What are the non-pharmacological recommendations for managing Postural Orthostatic Tachycardia Syndrome (POTS)?

Non-Pharmacological Management of POTS

All patients with POTS should begin with aggressive non-pharmacological interventions including 2-3 liters of fluid daily, 5-10 grams of dietary sodium, waist-high compression garments, and a structured exercise program starting with horizontal exercises before progressing to upright activities. 1, 2

Fluid and Salt Management

Volume expansion forms the cornerstone of initial therapy:

• Increase daily fluid intake to 2-3 liters per day to maintain adequate blood volume and reduce orthostatic symptoms 1
• Increase dietary sodium to 5-10 grams (1-2 teaspoons of table salt) daily 1
• Avoid salt tablets due to gastrointestinal side effects; instead use liberalized dietary sodium intake 1
• Short-term salt supplementation (approximately 3 months) improves susceptibility to syncope, increases plasma volume, and enhances peripheral vascular responses to orthostatic stress 3
• Salt supplementation is most effective in patients with baseline urinary sodium excretion <170 mmol/day 3
• Oral fluid loading has a pressor effect and may require less volume than intravenous infusion 1

Compression Therapy

Reduce venous pooling with external compression:

• Use waist-high compression garments or abdominal binders extending at least to the xiphoid for sufficient venous return 1, 2
• Compression reduces venous pooling in lower extremities during orthostatic stress 1

Physical Counter-Maneuvers

Teach patients immediate symptom relief techniques:

• Perform leg-crossing, squatting, stooping, and muscle tensing during symptomatic episodes 1, 2
• Squeeze a rubber ball to increase peripheral resistance 1
• Use negative-pressure breathing techniques 2
• These maneuvers provide immediate relief when symptoms occur 1

Exercise Training Program

Structured physical reconditioning is critical and should be initiated early:

• Start with horizontal exercise (rowing, swimming, recumbent bike) to avoid upright posture that triggers symptoms 2
• Progressively increase duration and intensity as fitness improves 2
• Gradually add upright exercise as tolerated once baseline fitness is established 2
• Supervised training is preferable to maximize functional capacity 2
• Exercise addresses the cardiovascular deconditioning (cardiac atrophy and hypovolemia) that significantly contributes to POTS 2

Positional Strategies

Optimize fluid distribution during sleep:

• Elevate the head of the bed by 10 degrees during sleep to prevent nocturnal polyuria, maintain favorable fluid distribution, and promote chronic volume expansion 1
• This intervention helps with chronic volume expansion over time 1

Acute Symptom Management

For immediate symptom relief during episodes:

• Rapid cool water ingestion can be effective in combating orthostatic intolerance 1
• Implement physical counter-maneuvers as described above 1

Medication Review

Critical medication adjustments:

• Carefully adjust or withdraw any medications that may cause hypotension 1
• Avoid medications that lower CSF pressure or reduce blood pressure as they may exacerbate postural symptoms 1
• Avoid medications that inhibit norepinephrine reuptake 1

Monitoring Response to Treatment

Track specific functional outcomes:

• Monitor peak symptom severity 1
• Assess time able to spend upright before needing to lie down 1
• Track cumulative hours able to spend upright per day 1
• Follow up at 24-48 hours initially, 10-14 days for intermediate assessment, and 3-6 months for late follow-up 1
• Monitor standing heart rate and symptom improvement to assess treatment response 1

Important Caveats

The evidence supporting non-pharmacological interventions is stronger than for most pharmacological treatments, though randomized clinical trials are still needed to fully evaluate efficacy 2. These interventions should be implemented simultaneously rather than sequentially, as they address different pathophysiologic mechanisms and work synergistically 4. For patients with heart rates reaching 180 bpm, perform cardiac evaluation to rule out other arrhythmias before attributing symptoms solely to POTS 1.