Clinical management
Muscle weakness post-COVID
Muscle weakness affects up to 60% of people with long COVID. Most don’t have any muscle-specific investigations and many don’t benefit from rehabilitation and psychological support offered.
Potential reasons for muscle weakness post-COVID:
Impact on metabolic processes- damage to mitochondria, problems with the electron transport chain supplying energy to muscles
Motor nerve damage, including acute Guillain–Barré syndrome or more prolonged muscle weakness, often associated with brain fog
Myelopathy due to damage to the anterior spinal cord
Localised nerve damage, potentially causing specific plexopathies (eg, brachial neuritis, lumbosacral plexopathy)
COVID-induced myasthenia gravis
Alternative non-COVID pathologies including vitamin B and D deficiencies, polymyalgia rheumatica and polymyositis.
Examination for the majority will be normal despite significant mitochondrial, muscle or nerve damage.
For localised symptoms examine tone, power, sensation and reflexes
Is there ptosis? Consider an upward gaze test (suspect myasthenia gravis if ptosis/ diplopia while maintaining an upward gaze for 30-60 seconds)
Consider myelopathy if there are abnormal sensory findings with muscle wasting and brisk reflexes bilaterally.
Investigation- potential tests include CK, CRP, Vitamin D, B12, folate, FBC & TFTs.
Management:
Establish a therapeutic relationship and offer an explanation to validate their lived experience/ support them to explain symptoms to relatives and employers
Explain recovery can take 2-3 years
Clinical judgement should guide referral to neurology (eg, suspected myasthenia gravis, localised neuropathy) and long COVID pathways (if they exist)
Identify and treat vitamin deficiencies and consider B vitamin supplementation
Offer holistic support, signpost to peer support (eg long COVID groups) and occupational therapy or citizens advice where relevant, encourage to maintain gentle levels of activity where possible, avoiding ‘boom–bust’ cycles and explore for co-morbid mood problems.
WiseGP Actions
Discuss post-COVID symptom management in a practice learning event. Could your team offer a more detailed explanation of why symptoms like muscle weakness are experienced and suggest a potential recovery time? What local services have colleagues found useful to provide holistic support?
Consider signposting affected patients to long COVID websites for further information, including https://www.longcovid.org and ‘Long Covid Kids’ for young people and their families (https://www.longcovidkids.org/).
Read more of the clinical practice article that informed this GEM here: https://bjgp.org/content/74/749/573
Long COVID in children and young people
A recent study has been investigating symptom patterns and life with Long COVID in children and young people.
The research team found people often lacked knowledge about the effects of Long COVID in children and young people.
Over 70 children and young people with and without Long COVID worked with the research team to inform development of information materials, including short videos and an illustrated leaflet.
See resources here: https://www.keele.ac.uk/research/ourresearch/medicine/primarycareresearchthemes/ppie/splattoon/
WiseGP Actions
Could you add a link to the above patient resources from your practice website or share them on social media?
To raise awareness, could one of your team share a case of Long COVID in a child/ young person they have managed during a practice educational session? How was the diagnosis reached and what advice did they offer? This NHS website offers further advice on general measures to support recovery from Long COVID in children and young people- https://www.yourcovidrecovery.nhs.uk/children-and-young-people-with-covid/
Prognostic factors for persistent fatigue after COVID-19
A prospective cohort study investigated prognostic factors for persistent fatigue after mild COVID-19 infection during the first wave of the pandemic.
Low educational level, absence of a partner, high neuroticism, low resilience, high frequency of GP contact and threatening experiences in the past were prognostic factors for persistent fatigue.
When a patient presents with fatigue after COVID-19 infection and meets some of the prognostic criteria, GPs should be aware of the increased risk of fatigue becoming persistent and consider this when advising on management.
WiseGP Actions:
Do you have support available for patients experiencing persistent fatigue? Is this something that your PCN occupational therapy team could help with? Have a look at our Wise General Practice Story, OTs and Chronic Pain Support for inspiration (https://www.wisegp.co.uk/chronic-pain-support)!
Read more about the research informing this GEM here: https://bjgp.org/content/73/730/e340
