How Long COVID Patients Can Combat Exercise Exhaustion

If you’ve had COVID-19 or the COVID vaccine and feel exhausted after brief periods of physical or mental exertion, you’re not alone. That’s according to a study entitled, “Prevalence and measurement of post-exertional malaise in post-acute COVID-19 syndrome: A systematic review and meta-analysis.”

This work, which was published in the October 20, 2024 version of the journal General Hospital Psychiatry, claims “Post-exertional malaise (PEM) is a common and debilitating symptom of post-acute COVID-19 syndrome (PACS). . . . Over half of PACS patients experience post-exertional malaise (PEM) after COVID-19.”

The conventional approach to treating post-exertional malaise centers on “pacing” — carefully balancing activity and rest — in order to avoid overexertion. However, when you’re trying your best to remain healthy and fit, hold down a job, raise a family, and maintain a social life, pacing yourself isn’t practical and may not even be possible.

Here at PROVOKE Health^®, we believe we offer a better solution. But before we get into those details, it’s important to understand what post-exertional malaise (PEM), is and what causes its potentially debilitating symptoms.

What Is Post-Exertional Malaise (PEM)?

PEM is a worsening of symptoms following even mildly or moderately strenuous physical or mental activity that could have been tolerated previously. It is a hallmark symptom of certain chronic conditions, particularly myalgicencephalomyelitis/chronic fatigue syndrome (ME/CFS). People with PEM may feel an increase in fatigue, pain, cognitive impairment (sometimes called “brain fog”), and other symptoms following activities they would normally tolerate without a problem.

PEM can occur even after low levels of exertion and can last for hours, days, or even weeks, depending on the severity. Symptoms of PEM include the following:

• Delayed onset: Symptoms don’t typically appear immediately after exertion. There may be a delay of several hours to a day.
• Worsening of existing symptoms: After exertion, the individual may experience an increase in fatigue, muscle pain, headaches, cognitive difficulties, and sleep disturbances.
• Duration: The effects can last for a long time, sometimes significantly impairing the person’s ability to function.
• Inability to recover normally: People with PEM may not be able to “bounce back” as quickly as they once did after rest.

PEM can be triggered by various activities, such as exercise, stress, or mental work. Obviously, it negatively impacts a person’s quality of life.

Triggering a Change in Muscle Tissue

Everyone can be sore following exercise; however, those who suffer from post-exertional malaise (PEM) experience extreme exhaustion after even mild to moderate exercise. This exhaustion can sometimes last for days or even a week. This is a unique characteristic of Long COVID or long-haul COVID and is present in patients with ME-CFS.

In a recent study entitled “Muscle abnormalities worsen after post-exertional malaise in long COVID,” researchers checked the muscle tissue and function of Long COVID patients (those who continued to have symptoms three months after their infection cleared) with PEM before and after exercise. They found no issue with blood flow into or out of the muscle, and no issue with low oxygen. These circumstances rule out blood flow issues or blood clots as a possible cause. And that’s even though we know that COVID and vaccines to prevent COVID are associated with clotting).

Here are four takeaways from the study:

Takeaway No. 1: Muscle fibers were altered in shape and type.

Muscle fibers that are easily fatigable are increased in Long COVID patients. Muscle fibers start to atrophy and become thinner. These changes lead to weakness. Most people have a good mix of slow and fast muscle fibers — slow fibers support endurance, whereas fast fibers provide a quick burst of power. In Long COVID patients, the muscle fibers become imbalanced, switching the anatomical makeup to fast burst fibers that quickly burn through fuel and do not support endurance. The more the person continues to exercise, the worse the switch becomes, leading to a worsening of symptoms.

Muscle fiber types:

• Type 1 — Slow muscle fibers: These muscle fibers favor endurance over power. They use oxygen and require high blood flow and high levels of mitochondrial energy to produce sufficient quantities of adenosine triphosphate (ATP) — a chemical compound that is the primary energy carrier in all living cells. Type 1 fibers are diminished in patients with Long COVID.
• Type 2X — Fast muscle fibers: These muscle fibers favor explosive power over endurance. They use glucose (byproducts of lactic acid) for bursts of energy, but they exhaust their supplies quickly. Patients who have Long COVID with PEM have excessive Type 2X fibers.
• Type 2A — Mixed fibers: These muscle fibers provide stamina and strength. Like Type 1 fibers, Type 2A fibers are diminished in people who have Long COVID with PEM.

Takeaway No. 2: Mitochondrial damage has occurred.

Mitochondria are the energy factories inside cells. In muscle cells, mitochondria normally produce energy in the presence of oxygen through a metabolic process called oxidative phosphorylation. This is the preferred method, because it leads to the best outcomes and makes the cells less prone to fatigue. However, muscles can also produce energy without oxygen, using glucose instead. This pathway is important but less efficient. In patients who have Long COVID with PEM, oxidative phosphorylation is replaced by the glucose pathway that makes the muscles more prone to fatigue.

Takeaway No. 3: Amyloids build up in skeletal muscles.

Amyloids are proteins that are susceptible to folding in odd ways and aggregating into clumps in muscles and organs. In Long COVID with PEM, amyloids tend to build up in skeletal muscles — the muscles that attach to bones and are responsible for voluntary movements, the type of movements you do when you exercise. These clumps are like mud or sludge that builds up in muscles impairing their function. Along with the amyloid buildup, patients who have Long COVID with PEM have a higher volume of immune cells in their muscles, specifically helper and cytotoxic T cells, which suggests the presence of an inflammatory process.

Takeaway No. 4: Exercise induces myopathy in Long COVID.

Myopathy is a term that means “muscle disease.” Researchers concluded that “severe exercise-induced muscle damage and subsequent regeneration are associated with the pathophysiology of post-exertional malaise, and can possibly explain muscle pain, fatigue, and weakness in patients with Long COVID experiencing post-exertional malaise.”

Solutions for Post Exertional Malaise by PROVOKE Health

Here at PROVOKE Health, we practice functional and integrative medicine. As such, our focus is on restoring health by providing the body and mind what is needed to heal and build resilience. In the presence of good health, illness has no place.

Our personalized approach involves identifying and addressing the root cause(s) of whatever ails you, which may include nutritional deficiencies, food sensitivities, lifestyle choices, and sources of physical and mental stress. Our treatments often include changes to diet, exercise, and lifestyle, along with therapies that target specific medical conditions. In the case of Long COVID with PEM, in addition to general healthcare recommendations, we may include one or more of the following therapies:

• Body Protecting Compound-157 (BPC-157) — a peptide to reduce inflammation, improve muscle recovery, and reduce atrophy.
• MOTS-c — a peptide to improve mitochondrial health and recovery and enable patients to exercise without damaging muscle tissue. MOTS-c induces the metabolic-positive effects of exercise.
• Mild exercise to gently stimulate but not overstimulate the muscles during recovery.
• High-dose intravenous (IV) Vitamin C to support the immune system and target inflammation by reducing oxidative stress.

Physical activity — especially strenuous exercise — is essential for good health and fitness. But when you have Long COVID with PEM, too much exercise without the right treatments to support it can cause more harm than good. If you feel exhausted after mild or moderate physical or mental exertion, or you don’t recover from exercise as quickly as you have in the recent past, we encourage you to consult a functional and integrative healthcare practice for an evaluation. With the right treatment, you can get back on the path to health and fitness and living your life fully.

If you’re in or near Tampa, Florida, are planning to visit, or would like us to consult with your primary care physician, contact us to schedule an evaluation.