Structuring a Yoga Class for folks with POTS

For individuals with POTS (Postural Orthostatic Tachycardia Syndrome), yoga can serve as a gentle, therapeutic method to manage symptoms, improve autonomic balance, and promote relaxation. However, due to the condition’s sensitivity to posture, transitions, and autonomic dysfunction, the class should be carefully designed.

POTS, Autonomic Dysfunction & Autism:

Owens, A. P., Mathias, C. J., & Iodice, V. (2021) examined the relationship between autonomic dysfunction (AD) and Autism Spectrum Disorder (ASD) in their comprehensive review. The study highlights how disruptions in the autonomic nervous system (ANS) may contribute to common features of Austism Spectrum, including altered sensory processing, emotional regulation, and social interaction challenges. The study discusses findings suggesting elevated resting heart rate, altered blood pressure regulation, and increased sympathetic dominance in individuals with ASD.

Please note: There are potential links between neurodivergent populations (ASD and ADHD) and POTS, although additional research is needed to establish direct connections.

General Advice: What to Avoid

1. Avoid Prolonged Upright Postures:  

  - As Andrade et al. (2024) highlight, upright exercises exacerbate tachycardia and cardiovascular stress in POTS patients. Prolonged standing poses, such as Mountain Pose (Tadasana) or Warrior Poses (Virabhadrasana series), should be avoided as they can worsen orthostatic intolerance.

2. Avoid Rapid Postural Transitions:  

• Sudden changes from supine to seated or standing positions may trigger autonomic instability (Andrade et al., 2024). Avoid fast-paced flows like Sun Salutations (Surya Namaskar), where quick transitions could exacerbate symptoms.

3. Minimise Cardiovascular Strain and Overexertion:  

• Intense poses, such as Wheel Pose (Urdhva Dhanurasana) or unsupported inversions (e.g., Headstand (Sirsasana)), place unnecessary strain on the cardiovascular system and should be replaced with gentler alternatives.

4. Avoid Excessive Sympathetic Activation:  

• Class elements that increase sympathetic nervous system activity—such as vigorous sequences or competitive cues—should be excluded. Stick et al. (2024) suggest incorporating practices that enhance parasympathetic activity for symptom relief.

Core Elements of a POTS-Friendly Yoga Class

1. Start with Gentle Breathing Practices 

Incorporate breathing practices based on findings from Stick et al. (2024), which demonstrated the clear benefits of deep abdominal breathing in reducing heart rate and symptoms during orthostatic stress.

  Deep Abdominal Breathing (Diaphragmatic Breathing):

• Folks can lie on their backs (Savasana) or remain semi-recumbent with a bolster for shoulder and neck support.  

• Offer slow, deep inhalations through the nose, expanding the belly (not the chest), followed by controlled exhalations out of the mouth.  

• Maybe aim for a breath cycle of 4-6 seconds inhale, 6-8 seconds exhale. 

• Encourage awareness of the parasympathetic activation (calming sensation) as they focus on their breath.

Simple Pranayama:

• Nadi Shodhana (Alternate Nostril Breathing), emphasizing slow, rhythmic breathing, which restores autonomic balance and helps calm the nervous system. Avoid breath retention (kumbhaka), as it may increase cardiovascular strain.  

2. Warm-Up with Supine and Semi-Recumbent Shapes

Based on Andrade et al. (2024), starting in supine (lying) or semi-recumbent positions reduces orthostatic stress, facilitates venous return, and prepares the body for movement.  

 Recommended Poses:

• Legs-up-the-Wall Pose (Viparita Karani): Encourages circulation and counters the effects of orthostatic intolerance.  

• Reclined Bound Angle Pose (Supta Baddha Konasana): Opens the hips gently while keeping the body grounded. (PLEASE NOTE THAT THIS SHAPE ISN’T ADVISED FOR A TRAUMA INFORMED CLASS)

• Supine Twist (Jathara Parivartanasana): A gentle spinal twist to release tension and promote relaxation.  

• Bridge Pose (Setu Bandhasana): Strengthens the core and legs without challenging the cardiovascular system—ensure the movement is slow and controlled.

3. Seated and Grounded Shapes

Transition into seated or grounded poses slowly to protect against sudden blood pressure fluctuations. These poses improve flexibility and strength while keeping autonomic stress low.

Recommended:

• Easy Pose (Sukhasana): Engage the spine and use blocks or cushions for added hip support.  

• Seated Forward Bend (Paschimottanasana): Slowly fold forward, keeping the head supported on a block or bolster if needed.  

• Child’s Pose (Balasana): Promotes relaxation while keeping the heart rate stable. Encourage adding slow abdominal breaths in this pose.

4. Cool-Down and Gentle Stretching 

Return to supine or fully supported positions to signal to the body that it is safe to relax. This phase further slows heart rate and enhances parasympathetic regulation.

Recommended Poses:

• Lying Down aka Corpse (Savasana): End practice with a long Savasana, incorporating slow diaphragmatic breathing and a guided body scan to promote full relaxation.  

• Happy Baby (Ananda Balasana): Gently stretches the hips and lower back while lying down.

Optional Element for Relaxation: Use weighted items or sandbags lightly placed on the thighs or pelvis during Savasana to enhance grounding and support venous return. Weighted blankets if on hand might be nice. 

Important Class Guidelines:

• Hydration and Compression (Optional):  

  • Encourage students to remain hydrated before and after class. If they find it helpful, wearing compression garments during the session can aid in circulation and minimise dizziness.

• Slow, Deliberate Movements:  

  • Transitions between poses (e.g., from lying to sitting) should be performed slowly to prevent sudden blood pressure drops or heart rate spikes. Encourage students to take breaks as needed. 

• Avoid Overexertion:  

  • Teachers should emphasise a non-competitive, restorative atmosphere to reduce sympathetic activation. Use props (e.g., bolsters, blankets, blocks) to support poses as needed.

• Emphasis on Deep Breathing Throughout:  

  • Integrate slow (over-breathing is likely going to be problematic) diaphragmatic breathing into every phase of the class to stabilise heart rate and autonomic responses, as shown in Stick et al. (2024).

• USE ALL THE PROPS!

What to Look Out For in POTS Students During Yoga Class

1. Physical Signs and Symptoms

POTS is characterised by an abnormal heart rate response to changing postures, especially when moving to or maintaining an upright position. Keep an eye out for:

  - Dizziness or Lightheadedness: Often occurs when transitioning from lying/seated to standing.

  - Fatigue or Weakness: May be a result of reduced blood flow to the brain or overexertion.

  - Palpitations (Racing Heart): Be attentive if they look distressed or mention feeling their heart pounding.

  - Sweating or Flushing: This may happen as their body attempts to compensate for blood pooling in the extremities.

  - Shortness of Breath: Indicates difficulty regulating the autonomic nervous system with exertion.

  - Clamminess or Nausea: Can signal sudden drops in blood pressure or autonomic dysregulation.

2. Emotional Responses

While POTS is primarily a physical condition, autonomic dysregulation can also lead to emotional distress during class. Be mindful of:

  - Overwhelm or Anxiety: Physical symptoms (e.g., palpitations or dizziness) can feel intense and sometimes induce panic.

  - Frustration or Fear: If someone worries about "keeping up" with others in the class or fears exacerbating symptoms, they may need reassurance.

3. Triggers to Watch For

Certain movements, poses, and environmental factors can exacerbate POTS symptoms. Keep an eye out for potential triggers during your class:

  - Rapid Postural Changes: Fast transitions, such as moving quickly from lying to standing, can cause dizziness due to delayed blood flow adjustments.

  - Prolonged Upright Postures: Holding poses like Mountain Pose or Warrior Poses for long periods can lead to blood pooling in the legs, worsening tachycardia.

  - Overheating: A warm room or intense exertion can exacerbate symptoms. Watch for flushed faces, sweating, or signs of discomfort.

  - Overexertion: Students may try pushing themselves too hard, resulting in breathlessness, fatigue, or palpitations.

  - Poor Hydration: Signs like dry mouth or lightheadedness may indicate dehydration, which can worsen POTS symptoms.

  - Low Blood Sugar: If yoga class takes place around meal times, low energy levels may exacerbate fatigue and dizziness.

Conclusion:

A yoga class for individuals with POTS should focus on supine and semi-recumbent poses, slow transitions, and deep abdominal breathing practices to promote parasympathetic activation and reduce orthostatic stress. Based on Andrade et al. (2024) and Stick et al. (2024), restorative yoga approaches combined with diaphragmatic breathing exercises offer an excellent, low-impact way to manage symptoms and support cardiovascular stability. Such classes should prioritise gentle movements, relaxation, and individual pacing, making yoga accessible and therapeutic for POTS patients.

References:

Andrade, C. P., Zamunér, A. R., Barbic, F., Porta, A., Rigo, S., Shiffer, D. A., Bringard, A., Fagoni, N., Ferretti, G., & Furlan, R. (2024). Effects of different postures on the hemodynamics and cardiovascular autonomic control responses to exercise in postural orthostatic tachycardia syndrome. European Journal of Applied Physiology. https://doi.org/10.1007/s00421-024-05662-5

Stick, M., Leone, A., Fischer, F., Schulz, J. B., & Maier, A. (2024). Deep abdominal breathing reduces heart rate and symptoms during orthostatic challenge in patients with postural orthostatic tachycardia syndrome. European Journal of Neurology, 31(10), e16402-n/a. https://doi.org/10.1111/ene.16402