Review Developing effective strategies to optimize physical activity and cardiorespiratory fitness in [LC] need for caution […], 2024, Faghy, Dalton+

SNT Gatchaman

SNT Gatchaman

Senior Member (Voting Rights)
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Developing effective strategies to optimize physical activity and cardiorespiratory fitness in the long Covid population- The need for caution and objective assessment
Faghy; Duncan; Hume; Gough; Roscoe; Laddu; Arena; Asthon; Dalton

The Post Covid-19 Condition (commonly known as Long Covid) has been defined by the World Health Organisation as occurring in individuals with a history of probable or confirmed SARS CoV 2 infection, usually within 3 months from the onset of acute Covid -19 infection with symptoms that last for at least two months which cannot be explained by an alternative diagnosis. Long Covid is associated with over two hundred recognised symptoms and affects tens of millions of people worldwide.

Widely reported reductions in quality of life(QoL) and functional status are caused by extremely sensitive and cyclical symptom profiles that are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli. This manifestation prevents millions of people from engaging in routine activities of daily living (ADLs) and has important health and well-being, social and economic impacts. Post-exertional symptom exacerbation (PESE) (also known as post exertional malaise) is an exacerbation in the severity of fatigue and other symptoms following physical, emotional, orthostatic and cognitive tasks. Typically, this will occur 24-72 hours after “over-exertion” and can persist for several days and even weeks. It is a hallmark symptom of Long Covid with a reported prevalence of 86%. The debilitating nature of PESE prevents patients from engaging in physical activity which impacts functional status and QoL.

In this review, the authors present an update to the literature relating to PESE in Long Covid and make the case for evidence-based guidelines that support the design and implementation of safe rehabilitation approaches for people with Long Covid. This review also considers the role of objective monitoring to quantify a patient’s response to external stimuli which can be used to support the safe management of Long Covid and inform decisions relating to engagement with any stimuli that could prompt an exacerbation of symptoms.

Link | PDF (Progress in Cardiovascular Diseases)
 
Whilst mechanisms are still being investigated, these symptoms may exist due to skeletal muscle myopathy including exacerbated muscle damage and subsequent regeneration, the increased presence of amyloid deposits, ischaemic-reperfusion injury, impaired oxygen delivery to tissue, impaired oxygen extraction, reduced anaerobic metabolism threshold and impaired mitochondrial function with reduced adenosine triphosphate production. Other wide-ranging mechanisms also exist including immune dysregulation, microbiota disruption, autoimmunity, clotting and endothelial abnormality, and dysfunctional neurological signalling. Regardless of the mechanisms, PESE can have debilitating effects on Long Covid patients, and these effects can be long-lasting.
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Whilst exercise rehabilitation and physical activity (PA) have been popular methods to improve cardiorespiratory fitness (CRF) broadly across chronic disease research and was even listed as a priority area for research in the National Institute for Health and Care Excellence guidelines, the risk and prevalence of PESE must be considered in Long Covid and the closely related condition of ME/CSF and supported with detailed diagnostic assessment and monitoring. For this reason, the World Health Organisation and World Physio Guidelines for Long Covid do not recommend graded exercise therapy for Long Covid patients with PESE due to the risk of potential harm.
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Many studies to date have reported positive findings following exercise rehabilitation strategies, however, have failed to measure PESE, and/or have conducted only short-term interventions (8-12 weeks typically). Due to the ‘relapsing’ nature of PESE, this is a glaring omission from the literature to date, with many studies not initially screening for, monitoring, or including a follow-up within the study design. This is problematic as patients with PESE could unknowingly be recruited and therefore placed at risk of exacerbating symptoms, and two, there is a clear lack of empirical evidence derived from appropriate study designs to demonstrate if Long Covid patients with PESE could benefit from rehabilitation programs if this was done following treatment of the underlying pathophysiology of the disease process first with detailed and highly individualised monitoring. For example, careful and symptom limited CPET can differentiate between cardiovascular deconditioning and impaired peripheral oxygen extraction and lowered anaerobic thresholds. The former may benefit from a carefully monitored rehabilitation program, the latter may be at risk from harm with exercise rehabilitation programs.
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ME/CFS is a poorly understood disease that unfortunately, to the detriment of patients, has had a paucity of investment in biomedical research for decades with no recognised successful treatment.
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It is therefore plausible that patients with ME/CFS and Long Covid are working with a much smaller energy envelope compared to healthy controls and are likely to breach aerobic thresholds and work in an anaerobic state at markedly lower intensities.
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the broad application of a deconditioning theory has been described as a reductionist view for many reasons. Firstly, the deconditioning effect does not explain the level of deconditioning observed within those who had asymptomatic/mild acute infection, many of whom required no hospitalisation or medical involvement. Equally, there is no linear relationship that has been observed between the length of hospitalisation (or inactivity) and the reduction in VO2max, which would be the case if it were only deconditioning. In fact, in one study, the intensive care unit (ICU) versus non-ICU treated patients only reported an 8% reduction in percent predicted VO2 max for the ICU group. Finally, some patients demonstrate preserved VO2max, yet still have persistent symptoms of dyspnoea, fatigue and PEM/PESE [...]. In these patients, it makes little sense that conditioning would be required if VO2max has been preserved and it points to more complex pathophysiological issues.
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They seem to understand a great deal, which is good. I've still got concerns about talk of rehabilitation, though, at whatever pace and with however much caution.

Rehabilitation's understood as supporting people to regain as much function as possible after an accident, illness or surgery, and it isn't usually started until recovery is underway. But few pwME ever get to that stage, and it looks likely to be the same for some with ME-like LC.

I suppose technically, learning how not to do some of the things you used to do—or do them differently and less often—is a form of rehabilitation, but for the avoidance of confusion among non-specialists it feels as if we need a different word.

It's more like a complete reframing of possibility.
 
Kitty said:
I suppose technically, learning how not to do some of the things you used to do—or do them differently and less often—is a form of rehabilitation, but for the avoidance of confusion among non-specialists it feels as if we need a different word.

It's more like a complete reframing of possibility.
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Adaptation?
 
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