Long COVID—ACOEM Guidance Statement, 2024, Stave et al.

[SNT Gatchaman]

Long COVID—ACOEM Guidance Statement
Stave, Gregg M.;Nabeel, Ismail;Durand-Moreau, Quentin

Persistent symptoms are common after acute COVID-19, often referred to as long COVID. Long COVID may affect the ability to perform activities of daily living, including work. Long COVID occurs more frequently in those with severe acute COVID-19. This guidance statement reviews the pathophysiology of severe acute COVID-19 and long COVID and provides pragmatic approaches to long COVID symptoms, syndromes, and conditions in the occupational setting. Disability laws and workers’ compensation are also addressed.

Link | Open Access (Journal of Occupational and Environmental Medicine)

 

[SNT Gatchaman]

Statement from the Association of Occupational and Environmental Medicine. Good coverage of the themes in LC research, focusing on physiological factors. References ME/CFS and POTS. Covers BPS with the following paragraph.

An extensive list of symptoms may be associated with long COVID. Persons with long COVID may also have symptoms related to comorbid conditions, including post-ICU syndrome or posttraumatic stress disorder among those with severe acute COVID-19. Mental health disorders may also be present and need to be assessed and treated. It may be helpful to apply the biopsychosocial model, which suggests that “(l)ong COVID could be explained as an embodied condition with heterogeneous biological, psychological (experiential), and social (or environmental) factors integrated in complex relationships.” Critics of this model raise the concern that this approach may lead to disregard of patient complaints that are perceived as primarily psychological. However, properly applied, this approach should lead to more holistic care.

While patients may have clusters of symptoms, from a pragmatic perspective, it is helpful to separate conditions to provide guidance related to specific aspects of long COVID.

In the section on ME/CFS, the statement promotes the IOM criteria and continues with —

As people may not be familiar with ME/CFS diagnostic criteria, some people who believe they have ME/CFS may not meet criteria, while others who do not recognize that they meet criteria may not be aware of the diagnosis. Whether a worker meets criteria, it is important to determine whether they have exertional intolerance and postexertional malaise because this may affect performance and recommendations for rehabilitation. The American Academy of Physical Medicine and Rehabilitation Multi-Disciplinary PASC Collaborative developed consensus guidance for the assessment and treatment of fatigue after SARSCoV-2 infection. The key elements of treatment programs include the following: (1) an individualized and structured, titrated return to activity program; (2) energy conservation strategies, (3) a healthy diet and hydration, and (4) treatment of any underlying medical conditions. Cognitive behavioral therapy was helpful to reduce severe fatigue in a small trial, although it is unclear whether any participants met criteria for ME/CFS.

For workers with postural orthostatic tachycardia syndrome, nonpharmacologic approaches include volume repletion, compression hosiery, and exercise conditioning as tolerated. If symptom control is not achieved, medications that control heart rate, increase peripheral vasoconstriction, and increase intravascular volume may be helpful.

Accommodations should be individualized. The Job Accommodation Network publishes an extensive online list of accommodation ideas for workers with ME/CFS by limitations and by work-related functions.

That last paragraph links to https://askjan.org/disabilities/Myalgic-Encephalomyelitis-Chronic-Fatigue-Syndrome.cfm

 

[Trish]

I assume an individualised structured titrated return to activity program is a version of GET.

 

[SNT Gatchaman]

The reference is to Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection PASC patients (2021, PM&R)

It's not graded, but symptom-dependent and they are aware of PEM, but yes there is a lot of enthusiasm for the idea that rehabilitation will inevitably help people. Also, that one might reliably engage in some form of sub-threshold exercise without inducing PEM over the cumulative. (I recall from Twitter days that one of the authors of this 2021 consensus paper had LC with POTS/PEM, though perhaps has fully recovered subsequently).

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 weightlifting to build strength and endurance. If the rehabilitation program is advanced too quickly or is too intense, it may worsen symptoms and lead to postexertional malaise (PEM), a diagnostic criterion of ME/CFS.9

The titrated approach encourages patients to perform activities at a submaximal level to avoid exacerbation of fatigue and PEM. Activity should be adjusted in response to symptoms that develop during or after activity. Before starting this program, it is crucial for the clinician to educate the patient on recognizing perceived exertion and the use of other metrics such as heart rate or exertion scales (such as the Borg Rating of Perceived Exertion Scale) that can guide the individual toward submaximal exertional activities. Smartphones and activity trackers may also be effective methods to monitor duration and intensity of activity.

 

[Sean]

(1) an individualized and structured, titrated return to activity program;

And the evidence for benefit from that is...?

(3) a healthy diet and hydration,

Because patients don't know how to eat food and drink water.

 

[rvallee]

Critics of this model raise the concern that this approach may lead to disregard of patient complaints that are perceived as primarily psychological. However, properly applied, this approach should lead to more holistic care.

Critics of this model are correct and are speaking to our own experience. This is literally what happened from day 1: gaslighting, dismissal, denial. But, hey, if you ignore that, it should lead to more holistic care. Assuming that more holistic care is a desired objective, and it seems here to be a stand-in for better care, which it simply never is. Ain't no True Scotsman in the whole of Scotland.

They mostly could have left it to the usual "you do you, we ain't got shit", which I guess is where medicine is all heading now. If you recover naturally, they'll take all the credit because it was all biopsychosocial, or whatever, and if you don't you get all the blame. It's the most perfect system of negligence ever put together.

 

[Kitty]

It's not graded, but symptom-dependent and they are aware of PEM, but yes there is a lot of enthusiasm for the idea that rehabilitation will inevitably help people.

I had some of this at work, there was always an underlying assumption that things will gradually get better.

Of course for some people with LC things do tend to improve with time, but managers seem baffled when they don't. They can't conceive of not being able to control it and manage it and subject it to a timetable.