POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME (POTS): SYMPTOMS, SCREENING, AND USING AN EXERCISE PROGRAM TO IMPROVE ACTIVITY TOLERANCE IN A YOUNGER FEMALE

The incidence of Postural Orthostatic Tachycardia Syndrome (POTS) is estimated to be 500,000 to over one million individuals in the United States and most commonly occurs in younger females. The recognition and management of POTS have increased over the past 20 years. The most common symptoms of POTS include light-headedness or dizziness, palpitations, fainting, near-fainting, intermittent muscle weakness (commonly in the legs), and fatigue after moving from lying down to standing. These symptoms occur in patients with POTS due to an abnormally rapid heart rate response cause by the change in position to standing. Lightheadedness, dizziness and/or near syncope after standing are classic symptoms with orthostatic hypotension. These symptoms also occur in patients with POTS. Most clinicians will monitor blood pressure at 1 and 3 minutes after standing to screen for orthostatic hypotension but will not monitor heart rate for 10 minutes during quiet standing to screen for POTS. Current research has demonstrated effectiveness of aerobic programs lasting 30-45 minutes per sessions, 2-4 times per week over 8-12 weeks. The researchers slowly progressed the subjects from semi-recumbent aerobic activities (recumbent biking, rowing, or swimming) to upright aerobic activities (upright biking, walking, or jogging) as long as the subjects remained symptom-free. The researchers initial strategy of avoiding upright activities allowed the subjects time to improve overall fitness levels without triggering the symptoms of POTS. The strength training followed the same pattern of semi-recumbent exercises (mat and chair) to upright exercises (standing.) The strengthening sessions were initially once weekly for 15-20 minutes and increased gradually to twice weekly for 30-40 minutes per session as tolerated by the subject. This case report describes the symptoms and screening for POTS, an evidence-based physical therapy intervention consisting of aerobic and strengthening components, and lifestyle modifications for a 34-year-old female who had experienced an exacerbation of POTS symptoms. This case report showed clinically significant changes (from the patient’s perspective) consistent with the previous research. The patient had steady improvements with her estimated VO2max testing at the discharge (4 weeks after the evaluation) and continued improvement at 8 weeks post discharge. The patient’s goals of improved work and life tolerance were achieved. A physical therapist must be able to recognize the symptoms of POTS and perform POTS screening as part of the differential diagnosing process. A patient could be suffering from undiagnosed POTS and present in a variety of different physical therapy settings with a variety of different diagnoses commonly seen by physical therapists such as: Chronic Fatigue Syndrome, muscle weakness, deconditioning, difficulty walking, vestibular issues, and migraines. Purpose (a): Postural Orthostatic Tachycardia Syndrome (POTS) is most prevalent in younger females and shares common symptoms with orthostatic hypotension (OH). Whereas the screening criteria for OH are well known in the physical therapy community, the symptoms and screening for POTS are not. The purposes of this case report were to: 1. describe the symptoms and current POTS screening guidelines, 2. address the role of the physical therapist in prescribing an effective exercise program. Methods (b): A 34-year-old female completed a 4-week course of physical therapy consisting of aerobic and strengthening exercise with an 8-week follow up after an exacerbation of POTS. Initial presenting symptoms included: dyspnea with mild exertion, light-headedness, fatigue, “heaviness” in her legs, and the inability to perform normal work duties. Results (c): The patient’s estimated VO2 max on the 1 mile timed walk test (1 MWT) improved from the 60th percentile at baseline to the 90th percentile at 8 weeks post discharge follow-up. In addition, the patient was able to return to work full time and resume all previous fitness activities. Conclusions (d): The patient demonstrated clinically meaningful improvements in estimated VO2max after the ‘reconditioning’ training. Physical therapists must be able to recognize the symptoms of and screen for POTS as part of a differential diagnosing process. Further research is needed with clinical trials to investigate the efficacy of other similar treatment strategies for POTS management.