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Ok. So I think next, we've got Tim Lloyd. Tim, I, Tim is a physiotherapist. He qualified in 2004 and for 17 years, he's been working with exercise reation in acute and community trust across Nottinghamshire, Derbyshire and South Yorkshire. And he's um predominantly in cardiac rehab. Over the last year, Tim has been working in cardiac and non COVID rehab in a split role. Um and you're gonna talk to us about autonomic dysfunction, how it impacts exercise, testing capacity and precautions with people. Hello, can you hear me? Don't worry, I'm not gonna sing to you. Um I've got the twilight er, talk at the end. Um Hopefully you'll all find it useful. Um I like to thank Joe and Leslie um and all of Pots UK for inviting me to this talk. Um Also to the other speakers today, I found it very informative. Um Obviously I've come here as a, as a speaker myself. Um but I have found it very useful, er, and I think it will definitely help with uh my future practice and I hope everyone else has found the same as well. I probably should have taken off that welcome you to our training event. Bit off the slide. So I do apologize for that. Um And you've got my Sunday name on the bottom Timothy, but you can call me Tim. Oh, sir, I'm thinking it's moving on, I'm here and it's not. Um, so obviously Leslie um has given, oh sorry, Helen has given me a bit of background on, on what I've, I've been doing in my career. II suppose it's kind of validating myself and my experience. Um when you're presenting to a national conference, you wanna kind of show that uh you do know something and hopefully, uh hopefully you can see that II do know a little bit about exercise. Um I qualified in 2004. So 20 years this year, it's scary. I've worked 17 years in exercise rehabilitation. So, um that's mainly been in cardiac rehab. Um So across uh mainly around Sheffield and surrounding areas, Basset Law. Um and I'm currently working in Doncaster. So the last 10 months I have been uh working in Long COVID rehab and cardiac rehab as a split post. So obviously, we see quite a lot of patients uh with dysautonomia um particularly in the one COVID service, but we do sometimes get some patients in cardiac rehab. And my colleagues knowing that I also work in Long COVID passed me the er complicated dysautonomia ones. Um return to exercise is key. So again, sort of explaining why, why it sort of fits in with Long COVID. What they found and studies have found is that, uh, 67% of Long COVID patients have du dysautonomia. So that's quite significant. And that's a lot of the patients we see in Long COVID and a lot of you work in Long COVID clinics will have seen that yourselves. The other thing is that pots has doubled since the pandemic. Um, and, er, I'm not exactly sure of the research but uh I found that online that uh pots has doubled since the pandemic. So, uh, and I suppose because of this awareness and pots um related to Long COVID has increased, which can only be a good thing, um, and leads to more research. So just in terms of the relevance studies have found that pots can cause a smaller heart, it can reduce stroke volume, um reduce venous return, reduce blood volume and impaired vasoconstriction. Um, so what we know with pots is that you get pulling in the blood vessels, which then leads to reducing stroke volume, reducing blood volume. Um, and we also know that vasoconstriction is impaired. So that kind of pumping mechanism to aid the venous return back to the heart is affected, there can be peripheral alterations. So, um, part of that can be related to deconditioning. And I know earlier there's been talk of deconditioning but we know, um, from seeing patients in Long COVID who have perhaps, um, it's perhaps taken a while as as Helen was saying to get that diagnosis, then there can be a lot of deconditioning which can lead to um reducing muscle mass, reducing flexibility. Um but we also know there can be a dysfunction of the peripheral sympathetic nerves. Um So that's obviously something that can affect things as well. Um It was just interesting with the tilt table testing that Helen was talking about earlier about um the fact that you get more of this um cognitive issues and the er brain fog. So what they found is with normal patients, er, with no sort of health conditions, there's a 10% reduce in blood flow in brain blood flow when they stand up in pots, it's 20% reduction in brain blood flow. Um So obviously, that's quite significant exacerbation and heightened psychological burden and effort. And obviously, a lot of these patients have, they've taken, it's been a long process, a lot of time to be diagnosed. A lot of the anxiety that's been talked about earlier and obviously some er went into that quite a bit. Um the deconditioning, er, the other thing to note um that I've found is the reduced aldosterone. So um what that does is it leads to reduce sodium, reduce potassium metabolic acidosis and that then increases the fatigue, the confusion and the heart rate. So, uh that's gonna have an effect as well in terms of our patients. So I thought I would bring this up. Um because there's, there's a lot of worry about exercise in patients. Um, and we found that through, through long COVID, particularly from the start, er, patients were advised not to exercise initially. So the two approaches here in activity and exercise. So I'll go into these in a bit more detail. So, regarding inactivity and dysautonomia, um, what they found is a lack of activity can prevent delay and hamper recovery for long COVID and dysautonomia. Ex exercise intolerance can then lead to neuromuscular and central fatigue. The cardiovascular conditioning and obviously, as a cardiac physio uh are now working in long COVID. Um this is particularly relevant cardiac atrophy hypervolaemia and that may contribute significantly to the parts and functional disability. We also know that venous pooling is one of the major causes of orthostatic intolerance. Um And a lot of that evidence is from Fu and Levine. Some of you will um have heard of Levine from the Levine Protocol. Um That was written in regard to er, exercise with patients with pots. I think this quote is, is very good. I can just leave the talk at this probably. Um So why should we exercise physical reconditioning with regular exercise is the cornerstone of treatment for pots, especially in the chronic state when physical disability has been compounded by cardiovascular deconditioning. So that just puts in a nutshell. Really? I guess. So why do we exercise? Um obviously in cardiac rehab, we're big advocates of exercise, but just in relation to um dysautonomia, we want to increase that vascular function. So, improve the venous return back to the heart. We know that exercise can improve that left ventricle, um which again helps with the reduced pooling and that blood flow and return to the heart also. And diastolic volume, stroke, volume and blood volume can be improved with exercise. And that's obviously something that we know is reduced with pots increased vo two max. For those of you who don't know what VO two max is, it's uh basically exercise capacity. So uh what you're able to do, um it's um they do it with expired oxygen. Um basically pushing people to the limit to, to work out their vo two max. But there are methods that you can use um you know, to work out that um without pushing a patient to the maximum um increased muscle changes, strength gains, peripheral recruitment and oxygen supply mental health is massive. Um from a long term condition, you're gonna get a lot of psychological issues as as some has already talked about. Uh and we know that that feeds into the sympathetic nervous system. So if you get more anxiety, um then that's gonna increase the sympathetic activity. So a lot of what we do in long COVID is trying to even out um that sort of natural balance in your body, trying to increase the parasympathetic nervous, parasympathetic activity and reduce that sympathetic activity. Sorry, I've just set 10 minute timer on my watch on um improved renal function, um reduction in sympathetic response. So that's obviously related to the aldosterone reduction in sympathetic response, prevents and reverses deconditioning, improves general function. So hopefully you can see that exercise is very beneficial for the patients with pots or dysautonomia. So just a word of caution. Um, those of you don't know what per er, post exertional malaise needs to be managed carefully because, um, particularly with long COVID and obviously we get a lot of, of dysautonomia patients within Long COVID, we wanna avoid tho those crashing episodes after exercise. So it needs to be symptom, titrated. Pot symptoms can worsen with exercise. And that's the important thing to know. And that's what I've kind of learned from working with Long COVID as opposed to cardiac rehab. They are very different. See, with cardiac rehab, it's much more of a linear progression with, uh, dysautonomia with Long COVID. You, you do find that you get patients getting worse, um, before they get better. Uh, so I suppose it's not been too disheartened with that. Um, when you're exercising, these patients say that I think over 50% of the ones that they used in their study didn't have pot symptoms at the end of their study, which in which case suggests that, um, it, it can sort of, um, you know, reduce those symptoms associated with pot. So these are just the protocols, I'm not gonna go into any great depth in these. But I just wanted to mention these because some of you will have come across these protocols. Um and basically Levine or Dallas Protocol and then the chops Children's Hospital of Philadelphia, um which was very much based on the Levine Protocol. Um but Levene started a lot earlier in terms of the rehabilitation, I'll talk a little bit about the disadvantages with that. Um I mean, as Helen was saying, we sometimes very much from the beginning when patients have got the really severe uh dysautonomia. So we sometimes don't see them at, at that stage. Um What these protocols generally involve is four months of recumbent exercise. So that's on a bike, rowing or swimming month, four, moving to an upright bike month, five, further upright training and then alternating strength and cardiovascular training. Um But those of you work in this time and pots will know that it's not easy to follow a protocol with these patients necessarily. Um in that you, you don't always have a sort of time aspect to it. You know, it can vary from patient to patient. So the disadvantages with these protocols, it can be very rigid. Um They very much go on heart rate training zones. So you need equipment, heart rate, monitor, rowing machine, et cetera. Yeah, it involves swimming. Then it involves the use of a leisure center which can associate costs to it. Um The other thing that I've kind of thought is if you're using a leisure center with patients who are very severely uh affected with this autonomy, then they might not be able to get to that leisure center. Um in order to do the treatment. Um So then does it mean the patient's gotta buy a rowing machine for home or do bed exercise time insensitive? Um And these protocols are sort of up to seven days a week, um which obviously needs a lot of commitment. Um And that's possibly why we've seen the drop out of some of these studies, eight month program. Uh We're fortunate that we do see patients sort of quite long term. Um We've had patients over a year within our service. Um but not all services can accommodate the sort of eight month program. And then, as I've said, patients who are severely affected might not be able to access the services so early. I'm sorry, I've not moved it on, am I? So that was so that was just that slide. Yeah, I'll just leave that on a minute. So in terms of relevance to long COVID where it sort of fits in with us. Um As I say, we often see the patients a bit further down the line. It's not a hard and fast way of saying a patient's got long COVID so often they'll have a lot of blood tests, a lot of tests at the GP and then they associate the symptoms with a diagnosis of COVID. So then they kind of come into us a little bit further on down the line. Um What we have tended to do in the long COVID service is have a, an approach which increases the parasympathetic activity, reducing the sympathetic activity. So that sort of, it's known as a polyvagal approach. Deconditioning is a problem in long COVID. And we know that deconditioning can lead to more fatigue and worsen symptoms of pots or dysautonomia. So we know that exercise can have a positive impact on this and is key to recovery. Um, exercise specialists agree with the benefits of exercise retraining. Um What, what we find is, um, when we get patients in to the long COVID clinic is many patients get into sort of boom or bust pattern. Um, so they'll either do too much and then have 23 days where they're not able to do very much. Sometimes with the dysautonomia patients, it can be even more if you, if they kind of push themselves a bit too much or they'll just get into a pattern of not of doing very little, which hopefully, as you can see, then increases the symptoms associated with it. So it can be a bit of a vicious cycle. So, where does it fit in our exercise path? Where does exercise fit into our pathway? Um, so we tend to get people into the exercise when the fatigue is a little bit stable. Although from, um, kind of understanding more about pots. Um, we are looking at whether we do a bit more exercise at an earlier stage, uh, with some of the, er, more symptomatic patients, um, but generally fatigue is stable. So a lot of them have done the sort of breathing exercises they're managing the breathing, um, they're managing their fatigue a lot better. Um, with the help of the occupational therapist, it's very slow recovery. Um, we know that deconditioning, as I've said, impacts on fatigue, breathlessness at rest. Um By the time they come into us, usually we will have sort of stabilized, a lot of them developed breathing pattern disorders uh which we work on in clinic patient um should have a good knowledge of that post exertional um symptom exacerbation. So that's what that stands for to be able to self monitor with exercise. Um Any concerns around chest pain, palpitations, dizziness abs have been explored. So, um before they come into exercise, often they'll have had the active stan test. If there's uh cardiac issues, we might have er loaned them a cardiac monitor. Um We might have referred them back to their GP um for support with, with um managing heart rate um or even uh referring into cardiology. So, decision to exercise needs to be appropriate patients happy to exercise and often see once this autonoma is stable. Um So what we'll do is we'll reinforce birth control techniques during exercise. Uh We provide World Health Organization booklet, introduce the ball scale as a measure of exertion levels. Explain that a degree of breathlessness is normal with exercise. Um, we introduce target heart rate if that is appropriate. And as I say, it's not always appropriate. Um, and because, um, sometimes as it's sort of been mentioned in some of the other talks is when you make a patient aware of their, uh, their heart rate, then they get more anxious. So then it feeds the sympathetic nervous system which makes the symptoms worse. So again, it can be a little bit of a vicious cycle. We explain the concept of T er symptom T treated exercise. Explain post exertional malaise how it affects energy, concentration, memory sleep, how it can have because of the effect on the autonomic nervous system, how it can impact on pain, myalgia, those type of things, uh explain self monitoring between sessions, give them a fatigue diary, safety exercise when doing exercise at home safety advisory. Um and then bring in any medication eeg inhalers and then it's about managing the patient's expectations as well. Um because it is a slow process. So we base the guidance on um World Health Organization on COVID um emphasis on symptom monitoring titration. We do preexercise tests, we'll do monitoring during exercise and then generally we don't increase that regularly. So, uh in terms of WW World Health Organization, each stage, they say you need at least one week of being pretty stable before you move on to the next stage. If there's a relapse, we step back a stage start lower and slower. And what we want to see is a normal response to exercise with the birth control and heart rate. So this is the um some of you will be aware of the borg scale, basically a 0 to 10 scale uh based on how much you feel you're exerting yourself going from rest being no exertion at all up to maximal exertion. So what the World World Health Organization in terms of long COVID have done is they've kind of characterized it into different phases. So obviously, phase one, you're working at borg 0 to 1, phase two or to borg three, phase three, up to five, phase four, up to seven and then five up to 10, which is basically saying you're back to normal activity. So these are just the the different phases. Um Phase one prepared to return to exercise might be gentle towards flexibility and balance stretches or Tai Chi I've just put in there that it you could do some recumbent based on the symptoms. Um just based on on some of the protocols around dysautonomia. Phase two, low intensity exercise, walking, light household garden task Pilates, yoga. That phase three is what you'd usually exercise, your cardiac patients around that sort of moderate intensity exercise, inclines, stairs perhaps. And that's where you start perhaps building in the weights. But obviously, from this autonomy. What you find is um with some of the protocols is that it's important to build in the strength a bit earlier on. So that's something we're looking at a little bit more in our service at the moment. Phase four, moderate intensity aerobic and strengthening might be brisk, walking, jogging, cycling, dance classes, Zumba, a patient might not be at that stage or they might not need to get to that stage within your service. So that might be further on down the line and then phase five sort of return to normal baseline. So just in terms of dysautonomia, cautious approach that increases parasympathetic activity reduces sympathetic activity to normalize sensory processing, physical, physical reconditioning according to studies should start early. So as I say, difference in long COVID is that we don't see patients perhaps in that early stage. So I know there's patients or people with, with pots um sort of online or, or in here today. Um And it, and it might be some of that early exercise will er will help slow progression, might need to start with bed exercise or recumbent before progressing pool or water submersion sh can help. So a little nugget that found um is that pool exercise at a depth of 4 ft is equivalent to 90 millimeters of mercury compression stockings. So, um actually the water based exercise might be an option. Um And I suppose that's why some of the protocols advocate this sort of water based exercise, exercise that doesn't cause orthostatic stress, leg, and core strength uh to reduce that orthostatic stress, body based therapies can help benefit the nervous system. So perhaps uh some of these sort of tai chi where you're using the breath work, where you're doing a bit of the mindfulness and, and B building that in increased frequency and d duration, then bringing in the upright exercise and then the lifestyle and symptom advice. So as has been talked about earlier with the fluids, with the salt, with the compression stockings. So the patients in our pathway young, fit working age, we have marathon runners, soldiers wanting to become more active. That's what I'd say. It's fairly, very rarely a linear progression, often take a bit of a step back in the recovery. So you need flexibility. Um When you're approaching this group of patients, you need to utilize skills in managing patient expectations. Um And don't be anxious if a patient does get worse. We, we're often hard on ourselves because we think these patients should be progressing. Um And it's not always the case, constant encouragement, measures of process and what we find in our service is that with the exercise, we do get improvement in all our patients in terms of um we do a six minute war test um at the beginning and the end of the exercise program. So just I know I've not got got long a lot. Um So just regarding a specific patient I've been seeing. Um so 32 year old female previously went to the gym, ran 10 KS high levels of fatigue. She was getting a lot of floaters, a lot of um symptoms around sort of dizziness, migraines had a breathing pattern disorder, lots of anxiety. So a lot of our treatments around the fatigue management around the anxiety. Um A lot of us within our team have done sort of basic CBT training. We do, we are able to refer to long um talking therapies, uh P HQ nine referral to the GP for medication. Although what I would say is that it's not, not always possible um to, um, get the GPS to prescribe certain medications. Sometimes they prefer to wait for the cardiologist, um, vestibular rehab, breathing exercise. Um, and then we got, got this lady into exercise pathway and lifestyle advice. So currently she's doing treadmill exercise, working to above three. So that's just getting your breathing up a little bit more than at rest, continuing to wear a compression stockings. But we're starting to build leg strength. And I suppose that's the one thing like a lot of these protocols start the, the strength exercise really early because we get patients in a little bit later. Um, then we're perhaps allowing a, it, there's a bit more time before sort of building in the strength exercise. Um, but that's some. So this just regarding our studies. Um, we use a lot of outcome measures. I think someone mentioned about Long COVID and we use C 19 shoulder fatigue, um, dys dysnea scale. Um, and we, we, we do get uh some really good improvements with our patients. So just a bit of a conclusion, obviously, it causes a number of debilitating symptoms. As you all know. Um, if there's an opportunity to exercise patients, an early approach is beneficial, providing fatigue is stabilized, has a number of benefits to the patient with a dysregulated autonomic nervous system must be carefully managed to avoid a boom or bust pattern. And as I say, we're gonna look into building a bit more, er, early exercise, perhaps some more of the strength exercise within our team. So that's just some of the, um, evidence of, of kind of you.