The Role of Physiotherapy in the Management of Postural Orthostatic Tachycardia Syndrome

The Role of Physiotherapy in the Management of Postural Orthostatic Tachycardia Syndrome (POTS)

Postural Orthostatic Tachycardia Syndrome (POTS) is a condition that affects the autonomic nervous system, particularly the body's ability to regulate blood flow and blood pressure when moving from a lying down to an upright position. The condition should atleast last for 3–6 months without presence of any chronic condition.

 

3 Main Types of Postural Orthostatic Tachycardia Syndrome

 

Causes of Postural Orthostatic Tachycardia Syndrome 

The causes of Postural Orthostatic Tachycardia Syndrome (POTS) are varied and often multifactorial. While the exact cause of POTS is not fully understood, several factors and conditions have been associated with its development:

• Autonomic Nervous System Dysfunction
• Hypovolemia
• Deconditioning - due to prolonged periods of inactivity.
• Autoimmune Disorders - like lupus, Sjögren's syndrome and celiac disease
• Mast Cell Activation Syndrome (MCAS)
• Genetic Predisposition - such as Ehlers-Danlos Syndrome (EDS)
• Infections - such as mononucleosis, Lyme disease or Epstein-Barr virus
• Hormonal Changes - worsen with menstruation, pregnancy or menopause
• Trauma or Surgery - particularly to the head or neck
• Small Fiber Neuropathy
• Diabetes - particularly those with diabetic neuropathy
• Anemia

 

Clinical Presentation of Postural Orthostatic Tachycardia Syndrome 

Other symptoms include:

• Dyspnea
• Raynaud's Phenomenon
• Venous Pooling
• Limb Edema
• Heat Intolerance
• Cognitive Impairment
• Concentration Problems
• Anxiety
• Dizziness

 

Diagnosing Postural Orthostatic Tachycardia Syndrome

Patient History

• Ask about the key symptoms of POTS, such as dizziness, rapid heart rate, fatigue, palpitations, headaches, nausea, and any instances of fainting or near-fainting. Specifically, focus on how these symptoms are triggered or worsened by standing or changing positions.
• Investigate any history of viral infections, autoimmune disorders, recent surgeries or trauma. Note any family history of similar symptoms or conditions.

 

Orthostatic Vital Signs Assessment

Heart Rate and Blood Pressure Measurement:

• Lying Down: Measure the patient's heart rate and blood pressure after they have been lying down for at least 5 minutes.
• Standing Up: Have the patient stand up and immediately measure their heart rate and blood pressure. Continue to monitor these parameters at 1-minute intervals for up to 10 minutes.
• Positive POTS Indicator: An increase in heart rate of 30 beats per minute or more (40 bpm in adolescents) within 10 minutes of standing, without a significant drop in blood pressure, is indicative of POTS.

 

Functional Testing

Standing Test:

• Observe the patient as they move from lying or sitting to standing. Monitor for symptoms like dizziness, palpitations or lightheadedness. Note any postural instability or difficulty maintaining an upright position.

Exercise Tolerance Test:

• Perform a submaximal exercise test or have the patient perform mild physical activities. Assess their heart rate response, level of fatigue and any onset of symptoms during or after the activity.

 

Physical Examination

Assessment of Autonomic Symptoms:

• Check for signs of autonomic dysfunction, such as abnormal sweating, cold extremities or skin color changes when the patient changes position.

Neurological Examination:

• Screen for any neurological deficits or abnormalities that might indicate co-existing conditions, such as small fiber neuropathy.

 

Important Diagnostic Tests to Consider

Head-up Tilt Test

• There is a significant increase in heart rate (typically an increase of 30 beats per minute or more) without a significant drop in blood pressure upon standing. The test can help distinguish POTS from other conditions like orthostatic hypotension.

24 (48)-h ECG Monitoring

• Although POTS primarily involves an exaggerated increase in heart rate upon standing, 24-hour ECG monitoring can help identify any arrhythmias that might occur during other activities or at rest, ensuring that other cardiac conditions are not mistaken for POTS.

External or Implantable Loop Recorders (ILRs)       

• ILRs can help detect episodes of tachycardia or other abnormal rhythms that might occur sporadically and are not captured by short-term monitoring methods. They are particularly useful in cases where symptoms are rare but concerning.

24-h Ambulatory BP Monitoring

• This test can help to rule out orthostatic hypotension (a significant drop in blood pressure upon standing) and other blood pressure abnormalities. It also provides insights into how blood pressure correlates with heart rate and symptoms throughout the day.         

Exercise ECG

• In POTS patients, the exercise ECG can reveal an exaggerated heart rate response to exercise. It is also used to rule out other cardiovascular conditions like ischemic heart disease or exercise-induced arrhythmias that could mimic or exacerbate POTS symptoms.          

Echocardiography

• In patients with POTS, echocardiography is usually normal. However, it is essential for ruling out other conditions such as cardiomyopathies, valvular heart disease, or congenital heart defects that might be causing or contributing to symptoms.

 

Postural Orthostatic Tachycardia Syndrome Checklist

 

Differential Diagnoses

• Orthostatic Hypotension
• Vasovagal Syncope
• Chronic Fatigue Syndrome (CFS)
• Anxiety Disorders
• Deconditioning
• Adrenal Insufficiency
• Inappropriate Sinus Tachycardia
• Hyperthyroidism
• Ehlers-Danlos Syndrome (EDS)
• Small Fiber Neuropathy
• Mast Cell Activation Syndrome (MCAS)
• Diabetes Mellitus (with autonomic neuropathy)
• Anemia
• Mitral Valve Prolapse
• Hypovolemia
• Neurocardiogenic Syncope
• Pheochromocytoma
• Cardiomyopathy

 

Physiotherapy Management of Postural Orthostatic Tachycardia Syndrome

Education and Symptom Management

• Educate the patient about POTS, focusing on the importance of pacing and avoiding symptom triggers.
• Instruct the patient to monitor heart rate and symptoms throughout the day and during exercises.
• Teach strategies to manage symptoms when standing, like crossing the legs, tightening the thigh muscles or shifting weight.

 

General Exercise Program Includes

Initial Focus on Recumbent Exercise:

• Recumbent Cycling: Use a recumbent bike, starting with 5-10 minutes of low-resistance cycling. Gradually increase time and resistance as tolerated.
• Rowing Machine: Begin with 5 minutes on a low resistance setting. Focus on smooth, controlled movements and gradually increase the duration.
• Swimming or Water Aerobics: Perform exercises in water, which reduces gravitational stress on the cardiovascular system. Start with gentle swimming or water walking on treadmill.

Progression to Upright Exercises:

• Treadmill Walking: Start with 5-10 minutes at a slow pace. Gradually increase the duration and speed, paying close attention to symptoms.
• Elliptical Trainer: Begin with short sessions at low resistance. This machine is less stressful than running but more upright than recumbent cycling.
• Walking Outdoors: Begin with short, flat walks, gradually increasing distance and speed.

Strength Training:

• Leg Press: Perform 2-3 sets of 10-15 reps with light weights. Focus on controlled movements.
• Calf Raises: Stand with feet shoulder-width apart and slowly raise onto the balls of your feet. Perform 2-3 sets of 10-15 reps.
• Wall Squats: With your back against a wall, slowly lower into a squat position. Hold for 10-20 seconds and repeat 2-3 times.

Cool Down:

• Gentle Stretching: After exercise, stretch the major muscle groups, holding each stretch for 20-30 seconds.
• Seated Breathing Exercises: Perform deep diaphragmatic breathing for 5-10 minutes in a seated or lying position to help the body cool down and reduce heart rate.

Physical Conditioning and Functional Activities

Graded Exposure to Upright Postures:

• Seated to Standing: Practice moving from sitting to standing slowly, holding the standing position for progressively longer periods.
• Sit-to-Stand Exercises: From a seated position, stand up slowly without using your hands. Perform 10-15 reps, gradually increasing as tolerated.

Functional Training:

• Step-Ups: Step up onto a low platform or step, alternating legs. Start with 5-10 reps on each side and increase gradually.
• Walking with Gradual Incline: Start on a flat surface, and as tolerance improves, introduce slight inclines to improve endurance.

Breathing and Relaxation Techniques

Diaphragmatic Breathing:

Practice deep breathing by placing one hand on the chest and the other on the abdomen. Breathe in slowly through the nose, ensuring the abdomen rises more than the chest. Practice for 5-10 minutes daily.

Progressive Muscle Relaxation:

Tense each muscle group for 5 seconds, then slowly release. Start from the feet and work up to the head. This helps reduce stress and autonomic symptoms.

Postural and Balance Training

Balance Exercises:

Single-Leg Stance: Stand on one leg for 20-30 seconds, then switch. Use a chair for support if needed.

Tandem Walking: Walk in a straight line placing one foot directly in front of the other. Perform for 10-15 feet and gradually increase distance.

Core Strengthening:

Planks: Start in a forearm plank position, holding for 10-20 seconds. Gradually increase the duration as strength improves.

Bridging: Lie on your back with knees bent and feet flat. Lift your hips to form a straight line from shoulders to knees. Hold for 5-10 seconds and repeat 10-15 times.

What More to Consider?

Fluid and Salt Intake:

• POTS patients should aim to drink up to 3 liters of water daily.
• Clinicians should provide support and positive reinforcement to help patients maintain hydration.
• A high-sodium diet (up to 10 g NaCl daily) is beneficial and can reduce orthostatic tachycardia; salt tablets should be avoided due to possible gastrointestinal issues.
• Normal saline infusions can provide quick relief during POTS crises but aren't a long-term solution due to risks with vascular access.

Environmental Considerations:

• Advise avoiding hot environments and using cooling techniques, like cooling vests or staying in air-conditioned spaces.

Exercise, crucial for managing POTS, is the only intervention shown to improve the aldosterone ratio and increase blood volumes. A multidisciplinary approach is essential: refer patients for Cognitive-Behavioral Therapy (CBT) if anxiety or depression affects coping, encourage support group participation, and regularly reassess and adjust exercise programs based on symptoms. Collaborate closely with the healthcare team to ensure coordinated care.