Author: Stephanie Biddell, Chipperfield Practitioner

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease (Covid-19) which has lead to persistent ill-health on a global scale. Post-covid-19 is an emerging condition that is not yet well researched but can be severely disabling, impacting people’s quality of life regardless of hospitalization or severity of acute covid-19. A proportion of those who were infected with covid-19 sustain long term effects which has been shown to leave lingering symptoms.“Post-covid-19 syndrome” or “Long Covid” are emerging terms used for those presenting with lingering signs and/or symptoms that are consistent with covid-19 that have developed during or after the initial acute infection of covid-19 which present for more than 12 weeks. Individuals may experience unpredictable new symptoms that may present independently, coincide with other new or ongoing symptoms, be consistent or fluctuating and/or change over time.

Recently, a Canadian review reported approximately one million Americans and one million individuals from Great Britain to have been experiencing post-covid-19 syndrome. This review conducted by the Public Health Agency of Canada analyzed over 24 studies around the world and investigated the prevalence of lingering symptoms. They found that more than half of the individuals reported long-lasting symptoms after 12 weeks of the initial positive test. It is important to note that many people’s symptoms do resolve within 12 weeks, however Long Covid can affect all age groups.

Researchers are suggesting that the lingering effects of covid-19 are not necessarily correlated to the severity of the initial acute stage of falling ill. The troubling issue people are finding is how these long term affects are impacting one’s quality of life and how people can manage it. Below you’ll discover the current research relating to the long-term effects of covid-19 and intel on how to manage it and improve function in people living with disability.

Quick Overview of Symptoms

Current research illustrates that Long Covid can affect multiple body systems including the respiratory, cardiac, renal, endocrine and neurological systems. People are presenting overlapping symptoms in clusters that may include:

  • fatigue or exhaustion
  • chest pressure or tightness
  • shortness of breath
  • sleep disturbances
  • headache, and
  • cognitive disturbances such as “brain fog”

The elaborated list can be viewed here. The symptoms presented in Long Covid can be multi-dimensional, leading to physical, emotional and social limitations and restrictions. Long Covid may also present as episodic and unpredictable in nature, where symptoms may fluctuate and change over time. As such, Long Covid impacts people’s functional ability, social and family life, ability to work, and quality of life. Due to the complexity and nature of these symptoms, a multidimensional approach and patient involvement is crucial. 

Management

It is important to remember that everybody is different and symptoms differ amongst one another! Safe and effective rehabilitation is a fundamental stage when recovering from illness. What is quite interesting is that there is currently insufficient evidence on whether a graded exercise approach is beneficial for this population. The National Institute for Health and Care Excellence in the United Kingdom have cautioned individuals using a graded exercise program for individuals recovering from Long Covid after removing graded exercise therapy from the draft Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) guidelines. The concerns were raised because individuals who live with CFS/ME may experience what’s called post-exertion malaise which may worsen one’s symptoms following minimal physical, cognitive, emotional or social activity, or activity that was previously tolerated. Symptoms and level of disability may worsen 12 to 48 hours after activity or can last for days or even weeks! Thus, this would contraindicate an exercise intervention in these individuals as currently, it is unknown when and what amount of physical activity is safe or beneficial so that function is not impaired. Due to the symptom overlap of fatigue between Long Covid and CFS/ME, caution is recommended when prescribing physical activity. This highlights the importance of tailoring physical activity prescriptions to each individual.

Below you will find the current recommendations and approaches from World Physiotherapy which can be accessed here.

Keeping It Safe

  • Screening! Before recommending physical activity or sport, individuals living with Long Covid should be screened for cardiac impairment and post-exertional symptom exacerbation via close monitoring of individual signs and symptoms before, during and following increased physical activity. Risk stratification is recommended if symptoms are suggestive of cardiac impairment prior to returning to exercise. Establishing the source of chest pain, shortness of breath, tachycardia or hypoxia is vital to help guide appropriate activity and further investigations if need be.

Management Approach

Safe and effective rehabilitation is a fundamental part of recovery from illness and can improve function in people living with disability. Following is the current advice on rehabilitation approaches for Long Covid:

  • Symptom Titrated Physical Activity
    • This is where physical activity is continuously monitored and adjusted according to the presenting symptoms aiming to achieve sustainable symptom stabilization. This recognizes that managing physical activity is no one size fits all and should be approached with caution being mindful of worsening symptoms.
      • If post-exertional symptoms exacerbate one’s symptoms, then “Stop. Rest. Pace” may be advantageous with heart rate monitoring to support self-management of symptoms.
  • Fatigue Management
    • Exertion should not be pushed to the point of fatigue or an exacerbation of symptoms during or in the days following activity. This approach may help increase strength and endurance through appropriate pacing.
  • Pacing
    • The boom-bust cycle refers to using too much energy one day to the point it depletes your energy the next day. Pacing is not an activity avoidance strategy, rather it is a strategy to minimize symptom exacerbation. The “Three P’s Principle” which stands for Prioritization, Planning and Pacing can be implemented to conserve energy. Planning daily activities ahead of time enables one to plan for rest throughout the day to avoid symptom relapses.
  • Education
    • The World Health Organization recommends that rehabilitation should focus on educating individuals to returning to everyday activities conservatively, at a pace that is safe and appropriate for energy levels within the limits of the current symptoms.
  • Peer Support
    • Peer support involves others sharing their experience and knowledge to others who present with the same condition. These groups have been established online to seek comfort from your own home.
  • Goal Setting
    • Goal setting is crucial to individual progress which have additional benefits of adherence and progress. Setting personalized and functional realistic goals will aim to keep one on track without doing too much at once.

Wrap Up

Hopefully this article has provided you with more insight into what is and how to manage post-covid-19 syndrome! As research is still flourishing on a global scale- there stands to be lots of room for well needed research. Physiotherapists can play an important role in the rehabilitation of people living with Long Covid, to balance activities with rest, to optimize recovery, and to consider other factors that are important in symptom management beyond solely physical activity. Currently, there are a lot of unknowns towards research on post-covid-19 syndrome. Hopefully researchers can soon discover what the prevalence is, or what the risk factors are for developing post-covid-19 syndrome. Or for how long post-covid-19 syndrome lasts for and it’s trajectory. Rehabilitation teams would want to know if early exercise would help improve the symptoms of post-covid-19 syndrome. Optimistically, it won’t be too long until there is more evidence to assist individuals and healthcare practitioners on this developing topic!


Chipperfield Physiotherapy has helped several clients in the Lower Mainland recover from Post-Covid syndrome – if you’re suffering from symptoms of long-term covid, give us a call at 604-828-2610 to learn about our rehab program!


References

Ahmed H, Patel K, Greenwood DC, Halpin S, Lewthwaite P, Salawu A, et al. Long-term clinical outcomes in survivors of severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) coronavirus outbreaks after hospitalisation or ICU admission: a systematic review and meta-analysis. Journal of Rehabilitation Medicine. 2020;52(5):1-11.

Alwan NA, Johnson L. Defining long COVID: Going back to the start. Med (N Y). 2021;2(5):501-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992371/.

Aucott JN, Rebman AW. Long-haul COVID: heed the lessons from other infection-triggered illnesses. Lancet. 2021;397(10278):967-8. https://www.ncbi.nlm.nih.gov/pubmed/33684352.

Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, et al. Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: prospective cohort study. BMJ. 2006;333(7568):575. https://www.ncbi.nlm.nih.gov/pubmed/16950834.

National Institute for Health Care Excellence. COVID-19 rapid guideline: managing the long-term effects of COVID-19. NICE Guideline [NG188]. London, UK: NICE; 2020. Available from: https://www.nice.org.uk/guidance/ng188.

Office for National Statistics. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 April 2021. 2021. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bullet insprevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/1april2021.

World Health Organization. Rehabilitation in health systems: Guide for action information sheet. 2019. Available from: https://www.who.int/rehabilitation/Guide-for-action-Infomationsheet.pdf?ua=1#:~:text=The%20World%20Health%20Organization%20%28WHO%29%20Rehabilitation %20in%20health,Guide%20is%20in%20line%20with%20recommendations%20in%20.

World Health Organization. Naming the coronavius disease (COVID-19) and the virus that causes it. 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technicalguidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it.

World Physiotherapy. World physiotherapy response to COVID-19: Safe rehabilitation approaches for people living with long covid: physical activity and exercise. June 2021. https://world.physio/sites/default/files/2021-06/Briefing-Paper-9-Long-Covid-FINAL-2021.pdf

Managing Post-Covid-19 Syndrome: What is it and how can Physiotherapy help?
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