World physiotherapy response to covid 19 (884.86 KB)

File Name: Briefing-Paper-9-Long-Covid-FINAL-English-202107.pdf

File Size: 884.86 KB

File Type: Application/pdf

Last Modified: N/A

Status: Available

Last checked: 29 days ago!

This Document Has Been Certified by a Professional

100% customizable

Language: English

We recommend downloading this file onto your computer

Summary

World Physiotherapy
response to COVID-19
Briefing paper 9
SAFE REHABILITATION APPROACHES FOR
PEOPLE LIVING WITH LONG COVID:
PHYSICAL ACTIVITY AND EXERCISE
June 2021
World Physiotherapy briefing papers
World Physiotherapy briefing papers inform our member organisations and others about key issues that
affect the physiotherapy profession

World Physiotherapy is producing a series of papers in response to COVID-19

Acknowledgement
In February 2021 World Physiotherapy collaborated with Long COVID Physio to develop a briefing paper
on safe rehabilitation for people living with Long COVID. The purpose was to gather key opinion leaders
and stakeholders from the global community in Long COVID and physiotherapy. This briefing paper brings
together individuals from across the World Physiotherapy regions, community groups, organisations,
interdisciplinary clinical practice, and academia to identify statements on safe rehabilitation approaches for
people living with Long COVID

This paper has been produced with the helpful contributions from the following:
Darren Brown, Caroline Appel, Bruno Baldi, Janet Prvu Bettger, Michelle Bull, Tracy Bury, Jefferson
Cardoso, Nicola Clague-Baker, Geoff Bostick, Robert Copeland, Nnenna Chigbo, Caroline Dalton, Todd
Davenport, Hannah Davis, Simon Decary, Brendan Delaney, Jessica DeMars, Sally Fowler-Davis, Michael
Gabilo, Douglas Gross, Mark Hall, Jo House, Liam Humphreys, Linn Järte, Leonard Jason, Asad Khan,
Ian Lahart, Kaba Dalla Lana, Amali Lokugamage, Ariane Mangar, Rebecca Martin, Joseph McVeigh, Maxi
Miciak, Rachael Moses, Etienne Ngeh Ngeh, Kelly O’Brien, Shane Patman, Sue Pemberton, Sabrina
Poirer, Milo Puhan, Clare Rayner, Alison Sbrana, Jaime Seltzer, Jenny Sethchell, Ondine Sherwood, Ema
Singwood, Amy Small, Jake Suett, Laura Tabacof, Catherine Thomson, Jenna Tosto-Mancuso, Rosie
Twomey, Marguerite Wieler, Jamie Wood

Recommended citation:
World Physiotherapy. World Physiotherapy Response to COVID-19 Briefing Paper 9. Safe rehabilitation
approaches for people living with Long COVID: physical activity and exercise. London, UK: World
Physiotherapy; 2021

ISBN: 978-1-914952-00-5
Author affiliations
 Introduction
Safe and effective rehabilitation is a fundamental part of recovery from illness and can improve
function in people living with disability. Currently insufficient evidence exists to guide best practice for
safe and effective rehabilitation in people living with Long COVID. Comparisons have been drawn
between the symptoms and experiences of people living with Long COVID and other infection
outbreaks such as severe acute respiratory syndrome (SARS), Middle East respiratory syndrome
(MERS), Chikungunya and Ebola,1-7 albeit now on an unprecedented scale. Selected symptoms also
overlap with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS), which is often triggered
by infection and immune activation.8,9 In the absence of evidence for best practice in Long COVID
rehabilitation, the heterogeneity of symptom presentation and clinical course in people living with
Long COVID, and the lessons learned in people living with ME/CFS, caution may be required when
recommending all forms of physical activity. In particular it is currently unknown when and by what
amount physical activity (including exercise or sport) is safe or beneficial, so that it does not impair
functioning among adults, young people and children living with Long COVID

 Key messages
Safe rehabilitation
• Post-Exertional Symptom Exacerbation: 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

• Cardiac Impairment: exclude cardiac impairment before using
physical activity (including exercise or sport) as rehabilitation
interventions for people living with Long COVID, with continued
monitoring for potential delayed development of cardiac dysfunction
when physical activity interventions are commenced

• Exertional Oxygen Desaturation: exclude exertional oxygen
desaturation before using physical activity (including exercise or
sport) as rehabilitation interventions for people living with Long
COVID, with continued monitoring for signs of reduced oxygen
saturation in response to physical activity interventions

• Autonomic Dysfunction and Orthostatic Intolerances: Before
recommending physical activity (including exercise or sport) as
rehabilitation interventions for people living with Long COVID,
individuals should be screened for autonomic nervous system
dysfunction, with continued monitoring for signs and symptoms of
orthostatic intolerance in response to physical activity interventions

Page 1 of 26
Long COVID
• Long COVID is an emerging condition that is not yet well
understood but can be severely disabling, impacting people
regardless of hospitalisation or severity of acute COVID-19

Assessment
• Asking people with Long COVID about their symptoms and the
impact of physical, cognitive, and social activities on symptoms 12
hours or longer after exertion, may help to identify people
experiencing post-exertional symptom exacerbation

• Risk stratification is recommended among people with symptoms
suggestive of cardiac impairment before returning to physical
activity

• It is critical to establish the reason or source of chest pain,
dyspnoea, tachycardia, or hypoxia, to prevent harm and
appropriately guide physical activity including exercise

• The possibility of persisting low-grade cardiac injury should be
considered when assessing protracted COVID-19 illness and
providing fitness for work advice, particularly in the context of jobs
involving strenuous physical activity

• Evidence of hyperventilation and breathing pattern disorders
identified through careful monitoring can facilitate access to
specialist respiratory physiotherapy

Rehabilitation approach
• Safe and effective rehabilitation is a fundamental part of recovery
from illness and can improve function in people living with disability

• Considering the clinical complexity and uncertainties of Long
COVID, functioning therapeutic relationships are critical in
maintaining safe rehabilitation approaches through recognition,
validation and inclusion of patient experiences as a means of
personalising treatment

• Long COVID rehabilitation should include educating people about
resuming everyday activities conservatively, at an appropriate pace
that is safe and manageable for energy levels within the limits of
current symptoms. Exertion should not be pushed to the point of
Page 2 of 26
fatigue or symptom exacerbation, both during and in the days
following exertion

• In the presence of post-exertional symptom exacerbation, “Stop

Rest. Pace”, activity management or pacing, and heart rate
monitoring may be effective rehabilitation approaches to support
self-management of symptoms

• Rehabilitation should aim to prevent desaturation on exertion, with
awareness that late deterioration of COVID-19 can still occur

Desaturation on exertion ≥3% requires investigation

• When orthostatic hypotension is present, the following interventions
could be considered: autonomic conditioning therapy, utilisation of
non-upright exercises, use of isometric exercises, compression
garments, and patient education for safety

• Aiming to achieve sustainable symptom stabilisation, whereby
symptom fluctuations are reduced to a manageable level over a
period of time, can constitute a rehabilitation approach that
improves symptom severity and daily functioning

• Physiotherapists can play an important role in the rehabilitation of
people living with Long COVID, to balance activities with rest to
optimise recovery, and consider other factors important in symptom
management beyond solely physical activity

Physical activity
• Physical activity of all forms might benefit some people living with
Long COVID, but could be contraindicated or exacerbate symptoms
in others. Using a cautious approach to physical activity will likely
support longer-term recovery

• Physical activity, including exercise, prescription in Long COVID
should only be approached with caution and vigilance, ensuring
rehabilitation programmes are restorative and do not make an
individual’s symptoms worse both during and in the days following

• Autonomic dysfunction, presenting as breathlessness, palpitations,
fatigue, chest pain, feeling faint (presyncope) or syncope, could
contribute to the exercise intolerance observed in people with Long
COVID

• Due to the risk of worsening symptoms with overexertion in Long
COVID, it is critical that physical activity, including exercise,
interventions are applied with caution and careful clinical decision
making based on symptoms during and in the days following
exertion

Page 3 of 26
 Context
World Physiotherapy comprises 125 member organisations across five regions and from low, middle
and high resource settings. Hence, there is great diversity in the delivery of physiotherapy and
rehabilitation services in the countries and territories of its member organisations

We note that there are various contexts in which practice takes place and a diversity of health care
delivery systems in which physiotherapy is practised globally. Moreover, the trajectory and impact of
the COVID-19 pandemic over time mean that as cases rise and fall in different regions, societies and
communities will be affected in different ways and at different times. We recognise that the statements
in this current briefing paper require consideration of available health care resources and
acknowledgement that health care disparities are affected by social determinants.10
World Physiotherapy is in close contact with its member organisations across all settings and has
been collating resources generated nationally and publications emerging via its COVID-19 knowledge
hub. We will continue to provide links to resources to inform practice, drawing on resources from
within the profession and other global organisations

 Purpose
This briefing paper aims to support physiotherapists and other healthcare professionals in the
provision of safe and effective Long COVID rehabilitation practice, research and policy until further
good quality evidence pertaining to physical activity (including exercise or sport) in Long COVID is
available

Statements are provided with supporting rationale and actions, to indicate when caution with
prescribing physical activity as rehabilitation interventions must be applied. Physical activity of all
forms might benefit some people living with Long COVID, but could be contraindicated or exacerbate
symptoms in others. Using a cautious approach to physical activity will likely support longer-term
recovery. This paper is not a guideline, standard, or policy. It is a consensus opinion statement based
on the experience of experts in the field of Long COVID, rehabilitation, lived experience, and related
impairments and conditions. The paper does not cover acute COVID-19 presentations managed in
hospital or community settings. This paper is a “living document” and will be updated as evidence
continues to emerge in the context of rehabilitation, physical activity, and Long COVID. This paper
may also be relevant to people living with other chronic illnesses commonly associated with
infections

 Key opinion leaders and stakeholders: bringing diverse perspectives
Physical activity, including exercise or sport, as rehabilitation approaches for people living with Long
COVID and other conditions commonly triggered by an infection, such as ME/CFS, has generated
debate. This necessitates considerations for the knowledge, skills and perspectives of rehabilitation
professionals, clinicians, academics and policymakers. Key opinion leaders and stakeholders were
assembled to generate statements on safe physical activity-based rehabilitation approaches from
diverse perspectives including people living with Long COVID, physiotherapists, physicians - including
physical medicine and rehabilitation physicians - exercise physiologists, psychologists, occupational
therapists, academics, advocacy groups, and people living with ME/CFS, from regions including
Africa, Asia Western Pacific, Europe, North America Caribbean, and South America

Page 4 of 26
 What is Long COVID?
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus
disease (COVID-19).11 COVID-19 can cause persistent ill-health. A quarter of people who have had
the virus may experience symptoms that continue for at least a month, more than 1 in 10 may remain
unwell after 12-weeks,12-15 and others may have ongoing symptoms for longer than 6 months.16-19 The
post-acute sequelae of COVID-19 have been described by patient groups as “Long COVID”,20-22 and
as “post-COVID conditions” by the World Health Organization (WHO) and United States Centers for
Disease Control and Prevention (CDC).23,24 Long COVID is an emerging condition that is not yet well
understood but can be severely disabling,13,15,25 impacting people regardless of hospitalisation or
severity of acute COVID-19.2,26-34 We do not yet know the risk factors for developing Long COVID,
who is more likely to recover, or how it can be treated. Research is urgently needed to better
understand the underlying pathophysiological mechanisms.20 Current knowledge demonstrates that
Long COVID can affect multiple body systems including the respiratory, cardiac, renal, endocrine and
neurological systems.15,16,19,26,28,35-38 People present with clusters of overlapping symptoms such as
fatigue or exhaustion, chest pressure or tightness, shortness of breath, headache, and cognitive
dysfunction.16,38 Long COVID can be multi-dimensional, spanning symptoms and impairments, activity
limitations and social participation restrictions.15,39-43 Long COVID may also be experienced as
episodic and unpredictable in nature, with symptoms fluctuating and changing over time.32,38 As such,
Long COVID impacts people’s functional ability, social and family life, ability to work, and quality of
life.12,15,19,25,40,44-48 Dealing with such complexity requires a multidisciplinary approach and patients'
involvement.3,49
 What is Rehabilitation?
Rehabilitation is defined as a set of interventions to optimise functioning in everyday activities, support
people to recover or adjust, achieve their full potential, and enable participation in education, work,
recreation and meaningful life roles.50-54 Along with recognition and research, access to rehabilitation
emerged as one of the three pillars of Long COVID campaigning,55 and succeeded in making
rehabilitation a Long COVID research priority,3 due to the disability experienced by people living with
Long COVID.16 Rehabilitation is a fundamental health service under Universal Health Coverage,56
addressing the impact of a health condition on a person’s life by focusing on improving functioning
and reducing experiences of disability.54 Rehabilitation is highly person-centred and goal-oriented,
meaning that the interventions and approaches selected are tailored to an individual depending on
their symptoms, goals and preferences.54 Physical activity (including exercise or sport) is a
rehabilitation intervention, often used in conjunction with other approaches, for a range of different
health conditions, to enhance function and wellbeing.57,58
Person-centred rehabilitation
Person-centred approaches to Long COVID rehabilitation will require conscious attention to the
therapeutic relationship; the relationship between clinician and patient also known as therapeutic or
working alliance.59 This important aspect of clinical interaction is a pillar of person-centred
rehabilitation,60,61 which improves clinical outcomes.62-64 Therapeutic relationships hinge upon
clinicians creating space where patients feel safe to openly engage in rehabilitation,65 with meaningful
connections established when clinicians acknowledge and believe patients’ lived experiences, actively
include them in decision making, and are receptive and responsive to their suggestions, needs and
values.65-69 Considering the clinical complexity and uncertainties of Long COVID, functioning
therapeutic relationships are critical in maintaining safe rehabilitation approaches, through
recognition, validation and inclusion of patient experiences as a means of personalising treatment

Page 5 of 26
Patient-reported outcome or experience measures (PROM or PREM) such as the EuroQOL EQ-5D-
5L, Consultation and Relational Empathy (CARE) Measure, and Working Alliance Inventory, can help
operationalise personalised treatment. Specific to physiotherapy, the Person-Centered Therapeutic
Relationship in Physiotherapy (PCTR-PT) scale (available in Spanish),70,71 and Physiotherapy
Therapeutic Relationship Measure (available in English),72 may support evaluation of therapeutic
relationships. Gaps in some areas of rehabilitation research exist, therefore Cochrane Rehabilitation
and WHO Rehabilitation Programme developed the COVID-19 rehabilitation research framework to
inform best practice and ensure rehabilitation services and health systems can best serve populations
affected by COVID-19 and Long COVID.73
What are physical activity and exercise?
“Physical activity” and “exercise” are different approaches that may be considered in the context of
rehabilitation. Each term refers to a different concept, however the terms are often confused with one
another and sometimes used interchangeably.74
Physical activity is defined as any bodily movement produced by skeletal muscles that results in
energy expenditure.74 Physical activity in daily life can be categorised into occupational, sports,
conditioning, household or other activities. Physical activity should not be confused with exercise,
which is a sub-category of physical activity. Exercise is defined as planned, structured, repetitive, and
purposeful activity focused on improvement or maintenance of physical fitness.74
Physical fitness is a set of attributes that are health- or skill-related.74 Exercise therapy used to treat
health conditions can be broadly categorised into aerobic, resistance, combined aerobic and
resistance, and condition-specific exercises used to target specific functional impairments, such as
stretches or balance training.57,58
Graded exercise therapy is an approach prescribed by clinicians, based on fixed incremental
increases in physical activity or exercise.19 Although physical activity including exercise is often
beneficial for health, this is not always the case,75 where different mechanisms can explain the
pathophysiology of exercise intolerance in a range of chronic conditions.76
Safe rehabilitation statement 1
Box 1: post-exertional symptom exacerbation
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

Rationale
The most common symptom of Long COVID is fatigue or exhaustion,6,16-19,28,34,77-84 a symptom which
does not result from unusually difficult activity, is not easily relieved by rest or sleep, can limit
functioning in day-to-day activities, and negatively impact quality of life.85 People living with Long
COVID can additionally experience post-exertional symptom exacerbation,16 also described as post-
exertional malaise (often abbreviated to PEM) or post-exertional neuroimmune exhaustion. Post-
exertional symptom exacerbation can be defined as the triggering or worsening of symptoms that can
Page 6 of 26
follow minimal cognitive, physical, emotional or social activity, or activity that could previously be
tolerated.86-91 Symptoms worsened by exertion can include disabling fatigue or exhaustion, cognitive
dysfunction or “brain fog”, pain, fever, sleep-disturbance, wheezing, diarrhoea, olfactory dysfunction
such as parosmia, and exercise intolerance. Symptoms typically worsen 12 to 48 hours after activity
and can last for days or even weeks,91,92 but with considerable variability.88,92 People may describe
experiencing a “crash” or “relapse” when a sustained or marked exacerbation of symptoms lasts
longer than shorter episodes or a flare-up, requiring a substantial and sustained adjustment to a
person’s activity management.91 During a relapse, symptoms and level of disability may be similar to
illness onset, and relapses can lead to a long-term reduction in a person’s capacity to perform
activities.91
Among a sample of 3,762 people living with Long COVID across 56 countries, 72% reported post-
exertional symptom exacerbation.16 People living with Long COVID describe the episodic nature of
Long COVID symptoms and impairments,15,16,19,38,83 and note exercise, physical activity, or cognitive
exertion as common triggers for symptom relapse.16,38,40 While there is evidence that physical activity
can reduce fatigue in some chronic conditions where fatigue is a common symptom,93-97 significant
negative impact can result if physical activity is not carefully tailored to the individual.98
Quota-based graded exercise programmes can result in harms to patients with post-exertional
symptom exacerbation.89,99-102 As such, in 2017 the United States Centers for Disease Control and
Prevention (CDC) removed graded exercise therapy from ME/CFS guidelines,89,99 and the United
Kingdom National Institute of Health and Care Excellence (NICE) recently removed graded exercise
therapy from draft ME/CFS guidelines.91 Recognising this, NICE cautioned against the use of graded
exercise therapy for people recovering from COVID-19.19,103,104
WHO recommends that Long COVID rehabilitation should include educating people about resuming
everyday activities conservatively, at an appropriate pace that is safe and manageable for energy
levels within the limits of current symptoms.105 Exertion should not be pushed to the point of fatigue
or symptom exacerbation, both during and in the days following exertion

Action
Assessment of post-exertional symptom exacerbation occurs by self-report. Asking people with Long
COVID about their symptoms and the impact of physical, cognitive and social activities on symptoms
12 hours or longer after exertion, may help to identify people experiencing post-exertional symptom
exacerbation.106 People may describe post-exertional exacerbation of fatigue as worsening tiredness
or exhaustion, heaviness in limbs or whole body, cognitive dysfunction or “brain fog”, muscle
weakness, and being drained of energy.107 Post-exertional exacerbation of other symptoms can be
described in various ways depending on the symptoms affected, with many people often able to
recognise a wave of associated symptoms and their triggers before symptoms worsen

A brief 5-item questionnaire to screen for post-exertional malaise (Box 2), a sub-scale of the DePaul
Symptom Questionnaire validated in people with ME/CFS,108 may be a useful screening tool in Long
COVID. It is designed to assess the frequency and severity of post-exertional symptom exacerbation
over a six-month time frame.108-110 A score of 2 on both frequency and severity on any items 1 to 5, is
indicative of post-exertional malaise.111 These five screening questions are recommended by the
National Institutes of Health/Centers for Disease Control and Prevention Common Data Elements
(CDE) post-exertional malaise working group.112 Five supplemental questions are also available to
examine duration, recovery and exercise exacerbation (Box 2).108 It may be beneficial to utilise both
screening and supplementary questions (questions 1-10) alongside self-report, until psychometric
property evaluation of this tool in the context of Long COVID is available. The new DePaul Post-
Exertional Malaise Questionnaire is also available to assess key characteristics, triggers, onset,
duration, and effects of pacing.113
Page 7 of 26
Box 2: A Brief Questionnaire to Screen for Post-Exertional Symptom Exacerbation
Supplementary Questions
Reprinted with permission of author LA Jason108
Two-day cardiopulmonary exercise testing (CPET) provides an objective measure of exercise
intolerance and impaired recovery and may have a role in assessing potential mechanisms of
exercise limitation among people with Long COVID.114,115The two-day CPET procedure first measures
baseline functional capacity and provokes post-exertional symptom exacerbation, then assesses
changes in CPET variables 24 hours later with a second CPET to assess the effects of post-
exertional symptom exacerbation on functional capacity.116 Reduced physiological function has been
observed on the second CPET test in people living with ME/CFS, including reduced workload at the
ventilatory threshold, chronotropic intolerance (blunted heart rate response), and higher blood lactate
at a given workload, that is not present in sedentary controls and therefore not a result of
deconditioning.117-121 This reduction in physiological function appears to be sensitive to stratifying
disease severity.121 As a result, CPET may provide important objective evidence of physiological and
functional impairment used in legal determination of eligibility for social benefits based on disability
status.122 However, CPET commonly results in symptom exacerbation or relapse so should be used
with caution.109,116
Additional approaches validated in other health populations could be conducted remotely, whilst still
vigilant to consider risk of symptom exacerbation, such as the 6-minute walk test, accelerometers,
and activity monitors.123 Information from commercially available heart rate and activity monitors may
be used to both establish objective criteria for pacing programmes, and provide an external prompt
Page 8 of 26

This briefing paper brings together individuals from across the World Physiotherapy regions, community groups, organisations, interdisciplinary clinical practice, and academia to identify …