POTS (Postural Orthostatic Tachycardia Syndrome) Treatment in Southampton

Ian Greaves

MOst, Registered Osteopath (GOsC 11228), iO 106967]

Standing up to make a cup of tea and your heart suddenly races. Feeling dizzy when you get out of bed. That overwhelming fatigue that makes basic tasks feel impossible.

POTS (Postural Orthostatic Tachycardia Syndrome) is a form of autonomic dysfunction characterised by an excessive increase in heart rate, at least 30 beats per minute in adults, within 10 minutes of standing, without a significant drop in blood pressure (Sheldon et al., Heart Rhythm, 2015). It affects roughly 0.2–1% of the population, with more than 75% of patients being female (Sheldon et al., 2015). At Southampton Physio, we’re a hypermobility-specialist clinic, and POTS commonly sits alongside the hypermobility conditions we work with every day. We’re POTS-aware and can help you build exercise tolerance safely, adapt movement around your symptoms, and work alongside your medical team.

Is This What You're Feeling?

POTS symptoms often develop gradually and can be bewildering, especially when they don’t fit a clear pattern:

Rapid heart rate on standing. Your heart pounds or races when you stand up, sometimes taking minutes to settle.
Dizziness or lightheadedness. Feeling faint or unsteady when upright, particularly first thing in the morning.
Overwhelming fatigue. Exhaustion that's out of proportion to what you've done, often worse after being upright for a while.
Brain fog and difficulty concentrating. Struggling to focus, find words, or think clearly, especially when standing.
Exercise intolerance. Physical activity that once felt manageable now leaves you wiped out for days.

These symptoms often fluctuate. Some days are better than others, and heat, dehydration, or stress can make everything worse. It’s like living with an unpredictable internal thermostat that makes your body feel foreign to you.

Why Does POTS Develop?

POTS develops when the autonomic nervous system, the part that controls automatic functions like heart rate and blood pressure, doesn’t regulate blood flow properly when you stand up. In healthy circulation, blood vessels in your legs constrict when you stand, pushing blood back to your heart and brain like a well-tuned hydraulic system. In POTS, this mechanism fails, blood pools in your legs, and your heart rate spikes to compensate.

Several factors can trigger or contribute to POTS:

Post-viral illness. POTS has been increasingly recognised after COVID-19 infection. Research published in Circulation: Arrhythmia and Electrophysiology (2024) found that 31% of highly symptomatic long COVID patients were diagnosed with POTS
Hypermobility and connective tissue conditions. There's substantial overlap between POTS and joint hypermobility syndromes like Ehlers-Danlos Syndrome (EDS). Stretchy blood vessels may struggle to constrict effectively.
Reduced blood volume. Up to 70% of POTS patients have lower-than-normal blood volume, meaning less circulating fluid for the heart to pump (Sheldon et al., Heart Rhythm, 2015).
Deconditioning. Prolonged illness or inactivity can worsen POTS symptoms. Deconditioning doesn't cause POTS, but it can make symptoms significantly worse once POTS has developed.
Mast cell activation or immune changes. Some patients have underlying immune or inflammatory processes that affect autonomic function.

A 2024 review in the Journal for Nurse Practitioners reported that POTS diagnosis requires an average of seven clinician consultations, and nearly three-quarters of patients experience diagnostic delays. If you suspect POTS, it’s worth seeking assessment from a cardiologist or autonomic specialist who can perform tilt-table testing and confirm the diagnosis.

How Can Southampton Physio Help You Build Exercise Tolerance with POTS?

We don’t medically treat POTS, that remains within the scope of your GP, cardiologist, or autonomic specialist. What we offer is hypermobility-specialist physiotherapy and strength work that adapts thoughtfully around POTS symptoms, particularly where POTS sits alongside hypermobility or EDS.

Your First POTS-Aware Assessment

We’ll spend time understanding your POTS diagnosis, your symptoms, and what makes them better or worse. We’ll ask about your medical team’s input, any medications you’re on, and whether you have other conditions like hypermobility or ME/CFS that need consideration. We’re looking at how your autonomic symptoms affect movement, what positions you tolerate best, and where your current capacity sits. The outcome is a clear picture of what’s safe to start with and how to progress without triggering flare-ups.

Strength, Pilates and Clinical Personal Training

Our core offer for people with POTS is strength and movement work, often through Pilates or Clinical Personal Training, adapted carefully around autonomic symptoms. This is where our hypermobility specialism does the heavy lifting. For people whose joints are stretchy, whose fatigue limits volume, and whose orthostatic tolerance varies day to day, we know how to build strength without provoking flare-ups. We start with positions that reduce orthostatic stress, often recumbent or semi-recumbent, and progress as tolerance allows. The pace is yours, not a protocol’s.

Exercise Tolerance and the Evidence Base

The strongest evidence for improving POTS symptoms comes from structured exercise training. In a modified Levine protocol study by Gibbons and colleagues, only 23% of the exercise group still met POTS criteria at six months, compared to 93% of controls (cited in AmeriHealth Caritas, 2025). Of 251 patients who began the protocol, however, only 41% completed it. Structured POTS rehabilitation programmes of this kind are typically delivered by specialist autonomic services. We’re not a specialist POTS rehab service. What we offer is informed by these principles and applied within the strength, movement and hypermobility work that’s our day-to-day practice. This approach is consistent with the Heart Rhythm Society 2015 expert consensus statement (Sheldon et al., Heart Rhythm, 2015; Class IIa, Level of Evidence B).

What Exercises Are Safe with POTS?

The short answer: it depends on your subtype, severity, and comorbidities. The general principle is to start with positions that reduce orthostatic stress and gradually progress towards upright activity.

Recumbent and semi-recumbent exercises are the safest starting point:

As tolerance improves, you can introduce:

What to avoid early on:

If you have comorbid ME/CFS, graded exercise therapy (GET) is contraindicated. NICE guideline NG206 (2021) explicitly recommends against GET for ME/CFS due to the risk of post-exertional malaise (PEM). If you have both POTS and ME/CFS, exercise must be individually tailored, symptom-contingent, and never progressed on a fixed schedule.

How Are POTS and Hypermobility Connected?

There’s significant clinical overlap between POTS and hypermobility conditions, particularly Ehlers-Danlos Syndrome (EDS) and hypermobility spectrum disorders. The mechanism is thought to involve connective tissue itself: stretchy, elastic blood vessels may struggle to constrict effectively when standing, contributing to the blood pooling that drives POTS symptoms.

If you have both POTS and hypermobility, exercise needs careful modification:

Hypermobility is our specialist area, and the patients we see with POTS most often have hypermobility alongside it. That’s where our day-to-day expertise meets your situation.

What Should I Avoid with POTS?

Prolonged bed rest and complete inactivity.

POTS is not caused by deconditioning, but deconditioning makes it significantly worse. Even on bad days, gentle recumbent movement is preferable to complete inactivity.

Graded exercise therapy (GET) if you have ME/CFS.

If you have both POTS and ME/CFS, do not follow a standard graded exercise protocol. NICE guideline NG206 recommends against GET in ME/CFS due to the risk of post-exertional malaise. Exercise must be symptom-led, flexible, and never progressed on a fixed timeline.

Environmental triggers that worsen symptoms:

Hot environments (saunas, hot showers, warm weather)
Prolonged standing without movement
Dehydration or inadequate salt intake
Large meals, particularly high-carbohydrate
Alcohol consumption
High-intensity exercise before establishing tolerance

Activities that exceed your current capacity.

Pushing through severe fatigue, dizziness, or rapid heart rate isn’t building resilience. It’s often counterproductive and can trigger longer flare-ups.

When Should I See a Specialist for POTS?

If you have confirmed or suspected POTS, you should be under the care of a cardiologist or autonomic specialist who can confirm the diagnosis with tilt-table testing, rule out other cardiac or neurological conditions, and prescribe first-line medications if needed (such as fludrocortisone or midodrine).

Red flags requiring urgent medical attention:

Chest pain with syncope (fainting) or near-syncope
Syncope during exercise or exertion
Family history of sudden cardiac death
Structural heart disease identified on echocardiogram
Arrhythmias on ECG monitoring

If any of these apply, seek urgent cardiology assessment.

When should you see a physiotherapist for POTS support?
If you have hypermobility alongside POTS, or if you’re struggling to rebuild strength and movement around your autonomic symptoms, physiotherapy can provide structured guidance. We won’t replace the role of your autonomic specialist, but we can be a useful part of the team working alongside them.

What You Can Start Doing Today

While you’re waiting for assessment or alongside other input, there are evidence-based self-management strategies you can start now. These interventions are endorsed by the Heart Rhythm Society 2015 expert consensus statement as first-line, non-pharmacological care (Sheldon et al., Heart Rhythm, 2015; Class I, Level of Evidence B).

Increase fluid and salt intake. Aim for 2–3 litres of fluid daily and 10–12g of sodium (unless you have high blood pressure or kidney disease, check with your GP first). This addresses the reduced blood volume present in up to 70% of POTS patients.
Wear compression garments. Abdominal binders and compression stockings (20–30 mmHg) improve venous return and reduce blood pooling. Many people find abdominal compression particularly helpful.
Try recumbent exercise. A rowing machine or recumbent bike for short, low-intensity sessions (5–10 minutes) is the safest entry point for rebuilding exercise tolerance.

Why Choose Southampton Physio for POTS Support?

We’re a hypermobility-specialist clinic. POTS often sits alongside the hypermobility conditions we work with every day, and we’ve built the strength, Pilates and Clinical Personal Training side of our practice to adapt around the complexity that comes with autonomic involvement.

Our approach is:

Hypermobility-led. Our day-to-day expertise is hypermobility, EDS and the complex presentations that come with them. POTS often forms part of that picture.
POTS-aware. We understand the principles of POTS rehabilitation, recognise red flags, and adapt our work accordingly. We're not a POTS rehab service in the specialist autonomic sense, and we'll always tell you if your situation needs that level of input.
Patient-centred. We start where you are and adjust as you progress.
Collaborative. We work alongside your medical team. Your cardiologist or autonomic specialist leads on POTS itself.

"I've had 3 sessions with Ian now and they have been so helpful already and I'm really excited and optimistic to see my progress working with him. I have a fairly complex medical history but am seeing him predominantly for strength and conditioning training due to Hypermobility/EDS issues and his specialist understanding of it makes me feel so supported."

- Sophie Marshall

Our clinic is located at 35 Bedford Place, Southampton, SO15 2DG, and we see patients from across Southampton, Eastleigh, Winchester, and the wider Hampshire area.

Frequently Asked Questions About POTS in Southampton

Can physiotherapy help with POTS?

Yes, but with an important framing: physiotherapy doesn’t treat POTS medically, that’s the role of your cardiologist or GP. The strongest evidence-based intervention for POTS is structured exercise training, typically delivered through specialist autonomic services. We’re not a specialist POTS rehab clinic. We’re a hypermobility-specialist physiotherapy practice that adapts strength, movement and Pilates work around POTS symptoms, particularly where POTS sits alongside hypermobility.

What physio exercises can you do with POTS?

Start with recumbent or semi-recumbent exercises that don’t trigger upright symptoms: rowing machines, recumbent bikes, swimming, or supine strengthening. As tolerance improves over weeks and months, you gradually introduce more upright activity. The key is starting low, progressing slowly, and monitoring symptoms closely. If you have comorbid ME/CFS, exercise must be symptom-led, not protocol-driven.

What can trigger POTS to flare up?

Common triggers include heat (hot showers, warm weather), dehydration, prolonged standing without movement, alcohol, large meals (particularly high-carbohydrate), stress, and poor sleep. Hormonal changes, illness, and certain medications (diuretics, vasodilators) can also worsen symptoms. Identifying your personal triggers is an important part of self-management.

How do you treat POTS in the UK?

POTS management in the UK typically involves lifestyle modifications (increased fluid and salt intake, compression garments), structured exercise training, and medications if needed (such as fludrocortisone or midodrine). You’ll usually be under the care of a cardiologist or autonomic specialist. There’s no specific NICE guideline for POTS, but NICE NG206 on ME/CFS is relevant if you have both conditions.

Do you have POTS your whole life?

Not necessarily. Research suggests many POTS patients experience improvement over time, particularly with structured exercise and lifestyle management. The Heart Rhythm Society notes that POTS tends to improve with appropriate management, and there is no reported mortality from POTS itself (Sheldon et al., Heart Rhythm, 2015).

Can emotional trauma trigger POTS?

There’s limited direct evidence linking emotional trauma to POTS onset, but stress, anxiety, and trauma can worsen autonomic symptoms and may contribute to the overall picture in some cases. POTS is primarily a physical, autonomic dysfunction, but psychological factors can influence symptom severity and recovery.

Do I need a scan for POTS?

POTS is diagnosed clinically, typically with a tilt-table test or active stand test showing a heart rate increase of at least 30 bpm within 10 minutes of standing, without a significant drop in blood pressure. You don’t usually need a scan, but your cardiologist may order an echocardiogram or ECG to rule out structural heart problems or arrhythmias. If you have unexplained syncope, chest pain, or a family history of sudden cardiac death, further investigation is warranted.

How many sessions will I need?

That depends on what you’re working on with us. If you’re using us for strength, Pilates or Clinical Personal Training adapted around POTS, that’s usually a longer-term partnership, often 12–16 weeks or more, particularly if hypermobility is also in the picture. We’ll review progress regularly and adjust frequency as needed.

What should I do if I feel faint during exercise?

Stop immediately, lie down with your legs elevated, and wait for symptoms to settle. Dizziness or near-syncope during exercise is a sign you’ve exceeded your current tolerance. When you restart, drop the intensity or duration and progress more gradually. If you experience full syncope (fainting) during exercise, stop and seek medical review.

Can I exercise if I have both POTS and ME/CFS?

Yes, but the approach must be very different. Graded exercise therapy (GET) is contraindicated in ME/CFS per NICE NG206 due to the risk of post-exertional malaise (PEM). Exercise must be symptom-led, flexible, and never progressed on a fixed timeline. This requires specialist input. Standard POTS exercise protocols don’t apply.

Ready to Get Moving Again?

Living with POTS is challenging, but structured, evidence-based movement can make a meaningful difference. If you have hypermobility alongside POTS, or if you’re looking for a clinic that will work patiently and thoughtfully with you around your autonomic symptoms, we can help.

We’ll work within your limits, adapt around your symptoms, and build a plan that respects where you are now.

Book your POTS-aware assessment today or call us on 023 8110 2077 to discuss your situation.

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