Skeletal Muscle Damage in COVID-19: A Call for Action

Impact of the COVID-19 pandemic on risk of sarcopenia: From lockdown and infection perspectives: A systematic review and meta-analysis

BACKGROUND

During the new coronavirus disease 2019 (COVID-19) pandemic, there are numerous symptoms in the skeletal muscular system, such as decreased skeletal muscle mass, strength, and muscle function, which are the main manifestations of sarcopenia. To investigate the impact of the COVID-19 pandemic on sarcopenia from the perspectives of COVID-19 pandemic lockdown and COVID-19 infection, we conducted this study.

METHODS

We searched for literature related to COVID-19 and sarcopenia published in PubMed, Embase, Cochrane Library, and Web of Science. Two researchers independently searched and screened the articles, extracted data, and assessed the quality of the final included literature. RevMan 5.4 was used for meta-analysis.

RESULTS

A total of 8 articles with a total of 1145 patients were included. There was a significant difference in SARC-F scores (MD = 0.67, 95%CI = [0.41, 0.93], Z = 5.00, P < .00001), handgrip (MD = -1.57, 95%CI = [-2.41, -0.73], Z = 3.66, P = .0002), body weight (MD = -1.87, 95%CI = [-3.69, -0.05], Z = 2.01, P = .04), and skeletal muscle mass index (MD = -0.28, 95%CI = [-0.54, -0.02], Z = 2.13, P = .03) between the time before the COVID-19 pandemic and during the COVID-19 pandemic. However, the results showed that there was no significant difference in muscle mass between the 2 groups (MD = -1.72, 95%CI = [-4.39, 0.94], Z = 1.27, P = .21).

CONCLUSION

The COVID-19 pandemic has had an impact on sarcopenia. Both infection with COVID-19 and lockdown during the COVID-19 pandemic increase the risk of sarcopenia. Research should pay more attention to this disease during the COVID-19 pandemic and adopt effective interventions to minimize adverse outcomes.

The Association between Body Composition Phenotype and Insulin Resistance in Post-COVID-19 Syndrome Patients without Diabetes: A Cross-Sectional, Single-Center Study

BACKGROUND

The most frequent body composition alterations in post-COVID-19 syndrome include low muscle mass, dynapenia, sarcopenia, and obesity. These conditions share interconnected pathophysiological mechanisms that exacerbate each other. The relationship between body composition phenotypes and metabolic abnormalities in post-COVID-19 syndrome remains unclear.

OBJECTIVE

To evaluate the association between body composition phenotypes and insulin resistance (IR) and metabolic abnormalities in non-diabetic individuals with post-COVID-19 syndrome.

METHODS

A cross-sectional, single-center study involving 483 subjects with post-COVID-19 syndrome following moderate to severe acute COVID-19 requiring hospitalization. Individuals with diabetes, those who declined to participate, or those who could not be contacted were excluded. Body composition phenotypes were classified as normal weight, dynapenia, sarcopenia, dynapenic obesity, and sarcopenic obesity (SO).

RESULTS

The average age was 52.69 ± 14.75 years; of note, 67.08% were male. The prevalence of body composition phenotypes was as follows: 13.25% were of normal weight, 9.52% had dynapenia, 9.94% had sarcopenia, 43.69% had obesity, 18.84% had dynapenic obesity, and 4.76% had SO. Additionally, 58.18% had IR. Obesity (OR: 2.98, CI95%; 1.64-5.41) and dynapenic obesity (OR: 4.98, CI95%; 1.46-6.88) were associated with IR.

CONCLUSION

The most common body composition phenotypes were obesity, dynapenic obesity, and dynapenia. Furthermore, obesity and dynapenic obesity were associated with IR in post-COVID-19 syndrome.

Effects of repetitive peripheral magnetic stimulation on a patient with severe lower limb muscle weakness due to coronavirus disease-2019

Kamiue M, Tsubahara A, Ito T. Effects of repetitive peripheral magnetic stimulation on a patient with severe lower limb muscle weakness due to coronavirus disease-2019. Jpn J Compr Rehabil Sci 2024; 15: 27-33.

Introduction

A patient developed severe lower limb muscle weakness and gait disturbance after receiving mechanical ventilation in the intensive care unit (ICU) due to coronavirus disease 2019 (COVID-19). We describe the effect of repetitive peripheral magnetic stimulation (rPMS) to strengthen his lower limb muscles.

Case

A 70-year-old man was mechanically ventilated due to COVID-19-related breathing difficulties. He was weaned off mechanical ventilation after 54 days, and the tracheostomy was closed after 225 days. However, his lower limbs remained significantly weak, and he was wheelchair-bound for daily activities. Despite approximately 6 months of functional training at a day-service center, his physical function and movement abilities did not improve. Therefore, 30-Hz rPMS was applied to both quadriceps for 20 minutes/day, three times a week, for 4 weeks (12 times). Knee extensor torque (KET) during maximum voluntary contraction (MVC) was greater after (right: 42.1 Nm, left: 40.7 Nm) than before the intervention (right: 33.7 Nm, left: 36.2 Nm). Before the intervention, KET induced by rPMS (rPMS-induced torque) was 0 Nm on both sides, the 30-second chair stand test (CS-30) was challenging to perform, and the walking item score of the Functional Independence Measure (FIM) was 2 points (endurance 30 m). Post-intervention, rPMS-induced torque was 6.5 Nm on the right and 4.7 Nm on the left side, CS-30 could be performed once, and the FIM walking score was improved to 6 points (endurance 60 m).

Discussion

The use of rPMS improved lower limb muscle strength in a patient who developed ICU-acquired muscle weakness after COVID-19.

Development of a screening system of gene sets for estimating the time of early skeletal muscle injury based on second-generation sequencing technology

The present study is aimed to address the challenge of wound age estimation in forensic science by identifying reliable genetic markers using low-cost and high-precision second-generation sequencing technology. A total of 54 Sprague-Dawley rats were randomly assigned to a control group or injury groups, with injury groups being further divided into time points (4 h, 8 h, 12 h, 16 h, 20 h, 24 h, 28 h, and 32 h after injury, n = 6) to establish rat skeletal muscle contusion models. Gene expression data were obtained using second-generation sequencing technology, and differential gene expression analysis, weighted gene co-expression network analysis (WGCNA) and time-dependent expression trend analysis were performed. A total of six sets of biomarkers were obtained: differentially expressed genes at adjacent time points (127 genes), co-expressed genes most associated with wound age (213 genes), hub genes exhibiting time-dependent expression (264 genes), and sets of transcription factors (TF) corresponding to the above sets of genes (74, 87, and 99 genes, respectively). Then, random forest (RF), support vector machine (SVM) and multilayer perceptron (MLP), were constructed for wound age estimation from the above gene sets. The results estimated by transcription factors were all superior to the corresponding hub genes, with the transcription factor group of WGCNA performed the best, with average accuracy rates of 96% for three models' internal testing, and 91.7% for the highest external validation. This study demonstrates the advantages of the indicator screening system based on second-generation sequencing technology and transcription factor level for wound age estimation.

Effect of COVID-19 pandemic on bioimpedance health indicators in young adults

OBJECTIVES

Herein, we investigate the relationships between the COVID-19 pandemic and overcoming the virus, and its effects on body composition parameters in young adults from Slovakia.

METHODS

We assessed 773 adults aged 18 to 30 years in pandemic-status sub-groups. Individual lifestyles and overcoming the COVID-19 effects were evaluated by a detailed questionnaire, and body composition parameters were analyzed using the InBody 770 bioimpedance analyzer.

RESULTS

Statistically significant lower values were observed in the male group during the pandemic for the following parameters; proteins and minerals, fat free mass (FFM), skeletal muscle mass (SMM), lean body mass (LBM) and its values in the right and left arm and trunk, total body water (TBW) and its values in the right and left arm and trunk, body cell mass (BCM), basal metabolic rate (BMR) and phase angle (PA). The regression analysis confirmed the negative pandemic effect and the negative impact of COVID-19 on men in the following parameters: proteins (p = .027 for pandemic and p = .005 for COVID-19), FFM (p = .023 for pandemic and p = .005 for COVID-19), LBM (p = .022 for pandemic and p = .004 for COVID-19), SMM (p = .028 for pandemic and p = .005 for COVID-19), TBW (p = .020 for pandemic and p = .004 for COVID-19), BMR (p = .024 for pandemic and p = .005 for COVID-19) and PA (p = .009 for pandemic). Physical activity was a further significant predictor in men for all the above parameters.

CONCLUSIONS

We observed significantly lower body composition parameters associated with fat free mass in young adult men during the pandemic than before it. However, future research is warranted to determine if these effects have long-term significance.

Association of Calf Circumference with Clinical and Biochemical Markers in Older Adults with COVID-19 Admitted at Intensive Care Unit: A Retrospective Cross-Sectional Study

BACKGROUND

COVID-19 is an infectious disease characterized by a severe catabolic and inflammatory state, leading to loss of muscle mass. The assessment of muscle mass can be useful to identify nutritional risk and assist in early management, especially in older adults who have high nutritional risks. The aim of this study was to evaluate the association of calf circumference (CC) with clinical and biochemical markers and mortality in older adults with COVID-19 admitted to the intensive care unit (ICU).

METHODS

A retrospective cross-sectional study was conducted in a public hospital. CC was adjusted for body mass index (BMI), reducing 3, 7, or 12 cm for a BMI of 25-29.9, 30-39.9, and ≥40 kg/m2, respectively, and classified as reduced when <33 cm for women and <34 cm for men. Pearson's correlation between BMI and CC was performed to assess the association between variables. Regression analysis was adjusted for sex, age, and BMI variables. Cox regression was used to assess survival related to CC.

RESULTS

A total of 208 older adults diagnosed with COVID-19 admitted to ICU were included, of which 84% (n = 176) were classified as having reduced CC. These patients were older, with lower BMI, higher nutritional risk, malnourished, and higher concentration of urea and urea-creatinine ratio (UCR) compared with the group with normal CC. There was an association between edematous patients at nutritional risk and malnourished with reduced CC in the Cox regression, either adjusted or not for confounding.

CONCLUSIONS

CC was not associated with severity, biochemical markers, or mortality in older adults with COVID-19 admitted to the ICU, but it was associated with moderately malnourished patients assessed by subjective global assessment (SGA).

Significance of nitrosative stress and glycoxidation products in the diagnosis of COVID-19

Nitrosative stress promotes protein glycoxidation, and both processes can occur during an infection with the SARS-CoV-2 virus. Therefore, the aim of this study was to assess selected nitrosative stress parameters and protein glycoxidation products in COVID-19 patients and convalescents relative to healthy subjects, including in reference to the severity of COVID-19 symptoms. The diagnostic utility of nitrosative stress and protein glycoxidation biomarkers was also evaluated in COVID-19 patients. The study involved 218 patients with COVID-19, 69 convalescents, and 48 healthy subjects. Nitrosative stress parameters (NO, S-nitrosothiols, nitrotyrosine) and protein glycoxidation products (tryptophan, kynurenine, N-formylkynurenine, dityrosine, AGEs) were measured in the blood plasma or serum with the use of colorimetric/fluorometric methods. The levels of NO (p = 0.0480), S-nitrosothiols (p = 0.0004), nitrotyrosine (p = 0.0175), kynurenine (p < 0.0001), N-formylkynurenine (p < 0.0001), dityrosine (p < 0.0001), and AGEs (p < 0.0001) were significantly higher, whereas tryptophan fluorescence was significantly (p < 0.0001) lower in COVID-19 patients than in the control group. Significant differences in the analyzed parameters were observed in different stages of COVID-19. In turn, the concentrations of kynurenine (p < 0.0001), N-formylkynurenine (p < 0.0001), dityrosine (p < 0.0001), and AGEs (p < 0.0001) were significantly higher, whereas tryptophan levels were significantly (p < 0.0001) lower in convalescents than in healthy controls. The ROC analysis revealed that protein glycoxidation products can be useful for diagnosing infections with the SARS-CoV-2 virus because they differentiate COVID-19 patients (KN: sensitivity-91.20%, specificity-92.00%; NFK: sensitivity-92.37%, specificity-92.00%; AGEs: sensitivity-99,02%, specificity-100%) and convalescents (KN: sensitivity-82.22%, specificity-84.00%; NFK: sensitivity-82,86%, specificity-86,00%; DT: sensitivity-100%, specificity-100%; AGE: sensitivity-100%, specificity-100%) from healthy subjects with high sensitivity and specificity. Nitrosative stress and protein glycoxidation are intensified both during and after an infection with the SARS-CoV-2 virus. The levels of redox biomarkers fluctuate in different stages of the disease. Circulating biomarkers of nitrosative stress/protein glycoxidation have potential diagnostic utility in both COVID-19 patients and convalescents.

Impact of COVID-19 versus other pneumonia on in-hospital mortality and functional decline among Japanese dialysis patients: a retrospective cohort study

Coronavirus disease 2019 (COVID-19) affects both life and health. However, the differentiation from other types of pneumonia and effect of kidney disease remains uncertain. This retrospective observational study investigated the risk of in-hospital death and functional decline in ≥ 20% of Barthel Index scores after COVID-19 compared to other forms of pneumonia among Japanese adults, both with and without end-stage kidney disease (ESKD). The study enrolled 123,378 patients aged 18 years and older from a national inpatient administrative claims database in Japan that covers the first three waves of the COVID-19 pandemic in 2020. After a 1:1:1:1 propensity score matching into non-COVID-19/non-dialysis, COVID-19/non-dialysis, non-COVID-19/dialysis, and COVID-19/dialysis groups, 2136 adults were included in the analyses. The multivariable logistic regression analyses revealed greater odds ratios (ORs) of death [5.92 (95% CI 3.62-9.96)] and functional decline [1.93 (95% CI 1.26-2.99)] only in the COVID-19/dialysis group versus the non-COVID-19/non-dialysis group. The COVID-19/dialysis group had a higher risk of death directly due to pneumonia (OR 6.02, 95% CI 3.50-10.8) or death due to other diseases (OR 3.00, 95% CI 1.11-8.48; versus the non-COVID-19/non-dialysis group). COVID-19 displayed a greater impact on physical function than other types of pneumonia particularly in ESKD.

Integrated assessment of computed tomography density in pectoralis and erector spinae muscles as a prognostic biomarker for coronavirus disease 2019

BACKGROUND ＆ AIMS: Muscle quantification using chest computed tomography (CT) is a useful prognostic biomarker for coronavirus disease 2019 (COVID-19). However, no studies have evaluated the clinical course through comprehensive assessment of the pectoralis and erector spinae muscles. Therefore, we compared the impact of the areas and densities of these muscles on COVID-19 infection outcome.

METHODS

This multicenter retrospective cohort study was conducted by the COVID-19 Task Force. A total of 1410 patients with COVID-19 were included, and data on the area and density of the pectoralis and erector spinae muscles on chest CT were collected. The impact of each muscle parameter on the clinical outcome of COVID-19 was stratified according to sex. The primary outcome was the percentage of patients with severe disease, including those requiring oxygen supplementation and those who died. Additionally, 167 patients were followed up for changes in muscle parameters at three months and for the clinical characteristics in case of reduced CT density.

RESULTS

For both muscles, low density rather than muscle area was associated with COVID-19 severity. Regardless of sex, lower erector spinae muscle density was associated with more severe disease than pectoralis muscle density. The muscles were divided into two groups using the receiver operating characteristic curve of CT density, and the population was classified into four (Group A: high CT density for both muscles, Group B: low CT density for pectoralis and high for erector spinae muscle. Group C: high CT density for pectoralis and low for erector spinae muscle, Group D: low CT density for both muscles). In univariate analysis, Group D patients exhibited worse outcomes than Group A (OR: 2.96, 95% CI: 2.03-4.34 in men; OR: 3.02, 95% CI: 2.66-10.4 in women). Multivariate analysis revealed that men in Group D had a significantly more severe prognosis than those in Group A (OR: 1.82, 95% CI: 1.16-2.87). Moreover, Group D patients tended to have the highest incidence of other complications due to secondary infections and acute kidney injury during the clinical course. Longitudinal analysis of both muscle densities over three months revealed that patients with decreased muscle density over time were more likely to have severe cases than those who did not.

CONCLUSIONS

Muscle density, rather than muscle area, predicts the clinical outcomes of COVID-19. Integrated assessment of pectoralis and erector spinae muscle densities demonstrated higher accuracy in predicting the clinical course of COVID-19 than individual assessments.

Outpatient rehabilitation in post-acute COVID-19 patients: a combined progressive treatment protocol

PURPOSE

to investigate the effectiveness of a 4-week combined progressive program on functional abilities, disability status and quality of life (QoL) in COVID-19 recovered patients.

MATERIALS & METHODS

18 COVID-19 recovered patients performed a combined rehabilitation treatment accounting for 12 sessions, including both respiratory and motor training sessions. A careful monitoring of exercise intensity, duration and progression to tailor complexity evolution on patients' competencies was carried out. Patients were monitored with different functional scales and self-reported questionnaires before (T0) and after (T1) rehabilitation.

RESULTS

6-Minutes Walk Test, Timed Up and Go Test and Short Physical Performance Battery significantly improved, while Physiological Cost Index presented a significant reduction after rehabilitation. Moreover, Barthel Index significantly improved and patients presented significantly increased upper and lower limbs strength at T1. Furthermore, mMRC Dyspnoea Scale presented a significant reduction after training. Finally, physical and psychological well-being scales improved according to Short-Form 36; while, self-reported questionnaires related to mood and depression showed no significant modification after rehabilitation.

CONCLUSIONS

results evidenced the efficacy of the combined progressive intervention in COVID-19 recovered patients. The specific customization on patients' needs and the careful exercise monitoring promoted improvements on functional abilities and disability status, with positive impact on QoL.

Alteration of skeletal muscle energy metabolism assessed by 31 P MRS in clinical routine: Part 2. Clinical application

In this second part of a two-part paper, we intend to demonstrate the impact of the previously proposed advanced quality control pipeline. To understand its benefit and challenge the proposed methodology in a real scenario, we chose to compare the outcome when applying it to the analysis of two patient populations with significant but highly different types of fatigue: COVID-19 and multiple sclerosis (MS). 31 P-MRS was performed on a 3 T clinical MRI, in 19 COVID-19 patients, 38 MS patients, and 40 matched healthy controls. Dynamic acquisitions using an MR-compatible ergometer ran over a rest (40 s), exercise (2 min), and a recovery phase (6 min). Long and short TR acquisitions were also made at rest for T1 correction. The advanced data quality control pipeline presented in Part 1 is applied to the selected patient cohorts to investigate its impact on clinical outcomes. We first used power and sample size analysis to estimate objectively the impact of adding the quality control score (QCS). Then, comparisons between patients and healthy control groups using the validated QCS were performed using unpaired t tests or Mann-Whitney tests (p < 0.05). The application of the QCS resulted in increased statistical power, changed the values of several outcome measures, and reduced variability (standard deviation). A significant difference was found between the T1PCr and T1Pi values of MS patients and healthy controls. Furthermore, the use of a fixed correction factor led to systematically higher estimated concentrations of PCr and Pi than when using individually corrected factors. We observed significant differences between the two patient populations and healthy controls for resting [PCr]-MS only, [Pi ], [ADP], [H2 PO4 - ], and pH-COVID-19 only, and post-exercise [PCr], [Pi ], and [H2 PO4 - ]-MS only. The dynamic indicators τPCr , τPi , ViPCr , and Vmax were reduced for COVID-19 and MS patients compared with controls. Our results show that QCS in dynamic 31 P-MRS studies results in smaller data variability and therefore impacts study sample size and power. Although QCS resulted in discarded data and therefore reduced the acceptable data and subject numbers, this rigorous and unbiased approach allowed for proper assessment of muscle metabolites and metabolism in patient populations. The outcomes include an increased metabolite T1 , which directly affects the T1 correction factor applied to the amplitudes of the metabolite, and a prolonged τPCr , indicating reduced muscle oxidative capacity for patients with MS and COVID-19.

Evaluation and treatment approaches for neurological post-acute sequelae of COVID-19: A consensus statement and scoping review from the global COVID-19 neuro research coalition

Post-acute neurological sequelae of COVID-19 affect millions of people worldwide, yet little data is available to guide treatment strategies for the most common symptoms. We conducted a scoping review of PubMed/Medline from 1/1/2020-4/1/2023 to identify studies addressing diagnosis and treatment of the most common post-acute neurological sequelae of COVID-19 including: cognitive impairment, sleep disorders, headache, dizziness/lightheadedness, fatigue, weakness, numbness/pain, anxiety, depression and post-traumatic stress disorder. Utilizing the available literature and international disease-specific society guidelines, we constructed symptom-based differential diagnoses, evaluation and management paradigms. This pragmatic, evidence-based consensus document may serve as a guide for a holistic approach to post-COVID neurological care and will complement future clinical trials by outlining best practices in the evaluation and treatment of post-acute neurological signs/symptoms.

Physical Rehabilitation Before and After Lung Transplantation for COVID-19 ARDS: A Case Report

Purpose

To describe the functional trajectory and physical rehabilitation of an individual who underwent lung transplantation for COVID-19 acute respiratory distress syndrome (ARDS).

Client Description

A previously healthy 60-year-old man admitted to critical care pre-transplantation and followed six months post-transplant.

Intervention

Physical rehabilitation in the critical care, acute ward and in-patient rehabilitation settings.

Measures and Outcome

Despite a successful surgery, a long and complex acute care admission contributed to a slow and variable functional recovery. Significant functional limitations and physical frailty were present in the early post-transplant period.

Implications

Little is known of the effects of COVID-19 superimposed upon lung transplantation on muscle function, exercise capacity, and physical activity. Future research should include case series to further understand the functional deficits and trajectory of recovery in this emerging clinical population. Standard core outcome measures should be identified for this population to enable synthesis of findings and inform short- and long-term rehabilitation strategies.

Impact of COVID-19 lockdown on injury risk in Qatar's professional football

OBJECTIVES

To compare injury incidence, burden and characteristics between the pre- and post-COVID-19 lockdown periods in Qatari professional football.

DESIGN

Prospective cohort study.

METHODS

Injury and exposure data for two post-COVID-19 lockdown periods [early post-lockdown period: short-term ~2 months (54 matches) and late post-lockdown period: long-term 8-months (183 matches)] were compared to the benchmark of the same periods from the three previous seasons (2017/18-2019/20).

RESULTS

We observed no difference in overall, training or match incidence between early post-lockdown period and the benchmark reference. However, this short-term period resulted in lower burden for overall- (RR 0.80, P < 0.0001), training- (RR 0.73, P < 0.0001) and match-injuries (RR 0.40, P < 0.0001) compared to the benchmark. During late post-lockdown period match injury incidence (RR 0.72, P = 0.0010) and match injury burden (RR 0.69, P < 0.001) were lower than the benchmark. In contrast, both overall- (RR 1.30, P < 0.001) and training-injury burden (RR 1.65, P < 0.001) were higher. A significant increase in adductor strains in both post-lockdown periods was observed.

CONCLUSIONS

Immediately after the COVID-19 lockdown (short-term effect), there was no difference in injury incidence but a lower injury burden compared to benchmark. Moreover, the rapid return to competition for the successive season (long-term effect) was associated with a higher overall- and training-injury burden, but a lower match-injury burden compared to the benchmark.

Resistance Training in Post-COVID Recovery: Rationale and Current Evidence

During hospitalisation with COVID-19, individuals may experience prolonged periods of immobilisation. Combined with the inflammatory effects of the virus, this may lead to a significant reduction in both muscle mass and strength. Data from several long-term studies suggest that these symptoms may not fully resolve within one year. Owing to its effectiveness at inducing muscle fibre hypertrophy and improving neuromuscular efficiency, resistance training is of great interest in the rehabilitation of this population. This narrative review aims to identify the rationale and potential efficacy of resistance training for restoring physical function following infection with SARS-CoV-2, as well as evidence of its use in clinical practice. The studies included in this narrative review consisted mostly of multi-component rehabilitation trials. Of these, widespread improvements in muscle strength were reported using intensities of up to 80% of participants' 1-repetition-maximum. Evidence thus far indicates that resistance training may be safe and effective in patients following COVID-19, although its individual contribution is difficult to discern. Future exercise intervention studies investigating the efficacy of resistance training as a sole modality are needed.

Multi-user upper limb rehabilitation training system integrating social interaction

COVID-19 causes persistent symptoms such as weakness and myasthenia in most patients. Due to the cross-infection of COVID-19, the traditional face-to-face rehabilitation services are risky for the elderly. To ensure that the elderly in urgent need of rehabilitation services receive training while minimizing the disturbance of the COVID-19 pandemic on their social activities. We have improved the existing virtual upper limb training system, and added a social factor to the system. Seniors with upper limb rehabilitation needs can use the system to compete or collaborate with others for training. In addition, a set of natural and scientific exclusive gestures have been designed under the direction of following the doctor's advice. The experiment is conducted jointly with the chief physicians of the geriatrics department in the authoritative class-A hospitals of Class III. Our experiment, which lasted for two months, showed that the virtual training system with social factors added had the best rehabilitation effect and enhanced the initiative of patients. The system has value for popularization during the COVID-19 epidemic.

Phase Angle and Handgrip Strength as Predictors of Clinical Outcomes in Hospitalized COVID-19 Patients

Phase angle (PhA) and muscle strength are predictors of clinical outcomes in critically ill patients. Malnutrition may affect body composition measurements. The aim of this prospective study was to investigate the association between PhA and handgrip strength (HGS), and clinical outcomes in hospitalized COVID-19 patients. The study included a total of 102 patients. Both PhA and HGS were measured twice, within 48 h of hospital admission and on the 7th day of hospitalization. The primary outcome was the clinical status on the 28th day of hospitalization. Secondary outcomes included the hospital length of stay (LOS), the concentrations of ferritin, C-reactive protein and albumin, oxygen requirements and the severity of pneumonia. A one-way analysis of variance (ANOVA) test and Spearman rS correlation coefficient were used for statistical analysis. No differences were found for PhA [on day 1 (p = 0.769) and day 7 (p = 0.807)] and the primary outcome. A difference was found between HGS on day 1 and the primary outcome (p = 0.008), while no difference was found for HGS on day 7 (p = 0.476). Body mass index was found to be associated with the oxygen requirement on day 7 (p = 0.005). LOS was correlated neither with PhA (rs = −0.081, p = 0.422) nor with HGS (rs = 0.137, p = 0.177) on the first day. HGS could be a useful indicator of clinical outcomes in COVID-19 patients, while PhA does not seem to have a clinical impact. However, further research is needed to validate the results of our study.

Are Football Players More Prone to Muscle Injury after COVID-19 Infection? The "Italian Injury Study" during the Serie a Championship

INTRODUCTION

Football was the first sport to resume competitions after the coronavirus disease 2019 (COVID-19) lockdown and promptly the hypothesis was raised of a potential relationship between the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and musculoskeletal injuries in athletes. This study aimed to confirm the association between SARS-CoV-2 infection and muscle strain injury in a large population of elite football players and to investigate if the COVID-19 severity level could affect the risk of injury.

METHODS

A retrospective cohort study involving 15 Italian professional male football teams was performed during the Italian Serie A 2020-2021 season. Injuries and SARS-CoV-2 positivity data were collected by team doctors through an online database.

RESULTS

Of the 433 included players, we observed 173 SARS-CoV-2 infections and 332 indirect muscle strains. COVID-19 episodes mostly belonged to severity level I and II. The injury risk significantly increased after a COVID-19 event, by 36% (HR = 1.36, CI_95% 1.05; 1.77, p-value = 0.02). The injury burden demonstrated an 86% increase (ratio = 1.86, CI_95% 1.21; 2.86, p-value = 0.005) in the COVID-19 severity level II/III versus players without a previous SARS-CoV-2 infection, while level I (asymptomatic) patients showed a similar average burden (ratio = 0.92, CI_95% 0.54; 1.58, p-value = 0.77). A significantly higher proportion of muscle-tendon junction injuries (40.6% vs. 27.1%, difference = 13.5%, CI_95% 0.002%; 26.9%, p-value = 0.047) was found when comparing level II/III versus Non-COVID-19.

CONCLUSIONS

This study confirms the correlation between SARS-CoV-2 infection and indirect muscle injuries and highlights how the severity of the infection would represent an additional risk factor.

Mapping peripheral and abdominal sarcopenia acquired in the acute phase of COVID-19 during 7 days of mechanical ventilation

Our aim was to map acquired peripheral and abdominal sarcopenia in mechanically ventilated adults with COVID-19 through ultrasound measurements. On Days 1, 3, 5 and 7 after admission to critical care, the muscle thickness and cross-sectional area of the quadriceps, rectus femoris, vastus intermedius, tibialis anterior, medial and lateral gastrocnemius, deltoid, biceps brachii, rectus abdominis, internal and external oblique, and transversus abdominis were measured using bedside ultrasound. A total of 5460 ultrasound images were analyzed from 30 patients (age: 59.8 ± 15.6 years; 70% men). Muscle thickness loss was found in the bilateral anterior tibial and medial gastrocnemius muscles (range 11.5-14.6%) between Days 1 and 3; in the bilateral quadriceps, rectus femoris, lateral gastrocnemius, deltoid, and biceps brachii (range 16.3-39.1%) between Days 1 and 5; in the internal oblique abdominal (25.9%) between Days 1 and 5; and in the rectus and transversus abdominis (29%) between Days 1 and 7. The cross-sectional area was reduced in the bilateral tibialis anterior and left biceps brachii (range 24.6-25.6%) between Days 1 and 5 and in the bilateral rectus femoris and right biceps brachii (range 22.9-27.7%) between Days 1 and 7. These findings indicate that the peripheral and abdominal muscle loss is progressive during the first week of mechanical ventilation and is significantly higher in the lower limbs, left quadriceps and right rectus femoris muscles in critically ill patients with COVID-19.

Musculoskeletal involvement: COVID-19 and post COVID 19

The worldwide pandemic of coronavirus disease 2019 (COVID-19) was known to predominantly affect the lungs, but it was realized that COVID-19 had a large variety of clinical involvement. Cardiovascular, gastrointestinal, neurological, and musculoskeletal systems are involved by direct or indirect mechanisms with various manifestations. The musculoskeletal involvement can manifest during COVID-19 infection, due to medications used for the treatment of COVID-19, and in the post/long COVID-19 syndrome. The major symptoms are fatigue, myalgia/arthralgia, back pain, low back pain, and chest pain. During the last two years, musculoskeletal involvement increased, but no clear consensus was obtained about the pathogenesis. However, there is valuable data that supports the hypothesis of angiotensinconverting enzyme 2, inflammation, hypoxia, and muscle catabolism. Additionally, medications that were used for treatment also have musculoskeletal adverse effects, such as corticosteroid-induced myopathy and osteoporosis. Therefore, while deciding the drugs, priorities and benefits should be taken into consideration. Symptoms that begin three months from the onset of the COVID-19 infection, continue for at least two months, and cannot be explained by another diagnosis is accepted as post/long COVID-19 syndrome. Prior symptoms may persist and fluctuate, or new symptoms may manifest. In addition, there must be at least one symptom of infection. Most common musculoskeletal symptoms are myalgia, arthralgia, fatigue, back pain, muscle weakness, sarcopenia, impaired exercise capacity, and physical performance. In addition, the female sex, obesity, elderly patients, hospitalization, prolonged immobility, having mechanical ventilation, not having vaccination, and comorbid disorders can be accepted as clinical predictors for post/long COVID-19 syndrome. Musculoskeletal pain is also a major problem and tends to be in chronic form. There is no consensus on the mechanism, but inflammation and angiotensin-converting enzyme 2 seem to play an important role. Localized and generalized pain may occur after COVID-19, and general pain is at least as common as localized pain. An accurate diagnosis allows physicians to initiate pain management and proper rehabilitation programs.

Graphene Oxide Decreases Pro-Inflammatory Proteins Production in Skeletal Muscle Cells Exposed to SARS-CoV-2 Spike Protein

Aim

The experiments aimed to document the presence of the ACE2 receptor on human muscle cells and the effects of the interaction of these cells with the spike protein of the SARS-CoV-2 virus in terms of induction of pro-inflammatory proteins, as well as to assess the possibility of reducing the pool of these proteins with the use of graphene oxide (GO) flakes.

Methods

Human Skeletal Myoblast (HSkM), purchased from Gibco were maintained in standard condition according to the manufacturer's instruction. The cells were divided into 4 groups; 1. C-control, 2. S-with addition of spike protein, 3. GO-with the addition of graphene oxide, 4. GO-S-with addition of GO followed by the addition of S protein. Protein S (PX-COV-P049) was purchased from ProteoGenix (France). GO was obtained from Advanced Graphene Products (Zielona Gora, Poland). The influence of all the factors on the morphology of cells was investigated using light and confocal microscopy. ACE2 protein expression on muscle cells was visualized and 40 pro-inflammatory cytokines were investigated using the membrane antibody array method. The protein profile of the lysate of cells from individual groups was also analyzed by mass spectrometry.

Conclusion

The experiments confirmed the presence of the ACE2 receptor in human skeletal muscle cells. It has also been documented that the SARS-CoV-2 virus spike protein influences the activation of selected pro-inflammatory proteins that promote cytokine storm and oxidative stress in muscle cells. The use of low levels of graphene oxide does not adversely affect muscle cells, reducing the levels of most proteins, including pro-inflammatory proteins. It can be assumed that GO may support anti-inflammatory therapy in muscles by scavenging proteins that activate cytokine storm.

Lung and physical function in post COVID-19 and clinical and functional associations: a cross-sectional study in Brazil

OBJECTIVE

The purpose of this study was to assess exercise capacity, lung and physical function in COVID-19 survivors, and the association of lesion-level characteristics assessed by chest computed tomography, probable sarcopenia, and percentage of diffusing capacity of the lung for carbon monoxide with clinical and functional variables.

METHODS

This study was conducted in Salvador, Bahia, Brazil. All patients had a laboratory-confirmed SARS-CoV-2 infection. The sociodemographic characteristics, COVID-19 exposure history, pulmonary function, computed tomography, and functionality of the participants between 1 and 3 months of diagnosis of the disease were collected.

RESULTS

A total of 135 patients after COVID-19 recovery were included in this study. Probable sarcopenia, reduction in percentage of diffusing capacity of the lung for carbon monoxide, and a lower 6-min walk distance were observed after COVID-19 infection. Computed tomography>50% was associated with a longer length of stay and a lower percentage of diffusing capacity of the lung for carbon monoxide. Probable sarcopenia diagnosis was associated with a worse percentage of the predicted 6-min walk distance in relation to the predicted, absolute 6-min walk distance (m), percentage of diffusing capacity of the lung for carbon monoxide, and percentage of total lung capacity.

CONCLUSION

Muscle disability and lung dysfunction are common in COVID-19 survivors. Hospitalization was associated with the worst muscle force and diffusing capacity of the lung for carbon monoxide. Computed tomography characteristics could be a marker of prolonged hospital stay after the acute phase of COVID-19. Additionally, the probable diagnosis of sarcopenia could be a marker of impact on walking distance. These results highlight the need for long-term follow-up of those patients and rehabilitation programs.

COVID-19 and athletes: Endurance sport and activity resilience study-CAESAR study

Background: The COVID-19 pandemic and imposed restrictions influenced athletic societies, although current knowledge about mild COVID-19 consequences on cardiopulmonary and physiologic parameters remains inconclusive. This study aimed to assess the impact of mild COVID-19 inflection on cardiopulmonary exercise test (CPET) performance among endurance athletes (EA) with varied fitness level. Materials and Methods: 49 EA (n_male = 43, n_female = 6, mean age = 39.94 ± 7.80 yr, height = 178.45 cm, weight = 76.62 kg; BMI = 24.03 kgm^-2) underwent double treadmill or cycle ergometer CPET and body analysis (BA) pre- and post-mild COVID-19 infection. Mild infection was defined as: (1) without hospitalization and (2) without prolonged health complications lasting for >14 days. Speed, power, heart rate (HR), oxygen uptake (VO₂), pulmonary ventilation, blood lactate concentration (at the anaerobic threshold (AT)), respiratory compensation point (RCP), and maximum exertion were measured before and after COVID-19 infection. Pearson's and Spearman's r correlation coefficients and Student t-test were applied to assess relationship between physiologic or exercise variables and time. Results: The anthropometric measurements did not differ significantly before and after COVID-19. There was a significant reduction in VO₂ at the AT and RCP (both p < 0.001). Pre-COVID-19 VO₂ was 34.97 ± 6.43 ml kg·min^-1, 43.88 ± 7.31 ml kg·min^-1 and 47.81 ± 7.81 ml kg·min^-1 respectively for AT, RCP and maximal and post-COVID-19 VO₂ was 32.35 ± 5.93 ml kg·min^-1, 40.49 ± 6.63 ml kg·min^-1 and 44.97 ± 7.00 ml kg·min^-1 respectively for AT, RCP and maximal. Differences of HR at AT (p < 0.001) and RCP (p < 0.001) was observed. The HR before infection was 145.08 ± 10.82 bpm for AT and 168.78 ± 9.01 bpm for RCP and HR after infection was 141.12 ± 9.99 bpm for AT and 165.14 ± 9.74 bpm for RCP. Time-adjusted measures showed significance for body fat (r = 0.46, p < 0.001), fat mass (r = 0.33, p = 0.020), cycling power at the AT (r = -0.29, p = 0.045), and HR at RCP (r = -0.30, p = 0.036). Conclusion: A mild COVID-19 infection resulted in a decrease in EA's CPET performance. The most significant changes were observed for VO₂ and HR. Medical Professionals and Training Specialists should be aware of the consequences of a mild COVID-19 infection in order to recommend optimal therapeutic methods and properly adjust the intensity of training.

C188-9, a specific inhibitor of STAT3 signaling, prevents thermal burn-induced skeletal muscle wasting in mice

Burn injury is the leading cause of death and disability worldwide and places a tremendous economic burden on society. Systemic inflammatory responses induced by thermal burn injury can cause muscle wasting, a severe involuntary loss of skeletal muscle that adversely affects the survival and functional outcomes of these patients. Currently, no pharmacological interventions are available for the treatment of thermal burn-induced skeletal muscle wasting. Elevated levels of inflammatory cytokines, such as interleukin-6 (IL-6), are important hallmarks of severe burn injury. The levels of signal transducer and activator of transcription 3 (STAT3)-a downstream component of IL-6 inflammatory signaling-are elevated with muscle wasting in various pro-catabolic conditions, and STAT3 has been implicated in the regulation of skeletal muscle atrophy. Here, we tested the effects of the STAT3-specific signaling inhibitor C188-9 on thermal burn injury-induced skeletal muscle wasting in vivo and on C2C12 myotube atrophy in vitro after the administration of plasma from burn model mice. In mice, thermal burn injury severity dependently increased IL-6 in the plasma and tibialis anterior muscles and activated the STAT3 (increased ratio of phospho-STAT3/STAT3) and ubiquitin-proteasome proteolytic pathways (increased Atrogin-1/MAFbx and MuRF1). These effects resulted in skeletal muscle atrophy and reduced grip strength. In murine C2C12 myotubes, plasma from burn mice activated the same inflammatory and proteolytic pathways, leading to myotube atrophy. In mice with burn injury, the intraperitoneal injection of C188-9 (50 mg/kg) reduced activation of the STAT3 and ubiquitin-proteasome proteolytic pathways, reversed skeletal muscle atrophy, and increased grip strength. Similarly, pretreatment of murine C2C12 myotubes with C188-9 (10 µM) reduced activation of the same inflammatory and proteolytic pathways, and ameliorated myotube atrophy induced by plasma taken from burn model mice. Collectively, these results indicate that pharmacological inhibition of STAT3 signaling may be a novel therapeutic strategy for thermal burn-induced skeletal muscle wasting.

Efficacy of Therapeutic Exercise in Reversing Decreased Strength, Impaired Respiratory Function, Decreased Physical Fitness, and Decreased Quality of Life Caused by the Post-COVID-19 Syndrome

In the current global scenario, many COVID-19 survivors present a severe deterioration in physical strength, respiratory function, and quality of life due to persistent symptoms and post-acute consequences of SARS-CoV-2 infection. These alterations are known as post-COVID-19 syndrome for which there is no specific and effective treatment for their management. Currently, therapeutic exercise strategies (ThEx) are effective in many diseases by reducing the appearance of complications and side effects linked to treatment, and are consequently of great relevance. In this study, we review the effect of ThEX in reversing decreased strength, impaired respiratory function, decreased physical fitness, and decreased quality of life (QoL) caused by post-COVID-19 syndrome. A literature search was conducted through the electronic databases, Medline (PubMed), SciELO and Cochrane Library Plus for this structured narrative review for studies published from database retrieval up till 12 December 2022. A total of 433 patients with post-COVID-19 syndrome condition (60% women) were included in the nine studies which met the inclusion/exclusion criteria. Overall, post-COVID-19 syndrome patients who followed a ThEx intervention showed improvements in strength, respiratory function, physical fitness and QoL, with no exercise-derived side effects. Thus, ThEx based on strength, aerobic and respiratory training could be an adjuvant non-pharmacological tool in the modulation of post-COVID-19 syndrome.

Safety and efficacy of electrical stimulation for lower-extremity muscle weakness in intensive care unit 2019 Novel Coronavirus patients: A phase I double-blinded randomized controlled trial

Background

Intensive care unit (ICU) prolonged immobilization may lead to lower-extremity muscle deconditioning among critically ill patients, particularly more accentuated in those with 2019 Novel Coronavirus (COVID-19) infection. Electrical stimulation (E-Stim) is known to improve musculoskeletal outcomes. This phase I double-blinded randomized controlled trial examined the safety and efficacy of lower-extremity E-Stim to prevent muscle deconditioning.

Methods

Critically ill COVID-19 patients admitted to the ICU were randomly assigned to control (CG) or intervention (IG) groups. Both groups received daily E-Stim (1 h) for up to 14 days on both gastrocnemius muscles (GNMs). The device was functional in the IG and non-functional in the CG. Primary outcomes included ankle strength (Ankle_s) measured by an ankle-dynamometer, and GNM endurance (GNM_e) in response to E-Stim assessed with surface electromyography (sEMG). Outcomes were measured at baseline, 3 and 9 days.

Results

Thirty-two (IG = 16, CG = 16) lower extremities in 16 patients were independently assessed. The mean time between ICU admission and E-Stim therapy delivery was 1.8 ± 1.9 days (p = 0.29). At 3 days, the IG showed an improvement compared to the CG with medium effect sizes for Ankle_s (p = 0.06, Cohen's d = 0.77) and GNM_e (p = 0.06, d = 0.69). At 9 days, the IG GNM_e was significantly higher than the CG (p = 0.04, d = 0.97) with a 6.3% improvement from baseline (p = 0.029). E-Stim did not alter vital signs (i.e., heart/respiratory rate, blood saturation of oxygen), showed no adverse events (i.e., pain, skin damage, discomfort), nor interfere with ICU standard of care procedures (i.e., mechanical ventilation, prone rotation).

Conclusion

This study supports the safety and efficacy of early E-Stim therapy to potentially prevent deterioration of lower-extremity muscle conditions in critically ill COVID-19 patients recently admitted to the ICU. If confirmed in a larger sample, E-Stim may be used as a practical adjunctive therapy.

Clinical trial registration

[https://clinicaltrials.gov/], identifier [NCT04685213].

Molecular and cellular mechanisms involved in tissue-specific metabolic modulation by SARS-CoV-2

Coronavirus disease 2019 (COVID-19) is triggered by the SARS-CoV-2, which is able to infect and cause dysfunction not only in lungs, but also in multiple organs, including central nervous system, skeletal muscle, kidneys, heart, liver, and intestine. Several metabolic disturbances are associated with cell damage or tissue injury, but the mechanisms involved are not yet fully elucidated. Some potential mechanisms involved in the COVID-19-induced tissue dysfunction are proposed, such as: (a) High expression and levels of proinflammatory cytokines, including TNF-α IL-6, IL-1β, INF-α and INF-β, increasing the systemic and tissue inflammatory state; (b) Induction of oxidative stress due to redox imbalance, resulting in cell injury or death induced by elevated production of reactive oxygen species; and (c) Deregulation of the renin-angiotensin-aldosterone system, exacerbating the inflammatory and oxidative stress responses. In this review, we discuss the main metabolic disturbances observed in different target tissues of SARS-CoV-2 and the potential mechanisms involved in these changes associated with the tissue dysfunction.

Rasch Modeling and Multilevel Confirmatory Factor Analysis for the Usability of the Impact of Event Scale-Revised (IES-R) during the COVID-19 Pandemic

BACKGROUND

Several instruments are currently used to assess Coronavirus Disease 2019 (COVID-19) -induced psychological distress, including the 22-item Impact of Event Scale-Revised (IES-R). The IES-R is a self-administered scale used to assess post-traumatic stress disorder (PTSD). The current study aimed to examine the construct validity of the IES-R, based on the Rasch model, with COVID-19-related data, as well as to test the multilevel construct validity of the IES-R within and among countries during the pandemic crisis.

METHODS

A multi-country web-based cross-sectional survey was conducted utilizing the 22-item IES-R. A total of 1020 participants enrolled in our survey, of whom 999 were included in the analyses. Data were analyzed using Rasch modeling and multilevel confirmatory factor analysis (MCFA).

RESULTS

The Rasch modeling results of the IES-R demonstrated that the IES-R is a satisfactory instrument with the five-point Likert scale, asserting that its 22 items are significant contributors to assessing PTSD as a unidimensional construct covered by the items of the IES-R. The MCFA confirmed that the 22-item IES-R, with its three factors, including intrusion, avoidance, and hyperarousal, demonstrates adequate construct validity at the within- and among-country levels. However, the results of the Akaike information criterion (AIC) model determined that the 16-item IES-R is better than the 22-item IES-R.

CONCLUSION

The results suggested that the 22-item IES-R is a reliable screening instrument for measuring PTSD related to the COVID-19 pandemic, and can be utilized to provide timely psychological health support, when needed, based on the screening results.

Low skeletal muscle radiodensity and neutrophil-to-lymphocyte ratio as predictors of poor outcome in patients with COVID-19

Inflammatory states and body composition changes are associated with a poor prognosis in many diseases, but their role in coronavirus disease 2019 (COVID-19) is not fully understood. To assess the impact of low skeletal muscle radiodensity (SMD), high neutrophil-to-lymphocyte ratio (NLR) and a composite score based on both variables, on complications, use of ventilatory support, and survival in patients with COVID-19. Medical records of patients hospitalized between May 1, 2020, and July 31, 2020, with a laboratory diagnosis of COVID-19 who underwent computed tomography (CT) were retrospectively reviewed. CT-derived body composition measurements assessed at the first lumbar vertebra level, and laboratory tests performed at diagnosis, were used to calculate SMD and NLR. Prognostic values were estimated via univariate and multivariate logistic regression analyses and the Kaplan–Meier curve. The study was approved by the local Institutional Review Board (CAAE 36276620.2.0000.5404). A total of 200 patients were included. Among the patients assessed, median age was 59 years, 58% were men and 45% required ICU care. A total of 45 (22.5%) patients died. Multivariate logistic analysis demonstrated that a low SMD (OR 2.94; 95% CI 1.13–7.66, P = 0.027), high NLR (OR 3.96; 95% CI 1.24–12.69, P = 0.021) and both low SMD and high NLR (OR 25.58; 95% CI 2.37–276.71, P = 0.008) combined, were associated with an increased risk of death. Patients who had both low SMD and high NLR required more mechanical ventilation (P < 0.001) and were hospitalized for a longer period (P < 0.001). Low SMD, high NLR and the composite score can predict poor prognosis in patients with COVID-19, and can be used as a tool for early identification of patients at risk. Systemic inflammation and low muscle radiodensity are useful predictors of poor prognosis, and the assessment of these factors in clinical practice should be considered.

COVID-19 as a Potential Cause of Muscle Injuries in Professional Italian Serie A Soccer Players: A Retrospective Observational Study

The COVID-19 pandemic has shocked the entire planet. The soccer world has also suffered major upheavals, and many professional soccer players have been infected with the virus. The aim of this study was to evaluate the incidence of injuries in Italian Serie A professional soccer players before and during the COVID-19 pandemic. Methods: We evaluated the incidence of muscle injuries between four competitive seasons of the Italian Serie A (2016-2017, 2017-2018, and 2018-2019 pre-COVID-19 vs. 2020/2021 post-COVID-19) in professional soccer players. Results: Significant differences were found in muscular injuries between the post-COVID-19 season and the previous seasons (p < 0.001). The median split of the players' positivity duration was of 15 days. The players' long positivity (PLP) group showed a significant number of muscular injuries compared to the players' short positivity (PSP) group (p < 0.0014, ES = 0.81, Large). The total teams' days of positivity were significantly related to the total team number of muscular injuries (r = 0.86; CI 95% 0.66 to 0.94; p < 0.0001). In conclusion, this data showed that the competitive season post-COVID-19 lockdown has a higher incidence of muscle injuries in Italian Serie A soccer players compared to the pre-pandemic competitive season.

From the Ketogenic Diet to the Mediterranean Diet: The Potential Dietary Therapy in Patients with Obesity after CoVID-19 Infection (Post CoVID Syndrome)

PURPOSE OF REVIEW

This review primarily examines the evidence for areas of consensus and on-going uncertainty or controversy about diet and physical exercise approaches for in the post-CoVID. We propose an ideal dietary and physical activity approach that the patient with obesity should follow after CoVID-19 infection in order to reduce the clinical conditions associated with post-CoVID syndrome.

RECENT FINDINGS

The CoVID-19 disease pandemic, caused by the severe acute respiratory syndrome coronavirus-2, has spread all over the globe, infecting hundreds of millions of individuals and causing millions of death. It is also known to be is associated with several medical and psychological complications, especially in patients with obesity and weight-related disorders who in general pose a significant global public health problem, and in specific affected individuals are on a greater risk of developing poorer CoVID-19 clinical outcomes and experience a higher rate of mortality. Little is still known about the best nutritional approach to be adopted in this disease especially in the patients post-CoVID syndrome. To the best of our knowledge, no specific nutritional recommendations exist to manage in the patients post-CoVID syndrome. We report a presentation of nutritional therapeutic approach based on a ketogenic diet protocol followed by a transition to the Mediterranean diet in patients post-infection by CoVID, combined to a physical activity program to address conditions associated with post-CoVID syndrome.

The Role of Obesity, Body Composition, and Nutrition in COVID-19 Pandemia: A Narrative Review

The coronavirus disease 2019 (COVID-19) pandemic has spread worldwide, infecting nearly 500 million people, with more than 6 million deaths recorded globally. Obesity leads people to be more vulnerable, developing worse outcomes that can require hospitalization in intensive care units (ICU). This review focused on the available findings that investigated the link between COVID-19, body composition, and nutritional status. Most studies showed that not only body fat quantity but also its distribution seems to play a crucial role in COVID-19 severity. Compared to the body mass index (BMI), visceral adipose tissue and intrathoracic fat are better predictors of COVID-19 severity and indicate the need for hospitalization in ICU and invasive mechanical ventilation. High volumes of epicardial adipose tissue and its thickness can cause an infection located in the myocardial tissue, thereby enhancing severe COVID-related myocardial damage with impairments in coronary flow reserve and thromboembolism. Other important components such as sarcopenia and intermuscular fat augment the vulnerability in contracting COVID-19 and increase mortality, inflammation, and muscle damage. Malnutrition is prevalent in this population, but a lack of knowledge remains regarding the beneficial effects aimed at optimizing nutritional status to limit catabolism and preserve muscle mass. Finally, with the increase in patients recovering from COVID-19, evaluation and treatment in those with Long COVID syndrome may become highly relevant.

Skeletal Muscles of Patients Infected with SARS-CoV-2 Develop Severe Myofiber Damage upon One Week of Admission on the Intensive Care Unit

Many critically ill patients infected with SARS-CoV-2 have been submitted to an intensive care unit (ICU). Patients with a SARS-CoV-2 infection that survive critical illness are confronted with months of physical impairments. To maximize recovery, it is important to understand the musculoskeletal involvement in critically ill patients infected with SARS-CoV-2. The aim of the present study was to assess the myocellular changes in SARS-CoV-2 patients that occur throughout the first week of ICU admission. In n = 22 critically ill patients infected with SARS-CoV-2, a biopsy sample from the vastus lateralis muscle was obtained at day 1–3 and day 5–8 following ICU admission. Fluorescence microscopy was used to assess type I and type II muscle fiber size and distribution, myonuclear content, and muscle tissue capillarization. Transmission electron microscopy was used to support quantitative data at an ultrastructural level. Changes in type I and type II muscle fiber size showed large inter-individual variation. The average change in type I fiber size was +309 ± 1834 µm2, ranging from −2129 µm2 (−31%) to +3375 µm2 (+73%). The average change in type II fiber size was −224 ± 1256 µm2, ranging from −1410 µm2 (−36%) to +2592 µm2 (+48%). Ultrastructural observations showed myofibrillar and hydropic degeneration, and fiber necrosis. This study shows that ICU patients admitted with SARS-CoV-2 suffer from substantial muscle fiber damage during ICU admission. These results are a call for action towards more specialized rehabilitation programs for patients admitted to the ICU with SARS-CoV-2 infection.

The successful rehabilitation of a 75-year-old female with debilitating long COVID: A case report

A 75-year-old previously healthy female became severely ill, functionally dependent, and required long-term home oxygen therapy, after recovery from coronavirus disease 2019 (COVID-19) with acute respiratory failure and extensive pulmonary fibrosis. After two months of respiratory muscle training and a comprehensive cardiopulmonary rehabilitation program, her dyspnea, physical performance, pulmonary function parameters, and activities of daily living rapidly improved. This Case highlights the importance of a timely active rehabilitation program for COVID-19 survivors experiencing the long-term effects of coronavirus (long COVID).

What Do We Need to Know About Musculoskeletal Manifestations of COVID-19?: A Systematic Review

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COVID-19 is a disease that is challenging science, health-care systems, and humanity. An astonishingly wide spectrum of manifestations of multi-organ damage, including musculoskeletal, can be associated with SARS-CoV-2.

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In the acute phase of COVID-19, fatigue, myalgia, and arthralgia are the most common musculoskeletal symptoms.

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Post-COVID-19 syndrome is a group of signs and symptoms that are present for >12 weeks. The associated musculoskeletal manifestations are fatigue, arthralgia, myalgia, new-onset back pain, muscle weakness, and poor physical performance.

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Data on COVID-19 complications are growing due to large absolute numbers of cases and survivors in these 2 years of the pandemic. Additional musculoskeletal manifestations encountered are falls by the elderly, increased mortality after hip fracture, reduced bone mineral density and osteoporosis, acute sarcopenia, rhabdomyolysis, Guillain-Barré syndrome, muscle denervation atrophy, fibromyalgia, rheumatological disease triggering, septic arthritis, adhesive capsulitis, myositis, critical illness myopathy, onset of latent muscular dystrophy, osteonecrosis, soft-tissue abscess, urticarial vasculitis with musculoskeletal manifestations, and necrotizing autoimmune myositis.

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A wide range of signs and symptoms involving the musculoskeletal system that affect quality of life and can result in a decrease in disability-adjusted life years. This powerful and unpredictable disease highlights the importance of multimodality imaging, continuing education, and multidisciplinary team care to support preventive measures, diagnosis, and treatment.

Resistance Training before, during, and after COVID-19 Infection: What Have We Learned So Far?

At the end of 2019, a severe acute respiratory syndrome caused by SARS-CoV-2 started a pandemic, leading to millions of deaths and many important political and social changes. Even in the absence of contamination, the mobility reduction, social distancing and closing of exercise facilities negatively affected physical activity and conditioning, which is associated with muscle atrophy, loss of muscle strength, and reductions in functional capacity. In cases of infection, it has been shown that increased physical capacity is associated with decreased hospitalization and mortality risk. Although millions of people have died from COVID-19, most contaminated individuals survived the infection, but carried different sequelae, such as the severe loss of physical function and a reduced quality of life. Among different physical exercise models that might help to prevent and treat COVID-19-related conditions, resistance training (RT) might be particularly relevant. Among its benefits, RT can be adapted to be performed in many different situations, even with limited space and equipment, and is easily adapted to an individual's characteristics and health status. The current narrative review aims to provide insights into how RT can be used in different scenarios to counteract the negative effects of COVID-19. By doing this, the authors expect to provide insights to help deal with the current pandemic and similar events the world may face in the future.

Myosteatosis Significantly Predicts Persistent Dyspnea and Mobility Problems in COVID-19 Survivors

Background

Persistent symptoms including dyspnea and functional impairment are common in COVID-19 survivors. Poor muscle quality (myosteatosis) associates with poor short-term outcomes in COVID-19 patients. The aim of this observational study was to assess the relationship between myosteatosis diagnosed during acute COVID-19 and patient-reported outcomes at 6 months after discharge.

Methods

Myosteatosis was diagnosed based on CT-derived skeletal muscle radiation attenuation (SM-RA) measured during hospitalization in 97 COVID-19 survivors who had available anthropometric and clinical data upon admission and at the 6-month follow-up after discharge. Dyspnea in daily activities was assessed using the modified Medical Research Council (mMRC) scale for dyspnea. Health-related quality of life was measured using the European quality of life questionnaire three-level version (EQ-5D-3L).

Results

Characteristics of patients with (lowest sex- and age-specific tertile of SM-RA) or without myosteatosis during acute COVID-19 were similar. At 6 months, patients with myosteatosis had greater rates of obesity (48.4 vs. 27.7%, p = 0.046), abdominal obesity (80.0 vs. 47.6%, p = 0.003), dyspnea (32.3 vs. 12.5%, p = 0.021) and mobility problems (32.3 vs. 12.5%, p = 0.004). Myosteatosis diagnosed during acute COVID-19 was the only significant predictor of persistent dyspnea (OR 3.19 [95% C.I. 1.04; 9.87], p = 0.043) and mobility problems (OR 3.70 [95% C.I. 1.25; 10.95], p = 0.018) at 6 months at logistic regression adjusted for sex, age, and BMI.

Conclusion

Myosteatosis diagnosed during acute COVID-19 significantly predicts persistent dyspnea and mobility problems at 6 months after hospital discharge independent of age, sex, and body mass.

Clinical Trial Registration

[www.ClinicalTrials.gov], identifier [NCT04318366].

Tryptophan Metabolism and COVID-19-Induced Skeletal Muscle Damage: Is ACE2 a Key Regulator?

The severity of coronavirus disease 2019 (COVID-19) is characterized by systemic damage to organs, including skeletal muscle, due to excessive secretion of inflammatory cytokines. Clinical studies have suggested that the kynurenine pathway of tryptophan metabolism is selectively enhanced in patients with severe COVID-19. In addition to acting as a receptor for severe acute respiratory syndrome coronavirus 2, the causative virus of COVID-19, angiotensin converting enzyme 2 (ACE2) contributes to tryptophan absorption and inhibition of the renin-angiotensin system. In this article, we review previous studies to assess the potential for a link between tryptophan metabolism, ACE2, and skeletal muscle damage in patients with COVID-19.

Requirements and Solutions for Motion Limb Assistance of COVID-19 Patients

COVID-19 patients are strongly affected in terms of limb motion when imbedded during the acute phase of the infection, but also during the course of recovery therapies. Peculiarities are investigated for design requirements for medical devices in limb motion assistance for those patients. Solutions are analyzed from existing medical devices to outline open issues to provide guidelines for the proper adaption or for new designs supporting patients against COVID-19 effects. Examples are reported from authors’ activities with cable driven assisting devices.

The Association Between Depressive Symptoms and Sarcopenia Among Community-Dwelling Older Adults: A Cross-Sectional Study

Purpose

To evaluate the relationship between depressive symptoms and sarcopenia among older adults.

Materials and Methods

This is a cross-sectional study. A total of 700 community-dwelling older persons enrolled in this study. Sarcopenia is defined according to the Asian Working Group for Sarcopenia 2019 (AWGS 2019). The bioelectrical impedance analysis assessed muscle mass while a digital dynamometer quantified muscle strength. Furthermore, a 6-meter gait speed test measured physical performance. The Geriatric Depression Scale (GDS-30) screened for depressive symptoms. Data collected include those of socio-demographic, lifestyle, and comorbidity.

Results

The sample comprised 700 participants (455 women) with a mean age of 70.4±6.8 years. 21.5% had sarcopenia, among them, 5.6% at severe stage, while depressive symptoms were present in 8.1% (57/700). After adjusting for the potential confounders of age, sex, marital status, living status, hypertension, body mass index, and physical activity, the depressive symptoms that were found were not associated with sarcopenia but, instead, low gait speed. However, severe sarcopenia significantly impacted the risk of depressive symptoms, particularly in females.

Conclusion

Depressive symptoms are not associated with sarcopenia, but severe sarcopenia increases the risk of depressive symptoms in females, according to updated AWGS 2019 criteria. Gait speed is independently associated with depressive symptoms. The finding highlights that older people with sarcopenia should be screened for depressive symptoms, especially females. Future studies should evaluate the value of gait speed interventions for depressive symptoms among older adults.

The Musculoskeletal Involvement After Mild to Moderate COVID-19 Infection

COVID-19, a disease caused by the novel coronavirus SARS-CoV-2, has been drastically affecting the daily lives of millions of people. COVID-19 is described as a multiorgan disease that affects not only the respiratory tract of infected individuals, but it has considerable effects on the musculoskeletal system, causing excessive fatigue, myalgia, arthralgia, muscle weakness and skeletal muscle damage. These symptoms can persist for months, decreasing the quality of life of numerous individuals. Curiously, most studies in the scientific literature focus on patients who were hospitalized due to SARS-CoV-2 infection and little is known about the mechanism of action of COVID-19 on skeletal muscles, especially of individuals who had the mild to moderate forms of the disease (non-hospitalized patients). In this review, we focus on the current knowledge about the musculoskeletal system in COVID-19, highlighting the lack of researches investigating the mild to moderate cases of infection and pointing out why it is essential to care for these patients. Also, we will comment about the need of more experimental data to assess the musculoskeletal manifestations on COVID-19-positive individuals.

The role of vitamin B12 in viral infections: a comprehensive review of its relationship with the muscle-gut-brain axis and implications for SARS-CoV-2 infection

This comprehensive review establishes the role of vitamin B12 as adjunct therapy for viral infections in the treatment and persistent symptoms of COVID-19, focusing on symptoms related to the muscle-gut-brain axis. Vitamin B12 can help balance immune responses to better fight viral infections. Furthermore, data from randomized clinical trials and meta-analysis indicate that vitamin B12 in the forms of methylcobalamin and cyanocobalamin may increase serum vitamin B12 levels, and resulted in decreased serum methylmalonic acid and homocysteine concentrations, and decreased pain intensity, memory loss, and impaired concentration. Among studies, there is much variation in vitamin B12 doses, chemical forms, supplementation time, and administration routes. Larger randomized clinical trials of vitamin B12 supplementation and analysis of markers such as total vitamin B12, holotranscobalamin, total homocysteine and methylmalonic acid, total folic acid, and, if possible, polymorphisms and methylation of genes need to be conducted with people with and without COVID-19 or who have had COVID-19 to facilitate the proper vitamin B12 form to be administered in individual treatment.

Unraveling Muscle Impairment Associated With COVID-19 and the Role of 3D Culture in Its Investigation

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been considered a public health emergency, extensively investigated by researchers. Accordingly, the respiratory tract has been the main research focus, with some other studies outlining the effects on the neurological, cardiovascular, and renal systems. However, concerning SARS-CoV-2 outcomes on skeletal muscle, scientific evidence is still not sufficiently strong to trace, treat and prevent possible muscle impairment due to the COVID-19. Simultaneously, there has been a considerable amount of studies reporting skeletal muscle damage in the context of COVID-19. Among the detrimental musculoskeletal conditions associated with the viral infection, the most commonly described are sarcopenia, cachexia, myalgia, myositis, rhabdomyolysis, atrophy, peripheral neuropathy, and Guillain-Barré Syndrome. Of note, the risk of developing sarcopenia during or after COVID-19 is relatively high, which poses special importance to the condition amid the SARS-CoV-2 infection. The yet uncovered mechanisms by which musculoskeletal injury takes place in COVID-19 and the lack of published methods tailored to study the correlation between COVID-19 and skeletal muscle hinder the ability of healthcare professionals to provide SARS-CoV-2 infected patients with an adequate treatment plan. The present review aims to minimize this burden by both thoroughly exploring the interaction between COVID-19 and the musculoskeletal system and examining the cutting-edge 3D cell culture techniques capable of revolutionizing the study of muscle dynamics.

COVID-19-Related Psychological Trauma and Psychological Distress Among Community-Dwelling Psychiatric Patients: People Struck by Depression and Sleep Disorders Endure the Greatest Burden

COVID-19 has created a general state of worry and distress, especially among vulnerable groups such as those with psychiatric diagnoses. Worldwide, psychiatric care provision has drastically suffered during the pandemic, with many patients unable to access proper care, which may have implications for increased mental health consequences in patients with psychiatric disorders (e.g., relapse and suicide). This cross-sectional study used structural equation modeling to investigate COVID-19-related trauma and distress among Arab psychiatric population during COVID-19 quarantine. Patients with pre-existing psychiatric disorders (N = 168) completed an online survey that comprised the Depression Anxiety Stress Scale 21 (DASS-21), the Impact of Event Scale-Revised (IES-R), and a questionnaire on COVID-19-related attitudes/perceptions, sources of information, used protective measures, and socio-demographic information. Respondents commonly reported feeling down-hearted/blue, trouble concentrating, along with symptoms of avoidance and rumination related to the pandemic. Patients with depression and sleep disorders expressed higher COVID-19-related trauma than patients with other disorders. Perceived physical health mediated the effect of co-morbid chronic physical disorders on COVID-19 trauma, psychological distress, perceived vulnerability to COVID-19, and perceived likelihood of recovery in case of contracting COVID-19. Perceived physical health and perceived vulnerability to COVID-19 were strong direct predictors of COVID-19-related trauma and psychological distress. Staying at home negatively predicted COVID-19 trauma and exerted an indirect negative effect on psychological distress via COVID-19 trauma. COVID-19 trauma, age, and marital status directly predicted psychological distress, with COVID-19 trauma being the strongest predictor. Educational level, income, having family members working in the medical field, keeping up to date with the news on deaths/infected cases or the development of COVID-19 drugs or vaccines, satisfaction with available information on COVID-19, and using different protective measures were not associated with significant differences in COVID-19 trauma and psychological distress scores. Immuno-psychiatric interventions should be designed to target COVID-19-trauma and distress among younger single patients with perceived poor physical health, especially those diagnosed with depression and sleep disorders.

Neuromuscular Impairment of Knee Stabilizer Muscles in a COVID-19 Cluster of Female Volleyball Players: Which Role for Rehabilitation in the Post-COVID-19 Return-to-Play?

COVID-19 athletes reported persistent and residual symptoms many weeks after initial infection, including cough, fatigue, and neuromuscular disorders. Poor neuromuscular control may cause inefficient movement strategies increasing anterior cruciate ligament load. This is particularly relevant in female athletes, who show a 3-time higher risk than male counterparts. Aim is to evaluate the impairment in thigh muscles activation, body composition, and physical performance after COVID-19 in volleyball athletes. We recruited a cohort of female professional players from the same team. We assessed the pre-activation time of Rectus Femoris (RF), Vastus Medialis (VM), Medial Hamstring (MH), and Lateral Hamstring (LH) before (T0) and after (T1) COVID-19 infection, bioelectrical impedance analysis (BIA), and jump tests. We included 12 athletes with COVID-19 infection diagnosis in January 2021. At T1 we found a significant (p < 0.05) delay (ms) of the activation time of RF (426 ± 188 vs. 152 ± 106); VM (363 ± 192 vs. 140 ± 96); BF (229 ± 60 vs. 150 ± 63); MH (231 ± 88 vs. 203 ± 89), and a significant reduction of body composition at BIA. The neuromotor imbalance of the knee stabilizer muscle in female athletes after COVID-19 infection determines a deficit of knee stabilization. Physicians should consider neuromuscular and metabolic sequelae to identify athletes at higher risk of injury and set up specific neuromuscular rehabilitation protocols.

Skeletal Muscle in Hypoxia and Inflammation: Insights on the COVID-19 Pandemic

SARS-CoV-2 infection is often associated with severe inflammation, oxidative stress, hypoxia and impaired physical activity. These factors all together contribute to muscle wasting and fatigue. In addition, there is evidence of a direct SARS-CoV-2 viral infiltration into skeletal muscle. Aging is often characterized by sarcopenia or sarcopenic obesity These conditions are risk factors for severe acute COVID-19 and long-COVID-19 syndrome. From these observations we may predict a strong association between COVID-19 and decreased muscle mass and functions. While the relationship between physical inactivity, chronic inflammation, oxidative stress and muscle dysfunction is well-known, the effects on muscle mass of COVID-19-related hypoxemia are inadequately investigated. The aim of this review is to highlight metabolic, immunity-related and redox biomarkers potentially affected by reduced oxygen availability and/or muscle fatigue in order to shed light on the negative impact of COVID-19 on muscle mass and function. Possible countermeasures are also reviewed.

COVID-19 in Elderly Patients Surgically Treated for Lower Limbs Fracture

Background: The coronavirus disease 2019 (COVID-19) pandemic outbreak has posed new problems in the context of patients suffering from other diseases. In particular, musculoskeletal sequelae related to the state of debilitation associated with COVID-19 are important to consider in elderly patients undergoing surgery after lower limbs fracture, especially in the post-operative period. The objective of this study was to evaluate whether COVID-19 influenced biochemical parameter, recovery and mortality of surgically treated patients suffering from lower extremity fractures. Methods: Laboratory and clinical data of 30 patients were extrapolated and analyzed in the pre-operative and post-operative periods. Among these patients, 13 had COVID-19 infection (COVID-19 +), whereas 17 had no signs of COVID-19 infections (COVID-19 −). Long-term clinical and functional outcomes were also analyzed. Results: Lower calcium, slightly higher values of CRP and much higher values of CPK and AST were observed pre-operatively in COVID-19 + patients, who also showed higher prevalence of long-term sequelae than COVID-19 − patients. Conclusions: COVID-19 affects long-term outcome of elderly patients with lower limb fractures in a multifactorial way. First, the virus directly damages the muscle tissue. Secondly, the lung function impairment worsens the overall performance, making rehabilitation more challenging.

Effects of Selenium Supplementation on Rumen Microbiota, Rumen Fermentation, and Apparent Nutrient Digestibility of Ruminant Animals: A Review

Enzymes excreted by rumen microbiome facilitate the conversion of ingested plant materials into major nutrients (e.g., volatile fatty acids (VFA) and microbial proteins) required for animal growth. Diet, animal age, and health affect the structure of the rumen microbial community. Pathogenic organisms in the rumen negatively affect fermentation processes in favor of energy loss and animal deprivation of nutrients in ingested feed. Drawing from the ban on antibiotic use during the last decade, the livestock industry has been focused on increasing rumen microbial nutrient supply to ruminants through the use of natural supplements that are capable of promoting the activity of beneficial rumen microflora. Selenium (Se) is a trace mineral commonly used as a supplement to regulate animal metabolism. However, a clear understanding of its effects on rumen microbial composition and rumen fermentation is not available. This review summarized the available literature for the effects of Se on specific rumen microorganisms along with consequences for rumen fermentation and digestibility. Some positive effects on total VFA, the molar proportion of propionate, acetate to propionate ratio, ruminal NH3-N, pH, enzymatic activity, ruminal microbiome composition, and digestibility were recorded. Because Se nanoparticles (SeNPs) were more effective than other forms of Se, more studies are needed to compare the effectiveness of synthetic SeNPs and lactic acid bacteria enriched with sodium selenite as a biological source of SeNPs and probiotics. Future studies also need to evaluate the effect of dietary Se on methane emissions.

The Predictive Value of Myoglobin for COVID-19-Related Adverse Outcomes: A Systematic Review and Meta-Analysis

Objective: Cardiac injury is detected in numerous patients with coronavirus disease 2019 (COVID-19) and has been demonstrated to be closely related to poor outcomes. However, an optimal cardiac biomarker for predicting COVID-19 prognosis has not been identified.

Methods: The PubMed, Web of Science, and Embase databases were searched for published articles between December 1, 2019 and September 8, 2021. Eligible studies that examined the anomalies of different cardiac biomarkers in patients with COVID-19 were included. The prevalence and odds ratios (ORs) were extracted. Summary estimates and the corresponding 95% confidence intervals (95% CIs) were obtained through meta-analyses.

Results: A total of 63 studies, with 64,319 patients with COVID-19, were enrolled in this meta-analysis. The prevalence of elevated cardiac troponin I (cTnI) and myoglobin (Mb) in the general population with COVID-19 was 22.9 (19–27%) and 13.5% (10.6–16.4%), respectively. However, the presence of elevated Mb was more common than elevated cTnI in patients with severe COVID-19 [37.7 (23.3–52.1%) vs.30.7% (24.7–37.1%)]. Moreover, compared with cTnI, the elevation of Mb also demonstrated tendency of higher correlation with case-severity rate (Mb, r = 13.9 vs. cTnI, r = 3.93) and case-fatality rate (Mb, r = 15.42 vs. cTnI, r = 3.04). Notably, elevated Mb level was also associated with higher odds of severe illness [Mb, OR = 13.75 (10.2–18.54) vs. cTnI, OR = 7.06 (3.94–12.65)] and mortality [Mb, OR = 13.49 (9.3–19.58) vs. cTnI, OR = 7.75 (4.4–13.66)] than cTnI.

Conclusions: Patients with COVID-19 and elevated Mb levels are at significantly higher risk of severe disease and mortality. Elevation of Mb may serve as a marker for predicting COVID-19-related adverse outcomes.

Prospero Registration Number:https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020175133, CRD42020175133.

Lifestyle Adjustments in Long-COVID Management: Potential Benefits of Plant-Based Diets

PURPOSE OF REVIEW

The SARS-CoV-2-pandemic has caused mortality and morbidity at an unprecedented global scale. Many patients infected with SARS-CoV-2 continue to experience symptoms after the acute phase of infection and report fatigue, sleep difficulties, anxiety, and depression as well as arthralgia and muscle weakness. Summarized under the umbrella term "long-COVID," these symptoms may last weeks to months and impose a substantial burden on affected individuals. Dietary approaches to tackle these complications have received comparably little attention. Although plant-based diets in particular were shown to exert benefits on underlying conditions linked to poor COVID-19 outcomes, their role with regard to COVID-19 sequelae is yet largely unknown. Thus, this review sought to investigate whether a plant-based diet could reduce the burden of long-COVID.

RECENT FINDINGS

The number of clinical trials investigating the role of plant-based nutrition in COVID-19 prevention and management is currently limited. Yet, there is evidence from pre-pandemic observational and clinical studies that a plant-based diet may be of general benefit with regard to several clinical conditions that can also be found in individuals with COVID-19. These include anxiety, depression, sleep disorders, and musculoskeletal pain. Adoption of a plant-based diet leads to a reduced intake in pro-inflammatory mediators and could be one accessible strategy to tackle long-COVID associated prolonged systemic inflammation. Plant-based diets may be of general benefit with regard to some of the most commonly found COVID-19 sequelae. Additional trials investigating which plant-based eating patterns confer the greatest benefit in the battle against long-COVID are urgently warranted.