Consensus Guidance Statement on PASC Fatigue, 2021, Herrera et al (AAPM&R)

[Three Chord Monty]

Full Title:

Multi-Disciplinary Collaborative Consensus Guidance Statement on the Assessment and Treatment of Fatigue in Post-Acute Sequelae of SARS-CoV-2 infection (PASC) Patients



Authors

American Academy of Physical Medicine and Rehabilitation Multi-
Disciplinary PASC Collaborative

1. Joseph E. Herrera, DO, Icahn School of Medicine at Mount Sinai
2. William N. Niehaus, MD, University of Colorado School of Medicine
3. Jonathan Whiteson, MD, Rusk Rehabilitation, NYU Langone Health
4. Alba Azola, MD, Johns Hopkins Medicine
5. John M. Baratta, MD, MBA, UNC-Chapel Hill
6. Talya K. Fleming, MD, JFK Johnson Rehabilitation Institute at Hackensack Meridian
Health
7. Soo Yeon Kim, MD, Johns Hopkins Medicine
8. Huma Naqvi, MD, Hartford Healthcare's COVID Recovery Center
9. Sarah Sampsel, MPH, SLSampsel Consulting, LLC
10. Julie K. Silver, MD, Spaulding Rehabilitation Hospital, Harvard Medical School
11. Monica Verduzco Gutierrez, MD, UT Health San Antonio
12. Jason Maley, MD, Beth Israel Deaconess Medical Center, Harvard Medical School
13. Eric Herman, MD, Oregon Health & Science University (OHSU)
14. Benjamin Abramoff, MD, MS, Penn Medicine


Introduction:

Large numbers of individuals who have been infected with SARS-CoV-2, the virus responsible
for COVID-19, continue to experience a constellation of symptoms long past the time that they
have recovered from the acute stages of their illness. Often referred to as “Long COVID”, these
symptoms, which can include fatigue, shortness of breath, palpitations, cognitive dysfunction
(“brain fog”), sleep disorders, fevers, gastrointestinal symptoms, anxiety, depression, and others, can persist for months and can range from mild to incapacitating. While still being defined, these effects can be collectively referred to as Post-Acute Sequelae of SARS-CoV-2 infection (PASC).(1) The magnitude of this problem is not yet known, but given the millions of individuals worldwide who have had, or will have, COVID-19, the societal impacts are likely to be profound and long lasting.(2,3,4,5)

It is widely acknowledged that systematic study is needed to develop an evidence-based
approach for caring for patients with PASC. At present, there is a dearth of rigorous scientific
evidence regarding effective assessment and treatment of PASC that prevents the creation of
evidence-based clinical guidelines. However, the U.S. health system is currently seeing an
increase in the number of patients presenting with PASC, and there is an urgent need for clinical
guidance in treating these patients. The goal of this, and future statements, is to provide practical guidance to clinicians in the assessment and treatment of patients presenting with PASC.


https://onlinelibrary.wiley.com/doi/epdf/10.1002/pmrj.12684

 

[Three Chord Monty]

They refer to PEM as a key component of diagnostic criteria in the IOM report on ME/CFS; and they also point out that post-exertional malaise is one of the most commonly reported symptoms in LC/PASC. Then:

1. Begin an individualized and structured phased return to activity program.

An individually titrated, symptom-guided program of return to activity is recommended for patients presenting with fatigue. The goal of a rehabilitation program is to restore patients to previous levels of activity and improve quality of life. Until those goals have been achieved, the rehabilitation program should not focus on high intensity aerobic exercises or heavy weight lifting to build strength and endurance. If the rehabilitation program is advanced too quickly or is too intense, it may worsen symptoms and lead to post-exertional malaise (PEM), a diagnostic criterion of ME/CFS. (9)

They have protocols for mild, moderate, and severe 'fatigue.'

Severe fatigue or significant PEM: Continue any household activities that have been tolerated without symptom exacerbation. Patients can begin a physical activity program,which should initially consist of upper and lower extremity stretching and light muscle strengthening prior to any targeted aerobic activity. Once tolerated, patients can begin an activity or aerobic exercise program at submaximal levels, RPE 7-9 / Extremely to Very Light. The activity or exercise can then be slowly advanced as the patient tolerates as long as it does not cause worsening of symptoms (which may be delayed until the evening and/or days after the activity/exercise session). If symptoms worsen, activity should be returned to the previously tolerated level.

'Nuff said.

 

[rvallee]

Anything that focuses on one symptom, misunderstanding most of it, is pointless. They just don't understand the words the patients are using and simply fill in whatever they want for their purpose. What's with the obsession with the most common symptom anyway? Statistically it's basically more common than others by about 5%. Why make it all about one thing when it's clearly multi-systemic? What good does that do when the symptoms are clearly part of patterns? Patterns which clearly matter more than the symptoms themselves.

This is a hammer defining how what's in front of them is nails and what a hammer should do to a nail because it's what a hammer does. It's supply-side medicine, by physicians for physicians (or in this case physical therapists but whatever). It's not built on demand or need, it's built from an existing supply that wants to find its place. It's about doing one thing because it's their job to do that thing, whether it makes sense or not.

So: pass. Also: get your shit together.

 

[Three Chord Monty]

Anything that focuses on one symptom, misunderstanding most of it, is pointless. They just don't understand the words the patients are using and simply fill in whatever they want for their purpose. What's with the obsession with the most common symptom anyway? Statistically it's basically more common than others by about 5%. Why make it all about one thing when it's clearly multi-systemic? What good does that do when the symptoms are clearly part of patterns? Patterns which clearly matter more than the symptoms themselves.

This is a hammer defining how what's in front of them is nails and what a hammer should do to a nail because it's what a hammer does. It's supply-side medicine, by physicians for physicians (or in this case physical therapists but whatever). It's not built on demand or need, it's built from an existing supply that wants to find its place. It's about doing one thing because it's their job to do that thing, whether it makes sense or not.

So: pass. Also: get your shit together.

The only good thing about this is that it seems to be, in spite of a list of names from well-regarded entities, from a group that's either small, niche, or both. Hopefully it won't inform anything; maybe it won't even be taken seriously.

Then again, recent events, in spite of that I'm cautiously optimistic about NICE, involve groups of people who should know better just rubber-stamping legit harmful modalities that so much lit has talked about to a great extent in recent years: no GET if there's PEM. And they & the clowns in Oregon who did the CDC review just ignored all of that, like it didn't even exist.

 

[Jonathan Edwards]

They should read what that guy said in the NICE appendix: don't confuse end with means.
The end may well be to do more normal activities.
That does not mean that the means is to do more normal activities.

If you have a leg fracture the end is to walk.
You don't get there by walking on a broken leg.

 

[Jonathan Edwards]

American Academy of Physical Medicine and Rehabilitation

That really says it all. Physical medicine was dead as a concept in 1975.

 

[cassava7]

The authors write: "At present, there is a dearth of rigorous scientific evidence regarding effective assessment and treatment of PASC that prevents the creation of evidence-based clinical guidelines".

If evidence is lacking for the treatment of long Covid, the authors could have deferred to other guidelines or recommendations based on existing evidence for ME/CFS, such as the CDC's or NICE's draft guidance -- at least for post-exertional malaise --. Instead, they preferred bringing their expert opinions forward, even though they are based on limited clinical experience (and no scientific evidence).

The acknowledgements read:

The content of this Multi-Disciplinary Consensus Guidance Statement was developed in consultation with the AAPM&R PASC Multi-Disciplinary Collaborative, comprised of 30 PASC Clinics (www.aapmr.org/PASC-guidance) who contributed to the development of the consensus statements via individuals working in their Post COVID/PASC Clinics or from their unique expertise in the assessment and treatment of PASC in their personal, expert capacity. The views and opinions expressed by Collaborative participants are their own and do not reflect the view of any organization.​

It is disappointing that they did not think to involve long Covid patients, despite the availability of a plurality of patient organizations. In fact, LC patients have more experience managing their condition than the authors do, as they have been ill for longer than PASC clinics have been open.