By Ruth Werner
Preface
I am a pathology educator, and it is my job to keep current with available information about pathologies, as it applies for massage therapists. This has been particularly challenging of late, because as we know, our understanding about COVID-19 changes hourly.
What I offer here is a brief overview of what we currently understand about this infection, presented in the same format that I use in my textbook (A Massage Therapist’s Guide to Pathology, www.booksofdiscovery.com), listing the definition, demographics, pathophysiology, signs and symptoms, treatment options, and implications for massage therapy. I find this is an effective way to provide the information that ultimately informs choices about massage therapy for most conditions. That said, this blog is a snapshot in time. This piece was written on April 22–23, and updated April 27, based on resources published before that point. It is completely plausible that in a week much of what you find here could be considered outdated. That’s OK—we have to start someplace.
Definition
COVID-19 is the name given to the disease caused by a virus called SARS-CoV-2. Its name derives from Corona Virus Disease of 2019—it did not have 18 predecessors. This pathogen is an RNA-based virus in the coronavirus family that attacks the respiratory system and other tissues with potentially deadly consequences.
Demographics
As of this writing, COVID-19 has been diagnosed in 3 million people worldwide, and it has caused 211,000 deaths so far. In the United States, it has been diagnosed in 1.1 million people and caused about 67,000 deaths. However, that diagnosis rate is falsely low because of shortages in testing capacity. Numbers of new diagnoses will certainly increase if and when testing becomes more widespread.
COVID-19 can affect people of all ages, but it appears to be rare in children (at least in terms of causing symptoms). It occurs on a spectrum of severity, and older people are most likely to have more severe versions of this disease. Other predictors for morbidity (how sick people get) or mortality (whether they survive) include pre-existing conditions like obesity, hypertension, diabetes, and other chronic diseases. That said, about a fifth of all the people in US hospitals with COVID-19 are between age 20 and 44.
Pathophysiology
Viruses aren’t technically living organisms. They are packets of genetic material that target specific cells in their hosts. The viruses invade those cells and retool them to become virus factories. The invaded cell dies, releasing copies of the virus to invade neighboring cells, and so the infection progresses.
Because viruses aren’t alive, they can’t be killed—but they can be destroyed when their molecular structure is dismantled. So instead of talking about “killing” viruses, we look at whether they can stay intact (and therefore potentially infectious) or disintegrate in various circumstances. SARS-CoV-2 appears to be sturdy on some surfaces, but it will fall apart with the application of soap and water.
SARS-CoV-2 enters the body most efficiently by way of the respiratory tract, although oral-fecal transmission is also possible. Most researchers agree that respiratory droplets are the most likely mechanism for the virus to spread from one person to another. This can happen when we’re in a 6-foot range of someone talking, singing, coughing, or sneezing—but one study showed that the virus spread from one person to others in a restaurant specifically along the draft line of an air conditioner that was blowing their respiratory droplets to other tables—much farther than 6 feet. And transmission can also happen when respiratory droplets fall on an object: a counter, a credit card, a computer keyboard . . . and then it is carried to the mouth, nose, or eyes by way of a contaminated hand.
Once the virus enters the body, it has been seen to be able to enter target cells through membrane markers called angiotensin converting enzyme 2 (ACE2) receptors. These receptors are found in cells that populate the lungs, heart, kidneys, intestines, and—this is vital—endothelial cells that line the blood vessels that supply all these organs. It has been noted that cellular disruption occurs both because of direct viral attack, and because of a secondary inflammatory response leading to endotheliitis: inflammation of the endothelium, with accompanying apoptosis—cell death and necrosis.
When the virus is in the lungs, it has access to pneumocytes: cells that manufacture surfactant, the substance that keeps alveoli inflated. As the infection progresses, alveoli collapse, and the capacity for gaseous exchange is lost. Further, the virus appears to stimulate an immune response that leads to massive blood clotting. By the time a person develops shortness of breath, they may have lost significant lung function. (Note: more on the role of blood clotting in COVID-19 and other conditions will be the focus of my column in the July/August edition of Massage & Bodywork magazine.)
About 20 percent of those who develop symptoms end up needing hospitalization. Symptoms are often the most extreme and threatening around day 10, when acute respiratory distress syndrome (ARDS) is likely to develop.
The incubation period between exposure and the development of symptoms ranges from 2–12 days, but is usually about 5 days long. Viral load builds first in the nose and upper respiratory tract, before symptoms develop. Communicability appears to be highest just before and after the onset of symptoms, but it is possible to shed virus with no symptoms at all—specialists estimate that 25–50 percent of infections are spread from people with silent infections.
Tests show that the virus can be intact and suspended in the air for an average of 3 hours, but in this form, it is in much lower concentration than seen in respiratory droplets. We also see that the virus can stay intact on some surfaces for many hours—about 4 hours for copper, 24 hours for cardboard, and up to 3 days on plastic and stainless steel. How long it stays intact on fabrics depends on many factors like temperature and humidity.
Some alarming tests have shown viral particles many days or even weeks after the last human contact, or after extreme environmental challenges, but viral particles are not the same as whole viruses, and they are not infectious.
Overall, COVID-19 appears to have a mortality rate between 2–3 percent of symptomatic people. Researchers from Wuhan, China, reported that when large-scale testing included infected-but-asymptomatic people in the count, the mortality rate was about .6 percent. (For comparison, the mortality rate of seasonal flu is about .1 percent.)
Complications
The primary complication associated with COVID-19 is ARDS, which can lead to blood clotting in the lungs, cytokine release syndrome (brilliantly described by Til Luchau in the May/June 2020 Massage & Bodywork article “Understanding COVID-19’s Cytokine Storm,” page 80), circulatory shock, and respiratory collapse. But the drastic inflammation and associated tissue damage seen with this infection is not always limited to the lungs.
Many patients experience heart damage, in the form of arrhythmia, cardiomyopathy, and/or pericarditis. It is unclear whether these problems develop because of a direct attack from the virus, or if they are secondary to inflammation and pneumonia.
Neurological damage is signaled by the loss of the sense of smell or taste, but other nervous system indicators include headaches, hallucinations, dizziness, confusion, or trouble speaking.
Renal failure is recognized as an important risk, and some patients have shown signs of viral attacks specifically in the kidney tissues.
For reasons we are still exploring, younger patients appear to carry an especially high risk for blood clotting in the extremities, and subsequent pulmonary embolism—leading to more damage and inflammation in the lungs.
Ultimately with progressive damage and an immune system in disarray, many people with COVID-19 succumb to multiple organ failure.
Signs and Symptoms
Most cases of COVID-19 are asymptomatic or mild (meaning, it doesn’t require hospitalization). Up to 80 percent of diagnosed people meet this description.
The most common symptoms of a new infection include fever, dry cough, shortness of breath, muscle aches and pains (myalgia), fatigue, and a loss of taste and/or smell. Note: these symptoms can be associated with non-COVID viral infections as well.
Less common symptoms include sore throat, headache, productive cough, gastrointestinal pain, and new skin lesions that can look like purple spots, measles, chickenpox blisters, or a rash—these usually appear on the extremities, typically the toes.
For 20 percent of patients, COVID-19 is severe enough to require hospitalization. These people are at increased risk for the most severe consequences of this infection. Low blood oxygen (hypoxemia), high and persistent fever, and other proinflammatory markers may be part of the process.
Testing
The issue of testing to find out who has the virus and who is at risk for catching it is a big unanswered question. Tests for current infection rely on a deep swab from the back of the sinuses, and the swabs don’t always pick up viral samples, so the possibility of false-negative tests is substantial. Further, people who are further along in the disease process have viral populations in the lower respiratory tract, so this type of test is likely to be inaccurate in that situation as well.
Antibody testing can help determine if a person has had a mild or asymptomatic case in the past, but this too is fraught with problems. Serum antibodies don’t develop until 5–10 days after exposure, so a premature test will be negative. Not all tests meet the same standards for accuracy, and while some provide information about the strength of the antibody reactions, others only give a yes-or-no answer to the question of past exposure.
In addition, we have some indication that a history of COVID-19 may not provide full immunity. We don’t know how long the antibodies last, or what the risk is of future infection, so a positive antibody test does not necessarily mean a person is fully immune.
Treatment
As of this writing, treatment for severe COVID-19 consists of symptom management, with special focus on inflammation and blood clotting risk. It has been found that “proning” patients, that is, positioning them on their bellies, seems to take some pressure off the lungs and reduce resistance in breathing.
Antiviral medications, anti-inflammatories, and immune system modulators are all being investigated, and the race toward a vaccine is of course under way. The use of convalescent plasma—that is, employing the antibodies of people who have recovered to treat those still under attack—is another new pathway toward treatment that has some promise, so those who have high antibody levels may be asked to donate plasma for this purpose.
If lung damage is severe and no other interventions have helped, then a patient might be intubated and attached to a ventilator in the hopes that their lungs will recover. This stage of disease has a poor prognosis, however, and only a minority of patients improve after this is instituted.
The Role of Massage Therapy
At this point, I can’t suggest that massage therapy serves any useful purpose for a client who is sick with COVID-19; the risks simply outweigh the benefits. If someone has recovered, then massage must be applied in such a way as to support but not overwhelm them through what may be a long and challenging recovery process.
Other implications for massage have to do with practicing in a way that protects ourselves and our clients (and by extension, virtually everyone else in our lives) from the risk of infection—even from people who appear to be completely healthy. The appearance of COVID-19 will lead to new protocols in hygienic practices. ABMP has published a set of guidelines to help practitioners begin to make this transition.
The possibility of life-threatening blood clots is another red flag for massage therapists. For this reason, any new skin lesions or signs of stroke or pulmonary embolism are reasons to go directly to the emergency room.
I hope this thumbnail sketch is helpful as you contemplate your next steps in this new world of massage therapy practice. I believe as soon as it is safe to share them, our skills will be in more demand than ever.
Resources
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Advisory Board. “It’s Not Just Lungs: Covid-19 May Damage the Heart, Brain, and Kidneys.” Last modified Apri 17, 2020. Accessed May 5, 2020. www.advisory.com/daily-briefing/2020/04/17/organ-damage.
Auwaerter, Paul G. “Coronavirus COVID-19 (SARS-CoV-2).” Last modified April 27, 2020. Accessed May 5, 2020. www.hopkinsguides.com/hopkins/.//view/Johns_Hopkins_ABX_Guide/540747/all/Coronavirus_COVID_19__SARS_CoV_2_?refer=true.
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