COVID-19-associated neurological and psychological manifestations, 2025, Wilson et al.

[Chandelier]

COVID-19-associated neurological and psychological manifestations

Spoiler: Authors

Wilson, Jo Ellen; Gurdasani, Deepti; Helbok, Raimund; Ozturk, Serefnur; Fraser, Douglas D.; Filipović, Saša R.; Peluso, Michael J.; Iwasaki, Akiko; Yasuda, Clarissa Lin; Bocci, Tommaso; Priori, Alberto; Altmann, Daniel; Alwan, Nisreen A.; Wesley Ely, E.

Abstract​

Long COVID is an infection-associated chronic condition that typically occurs within 3 months of acute COVID-19 infection in which symptoms are intermittently or continuously present for at least 3 months.
Long COVID is estimated to affect between 80 and 400 million people globally, with an incidence of 5–20% in the community and up to 50% among hospitalized patients following acute SARS-CoV-2 infection.
Common neuropsychiatric and mental health symptoms of long COVID include memory deficits, executive dysfunction, anxiety, depression, recurring headaches, sleep disturbances, neuropathies, problems with taste and smell, and dizziness that accompanies erratic heart rates and severe post-exertional malaise.
Underlying pathophysiological mechanisms includes SARS-CoV-2 viral persistence, herpesvirus reactivation, microbiota dysbiosis, autoimmunity, clotting and endothelial abnormalities, and chronic immune activation.
Owing to the variability in the clinical presentation, management must be tailored based on a patient’s presenting symptoms.

Web | DOI | PDF | Nature Reviews Disease Primers
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[Utsikt]

Underlying pathophysiological mechanisms includes SARS-CoV-2 viral persistence, herpesvirus reactivation, microbiota dysbiosis, autoimmunity, clotting and endothelial abnormalities, and chronic immune activation.
Owing to the variability in the clinical presentation, management must be tailored based on a patient’s presenting symptoms.

Is this another review taking every abstract at face value?

We have no idea about the pathophysiology and there are no treatments so presumably there is no management to tailor other than helping with the practical consequences of their disability.

 

[SNT Gatchaman]

These are probably the relevant sections for us.

Pharmacological management
Studies of new treatments for long COVID should focus on particular organ systems and specific symptoms of long COVID160. Although many studies are ongoing, only a few have been completed (Supplementary Table 1); therefore, there is little evidence for definite recommendations, and more clinical trials are still needed. Most studies focusing on neurological manifestations of long COVID have investigated the treatment cognitive impairments, including brain fog and fatigue although, few studies have been completed (Table 2 and Supplementary Table 1).

There are many systematic and other reviews as well as guidelines published for assessing the efficacy of different approaches to the treatment of long COVID symptoms. Despite all these studies, only a few potential treatment options for long COVID are available with some evidence base.

All guidelines for long COVID recommend that specific symptoms are referred to a specialist for treatment according to management guidelines for that condition. For example, stroke should be managed by a stroke specialist during the acute and chronic stages and for secondary prevention. Similarly, brain fog and other cognitive disorders, headaches and sleep disorders should be treated according to relevant guidelines and specialist advice. Specific recommendations are not available for fatigue and myalgia.

Non-pharmacological management
Some manifestations of long COVID (such as fatigue, PEM, cognitive impairment, anxiety and depression) are treated via non-pharmacological approaches. The most promising non-pharmacological approaches include psychological therapies with behavioural interventions, physiotherapy with occupational therapy, and non-invasive brain stimulation (NIBS).

Fatigue and post-exertional malaise
Fatigue and PEM are the most frequently reported long COVID symptoms. Although these symptoms often occur together, they are separate phenomena that require specific management approaches. Fatigue is the subjective sensation of lack of physical and/or mental energy not related to or in disproportion with previous and/or ongoing levels of activity, whereas PEM is the worsening of long COVID symptoms after physical and/or cognitive exertion, including overexertion. Although the exact biological mechanisms underlying PEM are unclear, some studies have suggested that with physical activity, systemic oxygen extraction and oxidative phosphorylation capacities are exceeded, mediated by dysfunction in mitochondria and microcirculation, which is maintained by latent immune activation. Impaired metabolism leads to the accumulation of lactate, reactive oxygen species or prostaglandins following physical exertion, which further potentiate systemic immune activation.

For rehabilitation management of PEM in adults with long COVID, education and skills training on energy conservation techniques, such as pacing, are important. Pacing is an activity and energy management technique consisting of balancing activities and rests contingent on symptoms. However, interventions for rehabilitation based on fixed incremental increases in the time spent being physically active or graded exercise, which is often suggested to people with ME/CFS, should not be offered to people experiencing PEM, or if used it should be overseen by a specialist ME/CFS physiotherapist and include regular review. An evaluation by a physical medicine and rehabilitation physician or an occupational or physical therapist in the provision and training in the use of assistive products and environmental modifications (for example, a bath grab bar, raised toilet seat, etc.) may also be useful for people experiencing moderate to severe PEM.

For both fatigue and PEM, behavioural management techniques (rest breaks, cognitive behavioural therapy (CBT) and mindfulness-based stress reduction programmes), as well as educational and self-management programmes (such as relaxation, avoiding multitasking and improved sleep hygiene), are recommended by the major guidelines (Table 1). In addition, physical activity programmes (such as aerobic exercise, strengthening exercises, hydrotherapy, yoga and tai chi) are also of considerable importance for in the management of fatigue.

However, almost all the recommendations in existing guidelines are based on expert consensus and other conditions with similar symptoms to long COVID. Randomized clinical trials involving people with long COVID are scarce. A reasonably sized study (n = 114) involving people with severe post-COVID-19 fatigue found a significant benefit of CBT compared with routine care. Interestingly, two reasonably sized randomized placebo-controlled studies found beneficial effects of transcranial direct current stimulation (tDCS), a form of NIBS, on post-COVID-19 fatigue. In one study including 47 patients (23 in the active treatment group and 24 in the sham treatment group), tDCS of the left dorsolateral prefrontal cortex improved subjective measures of fatigue, and in another study including 70 patients with long-COVID-related fatigue, high-density tDCS of the left motor cortex improved subjective measures of fatigue, anxiety and quality of life.

Other alternative medical regimens have been studied for the management of fatigue, although they have limited supporting evidence. Hyperbaric oxygen therapy led to improved subjective symptoms of fatigue in a small case series. Moreover, a randomized trial investigating 2 weeks of aromatherapy (including thyme, orange, clove bud and frankincense) also showed benefit in improving energy levels in a small group of female patients compared with placebo.

 

[Jonathan Edwards]

I am afraid that I cannot take any of the authors of this paper seriously if they are prepared to put out drivel like this. A rehab psychologist seems somehow to have been able to recruit a string of celebrity Twitterati to produce the same old jobs for the boys and girls analysis.

 

[NelliePledge]

Frankincense - that’s a new one for the yoga and kale list of patronising have you tried suggestions

 

[Eleanor]

I am afraid that I cannot take any of the authors of this paper seriously if they are prepared to put out drivel like this. A rehab psychologist seems somehow to have been able to recruit a string of celebrity Twitterati to produce the same old jobs for the boys and girls analysis.

I'm particularly disappointed to see Altmann on there as I'd previously got the impression he had an understanding of the seriousness of the problem. And now his name's on this piffle about tai chi and clove buds.