POTS Workout

 

Living with Postural Orthostatic Tachycardia Syndrome (POTS) can be incredibly draining. The constant fatigue and discomfort often make the idea of exercise feel impossible. But here's the good news: exercise is a vital part of managing POTS, helping to boost your heart health and improve your overall quality of life.

 

Why Exercise Matters for POTS

 

Many people with POTS experience deconditioning, meaning their bodies are out of shape because of reduced activity. This makes the heart pump less efficiently, which can worsen symptoms. Dr. Benjamin Levine, a leading researcher in POTS, has found that people with POTS often have a smaller heart and pump less blood with each beat. Regular exercise can actually help your heart grow stronger, increasing the amount of blood it pumps and improving your symptoms.

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But here’s the key: you need to start slowly and carefully, often beginning with exercises done while lying down to avoid triggering symptoms.

 

Understanding the Key Protocols: CHOP, Dallas, and Levine

 

The CHOP Protocol (developed at the Children's Hospital of Philadelphia) and the Dallas Protocol (also known as the Levine Protocol, created by Dr. Benjamin Levine in Dallas) are widely recognized exercise programs for POTS. They share a common goal: to gradually improve your ability to exercise.

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These protocols emphasize:

• Starting with horizontal exercises like recumbent biking, rowing, or swimming. This minimizes the effects of gravity that can worsen POTS symptoms.

• Slowly progressing to upright activities as your stamina improves.

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The idea behind these protocols is to gradually strengthen your heart and improve how your body circulates blood, helping to counteract the smaller heart size and reduced blood flow often seen in POTS patients.

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Start Low, Go Slow

 

While the CHOP and Dallas Protocols are excellent, they can seem overwhelming if you’re severely deconditioned or new to exercise. For many, a gentler approach is best to start.

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I've created a full-body strengthening workout to be more POTS-friendly, offering a simple, quick way to get moving without overdoing it. Dysautonomia International also provides great resources and suggestions on their website.

 

 

 

Working with a physical therapist who understands POTS and dysautonomia can be incredibly beneficial. They can help you create a personalized exercise plan, ensuring you're progressing safely and effectively. A physical therapist can also guide you through the more structured protocols like CHOP or Dallas when you're ready, providing crucial support and modifications.

 

Chair-Based POTS Workout

 

Goal: To gently improve cardiovascular fitness, strengthen a wide range of upper body, lower body, and core muscles, and enhance blood circulation, all from a seated position or with chair assistance.

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Total Time: Start with 15-22 minutes. Gradually increase duration as tolerated, adding 1-2 minutes per week, working towards 30-45 minutes.

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Frequency: Begin with 3-4 times per week on non-consecutive days. Increase to 5-6 times per week as tolerated.

 

Equipment Needed:

• Sturdy chair (no wheels)

• Water bottle

• Heart rate monitor (recommended)

• Light resistance band (essential for hamstring curl; optional for other exercises)

• Small hand weights (0.5-2 lbs, optional, for progression)

• Small ball or pillow (for inner thigh exercise)

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Key Adjustments for POTS Patients:

• Consult Your Doctor: Absolutely paramount. Do NOT begin any exercise program for POTS without medical clearance and guidance from a cardiologist or autonomic specialist. They can help determine appropriate heart rate zones and progression.

• Take longer breaks between exercises if you need to.

• Focus on seated or reclined exercises to reduce strain.

• Avoid standing for long periods until you build up your tolerance.

• Compression Garments: Consider wearing medical-grade compression garments (thigh-high or abdominal binders) as they can help reduce blood pooling in the lower extremities during exercise.

• Hydration & Sodium: Ensure adequate fluid and sodium intake before, during, and after exercise, as advised by your doctor. Electrolyte drinks may be beneficial.

• Cool Environment: Exercise in a cool environment, as heat can worsen POTS symptoms.

• Patience and Consistency: Progress with POTS exercise is often slow and non-linear. Consistency with small, manageable efforts is more effective than sporadic intense workouts that lead to setbacks.

• Listen to your body! You don't have to push hard. This is the most important rule. If you experience any worsening of POTS symptoms (dizziness, lightheadedness, nausea, excessive fatigue, significant palpitations, chest pain, brain fog, etc.), STOP IMMEDIATELY. Rest. It is always better to do less and be safe than to push too hard and trigger a symptom flare.

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Workout Structure

• Warm-up (3-4 minutes): Gentle movements to prepare muscles and circulation.

• Main Set (10-15 minutes): Focus on controlled, seated exercises for major muscle groups.

• Cool-down (2-3 minutes): Slowing down and gentle stretches.

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The POTS Workout

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A. Warm-up (3-4 minutes)

 

1. Seated Ankle Pumps (60 seconds):

   • Sit tall in your chair, feet flat on the floor.

   • Slowly lift your heels, keeping your toes on the ground, then lower.

   • Next, lift your toes, keeping your heels on the ground, then lower.

   • Alternate between heel lifts and toe lifts, creating a smooth pumping action.

   • Focus: Gentle circulation in the lower legs.

2. Seated Marching (60 seconds):

   • Sit tall, hands on your thighs or the chair's armrests.

   • Gently lift one knee towards your chest, then slowly lower your foot back to the floor.

   • Alternate legs, as if marching slowly in place while seated. Keep the movement controlled.

   • Focus: Gentle heart rate elevation and leg muscle engagement.

3. Seated Arm Circles (60 seconds):

   • Sit tall, arms extended out to the sides at shoulder height, or bent at 90 degrees if preferred.

   • Gently make small forward circles with your arms, then reverse direction. Gradually increase the size of the circles if comfortable, but keep it gentle.

   • Focus: Warming up the upper body and shoulders.

4. Gentle Seated Torso Rotations (30-60 seconds):

   • Sit tall, hands gently on your thighs.

   • Inhale, lengthen your spine. Exhale, and gently twist your upper body a few inches to the right, then back to center. Repeat to the left.

   • Focus: Gentle spinal mobility.

 

B. Main Set (10-15 minutes)

 

For this section, you have two options for structuring your workout:

• Option 1: Full Body Circuit. Choose one exercise from each of the four main sections (Lower Body, Upper Body, Core, Compound/Transitional) for a well-rounded session. You'll rotate through these 4 chosen exercises, performing each for 45-60 seconds with a 15-30 second rest in between. Repeat the circuit 2-3 times to reach your desired workout duration.

• Option 2: Focus Day. Dedicate your workout to a specific area. For example, choose 3-4 exercises from just the "Lower Body Focus" section for a leg day, or 3-4 from "Upper Body Focus" for an arm/chest/back day. You can also have a "Core Focus" day. This allows for more targeted muscle work.

Remember:

• Perform each chosen exercise for 45-60 seconds.

• Take a 15-30 second rest between exercises.

• Listen to your heart rate. If it climbs too high, rest longer or reduce intensity.

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Lower Body Focus - Seated

1. Seated Knee Extensions (45-60 seconds per leg, alternating):

   • Sit tall, feet flat.

   • Slowly extend one leg straight out in front of you, engaging your thigh muscle (quads). Keep your back pressed against the chair.

   • Hold for 1-2 seconds, then slowly lower the foot back to the floor.

   • Alternate legs.

   • Progression: Add a light ankle weight or loop a resistance band around your ankles.

2. Seated Hamstring Curl (with Resistance Band) (45-60 seconds per leg, alternating):

   • Sit tall, feet flat.

   • Loop a resistance band around one ankle, and anchor the other end securely around a sturdy chair leg or under your opposite foot.

   • Keeping your knee bent, slowly draw your heel back towards the chair leg or under your seat, engaging your hamstring (back of thigh).

   • Slowly return to the starting position.

   • Alternate legs.

   • Focus: Directly targeting the hamstrings.

3. Seated Inner Thigh Squeeze (45-60 seconds):

   • Sit tall, feet flat on the floor.

   • Place a small pillow, folded towel, or soft ball between your knees.

   • Squeeze your knees together, engaging your inner thigh muscles (adductors). Hold the squeeze for 2-3 seconds.

   • Slowly release the squeeze, but maintain slight tension on the object.

   • Focus: Strengthening the adductor muscles of the inner thigh.

   • Progression: Use a firmer ball for more resistance.

4. Seated Side Leg Raises (45-60 seconds per leg, alternating):

   • Sit tall, feet flat.

   • Keeping your knee bent, gently lift one leg out to the side, opening at the hip. Do not lean your torso.

   • Slowly lower the leg back to the center.

   • Alternate legs.

   • Focus: Targeting outer thigh and hip abductor muscles.

5. Seated Calf Raises (45-60 seconds):

   • Sit tall, feet flat on the floor, knees at 90 degrees.

   • Keeping the balls of your feet on the floor, slowly lift your heels as high as possible, engaging your calf muscles.

   • Slowly lower your heels back down.

   • Progression: Hold a light weight on your thighs for added resistance.

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Upper Body Focus - Seated

1. Seated Bicep Curls (45-60 seconds):

   • Sit tall, arms by your sides, palms facing forward.

   • Slowly curl your forearms up towards your shoulders, keeping your elbows close to your body.

   • Slowly lower your arms back to the starting position.

   • Progression: Use light hand weights (0.5-2 lbs) or a resistance band (standing on one end, curling the other).

2. Seated Triceps Extension (45-60 seconds):

   • Sit tall, back supported.

   • Option 1 (Overhead): Hold one light hand weight with both hands, or interlace your fingers. Extend your arms overhead. Keeping your elbows pointing forward and close to your head, slowly bend your elbows to lower the weight behind your head. Then extend your arms back up, squeezing your triceps.

   • Option 2 (Kickbacks - with light weights/band): Lean slightly forward (keeping back straight). Hold light weights or resistance band ends. Keeping elbows tucked in, extend your forearms straight back, squeezing your triceps. Slowly return.

   • Focus: Targeting the triceps (back of the upper arm).

   • Progression: Increase weight slightly or use a stronger band.

3. Seated Chest Press (45-60 seconds):

   • Sit tall, back supported.

   • Option 1 (With light weights): Hold a light weight in each hand. Start with elbows bent, weights at chest height, palms facing each other or forward. Slowly press the weights straight forward, extending your arms, squeezing your chest muscles. Slowly return.

   • Option 2 (With resistance band): Wrap a resistance band behind your back at chest height, holding an end in each hand. Press your hands forward against the band's resistance.

   • Focus: Targeting the chest muscles.

   • Progression: Increase weight slightly or use a stronger band.

4. Single Arm Back Row (45-60 seconds per arm, alternating):

   • Sit tall, or lean slightly forward with a straight back, placing one elbow on your thigh for support if needed.

   • Hold a light hand weight in one hand (or one end of a resistance band, with the other end anchored under the opposite foot). Let your arm hang straight down.

   • Slowly pull the weight up towards your chest/rib cage, squeezing your shoulder blade towards your spine. Keep your elbow close to your body.

   • Slowly lower the weight back down with control.

   • Alternate arms.

   • Focus: Targeting the upper back muscles (lats, rhomboids).

   • Progression: Increase weight slightly or use a stronger band.

5. Seated Overhead Press (45-60 seconds):

   • Sit tall, back supported. Start with arms bent at 90 degrees, hands at shoulder height, palms facing forward.

   • Slowly press your hands straight overhead, extending your arms. Avoid shrugging your shoulders too high.

   • Slowly lower your hands back to shoulder height.

   • Progression: Use light hand weights (0.5-2 lbs) or perform with no weights.

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Core Focus - Seated

1. Seated Core Twist (45-60 seconds):

   • Sit tall, feet flat on the floor, hands gently crossed over your chest or resting on your thighs.

   • Keeping your hips stable and facing forward, gently twist your torso to the right, leading with your shoulders.

   • Return to center slowly, then gently twist to the left.

   • Focus: Gentle core engagement (obliques, rotational core). Avoid forcing the twist.

2. Seated Knee-to-Elbow (Abs) (45-60 seconds):

   • Sit tall, hands gently behind your head or crossed over your chest.

   • Slowly lift one knee towards your chest while simultaneously bringing the opposite elbow towards that knee. Aim for a gentle crunch and twist, not a full touch if it's too strenuous.

   • Slowly lower both back to the starting position. Alternate sides.

   • Focus: Gentle core and oblique engagement. Keep the movement slow and controlled.

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Compound/Transitional Movements

1. Seated Goddess Pose with Side Bending (45-60 seconds):

   • Sit tall in your chair. Open your knees wide, keeping your feet flat on the floor, and toes angled slightly outwards (like a wide V-shape).

   • Bring your hands to rest gently on your inner thighs or in a prayer position at your chest.

   • For the side bend: Inhale, then as you exhale, gently lean your torso to one side, reaching one arm down towards the floor/chair leg, and the other arm overhead or resting on your hip. Feel a gentle stretch along your side. Avoid collapsing forward.

   • Inhale back to center. Exhale and repeat on the other side.

   • Focus: Gentle hip opening and side body stretch/strength, promoting spinal mobility and core stability.

2. Modified Chair Squats (Lifting Off Chair) (45-60 seconds):

   • EXTREME CAUTION ADVISED: This exercise involves a brief, partial weight-bearing position. Only attempt this if you have consistently tolerated all seated exercises for a prolonged period and have specific approval from your doctor. Have someone spot you if unsure.

   • Position your sturdy chair behind you. Sit tall with feet flat on the floor, hip-width apart, directly in front of the chair's edge, allowing you to lean slightly forward.

   • Extend your arms forward for balance (optional) or place hands on knees.

   • Engage your glutes and thigh muscles, then slowly and with control, push through your heels to lift your hips just a couple of inches off the chair seat. Maintain contact with your heels on the floor.

   • Hold this lifted position for 1-2 seconds, focusing on muscle engagement.

   • Slowly and with control, lower your hips back down to gently touch the chair.

   • CRITICAL: The goal is a tiny, controlled lift, not a full stand or even a full chair tap if that's too much. Keep the movement slow and continuous. Avoid rushing or pushing too hard. If you experience any dizziness, lightheadedness, vision changes, or significant heart rate spike, stop immediately and sit down.

   • Focus: Gentle introduction to weight-bearing, strengthening legs and glutes with minimal orthostatic stress.

 

C. Cool-down (2-3 minutes)

 

1. Seated Spinal Stretch (60 seconds):

   • Sit tall. Gently round your spine forward, letting your chin drop to your chest and your hands rest on your knees or shins. Feel a gentle stretch in your upper back.

   • Hold for 20-30 seconds, then slowly roll back up to a tall seated position.

2. Seated Neck Tilts (30-60 seconds):

   • Sit tall. Gently tilt your head to one side, bringing your ear towards your shoulder (without lifting your shoulder). Feel a stretch on the opposite side of your neck.

   • Hold for 15-20 seconds, then gently return to center. Repeat on the other side.

3. Deep Diaphragmatic Breathing (60 seconds):

   • Sit comfortably, hands resting on your belly.

   • Close your eyes if comfortable. Inhale slowly and deeply through your nose, feeling your belly expand.

   • Exhale slowly through your mouth, feeling your belly contract.

   • Focus: Slow, steady breaths to calm your nervous system.

 

Progression Strategy for POTS Patients (Crucial for Long-Term Success)

• Foundation First: Master the form and comfortably complete the initial 15-22 minute workout without symptom exacerbation before increasing anything.

• Increase Duration: Once you can consistently complete the initial duration, gradually add 1-2 minutes to your main set each week, working your way up to 30-45 minutes.

• Increase Frequency: Once you can do 30-45 minutes comfortably, increase the number of workout days per week (e.g., from 3-4 to 5-6).

• Increase Resistance/Intensity (Last): Only once you are consistently doing 30-45 minutes of seated exercise most days of the week, and only with your doctor's approval, consider adding light resistance (stronger resistance bands, slightly heavier hand weights). Avoid high-intensity bursts. For the Modified Chair Squats, once comfortable with the 2-inch lift, you can very, very gradually increase the lift height (e.g., 4-6 inches) before eventually progressing to light taps or partial stands, always with extreme caution and medical guidance.

• Upright Exercise (Much, Much Later & Carefully): The modified chair squats are a very cautious step towards upright movement. True sustained upright exercise like walking should only be considered after several months of consistent seated and/or recumbent exercise and significant symptom improvement, and always under specific medical guidance following established POTS exercise protocols.

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Other Gentle Starting Points

 

For those who are bedridden or have severe deconditioning, reclined exercises are excellent starting points.

 

​Reclined Exercises (Great for Bedridden Patients)

These help improve circulation and prevent muscle loss while minimizing strain.

• Leg Pillow Squeeze: Place a pillow between your knees and squeeze for 10 seconds.

• Arm Pillow Squeeze: Squeeze a pillow between your hands (like a prayer position) for 10 seconds.

• Alphabet Toes: Spell words in the air with your toes while lying down.

• Side and Front Leg Lifts: Lift your legs while lying on your back or side.

• Gentle Stretching: Stretch while reclined to improve flexibility.

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Pool Exercises (Aquatherapy)

Water exercises are fantastic for POTS patients because the water's pressure helps circulation and reduces orthostatic symptoms. The buoyancy also supports your body, making movement easier. Just make sure to exercise in a safe environment and avoid very warm water.

 

Key Exercise Tips for POTS Patients

 

• Consult with a Physical Therapist: Especially one knowledgeable about POTS, to create a safe and effective personalized plan.

• Start Slowly: Begin with just a few minutes daily and gradually increase. Aim for 30 minutes, 3-5 times per week.

• Mix Aerobic and Strength Training: Strengthen your leg and core muscles; these help return blood to your heart.

• Start with Recumbent/Reclined Exercises: Progress to upright activities only after building stamina.

• Monitor Your Heart Rate: Talk to your doctor about your target heart rate and use a monitor to stay within a safe range.

• Progress at Your Own Pace: Don't rush! Listen to your body. If symptoms worsen, go back to easier exercises.

• Reward Yourself: Track your progress! Add a bead to a jar for every 5 minutes of exercise to see your accomplishments grow.

 

Exercising with POTS might seem overwhelming, but protocols like CHOP, Dallas, Levine, and adaptable approaches—especially with the guidance of a physical therapist—can help you improve your stamina and heart function. No matter where you're starting, consistency and moving at your own pace can lead to significant improvements.

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Always consult your doctor before beginning any new exercise program, and most importantly, listen to your body.