Transmission risk assessment of airborne diseases such as COVID-19 requires a detailed understanding of respiratory aerosol generation and emission during activities such as breathing and speaking, as well as the influence of protective devices such as surgical face masks. We measured integral aerosol emission rates from n = 44 participants during breathing, speaking, and speaking while wearing a surgical mask, with each condition performed for 20 min. All measurements were conducted in a closed 20 m3 cabin under standardized initial conditions in an operating theater environment. Particle emission rates were log-normal distributed across participants. Median emission rates were 60 particles per second (P/s) for breathing (n = 35, IQR 24–152 P/s), 135 P/s for speaking (n = 41, IQR 56–327 P/s), and 278 P/s for speaking with a surgical mask (n = 29, IQR 157–492 P/s). Under the investigated conditions, wearing a surgical mask did not reduce total aerosol emission and was associated with a higher emission rate (median ratio 1.34, 95% CI [1.04–1.75], two clearly separated observations omitted). This observation may be explained by a combination of effects. First, the present measurements reflect total particle emission into the environment and therefore capture system-level behavior, including leakage, rather than material filtration efficiency. Second, previous studies have reported that mask use can alter respiratory mechanics, which may contribute to changes in aerosol emission. These findings may be relevant for assessing long-range transmission risk under comparable environmental conditions. At the same time, they do not contradict the established effectiveness of surgical masks in reducing droplet-mediated short-range transmission.

BACKGROUND:People with post-COVID syndrome (PCS) often suffer from long-term pulmonary consequences. Singing-based respiratory training (SBRT) has proven to be a valuable rehabilitative therapy for people with chronic lung diseases. OBJECTIVES:The aim of this study was to investigate the feasibility of SBRT in people with PCS breathing disorders, their compliance and adherence, and to obtain detailed findings on the effect of this training on people with PCS respiratory symptoms. METHODS:A randomized controlled, single-blind, bicentric study was conducted with 23 outpatient and 24 inpatient participants undergoing rehabilitation for PCS. Participants either received singing-based respiratory training with the intention of reducing breathing rate or training without the aim of influencing breathing rate. The main outcomes were patient compliance, determination of target parameters for a future efficacy study, and assessment of outcome differences between treatment groups. RESULTS:The 45 study participants were predominantly female (81 %) with a mean age of 51.5 (SD 10.44) years. There was a high level of compliance with SBRT, with 96 % of participants completing all training sessions led by vocal coaches. The overall comparison between baseline and follow-up assessments yielded improvements corresponding to medium effects in the physical component score of the Veterans RAND 12-Item Health Survey (VR-12) with a Cohen's d of 0.52 (95 % Confidence Interval, CI 0.05 to 0.99]), in the Generalized Anxiety Disorder Scale-7 (GAD-7) with a Cohen's d of 0.55 (95 % CI 0.11 to 0.9) and in the Patient Health Questionnaire-9 (PHQ-9) with a Cohen's d of 0.50 (95 % CI 0.06 to 0.93). CONCLUSION:SBRT was well-tolerated, with high adherence and compliance among participants in our study. Questionnaires assessing health-related quality of life and mental health may be suitable as primary outcomes for a future confirmatory study. The data suggest that SBRT aimed at reducing the respiratory rate does not have a positive effect compared to regular SBRT. TRIAL REGISTRATION:German Register of Clinical Trials (DRKS ID DRKS00028275).

IntroductionWe previously identified IgG autoantibodies targeting epitopes within brainstem proteins—disabled homolog 1 (DAB1), apoptosis-inducing factor 1 (AIFM1), and surfeit locus protein 1 (SURF1)—as markers of severe acute COVID-19. This study investigates whether the same autoantibodies contribute to the pathophysiology of Post COVID Syndrome (PCS).MethodsUsing a multiplexed bead-based immunoassay, we measured IgG levels against 18 synthetic peptides derived from DAB1, AIFM1, and SURF1 in serum samples from 45 PCS patients and 30 post-COVID controls without long-term symptoms. We employed generalized linear mixed models (GLMM) and nonlinear principal component analysis (CATPCA) to explore associations between antibody levels and clinical variables, including functional status (PCFS), respiratory symptoms, fatigue, cognitive impairment (as assessed by the Montreal Cognitive Assessment, MoCA), and mood.ResultsHigher IgG levels against the three autoantigens significantly predicted PCS at 3 months postinfection (t=2.21, p=0.03), whereas antibodies against a control peptide (polio) showed no such association. CATPCA identified a principal component capturing respiratory symptoms and functional impairment (PCFS), which was also significantly predicted by autoantibody levels (t=2.04, p=0.04). MoCA scores did not correlate with autoantibody levels, and subjective cognitive complaints were paradoxically linked to lower antibody titers and fewer physical symptoms.ConclusionsThe findings from the present explorative study, although largely correlative, appear to suggest a sustained autoimmune response targeting neuronal and mitochondrial proteins in PCS, particularly associated with respiratory dysfunction and reduced functional capacity. The results also highlight potential limitations of standard cognitive screening tools like the MoCA in detecting subtle deficits in PCS. The identified autoantibodies may serve as biomarkers for persistent post-COVID disability. Future research replicating present results on larger samples and specifically investigating a causal link between occurrence of the Auto-Abs and PCS is needed for shaping future immunomodulatory therapeutic strategies.

Manuelle Medizin befasst sich mit Diagnostik und Therapie von Funktions- und Strukturpathologien des Bewegungssystems. Sie hat als Behandlungsform in die wichtigen Leitlinien im Bereich der Wirbelsäulenbehandlung Eingang gefunden. Neurophysiologisch wirkt Manuelle Medizin auf schmerzinhibitorische Interneurone, welche die nozizeptiv verursachte Aktivität der entsprechenden WDR (wide dynamic range)-Hinterhornneurone reduzieren. In der klinischen Wertung von Anamnese, klinischer Untersuchung und Bildgebung kann die manualmedizinische Untersuchung reversible Funktionsstörungen detektieren, welche nicht in der Bildgebung sichtbar sind. Insbesondere können komplexe manualmedizinische Funktionsstörungen auch radikuläre Beschwerdemuster vortäuschen, so dass – vor dem Feststellen einer entsprechenden OP-Indikation – bei einer eher schwachen Korrelation zur Bildgebung unbedingt eine manualmedizinische Differentialdiagnostik einzuholen oder durchzuführen ist. Manuelle Medizin ist eine wichtige differentialdiagnostische Methode, um klinische und morphologische Befunde bei Schmerzerkrankungen der Wirbelsäule adäquat zu erfassen und zu bewerten.

Background: As a disease with a still largely unknown course, post-COVID requires a comprehensive multidimensional perspective and structured monitoring, as offered by the C19-YRSm. There has not yet been a German version of the scale. Methods: After the translation of the COVID-19 Yorkshire Rehabilitation Scale (modified version, C19-YRSm) into German, we conducted an online survey with it between 23 May 2023 and 10 May 2024 for patients with post-COVID condition. Participation took place twice; people received either only the German version or both the German and the original English versions of the scale at one-week intervals. Based on the results, reliability and validity of the German version of the C19-YRSm were extensively tested. Results: Data of 414 participants were analysed, 156 of whom took part twice at least seven days apart. Cronbach’s alpha coefficients of the subscales of the German version ranged from 0.75 to 0.93. In the English version, it ranged from 0.82 to 0.93. All the subscales correlate with each other with p < 0.001. For the overall scale and for three of the four subscales, the intraclass coefficients, as a measure of the agreement between measurement results at two points in time, showed good consistency. Conclusions: This study confirmed the reliability, applicability, and clinical utility of the C19-YRSm, aligning with previous studies. With its multidimensional structure and excellent quality criteria, the C19-YRS is a valuable asset for clinical practice and research. The validated German C19-YRSm holds significant potential to facilitate tailored interventions, destigmatise post-COVID conditions, and enhance patient care in medical contexts.

Objective:To evaluate the feasibility of early computer-based assessment, quantify cognitive impairments and identify factors influencing cognition. Design:Prospective, cross-sectional study. Setting:Data were collected on a surgical intensive care unit. All patients underwent cognitive assessment once they reached a Richmond Agitation-Sedation Scale (RASS) score of -1 or higher. Participants:During data collection, 60 patients (N=60) met the inclusion criteria: sepsis and 24 hours of ventilation. Patients with prior cognitive impairment, or neurologic or psychiatric diagnoses, were excluded. Therefore, a total of 28 patients were included in the study. Interventions:Not applicable. Main Outcome Measures:Primary outcome variables were tonic alertness, the general level of attention and phasic alertness, the temporarily increased attentiveness after a stimulus. They were normalized for age and sex. The hypothesis proposed was that testing would be feasible starting from a RASS score of -1. Results:Testing was only possible when patients had a RASS of 0 and had regained orientation. On average, a successful test could be performed 6.6 (mean) days from RASS≥-1 or 4.7 (mean) days after the end of ventilation. On average, the results of tonic alertness were 3 standard deviations (95% CI, -3.8 to -2.2) worse. For phasic alertness, the mean score was -2.3 standard deviations (95% CI, -3.1 to -1.5).There are significant typical markers for sepsis severity with moderate correlations between an increasing number of ventilation days [r=-0.38, 95% CI: -0.66 to -0.01], number of days required between the cessation of ventilation and testing [r=-0.40, 95% CI: -0.68 to -0.04], days with noradrenaline [r=-0.48, 95% CI: -0.73 to -0.13], and days from awakening to the day of testing [r=-0.5, 95% CI: -0.74 to -0.15] and worsened tonic cognition. Conclusions:Early cognitive impairments are common in sepsis patients. Although early rehabilitation might be beneficial within this early stage, the utilization of computer-based assessments, appear to be limited. Detailed analysis of cognition should be considered later in recovery process. Further approaches could use demonstrated times at which assessment is likely to be successful.

The aim was to determine the profile of long-term symptoms after known and undetected SARS-CoV-2 infections and to generate tools for risk and diagnostic assessment of Post-COVID syndrome (PCS). In the population-based Gutenberg COVID-19 Study ( N = 10,250), sequential, systematic screening for SARS-CoV-2 was performed in 2020/2021. Individuals received a standardized interview on newly occurred or worsened symptoms since the infection or the pandemic. Robust Poisson regression models were fit to compare the frequency of symptoms between groups. Two scores were developed using machine learning techniques and prospectively validated in an independent cohort. Among n = 942 individuals, prevalence of long-term symptoms was 36.4% among individuals with known SARS-CoV-2 infection, 25.0% in those unknowingly infected, and 28.1% among the controls. Individuals with known infection more often reported smell (Prevalence ratio [PR] = 13.66 [95% confidence interval 4.99;37.41]) and taste disturbances (PR = 5.57 [2.62;11.81]), forgetfulness (PR = 2.88 [1.55;5.35]), concentration difficulties (PR = 2.83 [1.55;5.16], trouble with balance (PR = 2.74 [1.18;6.35]), and dyspnea (PR = 2.22 [1.18;4.19]) than controls. The risk score for predicting long-term sequelae based on symptoms during the acute infection had a cross-validated AUC of 0.74 and 0.72 when applied in an independent cohort ( N = 6,570). The diagnostic score providing a probability of the presence of PCS had a cross-validated AUC of 0.66 and of 0.64 in the validation cohort ( N = 3,176). Individuals with and without SARS-COV-2 infection reported persistent symptoms, but symptoms attributable to PCS were identified. The data-driven scores may help guide further diagnostic decisions in the initial management of PCS.

New onset or worsening of a headache disorder substantially contributes to the disease burden of post-COVID-19. Its management poses a suitable means to enhance patients’ participation in professional, social, and personal activities. Unfortunately, the pathophysiology of post-COVID-19 headaches is poorly understood. This study aims to investigate the role of (neuro-) inflammatory mechanisms in order to guide the development of anti-inflammatory treatment strategies. We included patients from the interdisciplinary post-COVID-19 Rehabilitation Study (PoCoRe, n = 184 patients) run at a tertiary care university hospital, comprising patients with PCR-confirmed SARS-CoV-2 infection ≥ 6 weeks prior to their initial consultation. Patients reporting any headache since their infection were considered for this study (n = 93). These were interviewed and classified according to the International Classification of Headache Disorders, Third Edition (ICHD-3) by headache specialists. Patient sera were additionally analysed for levels of VILIP-1, MCP-1 (CCL2), sTREM-2, BDNF, TGF-ß1, VEGF, IL-6, sTREM-1, ß-NGF, IL-18, TNF-alpha, sRAGE, and CX3CL1 (Fractalkine). Markers of inflammation were compared between four groups of patients (none, unchanged, worsened, or new headache disorder). Patients reported experiencing more severe headaches (n = 17), new onset headaches (n = 46), unchanged headaches (n = 18), and surprisingly, some patients denied having any headaches (n = 12) despite self-reports. Serum levels of CX3CL1 were increased in the worsened (2145 [811–4866] pg/ml) and new onset (1668 [0-7357] pg/ml) headache group as compared to patients with no (1129 [0-5379] pg/ml) or unchanged (1478 [346–4332] pg/ml) headaches. Other markers also differed between groups, but most significantly between patients with worsened (TGF-ß1: 60 [0-310] pg/ml, VEGF: 328 [86–842] pg/ml, ß-NGF: 6 [3–38] pg/ml) as compared to unchanged headaches (TGF-ß1: 29 [0–77] pg/ml, VEGF: 183 [72–380] pg/ml, ß-NGF: 3 [2–89] pg/ml). The results did not differ between headache phenotypes. This study provides evidence that worsened or new headaches following COVID-19 are associated with pro-(neuro-)inflammatory profiles. This supports the use of anti-inflammatory treatment options in this population, especially in the subacute phase.

Manual medicine as a medical qualification is a further training program which is reflected in the Zusatzweiterbildung Manuelle Medizin. It includes content that is not part of a specialist or specialization specification. In the medical degree program, it is not defined as an independent specialist area; here, it is part of cross-sectional area 12 (rehabilitation, physical medicine, and naturopathy). Interestingly, in many specializations in which diseases of the musculoskeletal system are an important part of the curriculum, neither knowledge or skills in the clinical examination of the musculoskeletal system nor competencies in manual medicine are required. This stands in contradiction to the need to teach manual medical functional thinking as a prerequisite to understanding multimodal interdisciplinary therapies for complex diseases and for prevention.

Rehabilitation involves improving function in order to restore the greatest possible level of personal activity and participation in all areas of life during aftercare following serious illnesses, injuries, and operations; it also includes the care of people with physical disabilities or chronic illness. The medical rehabilitation services defined in Book IX of the German Social Code (SGB IX) only list manual therapy indirectly, among the methods of physical therapy. In the area of statutory accident insurance, manual therapy training for therapists is required for both Erweiterte Ambulante Physiotherapie (EAP; expanded outpatient physiotherapy) and Berufsgenossenschaftliche Stationare Weiterbehandlung (BGSW; continued inpatient physical and occupational therapy), but manual therapy is not listed in the rehabilitation treatment standards of the Deutschen Rentenversicherung. This is astonishing, as the goal of improving function is known to reflect a domain of manual therapy and medicine. This makes it clear that manual medicine techniques are useful in the rehabilitation process. Ultimately, the restoration of function in rehabilitation will be neither effective nor successful without the use of manual medicine principles and techniques.

Die manuelle Medizin als ärztliche Qualifikation ist eine Weiterbildung, die in der Zusatzweiterbildung Manuelle Medizin abgebildet ist. Sie umfasst Inhalte, die nicht Teil einer Facharzt- oder Schwerpunktbezeichnung sind. Im Medizinstudium ist sie nicht als eigenständiger Fachbereich hinterlegt, hier ist sie Bestandteil des Querschnittsbereichs 12 (Rehabilitation, Physikalische Medizin und Naturheilverfahren). Interessanterweise werden in vielen Facharztrichtungen, bei denen Erkrankungen des Bewegungssystems einen wichtigen Inhalt darstellen, weder Wissens- oder Handlungskompetenzen zur klinischen Untersuchung des Bewegungssystems noch manualmedizinische Kompetenzen gefordert. Dies steht im Widerspruch zur Notwendigkeit, manualmedizinisch-funktionelles Denken als Voraussetzung für das Verständnis multimodaler interdisziplinärer Therapien bei komplexen Erkrankungen und der Prävention zu vermitteln.

Die Aufgabe der Rehabilitation beinhaltet die Funktionsverbesserung zum Wiederherstellen der größtmöglichen Eigenaktivität und Partizipation in allen Lebensbereichen in der Nachsorge nach schweren Erkrankungen, Verletzungen und Operationen sowie der Betreuung von körperbehinderten oder chronisch erkrankten Menschen. Die im Neunten Buch des Sozialgesetzbuches (SGB IX) definierten Leistungen der medizinischen Rehabilitation führen die manuelle Therapie nur indirekt unter den Heilmitteln der physikalischen Therapie auf. Im Bereich der gesetzlichen Unfallversicherung wird sowohl für die Erweiterte Ambulante Physiotherapie (EAP) als auch für die Berufsgenossenschaftliche Stationäre Weiterbehandlung (BGSW) eine manualtherapeutische Ausbildung der Therapeuten gefordert, dagegen wird in den Rehabilitationstherapiestandards der Deutschen Rentenversicherung (DRV) manuelle Therapie nicht aufgeführt. Das ist erstaunlich, da das Ziel der Funktionsverbesserung bekanntlich eine Domäne der manuellen Therapie und Medizin darstellt. Dies macht deutlich, dass manualmedizinische Techniken im Rehabilitationsprozess sinnvoll sind. Letztlich wird die Wiederherstellung der Funktion in der Rehabilitation ohne den Einsatz manualmedizinischer Prinzipien und Techniken weder zielführend noch erfolgreich sein.

(1) Background: The aim of this study was to investigate and compare the effect of sensorimotor training on transversus abdominis activation. (2) Methods: Seventy-five patients with chronic low back pain were randomly assigned to one of three groups (whole body vibration training using Galileo®, coordination training using Posturomed®, or physiotherapy (control)). Transversus abdominis activation was measured by using sonography pre- and post-intervention. Second, changes in clinical function tests and their correlation with the sonographic measurements were determined. (3) Results: All three groups showed an improvement in activation of the transversus abdominis post-intervention, with the Galileo® demonstrating the largest improvement. There were no relevant (r > 0.5) correlations between activation of the transversus abdominis muscle and any clinical tests. (4) Conclusions: The present study provides evidence that sensorimotor training on the Galileo® significantly improves the activation of the transversus abdominis muscle.

(1) Background: COVID-19 is often associated with significant long-term symptoms and disability, i.e., the long/post-COVID syndrome (PCS). Even after presumably mild COVID-19 infections, an increasing number of patients seek medical help for these long-term sequelae, which can affect various organ systems. The pathogenesis of PCS is not yet understood. Therapy has so far been limited to symptomatic treatment. The Greifswald Post COVID Rehabilitation Study (PoCoRe) aims to follow and deeply phenotype outpatients with PCS in the long term, taking a holistic and comprehensive approach to the analysis of their symptoms, signs and biomarkers. (2) Methods: Post-COVID outpatients are screened for symptoms in different organ systems with a standardized medical history, clinical examination, various questionnaires as well as physical and cardiopulmonary function tests. In addition, biomaterials are collected for the analysis of immunomodulators, cytokines, chemokines, proteome patterns as well as specific (auto)antibodies. Patients are treated according to their individual needs, adhering to the current standard of care. PoCoRe's overall aim is to optimize diagnostics and therapy in PCS patients.

Post-COVID-19 syndrome (PCS) has been described as 'the pandemic after the pandemic' with more than 65 million people worldwide being affected. The enormous range of symptoms makes both diagnosis complex and treatment difficult. In a post-COVID rehabilitation outpatient clinic, 184 patients, mostly non-hospitalized, received a comprehensive, interdisciplinary diagnostic assessment with fixed follow-up appointments. At baseline, three in four patients reported more than 10 symptoms, the most frequent symptoms were fatigue (84.9%), decreased physical capacity (83.0%), tiredness (81.1%), poor concentration (73.6%), sleeping problems (66.7%) and shortness of breath (67.3%). Abnormalities were found in the mean values of scores for fatigue (FAS = 34.3), cognition (MoCA = 25.5), psychological alterations (anxiety, depression, post-traumatic stress disorder), limitation of lung function (CAT) and severity scores for PCS (PCFS, MCRS). Clinical abnormalities were found in elevated values of heart rate, breathing rate at rest, blood pressure and NT-proBNP levels. As the frequency of the described symptoms decreases only slowly but most often significantly over the course, it is important to monitor the patients over a longer period of time. Many of them suffer from an immense symptom burden, often without pre-existing clinical correlates. Our results show a clear association with objectifiable assessments and tests as well as pronounced symptoms.

(1) Background: Peripheral, as well as central, sensitization have been described in chronic low back pain (cLBP). The purpose of this study is to investigate the influence of psychosocial factors on the development of central sensitization. (2) Methods: This prospective study investigated local and peripheral pressure pain thresholds and their dependence on psychosocial risk factors in patients with cLBP receiving inpatient multimodal pain therapy. Psychosocial factors were assessed using the Örebro Musculoskeletal Pain Screening Questionnaire (ÖMPSQ). (3) Results: A total of 90 patients were included in the study, 61 (75.4% women, 24.6% men) of whom had significant psychosocial risk factors. The control group consisted of 29 patients (62.1% women, 37.9% men). At baseline, patients with psychosocial risk factors showed significantly lower local and peripheral pressure pain thresholds, suggesting central sensitization, compared to the control group. Sleep quality, measured by the Pittsburgh Sleep Quality Index (PSQI), was also correlated with altered PPTs. After multimodal therapy, all participants reported increased local pain thresholds compared to at admission, independent of psychosocial chronification factors. (4) Conclusions: Psychosocial chronicity factors measured using the ÖMPSQ have a significant influence on pain sensitization in cLBP. A 14-day multimodal pain therapy increased local, but not peripheral, pressure pain thresholds.

Secondary somatic dysfunctions are the main target of manual medicine. However, functional disorders of the locomotor system are more complex and also involve pathomorphological changes, primary and psychosocial dysfunctions, and changes in neurophysiological processing. Recognition and treatment of these dysfunctions is necessary for effective treatment of complex functional diseases. Psychosocial dysfunctions are generally reversible. Their diagnosis and treatment lies not only in the hand of psychiatrists and psychologists, but should also be part of daily practice in manual medicine.

ZUSAMMENFASSUNGRückenschmerzen stellen trotz eines hohen medizinischen Aufwandes weiterhin ein relevantes medizinisches und sozialmedizinisches Problem dar. Das medizinische Wissen über Rückenschmerzen ist über die letzten Jahre angewachsen, trotzdem setzen sich diese Erkenntnisse nicht in die alltägliche Versorgung von Patienten um. Es stellt sich die Frage, inwiefern neben der Durchdringung neuer Erkenntnisse auch strukturelle Probleme im Gesundheitssystem für diesen Mangel verantwortlich ist.

Sekundäre Funktionsstörungen sind das Hauptangriffsziel der manuellen Medizin. Funktionserkrankungen des Bewegungssystems sind jedoch bei Weitem komplexer und umfassen pathomorphologische Störungen sowie psychosoziale, primäre und neuromodulatorische Funktionsstörungen. Das Erkennen und die Behandlung dieser Funktionsstörungen sind die Voraussetzung für eine effektive Therapie komplexer Funktionserkrankungen. Psychosoziale Störungen sind grundsätzlich reversibel und gehören damit zu den Funktionsstörungen. Dabei liegen ihre Diagnostik und Therapie nicht allein in der Psychotherapie oder Psychiatrie. Die entscheidenden Weichen werden u. a. in der täglichen manualmedizinischen Praxis gestellt.