Graded exercise therapy should not be recommended for patients with post-exertional malaise


Major researchers from the US and Europe – including Todd Davenport, Carmen Scheibenbogen and David Putrino – have replied to Fedorowski et al’s Review, which supports the use of GET with long COVID patients.

“As clinicians involved in the care of, and research into, patients with long COVID, we endorse the statement that the recognition of CVAD (cardiovascular autonomic dysfunction) is essential to the adequate management of long COVID. However, we cannot agree with the recommendations for graded exercise therapy for people living with long COVID who have post-exertional malaise.”

Post-exertional malaise is a constellation of disabling signs and symptoms, which mainly begin after physical and cognitive exertion. Post-exertional malaise is characterized by a delayed onset after exertion, and the period of recovery from exacerbations of post-exertional malaise can be prolonged and can severely limit daily functioning.

…Up to 85% of chronically and severely ill people living with long COVID can have a combination of post-exertional malaise and CVAD…

Landmark research showed that exercise in people living with long COVID is significantly associated with abnormal immune and metabolic responses to exercise in skeletal muscle compared with healthy control participants.

Therefore, graded exercise therapy should not be recommended for people living with long COVID and post-exertional malaise… people living with long COVID and post-exertional malaise must be supported in keeping daily activities within their available fund of energy or ‘energy envelope’. We advise a ‘do no harm’ approach. All people living with long COVID and CVAD should be assessed for post-exertional malaise.

Read the full article:

Graded exercise therapy should not be recommended for patients with post-exertional malaise, by Femke Christina Ching-Chuan van Rhijn-Brouwer, Merel Hellemons, Michael Stingl, Kathryn Hoffmann, Joanne VanDerNagel, Todd E Davenport, Eva Untersmayr, Carmen Scheibenbogen & David Putrino in
Nature Reviews Cardiology (2024)

There is a reply to this letter by Fedorowski, A. et al. Nat. Rev. Cardiol. (2024).

Our understanding is that, in some cases, a standard approach to physical exercise might potentially harm patients with a still poorly defined susceptibility to post-exercise energy depletion. We apologize for our lack of clarity. Our intention was to raise awareness of this special subgroup of patients among those who have post-COVID-19 cardiovascular dysautonomia, rather than to promote the training programme in an indiscriminate way.

We, the authors of the Review, see many patients with POTS in our clinical practices, and each of us has seen patients who had initial worsening at the onset of an individual training programme, but who improved during follow-up under careful supervision by professional staff. Importantly, this approach is supported by the NICE guidelines3.

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