Associations between heart rate and physical activity in people with post-COVID-19 condition accounting for myalgic encephalomyelitis/chronic fatigue syndrome symptoms
DOI:
https://doi.org/10.2340/jrm.v58.43340Keywords:
post COVID-19 syndrome, long covid, heart rate, tachycardia, physical activityAbstract
Background: Tachycardia after mild activity or during rest is a common complaint among people with post-COVID-19 condition (PCC). Understanding the relationships between heart rate (HR) and physical activity (PA) in this population is crucial for developing appropriate rehabilitation protocols.
Objective: To investigate the associations between HR and PA in individuals with PCC, accounting for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) symptoms.
Design: Observational study.
Subjects: Sixteen adults with PCC (81% females, mean age 51 ± 12 years).
Methods: Participants were instructed to use 2 wearable devices (Garmin smartwatch and ActiGraph accelerometer) during waking hours over 4 days while performing daily activities. Average HR, percentage of time in tachycardia (time with HR > 100 bpm), and daily step count were assessed. The accelerometer counts per minute was used to categorize daily PA as sedentary, light intensity, and moderate-to-vigorous (MVPA).
Results: Participants wore the watches and accelerometers for a mean of 11.36 ± 2.60 and 12.51 ± 1.94 h per day, respectively. Average daily HR increased with increasing PA levels from sedentary to MVPA. However, the percentage of time in tachycardia was significantly lower during periods of MVPA compared with sedentary periods, even after adjusting for ME/CFS symptoms.
Conclusion: Individuals with PCC in our study experienced more tachycardia during periods of minimal physical activity compared with periods categorized as MVPA.
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World Health Organization. Post COVID-19 condition (long COVID) [Internet] [cited 2025 Dec 10]. Available from: https://www.who.int/news-room/fact-sheets/detail/post-covid-19-condition-(long-covid)
Taher MK, Salzman T, Banal A, Morissette K, Domingo FR, Cheung AM, et al. Global prevalence of post-COVID-19 condition: a systematic review and meta-analysis of prospective evidence. Health Promot Chronic Dis Prev Can 2025; 45: 112–138. DOI: https://doi.org/10.24095/hpcdp.45.3.02
https://doi.org/10.24095/hpcdp.45.6.06 DOI: https://doi.org/10.24095/hpcdp.45.6.06
Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med 2021; 4: 601–615.
https://doi.org/10.1038/s41591-021-01283-z DOI: https://doi.org/10.1038/s41591-021-01283-z
Twomey R, DeMars J, Franklin K, Culos-Reed SN, Weatherald J, Wrightson JG. Chronic fatigue and postexertional malaise in people living with long COVID: an observational study. Phys Ther 2022; 4: pzac005.
https://doi.org/10.1093/ptj/pzac005 DOI: https://doi.org/10.1093/ptj/pzac005
Dani M, Dirksen A, Taraborrelli P, Torocastro M, Panagopoulos D, Sutton R, et al. Autonomic dysfunction in ‘long COVID’: rationale, physiology and management strategies. Clin Med 2021; 21: e63-e67.
https://doi.org/10.7861/clinmed.2020-0896 DOI: https://doi.org/10.7861/clinmed.2020-0896
Park JH, Park S, Kim NH, Lee Y, Chang Y, Song TJ. Postural orthostatic tachycardia syndrome associated with COVID-19: a narrative review. Medicina (Kaunas) 2024; 60: 1325.
https://doi.org/10.3390/medicina60081325
Baruscotti M, Bucchi A, Milanesi R, Paina M, Barbuti A, Gnecchi-Ruscone T, et al. A gain-of-function mutation in the cardiac pacemaker HCN4 channel increasing cAMP sensitivity is associated with familial inappropriate sinus tachycardia. Eur Heart J 2017; 38: 280–288.
https://doi.org/10.1093/eurheartj/ehv582 DOI: https://doi.org/10.1093/eurheartj/ehv582
Goldstein DS. The possible association between COVID-19 and postural tachycardia syndrome. Heart Rhythm 2021; 18: 508–509.
https://doi.org/10.1016/j.hrthm.2020.12.007 DOI: https://doi.org/10.1016/j.hrthm.2020.12.007
Vernon SD, Hartle M, Sullivan K, Bell J, Abbaszadeh S, Unutmaz D, et al. Post-exertional malaise among people with long COVID compared to myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Work 2023; 74: 1179–1186.
https://doi.org/10.3233/wor-220581 DOI: https://doi.org/10.3233/WOR-220581
Cotler J, Holtzman C, Dudun C, Jason L. A brief questionnaire to assess post-exertional malaise. Diagnostics (Basel) 2018; 8: 66.
https://doi.org/10.3390/diagnostics8030066 DOI: https://doi.org/10.3390/diagnostics8030066
Zhou G, Meyer A, Li S, Chen Z, Lan W, Yang G, et al. Exercise intervention in treatment of neuropsychological diseases: a review. Front Psychol 2020; 11:569206.
https://doi.org/10.3389/fpsyg.2020.569206 DOI: https://doi.org/10.3389/fpsyg.2020.569206
Reiner M, Niermann C, Jekauc D, Woll A. Long-term health benefits of physical activity: a systematic review of longitudinal studies. BMC Public Health 2013; 13: 813.
https://doi.org/10.1186/1471-2458-13-813 DOI: https://doi.org/10.1186/1471-2458-13-813
Callow DD, Arnold-Nedimala NA, Jordan LS, Pena GS, Won J, Woodard JL, et al. The mental health benefits of physical activity in older adults survive the COVID-19 pandemic. Am J Geriatr Psychiatry 2020; 28: 1046–1057.
https://doi.org/10.1016/j.jagp.2020.06.024 DOI: https://doi.org/10.1016/j.jagp.2020.06.024
Pinckard K, Baskin K, Stanford K. Effects of exercise to improve cardiovascular health. Front Cardiovasc Med 2019; 4: 69. https:// doi: 10.3389/fcvm.2019.00069 DOI: https://doi.org/10.3389/fcvm.2019.00069
Spruit MA, Rochester CL, Kenn F, Schols K, Hart AMWJ, Wouters N, et al. Pulmonary rehabilitation, physical activity, respiratory failure and palliative respiratory care. Thorax 2019; 74: 693–699.
https://doi.org/10.1136/thoraxjnl-2018-212044 DOI: https://doi.org/10.1136/thoraxjnl-2018-212044
World Health Organization. Clinical management of COVID-19 patients: living guideline 2023 [cited 2025 Dec 10]. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2023.2
Torjesen I. NICE cautions against using graded exercise therapy for patients recovering from covid-19. BMJ 2020; 370: m2912.
https://doi.org/10.1136/bmj.m2912 DOI: https://doi.org/10.1136/bmj.m2912
Belman MJ, Brooks LR, Ross DJ, Mohsenifar Z. Variability of breathlessness measurement in patients with chronic obstructive pulmonary disease. Chest 1991; 99: 566–571.
https://doi.org/10.1378/chest.99.3.566 DOI: https://doi.org/10.1378/chest.99.3.566
Kleinman L, Zodet MW, Hakim Z, Aledort J, Barker C, Chan K, et al. Psychometric evaluation of the fatigue severity scale for use in chronic hepatitis C. Qual Life Res 2000; 9: 499–508.
https://doi.org/10.1023/a:1008960710415 DOI: https://doi.org/10.1023/A:1008960710415
Sunnquist M, Lazarus S, Jason LA. The development of a short form of the DePaul Symptom Questionnaire. Rehabil Psychol 2019; 64: 453–462.
https://doi.org/10.1037/rep0000285 DOI: https://doi.org/10.1037/rep0000285
Feng YS, Kohlmann T, Janssen MF, Buchholz I. Psychometric properties of the EQ-5D-5L: a systematic review of the literature. Qual Life Res 2021; 30: 647–673.
https://doi.org/10.1007/s11136-020-02688-y DOI: https://doi.org/10.1007/s11136-020-02688-y
Bohannon RW, Smith J, Hull D, Palmeri D, Barnhard R. Deficits in lower extremity muscle and gait performance among renal transplant candidates. Arch Phys Med Rehabil 1995; 76: 547–551.
https://doi.org/10.1016/s0003-9993(95)80509-5 DOI: https://doi.org/10.1016/S0003-9993(95)80509-5
Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, et al. The 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985; 132: 919–932. https://pubmed.ncbi.nlm.nih.gov/3978515/
Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158: 1384–1387.
https://doi.org/10.1164/ajrccm.158.5.9710086 DOI: https://doi.org/10.1164/ajrccm.158.5.9710086
Strassmann A, Steurer-Stey C, Lana KD, Zoller M, Turk AJ, Suter P, et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health 2013; 58: 949–953.
https://doi.org/10.1007/s00038-013-0504-z DOI: https://doi.org/10.1007/s00038-013-0504-z
Fuller D, Colwell E, Low J, Orychock K, Ann Tobin M, Simango B, et al. Reliability and validity of commercially available wearable devices for measuring steps, energy expenditure, and heart rate: systematic review. JMIR Mhealth Uhealth 2020; 8: e18694.
https://doi.org/10.2196/18694 DOI: https://doi.org/10.2196/18694
Ngueleu AM, Barthod C, Best KL, Routhier F, Otis M, Batcho CS. Criterion validity of ActiGraph monitoring devices for step counting and distance measurement in adults and older adults: a systematic review. J Neuroeng Rehabil 2022; 19: 112.
https://doi.org/10.1186/s12984-022-01085-5 DOI: https://doi.org/10.1186/s12984-022-01085-5
Troiano RP, Berrigan D, Dodd KW, Mâsse LC, Tilert T, Mcdowell M. Physical activity in the United States measured by accelerometer. Med Sci Sports Exerc 2008; 40: 181–188.
https://doi.org/10.1249/mss.0b013e31815a51b3 DOI: https://doi.org/10.1249/mss.0b013e31815a51b3
Freedson PS, Melason E, Sirard. Calibration of the Computer Science and Applications, Inc. accelerometer. Med Sci Sports Exerc 1998; 30: 777–781.
https://doi.org/10.1097/00005768-199805000-00021 DOI: https://doi.org/10.1097/00005768-199805000-00021
Tudor-Locke C, Bassett DR. How many steps/day are enough? Preliminary pedometer indices for public health. Sports Med 2004; 34: 1–8.
https://doi.org/10.2165/00007256-200434010-00001 DOI: https://doi.org/10.2165/00007256-200434010-00001
Page RL, Joglar JA, Caldwell MA, Calkins H, Conti JB, Deal BJ, et al. 2015 ACC/AHA/HRS guideline for the management of adult patients with supraventricular tachycardia: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol 2016; 67: e27–115.
https://doi.org/10.1161/cir.0000000000000310 DOI: https://doi.org/10.1161/CIR.0000000000000310
Katritsis DG, Boriani G, Cosio FG, Hindricks G, Jaïs P, Josephson ME, et al. European Heart Rhythm Association (EHRA) consensus document on the management of supraventricular arrhythmias, endorsed by Heart Rhythm Society (HRS), Asia-Pacific Heart Rhythm Society (APHRS), and Sociedad Latinoamericana de Estimulación Cardiaca y Electrofisiologia (SOLAECE). Europace 2017; 19: 465–511.
https://doi.org/10.1093/europace/euw301 DOI: https://doi.org/10.1093/europace/euw301
Ståhlberg M, Reistam U, Fedorowski A, Villacorta H, Horiuchi Y, Bax J, et al. Post-COVID-19 tachycardia syndrome: a distinct phenotype of post-acute COVID-19 syndrome. Am J Med 2021 134: 1451–1456. DOI: https://doi.org/10.1016/j.amjmed.2021.07.004
https://doi.org/10.1016/j.amjmed.2021.07.0043
Park JH, Park S, Kim NH, Lee Y, Chang Y, Song TJ. Postural orthostatic tachycardia syndrome associated with COVID-19: a narrative review. Medicina (Kaunas) 2024; 60: 1325.
https://doi.org/10.3390/medicina60081325 DOI: https://doi.org/10.3390/medicina60081325
Aranyó J, Bazan V, Lladós G, Dominguez MJ, Bisbal F, Massanella M, et al. Inappropriate sinus tachycardia in post-COVID-19 syndrome. Scie Rep 2022; 12: 298.
https://doi.org/10.1038/s41598-021-03831-6 DOI: https://doi.org/10.1038/s41598-021-03831-6
O’Brien KK, Brown DA, McDuff K, St Clair-Sullivan N, Chan Carusone S, Thomson C, et al. Episodic disability framework in the context of Long COVID: findings from a community-engaged international qualitative study. PLoS One 2025; 20: e0305187.
https://doi.org/10.1371/journal.pone.0305187 DOI: https://doi.org/10.1371/journal.pone.0305187
Leeuw M, Goossens MEJB, Linton SJ, Crombez G, Boersma K, Vlaeyen JWS. The fear-avoidance model of musculoskeletal pain: current state of scientific evidence. J Behav Med 2007; 30: 77–94.
https://doi.org/10.1007/s10865-006-9085-0 DOI: https://doi.org/10.1007/s10865-006-9085-0
Geraghty K, Jason L, Sunnquist M, Tuller D, Blease C, Adeniji C. The ‘cognitive behavioural model’ of chronic fatigue syndrome: critique of a flawed model. Health Psychol Open 2019; 6: 2055102919838907.
https://doi.org/10.1177/2055102919838907 DOI: https://doi.org/10.1177/2055102919838907
Lethem J, Slade PD, Troup JDG, Bentley G. Outline of a fear-avoidance model of exaggerated pain perception—I. Behav Res Ther 1983; 21: 401–408.
https://doi.org/10.1016/0005-7967(83)90009-8 DOI: https://doi.org/10.1016/0005-7967(83)90009-8
Legler F, Meyer-Arndt L, Mödl L, Kedor C, Freitag H, Stein E, et al. Long-term symptom severity and clinical biomarkers in post-COVID-19/chronic fatigue syndrome: results from a prospective observational cohort. EClinicalMedicine 2023; 63: 102146.
https://doi.org/10.1016/j.eclinm.2023.102146 DOI: https://doi.org/10.1016/j.eclinm.2023.102146
Wright J, Astill SL, Sivan M. The relationship between physical activity and long COVID: a cross-sectional study. Int J Environ Res Public Health 2022; 19: 5093.
https://doi.org/10.3390/ijerph19095093 DOI: https://doi.org/10.3390/ijerph19095093
Fernández-De-las-Peñas C, Palacios-Ceña D, Gómez-Mayordomo V, Palacios-Ceña M, Rodríguez-Jiménez J, de-La-Llave-Rincón AI, et al. Fatigue and dyspnoea as main persistent post-COVID-19 symptoms in previously hospitalized patients: related functional limitations and disability. Respiration 2022; 101: 132–141.
https://doi.org/10.1159/000518854 DOI: https://doi.org/10.1159/000518854
Rinaldo RF, Mondoni M, Parazzini EM, Baccelli A, Pitari F, Brambilla E, et al. Severity does not impact on exercise capacity in COVID-19 survivors. Respir Med 2021; 187:106577.
https://doi.org/10.1016/j.rmed.2021.106577 DOI: https://doi.org/10.1016/j.rmed.2021.106577
Torres-Castro R, Núñez-Cortés R, Larrateguy S, Alsina-Restoy X, Barberà JA, Gimeno-Santos E, et al. Assessment of exercise capacity in post-COVID-19 patients: how is the appropriate test chosen? Life 2023; 13: 621.
https://doi.org/10.3390/life13030621 DOI: https://doi.org/10.3390/life13030621
Neto FR, Marques JM, Brasiliano Da Paz M, Boiteux E, Cavalcanti U, Gomes Costa RR. Sit to stand test and handgrip strength in men and women with post-COVID-19 syndrome without invasive ventilator support: insights from a Brazilian observational study. Monaldi Arch Chest Dis 2023; 94.
https://doi.org/10.4081/monaldi.2023.2495 DOI: https://doi.org/10.4081/monaldi.2023.2495
Appelman B, Charlton BT, Goulding RP, Kerkhoff TJ, Breedveld EA, Noort W, et al. Muscle abnormalities worsen after post-exertional malaise in long COVID. Nat Commun 2024; 15: 17.
https://doi.org/10.1038/s41467-023-44432-3 DOI: https://doi.org/10.1038/s41467-023-44432-3
de Boer E, Petrache I, Goldstein NM, Olin JT, Keith RC, Modena B, et al. Decreased fatty acid oxidation and altered lactate production during exercise in patients with post-acute COVID-19 syndrome. Am J Respir Crit Care Med 2022; 205: 126–129.
https://doi.org/10.1164/rccm.202108-1903le DOI: https://doi.org/10.1164/rccm.202108-1903LE
Rinaldo RF, Mondoni M, Parazzini EM, Pitari F, Brambilla E, Luraschi S, et al. Deconditioning as main mechanism of impaired exercise response in COVID-19 survivors. Eur Respir J 2021; 58: 2100870.
https://doi.org/10.1183/13993003.00870-2021 DOI: https://doi.org/10.1183/13993003.00870-2021
Geidl W, Carl J, Cassar S, Lehbert N, Mino E, Wittmann M, et al. Physical activity and sedentary behaviour patterns in 326 persons with COPD before starting a pulmonary rehabilitation: a cluster analysis. J Clin Med 2019; 8: 1346.
https://doi.org/10.3390/jcm8091346 DOI: https://doi.org/10.3390/jcm8091346
Iwakura M, Spruit MA, Kawagoshi A, Tamaki A, Oki Y, Oshima Y. Physical activity measurements in individuals with interstitial lung disease: a systematic review and meta-analysis. Eur Respir Rev 2023; 32: 220165.
https://doi.org/10.1183/16000617.0165-2022 DOI: https://doi.org/10.1183/16000617.0165-2022
Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol 2012; 2: 1143-1211. DOI: https://doi.org/10.1002/j.2040-4603.2012.tb00425.x
https://doi.org/10.1002/cphy.c110025 DOI: https://doi.org/10.1002/cphy.c110025
De Rezende LFM, Lopes MR, Rey-Lo'p ez JP, Matsudo VKR, Luiz ODC. Sedentary behavior and health outcomes: an overview of systematic reviews. PLoS One 2014; 9: 105620.
https://doi.org/10.1371/journal.pone.0105620 DOI: https://doi.org/10.1371/journal.pone.0105620
Hejbøl EK, Harbo T, Agergaard J, Madsen LB, Pedersen TH, Østergaard LJ, et al. Myopathy as a cause of fatigue in long-term post-COVID-19 symptoms: evidence of skeletal muscle histopathology. Eur J Neurol 2022; 29: 2832–2841.
https://doi.org/10.1111/ene.15435 DOI: https://doi.org/10.1111/ene.15435
Haunhorst S, Dudziak D, Scheibenbogen C, Seifert M, Sotzny F, Finke C, et al. Towards an understanding of physical activity-induced post-exertional malaise: insights into microvascular alterations and immunometabolic interactions in post-COVID condition and myalgic encephalomyelitis/chronic fatigue syndrome. Infection 2025; 53: 1–13.
https://doi.org/10.1007/s15010-024-02386-8 DOI: https://doi.org/10.1007/s15010-024-02386-8
Jimeno-Almazán A, Franco-López F, Buendía-Romero Á, Martínez-Cava A, Sánchez-Agar JA, Sánchez-Alcaraz Martínez BJ, et al. Rehabilitation for post–COVID–19 condition through a supervised exercise intervention: a randomized controlled trial. Scand J Med Sci Sports 2022; 32: 1791–1801.
https://doi.org/10.1111/sms.14240 DOI: https://doi.org/10.1111/sms.14240
Ladlow P, Bennett AN, O’Sullivan O. Exercise therapy for post-COVID-19 condition – does no harm. JAMA Netw Open 2024; 7: e246959.
https://doi.org/10.1001/jamanetworkopen.2024.6959 DOI: https://doi.org/10.1001/jamanetworkopen.2024.6959
Marques KC, Quaresma JAS, Falcão LFM. Cardiovascular autonomic dysfunction in “Long COVID”: pathophysiology, heart rate variability, and inflammatory markers. Front Cardiovasc Med 2023; 10: 1256512.
https://doi.org/10.3389/fcvm.2023.1256512 DOI: https://doi.org/10.3389/fcvm.2023.1256512
Durstenfeld MS, Peluso MJ, Kaveti P, Hill C, Li D, Sander E, et al. Reduced exercise capacity, chronotropic incompetence, and early systemic inflammation in cardiopulmonary phenotype Long Coronavirus Disease 2019. J Infect Dis 2023; 228: 542–554.
https://doi.org/10.1093/infdis/jiad131 DOI: https://doi.org/10.1093/infdis/jiad131
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