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

Authors

Clayton D. Powers, University of Utah South Jordan Health CenterFollow
Nicole A. Miranda, Nicole Miranda Consulting, LLCFollow
Todd E. Davenport, University of the PacificFollow

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.

Author Bio(s)

CLAYTON D. POWERS, PT, DPT is a physical therapist with the University of Utah’s South Jordan Health Center, where he established the rehabilitation program for neuro-immune disorders such as myalgic encephalomyelitis/chronic fatigue syndrome and Long Covid.

NICOLE A. MIRANDA, PT, DPT is a clinical and educational consultant in Denver, Colorado.

TODD E. DAVENPORT, PT, DPT, PhD, MPH, Board Certified Clinical Specialist in Orthopaedic Physical Therapy is a tenured full Professor in the School of Health Sciences at the University of the Pacific in Stockton, California, where he teaches in and serves as Chair of the Doctor of Physical Therapy program.

Acknowledgements

An earlier version of this work was presented at the American Physical Therapy Combined Sections Meeting in San Diego, California, United States on February 25, 2023.

Recommended Citation

Powers CD, Miranda NA, Davenport TE. Physical Therapy Management of Postural Orthostatic Tachycardia Syndrome Using a Pacing-Forward Clinical Approach: A Case Report. The Internet Journal of Allied Health Sciences and Practice. 2025 Apr 15;23(2), Article 29.