Post-COVID syndrome: Things that trainers need to know

What are the latest scientific findings on the long-term effects of COVID-19? To what degree do seemingly fit patients suffer from impaired lung function – even after mild cases? What form might rehabilitation take? A talk with Prof. Dr. Koczulla, Chief Physician in the Pulmonology Department of the Schoen Clinic in Berchtesgaden and Professor for Pneumological Rehabilitation at Philipps-Universität Marburg:

Schoen Clinic Berchtesgadener Land is one of the leading clinics for rehabilitation treatments in the field of Pulmonology and is the teaching hospital for Philipps-Universität Marburg. Since May 2020, the clinic has been offering a special rehabilitation programme for people who have had the coronavirus under the leadership of Prof. Dr. Koczulla, Chief Physician in the Pulmonology Department and Germany's only Professor for Pneumological Rehabilitation. One of the focal points of their holistic concept is restoring the impaired lung function of COVID-19 patients. This does not simply involve patients who had a severe case, were placed on ventilators or ended up in the intensive care unit, because even patients who only had mild cases often suffer from the long-term effects of their COVID infection. Some of the most frequent symptoms of long COVID – defined as occurring more than twelve weeks after the start of the infection – include general fatigue, headaches, a loss of the sense of smell, and being short of breath. Prof. Dr. Koczulla works closely with patients suffering from post-COVID syndrome at the rehabilitation clinic, and in our talk he shared some insights into what he has learned from these efforts. According to his summary of the current state of knowledge, approx. 50 percent of those who have had COVID-19 in Germany have been affected by the post-COVID syndrome.

Prof. Dr. Koczulla, please share some insights into your daily work with us. How do you observe and treat post-COVID patients at the Schoen Clinic Berchtesgadener Land?

Our clinic is both a hospital and a rehabilitation clinic. This means that we were already treating COVID-19 patients during the first wave of the pandemic, and it goes without saying that we have seen a great many patients in recent months. In fact, 50 to 60 percent of the pulmonology patients here are suffering from what is known as post-COVID syndrome. Our scientific institute is following their cases and working on studies in this field. We draw a distinction between patients who were able to overcome their infections without being hospitalised (mild cases) and patients who had to be admitted to hospital on account of their infection (severe cases). On average, those patients with “mild” symptoms did not end up in rehab until six months after they were first diagnosed. For those patients who were admitted to hospital, the time that passed after their diagnosis was two months on average – meaning that they entered rehabilitation almost directly. We continuously observe our patients during their treatment (a period of approx. three to five weeks) and have been able to demonstrate that their symptoms – including breathlessness and fatigue – improved significantly during this time. In other words, a great deal can be done here, but there are a few factors that must be kept in mind. In addition to changes to the lungs, there may also be inflammation of the heart muscle that can still be diagnosed two to three months after the illness. These patients should not be pushed to their physical limits.

To sum up, post-COVID syndrome can create quite a wide spectrum of possible problems.

You have been offering a rehabilitation programme for persons recovering from COVID for nearly a year now. What form does this treatment take?

Since we began offering our post-COVID rehabilitation programme last May, we have learned a great deal and have changed numerous things. For example, we have brought froward the cardiological evaluation and devoted greater attention to the lungs – including the use of imaging. In addition, we have begun integrating cognitive training, because we observed that patients were also suffering from cognitive disorders. What we are referring to here are difficulties in concentrating, something that is also referred to as “brain fog”. Some patients, for example, have left their keys in the refrigerator and then spent half an hour trying to find them. That is why we have begun giving patients a test to determine their ability to concentrate and measure that mental performance. We are already seeing signs that our training programme is getting results.

Overall, we have seen that we must have a very personalised, interdisciplinary programme to treat post-COVID patients, because they are suffering from an extremely wide-rating ailment.

Are the effects of post-COVID syndrome any different for athletes who were already extremely fit?

We have treated numerous professional athletes and highly motivated amateurs, and we have seen that they naturally bring a whole different level of motivation to the table in their efforts to eradicate the physical impact of the infection as quickly as possible. Yet even in these cases, fatigue and cardiological limitations place limits on what is possible. It is clear that this is not an ideal combination. From what we now know, it is particularly important for patients like these that we take care not to push them too hard too quickly. When the presence of physical impairments is verified, including myocarditis (inflammation of the heart muscle) or fatigue syndrome, it is essential that we be cautious and deliberate with our treatments.

This also means that people pushing themselves to their limits when doing sports could actually have a negative impact.

The association of fatigue syndrome with COVID-19 is nothing new, however. In fact, we are already familiar with it from other viral ailments, particularly amongst women between the ages of 30 and 40.

How can fatigue syndrome be measured? How can trainers recognise it if their clients are in danger of this?

Naturally there are signs: if you push your limits today, for example, it is possible that you might find it difficult to get out of bed tomorrow morning. Anglo-Americans often assess this using spiroergometry and measuring the “VO2 max”, or maximum rate of oxygen consumption. One of the methods used in Germany is the grip test. For both fatigue and cardiological problems, professional expertise and diagnostic aids are necessary for many diagnostic aspects. When it comes to heart problems, you need lab tests, cardiac ultrasounds, perhaps even imaging, and you have to consider the findings as a whole.

In future it may be possible for fitness studios or trainers to work closely with medical specialists to serve specific patient groups.

Day 1 of the opening of fitness studios: Do you have any recommendations for fitness studio operators and trainers for dealing with athletes who have had COVID-19 and want to resume their training?

The fundamental recommendation that people pursue moderate physical activity enjoys widespread support. Before they begin pushing themselves, however, patients should first determine whether they might be suffering from fatigue syndrome or whether or not they have any heart problems. Assessing a patient's general clinical status can offer some guidance here. For trainers and fitness studios, this means enquiring about specific symptoms and making sure that the patient contacts their GP or even a specialist should any of these symptoms be present. In my opinion, the GP is the key person in these cases.

As a trainer, I would strive to convince my clients that they obtain the approval of their GP for their sports activities.

This may sound a bit over-cautious, but there are numerous areas in which we still do not have much data, and I believe it is essential that we protect the health of our patients and ensure that they are being monitored.