At 17 years old, Nia Raquelle Smith enlisted in the Navy, and subsequently hurt her legs in a training accident, sustaining injuries that left her with nerve damage and on crutches for nine months. She was told that she’d never run again, and, determined to prove her doctors wrong, proceeded to run three marathons.
Now, at 36, she is drawing on that experience as motivation to fight through her current setback: long-haul Covid symptoms so severe that until three months ago she could barely walk up a flight of stairs without needing an inhaler. Ms. Smith, who lives in Brooklyn, had planned to run in the 2020 New York City Marathon, which was eventually canceled; instead she has deferred that entry to the 2023 race.
“This is going to be an even bigger challenge,” she said.
As a veteran, she is being treated at the Margaret Cochran Corbin Campus of the VA New York Harbor Healthcare System and the New York University Veterans Clinic. There, as at many of the post-Covid-19 recovery clinics that have sprung up around the country, athletic ambitions are part of patients’ rehabilitation goals. Since the syndrome, sometimes known as post-Covid or long Covid, is still not well understood, doctors are throwing the kitchen sink at helping these patients get better — and get back to sport. They are adapting treatments used for other illnesses, and also — with permission — drawing data from athletes’ personal fitness trackers, like Apple Watches, Garmins and Fitbits, which endurance athletes use to tell them how fast and far they went. Some models also continuously track their heart rates to give clinicians a better look at how recovery is going, or not.
The inability to be physically active can hamper recovery, too. “It can become a downward spiral of not feeling well to not being as active, to endurance dropping, so activity levels further drop,” said Dr. Benjamin Abramoff, director of the post-Covid Assessment and Recovery Clinic at Penn Medicine in Philadelphia, which opened in June 2020. Athletic patients have also lost a piece of their identity, as well as access to a valve for stress relief.
“Running was how I managed my depression. It was the only time I was not thinking about everything that goes wrong in your life,” Ms. Smith said.
Not being able to run has made coping with the lingering side effects of her illness, which include reduced lung capacity, cognitive delays, edema, neuropathy and post-traumatic stress disorder, much more difficult. In the past, “running was how I was able to escape,” she said.
Patients with long Covid can present with a range of symptoms, including pain, breathing problems, heart abnormalities and fatigue. Nearly one-quarter of Covid patients have sought treatment for new health conditions one month or more post infection, according to a study from the nonprofit FAIR Health, which drew data from nearly 2 million patients’ private health insurance claims.
To treat these patients, post-Covid clinics have formed around the country, 33 at last count, according to Becker’s Hospital Review.
Penn’s clinic was the brain child of physical medicine and pulmonology specialists, with the idea of giving patients a medical home “where they can get an A-to-Z full evaluation, and we can track these patients when new research comes out,” said Dr. Abramoff, whose background is in treating spinal cord injuries. So far they’ve seen about 650 patients.
Fatigue is a common complaint of their patients, he said. For athletes, it’s lost endurance. “There’s a good segment of patients who might feel OK while doing an activity but in the evening or days after, they feel lousy, can’t get out of bed and feel sick.”
Penn developed a physical therapy program, which varies according to the severity of each patient’s symptoms. “For some patients who were really seriously affected and can’t do any activities, how do we build back to the housework that you have to do on a daily basis? How do we pace that out across the course of the day so you don’t have to do everything at once?”
For those with less severe symptoms, it’s a focus on gradually building back to activity, keeping the heart rate at 60 to 70 percent of their maximum at first. “If they tolerate it and are OK with it for a week or two weeks, we’ll build on that,” he said.
Long-haul Covid patients tend to “have a honeymoon period, maybe two or three weeks after the acute illness,” said Dr. R. Kannan Mutharasan, a cardiologist at Northwestern Memorial Hospital in Chicago and co-program director of sports cardiology. “They’re finally feeling back to themselves and say ‘I’m going to go out for a run,’” he said. But afterward, they notice they’re not feeling the way they used to. A few weeks later, they may experience “things like lightheadedness, or a rapid heartbeat even when walking.”
That’s what happened to one of his patients, Hannah Engle, 23, who was diagnosed with Covid-19 last July. She tried going for a run again in October, and her heart rate went up to 210 beats per minute. She is now on the “taking it slow” approach, but still hits setbacks if she overdoes it. In May, for example, she experienced chest pain and dizziness after what seemed like a simple workout with jumping jacks and stretching.
Ms. Engle had always been an active person. As a child, she competed in diving, cheerleading and gymnastics, and even did gymnastics at the club level through college. After graduating, she continued to stay active through CrossFit, weight lifting and running 5Ks while working in Arlington, Va., to encourage people to go into the STEM fields — science, technology, engineering and math.
Since long-haulers are still a new class of patient, Dr. Mutharasan is trying to take cues from treating patients with cardiac problems from conditions like postural orthostatic tachycardia syndrome (POTS), where problems with blood flow lead to abnormal heart rates, especially when sitting up or standing. That includes things like wearing compression socks to keep blood circulating to the head, and increasing salt intake to expand blood plasma volume. There’s no clinical data that this is effective with Covid long-haul patients, but anecdotally, Dr. Mutharasan said it’s helped about half his patients.
He’s also looking at data: If patients wear any sort of fitness device, like an Apple Watch or a Garmin smartwatch, he asks to see their data from before and after their Covid-19 infection. Research published Wednesday in the journal JAMA Network Open underscores the role that fitness trackers can play in monitoring long Covid. Dr. Mutharasan particularly likes WHOOP, a fitness device that tracks heart-rate variability — the variation in time between heart beats.
That number “will drop for a variety of reasons: overtraining, not enough sleep, too much alcohol, stress or where you are in your training cycle,” he said.
The idea that higher heart rate variability generally means better cardiovascular health isn’t new; the new part is that patients can have that information themselves. “With the democratization of health care data and the ability for patients to have that data rather than just health care providers, anyone can get at this information with a smart watch,” Dr. Mutharasan said. It can also show that the body is taxed from something like long Covid, and how much.
The goal is to make that number go up over time, which he said it typically does, even if it’s slowly.
“Day to day you’re not going to notice the difference, and week to week you probably won’t notice, but month to month, you probably will,” he said.
For Ms. Smith, the veteran, the slow pace of recovery has been challenging.
At the time of her Covid infection in March 2020, she went to a hospital emergency room with double pneumonia. She was not considered sick enough to be admitted, but her long-haul symptoms have been severe. At a pulmonary fitness test in July 2020, her lungs showed the same capacity as someone with emphysema, despite no physical signs of lung damage on an X-ray.
She is currently on four different medications, including Aricept (an Alzheimer’s drug), because of cognitive problems. On New Year’s Day, she and two friends from the NYC Bridge Runners, her running group, walked across the Brooklyn Bridge. What was formerly a small part of her regular running route took her nearly two hours to complete.
But, she said, she is improving. She got a dog, a Havanese named Chuleta, early this year, which has forced her to go outside, no matter how bad her fatigue. Her medical team, orchestrated by a nurse practitioner, includes specialists in cardiology, pulmonology, rheumatology, speech pathology, physical therapy, neurological psychiatry, psychology and post-traumatic stress disorder.
After a three-month leave of absence, she has returned to her job as a fund-raising manager for a nonprofit, and she started a new, gradual exercise program mid-June, beginning with yoga and stretching. Making it up the stairs without needing an inhaler is a victory, as well as a painful reminder of how far she has to go.
Ms. Smith said she’s already been through so much, mentally and physically, because of her injury and then Covid, that she’s determined to return to running, and to run the New York City Marathon. “I can’t let this be taken away from me,” she said.
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