A LITERATURE REVIEW
William Sullivan 1
1Nuffiled Research Placement at Bournemouth University
The novel coronavirus disease (COVID-19) is a pathogen that compromises the human respiratory system that has caused worldwide devastation. With an initial unknown cause, COVID-19 first appeared in Wuhan (China) before spreading across the globe. The musculoskeletal system is also affected by the disease, but today there is a lack of information about the overall physiological effects of COVID-19 upon the human body. Hence, the following review aims to bridge the gap by reporting the direct and indirect effect of COVID-19 upon the musculoskeletal system. The majority of COVID-19 patients reported mild or no symptoms, but there are many who experience severe loss of physical capabilities with decrement in quality of life. Using Google Scholar and PubMed, the literature review reports the known information on the effects COVID-19 has on the musculoskeletal system and outlines possible strategies to manage these effects. The results showed that there are direct and indirect effects related to COVID-19 or restriction (i.e. lockdown and intensive care). The research also highlighted that there are many ways to prevent the damage to the musculoskeletal system such as home-base exercises or the installation of specific clinics to support COVID-19 rehabilitation – all of which are in turn discussed.
Keywords: covid19, mobility, physical performance, daily activities, muscle damage.
Coronavirus Disease (COVID-19) is the name of the infection that has caused so much devastation. It is a pathogen that compromises the human respiratory system which first emerged in December 2019 in Wuhan (China). Initially, COVID-19 was diagnosed as pneumonia, but there was no clear understanding of its aetiology (cause) until more research concluded that the virus derives from bat origin . It was confirmed on the 7th of January; COVID-19 had >95% homology with bat coronaviruses . With time, COVID-19 was first named as a pandemic on the 11th February 2020 by the World Health Organization (WHO) due to the widespread effects of this coronavirus and the transmission path, human to human transmission. Therefore, the rapid and global transmission of the virus has caused a ‘tsunami’ of cases worldwide. In only Europe, there have been a total of approximately 3’755’000 COVID-19 cases and 214’092 deaths. Whereas globally, there have been approximately 21 million cases and 761’779 deaths according to the latest WHO report dated 16/AUG/2020 . It has been found that this cardio-respiratory disease can inflict many symptoms, including a fever, cough, and fatigue. In more severe cases, symptoms of sputum production, headache, haemoptysis, diarrhoea, dyspnoea, and lymphopenia have been reported . Specifically, the musculoskeletal symptoms can range from myalgias (i.e. muscle aches) and muscle loss leading to conditions such as cachexia or sarcopenia  – muscle wastage. The conditions listed above can have severe effects on the musculoskeletal system, eventually causing disabilities as well as in some scenarios, death . Yet, research has suggested both conditions could be avoided with correct physical therapy during the hospitalization period . But, the lack of information available hinders the ability for such conditions to be avoided. The following research aims to bridge the gap by producing a literature review and provide additional information on the effects of COVID-19 on the musculoskeletal system.
As there is a lack of research into the effects of COVID-19 on the musculoskeletal system, this review was needed in order to compile the information that there is. To collect information, Google Scholar and PubMed were used to research relevant articles between July and August 2020, with the following keywords ‘covid19’, ‘mobility’, ‘physical performance’, ‘daily activities’, and ‘muscle damage’. When using PubMed, the advanced search terms AND, OR, NOT were also used to refine the search (e.g. ‘covid19’ AND ‘daily activities’). The reliability of this review is also safeguarded as only peer-reviewed articles were considered to be used in the review. As there is not much primary research published, literature reviews were the main source of information. Systematic reviews and meta-analysis articles were therefore not used as much. The relevant information and data was then compiled from the articles and used in the review.
The research was conducted as part of the Nuffield Future Researchers Placement following good ethical and research practice guidelines of the host university (i.e. Bournemouth University) and fully monitored by one supervisor (i.e. Dr Francesco Ferraro)
The research has produced several journals, articles, and papers, but of which the most relevant sources to the review were chosen. The Google Scholar results have clearly provided a more general understanding of COVID-19 and its epidemiology, and pathogenesis. Whereas PubMed provided more in-depth results, specifically highlighting the musculoskeletal impacts of the disease. The majority of papers were literature reviews, collating information across all known aspects of COVID-19. Out of all papers researched, only one was not open access, which was accessed using Bournemouth Universities access. The articles referenced below have chosen to feature in this review as they provide the clearest information surrounding general details about COVID-19 and then the more specific association about the effects of COVID-19 upon the musculoskeletal system. The papers that were not used, were not chosen as they did not provide the completely relevant information and would have been outside the scope of the research.
From the research conducted, the majority of the results discussed directly how COVID-19 affects an individual patient. The symptoms specific to the musculoskeletal system are myalgias, muscle loss, myasthenia, and fatigue. All of the symptoms listed essentially describe developments of weaknesses in the musculoskeletal system. This means that using the musculoskeletal system becomes increasingly difficult – prolonging the recovery process. However, some of the symptoms listed are also due to some indirect effects of COVID-19. For example, the increased periods of isolation due to ‘lockdowns’ can lead to muscle loss due to an increase in inactivity. Therefore, both direct and indirect effects of COVID-19 can cause harm to the musculoskeletal system.
The aim of this review is to highlight and detail the effects COVID-19 has on the musculoskeletal system. There were a limited number of papers referencing the impacts that COVID-19 has on the musculoskeletal system, yet those who have had COVID-19 are subjecting themselves to daily life and activities without knowing the pressure this is putting on their bodies. This also stems to those who have not suffered from COVID-19, and still they do not understand the pressure of ‘lockdowns’ or time spent in isolation on their musculoskeletal system. Therefore, the direct and indirect effects of this coronavirus has widespread damage to the musculoskeletal system.
4.1 DIRECT EFFECT
The direct effects of COVID-19 on the musculoskeletal system refers to how the virus actively affects the patient’s musculoskeletal system. COVID-19 primarily targets the respiratory tract and in some cases, the alveoli epithelium becomes compromised which progresses into the development of viremas (i.e. where a virus has gained access to the bloodstream and so has access to the whole body) . Therefore, access to the blood allows the virus to travel through the body to cause damage to other systems, causing symptoms such as myalgias, muscle loss, myasthenias and fatigue. In one-quarter to one-half of cases, myalgias and myasthenias have been reported . These symptoms do not only have temporary effects whilst the person is suffering from the disease, but such symptoms can develop into conditions such as cachexia or sarcopenia. Cachexia develops with the loss of muscle and sarcopenia develops with the loss of muscle function due to a loss of muscle tissue .
4.2 INDIRECT EFFECT
The indirect effects can alternatively be categorised by how the restrictions of the COVID-19 pandemic have affected the musculoskeletal system of those who have experienced prolonged exposure to inactivity, such as those in intensive care units (ICU) or because of the imposed ‘lockdowns’. The Italian government, for example, has imposed such a strict lockdown so that only the very basics of trips out of your home are permitted . This is a necessary step in reducing the transmission of the virus, but it neglects to consider the impacts this will have on the people that can only exercise outside. Therefore, they are limited to exercising at home which is very difficult for some people . This has negative consequences as the muscle is unused and its allocated quota of energy is likewise not used, so metabolic substrates are reallocated to the liver. This leads to the increase of anthropogenic lipoprotein production, advocating obesity and increasing the risk of lipids collecting in blood vessels which might accelerate the development of diseases such as atherosclerosis . The time spent in an ICU has also an impact on the musculoskeletal system. For example, most people require the use of invasive ventilation to maintain a constant airflow. This has a detrimental effect that can lead to pro-inflammatory conditions, known to promote muscle and bone frailty , causing reductions in patient’s quality of life. Thus, there are many factors which lead to an increase in indirect effects on the musculoskeletal system.
To conclude, the COVID-19 pandemic has spread devastation worldwide. Many people have lost their lives and many more are left suffering. The musculoskeletal effects of COVID-19 have yet to be fully reviewed and documented. More can be done to prevent damage to the musculoskeletal system such as ensuring to keep active or the installation of clinics to manage life after suffering from COVID-19. Other approaches may be considered to manage the treatment of non-hospitalised patients, for example: telerehabilitation, where the use of telecommunications and social media can be used to ensure correct physiotherapy is adhered to . Furthermore, home-based exercise can be adopted to ensure muscles use their full energy quota to prevent reallocation to the liver, encouraging them to take up both cardiovascular and resistance training. This would also be useful as many would decrease their chances of catching COVID-19 if they lost weight . Additionally, recent app development showed that it is no longer necessary to buy expensive gym equipment as now there are training apps that encompass the non-equipment workout . Moreover, strenuous daily activities such as gardening or cleaning have been shown to keep people active sufficiently . From a research perspective, the need to be more detailed about the musculoskeletal system after rehabilitation and physiotherapy has occurred. Future researchers should investigate if specific rehabilitation strategies (e.g. respiratory resistance training) can safeguard the musculoskeletal system and improve patient quality of life.
1. Rothan, H. A. and S. N. Byrareddy. “The epidemiology and pathogenesis of coronavirus disease (covid-19) outbreak.” Journal of autoimmunity (2020): 102433.
2. Madabhavi, I., M. Sarkar and N. Kadakol. “Covid-19: A review.” Monaldi Archives for Chest Disease 90 (2020):
3. Hamid, S., M. Y. Mir and G. K. Rohela. “Noval coronavirus disease (covid-19): A pandemic (epidemiology, pathogenesis and potential therapeutics).” New Microbes and New Infections (2020): 100679.
4. (WHO), T. W. H. O. “Coronavirus disease (covid-19) weekly epidemiological update and weekly operation update.” from The World Health Organization. (2020): https://www.who.int/emergencies/diseases/novel-coronavirus-2019.
5. Morley, J. E., K. Kalantar‐Zadeh and S. D. Anker. “Covid‐19: A major cause of cachexia and sarcopenia?” Journal of Cachexia, Sarcopenia and Muscle (2020): 10.1002/jcsm.12589. https://dx.doi.org/10.1002/jcsm.12589.
6. Disser, N. P., A. J. De Micheli, M. M. Schonk, M. A. Konnaris, A. N. Piacentini, D. L. Edon, B. G. Toresdahl, S. A. Rodeo, E. K. Casey and C. L. Mendias. “Musculoskeletal consequences of covid-19.” Journal of Bone and Joint Surgery Publish Ahead of Print (2020): 1. 10.2106/jbjs.20.00847. https://dx.doi.org/10.2106/JBJS.20.00847.
7. Lippi, G., B. M. Henry and F. Sanchis-Gomar. “Physical inactivity and cardiovascular disease at the time of coronavirus disease 2019 (covid-19).” European Journal of Preventive Cardiology 27 (2020): 906-08. 10.1177/2047487320916823. https://dx.doi.org/10.1177/2047487320916823.
8. Lim, M. A. and R. Pranata. “Sports activities during any pandemic lockdown.” Irish Journal of Medical Science (1971-) (2020): 1-5.
9. Turolla, A., G. Rossettini, A. Viceconti, A. Palese and T. Geri. “Musculoskeletal physical therapy during the covid-19 pandemic: Is telerehabilitation the answer?” Physical therapy 100 (2020): 1260-64.
10. Stefan, N., A. L. Birkenfeld, M. B. Schulze and D. S. Ludwig. “Obesity and impaired metabolic health in patients with covid-19.” Nature Reviews Endocrinology (2020): 1-2.
11. Tavares, B. F., I. M. Pires, G. Marques, N. M. Garcia, E. Zdravevski, P. Lameski, V. Trajkovik and A. Jevremovic. “Mobile applications for training plan using android devices: A systematic review and a taxonomy proposal.” Information 11 (2020): 343.
12. Nyenhuis, S. M., J. Greiwe, J. S. Zeiger, A. Nanda and A. Cooke. “Exercise and fitness in the age of social distancing during the covid-19 pandemic.” The Journal of Allergy and Clinical Immunology. in Practice (2020)
ABOUT THE AUTHOR
William is from Dorset, UK and currently progressing into Year 13 at the Thomas Hardye School Sixth Form. He is studying Biology, Chemistry and Geography at A-level and hoping to pursue a career in Medicine. He aims to continue to research throughout his time in university and beyond.