Patients with long Covid experience a wide range of symptoms, both cognitive and physical, and several studies suggest that exercise may exacerbate these symptoms, Melinda Wenner Moyer writes for the New York Times.

Recovery clinics for Covid-19 long-haulers

Can exercise make long Covid worse?

According to Moyer, many doctors have advised their patients with long Covid to exercise as a way to alleviate their symptoms—but instead of helping, physical activity has often worsened symptoms for many patients.

For example, Natalie Hollabaugh, a lawyer from Oregon, found that her long Covid symptoms, including fatigue, shortness of breath, headaches, and joint pain, all worsened after she began a regular exercise regimen on her doctor's recommendation. "I had never felt worse," Hollabaugh said.

For many long Covid patients, experiencing worsening symptoms after exercise, which is sometimes called "post-exertional malaise," is not uncommon, Moyer writes. In fact, an online survey of 3,762 long Covid patients found that 89% reported post-exertional malaise.

Separately, Natalie Lambert, a biostatistician and health data scientist at the Indiana University School of Medicine who has collected self-reported data from more than a million long Covid patients, said many patients often report feeling worse after exercise.

"The research that I've done has shown that inability to exercise is one of the most common long-term symptoms," Lambert said. While some long Covid patients are simply too tired to exercise, others see their symptoms, such as fatigue, brain fog, or muscle pain, worsen significantly, she said.

How long Covid may be hindering patients' ability to exercise

These exercise-related problems are not just due to patients becoming out of shape, Moyer writes. According to David Systrom, a pulmonary and critical care physician at Brigham and Women's Hospital, the effects seen in long Covid patients are "very, very different from normal and simple detraining."

For example, a small study from Systrom and his colleagues found that while long Covid patients had normal chest CT scans and no problems with lung or heart function, some of their veins and arteries did not work properly during exercise. This prevented oxygen from reaching their muscles efficiently.

Although it is not clear why these blood vessel problems occur, another of Systrom's studies suggests that long Covid patients may experience damage to a specific nerve fiber related to organ and blood vessel functions.

Separately, a study published in The Physiological Society found that long Covid patients' heart rates may function differently than those who had never had Covid-19. In the study, the heart rates of women with long Covid did not accelerate as much or recover as quickly as other women after a six-minute walking test.

"Clearly, there's something going on that's interfering with that normal response," said Stephen Carter, an exercise physiologist at the Indiana University Bloomington School of Public Health and an author of the study.

Another potential explanation for long Covid patients' inability to exercise may be postural orthostatic tachycardia syndrome (POTS). According to Lambert, in patients with POTS, "the nervous system can't regulate the things it's supposed to automatically control, like heart rate, blood pressure, sweating and body temperature," which "are all things that when you're exercising need to be regulated properly."

Some doctors have also drawn parallels between patients with long Covid and patients with chronic fatigue syndrome, Moyer writes. Patients with chronic fatigue syndrome often experience memory and cognitive problems, muscle and joint pain, and severe fatigue. In addition, a study of 160 chronic fatigue syndrome patients found that many experienced the same blood vessel problems seen in long Covid patients when they exercised.

"We're essentially finding the exact same thing when it comes to potential mechanisms," said Systrom, one of the study's authors.

To exercise or not to exercise

Currently, physicians are divided on whether long Covid patients who are having difficulties with exercise should stop physical activity or continue to ramp it up, Moyer writes.

"There are both patients and doctors who are vehemently against any exercise" because of the potential to worsen long Covid symptoms, Systrom said.

However, Systrom noted that exercise can be possible, and even beneficial, if long Covid patients receive proper treatment first. "If you can get the patient in a better place with medications, then you can embark on a graded exercise program without precipitating crashes," he said.

Lambert agreed with Systrom's assessment. "You can't just jump into exercise, or you're going to be set back," she said. Instead, long Covid patients should "slowly try to reincorporate it if [they] are feeling better."

Overall, Lambert said doctors and patients may need to tailor their recommendations to patients' specific needs since patients will experience long Covid differently. "That's really the story of Covid—that for every patient, long Covid is different," she said. "There's probably never going to be a one-size-fits-all recommendation for exercise." (Moyer, New York Times, 2/13)