When people hear about “POTS” (short for Postural Orthostatic Tachycardia Syndrome) they often jump straight to the heart. After all, one of the hallmark symptoms is an abnormally fast heart rate with standing. But here’s the thing: POTS is not just a cardiac condition. It’s a form of autonomic nervous system dysfunction, and it affects far more than just your pulse.
At Marino Physiotherapy, we specialize in helping patients with complex conditions like POTS who have often been dismissed, misdiagnosed, or told “it’s all in your head.” We’re here to say: we see you, we believe you, and we can help.
What Is the Autonomic Nervous System?
Your autonomic nervous system (ANS) controls all the behind-the-scenes operations that keep your body balanced, like regulating your heart rate, blood pressure, digestion, breathing, temperature, and even your ability to sweat. In POTS, this system loses its balance, especially when you go from lying down to standing. Instead of calmly adjusting blood flow and heart rate to keep you safely upright, the system misfires and fails to regulate the system efficiently. Your heart may race, your blood vessels may fail to constrict, and symptoms flood in:
- Dizziness or lightheadedness
- Nausea
- Brain fog
- Fatigue or shakiness
- Shortness of breath
- Temperature dysregulation
And often, those symptoms change from day to day, which only adds to the confusion and, unfortunately, the invalidation many POTS patients experience when seeking care.
Why It’s Not Just a “Heart Problem”
Because the heart rate is so visibly affected, many people (even medical providers) mislabel POTS as purely cardiovascular. However, that view is incomplete, often leading to treatment that misses the mark.
Here’s what we know:
- POTS is a disorder of the autonomic nervous system, not a heart muscle problem.
- The variability of symptoms, some days being functional, other days feeling completely disabled, is a common and
expected result of nervous system dysregulation, not someone imagining issues. - It affects the entire body, including the GI system, cognition, temperature regulation, and emotional regulation.
When care focuses only on the heart, patients miss out on real, functional strategies that improve quality of life. And worse, many are told there’s nothing wrong when test results come back “normal.” Let us be clear: you can be symptomatic even when your labs are fine.
Our physical therapists often use the following treatments:
POTS-informed physical therapy for dizziness, exercise intolerance, and nervous system dysfunction is a huge part of the management and recovery process.
Nervous system retraining.
Breath work, vagal toning, and orienting practices support nervous system retraining through evidence-based regulation and graded exposure that promotes physiologic adaptation. These techniques calm the body’s stress response, improve heart rate variability, and support long-term resilience.
Graded upright tolerance.
Progressive activity is introduced in a safe, step-by-step manner, beginning with recumbent or semi-reclined exercises. Over time, this gradual progression helps patients tolerate sitting and standing without overwhelming symptoms.
Targeted strengthening.
Exercises focused on the core, legs, and postural muscles help improve circulation, stability, strength, and overall functional status. Improved muscle tone can better support blood flow and reduce dizziness or fatigue during daily activities, but, again, is only one piece of the puzzle.
Energy management strategies.
Through pacing techniques and concepts like “spoon theory,” patients learn to recognize and respect their body’s limits. This approach reduces the intensity and frequency of symptom flare-ups and promotes consistent progress.
Empowerment and self-trust.
POTS-informed physical therapy emphasizes rebuilding confidence in the body. By shifting focus from fear to empowerment, patients learn they can safely engage in movement and regain independence over time with appropriate strategy, physical improvements, and autonomic recalibration.
Collaboration with your Recovery Team
While POTS-informed physical therapy is a cornerstone of negotiating the recovery process, it is best managed in collaboration with other medical providers that specialize in the unique presentation that is YOUR POTS condition. Your Recovery Team typically includes your physical therapist and your primary care physician (or pediatrician), who will help you prioritize which other professionals need a spot in your Recovery Team lineup. This Team typically includes some combination of the following:
- Cardiologist
- Neurologist
- Endocrinologist
- Psychiatrist
- Gastroenterologist
- Electrophysiologist
- Nutritionist/Dietitian
- Rheumatologist
- Psychologist
- Pain specialist
- Integrative Recovery Coach
- Personal trainer
To Our POTS Community: You Are Not Making This Up or Imagining Your Symptoms
These symptoms are real and involuntary – not something you’re choosing or exaggerating. We know that POTS often comes with frustration, fear, and the pain of not being believed. Many patients have seen multiple specialists, only to be told their symptoms are anxiety, laziness, or “too inconsistent to be real.” In reality, when symptoms don’t follow a straight line, it doesn’t mean they’re imagined, it typically means the nervous system is involved.
We are here to say:
- Your symptoms are real, even when standard tests don’t capture them.
- What you’re experiencing is genuine, not imagined or exaggerated.
- Your body is responding to a real physiologic process.
- These symptoms reflect how your nervous system is functioning, not a lack of effort or motivation.
We believe in validating your lived experience and building a plan that gets you back to the things that matter.
Who needs POTS care at Marino Physiotherapy?
Is This You?
You might benefit from a POTS-informed physical therapy evaluation if you:
- You have been told “your tests are normal” but still don’t feel normal
- Your symptoms don’t quite add up, fluctuate from day to day, or fall outside the “typical” POTS
checklist - You’ve pulled back from activity due to symptoms, fear, or uncertainty—and want a plan that adapts to your body instead of pushing through it
If you nodded along to even one of these, you’re exactly who we help. A POTS-informed physical therapy evaluation can uncover what’s truly driving your symptoms and identify the individual factors shaping your best path forward.
Ready to Move Forward?
If you’ve been feeling stuck, discouraged, or unsure where to turn, let’s talk. We offer a safe space, an empathetic ear, specialized support, and a collaborative approach to managing POTS that puts your needs first.
We see the whole person, not just the heart rate. A POTS-informed evaluation helps us understand how your nervous system, movement tolerance, and daily demands interact—so we can build a plan that fits your body and your life
Call or text us to schedule an evaluation with our POTS-informed therapists at 865-236-0340
Or reach out with questions; we’re here for you.
POTS FAQ
What is POTS and how is it different from general dysautonomia?
POTS (Postural Orthostatic Tachycardia Syndrome) is a form of dysautonomia where the heart rate rises abnormally when moving upright, leading to lightheadedness, fatigue, and exercise intolerance. It’s related to, and has some shared characteristics with, general dysautonomia.
Does physical therapy help POTS?
Yes. While symptom-aware, graded activity has been shown to improve upright tolerance, circulation, and confidence, our POTS specialists have developed a more comprehensive management strategy utilizing the latest research and clinical expertise of the nation’s leaders in management options. Our Knoxville team builds individualized plans that not only progress from reclined to upright activities safely, but also include the oft-misse musculoskeletal and nutritional components, along with educating you in the real-world management strategies to get you back to living the life you love and deserve.
What are the best exercises for POTS? How do I start exercising with POTS without crashing?
A more useful question than “What exercises are best for POTS?” is “Where should I begin with POTS management?” There is no single ideal program, because POTS is highly individual and exercise tolerance is influenced by far more than heart rate or standing time alone.
In general, most people start with short, low-intensity sessions in reclined or supported positions, such as supine or side-lying strengthening, and may later progress to options like rowing, a recumbent bike, or swimming. From there, the program is gradually adjusted by increasing duration, intensity, and vertical demand — not all at once, and not on a fixed timeline.
Equally important is pacing. Planned rest days, interval-based work, and symptom-guided progression are essential to avoid post-exertional crashes. If you have not had an evaluation and program workup with a POTS specialist, this is a great first step. It is important not to just blindly follow a set program. This means avoiding “pushing through” preset targets and instead adapting the plan to your tolerance, recovery response, and symptom patterns. It is typical that your POTS clinician will have to modify your plan based on your individual tolerance and symptoms rather than forcing fixed targets, timelines, and protocols.
Finally, exercise selection and progression must account for individual modifiers such as
- heat tolerance
- spine and flexibility issues
- altered breathing patterns
- maladaptive pelvic floor strategies
- nutritional and hydration imbalance
- visual discoordination,
- general fatigue and malaise
- brain fog
- heavy legs
- shortness of breath
- headache/migraine
- Fainting and lightheadedness
While most people may hop into a New Year’s workout without issue, POTS patients are usually advised to consult with a clinical specialist to establish a workout plan to ensure both safety AND effectiveness. It is not unusual for individuals with POTS to give up on physical fitness goals due to the workout making symptoms worse or fear of fainting/safety concerns while exercising.
My doctor said this is probably just “Anxiety”
We hear this all the time – you are not alone. Our patients are often reporting physical symptoms similar to those attributed to anxiety. These include (but are not limited to):
- alterations in heart rate, breathing, and/or digestive function
- sweating
- muscular guarding and tension
- feelings of unrest or discomfort with holding still
- heart palpitations
These are often attributed to anxiety when they don’t clearly follow a diagnostic checklist. Often our patients will report that their “body ‘feels’ anxious” but the mind does not, which can be quite disconcerting. Again, this condition has a wide range of presentations, so you want a skilled and experienced POTS clinician helping you identify your individual pattern and path forward.
How do I start exercising with POTS without crashing?
The typical recommendations are to begin short, low-intensity sessions in reclined positions, then gradually increase time, intensity, and vertical nature of the training. You would also be encouraged to make sure to schedule rest days, and incorporate an understanding of the appropriate pacing/intervals for your specific presentation. If you have not had an evaluation and program workup with a POTS specialist, this is a great first step. It is also important not to just blindly follow a set program as typically we have to adjust your plan based on your individual tolerance and symptoms rather than forcing fixed targets and protocols.
Should I use salt, fluids, or compression for POTS?
Many patients benefit from medical guidance on hydration, electrolytes, and compression garments. We coordinate
with your Knoxville clinician so your PT plan aligns with medical recommendations to ensure dosing and use is
appropriate for your individual findings, activity level, and body composition/size.
How long before I notice improvement?
Timelines vary by patient, status, and influencing factors. Typical POTS management via consistent graded exercise often improves tolerance over several weeks. At Marino Physiotherapy, our comprehensive approach and inclusion of patient specific education often offers you in-the-moment relieving strategies and planning to limit POTS exacerbations, resulting in faster and more functional gains. We track progress with simple, functional measures you’ll feel in daily life.
What are some other useful articles for helping me to understand my condition better (for those who like data)?
Patients with POTS often see 5-7 providers & wait up to 5 years from symptom onset to official diagnosis (https://www.nhlbi.nih.gov/events/2019/postural-orthostatic-tachycardia-syndrome-pots-state-science-clinical-c
are-and-research?)
There’s a strong association between POTS and hEDS/HSD, around 30–50 % of people with POTS meet criteria for
hypermobile EDS or have generalized joint hypermobility. (https://pmc.ncbi.nlm.nih.gov/articles/PMC7282488/)
Brain fog is associated with changes in cerebral blood flow and autoregulation in POTS, particularly with
orthostatic stress and impaired neurovascular coupling—not exclusively heart rate alone. https://pubmed.ncbi.nlm.nih.gov/19502561/
Dr. Salah is from South Carolina and brings expertise to the team in the areas of exercise science and advanced clinical reasoning in orthopedics. His specialized training and research into autonomic dysregulation and comprehensive management of complex conditions has made him the foremost provider of POTS-informed clinical care in the region. He is the head of the Marino Physio’s Comprehensive POTS Treatment Team and is a resource for other clinicians in creative management strategies as well as integrative options for those whose condition is complicated by EDS and hypermobility issues. He is currently pursuing advanced level training within the American Academy Orthopedic Manual Therapists as well as with ASPIRE OMT. He has a fitness forward mindset and is the resident assessor of new research and findings that advance clinical practice. When he is not flexing his brain in the office, he is a social guy and enjoys checking out all that Knoxville has to offer!
