Long covid—mechanisms, risk factors, and management, 2021, Crook et al

Wyva

Wyva

Senior Member (Voting Rights)
Abstract

Since its emergence in Wuhan, China, covid-19 has spread and had a profound effect on the lives and health of people around the globe. As of 4 July 2021, more than 183 million confirmed cases of covid-19 had been recorded worldwide, and 3.97 million deaths. Recent evidence has shown that a range of persistent symptoms can remain long after the acute SARS-CoV-2 infection, and this condition is now coined long covid by recognized research institutes.

Studies have shown that long covid can affect the whole spectrum of people with covid-19, from those with very mild acute disease to the most severe forms. Like acute covid-19, long covid can involve multiple organs and can affect many systems including, but not limited to, the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems.

The symptoms of long covid include fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache.

This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure. Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed.

Open access: https://www.bmj.com/content/374/bmj.n1648
 
Parts on ME/CFS below.

It seems that the authors view ME/CFS mostly through the prism of chronic fatigue. They mention the wide array of symptoms that long Covid and ME/CFS share, but when comparing both conditions, they use the terms "long Covid fatigue" or "Post-COVID-19 fatigue" rather than directly writing "long Covid". Nevertheless, they acknowledge that research on either can help understand the other.

Unfortunately, while post-exertional malaise, pacing, and the July 2020 NICE interim statement cautioning on GET for long Covid are mentioned, the 2007 NICE guidelines and the Cochrane review of GET for CFS are cited to support it.

The update of the NICE guidelines is misrepresented as being the result of "backlash from the ME Association".

The authors do not support CBT -- they explain the findings of Mark Vink's reanalysis of the Cochrane review of CBT for CFS, as well as his article on CBT being probably ineffective for long Covid, judging by the (negative) QURE study on Q-fever fatigue syndrome.

Symptoms

Fatigue
Possible mechanisms

Post-COVID-19 fatigue has been compared with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), with many overlaps between the two.72 Symptoms common to both ME/CFS and long covid include fatigue, neurological/pain, neurocognitive/psychiatric, neuroendocrine, autonomic, and immune symptoms, with both ME/CFS and long covid patients having long symptom durations, reduced daily activity, and post-exertional malaise.72 ME/CFS remains enigmatic, therefore, research into long covid may assist in developing understanding of ME/CFS and vice versa.
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Treating fatigue, cognitive, and neuropsychiatric symptoms

Chronic fatigue is a common manifestation of long covid. NICE recommends that self-management and support are important in managing fatigue, owing to the poor availability of covid-19 specific treatment.9 A condition that may overlap with long covid fatigue is myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), therefore, the treatment algorithm designed for treating ME/CFS may prove useful in treating post-covid-19 fatigue. NICE has specific guidelines that outline how to refer and treat ME/CFS patients; these include cognitive behavioral therapy (CBT) and graded exercise therapy (GET).178 Following backlash over these guidelines from the ME Association,179 however, NICE aims to publish revised guidelines in August 2021.180

Randomized controlled trials have shown that CBT is beneficial in the treatment of chronic fatigue,181 however, this is conflicted by findings from a re-analysis of a Cochrane review which question its effectiveness and show a high incidence of adverse events. This re-analysis study states that if a trial of a drug or surgical procedure demonstrated similarly high rates of adverse effects, then it would not be accepted as a safe treatment option, therefore CBT should have to adhere to the same level of scrutiny.182

Another management strategy for fatigue is pacing, whereby patients manage tasks and activities to avoid over-exertion and exacerbating fatigue. NICE guidelines for ME/CFS178 describe pacing as a self-management strategy, however guidance and education from healthcare professionals may be useful for patients. Evidence from randomized controlled trials for the use of pacing in long covid is yet to be seen.

The implementation of group therapy via videoconferencing in people with early psychosis during the covid-19 pandemic shows promising results, with a pilot study showing improvements in psychotic symptoms and self-esteem,183 however, a review article provides information to suggest that CBT is ineffective in reducing long covid symptoms, including fatigue, with only 10% of participants achieving clinically meaningful improvements.184

GET is a structured intervention plan consisting of physical activities with a therapeutic goal.185 A systematic review of exercise therapy for CFS concluded that patients with ME/CFS generally feel less fatigued and have improved sleep and physical function following completion of exercise therapy, to a greater degree than following a program of either adaptive pacing or supportive listening.186 The NICE guidelines on ME/CFS recommend GET; however, in July 2020 NICE released a statement urging caution when implementing GET for people recovering from covid-19, stating that with guidelines currently being updated, these recommendations may change.187 This statement accompanies concerns over the potential negative effects of GET, including post-exertional malaise.188
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Some not quite awful bits, some other misinformed bits. Some actual disinformation relating to the NICE guidelines.

As a State of the art 17 months into it, this is pathetic failure. One foot is barely reaching the starting line while the other is trying to escape in the wrong direction. Absolutely nothing useful has been learned, no progress has been made and the entire field of medicine is stuck in paralysis.

There is still a common refrain of "new illness", which was false to begin with but even then by now that excuse has lost all credibility. It's true that no one has learned anything useful since, and that's complete failure, full stop. It's not an excuse or extenuating circumstances, the context makes it all so much worse.

As usual what I don't understand is the infinite tolerance for failure. Zero urgency, zero sense of doing more. Everything's fine, no need to change anything moving forward. Almost all that has been written in this article was previously known, fragmented in related topics.

Normally this would be the point at which people ask "have you no shame?" but we know the answer to that. Although it does place in context why it was impossible for us to make any progress. When so many obstacles and bad will are placed on the way to make sure no one moves an inch, you get full system paralysis. Hey no big deal it's just tens of millions of lives who cares right?

To clarify, this would have been fine the first month or so, maybe by 3 months. Not 17 months in, not even 12. This is all old stuff that medicine chose to dismiss and that's a big fracking deal.
 
Merged thread

Clinical review - Long Covid - mechanisms, risk factors, and management by Harry Crook, Sanara Raza, Joseph Nowell, Megan Young and Paul Edison

Abstract
Since its emergence in Wuhan, China, covid-19 has spread and had a profound effect on the lives and health of people around the globe.

As of 4 July 2021, more than 183 million confirmed cases of covid-19 had been recorded worldwide, and 3.97 million deaths. Recent evidence has shown that a range of persistent symptoms can remain long after the acute SARS-CoV-2 infection, and this condition is now coined long covid by recognized research institutes.

Studies have shown that long covid can affect the whole spectrum of people with covid-19, from those with very mild acute disease to the most severe forms.

Like acute covid-19, long covid can involve multiple organs and can affect many systems including, but not limited to, the respiratory, cardiovascular, neurological, gastrointestinal, and musculoskeletal systems.

The symptoms of long covid include fatigue, dyspnea, cardiac abnormalities, cognitive impairment, sleep disturbances, symptoms of post-traumatic stress disorder, muscle pain, concentration problems, and headache.

This review summarizes studies of the long term effects of covid-19 in hospitalized and non-hospitalized patients and describes the persistent symptoms they endure.

Risk factors for acute covid-19 and long covid and possible therapeutic options are also discussed.

 
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ME is mentioned a few times. Under the subtitle "Possible mechanisms:
Post-COVID-19 fatigue has been compared with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), with many overlaps between the two.72 Symptoms common to both ME/CFS and long covid include fatigue, neurological/pain, neurocognitive/psychiatric, neuroendocrine, autonomic, and immune symptoms, with both ME/CFS and long covid patients having long symptom durations, reduced daily activity, and post-exertional malaise.72 ME/CFS remains enigmatic, therefore, research into long covid may assist in developing understanding of ME/CFS and vice versa.
Click to expand...


And here:
Treating fatigue, cognitive, and neuropsychiatric symptoms
Chronic fatigue is a common manifestation of long covid. NICE recommends that self-management and support are important in managing fatigue, owing to the poor availability of covid-19 specific treatment.9 A condition that may overlap with long covid fatigue is myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), therefore, the treatment algorithm designed for treating ME/CFS may prove useful in treating post-covid-19 fatigue. NICE has specific guidelines that outline how to refer and treat ME/CFS patients; these include cognitive behavioral therapy (CBT) and graded exercise therapy (GET).178 Following backlash over these guidelines from the ME Association,179however, NICE aims to publish revised guidelines in August 2021.180

Randomized controlled trials have shown that CBT is beneficial in the treatment of chronic fatigue,181 however, this is conflicted by findings from a re-analysis of a Cochrane review which question its effectiveness and show a high incidence of adverse events. This re-analysis study states that if a trial of a drug or surgical procedure demonstrated similarly high rates of adverse effects, then it would not be accepted as a safe treatment option, therefore CBT should have to adhere to the same level of scrutiny.182

Another management strategy for fatigue is pacing, whereby patients manage tasks and activities to avoid over-exertion and exacerbating fatigue. NICE guidelines for ME/CFS178 describe pacing as a self-management strategy, however guidance and education from healthcare professionals may be useful for patients. Evidence from randomized controlled trials for the use of pacing in long covid is yet to be seen.

The implementation of group therapy via videoconferencing in people with early psychosis during the covid-19 pandemic shows promising results, with a pilot study showing improvements in psychotic symptoms and self-esteem,183 however, a review article provides information to suggest that CBT is ineffective in reducing long covid symptoms, including fatigue, with only 10% of participants achieving clinically meaningful improvements.184

GET is a structured intervention plan consisting of physical activities with a therapeutic goal.185 A systematic review of exercise therapy for CFS concluded that patients with ME/CFS generally feel less fatigued and have improved sleep and physical function following completion of exercise therapy, to a greater degree than following a program of either adaptive pacing or supportive listening.186 The NICE guidelines on ME/CFS recommend GET; however, in July 2020 NICE released a statement urging caution when implementing GET for people recovering from covid-19, stating that with guidelines currently being updated, these recommendations may change.187 This statement accompanies concerns over the potential negative effects of GET, including post-exertional malaise.188

Evidence specific to covid-19 is lacking, therefore cognitive impairment should be managed with support, including setting tailored, achievable goals and implementing validated screening tools.9 Managing cognitive impairment will require a holistic approach, however, patients should be advised that most people gradually recover from cognitive impairment following severe illness.106189 The holistic approach to treatment should extend to the services offered, with professionals including occupational and speech and language therapists addressing cognitive changes.190 Cognitive impairment in long covid, sometimes called “brain fog,” has been compared to “chemobrain.”191 The Mayo clinic recommendations suggest strategies to manage chemobrain including repeating exercises, tracking what influences deficits, and using stress relief and coping strategies. Furthermore, medications including methylphenidate, donepezil, modafinil, and memantine may be considered.192 These strategies may prove useful for long covid. Specific to long covid, luteolin, a natural flavonoid, may alleviate cognitive impairment by inhibiting mast cell and microglia activation,191 but clinical trials are required.

Sleep disturbances may be managed by following relevant guidelines on insomnia,193 and a range of treatment strategies can be considered.194195196197 Patients with mental health problems alongside or as a result of long covid can be managed following the relevant guidelines: depression,198 anxiety,199 PTSD,200 obsessive-compulsive disorder,201 and other mental health problems.202 Care home residents, including those with dementia, who acquire long covid have additional needs.116 Discussing mental health problems with patients requires compassion and understanding.203
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Moved post
Seen this today:

https://www.bmj.com/content/374/bmj.n1648

Any ideas / thoughts / feedback as to the quality of the rationales/arguments re the possible mechanisms for Long Covid suggested in the paper? https://www.s4me.info/members/jonathan-edwards.25/ @PhysiosforME

I see they state "Negative psychological and social factors associated with the covid-19 pandemic have also been linked to chronic fatigue." without any discussion to possible mechanisms or rationale.... ! Pretty lazy.
 
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It's a bit of a mish mash.... Doesn't read like there is clear thinking or a good, promising way forward - lots of bits - but no real coherent, cogent medical thinking. Just my impression. Suggests very much on the dark - as ever medically-wise.

Any thoughts / feedback as to the quality of the rationales/arguments re the possible mechanisms for Long Covid suggested in the paper? @Jonathan Edwards @PhysiosforME

I see they state "Negative psychological and social factors associated with the covid-19 pandemic have also been linked to chronic fatigue." Without any discussion to possible mechanisms or rationale.... ! Pretty lazy.
 
This reads like a student essay assignment. (In fact the assignment is likely to have been given to the senior author who passed it down to a fresh junior wanting publications.) It is devoid of any intelligent analysis and nobody has proof read the English properly.

Complete drivel again I am afraid.
 
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