Monthly Archives: February 2022

17th January – 23rd January

• Hours: 15

Main Theme Addressed During Phone Calls

• Trying to be aware of small improvements over a larger scale of time
• 2 x discussions around returning to work
• One participant paused due an elevated RHR and BP

Cardio Class

• (45 secs on (90 secs if singe leg), 15 seconds off x 3, followed by a 45 second rest) x 5
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Drop-in Session

• Cohort are fairly confident in using the facilities now.
• Offered additional exercises, e.g. tricep extension using the cable machine, and variations of exercises, e.g. underhand lat pulldown as opposed to the ‘traditional’ overhand grip.
• 2 participants stay for the full 2 hours – however, they have buddied up together so have lots of rest between different exercises and have not been experiencing any negative effects post-session.

Analysis & Evaluation 

• One discussion around returning to work involved the participant expressing their real want to get back to the workplace; however, occupational health and management are being very cautious and have yet to give him the go ahead. This participant notes that he is making small improvements over such an extended length of time that it is difficult to notice them. However, being able to exercise without significant exacerbations of his symptoms is a good indicator that he could start a phased return to work as previously any form of exertion resulted in excessive and debilitating proximal fatigue.
• Another discussion around this same topic involved the participant expressing the level of recovery they wish to be at before they return to work. This participant received semi-regular calls from her workplace to check-in and see how she was feeling. This participant was really firm with work and stated that she would not be returning to work until she could, on a regular basis, wake up early, do some house work, have coffee with a friend, go to the gym, make dinner and stay up until 9/10pm without, ‘feeling like the walking dead the next day.’ Her work are very supportive and as the participant is making progress agreed that all was moving in the right direction. I praised the participant for this as I have seen many participants or know many participants have returned to work far too early in their recovery. A number of people in the past have said to me, once they have taken time off work, that they feel better and will definitely go back at the end of their sick-note. I always celebrate the fact that they are feeling better with them; however, I do warn them that they may need more time before going back to work. This is because most people who are off work have the capacity to pace, plan and prioritise more effectively; therefore, their energy expenditure in comparison to a working day is markedly reduced. Rather than shift in their thinking to,  ‘I know need to stabilise at baseline and then make small incremental increases to my energy expenditure overtime to prepare myself for going back to work.’ they tend to think, ‘I feel better, I should go back to work.’ The latter sees many people go back to work and struggle and/or off work again due to going back too soon. When I ask people why do they struggle through or why do they put so much pressure on themselves the answer normally falls into one of the following: guilt or financial concerns. When their reason falls into guilt I remind them that their sick-note is to declare that they are off sick from work not off sick from their life. Many people who have guilt about not being at work wouldn’t want to be seen doing what my participant described this week as they worry what people from work would say if they saw them, e.g. if she is healthy enough to go out to dinner/gym then why isn’t she at work. I try and work with these participants to challenge their thinking and put themselves first; however it can be difficult as it is a deeply rooted belief that they hold.

Conclusion 

• I find it interesting that I have some people who don’t stress about not being back at work at all and others who have such an overwhelming sense of guilt who push themselves to return before they are ready. From this experience, I am going to explore any evidence that might exist on returning to work after a period of absence and what psycho-social factors play a role in this decision.

Revisiting Reflection

• On further investigation, I found the NHS offers guidance and support about returning to work – therefore, I will ensure I offer this to participants who may be struggling alongside advise of planning, pacing and prioritising.
• I found that the UK Government has acknowledged that psychosocial factors may impede an employees return to work. Fear of social stigmatisation, anxiety, depression and PTSD are quite common in those living with long covid. Therefore, it has been suggested that returning to work and moderate physical activity could be beneficial to those who have poor mental wellbeing. In terms of returning to work, it has been suggested that the employee have more control over the situation to reduce psychological distress or symptoms. I think in the future it would be beneficial to share this information with participants as some feel like have no say or guidance in their phased return process.

10th January – 16th January

• Hours: 15

Main Theme Addressed During Phone Calls

• Thoughts, feelings and questions from week 7’s gym drop-in.
• Discussing specific exercises that may benefit particular individuals
  • For example, calf raises for marathon runner and patient suffering from proximal fatigue.
• One patient, who has never, used the gym before was really lacking confidence and wasn’t sure if she would come again this week.
• All participants who attended the gym and/or class in person noted a real difference in motivation and enjoyment.

Mobility Class

• ((45s secs x 2 followed by a 30 second rest) x 3) x 3
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Gym Drop-In Session

• The participant who was lacking confidence joined me as I delivered another gym induction for a participant who couldn’t attend the week previously. She printed off the gym programme I provided during week 7 to carry around with her. After trying a couple pieces of equipment things started to click into place and she stated that she understood everything a bit more so felt more confident. I had to leave her and the individual who hadn’t completed the gym induction previously to help some of the other participants during the drop-in. When I came back she was mid-way through demonstrating how the leg extension worked to her fellow participant. After this the participant seemed to have found some confidence and happily approached some more equipment without needing my direct support.

Analysis & Evaluation 

• I was really keen to individualise programmes as best as possible for patients – not only to address specific concerns individuals may have e.g. knee pain, but also to keep the gym sessions relevant to their recovery goals. For example, the marathon runner would like to get back to running so I wanted to show him some strength and conditioning he could do to support his return to running e.g. calf raises. My aim here was to hopefully keep the individuals motivated to attend gym sessions as it is relevant to what they are looking to achieve from the programme. This was also the week that this participant introduced run/walk into his exercise routine – he completed 1km using a run/walk strategy. He noted that he was a bit more breathless and wheezy than he expected but he forgot to take his inhaler (asthmatic) prior, which he used to always do. Therefore, I encouraged him to try again next week with the inhaler to see if that makes his breathing easier.
• The participants noted that it was really nice and enjoyable to meet everyone in person and it lifted their spirits. This highlights that the virtual/telerehabilitation component of the programme, although beneficial for most, maybe wasn’t as enjoyable as the face-to-face component of the programme. Many noted that even though you are in a group setting during the virtual phase you feel like you are going it alone still but when you meet everyone in person you feel like you have more of a support network and a chance to form meaningful bonds with others who need your help and support too. This highlights both the benefits and drawbacks to telerehabilitation and potentially also group v individual rehabilitation. For example, telerehabilitation can be completed successfully in the convenience of your own home; however, it lacks the same social experience as face-to-face that people quite often prefer. Furthermore, group rehabilitation can provide a wider support network that might not be as easily accessible as individual rehabilitation. However, group rehabilitation can make it slighter harder for the therapist to individualise parts of the session. This is why I spend time working with individuals during the drop-in session as it is a chance to tackle the drawback of group rehabilitation.

Conclusion 

• From the feedback this week, I am going to explore ways in which to boost motivation and morale during the telerehabilitation stage of the programme.
• Psychosocial support is a key component of rehabilitation (Wade. 2020). There are many techniques that can be used to provide this support, such as rehabilitation in a group setting. I enjoy working with participants on a one to one basis; however, this experience and literature has highlighted that group rehabilitation is a useful strategy for helping individuals with their psychosocial needs. I feel this is particularly true of COVID-19 rehabilitation as nation wide lockdowns resulted in a significant lack of social interaction with friends and family – a key component to maintaining healthy emotional wellbeing.

Revisiting Reflection

References

• Wade D. T. (2020). Rehabilitation after COVID-19: an evidence-based approach. Clinical medicine (London, England), 20(4), 359–365. https://doi.org/10.7861/clinmed.2020-0353

3rd January- 9th January

• Hours: 15

Main Theme Addressed During Phone Calls

• Answering any further questions in regards to Week 7 transition
• Two individuals noted that they may need to some extra guidance on keeping within their energy expenditure allowance during gym sessions. Both of these individuals either enjoy the environment and/or kit available to them and were concerned they may get too excited and increase their intensity unintentionally.

Cardio Class

• ((45s secs x 2 followed by a 30 second rest) x 3) x 3
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Drop-In Session

• Club tour
• Group gym induction
  • Cardio, fixed resistance, functional equipment and floor space for body weight exercises.
  • Discussed appropriate durations, reps ranges and rest periods.
    • Durations for CV=3-5 minutes at a low to moderate intensity (should be able to maintain a conversation)
    • Rep ranges for resistance exercises = 10-12 with 45-60s rest (moderate intensity), 12-15 with 30-45s rest (low intensity). Depending on their capabilities or confidence would dictate what rep range they chose. I advised those who had not been in a gym environment for quite some time, or those who are reducing the intensity of the group classes, to stick with 12-15 reps at a low weight. Whereas, those who felt. a bit more confident in the gym setting, or who were improving their exercise tolerance, to try 10-12 reps at a moderate weight.
  • Generic exercise programme to guide structure

Analysis & Evaluation 

• One participant is a physio and admits that the reason she sought this out as a career path was due to her love of physical activity and the gym environment.
• Another participant is a marathon runner, he has gradually be increasing the duration of his walks (10% rule), in the hope that he can slowly build up to a run/walk. He is excited to make use of the treadmills.
• I was particularly proud of both these participants during the gym induction as the entire session lasted around 90 minutes. The bulk of this was watching, learning and having a go on a couple of pieces of kit. The session generally lasts 2 hours – this is to allow participants to drop-in at any stage during this time rather than stay for 2 hours, the latter is unadvisable. At the end of the session both of the participants who stated they were worried that their eagerness might be a hinderance to their recovery, chose to leave as 90 minutes was enough for them that day. This also encouraged the rest of the group to reflect and they decided to end the session there rather than stay on and risk tipping their energy balance in the wrong direction. This day, for those two participants specifically, showed that they had really gotten to grips with listening to their body, understanding and controlling their triggers. If this wasn’t the case they would have chosen to stay on and let their excitement for the environment overrule what their body is capable of at the moment.
• Many people on the programme describe being frustrated that their body can’t do what it used to and have often pushed it beyonds its current limits. Rather than listening to their body, they try to overrule it with what they think it should be doing as opposed to understanding where its new limits lie and working within them to allow adequate recovery. I spend a lot of my time iterating to participants that they cannot let their pre-covid brain rule their post-covid body and I feel for the participants I highlighted this week, that the message has started to sink in and they are consciously working within their new limits.

Conclusion 

• Even when you see a success like the one described this week, it doesn’t always translate to happy or please participants. I will praise them for setting boundaries and doing less to protect their energy levels whereas they may feel frustrated or limited. This highlights why rehabilitation is more than just physical recovery and the mind-set of individuals needs to be considered and addressed throughout the process.

Revisiting Reflection

27th December – 2nd January

• Hours: 15

Main Theme Addressed During Phone Calls

• Preparing for week 7
  • What to expect in the gym
  • How the group sessions will look moving forwards
  • What facilities they can and cannot use during their recovery

Mobility Class

• ((45s secs x 2 followed by a 30 second rest) x 3) x 5
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Analysis & Evaluation 

• Phone calls during week 6 involve getting prepared for week 7. Week 7 brings a close to the ‘virtual’ component of the programme as the group session will take place in a studio and the ‘build your own’ session will take place in the gym.
• There is naturally some anxiety around transitioning to on-site as most have some apprehension about being around a number of people in an enclosed space. However, many of them note something along the lines of, ‘at some point things have to be normal’ or ‘i need to stop avoiding things.’  Therefore, despite some concerns the consensus was positive about the transition. Interesting, one study found a very weak link between anxiety and depression and previous COVID-19 infection (Klaser, et al., 2021) which I was quite surprised about. However, this study is not exclusive to those with ‘long covid’ symptoms. Therefore, this finding may not be applicable to this particular population.
• Furthermore, publications are crying out for a multidisciplinary approach to the multi-faceted ‘long covid’ syndrome. Mental health support is not often omitted from papers focusing on the management of ‘long covid.’ Indeed, one review paper highlighted that many people are effected emotionally after COVID-19 and previously hospitalised patients, particularly women, are at risk of developing anxiety, depression and/or PTSD (Aiyegbusi, et al., 2021).
• On top of this health related anxiety patients may exhibit, there is also the anxiety that some people have in regards to entering a gym environment. Many are worried that they will be judged by others or that they will look silly if they make a mistake or need to ask for help. I am fairly confident in settling these worries; however, I am always mindful to programme their drop-in gym session during ‘off-peak hours’ to prevent them becoming overwhelmed. However, it is January, a well known busy period, so I have also prepared them for the possibility of it still being a busy area.

Conclusion 

• I have worked in a gym setting for a number of years now and as a result do not have any worries or anxieties about being in that environment. However, I remember a time when a gym environment would be intimidating to me and I have certainly helped a lot of people grow in confidence within a gym setting. Working with those who have had COVID-19 though brings additional challenges to easing concerns. Not only am I easing their concerns about entering an enclosed space with more people than what they are used to whilst the Omicron variant is circulating the UK but I am also trying to ease some pre-existing worries about the gym environment. This can be difficult but I believe it is a crucial part of their recovery. Physical activity aids immunity, reduces inflammation and has a positive impact on mental health which are all things which could potentially speed up their recovery. Therefore, I will spend a significant period of time discussing week 7 during week 6 to calm any concerns and create a safe and positive transition for the participants.

Revisiting Reflection

References

• Aiyegbusi, O. L., Hughes, S. E., Turner, G., Rivera, S. C., McMullan, C., Chandan, J. S., Haroon, S., Price, G., Davies, E. H., Nirantharakumar, K., Sapey, E., Calvert, M. J., & TLC Study Group (2021). Symptoms, complications and management of long COVID: a review. Journal of the Royal Society of Medicine, 114(9), 428–442. https://doi.org/10.1177/01410768211032850
• Klaser, K., Thompson, E. J., Nguyen, L. H., Sudre, C. H., Antonelli, M., Murray, B., Canas, L. S., Molteni, E., Graham, M. S., Kerfoot, E., Chen, L., Deng, J., May, A., Hu, C., Guest, A., Selvachandran, S., Drew, D. A., Modat, M., Chan, A. T., Wolf, J., … Steves, C. J. (2021). Anxiety and depression symptoms after COVID-19 infection: results from the COVID Symptom Study app. medRxiv : the preprint server for health sciences, 2021.07.07.21260137. https://doi.org/10.1101/2021.07.07.21260137