"Treating Long-COVID: Part 1" by Doctor B (the PT) i.e. a physical therapist

It is surprisingly good.

Let your patients lead by having them rank activities they have to perform by how much energy it takes to do each one. Maybe brushing their teeth takes 3 energy units compared to driving to work which takes 6 energy units. Make a chart with these values and ask them how many they can do before they are exhausted or before they know they will experience fatigue symptoms. Use that total number to help them build their day with activities that add up to less than that total number so they aren’t pushing their limits.
Allow them to make choices about what activities they put in their day.

Here’s the shock-value statement: There may be no room for your exercise program. You’ll have to adapt.

These energy charts are a concept I’ve often used for patients who experience chemo or cancer-related fatigue. The visual representation of activities helps to picture an entire day, build in rest breaks, and prevent fatigue.
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Of course there's the question of whether PT's really need to be involved and whether people with Long Covid really need detailed plans. But this article makes the point that an educated PT can advocate for the patient, informing other health care professionals and assessors for financial assistance.

You can all tell from previous posts that I’m a pusher. I’m usually the one pushing people further, physically and mentally, than they are otherwise willing to go. Even if I can achieve a fraction more today than I did yesterday, I’ll push for it.
BUT NOT HERE. I’ve drawn my line in the sand. This is where we have to think differently. Until that vascular system properly heals, we have to think about the acute phases of tissue healing, protection, providing building blocks, and ensuring the basic levels of function are maintained.
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Some of the detail about what is going wrong physically is pretty speculative. But, whatever. It looks as though content from this person can help make physical therapists less likely to do harm.
 
https://doctorbthept.com/about/

Who is Doctor B (the PT)?
In the clinical world, Doctor B goes by Kaelee Brockway. She is a Physical Therapist and Educator who works with patients, professionals, and students to improve their lives through activity and education. She is frequently called a “boat-rocker” and she is proud of it.
[...]
She is now a contributing faculty member at the University of St. Augustine for Health Sciences Doctor of Physical Therapy Program providing primary instruction for courses in geriatrics, cardiopulmonary rehabilitation, and pharmacology. Clinically, Kaelee works in the inpatient rehabilitation and acute care setting in Dallas, Texas.
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Did you see part 2 where she writes about high intensity training and says that not everyone with ME/CFS have PEM?

PLEASE… Do NOT throw the tomatoes at the messenger. The evidence for post-viral fatigue / myalgic encephalomyelitis / chronic fatigue syndrome even prior to COVID-19 supported the use of high-intensity interval training with this population IF they do not have post-exertional malaise. Remember, post-exertional malaise is just one of many symptoms of these post-viral conditions and DOES NOT happen to every patient who contracts them.

Specifically, there is evidence to support high-intensity interval training as a more tolerable method of exercise in patients with chronic fatigue syndrome because it does not exacerbate fatigue like moderate-intensity continuous exercise. It is thought that the shorter bursts of activity, followed by either complete rest or active rest are more tolerable than longer bouts of exercise because this design allows the body to have intermittent recovery periods while working. This evidence goes on to report that high-intensity interval training can actually help patients who experience other symptoms of chronic fatigue syndrome, such as insomnia and decreased physical function.
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https://doctorbthept.com/2022/04/19/treating-long-covid-part-2/
 
Hutan said:
Some of the detail about what is going wrong physically is pretty speculative. But, whatever. It looks as though content from this person can help make physical therapists less likely to do harm.
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I seriously doubt that. This is the usual pretence to know without knowing and selling of exercise that pervades the profession. Soft sell may be part of that but in some ways it is all the more worrying.
 
Specifically, there is evidence to support high-intensity interval training as a more tolerable method of exercise in patients with chronic fatigue syndrome because it does not exacerbate fatigue like moderate-intensity continuous exercise. It is thought that the shorter bursts of activity, followed by either complete rest or active rest are more tolerable than longer bouts of exercise because this design allows the body to have intermittent recovery periods while working. This evidence goes on to report that high-intensity interval training can actually help patients who experience other symptoms of chronic fatigue syndrome, such as insomnia and decreased physical function.
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Ehh, what is she talking about? HIIT is brutal, that's the point. I'm not even sure it is a good idea for beginners as it is a perfect fitness regimen to make someone lose motivation quickly because of how rigorous and demanding it is. It is for fitness freaks like I was and this was one of the things I did as my workouts. It is literally killing yourself for 20 seconds then rest for 10, then repeat over and over. That's the point. What the hell is she talking about.
 
I've found the paper about HIIT and CFS she was referring to. We have a thread on it: Fatigue Exacerbation by Interval or Continuous Exercise in Chronic Fatigue Syndrome (2016) Sandler, C; Llloyd, A; Barry, B

From the paper:

HIIT Challenge
The high-intensity interval (HIIT) exercise bout included the same warm-up as the continuous bout. Thereafter, participants completed five bouts of high-intensity cycling consisting of 100 s at approximately 75%–80% APHRM followed by 175 s of “recovery” cycling at a light workload, equating to a total of 20 min (or 10 min for the lower capacity participant). Workload was adjusted to reach target HR for the high-intensity active epochs and recovery epochs. Participants cycled at their desired cadence and the cycle ergometer adjusted its resistance to maintain the specified workload. RPE was recorded at the end of warm-up and in the last 10–15 s of each active interval (i.e., 100 s) and recovery interval (i.e., 175 s) during exercise and at the end of the cool-down phase.
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This doesn't actually sound like HIIT, it is not intense enough. HIIT is 80-95% of your maximum HR and the 100 seconds of activity also sounds too long for the typical intense HIIT interval. This sounds more like "moderate" intensity interval training.
 
Trish said:
It was being tested as an alternative version of GET, so not good for pwME.
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Yes, of course. I'm saying that when she said CFS patients without PEM can benefit from HIIT, even that is not correct, since the study wasn't about HIIT but about moderate level continuous exercise vs moderate level interval training. (This is because they had to match the workload of the two.) And the things she said about improving insomnia or that shorter bursts are more tolerable than continuous exercise are also not true. The paper actually said they expected interval training to exacerbate post-exertional fatigue more but it didn't and the two trainings actually had a similar impact. They also said the effect (slight improvement) of unrefreshing sleep is due to data from a single patient and otherwise there was no change in sleep.
 
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Hutan said:
It is surprisingly good.



Of course there's the question of whether PT's really need to be involved and whether people with Long Covid really need detailed plans. But this article makes the point that an educated PT can advocate for the patient, informing other health care professionals and assessors for financial assistance.


Some of the detail about what is going wrong physically is pretty speculative. But, whatever. It looks as though content from this person can help make physical therapists less likely to do harm.
Click to expand...

I like the bit about "you can probably tell that I'm a pusher". This reminder to people to be self-aware is so important. Surprising as it is there are many I've come across, particularly physios, where it has become such second nature they do not realise and it takes them huge restraint to not 'be in charge' and use every tactic to not only make people do something but get them saying 'yes that is great' at the same time (even if it isn't you find yourself saying it like an idiot as if it has been put in your mouth).

If physios don't both internalise this absolutely, and realise it needs an attitude/approach change in how they interact you have the same issue. Which is why I am so sceptical about BACME stuff and reading some of the job descriptions trying to OK exercise increases as long as they are 'patient-led'. There is no such thing with people with the wrong skillset/personal qualities inbuilt (listening isn't what many people nowadays think they are doing when they claim they are, and it involves a lot more than they realise).

This lack has been hidden by increasingly prescriptive approaches, but I fear isn't being acknowledged - or prized - when they tell themselves they'll be 'patient-led'. Yet no knowledge of the patient in being able to do that vs the physio. When it is people as ill as you get with these things there really should be whole sections on what to look out for rather than putting it on the patient to be dominant and rehearsed in such an encounter. It's so hard to have ME and 'negotiate' on a physios home turf, nevermind answer questions off the top of your head about future PEM in terms they'll understand.

I look at the visual pain scale and wonder why on earth all the measures don't employ this level of thought in ME, and the same with communication being absolute and simple. Why should someone write their whole personal ins and outs down for it to 'be assessed' for most of these things? They could easily have examples to point to.
 
bobbler said:
If physios don't both internalise this absolutely, and realise it needs an attitude/approach change in how they interact you have the same issue. Which is why I am so sceptical about BACME stuff and reading some of the job descriptions trying to OK exercise increases as long as they are 'patient-led'. There is no such thing with people with the wrong skillset/personal qualities inbuilt (listening isn't what many people nowadays think they are doing when they claim they are, and it involves a lot more than they realise).
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bobbler said:
When it is people as ill as you get with these things there really should be whole sections on what to look out for rather than putting it on the patient to be dominant and rehearsed in such an encounter.
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Such good points @bobbler.

There's also the problem that people with ME/CFS are trying to do things that were, pre-illness, easily accomplished. We expect to be able to do the things we could do. We often don't want to acknowledge, even to ourselves, that we can't do something. And, with the delay in the worst of symptoms, it is easy to not join the dots. 'Patient-led exercise ' is therefore only safe, even with an empathetic trainer, if the patient is well informed and has internalised the impact of their disease. (And, even a decade on, I think I probably have not completely and consistently internalised the impact of my disease.)
 
Jonathan Edwards said:
I seriously doubt that. This is the usual pretence to know without knowing and selling of exercise that pervades the profession. Soft sell may be part of that but in some ways it is all the more worrying.
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Agreed. Looks like they didn't even 'walk through' their own questions and tasks for sense and doability ('historical precedent' fallacy I assume).

What normal person without cognitive issues and PEM whilst answering and new variability due to PEM can rate how many 'energy units' brushing their teeth vs driving their car is? And why? :confused: Yet they seem very happy to boast about doing this.

How many of those would they try and answer before they got peed off? Or do they think feigned interest is still what people with ME/CFS/now LC want vs reality of it being a chore (and them feeling they've been taken the mick out of).

What sense does that make anyway? How is it really relevant or 'objective'? Does it mean anything (no, you are asking 'relative assessments' given the phrasing on things you know anyway, not 'absolute' - of course a car drive is more than toothbrushing) or just theatre?

Is it safe? She crowbarred in some good pieces of research then put her own conclusions on it - which is outrageous. Turned stop rest pace into graded exercise.

Because of trauma?! And the solution to that is to intrusively micromanage, despite having no direct experience of it, with a bit of fake sympathy because.....? She's right about being a pusher.
 
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