Getting our hands around Post-COVID-19 syndrome

Polio was once a looming threat in America, with outbreaks in the early 1950’s causing over 15,000 cases of paralysis each year prior to the introduction of the polio vaccine. The wide-scale vaccination process brought cases down to less than 100 cases in the 1960’s. In the 1970’s there were less than 10 cases, with the last reported case in the United States being in 1979. The most devastating symptom of polio is profound muscle weakness, with up to 10% succumbing to it, due to respiratory muscle involvement. Up to 40% of those who had recovered from polio had an unpleasant surprise 15-40 years after their original onset when they experienced the sudden return of muscle weakness, muscle and mental fatigue and joint pain, now called “Post-polio syndrome.” Thankfully this state is not contagious, nor is it considered life threatening, but it certainly can lead to profound disability. I remember my first post-polio syndrome patients as a young physical therapist in the 1980’s. While there is no true cure for the progression of symptoms, studies showed that non-fatiguing exercise could improve muscle strength and reduce tiredness; the key for us as therapists was to find a delicate balance of not too much exercise, but not too little.

Now here we are in the midst of a coronavirus pandemic, with far more cases than we saw with polio. Over 30 million people have been infected in the USA as of March 2021. Early studies report that 20-27% of those who have technically recovered from even mild cases of COVID-19 continue to show symptoms over 2 months later.

This group has been dubbed “COVID-19 long haulers,” with their presentation being called “long COVID syndrome,” “post-acute sequelae of SARS-CoV-2 infection,” or “Post-COVID-19 syndrome.” Their symptoms include various combinations of fatigue, weakness, low endurance, brain fog, headache, numbness and tingling, distorted sense of smell, altered taste, dizziness, blurred vision, chest pain, cough, shortness of breath, anxiety, variation of heart rate and blood pressure, abdominal pain, nausea, low back and other joint pain. It has become obvious that COVID-19 is a multi-organ disease with nervous system involvement that has a very broad reach. For some these symptoms are a bother; for others they are debilitating.

As the number of “long haulers” begins to increase, health care professionals are at a crucial point to find valid ways to help. Ai Chi is a credible intervention for many of the symptoms that COVID-19 long-haulers experience, as it provides core muscle strengthening, increases joint mobility, improves focus, brings relaxation and reduces stress, enhances breathing, decreases heart rate and blood pressure and relieves back and joint pain. Importantly however, we need evidence-based research showing its effectiveness in Post-COVID-19 syndrome. A good place for practitioners to start is with case studies employing good research practices, including informed consent, controlled parameters and valid test measures. And those who have the resources can undertake larger scale studies with control groups based on the initial findings suggested by case studies. As a reviewer for the APTA’s Journal of Aquatic Physical Therapy, I see this as an important research area today that can have a big impact on the lives of many. I am looking forward to seeing your research!

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Moving toward pain relief

A recent pilot study was done in Hong Kong that looks at how Ai Chi affects subjects with knee osteoarthritis, which was published in the Journal of Physical Therapy Science. Following just five weeks of bi-weekly Ai Chi classes, subjects reported significant decreases in chronic knee pain and knee stiffness and improved daily task performance. Why would doing Ai Chi have this effect?

Just being in warm water relaxes muscles and soft tissue. Knee joint temperature receptors block the signals from pain receptors. And the hydrostatic pressure of the water improves circulation to reduce joint swelling and pain. At shoulder depth, the water’s buoyancy unloads the lower limb joints by 90%, significantly lessening the pressure on the damaged knee joint.

But when my friends who spend nearly every weekday in a warm water pool joined me in Ai Chi, they reported relief of chronic knee pain for the remainder of the day that they had not experienced before. Something more was happening…

The diaphragmatic breathing that is a part of doing Ai Chi stimulates the parasympathetic “rest and digest” nervous system, enhancing relaxation. This is the type of breathing I used during childbirth to lessen pain, as a part of a battery of Lamaze techniques. Enhancing relaxation sets the foundation for another important component of Ai Chi: movement. The researchers in the Chinese study point out that Ai Chi involves a wide range of increasingly more complex movements on a diminishing base of support and uses both closed and open chain patterns and weight shifting, which place varying demands on muscles. These are progressive movements with constantly changing variables. Movement is important to normal joint function, and the water creates a comfortable environment to move in ways that are often painful outside of the water. As one of my group participants commented, “I finally felt like I was moving normally.” While doing Ai Chi cannot repair joint damage, it can allow for pain curbing movement in the water.

This pilot study supports the pain relieving effects of Ai Chi that I have seen anecdotally, but it only provides a preliminary look. It opens the door for future studies to substantiate these early results that include more participants and a non-Ai Chi performing comparison group.

You must take the first step. The first steps will take some effort, maybe pain. But after that, everything that has to be done is real-life movement.  Ben Stein