Understanding POTS: A Cardiorespiratory Physiotherapy Approach to Management

Understanding POTS: A Cardiorespiratory Physiotherapy Approach to Management

Dysautonomia refers to a disorder of the autonomic nervous system—the system responsible for regulating essential bodily functions such as heart rate, blood pressure, digestion, and temperature control. One of the more commonly recognised forms of dysautonomia is Postural Orthostatic Tachycardia Syndrome (POTS), a condition that primarily affects heart rate regulation and circulation.

Expert Cardiorespiratory Physiotherapy plays an important role in supporting individuals with both POTS and broader dysautonomia presentations. For simplicity, this article focuses on POTS, though many of the principles apply across Dysautonomia generally.

What is POTS?

When a person with POTS moves from lying down to standing, their heart rate increases excessively—typically by more than 30 beats per minute in adults or exceeding 120 beats per minute—without a significant drop in blood pressure. This abnormal response can lead to a range of symptoms, including:

• Dizziness or lightheadedness
• Palpitations
• Fatigue
• Shortness of breath
• Chest discomfort
• Occasional fainting

POTS often affects young women but can occur in anyone. It is commonly triggered by events such as viral illness (including COVID-19), concussion or trauma, growth spurts, or periods of prolonged inactivity.

Because POTS impacts multiple systems, effective management usually requires a multidisciplinary approach. This may include input from doctors, cardiologists, physiotherapists, exercise physiologists, psychologists, dietitians, and workplace or school support networks.

The Autonomic Nervous System and POTS

The autonomic nervous system controls the balance between the sympathetic (“fight or flight”) and parasympathetic (“rest and digest”) systems. In individuals with POTS, this balance is disrupted—often with increased sympathetic activity and reduced parasympathetic tone.

This imbalance leads to poor blood distribution when standing and contributes to many of the hallmark symptoms. While medications can play a role, conservative management strategies are widely regarded as first-line treatment and are often highly effective in improving long-term outcomes.

The Role of Breathing in POTS

Emerging research shows that many individuals with POTS also develop breathing pattern disorders. These may include:

• Shallow, upper chest breathing
• Mouth breathing
• Chronic over-breathing (hyperventilation)

These patterns can reduce carbon dioxide (CO₂) levels in the blood, leading to vasoconstriction (narrowing of blood vessels), reduced blood flow to the brain, and worsening symptoms such as dizziness, breathlessness, and anxiety.

Breathing Retraining

Breathing retraining focuses on restoring calm, efficient, and physiologically appropriate breathing patterns. This supports:

• Improved autonomic regulation
• Better circulation and oxygen delivery
• Reduced symptom severity

Physiotherapy-led management of POTS is always individualised and tailored to each person’s presentation. Key components may include:

• Respiratory control and breathing pattern assessment
• Pacing and symptom awareness
• Mindfulness and relaxation strategies
• Individualised rehabilitation programs

Inspiratory Muscle Training and Diaphragm Function

An often overlooked component of POTS management is the role of the breathing muscles—particularly the diaphragm. In some individuals with POTS, the diaphragm may be underactive or poorly coordinated, while accessory muscles in the neck and chest become overactive. This can contribute to inefficient breathing patterns, early fatigue, and increased breathlessness.

Diaphragm Weakness and Dysfunction

The diaphragm is the primary muscle of breathing and plays a key role not only in ventilation but also in:

• Supporting venous return to the heart
• Assisting pressure regulation within the abdomen and thorax
• Contributing to core stability

If the diaphragm is weak or not functioning optimally, individuals may rely more heavily on upper chest breathing. This is less efficient and can exacerbate symptoms such as dizziness, fatigue, and shortness of breath. Poor diaphragm function may also reduce the “respiratory pump” effect that helps return blood from the lower body to the heart—an important factor in POTS.

Inspiratory Muscle Training (IMT)

Inspiratory Muscle Training (IMT) is a targeted physiotherapy intervention designed to strengthen the muscles involved in breathing, particularly the diaphragm. This is typically performed using a handheld resistance device that provides load during inhalation.  Correct technique, and very low load is essential, and this must be prescribed by an experienced physiotherapist.

IMT can help to:

• Improve diaphragm strength and endurance
• Reduce breathlessness during daily activities
• Enhance exercise tolerance
• Support better autonomic regulation
• Improve venous return and circulation

Training is usually prescribed at an individualised intensity, often starting at a very low resistance and gradually progressing as strength improves. Sessions are short and manageable but require consistency to achieve meaningful results.

CO₂ Retraining and Breathing Efficiency

Another key component of physiotherapy management in POTS is carbon dioxide (CO₂) retraining. Many individuals with dysfunctional breathing chronically over-breathe, usually with bigger than average breaths (and less commonly with hyperventilation), which lowers CO₂ levels in the blood. While this may seem harmless, CO₂ plays a crucial role in regulating blood flow, oxygen delivery, and nervous system balance.

Low CO₂ levels can lead to:

• Reduced blood flow to the brain (contributing to dizziness and “brain fog”)
• Increased nervous system sensitivity and anxiety
• Greater breathlessness despite normal oxygen levels
• Worsening of POTS symptoms overall

What is CO₂ Retraining?

CO₂ retraining focuses on restoring normal tolerance and regulation of carbon dioxide levels through controlled breathing techniques. This often involves:

• Slowing the breathing rate
• Encouraging nasal breathing
• Reducing excessive breath volume
• Introducing gentle breath holds where appropriate

The goal is to normalise the body’s sensitivity to CO₂ and improve overall breathing efficiency.  Again these exercises are best taught by an experienced physiotherapist and with specific capnotherapy feedback.

Why It Matters in POTS

By improving CO₂ regulation, physiotherapy can help:

• Enhance cerebral blood flow
• Reduce dizziness and lightheadedness
• Improve autonomic nervous system balance
• Decrease symptoms of breathlessness and anxiety

Other Key Management Strategies

It is important to note that specific management strategies must also be optimised in POTS.

• Hydration: Aim for 2–3 litres of fluid daily to support blood volume.
• Compression: Waist-high garments can reduce blood pooling in the legs.
• Exercise: Start with gentle, recumbent exercise and progress gradually to improve tolerance.
• Pacing & Sleep: Balance activity with rest and prioritise good sleep habits.
• Diet: Small, regular meals with adequate electrolytes can help stabilise symptoms.
• Medical Input: Ongoing support from a doctor or cardiologist is often important.

Conclusion

Respiratory Physiotherapy plays a central role in the conservative management of POTS. By addressing breathing patterns, improving physical conditioning, and supporting autonomic regulation—including strengthening the diaphragm, improving inspiratory muscle function, and restoring healthy CO₂ balance—individuals can achieve meaningful improvements in symptoms and quality of life.

A structured, holistic physiotherapy approach helps patients regain control, build resilience, and move toward long-term recovery.

If you or someone you know is experiencing symptoms of POTS or dysautonomia, seeking early physiotherapy support can make a significant difference.

Author: Scott Peirce, Breathing Works Physiotherapy, Auckland, New Zealand

References

•      Reilly CC, Floyd SV, Lee K, Warwick G, James S, Gall N, Rafferty GF. Breathlessness and dysfunctional breathing in patients with postural orthostatic tachycardia syndrome (POTS): The impact of a physiotherapy intervention. Auton Neurosci. 2020 Jan;223:102601. doi: 10.1016/j.autneu.2019.102601. Epub 2019 Nov 12. PMID: 31743851.

•      Loughnan A, Gall N, James S. Observational case series describing features of cardiopulmonary exercise testing in Postural Tachycardia Syndrome (PoTS). Auton Neurosci. 2021 Mar;231:102762. doi: 10.1016/j.autneu.2020.102762. Epub 2020 Dec 16. PMID: 33348296.

•      Reilly CC, Floyd SV, Raniwalla S, Gall N, Rafferty GF. The clinical utility of the Breathing Pattern Assessment Tool (BPAT) to identify dysfunctional breathing (DB) in individuals living with postural orthostatic tachycardia syndrome (POTS). Auton Neurosci. 2023 Sep;248:103104. doi: 10.1016/j.autneu.2023.103104. Epub 2023 Jun 17. PMID: 37393657.

•      Lau DH, Fedorowski A, Raj SR, Schild C, Pace LA, Blitshteyn S, Raj V, Boris JR, Kavi L, Seeley MC, Gallagher C. Postural Orthostatic Tachycardia Syndrome: A State-of-the-Art Review. Heart Lung Circ. 2026 Feb;35(2):171-185. doi: 10.1016/j.hlc.2025.09.004. Epub 2026 Jan 9. PMID: 41519610.

•      Eastin EF, Machnik JV, Stiles LE, Larsen NW, Seliger J, Geng LN, Bonilla H, Yang PC, Miglis MG. Chronic autonomic symptom burden in long-COVID: a follow-up cohort study. Clin Auton Res. 2025 Feb 5. doi: 10.1007/s10286-025-01111-1. Epub ahead of print. PMID: 39907931.

•      Day H, Yellman B, Hammer S, Rond C, Bell J, Abbaszadeh S, Stoddard G, Unutmaz D, Bateman L, Vernon SD. Cognitive impairment in post-acute sequelae of COVID-19 and short duration myalgic encephalomyelitis patients is mediated by orthostatic hemodynamic changes. Front Neurosci. 2023 Jun 26;17:1203514. doi: 10.3389/fnins.2023.1203514. PMID: 37434760; PMCID: PMC10330752.

•      Elbeltagi R, Al-Beltagi M, Saeed NK, Bediwy AS. COVID-19-induced gastrointestinal autonomic dysfunction: A systematic review. World J Clin Cases. 2023 Aug 6;11(22):5252-5272. doi: 10.12998/wjcc.v11.i22.5252. PMID: 37621592; PMCID: PMC10445067.

•      Dhingra K, Salisbury BH, Chakko MN. Doppler Extra-Cranial Carotid Assessment, Protocols, and Interpretation. 2023 Aug 21. In: StatPearls [Internet] . Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PMID: 34033386.

•      Tomer Cramer, Shlomo Yeshurun, Merav Mor; Changes in Exhaled Carbon Dioxide during the Menstrual Cycle and Menopause. Digit Biomark 18 June 2024; 8 (1): 102–110. https://doi.org/10.1159/000539126

•      Stick M, Leone A, Fischer F, Schulz JB, Maier A. Deep abdominal breathing reduces heart rate and symptoms during orthostatic challenge in patients with postural orthostatic tachycardia syndrome. Eur J Neurol. 2024 Oct;31(10):e16402. doi: 10.1111/ene.16402. Epub 2024 Jul 4. PMID: 38962840; PMCID: PMC11414806.

•      Mehta P, Rosas IO, Singer M. Understanding post-COVID-19 interstitial lung disease (ILD): a new fibroinflammatory disease entity. Intensive Care Med. 2022 Dec;48(12):1803-1806. doi: 10.1007/s00134-022-06877-w. Epub 2022 Sep 8. PMID: 36074167; PMCID: PMC9453725.

•      Woo MS, Shafiq M, Fitzek A, Dottermusch M, Altmeppen H, Mohammadi B, Mayer C, Bal LC, Raich L, Matschke J, Krasemann S, Pfefferle S, Brehm TT, Lütgehetmann M, Schädler J, Addo MM, Schulze Zur Wiesch J, Ondruschka B, Friese MA, Glatzel M. Vagus nerve inflammation contributes to dysautonomia in COVID-19. Acta Neuropathol. 2023 Sep;146(3):387-394. doi: 10.1007/s00401-023-02612-x. Epub 2023 Jul 15. PMID: 37452829; PMCID: PMC10412500.

•      Wood J, Tabacof L, Tosto-Mancuso J, McCarthy D, Kontorovich A, Putrino D. Levels of end-tidal carbon dioxide are low despite normal respiratory rate in individuals with long COVID. J Breath Res. 2021 Dec 8;16(1). doi: 10.1088/1752-7163/ac3c18. PMID: 34808607.

•      Schondorf R, Low PA. Idiopathic postural orthostatic tachycardia syndrome: an attenuated form of acute pandysautonomia? Neurology. 1993 Jan;43(1):132-7. doi: 10.1212/wnl.43.1_part_1.132. PMID: 8423877.

•      Raj SR, Guzman JC, Harvey P, Richer L, Schondorf R, Seifer C, Thibodeau-Jarry N, Sheldon RS. Canadian Cardiovascular Society Position Statement on Postural Orthostatic Tachycardia Syndrome (POTS) and Related Disorders of Chronic Orthostatic Intolerance. Can J Cardiol. 2020 Mar;36(3):357-372. doi: 10.1016/j.cjca.2019.12.024. PMID: 32145864.

•      Shaw BH, Stiles LE, Bourne K, Green EA, Shibao CA, Okamoto LE, Garland EM, Gamboa A, Diedrich A, Raj V, Sheldon RS, Biaggioni I, Robertson D, Raj SR. The face of postural tachycardia syndrome - insights from a large cross-sectional online community-based survey. J Intern Med. 2019 Oct;286(4):438-448. doi: 10.1111/joim.12895. Epub 2019 Apr 16. PMID: 30861229; PMCID: PMC6790699.

•      Gamboa A, Paranjape SY, Black BK, Arnold AC, Figueroa R, Okamoto LE, Nwazue VC, Diedrich A, Plummer WD, Dupont WD, Robertson D, Raj SR. Inspiratory resistance improves postural tachycardia: a randomized study. Circ Arrhythm Electrophysiol. 2015 Jun;8(3):651-8. doi: 10.1161/CIRCEP.114.002605. Epub 2015 Mar 19. PMID: 25792354; PMCID: PMC4472504.