PoTS and exercise: why it is difficult and what the evidence says

The NHS describes postural tachycardia syndrome as a condition in which symptoms occur when you stand up and may improve when you sit or lie down. These include dizziness or light-headedness, noticeable heartbeats, chest pain, shortness of breath, shaking and sweating, and fainting or nearly fainting. The NHS also lists weakness and extreme tiredness, not being able to do much exercise, and sleeping badly among the other symptoms.

Upright exercise, particularly in the heat, asks the circulation to cope with exactly the circumstances that provoke symptoms. The researchers behind a 2025 UK feasibility trial describe activities of daily living as impaired in PoTS, compounded by progressive exercise intolerance and deconditioning. In other words, symptoms make people do less, doing less reduces fitness, and reduced fitness can make symptoms harder to manage. This cycle is the main reason exercise rehabilitation is of interest.

The NHS page on PoTS includes exercise on both sides of its advice. Exercise is listed among the things that can make symptoms worse, and so is resting too much. Under things you can do, it suggests that you try gentle exercise, such as walking, pilates and swimming, and adds that you should be careful when exercising and stop if you have any symptoms.

The page also lists practical measures that are often used alongside activity: drinking plenty of fluids until your pee is pale, raising the head of the bed, wearing support tights to improve blood flow, avoiding standing for too long and not getting up too quickly after lying down. If you suddenly feel faint or dizzy, it suggests lying down and raising your legs, or, if that is not possible, crossing your legs while standing, rocking up and down on your toes, or clenching your buttocks, tummy muscles or fists.

• Drink plenty of fluids before and after activity, as the NHS advises generally for PoTS.

• Stop if symptoms come on, and rest lying down if you can.

• Be aware that getting too hot and being on your period are listed by the NHS as things that can worsen symptoms.

• Sit for a while before standing after lying down.

The PULSE trial, published in BMJ Open in 2025, was a feasibility randomised controlled trial run at two NHS secondary care centres, with PoTS UK and NHS clinicians among the authors. It recruited adults aged 18 to 60 with PoTS. The exercise programme was designed with people with PoTS and had three parts: an individual online consultation, 12 weeks of supervised online group exercise with behavioural and motivational support, and a home exercise programme using a recumbent exercise bike. The comparison group received a single one-to-one session of best-practice advice.

In total 209 people were screened and 44 were randomised, 98% of whom were female, to usual care (21) or the programme (23). The median attendance was 15 of 18 live sessions. Home exercise bike use was highly variable, and the authors note that it was self-reported and may be subject to bias. There were two serious adverse events in each group, both judged unrelated to the trial.

The authors concluded that the trial procedures and interventions were acceptable and that a definitive trial of remotely supervised exercise rehabilitation is feasible in the NHS. They are explicit that the study was designed to test feasibility rather than to prove that the programme improves outcomes, so it cannot be used as evidence that any particular exercise plan works.

The sources do not give a prescribed exercise plan, and the NHS does not set targets, so the following reflects the general direction of the advice rather than a protocol. A GP, specialist or physiotherapist familiar with PoTS can tailor it to you.

Starting at a level you can tolerate, and progressing slowly, fits the NHS suggestion to be careful and stop when symptoms occur. The PULSE programme used a recumbent bike, meaning one where the body is supported in a reclined position, which reduces the upright stress on the circulation, and the authors describe the exercise intensity as guided by perception of effort rather than by objective measures. Pacing, hydration and avoiding heat are consistent with the NHS lists of triggers.

It is worth noting that PoTS can coexist with other conditions. The NHS says you may be more likely to have PoTS if you have long COVID, myalgic encephalomyelitis or chronic fatigue syndrome, or joint hypermobility syndrome. Where such conditions are present, activity planning may need extra care, and it is a good reason to agree the approach with a clinician.

The NHS advises seeing a GP if you have symptoms of PoTS. A GP may check blood pressure and heart rate before and after standing, sometimes repeated in an active stand test, and may arrange blood tests and an electrocardiogram. Referral to a specialist may follow if lifestyle changes do not help, if you are very unwell or if the cause is unclear, and further tests can include echocardiography, 24-hour monitoring and a tilt table test.

Treatment described by the NHS starts with lifestyle changes: more fluids, small meals with fewer carbohydrates and compression clothing. Medicines such as fludrocortisone or beta blockers may be tried. Some people choose private cardiology or autonomic clinics for assessment, which can offer quicker appointments, but the tests and lifestyle principles are broadly the same.

The NHS lists chest pain and fainting among PoTS symptoms, but these can also have other causes. Call 999 for chest pain that does not settle or a collapse; for non-urgent worries, the NHS advises seeing a GP.