Nature.com recently published (26/12/24) a response to a review by Fedorowski et al. (A. Fedorowski et al. Cardiovascular autonomic dysfunction in post-COVID-19 syndrome: a major health-care burden – available here). The response authors agree that recognizing cardiovascular autonomic dysfunction (CVAD) is important for managing long COVID patients. However, they disagree with recommending graded exercise therapy for patients with post-exertional malaise (PEM), a key symptom of long COVID.
PEM causes disabling symptoms that get worse after physical or cognitive exertion, with a delayed onset and prolonged recovery period. It is a hallmark of syndromes like ME/CFS that overlap with long COVID. The evidence does not support graded exercise therapy for PEM.
The authors argue the cited PACE trial claiming exercise benefits for ME/CFS has been discredited due to methodological flaws. Contemporary guidelines no longer recommend graded exercise therapy for ME/CFS.
Studies showing exercise benefits in long COVID did not properly include or account for PEM patients. Surveys show most PEM patients deteriorate with exercise recommendations. Recent research found abnormal physiological responses to exercise in long COVID patients.
Graded exercise should not be recommended for long COVID patients with PEM. Those without PEM can try exercise approaches while monitoring for PEM onset. Patients with PEM should stay within their ‘energy envelope’ and follow other non-exercise recommendations.
The authors agree with the rest of the review but call for a ‘do no harm’ approach, assessing long COVID patients for PEM before exercise therapy. Graded exercise should be avoided in those with PEM given the potential for harm.
You can see the full response here.