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

Nature Reviews Cardiology volume 21, pages 430–431 (2024)Cite this article

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We read with great interest the Review by Fedorowski et al. (A. Fedorowski et al. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-023-00962-3 (2024))1. The authors provide a timely overview of the aetiology and clinical management of cardiovascular autonomic dysfunction (CVAD) in patients with long COVID (also known as post-COVID-19 syndrome). As clinicians involved in the care of, and research into, patients with long COVID, we endorse the statement that the recognition of CVAD 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 exertion2. 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 functioning2. Post-exertional malaise is considered a hallmark of other syndromes commonly associated with infection, such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Up to 85% of chronically and severely ill people living with long COVID can have a combination of post-exertional malaise and CVAD3.

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References

  1. Fedorowski, A. et al. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden. Nat. Rev. Cardiol. https://doi.org/10.1038/s41569-023-00962-3 (2024).

    Article  PubMed  Google Scholar 

  2. National Institute for Health and Care Excellence. Myalgic encephalomyelitis (or encephalopathy)/chronic fatigue syndrome: diagnosis and management. NICE https://www.nice.org.uk/guidance/ng206 (2021).

  3. Davis, H. E., McCorkell, L., Vogel, J. M. & Topol, E. J. Long COVID: major findings, mechanisms and recommendations. Nat. Rev. Microbiol. 21, 133–146 (2023).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  4. Wilshire, C. E. et al. Rethinking the treatment of chronic fatigue syndrome–a reanalysis and evaluation of findings from a recent major trial of graded exercise and CBT. BMC Psychol. 6, 6 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  5. Biere-Rafi, S., Janssen, K., Jurgens, E., Kooij, S. & Hellemons, M. Is cognitive behavioural therapy effective for post-COVID fatigue? Clin. Infect. Dis. 77, 1074–1075 (2023).

    Article  PubMed  Google Scholar 

  6. Kielland, A., Liu, J. & Jason, L. A. Do diagnostic criteria for ME matter to patient experience with services and interventions? Key results from an online RDS survey targeting fatigue patients in Norway. J. Health Psychol. 28, 1189–1203 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

  7. Wright, J., Astill, S. L. & Sivan, M. The relationship between physical activity and long COVID: a cross-sectional study. Int. J. Environ. Res. Public Health 19, 5093 (2022).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Appelman, B. et al. Muscle abnormalities worsen after post-exertional malaise in long COVID. Nat. Commun. 15, 17 (2024).

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Blitshteyn, S. et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of autonomic dysfunction in patients with post-acute sequelae of SARS-CoV-2 infection (PASC). PM R 14, 1270–1291 (2022).

    Article  PubMed  Google Scholar 

  10. Sanal-Hayes, N. E. M. et al. A scoping review of ‘pacing’ for management of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS): lessons learned for the long COVID pandemic. J. Transl. Med. 21, 720 (2023).

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors thank A. van der Zee (patient representative) and G. Liebrand (patient representative from advocacy group #NietHersteld) for their thoughtful comments on an early draft of the manuscript.

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Authors and Affiliations

  1. Department of Internal Medicine, University Medical Center Utrecht, Utrecht, Netherlands

    Femke Christina Ching-Chuan van Rhijn-Brouwer

  2. Department of Pulmonary Medicine, Erasmus University Medical Center, Rotterdam, Netherlands

    Merel Hellemons

  3. Facharztzentrum Votivpark, Vienna, Austria

    Michael Stingl

  4. Department of Primary Care Medicine, Medical University of Vienna, Vienna, Austria

    Kathryn Hoffmann

  5. Department of Human Media Interaction, University of Twente, Enschede, Netherlands

    Joanne VanDerNagel

  6. Department of Physical Therapy, School of Health Sciences, University of the Pacific, Stockton, CA, USA

    Todd E. Davenport

  7. Institute of Pathophysiology and Allergy Research, Center for Pathophysiology, Infectiology and Immunology, Medical University of Vienna, Vienna, Austria

    Eva Untersmayr

  8. Institute of Medical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany

    Carmen Scheibenbogen

  9. Department of Rehabilitation and Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA

    David Putrino

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  1. Femke Christina Ching-Chuan van Rhijn-Brouwer
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Corresponding author

Correspondence to Femke Christina Ching-Chuan van Rhijn-Brouwer.

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Competing interests

F.C.C.-C.v.R.-B. and J.V. have not been practising medicine since March 2022 owing to long COVID. The other authors declare no competing interests.

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van Rhijn-Brouwer, F.C.CC., Hellemons, M., Stingl, M. et al. Graded exercise therapy should not be recommended for patients with post-exertional malaise. Nat Rev Cardiol 21, 430–431 (2024). https://doi.org/10.1038/s41569-024-00992-5

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