If you or someone you love is battling COVID-19, your first concern is the disease itself. But as patients struggle to regain everyday function, energy and strength long after recovery, it's becoming increasingly clear that muscle health is vital to COVID-19 health outcomes.
"Muscle plays a critical role," says Suzette Pereira, a muscle health researcher with Abbott, a global health care company. "It accounts for roughly 40% of our body weight and is a metabolic organ that works other organs and tissues in the body. It provides nutrients to critical organs during times of illness, and losing too much can put your health at risk. Loss can result not only in decreased mobility, strength and energy, but also changes in your metabolism, immune health and internal organ function."
How COVID-19 Attacks Muscle Strength and Function
Unfortunately, without intentional focus on muscle health, muscle strength and function can drastically deteriorate in COVID-19 patients -- negatively impacting every aspect of recovery.
"It's a Catch-22," says Brianne Mooney, a physical therapist at the Hospital for Special Surgery in New York City. She explains that lack of movement significantly exacerbates muscle loss, while movement can feel impossible with the energy-draining disease. To make matters worse, muscle atrophy increases fatigue, making movement even less likely.
After all, 2015 research published in the Journal of Critical Care shows patients can lose up to 30% of muscle mass in the first 10 days of intensive care unit admission. Patients hospitalized due to COVID-19 are usually in the hospital for at least two weeks, while those who go into the ICU spend about a month and a half there, according to Dr. Sol M. Abreu-Sosa, a physical medicine and rehabilitation specialist who works with COVID-19 patients at Rush University Medical Center in Chicago. Roughly 41% of patients admitted to the hospital with COVID-19 require critical care, according to a 2020 BMJ study.
Dr. Abreu-Sosa also notes that proning -- delicately flipping patients on their stomachs for 16 to 18 hours per day to increase their oxygen levels -- contributes to muscle pain, numbness and tingling in the neck and shoulders.
Still, bedrest is not necessarily any less extreme for people with COVID-19 who are able to recover at home, Mooney says. She explains that the tendency to "get in bed and stay there" is especially strong in people with COVID-19.
But it's not just bedrest that can compromise muscle health and function in COVID-19 patients. "Many COVID-19 patients are experiencing a cytokine storm, an uncontrolled immune response that can cause high levels of inflammation and accelerate muscle loss," Pereira says. Abreu-Sosa adds that damaging inflammatory markers have been found to be penetrating muscles at the cellular level.
She also notes that in the treatment of COVID-19, doctors sometimes use steroids with patients, as well as paralytic agents and nerve blocks in those requiring ventilators, all of which can speed muscle breakdown and weakness. In COVID-19 patients, this deterioration even includes the muscles that control inhalation and exhalation.
"The disease itself has respiratory effects on patients," Mooney says. "Respiration requires strong muscles."
A review published in the Annals of Medicine shows that increased muscle mass can reduce length of ICU stay and mechanical ventilation, lower the risk for infections and hospital readmissions, and also contribute to better respiratory outcomes for patients with chronic obstructive pulmonary disease and improve response to chemotherapy for cancer patients.
Maintaining Muscle Strength Through COVID-19
Even in the best of conditions, for those experiencing strong COVID-19 symptoms, it's likely that some muscle loss will occur.
However, patients can greatly influence the degree of muscle loss and, in mild cases, may be able to maintain muscle health, says Mooney, a member of the team that created the Hospital for Special Surgery's COVID-19 nutritional and physical rehabilitation guidelines.
Here are five expert-recommended strategies that can help protect muscle, strength and overall health during recovery.
-- Move as you're able.
-- Add resistance.
-- Prioritize protein.
-- Boost vitamin and mineral intake.
-- Keep close tabs with your medical team.
Move as you're able.
"The sooner you move, the better," Abreu-Sosa says, explaining that, in the hospital, the COVID-19 patients she works with have three hours of physical therapy five days per week. "Here in the hospital, we are starting exercise even on the day of admission if vitals are stable. Even in patients who are intubated, we work on passive raise of motion, raising their arms and legs and positioning muscles." Once home, Mooney recommends people get up and move every 45 minutes or so. Walking, performing acts of daily living like bathing and dressing as well as structured exercises such as cycling and squats are beneficial.
"Any physical activity should be based on symptoms and current levels of function," she says, explaining that the goal is to engage the muscles of the body without exacerbating any symptoms. Fatigue, shortness of breath and dizziness are all cause to stop exercise.
When integrating movement into your recovery routine, prioritize resistance-based exercises that challenge your body's largest muscle groups, Mooney recommends. She says that completing three 15-minute workouts per week is a great starting point, and patients can increase frequency and duration as recovery progresses.
Take special care to focus on the hips and thighs as well as back and shoulders, as these muscle groups tend to lose the most strength in COVID-19 patients, Abreu-Sosa says, and have wide-reaching effects on the ability to stand, walk and perform everyday tasks.
To strengthen the lower body, try exercises such as squats, glute bridges and side steps. For the upper body, incorporate row and shoulder-press variations. Your body weight, light dumbbells and resistance bands all make great at-home resistance gear, Mooney says.
Prioritize protein and HMB.
"Protein is needed to build, repair and maintain muscle, but also to support the production of antibodies and immune system cells," Pereira says. Unfortunately, protein intake is often lower than it should be in COVID-19 patients. While illness can decrease appetite, many older adults, who are at high-risk for coronavirus-related muscle loss and complications, do not meet current federal guidelines for daily protein intake, she says.
"Aim for 25 to 30 grams of protein at every meal if possible, by eating meats, eggs and beans or using an oral nutrition supplement," she says. Research published in the Journal of Parenteral and Enteral Nutrition in 2018 suggests that specialized nutritional beverages can help decrease length of stay in the hospital and help reduce chances for readmission. When trying nutritional beverages, look for options that include HMB (beta-hydroxy beta-methylbutyric acid), a metabolite of the amino acid leucine, that can aid in muscle retention, especially in times of bedrest, she says.
Boost vitamin and mineral intake.
Vitamin A, C, D and E and zinc are critical to immune function, but they also play a role in both muscle health and energy, Pereira says. She recommends incorporating milk, fatty fish, fruits and veggies and other plants like nuts, seeds and beans into your recovery diet. If you have trouble cooking for yourself at home, consider trying out healthy meal-delivery services to help you get a wide range of nutrients.
Even with the best whole-foods efforts, some people may have trouble maintaining optimal nutrition levels. That's especially true concerning vitamin D, which the skin produces in response to sunlight, Mooney says. (Until receiving medical clearance, it's important to stay inside during recovery to reduce the risk of spreading the infection to others.) Again, many complete nutritional beverages are rich in these vitamins and minerals, and you can also discuss supplementation with your doctor.
Keep close tabs with your medical team.
It's vital that, during recovery, you maintain an active relationship with your treating physician. COVID-19 patients who have had extended stays in the hospital or the ICU typically have assigned health care teams, Abreu-Sosa says. These teams comprise various experts across specialties who are great resources that patients should use throughout the recovery process.
Frequent patient-doctor collaboration is key. Talk to them about your concerns to maintain muscle health, and ask for help customizing nutrition and activity routines, asking any questions you have to troubleshoot issues along the way, Pereira says. Whether you're having trouble getting the nutrients you need or aches and pains that limit your workouts, that's what they are there for.
K. Aleisha Fetters, MS, CSCS, is a freelance Health & Wellness reporter at U.S. News. As a certified strength and conditioning specialist with a graduate degree in health and science reporting, she has contributed to publications including TIME, Women's Health, Men's Health, Runner's World, and Shape. She empowers others to reach their goals using a science-based approach to fitness, nutrition and health. You can follow her on Twitter or Instagram, find her on Facebook or the Web or email her at email@example.com.