Balancing the value and risk of exercise-based therapy post-COVID-19: a narrative review, 2023, Singh, Chalder et al.

SNT Gatchaman

SNT Gatchaman

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Balancing the value and risk of exercise-based therapy post-COVID-19: a narrative review
Sally J. Singh; Enya Daynes; Hamish J.C. McAuley; Betty Raman; Neil J. Greening; Trudie Chalder; Omer Elneima; Rachael A. Evans; Charlotte E. Bolton

Coronavirus disease 2019 (COVID-19) can lead to ongoing symptoms such as breathlessness, fatigue and muscle pain, which can have a substantial impact on an individual. Exercise-based rehabilitation programmes have proven beneficial in many long-term conditions that share similar symptoms. These programmes have favourably influenced breathlessness, fatigue and pain, while also increasing functional capacity. Exercise-based rehabilitation may benefit those with ongoing symptoms following COVID-19.

However, some precautions may be necessary prior to embarking on an exercise programme. Areas of concern include ongoing complex lung pathologies, such as fibrosis, cardiovascular abnormalities and fatigue, and concerns regarding post-exertional symptom exacerbation.

This article addresses these concerns and proposes that an individually prescribed, symptom-titrated exercise-based intervention may be of value to individuals following infection with severe acute respiratory syndrome coronavirus 2.


Link | PDF (European Respiratory Review)
 
The most likely mechanism and explanation for muscle fatigue with or without hospitalisation is deconditioning related to a period of significantly reduced physical activity, although a post-viral myopathy may be present in a subset of individuals [85].
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[85] Myopathy as a cause of fatigue in long-term post-COVID-19 symptoms: Evidence of skeletal muscle histopathology (2022, European Journal of Neurology)

The word "deconditioning" does not appear in that reference. Instead it states —

Immunohistochemistry showed muscle fiber atrophy in 38% in our patients, in both type 1 and type 2 fibers. Although immobilization might have caused the type 2 atrophy in some patients, none of our patients was critically ill or confined to bed, and type 1 atrophy cannot be explained by immobilization.
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One of the most prominent findings in our patients was basal lamina duplications. [...] Most remarkable were the two patients who after 10–13 months showed extensive basal lamina production, associated not only with muscle fibers but also with capillaries and nerves. [...] The microenvironment in the muscle of long-term-affected COVID-19 patients thus includes several factors that could be responsible for an upregulated production of basal lamina.
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Deconstructing fatigue and associations with physiological, behavioural, affective and perceptual processes are key to informing the development of targeted interventions. While pharmacological treatments aimed at reducing inflammation have been proposed to alleviate fatigue, evidence of their effectiveness is lacking. Treatments likely to hold the most promise are rehabilitative in nature and have an established moderate evidence base for effectiveness [93].
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[93] is Exercise therapy for chronic fatigue syndrome (2019, Cochrane Database of Systematic Reviews)
 
Graded-exercise therapy (GET) has been examined as a potential modality for managing the symptoms of fatigue in the absence of other LTCs [97], although this intervention has been met with the concern that it may cause harm and not be suitable for individuals with PESE/fatigue. Unlike symptom-titrated exercise, GET implements exercise training involving large increments of progression. A recent meta-analysis of the safety of GET for CFS, including two randomised controlled trials, found that it did not cause harm and was as effective for those with post-exertional malaise [98].
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[98] is Development of a fatigue scale (1993, Journal of Psychosomatic Research)

I presume this is an error in the reference and they intended [97] Adverse outcomes in trials of graded exercise therapy for adult patients with chronic fatigue syndrome (2021, Journal of Psychosomatic Research)

Similarly [97] should probably be [96] Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome PACE: a randomised trial (2011, The Lancet)
 
PESE has been associated with long COVID; however, to date, there are no studies quantifying its prevalence or burden in this population. As a precaution, a screening questionnaire has been proposed to evaluate symptoms of CFS and ME prior to any exercise-based therapy. However, its use has not yet been widely reported in long COVID populations.
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There is evidence from other LTCs to suggest that exercise-based therapy may be beneficial for long COVID sufferers with fatigue, though direct evidence is lacking. Vigilance for safety and harm is paramount, with the American College of Sports Medicine describing a comprehensive list of contraindications, most of which are unlikely to be relevant in sufferers of long COVID. It is crucial that exercise programmes are individualised and titrated to the symptoms of the individual presenting with long COVID, particularly as long COVID is heterogeneous in nature. Notably, individuals with profound fatigue and PESE associated with minimal exertion are unlikely to be referred for exercise-based rehabilitation programmes but instead may be referred to services specialising in managing individuals with disabling fatigue.
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CPET is widely acknowledged as a valuable tool for the assessment and prognostic stratification in health and cardiopulmonary diseases. In patients recovering from COVID-19, studies have identified the contribution of deconditioning and/or muscular impairment to exercise intolerance on CPET [104]. Longitudinal studies have further demonstrated that exercise limitation (due to skeletal muscle impairment) may persist in some patients, despite an interval improvement of cardiopulmonary abnormalities [105–108]. CPET has demonstrated benefits in distinguishing causes of breathlessness and, in particular, highlighted the presence and increased prevalence of breathing pattern disorder within COVID-19. A systematic review of the use of CPET post-COVID-19 has reported a lower peak oxygen uptake in those with breathlessness compared to those who report a full recovery. Deconditioning was the primary cause of breathlessness, although breathing pattern disorder was also commonly reported [109].
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I don't know which reference 109 is supposed to mean, take your pick from those in proximity —

[107] Durstenfeld MS, Sun K, Tahir P, et al. Use of cardiopulmonary exercise testing to evaluate long COVID-19 symptoms in adults: a systematic review and meta-analysis. JAMA Netw Open 2022; 5: e2236057.

[108] Gordon CS, Waller JW, Cook RM, et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in COPD: a systematic review and meta-analysis. Chest 2019; 156: 80–91.

[109] Aylett E, Small N, Bower P. Exercise in the treatment of clinical anxiety in general practice – a systematic review and meta-analysis. BMC Health Serv Res 2018; 18: 559.

[110] Recchia F, Leung CK, Chin EC, et al. Comparative effectiveness of exercise, antidepressants and their combination in treating non-severe depression: a systematic review and network meta-analysis of randomised controlled trials.
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Regardless, deconditioning has been shown to be specifically not the cause of exercise intolerance in long Covid. See Differential Cardiopulmonary Hemodynamic Phenotypes in PASC Related Exercise Intolerance (2023, ERJ Open Research). Deconditioning through bed rest studies does not decrease peripheral oxygen extraction. Deconditioning results in decreased peak cardiac output and LC patients had supranormal peak cardiac output. They are the opposite of deconditioned.
 
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Shareable Abstract: Those with ongoing COVID-19 symptoms could benefit from a symptom-titrated exercise training programme, provided considerations are given to complex cardiorespiratory pathologies, skeletal muscle dysfunction and fatigue.
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I'm sure that that sounds very reasonable to most people. But we know the quality of a lot of the "evidence" that is cited in support of the idea that exercise training programmes are useful.

Here's one I hadn't seen before, but the forum did already have a thread on it:
In previous similar viral pandemics, the value of exercise-based rehabilitation has been reported in small-scale observational cohorts [7].
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[7] Lau HM, Ng GY, Jones AY, et al.
A randomised controlled trial of the effectiveness of an exercise training program in patients recovering from severe acute respiratory syndrome. Aust J Physiother 2005
This was a study to investigate the effectiveness of an exercise training programme for people recovering from SARS-1.
Forum thread here:
A randomised controlled trial of the effectiveness of an exercise training program in patients recovering from SARS, 2005 Lau et al
There are significant issues with the study, and the benefits of the 6-week supervised intensive training treatment were unconvincing. While there was some improvement in hand grip strength following training, there was no benefit over the control group in SF-36 measures of any aspects of health e.g. physical functioning.

It's a bit like taking a group of people with broken legs and giving them exercises to improve their hand grip. Then, six weeks later when the people have stronger hands but are reporting their physical function is still rubbish, you say that the result proves that hand grip strength training is a useful treatment for broken legs.
 
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SNT Gatchaman said:
[98] is Development of a fatigue scale (1993, Journal of Psychosomatic Research)

I presume this is an error in the reference and they intended [97] Adverse outcomes in trials of graded exercise therapy for adult patients with chronic fatigue syndrome (2021, Journal of Psychosomatic Research)

Similarly [97] should probably be [96] Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome PACE: a randomised trial (2011, The Lancet)
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It looks like something has gone seriously awry with the reference citations.

Todd has also spotted it.


I suspect he'll have more to say in the morning.
 
This is a great example of why after almost 4 years of this exact model, there has been zero progress in Long Covid. This is the current model, applied for nearly 4 years onto millions of people. It's widely acknowledged that there are no effective treatments for Long Covid, and here they come along, suggesting it "may be of value", based on fully debunked assumptions like deconditioning and a complete lack of evidence for it.

There is really no need to look further as to why there is no progress, why it takes decades for medical treatments to become accessible to patients. It's accepting being stuck in a state of failure, perpetuated for absolutely no discernible reason, decade after decade of insisting against all evidence while calling it "evidence-based".

The problem isn't people like Chalder and other people involved in this. It's that this way of doing things isn't just accepted, it's demanded. Using basic common sense and lizard-brain reasoning alone, there is no need for evidence here. This is the current treatment paradigm. It has been a massive failure. Yet again, for 4 more years. But somehow it can be suggested as something that "may be of value", and that reaffirms how it's the right way. Even though it's a failure. There isn't even a need for evidence

Yesterday I saw someone share a notice from the LC clinic that it's closing down because GPs can now effectively treat most symptoms so there's no need for specialists. Reality just doesn't factor in here, it's either fully delusional, or blatant lying, or both. But in reality it's even worse, it's simply not caring, because it doesn't matter. Almost none of this gets properly recorded anyway, so it's like a police department not recording certain crimes and giving themselves credit and bonuses for it. It's an insane system that has no chance of producing anything of value anywhere, least of all in health care, but here it's demanded. It has to be that, there is no desire to do anything more. Lest it exposes just how little medicine really knows about health and illness.

A system that values performative failure more than it cares about its primary mission. It's just not believable that this problem doesn't affect and degrade everything it does. This is simply not normal. It's normal human behavior not to care when there are no stakes, but that there are no stakes is what's abnormal. It's an aristocratic model, where the people who make the decisions don't owe anything to anyone, and can always choose what they prefer, regardless of outcomes.

There is really no profession in greater need of being revolutionized by AI than medicine. Nowhere else sees that kind of failure, where basic stuff is failed again and again and nothing changes. It does worse at the basic stuff, and best at pushing the cutting edge. It's just built wrong.
 
rvallee said:
Yesterday I saw someone share a notice from the LC clinic that it's closing down because GPs can now effectively treat most symptoms so there's no need for specialists. Reality just doesn't factor in here, it's either fully delusional, or blatant lying, or both.
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Arse covering. They don't want to admit they have no explanation nor effective treatment.
 
NelliePledge said:
True but at least closing it down isn’t wasting money on useless CBT based pseudo treatment
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But replaced with the LC version of CBT/ GE which is breathing exercises with a Respiratory Nurse My LC refers everyone to her and she diagnoses every single person with 'disordered breathing'. Then she sees them for x number of months.

The Respiratory Nurse had no experience in this area pre Covid. She tried to diagnose me with 'disordered' breathing until I showed her that I already knew all the exercises from previous bad experience in that area.

Problem is the LC people want to see her and are desperate for help. They eventually get churned out the other end having spontaneously recovered or are just as bad after. It's CBT all over again.
 
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