Exercise with POTS: Dallas Protocol, Levine Protocol, and CHOP Protocol

Living with Postural Orthostatic Tachycardia Syndrome (POTS) can feel like an uphill battle, especially when it comes to exercise. With symptoms like dizziness, fatigue, and heart palpitations, even the thought of physical activity can be daunting. Yet, exercise has been shown to be one of the most effective ways to manage POTS symptoms over time. Also, many high performance athletes and olympians have POTS, and regular exercise can improve symtpoms. This blog will guide you through understanding the benefits of exercise for POTS and introduce you to three well-known exercise protocols designed specifically for this condition: the Dallas Protocol, the Levine Protocol, and the CHOP Modified Protocol.

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Why Exercise Matters for POTS

Exercise might seem counterintuitive when standing up alone can cause discomfort. However, research has shown that regular, tailored exercise can improve many of the symptoms associated with POTS. The main benefits of exercise include:

1. Increased Blood Volume: People with POTS often have low blood volume, which exacerbates their symptoms. Exercise can help increase blood volume, improving circulation and reducing dizziness.
2. Improved Heart Function: Regular cardiovascular exercise strengthens the heart, allowing it to pump more efficiently, which can help reduce heart rate fluctuations.
3. Reduced Deconditioning: Deconditioning, or the loss of physical fitness, is common in those with POTS due to inactivity. Exercise helps combat this, improving overall stamina and reducing fatigue. Keep in mind that POTS is NOT caused by deconditioning, but improved fitness may help improve symptoms.
4. Better Autonomic Regulation: Exercise helps retrain your autonomic nervous system, which controls involuntary functions like heart rate and blood pressure, leading to better symptom management.

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Exercise Protocols for POTS

Now that we understand why exercise is crucial, let’s look at some of the most effective exercise programs developed specifically for POTS patients. THe main protocols that the community discusses are the Dallas Protocl, the Levine Protocol, and the CHOP protocol. These all have the same roots with various adaptaions. Depending on which source you ask, the difference between the Dallas protocol and Levine protocol is neglible or even non-existant. The CHOP protocol is different from the other to because it is tailored for pediatric patients.

1. The Dallas Protocol

The Dallas Protocol is one of the earliest exercise regimens developed for POTS, created by Dr. Benjamin Levine at the Institute for Exercise and Environmental Medicine in Dallas, Texas. This program starts with recumbent exercises—like cycling on a recumbent bike or rowing—that keep you in a lying down or seated position to minimize the strain on your heart and reduce dizziness.

As you progress, the protocol gradually increases the intensity and shifts to upright exercises, helping you build tolerance and strength over time. The goal is to slowly improve your cardiovascular health without overwhelming your body.

2. The Levine Protocol

The Levine Protocol, also developed by Dr. Levine, is a more structured and intensive version of the Dallas Protocol. It’s a seven-month program that begins with very gentle exercises and gradually builds up to more strenuous activities as your tolerance improves. This protocol includes:

• Warm-Up: Gentle, recumbent exercises to prepare your body.
• Base Pace: A moderate level of exercise that challenges you without causing excessive symptoms.
• Cool Down: Light activity to help your body recover.

The Levine Protocol emphasizes patience and consistency, encouraging participants to progress at their own pace. Some may take longer than others to complete each phase, and that’s okay—the key is to keep moving forward.

3. The CHOP Modified Protocol

Developed by Dr. Jeffrey Boris at the Children's Hospital of Philadelphia (CHOP), this protocol is a modified version of Dr. Levine’s approach, tailored for younger patients or those with more severe symptoms. It starts with even more gradual increments and focuses heavily on recumbent exercises like swimming, rowing, or using a recumbent bike. This protocol is particularly useful for those who struggle with severe exercise intolerance.

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Tips for Exercising with POTS

Starting an exercise regimen with POTS requires a careful approach. Here are some tips to help you get started:

• Start Slowly: Begin with just a few minutes of exercise and gradually build up. Even five minutes a day can make a difference over time.
• Stay Hydrated: Drink plenty of water before, during, and after exercise to help maintain blood volume.
• Listen to Your Body: Pay attention to how you feel. It’s okay to take breaks or adjust the intensity if you start feeling unwell.
• Use a Heart Rate Monitor: Keeping an eye on your heart rate can help you stay within a safe range during exercise.
• Incorporate Strength Training: Alongside cardiovascular exercise, include strength training for your legs and core, which can improve your overall stability and reduce symptoms.

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Final Thoughts

Exercise can be a powerful tool in managing POTS, but it’s essential to approach it with care and the guidance of your healthcare provider. Whether you’re following the Dallas Protocol, the Levine Protocol, or the CHOP Modified Protocol, remember that progress may be slow, but it’s still progress. With time, patience, and perseverance, exercise can help you regain control over your symptoms and improve your quality of life.

If you’re considering starting an exercise program, be sure to discuss these protocols with your doctor to determine which one is right for you. Remember, every step forward, no matter how small, is a victory.

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References:

1. Harris, Jim. "Exercise for POTS: CHOP Protocol, Dallas Protocol, and Levine Protocol." Dr. Jim Harris MD, www.jimharrismd.com/articles/exercise-for-pots-chop-protocol-dallas-protocol-and-levine-protocol.
2. Dysautonomia International, CHOP Modified Dallas POTS Exercise Program. https://www.dysautonomiainternational.org/pdf/CHOP_Modified_Dallas_POTS_Exercise_Program.pdf
3. Exercises for Dysautonomia Patients. Dysautonomia International, https://www.dysautonomiainternational.org/page.php?ID=43.
4. Ziaks, Lauren, et al. "Adaptive Approaches to Exercise Rehabilitation for Postural Tachycardia Syndrome and Related Autonomic Disorders." Archives of Rehabilitation Research and Clinical Translation, 2024, https://doi.org/10.1016/j.arrct.2024.100366.
5. Fu, Qi, and Benjamin D Levine. “Exercise and non-pharmacological treatment of POTS.” Autonomic neuroscience : basic & clinical vol. 215 (2018): 20-27. doi:10.1016/j.autneu.2018.07.001