Katie Ledecky Has POTS. Swimming May Help Her Manage It.

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Katie Ledecky is the most decorated American female Olympian of all time, with 14 Olympic medals for swimming — nine of which are gold. But in her recently published memoir, “Just Add Water: My Swimming Life,” the athlete revealed that she has postural orthostatic tachycardia syndrome (POTS), a condition with no cure that impacts the autonomic nervous system.

One of the hallmark symptoms of POTS is exercise intolerance, though swimming is actually a common treatment for it. In her memoir, Ledecky wrote that “reclined aerobic exercise, such as swimming, and strengthening your core can provide relief,” which she noted “is kind of funny.”

People with POTS often have trouble transitioning from horizontal to vertical positions, which stems from blood circulation issues, Tae Chung, MD, an assistant professor of physical medicine and rehabilitation at Johns Hopkins University in Baltimore and director of its POTS clinic, told MedPage Today.

When adults with POTS transition from horizontal to standing, their heart rate increases by at least 30 beats per minute in the first 10 minutes of standing, Chung explained. For adolescents, it’s 40 beats per minute. While there’s a lower level of blood circulation, the heart itself is normal.

Ledecky explained this herself: “I pool blood in the vessels below my heart when I stand. My body then releases extra norepinephrine or epinephrine, which adds additional stressors on my heart, making it beat faster. Which, in turn, brings on dizziness, fainting, and exhaustion,” she wrote.

Chung noted that POTS most commonly develops in younger women, like Ledecky, and other major symptoms include chronic fatigue, brain fog, gastrointestinal symptoms, and sleep disturbance. There aren’t any FDA-approved drugs or treatments for POTS.

An increase in POTS diagnoses following SARS-CoV-2 infection drew more attention to the condition. Chung said a silver lining to this increase is that more doctors are taking the condition seriously and fewer are writing it off as psychological.

In terms of treatment, Chung said the main strategy is volume expansion therapy, in which the goal is to increase blood volume by drinking a lot of water and salt and using medications to retain fluid to increase blood flow. Some medications that help treat POTS symptoms include fludrocortisone, which helps retain fluid; pyridostigmine (Mestinon), which enhances neurotransmitters in the autonomic nervous system; and midodrine, a vasoconstrictor.

“Although it’s not a cure, their fatigue and exercise intolerance can improve with really aggressive volume expansion therapy,” Chung said.

Amanda Kaufman, PT, supervisor of rehabilitation services at Northwell Health STARS Rehabilitation in Glendale, New York, told MedPage Today that pool work is another treatment that can help people with POTS.

When it comes to swimming with POTS, “the body has a harder time bringing the blood from the legs back up to the body, and not from the upper part of the body down to the lower part. So doing that dive into the water is actually going the opposite way,” Kaufman explained.

“Getting in the pool helps to alleviate some of that stress on the body, because the water helps you be more buoyant, which creates less stress on the joints,” Kaufman added. Thus, transitioning between different positions and going from being horizontal to standing “is not such a dramatic change for the body.”

Kaufman follows “the Levine protocol,” a modified exercise protocol first developed by Benjamin Levine, MD, of the University of Texas Southwestern Medical Center in Dallas. In 2016, Levine and colleagues published a study in Heart Rhythm that tested his exercise training and lifestyle intervention protocol.

Over 3 months, POTS patients underwent supervised mild- to moderate-intensity endurance and strength training. While less than half of participants completed the program, 71% of those who did no longer qualified as having POTS and were thus deemed to be in remission.

Ledecky was already a world-renowned athlete when she got her diagnosis. She detailed in her memoir how she first noticed POTS symptoms back in 2015 at the World Aquatics Championships in Russia. Since then, she’s competed in three Olympic games while having the condition.

Kaufman emphasized that POTS presents with a wide range of severity and symptoms. For some people, POTS is completely debilitating — and the severity of Ledecky’s POTS is unknown.

“Those who have that moderate to severe [POTS] — they’re encouraged by what they see in Katie Ledecky — but also may have reservations like, ‘Oh well, I’m not trying hard enough’… where in reality, it’s that they just have more of a severe case,” she said.

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