Nonpharmacological Treatment of Postural Orthostatic Tachycardia Syndrome: Commentary and Implications for Psychologists

Postural orthostatic tachycardia syndrome (POTS) is a type of autonomic dysfunction characterized by orthostatic intolerance (i.e., symptomatic hypotension during gravitational stress), tachycardia, and presyncope. Youth with POTS also report concerns of deconditioning, “brain fog,” and musculoskeletal pain and their symptoms frequently result in functional impairments, decreased quality of life (QoL), and psychosocial concerns (McTate & Weiss, 2016). The etiology of POTS is multifaceted, though posited to develop from autoimmune disorder, excessive sympathetic activity, or reduced blood volume and reflex tachycardia. The onset of POTS typically begins within a few years of reaching puberty, though the heterogeneous symptom presentation has made establishing an incidence rate difficult. Population estimations of POTS range from 0.2% to 1% in developing countries, though this is likely an underestimation due to its unclear pathophysiology and shortage of specific biomarkers (Fedorowski, 2019).

Therapeutic response is highly variable in youth and adults with POTS, leading the Heart Rhythm Society to state that the treatment of POTS requires a combination of approaches as there is no single uniformly successful treatment (Sheldon et al., 2015). They further emphasize nonpharmacological treatments as a first-line treatment for all patients with POTS (Sheldon et al., 2015). Reviews of nonpharmacological treatments for POTS focus almost exclusively on lifestyle modifications (i.e., compression garments to improve circulation, aerobic conditioning to increase stroke volume and venous return, sodium and fluid intake to increase plasma volume), which have become standard interventions due to demonstrating improvements in symptomology, autonomic functioning, and orthostatic tolerance (i.e., the ability to remain upright without symptoms; Boris & Moak, 2022; Grubb & Grubb, 2022). Although research supports the efficacy of these interventions, little is known regarding other nonpharmacological treatment approaches that may benefit individuals with POTS and contribute to comprehensive care. It is important for pediatric psychologists to be familiar with other nonpharmacological treatments for POTS as they may deliver or recommend these therapies when working with this population. This topical review aims to explore evidence for nonpharmacological therapies beyond lifestyle modifications for POTS, establish an agenda for research, and provide psychologists with implications for clinical practice.

Literature Search

Consistent with the aims of this topical review, the research team reviewed the literature to determine the use of nonpharmacological interventions in the treatment of POTS. A search strategy was developed in consultation with an academic librarian. To capture relevant articles, a combination of MeSH terms and keywords were used including “Postural orthostatic tachycardia syndrome” or POTS and “nonpharmacological” or “alternative therapies” or “complementary therapies.” Abstracts, commentaries, dissertations, and articles describing invasive therapies were excluded. (Complete strategy in Table 1 in the online supplemental materials.) Of the 370 identified articles, 25 articles met the inclusion criteria of using a nonpharmacological intervention with outcomes related to changes in symptoms of POTS, psychological variables, or functioning. Articles that met criteria, but exclusively examined lifestyle modifications (e.g., fluid and sodium increase; exercise programs; compression garments; n = 16) were not reviewed in this manuscript as these interventions have already been well established in the POTS literature and treatment guidelines. Nine articles meeting inclusion criteria were reviewed. A list of identified interventions including lifestyle modifications for POTS can be found in Table 2 in the online supplemental materials. This study was exempt from Institutional Review Board review as it did not involve human subjects.

Nonpharmacological Treatments for POTS

Tactile Interventions

Three articles examining acupuncture, osteopathic manipulation, and inspiratory resistance to treat POTS were grouped as tactile interventions in which a noninvasive hands-on therapy approach was utilized. Acupuncture and osteopathic manipulation were both examined by case studies of adults, and demonstrated outcomes related to symptoms of POTS such as reduced fatigue, elimination of syncope, and improved blood pressure, heart rate, and orthostatic tolerance (Boyle, 2021; Goodkin & Bellew, 2014). The authors purported that tonifying the body's chi and fixing structural dysfunction through osteopathic techniques led to improvements, respectively. Notably, these interventions also incorporated exercise and increased salt and fluid recommendations. A 10-min intervention of inspiratory resistance via breathing through an impedance threshold device demonstrated improved heart rate in a group of primarily female adults with POTS (Gamboa et al., 2015). The authors expressed this intervention has potential for rescue therapy by causing negative intrathoracic pressure, thus enhancing venous return and stroke volume, but noted uncertainty regarding generalizability to chronic dysautonomic symptoms. None of these studies examined psychosocial variables or daily functioning.

Mind–Body Interventions

Three articles were grouped as mind–body interventions in which relaxation training or psychotherapy was delivered by a provider. Two studies combined relaxation training, Cognitive Behavioral Therapy, and Acceptance and Commitment Therapy, and reported that these therapies reduced anxiety and improved functioning, QoL, and activity level (Hawks et al., 2021; Ralston & Kanzler, 2016). Although demonstrating similar findings, Ralston and Kanzler (2016) examined a structured intervention for a pediatric sample of 25 predominately female youth with POTS, while Hawks et al. (2021) described the treatment of a 40-year-old female with POTS. The third study in this group examined the impact of physiotherapy for breathing training in a group of adult females with POTS and found this intervention led to improvements in symptoms of hyperventilation and respiratory rate (Reilly et al., 2020).

Interdisciplinary Treatment Programs

Three articles were grouped as interdisciplinary treatment programs which incorporated aerobic activities, increased salts and fluids, psychotherapy, biofeedback, and relaxation training. These studies were designated as interdisciplinary treatment programs due to participants having multiple providers from various disciplines who provided several different nonpharmacological interventions. Notably, these studies described the treatment of youth who experienced significant dysfunction from both chronic pain and POTS. One case study examined a 19-year-old male, while the other two studies consisted primarily of female adolescents, all within the context of a 3-week intensive outpatient treatment program for chronic pain and POTS (Bruce, Harrison, et al., 2016; Bruce, Weiss, et al., 2016; Junghans-Rutelonis et al., 2018). Results from these studies consistently demonstrated reduced functional disability and psychological distress, though given the interdisciplinary nature of treatment, these outcomes support the comprehensive treatment approach rather than the effect of individual nonpharmacological interventions.

Agenda for Future Research

Though these initial studies describe how nonpharmacological therapies can demonstrate beneficial outcomes for individuals with POTS, the limited number of published studies and small treatment group sizes do not allow us to fully evaluate these suppositions. Furthermore, the majority of available literature describes the impact of nonpharmacological therapies in adults with POTS, thus limiting generalizability to pediatric patients. Several of these nonpharmacological interventions have a scientific rationale for assisting with autonomic dysregulation, but require additional research to support their use in treating POTS. Specifically, acupuncture stimulation of the ear has been associated with a significant increase in parasympathetic activity (Haker et al., 2000; He et al., 2012), and similar outcomes such as increased heart rate variability (HRV) and decreased autonomic arousal are observed in mindfulness-based interventions (Nijjar et al., 2014). Even more compelling, yet understudied, is the role of biofeedback and HRV training, which can improve autonomic flexibility and regulate parasympathetic tone (Moss, 2004). Adult females with POTS have been found to have lower levels of HRV and sympathetic overactive when compared to healthy controls (Goff et al., 2017), though studies implementing HRV training to ameliorate autonomic dysfunction in POTS are yet to be conducted.

Given the dearth of research regarding nonpharmacological therapies for POTS, conducting case studies aimed at demonstrating effectiveness of specific nonpharmacological interventions is a necessary first step to building this literature base. Since there is no established structure for how these nonpharmacological interventions can be implemented for POTS, examining protocols specific to different treatment delivery methods and settings will be necessary. Well-designed randomized controlled trials may greatly improve current research methodology, though may require multicenter studies to obtain sufficient sample sizes. Pediatric hospitals and clinics that frequently see patients with POTS are well suited for this type of collaboration. Investigators should also consider qualitative and mixed methods research, which can enhance the understanding of patients' experience with interventions and provide robust data related to acceptability and outcomes. This research should track outcomes consistent with treatment goals such as symptom reduction, functional disability, and QoL.

Implications for Psychologists

Many psychologists possess knowledge of research methodology that can be utilized in developing studies and tracking nonpharmacological intervention outcomes. Psychologists can contribute to program development initiatives and should consider partnering with other therapies to establish interdisciplinary pathways and clinics for treating POTS, facilitate integrative medicine practices, and increase service accessibility. Psychologists may possess skills to deliver nonpharmacological interventions or can coordinate with disciplines that provide these services. Increasing accessibility to nonpharmacological treatments is especially useful in settings that do not have integrative medicine teams or infrequently offer nonpharmacological therapies. Adding these services to the menu of available treatment options is critical given that each individual copes and responds to treatments differently.

Psychologists can also assist by providing psychoeducation on nonpharmacological interventions and how these benefit individuals with POTS. Education regarding the biopsychosocial complexities of POTS and rationale for nonpharmacological strategies may reduce inaccurate beliefs that symptoms are purely psychological, which some patients are unfortunately told (Frye et al., 2022). Furthermore, education regarding the physiological impact of nonpharmacological interventions may help normalize these therapies as part of comprehensive treatment for POTS and complement recommendations provided in the POTS literature.

Conclusion

POTS has a complicated presentation that can negatively impact functioning and mood, though has no gold standard treatment. While lifestyle modifications are supported in the POTS literature, other types of nonpharmacological therapies still require initial research and improved methodology to determine their benefit. The agenda for future research and clinical implications are provided in hopes that implementation of these therapies will advance our understanding of holistic treatment and address the biopsychosocial needs of our patients with POTS.