The coronavirus disease outbreak has proven to be a major health crisis affecting virtually every facets of our lives. Coronavirus disease is an ongoing pandemic disease. The disease which is caused by a new type of virus, known as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Many patients hospitalized with COVID-19 will develop muscle weakness particularly those admitted in intensive care unit (ICU). Studies have shown that muscle weakness is one of the direct consequences of critical illness. We systematically reviewed literature that quantified changes in muscle strength and it relationship with COVID- 19 in Intensive care unit in humans.

1. Middle East Journal of Applied Science & Technology (MEJAST)
Vol.3, Iss.2, Pages 01-06, April-June 2020
ISSN: 2582-0974 www.mejast.com 1
Country: Nigeria
Covid-19: Intensive Care Acquired Weakness, A Possible Challenge in
Patient Recovery?
Oyeneyin Babatunde David1*
, Opeyemi Oluwasanmi Adeloye2
, Olukoju Idowu3
& OyeneyinTosin4
1,2,3
Department of Physiotherapy, University of Medical Science Teaching Hospital, Ondo, Nigeria.
4
General Hospital, Owo, Nigeria.
*Corresponding Author E-mail: pressydebado@gmail.com
Article Received: 22 May 2020 Article Accepted: 09 June 2020 Article Published: 11 June 2020
Introduction
Coronavirus disease is an ongoing pandemic disease (Oyeneyin et al, 2020.). The disease
which is caused by a new type of virus known as severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) (Astuti & Ysrafil, 2020). Many patients hospitalized with
COVID-19 will develop muscle weakness particularly those admitted in intensive care unit
(ICU) Studies have shown that muscle weakness is one of the direct consequence of critical
illness. Hermans and Van den Berghe (2015) refers to generalized muscle weakness,
which develops during the course of an ICU admission and for which no other cause can be
identified besides the acute illness or its treatment, as “intensive care unit acquired
weakness” (ICUAW). The cause of muscle weakness can be both in the muscle (critical
illness polymyopathy) and in the nerve (critical illness polyneuropathy). It can be classified
into three based on etiology; critical illness polyneuropathy (CIP), critical illness myopathy
(CIM), or critical illness neuromyopathy (CINM) (Zhou et al, 2014). It is a major problem in
weaning patient off ventilator and equally increases patient’s morbidity and mortality rate.
It slow down patient rehabilitation and is not totally reversible. It majorly affects extremities
and respiratory muscles.
Variation in the epidemiology of ICUAW is influenced by the population that are studied and
the criteria for diagnosis. In a study by Stevens et al (2007), the prevalence of CIP and CIM
of ICUAW was 46%. Prolong exposure to mechanical ventilation increases the chances of a
patient developing ICUAW. Research by Fan et al (2014), show that 33% of patients that
stayed on mechanical ventilator for 5 days developed ICUAW while 43% of patients on
mechanical ventilator for 7 days or more developed ICUAW. Probably because of the smaller
ABSTRACT
The coronavirus disease outbreak has proven to be a major health crisis affecting virtually every facets of our lives.
Coronavirus disease is an ongoing pandemic disease. The disease which is caused by a new type of virus, known as severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Many patients hospitalized with COVID-19 will develop muscle
weakness particularly those admitted in intensive care unit (ICU). Studies have shown that muscle weakness is one of the
direct consequences of critical illness. We systematically reviewed literature that quantified changes in muscle strength and it
relationship with COVID- 19 in Intensive care unit in humans.
Keyword: COVID-19, Respiratory, ICU, Muscle weakness, Pandemic.

2. Middle East Journal of Applied Science & Technology (MEJAST)
Vol.3, Iss.2, Pages 01-06, April-June 2020
ISSN: 2582-0974 www.mejast.com 2
muscle mass, the female gender are four times more likely to develop ICUAW compare to
the their male counterpart. It pathophysiology is still not well understood and so many other
conditions have been linked to it. The prognosis of ICUAW is largely dependent on factors
like patient age, number of days on ICU admission and other comorbidity. In this study, we
take a look at Covid-19 as a possible cause, prevention and management.
Covid-19 and Possible Relationship with Covid-19
The coronavirus disease outbreak has proven to be a major health crisis affecting virtually
every facets of our lives. Understanding of the virus and the diseases are still evolving. The
virus is an enveloped, positive single‐stranded large RNA virus that infect humans and also
many groups of animals. It has been established that the virus can cause respiratory
infection. Old people and people with underline medical condition such as diabetes, lung
disease, heart disease, compromised immune systems and chronic kidney or liver disease.
Symptoms of the viral infection often appear 2-14 days after exposure while some positive
patients are asymptomatic. Common signs and symptoms of the condition include fever,
cough, tiredness, sore throat, chills, shortness of breath or difficulty breathing, headache,
loss of taste or smell and chest pain.
Huang C and colleagues established that 20 percent of covid-19 positive patients develop
severe symptoms that require hospitalization. Most death that occurred as a result of
covid-19 are largely due to acute viral pneumonitis that later progress to acute respiratory
distress syndrome (ARDS).In a study carried out in Washington State, 81% out of 21
critically ill covid-19 patients were admitted to ICU and 71% of them were placed on
mechanical ventilator. In China, ICU admission of covid-19 patient that are critically ill
ranged from 7-26% (Yang et al, 2020). ICUAW can be a direct effect of SARS-CoV-2 and
also as a consequence of it precipitating factors such as prolonged hospitalization,
prolonged immobilization, sepsis and multiple organs failure (Hermans and Van den Berghe
2015).
Pathophysiology
Many covid-19 patients will become critically ill and need to be mechanically ventilated
following ICU admission (Yang et al, 2020). The pathophysiology of ICUAW is very complex,
not clearly defined and often time encompasses the affectation of both the muscles and the
nerves. Cases of polyneuropathy have been documented following covid-19. Abdelnour et
al, 2020 reported a case of a 69-year-old man who presented with motor peripheral
neuropathy after covid-19 infection. The relationship between neuropathy and myopathy
have shown both CIP and CIM cannot be separated but rather occur as CINM as a

3. Middle East Journal of Applied Science & Technology (MEJAST)
Vol.3, Iss.2, Pages 01-06, April-June 2020
ISSN: 2582-0974 www.mejast.com 3
consequent of multi-organ dysfunction and failure. It is believed to be as a result of problem
with motor unit (made up of peripheral nerve, neuromuscular junction and skeletal muscle
fiber). In it pathogenesis, severe sepsis which is a common complication in critical illness
occur in severe symptomatic covid-19 patients causing multiple organs failure. During this
septic phase, degradation of protein start to occur, synthesis of muscle protein are inhibited,
there is occurrence of mitochondrial loss and dysfunction and there is abnormality in the
sequestration of myocyte Ca++
. At the cellular level, Ubiquitination occur and is associated
with increased proteolysis resulting in atrophy of skeletal muscles. Though ICUAW is often
accompanied by muscle wasting, neuromuscular dysfunction doesn’t necessarily occur as
the strength of a muscle depends both on the muscle mass and the force it can generate.
Another mechanism which have been used in the explanation of ICUAW is “Sodium
channelopathy”, which talk about the impairment of muscle contraction and the generation
of it action potentials, secondary to the loss of muscle membrane excitability. Other
mechanism in it pathogenesis emphasis on mitochondrion dysfunction which causes muscle
weakness and fatigue.
Diagnosis
The specific diagnosis of ICUAW particularly in covid-19 using nerve conduction study and
electromyography. ICUAW can be diagnosed as early as 24 to 48 hours by observing
electrophysiological changes using electromyography. This diagnostic approach obviously
should be the goal standard, however this could be challenging based on how highly
contagious the disease is, financial implication and lack of trained personnel. Manual muscle
testing is still the most practicable approach in diagnosing ICUAW in covid-19 patients, but
this can sometime be limited by level of patient arousal as study have shown that only
around 25% to 29% of patients admitted in ICU are adequately awake to assess muscle
strength.
Management
The management of ICUAW in covid-19 patients should be a multidisciplinary approach,
although there is no definitive management for ICUAW. Sedation strategy should be
employed which include intermittent sedation or no sedation at all so as to improve patient
alertness and availability for physical therapy. Enforced bed rest should be avoided while
early mobilization of patient should be encouraged. Electrical muscle stimulation (EMS) and
Neuromuscular electrical stimulation (NMES) are also useful while patient are not fully
active as they help to improve and maintain muscle strength while preventing muscle
wasting. Active and passive exercise should be incorporated in patient management based

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on current condition of the patient. Patient diet also play important role, not only does it help
in boosting the immune system in fighting against covid-19, study have shown that anemia,
hypoalbuminemia, and vitamin D deficiency were found in patient with strength, balance,
coordination, mobility, and endurance impairment. Post-acute rehabilitation should be
instituted upon discharge from ICU as research have shown that many patients with ICUAW
do not fully recovered and the disability that follow can seriously affect their activity of daily
living.
Prognosis
The most important factor in the recovery of ICUAW in covid-19 is first the ability of the
patient to survive the viral infection. While knowledge about covid-19 is still evolving, there
have been improvement in the rehabilitation and medical management of patient with
ICUAW. Limitation in functional activities and muscular weakness have been observed in
ARDS survivors after 1 year, and after 5 years their 6-min walk tests scores were just 70%
of predicted results . The prognosis of CIM is better than CIN, however neuromuscular
damage in both can last up to 15 years.
Conclusion
ICUAW in covid-19 is a serious complication that can negatively affect patient survival,
affect their quality of life even after discharge from ICU and contribute to functional
disability. While it pathophysiology is still not clearly defined, attention should be paid to
critically-ill covid-19 to prevent ICUAW and timely medical management and rehabilitation
should be instituted once the clinical features of ICUAW are observed.
Acknowledgement
Sincere appreciation goes to all of our Colleagues at the department of physiotherapy in
UNIMEDTH, Ondo, Nigeria who have been very supportive during the time this study was
been carried out. Our dedication goes to all health workers that are working in ICU and
managing COVID-19 patients during this pandemic, worldwide.
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