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Why Exercise Doesn’t Help People With Long COVID

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Editor’s note: Find the latest news and guidance about COVID-19 at the Medscape Coronavirus Resource Center.

When Joel Frum woke up on the morning of March 12, 2020, he knew perfectly well why he was so lousy.

He lives in New York, where the first wave of coronavirus raged through the city. “I got it right away,” says the 55-year-old Broadway music director. It was COVID-19.

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What started as a general feeling of being hit by a truck soon developed into a sore throat and such extreme fatigue that one day he fell asleep in the middle of sending a message to his sister. The last symptoms were chest tightness and difficulty breathing.

And then he started to feel better. “By mid-April, my body was practically back to normal,” he says.

So he did what would have been sensible after almost any other illness: he started exercising. It didn’t last long. “It felt like someone had pulled the carpet out from under me,” he recalls. “I couldn’t walk three blocks without being out of breath and tired.”

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This was the first indication that Fram had long-term COVID.

According to the National Center for Health Statistics, at least 7.5% of American adults — about 20 million people — have symptoms of protracted COVID. And for almost all of these people, there is mounting evidence that exercise makes their symptoms worse.

According to a review published in June by researchers at the University of California, San Francisco, COVID-19 patients who had the most severe illness will struggle the most with exercise later. But even people with mild symptoms may struggle to regain their previous levels of fitness.

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“We have participants in our study who had relatively mild acute symptoms and really had a severe reduction in their ability to exercise,” says Matt Durstenfeld, MD, a UC San Francisco School of Medicine cardiologist and lead author. review.

As researchers at Yale University showed in a study published in August 2021, most people with long-term COVID will have lower-than-expected scores on aerobic fitness tests.

“Part of it has to do with deconditioning,” says Durstenfeld. “You don’t feel well, so you don’t exercise to the same degree you did before the infection.”

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In a study published in April, people with long-term COVID told researchers at the University of Leeds in the UK that they spend 93% less time on physical activity than before they got infected.

But numerous studies have shown that deconditioning is not entirely, or even more, to blame.

A 2021 study found that 89% of participants with long-term COVID had post-exercise malaise (PEM), which occurs when a patient’s symptoms worsen after performing even minor physical or mental activities. According to the CDC, post-exercise sickness can take up to 12 to 48 hours to appear after activity, and full recovery can take up to 2 weeks.

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Unfortunately, the advice patients get from their doctors sometimes exacerbates the problem.

How long does COVID not lend itself to simple solutions

Long-term COVID is a “dynamic disability” that requires healthcare professionals to act out of script when a patient’s symptoms don’t respond in predictable ways to treatment, says David Putrino, Ph.D., neuroscientist, physical therapist and director of rehabilitation innovation for the Health System Mount Sinai in New York.

“We’re not that good at dealing with someone who, for all intents and purposes, can appear healthy and not disabled one day and be completely debilitated the next,” he says.

Putrino says more than half of his clinic’s long-term COVID-19 patients have told his team they have at least one of these persistent problems:

  • Fatigue (82%)

  • Brain Fog (67%)

  • Headache (60%)

  • Sleep problems (59%)

  • Dizziness (54%)

And 86% said exercise made their symptoms worse.

The symptoms are similar to what doctors see in diseases like lupus, Lyme disease and chronic fatigue syndrome — something that many experts compare prolonged COVID to. Researchers and healthcare professionals still don’t know exactly how COVID-19 causes these symptoms. But there are some theories.

Potential causes of prolonged COVID symptoms

Putrino says it’s possible that the virus enters the patient’s cells and takes over the mitochondria, the part of the cell that provides energy. It can linger there for weeks or months – something known as viral persistence.

“Suddenly the body is getting less energy for itself, even though it is producing the same amount or even a little more,” he says. And there is a consequence of this additional load on the cells. “Energy creation is not free. You produce more waste, which puts your body in a state of oxidative stress,” says Putrino. Oxidative stress damages cells as the molecules interact with oxygen in a harmful way.

“Another important mechanism is autonomic dysfunction,” says Putrino. It is marked by breathing problems, heart palpitations, and other disruptions in areas that most healthy people never have to think about. About 70% of patients with long-term COVID at Mount Sinai have some degree of autonomic dysfunction, he said.

For a person with autonomic dysfunction, something as simple as a change in posture can trigger a storm of cytokines, chemical messengers that tell the immune system where and how to respond to problems like injury or infection.

“All of a sudden you have this switch,” Putrino says. “You go straight to fight-or-flight,” with a rush of adrenaline and heart palpitations, then slip back into rest-or-digest mode. You get so sleepy that you can’t keep your eyes open.”

A patient with viral persistence and a patient with autonomic dysfunction may have the same adverse reaction to exercise, even if the triggers are completely different.

So how can doctors help patients with long-term COVID-19?

The first step is to understand the difference between prolonged COVID-19 and prolonged recovery from COVID-19 infection, Putrino said.

Many patients from the last group still have symptoms 4 weeks after the first infection. “Yes, after 4 weeks they still feel symptoms, but this is a short-lived COVID,” he says. “It just takes time to heal from a viral infection.”

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The fitness advice for these people is simple: settle down first and gradually increase the amount and intensity of aerobic exercise and strength training.

But this advice will be disastrous for those who fit Putrino’s stricter definition of long-term COVID: “Three to four months after the initial infection, they experience extreme fatigue, exercise symptoms, cognitive symptoms, heart palpitations, shortness of breath,” he says. .

“Our clinic is extremely careful about exercise” for these patients, he says.

In Putrino’s experience, 20% to 30% of patients achieve significant progress after 12 weeks. “They feel more or less the way they felt before COVID,” he says.

The most unlucky 10-20% will not make any progress at all. Any kind of therapy, even something as simple as moving the legs from a horizontal position, worsens their symptoms.

Most—50% to 60%—will have some improvement in symptoms. But then progress will stop, for reasons that researchers are still trying to figure out.

“It seems to me that gradually increasing the amount of exercise is still good advice for the vast majority of people,” says Durstenfeld of UCSF.

Ideally, this exercise should be supervised by someone who has received training in cardiac, pulmonary, and/or autonomic rehabilitation, a specialized type of therapy aimed at resynchronizing the autonomic nervous system, which controls breathing and other unconscious functions, he says. But these treatments are rarely covered by insurance, meaning that most long-term COVID-19 patients live alone.

Durstenfeld says it’s important that patients keep trying and don’t give up. “With slow and steady progress, many people can become much better,” he says.

Fram, who has been working under close supervision, says he is getting closer to something like his pre-COVID-19 life.

But he’s not there yet. A lingering COVID, he says, “every single day affects my life.”

Sources

Joel Frum, New York.

CDC: “Nearly one in five American adults who have had COVID-19 still have ‘long-term COVID’.”

MedRxiv: “Cardiopulmonary exercise testing to assess the post-acute consequences of COVID-19 (“Long-term COVID”): a systematic review and meta-analysis.”

Matt Durstenfeld, MD, Cardiologist, University of California, San Francisco Medical School.

Chest: “Persistent exercise intolerance post-COVID-19.”

International Journal of Environmental Research and Public Health: “Relationship between physical activity and long-term COVID: a cross-sectional study.”

eClinicalMedicine: “Characterization of long-term COVID in an international cohort: 7 months of symptoms and their impact.”

Mount Sinai: “Post-Acute Covid-19 Program.”

David Putrino, PhD, Neuroscientist, Physical Therapist, Director of Rehabilitation Innovation, Mount Sinai Health System, New York.

American Journal of Physical Treatment and Rehabilitation: “Post-acute COVID-19 syndrome negatively impacts physical function, cognitive function, health-related quality of life, and participation.”

Journal of Orthopedic and Sports Physical Therapy: “Humility and Acceptance: Working within our limits with long-term COVID and myalgic encephalomyelitis/chronic fatigue syndrome.”

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