Orthostatic Intolerance & POTS
A clinical guide to Postural Orthostatic Tachycardia Syndrome (POTS) and Orthostatic Intolerance (OI). What it is, how it's diagnosed, and how The DAN Protocol, our structured, recumbent-first exercise method, can help you manage it.
What are POTS and Orthostatic Intolerance?
Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia, a dysfunction of the autonomic nervous system that regulates heart rate, blood pressure and blood flow. When a person with POTS moves from lying or sitting to standing, their heart rate rises abnormally (≥30 bpm in adults, ≥40 bpm in adolescents) without a matching drop in blood pressure.
Orthostatic Intolerance (OI) is the broader umbrella term for difficulty tolerating an upright posture. Symptoms appear on standing and ease when lying down. POTS is one specific, well-defined form of OI.
Both conditions come down to the same underlying problem: when you stand, roughly 500 to 700 mL of blood shifts to your legs and abdomen. Normally the nervous system compensates instantly with a small heart rate increase and vasoconstriction. In POTS and OI, that compensation is inefficient, insufficient, or excessive, leaving less blood returning to the heart and brain.
How We Help
I'm Daniel O'Sullivan, Exercise Physiologist at Accelr8 Rehab in Weetangera, Belconnen. Every POTS and OI program we build starts with The DAN Protocol, our own method for Deliberate Autonomic Normalisation. It's deliberate movement targeting the nervous system's response to posture and load, starting lying and seated, done consistently until your body can handle more.
From there we combine individualised movement with remedial massage to support circulation and manage the muscular fallout of deconditioning. We work alongside your GP or specialist rather than replacing them, handling the exercise and hands-on side of your management plan.
POTS and OI are also commonly associated with chronic fatigue syndrome / ME and Long COVID, so if either of those sound familiar too, it's worth mentioning at your first session.
It's Worth Reading This If You Have
Unexplained Dizziness or Fatigue
Especially in women and teenage girls with postural dizziness, brain fog or fatigue that doesn't have a clear cause on standard testing.
Long COVID or Post-Viral Symptoms
Studies show a large proportion of people with ongoing Long COVID symptoms meet the criteria for POTS. If your fatigue started after a viral illness, this is worth investigating.
Hypermobility, EDS or Chronic Fatigue
POTS commonly overlaps with hypermobile Ehlers-Danlos Syndrome, hypermobility spectrum disorder, migraine and ME/CFS.
Common Symptoms of POTS & OI
These symptoms can be worsened by dehydration, heat, large meals, alcohol, prolonged standing and menstruation.
Three Things You Can Do Right Now
These are the same first-line strategies used in POTS management programs, safe to start before or alongside a formal diagnosis, and the foundation of what we build on in clinic.
Exercise the Right Way
Start horizontal, not upright. Recumbent cycling, rowing or swimming lets you recondition your cardiovascular system without triggering symptoms. Add light resistance work for the legs. Upright exercise is reintroduced gradually as tolerance improves.
Increase Salt & Fluid
Gradually build to around 10g of dietary salt and 3L of fluid per day (if medically appropriate for you), taken together, since water alone doesn't expand blood volume. Avoid concentrated salt tablets, which can cause nausea.
Elevate & Compress
Raise the head of your bed 20 to 30cm to encourage blood volume retention overnight. Firm, full-length compression garments help return blood from the legs to the heart during the day.
"The epidemic of orthostatic intolerance and orthostatic tachycardia is an epidemic of disease recognition."
David Robertson MD, 1999How POTS Is Diagnosed
Diagnosis is clinical, not a single blood test. The internationally recognised criteria are:
- Unexplained symptoms of orthostatic intolerance for 3 months or more.
- Sustained heart rate increase within 10 minutes of standing: ≥30 bpm in adults, ≥40 bpm in adolescents, or an absolute rate ≥120 bpm.
- Absence of orthostatic hypotension in the first 3 minutes of standing (a drop of ≥20/10 mmHg would point elsewhere).
GPs can screen for this with a simple 10-minute active stand test: lying heart rate and blood pressure, then standing readings at set intervals. Blood tests, an ECG/Holter monitor and an echocardiogram are often used to rule out reversible causes first: thyroid disorders, anaemia, iron or vitamin D deficiency, and structural or rhythm problems with the heart.
A simple rule of thumb: does your heart rate consistently go up on standing and settle back down when you lie back down? If so, POTS is worth investigating with your GP.
When it's probably not POTS: fainting without any warning signs, fainting that causes injury, fainting unrelated to standing, or seizure-like activity with incontinence or a clear post-seizure recovery phase. These need urgent medical assessment, not an exercise program.
How POTS Is Managed
Management targets the same underlying problem from four angles. Lifestyle strategies are first-line and where we focus in clinic; medication is a conversation for you and your GP or specialist.
Blood Volume
- Oral salt & fluid loading
- Structured cardiovascular exercise
- Medication such as fludrocortisone (GP-prescribed)
Vasopressor Support
- Firm compression garments
- Medication such as midodrine (GP-prescribed)
Heart Rate
- Deep breathing / vagal techniques
- Individualised movement progression
- Medication such as beta-blockers (GP-prescribed)
Trigger Avoidance
- Heat, large meals, prolonged standing
- Alcohol and dehydration
- Pacing to avoid post-exertional crashes
This page is general information, not a substitute for individual medical advice. See your GP to confirm a diagnosis and discuss whether medication is appropriate for you.
Frequently Asked Questions
What's the difference between POTS and Orthostatic Intolerance?
OI is the umbrella term for any difficulty tolerating an upright posture. POTS is one specific, clinically defined type of OI, identified by a sustained heart rate rise on standing without a matching drop in blood pressure.
Do I need a referral to see you for POTS?
No referral is required to book, though we'll usually recommend confirming the diagnosis with your GP first, and we're happy to work alongside a referral if you have one from a GP or specialist.
Will exercise make my POTS worse?
It can, done the wrong way. Jumping straight into upright, high-intensity exercise often triggers symptoms. Done the right way, starting recumbent and building gradually, exercise reconditioning is one of the most evidence-supported ways to improve POTS.
Is POTS related to Long COVID?
Yes, a substantial proportion of people with ongoing Long COVID symptoms meet the diagnostic criteria for POTS. Viral illness, including COVID-19, is one of the most common known triggers.
Can POTS be cured?
There's currently no single cure, but most people can significantly improve their symptoms and function with the right combination of lifestyle management, individualised movement and, where appropriate, medication.
How long does diagnosis usually take?
Often longer than it should be. POTS is still under-recognised and can be mistaken for anxiety. If your GP suspects it, a 10-minute active stand test in the clinic is a fast, low-cost first step.
Start Managing Your POTS or OI
Based in Weetangera, Belconnen. Book a chat to talk through your symptoms, or book straight in for a session.
This page provides general information and does not replace individual medical advice. Always consult your GP or specialist for diagnosis and treatment decisions.