How To Exercise When You Feel Faint, Dizzy, or have Dysautonomia or POTS

Discouraged from exercise due to lightheadedness? Tackle your POTS symptoms without pharmaceuticals through hydration, salt, compression and movement.

A surprisingly large number of people are discouraged from exercise due to feelings of dizziness or lightheadedness when they move, change positions or exert themselves.

This frustrating condition can come up in discussion with physical therapy patients as we discuss how to set up sustainable exercise routines.

Therefore I was thrilled to hear a podcast episode chock full of practical information for exactly this group of people. And I had to share the information more widely.

The episode (#125 of Bendy Bodies) highlights impressive and practical knowledge shared by Dr. Satish Raj (MD). You will want to better understand the context and nuance of this subject beyond what I could include in this post, so please give the episode a listen when you get a chance: https://www.bendybodiespodcast.com/Hyperadrenergic-POTS-Treatment/

Wellilo Clinic treats many patients with hypermobility and / or the symptoms described in this post, so we hope you will find this summary useful.

For the Lightheaded Among Us

Starting to exercise or returning to exercise is difficult in general.

But imagine how challenging a basic movement like squatting is when every time you stand up you feel lightheaded and your heart races.

Or put yourself in the bare feet of someone attempting the up and down movements of a sun salutation while thinking that they might faint at any moment.

Postural Orthostatic Tachycardia Syndrome (POTS), or dysautonomia more generally, can cause these types of symptoms, and can be incredibly discouraging for folks who want to move more.

POTS is growing more common

You may have heard that POTS is found more often in those with a history of Covid-19 infection, which means it is more common in the general population than it may have been prior to 2020 (when it was estimated to affect around 0.2% in the general population, or an estimated 500,000 to 1,000,000 individuals in the United States https://pubmed.ncbi.nlm.nih.gov/25980576/ retrieved Jan. 15, 2025).

It is thought that now there are more than double the number of people living with POTS in the US. or at least 6 million since the pandemic began, and millions more around the world. (retrieved Jan. 15, 2025 from https://www.dysautonomiaintern... without further link to studies or methodologies indicating source of those numbers).

POTS is more likely to be present in individuals with hypermobility or Ehler’s Danlos Syndrome, but the criteria for a formal diagnosis of POTS is strict. Many people have symptoms of POTS, but no official diagnosis.

This is where a more general term gives language to those who don’t meet the cut off for POTS.

An umbrella term that also encompasses orthostatic hypotension, vasovagal syncope and a number of other conditions is “autonomic dysautonomia”. Or “dysautonomia” for short.

What is dysautonomia?

Dys - a combining form meaning “ill,” “bad,” used in the formation of compound words:

I.e. Dysfunction. https://www.dictionary.com/browse/dys retrieved Jan. 15, 2025.

Autonomia - related to “self-governing”, referring to our autonomic nervous system, which is like a background control center of our bodies. It controls the things we never (or rarely) have to think about: heart rate, blinking, breathing, digesting, etc.

In other words, dysautonomia means something is not working well in the background functioning of the body.

“Dysautonomias are a heterogenous group of disorders that can cause variable symptoms ranging from isolated impairment of one autonomic function to multisystem failure. The causes are also diverse and can be central or peripheral and primary (owing to an intrinsic neurologic cause) or secondary (owing to a disorder that secondarily causes damage to the autonomic nervous system).” https://pubmed.ncbi.nlm.nih.gov/36400555/ retrieved Jan. 15, 2025.

Specifically, many forms of dysautonomia indicate that the nerve functioning around the heart is not working properly.

Side note: Since dysautonomia is an umbrella term, it tells you very little about the cause of your symptoms, or the cure. As a label, it is limited in its usefulness, but nonetheless, if the label brought you to this page, and the simple suggestions here help you to reduce your symptoms, that is what matters most.

Dysautonomia, particularly POTS, can be related to other conditions like Ehlers Danlos Syndrome and Hypermobility. It is believed that laxity in the blood vessels, veins, structural fascia and tissues around the heart can contribute to poor circulatory management (pumping).

What are some of the symptoms of Postural Orthostatic Tachycardia Syndrome?

Persons with POTS have an orthostatic intolerance to being upright.

This means when they stand up, sit up, there are changes in their heart rate than can make them feel lightheaded, as if they are about the faint, like their heart is racing, or in some cases they can get chest pains, shortness of breath, GI upset, shaking, exercise intolerance, temperature sensitivity and more.

Orthostatic hypotension, which is closely related to POTS, is defined as a drop of 20 millimeters of mercury (mm Hg) in the top number (systolic blood pressure) within 2 to 5 minutes of standing or a drop of 10 mm Hg in the bottom number (diastolic blood pressure) within 2 to 5 minutes of standing. https://www.mayoclinic.org/diseases-conditions/orthostatic-hypotension/diagnosis-treatment/drc-20352553

POTS does not always have a definitive origin or cause, but according to surveys, its most frequent onset is after a viral infection, including post-COVID.

We know for sure that POTS is multifactorial and the causes of POTS are diverse, ranging from post-viral onset to structural and blood volume issues, requiring a nuanced, patient-specific approach to treatment.

More than 85% of people with POTS are women. (https://pmc.ncbi.nlm.nih.gov/articles/PMC8712580/ retrieved Jan. 15, 2025)

Working with your expert to get POTS diagnosis usually involves both clinical presentation plus: Tilt table test and 10 minute standing test, and may involve other tests as well.

Non-Pharmacological Treatments First:

The following suggestions should not be taken as medical advice from me or the Wellilo Clinic, but offer insight into the recommendations offered up by a leading autonomic expert, Dr. Satish Raj.

The following simple suggestions may be useful for reducing symptoms associated with the following conditions: Hyperadrenergic POTS Treatment (POTS: Postural Orthostatic Tachycardia Syndrome), dysautonomia, and orthostatic intolerance.

Most are based on the finding that stroke volume (how much blood gets pumped per heartbeat) is low in those with dysautonomia. The only way to increase a low stroke volume is to increase heart rate. (Mentioned at minute 47-1 hr, 10 min)

I love that these treatment ideas are practical, specific and tactical. They are not likely to eliminate the need for pharmacological medicine in severe cases, but these still should be implemented (under medical supervision) before appropriate prescriptions can be issued from your medical doctor.

Hydration

Aim to drink at least 3 liters of water per day. Keep a one liter water bottle with you at all times. Make sure to fill it 3 times daily and drink all of it each day. This strategy is the first step to help you to hold on to more fluid, therefore increasing your stroke volume. Peeing out most of the water is ok and expected, but adding salt will help with retaining the water in your system, and therefore keeping your heart rate up. Salt is the next step.

Increasing your sodium intake - i.e. consume more salt

Studies show that 10 g. Of extra salt per day, the equivalent of 2 tsp., increases plasma volume. Plasma volume is the liquid part of blood, which will increase your stroke volume when higher.

The prescription? Put 2 teaspoons of salt in a reusable bag or tiny tupperware each day, and make sure to use it all up by the end of dinner. As an alternative, you can buy buffered salt tablets, but you would have to take 10 1000mg tablets daily https://amzn.to/4hi0qNq , and it simply costs more compared to table salt. You are also welcome to add the salt to your water and consume it that way, if palatable.

Using compression garments

According to Dr. Raj, for folks with dysautonomia, 70% of the body’s fluid retention happens in the abdomen and pelvis. Therefore compression garments designed to reduce dysautonomia symptoms must focus on the area from the thighs to the mid-torso. Unfortunately calf compression, like compression stockings, helps very minimally, as that is not where the fluid stays.

To squish and compress in the right places, Dr. Raj recommends high waisted compression tights or shorts. (Tights are a little better than shorts). Prescription or medical-grade compression stockings can be very difficult to put on, and uncomfortable to wear. These two facts can discourage daily use. To make sure you actually wear compression garments, consider shopping in sporting goods stores for running stockings with a high waist; or for body shaping garments.

Data shows that commercial wear garments, although not as tight as prescription compression wear, still help with POTS.

Compression garments not only aid in blood flow, but as a bonus, may also provide joint stabilization benefits for hypermobile patients.

Tailored Exercise Programs

Exercise is the most challenging of all of the recommendations. But it is also the most important. Every subject in exercise studies ranging from 3-6 months (meaning participants exercised regularly for at least 3 months) improved their dysautonomia. Improvements were measured both subjectively and objectively. Objective findings included that cardiac mass increased, and stroke volume went up.

When setting up your exercise routine, the amount of time spent exercising, as well as the type of exercise, matters. To minimize symptoms from changing positions frequently, researchers recommended rowing machines. If you can’t use a rowing machine, it is recommended that you try a recumbent bike or swimming.

Aim for 30 minutes every other day or most days of the week, but keep the load (resistance) and speed low and gradually build up both speed and resistance over time. Stop if you cant do more, but know that if you keep it up, you will eventually feel better.

Exercise can take up to 6 weeks before you feel the improvement in dysautonomic symptoms.

Low-resistance, reclined exercises like rowing and cycling can improve cardiac output and quality of life, but patients need to commit for at least six weeks to notice meaningful improvements.

Please keep in mind when starting an exercise program that you can experience "post-exertional malaise”. In other words, you may feel worse when you first start exercising, but later you will feel worse if you miss a day of exercise.

Don’t wait for the perfect moment, but don’t try to start an exercise program when things are really stressful, like around exam time for university students or when travelling a lot makes things hectic.

A thorough POTS exercise program with more detail than above was developed by the Children's Hospital of Philadelphia. To see the CHOP protocol, check out this link: https://www.dysautonomiaintern...

Once you’ve tackled as many of the above non-pharmacological recommendations as possible, or at the same time, decide along with your physician whether pharmacological intervention is for you. An individualized approach to treatment is so essential, so please document and work with an expert.

This blog was based on notes from the Bendy Bodies podcast, episode 125, Strategies for POTS Relief with Dr. Satish Raj. Please listen to the whole podcast episode: https://www.bendybodiespodcast...

This blog post was originally written and posted on Jan. 19. 2025 by Dr. Ariele Foster (PT, DPT).

Categories: : Hypermobility