Physical Activity After Covid-19 with Dr David Salman

Dane talks to Dr David Salman about his BMJ paper ‘Returning to Physical Activity after Covid-19’

In the final episode of our podcast series, Dane catches up with Dr David Salman, a GP specialising in physical activity, sports and exercise, and musculoskeletal medicine. They discuss the key points from David’s recently published British Medical Journal (BMJ) paper on ‘Returning to Physical Activity after Covid-19’, the importance of a phased approach when returning to physical activity post-Covid, and the role of physical activity in those with long Covid. Read the full BMJ paper here.

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Episode
10
25 mins

Dr. Dane Vishnubala:

Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass. This is a podcast where we catch up with leading health care professions, discuss tips and tricks for carrying out remote consultations, as well as bringing the key nuggets of information for your CPD. Now you can listen to us on Apple Podcasts, YouTube, Spotify, or wherever you get your podcasts from, so hope you enjoy the episode. My name is Dane. I'm a GP and a sport and exercise medicine consultant based in Yorkshire. And today I'm joined by Dr. David Salman. We're going to be talking about his BMJ paper, Returning to Physical Activity after COVID-19, that was published fairly recently. So David, thanks for joining us.


Dr. David Salman:

No, thank you for having me Dane.


Dr. Dane Vishnubala:

Obviously you've got a range of experience doing remote consultation, both in general practice, but also in secondary care, so we'll touch on this later. Before we get started on the actual BMJ paper, which has had a lot of views and a lot of interest, we'll talk about it shortly. Tell us a little bit about yourself and what you're doing at the moment.


Dr. David Salman:

I'm a GP, but I've got a special interest in physical activity, sports and exercise, and musculoskeletal medicine. So I work as a GP, but also as a Fellow in sports and exercise clinics at Imperial College, London, and I'm also in a research and teaching role in physical activity.


Dr. Dane Vishnubala:

Perfect. That makes you the right person to talk about returning to physical activity after COVID-19. So tell us a little bit about this BMJ paper and how did it come about?


Dr. David Salman:

A lot of us in general practice, or certainly a lot of my colleagues were particularly in the first wave of infection and particularly early on in the pandemic were being asked by people who were previously quite active, who had what they thought was COVID-19 because we weren't testing in the community at the time, and were asking at what point would it be safe to return to physical activity. But we were also seeing people who had previously been, for example, runners, had a period of time where they'd been febrile, had recovered for a day, going out for a run and felt they'd been set back. That was something that we were seeing, not uncommonly. There was a fair bit of literature on returning to physical activity or routine training for athletes. What we wanted to do was to collate some of that information


Dr. David Salman:

into something that might be useful for the general public who are active, but also for general practitioners who might be fielding these questions. But also given the caveat, that we were dealing mostly with unknowns. So we wanted to do something that was pragmatic, that helped sustain physical activity in those who wish to do so and support those individuals, but also dealing with the uncertainty that we didn't actually know a lot about what the sick really might be and just trying to take account of what we didn't know and what we thought might be the potential consequences.


Dr. Dane Vishnubala:

I think a lot of people valued that because there wasn't that kind of guidance in primary care before. I guess for those who haven't read the paper, but are potentially seeing people post-COVID, would you be able to kind of summarise some of the key points and kind of take homes from the paper?


Dr. David Salman:

Yeah, certainly.


Dr. Dane Vishnubala:

Put you on the spot there.


Dr. David Salman:

I think one aspect is that this was written during the first wave and certainly in a situation like this, it's such a rapidly evolving landscape, that new information is coming out all the time. So we certainly know a lot more than we did when we wrote this. I still feel that a lot of the key points are important. One of those was ensuring that there was a gap between resolution of symptoms and restarting physical activity to some degree, because we were seeing people who were deteriorating in the second week of illness after a period of feeling relatively well, and we wanted to take account of that. A lot of the literature was saying, for example, 10 days from onset of symptoms or seven days following resolution of symptoms. We suggested that people restart following at least a seven day period of no symptoms. Again, more as a pragmatic approach rather than a set in stone


Dr. David Salman:

and evidence-based point in time. I think the prime aim of that is to slow down a return in those people who may be itching to return to physical activity when they were previously very active. Another aspect would be risk stratification. Again, dealing with what we know and what we don't know, we knew about the potential for myocarditis following any viral infection, but COVID-19 in particular. Therefore we suggested that anyone with a suggestion of cardiac involvement, for example, palpitations or chest pain as part of their illness, would need further assessment prior to being given a clear pass to return to physical activity. Again, we also knew that thromboembolic phenomena were a potential consequence, and we suggested that those with more complicated infections, certainly those who are hospitalised may need further assessment. And that was partly based on the fact that a lot of the people hospitalised in our areas where we work, had some input from a post-COVID rehab clinic in terms of returning to normal functioning.


Dr. David Salman:

And I think also we need to take into account the vast heterogeneity of presentations with COVID-19 from complete and asymptomatic to very mild illness, to more complicated illness. Therefore, again, this is not so much a guideline, more as a framework in which people might be able to consider certain points. So that was number one, leaving a gap, number two, was stratifying. I think that the very key part of this was just to encourage phased and gradual return to activity, but with an emphasis on self monitoring. Making sure that there's no return of symptoms or new symptoms, making sure that fatigue levels are normal, that there's no excessive lethargy. And also screening for mental health consequences of what has been for a lot of people, a very difficult period, not just in terms of their own health, but the health of their family, period of being locked down. There's a lot of complicated factors around people returning to activity.


Dr. Dane Vishnubala:

You talk about this phased approach. Why was the phased approach important?


Dr. David Salman:

Generally a phased approach to returning to activities is part of any return to play protocol and that's really to give somebody a series of checkpoints, which to self monitor, look out for any adverse signs or symptoms and seek help if needed. And I think those are helpful for people, particularly if they're time bound. We put in these, again, this is a framework, it's a kind of suggestion. It's very difficult to base something like this on the evidence that we had at the time that we were writing, but we hoped that it might be of help to somebody to support them being active. And we suggested that after that seven day period of no symptoms, then further seven days with very light intensity activity. So whether that's just focusing on breathing, on flexibility, or just making sure that people are ambulating or mobile where possible. But again, looking out for those things, returning symptoms, fatigue levels, lack of recovery.


Dr. David Salman:

And if they felt that they were able to progress to the next stage, we talked about incremental increases in walking and this gave some suggestions as to when people might feel that they'd be able to progress to further stages, which would then include very short bouts of aerobic activity, which the person would feel moderate, not hard. So you'd be able to have a conversation while doing it. And that could be from going up and down the stairs, to a gentle cycle. We talked about having a five minute block, two five minute blocks, separated by a period of recovery. Again, that's just to give somebody a chance to monitor, to look for any adverse signs or suggestions that they might need further input or further assessment. We incorporated another week of, or suggested another week where, again, a similar approach, to introduce some challenges to balance and stability, such as side steps or balance activities.


Dr. David Salman:

Only then if somebody feels absolutely well or comfortable, no return of symptoms, fatigue levels are normal, and there's been no issue with recovery then to return back to what they were doing, which for a lot of our patient population may be fairly high intensity activities. But those principles of watching out for any adverse effects still hold because we're dealing with a disease, the consequences of which we don't fully understand. So on one side, one potential criticism is this is very slow and it's slowing down people who want to be active based on risks that may not be valid, may not be fully true. Another side may be that it's encouraging physical activity in a situation where people don't understand the full consequences of the disease and there may be potential harms there.


Dr. David Salman:

And I think all of this has to be at balance because we know that inactivity is potentially harmful for people on many fronts, whether it's disease risk, whether it's decreased muscular, skeletal functioning, whether it's mental health. We know that being active has a very positive effect across the lifespan and across different systems. I think it's about supporting people to be active where possible from the best of our knowledge, and certainly at the time of writing versus being vigilant for any signs or symptoms that further additional help might be needed. I don't know if we've got that balance completely right, but at least we've tried and hopefully produce something that may be helpful for people.


Dr. Dane Vishnubala:

I think a cautious approach when you start with something that has so many unknowns is not an unreasonable way to start. And like you said, maybe some of these things we will revisit. And the phased approaches you mentioned already, it's not just for this, it's for any return to play isn't it. You've got deconditioning of muscles, tendons, a range of other issues, so actually you don't want to just jump straight back into what you did before. Particularly if some people might have been out for a few weeks, so there's an injury risk as well. So it does combine all of that. So, no, I thought it was a very reasonable stance of course, but I think it's something for us to be clear that it probably was a more cautious approach than the elite athletes and the kind of frameworks in place there.


Dr. David Salman:

I think the concept of de-conditioning is not that clear, understandably, to a lot of people because it's quite insidious. It doesn't take long for you to decondition in something that you were previously very able or active at and I know that elite athletes will notice this after a period of illness or injury. I think that it's something to bear in mind, following return to play from any sorts of illness is that your mind may want you to return at the same level as what you were doing before, and you may feel well, but your body may not be at that level yet. Therefore, a cautious and graded return allows you to develop that mobility, flexibility, and the coordination that you need to be able to do what you were doing before, if it was at the high level. For a lot of people, we're talking about weekly Zumba class, walking around the shops or walking their dog, because that was their form of physical activity. That is important and that's what helps. It has protective effects on people's mental health and also keeps them physically functioning. The same things apply, I think it's about supporting people where possible.


Dr. Dane Vishnubala:

Obviously with this paper, there was quite a lot of feedback from groups who were championing how to look at patients of long COVID and felt that it didn't come across here. What are your thoughts around the role of physical activity and long COVID and the limitations of obviously what we were trying to achieve with this paper versus what that group needs is a separate entity?


Dr. David Salman:

I think it's a really important question. I mean, when we wrote this, between the period of writing and it being published, there was more guidance on long COVID from, for example, Nice. But at the time of writing, it was something that we knew we didn't really know how extensive it was going to be in terms of incidents in the population or prevalence. I think the issue with long COVID is that it's really an umbrella term for what may be a wide range of systems and potentially different types of illness. I don't know yet. I know there's been some recent literature about the wide variety of systems that can be affected. And certainly from general practice, I see people who may have long COVID from mental health effects, to cognitive effects, to respiratory effects.


Dr. David Salman:

When we wrote this article, we felt that anyone with any ongoing symptoms or signs suggestive of an enduring disease would need further assessment. I still think that holds because the guidance is that if you are still suffering adverse effects in the long COVID period, then you do need further assessment because you need to know what is happening. I think we can't advise on returning to physical activity with such a broad brush approach in a patient population who need further support and assessment. But certainly, and I know that Jonathan Korgaonkar, my colleague, who you may speak to in further podcasts and works with patients with a long COVID, is one of the authors on the paper. We feel that the patient population certainly needs a holistic and individualised assessment and guidance based on the wide range of symptoms that they may have.


Dr. David Salman:

Therefore, whether physical activity and mobility plays a part in that kind of guidance would really depend on that individualised assessment. I think one of the concerns was that long COVID is certainly from the qualitative data seen, and I think there has been quite a bit of data on this now, kind of a relapsing remitting approach. So someone may feel fine and then have a setback. I think that's quite difficult to take into account with any sort of guidance, because if someone feels fine, they will want to return to work, they may want to return to physical activity. I think, again, it's just about getting the balance right. How do you support someone to achieve their aims, do the things that they find helpful in their daily lives while also seeking help when they need to. Again, I think it ultimately will come down to self-monitoring, certainly in those people who feel back to normal and well. But I think with long COVID, we will see a lot more information and guidance out there.


Dr. Dane Vishnubala:

Sounds good.


Dr. David Salman:

I think one aspect to take into account with long COVID is that people described setbacks from potential minimal activity. So, from things such as brushing hair, going back to work, bathing, giving the children a bath. Again, I know that long COVID clinics do use that kind of information as part of their screening criteria and I think that's important. We suggest in our guidance, any lack of recovery or ongoing or issues with excessive fatigue needs to be taken account of and may indicate the need for further assessment. And I think that takes into account these kinds of symptoms too.


Dr. Dane Vishnubala:

Now that makes sense. And for all the reasons you said, it's why we can't brush it into a guideline really. Maybe we'll know more things in the future. Kind of moving on from this really, I think the BMJ was extremely popular. A lot of clinicians really enjoyed it, and I got a lot of feedback from just general colleagues who had read it and found it a useful starting point. Well done on a great paper. Moving on from that, obviously this is a remote consultations podcast, so I wanted to kind of finish off talking a little bit about the fact that actually you do both primary care in terms of GP remote consultation, but also you're now working in a secondary care MSK service as well. What have you noticed in terms of differences between approaches for remote consultations in these different services?


Dr. David Salman:

Differences between the primary and secondary care interface, I don't actually see too much in terms of the similarity. I think it's certainly something that we've all got better at over time and certainly trying to do an MSK assessment on a phone or on a video where there's poor wifi or whatever can be challenging. I think we've all developed techniques for diagnosing shoulder issues by doing a truncated or kind of focused examination on the video. I think part of MSK care is that it has to be face-to-face and has to be interactive. I think both patients and clinicians gain a lot from that interaction. I think we've all been trained in terms of the physical examination. It's not just part of the consultation, it is a key aspect, palpating a joint, taking it through its motion and you can't really replicate that in any other way.


Dr. David Salman:

I think what the past year or two have taught us is that telephone triage is possible and a lot more than what we felt it was, and certainly in telephone consultations you can learn a lot about your patient. Although you may lose some of the opportunistic signs and things that you might pick up when seeing someone from looking at their gait, for example, as they walk into the clinic room. You can also gain a lot from the way people talk to you on the phone. And certainly, I've had situations where I've wondered if someone would have expressed so much to me in terms of social situation or family situation, if we were face-to-face rather than on the phone. Like all these things, there are certainly positives and negatives to take from all aspects. And I wonder if we're going to move to more of a blended type clinic, where you have some telephone, some video and some face-to-face.


Dr. Dane Vishnubala:

I think it sounds like there's going to be more of that and it's kind of how you organise general practice or secondary care services, to do a bit of both versus what it's always been like in primary care. Which I feel it always used to be, let's do a phone call initially, but really all we're doing with the phone call is deciding, do they need to come down or not? Versus the difference now seems to almost be this conversation of, can we actually deal with this over the phone, which has almost a different look at it.


Dr. David Salman:

I think we're moving in a way that I certainly recognise that from my early consulting, which was very much deferring decision-making till that face-to-face assessment was going to happen, and then realising that actually this was a long-haul pandemic and we were going to have to make decisions on the front. I think we've all got better at that. I definitely welcomed the face-to-face aspect again, but I've learned a lot about my consulting skills from the past year.


Dr. Dane Vishnubala:

Definitely. I guess just to finish off, given your amount of research and you're always doing something, what's currently on the project list at the moment, anything of interest?


Dr. David Salman:

A few things are bubbling in the background, but I think one of the key things we're working on at the moment is revisiting this building base fitness, following a period of inactivity or illness, and really providing something for returning to activity for the general population. I think the athletic population or the elite athletes have a lot of guidance and a lot of resources, we feel that there is something out there that we can produce something for people who do want to be more active but don't know where to start. And a part of that is correcting some of the base de-conditioning that people have undergone through June, a period of inactivity or illness. So we're trying to create a digital tool which can help guide people back to a point where they can then feel comfortable doing something more intense with hopefully less risk of injury. So that's what we're working on now.


Dr. Dane Vishnubala:

Perfect, sounds interesting, look forward to hearing more about it in due course. Thanks, David, really interesting. And thanks for kind of summarising your paper and some of their definitely a bit challenging pros and cons. That's it for our session today on the recently published BMJ paper Returning to Physical Activity after COVID-19. Thank you to you guys for listening to us on our remote consultation masterclass series. Hope you found it useful and remember, you can subscribe to our podcast through Apple podcasts or Spotify.

(01:07) Episode introduction
(01:39) Introduction to Dr David Salman
(02:10) The BMJ paper (‘Returning to Physical Activity after COVID-19’)
(04:24) Key points from the BMJ paper
(08:05) The importance of a ‘phased approach’ when returning to physical activity
(10:50) Criticisms of the approach
(14:49) The role of physical activity and long COVID
(19:29) Differences between the approaches to primary and secondary care services during remote consultations
(23:03) Future projects


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