The Utah ADaPT Program, Explained

If you have looked into exercise for POTS, you have almost certainly run into the Levine protocol, or the Dallas program, or the version of it that Children’s Hospital of Philadelphia adapted for younger patients. Those are the programs that get named. They have been around long enough to have accumulated studies, adaptations, and a body of people who have tried them.

ADaPT is newer and less familiar, and it is built on a specific criticism of all of them.

What it stands for

ADaPT is Autonomic Disorder adaptive Physical Therapy. It was developed at the University of Utah by a group of physical therapists and neurologists who work specifically with autonomic disorders — POTS, autonomic neuropathy, autonomic failure, and the broader set of conditions that make being upright difficult.

The approach was set out in a 2024 paper in Archives of Rehabilitation Research and Clinical Translation, and the University of Utah’s neurology department publishes the provider manual openly on its website. That last part matters more than it sounds, and we will come back to it.

If you looked at ADaPT and one of the older protocols side by side, the exercises themselves would not look very different. Both start with recumbent and semi-recumbent work to keep the load off your circulation while your heart does the work of getting stronger. Both build lower-body and core strength alongside the cardio. Both introduce upright time gradually rather than all at once.

The difference is not what you do. It is who decides when you do it.

The argument it is making

The published protocols work from a fixed schedule. Week four looks like this, month two looks like that, and you advance because the calendar says so. That structure is what makes them usable at all without a specialist beside you — the schedule carries the instructions, so the program can travel.

The ADaPT paper argues that the same structure is what breaks them.

Rigid timelines can outrun what a person is actually able to tolerate. When that happens, it does not usually appear in the record as a problem with the program. It appears as a person who stopped. Dropout in the published exercise studies runs high, and people who drop out are disproportionately the ones doing worst — which quietly makes the published results look better than the real-world average almost certainly is.

The paper also points out that fixed protocols take no account of the rest of your situation. What your function actually is at the start. What other conditions you have. What equipment you can get to. Whether the specific week-one prescription is even appropriate for you. A schedule written for a study population cannot answer any of that.

This is a criticism made from inside the field, by clinicians who use exercise as a treatment and want it to work better. It is not the argument that exercise is the wrong idea.

The four things it does differently

The paper sets out four departures from how these programs are usually run.

A comprehensive evaluation before anything begins. Not a heart rate and a start date, but an assessment of where your function currently is, what else is going on, and what you are actually trying to be able to do.

An individualized entry point. You do not start at week one because week one is where the document starts. You start where the evaluation says you should, which for some people is well below a published program’s first week and for others is above it.

Criteria to advance that come from the patient, not the calendar. You move up when you are ready to move up. A week that needs to be repeated gets repeated, and that is a normal event rather than a failure state.

Ongoing adaptation. The program changes as your circumstances change, because a six-month program will run through illnesses, seasons, and life.

Progression is monitored between stages by the physical therapist rather than assumed. Entry is guided by a baseline that includes fitness and heart rate response.

How well does it work

Less is known about ADaPT than about the older protocols, and it is worth being straight about that.

The 2024 paper describes the approach and its rationale. Formal clinical validation was still pending at publication, with data to be reported separately. An abstract presented at the American Academy of Neurology’s 2025 meeting reported on patient-rated global change after receiving an individualized prescription under the protocol, and described people’s own sense of their condition as stable or modestly improved.

That is an early picture rather than a bad one. It is also worth holding next to what is actually known about the alternatives. The older protocols rest largely on small studies at specialist centers, frequently without control groups and frequently with substantial dropout. They have had longer to accumulate evidence, and more of it. They have not accumulated the kind of evidence that would settle the question.

A separate line of research at Utah is looking at whether motivational interviewing improves adherence to therapeutic exercise for POTS, which tells you something about where the group thinks the real problem sits. Not in the physiology. In whether people can stay with it.

Getting access to it

Here is the part that makes ADaPT unusual, and it is the reason we think it is worth knowing about even if you never do the program.

The provider manual is published. Openly, on the University of Utah’s neurology site, written for clinicians and available to anyone.

Most structured programs of this kind do not work that way. They live inside a specialist clinic, in the training and the judgment of the people who work there, and if you cannot get to that clinic you cannot get the program. A published manual can be handed to a physical therapist who has never treated an autonomic disorder, which describes most physical therapists.

That does not make it a self-guided program. It is written for a clinician to deliver, the entry point depends on an evaluation, and the whole design assumes someone is adjusting it as you go. But it means the document is not the barrier, which removes one of the several barriers usually stacked in front of this.

If you are working with a physical therapist already, it exists as something to raise. If you are not, it is one of the things worth asking your clinician about when the conversation turns to exercise.

Why we are writing about a program we do not run

Pacecraft runs two published protocols with fixed weekly schedules — the CHOP Modified Dallas Program and the CHOP AADP Recumbent Training Program. Fixed schedules are what make a program deliverable by an app. The week can tell you what to do because it was written down in advance, and nothing waits on a clinician being in the room.

That is a real trade and we would rather name it than not. An app cannot evaluate you. It cannot watch you move, adjust the plan for the thing you did not think to mention, or notice that this month is different from last month for a reason that has nothing to do with your heart rate. What it can do is carry a structured program to people who have no access to a specialist clinic and no realistic prospect of getting one, which is a large number of people with this condition.

If you have access to a physical therapist who works with autonomic disorders, that is a better option than any app, and we would rather say so.

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Sources

• Utah ADaPT program — University of Utah Department of Neurology: https://medicine.utah.edu/neurology/research/autonomic/projects/adapt

• Utah ADaPT Protocol (Provider Manual), 10.9.24: https://medicine.utah.edu/neurology/documents/utah-adapt-protocol-provider-manual-10924

• Adaptive Approaches to Exercise Rehabilitation for Postural Tachycardia Syndrome and Related Autonomic Disorders, Archives of Rehabilitation Research and Clinical Translation, 2024

• Patient-Reported Global Change Following Individualized Exercise Prescription for Autonomic Disorders, abstract P1-7.002, Neurology, 2025

• POTS resources — University of Utah Department of Neurology: https://medicine.utah.edu/neurology/general-neurology/pots-resources