Nutritional Intervention and Rehabilitation Treatment in Patients With Post-COVID Condition

Patients who have contracted COVID-19 usually show various symptoms during the infection: Fever, cough, generalized pain, gastrointestinal disturbances, dyspnea, and fatigue. The latter two symptoms occur in about half of patients worldwide, although they are even more common in Europe. In addition to these respiratory symptoms, the disease can also have effects at the muscular, neurological, and cardiovascular levels.

After the acute phase of the disease, approximately 40% of discharged patients still have symptoms, and of these, 50% to 70% have symptoms up to three months later. These persistent symptoms include physical aspects such as fatigue and shortness of breath, but also cardiac symptoms such as palpitations, cognitive symptoms such as mental confusion, and psychoemotional symptoms such as depression, anxiety, and stress.

However, it is also observed how this clinic can be maintained beyond three months. It is known that there is a group of patients, about 5-10%, who have persistent symptoms over a period of up to 2 years, and new symptoms may even appear, leading to persistent COVID. Although the terminology for designating patients with this persistent clinical condition is changing, on October 6, 2021, the WHO published a consensus document defining the post-COVID condition (CPCOVID).

The possible mechanisms contributing to the overall pathophysiology of CPCOVID are still unclear, and numerous factors have been proposed to date. A key element may be the presence of a state of chronic hyperinflammation. In the lung context, the virus activates innate immunity, leading to a cascade of inflammatory cytokines, including interleukin-6 (IL -6), IL -1, tumor necrosis factor-alpha, and reactive oxygen species. Some studies have attempted to demonstrate the presence of T cells and NK lymphocytes in these patients, making it appear that COVID is characterized by alterations in TCD4+ cells and TCD8+ cells.

Other proposed mechanisms include autoimmune mechanisms through the presence of autoantibodies that act against modulatory proteins that alter immune function. Also, the hypercoagulable state (thromboinflammatory state) associated with SARS-CoV-2 infection is responsible for the disproportionately high rates (20-30%) of thrombotic complications observed in patients with COVID-19 and autonomic nervous system involvement leading to autonomic dysfunction.

Therefore, controlling systemic inflammation and eliminating it in general is as important as eradicating the virus itself. In particular, omega-3 fatty acids (EPA and DHA) are substrates that modulate the immune system response by promoting the resolution of inflammation by producing pro-resolving mediators that actively modulate and resolve the immune system response. Thus, omega-6 (ARA) and omega-3 fatty acids (EPA and DHA) are structural lipids, but the biological effects are carried out by their naturally produced metabolites (SPMs). In cases where the acute response of the immune system is chronic, deficiency of SPMs in the affected tissues has been observed (e.g., in metabolic diseases {obesity, metabolic syndrome, diabetes type II, fatty liver}, dry eye, atherosclerosis, autoimmune diseases, etc.). These effects on the metabolic pathways of SPM production may reduce resolution and thus contribute to the chronicity of the inflammatory response.

Recently, severe COVID-19 was shown to be associated with an altered profile of SPMs compared with healthy individuals. SPMs may have a new role in the essential nutritional management of deficiencies of these metabolites in COVID-19 disease.

Several recent articles have suggested that the change in prostaglandin profile and the increase in arachidonic acid derivatives may be indicative of the severity of the disease and the chances of recovery in the patient with COVID-19.

In addition, the emergence of this new health condition, CPCOVID, has prompted physiotherapists to renew their search for the best evidence to guide the investigative and rehabilitative interventions required for this type of patient. Evidence is currently sparse, but it is known that cognitive function and emotional health are aspects that need to be considered in the patient's treatment plan, as well as the dynamics of general condition (weakness, fatigue, concentration, dizziness, headaches, sleep disturbances), anxiety, debilitating symptoms of decreased aerobic tolerance, and subjective feelings of severity of asthenia (fatigue, physical and mental tiredness, decreased motivation and activity). Studies have shown that physical therapy sessions that include: aerobic exercise, resistance aerobic exercise, strengthening exercises, diaphragmatic breathing techniques, and mindfulness training are most appropriate for this type of patient. Moreover, the use of new information and communication technologies (digital health) for rehabilitation treatment has also proven effective for other diseases such as cardiac, neurological, respiratory or musculoskeletal disorders.

Objective: To evaluate the improvement in quality of life in CPCOVID patients after a 12-week specialized nutritional intervention with (natural and standardized SPMs nutritional supplement) together with a therapeutic exercise and education program via telerehabilitation compared to a group that underwent the tele-rehabilitation program and no supplements (placebo), as measured by the Quality of Life Scale ( EQ-5D).