Central Sensitization Phenotypes in Post Acute Sequelae of SARS-CoV-2 Infection (PASC): Defining the Post COVID Syndrome

A description of the development of an innovative multi-component long COVID treatment program based on central sensitization with preliminary patient satisfaction data

OBJECTIVE

Estimates of the prevalence of Long COVID in the United States or worldwide are imprecise, but millions of people are thought to be affected. No effective treatment exists for the often devastating symptoms of Long COVID. Central Sensitization has been postulated as a causal/explanatory mechanism for developing Long COVID. No treatment to date has targeted Central Sensitization. The present cross-sectional study describes the first 140 patients treated in a multi-component treatment program that targets Central Sensitization to reduce symptom burden, improve functioning, and lower the psychological distress observed in these patients.

METHODS

140 patients diagnosed with Long COVID after an extensive medical evaluation were assessed for function, depression, and pain catastrophizing using questionnaires and patient satisfaction measures after completion of a 16-h Cognitive Behavioral Therapy treatment program focused on Central Sensitization.

RESULTS

Upon admission, patients diagnosed with Long COVID were significantly impaired in their ability to function due to their symptoms. Further, 70% of the patients were depressed. Pain catastrophizing was observed in up to 20% of patients.

CONCLUSION

Patient satisfaction measures were high for the sample at the end of the treatment program suggesting that a multicomponent treatment program targeting Central Sensitization is acceptable to patients. Further research is needed to explore the effectiveness and durability of this treatment approach.

How to understand the overlap of long COVID, chronic fatigue syndrome/myalgic encephalomyelitis, fibromyalgia and irritable bowel syndromes

Long COVID should be limited to patients with multiple, persistent symptoms not related to well-defined organ damage. Once redefined, a focused review of long COVID demonstrates striking similarity to chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME), fibromyalgia (FM) and irritable bowel syndrome (IBS). Research in long COVID has revealed similar findings to those noted in CFS/ME and FM, characterized by central nervous system organ dysfunction. Long COVID, like CFS/ME, FM and IBS, is best understood as a bidirectional mind-body, neuroimmune illness.

A systematic review of quantitative EEG findings in Fibromyalgia, Chronic Fatigue Syndrome and Long COVID

Fibromyalgia Syndrome (FMS), Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) and Long COVID (LC) are similar multisymptom clinical syndromes but with difference in dominant symptoms in each individual. There is existing and emerging literature on possible functional alterations of the central nervous system in these conditions. This review aims to synthesise and appraise the literature on resting-state quantitative EEG (qEEG) in FMS, ME/CFS and LC, drawing on previous research on FMS and ME/CFS to help understand neuropathophysiology of the new condition LC. A systematic search of MEDLINE, Embase, CINHAL, PsycINFO and Web of Science databases for articles published between December 1994 and September 2023 was performed. Out of the initial 2510 studies identified, 17 articles were retrieved that met all the predetermined selection criteria, particularly of assessing qEEG changes in one of the three conditions compared to healthy controls. All studies scored moderate to high quality on the Newcastle-Ottawa scale. There was a general trend for decreased low-frequency EEG band activity (delta, theta, and alpha) and increased high-frequency EEG beta activity in FMS, differing to that found in ME/CFS. The limited LC studies included in this review focused mainly on cognitive impairments and showed mixed findings not consistent with patterns observed in FMS and ME/CFS. Our findings suggest different patterns of qEEG brainwave activity in FMS and ME/CFS. Further research is required to explore whether there are phenotypes within LC that have EEG signatures similar to FMS or ME/CFS. This could inform identification of reliable diagnostic markers and possible targets for neuromodulation therapies tailored to each clinical syndrome.

Persistent chest pain following COVID-19 infection - A scoping review

Persistent chest pain (PCP) following acute COVID-19 infection is a commonly reported symptom with an unclear etiology, making its management challenging. This scoping review aims to address the knowledge gap surrounding the characteristics of PCP following COVID-19, its causes, and potential treatments. This is a scoping review of 64 studies, including observational (prospective, retrospective, cross-sectional, case series, and case-control) and one quasi-experimental study, from databases including Embase, PubMed/MEDLINE, Cochrane CENTRAL, Google Scholar, Cochrane Database of Systematic Reviews, and Scopus. Studies on patients with PCP following mild, moderate, and severe COVID-19 infection were included. Studies with patients of any age, with chest pain that persisted following acute COVID-19 disease, irrespective of etiology or duration were included. A total of 35 studies reported PCP symptoms following COVID-19 (0.24%-76.6%) at an average follow-up of 3 months or longer, 12 studies at 1-3 months and 17 studies at less than 1-month follow-up or not specified. PCP was common following mild-severe COVID-19 infection, and etiology was mostly not reported. Fourteen studies proposed potential etiologies including endothelial dysfunction, cardiac ischemia, vasospasm, myocarditis, cardiac arrhythmia, pneumonia, pulmonary embolism, postural tachycardia syndrome, or noted cardiac MRI (cMRI) changes. Evaluation methods included common cardiopulmonary tests, as well as less common tests such as flow-mediated dilatation, cMRI, single-photon emission computed tomography myocardial perfusion imaging, and cardiopulmonary exercise testing. Only one study reported a specific treatment (sulodexide). PCP is a prevalent symptom following COVID-19 infection, with various proposed etiologies. Further research is needed to establish a better understanding of the causes and to develop targeted treatments for PCP following COVID-19.

Current landscape of long COVID clinical trials

Long COVID was reported as a multi-systemic condition after the infection of SARS-CoV-2, and more than 65 million people are suffering from this disease. It has been noted that around 10% of severe SARS-CoV-2 infected individuals are suffering from the enduring effects of long COVID. The symptoms of long COVID have also been noted in several mild or asymptomatic SARS-CoV-2 infected individuals. While limited reports on clinical trials investigating new therapeutics for long COVID exist, there is an abundance of scattered information available regarding these trials. This review explores the extensive literature search, and complete clinical trial database search to map the current status of long COVID clinical trials worldwide. The study listed about 110 long COVID clinical trials. In addition to conducting extensive long COVID clinical trials, we have comprehensively presented an overview of the condition, its symptoms, notable manifestations, associated clinical trials, the unique challenges it poses, and our recommendations for addressing long COVID.

Thematic analysis to explore patients' experiences with long COVID-19: a conceptual model of symptoms and impacts on daily lives

OBJECTIVES

There is limited qualitative research on patients' experiences with long COVID-19, and how specific symptoms impact their daily lives. The study aimed to understand patients' lived experiences of long COVID-19 and to develop a conceptual model representing the symptoms and their impact on overall quality of life.

SETTING

Qualitative study consisting of a comprehensive literature review, and in-depth clinician and patient semistructured interviews.

PARTICIPANTS

Forty-one adult patients with long COVID-19, of whom 18 (44%) were recruited through Regeneron Pharmaceuticals's clinical trials and 23 (56%) through recruitment agencies; 85.4% were female and 73.2% were White. Five independent clinicians treating patients with long COVID-19 were interviewed. Concept saturation was also assessed.

PRIMARY AND SECONDARY OUTCOMES

Interview transcripts were analysed thematically to identify concepts of interest spontaneously mentioned by patients, including symptoms and their impacts on daily life, to guide the development of the conceptual model.

RESULTS

Findings from the literature review and clinician and patient interviews resulted in the development of a conceptual model comprising two overarching domains: symptoms (upper respiratory tract, lower respiratory tract, smell and taste, systemic, gastrointestinal, neurocognitive and other) and impacts (activities of daily living, instrumental activities of daily living, physical impacts, emotional, social/leisure activities and professional impacts). Saturation was achieved for the reported impacts. The symptoms reported were heterogenic; neurocognitive symptoms, such as numbness, ringing in ears, haziness, confusion, forgetfulness/memory problems, brain fog, concentration, difficulties finding the right word and challenges with fine motor skills, were particularly pertinent for several months.

CONCLUSION

The conceptual model, developed based on patient experience data of long COVID-19, highlighted numerous symptoms that impact patients' physical and mental well-being, and suggests humanistic unmet needs. Prospective real-world studies are warranted to understand the pattern of long COVID-19 experienced in larger samples over longer periods of time.

Computable Phenotypes for Post-acute sequelae of SARS-CoV-2: A National COVID Cohort Collaborative Analysis

Post-acute sequelae of SARS-CoV-2 (PASC) is an increasingly recognized yet incompletely understood public health concern. Several studies have examined various ways to phenotype PASC to better characterize this heterogeneous condition. However, many gaps in PASC phenotyping research exist, including a lack of the following: 1) standardized definitions for PASC based on symptomatology; 2) generalizable and reproducible phenotyping heuristics and meta-heuristics; and 3) phenotypes based on both COVID-19 severity and symptom duration. In this study, we defined computable phenotypes (or heuristics) and meta-heuristics for PASC phenotypes based on COVID-19 severity and symptom duration. We also developed a symptom profile for PASC based on a common data standard. We identified four phenotypes based on COVID-19 severity (mild vs. moderate/severe) and duration of PASC symptoms (subacute vs. chronic). The symptoms groups with the highest frequency among phenotypes were cardiovascular and neuropsychiatric with each phenotype characterized by a different set of symptoms.

Longitudinal Progression of Patients with Long COVID Treated in a Post-COVID Clinic: A Cross-Sectional Survey

BACKGROUND

In addition to the morbidity and mortality associated with acute infection, COVID-19 has been associated with persistent symptoms (>30 days), often referred to as Long COVID (LC). LC symptoms often cluster into phenotypes, resembling conditions such as fibromyalgia, postural orthostatic tachycardiac syndrome (POTS), and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). LC clinics have been established to best address the needs of LC patients and continuity of care. We developed a cross-sectional survey to assess treatment response through our LC Clinic (LCC).

METHODS

A 25-question survey (1-10 Likert scale) was expert- and content-validated by LCC clinicians, patients, and patient advocates. The survey assessed LC symptoms and the helpfulness of different interventions, including medications and supplements. A total of 852 LCC patients were asked to complete the survey, with 536 (62.9%) responding.

RESULTS

The mean time from associated COVID-19 infection to survey completion was 23.2 ± 6.4 months. The mean age of responders was 52.3 ± 14.1 (63% females). Self-reported symptoms were all significantly improved (P < .001) from the initial visit to the LCC (baseline) to the time of the follow-up survey. However, only 4.5% (24/536) of patients rated all symptoms low (1-2) at the time of the survey, indicating low levels of full recovery in our cohort. The patients rated numerous interventions as being helpful, including low-dose naltrexone (45/77; 58%), vagal nerve stimulation (18/34; 53%), and fisetin (28/44; 64%).

CONCLUSIONS

Patients report general improvements in symptoms following the initial LCC visit, but complete recovery rates remain low at 23.2 ± 6.4 months.

The impact of SARS-CoV-2 on healthcare workers of a large University Hospital in the Veneto Region: risk of infection and clinical presentation in relation to different pandemic phases and some relevant determinants

Aim

The aim of this study is to evaluate the incidence of SARS-CoV-2 infection and the prevalence of COVID-19-related symptoms in relation to pandemic phases and some relevant variables in a cohort of 8,029 HCWs from one of the largest Italian University Hospitals.

Methods

A single-center retrospective study was performed on data collected during SARS-CoV-2 infection surveillance of HCWs. Cox's multiple regression was performed to estimate hazard ratios of SARS-CoV-2 infection. Logistic multivariate regression was used to assess the risk of asymptomatic infections and the onset of the most frequent symptoms. All analyses were adjusted for sociodemographic and occupational factors, pandemic phases, vaccination status, and previous infections.

Results

A total of 3,760 HCWs resulted positive (2.0%-18.6% across five study phases). The total incidence rate of SARS-CoV-2 infection was 7.31 cases per 10,000 person-days, significantly lower in phase 1 and higher in phases 4 and 5, compared to phase 3. Younger HCWs, healthcare personnel, and unvaccinated subjects showed a higher risk of infection. Overall, 24.5% were asymptomatic infections, with a higher probability for men, physicians, and HCWs tested for screening, fully vaccinated, and those with previous infection. The clinical presentation changed over the phases in relation to vaccination status and the emergence of new variants.

Conclusion

The screening activities of HCWs allowed for the early detection of asymptomatic cases, limiting the epidemic clusters inside the hospital wards. SARS-CoV-2 vaccination reduced infections and symptomatic cases, demonstrating again its paramount value as a preventive tool for occupational and public health.

Return to work after Post-COVID: describing affected employees' perceptions of personal resources, organizational offerings and care pathways

Background

Most individuals recover from the acute phase of infection with the SARS-CoV-2 virus, however, some encounter prolonged effects, referred to as the Post-COVID syndrome. Evidence exists that such persistent symptoms can significantly impact patients' ability to return to work. This paper gives a comprehensive overview of different care pathways and resources, both personal and external, that aim to support Post-COVID patients during their work-life reintegration process. By describing the current situation of Post-COVID patients pertaining their transition back to the workplace, this paper provides valuable insights into their needs.

Methods

A quantitative research design was applied using an online questionnaire as an instrument. Participants were recruited via Post-COVID outpatients, rehab facilities, general practitioners, support groups, and other healthcare facilities.

Results

The analyses of 184 data sets of Post-COVID affected produced three key findings: (1) The evaluation of different types of personal resources that may lead to a successful return to work found that particularly the individuals' ability to cope with their situation (measured with the FERUS questionnaire), produced significant differences between participants that had returned to work and those that had not been able to return so far (F = 4.913, p = 0.001). (2) In terms of organizational provisions to facilitate successful reintegration into work-life, predominantly structural changes (i.e., modification of the workplace, working hours, and task) were rated as helpful or very helpful on average (meanworkplace 2.55/SD = 0.83, meanworking hours 2.44/SD = 0.80; meantasks 2.55/SD = 0.83), while the remaining offerings (i.e., job coaching or health courses) were rated as less helpful or not helpful at all. (3) No significant correlation was found between different care pathways and a successful return to work.

Conclusion

The results of the in-depth descriptive analysis allows to suggests that the level of ability to cope with the Post-COVID syndrome and its associated complaints, as well as the structural adaptation of the workplace to meet the needs and demands of patients better, might be important determinants of a successful return. While the latter might be addressed by employers directly, it might be helpful to integrate training on coping behavior early in care pathways and treatment plans for Post-COVID patients to strengthen their coping abilities aiming to support their successful return to work at an early stage.

Post-COVID-19 depression and serum interleukin 6 levels: A systematic review and meta-analysis of COVID-19 convalescents with and without depression

OBJECTIVES

Depression is among the psychiatric sequelae of COVID-19, affecting more than 20% of the convalescents. Its underlying pathophysiology remains unclear. Interleukin 6 (IL-6), a pro-inflammatory cytokine, plays a critical role in the COVID-19-associated cytokine storm, has been implicated in depressive disorders, and may thus be involved in post-COVID-19 depression.

METHODS

PubMed, Scopus, Embase, and Web of Science were systematically searched for relevant studies assessing peripheral IL-6 levels in convalescents who developed depression after COVID-19 vs. convalescents who did not.

RESULTS

Five studies were included in our systematic review, and four entered the meta-analysis. The meta-analysis revealed that post-COVID people with de novo depression did not have statistically significant differences in IL-6 levels compared to those without depression (standardised mean difference (SMD) = 0.09, 95% confidence interval (CI) = -0.35, 0.54, p-value = 0.68).

CONCLUSIONS

Although convalescents with depression did not have significantly higher IL-6 levels than convalescents without depression, the results should be interpreted considering the limited sample size and the low power of the included studies.

Melatonin as a Coadjuvant in the Treatment of Patients with Fibromyalgia

Fibromyalgia syndrome (FMS) is a chronic widespread pain syndrome that is accompanied by fatigue, sleep disturbances, anxiety, depression, lack of concentration, and neurocognitive impairment. As the currently available drugs are not completely successful against these symptoms and frequently have several side effects, many scientists have taken on the task of looking for nonpharmacological remedies. Many of the FMS-related symptoms have been suggested to be associated with an altered pattern of endogenous melatonin. Melatonin is involved in the regulation of several physiological processes, including circadian rhythms, pain, mood, and oxidative as well as immunomodulatory balance. Preliminary clinical studies have propounded that the administration of different doses of melatonin to patients with FMS can reduce pain levels and ameliorate mood and sleep disturbances. Moreover, the total antioxidant capacity, 6-sulfatoxymelatonin and urinary cortisol levels, and other biological parameters improve after the ingestion of melatonin. Recent investigations have proposed a pathophysiological relationship between mitochondrial dysfunction, oxidative stress, and FMS by looking at certain proteins involved in mitochondrial homeostasis according to the etiopathogenesis of this syndrome. These improvements exert positive effects on the quality of life of FMS patients, suggesting that the use of melatonin as a coadjuvant may be a successful strategy for the management of this syndrome.

Clinical differences in symptomology, characteristics, and risk factors in patients with post-acute sequelae of COVID-19: an experience from a tertiary-care academic center

Coronavirus disease 2019 (COVID-19) is caused by the novel coronavirus SARS-CoV-2 and has caused significant mortality and morbidity since it was first recognized in Wuhan, China in December 2019. Patients may suffer from a constellation of symptoms termed post-acute sequelae of COVID-19 (PASC) . Here we present findings of a retrospective cohort study describing the prevalence and predicting factors of patient-reported post-acute sequelae of COVID-19 (PASC). Categorical variables were summarized as frequency (percentage) and compared between vaccine status groups using Fisher's exact test. Continuous variables were reported as median (range) and compared between the groups using Kruskal-Wallis test. All tests were two-sided with p value <0.05 considered statistically significant. Survey data from 132 patients with a median age of 45 years, 68% female, 83% Caucasian/Non-Hispanic. The most frequently reported PASC symptoms include fatigue (84.8%), dyspnea (54.5%), cognitive dysfunction (53%), myalgias (37.1%), lightheadedness or vertigo (36.4%), chest pain (34.8%), palpitations (34.8%), headaches (34.1%), arthralgias (31.8%), and unrefreshing sleep (31.1%). There is mounting evidence that supports higher prevalence of PASC in women, White/Caucasian, and middle-aged individuals. This knowledge can provide guidance to clinical practices to anticipate and support healthcare and self-care needs for patients at higher risk to developing PASC.

Association between Experimental Pain Measurements and the Central Sensitization Inventory in Patients at Least 3 Months after COVID-19 Infection: A Cross-Sectional Pilot Study

Fatigue, pain, headache, brain fog, anosmia, ageusia, mood symptoms, and sleep disorders are symptoms commonly experienced by people with post-COVID-19 condition. These symptoms could be considered as manifestations of central sensitization. The aim of this study is to evaluate whether there are indicators of central sensitization by using experimental pain measurements and to determine their association with patient-reported outcome measures (PROMs). A cross-sectional study including 42 patients after COVID-19 infection was conducted. The central sensitization inventory (CSI) was administered as a PROM to evaluate central-sensitization-associated symptoms. Pressure pain thresholds (PPT), temporal summation, and descending nociceptive pain inhibition (CPM) were assessed as experimental pain measurements. The median score on the CSI was 46.5 (Q1-Q3: 33-54). The presence of central-sensitization-associated symptoms was seen in 64.3% of patients based on the CSI (≥40/100 points). A deficient CPM was seen in 12% and 14% of patients when measured at the trapezius and rectus femoris, respectively. A negative correlation between pressure sensitivity on the rectus femoris and the CSI score (r = -0.36, 95%CI -0.13 to -0.65, p = 0.007) was observed. Central-sensitization-associated symptoms were present in up to 64.3% of patients post-COVID-19 infection, based on a PROM, i.e., the CSI. A more objective evaluation of nociceptive processing through experimental pain measurements was less suggestive of indicators of central sensitization. Only a small negative correlation between pressure sensitivity and the CSI was observed, thereby pointing towards the discrepancy between the CSI and experimental pain measurements and presumably the complementary need for both to evaluate potential indicators of central sensitization in this population.

Clinical trials on the pharmacological treatment of long COVID: A systematic review

The postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC), also known as post-acute coronavirus disease 19 (COVID-19) or the long COVID syndrome (long COVID) is an emerging public health concern. A substantial proportion of individuals may remain symptomatic months after initial recovery. An updated review of published and ongoing trials focusing on managing long COVID will help identify gaps and address the unmet needs of patients suffering from this potentially debilitating syndrome. A comprehensive literature search was conducted on the international databases and clinical trial registries from inception to 31 July 2022. This review included 6 published trials and 54 trial registration records. There is significant heterogeneity in the characterization of long COVID and ascertainment of primary outcomes. Most of the trials are focused on individual symptoms of long COVID or isolated organ dysfunction, classified according to cardiovascular, respiratory and functional capacity, neurological and psychological, fatigue, and olfactory dysfunction. Most of the interventions are related to the mechanisms causing the individual symptoms. Although the six published trials showed significant improvement in the symptoms or organ dysfunction studied, these initial studies lack internal and external validity limiting the generalizability. This review provides an update of the pharmacological agents that could be used to treat long COVID. Further standardization of the diagnostic criteria, inclusion of participants with concomitant chronic cardiometabolic diseases and standardization of outcomes will be essential in future clinical trials.

Most Common Long COVID Physical Symptoms in Working Age Adults Who Experienced Mild COVID-19 Infection: A Scoping Review

BACKGROUND

One-third of patients who recover from COVID-19 present with long COVID. Their symptoms are broad, affecting their physical functioning and, ultimately, their quality of life. Many of those individuals who develop long COVID, possibly from a mild COVID-19 infection, are in the 18-65 age group. This prolongation of malaise directly influences national workforce economies.

OBJECTIVES

To summarise the commonly reported physical symptoms of long COVID in order to inform potential adjustments in healthcare for the employable population.

METHODS

The Embase, CINAHL, Medline, SCOPUS, and WHO COVID-19 databases were searched. The study selection process was based on the PRISMA guidelines. The extracted data were synthesised and presented narratively.

RESULTS

7403 studies were accessed, comprising 60 cohort studies and 10 case series/studies, representing 289,213 patients who met our criteria. The most frequently reported physical symptoms were fatigue (92%), shortness of breath (SOB) (81.8%), muscle pain (43.6%), and joint pain (34.5%).

CONCLUSIONS

The range of reported physical symptoms was broad and varied; the main ones being fatigue, breathlessness/SOB, and pain. Similarities observed between long COVID and other post-acute infection syndromes may help formulate protocols to manage and promote recovery for long COVID patients. Inconsistencies were evident, particularly with a lack of adherence to the standardised definitions of long COVID.

Global prevalence of chronic fatigue syndrome among long COVID-19 patients: A systematic review and meta-analysis

Background

Chronic fatigue syndrome is a persistent and debilitating disorder. According to several studies, chronic fatigue syndrome has been identified among recovered COVID-19 patients as the most common symptom of long COVID. The aim of this systematic review and meta-analysis study was to obtain the prevalence of chronic fatigue syndrome in long COVID cases.

Methods

In this systematic review and meta-analysis, we analysed reported results of studies that assessed the occurrence of chronic fatigue syndrome among COVID-19 patients four weeks after the onset of symptoms. The study selection was commenced by searching PubMed, Web of Science, Science Direct, Scopus, Embase, and Google scholar using the keywords of Chronic fatigue syndrome, COVID-19, and post-COVID-19 syndrome. The searches were without a lower time limit and until April 2022. Heterogeneity of studies was assessed using the I² index, and a random effects model was used for analysis. Data analysis was performed within the Comprehensive Meta-Analysis software (version 2).

Results

The pooled prevalence of chronic fatigue syndrome four weeks after the onset of COVID-19 symptoms, in 52 studies with a sample size of 127,117, was 45.2% (95% CI: 34.1-56.9%). Meta-regression analysis in examining the effects of the two factors of sample size, and year of study on the changes in the overall prevalence, showed that with increasing sample size, and year of study, the prevalence of chronic fatigue syndrome among long COVID patients (p < 0.05).

Conclusion

Our results show that the overall prevalence of chronic fatigue syndrome as a long COVID symptom is 45.2%. Chronic fatigue after infection with COVID-19 can negatively affect personal and social lives. Given such significant negative consequences caused by the syndrome, it is recommended that health policymakers allocate funds to reduce the adverse effects of this syndrome, by creating programs to support long COVID patients.

Health-related quality of life in persons post-COVID-19 infection in comparison to normative controls and chronic pain patients

The Coronavirus disease 2019 (COVID-19) pandemic exerted a tremendous pressure on the healthcare system, people's social life, mental health and financial status with profound implications for the general population. The exact impact of the pandemic on the overall physical, mental and social wellbeing of COVID-19 infection survivors on the long term has not yet been explored in a thorough way. Based on the reporting of persistent pain, fatigue and dyspnea symptoms by these survivors, it is our hypothesis that their quality of life will be extremely impacted, as is observed in patients with chronic pain. Therefore, the first aim of this study was to perform an in-depth evaluation of the quality of life of post-COVID-19 infected persons. The second aim was to compare the quality of life of these persons with a normative population and with patients with chronic pain. Health-related quality of life, as a measure for a person's overall physical, mental, and social wellbeing, was measured with the 3-level EQ5D in 547 post-COVID-19 infected persons. These data were compared to reference data from normal population records for Belgium and to data from patients with chronic pain after spinal surgery with two-way analyses of variance. In total, 89.58% of the post-COVID-19 infected persons reported pain/discomfort and 82.45% indicated limitations when performing usual activities, when evaluated 287 days (SD: 150) after the infection. Self-care was preserved in most post-COVID-19 persons, whereby only 13.16% indicated problems. The mean EQ5D-3L index score was 0.57 (SD: 0.23) and EQ5D VAS mean score was 56.6 (SD: 18.2). The mean index score for the normative population was significantly higher than for COVID-19 infected persons [mean difference of 0.31 (95% from 0.29 to 0.33), p < 0.01] while the mean score of chronic pain patients was significantly lower than the score of COVID-19 infected persons [mean difference of -0.31 (95% from -0.29 to -0.33), p < 0.01]. Compared to age-and sex adjusted reference data, health-related quality of life of persons with long COVID is severely impacted. In relation to patients with chronic pain after spinal surgery, the quality of life of post-COVID-19 infected persons seemed to be better.

Clinical trial registration

https://www.clinicaltrials.gov/, identifier: NCT04912778.

Pain Extent Is Not Associated with Sensory-Associated Symptoms, Cognitive or Psychological Variables in COVID-19 Survivors Suffering from Post-COVID Pain

We aimed to investigate the relationship between pain extent, as a sign of sensitization, and sensory-related, cognitive and psychological variables in hospitalized COVID-19 survivors with post-COVID pain. One hundred and forty-six (67 males, 79 females) previously hospitalized COVID-19 survivors with post-COVID pain completed demographic (age, sex, height, weight), sensory-related (Central Sensitization Inventory, Self-Report Leeds Assessment of Neuropathic Symptoms), cognitive (Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia) and psychological (Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index) variables. Pain extent and frequency maps were calculated from pain drawings using customized software. After conducting a correlation analysis to determine the relationships between variables, a stepwise linear regression model was performed to identify pain extent predictors, if available. Pain extent was significantly and weakly associated with pain intensity (r = −0.201, p = 0.014): the larger the pain extent, the lower the pain intensity. No other significant association was observed between pain extent and sensory-related, cognitive, or psychological variables in individuals with post-COVID pain. Females had higher pain intensity, more sensitization-associated symptoms, higher anxiety, lower sleep quality, and higher kinesiophobia levels than males. Sex differences correlation analyses revealed that pain extent was associated with pain intensity in males, but not in females. Pain extent was not associated with any of the measured variables and was also not related to the presence of sensitization-associated symptoms in our sample of COVID-19 survivors with long-term post-COVID pain.

Sensitization symptoms are associated with psychological and cognitive variables in COVID-19 survivors exhibiting post-COVID pain

OBJECTIVE

To investigate the association between demographic, clinical, psychological, cognitive, and health-related variables and the Central Sensitization Inventory (CSI) in previously hospitalized COVID-19 survivors exhibiting "de novo" post-COVID pain.

METHODS

Seventy-seven (n = 77) COVID-19 survivors with "de novo" post-COVID pain completed demographic (age, height, and weight), clinical (duration and intensity of the pain), psychological (depressive/anxiety levels and sleep quality), cognitive (catastrophizing and kinesiophobia levels), and health-related quality of life variables as well as the CSI. A multivariable correlation analysis was conducted to determine the association between variables, and a stepwise multiple linear regression model was performed to identify CSI predictors.

RESULTS

Patients were assessed a mean of 6.0 (SD 0.8) months after hospital discharge. Twenty-six (33.7%) individuals showed indications of sensitization-associated symptoms (CSI score ≥40 points). The CSI score was positively associated with pain intensity (r: 0.371), anxiety (r: 0.784), depressive (r: 0.709), catastrophizing (r: 0.620), and kinesiophobia (r: 0.359) levels (all, p < 0.001). The stepwise regression analysis revealed that 60.2% of CSI was explained by anxiety levels and pain intensity.

CONCLUSION

This study found that psychological and cognitive variables were associated with the CSI score in previously hospitalized COVID-19 survivors with "de novo" post-COVID pain. Anxiety levels and the intensity of pain symptoms were independently associated with CSI score suggesting a significant overlap with psychological construct. The "de novo" post-COVID pain association with CSI may indicate changes in the pain processing important for managing the pain.

Long COVID (post-COVID-19 condition) in children: a modified Delphi process

OBJECTIVE

The aim of this study was to derive a research definition for 'Long COVID (post-COVID-19 condition)' in children and young people (CYP) to allow comparisons between research studies.

DESIGN

A three-phase online Delphi process was used, followed by a consensus meeting. Participants were presented with 49 statements in each phase and scored them from 1 to 9 based on how important they were for inclusion in the research definition of Long COVID in CYP. The consensus meeting was held to achieve representation across the stakeholder groups. Statements agreed at the consensus meeting were reviewed by participants in the Patient and Public Involvement (PPI) Research Advisory Group.

SETTING

The study was conducted remotely using online surveys and a virtual consensus meeting.

PARTICIPANTS

120 people with relevant expertise were divided into three panels according to their area of expertise: Service Delivery, Research (or combination of research and service delivery) and Lived Experience. The PPI Research Advisory group consisted of CYP aged 11-17 years.

MAIN OUTCOME MEASURES

Consensus was defined using existing guidelines. If consensus was achieved in two or more panels or was on the border between one and two panels, those statements were discussed and voted on at the consensus meeting.

RESULTS

Ten statements were taken forward for discussion in the consensus meeting and five statements met threshold to be included in the research definition of Long COVID among CYP. The research definition, aligned to the clinical case definition of the WHO, is proposed as follows: Post-COVID-19 condition occurs in young people with a history of confirmed SARS-CoV-2 infection, with at least one persisting physical symptom for a minimum duration of 12 weeks after initial testing that cannot be explained by an alternative diagnosis. The symptoms have an impact on everyday functioning, may continue or develop after COVID infection, and may fluctuate or relapse over time. The positive COVID-19 test referred to in this definition can be a lateral flow antigen test, a PCR test or an antibody test.

CONCLUSIONS

This is the first research definition of Long COVID (post-COVID-19 condition) in CYP and complements the clinical case definition in adults proposed by the WHO.

Clinical Characteristics and Mechanisms of Musculoskeletal Pain in Long COVID

Objective

Musculoskeletal (MSK) pain is being increasingly reported by patients as one of the most common persistent symptoms in post-COVID-19 syndrome or Long COVID. However, there is a lack of understanding of its prevalence, characteristics, and underlying pathophysiological mechanisms. The objective of this review is to identify and describe the features and characteristics of MSK pain in Long COVID patients.

Methods

The narrative review involved a literature search of the following online databases: MEDLINE (OVID), EMBASE (OVID), CINAHL, PsyclNFO, and Web of Science (December 2019 to February 2022). We included observational studies that investigated the prevalence, characteristics, risk factors and mechanisms of MSK pain in Long COVID. After screening and reviewing the initial literature search results, a total of 35 studies were included in this review.

Results

The overall reported prevalence of MSK pain in Long COVID ranged widely from 0.3% to 65.2%. The pain has been reported to be localized to a particular region or generalized and widespread. No consistent pattern of progression of MSK pain symptoms over time was identified. Female gender and higher BMI could be potential risk factors for Long COVID MSK pain, but no clear association has been found with age and ethnicity. Different pathophysiological mechanisms have been hypothesized to contribute to MSK pain in Long COVID including increased production of proinflammatory cytokines, immune cell hyperactivation, direct viral entry of neurological and MSK system cells, and psychological factors.

Conclusion

MSK pain is one of the most common symptoms in Long COVID. Most of the current literature on Long COVID focuses on reporting the prevalence of persistent MSK pain. Studies describing the pain characteristics are scarce. The precise mechanism of MSK pain in Long COVID is yet to be investigated. Future research must explore the characteristics, risk factors, natural progression, and underlying mechanisms of MSK pain in Long COVID.

Postacute Sequelae of Severe Acute Respiratory Syndrome Coronavirus 2 Infection

Postacute sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) or long coronavirus disease (COVID) is an emerging syndrome characterized by multiple persisting or newly emergent symptoms following the acute phase of SARS-CoV-2 infection. For affected patients, these prolonged symptoms can have a relapsing and remitting course and may be associated with disability and frequent health care utilization. Although many symptom-driven treatments are available, management remains challenging and often requires a multidisciplinary approach. This article summarizes the emerging consensus on definitions, epidemiology, and pathophysiology of long COVID and discusses what is understood about prevention, evaluation, and treatment of this syndrome.

The Role of Acetyl-Carnitine and Rehabilitation in the Management of Patients with Post-COVID Syndrome: Case-Control Study

Post-COVID syndrome is characterized by the persistence of nonspecific disabling symptoms, even several months after the resolution of the infection, with clinical characteristics similar to fibromyalgia (FM) and a prevalence of 31%. We evaluated the effectiveness of physical exercise, in association with L-acetyl-carnitine (ALC) therapy, in patients with Post-COVID syndrome, on musculoskeletal pain, dyspnea, functional capacity, quality of life, and depression. We conducted an observational case-control study on patients with Post-COVID syndrome. The patients were randomly divided into two groups: a treatment group that received rehabilitation treatment in combination with ALC 500 mg therapy; a control group that received only rehabilitation treatment. Patients were assessed at the time of recruitment (T0) and one month after the end of therapy (T1), with the administration of rating scales: NRS, Barthel Dyspnea Index (NPI), 12-Item Short Form Survey (SF-12) scale, Fibromyalgia Impact Questionnaire (FIQ), and Patient Health Questionnaire (PHQ-9). The treatment group showed statistically higher variations in pain scores, quality of life, and depression. No statistically significant differences between the two groups emerged regarding changes in dyspnea and functional capacity scores. Combining exercise with ALC is a promising and effective treatment in the management of Post-COVID syndrome, especially for musculoskeletal pain, depression, and quality of life.

Post-acute sequelae of COVID-19 (PASC): a meta-narrative review of pathophysiology, prevalence, and management

Coronavirus Disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Over 220 countries and territories have been affected by this virus, and the infection rate has continued to rise. As patients recover from the virus, many are experiencing lingering symptoms. Understanding the impact of demographics and comorbidities on symptom prevalence, manifestations, and severity is not only relevant during acute infection, it is critical to the clinical management of patients with post-acute sequelae of COVID-19, also known as PASC. Herein, we provide a comprehensive review on the most recent research related to PASC. Specifically, we focus on the description of the disorder itself, compared to acute COVID-19, and which types of patients are most affected by long-term sequelae. Further, we share recommendations for management of the most common complications of PASC.

Post-COVID-19 syndrome: persistent neuroimaging changes and symptoms 9 months after initial infection

A previously healthy and active middle-aged woman acquired COVID-19 as an occupational exposure with subsequent persistent post-COVID-19 symptoms including headache, dyspnoea on exertion, chest pressure, tachycardia, anosmia, parosmia, persistent myalgia, vertigo, cognitive decline and fatigue. She presented to a tertiary medical centre for further evaluation after 9 months of persistent symptoms and had a largely unremarkable workup with the exception of a persistently elevated monocyte chemoattractant protein 1, blunted cardiovagal response and non-specific scattered areas of low-level hypometabolism at the bilateral frontal, left precuneus, occipital and parietal regions on PET scan.

New Clinical Phenotype of the Post-Covid Syndrome: Fibromyalgia and Joint Hypermobility Condition

Fibromyalgia can be defined as a chronic pain condition, affecting the musculoskeletal system, etiology and pathophysiology of which is sufficiently understudied. Despite the fact that many authors consider this entity to be a manifestation of central sensitization, and not an autoimmune disease, the high prevalence of fibromyalgia in patients with post-COVID-19 conditions requires taking a fresh look at the causes of the disease development. During the patient examination, the authors identified a combination of symptoms that occurs so often, that they can be carefully described as a clinical pattern. These manifestations include young age, female gender, joint hypermobility, the onset of pain after COVID-19, physical traumatization of one particular tendon and the development of the fibromyalgia pain syndrome during the next several weeks. As well as an increase in the titer of antinuclear antibodies and some other systemic inflammation factors. It can be assumed with great caution that local damage to the connective tissue in patients with joint hypermobility, having COVID-19 as a trigger factor can lead to the development of fibromyalgia syndrome. This article presents three clinical cases that illustrated this hypothesis.