Review Interventions for the management of long covid post-covid condition: living systematic review, 2024, Zeraatkar, Flottorp, Garner, Busse+

[EndME]

This is all based on the 1 Dutch trial by Hans Knoop (Kuut et al. 2023, discussed here). A study on COPD patients found the minimal importance difference for the CIS-fatigue scale to be 9.3 points, so bigger than the 8.4 difference found in the CBT trial. The reviewers rated the Kuut 2023 study at high risk of bias because of lack of blinding but this resulted in only 1 downgrading in GRADE hierarchy from high to moderate certainty of evidence.

Curiously, the RCT on hyperbaric oxygen therapy also reported positive effects but here the evidence was downgraded by two levels (from High to Low) 'due to very serious imprecision' even though for some outcomes the 95% confidence intervals do not cross 0.


This all seems to be based on 1 trial on 'People who were still suffering from breathlessness three months after being discharged from hospital with COVID-19-related acute respiratory distress syndrome.'
https://pubmed.ncbi.nlm.nih.gov/37271020/
EDIT: It seems to be the REGAIN trial that we has was discussed here:
https://www.s4me.info/threads/clini...9-condition-regain-study-2024-mcgregor.37174/


This compares 2 forms of exercise, so provides no evidence that exercise is helpful or not.

I'm also curious how they rated the synbiotic study (thread here) as lower quality of evidence. Not that I believe it has any value in the treatment of LC (the authors didn't report any meaningful data and the LC classifications were nonsense), but it was at least a double blind placebo controlled trial with a "positive outcome".

 

[EndME]

Curiously, the RCT on hyperbaric oxygen therapy also reported positive effects but here the evidence was downgraded by two levels (from High to Low) 'due to very serious imprecision' even though for some outcomes the 95% confidence intervals do not cross 0.

Haven't looked at it yet, but from what I recall there have been at least 2 HBOT RCTs by the same group on LC. Will have to look into why one was included and the other excluded.

 

[SNT Gatchaman]

Not surprisingly getting quite a bit of press.

Original from Telegraph: Long Covid can only be treated with therapy, study suggests
MSN: Long Covid can only be treated with therapy, study suggests
Daily Mail: Scientists discover the only treatment that could cure long Covid

Therapy may be the only treatment to successfully cure lingering Covid symptoms, landmark new research has suggested.

Canadian scientists found talking therapies and physical and mental rehabilitation 'probably improve symptoms' among those struck down with the virus.

 

[EndME]

Not surprisingly getting quite a bit of press.

Original from Telegraph: Long Covid can only be treated with therapy, study suggests
MSN: Long Covid can only be treated with therapy, study suggests
Daily Mail: Scientists discover the only treatment that could cure long Covid

A bit like saying: The only thing that can treat Alzheimers is moonstones. The conclusion was made on subjective outcome measures. In fact when assessing patients post moonstone therapy to examine whether they had Alzheimers after treatment most couldn't remember that they did, suggesting a high level of effectivity.

 

[rvallee]

All weak randomized trials. Somehow moderate quality evidence even though it's literally the lowest possible level of quality with the highest possible bias. GRADE is just arbitrary nonsense. This is obviously not a systematic review, there have been many more trials, but it's already known that there are no treatments. This is literally what patients mean when they say that, but reality does not factor into any of this.

The authors started with the conclusion that those two work, and made a political document that BMJ published because they have given up doing legitimate science.

Again all this shows is that this paradigm is entirely useless, both the randomly trialing biased stuff and doing biased reviews. Change the people and you completely change the conclusions. Quality is irrelevant. So are facts and reality.

Both CBT and physical activity have long been shown to improve health and quality of life for people living with other chronic diseases.116117118119 Notably, both graduated physical activity and CBT have been found effective for myalgic encephalomyelitis (chronic fatigue syndrome or ME/CFS)—a condition with a striking resemblance to long covid that often emerges after viral infection.

Always the same crap:

Consequently, patients may become physically deconditioned, develop disrupted sleep-wake patterns, and hold unhelpful beliefs about fatigue.

Doesn't matter that none of this is true, but because this is entirely political it will get loads of misleading press. The exact same cycle of the last 40 years on repeat.

 

[ME/CFS Skeptic]

If I understand correctly, they didn't do any meta-analysis at all. For all outcomes summarised, the number of trials = 1. So they simply reiterate results from individual studies, most notably the Knoop trial (for CBT) and the REGAIN trial (for rehab).

Both trials were high risk of bias for all outcomes. The review agreed with this using the Cochrane risk of bias tool: the overall rating is the highest risk of bias in any of the subdomains.




But nonetheless, using GRADE they conclude that this provides moderate certainty evidence. I think this mostly highlights a problem with GRADE and the low importance it places on methodological quality.

In comparison, GRADE does suggest downgrading with 2-3 levels is sometimes needed because of low precision (which often just means a too low sample size). The result is that big studies with lots of flaws do better than higher quality but smaller studies.

@Jonathan Edwards

 

[ME/CFS Skeptic]

o they simply reiterate results from individual studies, most notably the Knoop trial (for CBT) and the REGAIN trial (for rehab).

It's actually worse because they recalculate the results based on summary data which is less precise compared to what the original study reported.

For example, the REGAIN study primary result for the PROPr questionnaire was 0.03 (95% confidence interval: 0.01 to 0.06) which is lower than the Minimal Importance Difference (MID) of 0.04. Remember, David Tuller wrote about this and contacted the journal.

Those estimates were the result of statistical modelling that takes various differences and confounding factors into account. What the authors of this review have done is ignored all of that modelling, and simply compared the means after treatment between both groups. This gives a much more crude estimate as it does not control for potential differences in baseline factors.

Their approach gave an estimate of 0.04 (0.00 - 0.08) which was just big enough to be equal to the MID. If they had used the more accurate estimate from the paper itself, it would have been lower than the MID and could not have featured in the abstract.

 

[Sean]

Honest mistakes don't all point in the same direction.

Deliberate manipulation of data and methodology to deliver a predetermined result do.

 

[Andy]

That BMJ review of Long Covid therapies does not show what it says it does

"The BMJ have published a “living systematic review” of interventions for the management of Long Covid. It sets out to gather all relevant studies, and to comb their findings in order to see what works and what doesn’t. Having assessed 24 trials looking at drug and non-drug therapies, they draw this pretty oddly-worded conclusion:

“Moderate certainty evidence suggests that CBT and physical and mental health rehabilitation probably improve symptoms of long covid.”

I have had a look over everything and I have to say, I am far from convinced. I am also quite puzzled by some of the choices made in presenting this review to the public. Something seems very off about how it’s all done."

https://thesciencebit.net/2024/11/2...therapies-does-not-show-what-it-says-it-does/

 

[Sean]

In short, based on the authors own risk-of-bias analyses (which are buried away in an online supplement), the findings of the latest BMJ long Covid review certainly fail to impress.

In fact, when you properly consider risk of bias, we can see the following:

(a) There are plenty of studies: six on physical rehabilitation and three on “behavioural interventions” (CBT)

(b) Virtually all of the studies have “High” or “Probably High” risk of bias, meaning that their findings are very likely to be misleading and so should be considered unreliable

(c) The one unbiased study to look at physical outcomes after physical intervention compared two different types of physical intervention, and had no non-therapy control group. Therefore it cannot be used to recommend physical therapy over no therapy

(d) The only way to derive any “evidence” from these reviewed studies is if you deliberately choose to include studies that you know have “High” or “Probably High” risk of bias

It seems incredibly odd to me that the critical information here is stored in an online supplement that the majority of readers will never see, especially when room was found to include much less important information, in depth, in the actual paper.

But once you see the supplemental tables the state of the evidence becomes pretty clear.

The studies certainly do not support the authors’ conclusions that “Moderate certainty evidence suggests that CBT and physical and mental health rehabilitation probably improve symptoms of long covid“.

How is this behaviour from both the authors and the BMJ not scientific misconduct, at best, and a particularly cruel example of it?

 

[Trish]

Excellent demolition job by Brian Hughes.

 

[rvallee]

Something I noticed in hindsight for its oddity. There is a rather long section that is basically focused on selling CBT and GET. It rehashes all the usual tropes and basically tries to upsell both, for the same reasons. They give reasons, speculate plenty about deconditioning and beliefs and so on, how it doesn't mean that it's psychological and so on.

Which is really like a judge or arbiter who openly praises one party despite being tasked, technically, to give an unbiased judgment based on procedure. And not just praise but go deep into arguments that none of the trials evaluated brought up, and is obviously completely out of line.

I get that this is now basically normalized since nothing matters in evidence-based medicine, but it's still so obviously biased that it's easy to overlook just how absurd this is. Especially when you consider who did the trials, their public statements of support, and so on. And who did the review, literally buddies of the trialists who share the same goals and biases. It all feels like some "doctors for smoking" front funded by tobacco companies that doesn't even bother hiding the fact, even have executives and physicians on the payrolls of companies and the front alike.

It's all the pretense of a neutral process but no one involved really bothers sticking to the pretense. Basically like a referee in pro sports who wears a cap for one of the teams, their favorite teams, which they are known to bet on. It's so many layers of absurd, but none of it matters. It's all so bizarro world.

Also more technical but given the difficulty of even simply describing what Long Covid is, how it's been known for years that it causes a huge set of different health problems, all of the trials should be downgraded for indirectness since there is no one Long Covid condition that can form any strict cohort. But of course nothing matters so by bother?

 

[hibiscuswahine]

That Sciencebit piece by Professor Brian Hughes covers the shenanigans of this paper by Garner et al, very well.

He notes a seemingly thorough review of the evidence to do with medications, supplements etc and a discussion on risk of bias etc but inexplicably, they do not do the same thorough review of physical rehabilitation and CBT. They hide the high risk of bias data in the supplementary material of the article (which is likely to never be read by health professionals or the public) and then deliberately ignore the findings of high risk of bias in these studies.

I do wonder if the Oslo Fatigue Consortium are thinking up a new CBT for LC - rehash the health anxiety CBT, put some pandemic anxiety/mass hysteria rubbish in, add some positive psychology, the pseudoscience of NLP and LP and say it is proven neuroscience. Copyright the manual, do lots of publicity, get a trial going, start appearing at conferences, influencing guidelines of many countries (already doing). Start running workshops for psychologists or any health professional who wish to learn this new CBT and "treat" LC. and the money starts rolling in. They can hedge their bets on effectiveness as saying it can have some effect on "well being". And the whole sad and harmful cycle starts again. LC is psychologised and stigmatised like ME and the biological underpinnings ignored.

Edit: added a few words for clarification

 

[Sean]

I do wonder if the Oslo Consortium are thinking up a new CBT for LC, rehash the health anxiety CBT, put some pandemic anxiety/mass hysteria rubbish in, add some positive psychology, NLP and LP and say it is proven neuroscience. Copyright the manual, do lots of publicity, get a trial going, start appearing at conferences, influencing guidelines of many countries (already doing). Start running workshops for psychologists or any health professional who wish to learn this new CBT and "treat" LC. and the money starts rolling in. They can hedge their bets on effectiveness as saying it can have some effect on "well being". And the whole sad and harmful cycle starts again. LC is psychologised and stigmatised like ME and the biological underpinnings ignored.

That is exactly what is happening, and they will employ the usual sophistic appeals to cost-cutting and victim blaming to cover their arses.

Rinse and repeat.

 

[Hutan]

I do wonder if the Oslo Fatigue Consortium are thinking up a new CBT for LC - rehash the health anxiety CBT, put some pandemic anxiety/mass hysteria rubbish in, add some positive psychology, the pseudoscience of NLP and LP and say it is proven neuroscience. Copyright the manual, do lots of publicity, get a trial going, start appearing at conferences, influencing guidelines of many countries (already doing). Start running workshops for psychologists or any health professional who wish to learn this new CBT and "treat" LC. and the money starts rolling in. They can hedge their bets on effectiveness as saying it can have some effect on "well being". And the whole sad and harmful cycle starts again. LC is psychologised and stigmatised like ME and the biological underpinnings ignored.

Yes, there are and will be more apps for that - relatively low cost and easily rolled out to give the appearance of doing something. The people taking in the money don't have to deal with patients who get upset at not being cured, they don't have to feel inadequate, as it's all arms length and the patients are trained that if they aren't cured, they didn't try hard enough. The net effect is still-sick patients sitting in their houses, feeling ashamed of their lack of capacity to think themselves well.

It's the perfect answer to a health condition that nearly everyone not directly affected by it would really prefer didn't exist, as, well you know, it makes it hard to pretend that the pandemic is over and it's perfectly safe to go about in a crowded world with no mask.

 

[SNT Gatchaman]

Toby Young: Director of freespeechunion.org Editor-in-Chief of Daily Sceptic (dailysceptic.org) Associate Editor of the Spectator
Currently with just the 67 followers on Bluesky.

(See previous S4ME comments about Young here)

Psychological therapy may be the only treatment to successfully cure lingering 'Long Covid' symptoms, landmark new research in the BMJ has suggested.

Links to an article on DailySceptic.org which simply quotes the Daily Mail article and is titled: "Only Psychological Therapy Could Cure Long Covid, Major BMJ Study Finds".

So he's not simply jumped the shark, he's gone back to the Pliocene and vaulted over the nearest megalodon.

We're so far beyond the biased review of the biased studies as aptly described by Brian Hughes, that even the article talking about the article talking about the biased review has managed to take the idea that "CBT and exercise might possibly maybe help some people maybe maybe if we ignore the fact that it doesn't" and headline that it's a) a cure and b) the cure.

https://bsky.app/profile/toadmeister.bsky.social/post/3lc2dd4wets2p

 

[Nightsong]

This study was apparently funded by the Canadian Long COVID Web and the Canadian Institute of Health Research. The former does not seem to publish detailed information about their funding decisions but I think this is the CIHR one:

https://webapps.cihr-irsc.gc.ca/decisions/p/project_details.html?applId=500878&lang=en

237,150 Canadian dollars, and who knows how much they got from the other funder. What a monumental waste of public funds.

Perhaps notable that Guyatt was listed as a co-investigator there.

 

[hibiscuswahine]

Incidentally, I was listening to Skeptics with a K (podcast for the Merseyside Sceptics Society) recently, and almost fell off my chair, when they said Professor Paul Garner had talked at one of Toby Young's events about science. I didn't know much about Toby Young or the paper The Spectator, but they appear to be climate change deniers and antivaxxers. The podcast definitely outlines the alternate views this group of people have about health, science and "free speech".
https://www.merseysideskeptics.org.uk/podcasts/skeptics-with-a-k/episode-377

Of course they also are not sceptical as I would understand the term. So if Garner is being endorsed by Toby Young, one could presume he might be part of the Freespeech Union. Garner does like to publicise his views and talk about cancel culture...and perhaps he got his mate Toby to disseminate his flawed paper.

 

[SNT Gatchaman]

So if Garner is being endorsed by Toby Young, one could presume he might be part of the Freespeech Union

He spoke at one of their events in May.

 

[Midnattsol]

@hibiscuswahine There is already an ongoing study at Oslo University on LC and a «mental training programe» where participants are told (among other things) to look in the mirror upon waking and tell themselves they are healthy. By people from the fatigue consortium and COFFI. It’s called Minirico.

Posts about this trial are being moved to this thread:
Minirico Mental Intervention and Nicotineamide Riboside Supplementation in Long Covid