The therapeutic potential of non-invasive brain stimulation for the treatment of Long-COVID-related cognitive fatigue

Stefanie Linnhoff, Lilli Koehler, Aiden Haghikia, Tino Zaehle, Stefanie Linnhoff, Lilli Koehler, Aiden Haghikia, Tino Zaehle

Abstract

Following an acute COVID-19 infection, a large number of patients experience persisting symptoms for more than four weeks, a condition now classified as Long-COVID syndrome. Interestingly, the likelihood and severity of Long-COVID symptoms do not appear to be related to the severity of the acute COVID-19 infection. Fatigue is amongst the most common and debilitating symptoms of Long-COVID. Other symptomes include dyspnoea, chest pain, olfactory disturbances, and brain fog. Fatigue is also frequently reported in many other neurological diseases, affecting a broad range of everyday activities. However, despite its clinical significance, limited progress has been made in understanding its causes and developing effective treatment options. Non-invasive brain stimulation (NIBS) methods offer the unique opportunity to modulate fatigue-related maladaptive neuronal activity. Recent data show promising results of NIBS applications over frontoparietal regions to reduce fatigue symptoms. In this current paper, we review recent data on Long-COVID and Long-COVID-related fatigue (LCOF), with a special focus on cognitive fatigue. We further present widely used NIBS methods, such as transcranial direct current stimulation, transcranial alternating current stimulation, and transcutaneous vagus nerve stimulation and propose their use as possible therapeutic strategies to alleviate individual pathomechanisms of LCOF. Since NIBS methods are safe and well-tolerated, they have the potential to enhance the quality of life in a broad group of patients.

Keywords: Long-COVID; NIBS; Post-COVID; cognitive fatigue; fatigability; tACS; tDCS; tVNS.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2023 Linnhoff, Koehler, Haghikia and Zaehle.

Figures

Figure 1
Figure 1
Non-invasive brain stimulation (NIBS) techniques for the treatment of individual pathomechanisms of Long-COVID-related fatigue (LCOF). Transcutaneous auricular vagus nerve stimulation (taVNS) has been shown to have anti-inflammatory effects through its efferent projections, the so-called cholinergic anti-inflammatory pathway (1 81), and could have a stabilizing effect on the dysregulated immune-system after an acute COVID-19 infection that could lead to LCOF. First positive effects support this hypothesis and show a reduction of mental fatigue in people with LCOF after repetitive taVNS sessions (2 16). Transcranial direct current stimulation (tDCS) and alternating current stimulation (tACS) have been shown to modulate neuronal responsiveness (3 78) and to induce long-term effects via long-term potentiation (4 82). They could therefore be used to counteract the observed frontoparietal hypometabolism after an acute COVID-19 infection that has been associated with LCOF. Preliminary data to support this hypotheses show positive effects on self-reported fatigue scores after repetitive sessions in people with LCOF (5 , 6 84). Following neuronal acitivity or via direct vascular responses, tDCS and tACS have also been shown to increase cerebral blood flow (7 85). Therefore they might also be an optimal strategy to counteract the observed blood flow reduction in people with LCOF. However, while several data exists that has shown increased cerebral blood flow after tDCS and tACS in healthy subjects and other neurological diseases, no data exists for LCOF.

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