Aerobic exercise, or really anything that requires physical exertion can be exhausting for people with POTS. While the research suggests that regular aerobic exercise helps people with POTS feel better because it encourages their bodies to make and store more blood volume, most patients will quickly interject "I want to, but I can't tolerate exercising."
The reality is that getting started with exercise has extra challenges for people with POTS. Their bodies have a hard time getting blood to the right places at the right times (see: POTS University). The additional blood supply required by the muscles to exercise puts even more stress on their cardiovascular system. For a person with POTS, their cardiovascular system was struggling to begin with. The demands of exercise can lead to headaches, lightheadedness, a racing heart rate, and extreme fatigue. Many who attempt cardiovascular exercise will stop within a few minutes because their symptoms make them feel like they just can't continue.
For most people who haven't exercised in a while (whether they have POTS or not), the hardest part is just getting started. In order to be successful in doing aerobic exercise with POTS, we have to start with tackling:
Reframing Our Idea Of Exercise
Physical therapists go to graduate school for a doctorate degree to learn to dose exercise like your medical doctor goes to school to learn how to dose medication. When it comes to any treatment, the right kind of medicine and the right amount of it are important.
The appropriate amount of activity we consider to be exercise depends on the fitness level of the person doing the exercise. Exercise looks different for a marathon runner than for a person who has been hospitalized and in bed for a week. The first physical therapy session for the person who's been hospitalized might only involve an exercise prescription of walking to the bathroom and returning back to bed. In some cases, just being able to sit up on the edge of the bed is as much as exercise as they can tolerate. To be successful, the exercise prescription has to match the starting level of the person doing the exercise.
Warming Up With POTS
When building a good exercise routine, it should have a warm-up. Even the idea of warming up can sound daunting to a POTS patient in all senses of the phrase. Many people with POTS are symptomatic when they get too hot. Temperature control is a struggle for people with POTS because the body directs blood flow to help regulate our body temperature. Exercise warm-ups not only affect their body temperature, but exercise increases blood flow demands to the muscles and can stress their cardiovascular system to the max.
When a typical person exercises, as their body senses an increase in demand for energy to the muscles, the cardiovascular system kicks into gear. The heart begins to pump more quickly and our blood pressure elevates so that the supply of oxygen and nutrient rich blood is pressurized to move through our blood vessels at faster speeds.
For a person with POTS, however, their body struggles to figure out where to send blood and at what time. The system may not realize you've started exercising, and your heart rate may stay flat and even. This creates a problem because it leaves your muscles hungry for blood and oxygen and unable to produce energy to keep you moving.
In some cases, not only does the heart rate not increase, but it dips even lower and slows down. When this happens, a person will most likely experience extreme fatigue and a feeling that they have to stop exercising. This is where most people with POTS get stuck.
If you think about your body like a car, POTS bodies struggle to go from zero to sixty in 3 seconds. They may be able to get up to sixty over several minutes. A common mistake when trying to exercise with POTS is doing too much too soon. Patience is something most of us aren't naturally good at, but we're going to need it to be successful long term. The secret is to "start low, and go slow."
A warm-up should be slightly more activity than you were doing at rest. If your goal is to go for a hike, it isn't best to just start working your way up the hill. Taking some time to walk slowly on a flat surface, or stand in place and kicking your bottom alternating gently and slowly one foot at a time gives your body a chance to realize you're starting to move. This may take several minutes.
To know how your body is responding, use a heart rate monitor or a smart watch. These devices let you track your pulse in real time. If you have a sense of what your typical resting heart rate is, you can monitor for changes. If your resting heart rate is usually 70 beats per minute, and while you are doing your warm-up, it hasn't changed, you may need to warm up longer. If your heart rate starts to increase slightly, test out increasing your activity level a little and see how you feel.
If your heart rate decreases from your resting level of 70 down to 60 beats per minute, don't panic. Just keep moving slow and steady. This sometimes happens to people with POTS. Your body may just need a little extra time to realize what is happening and adjust your heart rate. If you are symptomatic, it's ok to slow down the pace of your activity during this phase. Your warm-up speed may have been a little too fast. If safely possible, don't stop moving entirely. This may mean moving at a snail's pace for a minute or two, to give your body time to catch up. If given enough time, the body usually gets the message and the heart rate will begin to climb.
Once your heart rate is climbing, you're ready to start climbing too. Hiking the hill won't feel as difficult once your muscles are getting the blood flow that they need.
Progress With POTS: A Percentage Perspective
When it comes to exercise progression, we have to start to think in terms of percentages rather than amounts. For example, if a weightlifter was exercising in the gym, and they were able to squat 200lbs without difficulty, you wouldn't advise them to go back the following day and attempt to squat 400lbs. Typically, a weightlifter might only increase their weights by increments of 10 or 20lbs at a time. We wouldn't say that makes them weak or a wimp. For those who don't love math, that would mean an increase of 5-10% from one workout to the next.
This concept has to come into play when we think about progressing exercise for a person with POTS. If your current exercise tolerance is to walk for 5 minutes, while walking for 10 minutes doesn't sound like that long, it is a 100% increase in your activity level. If we followed the rules of our weightlifter, a 10% increase from your 5 minute walk is actually 30 seconds.
The problem in our ability to be patient in the early phases of exercise is in our perception. When we are able to do a smaller amount of activity to begin with, the increase in activity has to be smaller. If we think about exercise increases in percentages rather than solid numbers, it helps us to be less upset about the "slowness" of progress, and more successful in the end.
When we fail to do this, we end up riding the chronic illness roller coaster instead of steadily climbing the mountain (see, Pacing Activity: Mountain Climbers and Rollercoaster Riders).
Sealing the Deal: Cool Downs Matter
After the first successful exercise attempt, it's tempting in the excitement to skip the cool-down and celebrate. Unfortunately, people with POTS aren't quite out of the woods yet. In POTS, the cardiovascular system doesn't handle rapid changes well, and that applies to when a person stops exercising too.
As a general rule of thumb, the amount of time it takes you to warm up, is about the same amount of time it will take to cool-down. The goal is to gradually decrease your activity level and your heart rate back to it's typical resting level. If you don't give your body time to recognize the activity level change, your heart rate may stay elevated for a while after you stop exercising unnecessarily.
If your heart is still exercising even when you're not, it causes the body to expend extra energy. This can leave people with POTS feeling unwell after exercise. They are often all too familiar with the discomfort of a racing heart rate, and the struggles of chronic fatigue.
Cool-downs should look similar to warm-ups. Slowed, gentle activity levels can look different depending on the type of exercise you were doing. If you aren't sure what kind of movements are the right ones for your warm-up or cool-down, consult with your physical therapist for help.
This article is intended for educational purposes and is not a replacement for individual medical advice from a licensed healthcare provider. If you are interested in an evaluation of your unique situation, you can call or book online to schedule an appointment.
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