BJMB
Brazilian Journal of Motor Behavior
Special Issue:
COVID-19 (coronavirus disease): Impacts on motor behavior
!
Pelicioni et al.
2021
VOL.15
N.1
COVID-19 and its impact on human motor control
PAULO H. S. PELICIONI
1
| AURELIO D. SANTOS
2
| KARINE V. TAKO
3
| PAULO C. R. SANTOS
4,5
1
Falls, Balance and Injury research Centre - Neuroscience Research Australia, Sydney, NSW, Australia.
2
Centro Universitário Leão Sampaio, Juazeiro do Norte, CE, Brazil.
3
Universidade Federal de Sergipe, Lagarto, SE, Brazil.
4
University of Groningen, University Medical Center Groningen, Department of Human Movement Sciences, Groningen, The Netherlands.
5
São Paulo State University (UNESP), Graduate Program in Movement Sciences, Institute of Biosciences, Posture and Gait Studies Laboratory (LEPLO), Rio Claro, SP,
Brazil.
Correspondence to: Paulo Henrique Silva Pelicioni - Neuroscience Research Australia - 139 Barker Street - Randwick 2031 NSW Australia.
email: p.pelicioni@neura.edu.au
https://doi.org/10.20338/bjmb.v15i1.196
ABBREVIATIONS
CNS Central Nervous System
COVID-19 Coronavirus disease 2019
LoS Length of stay
SARS-CoV-2 Severe acute respiratory
syndrome coronavirus 2
WHO World Health Organization
PUBLICATION DATA
Received 24 09 2020
Accepted 19 11 2020
Published 01 03 2021
ABSTRACT: COVID-19 is affecting people differently worldwide with its impact ranging from pneumonia, acute
respiratory distress syndrome to death. The direct and indirect effects of COVID-19 on a person’s motor control
including on the execution of balance and gait tasks varies. This paper outlines why this may occur and explores
neurological complications, mental health, cardiorespiratory complications, hospitalization and reduced physical
activity level from COVID-19, and how these issues might affect human motor control. This paper also suggests
how these issues may be minimised through strategies such as telehealth and physical exercise programs.
KEYWORDS: COVID-19 | Motor control | Gait | Balance
INTRODUCTION
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, also
known as coronavirus disease 2019 (COVID-19), can lead to acute respiratory distress
syndrome, pneumonia, and, other health problems, which can lead to poor prognoses,
including death.
1
Consequently, in March 2020, the World Health Organization (WHO)
declared COVID-19 a pandemic. There have been approximately 1.33 Million deaths
worldwide, at the time of writing in mid-November 2020. Despite not being infected, the
lockdown measures may impact people’s health with an increase in health issues such as
mental health, reduced physical activity levels and social disconnection.
2,3
Unfortunately,
this scenario may be worsened for individuals who have been affected by COVID-19,
especially human motor control. By affecting neurological features COVID-19 may impair
the central mechanisms involved in the planning, execution and adaptation of motor tasks.
The objectives of this paper are to outline the neurological, mental health, and
cardiorespiratory issues caused by the COVID-19 infection on motor control and more
specifically to human gait and balance control. In addition, we highlight how the
hospitalization and mandatory isolation (to contain the spread of the infection) might also
affect human gait and balance control. This paper discusses how the neurological, mental
health, cardiorespiratory, hospitalization and mandatory isolation issues combined are
perhaps affecting human balance and gait. In addition, we briefly discuss the importance of
physical activity strategies to further reduce the disadvantages caused by COVID-19
infection and its negative impact on human health, such as the promotion of physical
exercise regimes.
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1. Neurological complications
Recent growing evidence showed that several impairments on the Central
Nervous System (CNS) were caused by COVID-19 infection.
4,5,6
Such evidence also
suggested that over one-third of COVID-19 patients manifest neurological complications,
7
such as headaches, impaired consciousness, anosmia, paresthesia, and myalgias.
5
As
well as the typical neurological manifestations, abnormalities in CNS may be present in
postmortem brains due to SARS-CoV-2. For instance, regarding coronaviruses, Ding and
colleagues
8
indicated the presence of SARS-CoV viral RNA within brain tissues of infected
patients. SARS-CoV infection can easily spread through brain areas, such as thalamus
and brainstem and related pathways.
9
Furthermore, like many other coronaviruses
infections, patients infected with COVID-19 are more susceptible to present with additional
CNS damage, such as toxic encephalopathy and severe acute demyelinating lesions.
10
!
Physiological aspects related to COVID-19 infection presumably explain the
neurological damage in patients. Brain hypoxic is normally evident in COVID-19 patients
and can lead to toxic encephalopathy,
4
which increases the risk of ischemic brain injury
and cerebral haemorrhage. Previous evidence also indicated that SARS-CoV can directly
affect the CNS via the cerebral spinal fluid,
11
causing nerve damage, and consequently,
lead to the neurological symptoms mentioned above.
4
2. Mental Health issues
Psychological distress and mental illness can be directly and indirectly related to
COVID-19 outbreaks.
12
Directly, theoretical models and physiological aspects related to
the infection also explain the increase in psychological symptoms. In particular, COVID-19-
related infections on cerebral spinal fluid and CNS may result in changes in
neurotransmitter pathways such as serotoninergic dorsal raphe system.
9
Deficits on
neurotransmitters are closely related to an increase in the prevalence of depression,
anxiety, and fatigue symptoms.
13,14,15
Furthermore, the serotoninergic dorsal raphe system
(system related with non-motor symptoms – anxiety, depression, fatigue) are connected
with several other brain regions (cortex, striatum, amygdala, substantia nigra,
hippocampus, and locus coeruleus).
16
Among the recommendations to mitigate the spread of the virus, the WHO is
strongly advising measures of mandatory isolation and quarantine. Mathematical models
and databases reliably suggest that quarantine measures are important to reduce
incidence and mortality resulting from COVID-19.
17,18
However, consequences of
mandatory isolation and quarantine involve drastic changes in human behaviour and
lifestyle, exacerbating the risk of mental illness in these individuals. For example, people in
quarantine are more susceptible to develop anxiety, fatigue, insomnia, irritability, and
indecisiveness.
19
Specifically considering anxiety and depression, Tang and colleagues
20
verified a high trait of both anxiety and depression among quarantined vs. not quarantined
people and, perhaps, the most worrying of the results is that approximately 80% of 1160
responders indicated an anxiety trait. Therefore, the direct and indirect effects of COVID-
19 on mental health indicators are a huge concern to health systems worldwide.
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3. Cardiorespiratory complications
COVID-19 infection is associated with several cardiovascular complications, such
as myocarditis, arrhythmias, and venous thromboembolism.
21
Cardiovascular comorbidities
are frequent in people infected with COVID-19, maybe as a consequence of myocarditis.
22
Patients who present with severe complications from COVID-19 are identified only one
week after the onset of symptoms of respiratory distress and/or hypoxemia and may
progress rapidly to acute respiratory distress syndrome.
23
Such complications can hinder
the cardiovascular rehabilitation process.
4. Hospitalization
Patients with COVID-19 infection present with different levels of severity. Those
individuals presenting with moderate to severe complications are more likely to be
hospitalized. Hospital care can vary from general ward-based care to high dependency
units with oxygen support and intensive care, where patients may be intubated for
mechanical ventilation.
24,25
The patients’ length of stay (LoS) depends on the level of care
required, as well as on the geographic setting the patients are hospitalized in since there is
a heterogeneity of COVID-19 care guidelines within countries.
A recent systematic review reported LoS of patients infected with COVID-19 in
hospital and intensive care units (ICU) worldwide.
26
The median hospital LoS ranged from
3 to 19 days and the median of intensive care patients LoS ranged from 4 to 19 days. This
study also revealed that patients who survived had longer LoS than those who died. In a
different study, Mishra and colleagues reported that the median length of hospital stay in
India was 17 days.
27
In all these studies, the mean age of people hospitalized due to
COVID-19 was approximately 59 years.
26
Since scientific evidence suggests that
hospitalization causes several negative impacts on motor function, long hospitalization as
a result of COVID-19 infection can exacerbate these negative effects, consequently
affecting individuals’ mobility and quality of life, especially older and vulnerable people.
28,29
5. Physical inactivity
The COVID-19 pandemic is an unprecedented, global, public health crisis. Entire
populations have been under strict lockdown measures, and, for those infected with
COVID-19, they have had to follow strict, mandatory, self-isolation measures. Mandatory
isolation, in addition to the decline in the health status described in sections 1-4 (above), is
increasing individuals’ sedentary behavior. In addition, immobilization and bed rest due to
hospitalization and physical inactivity can decrease the ability of organ systems to resist
viral infection and increase the risk of damage to the immune, respiratory, cardiovascular,
musculoskeletal and CNS.
30
Confinement and a sedentary lifestyle can cause a rapid deterioration of
cardiovascular health and premature deaths among populations of increased
cardiovascular risk. Reduced physical activity levels lead to an impaired aerobic capacity
at all levels of the oxygen cascade, from the cardiovascular system, including peripheral
circulation, to the oxidative function of skeletal muscle.
31
Even a short period of physical
inactivity (1-4 weeks) can lead to deficits in cardiovascular function and structure and
increased cardiovascular risk factors.
32
Physical inactivity due to COVID-19 infection can lead to changes in the
musculoskeletal system. For example, muscle mass loss occurs quickly, being detectable
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within two days of a period of inactivity. This loss of muscle mass is associated with
denervation of muscle fiber. Damage to neuromuscular junctions is mainly explained by
the suppression of muscle protein synthesis.
30,31,33
A simple short-term reduction in
physical activity levels significantly impacts skeletal muscle protein and carbohydrate
metabolism, causing anabolic resistance and peripheral insulin resistance. Peripheral
insulin resistance induced by short-term inactivity in skeletal muscle and adipose tissue,
with consequent accumulation of triglycerides in the liver, can lead to hepatic insulin
resistance and dyslipidemia. With regard to the endocrine system, physical inactivity
affects glucose homeostasis and reduces insulin sensitivity. Physical inactivity is
associated with fat deposition, associated with systemic inflammation and activation of
antioxidant defenses, exacerbating muscle loss.
31
Due to COVID-19, hospitalization is more prevalent in older adults and vulnerable
people. These individuals may be more likely to have cardiometabolic diseases, as well as
frailty.
2,3,33
A transition from active-to-sedentary and sedentary behaviour leads to slower
gait speed and deficits in the mobility of healthy older adults and people with neurological
disorders.
34,35,36,37,38
DISCUSSION
We have discussed, with some evidence how health and cardiorespiratory issues,
hospitalization and physical inactivity due to COVID-19 may affect human gait and balance
control. Although there is no direct evidence showing that COVID-19 would affect human
motor control, brain damage resulting from COVID-19 infection is plausible affecting the
planning and organization of movement outputs. As stated in section 1, some neurological
impairments were caused by the COVID-19 infection. Thus, impairments in brain structure
and function, such as thalamus and brainstem, directly affect human movement.
39
The
thalamus and brainstem are essential for controlling motor tasks, such as posture and gait.
The brainstem is involved in the automatic process of the regulation of postural muscle
tone and postural reflexes, and CNS structures seem to be involved in the cognitive
process of postural maintenance when humans are learning new motor skills or need to
adapt their posture.
40,41
Such assumptions are supported by data from neurological
populations, such as Parkinson’s disease and thalamic disease, where these patients
show deficits in postural and gait control when these areas are affected.
42,43,44,45
Similarly, neurological COVID-19-related symptoms might also affect motor control.
Myalgias may acutely impair the movement execution. Previous data indicates that pain is
related to gait disturbances.
46,47
Myalgias is therefore presumably affected by peripheral
and central features also involved in motor control. Also, COVID-19 sensorial-related
impairments (e.g. anosmia, paresthesia) could affect motor control. Sensorial information
is essential to cognitive control of human movement, as well as movement planning,
organization, and execution.
48
Therefore, if the quality and processing of sensorial
information is impaired, the motor performance (e.g., gait) is also affected.
40
Mental health issues are also associated with a decline in motor control.
Experimental data indicated that anxiety affects the efficiency of tasks that require
relatively high levels of attention.
49
The interference of anxiety and depression on gait
control is also observed in the literature.
50,51
The most common changes in gait control
exhibited by people who have anxiety include slower walking speed, shorter step length,
reduced cadence, and dysfunction in balance and mobility.
52
Similarly to anxiety,
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depression also affects the gait and posture control,
53
as well as spatial-temporal
characteristics of human gait.
54
Depression and falls have a bidirectional relationship.
55
Older adults who experienced falls are twice as likely to be depressed.
56
The interplay
relationship between depression and gait/postural impairments, which can result in falls, is
explained by the underlying mechanism of depression and motor impairments.
55
Both
depression and impairments in gait/posture control are mediated through cognitive,
sensory, and motor pathways.
55
Therefore, impairments caused by COVID-19 on CNS
may result in serious consequences to mental health, such as the development of anxiety
and depression, by affecting brain areas and pathways also involved in motor control.
As mentioned in section 3, cardiorespiratory complications caused by COVID-19
may also affect balance and gait control. Individuals with acute cardiovascular diseases
caused by the COVID-19 infection may be more prone to periods of prolonged inactivity:
bed rest, reduced number of steps and sitting for long periods of time. This prolonged
period of physical inactivity contributes to the reduction of muscle mass and strength, as
well as a decline in cardiorespiratory fitness.
33,57,58
It is possible that physical inactivity is
associated with limitations of static balance, causing a decline in gait speed,
34
as well as
walking speed, which corresponds to a robust indicator of health status. This in turn is a
strong predictor of morbidity and mortality, mainly in older adults.
59
It is well-known that the impact of hospitalization can negatively affect mobility
among older adults.
28,29
A study of 959 hospitalized patients aged over 65 years showed
that younger patients and longer LoS (among other factors) were associated with mobility
decline.
60
This mobility decline is more accentuated in older adults, coinciding with the
average age of hospitalized patients due to COVID-19.
26
In summary, the numerous neurological complications associated with COVID-19
are likely to be associated with impairments in motor control, resulting in poor motor
behaviour. Drastic consequences of COVID-19 might occur in the functionality and
independence of patients, mainly when accompanied by other factors, such as aging
and/or the presence of comorbidities. However, the interpretation regarding the COVID-19
effect on motor control should be treated cautiously since it is still early to have a
consistent overview of the long-term neurological, mental health and cardiorespiratory
issues caused by COVID-19.
Although the consequences of COVID-19 extend to different age groups,
presumably, such consequences may manifest more often in older and vulnerable
populations. Even healthy ageing is associated with typical declines in neurological and
cardiorespiratory functions, which are reflected in mental health issues, decreased physical
activity levels and increased risk of falling.
61,62,63,64
These age-related characteristics are
examples of why WHO have recognized older adults as a “vulnerable” population with
regards to COVID-19. In combination with the latter, there is a relatively higher number of
hospitalization, readmission and deaths related to this population.
1,29,65
Reasonably, the
potential direct and indirect effects of COVID-19 on motor control may be more prominent
in older people than in young adults. Since the declines on multi-systems are even more
pronounced in vulnerable populations, the consequences of COVID-19 might drastically
affect their use of internal resources, as well as their capacity to effectively allocate such
resources during a motor task.
A multidisciplinary approach should be encouraged (including psychologists,
neurologists, physiotherapists and exercise physiologists) for patients who were
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hospitalised as soon as they are discharged from the hospital settings. Regarding the
serious impact on the cardiorespiratory system caused by COVID-19, a program focusing
on improving the symptoms of dyspnea, reducing possible complications, minimizing
disabilities and preserving physical function
20
should be encouraged. Allied-health
professionals should focus on gradual recovery models in order to promote patients’ return
to their activities in society as soon as possible. Considering the average age of patients
hospitalized due to COVID-19 (59 years) and the average length of hospital stay, early
mobilization should be considered to minimize the negative impacts on mobility and motor
control.
CONCLUSION
Respecting individuals’ limitations and regardless of individuals’ ages, a physical
activity program should be encouraged and prescribed.
66
Jimenez-Pavon and colleagues
67
presented a special commentary giving details about how physical exercise can work as a
therapy against mental and physical consequences of COVID-19. These exercises should
be adjusted for older and vulnerable people to reduce the deficits caused by COVID-19.
Either regular face-to-face protocols (for countries which do not have any more lockdown
restrictions, or if these restrictions were eased) and/or via telehealth (for countries which
are still dealing with lockdown measures, for example, Brazil and the United States) are to
be encouraged in order to manage the deficits caused by neurological, mental,
cardiorespiratory issues, hospitalization, and physical inactivity.
ACKNOWLEDGMENTS
We wish to thank Susanne Robinson (MSc) for helping with English revisions.
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Citation: Pelicioni PHS, Santos AD, Tako KV, Santos PCR. COVID-19 and its impact on human motor control. BJMB.
2021:15(1):9-19.
Editors: Dr Fabio Augusto Barbieri - São Paulo State University (UNESP), Bauru, SP, Brazil; Dr José Angelo Barela -
São Paulo State University (UNESP), Rio Claro, SP, Brazil; Dr Natalia Madalena Rinaldi - Federal University of
Espírito Santo (UFES), Vitória, ES, Brazil.
Copyright:© 2021 Pelicioni, Santos, Tako and Santos and BJMB. This is an open-access article distributed under the
terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: There was no funding for this study.
Competing interests: The authors have declared that no competing interests exist.
DOI:!https://doi.org/10.20338/bjmb.v15i1.196
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