What is the best course of action for a patient experiencing worsening tremors and collapsing after a COVID-19 (Coronavirus Disease 2019) infection?

Management of Worsening Tremors and Collapsing After COVID-19 Infection

Patients experiencing worsening tremors and collapsing after COVID-19 infection should be screened for post-COVID brain fog and neurological complications, with treatment focused on cognitive rehabilitation, psychological support, and symptom-targeted interventions while avoiding exercise if post-exertional malaise is present. 1

Initial Assessment

• Screen for post-exertional malaise first, as this will determine exercise recommendations
• Evaluate for specific neurological complications:
  • Internal tremors/vibrations (commonly reported in post-COVID patients) 2
  • Collapsing episodes (may indicate cardiovascular, neurological, or post-exertional malaise)
  • Cognitive dysfunction (brain fog)
  • Autonomic dysfunction

Treatment Approach

For Patients WITH Post-Exertional Malaise

1. Implement pacing strategies:

   • Avoid exercise and physical exertion that worsens symptoms 1
   • Use energy conservation techniques
   • Plan activities with rest periods

2. Breathing control techniques:

   • High side lying position
   • Forward lean sitting
   • Pursed lip breathing
   • Square box breathing 1

3. Gradual activity management:

   • Resume daily activities conservatively at a safe pace
   • Increase activity based on symptoms, not a predetermined schedule 3
   • Appropriate walking pace regulation to prevent oxygen desaturation 3

For Patients WITHOUT Post-Exertional Malaise

1. Gentle traditional exercises:
   • Tai Chi or Baduanjin with gradual progression 1
   • Pulmonary rehabilitation training for those with impaired function 3

For All Patients

1. Cognitive rehabilitation:

   • Memory exercises
   • Attention training
   • Executive function support

2. Psychological support:

   • Mindfulness training
   • Breathing relaxation techniques
   • Cognitive behavioral therapy
   • Group interventions 1

3. Consider pharmacological interventions:

   • Triple anticoagulant therapy may help resolve symptoms by addressing abnormal clotting 1
   • Coenzyme Q10 and D-ribose for fatigue symptoms 1
   • Short-acting anti-anxiety medications with low drug-drug interaction risk for severe anxiety 1

4. Traditional Chinese Medicine (TCM) options:

   • TCM decoctions based on syndrome differentiation
   • Non-oral TCM therapies like acupuncture, moxibustion, manipulation
   • Diet therapy and emotional therapy 3

Management of Associated Symptoms

Gastrointestinal Symptoms

• For abdominal fullness, anorexia, nausea: Consider TCM herbs with "regulating stomach and dissipating dampness" effects 1
• For constipation and abdominal distension: Consider Chengqi decoction series 1

Respiratory Support

• For those with respiratory symptoms: Provide education on breathing control techniques 3
• For severe respiratory symptoms: Consider TCM herbs with "dispelling wind, dredging collaterals, and resolving hard lumps" effects to reduce pulmonary fibrosis 3

Important Considerations and Pitfalls

1. Avoid overexertion:

   • 75% of patients report worsening with physical activity if they have post-exertional malaise 1
   • Caution patients against pushing through symptoms

2. Early intervention is crucial:

   • All COVID-19 long haulers should be screened for rehabilitation needs in terms of physical, cognitive, and mental disorders 3
   • Prompt treatment may reduce severity of long-term symptoms

3. Recognize the legitimacy of symptoms:

   • Internal tremors and vibrations are well-documented post-COVID symptoms 2
   • Patients often report frustrating experiences with healthcare systems that dismiss these symptoms

4. Monitor for cardiovascular complications:

   • COVID-19 can cause myocardial injury and reduced systolic function 3
   • Collapsing episodes may indicate cardiovascular involvement requiring specific management

By following this approach and recognizing the complex nature of post-COVID neurological symptoms, clinicians can provide effective support for patients experiencing worsening tremors and collapsing after COVID-19 infection.