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Ladlow P, Bennett AN, O'Sullivan O. Exercise Therapy for Post-COVID-19 Condition-Does No Harm. JAMA Netw Open 2024; 7:e246959. [PMID: 38573640 DOI: 10.1001/jamanetworkopen.2024.6959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
- Peter Ladlow
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, United Kingdom
- Department for Health, University of Bath, Bath, United Kingdom
| | - Alexander N Bennett
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Oliver O'Sullivan
- Academic Department of Military Rehabilitation, Defence Medical Rehabilitation Centre (DMRC) Stanford Hall, Loughborough, United Kingdom
- Academic Unit of Injury, Recovery and Inflammation Science, School of Medicine, University of Nottingham, Nottingham, United Kingdom
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Tryfonos A, Pourhamidi K, Jörnåker G, Engvall M, Eriksson L, Elhallos S, Asplund N, Mandic M, Sundblad P, Sepic A, Rullman E, Hyllienmark L, Rundqvist H, Lundberg TR, Gustafsson T. Functional Limitations and Exercise Intolerance in Patients With Post-COVID Condition: A Randomized Crossover Clinical Trial. JAMA Netw Open 2024; 7:e244386. [PMID: 38573638 DOI: 10.1001/jamanetworkopen.2024.4386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Abstract
Importance Many patients with post-COVID condition (PCC) experience persistent fatigue, muscle pain, and cognitive problems that worsen after exertion (referred to as postexertional malaise). Recommendations currently advise against exercise in this population to prevent symptom worsening; however, prolonged inactivity is associated with risk of long-term health deterioration. Objective To assess postexertional symptoms in patients with PCC after exercise compared with control participants and to comprehensively investigate the physiologic mechanisms underlying PCC. Design, Setting, and Participants In this randomized crossover clinical trial, nonhospitalized patients without concomitant diseases and with persistent (≥3 months) symptoms, including postexertional malaise, after SARS-CoV-2 infection were recruited in Sweden from September 2022 to July 2023. Age- and sex-matched control participants were also recruited. Interventions After comprehensive physiologic characterization, participants completed 3 exercise trials (high-intensity interval training [HIIT], moderate-intensity continuous training [MICT], and strength training [ST]) in a randomized order. Symptoms were reported at baseline, immediately after exercise, and 48 hours after exercise. Main Outcomes and Measures The primary outcome was between-group differences in changes in fatigue symptoms from baseline to 48 hours after exercise, assessed via the visual analog scale (VAS). Questionnaires, cardiopulmonary exercise testing, inflammatory markers, and physiologic characterization provided information on the physiologic function of patients with PCC. Results Thirty-one patients with PCC (mean [SD] age, 46.6 [10.0] years; 24 [77%] women) and 31 healthy control participants (mean [SD] age, 47.3 [8.9] years; 23 [74%] women) were included. Patients with PCC reported more symptoms than controls at all time points. However, there was no difference between the groups in the worsening of fatigue in response to the different exercises (mean [SD] VAS ranks for HIIT: PCC, 29.3 [19.5]; controls, 28.7 [11.4]; P = .08; MICT: PCC, 31.2 [17.0]; controls, 24.6 [11.7]; P = .09; ST: PCC, 31.0 [19.7]; controls, 28.1 [12.2]; P = .49). Patients with PCC had greater exacerbation of muscle pain after HIIT (mean [SD] VAS ranks, 33.4 [17.7] vs 25.0 [11.3]; P = .04) and reported more concentration difficulties after MICT (mean [SD] VAS ranks, 33.0 [17.1] vs 23.3 [10.6]; P = .03) compared with controls. At baseline, patients with PCC showed preserved lung and heart function but had a 21% lower peak volume of oxygen consumption (mean difference: -6.8 mL/kg/min; 95% CI, -10.7 to -2.9 mL/kg/min; P < .001) and less isometric knee extension muscle strength (mean difference: -37 Nm; 95% CI, -67 to -7 Nm; P = .02) compared with controls. Patients with PCC spent 43% less time on moderate to vigorous physical activity (mean difference, -26.5 minutes/d; 95% CI, -42.0 to -11.1 minutes/d; P = .001). Of note, 4 patients with PCC (13%) had postural orthostatic tachycardia, and 18 of 29 (62%) showed signs of myopathy as determined by neurophysiologic testing. Conclusions and Relevance In this study, nonhospitalized patients with PCC generally tolerated exercise with preserved cardiovascular function but showed lower aerobic capacity and less muscle strength than the control group. They also showed signs of postural orthostatic tachycardia and myopathy. The findings suggest cautious exercise adoption could be recommended to prevent further skeletal muscle deconditioning and health impairment in patients with PCC. Trial Registration ClinicalTrials.gov Identifier: NCT05445830.
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Affiliation(s)
- Andrea Tryfonos
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Life Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus
| | - Kaveh Pourhamidi
- Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Gustav Jörnåker
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Martin Engvall
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Eriksson
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Sara Elhallos
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Nicole Asplund
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mirko Mandic
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Patrik Sundblad
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Atif Sepic
- Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Eric Rullman
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Lars Hyllienmark
- Department of Clinical Neurophysiology, Karolinska University Hospital, Stockholm, Sweden
| | - Helene Rundqvist
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Tommy R Lundberg
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Gustafsson
- Division of Clinical Physiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Unit of Clinical Physiology, Karolinska University Hospital, Stockholm, Sweden
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Tamariz L, Bast E, Klimas N, Palacio A. Low-dose Naltrexone Improves post-COVID-19 condition Symptoms. Clin Ther 2024; 46:e101-e106. [PMID: 38267326 DOI: 10.1016/j.clinthera.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/29/2023] [Accepted: 12/24/2023] [Indexed: 01/26/2024]
Abstract
PURPOSE Treatments for myalgic encephalomyelitis and chronic fatigue syndrome can be adapted for post-COVID-19 condition. Our aim was to compare treatments in patients from our post-COVID-19 clinic. METHODS We conducted a retrospective cohort study and included consecutive patients enrolled in our post-COVID-19 clinic. We included patients who received low-dose naltrexone, amitriptyline, duloxetine, and physical therapy, and evaluated improvements in fatigue, pain, dyspnea, and brain fog recorded in the electronic health record. We calculated the adjusted relative hazard of improvement using Cox proportional models. We adjusted for demographic characteristics, comorbidities, and prior COVID-19 hospitalization. FINDINGS We included the first 108 patients with post-COVID-19 enrolled in the clinic. Most of the patients received amitriptyline. The relative hazard of improvement for those taking low-dose naltrexone was 5.04 (95% CI, 1.22-20.77; P = 0.02) compared with physical therapy alone. Both fatigue and pain were improved in patients taking low-dose naltrexone; only fatigue was improved in patients taking amitriptyline. IMPLICATIONS Post-COVID-19 condition symptoms may improve in patients taking medications adapted from myalgic encephalomyelitis and chronic fatigue syndrome. Randomized controlled trials should evaluate these medications and translational studies should further evaluate their mechanisms of action.
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Affiliation(s)
- Leonardo Tamariz
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Miami, Florida; Department of Public Health Sciences, University of MIami, Miami, Florida.
| | - Elizabeth Bast
- Department of Ambulatory Medicine, Veterans Affairs Medical Center, Miami, Florida
| | - Nancy Klimas
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Miami, Florida; Institute for Neuro Immune Medicine, Dr. Kiran Patel College of Osteopathic Medicine, Nova Southeastern University, Ft. Lauderdale, Florida
| | - Ana Palacio
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Medical Center, Miami, Florida; Department of Public Health Sciences, University of MIami, Miami, Florida
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