As you build strength and fitness, you can try upright cycling, treadmill walking, elliptical, and then running. An AlterG antigravity treadmill can also help you get back into running, Dr. Levine says; check their website at alterg.com to find one near you.
A similar progression works for strength training. Dr. Spirlock began with seated or close-to-the-ground exercises as an “entry point:” hip thrusts and leg presses instead of squats and deadlifts, and upper-body movements like rows and overhead presses on a bench. “As your body adapts—because the body is widely adaptable—you can start incorporating other things,” she says. For example, she went from a leg press to a box squat with a high box, which involved less range of motion than a full squat and also offered her a place to sit if she felt dizzy. “As symptoms started to decrease, then I would lower that box,” she says. “Now I’m back to full-depth squats.”
Also, some people find strength training causes fewer symptoms than cardio (or vice versa). While you’d ideally work up to doing both, it’s okay to start with what’s most comfortable for you—doing anything may eventually make it easier to do everything, Dr. Grubb says.
4. Stay hydrated and supplement with sodium.
Drinking lots of water boosts your blood pressure and blood volume, and salt helps your body retain fluids as well as offsets the extra norepinephrine that’s jacking up your heart rate. In fact, people with POTS might need between 3,000 and 10,000 milligrams of the mineral daily, which is way more than the typical government-recommended 2,300-milligram guideline for the general population.
Dr. Spirlock has found her sweet spot at two to four liters of water and 6,000 milligrams of sodium per day, which she hits by salting her food and using LMNT electrolyte drink packets. She also recommends a boost of 500 milligrams about an hour before you work out to ensure you’re prepared. (Just avoid salt tablets, Dr. Levine says—they’re so concentrated that they can be dehydrating.)
5. Don’t forget the warm-up and cooldown.
A good warm-up helps everyone, but it’s critical for folks with POTS, Dr. Spirlock says. Before strength training, she spends five to 10 minutes on dynamic movements like dead bugs and thread the needle that increase her heart rate and circulation and fire up the connections between her mind and muscles. If you’re doing cardio, ease in with five to 10 minutes of lower-intensity work—think easy biking.
Cooling down afterward can help your body relax into a more parasympathetic state. One of Dr. Spirlock’s favorite post-lift routines is lying on the floor, elevating her feet and legs on a bench, and doing some 360-degree diaphragmatic breathing: inhaling deep into your chest, so your ribcage expands in all directions.
6. Consider the conditions.
Most people with POTS feel worse in the heat. Working out indoors in air conditioning can help, or you can modify your routine to adjust to the conditions, Dr. Spirlock says. For example, she often reduces her intensity or shortens her session if she’s lifting in her hot garage gym in the summer. You can also try cooling towels or spritzing yourself with cold water.
7. Add in more rest breaks—and make them longer too.
Dr. Bauer encourages people with POTS to use pacing, a method that can help you learn to manage your energy and prevent you from overexerting yourself and then crashing. What this looks like is highly individual, but it may involve taking a rest break—whether that’s five minutes of deep breathing or 30 minutes of yoga nidra—before and/or after you exercise. Experiment with different types and durations of rest and exertion, tracking to see how they affect you, she says.