POTS — Postural Orthostatic Tachycardia Syndrome
What is POTS?
Postural Orthostatic Tachycardia Syndrome — POTS — is a form of dysautonomia, a dysfunction of the autonomic nervous system that governs automatic body functions including heart rate, blood pressure, digestion and temperature regulation. In POTS, the autonomic system fails to adequately compensate for changes in posture — particularly moving from lying or sitting to standing — resulting in an abnormal increase in heart rate of 30 beats per minute or more within ten minutes of standing, without a significant drop in blood pressure.
The experience of POTS is often described as feeling like running a marathon while standing still. Symptoms can include rapid or pounding heartbeat on standing, dizziness and lightheadedness, brain fog and difficulty concentrating, extreme fatigue, nausea, headaches, blurred vision, shakiness and exercise intolerance. Symptoms typically improve or resolve on lying down, which is a characteristic feature that distinguishes POTS from many other conditions with overlapping presentations.
POTS is far more common than previously recognised. Estimates suggest it affects between one and three million Australians, with the vast majority being women between the ages of fifteen and fifty. It gained significantly wider public awareness following the COVID-19 pandemic, with post-COVID POTS emerging as one of the more common long COVID presentations. Australian POTS Foundation is the peak Australian patient organisation for POTS and related conditions and provides excellent resources for patients and families.
What causes POTS?
POTS is not a single disease but a syndrome with multiple potential underlying mechanisms. In many patients it is associated with Ehlers-Danlos Syndrome or hypermobility spectrum disorders — the connection is thought to relate to hypermobile blood vessels that pool blood in the lower body on standing rather than constricting normally, combined with reduced venous return to the heart. Understanding and addressing the hypermobility component is often central to effective POTS management in this population.
Other recognised triggers and associations include viral illness (including COVID-19), autoimmune conditions, pregnancy, significant blood loss or dehydration, prolonged bed rest or deconditioning, and certain medications. In some patients no clear precipitant is identified. The Ehlers-Danlos Society provides detailed information on the relationship between connective tissue disorders and dysautonomia.
How is POTS diagnosed?
POTS is diagnosed by a physician or cardiologist using a tilt table test or an active stand test — measuring heart rate and blood pressure responses to postural change over a ten-minute period. A sustained heart rate increase of 30 beats per minute or more on standing (or 40 beats per minute in those aged under nineteen) in the absence of orthostatic hypotension meets the diagnostic criteria. Diagnosis also involves ruling out other conditions that can cause similar symptoms including anaemia, thyroid disorders, adrenal insufficiency and structural cardiac problems.
The diagnostic journey for many POTS patients is frustratingly long — the average time from symptom onset to diagnosis in Australia is reported at several years. If you suspect you may have POTS and haven't yet received a formal diagnosis, Australian POTS Foundation maintains a list of knowledgeable clinicians.
How can physiotherapy and exercise physiology help?
Exercise is one of the most evidence-based interventions for POTS, but it is also one of the most misunderstood — both by patients and by some healthcare providers. Standard exercise advice is often counterproductive for POTS patients, and a programme that works well for the general population can significantly worsen symptoms if applied without understanding the condition.
The evidence-based exercise approach to POTS is grounded in a structured, graduated recumbent training protocol — starting with horizontal or semi-reclined exercises that avoid the orthostatic challenge of upright activity, and very gradually progressing toward more upright positions as cardiovascular adaptation improves. The most well-studied protocol for POTS is the Levine Protocol, developed at the Institute for Exercise and Environmental Medicine in Dallas, which has been shown to produce meaningful and sustained improvement in POTS symptoms over a three to six month period in the majority of patients who complete it.
At Articulate, our approach to POTS management is built around this evidence base but adapted to each individual's presentation, co-occurring conditions, symptom severity, and exercise tolerance. We begin with a thorough assessment of functional capacity and symptom triggers before prescribing any exercise, and we progress conservatively — the goal is to build cardiovascular and autonomic adaptation without triggering symptom flares that set recovery back.
Pacing is a critical skill that many POTS patients struggle with, particularly those who are high achievers and push through symptoms instinctively. We work with patients to understand their symptom patterns and energy envelope, and to structure their activity accordingly. Post-exertional symptom worsening — sometimes called a "crash" — is a sign that activity has exceeded the patient's current capacity, and it is something we work actively to avoid rather than push through.
For patients with co-occurring hypermobility, joint pain, cervical instability or atlantoaxial instability, we integrate management of these conditions into the overall program rather than treating POTS in isolation. The interaction between these conditions is significant — poorly managed hypermobility can perpetuate POTS symptoms, and poorly managed POTS can make hypermobility rehabilitation much more difficult.
Non-exercise components of POTS management — including hydration and salt loading strategies, compression garments, positional strategies and sleep positioning — are covered in our education sessions and coordinated with the patient's treating physician.
Our physiotherapist Yulia Khasyanova has specific experience in POTS and dysautonomia management, particularly in patients with co-occurring Ehlers-Danlos Syndrome and hypermobility spectrum disorders. She holds multiple certifications through the Ehlers-Danlos Society and is one of a small number of physiotherapists in Brisbane with specialist training in this area. Our Exercise Physiologist Ash O'Regan works alongside Yulia for patients who benefit from a combined physiotherapy and exercise physiology approach to cardiovascular and functional rehabilitation.
Hypermobility Connect Australia is a valuable peer support and information resource for Australians living with POTS and related conditions.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
Postural Orthostatic Tachycardia Syndrome — POTS — is a form of dysautonomia, a dysfunction of the autonomic nervous system that governs automatic body functions including heart rate, blood pressure, digestion and temperature regulation. In POTS, the autonomic system fails to adequately compensate for changes in posture — particularly moving from lying or sitting to standing — resulting in an abnormal increase in heart rate of 30 beats per minute or more within ten minutes of standing, without a significant drop in blood pressure.
The experience of POTS is often described as feeling like running a marathon while standing still. Symptoms can include rapid or pounding heartbeat on standing, dizziness and lightheadedness, brain fog and difficulty concentrating, extreme fatigue, nausea, headaches, blurred vision, shakiness and exercise intolerance. Symptoms typically improve or resolve on lying down, which is a characteristic feature that distinguishes POTS from many other conditions with overlapping presentations.
POTS is far more common than previously recognised. Estimates suggest it affects between one and three million Australians, with the vast majority being women between the ages of fifteen and fifty. It gained significantly wider public awareness following the COVID-19 pandemic, with post-COVID POTS emerging as one of the more common long COVID presentations. Australian POTS Foundation is the peak Australian patient organisation for POTS and related conditions and provides excellent resources for patients and families.
What causes POTS?
POTS is not a single disease but a syndrome with multiple potential underlying mechanisms. In many patients it is associated with Ehlers-Danlos Syndrome or hypermobility spectrum disorders — the connection is thought to relate to hypermobile blood vessels that pool blood in the lower body on standing rather than constricting normally, combined with reduced venous return to the heart. Understanding and addressing the hypermobility component is often central to effective POTS management in this population.
Other recognised triggers and associations include viral illness (including COVID-19), autoimmune conditions, pregnancy, significant blood loss or dehydration, prolonged bed rest or deconditioning, and certain medications. In some patients no clear precipitant is identified. The Ehlers-Danlos Society provides detailed information on the relationship between connective tissue disorders and dysautonomia.
How is POTS diagnosed?
POTS is diagnosed by a physician or cardiologist using a tilt table test or an active stand test — measuring heart rate and blood pressure responses to postural change over a ten-minute period. A sustained heart rate increase of 30 beats per minute or more on standing (or 40 beats per minute in those aged under nineteen) in the absence of orthostatic hypotension meets the diagnostic criteria. Diagnosis also involves ruling out other conditions that can cause similar symptoms including anaemia, thyroid disorders, adrenal insufficiency and structural cardiac problems.
The diagnostic journey for many POTS patients is frustratingly long — the average time from symptom onset to diagnosis in Australia is reported at several years. If you suspect you may have POTS and haven't yet received a formal diagnosis, Australian POTS Foundation maintains a list of knowledgeable clinicians.
How can physiotherapy and exercise physiology help?
Exercise is one of the most evidence-based interventions for POTS, but it is also one of the most misunderstood — both by patients and by some healthcare providers. Standard exercise advice is often counterproductive for POTS patients, and a programme that works well for the general population can significantly worsen symptoms if applied without understanding the condition.
The evidence-based exercise approach to POTS is grounded in a structured, graduated recumbent training protocol — starting with horizontal or semi-reclined exercises that avoid the orthostatic challenge of upright activity, and very gradually progressing toward more upright positions as cardiovascular adaptation improves. The most well-studied protocol for POTS is the Levine Protocol, developed at the Institute for Exercise and Environmental Medicine in Dallas, which has been shown to produce meaningful and sustained improvement in POTS symptoms over a three to six month period in the majority of patients who complete it.
At Articulate, our approach to POTS management is built around this evidence base but adapted to each individual's presentation, co-occurring conditions, symptom severity, and exercise tolerance. We begin with a thorough assessment of functional capacity and symptom triggers before prescribing any exercise, and we progress conservatively — the goal is to build cardiovascular and autonomic adaptation without triggering symptom flares that set recovery back.
Pacing is a critical skill that many POTS patients struggle with, particularly those who are high achievers and push through symptoms instinctively. We work with patients to understand their symptom patterns and energy envelope, and to structure their activity accordingly. Post-exertional symptom worsening — sometimes called a "crash" — is a sign that activity has exceeded the patient's current capacity, and it is something we work actively to avoid rather than push through.
For patients with co-occurring hypermobility, joint pain, cervical instability or atlantoaxial instability, we integrate management of these conditions into the overall program rather than treating POTS in isolation. The interaction between these conditions is significant — poorly managed hypermobility can perpetuate POTS symptoms, and poorly managed POTS can make hypermobility rehabilitation much more difficult.
Non-exercise components of POTS management — including hydration and salt loading strategies, compression garments, positional strategies and sleep positioning — are covered in our education sessions and coordinated with the patient's treating physician.
Our physiotherapist Yulia Khasyanova has specific experience in POTS and dysautonomia management, particularly in patients with co-occurring Ehlers-Danlos Syndrome and hypermobility spectrum disorders. She holds multiple certifications through the Ehlers-Danlos Society and is one of a small number of physiotherapists in Brisbane with specialist training in this area. Our Exercise Physiologist Ash O'Regan works alongside Yulia for patients who benefit from a combined physiotherapy and exercise physiology approach to cardiovascular and functional rehabilitation.
Hypermobility Connect Australia is a valuable peer support and information resource for Australians living with POTS and related conditions.
To book or find out more, call us on 07 3706 3407 or book online below. We see patients from across Brisbane's southside including Tarragindi, Coorparoo, Holland Park, Greenslopes and Mt Gravatt.
