Monthly Archives: March 2022

7th February – 13th February

• Hours: 15

Main Theme Addressed During Phone Calls

• Thoughts and feelings around continuing with their rehabilitation independently.
• How was the programme helped each participant individually.

Functional Exercise Class

• ((45s  x 15s rest) x 3 followed by a 30 second rest) 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.
• Increase of 15 seconds during working phase due to familiarity of new exercises.

Drop-in Session

• Once again, this was a fairly hands-off session in terms of guidance from me. All participants were happy with their training and looked confident doing so. They required no prompting from me which indicates that they would be capable of continuing their training sessions without guided support.

Analysis & Evaluation 

• All participants, excluding one, reported improvements since starting the programme. Improvements noted were; improved energy levels, reduced fatigue, improved sense of wellbeing, decreased breathlessness and an increased exercise capacity.
• Many reported that it was having a group of people going through something very similar to them that helped their recovery. They felt they were surrounded by people who understood what they were going through and that it was nice to be on a programme where people didn’t just think they were ‘making up’ their symptoms.
• One participant ran 5k the weekend before our final week and he was delighted. One of his goals was to return to running but he never expected to be this far along already. At the very beginning of the programme this participant was completing 1 mile walks and suffering from fatigue on a daily basis. We focused on the 10% rule with his walks and only increased his walking distance or time if he felt he was able to, in accordance with his fatigue. When we reintroduced running, which was only a few weeks ago, we looked at doing 30 secs of running to 90 secs of walking. This worked well and then participant was then happy to control his pacing from this point onwards. To have run a continuous 5k at this stage does seem like a steep increase and it is more than likely his incremental adjustments were too large. However, the participant noted that there were no ill effects after the run so we could have potentially been erring on the side of caution previously.
• Interestingly, the patient above seems to have made a spontaneous recovery. He is also not the first one I have seen do so. There has been a handful of participants that I have worked with over the past year who at any stage during their recovery seem to make such a steep improvement in such a short space of time that they appear to have improved overnight. Very little is still known about long covid and why some people make fast recoveries than other is still unknown. However, it is known that the more symptoms you present with during the acute infection the more likely you are to develop long covid (Sudre, et al., 2021). Furthermore, being over the age of 50 and having pre-existing health conditions – mental of physical -increased the risk of developing long covid (Crook, et al., 2021). Therefore, maybe having less of these risk factors may contribute to faster or even spontaneous recovery if the correct strategies, such as pacing, are put in place to allow optimal healing.

Conclusion 

• It has been a great challenge to work with people experiencing symptoms of long covid. It doesn’t exactly fit in with what we have been learning but there is an overlap in the knowledges and skills. For example, I have been able to use my exercise knowledge to create appropriate activities for the group and individuals. However, I have probably learned more from the experience than what I took to it. I think before the rehab programme I didn’t really consider psychosocial factors as important. This is likely because learning anatomy, pathologies and rehabilitation was such a challenge to me that I prioritised it over the psychology of rehabilitation. However, I have learned that this can be such a determining factor to successful rehabilitation. If a person doesn’t believe what you or they are doing will help them, then they are less likely to adhere and/or see positive results.
• Moving forward, with all my rehab, I will be working with patients to explain the benefits and the underpinnings of treatment so they fully understand why they are doing or receiving a certain course of treatment.

Revisiting Reflection

• Crook, H., Raza, S., Nowell, J., Young, M., & Edison, P. (2021). Long covid-mechanisms, risk factors, and management. BMJ (Clinical research ed.), 374, n1648. https://doi.org/10.1136/bmj.n1648

• Sudre, C. H., Murray, B., Varsavsky, T., Graham, M. S., Penfold, R. S., Bowyer, R. C., Pujol, J. C., Klaser, K., Antonelli, M., Canas, L. S., Molteni, E., Modat, M., Jorge Cardoso, M., May, A., Ganesh, S., Davies, R., Nguyen, L. H., Drew, D. A., Astley, C. M., Joshi, A. D., … Steves, C. J. (2021). Attributes and predictors of long COVID. Nature medicine, 27(4), 626–631. https://doi.org/10.1038/s41591-021-01292-y

31st January – 6th February

• Hours: 15

No phone calls this week

• The reasoning behind no phone calls this week is to allow participants the opportunity to experience what a week will be like without that 1-1 tailored support. However, they have the safety of knowing that if they need further advice and support they have the following weeks to ask questions they may not have thought of previously.
• It is also not a week of having support completely removed as I am still there during the gym drop-in and to teach the group class. So any immediate concerns can be addressed if necessary.
• Most participants respond well to this set-up. Many of them state that they miss their weekly phone call; however, there is never really a complaint of feeling they can’t continue their rehabilitation independently.

Functional Exercise Class

• ((30s secs x 3 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.
• There is a slight regression in intensity this week due to the change in exercise. Previously, the participants have been completing the same exercises each with only the duration increasing. Due to the change in exercise, it was important to reduce the intensity to allow them to adjust to the new exercise. The theory underlying this decision was from Blanchard and Glasgow (2014).

• The diagram from their paper highlights a staged progression to rehabilitation.

• Over the past 11 weeks, I have introduced 3 different types of exercise with small increases in intensity over time. As there are always variations, participants may choose to complete a simplified version of an exercise when the intensity increases or choose to remain at their current level with or without an intensity increase. As week 11’s class had new, but familiar movements, it was still important to remain in-keeping with this staged progression and therefore, reduce the time to prevent too steep a progression.

Drop-in Session

• I remained very hands-off during this session as it was about the participants coming and completing their rehabilitation independently. I was still there to talk with the participants on a social basis and if anyone had any questions they of course knew I was there to help.
• The cohort did extremely well and were even able to appropriately substitute exercises if the kit they were familiar with using was unavailable. E.g. BW squats instead of leg press.

Analysis & Evaluation 

• Most of the participants report that the class feels more challenging, even though the intensity has been reduced. Therefore, choosing to lower the intensity was the correct approach in this instance. Many also reflect on how far they have come at this stage and note that they would not have been able to complete this class at the early stages of rehabilitation.
• I think at this stage it is really important to ensure that participants aren’t given something so challenging that it overwhelms them and makes them feel as though they potentially haven’t made any progress.

Conclusion 

• As the programme comes to an end, I am taking more of a hands off approach to give participants an insight into carrying on their rehabilitation after the programme comes to an end. However, I am still applying principles of rehabilitation to the elements that I am still heavily involved in and considering participant response the adjustments made this week were suitable.

Revisiting Reflection

• Blanchard. S., & Glasgow., P. (2014). A theoretical model to describe progressions and regressions for exercise rehabilitation. Physical Therapy in Sport, 15(3), 131-135. https://doi.org/10.1016/j.ptsp.2014.05.001

24th January – 30th January

• Hours: 15

Main Theme Addressed During Phone Calls

• 2 participants starting to feel like themselves anymore and rarely think about long-covid
• 1 participant opened up to have been dealing with a breast cancer scare since Christmas.

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.

Analysis & Evaluation 

• Interestingly, two of the participants who have started to feel much better as the two participants whose attendance is a bit up and down. One more so than the other but attendance isn’t what it once was. As they both started to report in phone calls that they started to feel better other things started to take priority, e.g. taking kids to a football match or taking the kids to football.
• I found myself really conflicted with both these participants as I felt I needed to encourage them to maintain their rehabilitation in order to ensure they were stable. I didn’t want either of them to do too much one day and then experience a relapse. However, the things they were doing instead of the programme were elements of their life that they missed due to their long covid so, I felt their progress needed to be celebrated.
• We have been taught that rehabilitation should be patient-centred and fit the patient’s lifestyle. And, unlike many sports injury, there isn’t a set protocol on how to successfully rehabilitate people living with long COVID. As the activities that these participants were doing, required an energy expenditure that they were not capable of before then there is no reason for me to assume that ‘unstructured’ exercise doesn’t hold a place in their rehabilitation. Especially, when I consider the psycho-social impact COVID can have on participants. It is worth noting that limited social support or family support has been shown to be a barrier to adherence (Jack, et al., 2010); however, in this instance it seemed actually having that support hindered their adherence. Both of these participants reported extremely supportive families and that they wanted to get back to feeling normal with them again.
• Another participant this week opened up about a breast cancer scare she has been dealing with since Christmas. She initially told me via email and we then discussed how she was at her weekly 1-1 phone call. Naturally, the scare had been weighing on her mind – her biopsy was coming up soon and she was dreading the thought of having to deal with cancer on top of her long covid. I just listened to what the participant had to say and refrained from offering advice in this situation. During our EWB training, when dealing with significant EWB concerns that are beyond our scope of practice we are to practice repeat back what the participant has said, thanking them for sharing the information and asking questions such as, ‘ is there anything you would like me to do know that you have shared this with me?’ The participant confirmed that she just wanted to keep me informed and that she would need a some time off from exercise as he biopsy fell the day before an exercise class. This particular participant has reported no improvements in her fatigue since starting the programme. However, she has also been quick to reject any possibility of time off work or trying to slow down. So, I did wonder if since the scare started if she has been trying to keep herself busy so she would be distracted and maybe not think about it as much. Situations like this, highlight that rehabilitation needs to be flexible when it is called for. Many participants worry that if they don’t attend for whatever reason that we would remove the from the programme. However, as this situation and also the previous two highlight, there are many reasons to justify non-attendance. I think the important thing is ensuring that attendance doesn’t start to diminish entirely.

Conclusion 

• I have always assumed that people don’t adhere to rehabilitation because they don’t understand why it is relevant to them, they find it boring or they don’t see results quickly enough. However, adherence is much more nuances than that. This week has shown me that actually non-adherence may be a sign of successful rehabilitation that requires further progression or it may be a sign of more complex matters at hand that need to be addressed above their current rehabilitation programme. I think the challenge then lies in having these participants return to the programme on a consistent basis. Non-adherence, although not ideal, is sometimes not avoidable; however, it is important to get people back on track once this has happened and have a shared discussion about how this may look for them going forwards.

Revisiting Reflection

• Jack, K., McLean, S. M., Moffett, J. K., & Gardiner, E. (2010). Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy, 15(3), 220–228. https://doi.org/10.1016/j.math.2009.12.004