Living with POTS: why structured exercise - unlike with PEM - is part of the standard approach
Structured exercise programs, increased salt and fluid intake, and compression clothing are evidence-based first-line treatments for POTS. Here's what that means and how it differs from PEM.
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If you live with POTS, you may have heard contradictory advice: "move more" or "take it easy." The answer is nuanced - and critically, it's different from what applies to post-exertional malaise (PEM). Sam doesn't replace that judgment, but it can show you, free of charge, how your daily activity patterns are evolving.
Does exercise help POTS - differently than with PEM?
A central difference from ME/CFS or Long COVID with PEM: medical literature treats structured exercise programs as first-line therapy for POTS. Well-known protocols (named after their research centers, such as the Levine or CHOP protocol) are described in the literature as deliberately starting out lying down or seated - for example, rowing, swimming, or recumbent cycling - to avoid gravitational stress at first, then progressing over several months toward upright activity. The exact duration and pace of progression varies from person to person.
This is explicitly the opposite of what the evidence shows for PEM, where increasing structured activity can cause harm. For this reason, regardless of whether you also have PEM, your healthcare team needs to work out which exercises, what pace, and what progression are right for you, and must supervise the process. Do not start an exercise program on your own based on this article - it describes what's in the literature, not instructions to follow.
Salt and fluid
Increased salt and fluid intake are among the first foundational measures recommended for POTS - the idea is to increase circulating blood volume. Important exception: if you have hyperadrenergic POTS or kidney problems, more salt isn't automatically the right approach and should be cleared with a doctor first.
Compression clothing
Compression clothing aims to reduce blood pooling in the legs when you stand. Current research suggests that abdominal or waist-high compression is more effective than knee-high socks alone. The right compression solution for you - material, compression grade, fit - is best discussed with your healthcare team.
What causes POTS: origins and risk factors
POTS has multiple causes: viral infections (including Long COVID), autoimmune processes, prolonged bed rest after surgery, hormonal changes, and genetic factors are all discussed in the literature. A link to hypermobility spectrum disorders and hypermobile Ehlers-Danlos syndrome is also described - more on that in the article POTS, Long COVID, and ME/CFS: How Are They Connected?
Where Sam Health fits in
Sam reads resting heart rate, sleep, and activity from Apple Health and compares them against your personal baseline - an honest picture of your daily life that you can discuss with your healthcare team, for example when evaluating how an exercise program is working for you. To set up Sam for POTS tracking, see How to Set Up Apple Watch for POTS.
Try Sam HealthImportant disclaimer
Sam is a wellness companion, not a medical device. Sam does not diagnose, treat, or prevent POTS and does not provide individual exercise or therapy recommendations - those belong with your healthcare team.
Sources
- Practice Guideline for Orthostatic Intolerance / POTS / Orthostatic Hypotension (mecfs.de)
- Medical literature on non-pharmacological POTS treatment: structured exercise programs, salt and fluid intake, compression
- German Society for Cardiology (DGK): Position Paper on Post-COVID Syndrome (2025)
Frequently Asked Questions
Should I exercise more or less if I have POTS?+
Medical literature treats structured exercise programs - starting out lying down or seated, such as the Levine or CHOP protocols - as first-line therapy for POTS, with gradual progression to upright activity. This is explicitly different from post-exertional malaise (PEM), seen in ME/CFS or Long COVID, where increasing structured activity can be harmful. But regardless of whether you also have PEM, your healthcare team needs to determine whether, how, and at what pace such a program is right for you, and needs to supervise it. Do not start an exercise program on your own based on this article.
Does more salt actually help POTS?+
Increased salt and fluid intake are among the first foundational measures recommended for POTS, because they may help increase circulating blood volume. Important exception: if you have hyperadrenergic POTS or kidney problems, more salt isn't automatically the right approach and should be discussed with your doctor first.
How much salt per day should I take with POTS?+
Studies and clinical practice guidelines for POTS cite different targets, but they usually come out to several grams of additional salt per day plus roughly 2 to 3 liters of fluid daily - substantially more than general population recommendations. The exact amount varies across sources. Whether and how much salt is right for you depends on your specific POTS subtype and any other conditions you have, and should be discussed individually with your healthcare provider.
What compression clothing is recommended for POTS?+
Some studies suggest that abdominal or waist-high compression garments may reduce blood pooling in the abdomen and legs more effectively than knee-high compression socks alone - but well-designed randomized controlled trials comparing them directly are still lacking. Your healthcare team can help you determine the right compression solution for you.
What helps immediately when I feel dizzy standing up?+
Short-term physical counter-maneuvers can help: crossing your legs, tensing your leg, abdominal, and buttock muscles, or briefly squatting - these support blood return to the heart. If dizziness becomes frequent or severe, or if it involves fainting, see a doctor for evaluation.
What if I also have PEM or ME/CFS?+
Your approach will need individual adjustment. A structured exercise program following standard POTS protocols may be unsuitable if you also have PEM, or it may need significant modification. This requires medical oversight, ideally from someone experienced with both conditions.