Impact of Exercise to Treat Postural Orthostatic Tachycardia Syndrome: A Systematic Review

Melissa M Cortez ^1* Kayla Aikins ² Amy C Arnold ³ Jeffrey R Boris ⁴ Todd E Davenport ⁵ Katie Johnson ¹ Hagar S Kattaya ⁶ Laurence Kinsella ⁷ Mary M McFarland ¹ Ryan Pelo ¹ Clayton D Powers ¹ Kelsi Schiltz ¹ Lauren E. Stiles ⁸ Lauren Ziaks ⁹ Tae Hwan Chung ¹⁰ Claudia DalMolin ¹¹

• ¹ The University of Utah, Salt Lake City, United States
• ² University of Nevada, Reno, Reno, Nevada, United States
• ³ The Pennsylvania State University (PSU), University Park, Pennsylvania, United States
• ⁴ Jeffrey Boris, MD LLC, Moylan, United States
• ⁵ The University of the Pacific, Stockton, California, United States
• ⁶ Zaitoun Specialized Hospital, Cairo, Egypt
• ⁷ SSM Health Care, St Louis, Missouri, United States
• ⁸ Stony Brook University, Stony Brook, New York, United States
• ⁹ Intermountain Health Care, Salt Lake City, Utah, United States
• ¹⁰ Johns Hopkins Medicine, Johns Hopkins University, Baltimore, Maryland, United States
• ¹¹ University of Maryland, Baltimore, Maryland, United States

Background: Postural orthostatic tachycardia syndrome (POTS) is a chronic condition associated with a high symptom burden and decreased quality of life (QOL). Exercise is currently considered to be a first line non-pharmacological treatment for POTS. The purpose of this systematic review was to evaluate the impact of exercise on cardiovascular and patient-centered outcomes in patients with POTS.Purpose: To evaluate whether exercise benefits patients with POTS by synthesizing data from published clinical studies. Methods: Electronic databases, including Medline, Embase, CINAHL Complete, Cochrane CENTRAL, and others were searched and results were exported on May 2, 2023. Study inclusion: those that utilized an exercise program as an intervention for POTS and were conducted as experimental or quasi-experimental design. Exclusions: Non-English language papers and opinion-based/theoretical/non-empirical studies/case reports. Data extraction was based on Cochrane Handbook guidance and summarized according to Synthesis Without Meta-analysis (SWiM) guidelines; methodological quality and risk of bias was evaluated using the JBI Critical Appraisal tools. Standardized effects were calculated and summarized based on the direction of effect.Results: Seven studies included in the final review are described in the data summary and synthesis. Improvements in heart rate were reported across all studies reviewed, while stroke volume and QOL improvements were also found. Notably, not all studies reported on the latter two outcomes. Methodological variability across studies precluded meta-analysis, and risk of bias was considered moderate-high in all but a single study.BP: blood pressure CO: cardiac output EDS: Ehlers-Danlos syndrome FITT: frequency, intensity, time and type HR: heart rate IBS: irritable bowel syndrome ITT: intention-to-treat JBI: Joanna Briggs Institute LOCF: last observation carried forward MAP: mean arterial pressure MCAS: mast cell activation syndrome ME/CFS: myalgic encephalomyelitis/chronic fatigue syndrome PEM: post-exertional malaise POTS: Postural Orthostatic Tachycardia Syndrome PP: per-protocol QOL: quality of life SWiM: Synthesis Without Meta-analysis SV: stroke volume TPR: total peripheral resistance