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Graded exercise and relation to chronic fatigue syndrome cardiac findings
Ian Stirling

Published on: 06 December 2020
When is it safe to return to exercise post COVID?
Irfan Ahmed and Aessa Tumi

Published on: 02 November 2020

Published on: (6 December 2020)

Graded exercise and relation to chronic fatigue syndrome cardiac findings
Ian Stirling, Patient Advocate., n/a
On the topic of the paper, readers may be interested in this www.jstage.jst.go.jp/article/internalmedicine/48/21/48_21_1849/_article paper 'Cardiovascular Dysfunction with Low Cardiac Output Due to a Small Heart in Patients with Chronic Fatigue Syndrome'.

Which found:

'Electrocardiograms frequently revealed right axis deviation (21%) and severe sinus arrhythmia (34%) suggesting accentuated parasympathetic nervous activity. Small heart shadow (cardiothoracic ratio ≤42%) was noted on the chest roentgenogram in 32 patients (60%). Echocardiographic examination demonstrated low cardiac indexes (<2 L/min/m2) with low stroke volume indexes (<30 mL/m2) due to a small left ventricular chamber in 19 (36%, p<0.05 vs. 8% in 36 controls). None had reduced left ventricular ejection fraction.'

(There has been depressingly little cardiac follow-up work)

On the comment advocating graduated exercise. I note that 'long COVID' has a symptom spectrum that apart from COVID toe and other particular sequelae is indistinguishable from chronic fatigue syndrome. And further that 'graduated exercise' has been specifically removed as harmful for its treatment in the latest NICE draft of CG53.¹

...
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On the topic of the paper, readers may be interested in this www.jstage.jst.go.jp/article/internalmedicine/48/21/48_21_1849/_article paper 'Cardiovascular Dysfunction with Low Cardiac Output Due to a Small Heart in Patients with Chronic Fatigue Syndrome'.

Which found:

'Electrocardiograms frequently revealed right axis deviation (21%) and severe sinus arrhythmia (34%) suggesting accentuated parasympathetic nervous activity. Small heart shadow (cardiothoracic ratio ≤42%) was noted on the chest roentgenogram in 32 patients (60%). Echocardiographic examination demonstrated low cardiac indexes (<2 L/min/m2) with low stroke volume indexes (<30 mL/m2) due to a small left ventricular chamber in 19 (36%, p<0.05 vs. 8% in 36 controls). None had reduced left ventricular ejection fraction.'

(There has been depressingly little cardiac follow-up work)

On the comment advocating graduated exercise. I note that 'long COVID' has a symptom spectrum that apart from COVID toe and other particular sequelae is indistinguishable from chronic fatigue syndrome. And further that 'graduated exercise' has been specifically removed as harmful for its treatment in the latest NICE draft of CG53.¹

Reference

1. NICE. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. Draft for consultation, November 2020. www.nice.org.uk/guidance/GID-NG10091/documents/draft-guideline.

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Competing Interests: None declared.
Published on: (2 November 2020)

When is it safe to return to exercise post COVID?
Irfan Ahmed, GP / Sport & Exercise Medicine registrar, University College London Hospital
Other Contributors:
Aessa Tumi, GP ST1 registrar, St Marys Hospital, London
A’court et al suggest that patients with “mild” COVID-19 illness, and who are asymptomatic do not need to restrict exercise. While this seems to be a straightforward distinction, new evidence on “long COVID” presentations even in patients with “mild” illness is starting to question how we define the severity of COVID illness. The NIHR recently suggested that patients with “long COVID” may well represent four subgroups of clinical syndromes, and therefore have different rehabilitation needs.¹

Often patients report symptoms that are refractory, intermittent or resolve before returning in episodic bouts, these include (muscle aches, chest pains, dyspnoea and fatigue); many of which are relative contraindications to exercise.² The reality of COVID is that the clinical course of infection and recovery does not fit clearly defined categories of (mild, moderate or severe illness) and symptoms rarely fit into the binary category of (cardiac or non-cardiac). In addition to this, patients’ rehabilitation goals are very unique and often relate to their pre-morbid status, and this requires a tailored approach that takes into account the physical demands of their day to day activities and occupation.

We propose that patients and clinicians alike would benefit from primary care focused “graduated return to exercise...
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A’court et al suggest that patients with “mild” COVID-19 illness, and who are asymptomatic do not need to restrict exercise. While this seems to be a straightforward distinction, new evidence on “long COVID” presentations even in patients with “mild” illness is starting to question how we define the severity of COVID illness. The NIHR recently suggested that patients with “long COVID” may well represent four subgroups of clinical syndromes, and therefore have different rehabilitation needs.¹

Often patients report symptoms that are refractory, intermittent or resolve before returning in episodic bouts, these include (muscle aches, chest pains, dyspnoea and fatigue); many of which are relative contraindications to exercise.² The reality of COVID is that the clinical course of infection and recovery does not fit clearly defined categories of (mild, moderate or severe illness) and symptoms rarely fit into the binary category of (cardiac or non-cardiac). In addition to this, patients’ rehabilitation goals are very unique and often relate to their pre-morbid status, and this requires a tailored approach that takes into account the physical demands of their day to day activities and occupation.

We propose that patients and clinicians alike would benefit from primary care focused “graduated return to exercise” guidelines for the post-acute period of COVID-19.³. These guidelines could help patients to navigate milestones in their recovery, while outlining clear symptom-based criteria for stopping exercise, or when GP’s should refer patients on for further investigation due to a failure to progress during rehabilitation. In the current climate of remote consulting, we will have to think of innovative ways to safely prescribe exercise and use technology or web based exercise groups (such as pulmonary rehab) to support patients during the COVID-19 pandemic.⁴

References
1. Mahase E. Long covid could be four different syndromes, review suggests. BMJ 2020; 371:m3981.
2. Nabavi N. Long covid: How to define it and how to manage it. BMJ 2020; 370: m3489.
3. Do we need new COVID-19 specific 'return to exercise' protocols? | BJSM blog - social media's leading SEM voice [Internet]. BJSM blog - social media's leading SEM voice. 2020 [cited 2 November 2020]. Available from: /bjsm/2020/09/13/do-we-need-new-covid-19-specific-return-to-exercise-protocols/
4. Wilkinson E. The NHS virtual gym boosting fitness and social connections for cystic fibrosis patients. BMJ 2020; 371:m4063.

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Competing Interests: None declared.