Returning to physical activity after covid-19
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.m4721 (Published 08 January 2021) Cite this as: BMJ 2021;372:m4721Read our latest coverage of the coronavirus outbreak
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Dear Editor
It is pleasing to read a very practical guide to helping people back towards recovery and even think new opportunities for a healthy lifestyle.
I am a little concerned that the message about not returning to exercise until at least 7 days symptom free may be mistaken as avoidance of activity until fully recovered; something we know does not happen for many patients after covid19. I appreciate the authors qualify their advice by (I think) excluding those with 'long covid; but it may be worth emphasising this point. The recent rapid NICE guide on 'long covid' (preferred term post covid-9 syndrome) talks about supporting self-management which may include activity/exercise strategies. A message to only return to exercise after 7 days free of symptoms may deter some patients from thinking about recovery strategies or guided self management.
My second concern is the daily % increase in exercise within the phases and wonder if this is too fast. Again, I acknowledge that in the text the authors offer qualifying statements and are not referring to those patient with post covid-19 syndrome, where I suspect activity increases would fall more within the CFS/ME spectrum of care.
with regards
keith
Competing interests: No competing interests
Dear Editor
We commend Salman et al (1) for their guide to a pragmatic risk-stratification for returning to physical activity following COVID-19 infection. The emphasis on both the cardiorespiratory and the psychological screening as well as the prudent and gradual approach “ask, assess and advise/assist”, integrating the subjective feeling of the patients, are highly appreciated. We would like to point out three complementary points that are key for an effective monitoring of COVID-19 patients returning to physical activity.
First, the measurement of pulse oxygen saturation (i.e., pulse oximetry , measurable by low-cost fingertip sensors) was recommended both during admission to the emergency department (2) and at home post-hospitalization (3) as a means to monitor “silent hypoxemia”. Pulse oximetry is especially valuable during and immediately after exercise in COVID-19 patients at least from phase 1 to phase 4 (see figure 1 in (1)).
Second, skeletal muscle function - including mitochondrial fitness (4) - is an important component of health in general (5) and of specific relevance for COVID-19. COVID-19 infection and pandemic-related restrictions of physical activity aggravate the risk of muscle loss and the decrease in strength (6, 7). The monitoring of muscle strength (e.g. using the simple and costless “hang grip” test) is a paramount factor in risk assessment and for consulting of patients returning to physical activity.
Third, the non-invasive assessment of cardiovascular or autonomic responses (i.e., heart rate variability or photoplethysmography via smartwatch (8) or portable wearable (9)) was shown effective for diagnosis of COVID-19 and is a simple means to monitor patient fatigue and coping with post-hospitalization physical activity programmes.
To conclude, we recommend the extension of the authors’ laudable multidisciplinary approach by the additional consideration of oxygen saturation, grip strength and heart rate variability / photoplethysmography for optimal personalized monitoring of COVID-19 patients returning to physical activity.
1. Salman D, Vishnubala D, Le Feuvre P et al. Returning to physical activity after covid-19. BMJ. 2021;372:m4721.
2. Akhavan AR, Habboushe JP, Gulati R et al. Risk Stratification of COVID-19 Patients Using Ambulatory Oxygen Saturation in the Emergency Department. The western journal of emergency medicine. 2020;21(6):5-14.
3. Shenoy N, Luchtel R, Gulani P. Considerations for target oxygen saturation in COVID-19 patients: are we under-shooting? BMC medicine. 2020;18(1):260.
4. Burtscher J, Millet GP, Burtscher M. Low cardiorespiratory and mitochondrial fitness as risk factors in viral infections: implications for COVID-19. Br J Sports Med. 2020.
5. Wolfe RR. The underappreciated role of muscle in health and disease. The American journal of clinical nutrition. 2006;84(3):475-82.
6. Kirwan R, McCullough D, Butler T, Perez de Heredia F, Davies IG, Stewart C. Sarcopenia during COVID-19 lockdown restrictions: long-term health effects of short-term muscle loss. GeroScience. 2020;42(6):1547-78.
7. Wang PY, Li Y, Wang Q. Sarcopenia: An underlying treatment target during the COVID-19 pandemic. Nutrition. 2020;84:111104.
8. Mishra T, Wang M, Metwally AA et al. Pre-symptomatic detection of COVID-19 from smartwatch data. Nat Biomed Eng. 2020;4(12):1208-20.
9. Bourdillon N, Yazdani S, Schmitt L, Millet GP. Effects of COVID-19 lockdown on heart rate variability. PLoS One. 2020;15(11):e0242303.
Competing interests: No competing interests
Dear Editor
We are grateful for the helpful, important and constructive comments from Professor Lokugamage and Dr. Järte. We value their comment that those who go on to develop post-acute COVID-19 or Long Covid can have a delayed presentation and complex course of disease with fluctuating symptoms over time, and note how this has been described in accounts of the illness.1 We also take account of their helpful comment regarding monitoring for cardiac dysautonomia, and its potential role in detecting those who are likely to have enduring illness.
We aimed this guidance specifically for primary care clinicians caring for individuals who do not have enduring symptoms suggestive of Long Covid. The article was written in response to a question many of us had encountered in primary care consultations with people recovering from COVID-19 infection; of when and how to re-start exercise. Our primary aim was to support individuals re-engaging in physical activity that would benefit their health, while stopping them from doing too much, too quickly. We wanted to incorporate much of the guidance developed for athletes into something that could help support the physically active public, and feel that this is a starting point and a template open to refinement and development.
We are not suggesting exercise as an intervention for those with Long Covid. We specifically try to ensure that those with enduring symptoms suggestive of this condition obtain additional support and guidance through local post-Covid services, and we discuss that there is uncertainty as to whether graded physical activity will have any role in the rehabilitation of individuals with Long Covid. Accounts of Long Covid symptoms include feeling excessive fatigue after what would have been considered as minimal exertion in the pre-morbid state, and we think it important that those with this condition are supported with holistic and individualised care. We advocate self-monitoring checks for impaired recovery at one and twenty-four hours post-activity so that those who have features suggesting they need additional support know to access this; and similarly, that those who have evidence of returning or new symptoms know to stop or ease off their physical activity, and seek medical help. From our suggested template, it would take a minimum of 5 weeks before starting strenuous or hard activity, with monitoring for return of symptoms and fatigue along the way, and an emphasis for fatigue levels to be normal before returning to pre-morbid activity.
Our aim was for the suggested pathway to detect those suffering post-activity symptoms or regression, from Long Covid or other causes, before any strenuous activity is attempted. However, the relapsing and remitting nature of Long Covid, and the delayed onset, might mean that this is not always the case. Ultimately, as we progress this work, we will need to achieve a balance between detecting and protecting people who are not progressing as they would expect, while also ensuring that those who will not develop enduring symptoms of Long Covid are supported and guided in their return to physical activity. To this end, understanding which patients might be more likely to develop Long Covid will be important,2 along with advocating pacing techniques for all people in the early stages of recovery. Finally, we feel it important and necessary to involve the views and input of patients and colleagues with experience and expertise in Long Covid to ensure we are creating guidance that supports most people, and are actively doing this.
1. Garner P. Paul Garner on long haul covid-19—Don’t try to dominate this virus, accommodate it - The BMJ. BMJ Opinion, https://blogs.bmj.com/bmj/2020/09/04/paul-garner-on-long-haul-covid-19-d... (accessed 13 January 2021).
2. Sudre CH, Murray B, Varsavsky T, et al. Attributes and predictors of Long-COVID: analysis of COVID cases and their symptoms collected by the Covid Symptoms Study App. medRxiv 2020; 2020.10.19.20214494.
Competing interests: No competing interests
Dear Editor
We welcome Salman et al’s(1) attempt to advise on practical tips regarding return to physical activity after COVID-19, as we can understand that there is a need to mobilise NON-Long Covid patients and reduce chance of thrombo-embolism and other sequelae of inactivity. We understand that this article does not apply to the Long Covid patient cohort. However, we feel that the recommendation would be improved if additional nuance could have been applied.
The concept of diagnosis of recovery is less black and white than laid out by the article. Long Covid often not only has a relapsing and remitting pattern, but often does not present itself until several weeks or months following an acute COVID-19 infection.(2,3) We are therefore unsure if you can safely exclude Long Covid after only 7 days of the absence of symptoms following initial infection. As many as 20% of people testing positive for COVID-19 still report symptoms after 5 weeks.(4,5) Due to the uncertainty surrounding exercise in the early phase of recovery as a predisposing factor for Long Covid, we believe that it is vital that sufficient emphasis is given to the encouragement of a full recovery to pre-infection health status prior to return to strenuous activity, and further feel that these guidelines would benefit from highlighting the high proportion of individuals that go on to develop Long Covid.
In this context, we also wish to highlight that graded exercise therapy is cautioned against by NICE. (6) Exercising too early may exacerbate or potentially precipitate Long Covid - although there is no direct evidence for this, it has some plausibility from a Lancet article related to lived experience.(2) We reflect on the general lack of evidence in this area for this ‘best guess’ practice guideline as well as the consensus statements that it refers to. However, we appreciate the flexibility and reversibility in the algorithm described in the paper 'They should monitor for any inability to feel recovered at 1 hour after exercise and on the day after, abnormal breathlessness, abnormal heart rate, excessive fatigue or lethargy’.
We agree that it is prudent to exclude myocarditis before recommending any exercise, particularly phase 3/4. The article comments on guidelines regarding exercise restriction following myocarditis as diagnosed by cardiac MRI, yet this diagnostic tool is not advised in the secondary care investigations of cardiac symptoms suggested by the authors, highlighting an incongruity in these guidelines. It may also be prudent to also exclude the dysautonomia that can occur with COVID-19 (such as tachycardia on minimal exertion, with or without postural orthostatic tachycardia syndrome) in order to make the exercise safer.(7) However, it may be that yoga or other gentle activities described in phase 1 and 2 (1) could also include Tai Chi (8,9) which has some evidence base in cardiopulmonary rehabilitation which may be safe in the initial stages of recovery and potentially provided online, but would benefit from further rehabilitation research.
References
1. Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Majeed A, et al. Returning to physical activity after covid-19. BMJ [Internet]. 2021 Jan 8 [cited 2021 Jan 9];372:m4721. Available from: https://www.bmj.com/lookup/doi/10.1136/bmj.m4721
2. Gorna R, MacDermott N, Rayner C, O’Hara M, Evans S, Agyen L, et al. Long COVID guidelines need to reflect lived experience. Lancet [Internet]. 2020 Dec [cited 2021 Jan 11];0(0). Available from: https://linkinghub.elsevier.com/retrieve/pii/S0140673620327057
3. Rayner C; Lokugamage AU; Molokhia M. Covid-19: Prolonged and relapsing course of illness has implications for returning workers - The BMJ [Internet]. BMJ Opinion. 2020 [cited 2020 Nov 23]. Available from: https://blogs.bmj.com/bmj/2020/06/23/covid-19-prolonged-and-relapsing-co...
4. ONS. The prevalence of long COVID symptoms and COVID-19 complications - Office for National Statistics [Internet]. [cited 2021 Jan 11]. Available from: https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovi...
5. Greenhalgh T, Knight M, A’Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ [Internet]. 2020 Aug 11 [cited 2020 Nov 8];370. Available from: http://dx.doi.org/10.1136/bmj.m3026
6. Torjesen I. NICE advises against using graded exercise therapy for patients recovering from covid-19. BMJ [Internet]. 2020 Jul 21 [cited 2021 Jan 11];370:m2912. Available from: http://dx.doi.org/10.1136/bmj.m2912
7. Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, et al. Autonomic dysfunction in ‘long COVID’: rationale, physiology and management strategies. Clin Med (Northfield Il) [Internet]. 2020 Nov 26 [cited 2021 Jan 11];clinmed.2020-0896. Available from: https://pubmed.ncbi.nlm.nih.gov/33243837/
8. Wu W, Liu X, Wang L, Wang Z, Hu J, Yan J. Effects of tai chi on exercise capacity and health-related quality of life in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis. Vol. 9, International Journal of COPD. Dove Medical Press Ltd.; 2014. p. 1253–63.
9. Liu T, Chan AWK, Liu YH, Taylor-Piliae RE. Effects of Tai Chi-based cardiac rehabilitation on aerobic endurance, psychosocial well-being, and cardiovascular risk reduction among patients with coronary heart disease: A systematic review and meta-analysis [Internet]. Vol. 17, European Journal of Cardiovascular Nursing. SAGE Publications Inc.; 2018 [cited 2021 Jan 11]. p. 368–83. Available from: https://pubmed.ncbi.nlm.nih.gov/29256626/
Competing interests: We are both members of the UK Doctors Long Covid group
Dear Editor, I read the article Returning to physical activity after covid-19 with extreme concern.
I believe it is possible that following the recommendations in the article may disable a substantial fraction of patients for life.
I say this as the article does not mention the nearly identical symptom spectrum and symptom spectrum trajectory between those with ME/CFS and those with longcovid.
https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v1 'Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact'.
Many with severe longcovid are now meeting the diagnostic criteria in the current NICE guidelines for ME/CFS.
The approach in the paper is basically 'graduated exercise' that assumes there are no possible physical outcomes of exercise other than getting healthier once thrombotic or other severe events have been taken into account. The draft guidance for ME/CFS from NICE finds that it does not help patients. ( https://www.bmj.com/content/371/bmj.m4356 NICE backtracks on graded exercise therapy and CBT in draft revision to CFS guidance)
I note that 'psychiatric' symptoms are mentioned in the paper.
These are not as proven as the authors hope.
Consider https://pubmed.ncbi.nlm.nih.gov/32738287/ 'Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors' that they cite. This reads ' A significant proportion of patients self-rated in the psychopathological range: 28% for PTSD, 31% for depression, 42% for anxiety, 20% for OC symptoms, and 40% for insomnia.'.
However, if you dig into the actual scales used, all of these are hugely inappropriate for measuring fatigued and unwell patients. (see the characterising longcovid paper for a list)
They All conflate 'can't due to MH' with 'can't due to physical health'. At best MH scales used need careful per-question analysis to see appropriateness and working out a baseline score appropriate for a patients physical condition.
Not doing this for patients that may be severely fatigued, with 'brain fog' , facing a disease of an uncertain prognosis is dangerous.
I do not use the term dangerous, or disabling for life lightly.
I have read way, way too many papers on the biochemistry and symptoms of ME/CFS (did you know for example over half have cardiac abnormalities? https://www.jstage.jst.go.jp/article/internalmedicine/48/21/48_21_1849/_... ) to know that the core pathology leading to the symptoms is unknown.
The core pathology leading to the symptoms of longcovid is also unknown, and yet the symptom spectrum and progression is nearly identical in a subset of patients.
I should note what some may view as a 'conflict of interest'.
I followed advice (and my parents too) some decades ago as a small boy following a trivial virus that reads almost identically to the above in the paper.
That small boy was disabled for life, and is now doubtful that he will be cured by retirement, given the 15 years from core pathology to drug development, and the unknown core pathology.
Mr Ian Stirling.
ps. I had hoped at this point to have more titles, but education was one thing stolen from me.
Competing interests: No competing interests
Re: Returning to physical activity after covid-19
Dear Editor
I commend the authors for their practical guide and resources to support patients achieve a more physically active lifestyle following covid-19. But I would like to highlight the elephant in the room - the austerity policies that do little to encourage or support individuals maintain a physically active lifestyle.
The health and economic burdens of physical inactivity are well documented [1,2]. In the UK, physical inactivity is responsible for the same number of deaths as smoking (one in six) and costs the economy over £7 billion every year. Based on current trends, the UK population is predicted to be 35% less active by 2030 [3].
The UK Government has set a year on year target to increase the number of adults taking part in at least 150 minutes of physical activity a week and to reduce the number taking part in less than 30 minutes per week. But their ambitious goal is destined to fail. Fail they will because they do the same thing over and over again, but expect different results. The definition of “insanity” according to Albert Einstein.
The Government’s favoured use of educational campaigns neglects the fact that many people simply don’t have the same opportunities or resources to be as physically active as others do. The reality is that people’s activity behaviours are heavily influenced by the conditions in which they live. Whether they have the time, money, and resources to have an active lifestyle. Whether they have a safe walkable community that provides access to green space and essential services.
A decade of austerity has impacted the physical activity opportunities of all people in the UK but especially the poorest. At the individual level, living costs in the UK have risen, wages have stagnated, and welfare benefits have been cut heavily [4,5]. A consequence of these social and economic changes is that a majority of families have less disposable income now than they otherwise would have had [6]. The reality is, when family budgets shrink, leisure opportunities are reduced.
Against this backdrop, local authorities in the poorest parts of the country have faced the largest budgetary cuts. These cuts have impacted the provision of leisure and recreational services, either through facility closures, reduced opening hours, increased user charges, or reduced commitments to the maintenance of parks and green spaces.
Evidence of the impact of austerity on child and adult health is extensive [7,8]. Austerity kills [9,10]. Adverse health trends were apparent in the UK even before the covid-19 pandemic hit following almost a decade of austerity. Life expectancy had stalled, infant mortality was rising, a growing number of children were living in poverty, more families were using food banks and more people were living on the streets [11,12,13,14]. But the pandemic has exacerbated these social inequalities.
Physical activity promotion is critical in tackling many of the public health challenges of our time including obesity, mental health and health inequalities [15,16,17,18]. Rates of obesity in adults had nearly doubled in just over a decade to 2015 and almost one third of children under the age of 16 in England are currently overweight or obese [19]. The long-term economic impacts of the covid-19 pandemic are predicted to be greater than the 2008 financial crisis, with the resulting adverse mental health impacts likely to be just as grand if not greater [20,21].
Physical activity behaviour change is much easier when people have a sense of control and are in a good emotional state. In a bid to build back better from the covid-19 pandemic [22], the UK Government has just ended the £20 increase to universal credit payments which was introduced to support low-income households deal with the extra adversity brought by the pandemic.
When people lose income their leisure activity is impacted in two ways – directly and indirectly through its effect on motivation. The last thing on a person’s mind when they’re struggling to make ends meet, either because of a loss of work, wage stagnation or cuts to welfare benefits – is to exercise more.
As the country comes out of the covid-19 pandemic, it’s more important than ever that the Government adopts a new approach to tackling physical inactivity, and reducing inequalities linked with poor health. Policies of austerity will no doubt exacerbate existing inactivity and health inequalities.
The costs of reinvesting in preventive services like leisure centres and green spaces and increasing revenue to support the most vulnerable in society will prove a great investment compared to the scale of future health costs. By failing to tackle the social conditions that underpin physical inactivity the Government will be walking backwards not forwards.
The economist Milton Friedman is credited for saying that “Only a crisis – actual or perceived – produces real change”. The covid-19 pandemic has been a crisis and a period of great change – spanning many spheres of life. If ever there was an opportunity to entrench physical activity into our daily lives, and shift society to a more active, more equitable and more sustainable one, surely this must be it! To achieve this goal the Government will need to “build back fairer.” [23].
References
1. Ding D, Lawson KD, Kolbe-Alexander TL, et al. Lancet Physical Activity Series 2 Executive Committee. The economic burden of physical inactivity: a global analysis of major non-communicable diseases. Lancet 2016;388:1311-24.
2. Lee IM, Shiroma EJ, Lobelo F, et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. Lancet 2012;380:219-29.
3. Public Health England. Physical activity: applying All Our Health. London: Public Health England, 2019.
4. Jenkins RH, Aliabadi S, Vamos EP, et al. The relationship between austerity and food insecurity in the UK: A systematic review. EClinicalMedicine 2021;33:100781.
5. Lancet Public Health. Poverty is a political choice. Lancet Public Health 2018;3(12):e555.
6. Padley MA, Stone J. Households below a Minimum Income Standard: 2008/09 - 2018/19. York: Joseph Rowntree Foundation, 2021.
7. Taylor-Robinson D, Whitehead M, Barr B. Great leap backwards. BMJ 2014;349:g7350.
8. Taylor-Robinson D, Wickham S, Barr B. Child health at risk from welfare cuts. BMJ 2015;351:h5330.
9. McKee M, Karanikolos M, Belcher P, et al. Austerity: a failed experiment on the people of Europe. Clin Med 2012;12(4):346–350.
10. Stuckler D, Reeves A, Loopstra R, et al. Austerity and health: the impact in the UK and Europe. Eur J Public Health 2017;27(4):18–21.
11. Loopstra R, Reeves A, Taylor-Robinson D, et al. Austerity, sanctions, and the rise of food banks in the UK. BMJ 2015;350:h1775.
12. Taylor-Robinson D, Barr B. Death rate now rising in UK’s poorest infants. BMJ 2017;357:j2258.
13. Taylor-Robinson D, Barr B, Whitehead M. Stalling life expectancy and rising inequalities in England. Lancet 2019;394:2238-9.
14. Taylor-Robinson DC, Lai ET, Whitehead M, Barr B. Child health unravelling in UK. BMJ 2019;364:l963.
15. Geidl, W, Schlesinger S, Mino E, et al. Dose–response relationship between physical activity and mortality in adults with noncommunicable diseases: a systematic review and meta-analysis of prospective observational studies. Int J Behav Nutr Phys Act 2020;17:109.
16. Strain T, Wijndaele K, Dempsey PC, et al. (2020). Wearable-device-measured physical activity and future health risk. Nat Med 2020;26:1385–1391.
17. White RL, Babic MJ, Parker PD, et al. Domain-Specific Physical Activity and Mental Health: A Meta-analysis. Am J Prev Med 2017;52(3):653–666.
18. Zhao M, Veeranki S P, Magnussen C G, et al. Recommended physical activity and all cause and cause specific mortality in US adults: prospective cohort study. BMJ 2020;370:m2031.
19. Public Health England. Tackling obesity: empowering adults and children to live healthier lives. London: Public Health England, 2020.
20. Barr B, Taylor-Robinson D. Recessions are harmful to health BMJ 2016; 354 :i4631.
21. Whitehead M, Taylor-Robinson D, Barr B. Poverty, health, and covid-19. BMJ 2021;372:n376.
22. UK Government. Build Back Better: our plan for growth. London: UK Government, 2021.
23. Marmot M, Allen J, Goldblatt P, et al. Build back fairer: the covid-19 Marmot review. Institute of Health Equity, 2020.
Competing interests: No competing interests