BLOG: The Role of Exercise in COVID-19

Professor Roger Wolman MD(Res) FRCP FFSEM - Visiting Professor - Institute of Human Sciences and Consultant in Rheumatology and SEM blogs about the role of exercise during the pandemic.

The world only became aware of Covid-19 in December 2019. Since that point the medical and scientific communities have been on a very steep learning curve trying to come to terms with this disease.

Exercise has an important role to play at several key points in the management of the disease. This includes the prevention of severe disease, the management during recovery following Covid-19 infection and in the regaining of fitness and wellbeing in those who have been shielding.

Covid-19 is predominantly a respiratory virus with the potential to cause a major cardio-respiratory illness. This includes a severe respiratory infection, pulmonary thrombotic disease and myocardial involvement (acute coronary syndrome and myocarditis). It may be possible to reduce the impact of the infection by improving cardio-respiratory fitness. Although there is no strong evidence-base for this approach, common sense suggests that aerobic fitness can mitigate the impact of the virus. Therefore, regular aerobic exercise (3 or more times per week), and use of HIIT training if possible, should be recommended. Groups who are at higher risk of severe infection, such as those with obesity and chronic lung and heart conditions, may get even greater benefit. Clearly these vulnerable groups would need to get further guidance from their doctor before embarking on such a programme.¹

Following Covid-19 infection many patients have a prolonged, slow recovery. This is increasingly recognised as a post-Covid syndrome and may continue for as long as 18 months.^{2,3, 4} This has already been seen in the 2 previous Coronavirus pandemics, SARS and MERS, and is well recognised in anyone who has spent a considerable period of time in an intensive care unit (ICU).⁵ It is estimated that over 60% of patients admitted to hospital with Covid-19 will have a prolonged recovery of over 3 months. What is more surprising is that some patients who had a mild disease, and were treated by isolation at home, may go on to a slow, prolonged recovery. The emerging evidence suggests that this may affect 10 -20% of this group.

A range of physical and psychological effects can occur as a result of Covid-19 infection. This includes profound muscle and cardio-respiratory de-conditioning. Weight loss of up 20 kg has been recorded predominantly due to muscle atrophy. There is growing concern that some patients may be left with permanent lung and cardiac damage, including pulmonary scarring and fibrosis and cardiac muscle impairment (myocardial infarction and cardiomyopathy). It is estimated that this may affect 20% of those admitted to ICU. Psychological effects include guilt, anxiety, depression and post-traumatic stress disorder. As a result of this the patient may complain of a range of symptoms. These include weakness, fatigue, exhaustion after minimal exertion, shortness of breath, chest pain, cough and musculoskeletal pain, dizziness and inability to concentrate.

Post-viral fatigue is a well recognised condition following a viral infection. There has also been much debate in the medical literature about the existence of Myalgic Encephalomyelitis (ME) and whether this occurs following a viral illness.  Covid-19 has the potential to cause a severe prolonged, infection and therefore it is likely that post-viral fatigue will account for a significant proportion of patients with a prolonged illness. However, there are a growing number of reports regarding permanent damage caused by this virus, not just to the cardio-respiratory system, but also to the brain, kidney and endocrine organs and this may explain a percentage of the prolonged illness we are now witnessing.

Exercise has a key role to play for those patients whose ongoing symptoms are due to de-conditioning and post- viral fatigue. As the symptoms can vary from day-to-day there is a tendency for patients to overdo it on the good days to try to return to their pre-Covid fitness level. This can lead to post-exercise exhaustion which can last for several days and is known as the “boom and bust” cycle. This should be avoided at all costs as it can lead to an even more prolonged illness and de-conditioning. A more successful approach is to identify a level of exercise that the patient can tolerate, without causing prolonged pain or exhaustion, and use this as a baseline from which to progress. Simple ways of measuring a baseline include the one minute sit-to-stand test, measuring the number of times the patient can do this activity in one minute, or the 6 minute walk test, measuring the distance walked in 6 minutes. A baseline level of aerobic activity can then be prescribed which will depend on the baseline measurement. Initially there will be a degree of trial and error but once this is established it should be possible to map out a graded exercise programme. If the patient has significant cardio-respiratory damage, the oxygen saturation levels in the blood may decrease on exercise. One simple way to measure this is to use a pulse oximeter and measure the pre- and post-exercise oxygen saturation in the blood following a simple exercise test, such as the ones described above. A drop in saturation of 4% or more would be significant and merit a referral to a cardio-respiratory specialist.

Graded strength, proprioception and balance training should be developed in parallel with the graded aerobic exercise programme.  Strength training should include exercises for the trunk, lower and upper limbs. Proprioceptive training is important to reduce the risk of falls and injury.

It is important to recognise that the rate of recovery will vary between individuals and will partly depend on the additional medical problems they may have. Psychological issues may delay the rate of progress and therefore, ideally should be dealt with at an early stage. The recovery process should be monitored by the patient’s doctor and if, at any point, new symptoms emerge then these can be fully addressed.

In the early stages of the Covid-19 pandemic in the UK, the government identified high risk groups for severe infection and asked them to shield at home for at least 16 weeks. This included the elderly and those with a range of medical conditions such as obesity, type2 diabetes, hypertension, chronic cardiorespiratory conditions and those with impaired immunity. Many of these patients will have progressively de-conditioned during this period and therefore may benefit from advice on regaining fitness as we emerge from lockdown. This may not be straightforward as their underlying health condition is likely to complicate a smooth return to regular exercise. Further guidance from the patient’s GP with support from local physiotherapy services would help to restore fitness in a safe way.

The Covid-19 pandemic is proving to be one of the greatest challenges to society and to healthcare services around the world. We are all learning on the job. Well understood medical and scientific principles can help guide us through this crisis. Recognising the importance of exercise on physiological systems offers us an opportunity to improve the management of this very serious illness and could potentially put us on a roadmap to healthier living.

References

1 - https://cpoc.org.uk/guidelines-resources-guidelines-resources/covid-19-and-perioperative-care

2 - Barker-Davies RM, O’Sullivan O,Senaratne KPP, et al. Br J Sports Med Epub ahead of print: [please include DayMonth Year]. doi:10.1136/bjsports-2020-102596.

3 - BMJ 2020;369:m1787 doi: 10.1136/bmj.m1787 (Published 6 May 2020)

4 - Simpson R, Robinson L. Rehabilitation After Critical Illness in People withCOVID-19 Infection. Am J Phys Med Rehabil 2020;99:470–474

5 - Rawal G, Yadav S, Kumar R. Post-intensive care syndrome: an overview. J Transl Int Med 2017;5:90–2.

Following original publication of this blog post, we have received some messages of concern with regards to Graded Exercise Therapy (GET), ME/CFS and its place for 'long COVID' patients, including a copy of this letter. The following response was published 11/09/2020 in relation to these concerns.

From: Professors Roger Wolman and Matthew Wyon

Thank you for your responses and the concerns raised. We argue, and a great deal of evidence will support our argument^1-3, that physical activity and the capacity to do basic functional movements are fundamental for physical and mental health. If people are inactive, and inactive for some period, even the smallest amount of activity is likely to be tiring and be perceived as difficult^4,5. We suggest that if managed carefully, around individual abilities, then people can progress in their physicality and this will benefit physical and mental health. We argue that the reverse of being inactive will lead to a deterioration and agree that it is a fine line to identify how much activity people should do. We recognise that Graded Exercise Therapy is under review by NICE and isn’t for every person with ME/CFS unless the starting point of exercise/activity is tailored individually and monitored closely. Some evidence shows that Graded Exercise Therapy seems to only benefit those with mild to moderate symptoms as part of a wider individualised holistic intervention^6,7. For patients with more severe ME/CFS a functional restoration approach will be needed that involves planning and prioritising physical and cognitive activities and very importantly rest so that their activity can be paced over a period of time. It should be noted that this will still involve activity and the goal is that over time, people adapt. If done individually, this should prevent a “boom or bust” outcome, where too much activity is undertaken which results in bedridden fatigue over the following days. We understand that “recovery” may not ever be achieved for those with ME/CFS and the aim of any intervention is to improve the quality of life of the individual within their own functional capabilities.

The focus of the blog was on recovery strategies for those who had Covid-19 and to provide a perspective based on the current evidence available. We appreciate that the evidence of how Covid-19 will affect people long term is constantly being updated and amended as more data become available and the NHS has provided a website to help survivors with this progression (https://www.yourcovidrecovery.nhs.uk/). Some Covid patients do display symptoms similar to Post-Exertion Malaise, but the evidence is still arbitrary. For some Covid patients who were admitted to Intensive Care Units in hospital, a reasonable high proportion of them (40%) will have suffered from Intensive Care Unit Acquired Weakness (ICUAW)⁸. The symptoms are muscle weakness, bioenergetic failure, muscle inflammation, reduced deep tendon reflexes, and sensory loss⁹. The long-term bed rest will also affect specific postural muscles (calf, core, and upper leg) and balance. Depending on how long the patient was in ICU, recovery can be a long process lasting months or years.

Guidelines from the National Post-Intensive Care Rehabilitation Collaborative highlight the need for therapeutic interventions with a multidisciplinary approach and understanding where the participant is starting from is imperative¹⁰. Setting realistic goals, based on their current abilities and not their previous capabilities is also vital, an initial goal might be managing to walk upstairs unaided.  Managing those expectations with the realisation that previous physical and cognitive competences might never be achieved is a vital component of an intervention. How they respond to an intervention (both physically and mentally) needs to be monitored closely to make sure there are no negative consequences. An important aspect of the intervention is not just the activity completed but the recovery afterwards, planned sleep and during-the day-down-time also need to form part of an intervention. Alongside this there is a need to focus on healthy nutrition and fluid intake, focusing on the reduction of simple sugars, alcohol, and caffeine intake. How this provision is then taken into the community for long term care also needs to be developed and initial steps have been suggested¹¹.  

We recognised that everyone is an individual and no one therapeutic intervention is suited to all but should be focused on maximising an individual’s quality of life within the confides of their capabilities.

REFERENCES

1 - Bertheussen GF, Romundstad PR, Landmark T, Kaasa S, Dale O, Helbostad JL. Associations between physical activity and physical and mental health--a HUNT 3 study. Med Sci Sports Exerc. 2011;43(7):1220

2 - Stephens T. Physical activity and mental health in the United States and Canada: evidence from four population surveys. Prev Med. 1988;17(1):35-47

3 - Paluska SA, Schwenk TL. Physical activity and mental health. Sports Med. 2000;29(3):167-180

4 - Convertino VA, Bloomfield SA, Greenleaf JE. An overview of the issues: physiological effects of bed rest and restricted physical activity. Med Sci Sports Exerc. 1997;29(2):187-190

5 - Thomas N, Alder E, Leese G. Barriers to physical activity in patients with diabetes. Postgrad Med J. 2004;80(943):287-291

6 - Castell BD, Kazantzis N, Moss‐Morris RE. Cognitive behavioral therapy and graded exercise for chronic fatigue syndrome: A meta‐analysis. Clinical Psychology: Science and Practice. 2011;18(4):311-324

7 - Nijs J, Paul L, Wallman K. Chronic fatigue syndrome: an approach combining self-management with graded exercise to avoid exacerbations. J Rehabil Med. 2008;40(4):241-247

8 - Appleton RT, Kinsella J, Quasim T. The incidence of intensive care unit-acquired weakness syndromes: a systematic review. Journal of the Intensive Care Society. 2015;16(2):126-136

9 - Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19(1):1-9

10 - Collaborative NP-ICR. Responding to COVID-19 and beyond: A framework for assessing early rehabilitation needs following treatment in intensive care. 2020; https://www.bsrm.org.uk/downloads/2020.06.23--icsframework-for-assessing-early-reha-(1).pdf, 2020.

11  - HICKMAN K, CLIFTON IJ. Development of an integrated rehabilitation pathway for individuals recovering from COVID-19 in the community. 2020