Compression:
Compression of the legs or abdomen can help to decrease pooling of blood in these areas, which may increase the amount of blood that gets back to your heart. The abdomen is the area with the greatest pooling when standing, so that may be the best area to target with compression first.
We have recently shown that abdominal compression in combination with propranolol decreases upright symptoms in POTS. Abdominal binders or back braces that can be loosened when sitting and then tightened when standing may be the best option.
Compression stockings or leggings may also be helpful, but some patients report that they are too hot or difficult to put on. The most effective stockings offer at least 30-40 mmHg of compression and are waist high.
Sleep:
We have reported a correlation between sleep problems and heath related quality of life in POTS.
Patients should practice good sleep hygiene including
- Having a set bedtime and time to wake up
- Avoiding alcohol, caffeine, and exercise before bed
- Avoiding naps when possible
- Optimizing bedroom comfort including lighting and temperature
Diet:
Because many patients with POTS have low blood volume, patients are encouraged to increase their salt and fluid intake in an attempt to increase blood volume.
- We recommend up to 10 grams of dietary salt per day. A teaspoon of table salt is about 2 grams, so many patients put a teaspoon into a baggie and then sprinkle it on their food throughout the day. The pre-packaged food you eat probably already contains several grams of salt, so an additional teaspoon of salt each day should be sufficient.
- If you have trouble adding salt to your diet, sodium chloride (salt) tablets can be given to supplement sodium intake.
- You will need to drink 2-3 liters of water daily along with the increased salt to increase your blood volume
Because eating large meals diverts blood flow to digestive organs, patients with POTS may feel worse following large meals. These patients may benefit from eating several small meals instead of a few larger meals.
Some patients have found that certain types foods trigger their symptoms. These include: alcohol, caffeinated beverages, and carbohydrates.
Temperature:
Because heat causes vasodilation (which diverts blood flow from other organs) and fluid loss through sweating (which decreases blood volume), many patients find that heat is a major trigger of their symptoms. Some patients have found that cooling vests and increasing fluid intake can help minimize the impact of heat on their symptoms.
Physical Counter Maneuvers:
Patients are encouraged to be observant for symptoms associated with presyncope. These can include lightheadedness, dizziness, weakness and vision changes.
When these symptoms occur, patients should lie down immediately, and if that is not possible, move around. Movement that uses the muscles in the legs may be helpful. Some patients stand on their toes, others cross their legs and flex the muscle in the legs and buttocks in an attempt to drive blood out of the legs.
Exercise:
Researchers at UT Southwestern have found that exercise may be more helpful for POTS patients than long-acting propranolol. They recommend an exercise program that starts with recumbent exercise and strength training and progresses to more upright exercise.
The Dysautonomia International team have made an adapted version of this protocol available online.
We have also published that the addition of propranolol may improve exercise capacity in POTS.