Review Pulmonary Rehabilitation for individuals with persistent symptoms following COVID-19 2024 Daynes et al

Abstract

Topic importance
COVID-19 can cause ongoing and persistent symptoms (such as breathlessness and fatigue) that lead to reduced functional capacity. There are parallels in symptoms and functional limitations in adults with post-COVID symptoms and adults with chronic respiratory diseases. Pulmonary Rehabilitation is a key treatment for adults with chronic respiratory diseases with the aims to improve symptom management, increase functional capacity. Given the similarities in presentation and aims, a Pulmonary Rehabilitation programme may be optimally placed to meet the needs of those with ongoing symptoms following COVID-19.

Review findings
Aerobic and strength training has shown benefit for adults living with Long COVID though there is little evidence on structured education in this population. Breathing pattern disorder is common in adults with Long COVID and considerations to treatment prior to rehabilitation, or alongside rehabilitation are necessary. Considerations to Post Exertional Malaise is important in this population and evidence from the Chronic Fatigue Syndrome literature supports the need for individualisation of exercise programmes, and considerations for those that have an adverse reaction to activity and/or exercise.

Summary
This narrative review summarises the current evidence of Pulmonary Rehabilitation programmes in a long COVID population. Where the evidence is lacking in long COVID the supporting evidence of these programmes in chronic respiratory diseases has highlighted the importance of aerobic and strength training, considerations for fatigue, potential mechanism for immunology improvement and management of breathing pattern disorders in these programmes.

Paywall, https://journal.chestnet.org/article/S0012-3692(24)00040-0/pdf#

 

Yikes. The main takeaway from papers like this is that such claims:

are probably just as suspicious as the rest, and that those treatments don't actually make any difference. For sure neither clinicians nor researchers can tell the difference. Maybe they aren't, but when you find a batch of clearly broken items in the "passed quality control" bin, you have to be dubious about not just the rest of the items, but the entire quality control process.

Especially BS like:

This idea that people aren't breathing right as the cause of unexplained breathlessness has been there from the start, and somehow is still around. Just because. No explanation needed.

At least they're not promoting the use of smoke inhalation therapy for chronic respiratory diseases, because that's basically their level of understanding of exercise rehabilitation programs and PEM. The download link doesn't work so I can't check, but I'd be surprised if ye old chestnut of deconditioning isn't in there as well.

It's been 4 years, and there are still takes like this. About all the things that have already been tried and failed. And are presented as a "hey, maybe this could work?!". Amazing.

 

https://journal.chestnet.org/article/S0012-3692(24)05599-5/fulltext

Postexertional Malaise and Rehabilitation in Long COVID

To the Editor:

Daynes et al1 published a review in an issue of CHEST (September 2024) that analyzed the literature on pulmonary rehabilitation in patients with persistent symptoms after COVID-19 infections. They concluded that these patients benefit from aerobic exercise, resistance training, education, and the development of self-management strategies. They note that these patients frequently have fatigue and can have postexertional malaise and postexertional symptom exacerbation. These symptoms occur in patients with myalgia encephalomyelitis/chronic fatigue syndrome and probably require more attention during rehabilitation in patients with post-COVID syndrome.

Twomey et al2 reported a cross-sectional survey that included 213 participants to determine the level of fatigue and postexertional malaise in patients with long COVID syndrome. This study determined that 194 participants (91.1%) had significant fatigue and 202 respondents (94.8%) had at least one positive response in the postexertional malaise questionnaire. A total of 125 participants (58.7%) met the threshold used for patients with myalgia encephalomyelitis and chronic fatigue syndrome. These symptoms complicate rehabilitation programs because many participants note extreme exhaustion/malaise for periods that can range from hours to several weeks after exercise. The best approach to managing these patients is somewhat controversial. The National Institute for Health and Care Excellence guidelines for myalgia encephalomyelitis/chronic fatigue syndrome published in 2021 did not recommend graded exercise therapy in patients with that disorder.3 However, recent studies have not reported any harm with exercise therapy for patients with post-COVID conditions.4,5 Tryfonos et al4 randomized 31 nonhospitalized patients with prior COVID infection into three exercise groups, including high-intensity interval training, moderate-intensity continuous training, and strength-based training. The primary outcome was the fatigue level at baseline and 48 hours after exercise. There was no difference in fatigue after these exercise sessions. However, patients with post- COVID condition did report higher levels of impaired concentration and increased muscle soreness. Ladlow et al5 reviewed this study and the literature and published a commentary in JAMA Network Open in April 2024. They concluded that exercise was beneficial and did not cause harm in these patients.

Most established pulmonary rehabilitation programs probably have not managed patients with myalgia encephalomyelitis/chronic fatigue syndrome and may not be familiar with postexertional malaise. Consequently, patients who are post-COVID probably need more attention to ongoing benefits with rehabilitation and the possibility of postexercise malaise. A simple approach to this would use a questionnaire for postexertional malaise, such as the DePaul Symptom Questionnaire, after rehabilitation sessions.

Kenneth Nugent, MD Lubbock, TX AFFILIATIONS: From the Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX.

CORRESPONDENCE TO: Kenneth Nugent, MD; email: Kenneth. nugent@ttuhsc.edu
DOI: https://doi.org/10.1016/j.chest.2024.10.056 Financial/Nonfinancial Disclosures None declared.

References

1. Daynes E, Mills G, Hull JH, et al. Pulmonary rehabilitation for people with persistent symptoms after COVID-19. Chest. 2024;166(3):461-471.

2. Twomey R, DeMars J, Franklin K, et al. Chronic fatigue and postexertional malaise in people living with long COVID: an observational study. Phys Ther. 2022;102(4)zac005.

3. National Institute for Health and Care Excellence. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: Diagnosis and management. NICE guideline [NG206], Published October 29, 2021. National Institute for Health and Care Excellence website. Accessed October 15, 2024. https://www.nice.org.uk/ guidance/ng206

4. Tryfonos A, Pourhamidi K, Jörnåker G, et al. Functional limitations and exercise intolerance in patients with post-COVID condition: a randomized crossover clinical trial. JAMA Netw Open. 2024;7(4): e244386. [ Correspondence ]

5. Ladlow P, Bennett AN, O’Sullivan O. Exercise therapy for post-COVID-19 condition—does no harm. JAMA Netw Open. 2024;7(4):e246959.

 

Correspondence
Volume 167, Issue 3
e96-e97
March 2025
Response
Enya Daynes enya.daynes@uhl-tr.nhs.uk ∙ Neil J. Greening ∙ Sally J. Singh
NIHR Leicester Biomedical Research Centre, Glenfield Hospital, and the Department of Respiratory Sciences, University of Leicester, Leicester, England




To the Editor:

Dr Nugent provided a letter to the editor highlighting the importance and prevalence of postexertional malaise (PEM) in those living with long COVID, as outlined in our review.1 We agree that it is important to be aware of these symptoms when assessing and treating those with long COVID, but we also must consider the challenges these complexities can present within this population.

The authors highlight a prevalence of at least one symptom of PEM as 94.8% through a purposive sample within the long COVID community and long COVID support groups, which could of course inflate the prevalence.2 Other statistics suggest between 45% and 89% of people with long COVID may experience PEM; however, it is often incorrectly assumed that the prevalence of persistent fatigue can be attributed to PEM.3 Additionally, Daynes et al4 have examined PEM using the DePaul Symptom Questionnaire as Nugent et al suggest, and similarly to Twomey et al,2 this identified a high prevalence of fatigue, which could be interpreted as PEM.4 However, participants had a significant improvement in both the severity and frequency of symptoms reported using the DePaul Symptom Questionnaire, therefore not supporting the idea that exercise will worsen these symptoms.4 Possibly these participants, while meeting the thresholds of the DePaul Symptom Questionnaire for PEM, did not truly have a diagnosis of PEM, and as such we would discourage health care professionals from using this tool as an indication alone. Diagnoses should be considered alongside a thorough clinical assessment by a qualified health care professional. From a rehabilitation delivery perspective, we would recommend health care professionals carefully monitor any symptoms throughout programmes (not just fatigue), and where there is a sustained worsening, seek further support or reconsider intervention(s)/timing. Services or further research should consider an appropriate way to measure and monitor this that fits within their delivery model, paying consideration to the 6-month recall required for the DePaul Symptom Questionnaire.

The authors highlight that the National Institute for Clinical Excellence guidelines (United Kingdom) for myalgia encephalomyelitis/chronic fatigue syndrome (2021) do not recommend graded exercise therapy for these populations,5 although there is not a global consensus.6,7 Although this is an important consideration, we must consider long COVID and its associated symptoms on their own merit. Additionally, pulmonary rehabilitation is not a program of graded exercise therapy. Rather, it is an individually tailored and prescribed intervention that responds to patient symptoms and hence is an appropriate option for those living with long COVID as we highlighted in our review. Importantly this would meet the criteria highlighted by National Institute for Clinical Excellence guidelines for myalgia encephalomyelitis/chronic fatigue syndrome that consist of a thorough baseline assessment, ensuring the program does not worsen symptoms, and making flexible adjustments to the program to suit individual’s needs, all of which trained pulmonary rehabilitation specialists would be experienced in providing.5

Undoubtedly, pulmonary rehabilitation may not be suitable for all with long COVID, and as with any intervention, this decision should be made by an appropriately trained and skilled health care professional in collaboration with patients. We agree that PEM should be a consideration in this decision and reported using accurate, validated tools, alongside the other symptoms and complexities we have highlighted in our review that are unique to those living with long COVID.

Financial/Nonfinancial Disclosures
See earlier cited article for author conflicts of interest.

References
1. Daynes, E. ∙ Mills, G. ∙ Hull, J.H. ...
Pulmonary rehabilitation for people with persistent symptoms after COVID-19
Chest. 2024; 166:461-471
2. Twomey, R. ∙ DeMars, J. ∙ Franklin, K. ...
Chronic fatigue and postexertional malaise in people living with long COVID: an observational study
Phys Ther. 2022; 102, pzac005
3. Grabowska, A.D. ∙ Westermeier, F. ∙ Nacul, L. ...
The importance of estimating prevalence of ME/CFS in future epidemiological studies of long COVID
Front Public Health. 2023; 11, 1275827
4. Daynes, E. ∙ Baldwin, M.M. ∙ Annals, M. ...
Changes in fatigue symptoms following an exercise-based rehabilitation programme for patients with long COVID
ERJ Open Res. 2024; 10:00089-2024
5. National Institute for Health and Care Excellence
Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NICE guideline [NG206]. October 29, 2021. National Institute for Health and Care Excellence website
https://www.nice.org.uk/guidance/ng206
Date accessed: November 1, 2024
Google Scholar
6. Royal Australian College of General Practitioners
Incremental physical activity for chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (ME), 2015. Royal Australian College of General Practitioners website
https://www.racgp.org.au/clinical-r...cise/incremental-physical-activity-for-cfs-me
Date accessed: November 1, 2024
Google Scholar
7. Larun, L. ∙ Brurberg, K.G. ∙ Fønhus, M.S. ...
Treatment of chronic ratigue syndrome CFS/ME. Norwegian Institute of Public Health website. 2011
https://www.fhi.no/en/publ/2011/treatment-of-chronic-fatigue-syndrome-cfsme/
Date accessed: November 1, 2024

 

Both of them seem set on using rehab and flawed studies, so they are bound to be wrong.

 

but also

Reconsider the intervention if there is worsening, but the baseline assessment ensures there won't be any worsening. Because who needs joined-up thinking when you've got box-ticking.

 

So many people imagining they have skills and knowledge they absolutely do not possess, but lacking those skills and knowledge, they don't even know they are lacking them, because they wouldn't recognize those skills or knowledge if they ever came across it.

Also, way to miss the entire point about NICE'S warning about exercise programs, of trying to find the right way of explaining they are not doing this, while explicitly doing this, which is why the warning was phrased exactly the way it is. There is no combination of words that can't be twisted to suit their fancy. Texts can explicit write down: up is up, it is never down, never say or suggest up may be down, and they'd just argue up is down anyway, using bullshit terms that everyone understands they mean up is down.

Really tired of an entire profession being textbook examples of both Dunning-Kruger and Hanlon's razor.

 

"Long Covid clinical trial helped me return to work"

When Sharon Baker tested positive for Covid-19 three and a half years ago, she had little idea it would lead to an 18-day hospital stay and debilitating long-term symptoms.

The 64-year-old, from Rothley in Leicestershire, is one of an estimated two million people in the UK who are now living with "long Covid".

She said chronic symptoms, like intense fatigue, made it impossible for her to work, and even getting out of bed and walking became difficult.

However, she said taking part in a clinical research trial at Glenfield Hospital, in Leicester, had allowed her to get her life back while managing ongoing symptoms.

Mrs Baker, an office worker for an ultrasound company, was one of 181 patients involved in the study, which explored the effects exercise can have on their symptoms.

She took part in walking, cycling and strength-based training during an eight-week programme.

Dr Daynes said: "We had an increase in exercise capacity in those that attended the face-to-face and digital rehab group, over and above what people in the control group would have.

"There was some signal that people were feeling better and less fatigued.

"We did some blood tests and we were able to show there was an improvement in their immune system."

 

Strange to compare with what controls 'would have' shown!
Some signal might have been a fleeting embarrassed smile on the patient's face when asked if they were better and less fatigued? (Even an audible 'yes miss' under the breath?)

How do you show an improvement in the immune system with a blood test I wonder? Never had the pleasure of such a result myself.

Dr Daynes is apparently an academic physio (doctor of philosophy) at Leicester.

 

Clearly, it has been optimized. Boosted. Cleansed. Supercharged. Enhanced.