6.1. Lifestyle modifications and non-pharmacological approaches

← PREVIOUS: [[6. Management and Treatment Strategies]] | NEXT: [[6.2. Pharmacological interventions]] → -------- ##### Summary >[!Summary] >- Patients should be informed about the differences between the symptoms that are due to orthostatic intolerance and those that are not and about potential aggravating or precipitating factors that may exacerbate their postural and exercise intolerance[[#^1]][[#^11]] >- helpful for improving brain fog: lying down (81 %), avoiding heat (68 %), high fluid intake (66 %), acute ingestion of at least 16 oz of water in<5 min (63 %), and high salt diet (60 %)[[#^02]] >- interventions reported to make brain fog worse: showering (61 %), exercise (56 %), walking (47 %), and ingestion of caffeinated beverages (33 %)[[#^02]] > >---------------- > >**Precipitant Factors** > | PRECIPITANT FACTOR | RATIONALE | |:-------------------------------------------------- |:---------------------------------------------------- | | Sudden head-up postural changes[[#^6]] | Reduce orthostatic stress[[#^6]] | | Prolonged recumbency[[#^6]] | Avoid deconditioning[[#^6]] | | High environmental temperatures[[#^6]] | Reduce peripheral vasodilatation[[#^6]] | | Large meals[[#^6]] | Avoid blood pooling in mesenteric vessels[[#^6]] | | Alcohol[[#^6]] | Prevent vasodilatation[[#^6]] | | Vasodilator drugs[[#^6]] | Prevent excessive vasodilatation[[#^6]] | | Sympathomimetic drugs (eg, methylphenidate)[[#^6]] | Prevent excessive synaptic NE levels[[#^6]] | | Medications that interfere with fluid balance (drospirenone, diuretics)[[#^28]] |*N/S* | | Excessive caffeine intake[[#^2]] | May increase diuresis and promote hypovolemia[[#^2]] | > >- 35 % of POTS subjects reported that caffeine improves brain fog, 33 % stated that it made their brain fog worse[[#^19]]. Despite caffeine’s vasoconstrictive qualities, perhaps in some cases diuresis and tachycardia outweighed benefit[[#^27]] >- brain fog was aggravated by excessive cognitive challenges, poor sleep, showering, and acute exercise[[#^26]] > >----------------- > >**Regimen** > > | REGIMEN | DETAILS | RATIONALE | |:----------------------------- | --------------------------------------------- |:----------------------------- | | Increased water intake[[#^13]] | 1.5-2 L/day[[#^2]] ; 2-3L/day[[#^13]][[#^16]] ; at least 1 glass or cup of fluids with their meals and at least 2 at other times each day to obtain 2–2.5 L/day[[#^34]]| Increase blood volume[[#^13]] | | Increased sodium intake[[#^13]] | >200 mEq/day[[#^13]] ; 10–12g/day[[#^16]] ; 150–250 mEq of sodium (10-20 g of salt)/day[[#^33]] | Increase blood volume[[#^16]] | | Dietary modifications[[#^22]] |Where food intolerances are problematic with suspected splanchnic pooling, providing dietary advice and referral to a dietician may be of benefit[[#^28]] |*N/S* | > >-------------------- > >**Physical Countermaneuvers** > |METHOD| RATIONALE | |:------------------------------------------------------------------------------------------ |:---------------------------------------------------------------------------------------------------- | | Contract muscles below the waist, typically for about 30 seconds (repeat if needed)[[#^7]] | Reduces venous capacity and increases total peripheral resistance[[#^7]] | | Leg crossing[[#^3]][[#^24]] | Produce small increases in mean arterial pressure to maintain an adequate cerebral blood flow[[#^3]] | | Bending forward and placing a foot on a chair[[#^3]] | Produce small increases in mean arterial pressure to maintain an adequate cerebral blood flow[[#^3]] | | Making a fist[[#^3]] | Produce small increases in mean arterial pressure to maintain an adequate cerebral blood flow[[#^3]] | | Active contraction of abdominal or buttock muscles[[#^3]] | Produce small increases in mean arterial pressure to maintain an adequate cerebral blood flow[[#^3]] | | Water bolus therapy (drink two 8 ounce glasses of water sequentially)[[#^7]] | Sympathetically-mediated pressor response that is sustained for 1–2 hours[[#^7]] | > >- a situation with an increasing need to maintain balance might however also result in impaired cognition (leg-crossing)[[#^25]] > >--------------------- > >**Medical Products**[[#^14]] > | PRODUCT |DETAILS | RATIONALE | |:--------------------------------------------------- | --- |:------------------------------------------------------------------------------------------------------------------------------------- | | Abdominal binder[[#^7]] |*N/S* | Reduces splanchnic-mesenteric venous capacity (especially helpful in patients with poor venomotor tone or who are hypovolemic)[[#^7]] | | Thigh- or waist-high tight support stockings[[#^4]] |Panty-hose (waist high) style stockings with 30-40 mm Hg of pressure[[#^8]] | Minimize the degree of peripheral venous pooling and enhance venous return[[#^8]] ; mitigate the gravity-induced fluid shifts that occur on standing, and decrease orthostatic tachycardia and standing tachycardia[[#^21]] | > >- difficulty in applying compression garments and reduced user compliance during warmer weather (when they are likely to be of greatest benefit) limit the translation of potential benefits from external compression into significant benefit in many patient[[#^28]] > >------------------------ > >**Exercise**[[#^9]][[#^11]] > | EXERCISE |DESCRIPTION | RATIONALE | |:----------------------------------------------------------- | --- |:------------------------------------ | | Graded aerobic exercise[[#^6]][[#^12]] |*N/S* | Improve physical conditioning[[#^6]] | | Resistance exercises for the lower limbs[[#^6]][[#^12]] |*N/S* | Reduced venous pooling[[#^6]] | | Short-term exercise training (recumbent cycle or treadmill)[[#^5]] |Should be began with a very small amount of exercise, due to POTS patients becoming rapidly symptomatic and gradually increased over the next 6 to 8 weeks[[#^5]] |Improves physical fitness and cardiovascular responses during exercise[[#^5]] ; Increase the baroreflex sensitivity in POTS patients and decrease the upright HR[[#^30]] | | Light strengthening exercises for the major muscle groups using weight machines[[#^5]] |*N/S* |*N/S* | > >- importance of heeding symptoms as a warning sign and not to overstep the patient's limitations based on misguided advice, which has the potential to worsen physical symptoms and result in a relapse[[#^01]] >- The challenge with an exercise program in POTS is the marked exercise intolerance and debilitating post-exercise fatigue[[#^15]] >- patients must be informed that it can take 5-6 weeks before they notice any improvement, and in the interim, the patients may transiently feel worse[[#^15]] >- acute exercise was reported to make brain fog worse yet regular aerobic exercise was reported to improve brain fog[[#^18]] >- exercise was viewed as a useful management tool, but not for everyone[[#^23]] >- regular exercise programs are reported to improve cognitive symptoms, as well as physical symptoms of POTS[[#^26]] >- graduated exercise program incorporating recumbent exercises may also be beneficial in POTS[[#^30]] >- important to keep a modest expectation of activity levels in the early phase to avoid postexertional fatigue and abandonment of the program, as a gradual increase in exercise can result in significant improvement in both symptoms and orthostatic HR in patients with POTS[[#^30]] > >----------------------------- > >**Exercise Programs** > >- three month Dallas Program (involves aerobic exercise coupled with resistance training. focuses on starting with seated or supine exercises (e.g. rowing machine, recumbent cycle, or swimming) 3 times per week) improves orthostatic and exercise tachycardia, symptoms, and quality of life. The improvement is related to an increase in the size of the heart and increased blood volume, the improved stroke volume decreases tachycardia [[#^15]] > >---------------------------- > >**Other** > | MANAGEMENT | DETAILS | RATIONALE | |:-------------------------------------- |:---------------------------------------------------------- |:-------------------------------------------------------------------------------------------------------------------- | | Bed-tilting[[#^22]] | Sleeping with the head of the bed raised by ~10 cm[[#^29]] | Increased renin secretion and consequent aldosterone increase can occur with reduced renal arterial pressure[[#^29]] | | Adoption of good sleep hygiene[[#^31]][[#^16]] |*N/S* | To address disrupted circadian rhythm[[#^31]] | | Psychologic support[[#^31]] |*N/S* |To encourage realistic expectations of integration back into the study or workplace[[#^31]] | > >- top two reported brain fog triggers were fatigue and lack of sleep[[#^20]] -------- >*“Participants also had to fight against misguided advice, which had the potential to worsen physical symptoms. Dani explained how she was told to carry on as normal, to ignore her symptoms, but this resulted in a relapse. ([p. 4](zotero://open-pdf/library/items/P2VFKVHY?page=4&annotation=HNUI2B6F)) This was also echoed by Margot, who highlighted the importance of heeding symptoms as a warning sign and not to overstep their limitations based on HCP advice.”* ([[Knoop-2023]], [p. 4](zotero://open-pdf/library/items/P2VFKVHY?page=4&annotation=Y2VBN9KI))^01 >![[Zotero/Zotero Images/Ross-2013-11-x74-y397.png#invert_B| 900]] >([[Ross-2013]], [p. 11](zotero://open-pdf/library/items/5NBCV5L2?page=11&annotation=WEVW9FHD)) > >*“Over 75 % of subjects had tried each of the nonpharmacological agents for POTS in this questionnaire with the exception of cooling vests (18 %), physical therapy (48 %), and compression stockings (63 %). As shown in Fig. 3a, subjects reported the following as helpful for improving brain fog: lying down (81 %), avoiding heat (68 %), high fluid intake (66 %), acute ingestion of at least 16 oz of water ([p. 3](zotero://open-pdf/library/items/5NBCV5L2?page=3&annotation=BBUL3ME3)) in<5 min (63 %), and high salt diet (60 %). The interventions that were reported to make brain fog worse were showering (61 %), exercise (56 %), walking (47 %), and ingestion of caffeinated beverages (33 %)”* ([[Ross-2013]], [p. 4](zotero://open-pdf/library/items/5NBCV5L2?page=4&annotation=N68KQA38))^02 >_“Patient education is a fundamental aspect of POTS management. Patients should be informed about the differences between the symptoms that are due to orthostatic intolerance and those that are not and about potential aggravating or precipitating factors that may exacerbate their postural and exercise intolerance.”_ ([[Benarroch-2012]], [p. 7](zotero://open-pdf/library/items/WEZLT9QC?page=7&annotation=XNTRFZL3))^1 >_“Regardless of the basic pathophysiologic mechanism, most patients require volume expansion with adequate daily water (1.5-2 L) and sodium intake. This is particularly important on awakening or before a predictable orthostatic stress. Excessive caffeine intake should be avoided because it may increase diuresis and promote hypovolemia.”_ ([[Benarroch-2012]], [p. 7](zotero://open-pdf/library/items/WEZLT9QC?page=7&annotation=W3B9WEQN))^2 >_“Physical countermaneuvers, such as leg crossing, bending forward and placing a foot on a chair, making a fist, or active contraction of abdominal or buttock muscles may produce small increases in mean arterial pressure to maintain an adequate cerebral blood flow and prevent fainting in patients with all forms of orthostatic intolerance, including neurogenic orthostatic hypotension, vasovagal syncope, and POTS.”_ ([[Benarroch-2012]], [p. 8](zotero://open-pdf/library/items/WEZLT9QC?page=8&annotation=TML2X5HZ))^3 >_“Because blood pooling on standing occurs both in the abdomen and lower limbs, some patients with POTS may benefit from wearing support garments, such as thigh- or waist-high tight support stockings or an abdominal binder”_ ([[Benarroch-2012]], [p. 8](zotero://open-pdf/library/items/WEZLT9QC?page=8&annotation=Z5KQ7URU))^4 >_“As in all causes of physical deconditioning, reduced stroke volume is a key component in the pathogenesis of POTS. As described by Shibata et al, short-term exercise training improves physical fitness and cardiovascular responses during exercise in patients with POTS. Given that deconditioned patients with POTS may rapidly become symptomatic during exercise, they should begin with a very small amount of exercise, using either a recumbent cycle or treadmill and gradually increasing the regimen over the next 6 to 8 weeks. Patients also benefit from light strengthening exercises for the major muscle groups using weight machines.”_ ([[Benarroch-2012]], [p. 8](zotero://open-pdf/library/items/WEZLT9QC?page=8&annotation=BJ5RXC2B))^5 >![[Benarroch-2012-8-x265-y402.png#invert_B| 500]] >([[Benarroch-2012]], [p. 8](zotero://open-pdf/library/items/WEZLT9QC?page=8&annotation=ID9VY7Q8))^6 >*“All patients need to learn to maintain a high salt and high fluid intake. Some fine-tuning is helpful depending on pathophysiology. They need to recognize orthostatic stresses and how to avoid or minimize them. They need to be educated on measures that improve orthostatic tolerance. Three measures are often beneficial. The first is physical countermaneuvers. Patients are taught to contract muscles below the waist, typically for about 30 seconds, and the measure could be repeated. This method reduces venous capacity and increases total peripheral resistance. A second approach is to wear an abdominal binder. This reduces splanchnic-mesenteric venous capacity and is especially helpful in patients with poor venomotor tone or are hypovolemic. The third maneuver is water bolus therapy. The subject drinks two 8 ounce glasses of water sequentially. This results in a sympathetically-mediated pressor response that is sustained for 1–2 hours.” *([[Low-2009]], [p. 6](zotero://open-pdf/library/items/I4WAD8AG?page=6&annotation=PF5HSCNF))^7 >*“Elastic support hose can help to minimize the degree of peripheral venous pooling and enhance venous return. We recommend panty-hose (waist high) style stockings with 30-40 mm Hg of pressure.” *([[Raj-2013]], [p. 6](zotero://open-pdf/library/items/CCJLQKRB?page=6&annotation=CJ9UQR9A))^8 >*“Exercise has routinely been recommended as a part of the treatment regimen for many years.” *([[Raj-2013]], [p. 6](zotero://open-pdf/library/items/CCJLQKRB?page=6&annotation=XHIW3QQU))^9 >*“Salt supplementation and β-blockers were the most efficacious therapies.” *([[Sandroni-1999]], [p. 1](zotero://open-pdf/library/items/X25GXI7E?page=1&annotation=RYJWNBGV))^10 >*“After the diagnosis has been established, patient should be thoroughly educated about non-pharmacological measures alleviating the symptoms. Exercise training may be very effective and counteract deconditioning.” *([[Fedorowski-2019]], [p. 1](zotero://open-pdf/library/items/BZ35QDLR?page=1&annotation=KP87JBEB))^11 >*“many patients with POTS do have cardiovascular deconditioning and do benefit from a program of aerobic exercise and resistance training” *([[Garland-2015]], [p. 8](zotero://open-pdf/library/items/CAWTWYLR?page=8&annotation=AL3DJFDW))^12 >*“Patients are encouraged to increase their blood volume by drinking 2-3L/day of water and ingesting >200 mEq sodium/day” *([[Garland-2015]], [p. 9](zotero://open-pdf/library/items/CAWTWYLR?page=9&annotation=PNXPSV4E))^13 >*“Abdominal compression with elastic waist-high support hose and abdominal binders can help decrease splanchnic-mesenteric venous pooling during standing [43]. The increase in venous return and stroke volume can decrease the orthostatic tachycardia” *([[Garland-2015]], [p. 9](zotero://open-pdf/library/items/CAWTWYLR?page=9&annotation=DGNJ7FET))^14 >*“As patients find it difficult to exercise, they can become increasingly deconditioned. The three month Dallas Program, which involves aerobic exercise coupled with resistance training, improves orthostatic and exercise tachycardia, symptoms, and quality of life [13;62;63]. Improvement is related to an increase in the size of the heart and increased blood volume [13]. The improved stroke volume decreases tachycardia. The challenge with an exercise program in POTS is the marked exercise intolerance and debilitating post-exercise fatigue. The Dallas Program focuses on starting with seated or supine exercises (e.g. rowing machine, recumbent cycle, or swimming) 3 times per week. Patients must be informed that it can take 5-6 weeks before they notice any improvement, and in the interim, the patients may transiently feel worse” *([[Garland-2015]], [p. 9](zotero://open-pdf/library/items/CAWTWYLR?page=9&annotation=EGTJJ7JK))^15 >*“It is recommended that all POTS patients increase intake of sodium to 10–12 g per day (Nwazue et al., 2013) and 2–3Lof water, in an effort to increase blood volume (Sheldon et al., 2015). Often POTS patients drink copious amounts of water which is ineffective without the addition of sodium to the diet. Another recommendation is to participate in a graded aerobic exercise program (Fu et al., 2010;Fu et al., 2011; George et al., 2016;Winker et al., 2005). The use of compression garments such as medical grade compression stockings, abdominal binders, and sports recovery suits may prevent blood pooling and lessen symptoms in some patients. Learning physical counter-measures such as squeezing the buttocks and crossing the legs while standing may alleviate pre-syncope. Since POTS patients have low sleep quality (Bagai et al., 2016), improving sleep hygiene may also be an important consideration”* ([[Miller-2018]], [p. 2](zotero://open-pdf/library/items/A3CIPE3G?page=2&annotation=AMEGM9TP))^16 >*“Most common were non-pharmacologic interventions for POTS, such as increased fluid and salt intake”* ([[Ross-2013]], [p. 5](zotero://open-pdf/library/items/5NBCV5L2?page=5&annotation=VQZ4H2YU))^17 >*“acute exercise was reported to make brain fog worse yet regular aerobic exercise was reported to improve brain fog”* ([[Ross-2013]], [p. 6](zotero://open-pdf/library/items/5NBCV5L2?page=6&annotation=IU8GH3SS))^18 >*“Although 35 % of POTS subjects reported that caffeine improves brain fog, 33 % stated that it made their brain fog worse ([p. 5](zotero://open-pdf/library/items/5NBCV5L2?page=5&annotation=R738I5V6)) [...] Yet, the adverse effects of caffeine, diuresis and tachycardia could exacerbate POTS symptoms in some subjects, outweighing its beneficial effects”* ([[Ross-2013]], [p. 5](zotero://open-pdf/library/items/5NBCV5L2?page=5&annotation=V45LKJLP))^19 >*“top two reported brain fog triggers were fatigue and lack of sleep”* ([[Ross-2013]], [p. 5](zotero://open-pdf/library/items/5NBCV5L2?page=5&annotation=Y6ECQLKF))^20 >*“Compression garments for the lower body can mitigate the gravity-induced fluid shifts that occur on standing, and decrease orthostatic tachycardia and standing tachycardia”* ([[Raj-2022]], [p. 5](zotero://open-pdf/library/items/YN8BG2FZ?page=5&annotation=GZ29MK9F))^21 >*“Current self-management advice includes exercise training, volume loading (through increased water and salt consumption), and lifestyle adaptations, such as dietary modifications, avoidance of triggers, counter-manoeuvres, pacing, and bed-tilting”* ([[Knoop-2023]], [p. 2](zotero://open-pdf/library/items/P2VFKVHY?page=2&annotation=2PP5WLZV))^22 >*“Exercise was viewed as a useful management tool (N ¼ 4), but not for everyone.”* ([[Knoop-2023]], [p. 5](zotero://open-pdf/library/items/P2VFKVHY?page=5&annotation=5KEBDM3I))^23 >*“Large muscles contract during active standing and release pressure on veins in the lower extremities; thus, skeletal muscle pumps improve venous return to the heart [15]. Therefore, leg crossing is an easy and effective way to increase the central blood volume [16]. In PoTS therapy, counter manoeuvres, such as leg crossing, are recommended during acute dizziness”* ([[Maier-2023]], [p. 2](zotero://open-pdf/library/items/LQMXCPGX?page=2&annotation=4MG6WTYJ))^24 >*“A second important finding was that leg crossing did not improve executive function in patients with PoTS. Crossing the legs increases the venous return and improves cerebral perfusion, but also reduces the balance compared with standing. A situation with an increasing need to maintain balance might result in impaired cognition [44].”* ([[Maier-2023]], [p. 7](zotero://open-pdf/library/items/LQMXCPGX?page=7&annotation=LYMX52PD))^25 >*“In a survey-based study, POTS patients self-reported that lying down, avoiding heat, and increasing fluid and sodium intake can non-pharmacologically alleviate cognitive symptoms. Conversely, brain fog was aggravated by excessive cognitive challenges, poor sleep, showering, and acute exercise.14 While exercise may acutely worsen patient perception of cognitive function, regular exercise programs are reported to improve cognitive symptoms,14 as well as physical symptoms of POTS.”* ([[Raj-2018]], [p. 11](zotero://open-pdf/library/items/IYRK4T6C?page=11&annotation=3JGACNLL))^26 >*“Finally, POTS patients equally self-report caffeine as helpful or a hindrance cognitively.14 Despite caffeine’s vasoconstrictive qualities, perhaps in some cases diuresis and tachycardia outweighed benefit.”* ([[Raj-2018]], [p. 11](zotero://open-pdf/library/items/IYRK4T6C?page=11&annotation=FGC9MGQ7))^27 >*“Nonpharmacologic strategies include avoidance of exposures that may contribute to overheating, improving venous return by activation of calf muscles and tonic muscle contraction when lightheaded. Maintaining good hydration may include supplementing salt and water intake and withdrawal of medications that interfere with fluid balance (drospirenone, diuretics). Where food intolerances are problematic with suspected splanchnic pooling, providing dietary advice and referral to a dietician may be of benefit. The use of full-length pressure stockings can be of considerable benefit in reducing POTS symptoms. Previously, it has been demonstrated that a 45–50 mmHg inflatable pressure suit significantly reduced abnormal HR and blood pressure responses when patients with orthostatic intolerance were upright.51 However, difficulty in applying compression garments and reduced user compliance during warmer weather (when they are likely to be of greatest benefit) limit the translation of potential benefits from external compression into significant benefit in many patients.”* ([[Wells-2017]], [p. 8](zotero://open-pdf/library/items/HLELIN7I?page=8&annotation=5MENPE6P))^28 >*“It has been postulated that increased renin secretion and consequent aldosterone increase can occur with reduced renal arterial pressure when a patient sleeps with the head of the bed raised by ~10 cm.”* ([[Wells-2017]], [p. 8](zotero://open-pdf/library/items/HLELIN7I?page=8&annotation=9DU5M5MG))^29 >*“Further, a graduated exercise program incorporating recumbent exercises may also be beneficial in POTS.65 Short-term exercise training has been shown to increase the baroreflex sensitivity in POTS patients and decrease the upright HR.66 It is important to keep a modest expectation of activity levels in the early phase to avoid postexertional fatigue and abandonment of the program, as a gradual increase in exercise can result in significant improvement in both symptoms and orthostatic HR in patients with POTS.”* ([[Wells-2017]], [p. 8](zotero://open-pdf/library/items/HLELIN7I?page=8&annotation=4UHYMEJL))^30 >*“Other lifestyle factors include adoption of good sleep hygiene to address disrupted circadian rhythm, and psychologic support, to encourage realistic expectations of integration back into the study or workplace.”* ([[Wells-2017]], [p. 8](zotero://open-pdf/library/items/HLELIN7I?page=8&annotation=C4EAVRDM))^31 ##### [[5.1. Hyperadrenergic POTS | Hyperadrenergic POTS]] >*“It is important to minimize the orthostatic reduction in venous return and pulse pressure. To this end, volume expansion and wearing an abdominal binder are helpful. The latter reduces venous capacitance. Some patients are also helped by physical countermaneuvers, where the subject contracts dependent muscles” *([[Low-2009]], [p. 7](zotero://open-pdf/library/items/I4WAD8AG?page=7&annotation=LAX6WW7C))^32 ##### [[5.2. Hypovolemic POTS | Hypovolemic POTS]] >*“The salt intake should be between 150–250 mEq of sodium (10-20 g of salt)” *([[Low-2009]], [p. 6](zotero://open-pdf/library/items/I4WAD8AG?page=6&annotation=DXME4D34))^33 >*“The patient should have at least 1 glass or cup of fluids with their meals and at least 2 at other times each day to obtain 2–2.5 L/day.” *([[Low-2009]], [p. 7](zotero://open-pdf/library/items/I4WAD8AG?page=7&annotation=GIMZ5U66))^34