Exercise and non-pharmacological treatment of POTS

Abstract

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.

Postural Tachycardia Syndrome: Nutrition Implications

“…Several physiologic changes have been implicated, including overactivation of the sympathetic adrenergic system, autonomic dysfunction, cardiovascular deconditioning, hypovolemia, and peripheral pooling of blood. 2,13 Through any combination of these factors, the net effect is that of impaired response to positional change with characteristic clinical features being symptoms of orthostatic intolerance and an increase in HR. Patients with POTS have been generally divided into 3 phenotypes based on symptoms, autonomic testing, and plasma norepinephrine levels: neuropathic, hyperadrenergic, or hypovolemic.…”

“…This can be done by increasing salt and water intake and has been shown to decrease orthostatic intolerance. 13,33 Patients are recommended to increase their dietary salt intake to 10 g/d (4000 mg of sodium) as tolerated and to increase their water intake to 3 L per day. 13 In patients who are unable to adequately increase their daily dietary salt intake, sodium chloride tablets may be used.…”

“…Additional countermeasures that have been described are related to relieving the orthostatic insult by squatting, sitting, or lying down when patient becomes symptomatic. 13…”

“…Patients who underwent this protocol reported increased well-being and quality of life and up to 70% of these patients no longer met objective criteria for POTS after 3 months of training. 13,[40][41][42][43]…”

Heart rate regulation in patients with anorexia nervosa

“…Deconditioning was used as an unproven therapy during refeeding in patients with anorexia nervosa that should be avoided to prevent POTS. Controlled exercise may use to improve POTS symptoms [17].…”