Dane catches up with Dr Rebecca Robinson, a Consultant in Sport and Exercise Medicine with a special interest in female athlete health and oncology. They discuss cancer and exercise, Covid-19, long Covid and remote consultations.
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Dane: Hi there, Dane here from Arc Health. Welcome to Remote Consultation Masterclass. This a podcast where we catch up with leading healthcare professions to discuss tips and tricks for carrying out remote consultations, as well as bringing you key nuggets of information for your CPD. Now you can listen to us on Apple Podcast, YouTube, Spotify, or wherever you get your podcasts from. So I hope you enjoy the episode.
Dane: Today I'm joined by Dr Rebecca Robinson, who's an SEM consultant. Today we're going to be talking about a range of things but it's going to include cancer and exercise, long Covid and remote consultations. Rebecca, thanks for joining us today.
Rebecca: Thanks very much Dane, it's a pleasure to be here.
Dane: Before we get started I guess everyone likes to know someone's story to begin with. Tell me a bit about yourself and your career today.
Rebecca: I'm a consultant in sports and exercise medicine. And usually when I say that people are straight away, "What does that mean?" It's a real range of work as you'll know too, Dane. I really spend half of my time looking after athletes who are at the highest level, usually aiming for the Olympics or are in professional sports, and we're trying to keep them healthy because they often come down with injury or illness and trying to rehabilitate them back to be the best they can be.
However, on the other side exercise medicine is really all about trying to optimize health. And that's looking at the general population and also people who've had long-term illness whereby they actually may have made a good recovery from the initial illness, but how do we try to get their general health back because we know that being fit can help on a lot of illnesses, a lot of prevention. Also, trying to optimize physical activity in the general population because people are less fit often and it's good for their general health.
And actually, in both aspects, there's research involved. In the latter there's certainly a lot of areas where we need to try and help this become part of what we do, especially in the National Health Service. And I guess within that, one of my interests therefore is in cancer because that really is a long-term condition for many people now, and one way we think exercise could be really, really exciting too.
Dane: Cool. As with all sports medicine doctors, I guess that is a portfolio career of interest and I guess a varied set of roles. And obviously we're going to talk about the Covid stuff in a bit, but let's start with the cancer and exercise stuff. You've actually piloted and run a service in the past and you're still running a service at the moment? Tell us a little bit more about that. What's the service look like, who's it aimed at?
Rebecca: I guess one of the best ways maybe for me to try and explain it is how this evolves. When I was training in sports exercise medicine, before I was a consultant, I had great opportunity to travel abroad and see what was happening in different centers, because this is an area that is still growing. Basically what we know is that exercise can be really good in cancer. We don't quite know why, we don't quite know what type of exercise, we don't know how good it is in prevention or secondary prevention or in actual treatment of cancer. And obviously that is not one disease, it's many subtypes.
But basically I was really fortunate in Sheffield, which is where I finished my training in sports exercise medicine, to work in clinical research for a couple of years and basically worked within the teaching hospital at the time. And what we really looked at there in terms of the research question was, what did health professionals think about physical activity so those at the frontline in oncology really, so within the hospital. And in a similar way, that question has been asked in the patient group and more in primary care to say, "Well, what actually do we need people to know? What do they know already?" And the answer overwhelmingly was that people are very keen and understand the need but don't quite know where to place this yet.
In terms of a service, what I've been doing more recently is working remotely, as well as in-person. And I guess the ideal... I'm able at the moment to deliver it in private practice, which is not my ideal in terms of where I want all of my work, but I'm very, very fortunate to work in a clinic with a brilliant team. So it's fascinating to be able to do that, I just want that reach to be for all patients.
What we can do within sports exercise medicine is basically, looking at a patient wherever they are in their journey with cancer. So often that's during treatment, but it can be before treatment. Looking at how they might have to be for an operation or to tolerate treatment. What happens during the treatment? How do they continue to exercise? Very, very significantly, and probably where I see most of my patients, is after cancer. Because if someone has done very well, which they often do, fortunately now from the treatment, they can often have what we call late effects, and these can be very significant impacting on their quality of life, such as looking at fatigue, but also looking at some other aspects like cardiotoxicity, which can happen due to the drugs that people are on.
But we also see increases in problems like cardiovascular disease, in a population that's had cancer. Impact on their bone health, and actually lots of the questions come from all different aspects and all different types of cancer. Can I cycle when I'm having treatment for my prostate cancer? Can I swim when I'm on chemotherapy? What can people do, how to adapt to the fact they might not be able to do what they want to do, and that's just for the active population.
So for those people, for whom physical activity, wasn't something normal in their life for a certain level before cancer... Just to sort of say, oh well, you must exercise and get fit, sometimes seems a hard thing to say. But actually, how can we enable someone to be a bit more active? And that might just be at home, in the garden, when they've had a cancer diagnosis, but alongside all of that kind of must come the clinical research to say, well, is this important and why?
So in an ideal world, I'll see somebody at any of those stages. Often we'll have some markers in terms of knowing where all their scans are at. We'll be able to look at where their blood tests are at. In the world that I can work in a clinic currently, in a private clinic, we can work with exercise, physiology and physiotherapy.
In terms of how that would translate into an NHS clinic, which I'm hoping to pilot quite soon. It would be very interesting because actually, there is a cost that is additional to the standard treatments that people have. But relative to the cost of the treatments that people have, it's really quite low. And if we can start to look at what that might mean to people's quality of life, the ability to be more mobile to get back to work, I think hopefully we'll be able to say that it's really something worth doing. So...
Dane: Yeah. That sounds great. And I guess with that question, you mentioned that you're doing a lot of it remotely. Have you noticed that it's had an impact by going remote or has actually been beneficial and kind of, what have you learned from that?
Rebecca: I think in terms of... Obviously like this year has had a massive impact on people's treatments, sort of like negatively because people can't have, or haven't been able to have the normal treatments in the same way. For me personally, remote has been eye opening in a good way. I didn't really consider remote medicine before. I deliver remote medicine in the cohort of athlete patients that I have usually kept the same patients from an Olympic cycle right through, because basically you've got athletes who are fit and healthy, but you're kind of providing that sports medicine care up until the Olympics. So once you get to know them and work with them, sometimes you'll follow up with a phone call or a video call, but to do that for full sports and exercise medicine clinic appointments at first, I thought, gosh, it will be so different.
I really underestimated, especially in the exercise medicine fields, how much we learn still from the history. Also, suddenly I'd have a clinic where my patients were really spread across the country. And I think that's something interesting because exercise medicine is a field that can apply to all illnesses, really. I was going to say noncommunicable, but of course Covid is another area where we think that exercise medicine can be beneficial in the rehabilitation and certainly beforehand too.
But for example, in cancer and exercise, at any one time there might be a lot or a small amount of patients that you need to see them on locality. And also, it can be tremendously more responsive because if the clinic I would normally turn up to on a Friday, say that they need me to come and see this patient who is struggling, then I can actually be there remotely much, much more immediately. So that's made life very busy in the sports medicine part of my job, but much more responsive. And I think actually maybe for a cohort of patients who wouldn't need or want possibly to come back into a hospital for another appointment, there can be a way that we serve their needs quite readily through remote medicine. So yeah.
Dane: Yes, so it's kind of opened up the number of patients and the people that can access your service. And actually, yeah, you make a good point that I didn't consider, which is, I guess a lot of cancer patients might still have some form of immunocompromise. So actually when you don't want them in these settings and you can do it from home, why wouldn't you?
Rebecca: Yeah, I think also it's been interesting, something I've reflected on with some of my colleagues is, sometimes patients travel quite a long way to come for an appointment. I've been kind of lucky to be based partly back up in the Lake District recently, which is where I'm from, but not where I've traditionally worked. We don't have many big hospitals in the area, but for example, a patient from here would usually go to Manchester or Preston, sort of nearby cities. Well not nearby, but a couple of hours really for their follow-up. So if they're able to have remote consultation, gosh, suddenly they might have that half an hour, or hour, to do some physical activity and rehab instead of traveling down. But also meaning sometimes that maybe health inequalities that we get due to geography are reduced.
Of course, we do still have the issue that some people won't have the same access to video consults. And personally, I found the video consults much more helpful for me than just the straight phone call. Cause you can kind of interact a lot more, but again, interesting to reflect if that's just me or if that's the patients, hopefully it's the patients.
Dane: Yeah. No, definitely, and I think things are moving that way, aren't they, for all the reasons you just said. Picking up on that point, the other point you made when you said noncommunicable was kind of moving on a bit, was around Covid and exercise. And before we go there, obviously Covid is a big problem. That's why we're all doing remote stuff now. And from a sport and exercise medicine point of view, lots of people are asking these questions, including questions that patients ask in general practice, which is, I've got Covid when can I return to exercise? When can I return to physical activity? What are your thoughts on that and what you're doing with athletes at the moment?
Rebecca: So my thoughts are very much guided by the early input we've had from some of the specialists. There's some brilliant specialists... I work within the English Institute of sports and luckily we're able to collaborate and work with. So I guess a couple of them that have led on this are Dr. James Hull, who's a respiratory consultant. Professor Sanjay Sharma, who's a consultant in cardiology. And there are numerous others as well, who've worked in this field, but basically what was the big concern at first was that this is a new virus, but one that we know is affecting the lungs and causing inflammation in the area of the lungs and the heart, in very, very basic terms, because we don't always know how.
And I think, there's been a degree of... For example, subclinical myocarditis in some, but we don't really know in some people cause they might not feel ill. Some athletes have very, very mild symptoms, but from what we know about even asymptomatic patients, having changed on their x-rays, it's basically, on the very bottom line, it became a question of, let's not push people physiologically as we just do by the nature of high-intensity training for elite athletes, let's not push through any symptoms that they have.
So early on, it was incredibly helpful to have this guidance that just basically said, any symptoms, just rest and rest for 10 days. I think that was Dr. Hull, who first mooted that point, and then backing it up with some of the evolving science. And again, it's a brand new virus. As everybody listening to this will know we have apparently so little evidence, which by the time we start to look to build it... Obviously now we're going to a second phase probably of lockdown and just to learn about how it affects the athletes, we can't get them into outpatients routine screening. Kind of the same if there are high pressures on the NHS. But 10 days of absolute rest was put forward. And that was really to protect the cardiorespiratory system.
After that, there was a period of time proposed seven days whereby you get back into activity gently. So basically we're talking about runners, just walking, getting into that light aerobic activity for at least a week.
Now, if people have developed symptoms and they haven't settled in 10 days, you've got to wait, can't just again in 10 days. You've got to wait til they're totally settled, then you start that seven day return. In elite sport it's brilliantly easy. Although obviously, it needs the whole team to understand it, when we've got physiologists we can sit down and make a plan and say, well, let's get someone just being active, let's monitor their heart rate. And more importantly, probably how they feel with regards to recovery, because we know that fatigue can be a big factor.
So in a best case scenario, if we get someone feeling good and they feel like we're actually holding them back, but we're getting no kind of spikes in the heart rate that have been picked up in that first week and they're just getting back adapting - if they do strength work body weight work - then the next week we kind of moved back into some steadier, if it's a runner, steady runs or cycling. Or if it's somebody... I worked with boxing, so they might get back into a bit of training. So that might be the bags and pads, sort of things. Somebody in a boat, somebody canoeing, they might just get back on the water and start increasing there. But at every step, we were able to take a check and say, look, if you're feeling worse, we want to back off. Because again, it's probably more anecdotal and case-based than bigger studies at the moment, but it just seemed that if people start to struggle with fatigue and carry on, then that's where it gets trickier to settle down again.
I would say as well that I've seen quite a few patients and it's been really fun, I would say. I work in this clinic in London called the Centre of Health and Human Performance. And basically because I was really quite worried about what athletes would do and because I compete and won quite a lot, I know what runners do. We try and get back as soon as we can, I think, well the virus, assuming it's gone, let's carry on. But because I was worried that that general awareness that we really had in elite sport might not be as pervasive into people that do their sport for fun, but obviously why would they? they wouldn't read the rule books, because there aren't any really. Basically we put a clinic on... that's still running actually, that's a non-charge one, just to look and see patients with Covid.
And to be honest, I learned an awful lot from that. And one big thing I've learned is from some of the patients who had presented and said, well actually I had what I think it was Covid or they'd had a test, a couple weeks later, I tried to get back into sports and I tried to do a couple of sessions and gosh, I was really, really tired. And then I had to back off again for a week.
So that kind of pattern of it just not settling like a normal flu might, but settling eventually, was one of the things that I'd seen. And one of the things since then the, in that clinic, we've been able to formalize a little bit more what these athletes do. And then I know we're going to mention a little bit about long Covid later, but again, in that scenario, just trying to help support any athlete that comes into a situation where they've had Covid they expected they were getting better, but actually they've got symptoms now that are impacting on their life in general but also in that sport.
Rebecca: So. We've been quite busy.
Dane: Yeah. No, sounds it. And I think as you said, the evidence is constantly evolving at the moment, isn't it? So these decisions around guidelines for when can you return to exercises is fairly pragmatic and I'm sure will change. So just to summarize what you said, just cause a lot of people in general practice do get... And we do go ask these questions, so if they've had Covid symptoms, it's going to be 10 days of rest, but it's got to be at least seven days clear of symptoms before they can start back and then they've got a week of slowly progressing back up. Haven't they, essentially?
Rebecca: Yeah. Yeah. So I mean if it got to day 10 and the symptoms have all settled, then they can go into that first week of general activity going forward. But basically got to wait until that point, if that's longer than 10 days, got to wait till that point.
For some people, fortunately, if they get mild illness, they will probably say, and some of the athletes I work with they say, Oh my gosh, could be doing more. But actually what we want in that first week is getting to the end of it without feeling extra fatigue, because the body's already been under physiological stress because of illness.
Rebecca: To a degree, we should probably respect the body more when we push people through training, anyway. But yeah, it's that gradual coming back and hoping that people will just actually enjoy feeling more well, really. And most people who aren't elite athletes have other stresses in their life. Like work to balance, which again, always adds on to tiredness. So with work and family, not to say a lot of elite athletes don't have this too, but it's just respecting that there's only so much that we can adapt to physiologically, psychologically as well. So I think it's a helpful paradigm and it has been very, very helpful the last few months, for sure.
Dane: Is there any point at which you're thinking about actually when would you say someone needs to actually get further tests and investigations done and shouldn't continue down the kind of return to play route?
Rebecca: This is something that, again, the English Institute of Sports have really lead on and has been really, really good. So if we've got athletes who, after a couple of weeks longer than we think that they should have had symptoms settled, we can really look into what's happening with their health. So personally, I've tended for someone who's like an elite high-performance, to run an ECG. If I can, just to get a baseline.
I have had some athletes who then had issues with palpitations and just kind of feeling their heart rate was higher or looked like it was higher for a given intensity than the amount of the conditioning that they've had. So either they've lost time from training, but we would expect the heart rate to be in a certain area and it suddenly looked higher.
So that's just something that I've been doing. It's not currently set in stone, but what is definitely recommended is that if you've got somebody whose symptoms are going up towards say 30 days from onset. So basically they've had that first period of being unwell, but after an extra kind of couple of weeks, still unwell then we definitely want to be investigating. Looking at a chest x-ray, looking at an ECG. In elite sport, we are looking at high resolution CT. We are looking at cardiac MRIs. And I think there is decent evidence that unfortunately we have seen a number of people, not fortunately within sports in the UK at the moment, but in the general population, we do know that some people are experiencing myocarditis and with that you've got to rest for three months and then gradually get back into it. But you don't obviously want someone to train through it.
There have been a number of people with pulmonary emboli from groups that I have been seeing... The heart, as well, on scans. So we want to be over, not over investigating, but investigating thoroughly when appropriate, because I think it's just that consideration that the mixture between a highly inflammatory and it appears prothrombotic condition, in some people, mixed with high intensity sports.
So basically we're lucky we can now send people to a really great setup, which is being run in London for all these elite athletes to go through. But the same would apply... For me, I'd be directing patients and say, go see a GP and if it can help, writing a letter and saying, yeah, we want to do these tests because... Then I think that should hopefully help to support people. So again, we're hoping that the majority of people who are fit and active may have less severe symptoms. That's what we appear to be seeing, but in the case of people that love their sport, it's really important they get back to it, but get back safely. So yeah, there are some other tests.
Dane: Yeah. Cool. Okay. So we'll come back to that, but hopefully you guys are happy with that and we'll pop a link in about the return you can ever read about some of the EIS stuff that's published. So we've talked about the normal return to exercise physical activity, but also when you might want to investigate. So these are the prolonged symptoms. Perfect. So I guess the last point to pick up on is, is the age old long Covid, which seems to be coming up more and more. So I guess my first question is what is long Covid?
Rebecca: So I don't know if I want to put it out there and like define it because I guess we're all still trying to try to do that. I guess, from a personal perspective of what I've seen, it's a constellation of symptoms. Fatigue seems to be really one of the predominant features. Basically someone has had coronavirus by definition. So, and again, we've got the testing. We do have a lot of people that never had the testing earlier on, especially like in lockdown, but presume they had symptoms, but whereby these symptoms just either haven't gone away.
So again, probably not like a definition that's in print, but like from what I've seen, it would be those patients presenting with quite significant fatigue, sometimes loss of concentration, quite often relapse in the symptoms of Covid that they had, especially with regards to fever, especially with regards to the myalgia. Sometimes and whether this is a feature of long Covid or complications of, but there have been people with quite significant impact in terms of neurological features, or I suspect quite a few GPs that have seen people with skin manifestations of Covid. So it's basically the syndrome that appears to be lasting much, much longer than the acute infection.
And I think on a personal point of view, when I've seen patients, there is a higher element of distress because likely they don't know when it's going to get better. And also because it's impacting on their life and the fatigue side too, which is, again, something I'm used to seeing with cancer related fatigue patients, and also athletes who have overtrained, there's an over-training syndrome whereby they're just tremendously fatigued basically, and can't attain the same exercise levels. So that's, I guess that's my version of a definition.
Dane: So that's kind of... Yeah. Okay. And I guess, we are seeing more and more patients with these kinds of symptoms, now aren't we? So I guess the next question really for you is this kind of talk about long Covid clinics and Covid rehab clinics, and it's been mooted up and down the country and a range of people are talking about it. And I know you were either looking at setting one up. So tell us a bit about what a clinic like that would do and what the aims are.
Rebecca: So this is quite an easy one. Again, because of working with a few athletes, who've had long Covid and basically, but also because the opportunity has arisen to run a service, which is going to hopefully happen in the next few months. A virtual clinic that's being supported by Sport England, which is brilliant, but it's looking at supporting patients, basically. I've mooted and I think sort of what we're going to do is looking at that from the angle of sports and exercise medicine. And I think it's important to emphasize that this isn't about using exercise necessarily as the first thing to get people back feeling well. And that's understandable because we know in the chronic fatigue syndrome, it appears to be sort of... it does appear that the central nervous system is kind of the modulator. We just don't understand quite how. But graded exercise, for example, does have a place in chronic fatigue syndromes. But in this instance, I think it's more than that it's looking at. It's really important for people to have physical activity and movement in their life.
And we've got other aspects that are going to suffer if someone has long Covid and can't be as active because we know that musculoskeletaly, they're going to become weaker. We know that we've got to keep people healthy from a cardiovascular point of view. So trying to shore up those systems would be a place to help with some exercise interventions, but also really important to go slow as that patient can tolerate. And that's where you're looking at things like seated exercise, you're looking at just like movement in the day. But really important for me in that is in a sports medicine consultation, you just find out where is that person at in terms of their life, their general health, what's the minimum that they can do, but also really important to work in a multidisciplinary team.
I guess I really like how in sports medicine, we can work with physiology and it doesn't have to be really clever metrics, but it can be that rate of perceived exertion. And sometimes the physiologists can also work as like a personal trainer and to just help give someone... Just someone to listen to somebody to support them through that journey and the other sides, but obviously the psychology, managing and dealing with the symptoms they are getting.
But also really, really important. So this is quite a small service in itself and this we'll be doing remotely, but we also want to link it. So if we're worried about someone that has these symptoms, but they've got prolonged breathlessness that needs to be investigated. So it might be just being able to signpost them, whether that be to their GP or directly to services to get further the tests and investigation. So were not trying to do all of that complex side, but to recognize when that might be something that needs further intervention too.
Dane: Sure. Cool. No, that sounds great. So I guess to probably finish off, where's that clinic going to be running?
Rebecca: So this is going to be virtual, it's run from Sheffield, but it will be virtual. So in terms of the initial phase, we're going to have like a small cohort to run through, but hopefully then after broadening out... And the main thing is that this would be free of charge for the patients, but they should be able to refer in. And obviously those routes will work out soon, but it might be that people can be referred themselves and, or from their GP too.
Dane: And if people want to see or speak to you at CHHP, is that just by the website or is there a better way?
Rebecca: They can definitely email. Probably easiest to email email@example.com. I think at the moment we are going to keep on running a non-charge Covid clinic for athletes because unfortunately, I'd love to say we didn't need it anymore, but obviously we're still living in a pandemic and yeah. If we can provide that support, then that'd be ongoing and we're actually going to be running - probably should have mentioned too - we are actually doing a long Covid clinic in that clinic. So the setup there is sports and exercise medicine, but because in there we have the CPET Cardiopulmonary Exercise Testing, and we've also got some really good physiologists and physios as well. So what we can do there is, support patients. We're getting the first ones sort of through, at the moment, but basically finding out where they are after Covid. And some people want to get back to fitness, and obviously we can check where they are compared to where they were before the illness. But again, anyone recuperating from long Covid, we can just be a bit more hands-on in terms of supporting them back too.
Dane: Perfect. All right, well, Rebecca, firstly thanks really much for joining us and for your time. That was really useful and I hope you guys found it useful. So we've covered a little bit about cancer and exercise. So again, do have a look around to see what's available for patients that either are kind of during cancer treatment, or maybe even post for primary or secondary prevention. We've also talked a bit about Covid and return to exercise. And we've talked about the English Institute of Sport guidelines that were published, which was around that kind of 17 days of a slow phase return with rest. So again, we'll pop the links in so do have a look at that.
And then we've talked about this concept of long Covid and maybe one role being exercise, but obviously it's a bit wider than that as well. So again, do have a look around those and we'll pop some links in with this podcast. And of course, if you do want to see Rebecca or read more about her and stuff do check out the CHHP website, and hopefully you can check her out there. All right. Thanks guys. And see you on the next one.
As always, do keep in touch with us for future episodes by clicking the subscribe button on Apple Podcast, YouTube or Spotify, see you on the next one.
(00:00) Episode introduction
(00.50) Introduction to Dr Rebecca Robinson
(02:37) Service developed for cancer and exercise
(06:50) Impact of remote medicine
(10:55) Returning to exercise after Covid-19
(18:30) When further tests are needed post-covid
(21:22) What is long Covid?
(23:30) Long Covid clinics and Covid rehab clinics