Physical Medicine Academy Issues Guidance on Long COVID Neurologic Symptoms

Clinicians need to evaluate new or worsening neurologic symptoms of post-acute sequelae of SARS-CoV-2 infection (PASC) and treat or refer them to specialists when appropriate, according to new guidance from the American Academy of Physical Medicine & Rehabilitation (AAPM&R).

Neurologic symptoms related to PASC — commonly known as long COVID — include headache, weakness, muscular numbness, pain, tremors, and palsy, according to Leslie Rydberg, MD, of the Northwestern University Feinberg School of Medicine and the Shirley Ryan AbilityLab in Chicago, and Sarah Sampsel, MPH, of SL Sampsel Consulting in Albuquerque, and co-authors.

Clinicians should pursue appropriate diagnostic workup and collaborate with multidisciplinary clinical teams to address specific neurologic symptoms for long COVID patients, while aiming to reduce polypharmacy and avoiding a rapid escalation of activities that might trigger symptom worsening, the authors said in PM&R.

“What we know is that many people with mild or moderate COVID infections end up with neurologic sequelae that lasts longer than 4 weeks, and we see a very wide variety of neurologic symptoms,” Rydberg said in a press briefing. “Whether these patients were hospitalized or not, they continue to have these neurologic symptoms that are persistent and prevalent.”

In collaboration with primary care providers or appropriate specialists, clinicians also should look to treat underlying medical conditions — including psychiatric, pain, renal, endocrine, cardiovascular, neurological, respiratory, and other conditions — which may be contributing to neurologic symptoms, the guidance authors wrote.

For patients with neurologic sequelae affecting gait, mobility, cognitive status, or activities of daily living, referrals to physical medicine and rehabilitation physicians or other health professionals including physical therapists, occupational therapists, speech language pathologists, and social workers, may help increase function and independence, they added.

The statement was developed by AAPM&R’s PASC Collaborative, a multidisciplinary group of physicians, clinicians, and patient advocates. The authors outlined red flags clinicians should identify and address with immediate interventions, including:

• Sudden or progressive weakness or sensory changes
• Unexplained upper motor neuron signs in the setting of weakness
• Bowel or bladder incontinence or retention
• Syncope or transient loss of consciousness
• Acute neuropsychiatric symptoms or psychosis
• Positional headache, headache associated with focal neurologic signs, or rapid-onset “thunderclap” headache
• Cranial nerve abnormalities on physical exam

Many of these neurologic red flags may require a referral to the emergency department versus neurology or cardiology, depending on the time course and urgency, Rydberg and colleagues emphasized.

Rydberg also said it’s important to learn whether patients are experiencing other symptoms, such as sleep issues, cardiopulmonary symptoms, mood issues, or functional limitations.

“When we’re talking about people who have neurologic sequelae of long COVID, it’s so important to really step back and take a big picture history and really think about all the things that are affecting these patients,” Rydberg said. “Neurologic symptoms greater than 4 weeks should absolutely be investigated.”

“The most important thing is really highlighting that neurologic sequelae are common in long COVID, and it’s really something that’s an ongoing problem that we need to be aware of, that we need to be ready to treat, [and] that we need to have the resources to treat,” she added.

The AAPM&R has released several consensus guidance statements on long COVID, including papers on fatigue, cardiovascular issues, autonomic dysfunction, and pediatric long COVID, and will publish one on long COVID mental health symptoms next.

“For physicians who are not seeing a lot of [long] COVID… having these statements really is a great resource where all the data and all the information is put into one place, and hopefully, it will give them some big-picture ideas of how to manage this group,” Rydberg said.

The organization also is preparing on a master guidance statement for the full range of known long COVID symptoms, said co-author Monica Verduzco-Gutierrez, MD, of the University of Texas Health Science Center at San Antonio.

“Patients don’t come in with just one type of symptom,” she said. “It’s going to cross all the different statements that have come out with symptoms being in pulmonary, cardiac, neurologic, [and] cognitive.”

The best approach may be to focus first on those symptoms most affecting a patient’s quality of life, using the relevant guidance statement before moving on to lesser symptoms, Verduzco-Gutierrez noted.

“We understand there’s a lot of pressures for clinicians to see a patient in a short period of time, so maybe they focus on one thing,” she said. “Okay, this week we’ll focus on the neurologic and work through these symptoms, and maybe the next visit you can come back and we’ll talk about your cardiac symptoms.”