Physical therapy management of postural orthostatic tachycardia syndrome using a pacing approach: a case report

Background and Purpose: Postural Orthostatic Tachycardia Syndrome (POTS) is a form of autonomic dysfunction affecting blood circulation characterized by excessive tachycardia and orthostatic intolerance.1 Patients who develop POTS experience symptoms affecting multiple bodily functions that, in turn, severely limit functioning.2,3 One of the main non-pharmacological interventions recommended for POTS management is aerobic exercise to improve cardiovascular function4; however, some POTS patients may not tolerate aerobic exercise due to post-exertional malaise (PEM).5,6 For these patients, a pacing approach may be more appropriate.5 This case report describes the effect of pacing in the context of a pragmatic multimodal approach applied to a person living with POTS and vasovagal syncope.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 her initial evaluation, she was attending 6 hours of school followed by 1-2 days recovering at home due to PEM. She experienced 5 syncope episodes/day and was only able to tolerate 3 hours of upright activity with feet on the floor/day on non-school days and 6 hours of upright activity on school days. Her Chronic Fatigue Syndrome Symptom Scale (CFSSS) total was 49/80. Her Dizziness Handicap Inventory (DHI) was 72%. Orthostatic vitals during tilt table testing were 68bpm heart rate (HR) and 102/55 blood pressure (BP) in supine and 127bpm HR and 96/67 BP after 7 minutes in 70° head-up tilt before patient experienced a syncope episode and testing was terminated. The patient was advised on lifestyle modifications for orthostatic intolerance management (e.g., wear compression, increase electrolyte and fluid intake). Other interventions included pacing using a heart rate monitor to alert the patient to lower her heart rate to avoid exceeding calculated ventilatory anaerobic threshold based on age, education on recognizing immediate and delayed signs of PEM, dietary advice, instruction in diaphragmatic breathing and recumbent strengthening exercises.Outcomes: After 6 visits over the span of 3 months, the patient’s DHI improved from 72/100 to 44/100 and CFSSS improved from 49/80 to 10/80. Her hours of upright activity with feet on the floor improved from 3 hours to 11 hours on non-school days and 6 hours to 8 hours on school days. By her 7th visit, 4 months from initial evaluation, her syncope episodes improved from 5 episodes/day to 1 episode/week. Her rating of perceived function improved from 20% to 45%. She was able to stand for 30 minutes while playing mallets during a school concert without PEM the next day. She experienced more good days than bad days, and was able to attend a half-day of school without significant PEM the next day.Discussion: The patient described in this case is an example of a subset of POTS patients that experience PEM as part of their symptomology. She appeared to benefit from a pacing approach to manage her symptoms and functioning instead of an aerobic exercise-based approach.