POST-TRAUMATIC STRESS DISORDER IN INDIVIDUALS WHO REQUIRED HOSPITALIZATION FOR COVID-19: A CROSS-SECTIONAL STUDY

Background: COVID-19 can result in a wide variety of chronic health issues, taking an emotional toll with post-traumatic stress disorder (PTSD) such as impaired lung function, reduced exercise performance and decreased quality of life. Objectives: To evaluate post-traumatic stress disorder (PTSD) in individuals after hospital discharge due to COVID-19 and its relationship with sociodemographic variables, quality of life, muscle strength, and functional capacity. Methods: This is a cross-sectional study , conducted at the Laboratory of the Federal University of Pernambuco, including individuals of both genders aged between 31 and 79 years, recovered from COVID-19 and required hospitalization. Individuals with musculo-skeletal disorders and cognitive disorders were excluded. Results: A total of 153 individuals were deemed eligible for the study, and 60 completed the assessments. The age range ranged from 31 to 77 years, and 63.3% were female. PTSD was found in 48.3%, and 38.7% had partial symptoms; moreover, 65.5% of those with PTSD were obese and 62.1% were hypertensive. They were also more sedentary (p=0.009), were hospitalized in the ICU, and had more days hospitalized, respectively (p < 0.001 and p=0.010), longer times on the TUG (p=0.014), shorter distances than those predicted in the 6MWT (p=0.001) and a reduction in all domains of the SF-36. Conclusion: Individuals who recovered from COVID-19 with PTSD were characterized as being more sedentary, requiring ICU admission, more days in the hospital, presented a moderate risk of falling, had lower performance in functional capacity, and had respiratory muscle strength below the predicted values. Implications: Analyzes of the results obtained from the study showed a marked presence of PTSD in patients who were hospitalized for COVID-19, in addition to showing a reduction in lung function, exercise performance, and impaired quality of life, even after recovery from the disease. Therefore, the results started for an early identi ﬁ cation of the clinical conditions of the post-COVID-19 patient pro ﬁ le.


INTRODUCTION
With the exponential increase of Covid-19 in mid-March 2020, the spread of news about contagion forms, disease severity and the need for social isolation as mitigation efforts led to emotional impacts which became more evident with its spread 1 .
COVID-19 triggers inflammation in both the body and the brain, giving rise to psychiatric symptoms, particularly in individuals who have been discharged from the hospital after experiencing a significant level of emotional stress due to confinement within the hospital setting and the impact of the disease itself 2 .Social distancing and social isolation measures 3 have led patients being more prone to anxiety symptoms, depressive disorders and insomnia, resulting in the occurrence of post-traumatic stress disorder (PTSD) 2 .PTSD is a persistent and intense experience of traumatic memories, psychological and physiological suffering, symbolizing aspects of the traumatic event, continuous symptoms of increased excitability and occupational impairment in several important areas of their life 4 .
According to previous evidence, individuals with COVID-19 manifest psychiatric symptoms that persist or become present months after the initial infection 5 .In a study carried out in Italy, about 56% of COVID-19 survivors had at least one of the domains evaluated for psychiatric sequelae (PTSD, depression, anxiety, insomnia and obsessivecompulsive symptomatology) after one month of hospitalization 6 .
Patients who required hospitalization witnessed traumatic events during their hospitalization, such as sudden deterioration from the disease, emergency resuscitation procedures, or even death 7 .Situations of this nature can trigger PTSD, which is manifested by a set of emotional and behavioral reactions 8 .https://doi.org/10.7322/abcshs.2023158.2451 At the time of this study, no literature findings were available regarding the impact of Covid-19 on the occurrence of PTSD, quality of life, muscle strength, or functional capacity among patients who had required hospitalization.Corral et al. 9

Measures
The individuals initially had their sociodemographic (age, gender, marital status and nationality), symptoms (fever, asthenia, anosmia, dyspnea, headache and dizziness), weight (kg), height (meters) and body mass index (BMI), length of stay in the ward or ICU (days), use of invasive mechanical ventilation (yes/no) and time (days), or time of oxygen therapy support (days) and presence of previous comorbidities data collected.
The patients were subsequently evaluated for: PTSD (event impact scalerevised (IES-R), physical activity level (IPAQ), body composition, maximal inspiratory (MIP) and expiratory pressure (MEP) muscle strength, hand grip (dynamometry), mobility and balance (Timed Up and Go test), quadriceps muscle thickness of the dominant lower limb (muscle ultrasound), the distance covered in the 6-minute walk test (6MWT) and quality of life (SF) -36), all evaluations were performed by a single evaluator.

Post-traumatic stress disorder
The event impact scalerevised (IES-R) translated into Portuguese was applied to assess post-traumatic stress disorder 10 .This scale is self-administered, composed of 22 items distributed in 3 subscales (avoidance, intrusion and hyperstimulation) that include the evaluation criteria for post-traumatic stress disorder published in the 4th edition of the American Diagnostic Classification (DSM-IV) of the American Psychiatric Association.
The individuals responded based on the pre-defined stressor event "hospitalization period".
The score for each question ranges from 0 to 4 points.Responses are scored on a Likert scale, and their total score ranges from 0 to 88 points.A score > 24 indicates the presence of partial symptoms of PTSD 11 and ≥ 33, a probable diagnosis for PTSD 12 .

Physical activity level was verified using the short version of the International
Physical Activity Questionnaire (IPAQ).This questionnaire consists of 8 open questions about the time and frequency of activities performed in the last week, and assesses the time spent per week in physical activities.The questionnaire classifies the physical activity level into "sedentary", "irregularly active A and B", "active" and "very active" 13 ; however, the classification of patients for this study were considered as "active" (very active and active categories) and "sedentary" (irregularly active and sedentary categories) 14 .

Body composition
Body composition was analyzed using body bioimpedance (InBody R20, Dogok 2-Dong, Gangnam-Gu, Seoul, South Korea).The individual was instructed to wear light clothes, and empty their bladder before the examination.The patient remained in an orthostatic position during the test with their feet positioned on the electrodes on the surface of the digital scale and the other electrodes attached to a bar held by their hands.
The bioimpedance lasted 30 seconds and was repeated in case of a reading error 15 .Body weight (Kg), body mass index (BMI, Kg/m 2 ), lean mass (Kg) and the calculated lean mass index (lean mass divided by height squared) were obtained [Kg/m²]).

Respiratory muscle strength
Individuals were instructed to perform a maximum inspiratory effort from the residual volume to measure maximal inspiratory pressure (MIP) (Global Med MVD300-U, Brazil), and then they were instructed to perform a maximum expiratory effort from their total lung capacity to determine maximal expiratory pressure (MEP).The greatest negative pressure sustained for at least one second was recorded.At least three reproducible maneuvers were repeated, with variability <10 cmH2O between measurements, and a one-minute rest between them 16 .The predicted values were calculated according to the study by Neder et al. 17 , and the predicted percentage was then calculated.

Handgrip strength
The handgrip strength measurement was performed on the dominant upper limb with the patient seated (Dinamometer Smedley-Typehand, Saehan, South Korea).https://doi.org/10.7322/abcshs.2023158.2451 Patients performed three attempts with an interval of 30s between each execution and the highest value obtained between the maneuvers was recorded; the highest value reached for the dominant limb was considered as long as the measurements differed below 10% 18 .
Next, the equation proposed by Novaes et al. 19 was used to determine the predicted value for each patient.The present study classified handgrip strength as low for values <32 kg for men and <17 kg for women, based on the 20 th percentile of the sample 20 .

Timed Up and Go (TUG) test
Patients performed the TUG test according to the instructions provided, being classified as totally free and independent for time <10 seconds and independent, with time between 10 and 19 seconds.The examiner accompanied the patient for their safety 21 .

Quadriceps muscle thickness
Quadriceps muscle thickness was measured using a portable high-definition ultrasound device using B-mode images (Sonoace R3, SamgungMedison, South Korea), with a linear type transducer and a frequency of 10Mhz.The transducer was positioned perpendicularly on the anterior thigh region of the dominant lower limb, viewing the cross-sectional image of the quadriceps muscle.Thus, three thickness measurements of each portion of the quadriceps femoris were performed: the vastus intermedius (VI) and the rectus femoris (RF), in millimeters, from the frozen image.The means of the 3 values obtained were <10% difference between measurements 22 .https://doi.org/10.7322/abcshs.2023158.2451

The 6-minute walking test
The 6MWT was performed according to the guidelines established by the American Thoracic Society 23 .The predicted distance was based on the study by Britto et al. 24 and then the predicted percentage in relation to the expected for each patient was calculated.

Quality of life
A questionnaire consisting of 36 items was applied for the quality of life assessment and subdivided into 8 domains called: "functional capacity" (FC), "physical aspects", "pain", "general health status", "vitality", "social aspects", "emotional aspects" (EA), and "mental health" (MH) 25 .The values for each domain were corrected and scored according to Simionato et al. 26 .The results were evaluated by assigning scores to each question, which were transformed into a scale from zero to 100, where zero corresponded to a worse quality of life and 100 to a better quality of life.Each domain was analyzed separately 27 .

Data analysis
Data normality distribution was initially verified using the Kolmogorov-Smirnov test.Data were presented using central tendency and dispersion measures.The association was verified by Pearson's Chi-Squared Test and/or Fisher's Exact Test.Comparisons between the group with and without PTSD were performed using the Student's t-test or the Mann-Whitney test.All tests were applied with 95% confidence.The analysis was performed using the Statistical Package for the Social Sciences (SPSS), version 13.0 for Windows.

RESULTS
Of the 153 individuals initially eligible for the study, 60 completed the assessments, as can be seen in Figure 1.
The age group ranged from 31 to 77 years (median 54.40) and 63.3% of the individuals evaluated were female.PTSD was found in 48.3%; however, 38.7% of individuals without PTSD presented criteria for the development of partial symptoms when the cut-off point > 24 was used.Among the main comorbidities in individuals with PTSD, 65.5% were obese and 62.1% were hypertensive.Fatigue and fever (93.1%), ageusia, anosmia and cough (82.4%), asthenia and headache (79.3%), and dizziness and nausea (72.4%) symptoms were the most frequent among them.The other characteristics are described in Table 1.
Table 2 demonstrates that individuals who had PTSD had a moderate risk of falling, lower performance on the 6-minute walk test, and reduced respiratory muscle strength compared to the group without PTSD.

DISCUSSION
The presence of PTSD in individuals who had severe and moderate COVID-19 was 48.3%; however, 38.7% of individuals without symptoms began to present criteria to develop partial symptoms for PTSD when the lowest cut-off point was considered.https://doi.org/10.7322/abcshs.2023158.2451 All the individuals evaluated in our study had the moderate and severe form of COVID-19 and required hospitalization in a hospital ward or in the ICU.The presence of PTSD after hospitalization for COVID-19 may be due to their experience in the context of hospitalization during the pandemic, in which they needed to be isolated in a hospital bed, they experienced the physical impacts of the disease, exposure to invasive procedures and had a constant fear of death 2 .
In a cohort developed by Vlake et al. 28 , it was found that the presence of PTSD in the first month after hospitalization for Covid-19 dropped from 16% to 7% at the end of the third month.The difference between the study by Vlake et al. 28 and ours may be related to the presence of different ethnicities (Asian, African, unknown and others) and the follow-up time of these individuals after discharge in the latter study.Our results point to PTSD persisting even after the fourth month of hospital discharge when data began to be computed.Individuals who presented PTSD were characterized as being more sedentary, having required hospitalization in the ICU and spending more days in the hospital.This may be associated with the use of sedative medications during the hospitalization period in the ICU 29 , generating an increase in traumatic delusional memories and high rates of PTSD 30 .A sedentary lifestyle was considered a risk factor for the severe form of the disease in a study by Hamer et al. 31 .
From a functional point of view, individuals with PTSD who participated in the study had a moderate risk of falling, took longer to perform the TUG, had lower performance on the walking test and reduced muscle strength, as in the studies by Guler et al. 32 and Huang et al. 33 .These authors associated the severe phenotype of COVID-19 and found a longer hospital stay among those who had a worse prognosis for recovery 34 , https://doi.org/10.7322/abcshs.2023158.2451thus justifying the performance in this test.The individuals with PTSD in our study also had worse functional performance and longer ICU stays, which may have contributed to this behavior.The lower functional performance on the walking test was also found in the study by Gloeckl et al. 35 , who found a shorter distance covered in the test in patients who had the most severe form of the disease.
Respiratory muscle strength was also below the predicted values for the evaluated individuals, especially for those who had PTSD.These results coincide with a higher frequency of ICU admission, a greater number of days hospitalized and the presence of a sedentary lifestyle among these individuals.These factors, associated with the use of corticosteroids, sedatives and/or neuromuscular blockers 36,37 and mechanical ventilation, may have contributed to clinical deterioration and repercussions on the emotional state and permanent sequelae of these individuals 29,37 .
According to our results regarding quality of life, individuals with PTSD had lower scores than those without it, which is similar to the study by Becerra-Canales et al. 38 .According to these authors, a direct relationship between quality of life and PTSD can be verified 38 .The impact of the disease on quality of life during coronavirus outbreaks (MERS, SARS and COVID-19) can be attributed to changes in lifestyle and the presence of memories arising from the persistence of symptoms 39 , even after hospital discharge.
The presence of PTSD persisted in the evaluated individuals who recovered from the moderate and severe phases of COVID-19 in our study, which is noteworthy.These same individuals also had repercussions on functional performance.Understanding that the presence of persistent mental health impairment associated with a decline in functional performance should very much be considered in clinical practice.https://doi.org/10.7322/abcshs.2023158.2451 A possible limitation of this study is the prior lack of knowledge of the PTSD history among the assessed individuals, as well as the lack of assessment of the presence of depression/anxiety, which are frequent in these individuals.Another noteworthy consideration pertains to the convenience sample assessed in our study.The extent to which participants may have had better physical conditions for involvement in the study remains unknown.Consequently, the prevalence of PTSD may not precisely depict the situation for all individuals who underwent moderate/severe forms of Covid-19.As a positive point of the present study, the functional repercussions of these individuals were evaluated four months after recovery, thus proving the persistence of late effects from Covid-19.
The findings of this study showed that moderately to severely recovered individuals from COVID-19 had PTSD, and were characterized as being more sedentary, requiring ICU admission and spending more days in the hospital.From a functional point of view, individuals who had PTSD had a moderate risk of falling, lower performance in both functional capacity and respiratory muscle strength below predicted values.
Considering the results of the present study, the follow-up of these individuals needs to be continued in order to verify the permanence of these symptoms and functional manifestations.
elucidated the effects of symptoms, encompassing dyspnea, fatigue/muscle weakness, PTSD, anxiety, and depression in patients who had recovered from Covid-19 without hospitalization, revealing impairment across all the aforementioned outcomes.Therefore, it is imperative to investigate the occurrence of analogous manifestations in patients who have recovered from moderate to severe Covid-19 and underwent hospitalization.Thus, this study aimed to evaluate the presence of PTSD in individuals who required hospitalization for COVID-19 and its relationship with sociodemographic variables, quality of life, muscle strength and functional capacity.METHODS Participants Individuals of both genders aged between 31 and 79 years, clinically recovered from COVID-19 (diagnosis confirmed by positive RT-PCR test or positive IgG serology for COVID-19), and who required admission to the ICU or ward of public or private hospitals were invited to participate in this study.Individuals who presented musculoskeletal alterations that prevented the performance of functional tests and cognitive alterations that made it difficult to understand the applied questionnaires were excluded.Participants were evaluated 120 days after hospital discharge.https://doi.org/10.7322/abcshs.2023158.2451Procedure Study design This is a cross-sectional study developed at the Laboratory of Cardiopulmonary Physical Therapy of the Federal University of Pernambuco from May 2021 to April 2022.The present study was approved by the institutional ethics committee (number 4,666,479) in accordance with Resolution 466/12 of the National Health Council.Study participants were recruited through dissemination on social media and by indication of health professionals during the study period.

Figure 1 :
Figure 1: Flowchart of the total number of individuals included in the study.

Table 2 :
Risk of falls, functional capacity, muscle strength and thickness in post-COVID-19 individuals with and without PTSD.