While controversial, US heart experts say a personalised program could alleviate symptoms and improve quality of life.
The American Heart Association has endorsed the controversial stance that a tailored exercise program should be prescribed to long covid patients.
Australian experts supported the advice, saying activity was the cornerstone of long covid management, but cautioned that a one-size-fits-all approach could do more harm than good.
The controversy over whether exercise helps or hinders patients centres around the claim that cardiovascular deconditioning plays a pivotal role in long covid.
While acknowledging the many factors that contributed to the development of long covid, the new scientific statement cited a litany of studies in support of the role deconditioning played.
The AHA statement said covid infection could lead to reduced physical activity and confinement, causing cardiac atrophy, a reduction in ventricular distensibility and steepening of the Frank-Starling curve.
Studies have shown that Vo2 reduction in individuals with long covid was comparable to deconditioning resulting from bed rest, it said.
Clinically, cardiovascular deconditioning and symptoms of long covid have some overlap, with the most frequently reported symptoms of both conditions being severe fatigue, orthostatic intolerance and shortness of breath.
Long covid may affect up to a quarter of individuals diagnosed with covid, and more than 100 symptoms have been reported by patients, commonly including palpitations, tachycardia, brain fog and confusion.
The AHA said exercise was safe and effective for patients, and that prescriptions should be specifically tailored to the patient and be adopted as part of a shared decision-making process.
As part of its guidance around reintroducing exercise for athletes, it said a rapid return to regular physical activity could significantly cut the risk of athletes developing long covid in the first place.
“Concern has been raised about the use of exercise training as part of the management strategy for patients with long covid,” the authors wrote.
“However, exercise training appropriately tailored to the patient with cardiovascular deconditioning may be an effective strategy to facilitate improvement in symptoms.”
Safety concerns centred around the potential exacerbation of post-exertional malaise among individuals who are deconditioned and experiencing exercise intolerance, authors explained.
However, appropriate exercise programs in other populations with similar symptoms had demonstrated efficacy and safety, they wrote.
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These other populations include POTS – which the AHA said shared features with long covid, namely cardiovascular deconditioning leading to a compensatory rise in heart rate in response to orthostatic challenge – which responded positively to exercise training.
“The Levine protocol is an illustrative example of a protocol applied to patients with POTS, which over a three-month period led to marked improvement in quality of life, orthostatic tolerance, and functional capacity,” authors wrote.
A spokeswoman for the Heart Foundation told TMR it supported the recommendations and the role of deconditioning, saying it considered physical activity to be a cornerstone of long covid management.
“We suggest clinicians encourage their patients to return to appropriate levels of movement, if possible,” she said.
The return to vigorous sport should be gradual and adapted to an individual, she said. Cardiac and respiratory symptoms should fully assessed and resolved before resuming high-intensity exercise and medical clearance is recommended, especially for those with persistent symptoms or abnormal findings.
“For people with cardiovascular involvement, cardiac rehabilitation and specialist referral may also be appropriate,” she said.
Associate Professor Anthony Byrne, senior staff specialist respiratory physician at St Vincent’s Hospital’s long covid outpatient service in Sydney, told TMR the AHA guidelines were appropriate for the most part, but that he would include some additional points.
“Long covid patients have an increased risk of medical conditions that can be mistaken for deconditioning or post-exertional flares of symptoms,” Professor Byrne said.
“For example, a higher risk of cardiovascular disease, pulmonary embolism, asthma, respiratory tract infections to name a few. It is important that medical and other health professionals appropriately test for, exclude and/or treat these conditions first,” he said.
Awareness of exercise intolerance as a symptom of deconditioning, as well as of myositis and neuropathic syndromes, was extremely important for all health practitioners, he added.
“Medical gaslighting or the practice of saying, ‘Spirometry is normal, CT is normal, echocardiogram is normal, so you are fine’ and ‘Just get on with life’, continues to be experienced by many of our patients,” Professor Byrne said.
He said some patients do not describe POTS or experience symptoms such as post-exertional crashes, despite these being common features that pointed to long covid.
Professor Byrne also emphasised the need to personalise the exercise prescription, explaining that it is critical not to use a one size fits all approach.
“[It] is not only wrong, but has the potential to do more harm.”
