Physical Therapy Management of Postural Orthostatic Tachycardia Syndrome Using a Pacing-Forward Clinical Approach: A Case Report, 2025, Powers et al

Physical Therapy Management of Postural Orthostatic Tachycardia Syndrome Using a Pacing-Forward Clinical Approach: A Case Report

Powers CD, Miranda NA, Davenport TE

Abstract
Objective: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of autonomic dysfunction that affects hemodynamic responses to position and movement, characterized by excessive tachycardia and orthostatic intolerance. Aerobic exercise historically has been recommended to improve cardiovascular function. However, some individuals living with POTS may not tolerate aerobic exercise due to post-exertional malaise (PEM). This case report describes the effect of pacing in the context of a pragmatic multimodal approach applied to a person living with POTS, vasovagal syncope, and PEM.

Case Description: A 16-year-old female diagnosed with POTS and vasovagal syncope presented to physical therapy with goals to tolerate a full day of school and participation in band again. At initial evaluation, she was attending six hours of school followed by 1-2 days recovering at home due to PEM. She experienced five syncope episodes/day and was able to tolerate three hours of upright activity with feet on the floor/day on non-school days and six hours of upright activity on school days. The patient was advised on lifestyle modifications including lower extremity compression, increased hydration and electrolyte consumption, and pacing using heart rate biofeedback. Breathing exercises and recumbent strengthening exercises eventually were prescribed when PEM was managed, and progressed and regressed to ensure exercise did not occur at the exclusion of daily activities.

Results: After 12 visits over the span of 11 months, the patient’s syncope episodes improved from five episodes/day to zero to one episode/week. Her rating of perceived function improved from 20% to 70%. She could stand for thirty minutes while playing percussion during a school concert and was able to attend a half-day of school without significant PEM the next day.

Conclusion: The patient appeared to benefit from a pacing approach to manage her symptoms and functioning instead of an approach based on aerobic exercise.

Link (The Internet Journal of Allied Health Sciences and Practice)

 

I don’t think they assessed her for ME/CFS, which is a bit weird given her symptoms.

It also seems like they kept trying to introduce tiny amounts of exercise after she had stabilised by pacing, even though she repeatedly had to discontinue the exercise.

I can’t help thinking that the exercises might have done more harm than good, and I wonder how the outcome would have been if they only instructed her to pace.

They also stated that it took multiple sessions for her to learn pacing, and they had to keep reminding her. It also seems like she received help from her parents and school. This is an important mention because so many of the studies that «test» pacing just give the participants a booklet. That’s clearly not enough.



Overall, it’s good to have something like this against the narrative of «exercise is always good for PoT(S)».

 

My understanding is that the young POTS group do well over time, and she may well have benefitted from some of the many interventions described. But I'd be a bit concerned that in the latter sessions she's developing a number of new/worsening issues: allergies/MCAS, visual motion sensitivity, neck pain and lumbosacral pain.

She's functioning better, for sure, but if that's mostly due to adapting better (eg lying down in school), then functioning at a higher level could backfire long-term.

Hope she has a good outcome. This sounds hard for a 16 year old.

 

An interesting report, but I echo @Evergreen ’s concerns that good pacing/adapting to the condition can result in an illusion that ongoing recovery is taking place, so with PEM present it is important to be careful that the patient is not being setup for an over exertion triggered relapse.

Given such intervention is often time limited any potential relapse may not occur until later.