The Food Medic - S8 E4: Exercise after covid

Episode Date: July 21, 2022

Welcome back to another episode of The Food Medic podcast with Dr Hazel. On this episode we are chatting about returning to exercise after having covid.Our guest this week is Dr Amal Hassan - a Sport & Exercise Medicine Consultant Physician, working in elite sport, ballet, and at the Institute for Sport, Exercise and Health in London.This episode covers*Risks of returning to early to exercise post-covid*when to safely return to exercise *How to phase your return to exercise*Long-covid complications impacting physical activity *managing long-covid fatigue *fitness and recovery related to the covid vaccine If you loved this episode make sure to give it a review, rating (hopefully 5 stars) and share it with your friends and family. Thank you to our season sponsor WHOOP. Right now, you can get your first month free when you checkout through join.whoop.com/thefoodmedic@thefoodmedic / www.thefoodmedic.co.uk Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

Hello, and welcome back to another episode of the Food Medic podcast. I'm your host, Dr. Hazel. On this episode, we're chatting about returning to exercise after having COVID. Unfortunately, COVID is very much still here. And in the UK, cases of COVID have rose 29% in the week ending 6th of July. And in the latest ONS report, it found that one in 19 people in England tested positive for the virus. So I know this episode applies to many people listening, or at least someone that you know. In this episode, I speak to Dr. Amal Hassan, a sport and exercise medicine consultant, working in elite sport, ballet and at the Institute for Sport, Exercise and Health in London.

She has a subspecialist interest in female athlete across the lifespan and in women's health for sport and exercise participation. She's also worked in post-COVID clinics throughout the pandemic and continues to consult those struggling with return to exercise post-COVID. So no better person for the job. Let's hear from Amal. Today's podcast is brought to you by our seasoned sponsor, Whoop. Whoop 4.0 is a 24-7 digital fitness and health coach that provides actionable insights to help you recover faster, train smarter and sleep better. And unlike most other wearables in the sense that it doesn't just tell you what you've done, but it tells you what you really need to know. Now, as many of you know, I've been using my WHOOP for the last couple of years and I'm constantly impressed by how

accurately it can quantify how I'm feeling. So each morning when you wake up, you get a recovery score from WHOOP and this is based on your sleep and other health metrics. Now that score can help guide your day and informs you how much strain you're ready to take on. One of my favorite features is the built-in sleep coach. It lets you know how much sleep you should be getting based on your expected activity level for the following day. WHOOP can help anyone perform better so whether you're preparing for a 5k, training for an event or just looking to build healthier habits, Whoop can help you make smarter lifestyle decisions with data that is personalized to you. And right now, you can get your first month free when you check out through join.whoop.com slash thefoodmedic. Amal, welcome to the Food Medic podcast.

Thank you. It's so nice to actually meet you the first time in person. I can't believe that. I know. I feel like I know you, but it is really nice to see you face to face. That's it. That's it. Well, thank you for coming on the podcast.

We had a little chat before we came into the studio, but I would love to find out a bit more about you and your background and what led you into your area of specialty today. Of course. So I'm a sport and exercise medicine consultant working at the Institute for Sport, Exercise and Health in London. That means I am a physician. I'm not a surgeon. And my medical training background is in hospital medicine. And I did a MSc in sport and exercise medicine, which essentially opened the doors to this practice that I now specialize in. And I sub specialize in female athlete health and women's health for sport and exercise participation. And I also work in pre professional ballet, and in professional

rugby for a women's team. Amazing I love that and we're going to speak more about your area of specialty and I do want to chat a little bit more about female athletes but I imagine your practice has changed in the last two to three years as many specialties in medicine have and one of the topics that I really want to cover on today's podcast is how you're dealing with people who are coming back to exercise after COVID. Because I know I'm getting asked all the time, people are still experiencing COVID. We're still living through that period. And a lot of active people listen to this podcast and like, when can I get back? When is safe for me to start exercising again?

And how should I do it? So big question. But what advice do you have to people listening so a bit like you throughout the COVID pandemic although I wasn't in hospital throughout I did work in post-COVID clinics and I still see patients in my private practice and the athletes for the teams that I work with who are returning to exercise training, performance and competition post-COVID. And guidelines were originally developed for safe return for elite athletes during the initial lockdown period. And that was a collaboration between various regional institutions and governing bodies, such as the English Institute for Sport,

and then quickly followed by the publication of guidelines for the general population. So they do exist. The key difference between professional athletes and those who aren't are that occupational or vocational pressure to return to performance and competition and the level of available clinical assessment, so from doctors, supervision and monitoring

for those in and out of sport. They're the main difference. But the overarching theme, essentially from a medical perspective, is of caution and of graduated phased return after a significant period of rest and a specific duration of symptom-free days. So that's really key and it applies to all athletes or not. This is mainly out of consideration for the

multi-system inflammatory and sometimes as you'll know thrombotic or what we call clot forming nature of the COVID-19 virus which essentially if you if you've had the virus, you'll know, at least to moderate effect, if you've had it that badly, you'll recall that you can appear to get better before you then deteriorate in that perhaps second week or first few weeks after. And this was illustrated in the early publications on therapeutic steroid use in patients admitted to ICU where you had those three demonstrated phases of acute infection. So early infection on admission, the pulmonary phase as we call it during week one where you get the cough and the breathlessness and then the inflammatory phase in the weeks that follow. So what we don't want is to encourage people to

return to exercise too quickly when they might be going on to develop, for example, clots or inflammation of the heart tissue or the lining of the lungs, so myopericarditis, fibrosis of the lung tissue and post-COVID autoimmunity, where exercise then puts additional strain on important organs and bodily systems. And where we can be more assured that it's safe to gradually start working towards returning to unrestricted activity after mild to moderate illness in the community, so you've not been hospitalized, is when you've been symptom-free for seven days and have rested for at least 10 days consecutively, that you're off all medication, that you're not needing, for example, daytime naps or more sleep overnight, more than usual for you. And if you

have a fitness tracker when you're resting heart rate, you're resting respiratory rate, and your heart rate variability are back to normal levels. And the guidance states that you need to demonstrate all of that consistently for seven days before starting to incorporate exercise and even then starting at much lower intensities than you think you might want to which reflects again the importance of observing that inflammatory response in those few weeks after getting your initial infection. So needing to demonstrate that you can cope with the day to day demands of life first before incorporating exercise activity. Yeah, that was really comprehensive. Thank you. But it's funny because I have a lot of friends who, you know, are in CrossFit and are very active and very avid runners and they've had COVID over the last couple of months and once they stopped

testing positive or they felt like their symptoms were mild they were back out on the road they were back in the gym they were back doing back-to-back CrossFit classes so what you're saying is you need to observe that seven-day symptom-free period and then go back to 50% of what you're saying is you need to observe that seven day symptom-free period and then go back to 50% of what you were doing before or? Yeah I think the key message is to do it via a graduated phased progressive process and actually the guidance suggests to do this if you are not an athlete so again you're outside of that monitored, medically monitored environment over a minimum of five weeks. It seems so long. Yeah.

Following that initial rest period of seven days. Sorry, that 10 days rest, but seven days symptom free. I know to most it would sound absolutely ridiculous. And, you know, I completely understand that it sounds way too cautious, unnecessarily slow, especially if you're a fit and active individual usually, but there is a reason for observing that pace. And the guidelines published for the general population, they are a catch all for all ages, all abilities. And I appreciate that a lot of your listeners will fall outside of that normal bell curve. So, you know, way and beyond what normal activity is.

But the guidance for what to do in each phase as you progress over those five weeks, might again seem too trivial to be classified as exercise for some, but I would recommend sticking to the assigned intensities of activity for each phase in case you hear them or read them and you get disheartened or have that response which is you know this is ridiculous so as a reminder in addition to being symptom free in day-to-day life so that's including work commuting it might be parenting whatever else you need to be doing whilst initially recovering from that ill phase a 500 meter walk test or a distance that's essentially normal for you to walk might also be a good way of determining your readiness to start on that phase progression and and if you've got a tracker again it might be helpful to watch what your heart rate is doing in

response to that very light intensity of activity like walking throughout. So if you have a tracker again it can be really helpful to watch what your heart rate is doing in response to activity throughout each of the phases particularly but also when you're doing that initial test of you know how am I responding to day-to-day activities and perhaps that walk test because it's something that we watch out for in the gym in a sporting or clinic environment, which is essentially appropriate heart rate response to activity and heart rate recovery upon stopping in addition to a normalized resting heart rate and heart rate variability. So you can use some data there to help you. Yeah, I was going

to actually ask you about that. Because when we were running long COVID clinics, quite a lot of active people were coming into the gym and they were tracking their data on Strava and also using like Apple Watches or Whoop and we're saying, you know, my resting heart rate is much higher than it used to be and then my heart rate's climbing at lower intensities than before. Is that something that you're commonly seeing? Yeah, definitely. There are actually many reasons why heart rates can be raised post-COVID. And in the vast majority of cases, it will definitely not be related to deconditioning and might actually be quite a significant jump from baseline, you know, 10 beats and above. I guess possible reasons early on might include that you're still recovering post-acutely in that initial phase and with that prolonged inflammatory phase.

Post-COVID complications are really important to pick up in this context. And that's why it's good that those patients you were seeing were in a specialist clinic, because in the context of other symptoms, it might be related to, for example, a clot in the lungs or micro clots for example cardiac problems like I mentioned before inflammation of the heart muscle tissue itself or the lining around the heart or even having low oxygen levels in response to a clot for example so it's important to rule out serious medical complications post-COVID before increasing your activity levels if you are noticing that you have abnormally high heart rates. But again, in isolation, a higher than normal resting heart rate or lower than normal heart rate variability may just be that you're slowly recovering and these will normalize. But, you know, if you've got any concern at all, it's definitely important to get those things ruled out yeah absolutely so if someone's getting back to fitness you mentioned

the different phases do you think we could briefly run through them absolutely so the recommendation I think that I need to make clear is that each phase has a specific goal so there's a reason why it's phased and I'll try and make that clear. And each phase should last a minimum of seven days according to the guidance. And I appreciate that these are guidelines, but they're medical guidelines. So it would be worth consulting a clinician if you want to kind of go outside of the guidance, because that would need some form of clinical assessment and investigation potentially before you take it any quicker. So yes, a minimum of seven days per phase. And it's recommended like any phased progressive program that you drop back down a level if your symptoms that you had initially

recur, if you get new ones, or if any weird feelings or symptoms get worse during the program. And this includes fatigue that is common post-COVID infection, but can be triggered up to 72 hours after the initial activity. So you might not feel tired during, you might not feel tired straightaway afterwards, or even into the next day. And this is representative of something called post-exertional symptom exacerbation, or post-exertional malaise, PEM, which is a hallmark

of a lot of chronic fatigue presentations, including long COVID. So that needs to be respected. And I would almost go back down to a level where any activity you're doing is not triggering that kind of symptomatology. And before, again, sorry to hold off, but before I get into the protocol, I just want to flag a reminder that daily activity always goes beyond structured exercise. So you need to be mindful of the amount of day-to-day walking you're doing, how long you're on your feet day-to-day, and then factor that into your activity allowance. Yeah, that's so important. So during the first phase, the goal is to prepare

for the introduction of low intensity activities. So the focus traditionally is on, wait for it, breathing exercises. So again, really, really exciting stuff, but very important. So nice diaphragmatic breathing, mobility work, gentle walking. And the guidance is to do this at an rpe so a rate of perceived exertion of six to eight out of twenty so that means three to four out of ten so you're not even getting breathless and what you do here might look different in comparison to another person but the key is sticking to that level of intensity which will 100 be individual to you. And I know for many fit, active people, this might be really challenging to observe in reality. But then you get to go on to the second phase and the intensity range increases at this point. So your allowance is six to 11 out of 20.

So that range, or three to about five and a half out of 10, allowing for more walking, perhaps some light yoga, more household and garden tasks. But again, you're keeping the duration low here. So 10 to 15 minutes at a time, gradually increasing to 30 minute durations by the end of that phase or that seven days. And again, recovery and being symptom free is absolutely key to progression and increasing the duration of low intensity activities across those seven days. The goal for the third phase is then to challenge intensity further by bringing in moderate intensity aerobic or strength work. So things might just start feeling a bit more normal at this point. But for that reason, at this point, you need to bring the duration of the moderate intensity bouts right back down to challenge the

body but also give it enough chance to demonstrate good recovery so an example of what you might do here is start with a five to ten minute interval at moderate intensity and again that rpe range you're looking 12 to 14 out of 20 or 6 to 7 out of 10 where you are breathless but you can complete a sentence when you're talking rather than being able to sing a line from a song so that's the sing talk test and then you might want to follow this with initially 15 minutes of low intensity work to complete your session in the first part of the week and then working towards being able to successfully complete again without symptom or symptom flare 30 minutes of moderate intensity in a row so in one go with good recovery into the next three days and if you're all good there then you're ready to progress into the fourth phase where you're going to challenge yourself further

but stick at moderate intensity and you're going to start incorporating tests of coordination and skills so if you lift in the gym this is where your compound movements start coming in and before that you want to keep it quite basic the goal for the fourth phase is to challenge yourself further at moderate intensity incorporating a test now of coordination and skills into both your aerobic and strength work if possible depending on what you do but sticking to that rpe of 12 to 14 out of 20 or 6 to 7 out of 10 so if you're in the gym at this point your lifts might start to include some compound work you might be focusing on 30 minute bouts in one go now at this point and that reason, the guidance is to do two days on with one recovery day to allow you to demonstrate that good recovery for progression towards your final phase, your

fifth phase before unrestricted activity. And at the fifth week, again, fifth week minimum, generally, you're preparing to return to your regular exercise pattern and prepare is the key word here particularly if your usual exercise includes high intensity bouts or contact or collision so just as with the third phase which is when we saw the reintroduction of moderate intensity physical activity or exercise for the first time you need to aim for short intervals at high intensity here where you can't complete a sentence but you can say words so you're not gassed yet and that will be a test of your tolerance for the activity and recovery again and these intervals can increase in duration

towards the end of the week before entering the next phase hopefully unrestricted with no problems and it goes without saying and i know you all agree with this because it's very much your ethos that sleep and a diet that supports energy sustainably throughout the day being sensible about managing your workload including parenting in the context of now increasing your exercise load and easier said than done but reducing your exposure to stress as much as possible will go such a long way to supporting you throughout your return to fitness yeah absolutely well five weeks and then you're back to hopefully your regular exercise pattern and to be clear each phase is

seven days long that's the guidance unless you get symptoms and then you need to go back a phase absolutely so hopefully it's uncomplicated and I appreciate that for many you know they'll be doing it quicker than this but this is the guidance you know as a as a doctor that I would I would give yeah and I think it's helpful for people to be aware of that and I think you've explained really well why that guidance is there and it's not just kind of the symptomatic phase that could potentially cause issues it's what's happening afterwards in that recovery period I had COVID I think I've had COVID twice but the first time was in the very first lockdown um and at the time I was working at UCLH

which I know you've worked at which has a really big tower and the lifts were really busy and you could only have four in a lift so everyone was taking the stairs and I was on the ninth floor so this was maybe three weeks after I had COVID and I was so breathless. I mean, nine flights of stairs would get me out of breath anyway, but I'm a relatively fit person and I was literally sweating by the time I got to the top. I couldn't believe that I was still feeling that way after being symptom free for three weeks by then. What should people expect kind of when they are returning to fitness? Should they, in terms of them kind of bouncing back, let's just say,

what kind of things should they, what kind of advice would you give someone who is very active and they're coming back from a period of rest after COVID? So I think that story is really typical and how you were saying that, you know, you feel symptom

free, but when you test your physiology, you do actually get some symptoms. And I think that just reflects everything that's unseen physiologically about being in that post-COVID state. We are learning a lot more. Unfortunately, we didn't know too much back then. But, you know, as the years progress, and thanks to a lot of the effort of the long COVID community, particularly, we are learning about the mechanisms that drive prolonged symptoms. So I think one of the first things I would say to someone who's chomping at the bit was you know I want to reassure everybody that essentially your fitness on the whole might not be hugely affected in the long term particularly depending on you know the duration and severity of your illness so if it's been mild and you've taken

good rest there's no rush and it will be okay but owing to that inflammatory nature of the acute illness and the post-infective period, and in the case of possible onward development of long COVID or post-COVID medical complications, which we've spoken about, returning to training might not go to plan. And that's normal. And if that's the case, and you have ongoing symptoms symptoms or you are finding it difficult please ask for help it might be normal but there may be something going on underlying that um so that would be my my main tip and then long covid which you've mentioned a couple of times and we've talked about already is having covid symptoms 12 weeks after the initial infection that can't be attributed to something else. And I've also worked in a COVID clinic for a long time. So we've seen a lot of people who

were having issues with activity and their fitness. It was a very broad spectrum of symptoms, whether that was very high heart rates when returning to exercise, chest palpitations, chest pain, and fatigue was the big one. So there's like almost these different phenotypes of people who had long COVID. How is exercise and performance impacted by long COVID? I think it's one of the most frequently reported issues is that activity intolerance, that might not be exercise related. In fact, that could be cognitive. Yes. Any kind of physiological task that the body has to mount a response to can be impacted by having

long COVID. And so there's a lot we need to do to unpick the mechanisms driving that. We've got some good theories. I think one of the most interesting statistics I've read or alarming is that where 70% of the population have had COVID as of May 2022 in the UK, and given the current wave, it's likely to be higher still. Two million people in the UK are living with long COVID. And over 65% of those are struggling to manage day-to-day tasks as a result of their symptoms. So we, I think in our clinics, probably scratch the surface of that number.

And you've named some of those important symptoms, but some of those that are common to the cardiorespiratory system which is really important from an exercise physiology perspective as well as neuromuscular include breathlessness, ongoing cough, chest pain, difficulty maintaining your blood pressure in upright positions, and as we've mentioned already, an unusually fast heart rate with the possibility for associated abnormal heart rhythms. Some of these things can become magnified, more of a problem on activity. Mechanisms underpinning some of those symptoms in the lungs include endothelial damage,

so damage to the cell lining within the lung tissue with intense associated inflammation and fibrotic change in the lungs so scarring of the lungs one that i think explains a lot of post-covid recurrent viral infections is ciliary dysfunction in the upper respiratory tract so you know those hairs that wave up particles and debris in the big airways of the lungs in the nose in the eustachian tubes of the ears and so difficulty clearing infection alongside immune dysfunction giving you that propensity towards ongoing cough potentially infection driven you've got micro clot formation in pulmonary vessels, so blood vessels supplying the lungs,

which will make it harder for your lungs to supply oxygen to your working muscles during activity. And actually that is suggested to be an issue throughout the body, not just in the lungs. And then finally, small fiber neuropathy or direct damage to small nerves supplying blood vessels so big blood vessels in the body making it difficult for you to constrict your blood vessels and up your blood pressure when you need to so the symptoms because of those mechanisms can definitely impact exercise participation in the moment so acutely but also consistent exercise participation and then progressive improvement with unfortunately sometimes the worsening of symptoms. Yeah it can be really scary as well for people when they're experiencing especially cardiac symptoms because it's hard to

pin down what it actually is and if you're not under the care of a doctor or a clinic definitely do go seek some help for people experiencing extreme fatigue which was something that we definitely seen a lot of and like you mentioned sometimes it was you know they were doing very minimal activity and it would be based on going back to work and sitting at their desk all day and they would be so exhausted they would be in bed for days or they would go for a very short walk and and it would be people who are reporting to me that they were doing like 10k's a week you know and then they weren't able to walk to the shop without like having to come back and have a nap and I know

that a lot of people are experiencing that still what's the best advice for people when it comes to pacing and avoiding that like boom and bust cycle? I think it's a really important question and I think it's a great opportunity for me to be able to say to anyone who's experiencing this or to anyone who knows someone who is experiencing this that you're not going mad. There is an association between post-covid fatigue or symptom exacerbation and activity. So as easy as it is for me to say, be kind to yourself and do what you know you need to do instinctively, which inevitably is rest. But something that's harder to do is to seek investigation and help for those symptoms. I appreciate that access to specialist services can be limited depending on where you're listening to

this at least your GP is your first port of call and of contact and I think it's important that you advocate for yourself as best as possible or with the help of others to reduce your exposure to triggering activities because ultimately modifying your exposure to those activities is what is going to set you on the path of improvement and consistency in terms of feeling well. I think another thing that I would want to say here is that the definition of being active, whether it's physically or mentally, might need a challenge at this point. So you might need to challenge your definition of being active because it all becomes relative to what your body can cope with in the moment and what it can recover from. Functioning day-to-day is the most important thing and can in itself be you know challenging to achieve in the first instance so I often discuss with patients prioritizing for example being able to returnizing, for example, being able to return to work

over exercise, being able to parent for a full day and to commute ahead of increasing their physical activity participation, because these things have more currency in your life in the short term. And yes, you know, we've spoken about this physical activity offers a number of benefits in the short and long term. But in this short term period, the benefit I think lies in pulling back, prioritizing other areas of your life, essentially. And as an aside, in this sense, I think exercise is truly a luxury afforded to the well body. And anyone who is navigating long COVID or post-COVID fatigue or symptoms will 100% be able to vouch for that. So just a little thought there.

But, you know, I do think as a sport and exercise medicine physician, it can feel counterintuitive because we're trained to plug the benefits of exercise rehab. But for long COVID patients, exercise really is a physiological stressor. It can be a huge trigger for symptoms. And on balance, like I said, you know, in short term, what we're working towards is getting consistency in day to day life and day to day functioning without triggering severe fatigue to the point where you know you're bed bound and sometimes you know that that can happen so so that's really important to avoid that boom-bust cycle you know as you mentioned and at some point either simply as a result of time or of nature taking its course or through medical assistance, most people will eventually return to at least greater levels of activity or being able to

sustain greater levels of activity whilst being less symptomatic. Yeah, it's difficult to predict the length of time it will take and that was always the kind of golden question how long am I going to feel like this for and when will I be able to get out and go for a run or when will I be able to go a weekend you know spending the day out going to coffee shops and things and not feeling exhausted I could never answer that question or they'd hear from their friends who are feeling better but they're not feeling better yeah the don't knows are really difficult to navigate and I think as clinicians, we want to provide answers. And I think working with long COVID patients has taught me very quickly that my role is not necessarily to provide answers rather than to help someone navigate a difficult time, find answers if they're there. But also,

you know, help with that sort of psychological element of having to sit with uncertainty. And it's really hard. You know, we've spoken about how for a lot of people, a lot of people who might be listening to this podcast, that fitness very much fits within their identity, who they see themselves as perhaps a gateway to their social life. It completely integrated into their social life, maybe even their work. Yeah. So the impact of not being able to engage in a fitness space or an active space can be huge. Yeah, huge in the mental health. I mean, even at the moment, I know this is unrelated to COVID but I've experienced

an injury and I can you know I can still wait there I can walk without pain but I can't run and right now it's quite busy for me so running has been my outlet and the fact that I can't go for a run has massively affected my mental health so I completely empathize with anyone who cannot who is experiencing injury or is recovering from COVID or for what whatever reason can't exercise and that is important for their mental health because it does it's it's huge and you don't realize how huge it is until you're in in that situation yeah and then you know those thoughts and feelings that come with being in that position completely separate to the fact that you're experiencing something that is actually complex, both medically, both within our culture, not necessarily fully understood,

might come with some misconceptions, some stigma, etc. I think it's just a double, triple, quadruple whammy of, you know, difficulty. Yeah, 100%. I'd love to ask you about, and I don't know if there's much research in this, but around fitness and recovery related to the vaccine. Because I know that Whoop shared on their journal, which is their blog, some kind of preliminary data that they had what do we know if anything when it comes to the vaccine yeah i remember seeing that that was january 2021

and i immediately posted it on my instagram because i found it really interesting at the time but essentially you're right they published just a simple analysis of data submitted by their users who reported having received the COVID vaccine. I should say that I have a WIP band, by the way, just for full declaration. So they found that most WIP users who reported having the vaccine, who are actually likely to be a specific cohort of people, right? So health conscious, maybe more active than most. So potentially have some protection, arguably from severe COVID infection or post vaccine symptoms. So this particular group didn't show any signs on the whole of decreased recovery, according to their algorithm, which uses

resting heart rate, sleep duration and quality and heart rate variability to give you a recovery score however around 20 percent did demonstrate elevated resting heart rate values so a jump of over 10 beats per minute and around 29 so nearly a third demonstrated significantly reduced heart rate variability according to their calculation so the way they measure it every fitness tracker will do it differently and they define that as a greater than 20 percent decrease from baseline in heart rate variability and they then saw a doubling in the number of red recoveries reported by those who'd had the vaccine anecdotally some individuals reported feeling more fatigued in the 24 hours following their vaccine. I don't

know if you did, but I did. And perhaps developed a mild temperature. But essentially, all this put together suggests that the vaccine might be associated with a reduced readiness to train as a result of reduced recovery. And if we go on and we have further vaccines in the future, you might want to consider reducing the intensity of the activity you do before you have the vaccine and not return until your recovery levels are back to normal or if you don't have a tracker or a whoop that you feel ready to go back. But certainly there's no evidence to suggest that there's this sort of post-vaccine inflammatory response that would mean you'd have to observe a similar phased return to post

infection yeah i guess it makes sense doesn't it you know your your body's mounting an immune response and it's going to affect the physiology of you and how you recover um but i completely did feel that post vaccine fatigue for like 24 hours and a sore arm and then I was fine the sore arm is the worst bit then that was definitely stopping me from going to the gym definitely not arm day no it's definitely not arm day oh amazing um well hopefully there's more research coming out in that space I think I'm interested especially from the kind of exercise and activity point of view from COVID long COVID and also the vaccine I'm sure over the next couple of years we will get more and more research and we'll be able to kind of find out more and maybe the guidance

around returning to exercise will also become more refined as we understand more yeah certainly and I think understanding the mechanisms that underpin post-covid complications developing long covid the different type potentially there might be different subtypes of long covid as you were saying like different phenotypes depending on the different symptoms that are experienced which have been reported to be around you know 200 250 different different symptoms absolutely yeah in the long COVID community. So if we understand that, we then understand how that impacts exercise physiology. If we understand what the treatments might be,

we can determine the safety of exercising whilst on those treatments. And then we can develop some specific return to activity guidelines for those who have that kind of more complicated return to exertion post-COVID. But yeah, watch this space. Yeah, absolutely. We're coming up on time. So I've got three more questions for you. I feel like I'll have to get you back to talk about female athlete specifically. That's going to take a whole other. It will. It will. What would be your number one takeaway you want people to take from this particular episode? So I really want everyone to walk away feeling reassured that it's okay to take rest from exercise training after you've had COVID or for whatever reason.

Sometimes there are real consequences for going too hard too soon. And in some cases, these consequences can be long-lasting and I hope I've illustrated that. If you do get ill take the opportunity tune in with your feelings around having to reduce your exercise activity. If the need to return quickly strongly overrides your short and long-term health and well-being needs I would urge you to seek help because it doesn't always have to feel like that when it comes to taking rest from training healthy sustainable relationships with exercise are definitely possible to work towards and can be way more positive than you think again both for your short and long-term physical and mental

health amazing the next one's about you what's the most important lesson you've learned over your career this is a hard question I know so many I'm gonna go with a soft a soft skill I think it would be the importance of listening of understanding the why underpinning what someone is telling you because it's absolutely fundamental to our clinical consultations and I think linked to that is the power of teamwork and I know if you're particularly if you're a medical student listening to this I think teamwork gets so oversold and you kind of lose the the essence of what what mean. But whether it's between a doctor and a patient or between a multidisciplinary team,

so different members of a team, it is gold. And in medicine, we are absolutely nothing alone. So thank you to all my patients and anyone who's worked with me for contributing to my development because without them, I'll have learned nothing that's completely completely true and the final one is what is your motto in life um this is I don't think it's a motto I think it's um more an outlook um or an energy enthusiasm so if something doesn't enthuse you don't do it i love that thank you

so much amal for coming on the podcast i'm sure there will be people who want to know more um about you and the information that you're providing so where's the best place to find you so i am on instagram at sport exercise underscore doctor underscore Amal. And you can find me at the Institute for Sport, Exercise and Health, which is on Tottenham Court Road in London. Amazing. Thank you so much. Thanks for having me. Thank you for tuning in today.

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