THE COVID-19 PANDEMIC has turned the world upside down. Never before have we encountered such health and economic crises at the same time.
Now that we are hopefully emerging from the height of the pandemic we are faced with the fall-out for many patients, which is Long Covid. This describes the symptoms that continue in some patients after the initial illness has resolved.
The main symptoms include fatigue, poor sleep, brain fog, exercise intolerance and shortness of breath. Brain fog is a term that describes difficulty with concentration and short-term memory.
These symptoms, whilst non-specific, can translate into people being unable to return to their normal lives. People with Long Covid report being unable to return to work, play with their children, take part in hobbies and previously enjoyed sporting activities. In short, the impact of Long Covid can be life-changing and can last for several months, especially if not treated appropriately.
Research is now emerging as to what underlies Long Covid, who is likely to get it and how long the symptoms should last. A common theme is that patients are suffering and there does not appear to be much help aside from reassurance and making sure nothing sinister is underlying the symptoms. I think we can do better.
Causes of Long Covid
It is likely that the causes of Long Covid are many and the symptoms are the final common pathway. Having a viral illness can lead to dehydration and reduce overall circulating fluids in the body – simply because of the fever and the lack of appetite that often accompanies a viral illness.
People can become deconditioned when they have a viral illness – they are unable to participate in normal activities and thus the heart and muscles get used to doing less. Then they will expect once they are feeling better to return to normal life and this is a challenge on the heart and muscles and the result can be fatigue and inability to participate in what they would consider normal day-to-day activities.
Other mechanisms of a post-viral syndrome could be that the virus itself can infect brain and heart cells – the research on this is still in its infancy for Covid-19.
A cause that often receives significant attention is the concept of “autoimmunity”. This simply means that in fighting an infection your immune system develops antibodies. However, the target of the antibody on the virus can be identical to certain molecules on normal functioning nerves and other cells in the body.
The antibody cannot decipher between what is foreign and what is not and so mounts an attack against itself (and then the antibody is referred to as an autoantibody).
It could be looked at as collateral damage. Your immune system has done its job by getting rid of the virus and the autoantibody attack is the fall-out.
Blood clots
More recent research has suggested that blood clotting contributes to Long Covid. It is not unusual for blood clots to form in any infectious illness but usually, this tendency for blood clots resolves with the illness.
What is emerging is that blood clots that may have formed during the illness do not resolve and lead to impairment of oxygen transfer in blood vessels exacerbating symptoms such as fatigue.
It is apparent that some of the symptoms of Long-Covid have overlap with a condition called POTS – Postural Orthostatic Tachycardia Syndrome. This describes the situation where standing up (orthostasis) results in an overexaggerated increase in the heart rate.
This may not sound like all that big of an issue however if you consider the number of times you go from the seated to standing position and the number of routine activities that involve changes of position throughout the day you can begin to see why something that seems quite simple can have a huge impact on day-to-day activities.
People will report the inability to exercise and the irony of this is that exercise could actually be the recommended “treatment” for this condition.
The other challenge with a condition like POTS is that outwardly you look completely normal and this leads other people to be somewhat dismissive of the condition – this is already a commonly reported issue amongst people with Long Covid – that clinicians and others simply do not believe there is anything seriously wrong with them. This results in them being unable to receive appropriate treatment in time.
Help is available
So, what can we do for those suffering with Long Covid? The answer to this question is challenging because the symptoms are quite non-specific and as there is no one blood test or x-ray treatment with one tablet doesn’t work.
GPs and specialists are going to be hesitant to treat something they can’t definitively diagnose easily or treat with a single prescription. The first step is to acknowledge that the condition exists and the symptoms are as real as any other condition.
Each patient should have a clinical assessment to discuss in detail the symptoms that they are experiencing. For the patients who have the symptoms of conditions such as POTS formal testing of the autonomic nervous systems control of heart rate and blood pressure should be undertaken.
Briefly, the autonomic nervous system is the automatic part of our nervous system. It takes care of functions we don’t give too much thought to during the day. A simple example would be sweating – we don’t decide to sweat if the weather is warm, the autonomic nervous system just does this for us.
Another example is how our heart rate and blood pressure will adjust for changes in position between lying and standing so you don’t faint every time you stand up! If testing of the autonomic nervous system is abnormal then the patient should be managed by a regime that will be a combination of lifestyle measures, medication, and most importantly exercise.
Exercise as ‘treatment’ for Long Covid
If the autonomic test is normal then the patient should go on to have exercise testing to get a baseline of their exercise capacity and what should follow on from that is an individualised exercise programme.
To be told that exercise will help you feel better is not novel. However, the nuance is important. To tell a person whos’ life is being made miserable by these types of symptoms to start exercising may actually be unhelpful if there is no particular programme given.
For someone who is debilitated and has spent weeks or even months being just about able to get out of bed in the morning the idea of exercise to fix that sounds ridiculous. They need to start low and go slow. They also need to understand what to expect from an exercise programme.
It is known that it can take up to 12 weeks for any appreciable change in the function of the heart and muscles to occur in the body following initiation of any exercise. The patient should understand from the get-go that this is the “long game”. There is no quick fix but sticking to an exercise programme may be far more beneficial than they can imagine.
The reality is that Long Covid is just emerging and we currently only have estimates of what is to come. Based on UK data we are expecting between 30,000-50,000 cases of Long Covid and with the delta variant this number is likely to rise.
We have the expertise in this country to evaluate and manage these people suffering with Long Covid. It won’t be a quick fix, not everyone will improve 100% but there is definitely the potential for significant improvements if they are empowered in their recovery.
Dr Jennifer Dineen is a Consultant Neurophysiologist/Neurologist based at Cork University Hospital. She trained in Ireland followed by Harvard and has developed a unique background in both autonomic neurology and exercise medicine.
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