How Physical Therapy Can Support POTS Treatment

Written by Julie Woon, MSJ

Dr. Kelsey Botti brings a unique perspective to treating Postural Orthostatic Tachycardia Syndrome (POTS) - she's both a doctor of physical therapy and someone who has lived with the condition for over a decade. After earning her doctorate from Chatham University in 2014, she spent years struggling with unexplained symptoms before finally receiving her diagnosis in 2021. Today, she specializes in helping POTS patients through her Pittsburgh-area clinic, KB Physical Therapy and Wellness and the POTS Life app, offering hope and practical guidance to those navigating this challenging condition.

Dr. Botti’s Journey to Diagnosis

Can you tell us about your experience with POTS before you were diagnosed?

Looking back through a POTS lens, so much makes sense now. But when you're going through it, you feel crazy - all these symptoms don't add up. It started in 2012 during my senior year at the University of Pittsburgh when I had a concussion. Many of my symptoms were labeled as post-concussive, which made sense at the time: brain fog, neck pain, and other issues.

The problem was that after I finished my concussion protocol and transitioned into PT school that fall, things just weren't going away. I was left with intense hand tremors and brain fog. I never felt right, but they told me post-concussive symptoms could last indefinitely. Now, knowing how sensitive POTS bodies are, no wonder I didn't respond well to the medications they tried.

How long did it take to get your diagnosis?

I made it through PT school, but it wasn't easy. I just didn't feel like myself. The hand tremors were particularly difficult - I worried patients would think I'd had too much coffee or was on medication. Over the 10-year period before my diagnosis, I had so many ER trips that I used to joke. I was the most expensive person on my health plan.

The challenge was that each specialist looked only at their area. Gastroenterology would clear me, cardiology would clear me - I was "fine" in each realm, but I was still falling apart. No one looked at the whole picture.

It wasn't until after the birth of my second son in July 2020 that things really escalated. I was crawling to his bedroom and could feel what I now know are PVCs (premature ventricular contractions). Because I work in healthcare and had already ruled out so many things, once I got to cardiology in early 2021, the path to diagnosis through a tilt table test came relatively quickly. But I had suffered for over 10 years with symptoms - and looking back, probably even longer than that. I just thought certain things were normal, like getting dizzy or seeing stars when standing.

How POTS Influenced Her Career Path

How did your diagnosis change your approach to physical therapy?

When I was diagnosed, I was barely surviving. I was working in home health and would pull into a patient's house, lay my head on the steering wheel, give myself a pep talk, go in and treat, then come out and cry before driving to the next place.

When they called with my diagnosis, they told me to drink water, have salt, and spend time in each position. Being Type A, I said I needed more - I have two little boys, I need something concrete. But they didn't have more to offer. I felt completely out of control.

I eventually found the Cleveland Clinic and went through their program, but as I went through it, I realized there was no support system. There was no community, no clear path, no one to ask questions. When my first October came and I experienced the "October slide," I had no idea what was happening to my body. After I started feeling better, I thought: this needs to change. That grew into treating patients locally in my office, and then we developed the POTSLife app.

The Physical Therapy Approach to POTS

How does your approach to treating POTS differ from traditional physical therapy?

The biggest difference - and this was even a surprise to me - is that the traditional "no pain, no gain" mentality is the worst thing for POTS. In PT school, we learned you have to push through a bit to make gains. Yes, there's a time and a place for that, but probably 99.9% of the time with POTS, that's not the case.

With POTS, we have very poor blood flow - blood gets stuck in our legs. The misconception is that if you're young and look fine, you should be able to exercise at a certain heart rate. But when we push to that level, people become symptomatic. You might not feel bad during the exercise, but you'll feel terrible afterward, and by that point, you've done more harm than good.

My approach is: less is more. I get everyone from bed-bound patients to people who were running ultra marathons two weeks ago. Everybody starts at the same low and slow point. Sometimes they push back, saying they can do more. But I ask: are you feeling good? And they say no. So we go way back and build a solid framework instead of one with gaps that can't withstand illness, stress, or anything that tips the adrenaline over.

How does physical therapy complement other medical management for POTS?

I always say it's like a recipe. Exercise is your main ingredient - the right type, with the right guidance, slow and steady. Hydration and electrolytes are right up there too, because we need that salt to bind to the water to improve blood volume and allow the exercise to work.

Medication is important, though not everybody needs it. I've seen the whole spectrum - some people take a lot, some manage without. That's very personal and individual.

The other things are complementary. Compression garments are often recommended, though I personally felt worse with them. Abdominal compression has been shown in studies to be helpful, and some of my patients use it. Other additions like elevating the head of the bed are extra ingredients. But really, the medication management, water, and other supports are like band-aids that allow the exercise piece to work at its best. Everything needs to be just right to see improvements, which is frustrating but necessary.

The Exercise Protocol

What makes your exercise program different from standard protocols?

The problem with many existing protocols is they're just printed papers handed to patients - there's no accountability. I went through a program where I biked seven days a week because I was desperate, but most don't do that.

Other protocols out there might have a three-day-a-week model, and months one or two are fine, but then they ramp up really quickly. People feel worse and fall off the wagon.

What I've done, based on my clinic experience and personal journey, is build a program that's lower and slower. It's structured around biking - research shows that's the gold standard for POTS treatment. It's three days a week at much slower intensities. You have to go way back to help people stick with it and feel okay.

My goal is for people to exercise and feel nothing. When patients come to my office and I ask how they felt, I want to hear "fine." I don't want to hear they felt horrible, because the minute they feel horrible, we've made it worse.

Another key element: existing protocols don't really incorporate strength training. What happened was people were improving blood flow through aerobic reconditioning, but there was no strength training to complement it. Using my PT knowledge, I've added exercises that slowly progress every week and meet people where their blood flow is.

Yes, day one you might be doing a straight leg raise like other protocols, but by the end you're doing what I jokingly call "real life exercise" - actual challenging movements. By month 12, you're exercising at a level that feels real, but you're not symptomatic because your body's ready for it.

Why is biking preferred over other forms of exercise like walking on a treadmill?

Let's go back to what POTS actually is. When anyone stands, two water bottles worth of blood go to your feet. In a normal body, it just pumps back up. In a POTS body, it stays there.

That's why we turn to biking - it takes the gravity component out as much as possible. You're allowing yourself to exercise in a decreased adrenaline state. If you go straight to the treadmill, especially if you're young and that's what you think you should do, you're starting in an upright position. And no one's going to get on the treadmill and barely walk at a slow speed with no incline - we naturally go too hard, too fast.

You might not feel bad while you're doing it, but if two to three days later you're struggling, you have to look back at what you did to feel this way now.

Staying Motivated and Avoiding Common Mistakes

How do you help patients stay committed to their exercise programs?

Honestly, I think it's the community we build and the access to open dialogue. Whether you're in my office or on the app, there's a chat feature that comes right to me. I never wanted someone to feel like they signed up and then were on their own, because I've been there.

There are plenty of tears. Things change with weather, women's cycles cause issues, or people get sick. You have to have open dialogue. I can share that I've seen something before, or if I haven't experienced it personally, I've probably heard about it from someone else. I call it "KB research."

Creating that community gives people an outlet, even just to complain about how hard it is. I always tell people when they start: the goal is to never be as low as you are at the beginning. You're going to go up, but it's going to be bumpy, and that's okay.

In my office, patients get to meet others with POTS - I didn't know anyone when I was diagnosed. On the app, there's a community page where people have created relationships outside the app. They check in on each other, learn from what I and my team post, and lean on each other. Because there are definitely days when you want to give up - I've been there, and it's usually not just once. It's frustrating to have to get on a bike just to walk around like everybody else in the world.

What are the most common mistakes you see people make?

One of the biggest is just going to get on a treadmill. A good example: I had a patient who grew up here, graduated from my program, and is now a teacher with young kids. Her husband runs a business and she coaches soccer. Someone asked her how she does it all, because she was struggling every day before she graduated from the program. She said, "I just do it."

Just because you're doing something and you can do it doesn't mean it's the right thing. So many people get on a treadmill, even starting slow. But if we go back to the physiology of POTS - that blood pooling in the feet when standing - going straight to upright exercise means you're already at a disadvantage.

Another common pattern: maybe you don't feel bad while exercising, but if two to three days afterward you're struggling, you need to look back and figure out what you did. Once people understand where that blood is going, it's eye-opening.

Dr. Botti working with patients at KB Physical Therapy & Wellness, Pittsburgh’s only POTS Physical Therapy Clinic.

Success Stories and What to Expect

What kind of results have you seen with your patients?

At the Cleveland Clinic, they told me: "Kelsey, the person you were before POTS is gone." I looked at my husband and started crying. I had just had my second baby, and I cried the whole way home. But then they said the person after POTS can be just as good. Honestly, I didn't believe them because I was at such a low point.

But I can say we have many graduates now, and I'm an example myself. I always tell people it's not a sales pitch - it's hope. The program is a year long, and I tell patients to give themselves a year even if they're not doing this specific program. If it's the right type of treatment, by months two to three, you should see little wins. Maybe to someone else they don't seem like much, but perhaps you or people around you notice you're doing things easier - even something as simple as standing at the kitchen counter making something on the stove.

By months six and seven, you really start stacking those wins. You're not perfect, but you string together more good days and have fewer highs and lows. You're trying to even things out to live a steadier life.

By the end of year one, life isn't perfect, but you have a sense of yourself back. I'm almost at year five now, and I'm even better than I was at year one. I don't think I knew how sick I was for so long before my diagnosis. You see the wins slowly and steadily. Once you get that blood flow back, nobody has to convince you - you just start to feel it. People tell me they know if they don't feel good, they're going to get on that bike because they physically feel that change.

Advice for Those Without Access to Specialized Care

What can someone do if they don't have access to a POTS-trained physical therapist?

Any movement is better than no movement, though I know that's a hard concept when you already feel terrible. I'm not suggesting crazy movements - even some lying down exercises to start. If you can find some supine exercises, just start activating those muscles.

POTS makes you feel terrible, so you feel like you shouldn't move. But then you don't move and you feel worse. It's a mindset thing - you just have to start small. Even if you can only do five reps, that's okay. We just have to start somewhere.

Set small goals. If you're lying in bed most of the day, maybe get up and walk to and from the kitchen five times. That might take all day, but that's okay. You just have to start small and give yourself goals. I promise you will build that tolerance. It's not quick, but you have to start somewhere - as hard as that is, I know.

The Future of POTS Care

Where do you see the role of physical therapy in POTS care evolving?

I hope it changes drastically. I've been a PT for almost 11 years, and we didn't learn about POTS in school. My neuro professor, who was brilliant, called me for guidance when her daughter was diagnosed. I think getting this information into PT school curriculums is a main component.

COVID brought a ton of POTS research, and that's still evolving, which is awesome. I hope that translates into future PT education. Even if therapists aren't treating it directly, just being aware of it matters. We spend one-on-one time with patients, so we can be quarterbacks who notice when things don't add up and suggest patients see cardiology. This could help people get diagnosed quicker so they're not suffering as long.

What do you wish other healthcare providers understood about using PT for POTS management?

That it's so beneficial. POTS patients need guidance because we all tend to push too hard, too fast. Having somebody to guide them on what's too much, or to tell them that just because they can do something doesn't mean they should feel terrible three days later - that's invaluable. Having a teammate to bounce symptoms and ideas off of is crucial.

I think the role of PT is underestimated. But I've also heard stories from patients who tried PT and were pushed too hard. These are great physical therapists - it doesn't mean they're not good at what they do. It's just the knowledge gap. It's not their fault. I probably would not have treated the same way if I didn't have POTS myself. Until you feel what it's like, it's hard to understand how the simplest thing, like just walking on a treadmill, can make somebody feel worse two days later.

Getting Help

How can people access your services?

My clinic is located outside of Pittsburgh, Pennsylvania - it's called KB Physical Therapy and Wellness, and we only treat POTS here. The website is kbptwellness.com. We just had a POTS awareness night this past week, and people came from all over. They were surprised to learn we exclusively treat POTS, but there are so many people diagnosed just in this area.

For those not local to Pittsburgh, we have the POTSLife app, which launched about two years ago. I realized I could only be in so many places at one time, but the need extends far beyond Pennsylvania. The program in the app is exactly what I do in my office - biking and strength training - with nutrition support from our nutritionist Brittany, helpful documents and videos I've recorded, meditation ideas, and community support.

We have people from different countries in the app. They can all relate and have created connections outside of it, which is really cool. The chat feature comes directly to me because I want to be as involved with app users as I am with my in-office patients. POTS is unpredictable - you might need to repeat a week, adjust something, or just vent about how rough it is. I want people to feel like we're walking with them, not that they're doing it alone. The website is thepotslife.com.

We also have our own podcast called "Let's Talk About the POTS Life" where I share my story and graduates share theirs. People have told us it's relatable and hopeful - it shows that things can get better. You can find us on social media through those websites - Facebook, Instagram, all the platforms.

Want to hear more from Dr. Botti? Check out the YMyHealth podcast on Apple Podcasts and Spotify or watch episodes for free on YouTube!