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SAN ANTONIO SAN ANTONIO
MEDICINE MEDICINE

Post-COVID Complications
and Neurological Sequelae:

PM&R Perspective combination of magnesium oxide, riboflavin and coenzyme Q10 can 2. Mao L, Jin H, Wang M, et al. Neurologic Manifestations of Hos-

be a good prophylactic before considering other sedative pharmaco- pitalized Patients With Coronavirus Disease 2019 in Wuhan,
By Monica Verduzco-Gutierrez, MD and Carol Li, MD logic alternatives. Advanced imaging should be considered in pa- China. JAMA Neurol. 2020;77(6):683-690. doi:10.1001/jama-
tients with new onset headaches with auras or focal neurologic neurol.2020.1127
deficits. Anosmia may persist for as long as six months post infection, 3. Carvalho-Schneider C, Laurent E, Lemaignen A, et al. Follow-up
To date, millions of Americans who have been affected by COVID- and a trial of intranasal steroids in conjunction with olfactory train- of adults with noncritical COVID-19 two months after symptom
19 have residual symptoms that result in a heterogenous post-infec- ing can be considered before consulting ENT, while simultaneously onset. Clin Microbiol Infect. 2021;27(2):258-263. doi:10.1016
tious condition referred to as “long COVID syndrome,” or Post-Acute monitoring for malnutrition as the impact of anosmia can affect oral /j.cmi.2020.09.052
Sequelae of SARS-CoV-2 infection (PASC). The CDC has now de- There intake. In addition to evaluating cardiopulmonary status, assessing 4. Lippi A, Domingues R, Setz C, Outeiro TF, Krisko A. SARS-CoV-
fined this as persistent symptoms after initial infection with a lack of may also be autonomic dysfunction with regards to volume status, orthostatic 2: At the Crossroad Between Aging and Neurodegeneration. Mov
return to usual state of health that lasts more than four weeks. exacerbations of intolerance with sit to stand changes and need for compression gar- Disord. 2020;35(5):716-720. doi:10.1002/mds.28084
Severity of acute illness correlates with post-COVID complications, chronic pain symptoms. ments may also be necessary. 5. Barratta JM et al. Post Acute Sequelae of COVID-19 Infection and
as 36.4% of patients with severe COVID had a higher probability of Multi-joint arthralgias or generalized myalgias can be responsive to Adjustment post-COVID recovery can present as increased anxiety Development of a Physiatry-Led Recovery Clinic. American Jour-
neurological symptoms, such as acute disseminated encephalomyelitis, NSAIDs, given the inflammatory pathophysiology of PASC. New or depression. Patients with pre-morbid psychiatric conditions may nal of Physical Medicine & Rehabilitation. 2021
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ischemic stroke and Guillain-Barre syndrome, compared to those onset paresthesias involving upper extremities or unmasking of premor- be more at risk. This makes the collaboration with psychology and 6. Ellul MA, Benjamin L, Singh B, Lant S, Michael BD, Easton A,
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with mild to moderate disease. However, persistent symptoms can bid asymptomatic neuropathies may also occur. In cases where pares- neuropsychology specialists invaluable. It is in this author’s opinion Kneen R, Defres S, Sejvar J, Solomon T. Neurological associations
also occur after noncritical COVID-19 infection. A recent prospective thesia symptoms fall within a certain nerve distribution or associated that managing neuropsychiatric symptoms can synergistically improve of COVID-19. Lancet Neurol. 2020 Sep;19(9):767-783. doi:
study reported 66% of patients with mild-moderate course had at least with focal weakness, electrodiagnostic and nerve conduction studies management of other symptoms of cognition, sleep disorders, 10.1016/S1474-4422(20)30221-0. Epub 2020 Jul 2. PMID:
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one symptom that persisted beyond 60 days. may be indicated to localize the lesion or look for myopathy. Further headaches and fatigue, as they often coexist with each other. Most im- 32622375; PMCID: PMC7332267.
Management of this patient population has yet to be standardized, physiatric evaluation on how these symptoms can be managed to max- portantly, empowering patients with self-management strategies, ap- 7. Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Ma-
but a comprehensive and multidisciplinary approach is necessary. Since imize patient’s functional ability with orthotics, PT/OT, steroid injec- propriate coping strategies, educational resources about vaccination jeed A, McGregorA. Returning to Physical Activity after COVID
physiatry has a strong focus on medical complications impacting func- tions or nerve blocks can be done. and data regarding the risk of re-infection is also important. 19. BMJ 2021;372:m4721. http://dx.doi.org/10.1136/bmj.
tion, and many of PASC symptoms can have significant implications “Brain fog” can manifest as cognitive impairment, behavioral The frequency of outpatient follow-up care is variable and individ- m4721. Published: 08 January 2021
on quality of life and functional status, a multi-disciplinary PM&R led changes, poor concentration and attention, short term memory ualized depending on when the decision about clinical resolution of 8. Al Chikhanie Y, Veale D, Schoeffler M, Pépin JL, Verges S, Hérengt
outpatient clinic for post-COVID recovery has been suggested. deficits and psychological symptoms. A brief neurocognitive screen PASC symptoms is made and the return to baseline function has oc- F. Effectiveness of pulmonary rehabilitation in COVID-19 respi-
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can be helpful. The mini mental status exam can be completed for in- curred. Given the complexity and variety of presentations of PASC, ratory failure patients post-ICU. Respir Physiol Neurobiol. 2021
A Physiatric Approach to Care for Post-COVID Conditions: person encounters. For patients with physical limitations where a collaboration between PM&R, primary care, therapy teams and var- May;287:103639. doi: 10.1016/j.resp.2021.103639. Epub 2021
A Brief Overview telemedicine platforms may be more effective, the Modified Telephone ious subspecialties is essential to further deepen our understanding Feb 12. PMID: 33588090; PMCID: PMC7879818.
The most common PASC symptoms include fatigue, post-exer- Interview for Cognitive Status can be useful in screening for mild cog- of how to best manage the unique needs of this patient population. 9. Update: Pharmacologic treatment for episodic migraine prevention
tional malaise and decreased endurance. There are different therapeu- nitive impairment. Speech therapy can provide compensatory strate- The increasing prevalence of PASC suggests that even as the pan- in adults. American Academy of Neurology Summary of Evidence-
tic approaches when addressing these symptoms. Some patients may gies and structured cognitive retraining, especially for patients who demic evolves and restrictions begin to decrease, the demand for long- based Guideline for Clinicians. American Headache Society. 2012.
respond very well to a structured, progressive return-to-activity pro- are experiencing cognitive symptoms that are functionally disruptive. term follow up and rehabilitation management for COVID-19
gram with physical therapy. A proposed protocol for this progressive The long-term effects on the central nervous system are poorly under- survivors will continue to increase. The end goal is learning how to
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reconditioning is described in the Salman study, as well as by other stood at this time, but because the inflammatory changes parallel that balance the use of available public health resources to match this de-
resources such as ‘Couch to 5K’ put forth by National Health Service of accelerated intracellular aging exposed to multiple stressors over mand while optimizing a patient’s daily routine, lifestyle or
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– England. For others who present more like myalgic en- time, it has been suggested that the very persistence of this inflamma- work/school performance.
cephalomyelitis/chronic fatigue syndrome, slower paced physiother- tion in the brain can potentially be associated with neurodegeneration. Monica Verduzco-Gutierrez, MD runs the Post-COVID Recovery
apy to address breathing pattern disorders and education on pacing This may bring into light the potential role of incorporating a well- References Clinic at UT Health San Antonio. Carol Li, MD is the medical director
and energy conservation are more helpful. For patients with persistent balanced, anti-inflammatory diet and certain nootropic supplements 1. Helms J, Kremer S, Merdji H, Clere-Jehl R, Schenck M, Kum- of outpatient neurorehabilitation services at the Polytrauma Rehabilita-
dyspnea with minor activities, pulmonary rehabilitation can be con- in neuro-recovery. merlen C, Collange O, Boulay C, Fafi-Kremer S, Ohana M, An- tion Center of the Audie L. Murphy VA Hospital. Dr. Verduzco-Gutier-
sidered, especially for patients with respiratory failure requiring ICU Other common PASC symptoms seen in PM&R clinic include heim M, Meziani F. Neurologic Features in Severe SARS-CoV-2 rez and Dr. Li are members of the Bexar County Medical Society.
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admission. More research is needed for pharmacologic interventions, headaches, autonomic dysfunction and anosmia. Episodic migraine Infection. N Engl J Med. 2020 Jun 4;382(23):2268-2270. doi:
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but amantadine and duloxetine have shown some benefits for improv- management can mostly follow the AAN guidelines, depending on 10.1056/NEJMc2008597. Epub 2020 Apr 15. PMID: 32294339;
ing central fatigue in the right patient population. phenotype. For migraines occurring more than 15 times a month, a PMCID: PMC7179967.

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