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Putrino worked with his patients to come up with this protocol

Our last blog covered a study showing that intense exercise messes with the mitochondria, inhibits energy production, and can even produce muscle damage in some people with long COVID.

Is all exercise necessarily bad, though? ME/CFS experts, and now David Putrino in long COVID, have produced gentler exercise programs that, when done correctly, can help some patients.

In a recent National Public Radio piece, “A discovery in the muscles of long COVID patients may explain exercise troubles“, David Putrino of the Mt. Sinai Center stated, “Physical exertion does harm to the bodies of people with these illnesses.His general guidance is to avoid exercise, practice “energy conservation, and engage in “autonomic rehabilitation”.

Exercise Causes Muscle Damage and Energy Depletion in Long COVID

Putrino quickly glommed onto the long-COVID problem and began trying new things early in the pandemic, one of which he called “autonomic rehabilitation”. Far from avoiding exercise, his approach embraces it, albeit slowly, while using breathwork to reset an unbalanced autonomic nervous system so that it can respond more normally to challenges. (Putrino believes the ANS  in long COVID is over-responding to any challenge.)  Putrino actively worked with patients to create the protocol. The aerobic parts of his approach – which comes later in the program – are based on a modified (toned-down) exercise protocol for postural orthopedic tachycardia (POTS) produced by Robert Levine.

The Study

In a 2021 preprint, “Autonomic conditioning therapy reduces fatigue and improves global impression of change in individuals with post-acute COVID-19 syndrome“, Putrino and colleagues reported on their study findings.

Study Assessments

The following symptom assessments were used:

  • Fatigue visual analogue scale (VAS),
  • Medical Research Council (MRC) Breathlessness Scale,
  • EuroQol health-related quality of life (EQ-5D-5L),
  • Pain VAS,
  • General Anxiety Disorder-7 (GAD-7),
  • WHO Disability Assessment Schedule (WHODAS),
  • Patient Global Impression of Change (PGIC).

David Putrino’s Autonomic Rehabilitation Program

Phase IA – The Setup

The first phase typically takes 4-6 weeks.

Recovery Breathwork

Putrino very early recognized that the breathing was off in long COVID. A 2021 Atlantic magazine article reported:

“Evidence began to accrue that long-COVID patients were breathing shallowly through their mouths and into their upper chest. By contrast, a proper breath happens in the nose and goes deep into the diaphragm; it stimulates the vagus nerve along the way, helping regulate heart rate and the nervous system. Many of us breathe through our mouths, slightly compromising our respiration, but in patients with post-acute COVID syndrome, lung inflammation or another trigger appeared to have profoundly affected the process. In these cases, patients’ breathing “is just completely off,” stated Dayna McCarthy of Putrino’s Mt. Sinai Center.”

Putrino began to use a program called “Stasis” to recover normal breathing patterns and in some patients, it helped. (Stasis provides different programs (Basic, Advanced breather, Master breather from free to $10/month) and breathwork coaching for those who desire it. Health Rising is not affiliated with Stasis in any way) The Atlantic article reported on it:

The program, which “involves inhaling and exhaling through your nose in prescribed counts in the morning (inhaling for 4 counts and exhaling for 6) and at night (inhaling for 4 counts, holding for 4 counts, and exhaling for 4 counts” was developed by Josh Duntz, a Navy Special Operations veteran, and his co-founder, Dan Valdo.

The idea was that a breathing program could help with the hypocapnia, or low CO2, levels found in long COVID (as well as ME/CFS) brought on by rapid, shallow breathing. Regulating the breathing can also reduce the stress response and enhance the immune response.

Putrino reported that everyone in the pilot program reported improvements in shortness of breath and fatigue. Breathwork didn’t cure anyone but it did “take the edge off their symptoms”.  He felt that breathwork helped get patients to a “place where the healing can start.” Note that ME/CFS exercise physiologist Staci Stevens of the Workwell Foundation also starts her patients off with breathing exercises.

The recovery breathwork in this study included 4-second inhalation/6-second exhalation nasal breathing during the rest breaks between each exercise set. Each rest break was less than 5 minutes.

Patients could progress to the next phase of the ACT for PACS program if they could tolerate the program for a week. Patients with greater than a 3-point change in their pain (using the VAS scale), who required greater than 5 minutes between exercise sessions to rest, or who simply wanted to stop the program, stopped at this point.

Even though the autonomic nervous system results, and symptoms, and the post-exertional malaise found in long COVID and ME/CFS are identical, Putrino never mentions ME/CFS in the paper. Only Gullain-Barre Syndrome, and post-viral autonomic dysfunction syndromes (post-viral orthostatic hypotension, postural orthostatic tachycardia syndrome POTS) are noted.

THE GIST

  • The last blog featured a study showing that intense exercise whacked the mitochondria and even caused muscle damage in many people with long COVID.
  • In an NPR article, David Putrino bemoaned the doctors who tell long COVID patients to hit the gym and noted that he’d created an autonomic rehabilitation program that was able to reduce fatigue.
  • Putrino’s autonomic rehabilitation is a breathwork/gradual exercise program, but it’s a very gradual program that seeks to slowly rehabilitate the ability of the autonomic nervous system to respond to challenges.
  • Putrino early on found evidence of hypocapnia (low CO2 levels) in his long COVID patients. (Low CO2 levels have also been found in ME/CFS) and can produce many symptoms. He has been using breathwork practices produced by a company called Stasis in his protocol. (The protocol is described in detail in the blog. Among other things Stasis provides breathwork coaching.)
  • Putrino starts his program with breathwork and range of motion exercises in an attempt to reset the autonomic nervous system, stimulate the vagus nerve, tone down the stress response, rebalance the immune system, provide mobility, and ultimately help prepare the ANS for exercise. (See the blog for details)
  • A study on his ACT exercise program for long COVID indicated that the program was not a game-changer, but it did improve fatigue (from very fatigued to moderately fatigued) and produced a slight but noticeable change in overall health for those who completed it (about 40% of the original group). Other aspects (breathlessness, pain, quality of life, anxiety, disability) were not impacted.
  • In the video interview, Putrino said some people did recover and it took about 100 days on the program for that to happen.
  • Most of the participants (60%), however, did not complete the program and we don’t know why. Levine’s exercise-based protocols for POTS – which this study was partially based on – can be quite successful for some, and have high dropout rates as well. While Putrino’s program is less taxing than Levine’s, a large Levine POTS study had a 70% dropout rate.
  • Putrino is not the only practitioner to try to get his patients to a better place before they attempt any exercise. Peter Rowe uses bodywork and stretching. Staci Stevens and Todd Davenport of Workwell use breathwork and stretching, and David Systroms wants to see progress on Mestinon before he starts to prescribe exercise. (These are discussed in the blog).

Supine Exercises

  • supine exercises that simply increase range of motion are done while a patient is lying down,
  • active range of motion open chain knee flexion heel slides,
  • active range of motion open chain hip abduction,
  • active range of motion concentric quadriceps activation via straight leg raise, concentric closed chain hip extension bridges.

Each exercise was performed over a 30-second interval. Patients performed exercises at their own, self-selected speed and repetition (to meet standardized RPE metrics). They were encouraged to perform each exercise at a rate of perceived exertion of 2/10 (very light exertion) on a modified Borg scale. The exertion is so light that Putrino said he had to convince some formerly healthy long COVID patients that it was worth doing.

Phase II – Isometric Exercises

After 4-6 weeks comes seated or upright isometric exercises:

  • seated hip adduction ball squeeze,
  • seated active range of motion hip flexion marches,
  • seated concentric quadriceps long arc quadriceps (LAQ),
  • side-lying hip abduction clamshells,
  • modified (high kneeling) plank,
  • the patients also continued with straight leg raises and bridges from phase IA.

Exercises were performed at an intensity of 2 sets of 10 repetitions each. For the plank exercise, patients completed 2 sets of 10-second holds.

The same stop protocol for Phase I applied to Phase II.

In Phase IIA and IIB – submaximal aerobic exercise. Heart rate, pulse oximetry, and chief complaint VAS were established at the start of the session.

Phase IIA 

Four stages – each lasting one week. Patients go from performing 5 repetitions at 1-minute intervals in week 1, up to 5 repetitions of 90-second intervals in week 4.

The goal is to complete 6 minutes of total aerobic training time without symptom exacerbation and be able to complete a 6-minute walk test (6MWT) at the end of week 4.

Phase IIB

Starting with 3 repetitions at 2-minute intervals in week 1, participants work up to 6 repetitions at 2-minute intervals in week 4.

The goal is to be able to complete 12 minutes total aerobic training time and set the participants up for a submaximal exercise test to begin Phase III.

Note that participants move to the next stage only if they can tolerate the present stage.

Phase III – the Modified Levine Protocol

Only at phase Phase III does Putrino employ a modified (toned down) Levine protocol which includes a 3-month long progressive and graded aerobic exercise training program. Patients only progress when they can tolerate the exertion without exacerbating their symptoms.

Using an established age-predicted heart rate maximum (75% of it) – a base rate of perceived exertion of (13-16 Borg scale), a “maximum steady state” (16-18 Borg scale), and a “recovery pace” (6-12 Borg scale) are established.

First, patients complete three sessions per week on a recumbent bike using the base and recovery pace for approximately 25-30 minutes per session. As the patients proceed, maximum steady-state intervals are introduced. Baseline, midpoint, and end-of-session heart rate, pulse oximetry, and chief complaint visual analog scale (VAS) data are collected.

Patients are encouraged to continue aerobic training, consistent with the guidelines of the Levine protocol, beyond discharge from therapy to maximize gains, maintain symptom stability, and promote exercise tolerance and the benefits of aerobic training.

Results

Of the 78 people who consented to be in the trial, 40% completed it. Unfortunately, the reasons 60% of participants discontinued the program were not clear. The authors cited problems with administrative follow-up and/or referral to physical therapy, or the patients’ own choice as reasons.

As noted earlier, the study used 7 symptom assessments:

  • Fatigue visual analogue scale (VAS),
  • Medical Research Council (MRC) Breathlessness Scale,
  • EuroQol health-related quality of life (EQ-5D-5L),
  • Pain VAS,
  • General Anxiety Disorder-7 (GAD-7),
  • WHO Disability Assessment Schedule (WHODAS),
  • Patient Global Impression of Change (PGIC).

Of those, the Fatigue Visual Analogue Scale (VAS) and the Patient Global Impression of Change assessments showed improvement.

Fatigue – The participants started off with a mean score of 51 (very fatigued, significant difficulty with daily activities) and ended with a mean score of 36 (moderately fatigued, some difficulty with daily activities).

Plus, the long-COVID controls who did not participate in the ACT exercise study did not progress and remained “very fatigued”. Overall, the people in the ACT exercise study judged they were less fatigued after taking the program (p<.03) than at the start of the program.

Global Impression of Change – The Patient Global Impression of Change (PGIC) (how much improvement occurred over the program) was increased in the ACT exercise group (p<.01) relative to the patient group who did not participate in the program. The median score of 5 in the exercise group (a slight but noticeable change) was a bit better than the mean score of 4 (somewhat better but no real difference made) in the control, non-exercising group, but nothing to write home about.

Putrino reported that the ACT for PACS program has been implemented across 53 physical therapy centers in the greater New York area and that he’s trained 700 doctors in its use.

Conclusion

Putrino’s autonomic rehabilitation is a breathwork/gradual exercise program, but it’s a very gradual program that seeks to slowly rehabilitate the ability of the autonomic nervous system to respond to challenges. Putrino starts his program with breathwork and range of motion exercises in an attempt to reset the autonomic nervous system, stimulate the vagus nerve, tone down the stress response, rebalance the immune system, provide mobility, and ultimately help prepare the ANS for exercise.

The ACT exercise program for long COVID was not a game-changer, but for those able to get through, it helped. It worked to improve fatigue (from very fatigued to moderately fatigued) and produced a slight but noticeable change in overall health for those who completed it (about 40% of the original group). In the video interview, Putrino said some people did recover and it took about 100 days on the program for that to happen. Other aspects (breathlessness, pain, quality of life, anxiety, disability) were not impacted.

Most of the participants (60%), however, did not complete the program and we don’t know why. Levine’s exercise-based protocols for POTS – which this study was partially based on – can be quite successful for some, and have high dropout rates as well. While Putrino’s program is less taxing than Levine’s a large Levine POTS study, for instance, had a 70% dropout rate.

Other Approaches

Other approaches to exercise in ME/CFS exist.

Putrino is not alone in his belief that work needs to be done to prepare long-COVID/ME/CFS patients for exercise. Staci Stevens starts off her heart-rate-based exercise system with breathwork, Todd Davenport uses breathwork and stretching, Peter Rowe uses stretching and bodywork, and David Systrom uses Mestinon to set the stage for exercise.

Mestinon (Pyridostigmine bromide)

Systrom only employs exercise in his patients after they’ve improved using Mestinon (or perhaps other treatments).

A quickie Mestinon study – the drug was given in between two exercise tests – suggested Mestinon may indeed help some patients exercise. Peak VO2 – the maximum amount of energy produced at a point during the exercise test – decreased in the patients given the placebo but increased in the patients given Mestinon.

Mestinon Moves the Needle on ME/CFS in Exercise Study

Mestinon also stopped the after-exercise energy drain; i.e. the increased oxygen consumption (peak resting VO2) that showed up during the resting period in the patients who didn’t get the drug. In fact, instead of increasing their oxygen consumption, the people receiving Mestinon significantly decreased their peak oxygen consumption during the rest period.

A placebo-controlled, blinded study of Mestinon by itself and in combination with low-dose naltrexone (LDN) is underway in ME/CFS.

Lifting ME/CFS: The OMF’s Unique Two-Drug Clinical Trial to Begin Soon

Check out one story of a longtime ME/CFS patient who was able to exercise after using Mestinon.

A Mestinon Miracle: Vagus Nerve Stimulating Drug Helps Long Time ME/CFS Patient Exercise

Stretching and Bodywork

Peter Rowe and Workwell (Staci Stevens, Todd Davenport) have found that stretching and/or bodywork can help their patients tolerate and improve with exercise.

Rowe – who has found that people with ME/CFS exhibit areas of “neuromuscular strain” that impede their range of motion and cause pain and fatigue, stated that “manual forms of physical therapy have been quite helpful for improving overall function, especially when people had not done well with exercise-based therapies alone. In those cases, the exercise ended up being “too much, too soon.”

After the areas of restricted movement have been treated, people find that they can tolerate gradual increases in exercise without as much post-exertional worsening of symptoms. This then allows them to obtain some of the expected benefits of regular exercise. To my surprise, I have found that stretching in combination with exercise band exercises works!  It’s probably all anaerobic yet I feel a stronger and more resilient as a result of it. It’s one of the few things I can say that has helped my ME/CFS/FM.

Getting Unrestrained: Dr. Peter Rowe on Neuromuscular Strain in Chronic Fatigue Syndrome (ME/CFS)

Similarly, Davenport combines stretching exercises with deep diaphragmatic breathing exercises in order to increase oxygenation and energy availability. When the patient’s system has rehabilitated a little bit, he adds very short-term, low-load, strengthening exercises.

How Physical Therapists are Getting it About Chronic Fatigue Syndrome (ME/CFS): The Workwell Foundation Pt. I

Heart Rate-Based Approaches

Putrino employs a heart rate-based approach in the later stages of his protocol. In an attempt to avoid stressing the aerobic energy production system -some ME/CFS experts do as well.

Staci Stevens and Workwell use cardiopulmonary exercise tests to identify heart rates which should not be exceeded to avoid taxing a broken aerobic energy system. They recommend that exercises, in general, last less than two minutes.

One patient who followed Staci Stevens’ activity and exercise program religiously used a heart rate monitor to ensure that she operated in her anaerobic “safe-zone”. She did diaphragmatic breathing, upper body flexibility stretches, and resistance and short-term endurance exercises three times a week.

A follow-up a year later indicated that not only had she stopped her activity regression, but she had been able to increase her activity levels without causing ill effects. Even though she had only been engaging in anaerobic activity, her CPET tests revealed significant improvements in virtually every category ((Peak VO2 (26.1 ml/kg/min), ventilation (90 L/min), respiratory rate (54 breaths/min), heart rate (189 beats/min), and systolic blood pressure (170/98)).

How Physical Therapists are Getting it About Chronic Fatigue Syndrome (ME/CFS): The Workwell Foundation Pt. I

  • Coming up – a new anaerobic exercise approach from Germany

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Nobody who knows these diseases thinks exercise is the way out – quite the contrary. Some ME/CFS experts have found that “exercise”, properly done, can be helpful for some people.

It’s not a game-changer but we’re not at the game-changer stage yet. We’re at the “anything that can move the needle a bit” stage and that’s what this blog is about. If you’re interested in finding ways to “move the needle” in even small amounts please support us in a way that works for you.

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