Sleep and pacing
Poor sleep exacerbates autonomic instability. Physiotherapists often incorporate energy pacing strategies, helping patients balance activity and recovery rather than adopting an all‑or‑nothing approach.
Common Myths About Physiotherapy and POTS
“Exercise makes POTS worse.”
Exercise makes unstructured or inappropriate exercise worse. Evidence‑based physiotherapy does the opposite.
“If I rest long enough, it will resolve on its own.”
Prolonged inactivity often worsens autonomic dysfunction and prolongs recovery.
“Physiotherapy only helps mild cases.”
Even patients with severe symptoms can benefit when programmes are individualised and medically coordinated.
When to Seek Professional Physiotherapy Support
Physiotherapy for POTS should ideally be delivered by clinicians familiar with autonomic disorders. Red flags requiring medical review before exercise include unexplained syncope, chest pain, or significant blood pressure instability.
A collaborative approach between physicians, physiotherapists, and patients consistently produces the best outcomes.
How We Provide POTS‑Focused Physiotherapy at Cure On Call
At Cure On Call, we provide evidence‑based physiotherapy for POTS through personalised, medically informed rehabilitation programmes. Our approach integrates graded exercise therapy, autonomic regulation techniques, patient education, and remote monitoring—allowing individuals to receive expert care from home while remaining closely supervised. Each programme is tailored to symptom severity, lifestyle demands, and recovery goals, ensuring safety, consistency, and long‑term functional improvement.
Actionable Takeaways You Can Apply Immediately
- Stop forcing upright exercise if it consistently worsens symptoms
- Begin with recumbent or seated movements
- Track recovery heart rate rather than peak heart rate
- Focus on frequency, not intensity
- Seek physiotherapy input early rather than after months of inactivity
Frequently Asked Questions (FAQ)
Can physiotherapy cure POTS?
Physiotherapy does not “cure” POTS in all cases, but strong evidence shows it can significantly reduce symptoms and restore function, and some patients no longer meet diagnostic criteria after structured rehabilitation.
How long does it take to see improvement?
Most patients notice functional improvements within 6–12 weeks, though full rehabilitation may take longer depending on severity and consistency.
Is home‑based physiotherapy effective?
Yes—when programmes are structured, monitored, and progressively adjusted, home‑based physiotherapy can be highly effective.
Should I stop exercise during flare‑ups?
Not necessarily. Physiotherapists often adjust intensity and position rather than stopping entirely, maintaining autonomic stability.
Final Thoughts
Living with POTS can feel isolating, particularly when symptoms are invisible and misunderstood. Physiotherapy offers something profoundly important: a structured path forward grounded in science, compassion, and realistic expectations.
If you are navigating POTS—personally or professionally—I invite you to share your experience or questions below. Thoughtful discussion helps build understanding, and understanding is often the first step towards recovery.
