If you have POTS or another form of orthostatic intolerance, someone has probably mentioned “the Levine protocol” or “the CHOP protocol” to you. They are the two most widely circulated exercise programmes for POTS, they are closely related, and they are surrounded by confident claims in many directions.

What is the Levine protocol?

The Levine protocol is the informal name for a three-month endurance training programme developed by Dr Benjamin Levine’s group at the Institute for Exercise and Environmental Medicine in Dallas, originally for research studies in POTS.

Its defining ideas:

Start horizontal. The programme begins with recumbent exercise modes: recumbent cycling, rowing, or swimming. Upright exercise is the thing POTS makes hardest, so training starts in positions where gravity is not fighting you, and upright modes such as walking arrive only in the later months.

Mostly easy, occasionally harder. The bulk of sessions are at an easy “base pace”, with effort kept conversational. Session length and frequency build gradually, from roughly half an hour a few times a week towards five to six sessions a week by the end.

Strength work for the legs. Alongside the endurance sessions, the programme includes resistance work focused on the legs and core, because leg muscle acts as the pump that returns blood to the heart when upright.

The physiological rationale is reasonably well grounded: many people with POTS have a smaller-than-normal cardiac chamber size and blood volume, and endurance training in recumbent positions can expand plasma volume and cardiac capacity without provoking orthostatic stress.

What did the studies actually find?

The most cited study is Fu and colleagues, 2011, in Hypertension. POTS patients did a month of drug trial (propranolol or placebo) followed by three months of the training programme. Nineteen patients completed it. After training, standing heart rate fell, quality of life scores improved, and just over half of the completers (53%) no longer met the heart rate criteria for POTS. Training compared favourably with propranolol on several outcomes.

The second key paper is George and colleagues, 2016, in Heart Rhythm, which moved the programme out of the laboratory into a community setting through a registry. Around 250 patients enrolled. Only about four in ten completed the three months. Of those completers, 71% no longer met POTS heart rate criteria at follow-up.

A reasonable summary from these papers might be: of the subset of people who can do this programme and finish it, a majority see meaningful improvement, and some no longer meet POTS criteria. But the studies are small, there was no untreated control group, and the completers are self-selected. None of this makes the work worthless. It is genuinely among the better-supported non-drug interventions in POTS.

What is the CHOP modified Dallas programme?

The Children’s Hospital of Philadelphia (CHOP) adapted the Dallas programme for its own patients, mostly adolescents. The adaptation keeps the same core logic (recumbent first, mostly easy effort, leg strength work, gradual move to upright) but stretches the timeline out over roughly seven to eight months rather than three, with a gentler ramp and more explicit month-by-month structure. This version circulates widely as a PDF via Dysautonomia International, and it is what most people mean when they say “the CHOP protocol”.

Two things are worth knowing about it:

It is the more realistic version for most people. The original three-month timeline came out of a research setting. The slower CHOP ramp acknowledges what the community study demonstrated: most people cannot hold the original schedule.

To the best of my knowledge, it has never been separately validated. The published evidence is for the Dallas programme; claims of a specific success rate for “the CHOP protocol” are borrowing those numbers.

Who these programmes are not for

They assume that the person doing them does not have post-exertional malaise (PEM): the delayed, disproportionate worsening of symptoms a day or two after exertion that defines ME/CFS. Progressive exercise programmes are built on the assumption that the body tolerates and adapts to a gradually rising load. PEM breaks that assumption. For people with PEM, programmes that expect linear escalation have a well-documented history of causing harm, which is why the 2021 NICE guideline for ME/CFS explicitly warns against fixed incremental graded exercise therapy.

POTS and ME/CFS overlap heavily, and long COVID produced a large group of people who appear to have both orthostatic intolerance and PEM. That PEM is not an easily defined binary makes identification much harder. If that might be you, the screening question (“do my symptoms flare a day or two after activity?”) should be most useful: the DSQ-PEM questionnaire asks it properly in about three minutes, and pacing is the evidence-aligned starting point, not progressive training.

A small set of red flags also needs a clinician before any activity plan: chest pain on exertion, exertional fainting, breathlessness out of proportion to effort, known cardiac disease, or unresolved cardiac findings after COVID.

Beyond that, chronic fatigue conditions are multi-faceted and very individual. Even a genuinely evidence-based protocol can be unsuitable for a given person at a given time. Take things slowly, in your own time, and let your body and how you are feeling be the guide rather than a calendar.

If you want to try the structure

Three tools on this site are built around trying to help you figure out whether this might be useful for you:

The exercise readiness screen walks through the red flags and the PEM question in a few minutes, and routes you accordingly.
The pacing and heart rate guide is the default starting point, and for anyone with possible PEM it provides an energy envelope, a heart rate ceiling as a guardrail, and a private session log.
The exercise progression tool is for people who screen clear of PEM. It explains the tier structure these protocols share and keeps your record against it, with a check-in two days after each session, because that is when the honest answer arrives. It never advances you automatically: repeating a week is treated as the normal outcome, which is the opposite of how a paper calendar behaves, and closer to how the slower CHOP adaptation is meant to be used in practice.

Everything you enter stays on your device. Nothing is stored at this end.

Sources

This article describes the published programmes in its own words and reproduces nothing from them. It is information, not individual medical advice: decisions about exercise belong with you and your clinician.