Inspiratory Muscle Training in ME/CFS and COVID-19 Survivors
Condition: Myalgic Encephalomyelitis; Post-acute COVID-19 Syndrome
MeSH terms: COVID-19; Encephalomyelitis; Post-Acute COVID-19 Syndrome; Myalgia; Fatigue Syndrome, Chronic; Syndrome
Study type: Interventional

Summary: 
      Coronavirus-2019 (COVID-19) is a viral disease leading to respiratory dysfunction, but it may
      also affect the brain and result in the development of myalgic encephalomyelitis/chronic
      fatigue syndrome (ME/CFS). This may be the result of the COVID-19 virus infecting regions of
      the brain responsible for respiratory control. The symptoms of COVID-19 long haulers and
      ME/CFS may be lessened via an 8-week inspiratory muscle training protocol which is a simple
      and easy training protocol which can be done at a patient's home.

      Thus, this project will investigate changes in the breathing and cardiovascular responses to
      stimuli in three groups of participants: 1) healthy control individuals; 2) patients
      diagnosed with ME/CFS (mild to moderate symptoms); and 3) individuals with previous COVID-19
      infection with long-haul symptoms lasting for at least 3 months. Participants will 1) breathe
      hypoxic gas (10% O2) for 5 minutes; 2) breath hypercapnic gas (5% CO2) for 5 minutes; 3)
      breathe at a rate of 6 breaths per minute for a total of 8 breaths (paced deep breathing);
      and 4) complete 10 minutes upright tilt (70 degrees head up on a tilt-table). Patients will
      also complete 2 questionnaires concerning their symptoms and a 15 minute cognitive function
      test on a lab laptop. This will allow for the assessment of the brain's control over blood
      pressure and breathing. Participants will also complete a 6-minute walking exercise test at
      their own speed as a measure of their aerobic fitness. We hypothesize that COVID-19 survivors
      will have a worse cardiovascular and autonomic response and lower fitness, similar to ME/CFS
      patients, compared to healthy participants.Further, this will be improved after 8-weeks of
      inspiratory muscle training. These results may help clinicians recognize ME/CFS symptoms in
      patients recovering from COVID-19.
    

Detailed description: 
      Approximately 10 women and 10 men between the ages of 18-65 will be tested in each of 3
      groups:

        1. Control participants will be free of previously diagnosed cardiovascular, metabolic,
           autonomic, or respiratory disease.

        2. COVID-19 participants will have both an official diagnosis and an official clearance of
           COVID-19. Patients will have long-haul symptoms for at least 3 months. Patients will be
           recruited via media, social media and clinical collaborators.

        3. ME/CFS participants will be recruited via media, social media and clinical
           collaborators. Only those with mild to moderate symptoms who can complete a 6 minute
           walk test will be recruited.

      Prospective participants will be patients of the University Health Network (UHN) or Women's
      College Hospital, community members, friends, family, and co-workers of laboratory staff and
      students. Patients will be recruited from clinical sites by poster recruitment at
      collaborative clinics.

      Exclusion criteria are severe symptoms of chronic fatigue syndrome, inability to stand on a
      tilt table, inability to walk for 6 minutes, previous cardiorespiratory disease (except for
      COVID-19 long-hauler symptoms and chronic fatigue syndrome itself), and inability to
      understand and read English.

      Participants will be recruited via established clinical collaborators, from York University's
      student and staff population, previously known relationships with the research staff, poster
      recruitment, and advertisements on social media sites (e.g. York U reddit, Facebook,
      Instagram, LinkedIn and Twitter). Social media will not be used for conversations, only for
      advertisement purposes. Postings will include only the information that is included on the
      print poster. Recruitment at clinics will be done via posters.

      Participants will fill out clinical questionnaires (COMPASS31 and DePaul Symptom
      Questionnaire) and complete a cognitive function test using BrDI software developed by Dr.
      Lauren Sergio. This software program is located on a lab laptop and consists of trials
      whereby participants move a mouse on a screen in particular directions as instructed. They
      will then complete the following in random order: 1) breathe hypoxic gas (10% O2) for 5
      minutes; 2) breathe hypercapnic gas (5% CO2) for 5 minutes; 3) breathe at a rate of 6 breaths
      per minute (paced deep breathing); and 4) 10 minutes upright tilt (70 degrees on a
      tilt-table). Each trial will be separated by 10 minutes of supine rest. Participants will
      also complete a voluntary walking test whereby the distance walked in 6 minutes will be
      measured as an index of aerobic fitness. All of these trials will be conducted in 336 Calumet
      College and will be conducted both before and after the 8-weeks of inspiratory muscle
      training described below (i.e. at both their first and second visits).

      All participants will be equipped to measure heart rate, beat-to-beat blood pressure, brain
      blood flow, ventilation and end-tidal gases. Heart rate (HR) will be measured by
      electrocardiogram (ECG), and blood pressure will be monitored using a beat-by-beat
      non-invasive blood pressure device on the middle finger (NexFin). Brain blood flow velocity
      from the middle cerebral artery in the brain will be recorded using ultrasound and a 2MHz
      probe (Multigon Industries Inc.) positioned on the temple and held in place by an adjustable
      head-band. Respiratory outcomes such as ventilation, tidal volume, breathing frequency,
      exhaled gases will be measured through a mouthpiece that will be attached to a
      pneumotachometer (a nose plug will be worn).

      These experiments will take approximately 2.5 hours per testing session.

      Using commercially available devices, the 8-week inspiratory muscle training protocol
      consists of using 80% of maximal inspiratory pressure (determined in lab), 3x per week, 6
      sets of 6 repetitions. Each set will be separated by decreasing lengths of time over the 8
      weeks starting at a 30 second interim. This totals 36 inhalations 3 times per week. Progress
      will be determined via weekly phone calls with the participants and progress will also be
      logged by participants over the 8 weeks
    

Intervention name(s): Inspiratory muscle training
Intervention type(s): Other
Intervention description(s): All participants will undergo inspiratory muscle training.
Intervention model: Single Group Assignment
Intervention model description: Three groups (controls, ME/CFS, COVID long-haulers) will all conduct an inspiratory training protocol and cardiovascular and autonomic measures will be measured before and after.
Masking: None (Open Label)
Primary purpose: Basic Science