Prehabilitation the ultimate in self-help
How to optimise your health to give you the best chance of surviving a severe infection such as COVID-19
It is likely that as a society we are going to have to begin to live with COVID-19 and with many new and emerging coronavirus variants and new strains (SARS-CoV-3). On top of this will remain the annual threat of annual new influenza strains and other emerging infections, including hospital-acquired and multi-antibiotic resistant infections.
What this means is that many of us will become infected with serious infections at some point in the future and a significant proportion of us will get a severe infection, which is potentially life-threatening and will require hospital admission. Therefore you should always be prepared to get a severe infection.
To maximise your chances of surviving infection and its immune complications there are several things you can do to prepare for a physiological stressor like COVID-19. This preparation is called prehabilitation. Prehabilitation is usually used for patients about to have major elective surgery with the objective of reducing the chances of operative and post-operative complications.
Prehabilitation
So if you have multiple sclerosis a pre-infection prehabilitation programme makes sense. The following is a list of things I recommend you all should do:
Smoker? If you are a smoker, please try and stop smoking. Smokers are more likely to die from respiratory infections than non-smokers. Smoking is an addiction and you may need professional help. There are many self-referral clinics you can access yourself or ask your GP. The medical profession has gotten much better and helping people stop smoking; so please ask for help.
If you have comorbidities make sure their management is optimised.
Hypertension: Check your blood pressure yourself. If it is high see your GP. If you have established hypertension make sure your medications have been adjusted to render you normotensive.
Diabetic? Make sure you adhere to your diabetic medication and be extra vigilant with your glucose monitoring. You may need to check in with your diabetic nurse or diabetologist for advice if your blood glucose levels are all over the place.
Overweight or obese? Maybe it is time to address your lifestyle and try to lose some weight. Again sugar addiction is a big problem and you may need some professional help via your GP.
Alcohol misuse: If you drink more than the national guidelines please try and cut back on your excessive drinking. If you have a drinking problem and need help please speak to your GP.
Asthmatic? Is your asthma under control? If you have bronchospasm you may need to get your meds/inhalers changed. You don’t want to have poorly controlled asthma when you get COVID-19 or another respiratory infection.
Sleep-deprived or sleep disorders? It is important you optimise the amount of sleep you are getting. Sleep deprivation is associated with multiple poor health outcomes. PwMS are more likely than the general population to have a sleep disorder. If you use sedatives to sleep you may want to try and wean these as they can affect respiratory function, which can make respiratory infections worse.
Diet? This is a good time to review your diet to see if you can improve it. A healthy balanced diet with as little processed and ultra-processed food is what you should be aiming for.
Dietary supplements? It may be a good time to make sure you are vitamin replete. I recommend adults take 4,000U of vitamin D3 per day. In general, if you eat a balanced diet you do not need other dietary supplements. However, if you have an unbalanced diet, for example, a vegan diet you may need to take extra zinc, iron and selenium. There are theoretical reasons why zinc may help your immune system during an infection.
Exercise? There is no doubt that being deconditioned or unfit is a risk factor for a poor outcome from many serious diseases. If you are unfit you should trya and start exercising with the aim of increasing your fitness. For those of you who are mobile, I would suggest the couch-to-5 programme. If you are not mobile there are upper body exercises that you can do. Ideally, an exercise programme should be personalised with a physiotherapist, but if this is not possible there are pragmatic ways of getting going on your own.
Breathing exercises? If you are disabled and not exercising very much you should start doing deep breathing exercises to increase the ventilation of the little-used parts of the lung. This can be done before or in the event, you develop a respiratory infection such as COVID-19. The following breathing exercises have been kindly provided by Sally Roberts, a physiotherapist:
Start by sitting in a comfortable position- back supported, knees slightly bent.
You are going to localise your breathing to the three areas of the chest/lungs in turn.
Start by placing your hands on your upper chest with fingers touching your collar bones (clavicle) take two to three deep breaths, breath in through your nose and out through your mouth. Feel your upper chest (apical region) rise and fall as you breathe in and out.
Next, place your hands onto your lower ribs at the sides. If you find it difficult to use the palm of your hand, place the back of your hand against your ribs. Two or three more deep breaths – in through the nose, out through the mouth.
As you breathe in, feel your ribs expand outwards. If you apply a bit of pressure onto your ribs with your hands it will help you to expand this part of your chest.
Now place one hand into the soft area between the bottom of your ribs – as you breathe in feel the soft part rise and descend on breathing out – again 2-3 breaths in through the nose and out through the mouth. This is using your diaphragm efficiently.
If you begin to feel dizzy – take a rest in between each exercise and breath normally.
All of these exercises are designed to increase your lung capacity and use areas of the lung you may not use regularly except on physical exercise.
If you feel breathless it may help to stand and lean against some support on your forearms – not gripping – a bannister or work surface may be the right height and breathe slowly and as deeply as you can.
If you have an underlying chronic chest disease e.g. COPD or asthma, you need to consult your respiratory physiotherapist for more detailed or specific advice.
Mental health: Anxiety and depression are stressors in themselves and will affect how your body responds to infection. It is important that if you are anxious and/or depressed you get this treated. Exercise, mindfulness (meditation) and cognitive behavioural therapy have all been shown to reduce anxiety and improve depression. These are things you can do yourself. I am aware that it has been hard to address depression and anxiety during the lockdown, but there are things you can do to help yourself; but, if you think you need help, please reach out to your general practitioner and/or MS team.
Advanced directives / Living wills: It is important to prepare for things in advance. If you did get a severe infection and needed to go to ITU, possibly be ventilated and receive advanced life support. Is that what you would want? If it is not, make sure this is documented formally with your general practitioner and is included in your medical records. Also, let your family know what your wishes are. It may be a good time to update your will and instructions for your family in the event of you getting a severe infection and passing away. You may want to prepare a folder summarising your medical condition, including your advanced directive, with all the necessary contact details of your next of kin. Also, make a list of things you will need to take to the hospital in the event of you getting severe COVID-19 or another infection. Please don’t forget your mobile charger; remember visitors are not allowed for COVID-19 patients so having a functioning mobile phone is an important way of keeping in contact with your family and friends.
The advice above is really quite obvious and you may be tempted to ignore it, but before you ignore it think about your general health and how you feel. Prehabilitation is simply taking control of your own health and preparing for what lies ahead. Think of it as an insurance policy.
I would be interested to know if any of you have anything to add to this list. Thank you.
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General Disclaimer: Please note that the opinions expressed here are those of Professor Giovannoni and do not necessarily reflect the positions of Barts and The London School of Medicine and Dentistry nor Barts Health NHS Trust. The advice is intended as general advice and should not be interpreted as being personal clinical advice. If you have problems please tell your own healthcare professional who will be able to help you.
Just to say the most important thing I can do as an HCP working in the field of MS is to walk the talk and to engage in my own prehabilitation programme, which is what I did at the beginning of the COVID-19 pandemic and what I continue to do.
Yes I totally agree, not wishing to point out the obvious, go swimming! I have Little function in my legs, but with a figure of eight type float ( all pools have them) jammed between the legs ,front crawl using just upper my body is not that much slower than with legs. With a pair of goggles, good regulated breathing it has to be the best way to improve lung / heart function for someone with compromised lower body function. It’s alarming how quickly lung capacity improves.From a mental/ motivational perspective, covering a few hundred meters, maybe further becomes a very calming and mediative experience. It increases blood flow, inadvertently exercises many other less used long forgotten muscle groups inadvertently gaining you a little more strength and stability. The endorphin increase, makes you feel great. If you do enjoy it and build up to a couple of good sessions per week the bad habits listed above, smoking, bad diet etc start to become a hinderance, giving one a tangible reason to cut down or stop. Ultimately the joy of being able to once again propel one’s self without the aid of wheels, walkers etc cannot be underestimates. Under the equalities act all pools have to make a reasonable effort to accommodate your needs. Most have hoists to help you get in and out. I’m not saying this is for everyone, but if you swam fairly competently in you youth or pre MS days, it shouldn’t be too hard to pick up again. For those (like myself) who are heat intolerant, remember that you are exercising in a vast tank of coolant. Sorry to appear a little over zealous but it does tick a number of boxes in the prehabilitation box.
RV