POTS: A Trauma-Sensitive Approach

Recovering from POTS can feel like a mountain to climb, and for many, it’s made even harder by past trauma.

Trauma could be emotional, physical, or even the result of repeated experiences of not being believed by medical professionals.

Unfortunately, traditional “do this plan, stick to it” rehab approaches can unintentionally make things worse for someone dealing with both POTS and trauma.

Why Trauma Matters in Recovery

Trauma changes how we feel safe in the world—and in our own bodies.

David Emerson, in his book Trauma-Sensitive Yoga, explains that trauma survivors often feel unsafe when being told what to do, especially by an authority figure like a doctor or trainer.

For someone with POTS, being handed a rigid exercise plan with no say in the process can feel overwhelming or even triggering.

Instead of building confidence, it can ramp up stress and worsen symptoms.

The key is to give control back to you, the person doing the work.

A Smarter Way Forward: Patient-Led Experimentation

Exercise for POTS doesn’t have to follow a one-size-fits-all model. Here’s how a trauma-sensitive, patient-first approach works:

1. You’re in the Driver’s Seat

• Every choice starts with you. You decide what feels safe to try, whether it’s gentle stretching, seated yoga, or just focusing on your breath.

• The role of a guide or physiotherapist isn’t to tell you what to do—it’s to provide options and support while you explore what works.

2. Plenty of Options, No Pressure

• Movement doesn’t have to look like “traditional” exercise. It can be as simple as lying-down cycling, a slow walk, or even sitting quietly and engaging your core.

• If something doesn’t feel right today, that’s okay. Try something else. The goal is flexibility, not perfection.

3. Adjust in Real Time

• Instead of sticking to a strict plan, give yourself permission to adapt. If something feels like too much, scale it back. If something feels good, lean into it a bit more.

• This moment-by-moment approach builds trust in your body and helps you reconnect with what it can do, without overwhelming your system.

Recovery is Personal, Not Perfect

Getting better from POTS isn’t about sticking to someone else’s plan—it’s about rediscovering what your body is capable of, one small, safe step at a time.

This isn’t linear, and it isn’t always easy.

But with a trauma-sensitive approach that puts you in control, recovery can feel less like a battle and more like a partnership between you and your body.

Your journey is yours to lead. Start where you are.

Move at your pace.

And remember, every small step forward is progress.

Reference

Trauma-Sensitive Yoga in Therapy: Bringing the Body into Treatment

Pain and POTS

Why Even Small Exercises Can Feel Overwhelming: The Science Behind Your Pain

If anyone’s ever dismissed the pain or fatigue you feel after the tiniest bit of exercise as “all in your head,” let’s stop right there.

Science is on your side, and Bud Craig’s homeostatic model of pain explains exactly why this happens.

It’s not about muscle damage or injury—it’s about how your body manages (or struggles to manage) balance.

Why Does Exercise Feel So Hard?

Craig’s research flips the old ideas about pain on their head. Pain isn’t just caused by visible damage like tears or injuries—it’s your body’s way of saying something is out of balance. When you push beyond what your body can handle, even slightly, here’s what can happen:

1. Inflammation
   Your body might react to exercise by kicking off an inflammatory response if it’s not ready to handle the stress.

2. Metabolic Waste Buildup
   Exercise creates byproducts like lactic acid, which lowers the pH in your muscles. If your body isn’t conditioned to clear this waste efficiently, it can trigger pain and discomfort.

Why This Doesn’t Show Up on Scans

Here’s the frustrating part: modern medical technology isn’t designed to “see” this kind of pain.

There’s no visible injury or damage to point to on an MRI or X-ray.

Because of this, many people are unfairly dismissed by doctors, told their symptoms are psychological, or simply not believed.

This creates a vicious cycle:

• Frustration and Emotional Burnout: Not being taken seriously is exhausting.

• Stress Response Overload: Emotional distress ramps up your body’s stress system (the sympathetic nervous system, or SNS), worsening inflammation and pain sensitivity.

A New Way to Understand Pain: Nociplastic Pain

The kind of pain many people with POTS experience, especially after exercise, fits into a groundbreaking new category called nociplastic pain.

Unlike pain caused by injury (nociceptive pain) or nerve damage (neuropathic pain), nociplastic pain is driven by how the nervous system processes pain signals, even when there’s no visible tissue damage or structural issue.

This revolutionary definition validates the experiences of people with persistent pain, showing that their pain is real and rooted in biological changes—not in their imagination.

For people with POTS, this recognition can be a game-changer, offering hope and paving the way for better understanding and treatment.

Finding Your “Exercise Tolerance Window”

For people with POTS, exercise tolerance is like walking a tightrope.

Your body has a narrow window of what it can handle, and stepping outside of it—even a little—can trigger a cascade of symptoms.

When you exceed your threshold:

1. The Fight-or-Flight System Kicks In
   Your SNS goes into overdrive, increasing your heart rate, inflammation, and stress hormones.

2. Tracking Can Help
   Using tools like the ELITE HRV app, you can monitor your heart rate variability (HRV). A lower HRV means your body is in a stressed, inflamed state. Recognizing these signs early can help you adjust before things spiral.

This Isn’t Your Fault

Feeling this way after exercise isn’t a sign of failure—it’s your body telling you it needs to start smaller and slower.

Recovery isn’t about pushing harder; it’s about finding your unique window of tolerance and working within it.

Over time, with patience and the right approach, your body can learn to handle more without pushing back.

Trust the process, respect your limits, and know that your experience is valid—even if the medical world doesn’t always make you feel that way.

Resources:

A new view of pain as a homeostatic emotion

Nociplastic Pain

POTS & Exercise

Exercise, POTS, and the Art of Doing Hard Things: A No-B.S. Guide to Moving Forward

Let’s get real for a minute: if you’re living with Postural Orthostatic Tachycardia Syndrome (POTS), exercise can feel like the cruelest joke.

It’s supposed to help you feel better, right?

So why does it sometimes make you feel like you’ve been hit by a truck?

And why does every rehab plan out there seem like it was designed for someone with a completely different body?

This isn’t just frustrating—it’s one of the greatest challenges of your recovery journey.

The problem?

Most exercise protocols for POTS are rigid, cookie-cutter, and completely out of touch with the messy, unpredictable reality of how your body responds.

But here’s the thing: you’re not broken.

Your body isn’t a failure.

It’s just stuck in a loop it hasn’t yet learned how to break.

And today, we’re talking about how to change that—without toxic positivity, fluff, or empty promises.

Let’s dive into the real science, the struggles, and why hope isn’t just a cliché when it comes to your recovery.

Why Exercise Can Feel Like Your Worst Enemy

First, let’s validate what you’ve been through. If you’ve tried to follow a traditional exercise program and felt worse, it’s not because you didn’t try hard enough. It’s because most rehab plans don’t account for what’s really happening in a body with POTS.

The Science of “Why Do I Feel Worse After Exercise?”

When your body is “unconditioned”—which is common if you’ve had to limit activity due to POTS—exercise can actually cause inflammation.

Here’s why:

• Inflammatory Storm: Your muscles release chemicals (cytokines) that irritate nerves and trigger pain. It’s like your body’s alarm system is on overdrive​

• Hyperactive Pain Signals: Your nervous system hasn’t learned how to regulate itself yet, so it amplifies every signal—making soreness, fatigue, and dizziness feel 10 times worse​

• Emotional Fallout: Let’s not ignore this. When exercise leaves you bedridden or flaring, it’s not just physical—it’s emotionally crushing. You start to wonder, “What’s wrong with me? Am I ever going to feel normal again?”

But here’s the thing: this isn’t permanent.

Your body can learn to respond to exercise differently.

You just need a smarter, more compassionate approach.

Moving Beyond Rigid Rehab: A Smarter, Science-Backed Way Forward

The old way of exercising for POTS goes something like this: start slow, progress in fixed stages, and hope for the best.

Sounds harmless, right?

Wrong.

For many people, these programs feel like a one-way ticket to symptom flare-ups.

It’s time to move on from one-size-fits-all.

Here’s how we make exercise work for you, not against you:

1. Start Horizontal—Seriously

Forget about jumping straight into standing exercises. Your body needs to build tolerance without gravity messing things up. Supine or recumbent exercises, like cycling or leg lifts, are the best place to start.

“Programs should begin with horizontal exercises to minimize orthostatic stress while building tolerance.” (Ziaks et al., 2024)

2. Understand the Transition to Anti-Inflammatory Exercise

When you stick with gentle, regular movement, something magical happens: your body adapts.

Over time:

• Your muscles start producing anti-inflammatory chemicals that calm pain sensors.

• Your nervous system learns to stop amplifying pain signals and starts calming down instead.

• Your immune system shifts from a “fight” mode (inflammatory cytokines) to a “heal” mode (anti-inflammatory cytokines).

This is why exercise feels hard at first but gets easier the more conditioned you become.

Reference: Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation

This diagram shows how your muscles, immune cells (called macrophages), and pain sensors (nociceptors) interact.

When your body is under stress or inactive for long periods, more macrophages take on the “M1” role.

These M1 macrophages release chemicals that cause inflammation, which makes your pain sensors more active and leads to pain.

However, when you do regular, gentle exercise, your immune system starts shifting.

More macrophages become “M2” instead, which release anti-inflammatory chemicals.

These chemicals calm down your pain sensors, reducing pain and helping your body feel better.

The takeaway?

Over time, consistent movement can teach your body to create more M2 macrophages, reducing inflammation and improving how your body handles stress and pain.

3. Go at Your Own Pace—No Timelines

Progression isn’t about rigid timelines. It’s about listening to your body. You’re ready to move to seated or standing exercises when you can handle 20 minutes of horizontal movement without flaring up. Not before.

4. Use Interval Training for Recovery

If steady-state exercise feels overwhelming, try intervals: short bursts of effort followed by rest. For example, 30 seconds of light movement and 1–2 minutes of rest. It’s a gentle way to build endurance without overloading your system​.

The Philosophical Side of Doing Hard Things

Here’s the tough truth: recovery is hard.

Exercise with POTS forces you to face both physical and emotional challenges head-on.

It’s uncomfortable, messy, and often feels like two steps forward, one step back.

But what if the struggle is the point?

Every time you listen to your body and adjust instead of pushing through, you’re practicing self-compassion. Every time you show up, even when you’re scared of flaring, you’re building resilience. And resilience isn’t just physical—it’s emotional, too.

By focusing on small, consistent actions instead of fearing the big picture, you’re taking back control.

Hope, Without the Fluff

Let’s get one thing straight: this isn’t about toxic positivity. Hope doesn’t mean pretending everything is fine when it’s not. Hope is understanding that your body isn’t your enemy—it’s just trying to protect you in ways that aren’t helpful right now.

With the right approach, exercise can go from being a trigger to being a tool. It can become something that strengthens you—physically, emotionally, and even spiritually.

So, start small. Stay consistent. And remember: every step forward, no matter how tiny, is progress.

You’ve got this. One rep, one breath, one day at a time.

References:

Exercise-induced pain and analgesia? Underlying mechanisms and clinical translation

Adaptive Approaches to Exercise Rehabilitation for Postural Tachycardia Syndrome and Related Autonomic Disorders