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Weigel B, Eaton-Fitch N, Thapaliya K, Marshall-Gradisnik S. Illness presentation and quality of life in myalgic encephalomyelitis/chronic fatigue syndrome and post COVID-19 condition: a pilot Australian cross-sectional study. Qual Life Res 2024:10.1007/s11136-024-03710-3. [PMID: 38961009 DOI: 10.1007/s11136-024-03710-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2024] [Indexed: 07/05/2024]
Abstract
PURPOSE Post COVID-19 Condition (PCC), being persistent COVID-19 symptoms, is reminiscent of Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)-a chronic multi-systemic illness characterised by neurocognitive, autonomic, endocrinological and immunological disturbances. This novel cross-sectional investigation aims to: (1) compare symptoms among people with ME/CFS (pwME/CFS) and people with PCC (pwPCC) to inform developing PCC diagnostic criteria; and (2) compare health outcomes between patients and people without acute or chronic illness (controls) to highlight the illness burdens of ME/CFS and PCC. METHODS Sociodemographic and health outcome data were collected from n = 61 pwME/CFS, n = 31 pwPCC and n = 54 controls via validated, self-administered questionnaires, including the 36-Item Short-Form Health Survey version 2 (SF-36v2) and World Health Organization Disability Assessment Schedule version 2.0 (WHODAS 2.0). PwME/CFS and pwPCC also provided self-reported severity and frequency of symptoms derived from the Canadian and International Consensus Criteria for ME/CFS and the World Health Organization case definition for PCC. RESULTS Both illness cohorts similarly experienced key ME/CFS symptoms. Few differences in symptoms were observed, with memory disturbances, muscle weakness, lymphadenopathy and nausea more prevalent, light-headedness more severe, unrefreshed sleep more frequent, and heart palpitations less frequent among pwME/CFS (all p < 0.05). The ME/CFS and PCC participants' SF-36v2 or WHODAS 2.0 scores were comparable (all p > 0.05); however, both cohorts returned significantly lower scores in all SF-36v2 and WHODAS 2.0 domains when compared with controls (all p < 0.001). CONCLUSION This Australian-first investigation demonstrates the congruent and debilitating nature of ME/CFS and PCC, thereby emphasising the need for multidisciplinary care to maximise patient health outcomes.
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Affiliation(s)
- Breanna Weigel
- National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD, 4222, Australia.
- Consortium Health International for Myalgic Encephalomyelitis, Griffith University, Gold Coast, QLD, 4222, Australia.
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, QLD, 4222, Australia.
| | - Natalie Eaton-Fitch
- National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD, 4222, Australia
- Consortium Health International for Myalgic Encephalomyelitis, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Kiran Thapaliya
- National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD, 4222, Australia
- Consortium Health International for Myalgic Encephalomyelitis, Griffith University, Gold Coast, QLD, 4222, Australia
| | - Sonya Marshall-Gradisnik
- National Centre for Neuroimmunology and Emerging Diseases, Griffith University, Gold Coast, QLD, 4222, Australia
- Consortium Health International for Myalgic Encephalomyelitis, Griffith University, Gold Coast, QLD, 4222, Australia
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Feldman DE, Guillemette A, Sanzari J, Youkheang S, Mazer B. Decline in Mobility and Balance in Persons With Post-COVID-19 Condition. Phys Ther 2024; 104:pzae042. [PMID: 38501884 DOI: 10.1093/ptj/pzae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/30/2023] [Accepted: 12/11/2023] [Indexed: 03/20/2024]
Abstract
OBJECTIVES Post-COVID-19 condition (PCC) may impact mobility and balance and affect physical function. The objectives of the study were to estimate the prevalence of decline in balance and mobility in individuals with PCC; explore the association between comorbidities and sociodemographic characteristics with decline in balance and mobility; and evaluate correlations between decline in mobility and balance with change in performance of usual activities, personal care, and global health perception. METHODS The design was a cross-sectional study of persons with a COVID-19 diagnosis that was confirmed at least 3 months before the study. Those with PCC, defined as those still troubled by symptoms, were evaluated for decline in mobility and balance and with associated clinical and demographic factors using bivariate analysis and multivariable logistic regression. Correlations between decline in mobility and balance were also examined with change in ability to perform usual activities, personal care, and global health perception. RESULTS In 1031 persons with PCC, mobility deteriorated in 44.9%, and balance deteriorated in 37.1%. Older age, hospitalization, comorbidities, and obesity were associated with decline in mobility, while decline in balance was associated with older age and comorbidities. Reduced mobility was associated with changes in ability to carry out usual activities (rp = 0.6), conduct personal care (rp = 0.6), and global health status (rp = 0.5). Correlations between decline in balance and these same outcomes were 0.5, 0.5, and 0.45, respectively. CONCLUSIONS Almost half the participants with PCC had reduced mobility, and over a third reported deterioration in balance, with associated difficulties with daily functioning. Factors associated with greater decline help identify those most at risk. IMPACT Many people with PCC experience changes in mobility and balance, which can affect functional capacities and lead to physical therapist consultations. Further study should assess specific needs of these patients and determine effective physical therapist interventions to meet these needs. LAY SUMMARY Many persons with post-COVID-19 condition (PCC) experience symptoms resulting in functional problems, such as difficulties with personal care and performing usual activities. This study focused on difficulty in mobility and problems with balance. Almost half of persons with PCC in the study had declines in getting around and over a third had declines in balance. These problems were associated with older age and having other comorbid health conditions and were linked with decline in ability to perform personal care, carry out usual activities, and perceived global health status.
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Affiliation(s)
- Debbie Ehrmann Feldman
- École de Réadaptation and École de Santé Publique, Université de Montréal, Centre de Recherche Interdisciplinaire en Réadaptation (CRIR) and Centre de Recherche en Santé Publique (CReSP), Montreal, Quebec, Canada
| | - Albert Guillemette
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Juliana Sanzari
- École de Réadaptation Université de Montréal, Montreal, Quebec, Canada
| | | | - Barbara Mazer
- School of Physical and Occupational Therapy, Faculty of Medicine and Health Sciences, McGill University, and Centre for Interdisciplinary Research in Rehabilitation (CRIR), Montreal, Quebec, Canada
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Dzięcioł-Anikiej Z, Kuryliszyn-Moskal A, Pociene M, Dzięcioł J, Dakowicz A, Kostro A. Clinical and Functional Effects of Rehabilitation of Patients after COVID-19 Infection. J Clin Med 2024; 13:3257. [PMID: 38892974 PMCID: PMC11173142 DOI: 10.3390/jcm13113257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: The most common post-acute consequences of SARS-CoV-2 include lung dysfunction, the impairment of cognitive functions and mental health, as well as the impairment of the musculoskeletal system in the form of fatigue and muscle weakness. Post-COVID-19 patients often experience impaired balance and reduced physical capacity. It is important to implement a rehabilitation program that eliminates the side effects of COVID-19 and allows for significant improvement in the patient's functionality. The aim of our study was to assess patient functionality after a 6-week rehabilitation program on balance, foot pressure distribution, and physical capacity in post-COVID-19 patients. Methods: The clinical study group consisted of 53 people 3 months after COVID-19 infection, confirmed by a positive PCR test. Exclusion from the study included people with comorbidities that impaired balance and gait. The patients underwent a posturographic assessment-Romberg test, a baropodometric assessment-static and dynamic, and a performance assessment-a 6 min walk test determining shortness of breath on the mMRC scale, blood pressure, heart rate, and saturation. Patients participated in rehabilitation until the sixth week, after which they were assessed again. Comparisons were made using IBM SPSS Statistics 27.0 software using the Wilcoxon pairwise order test, at a significance level of p < 0.05. Results: The result of the postural control assessment showed an improvement in the ability to maintain the centre of gravity in terms of the foot support area-statistical decreases were observed in the ellipse area, from 745.28 mm2 to 453.52 mm2 (p = 0.009), as well as maximum (from 3133.5 gr/cm2 to 2994.2 gr/cm2; p = 0.065) and average load on the left foot (from 1010.1 gr/cm2 to 969.38 gr/cm2; p = 0.028). In the 6 min walk test before and after exercise, the heart rate decreased after the therapy (shortness of breath on the mMRC scale also decreased from 79.12 to 74.95). This means that patients achieved better physical fitness and efficiency. Conclusions: Rehabilitation significantly improved balance, as measured by a decrease in ellipse area during the Romberg test.
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Affiliation(s)
- Zofia Dzięcioł-Anikiej
- Department of Rehabilitation, Faculty of Health Sciences, Medical University of Białystok, Skłodowskiej-Curie 7A Street, 15-096 Białystok, Poland; (A.K.-M.); (A.D.); (A.K.)
| | - Anna Kuryliszyn-Moskal
- Department of Rehabilitation, Faculty of Health Sciences, Medical University of Białystok, Skłodowskiej-Curie 7A Street, 15-096 Białystok, Poland; (A.K.-M.); (A.D.); (A.K.)
| | - Monika Pociene
- Department of Physiotherapy and Beauty Therapy, Klaipedos Valstybine Kolegija, 91274 Klaipeda, Lithuania;
| | - Janusz Dzięcioł
- Department of Human Anatomy, Faculty of Medicine, Medical University of Bialystok, Mickiewicza 2A Street, 15-230 Białystok, Poland;
| | - Agnieszka Dakowicz
- Department of Rehabilitation, Faculty of Health Sciences, Medical University of Białystok, Skłodowskiej-Curie 7A Street, 15-096 Białystok, Poland; (A.K.-M.); (A.D.); (A.K.)
| | - Amanda Kostro
- Department of Rehabilitation, Faculty of Health Sciences, Medical University of Białystok, Skłodowskiej-Curie 7A Street, 15-096 Białystok, Poland; (A.K.-M.); (A.D.); (A.K.)
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Tesarz J, Lange H, Kirchner M, Görlach A, Eich W, Friederich HC. Efficacy of supervised immersive virtual reality-based training for the treatment of chronic fatigue in post-COVID syndrome: study protocol for a double-blind randomized controlled trial (IFATICO Trial). Trials 2024; 25:232. [PMID: 38570805 PMCID: PMC10993519 DOI: 10.1186/s13063-024-08032-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 03/04/2024] [Indexed: 04/05/2024] Open
Abstract
BACKGROUND The treatment of persistent fatigue after COVID-19 infection is complex. On the one hand, it involves maintaining a sufficient level of physical and mental activity to counteract possible degenerative processes of the body and nervous system. On the other hand, physical and mental activities can also lead to worsening of symptoms. Therefore, the challenge in treating Post-COVID fatigue is to stimulate the body and central nervous system in a way that stimulates growth and improvement, but does not overtax individual physical and mental limits. Special training programs try to take these characteristics into account, but often reach their limits. A promising approach is offered by new fitness technologies based on immersive virtual realities that stimulate both body and brain while minimizing physical and psychological stress. The aim of this study is to investigate the efficacy of supervised immersive Virtual Reality (VR)-based activity training compared to conventional activity training for patients with Post-COVID-associated fatigue. METHODS In a single centre, individually randomised, prospective, double-blind two-arm exploratory superiority trial with parallel group design, N = 100 patients with persistent fatigue after COVID-19 infection will be recruited. The intervention includes a supervised immersive neuromuscular training (12 sessions of 30 min over 6 weeks) based on a novel VR-exercise device. We will systematically compare the effects of this intervention on Post-COVID-associated fatigue with a supervised conventional activation program of comparable scope without an immersive environment. The primary outcome is the difference between groups in absolute change in the mean fatigue symptom severity measured on the Fatigue Severity Scale (FSS) from baseline to posttreatment assessment. Posttreatment assessment in both groups will be conducted by blinded outcome assessors. At three and six months afterwards, patients are sent self-report questionnaires for follow up. The main analysis will be based on the intention-to-treat principle. DISCUSSION To the best of our knowledge, this is the first exploratory study on a supervised immersive neuromuscular training for the treatment of persistent fatigue after COVID-19 infection. TRIAL REGISTRATION German register for clinical studies (ID: DRKS00032059) Prospectively registered on June 16th 2023. URL of trial registration.
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Affiliation(s)
- Jonas Tesarz
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany, Germany.
- DZPG (German Centre for Mental Health), Partner Site Heidelberg/ Mannheim/ Ulm, Heidelberg, Germany.
| | - Hannah Lange
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany, Germany
| | - Marietta Kirchner
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Axel Görlach
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany, Germany
| | - Wolfgang Eich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany, Germany
| | - Hans-Christoph Friederich
- Department of General Internal Medicine and Psychosomatics, Heidelberg University, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany, Germany
- DZPG (German Centre for Mental Health), Partner Site Heidelberg/ Mannheim/ Ulm, Heidelberg, Germany
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Thomas B, Pattinson R, Edwards D, Dale C, Jenkins B, Lande H, Bundy C, Davies JL. Definitions and measures of long COVID fatigue in adults: a scoping review protocol. JBI Evid Synth 2024; 22:481-488. [PMID: 38112241 DOI: 10.11124/jbies-23-00277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
OBJECTIVE The aim of this scoping review is to investigate how fatigue is defined and measured in adults with long COVID. INTRODUCTION Following COVID-19 infection, 10% to 20% of individuals experience persisting symptoms for a minimum of 3 months; this is commonly known as long COVID. Fatigue is one of the most prevalent symptoms of long COVID, but there is currently no consistently applied definition of long COVID fatigue. To advance our understanding of long COVID fatigue, we must first identify the current definitions and measures being used to describe and mesure this condition. INCLUSION CRITERIA This review will consider published and unpublished studies involving adults (≥18 years) that define and/or measure long COVID fatigue. Papers using quantitative or qualitative designs will be included. Conference abstracts, editorials, and opinion papers will be excluded. METHODS Published studies from January 2020 onwards will be searched for across MEDLINE (Ovid), CINAHL (EBSCOhost), Embase (Ovid), Scopus, PsycINFO (Ovid), Web of Science Core Collection, Epistemonikos, and Cochrane Central Register of Controlled Trials (CENTRAL). Dimensions, Overton, and ProQuest Dissertations and Theses will be searched for unpublished literature. Eligible records will be de-duplicated, and 2 independent reviewers will carry out title, abstract, and full-text screening. A data extraction tool will be pilot tested on a small number of papers, then modified as necessary, with any modifications detailed in the scoping review. Findings will be presented in tables and charts, supported by a narrative summary. REVIEW REGISTRATION Open Science Framework https://osf.io/hnf8z.
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Affiliation(s)
- Bethan Thomas
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | | | - Deborah Edwards
- Wales Centre For Evidence Based Care: A JBI Centre of Excellence, Cardiff University, Cardiff, UK
| | - Carys Dale
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | | | - Helena Lande
- School of Psychology, Cardiff University, Cardiff, UK
| | - Christine Bundy
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
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Sanal-Hayes NEM, Hayes LD, Mclaughlin M, Berry ECJ, Sculthorpe NF. People with Long Covid and ME/CFS Exhibit Similarly Impaired Dexterity and Bimanual Coordination: A Case-Case-Control Study. Am J Med 2024:S0002-9343(24)00091-3. [PMID: 38403179 DOI: 10.1016/j.amjmed.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/05/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE Dexterity and bimanual coordination had not previously been compared between people with long COVID and people with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS). Therefore, this study determined dexterity and bimanual coordination in people with long COVID (∼16 month illness duration; n=21) and ME/CFS (∼16 year illness duration; n=20), versus age-matched healthy controls (n=20). METHODS Dexterity, and bimanual coordination was determined using the Purdue pegboard test. RESULTS The main findings of the present investigation were that people with ME/CFS and people with long COVID were generally comparable for Purdue pegboard tests (p>0.556 and d<0.36 for pairwise comparisons). It is worth noting however, that both these patient groups performed poorer in the Perdue pegboard test than healthy controls (p<0.169 and d>0.40 for pairwise comparisons). CONCLUSIONS These data suggest that both people with long COVID and people with ME/CFS have similarly impaired dexterity, and bimanual coordination. Therefore, there is an urgent need for interventions to target dexterity and bimanual coordination in people with ME/CFS, and given the current pandemic, people with long COVID.
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Affiliation(s)
- Nilihan E M Sanal-Hayes
- School of Health and Society, University of Salford, Salford, UK; Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK.
| | - Lawrence D Hayes
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK
| | - Marie Mclaughlin
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK; School of Sport, Exercise & Rehabilitation Sciences, University of Hull, Hull, UK
| | - Ethan C J Berry
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK
| | - Nicholas F Sculthorpe
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, UK
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Halvorsen J, Henderson C, Romney W, Hågå M, Barkenæs Eggen T, Nordvik JE, Rosseland I, Moore J. Feasibility and Safety of Early Post-COVID-19 High-Intensity Gait Training: A Pilot Study. J Clin Med 2023; 13:237. [PMID: 38202245 PMCID: PMC10780026 DOI: 10.3390/jcm13010237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/13/2023] [Accepted: 12/28/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The feasibility and safety of rehabilitation interventions for individuals recovering from COVID-19 after the acute stage is not well understood. This pilot study aims to provide a preliminary investigation of the feasibility and safety of providing high-intensity gait training (HIT) with a targeted cardiovascular intensity of 70-85% of the age-predicted maximum heart rate (HRmax) for individuals undergoing rehabilitation post-COVID-19. METHODS Consecutive patients who were medically cleared for HIT were invited to participate in the study. Participants practiced walking in varied contexts (treadmill, overground, and stairs), aiming to spend as much time as possible within their target cardiovascular intensity zone during scheduled physical therapy (PT) sessions. Training characteristics and adverse events were collected to determine the feasibility and safety of HIT. The severity of adverse events was graded on a 1-5 scale according to the Common Terminology Criteria for Adverse Events. RESULTS The participants (n = 20) took a mean of 2093 (±619) steps per PT session. The average peak heart rate during PT sessions was 81.1% (±9.4) of HRmax, and 30.1% (±21.0) of the session time was spent at heart rates ≥ 70% HRmax. Mild adverse events (grade 1) occurred in <5% of the sessions, and no intervention-requiring or life-threatening adverse events (grade 2-5) occurred. CONCLUSION This pilot study provides preliminary evidence that HIT may be feasible and safe during inpatient rehabilitation for patients post-COVID-19 following medical clearance.
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Affiliation(s)
- Joakim Halvorsen
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | - Christopher Henderson
- Institute for Knowledge Translation, Carmel, IN 46033, USA; (C.H.); (J.M.)
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN 46254, USA
| | - Wendy Romney
- Department of Physical Therapy and Human Movement Science, Sacred Heart University, Fairfield, CT 06825, USA;
| | - Magnus Hågå
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | | | - Jan Egil Nordvik
- Faculty of Health Sciences, Oslo Metropolitan University, 0166 Oslo, Norway;
| | - Ingvild Rosseland
- Forsterket Rehabilitering Aker, Helseetaten, Oslo kommune, Trondheimsveien 235, 0586 Oslo, Norway; (M.H.); (I.R.)
| | - Jennifer Moore
- Institute for Knowledge Translation, Carmel, IN 46033, USA; (C.H.); (J.M.)
- Regional Kompetansetjeneste for Rehabilitering, Sunnaas HF, Trondheimsveien 235, 0586 Oslo, Norway
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Corrêa BDC, Santos EGR, Belgamo A, Pinto GHL, Xavier SS, Silva CC, Dias ÁRN, Paranhos ACM, Cabral ADS, Callegari B, Costa e Silva ADA, Quaresma JAS, Falcão LFM, Souza GS. Smartphone-based evaluation of static balance and mobility in long-lasting COVID-19 patients. Front Neurol 2023; 14:1277408. [PMID: 38148981 PMCID: PMC10750373 DOI: 10.3389/fneur.2023.1277408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 11/20/2023] [Indexed: 12/28/2023] Open
Abstract
Background SARS-CoV-2 infection can lead to a variety of persistent sequelae, collectively known as long COVID-19. Deficits in postural balance have been reported in patients several months after COVID-19 infection. The purpose of this study was to evaluate the static balance and balance of individuals with long COVID-19 using inertial sensors in smartphones. Methods A total of 73 participants were included in this study, of which 41 had long COVID-19 and 32 served as controls. All participants in the long COVID-19 group reported physical complaints for at least 7 months after SARS-CoV-2 infection. Participants were evaluated using a built-in inertial sensor of a smartphone attached to the low back, which recorded inertial signals during a static balance and mobility task (timed up and go test). The parameters of static balance and mobility obtained from both groups were compared. Results The groups were matched for age and BMI. Of the 41 participants in the long COVID-19 group, 22 reported balance impairment and 33 had impaired balance in the Sharpened Romberg test. Static balance assessment revealed that the long COVID-19 group had greater postural instability with both eyes open and closed than the control group. In the TUG test, the long COVID-19 group showed greater acceleration during the sit-to-stand transition compared to the control group. Conclusion The smartphone was feasible to identify losses in the balance motor control and mobility of patients with long-lasting symptomatic COVID-19 even after several months or years. Attention to the balance impairment experienced by these patients could help prevent falls and improve their quality of life, and the use of the smartphone can expand this monitoring for a broader population.
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Affiliation(s)
| | | | | | | | - Stanley Soares Xavier
- Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará, Belém, Brazil
| | - Camilla Costa Silva
- Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará, Belém, Brazil
| | | | - Alna Carolina Mendes Paranhos
- Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará, Belém, Brazil
- Núcleo de Medicina Tropical, Universidade Federal do Pará, Belém, Brazil
| | | | - Bianca Callegari
- Instituto de Ciências da Saúde, Universidade Federal do Pará, Belém, Brazil
| | | | - Juarez Antônio Simões Quaresma
- Centro de Ciências Biológicas e da Saúde, Universidade do Estado do Pará, Belém, Brazil
- School of Medicine, São Paulo University, São Paulo, São Paulo, Brazil
| | | | - Givago Silva Souza
- Núcleo de Medicina Tropical, Universidade Federal do Pará, Belém, Brazil
- Instituto de Ciências Biológicas, Universidade Federal do Pará, Belém, Brazil
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Neto RBD, Reis LFF, Ferreira ADS, Alexandre DJDA, de Almeida RS. Hospital admission is associated with disability and late musculoskeletal pain in individuals with long COVID. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:1186499. [PMID: 37965093 PMCID: PMC10641772 DOI: 10.3389/fresc.2023.1186499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 10/04/2023] [Indexed: 11/16/2023]
Abstract
Background The acute clinical repercussions of SARS-CoV-2 infection have been widely studied. However, the possible late repercussions of long COVID have not yet been well defined in the literature. Objectives To identify the presence of pain and musculoskeletal disability in patients with Long COVID and also to identify predictive factors for pain intensity in this population. Methods In this cross-sectional and retrospective observational study individuals with Long COVID symptoms were included. It was collected musculoskeletal disability measures, data from patient-related outcome measures and variables from a COVID-19 outpatient service database. Associations and sub-group analyses were performed considering the variables pain, disability and hospitalization. Linear regression was performed to identify predictive factors for pain intensity in Long COVID patients. Results We evaluated 195 patients and most of them (57%) presented musculoskeletal pain in one area of the body. Pain sub-group presented worse disability indices and worse clinical course during hospitalization. Hospitalized patients presented worse disability indices comparing to non-hospitalized. Significant correlations were found between pain and days of non-invasive oxygen support (r = 0.21; p = 0.003); days in intensive care unit (r = 0.22; p = 0.002) and days in invasive mechanical ventilation (r = 0.35; p = 0.001). Hospitalized individuals showed a higher chance of presenting late musculoskeletal pain (OR = 1.42: 95%CI 1.09-2.04). Days in intensive care unit (β = 0,234: P = 0,001) and days in invasive mechanical ventilation (β = 0.764: P = 0.001) were predictors of pain intensity [F(2,192) = 18.559; R2 = 0.231; p = 0.001]. Conclusion Individuals with Long COVID presented musculoskeletal pain and disability. Hospitalized patients showed a greater chance of having musculoskeletal pain. Days in intensive care unit and days in invasive mechanical ventilation were predictors of late musculoskeletal pain intensity.
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Affiliation(s)
- Ricardo Bezerra Duarte Neto
- Post Graduation Program in Rehabilitation Sciences, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | - Luis Felipe Fonseca Reis
- Post Graduation Program in Rehabilitation Sciences, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
- Physiotherapy Department. Rio de Janeiro Military Police Rehabilitation Center (CFRPM-RJ), Rio de Janeiro, Brazil
| | - Arthur de Sá Ferreira
- Post Graduation Program in Rehabilitation Sciences, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
| | | | - Renato Santos de Almeida
- Post Graduation Program in Rehabilitation Sciences, Augusto Motta University Center (UNISUAM), Rio de Janeiro, Brazil
- Physiotherapy Department. Serra dos Órgãos University Center (UNIFESO), Teresópolis, Brazil
- Physiotherapy Department, Rio de Janeiro Federal Institute (IFRJ), Rio de Janeiro, Brazil
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Amput P, Tapanya W, Sangkarit N, Konsanit S, Wongphon S. Balance Ability and Quality of Life in Older Adult with Recovery from Mild COVID-19. Ann Geriatr Med Res 2023; 27:235-240. [PMID: 37592748 PMCID: PMC10556712 DOI: 10.4235/agmr.23.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/24/2023] [Accepted: 08/05/2023] [Indexed: 08/19/2023] Open
Abstract
BACKGROUND In this study, we aimed to assess the ability to balance and quality of life (QoL) among older adults without a history of coronavirus disease 2019 (COVID-19) and those who had recovered from mild COVID-19. METHODS We recruited 80 older adults and categorized them into the following two groups based on their history of COVID-19: those without COVID-19 (n=40) and those who had recovered from mild COVID-19 (n=40). We assessed the participants' ability to balance using the multi-directional reach test and timed up and go (TUG) test, and evaluated their QoL using the Short Form-36. RESULTS Compared with older adults without a history of COVID-19, those who had recovered from mild COVID-19 demonstrated no differences in the scores of the forward, backward, right, and left directions (p>0.05), but a significantly longer duration for the TUG test (p=0.02) and a reduced QoL. CONCLUSION Our study results demonstrated decreased ability to balance and poor QoL among older adults who had recovered from mild COVID-19.
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Affiliation(s)
- Patchareeya Amput
- Department of Physical Therapy, School of Allied Health Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence of Human Performance and Rehabilitations, University of Phayao, Phayao, Thailand
| | - Weerasak Tapanya
- Department of Physical Therapy, School of Allied Health Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence of Human Performance and Rehabilitations, University of Phayao, Phayao, Thailand
| | - Noppharath Sangkarit
- Department of Physical Therapy, School of Allied Health Sciences, University of Phayao, Phayao, Thailand
- Unit of Excellence of Human Performance and Rehabilitations, University of Phayao, Phayao, Thailand
| | - Saisunee Konsanit
- Department of Physical Therapy, School of Allied Health Sciences, University of Phayao, Phayao, Thailand
| | - Sirima Wongphon
- Department of Traditional Chinese Medicine, School of Public Health, University of Phayao, Phayao, Thailand
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11
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Fonseca BHDS, de Andrade PHS, Henrique MESA, Baggio JADO, Bazan R, de Souza LAPS, Luvizutto GJ. Perception of verticality in the post-COVID-19 condition correlates to infection severity. J Cent Nerv Syst Dis 2023; 15:11795735231195693. [PMID: 38025401 PMCID: PMC10655649 DOI: 10.1177/11795735231195693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 08/02/2023] [Indexed: 12/01/2023] Open
Abstract
Background SARS-CoV-2 infection affects multiple systems, including musculoskeletal, neurological, and respiratory systems. Changes associated with physical inactivity due to prolonged hospitalization can affect the functional capacity of individuals with long coronavirus disease 2019 (COVID-19) or post-COVID-19 condition and may cause changes in some postural control functions, such as verticality. Objectives This study aimed to evaluate the perception of verticality in individuals with long COVID. Design Cross-sectional study. Methods This study included 60 participants with post-COVID-19 condition divided into 2 groups: hospitalized group (n = 24), those hospitalized owing to SARS-CoV-2 infection; and non-hospitalized group (n = 36), those infected with SARS-CoV-2 but not hospitalized. All participants were examined using a post-COVID-19 functional status (PCFS), sit-to-stand test, grip strength assessment, painful and tactile sensory assessments, visual acuity assessment, and vestibular assessment. Verticality perception was evaluated using the subjective visual vertical (SVV) and subjective haptic vertical (SHV) tests. In both tests, the absolute values (positive values only) and true values (positive and negative values) were considered. To verify potential confounders that could influence the verticality of the results, logistic regression models were used for categorical variables and multiple linear regressions were used for continuous variables. For analysis between groups, the independent samples test (Mann-Whitney U test) was used. Results There were no confounders between clinical variables and verticality in either group. There was a significant increase in absolute SVV (mean deviation [MD]: 2.83; P < .0001) and true SVV (MD: -4.18; P = .005) in the hospitalized group compared to the non-hospitalized group. Furthermore, there was a significant increase in the true SHV (MD: -3.6; P = .026) in the hospitalized group compared to that in the non-hospitalized group. Conclusion Less accurate visual and haptic verticality perception task performance was observed in hospitalized patients with post-COVID-19 condition.
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Affiliation(s)
| | | | | | | | - Rodrigo Bazan
- Department of Neurology, Psychology, and Psychiatry, Botucatu Medical School, Botucatu, Brazil
| | | | - Gustavo José Luvizutto
- Department of Applied Physical Therapy, Federal University of Triângulo Mineiro, Uberaba, Brazil
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12
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Hayes LD, Sanal-Hayes NEM, Mclaughlin M, Berry ECJ, Sculthorpe NF. People with Long Covid and ME/CFS Exhibit Similarly Impaired Balance and Physical Capacity: A Case-Case-Control Study. Am J Med 2023:S0002-9343(23)00465-5. [PMID: 37490948 DOI: 10.1016/j.amjmed.2023.06.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 06/23/2023] [Accepted: 06/26/2023] [Indexed: 07/27/2023]
Abstract
PURPOSE Postural sway and physical capacity had not previously been compared between people with long COVID and people with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). Therefore, this study determined postural sway and physical capacity in people with long COVID (∼16-month illness duration; n = 21) and ME/CFS (∼16-year illness duration; n = 20), vs age-matched healthy controls (n = 20). METHODS Postural sway was during a 30-s static stand test. Physical capacity was determined using the Timed Up and Go test and 5 Times Sit to Stand test. Throughout, participants wore isoinertial measurement units. RESULTS Postural sway was worse (ie, greater) in people with long COVID and ME/CFS than controls, but not different between long COVID and ME/CFS. Performance of the Timed Up and Go test and 5 Times Sit to Stand test were worse in long COVID and ME/CFS than controls, but not different between long COVID and ME/CFS. Of long COVID and ME/CFS participants, 87% and 13% exceeded the threshold for muscle weakness in the 5 Times Sit to Stand test and Timed Up and Go test, respectively. CONCLUSIONS These data suggest that both people with long COVID and people with ME/CFS have similarly impaired balance and physical capacity. Therefore, there is an urgent need for interventions to target postural sway and physical capacity in people with ME/CFS, and given the current pandemic, people with long COVID.
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Affiliation(s)
- Lawrence D Hayes
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, United Kingdom.
| | - Nilihan E M Sanal-Hayes
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, United Kingdom; School of Health & Society, University of Salford, Salford, United Kingdom
| | - Marie Mclaughlin
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, United Kingdom
| | - Ethan C J Berry
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, United Kingdom
| | - Nicholas F Sculthorpe
- Sport and Physical Activity Research Institute, School of Health and Life Sciences, University of the West of Scotland, Glasgow, United Kingdom
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Teixeira-Vaz A, Rocha JA, Oliveira M, Simões-Moreira T, Reis DAE, Silva AI, Paiva JA. Surviving critical COVID-19: How functionality, physical, mental and cognitive outcomes evolve? PLoS One 2023; 18:e0284597. [PMID: 37352178 PMCID: PMC10289386 DOI: 10.1371/journal.pone.0284597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/03/2023] [Indexed: 06/25/2023] Open
Abstract
PURPOSE To analyze the long-term consequences of critical COVID-19, regarding physical, mental, cognitive and functional impairments, and to describe its evolution through time. METHODS Prospective cohort study, with consecutive inclusion of patients admitted due to SARS-CoV-2 to intensive care units(ICU) of a tertiary-care center, between May/2020 and September/2021. All included patients were included in Physical and Rehabilitation Medicine(PRM) inpatient programs during ICU stay. Eligible patients were evaluated on PRM appointments 6 and 12 months after ICU discharge. In each visit, physical examination and a predefined set of scales were applied, aiming to comprehensively evaluate the three domains (physical, mental and cognitive) of post-intensive care syndrome and the patients' functionality. Statistical analysis encompassed descriptive and univariate analysis. RESULTS A total of 42 patients were included: 66.7% males, mean age of 62 yo. In the physical domain, 6 months after ICU discharge, there was a significant reduction in quality of life (p-value = 0.034), muscle strength (p-value = 0.002), gait ability (p-value<0.001) and balance (p-values<0.001) and increased fatigue levels (p-value = 0.009), in comparison with reference values. Yet, a significative positive evolution was observed in all referred subdomains (p-values<0.05). Nevertheless, 12 months after discharge, muscle strength (p-value = 0.001), gait (p-value<0.001) and balance (p-value<0.001) were still significantly compromised. Regarding the mental domain, both at 6 and 12 months after discharge, the levels of anxiety and depression were significantly increased (p-values<0.001). Nonetheless, a positive evolution was also found (p-values<0.02). Cognitive performance was significantly impaired in comparison with reference values, both at 6 and 12 months (p-value<0.001). Yet, a global improvement was also depicted (p-value = 0.003). Six months after ICU discharge, 54.8% were autonomous in activities of daily living, a value that improved to 74.0% in the subsequent 6 months (p-value = 0.002). CONCLUSION Critical COVID-19 survivors present significant physical, mental and cognitive impairments 6 and 12 months after ICU discharge, despite their positive evolution through time.
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Affiliation(s)
- Ana Teixeira-Vaz
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Afonso Rocha
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Mafalda Oliveira
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Tiago Simões-Moreira
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - David Almeida e Reis
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Ana Isabel Silva
- Physical Medicine and Rehabilitation Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - José Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- Faculty of Medicine, University of Porto, Porto, Portugal
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14
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de Azevedo Vieira JE, Mafort TT, Monnerat LB, da Cal MS, Ghetti ATA, Lopes AJ. Assessment of short- and long-term functionality and quality of life in patients with post-acute COVID-19 syndrome. J Back Musculoskelet Rehabil 2023; 36:541-550. [PMID: 36776041 DOI: 10.3233/bmr-220308] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND Although the number of new cases of coronavirus 2019 (COVID-19) has been drastically reduced worldwide, patients who demonstrate long-term symptoms need more attention from health systems, as these symptoms can negatively affect functionality and quality of life. OBJECTIVE To evaluate muscle function and quality of life at 3, 6, 9 and 12 months in patients with post-acute COVID-19 syndrome and to assess their associations with general fatigue and lung function. METHODS This observational and longitudinal study evaluated patients with post-acute COVID-19 syndrome. Participants were subjected to the following evaluations: Short Form-36; handgrip strength; Functional Assessment of Chronic Illness Therapy-Fatigue scale; and spirometry. RESULTS Among the 350 participants who were evaluated in the third month, 74.6%, 61.4% and 45.4% reported general fatigue, dyspnoea and cough, respectively. In the comparisons between the third month and the sixth month, there were significant increases in Functional Assessment of Chronic Illness Therapy-Fatigue scale, pulmonary function and several Short Form-36 domains. In the comparisons between the sixth month and the ninth month, there was a significant increase only in the social functioning domain of the Short Form-36. In the comparisons between the ninth month and the twelfth month, there was an increase only in some Short Form-36 domains. Significant correlations were observed between the Short Form-36 domains with Functional Assessment of Chronic Illness Therapy-Fatigue scale, handgrip strength and pulmonary function. CONCLUSION In patients with post-acute COVID-19 syndrome, there was a progressive improvement in quality of life, general fatigue and pulmonary function during the 12 months of follow-up, with this improvement being more pronounced in the first 6 months. There was a relationship between functionality and quality of life in these patients.
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Affiliation(s)
| | - Thiago Thomaz Mafort
- Post-Graduation Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Department of Pulmonology, Piquet Carneiro Policlinic, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Laura Braga Monnerat
- Department of Pulmonology, Piquet Carneiro Policlinic, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Mariana Soares da Cal
- Department of Pulmonology, Piquet Carneiro Policlinic, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Angelo Thomaz Abalada Ghetti
- Department of Pulmonology, Piquet Carneiro Policlinic, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
| | - Agnaldo José Lopes
- Rehabilitation Sciences Post-Graduation Programme, Augusto Motta University Centre (UNISUAM), Rio de Janeiro, Brazil.,Post-Graduation Programme in Medical Sciences, School of Medical Sciences, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil.,Department of Pulmonology, Piquet Carneiro Policlinic, State University of Rio de Janeiro (UERJ), Rio de Janeiro, Brazil
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Lippi L, Turco A, Folli A, Vicelli F, Curci C, Ammendolia A, de Sire A, Invernizzi M. Effects of blood flow restriction on spine postural control using a robotic platform: A pilot randomized cross-over study. J Back Musculoskelet Rehabil 2023; 36:1447-1459. [PMID: 37694351 DOI: 10.3233/bmr-230063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
BACKGROUND Blood flow restriction (BFR) training improves muscle strength and functional outcomes, but the proprioceptive implications of this technique in the rehabilitation field are still unknown. OBJECTIVE The present study aimed at assessing the effects of BFR in terms of stabilometric and balance performance. METHODS In this pilot randomized cross-over study, healthy young adults were included and randomly assigned to Groups A and B. Both groups underwent a postural assessment with and without wearing a BFR device. Study participants of Group A underwent postural baseline assessment wearing BFR and then removed BFR for further evaluations, whereas subjects in Group B performed the baseline assessment without BFR and then with BFR. Stabilometric and balance performance were assessed by the robotic platform Hunova, the Balance Error Scoring System (BESS), the self-reported perceived balance (7-point Likert scale), and discomfort self-rated assessment. Moreover, the safety profile was recorded. RESULTS Fourteen subjects were included and randomly assigned to Group A (n: 7) and Group B (n: 7). Significant differences were shown in balance tests in static conditions performed on the Hunova robot platform in terms of average distance RMS (root-mean-square) with open eyes (OE), anteroposterior (AP) trunk oscillation range with OE, mediolateral (ML) average speed of oscillation with OE, and total excursion AP range with closed eyes (CE) (BFR: 3.44 ± 1.06; without BFR: 2.75 ± 0.72; p= 0.041). Moreover, elastic balance test showed differences in Romberg index (BFR: 0.16 ±0.16; without BFR: 0.09 ± 0.07; p= 0.047). No adverse events were reported. CONCLUSION Taken together, our data showed that BFR affects balance performance of healthy subjects. Further studies are needed to better characterize the possible role of BFR treatment in the context of a specific rehabilitation protocol.
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Affiliation(s)
- Lorenzo Lippi
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
| | - Alessio Turco
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Arianna Folli
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Federico Vicelli
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
| | - Claudio Curci
- Physical Medicine and Rehabilitation Unit, Department of Neurosciences, ASST Carlo Poma, Mantova, Italy
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", Catanzaro, Italy
| | - Marco Invernizzi
- Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Novara, Italy
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy
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