Physical exertion worsens symptoms in patients with post-COVID condition : Post-exertional malaise in patients with post-COVID condition

Grigor

Grigor

Senior Member (Voting Rights)
"Patients with post-COVID condition suffer from fatigue, limited exercise capacity, and post-exertional malaise. Post-exertional malaise is the worsening of symptoms after physical or mental exertion, which reduces the efficacy of most forms of rehabilitation. This article presents the current understanding in the pathophysiology of post-COVID condition, particularly the underlying causes of post-exertional malaise."

Ellen A. Breedveld 1*, Braeden T Charlton 1*, Brent Appelman 2, Sarah Biere-Rafi 3,
Kasper Janssen 4, Michèle van Vugt 5, Rob C.I. Wüst 1.

* "The authors would like to thank Anil van der Zee for his contribution to the text." :)

https://www.scienceopen.com/document/read?vid=6ebbad1a-4c23-4323-b20c-e57a346ce9f9
 
This article was first published in Dutch for a journal of rehabilitation physicians. I was asked to correct the text. I didn't comment on the biomedical part. It's not perfect as not everything I adviced was added (which I think was due to a limited amount of words they were allowed to use) and some things I'm not completely in agreement with. Nevertheless it's an important step in the right direction. I wrote this additional information in a post:

"A very important article about long COViD, ME, post-exertional malaise and rehabilitation.

People who suffer from post-exertional malaise (PEM) can become sicker after minimal exertion, sometimes even permanently. Unfortunately, this is often not taken into account, with all the dire consequences that entails.

The authors indicate that the slogan 'Exercise is Medicine' does not apply to patients with Long Covid and other conditions with PEM. For the time being, it seems the right approach to follow a personal program aimed at preventing post-exertional malaise in this patient population.

I would like to add that orthostatic intolerance, the inability to sit or stand upright for long periods of time due to problems with the autonomic nervous system and blood flow, can also cause PEM. For very severely affected people who are bedridden, even sitting up to a 45-degree angle can cause a PEM crash. This should also be considered as a physical exertion.

My personal opinion is that any expansion of activities should only be considered after a long-term reduction in complaints. The WHO, for example, talks about at least a month. (*I read this somewhere but honestly I don't remember where exactly). It is also important to note that stabilization is not the same as reducing symptoms.

It was very special for me to be able to contribute to this paper. As a professional ballet dancer, I was surprised 16 years ago that no one understood why I became sicker after exercise. There was no guidance whatsoever, and even though I had clearly become sicker, I was not taken seriously. Over the years, my mission has been to publicize PEM and thus prevent iatrogenic damage.

As far as I know, we have never seen a paper with so many Dutch specialists writing about PEM and rehabilitation. In my opinion, this is truly a milestone, and the authors can certainly be very proud of this. In any case, my gratitude is enormous! I say encore! ❤️"
 
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Trish said:
Brilliant, well done, @Grigor. Thank you.
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Thanks. Do criticize it. It will be good for a new project or paper.

I personally was a bit on the fence about this sentence. It was not part of the Dutch version.

"For those post-COVID condition patients exhibiting PEM, the reduction in physical capacity is likely more a result of the so-called “push and crash cycle”.

What is this based on?
 
Well done @Grigor!

I tried to scrutinize it to my very limited abilities, but there isn't anything I can criticise.

I do believe the sentence "As a result, the term 'Exercise is Medicine' may not be directly applicable post-COVID condition
patients exhibiting PEM. (1,3)" is missing a "to" though.

"Viral proteins and RNA have been found in the lungs, brain, cardiovascular system, and muscle tissue, but it is likely simply remnants of dead virus, rather than live virus (27)." Perhaps seems a bit too speculative, perhaps something like "currently most studies have detected viral antigens, rather than a reservoir" would be more accurate.

I am particularly fond of the sentence "While there is variable evidence, there is a tendency for milder cases of acute COVID-
19 infections to result in post-COVID condition exhibiting PEM(13)." given the still the wide misunderstanding of focusing on hospitalized and severe acute infections.

I hope this text will only gain in value once Wüst's paper on PEM in LC is published in the upcoming weeks.
 
For those post-COVID condition patients exhibiting PEM, the reduction in physical capacity is likely more a result of the so-called “push and crash cycle”. However, in the present state, it is not clear whether PEM is the sole reason for the reduction in exercise tolerance, and as such it is difficult to completely separate the symptoms of fatigue, reduced exercise capacity and PEM.
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I agree the introduction of 'push and crash cycle' into this section is unhelpful, though at least it's better than 'boom and bust'. PEM does lead to reduced exercise capacity for a short or long period, but the reduced exercise capacity is always there, whether you've pushed and crashed or not. Frequently triggering PEM by pushing beyond one's current activity limit is likely to lead to long term worsening.

I think reduced exercise tolerance is based on pathologically rapid muscle fatiguability and slow recovery which limits what one can do at any time, whether it reaches PEM triggering levels or not. I think PEM is something different, as it's a delayed and prolonged increase in all symptoms, not just reduced activity capacity.
 
Trish said:
I agree the introduction of 'push and crash cycle' into this section is unhelpful, though at least it's better than 'boom and bust'. PEM does lead to reduced exercise capacity for a short or long period, but the reduced exercise capacity is always there, whether you've pushed and crashed or not. Frequently triggering PEM by pushing beyond one's current activity limit is likely to lead to long term worsening.

I think reduced exercise tolerance is based on pathologically rapid muscle fatiguability and slow recovery which limits what one can do at any time, whether it reaches PEM triggering levels or not. I think PEM is something different, as it's a delayed and prolonged increase in all symptoms, not just reduced activity capacity.
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Yeah, I agree. I understand what they're saying. It might be true that the push crash cycle worsens the capacity but a reduction is always there. I'm not totally comfortable with their description.

On a positive note, it will atleast warn HCP not to push and therfore crash people.
 
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