Effect of 8-week exercise-based rehabilitation on immune cell counts in Post-COVID syndrome following hospitalisation: a RCT, 2025, Bishop

[poetinsf]

The problem with post-COVID, long-COVID, PASC, etc is that it means anything left over from COVID. If you have anosmia after COVID, you have post-COVID. The trial has nothing to do with overactive immune system. It only means it improved PASC patients' T cell memory or whatever, however they defined PASC. And how does improving T cell memory mean improving overactive immune system anyway? You'd think it's the other way around. This kind of paper is what gives science bad name these days.

 

[Evergreen]

I doubt we have reason to think exercises are useful for anyone covalescing, including pneumonia ccases. Any evidence for benefit in such cases is probably as flawed as any other rehab trial.

Well I'd be open to evidence with objective measures, like if forced expiratory volume were measured using spirometry. It was able to separate the wheat from the chaff in Wechsler's asthma study. So if someone were able to show that people with chronic dyspnoea following Sars-CoV-2 have significantly improved FEV after an exercise programme, I'm open to it. But am not going to spend my meagre energy looking for it!

 

[Jonathan Edwards]

So if someone were able to show that people with chronic dyspnoea following Sars-CoV-2 have significantly improved FEV after an exercise programme, I'm open to it.

An objective measure would show an effect but it does not necessarily show any benefit. I could probably increase my FEV1 or FVC by going to the gym every day for three months. But it would be entirely pointless and miserable because I don't like going to to the gym every day and have got used to my level of ability for other, productive, activities.

There are studies showing that people with ME/CFS have objective improvements in fitness after an exercise programme but they don't show that the people feel better.

 

[Evergreen]

An objective measure would show an effect but it does not necessarily show any benefit. I could probably increase my FEV1 or FVC by going to the gym every day for three months. But it would be entirely pointless and miserable because I don't like going to to the gym every day and have got used to my level of ability for other, productive, activities.

There are studies showing that people with ME/CFS have objective improvements in fitness after an exercise programme but they don't show that the people feel better.

I agree that an improvement in an objective measure alone does not prove benefit. But if that is coupled with improvement on a subjective measure of functioning, or something like return to work, I'm open to considering whether real benefit has occurred. In ME/CFS we have not seen that. But I think it's possible that things could be different for chronic dyspnoea following covid.

I would guess that during my GET certain objective measures would have shown improvement eg measure of quad strength. But the decline in functioning and having to stop work would clarify that no benefit occurred.

 

[Utsikt]

I agree that an improvement in an objective measure alone does not prove benefit. But if that is coupled with improvement on a subjective measure of functioning, or something like return to work, I'm open to considering whether real benefit has occurred.

If «doing more» is part of the intervention, then «doing more» short term can’t be a measure of benefit. If they are able to do more long term and it doesn’t come at the cost of other aspects of their health or life in general, we can start talking about actual benefits.

 

[Evergreen]

If «doing more» is part of the intervention, then «doing more» short term can’t be a measure of benefit. If they are able to do more long term and it doesn’t come at the cost of other aspects of their health or life in general, we can start talking about actual benefits.

Exactly.

 

[rvallee]

It only means it improved PASC patients' T cell memory or whatever, however they defined PASC. And how does improving T cell memory mean improving overactive immune system anyway? You'd think it's the other way around. This kind of paper is what gives science bad name these days.

Pretty much this. It increased some value. Is that an improvement? Says who? Based on what?

 

[Jonathan Edwards]

But I think it's possible that things could be different for chronic dyspnoea following covid.

It is possible but I think we should push back against the rehabilitationists' assumption that it is the norm - exercise makes you better. As far as I know all we know is that exercise keeps you well.

I got my accreditation in rehabilitation but never came across a shred of evidence for this sort of convalescent exercising doing anyone any good.

 

[rvallee]

If «doing more» is part of the intervention, then «doing more» short term can’t be a measure of benefit. If they are able to do more long term and it doesn’t come at the cost of other aspects of their health or life in general, we can start talking about actual benefits.

Like increasing power to a machine and noting how it increases power to the machine, without caring that it reduces the machine's ability to do work. "We increased the power input of the machine boss, and thus its power output." "Does it improve its performance?" "No, actually it decreases it, but we increased the power input so that's better."

I don't understand why this discipline is indifferent to failing in ridiculous ways like this. You can easily overclock CPUs to get them to do more processing. But you will shorten its lifespan, and increase it slightly too much and it will start becoming unstable and crash. The kind of assessment done in clinical psychology is equivalent of doing only short-term tests that simply ignore crashes and hangs or long-term stability. It's so obviously wrong.

 

[Evergreen]

It is possible but I think we should push back against the rehabilitationists' assumption that it is the norm - exercise makes you better.

Agree 100%. I think we need to be equally critical of the assumption that exercise doesn't make anyone, with any condition, better. If there's good quality evidence out there for other conditions, I'm open to looking at it and seeing whether there's something there or not. To be credible sources of well-founded criticisms of the evidence for exercise in ME/CFS, I think we have to be able to put aside the biases we want others to put aside.

There are studies showing that people with ME/CFS have objective improvements in fitness after an exercise programme but they don't show that the people feel better.

Don't the majority of studies in ME/CFS show the opposite - that people say they feel better but don't have objective improvements in fitness/work/etc?

No objective measures here, but this study found that endurance training improved dyspnoea more than standard physiotherapy. Same number of sessions, but the endurance training sessions were longer and more intense. See quote box below for what each intervention included. Whether this translated into meaningful benefit or not, that's interesting. Is it a real effect? Or does it come down to differences in weight reduction or baseline characteristics? Regardless, I would eat my hat if a similar study in ME/CFS found the same thing. I'd eat my scarf if people with ME/CFS could actually do the interventions.

Method​

Exercise Training Rehabilitation: a prescription was made by a pulmonologist for “exercise training rehabilitation following severe COVID” following an AMK28 rating (60-90 minutes, 20 sessions)

An initial 6 minutes walking test should be made upon first mandatory assessment (AMK10.7) to determine target heart rate (HR), and at the end of care to evaluate progression

Endurance training will be carried using a cycle ergometer device, with a continuous monitoring of heart rate and oxygen saturation to check the tolerance of the exercises

Continuous endurance training will start at 60-70% of the participant’s maximal peak power. For participants unable to maintain continuous training, interval training sequences (30 seconds of effort followed by 30 seconds of rest) may be proposed. A target dyspnoea of 4-6 on the modified BORG scale should be achieved (10.1378/chest.109.5.1169 )

Initially, the effort will last for 15 minutes, then will be gradually increased to reach an exercise duration of 40 minutes or 45-60 minutes for continuous endurance training or interval training respectively

The power should be adjusted according to the participant's progress, to reach the target heart rate and dyspnoea at 4-6 on the BORG scale

All participants will be offered muscle strengthening exercises. Strengthening of the lower limbs is to be prioritised, but additional exercises for the upper limbs and core can be included. Each exercise will consist of 3-4 sets of 6-12 repetitions. Devices can be used to implement those exercises, including but not limited to leg press, leg curl, leg extension, stepper, rower, treadmill, weights etc

The exercises are up to the discretion of the physiotherapist BUT muscle fatigue should be felt at the end of each set



Standard Physiotherapy: a prescription was made by an intensive care physician for “4 limbs physical therapy and respiratory disorders following severe COVID” following an AMK20 rating (at least 30 minutes, 20 sessions)

Course of the physiotherapy sessions will be left to the discretion of the physiotherapist according to his/her mandatory initial assessment (AMK10.7).

Sessions should consist of

Strength training of limbs and trunk muscles (weight bench with guided loads, weights, elastics...)

Aerobic training (cycle ergometer, treadmill…)

Active and passive mobilisation by the physiotherapist for articular range of motion gain

Balance exercices

Respiratory muscle training (pressure-resistant valves)

Respiratory therapy

Return to the previous sport, reintegration of the sport gesture

Electrostimulation

Education on perpetuating physical activity

Autonomous rehabilitation exercises

 

[Jonathan Edwards]

No objective measures here, but this study found that endurance training improved dyspnoea more than standard physiotherapy.

Trouble is, it is an open label study with dyspnoea being a subjective outcome so open to exactly the same expectation bias as PACE? And presumably during the training there was quite a bit more dyspnoea than in the controls! I prefer to take life as it comes without sweaty changing rooms.

But I agree. I don't think any of us is in danger of indigestion relating to hats or scarves much!!

 

[Evergreen]

Trouble is, it is an open label study with dyspnoea being a subjective outcome so open to exactly the same expectation bias as PACE? And presumably during the training there was quite a bit more dyspnoea than in the controls! I prefer to take life as it comes without sweaty changing rooms.

But I agree. I don't think any of us is in danger of indigestion relating to hats or scarves much!!

Agreed re expectation bias. What's interesting to me is that they found a difference between more intense and less intense exercise. The PACE investigators, on the other hand, seemed to expect CBT/complex incremental pacing to be more effective than GET but it wasn't. The 2007 Jason et al. study that compared different interventions also found no difference. That lack of difference always looked to me like whatever changes occurred were not therapy-specific.

Yep, I hear you, if you don't like exercise, then none of this is going to appeal, unless maybe if seriously debilitated (by dyspnoea following covid). I loved exercise, but not of the gym variety or anything requiring changing rooms or people telling me what to do! Fresh air, nature and either alone or with one excellent person. Wearing crap clothes.

Let's say someone used to really enjoy walking their dog every day, but since being hospitalised for covid they haven't been able to do that due to dyspnoea, and they really miss it. That person might be motivated to do an exercise programme, and if it got them back to walking their dog, that would be a good thing. Whether people see those kind of benefits, I don't know.

Good re hats and scarves because my scarf is really bloody long.

 

[Jonathan Edwards]

Yep, I hear you, if you don't like exercise,

Oh but I do. I spent the summer sailing a keelboat, involving winching for all I was worth, or birding which usually meant a 7 mile walk. I like to be able to do the exercise I like. In the winter I do a month of skiing, including some gentle off-piste if I can be sure I am not putting others at risk. I rowed for Trinity, but only in the bumps. I used to spend 6 hours windsurfing non-stop. But going to the gym - arrrgh!! I spent this week pruning trees.

I never did an exercise program and it never caused me any problems. I see it as a fetish of modern life that we could well do without.

 

[Evergreen]

Oh but I do. I spent the summer sailing a keelboat, involving winching for all I was worth, or birding which usually meant a 7 mile walk. I like to be able to do the exercise I like. In the winter I do a month of skiing, including some gentle off-piste if I can be sure I am not putting others at risk. I rowed for Trinity, but only in the bumps. I used to spend 6 hours windsurfing non-stop. But going to the gym - arrrgh!! I spent this week pruning trees.

I never did an exercise program and it never caused me any problems. I see it as a fetish of modern life that we could well do without.

That all sounds lovely to me. I don't understand the gym obsession either.

 

[bobbler]

I agree that an improvement in an objective measure alone does not prove benefit. But if that is coupled with improvement on a subjective measure of functioning, or something like return to work, I'm open to considering whether real benefit has occurred. In ME/CFS we have not seen that. But I think it's possible that things could be different for chronic dyspnoea following covid.

I would guess that during my GET certain objective measures would have shown improvement eg measure of quad strength. But the decline in functioning and having to stop work would clarify that no benefit occurred.

That last sentence is pretty key (and why the approach of only ticking if you did it once from a limited no of activities is an issue for the MEA PROMS) because it is looking at that overall envelope.

And looking at the longer period of time for these objective measures.

It might be so nice to be distracted and to feel the self-efficacy of pushing and using every trick in the book to turn up for work, along with adjusting everything else out of one's life that for quite a long period of time the 'feel better' would also be there.

But I have found that it starts to creak at the seams at around 6months. That there has had to be readjustment by 12months (homeworking, starting late, showering less 'because maybe I don't need to be' following skipping a shower when you'd normally once and realising it was OK maybe, getting lunches based on ease rather than what you want). And as we know it takes a certain amount of time for someone to end up actually leaving due to the way processes work.

I think there probably needs to be a bit of getting head around the idea that a package of measures isn't going to be that all measures are relevant at the same period of time as the 'primary thing'. But all need to be collected perhaps over that extended period to give some insight (for example what if these cell differences 'drop off' over 2yrs, or don't - but the functional measures do) and mean we aren't left with assuming and inferences.

 

[bobbler]

Pretty much this. It increased some value. Is that an improvement? Says who? Based on what?

Indeed. In the theoretical list it could indicate that exercise meant the body thought it 'needed more' rather than the assumption it is a good thing.

 

[bobbler]

It is possible but I think we should push back against the rehabilitationists' assumption that it is the norm - exercise makes you better. As far as I know all we know is that exercise keeps you well.

I got my accreditation in rehabilitation but never came across a shred of evidence for this sort of convalescent exercising doing anyone any good.

But even that [keeps you well] must be clouded methodology-wise in 'those who keep well can exercise' complicating what you are actually observing/measuring.

Are the historical origins in rehab generally in one-hit disabilities such as stroke or accident where the cause is no longer 'active' in the sense of a bleed having stopped or the broken leg operated on or put in cast.

I imagine there are some conditions where understanding that someone's messaging or body 'works differently' and 'finding a new way to do x, without using y' is helpful if you understand that there isn't something that is affecting both y and the new 'z' that is being employed for said task or it is at least making it 'lower demand'.

But is it an area that really understands 'illnesses' or has it just ended up wandering into it somewhat blindly? It feels like it is drawing its boundaries quite clearly around 'exercise must be involved' at the same time as going into new turf meaning it is asking questions for which there should be more open-minded/ended hypotheses and interpretations unaware of the bias this is creating.

The word blindspot is ringing in my head but it is bigger than that bit between the mirror and looking over your shoulder in a big lorry and more like don't look left at all with the 'only report/see things that correlate or are seen as 'positive''. which is sad because it could mean that things that are actually in the data and could be useful findings are ending up being trashed for things that are only significant in a distorted reality world being reported because they align with implicit assumptions or models these people mightn't even realise they are being limited by.

 

[Sean]

An objective measure would show an effect but it does not necessarily show any benefit.

+1

I never did an exercise program and it never caused me any problems. I see it as a fetish of modern life that we could well do without.

I am increasingly of the view that the whole formalised rehab approach, with few exceptions, has been a disaster. It has metastasised out of control way beyond any benefit to the vast majority of all patients.

Are the historical origins in rehab generally in one-hit disabilities such as stroke or accident where the cause is no longer 'active' in the sense of a bleed having stopped or the broken leg operated on or put in cast.

Important distinction. Rehab basically doesn't work for ongoing active disease process.

 

[Utsikt]

I’m convinced rehab is still around because people that got sick, and then are no longer actively sick, will improve while they are in rehab. Like an open heart surgery patient. Or someone that were in a car crash. Sure, they might have some lasting impact and disability, but their overall trajectory is usually upwards. So if you put them somewhere, they will credit whatever happened at that somewhere with helping them.

It’s probably nice to feel taken care of after a traumatic experience and maybe some need some guidance and reassurance along the way, but 99 % of rehab patients could do without the curative aspects of rehab. So we could just go back to doing convalescence and enable people to use their bodies in a manner that gives them joy.

It’s ironic that the same people that obsess over how thinking about illness is bad for you, have such a controlling and perfectionist approach to what you should think and do.

 

[Evergreen]

@Jonathan Edwards, I was thinking about our conversation above, and another thread where you talked about dose-response studies and sigmoid curves. Here's what we were talking about:

Trouble is, it is an open label study with dyspnoea being a subjective outcome so open to exactly the same expectation bias as PACE?

What's interesting to me is that they found a difference between more intense and less intense exercise. The PACE investigators, on the other hand, seemed to expect CBT/complex adaptive pacing to be more effective than GET but it wasn't. The 2007 Jason et al. study that compared different interventions also found no difference. That lack of difference always looked to me like whatever changes occurred were not therapy-specific.

What I'm interested in is this:

Let's say, hypothetically, we could do a study investigating different intensities of exercise in ME/CFS, where patients were blind to which intensity they were at relative to the others being trialled. If we found that there was no sigmoid response curve, would that suggest that exercise was not effective for ME/CFS? If we found, instead, that there was a kind of reverse situation where the more intense the exercise, the more harm, would that demonstrate that exercise was harmful for ME/CFS? If we found that the more intense the exercise, the higher the dropout rate, would that suggest that exercise was harmful for ME/CFS?

I'm not suggesting this is a study that should be done. I just want to know what we could learn from a study like that.