This article by BAPAM Physiotherapist, Lucie Rayner, is the second in our series covering aspects of returning to performance environments, and building up work schedules and routines in the light of the COVID 19 pandemic and lockdowns. We will update the article based on developing research and evidence. Last updated: 19 April 2021.
Since the first reported case of COVID-19 in January 2020, over 4 million people in the UK have tested positive for the virus. Many have been asymptomatic, but the majority will have suffered the common symptoms of an acute viral infection. Some may have been hospitalised, whilst others self-cared at home. Some people have experienced persistent symptoms, often referred to as Long COVID. This article aims to provide information and guidance to those working in the performing arts who have suffered acute or chronic COVID symptoms and are resuming training, practising and performing.
Acute COVID Infections
The COVID-19 virus enters the body through the nose, mouth or eyes. Once infected, the severity and duration of symptoms vary and can include: a continuous cough, fever, shortness of breath, fatigue, muscle aches and loss of taste/smell. To help manage symptoms you should stay hydrated and rest but get up and move regularly. You can also take paracetamol to help manage fever and joint/muscle aches. If you need further advice, use the NHS 111 service: NHS 111 online.
The term ‘Long COVID’ is an umbrella term that describes a cluster of symptoms related to an initial COVID infection where symptoms persist after the acute infection phase. Recent research suggests that 1 in 5 will experience symptoms for more than 5 weeks and 1 in 10 will experience symptoms for more than 12 weeks. It appears that Long COVID can affect the whole body including the respiratory, cardiovascular, neurological and gastrointestinal systems. Symptoms vary significantly between individuals, but the most commonly reported are:
- Chest pain
- Brain fog
- Joint and muscle pain
- Psychological symptoms such as depression and anxiety.
Long COVID patients have referred to themselves as ‘Long Haulers’ and report that recovery is not straight forward, with the illness showing an unpredictable nature with cyclical relapses. Evidence is emerging that Long COVID may be related to organ damage due to the viral infection and subsequent inflammatory response. Some medical professionals familiar with managing Chronic Fatigue Syndrome (CFS) or Myalgic Encephalomyelitis (ME) predicted the emergence of some kind of post-viral syndrome related to COVID-19. There is an urgent need for more research but included here are some of the factors to consider based on our current knowledge.
Ensuring that you have appropriate medical support for Long COVID is vital. Many sufferers may not have consulted their GP or may have previously tried to seek help but been unable to access services. Those with Long COVID require specialist, timely, multi-disciplinary support. Contact your GP for an appointment to discuss your concerns and keep a symptom diary to show how you are being affected. Blood tests, blood pressure measurements, chest x-rays and specialist referrals may be indicated. Health tracking devices such as heart rate monitors or pulse oximeters (which measures blood oxygen levels) may be used to help inform progress. In addition, the NHS now has over sixty dedicated Long COVID clinics in the UK which can take GP referrals. Some patients are reporting long waiting lists due to overwhelming demand. If you continue to have trouble accessing healthcare, contact your GP Practice Manager or your local Healthwatch to get further help and advice.
Feeling breathless is a commonly reported symptom of Long COVID, especially if you have been admitted to hospital. There are several ways to help reduce breathlessness such as breathing control and other exercises, as well as using specific body positions which help with breath recovery. If you are referred to a Respiratory Physiotherapist, they may use breathing pattern re-education or inspiratory muscle training to restore respiratory function. The British Lung Foundation website gives more details on managing breathlessness as well as offering a free, confidential helpline number for anyone needing support. The English National Opera has also developed a breathing programme for people suffering from COVID, which focuses on breathing re-training through singing.
Some people with Long COVID experience Post-Viral Fatigue (PVF). This type of fatigue does not resemble everyday tiredness but is an all-encompassing exhaustion, which can be exacerbated by even small amounts of exertion. It is also common for energy levels to vary unpredictably from day-to-day. In these circumstances, the body will need complete rest from all activities including physical (e.g., housework), mental (e.g., reading, problem-solving) and emotional (e.g., talking to family). Long COVID support groups have advised sitting or reclining in a quiet space with eyes closed. Avoid TV, phones and social media. Listening to relaxing music, nature sounds, or a guided meditation can also be effective.
In addition to getting sufficient rest, adopting principles of energy conservation will be valuable as it can help prevent the ‘boom/bust’ cycle often seen in those recovering from Long COVID. There are small changes you can make to conserve energy and manage your daily tasks. This could include breaking the day into sections, planning rest between activities and setting realistic goals for each day. Keeping an activity diary can also be helpful. The 3 Ps Principle allows you to Pace, Plan and Prioritise your day-to-day workload. The Royal College of Occupational Therapists have produced a downloadable PDF on the principles of conserving energy.
Activity and Exercise
“It is common that energy levels are lower after a period of illness, so it is important to start rebuilding your routine and activities slowly.” (Chartered Society of Physiotherapists)
Long COVID sufferers are likely to be deconditioned and will benefit from building physical strength and resilience as part of their recovery. However, in some circumstances exercise may be harmful for people with Long COVID. Long Covid Physio highlight the importance of caution with exercise, and advice from the National Institute of Health and Care Excellence (NICE) cautions against graded exercise programmes Exercise — Long COVID Physio.
Further information from Long COVID Physio: Resources — Long COVID Physio
The Chartered Society of Physiotherapists (CSP) has produced guidance on rebuilding your strength, routines and activities. Covid-19: the Road to Recovery (csp.org.uk)
The World Health Organisation (WHO) has also published information about rehabilitation and self-management. Support for Rehabilitation: Self-Management after COVID-19 Related Illness (who.int)
Post-Exertional Malaise (PEM) is a significant worsening of symptoms 12-48 hours following exercise and can severely affect function, sometimes lasting for several days. Some Long COVID patients have reported experiencing PEM, so any exercise rehabilitation must be guided by specialist supervision and careful monitoring to remain within individual limits of exertion. To avoid setbacks or serious deterioration, those who suffer from PEM should not push through fatigue or do vigorous, high-intensity exercise. Some patients have successfully used heart rate monitoring to avoid PEM as it enables them to remain within a target heart rate, so they can exercise safely.
Nutrition and Hydration
A healthy, balanced diet is the foundation for health and recovery following illness. The normal functioning of the immune system requires certain nutrients including Vitamins A, B6, B12, C and D. Between September and March, adults are advised to take a daily 10 microgram supplement of Vitamin D. This is because a large proportion of our Vitamin D supply comes from being in sunlight. Therefore, during the months when the days are shorter and we spend more time indoors, a supplement becomes important. Keeping well hydrated is also vital. Checking the colour of your pee is a useful way of assessing whether you are drinking enough fluids. If your pee is a pale straw colour or clear, you are well hydrated. If it is dark yellow, orange or brown you need to drink more to restore hydration levels. The Association of UK Dieticians has produced some useful information.
Sleep plays a critical role in the healthy functioning of our immune system. Many people have reported sleep disturbances related to being ill with COVID. The normal sleep cycle can be interrupted by coughing, breathlessness, medication or anxiety. A viral infection such as COVID creates an immune response that can also affect sleep. Practicing good ‘Sleep Hygiene’ is a way of helping the body prepare for sleep and can help improve sleep quality. The NHS has some useful information on sleeping well. Another option is the Sleepio app which is an online sleep improvement programme.
The Zoe app, which monitors COVID symptoms, reports that nearly 20% of people experienced voice hoarseness with their initial symptoms. It is common to experience some temporary voice changes following a viral infection as coughing and clearing mucus can inflame the vocal folds, preventing them from vibrating normally. Being intubated (where a breathing tube passed down the throat), can also result in inflamed vocal folds. This normally resolves within 6-8 weeks, but there have been some reports that Long COVID patients can suffer prolonged voice problems. The British Voice Association has produced a guide on how to protect your vocal cords and promote healing, as well as when to seek help.
Phased Return to Work
It can be challenging to return to work following illness and many people with Long COVID report a stop/start process. This struggle could be more profound for performers due to their work environment, which can often involve long, unsociable hours and last-minute scheduling changes. If you are employed, you may have access to an Occupational Health practitioner who can assess your fitness to return to work. Initially, they may advise a phased return, with modified hours or duties for a while. Your employer has a responsibility to have a sickness absence and flexible working policy. Performing arts workers who are freelance or self-employed face the difficult challenge of trying to balance accepting work offers whilst not taking on too much and risking a relapse. Equity has been working on securing government support for freelance creative workers. The Society of Occupational Medicine (SOM) also has a useful return-to-work guide.
Taking the time off required for recovery from Long COVID may further threaten the financial security of some arts professionals, already hard hit by the closure of performance venues. Self-employed performers are not entitled to sick leave or pay. They may also fear that time away from their work will harm their employability and future careers. If you cannot work because of Long COVID symptoms you may be eligible for Personal Independence Payment (PIP) to help cover living costs. There are various organisations and charities for performing artists which offer financial support.
Family and Friends
Watching a loved one go through serious illness can be difficult for friends and family. As well as the physical symptoms of Long COVID, the person may be irritable, have memory problems or suffer from low mood and need extra support. Family, friends and carers of those with Long COVID must look after themselves and seek support too.
There are many research projects related to Long COVID currently underway. Volunteering to take part in research or surveys will not only help improve our current knowledge and understanding of the condition but also have a positive impact on those taking part. As well as learning more about your own health, volunteering could give you early access to new treatment options and help connect you with the Long COVID community.
The experience of suffering from Long COVID can be isolating, especially as we currently don’t have access to our usual support network of family, friends and colleagues. Sharing experiences and thoughts with other people going through a similar experience can be invaluable. There are several support groups that can offer advice and resources.
Long COVID: Patient Experience and Support Groups | BAPAM – in this article we link to support groups sharing advice and resources, and talk to opera singer, Lee David Bowen, who set up Long COVID Wales, the devolved Welsh campaigning offshoot of the 36000 strong patient-led UK Support Group, longcovid.org.
As well as support groups, some people may benefit from counselling or talking therapies. Severe illness, hospitalisation and time in intensive care can be scary and often traumatic. Even those who have not been hospitalised may have experienced significant changes to their life, feelings of helplessness or loss of identity. Their close relationships may also have been negatively affected. Talking to a trained counsellor or therapist may help a person to process and overcome these difficulties.
If you work or study in the performing arts you can book a free appointment with a BAPAM GP or psychologist to discuss mental (and physical) health concerns affecting your work, and we can help you access career-specific care including counselling and psychotherapy.
Long COVID is a new condition that is having a serious impact on people’s lives. Long Haulers have had to campaign to get access to appropriate medical support and treatment.
Long COVID clinics are being established, awareness is increasing and research emerging. With a significant number of performing arts professionals affected by Long COVID and related problems, we aim to support performing arts workers accessing mainstream health provision in addition to highly specialised BAPAM services. If you would like further information about BAPAM clinical services and how we can help you, please contact us on 020 8167 4774 / firstname.lastname@example.org.
NIHR Themed Review: Living with COVID-19; October 2020: NIHR Evidence – Living with Covid19 – Informative and accessible health and care research
World Health Organisation (WHO). Policy Brief: In the Wake of the Pandemic: Preparing for Long COVID (2021): WHO/Europe | Coronavirus disease (COVID-19) outbreak – In the wake of the pandemic: preparing for Long COVID (2021)
National Institute for Health and Care Excellence (NICE). Managing the Long Term Effects of COVID-19. Nice Guideline [NG188]. 18 December 2020 : Overview | COVID-19 rapid guideline: managing the long-term effects of COVID-19 | Guidance | NICE