Postural Orthostatic Tachycardia Syndrome (POTS) is a disorder of the autonomic nervous system, characterized by an abnormal increase in heart rate upon standing. This condition is a form of orthostatic intolerance, meaning the body struggles to manage the shift from lying down to an upright position. For many people with POTS, attempting physical activities like running is profoundly challenging due to symptom flares. While exercise is beneficial for managing the condition, running is a high-demand, upright activity that requires careful medical management and specialized guidance.
Physiological Hurdles to Upright Exercise
The primary challenge in POTS is the body’s inability to effectively counteract the gravitational pull on blood volume when standing or exercising in an upright posture. Normally, when a person stands, blood vessels in the lower body constrict slightly, and the heart rate increases modestly to maintain blood flow to the brain and heart. For individuals with POTS, this reflex is dysfunctional, leading to excessive blood pooling in the abdomen and lower extremities. This pooling reduces the amount of blood returning to the heart (venous return), which consequently lowers the heart’s stroke volume. To compensate, the autonomic nervous system triggers an excessive and rapid increase in heart rate, a state called compensatory tachycardia.
This disproportionate heart rate response during running can lead to lightheadedness, dizziness, fatigue, and pre-syncope. Sustained upright exercise significantly increases the body’s demand for blood flow, intensifying the core physiological problem. The combination of gravity-induced blood pooling and the body’s over-reliance on a high heart rate often results in exercise intolerance. This excessive cardiovascular strain makes maintaining a running pace extremely difficult and can easily trigger a symptom flare, known as post-exertional malaise.
Low-Impact Alternatives to Running
To build cardiovascular fitness without triggering severe orthostatic symptoms, starting with recumbent or semi-recumbent exercise is highly recommended. These activities minimize the intense gravitational stress on the circulatory system by keeping the body horizontal or supported. Recumbent cycling is often well-tolerated because the leg muscles actively pump blood back toward the heart without fighting gravity in a fully upright stance.
Swimming and water aerobics are also excellent choices, as the hydrostatic pressure of the water helps compress the body and prevent blood pooling in the lower limbs. For those who prefer gym equipment, using a rowing machine allows for a full-body workout while maintaining a seated position. Floor-based exercises, such as certain yoga poses, core strengthening routines, and seated resistance training, are useful for building muscle mass, especially in the legs, which can aid in venous return.
Essential Preparation Protocols
Before attempting any upright activity, careful preparation is necessary to increase blood volume and improve circulation. A primary non-pharmacological intervention involves chronic volume expansion through increased fluid and salt intake. Patients are advised to consume a high-sodium diet (3,000 to 10,000 milligrams daily) under medical supervision. This must be paired with significantly increased fluid consumption, typically aiming for at least two to three liters of water or electrolyte-enhanced fluids daily. The combination of salt and fluid helps to expand plasma volume, providing a larger reserve for the circulatory system during exercise. Extra fluid and electrolytes should be consumed both before and after exercise.
Another layer of preparation involves the use of medical-grade compression garments, which mechanically reduce venous pooling in the lower body. These garments should provide a compression strength of at least 20–30 mmHg and must extend high up the body, ideally covering the legs and including an abdominal binder. The compressive pressure prevents blood from accumulating in the extremities, assisting in the return of blood to the heart. When starting to run, it is imperative to begin with an extremely slow and short duration, perhaps alternating between running and walking, while avoiding rapid changes in posture.
Monitoring Symptoms and Medical Guidance
Anyone with POTS considering running must first establish an individualized exercise plan in consultation with a specialist, such as a cardiologist or dysautonomia expert. A supervised progression, sometimes based on protocols like the modified Levine Protocol, begins with recumbent work and gradually introduces upright exercise as tolerance improves. This gradual approach is crucial for cardiovascular reconditioning and avoiding post-exertional symptom flares.
During exercise, it is important to continuously monitor symptoms and use a heart rate monitor to stay within a safe, predetermined zone. Specific warning signs that require stopping the activity immediately include severe dizziness, chest pain, sudden vision changes, or pre-syncope. If symptoms become overwhelming, the safest response is to stop and lie down to facilitate blood flow back to the brain. The goal is to consistently challenge the body enough to promote fitness without triggering a severe symptomatic crash.