Those who suffer from the health problem "Long
Covid syndrome" show problems in concentration, emotions (depression),
physical fitness and fatigue in the area of body functions. This is attributed
to damaged body structures, in the area of brain structures, cardiovascular
system, respiratory system, lower extremity structures and trunk. This affects
activities, especially mobility. The patient is unable to drive a car. As a
result, she/he is also limited in her/his participation, so she/he cannot
attend a family party. She/he is thus limited in social activities with friends
and family, which leads to frustration and lowers self-esteem.
Much research is being done in the field of
conventional therapy, such as antiviral drugs, antibody treatment, or plasma therapy
[6]. A review showed that there are no concrete studies on the efficacy of
exercise therapy on symptomatology so far [7].
Exercise therapy has been well studied in many
disorders that have depression, fatigue, cognitive, or motor deficits as symptoms:
Carek et al. [8] state in their review that physical exercise is an effective
alternative to medication for depressive and anxiety syndromes. Gujral et al.
[9] demonstrate why exercise can help improve symptoms of depression. Some
brain structures associated with depression could be positively affected by
exercise, such as hippocampal volume and regional tissue density, prefrontal
cortex, striatum, or white matter. A meta-analysis shows that exercise has a
significant positive effect on fatigue in cancer patients [10], as well as
another meta-analysis showing positive effects of exercise on fatigue in
patients with multiple sclerosis [11]. It is concluded that exercise improves
cognitive function [12]. Physical activity is thought to influence various aspects
of cognitive mechanisms. The physiological mechanisms, such as increased
cerebral blood flow, altered neurotransmitter release, structural changes in
the central nervous system, and altered arousal levels, are due to physical
changes that are a consequence of physical activity. Similarly, it is possible
that physical training selectively increases angiogenesis, synaptogenesis, and
neurogenesis. In addition, there are consistent data at the molecular,
cellular, behavioral, and systemic levels supporting the notion that physical
activity positively affects cognition [13]. Whole Body Vibration (WBV) is a
gentle form of exercise therapy. It involves the patient standing or sitting on
a vibration platform in a predetermined, standardized manner or performing
strengthening or stretching exercises on the plate. There are different
systems: vertical and sinusoidal vibrating plates. There are virtually no side
effects, and few contraindications that need to be considered [14,15]. In the
last 20 years, there have been numerous studies with different groups of
patients suffering from depression, fatigue, or cognitive deficits, testing the
efficacy of short- and long-term applications on improving motor skills. WBV
was shown to have a significant positive effect on depression, anxiety, stress,
and quality of life compared to an exercise program without vibration [16]. A
rat model is used to show why these effects of WBV on depression and stress
could be achieved: it could reverse depressive-like behavioral disorders,
inhibit neuronal degeneration, alleviate neuronal damage and pathological
changes of glial cells, increase the expression of trophic factors, and improve
the downregulation of dendritic and synaptic proteins after chronic stress. The
effect could be achieved by decreasing neuronal degeneration in hippocampus and
improving the expression of synaptic proteins. Here, it is concluded that WBV
training has multifactorial benefits in depression, supporting its use as a
promising alternative therapeutic option to improve depression-like behaviors
[17]. Moretti et al [18] do not find any positive effects of WBV on fatigue in
fibromyalgia patients, in contrast to Collado-Moreno et al [19] who consider
that WBV has a positive effect on fatigue in this group of patients, but it
depends on the duration of training and the type of vibration plate used,
preferring the Galileo system. Wen et al [20] summarized in their review that
WBV can improve cognitive functions, especially attention and inhibition, even
with a short-term intervention. Positive effects of WBV on flexibility are also
noted, although the improvements seem to depend on the amplitude and frequency
used [21]. WBV can also improve coordination ability, which has been shown in
patients with cerebral palsy [22]. Another review summarizes the significant
positive effects on leg strength [23]. In addition, Gloeckl et al [24] showed
in their review that WBV can significantly improve endurance performance in
COPD patients.
As shown, exercise and especially WBV can improve
depression, fatigue, cognition and motor fitness in various disorders.
So far there is no meaningful study that investigates
WBV on Long Covid symptoms. However, the application is already recommended
during treatment in the hospital [25].
For this, the present single case study wants to
investigate the effect of WBV on the described Long Covid symptoms.
Hypothesis
A 12-week training program with WBV will improve
physical fitness, concentration, depression, and fatigue in Long Covid
syndrome.
2. Material and Methods
2.1 Sample
of persons
One female
participant, 42 years old, regularly physically active until corona infection
in October 2020 (about five hours per week of housework and gardening, about
two hours per week of walk with the family dog). She was hospitalized for two
weeks for treatment of the infection. Concomitant diseases: Hypertension,
obesity, and lipedema, 1.63 m tall, 95 kg. Long Covid syndrome was suspected by
the primary care physician because she complained of constant fatigue, concentration
problems, and aphasia.
2.2
Variable sample
BDI-II: Beck
Depression Inventory, second edition. Here, a total of 21 questions are
answered regarding pessimism, sadness, feelings of failure, loss of pleasure,
self-worth, fatigue, energy, etc. Between 0 and 3 points are awarded per task.
All points are added to a total score. A classification of the total score is
made as follows: 0 to 13 points = no depression, 14 to 19 points = mild
depression, 20 to 28 points= moderate depression, 29 and more points = severe
depression [26]. The total score of the questionnaire is evaluated.
FAS: Fatigue
Assessment Scale. The questionnaire consists of ten questions about physical
and mental fatigue, tiredness, concentration, etc. The total score of the
questionnaire is evaluated. Between 1 and 5 points are awarded for each task.
All points are added up to a total value. A classification of the total score
is made as follows: 10 to 21 points = no fatigue, 22 to 34 points = moderate
fatigue, 35 to 50 points = extreme fatigue. A minimally important difference is
given as 4 points or 10% change [27]. The total score of the questionnaire is
evaluated.
D2 test: D2 test
for measuring the ability to concentrate. The test consists of 14 test rows
with "d" and "p”, each with one to four small dashes at the top
and/or bottom. For each row, the respondent has 20 seconds to circle as many
"d"s with 2 dashes. For the 40- to 60-year-old age group, a GZ (total
number of items processed) of 340 or an F% (proportion of errors) of 17.4% with
a SW (standardized value) of 87 is classified (corresponding to the 10th
percentile), a GZ between 366 and 392 or an F% between 17.3% and 8.9% with a SW
between 90 and 93, a GZ of 453 or an F% of 4.7% with a SW of 100, a GZ of 506
or an F% of 2.5% corresponds to a SW of 106, a GZ between 541 and 567 or an F%
between 2.4 and 1.1% corresponds to a SW of 110 to 113, a GZ of 628 or an F5 of
1.0% corresponds to a SW of 120 [28]. Total number of items processed (GZ),
correctly solved items (R), incorrectly solved items (F), proportion of errors
(F%), total number minus errors (GZ-F), and standardized value (SW) are
evaluated.
Motor fitness
test: Testing of motor abilities (fitness) with the tasks hop run, ball
grasping, ball throw with rotation, figure-eight circles in one-leg stand,
walking backwards (coordination), sit-ups, push-ups, standing long jump
(strength), shouldering out, stand & reach (flexibility) and 2 km walking
(endurance). With the exception of walking, the subject has two attempts at
each task. The items are scored according to age and gender [29]. The raw
scores and age- and gender-normalized scores of the tasks as well as the total
score are evaluated.
2.3 Treatment sample
Training twice a
week for 30 minutes over a period of 12 weeks with a vibration plate (Galileo
Med Advanced). A frequency of 20 Hz was applied with a set length of one minute
followed by a set break of one minute. The exercises (number of sets,
static/dynamic) were increased in the course of the weeks according to the personal
feeling of the test person as follows: In the first training session, two sets
were performed in a hip-width stance with slightly bent knees for
familiarization. This was followed by one set each of static squat position
(hip-width stance, mark 1.5), static sit-up position, static push-up position
(hands shoulder-width, mark 2.5, arms slightly flexed). From the fourth week,
the number of sets was increased to two for all exercises. From the eighth
week, all exercises were performed dynamically. From the ninth week, the number
of sets was increased to three for squats, sit-ups, and push-ups.
3. Results
The test person
tolerated the intervention well. On two of the sessions, she felt that during
the standing application, her ankles became hot and itchy. This could be an
unwanted side effect, if applicable. In addition, a positive side effect
occurred, namely that the lipedema on the upper arms and thighs was reduced.
The circumference of the upper arm was reduced by three cm and that of the
thigh by five cm. During these 12 weeks, she lost 3 kg of weight.
The following
table 1 provides an overview of the results in pre- and posttest in BDI-II,
FAS, D2 test and motor fitness test.
There are both decreases in values (BDI-II, FAS, D2
GZ-F, and 2 km walking RV), increases in values (D2 GZ, D2 R, D2 F, D2 F %, D2
SW, ball throw RV and SV, walking backwards RV and SV, shouldering out RV and
SV, stand & reach RV and SV, standing long jump RV and SV, sit-ups RV,
push-ups RV and SV, and total fitness value). Some values show no change (hop
run RV and SV, ball grasping RV and SV, figure eight circles RV and SV, sit-ups
SV, and 2 km walking SV).
4. Discussion
The test person showed an immense reduction
of seven points in the BDI-II. This symptom has thus improved from a medium to
a light status, and in total about 30 % of the raw value. This is consistent
with the findings of Chawla et al. [16] who show a significant positive effect
of WBV on depression.
In the FAS, an immense reduction of
nineteen points can be observed. In the pretest, the result is to be classified
as extreme fatigue, in the posttest as medium fatigue [27]. Thus, this symptom
has also improved about 43 % concerning the raw value. This result is
consistent to Collado-Moreno et al. [19] who are in the opinion that WBV has a
positive effect on, depending on the duration and the vibration plate used,
favoring the Galileo system.
In the D2 test, 96 more items were
processed in the posttest and 15 more were solved correctly. The error rate has
thus increased by 3.26 %. The total number minus errors has not improved and
the classification of the standard value has risen from the 5th quintile to the
4th quintile [28]. Thus, it can be assumed that the concentration performance
has partly improved. It seems that only the processing speed has increased,
i.e., more items were processed, but also more errors were made. This is
consistent with the findings from Wen et al. [20] who summarize in their review
that WBV can improve cognitive functions, especially attention.
In the area of physical fitness, many
improvements can be found in the raw values for nearly all test items,
excepting ball grasping and hop run. Here, the maximum value was already
reached in the pretest.
With an age of 42 years, the test person is
in the range of middle adulthood, which is characterized by a decrease in motor
performance if no training takes place [30]. There is a clear difference
between exercisers and non-exercisers in coordination and flexibility [31]. The
improvement in flexibility is consistent with the findings by Fowler et al.
[21], as well as the improvement in coordination to Duquette et al. [22]. Even
if no specific flexibility exercises were performed on the vibration plate, the
flexibility improved. This could possibly be related to the fact that the
vibration loosened the muscles and made them more elastic.
The trunk strength has improved
significantly, for abdominals about 50 %, for upper arms/chest more than 100 %,
and for legs about 21 %. This was to be expected, since exactly these muscle
groups were also trained. In middle adulthood, strength continues to decline,
although this decline can be slowed, or even prevented or reversed, through
regular training [32]. Strengthening exercises not only strengthen the muscles
themselves, but also increase self-confidence, body awareness, and confidence
in movement [30]. The improvement in strength is consistent to the findings by
Osawa et al. [23]. Nevertheless, the abdominal muscles in particular are still
very weak, which the patient must continue to work on.
There is an improvement in the 2 km walking
of 3:45 min. This is consistent to the findings by Gloeckl et al. [24] who show
an improved endurance capacity. However, this improvement could also have been
due to an increase in strength in the leg muscles, as no specific endurance
exercises were performed, but the focus was on strengthening exercises.
In comparison with a recent single case
study using WBV once a week, many results are in the same direction.
Improvements are found in both test persons in BDI-II, FAS, D2-GZ, D2-R, D2-SW,
as well as in the raw values of walking backwards, stand & reach,
shouldering out, sit-ups, push-ups, 2 km walking and total fitness value. All
raw values in hop run, ball grasping and figure eight circles show no changes.
The values for D2-F, and D2-F% show an improvement in the patient with
once-a-week training and a deterioration in the patient with the current study.
This could be related to the fact that the test person in the first study has
been able to work again for some time, while the test person in the current
study has been on sick leave for five months and will not be able to work again
in the near future.
Limitations: Since this is a single case
study, the results should be treated with caution. It is possible that the test
person would also have improved if the exercises had been performed without
support from the vibration plate. Therefore, further studies must follow.
5. Conclusions
The present single case study was able to
show that an improvement of depressiveness, fatigue, concentration and physical
fitness in Long Covid syndrome is possible, even if an exercise session takes
place twice a week. Therefore, a pilot study should follow to compare the
effectiveness of one with two training sessions per week as well as a training
condition without WBV. It seems to be important that the intensity is regularly
adapted to the subjective condition of the test persons (individualization), or
if the training leader determines that an increase in the number of sets or transition
from static to dynamic exercises seems to be useful.
Acknowledgements
There was no financial support. There is no
financial benefit or interest in this work. There are no conflicts of interest.
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Effects of 12 Weeks Whole Body
Vibration Training on Long Covid Syndrome Symptoms – A Single Case Study