The POTS exercise protocol
A 12 week plan that starts lying down and ends upright. Exercise is the POTS treatment with the strongest evidence.
From Dr. Kenny Civello, cardiologist and electrophysiologist
Upright exercise brings on POTS symptoms. Lying down or seated exercise does not. You build fitness first, then move upright slowly.
A stronger heart
Many people with POTS have a slightly smaller heart and less blood volume. In the Dallas study, 3 months of training grew both and lowered standing heart rate.
Most finishers improved
In a registry of 251 patients, 103 finished. Of those, 71 in 100 no longer met the definition of POTS.
Finishing is the hard part
More than half did not finish. That is why the plan starts small and builds slowly.
Before you start
Get your starting numbers
Do the 10 minute stand test and write down your heart rate lying down and after standing. Repeat it at week 6 and week 12.
Have the basics in place
Fluid, salt, and compression make exercise easier. See the four daily basics.
Pick your machine
A recumbent bike, rowing machine, or pool. A used recumbent bike at home makes it easier to stick with.
Check with us first
Especially if you have fainted during exercise, have chest pain, or have another heart condition.
The 12 weeks
Check off each week as you finish it. Your progress stays on this device. If a week feels too hard, repeat it. Moving slower is fine.
Each session
Before
Drink 16 ounces of fluid with salt. Put on compression if you use it.
Warm up
5 minutes, easy.
Pace
You can talk but not sing. Breathe steadily. Do not hold your breath.
Cool down
5 minutes, easy, still on the machine. Do not stop and stand still.
Log it
Minutes, heart rate if you have it, and how you felt from 0 to 10.
Avoid
Heat, hot tubs, and big meals right before. They pull blood away from your brain.
Strength, twice a week
Strong legs and core squeeze blood back up to your heart. Keep strength work in all 12 weeks.
Weeks 1 to 4: on the floor
Bridges, leg lifts, clamshells, side planks. 2 sets of 10.
Weeks 5 to 8: seated
Leg press, seated row, chest press, and calf raises on a machine.
Weeks 9 to 12: standing
Wall sits, squats to a chair, and step ups, with something to hold.
When to stop
- Chest pain or pressure
- You feel like you will faint, or you do faint
- Shortness of breath that is far more than the effort
- A heartbeat that stays fast or irregular after you rest
Call us before your next session. Call 911 for fainting, chest pain, or any symptom that worries you.
Common questions
What is the Levine protocol, or Dallas protocol?
The original POTS exercise program, built by Dr. Benjamin Levine and Dr. Qi Fu in Dallas. It starts on a recumbent bike or rower, builds time and effort, then moves upright over about 3 months. The plan on this page follows the same steps.
What is the CHOP protocol for POTS?
A version of the Dallas program used at Children’s Hospital of Philadelphia for teens. The idea is the same: start lying down, build slowly, then move upright.
Do I need physical therapy for POTS?
Not always. Many people can follow this plan at home. A physical therapist who knows POTS helps if you do not know where to start, if you keep stalling at the same week, or if you also have joint hypermobility.
What heart rate should I aim for?
Use the talk test. You should be able to talk but not sing. If you use a watch or chest strap, ask us for a target range that fits you.
Is walking enough?
Walking is upright, so it is harder with POTS than it looks. Start lying down or seated. Walking comes in month 3.
Can I do yoga or Pilates?
Floor based classes are a good fit early on. Avoid moves that take you quickly from lying to standing, and avoid hot rooms.
I feel worse. Should I stop?
Feeling more tired in the first 2 to 3 weeks is common, and it passes. Drop back to the last week that felt manageable and rebuild. Stop and call us for the warning signs below.
I missed a week. Do I start over?
No. Drop back one week and rebuild from there.
Can I stop after 12 weeks?
No. The gains fade within weeks if you stop. Keep at least 3 to 4 sessions a week for good.
Is exercise a cure for POTS?
For many people it is the most effective treatment we have. In the Dallas studies, most people who finished the program no longer met the definition of POTS. Not everyone gets there, and it works best alongside fluid, salt, and compression.
This page is general education for my patients. It does not replace advice from your own doctor. Talk with us before you start an exercise program.
Based on: Sheldon RS, et al. 2015 Heart Rhythm Society Expert Consensus Statement on the Diagnosis and Treatment of Postural Tachycardia Syndrome, Inappropriate Sinus Tachycardia, and Vasovagal Syncope. Heart Rhythm. 2015;12(6):e41-e63.
Studies cited: Fu Q, et al. Cardiac origins of the postural orthostatic tachycardia syndrome. J Am Coll Cardiol. 2010;55(25):2858-2868. Fu Q, et al. Exercise training versus propranolol in the treatment of the postural orthostatic tachycardia syndrome. Hypertension. 2011;58(2):167-175. George SA, et al. The international POTS registry: evaluating the efficacy of an exercise training intervention in a community setting. Heart Rhythm. 2016;13(4):943-950. Ziaks L, et al. Adaptive approaches to exercise rehabilitation for postural tachycardia syndrome and related autonomic disorders. Arch Rehabil Res Clin Transl. 2024;6(4):100366.