Chest mobility, cough strength, muscle strength, physical activity, and quality of life in parkinson’s patients who had COVID-19 | BMC Pulmonary Medicine

Our study, whose primary research aim was to investigate impacts of a confirmed history of COVID-19 on muscle strength, chest mobility, physical activity, cough force, and QOL in Parkinson’s patients, yielded important results. Among Parkinson population of our study, individuals with a confirmed history of COVID-19 had higher scores in the MDS-UPDRS part I and PDQ-39 (daily living activities, emotional well-being, cognition, physical discomfort domains and total score) compared to individuals without a history of COVID-19. Conversely, individuals with a history of COVID-19 had lower the difference in chest circumference measurements at the subcostal level, left-hand grip strength, and the number of steps recorded on the first day.

During the COVID-19 pandemic, worsening of stress, depression, anxiety, physical activity level, and QOL was observed in Parkinson’s patients [7, 14]. Many patients have also specified deteriorations in Parkinson’s motor and nonmotor symptoms such as pain, rigidity and tremor during quarantine periods. The QOL scores were worse in community-based Parkinson’s patients than in hospital-based Parkinson’s patients [14]. In our study, QOL and exercise duration were found to be worse in individuals with Parkinson’s disease who had COVID-19 compared to others. Similar to this result of our study, it was found that Parkinson’s patients had worse QOL after quarantine, and those who had COVID-19 had higher PDQ-39 scores than Parkinson’s patients who had never had COVID-19 [11]. The poorer QOL observed in Parkinson’s patients with a history of COVID-19 may be attributed to the negative impact of the COVID-19 pandemic on exercise and subjective symptoms of individuals with Parkinson’s disease. In these individuals, reduced exercise was associated with a subjective increase in both motor and nonmotor symptoms of Parkinson’s disease. Therefore, maintenance of exercise in individuals with Parkinson’s disease should be emphasized even in situations such as the COVID-19 pandemic [8]. The fact that it was obtained by comparing with controls who had no COVID-19 contact is the superior aspect of our study compared to the studies in literature. Another contribution to the literature is that the effects of the pandemic have decreased, and the late-term effects of the patients have been evaluated after a long time has passed since the disease contact. It can therefore guide the approach to Parkinson’s patients with a COVID-19 history.

The first part of the MDS-UPDRS is concerned with non-motor problems experienced by individuals with Parkinson’s disease in their daily lives, such as memory and cognitive functions, feelings of depression and anxiety, sleep disturbances, pain and other sensory problems, and difficulties with urinary and bowel functions [23]. Based on the results of our study, individuals with Parkinson’s disease who had COVID-19 had worse MDS-UPDRS part I scores than others; that is, these individuals had a higher disease severity and poorer health status associated with non-motor symptoms [23]. A study reported that the MDS-UPDRS motor scores of Parkinson’s patients increased in the post-COVID period compared to the pre-COVID period [11]. In addition, parallel to the results of our study, the increase in the MHYS score, post-COVID period MDS-UPDRS motor scores, and the total score of the PDQ-39 in Parkinson’s patients who had COVID-19 compared to those who had not had COVID-19 was also found to be significant [11]. Individuals with Parkinson’s disease who had COVID-19 reported greater worsening of motor symptoms (63% vs. 43%) and non-motor symptoms (75% vs. 52%) than others [9]. It has been reported by another study that motor and non-motor clinical symptoms of Parkinson’s patients worsened, the amount, duration and frequency of exercise decreased and the number of individuals who did not exercise increased during the pandemic period [8]. When individuals who performed continuous and reduced exercise were compared, although there was no significant difference between the MDS-UPDRS part 3 scores, patients in the reduced exercise group reported greater motor and non-motor deterioration than the others [8]. Although the individuals in our study were evaluated after a long time had passed since the pandemic, in parallel with result of this study [8], approximately 62% of Parkinson’s patients without a history of COVID-19 had higher exercise times (about 20 min per a day) than others, while the deterioration in non-motor symptoms of those was lower. The lower incidence of non-motor symptoms in individuals with Parkinson’s disease who exercise regularly may be attributed to the positive effects of physical activity on neuroplasticity, dopamine regulation, and general brain health. These factors contribute to improved motor function, cognitive abilities, and emotional health, potentially reducing the development and severity of non-motor symptoms such as depression, anxiety, and sleep disorders [37].

Pulmonary system problems that are frequently seen in Parkinson’s patients include chest wall rigidity/abnormalities, posture disorders, respiratory muscle weakness, central respiratory dysfunction, impaired respiratory sensation, and dyspnea as a side effect of medications such as levodopa [2]. These impairments lead to reduced chest wall mobility, decreased lung volumes and capacities, and increased difficulty in performing breathing activities [2]. In our study, although the respiratory depth was found to be similar in the groups, the difference value of the chest circumference measurement from the subcostal level in individuals with Parkinson’s disease who had COVID-19 was found to be lower than the others. When the literature was examined, no study investigating the thoracic cage mobility in individuals with Parkinson’s disease who had COVID-19 during the pandemic period has yet been found. The result of an online study, which is that motor symptoms are more pronounced in Parkinson’s patients with COVID-19 [9], is consistent with the result of our study of a significant decrease in subcostal breathing in Parkinson’s patients with COVID-19. It was also observed that Parkinson’s patients who had COVID-19 were more likely to smoke (5.9% vs. 1.6%) and to have the histories of heart (20% vs. 8.2%) and lung (14% vs. 8.1%) diseases in the study of Fox Insight [9]. In contrast to these results, in our study, smoking and alcohol use and chronic disease history were similar in groups. Symptoms may worsen in individuals with Parkinson’s disease exposed to infections such as COVID-19 [38]. The decline in respiratory function observed in individuals with Parkinson’s disease who have any infectious disease may be attributed to systemic inflammation, altered dopaminergic signaling, impaired drug absorption, or changes in drug pharmacokinetics [39]. A study proved that breathing exercises applied regularly to Parkinson’s patients increase chest mobility by increasing the difference between deep inspiration and deep expiration in chest circumference measurements taken from the axillary, epigastric and subcostal regions, as well [40]. For this reason, rehabilitation programs including breathing exercises and trunk mobility for Parkinson’s patients can be adapted to the specific needs of each patient through online services in cases of high risk of infection such as COVID-19 [10, 40].

The PCEF measurement can predict the risk of aspiration or impairments in respiratory muscles (trunk muscles etc.) and reflects disease severity in individuals with Parkinson’s disease [41]. It was found that young individuals who had been infected with COVID-19 in the last 6 months had weakness in the respiratory and upper extremity peripheral muscles and similar values in pulmonary function test compared to controls who had not had COVID-19 [16, 42, 43]. Similar to the results of these studies, in our study, it was observed that the PCEF value did not differ between the groups. As in other studies, the individuals with Parkinson’s disease who had COVID-19 in our study were individuals who had been diagnosed with COVID-19 at least 12 weeks ago and had recovered. However, although the individuals in our study were older and had a neurological disease, unlike the population in these studies [16, 42, 43], the preservation of the PCEF value in individuals with Parkinson’s disease can be attributed to the fact that approximately 25 months have passed since COVID-19 contact and that they had mild COVID-19. Likewise, the results of a study that included a larger sample, a wider age range, and more severe COVID-19 cases (those that developed acute respiratory distress syndrome (ARDS) are striking [6]. Individuals with ARDS who developed pneumonia had lower oxygen saturation and total lung capacity, and higher dyspnea rates [6]. The change in pulmonary functions following contact to COVID-19 appears to be more pronounced in patients who develop ARDS and require invasive mechanical ventilation [6]. Pulmonary function deterioration is greater in individuals with Parkinson’s disease compared to healthy individuals, and this deterioration increases as the severity of Parkinson’s disease increases [4]. Considering that both the diagnosis of COVID-19 has negative effects on the respiratory system and respiratory system problems such as cough strength insufficiency are important disorders seen in patients with Parkinson’s disease, we recommend regular monitoring of lung functions and chest mobility in these patients. As known, regular exercise can improve ventilatory parameters in Parkinson’s disease patients [44]. Therefore, individual exercise planning may be recommended to improve the decreased ventilation in the lung bases, especially in Parkinson’s disease patients who had COVID-19.

In people exposed to COVID-19 infection, the SARS-CoV-2 virus leads to a decrease in peripheral and respiratory muscle strength by causing an increase in caspase 3, which is suggestive of muscle apoptosis [15]. It is also known that there is a linear relationship between increased endothelin-1 synthesis and sarcopenia [45]. Our results show that most individuals with Parkinson’s disease (disease duration of approximately 2–3 years) have muscle weakness regardless of COVID-19 history, but those who had COVID-19 have a greater decrease in upper extremity muscle strength, even though approximately 1 year has passed since the infection. In line with the results of our study, a study showed that 39.6% of adult patients who had COVID-19 had weakness in hand grip muscles and 35.4% had weakness in quadriceps femoris muscle [18]. Additionally, peripheral muscle weakness was found to be more evident in individuals with moderate COVID-19 compared to those with mild COVID-19 [18]. In young adults who had at least 6 months of post-COVID-19, respiratory and shoulder abduction muscle strength were found to be lower compared to controls who had not been exposed to COVID-19 [16]. The fact that muscle weakness continues to be seen days to months after COVID-19 may be attributed to the systemic effect of the viral infection, muscle weakness and deconditioning due to long-term underlying chronic disease, and other combined effects of COVID-19, including decreased physical activity during the recovery process. The basis of these destructive effects of COVID-19 is myofibrillar destruction, muscle degradation and muscle apoptosis [15]. Therefore, it is recommended that individuals with Parkinson’s disease be evaluated regularly and in detail, considering their advanced age, COVID-19 history, and related disorders, and that they be directed to rehabilitation programs in line with their identified needs.

It is a striking finding in our study that left-hand grip strength was found to be significantly lower in individuals with Parkinson’s disease who had a history of COVID-19, without any difference in the right-hand grip strength, compared to individuals without a history of COVID-19. This asymmetric finding may be partly explained by hand dominance, as all Parkinson’s patients included in our study were right-hand dominant, and typically the right-dominant limb is stronger and has higher functional reserve [46]. Furthermore, Parkinson’s disease itself is a disease characterized by asymmetrical motor symptom onset and progression, often starting and remaining more severe on one side of the body [47]. However, since no significant difference was found between our groups regarding the side of disease onset, this may not have contributed to the observed asymmetry in grip strength. Variability in fatigue perception across repeated measurements may be another possible contributing factor, particularly in patients with neurological motor disorders such as Parkinson’s disease. Patients with Parkinson’s disease may experience fatigue due to low dopamine, as well. Therefore, familiarization, depending on how it is performed, may result in greater fatigue before the tests are performed [48]. It is also plausible that COVID-19-related muscle deconditioning or inflammatory effects may have had an uneven impact depending on pre-existing lateralized weakness or disuse. Future studies that include detailed data on hand dominance, symptom laterality, and side-specific muscle strength in individuals with Parkinson’s disease who had COVID-19 may help clarify the mechanisms underlying this asymmetry.

Parkinson’s patients were vulnerable to physical inactivity and inactivity-related adverse health outcomes due to social distancing recommendations during the COVID-19 pandemic [5]. During the first wave of the pandemic, Leavy et al. found that individuals with Parkinson’s disease took an average of approximately 5900 steps per day, and 40% of these individuals took less than 5000 steps per day [5]. In line with the results of this study, the average daily step count of the individuals in our study was approximately 6000 steps, and individuals in both groups were physically active. Although individuals with Parkinson’s disease in our study were assessed several years after the first wave of the pandemic, the fact that the average daily step count of the individuals included in our study was over 4200 steps, regardless of their COVID-19 history, also coincides with the recommendations of physical activity guidelines to be active [33]. On the other hand, studies conducted on Parkinson’s patients during the pandemic period have stated that the majority of these individuals reduced their physical activity compared to before the pandemic and these individuals were less active [10, 12, 13]. During the COVID-19 pandemic, a decrease in physical activity was observed in Parkinson’s patients due to lack of motivation and social restrictions. We recommend regular physical activity monitoring in these patients, not only during the pandemic period, to prevent a sedentary lifestyle that may worsen motor and mood symptoms.

This study has several limitations that should be acknowledged. First, due to its cross-sectional design, causal inferences between a history of COVID-19 and the observed impairments in non-motor symptoms, abdominal breathing, peripheral muscle strength, daily step count, and QOL in individuals with Parkinson’s disease cannot be made. Although a significant amount of time has passed since the COVID-19 infection, the temporal sequence between COVID-19 contact and outcomes remains unclear. It is also possible that unmeasured confounding factors such as differences in disease severity, comorbidities, or access to rehabilitation services may have influenced the results. Therefore, these findings should be interpreted with caution, and prospective longitudinal studies are needed to further investigate potential causal relationships. Another limitation may be that all participants were recruited from a single outpatient neurology clinic. This may limit the generalizability of our findings to other populations, such as patients in different geographic regions or healthcare systems. Finally, another limitation is the inability to reach the targeted number of individuals with Parkinson’s disease who have had COVID-19. However, since the literature suggests the probability of COVID-19 in individuals with Parkinson’s disease is approximately 1% [9] and patients were recruited from a single center, this number may not have been reached. Further multicenter studies are needed to confirm the findings in more diverse cohorts.