Treating Long-COVID: Part 2

So, like I mentioned in Part 1 of this post, I might get some hate mail for this. Keep in mind that research is constantly changing around Long-COVID and that I’m just trying to stick with what the research tells us. I know some or many may not agree, but these aren’t my opinions, they are evidence-based statements and I’m going to keep them that way. I’ll update this information as the evidence changes so keep checking back!

Post-COVID without PEM

It is important to remember that, although ANY case of COVID-19 can eventually develop into Long-COVID, not all of them do. Not everyone experiences diffuse vascular damage. We don’t know what makes the difference between who does and who does not get Long-COVID. We do know that it is important to monitor all post-COVID patients for symptoms of Long-COVID.

“Before recommending physical activity (including exercise or sport) as rehabilitation interventions for people living with Long COVID, individuals should be screened for post-exertional symptom exacerbation through careful monitoring of signs and symptoms both during and in the days following increased physical activity, with continued monitoring in response to any physical activity interventions.”

World Physiotherapy, 2021

So how do you screen for Long-COVID or PEM, then? According to World Physiotherapy, here’s what to look for:

  • Patient-specific symptom exacerbation 12-48 hours after exercise or cognitive strain that lasts days or longer
  • Objective, measurable decline in aerobic capacity and anaerobic threshold on serial cardiopulmonary exercise testing due to neuroimmmune and metabolic dysregulation
Photo by Anna Shvets on

That means you have to know what baseline symptoms are and what symptoms are the most often exacerbated. This is likely to be different for each patient, but the most likely ones are generalized fatigue and decreased cognitive function/fogginess. You can read more about that in Part 1.

This also means you need to have a baseline test of some kind to demonstrate this “objective, measurable decline.” But that’s problematic, isn’t it? Patients with Long-COVID can’t often tolerate an official cardiopulmonary exercise test. So, you’ll have to talk to them about how much activity they can tolerate and if there is a significant change in that level of activity.

Post-COVID Exercise Prescription

Here is where I’m going to get hate mail.

But what about the exercise? Isn’t well-prescribed exercise the best possible intervention to expedite the healing of damaged vasculature? Yes. Yes it is. We know that from hundreds, if not thousands, of studies on vascular diseases and diseases that cause vascular damage. So, can a patient who is post-COVID without post-exertional malaise exercise to the extent of their ability? According to the evidence, the answer is YES! Here’s the breakdown.

Photo by Andrea Piacquadio on

Remember, not ALL cases of Long-COVID come with PEM, PEM is just one symptom. So, if your patient doesn’t have PEM, exercise may be very helpful for them. It might be a slow start, and that’s ok. Remember that COVID-19 is a systemic vasculitis. You have miles of vasculature in your body, and that’s miles of potential damage. That damage takes time to heal and the greater the extent of the damage, the longer it may take. That systemic vasculitis comes along with the potential for post-exertional symptom exacerbation which you DO NOT want happening because of the exercise you prescribed. You can prescribe activity and you can prescribe exercise, but you have to make sure that is within the patient’s ability and goals.

Well, that’s great! But what kind of exercise is the best exercise for people after they have COVID-19? The answer may shock you…

High-Intensity Interval Training

Yep, I know, I know. But it’s true. High-intensity interval training has some of the strongest evidence for people with vascular disease. It also has very strong evidence for people with vascular disease who has a host of comorbidities. However, this high-intensity interval training isn’t the same thing you see in infomercials, fitness classes, or gyms. The design and framework are the same but it is used differently, with skilled precision and constant monitoring.

Some evidence translated from pre-COVID vascular diseases indicates that using an inverse design to high-intensity interval training is a great place to start. This is because high-intensity interval training has the strongest evidence for providing anti-inflammatory effects by decreasing the production of inflammatory factors and increasing the clearance of inflammatory substances already in the body. High-intensity interval training does this better than moderate-intensity continuous exercise. High-intensity interval training is also more effective at promoting the healing of vascular and cardiac tissues and can even induce left ventricular remodeling.

Patients with systemic vasculitis secondary to COVID-19 have A LOT of inflammatory junk in their systems. Their entire vascular system is damaged meaning that there are byproducts of the cellular damage, cellular metabolism, and apoptosis circulating everywhere and the load has exceeded the body’s natural ability to clear it. High-intensity interval training can give your patient the extra assistance they need, but only if you design their programs properly. Designing programs that have longer rest intervals and shorter work intervals, at least to start with, has shown to be more effective for patients post-COVID. These programs should include functional and meaningful movements and activities so that the daily workload can be built into the exercise program to prevent over-taxing the system. I’ve heard recent patient stories that report heart rates over 200 beats per minute simply vacuuming, or walking up a single flight of stairs! Don’t be afraid to progress, but let the patient’s symptoms and tolerance lead you.

Photo by Roger Brown on

We learned in Part 1 of this post that you cannot calculate max heart rate the same way for patients post-COVID as you do for patients who haven’t had COVID. People who have the cardiac effects of long-COVID (elevated heart rate at rest and exaggerated heart rate response to minimal activity) may be on medications, like beta-blockers, to control their heart rate. That means that determining what “high” intensity is for that specific patient includes hitting a specific heart rate window. It also means that the “low” intensity target is also a very specific window. And there is no way to know you hit those windows unless you are constantly monitoring vitals before, during, and after exercise, and also with recovery. Make sure to go back to Part 1 and read the specifics on calculating max heart rate in patients with long-COVID!

Don’t forget about the other vitals, either. Many patients post-COVID have excessive respiratory rates, but normal heart rates, with activity. This should be equally concerning and should tell you they need a different exertion scale! Keep your eyes on the blood pressures and pulse oximeter readings, also. You have to keep the big picture in front of you at all times!

Take-Home Points:

Calculate heart rate max and target heart rate zones properly.
Design HIIT programs to match those heart rate zones.
Monitor vitals to ensure you are reaching, but not exceeding the heart rate zones.
Use the right exertional scales for your patient.
Always be assessing symptoms!

Evidence for ME/CFS

PLEASE… Do NOT throw the tomatoes at the messenger. The evidence for post-viral fatigue / myalgic encephalomyelitis / chronic fatigue syndrome even prior to COVID-19 supported the use of high-intensity interval training with this population IF they do not have post-exertional malaise. Remember, post-exertional malaise is just one of many symptoms of these post-viral conditions and DOES NOT happen to every patient who contracts them.

Photo by Jonathan Borba on

Specifically, there is evidence to support high-intensity interval training as a more tolerable method of exercise in patients with chronic fatigue syndrome because it does not exacerbate fatigue like moderate-intensity continuous exercise. It is thought that the shorter bursts of activity, followed by either complete rest or active rest are more tolerable than longer bouts of exercise because this design allows the body to have intermittent recovery periods while working. This evidence goes on to report that high-intensity interval training can actually help patients who experience other symptoms of chronic fatigue syndrome, such as insomnia and decreased physical function.

Take-home points:

Not every case of ME/CFS or post-viral syndrome or long-COVID will have the same presentation and/or symptoms.
Not every person who has ME/CFS has post-exertional malaise.
Not every person will be intolerant of physical activity.
Let the symptoms (and the patient) be your guide.
Refer to Part 1 for more info on other options besides exercise.

Can you take this back to the clinic tomorrow? Will you take this back to the clinic tomorrow? Let me know in the comments.

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Sandler, C. X., Lloyd, A. R., & Barry, B. K. (2016). Fatigue Exacerbation by Interval or Continuous Exercise in Chronic Fatigue Syndrome. Medicine and science in sports and exercise48(10), 1875-1885.

Foged, F., Rasmussen, I. E., Budde, J. B., Rasmussen, R. S., Rasmussen, V., Lyngbæk, M., … & Christensen, R. H. (2021). Fidelity, tolerability and safety of acute high-intensity interval training after hospitalisation for COVID-19: a randomised cross-over trial. BMJ open sport & exercise medicine7(3), e001156.

Larun, L., Brurberg, K. G., Odgaard-Jensen, J., & Price, J. R. (2017). Exercise therapy for chronic fatigue syndrome. The Cochrane database of systematic reviews4(4), CD003200.

Keech, A., Way, K., Holgate, K., Fildes, J., Indraratna, P., & Yu, J. (2021). HIIT for post-COVID patients within cardiac rehabilitation: Response to letter to the editor. International journal of cardiology322, 291–292.

Nelson, M. J., Bahl, J. S., Buckley, J. D., Thomson, R. L., & Davison, K. (2019). Evidence of altered cardiac autonomic regulation in myalgic encephalomyelitis/chronic fatigue syndrome: A systematic review and meta-analysis. Medicine98(43), e17600.

Décary, S., Gaboury, I., Poirier, S., Garcia, C., Simpson, S., Bull, M., … & Daigle, F. (2021). Humility and acceptance: working within our limits with long covid and myalgic encephalomyelitis/chronic fatigue syndrome. journal of orthopaedic & sports physical therapy51(5), 197-200.

Christensen RH and Berg RMG (2021) Vascular Inflammation as a Therapeutic Target in COVID-19 “Long Haulers”: HIITing the Spot? Front. Cardiovasc. Med. 8:643626. doi: 10.3389/fcvm.2021.643626

Brockway, K., Ayers, L., Shoemaker, M. (2022). HIIT-ing Your Target: Applying High-Intensity Interval Training in Special Populations. APTA Cardiovascular and Pulmonary Academy. Presentation at APTA Combined Sections Meeting, San Antonio, TX.

The contents of this blog and all associated pages reflect the opinions of the author and should not be construed as medical advice. Please consult your doctor for medical advice.

Follow @DoctorBthePT on Twitter for regular updates!

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