DOCUMENT 21 FOI 25/26-1343 Research paper
OFFICIAL For Internal Use OnlyPostural Orthostatic Tachycardia Syndrome
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- Contents
Postural Orthostatic Tachycardia Syndrome …………………………………………………………………… 1
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Contents ………………………………………………………………………………………………………….. 1
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Summary …………………………………………………………………………………………………………. 2
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What is Postural Orthostatic Tachycardia Syndrome ……………………………………………… 2
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Clinical Presentation ……………………………………………………………………………………. 3
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Diagnostic Criteria ……………………………………………………………………………………. 4
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Management ………………………………………………………………………………………………….. 6
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Interventions and their Efficacy ……………………………………………………………………… 8
7.1 General Multidisciplinary Teams ................................................................. 87.2 Occupational Therapy ................................................................................. 8
7.3 Psychologist ................................................................................................. 9
7.4 Nutrition ....................................................................................................... 9
7.5 Chiropractic ............................................................................................ 10
7.6 Physical Exercise ................................................................................... 108. References ………………………………………………………………………………………………….. 12
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OFFICIAL For Internal Use Only2. Summary
Postural orthostatic tachycardic syndrome (POTS) is a type of cardiovascular autonomic disorder with three different phenotypes: hypovolemic, hyperadrenergic and neuropathic. It can cause many symptoms, some of which occur on standing. Standing-related symptoms include tachycardia, weakness, blurred vision, headaches, or fainting. Symptoms not related to standing can include gastrointestinal issues, thermoregulatory issues, pain, sleep problems and brain fog. POTS is associated with comorbidities such as migraines, coeliac disease, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome and Ehlers-Danlos syndrome. POTS can lead do a high degree of functional impairment and decreased quality of life.
The diagnosis of POTS is typically carried out via an Active Standing Test or a tilt table test but should also include a patient history, physical examination, and 12-lead electrocardiography. The first-line treatment is lifestyle modifications including increased fluid and salt intake, compression garments, graded physical exercise, and the limiting of hot environments and prolonged standing. The consumption of tea, coffee, alcohol, energy drinks and large meals should also be limited. Pharmacology should be considered if lifestyle modifications prove ineffective.
There is evidence that a multidisciplinary team including physicians, psychologists, occupation therapists, physical therapists, nurses, and recreational therapists may positively affect functional ability in adolescents and young adults with POTS. The evidence for single-clinician interventions such as occupational therapy or chiropractic is extremely limited and based only on case studies. We found limited evidence of the efficacy of psychologists in assisting individuals with POTS. While there are recommendations for the involvement of a dietician in the management of POTS, we did not find study-based evidence to this effect.
Physical exercise programs have been shown to improve the heart rate and quality of life of patients with POTS. There is preliminary evidence that supervised, individualised and progressive programs may be more beneficial than those that are unsupervised, standardised, and rigid in timeframes.
- What is Postural Orthostatic Tachycardia Syndrome
Postural orthostatic tachycardia syndrome (POTS) is a variant of cardiovascular autonomic disorder (Ghazal et al., 2025, p. 1). It causes unpleasant symptoms on standing such as tachycardia (see section 4 for more information) which are resolved once the individual lies down (HealthDirect, 2024). It is predominantly diagnosed in younger (pre-menopausal) women (Zhao & Tran, 2023).
POTS is caused by a problem in the autonomic nervous system and is considered to be a form of dysautonomia (Bryarly et al., 2019, p. 1208; HealthDirect, 2024). When a healthy individual stands up, gravity pulls blood down into the lower part of their body, away from their brain.
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OFFICIAL For Internal Use OnlyTheir autonomic nervous system reacts instantly to push the blood back up towards their heart and brain. In individuals with POTS, there is a problem with this process and blood does not get pushed up to brain as it should. This results in the heart beating faster to improve blood flow (HealthDirect, 2024).
There are three distinct phenotypes of POTS: hypovolemic, hyperadrenergic, and neuropathic. Individuals may display characteristics consistent with more than one subtype of POTS (El Hussein & Hewko, 2025, p. 1; Ghazal et al., 2025, p. 1; Lau et al., 2022).
The aetiology of POTS is unclear, although most evidence points to it being heterogeneously complex (Lau et al., 2022; Zhao & Tran, 2023). There are three main hypotheses which include an autoimmune disorder, abnormally increased sympathetic activity and catecholamine excess, and sympathetic denervation leading to central hypovolaemia and reflex tachycardia (Fedorowski, 2019). POTS can occur after a viral infection, such as COVID-19 or infectious mononucleosis and many people with long COVID have POTS. It can also occur after surgery, hormonal changes (pregnancy, the onset of menstruation or menopause), or concussion or other injuries (Australian POTS Foundation, n.d.a; HealthDirect, 2024). People are more likely to have POTS if they also have migraines, coeliac disease, irritable bowel syndrome, fibromyalgia, chronic fatigue syndrome and Ehlers-Danlos syndrome (Australian POTS Foundation, n.d.a; HealthDirect, 2024; Lau et al., 2022).
- Clinical Presentation
POTS symptoms which can occur on standing (orthostatic symptoms) include dizziness, nausea, light-headedness, brain fog, shakiness, a fast heartbeat (tachycardia), chest pains, weakness, palpitations, fatigue, blurred vision, and headaches. It may also cause the individual to faint when they stand up (Ghazal et al., 2025, p. 2; HealthDirect, 2024; Lau et al., 2022).
Other symptoms can occur that are not related to standing (non-orthostatic symptoms). These include tiredness and sleep problems, difficulty thinking, problems passing urine, bloating, constipation and diarrhoea, sensitivity to light, noise, smell or taste, thermoregulatory disturbance; reduced ability to do intense activities, and pain, especially in the head, neck and shoulders (Australian POTS Foundation, n.d.a; HealthDirect, 2024; Lau et al., 2022). They may also include acrocyanosis, unexplained fever and dry mouth (Raj et al., 2022, p. 381).
Individuals with POTS who have one or more of the above-mentioned non-orthostatic symptoms and one or more associated comorbidity (including hypermobile Ehlers Danlos syndrome, coeliac disease, chronic migraines, hypermobile spectrum disorder, mast cell activation disorder, chronic fatigue syndrome/ME, autoimmune disorder, cerebrospinal fluid leak, mitochondrial mutations disorders, multiple sclerosis) can be said to have POTS plus (Raj et al., 2020, p. 359).
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OFFICIAL For Internal Use OnlyThe severity of symptoms can differ widely among individuals with POTS and it is common for individuals to have ‘flares’ interspersed with periods of relative well-controlled symptoms (Australian POTS Foundation, n.d.a; Lau et al., 2022).
Individuals with POTS may also experience difficulty with movement, anxiety, depression, and difficulty caring for themselves. POTS may also make it difficult to work, study or carry out daily activities, and can lead do a high degree of functional impairment and decreased quality of life (Australian POTS Foundation, n.d.a; HealthDirect, 2024; Lau et al., 2022; Zhao & Tran, 2023).
- Diagnostic Criteria
The diagnosis of POTS is based on symptomatology (Lau et al., 2022). The diagnostic criteria for POTS include:
a significant increase in heart rate within the first 10 minutes of standing up (>30
beats heart rate rise from laying to standing for adults, or >120 bpm during the
standing test, described below)
no significant drop in blood pressure upon standing (systolic blood pressure drops
by no more than 20 mm Hg) within 3 minutes of standing
orthostatic intolerance (symptoms like dizziness, light-headedness, or fainting that
improve when lying down)
symptoms lasting for at least 3 months
no other known illnesses that may be causing the symptoms (Australian POTS
Foundation, n.d.a; Lau et al., 2022; Lee Lewis, 2024; Raj et al., 2020, p. 361).The Canadian Cardiovascular Society’s 2020 position statement on POTS provides additional clarifications to these criteria.
The heart rate above threshold should be seen on at least 2 measurements at least 1 minute apart (Raj et al., 2020, p. 361). The patient’s supine heart rate should be a minimum rate of 60 beats/min to prevent the diagnosis of POTS being made in a patient with a low resting heart rate that increases to a normal level on standing (Raj et al., 2022, p. 378). If the patient has a low supine resting heart rate (<60 bpm), the threshold will be on the basis of an increase from a resting heart rate of 60 bpm (Raj et al., 2020, p. 361). While the orthostatic tachycardia must occur in the absence of classical orthostatic hypotension, transient initial orthostatic hypotension does not preclude a diagnosis of POTS (Raj et al., 2020, p. 361).
It is normal for orthostatic tachycardia to vary slightly from day to day and the abovementioned hemodynamic criteria do not need to be met at every visit (Raj et al., 2020, p. 361). There may be greater orthostatic tachycardia in the morning compared to later in the day. If a clinician has a high suspicion of POTS, but the patient does not meet the criterion for orthostatic
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OFFICIAL For Internal Use Onlytachycardia at their initial evaluation, reassessment at a later date is advised, preferably in the morning (Raj et al., 2022, p. 378).
The Active Standing Test can be used to diagnose POTS as described above. The Active Standing test involves a doctor checking an individual’s heart rate and blood pressure after they have been lying down for 5 minutes and then again after they stand up. The testing is conducted at regular intervals over a period of 10 minutes. If their heart rate increases by at least 30 beats per minute (or 40 beats per minute for 12-19-year-olds) within 10 minutes of standing up, it might suggest POTS (Australian POTS Foundation, n.d.a; Bryarly et al., 2019, p. 1218; Lau et al., 2022; Steinberg et al., 2023, p. 1). An absolute heart rate of 120 beats per minute or greater at any time during the standing test is also diagnostic (Lau et al., 2022).
The heart rate criteria have been disputed and a negative active standing test does not conclusively exclude POTS. If symptoms suggestive of POTS are present but there is no evidence of orthostatic tachycardia and orthostatic hypotension, the Canadian Consensus Statement suggests a diagnosis of postural symptoms without tachycardia (PSWT) (Raj et al., 2022, p. 359).
Individuals with PSWT who also have one or more comorbidities (including hypermobile Ehlers Danlos syndrome, coeliac disease, chronic migraines, hypermobile spectrum disorder, mast cell activation disorder, chronic fatigue syndrome/ME, autoimmune disorder, cerebrospinal fluid leak, mitochondrial mutations disorders, multiple sclerosis) can be described as having PSWT plus (Raj et al., 2022, p. 359). Postural tachycardia of other causes (PTOC) is a diagnosis used for patients who have the same hemodynamic and clinical criteria as POTS but there is a clear underlying cause for the excessive orthostatic tachycardia such as bedrest, hypovolemia, or medications. The excessive orthostatic tachycardia is expected to resolve with treatment of the underlying cause and the patient should not be diagnosed with POTS (Raj et al., 2020, p. 362).
Tilt tables can also be used to confirm the diagnosis of POTS, particularly if the active standing test is deemed unsafe (Australian POTS Foundation, n.d.a; Lau et al., 2022). However, tilt table testing is not mandatory for the diagnosis of POTS (Australian POTS Foundation, n.d.a).
Other conditions that may cause orthostatic tachycardia should be excluded. These include anaemia, anxiety, fever, pain, infection, dehydration, hyperthyroidism, pheochromocytoma, prolonged bed rest or the use of medications that can increase heart rate (including stimulants, diuretics, and norepinephrine reuptake inhibitors) (Raj et al., 2022, p. 378). Core laboratory investigations should screen for secondary causes of orthostatic tachycardia, including haemoglobin, electrolytes, renal function, ferritin, thyroid-stimulating hormone, and morning cortisol (Raj et al., 2022, p. 382).
In addition to the diagnostic tools mentioned above, clinicians should take a patient history, conduct a physical examination, and order a 12-lead electrocardiography to assess for persistent underlying arrhythmias (Raj et al., 2022, p. 381; Raj et al., 2020, p. 363).
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OFFICIAL For Internal Use OnlyThe patient history should focus on possible underlying causes and associated disorders, potential POTS triggers and precipitating events, severity of symptoms, factors that can improve or worsen symptoms, the patient’s ability to exercise and how the symptoms affect the patient’s quality of life. Clinicians should ask about symptoms that suggest possible signs of autonomic dysfunction, such as gastrointestinal or urinary dysfunction, abnormal sweating, acrocyanosis, dry mouth and unexplained fever. Patient medications should be reviewed as some may worsen symptoms. Salt and water intake should be recorded (Raj et al., 2022, p. 381).
The physical examination should include orthostatic vital signs at regular intervals after standing up with recording of associated symptoms (Raj et al., 2022, p. 381). A 24-hour Holter monitor can be used for detection of the presence of inappropriate sinus tachycardia (Raj et al., 2022, p. 380).
Testing for supine and upright fractionated plasma catecholamines and other hormones involved in regulation of blood pressure and blood volume is sometimes done as part of an advanced evaluation (Raj et al., 2022, p. 382).
The Malmö POTS Score (MAPS) survey is also available. It is a 12-item survey based on self- ratings of patients’ symptoms. According to the survey developers, it can be used to assess symptom burden, monitor disease progression, and evaluate pre-test likelihood of disease (Spahic et al., 2022, p. 91).
- Management
There is no known cure for POTS but there are treatments that can relieve symptoms. First- line therapy is lifestyle modification, including the following:
drink 2 to 3 litres of water every day
increase salt intake (10 to 12 grams of salt per day)
limit tea, coffee, alcohol, energy drinks and large meals
undertake graded physical exercise
avoid hot environments and hot showers
wear compression garments (e.g., for the abdomen and legs)
avoid prolonged standing
vagus nerve stimulation
medications that might exacerbate orthostatic tachycardia may be stopped
(Australian POTS Foundation, n.d.a; HealthDirect, 2024; Lau et al., 2022; Raj et al.,
2022, p. 382).Depending on the symptoms present, individuals with POTS may be referred to specialists such as a POTS specialist or pain physician, neurologist, gastroenterologist, vascular surgeon,
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OFFICIAL For Internal Use Onlypsychologist, or allied health professionals, such as a physiotherapist, occupational therapist, dietician, or exercise physiologist (HealthDirect, 2024; Lau et al., 2022). Orthopaedic, rheumatology, immunology and psychiatry input may also be required (Lau et al., 2022).
Pharmacotherapy has limited evidence but it utilised to reduce symptom burden and improve day-to-day function in those with persistent symptoms who have already tried lifestyle modifications (Australian POTS Foundation, n.d.a; Lau et al., 2022; Zhao & Tran, 2023).
Medications that may be prescribed to help with POTS symptoms include midodrine, ivabradine, fludrocortisone and propranolol. Midodrine helps to constrict blood vessels in the legs and abdomen, helping to improve blood flow to the heart and brain. Ivabradine can lower heart rate. Fludrocortisone can help increase blood volume by promoting salt and fluid retention. Propranolol can help control heart rate and reduce palpitations and tachycardia (Australian POTS Foundation, n.d.a; Lau et al., 2022). Pyridostigmine, which reduces upright heart rate, is generally well tolerated. It can increase colonic motility and should be avoided in patients prone to diarrhea but can be helpful in patients with constipation (Raj et al., 2022, p. 382). Other medications may also be prescribed.
There is currently no pharmacological therapy approved for POTS management in Australia, the USA or Canada (El Hussein & Hewko, 2025, p. 6; Ghazal et al., 2025, p. 4). The medications described above are prescribed “off-label.” The Australian POTS Foundation is currently putting forward Midodrine for repurposing through the Therapeutic Goods Administration program (Australian POTS Foundation, n.d.b). The pharmacological management is mostly considered in patients who do not respond to conservative measures (Ghazal et al., 2025, p. 4).
Patient education and therapy adherence play a key role in successfully managing POTS (Zhao & Tran, 2023). This involves detailed discussions about the syndrome, supported by printed materials, brochures, and trusted online resources. Patients should be informed about symptom-relief strategies, non-pharmacological measures, and long-term outcomes. Education on available treatment options tailored to the individual’s condition is essential, fostering better understanding and adherence to management plans (Ghazal et al., 2025, p. 4).
The treatment of POTS often requires individualised, multimodal approaches. There is ongoing debate about whether treatments should be tailored to specific POTS subtypes or applied uniformly (Ghazal et al., 2025, p. 4). El Hussein and Hewko (2025) give the following suggestions for effective treatments for different POTS subtypes.
For neuropathic POTS, compression garment use, exercise training and midodrine are particularly effective. For hypovolemic POTS, exercise training, increased fluid and sodium intake, fludrocortisone and desmopressin can be effective. For hyperadrenergic POTS, patients should avoid medications that may aggravate the condition such as serotonin- norepinephrine reuptake inhibitors, selective-serotonin reuptake inhibitors, and norepinephrine
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OFFICIAL For Internal Use Onlyreuptake inhibitors. Beta-blockers, pyridostigmine, ivabradine, and central-acting sympatholytic drugs are of value for this subtype (El Hussein & Hewko, 2025, pp. 1-2).
- Interventions and their Efficacy
POTS is now recognised as a fluctuating condition that can affect individuals for a long time (Australian POTS Foundation, n.d.a). The trajectory of POTS is largely unknown due to a lack of long-term data (Lau et al., 2022). There is evidence that symptoms disappear within 5 years of onset (and mostly within the first 1-2 years) in over 50% of patients (Zhao & Tran, 2023).
In children, orthostatic intolerances may improve over time with treatment, although a longer duration of symptoms before therapy has been associated with poorer long-term outcomes (Raj et al., 2022, p. 379).
7.1 General Multidisciplinary Teams
Several studies have shown the efficacy of interdisciplinary care teams for adolescents and young adults with POTS (see Bruce et al. 2016 and Oetjen et al., 2024). These studies showed the effects of a 3-week intensive program during which adolescents worked with physicians, psychologists, occupation therapists, physical therapists, nurses, and recreational therapists to meet their goals surrounding POTS. In Bruce et al. (2016). 33 adolescents were provided with occupational therapy, physical therapy, cognitive behavioural therapy (CBT) therapy, stress management, wellness instruction and symptom management training. At the end of the program, patients showed a significant increase in overall functional ability and significant reductions in depression and pain catastrophising (as measured by the Functional Disability Index, Centre for Epidemiological Studies-Depression-Child Scale and Pain Catastrophising Scale for Children). In Oetjen et al. (2024), 111 adolescents and young adults underwent the program to improve goals around self-care, school, and leisure. They received medical care and support including increasing and balancing salt and fluid intake, gradually increasing exercise, taking medications as prescribed, practising good sleep hygiene, and returning to school and increasing social support. They also received 1 hour of physical therapy daily which included strength training, upright cardio workouts and return to sports activities. CBT and acceptance and commitment therapy were used for symptom management strategies. Occupational therapists helped them to utilise the learned skills including maintenance of routines despite symptoms. On discharge, patients reported significant positive changes in their Canadian Occupational Performance Measure (COPM) satisfaction, performance, and functional disability scores.
7.2 Occupational Therapy
In 2022, Dochod published a retrospective case report on the effect of occupational therapy in a 37-year-old female patient with POTS and chronic headaches. The intervention involved twice-weekly meetings for 10 weeks and then once-weekly meetings for 6 weeks. Sessions focused on energy conservation and pacing training to improve the patient’s ability to complete
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OFFICIAL For Internal Use Onlydaily tasks such as getting ready for the day, grocery shopping and cooking. Positive outcomes from this treatment included an increase in strength and stamina, allowing the patient to begin selling handmade goods online, increases in perception of health, mood energy and social activities and decreases in pain and health interference. Improvements were measured using the Medical Outcomes Survey 36-Item Short-Form (SF-36) and COPM.
7.3 Psychologist
We found a limited amount of information addressing the efficacy of psychological intervention for individuals with POTS.
According to POTS UK (2021), CBT can help to improve recovery, ability to function and quality of life in individuals with POTS.
Raj et al. (2019) described the psychological challenges that individuals with POTS may face including depression symptoms and symptoms of anxiety disorders which can lead to sub- clinical low mood and sleep disturbances. They state that there is a likely role for psychotherapy in helping control adjustment-related issues, and possibly aberrant physiology in individuals with POTS (p. 1).
In 2016, Ralston and Kanzler described a case study which employed elements of CBT including in-vivo exposure and symptom discrimination to treat a patient with POTS. They report that over the course of 10 sessions, the patient learned to discriminate POTS symptoms from anxiety and displayed a significant self-reported decrease in POTS-related functional impairment, resulting in her being able to maintain her employment.
7.4 Nutrition
The Association of UK Dieticians (2023) states that up to 90% of patients with POTS have gut symptoms, and that nutrient deficiencies can occur due to a combination of restrictive diets caused by challenging symptoms and malabsorption. The correction of these issues can improve some of the orthostatic symptoms found in POTS (see Mittal et al., 2021).
According to Ganesh et al. (2020, p. 818), the majority of patients with POTS also experience gastrointestinal (GI) and systemic symptoms and conditions that may contribute to functional debility and poor quality of life. This can lead to significant issues in meeting nutrition and hydration needs. Severe symptoms may prevent sufficient oral intake and may result in weight loss, enteral nutrition or parenteral nutrition support being required The authors also state that a nutritional assessment should be offered to all those with POTS (p. 822). Nutrient deficiency, malnutrition, dehydration, and other potential symptom-generating aetiologies should be explored in patients with POTS (p. 822). The optimal diet for these patients and the role of dietary modification in POTS management requires further study.
According to the Association of UK Dieticians (2023), dietary changes and fluids can help orthostatic and gastrointestinal symptoms, ensuring patients are able to get the nutrients they need whilst minimising symptoms. Individuals with POTS and co-existing conditions may
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OFFICIAL For Internal Use Onlyfollow a range of diets, such as the low histamine diet or the low FODMAP diet, which may impact on their nutritional intake further so dietetic support is particularly important if any of these diets are being followed. Practical dietary advice is essential if patients’ symptoms make preparing and cooking food challenging without support.
In a not yet peer-reviewed preprint of recent research, time-restricted eating whereby caloric intake was limited to an 8-10 daily window, was tested in 20 patients with POTS over a 12- week period. Post-intervention results showed reduced heart rate increase upon standing and improved quality of life metrics including POTS symptom severity, physical functioning, and energy/fatigue (Dzotsi et al., 2025).
Zha et al. (2023) conducted a retrospective study with 20 patients with POTS and without coeliac disease to determine the effect of a gluten free diet. Based on self-assessments, they reported improvements in patients’ orthostatic intolerance, vasomotor and GI symptoms.
A 2020 systematic review and meta-analysis (Loughlin et al.) of studies investigating the effect of salt intake in individuals with POTS found low-quality evidence of short-term improvement in orthostatic intolerance with increased salt intake but noted there are no clinical trials demonstrating the efficacy and safety of increased salt intake on long-term clinical outcomes.
7.5 Chiropractic
There is very preliminary evidence of the efficacy of chiropractic treatment in individuals with POTS (see Chu & Lin, 2022; Jarosz, 2021; Wilson, 2022). The evidence is based on case studies with patient numbers ranging from 1 to 3. While the chiropractic interventions did lead to the resolution or improvement of POTS symptoms including neck pain, dizziness and motor coordination, the evidence is limited and not generalisable.
7.6 Physical Exercise
Exercise training programs are often cited as a key component of POTS management to decrease upright tachycardia and improve symptoms and quality of life. The exercise program must be introduced gradually to avoid aggravating symptoms (Lei et al., 2020, p. 113). Lei et al. (2020, p. 113) recommend slowly progressing from non-upright activities (rowing machines, recumbent cycles) to upright aerobic exercises at a frequency of 4 to 6 times a week. They clarify it can take 4 to 6 weeks of consistent adherence to the program for benefits to begin to take effect and regression may occur if regular physical activity is terminated (p. 113).
Previous evidence has also demonstrated that a 3-month exercise program can help treat the cardiac origins of POTS, with an active lifestyle being key to reducing and eliminating symptoms. The current standard of care includes recommendations for physical therapy and/or aerobic exercise. The recommendation comprises a graded exercise regimen building to a target of 30 minutes per day, 5 days a week starting with recumbent exercises (Wheatley- Guy et al., 2023, p. 660). However, there is criticism in the literature that this format is typically
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OFFICIAL For Internal Use Onlynot personalised, progressive or supervised and can be too rigid for many patients (see Wheatley-Guy et al., 2023, p. 660 and Ziaks et al., 2024, p. 1).
Ziaks et al. (2024) discuss the need for adaptive approaches to exercise rehabilitation in POTS and related autonomic disorders given that current exercise rehabilitation protocols for POTS contain rigid timelines and progression paradigms that negatively affect the tolerability of these programs and the adherence of patients to the programs. Based on existing standards in exercise physiology and rehabilitation science, they suggest 4 key advances to improve autonomic rehabilitation. These include comprehensive evaluation of the patient, individualised program entry and initial exercise prescription, patient-driven criteria, and adaptation to patient needs. The authors cite a novel exercise program called the Utah Autonomic Disorder adaptive Physical Therapy (ADaPT) program which provides patients with a progressive exercise program under the supervision of a physical therapist. The program was undergoing formal clinical evaluation in 2024 and we did not find any publications relating to the program.
A randomised trial by Wheatley-Guy et al. (2023) with 49 participants involved one group of patients receiving the recommended standard of care (described above) for 3 months and a second group receiving an in-person exercise consultation and 8 supervised in-person or virtual exercise sessions, weekly for 1 month and bi-weekly for the remaining 2 months. The supervised exercise sessions comprised three aerobic sessions per week which started with short durations (3 minutes) and progressed by increasing working interval and shortening recovery time, progressing to 30 minutes of continuous exercise at a moderate intensity. The supervised group showed greater improvements in aerobic fitness, orthostatic intolerance and vasomotor, and a greater reduction in heart rate, shortness of breath and bodily pain. There was no difference in symptom severity and functional ability between groups, although the supervised group did demonstrate a trend in the positive direction. The supervised group was more likely to complete at least 2 sessions per week and have fewer weeks with no exercise.
Zeznick Trimble et al. (2024) also provide evidence that patients with POTS, particularly those with severe orthostatic intolerance and fatigue, may benefit from a home-based exercise approach with individualised exercise programs that are delivered remotely by a certified physical therapist. Such programs can be convenient, easily accessible, and safe for patients with POTS who have severe symptoms and may be home- or bedbound.
A 2025 systematic review (Cortez et al.) examined the impact of exercise in the treatment of POTS. It reviewed 7 studies including the 2023 study by Wheatley-Guy et al. described above. The review found improvements in heart rate noted in all studies, with improvements in quality of life and stroke volume found in some but not all studies. The risk of bias was moderate-high in all but one of the studies and the authors underlined the need for additional studies assessing the effect of exercise on symptom burden and daily function.
A 2024 scoping review (Peebles et al.) of the use and effectiveness of exercise for managing POTS in young adults with joint hypermobility and related conditions found evidence in 10 articles that 3 months of endurance exercise followed by resistance exercise, graduating from the horizontal-to-upright position reduced orthostatic symptoms and improved quality of life.
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OFFICIAL For Internal Use Only8. References
Australian POTS Foundation. (n.d.a). What is POTS? https://potsfoundation.org.au/living-with- pots/
Australian POTS Foundation. (n.d.b). Therapeutic Goods Administration (TGA) Medication Repurposing. https://potsfoundation.org.au/therapeutic-goods-administration- repurposing-program/
Bruce, B. K., Harrison, T. E., Bee, S. M., Luedtke, C. A., Porter, C.-B. J., Fischer, P. R., Hayes, S. E., Allman, D. A., Ale, C. M., & Weiss, K. E. (2016). Improvement in Functioning and Psychological Distress in Adolescents With Postural Orthostatic Tachycardia Syndrome Following Interdisciplinary Treatment. Clinical Pediatrics, 55(14), 1300–1304. https://doi.org/10.1177/0009922816638663
Bryarly, M., Phillips, L. T., Fu, Q., Vernino, S., & Levine, B. D. (2019). Postural Orthostatic Tachycardia Syndrome: JACC Focus Seminar. Journal of the American College of Cardiology, 73(10), 1207–1228. https://doi.org/10.1016/j.jacc.2018.11.059
Chu, E. C. P., & Lin, A. F. C. (2022). Relief of postural orthostatic tachycardia syndrome with chiropractic rehabilitation. Journal of Family Medicine and Primary Care, 11(7), 4006– 4009. https://doi.org/10.4103/jfmpc.jfmpc_2108_21
Cortez, M. M., Aikins, K., Arnold, A. C., Boris, J. R., Davenport, T. E., Johnson, K., Kattaya, H. S., Kinsella, L., McFarland, M. M., Pelo, R., Powers, C. D., Schiltz, K., Stiles, L. E., Ziaks, L., Chung, T. H., & Dal Molin, C. (2025). Impact of exercise to treat postural orthostatic tachycardia syndrome: a systematic review. Frontiers in Neurology, 16, Article 1567708. https://doi.org/10.3389/fneur.2025.1567708
Dochod, J. R. (2022). Enhancing Health-Related Quality of Life through Occupational Therapy: A Case Report of a Client with Postural Orthostatic Tachycardia Syndrome. Occupational Therapy in Health Care, 36(3), 202–219. https://doi.org/10.1080/07380577.2022.2051218
Dzotsi, M., Strohm, A., Varshney, S., Zuniga-Hertz, J. P., Chitteti, R., Manoogian, E., Sethi, A., Panda, S., Patel, H. H., Doherty, T. A., & Taub, P. (2025). Time-Restricted Eating Improves Quality of Life, Heart Rate, and Mitochondrial Function in Patients with Postural Orthostatic Tachycardia Syndrome. MedRxiv. https://doi.org/10.1101/2025.05.29.25328448
El Hussein, M. T., & Hewko, A. (2025). Management of Postural Orthostatic Tachycardia Syndrome: A Canadian Approach. Journal for Nurse Practitioners, 21(1), Article 105258. https://doi.org/10.1016/j.nurpra.2024.105258
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