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.

Cardiorespiratory physiotherapy can play an important role in supporting individuals with both POTS and broader dysautonomia presentations. For simplicity, this article focuses on POTS, although many of the same principles apply more broadly across dysautonomia conditions.

What is POTS?

When someone 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 symptoms such as dizziness, palpitations, fatigue, shortness of breath, chest discomfort, and occasionally fainting.

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

Because POTS affects multiple body systems, management is usually multidisciplinary and may involve doctors, cardiologists, physiotherapists, exercise physiologists, psychologists, dietitians, and workplace or school support networks.

The Autonomic Nervous System and POTS

The autonomic nervous system regulates the balance between the sympathetic “fight or flight” response and the parasympathetic “rest and digest” response. In people with POTS, this balance is often disrupted, with increased sympathetic activity and reduced parasympathetic tone.

This imbalance can impair blood distribution when standing and contributes to many of the hallmark symptoms of POTS. Although medications can sometimes help, conservative management strategies are widely regarded as first line treatment and are often effective in improving long term outcomes.

The Role of Breathing in POTS

Research increasingly suggests that many individuals with POTS also experience breathing pattern disorders. These may include shallow upper chest breathing, mouth breathing, or chronic over breathing.

These dysfunctional patterns can lower carbon dioxide dioxide levels in the blood, leading to narrowing of blood vessels, reduced blood flow to the brain, and worsening symptoms such as dizziness, breathlessness, and anxiety.

Breathing retraining aims to restore calm, efficient, and physiologically appropriate breathing patterns. This can support improved autonomic regulation, better circulation and oxygen delivery, and reduced symptom severity.

Physiotherapy management should always be individualised and tailored to the person’s presentation. Treatment may include breathing pattern assessment, pacing strategies, symptom awareness, mindfulness and relaxation techniques, and graded rehabilitation programs.

Inspiratory Muscle Training and Diaphragm Function

An often overlooked aspect of POTS management is the role of the breathing muscles, particularly the diaphragm. In some people 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, early fatigue, and increased breathlessness.

The diaphragm is the primary muscle of breathing and plays an important role not only in ventilation but also in supporting venous return to the heart, assisting pressure regulation within the abdomen and thorax, and contributing to core stability.

When diaphragm function is poor, people may rely more heavily on upper chest breathing, which is less efficient and can worsen symptoms such as dizziness, fatigue, and shortness of breath. Reduced diaphragm function may also impair the “respiratory pump” effect that helps return blood from the lower body to the heart, an important factor in POTS.

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

IMT may help improve diaphragm strength and endurance, reduce breathlessness during daily activities, improve exercise tolerance, support autonomic regulation, and enhance circulation and venous return.

Training is usually prescribed at a low, individualised intensity and progressed gradually as tolerated. Sessions are generally short and manageable, but consistency is important to achieve meaningful improvements.

CO₂ Retraining and Breathing Efficiency

Another important aspect of physiotherapy management in POTS is carbon dioxide oxide retraining. Many people with dysfunctional breathing chronically over breathe, often with larger than average breaths, which lowers carbon dioxide oxide levels in the blood.

Although this may seem harmless, carbon D oxide plays a critical role in regulating blood flow, oxygen delivery, and nervous system balance.

Low carbon dioxide oxide levels can contribute to reduced blood flow to the brain, increased nervous system sensitivity and anxiety, persistent breathlessness despite normal oxygen levels, and worsening overall POTS symptoms.

CO₂ retraining focuses on restoring normal tolerance and regulation of carbon dioxide outside through controlled breathing techniques. This may involve slowing the breathing rate, encouraging nasal breathing, reducing excessive breath volume, and introducing gentle breath holds where appropriate.

The aim is to normalise the body’s sensitivity to carbon dioxide and improve overall breathing efficiency. These techniques are best taught by an experienced physiotherapist, often with the support of capnography feedback.

Improving carbon dioxide regulation may help enhance cerebral blood flow, reduce dizziness and lightheadedness, improve autonomic nervous system balance, and decrease symptoms of breathlessness and anxiety.

Conclusion

Respiratory physiotherapy can play a central role in the conservative management of POTS. By addressing breathing patterns, improving physical conditioning, and supporting autonomic regulation, including diaphragm function, inspiratory muscle strength, and healthy carbon dioxide balance, many individuals can experience meaningful improvements in symptoms and quality of life.

A structured and holistic physiotherapy approach can help patients regain confidence, build resilience, and work toward long term recovery.

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

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