Long COVID: Difference between revisions

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</ref><ref name=":25" /><ref>M.Augustin, P.Schommers, M.Stecher, F.Dewald, L.Gieselmann, H.Gruell, C.Horn, K.Vanshylla, V.Di Cristanziano, L.Osebold, M.Roventa, T.Riaz, N.Tschernoster, J.Altmueller, L.Rose, S.Salomon, V.Priesner, JC.Luers, C.Albus, S.Rosenkranz, B.Gathof, G.Fätkenheuer, M.Hallek, F.Klein, I.Suárez, C.Lehmann. [https://www.medrxiv.org/content/10.1101/2021.03.11.21253207v1 Recovered not restored: Long-term health consequences after mild COVID-19 in non-hospitalized patients]. MedRxiv, 2021.  
</ref><ref name=":25" /><ref>M.Augustin, P.Schommers, M.Stecher, F.Dewald, L.Gieselmann, H.Gruell, C.Horn, K.Vanshylla, V.Di Cristanziano, L.Osebold, M.Roventa, T.Riaz, N.Tschernoster, J.Altmueller, L.Rose, S.Salomon, V.Priesner, JC.Luers, C.Albus, S.Rosenkranz, B.Gathof, G.Fätkenheuer, M.Hallek, F.Klein, I.Suárez, C.Lehmann. [https://www.medrxiv.org/content/10.1101/2021.03.11.21253207v1 Recovered not restored: Long-term health consequences after mild COVID-19 in non-hospitalized patients]. MedRxiv, 2021.  
</ref><ref name=":22" /><ref>PHOSP-COVID Collaborative Group. [https://www.medrxiv.org/content/10.1101/2021.03.22.21254057v1 Physical, cognitive and mental health impacts of COVID-19 following hospitalisation – a multi-centre prospective cohort study]. MedRxiv, 2021.  
</ref><ref name=":22" /><ref>PHOSP-COVID Collaborative Group. [https://www.medrxiv.org/content/10.1101/2021.03.22.21254057v1 Physical, cognitive and mental health impacts of COVID-19 following hospitalisation – a multi-centre prospective cohort study]. MedRxiv, 2021.  
</ref><ref name=":9" />  
</ref><ref name=":9" />. Long COVID is both common and debilitating.<ref name=":23">S.Rajan, K.Khunti, N.Alwan, C.Steves, T.Greenhalgh, N.MacDermott, A.Sagan, M.McKee. [https://apps.who.int/iris/bitstream/handle/10665/339629/Policy-brief-39-1997-8073-eng.pdf In the wake of the pandemic: preparing for Long COVID]. World Health Organization regional office for Europe, 2021. Policy Brief 39. </ref>  
 
 
 
however there is mounting evidence that Long COVID is both common and debilitating.<ref name=":23">S.Rajan, K.Khunti, N.Alwan, C.Steves, T.Greenhalgh, N.MacDermott, A.Sagan, M.McKee. [https://apps.who.int/iris/bitstream/handle/10665/339629/Policy-brief-39-1997-8073-eng.pdf In the wake of the pandemic: preparing for Long COVID]. World Health Organization regional office for Europe, 2021. Policy Brief 39. </ref> Attempts have been made to characterise Long Covid as prolonged with multi-system involvement and significant disability.<ref name=":5">Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, Redfield S, Austin JP, Akrami A. [https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.full.pdf Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact]. medRxiv. 2020 Jan 1.</ref><ref name=":26">N.Ziauddeen, D.Gurdasani, ME.O’Hara, C.Hastie, P.Roderick, G.Yao, NA.Alwan. [https://www.medrxiv.org/content/10.1101/2021.03.21.21253968v1.full.pdf?fbclid=IwAR0pV8LBthvrj_USuO3wYe63pOUvIDIRsjKuBLvbh-pBsSTHQGE1P4MZGRM Characteristics of Long Covid: findings from a social media survey]. MedRxiv, 2021. </ref>


As of October 2021, the [https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1 World Health Organization (WHO)] has developed a case definition of post COVID-19 condition.  
As of October 2021, the [https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1 World Health Organization (WHO)] has developed a case definition of post COVID-19 condition.  


''"Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS- CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others* and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time."''<ref>WHO [https://apps.who.int/iris/bitstream/handle/10665/345824/WHO-2019-nCoV-Post-COVID-19-condition-Clinical-case-definition-2021.1-eng.pdf Diaz JV, Soriano JB. A Delphi consensus to advance on a Clinical Case Definition for Post COVID-19 condition: A WHO protoco]l.  6.10.2021 Available: https://apps.who.int/iris/bitstream/handle/10665/345824/WHO-2019-nCoV-Post-COVID-19-condition-Clinical-case-definition-2021.1-eng.pdf (accessed11.10.2021)</ref>
''"Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS- CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others* and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time."''<ref>WHO [https://apps.who.int/iris/bitstream/handle/10665/345824/WHO-2019-nCoV-Post-COVID-19-condition-Clinical-case-definition-2021.1-eng.pdf Diaz JV, Soriano JB. A Delphi consensus to advance on a Clinical Case Definition for Post COVID-19 condition: A WHO protoco]l.  6.10.2021 Available: https://apps.who.int/iris/bitstream/handle/10665/345824/WHO-2019-nCoV-Post-COVID-19-condition-Clinical-case-definition-2021.1-eng.pdf (accessed11.10.2021)</ref>
A separate definition may be applicable for children.
This definition is expected to change as new evidence emerges and our understanding of the consequences of COVID-19 continues to evolve.


== Long COVID Symptoms ==
== Long COVID Symptoms ==
Long COVID usually presents as clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. <ref name=":23" /><ref name=":4" /><ref name=":5" /><ref name=":18">Carfì A, Bernabei R, Landi F. [https://jamanetwork.com/journals/jama/fullarticle/2768351 Persistent symptoms in patients after acute COVID-19]. Jama. 2020 Aug 11;324(6):603-5.</ref><ref name=":6">Assaf G, Davis H, McCorkell L. [https://patientresearchcovid19.com/research/report-1/ Report: What Does COVID-19 Recovery Actually Look Like? An analysis of the prolonged COVID-19 symptoms survey by Patient-Led Research Team]. Patient-Led Research [online]. Patient-Led Research. 2020.</ref><ref>Salmon-Ceron D, Slama D, Broucker TD. [https://www.journalofinfection.com/article/S0163-4453(20)30762-3/fulltext Clinical, virological and imaging profile in patients with prolonged forms of COVID-19: A cross-sectional study]. J Infect. 2020.</ref><ref name=":14">Chaolin Huang, Lixue Huang, Yeming Wang, Xia Li, Lili Ren, Xiaoying Gu, Liang Kang, Li Guo, Min Liu, Xing Zhou, Jianfeng Luo, Zhenghui Huang, Shengjin Tu, Yue Zhao, Li Chen, Decui Xu, Yanping Li, Caihong Li, Lu Peng, Yong Li, Wuxiang Xie, Dan Cui, Lianhan Shang, Guohui Fan, Jiuyang Xu, Geng Wang, Ying Wang, Jingchuan Zhong, Prof Chen Wang, Prof Jianwei Wang, Dingyu Zhang, Prof Bin Cao. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32656-8/fulltext 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study]. The Lancet, 2021. </ref> Long COVID can include a range of different signs and symptoms across body systems including, but not limited to: pulmonary, cardiovascular, gastrointestinal, reproductive, genitourinary, endocrine, renal, dermatologic, musculoskeletal, neurological, neuropsychiatric, immunological, ophthalmic, and audiological.<ref name=":5" /> A list of common Long COVID symptoms is provided by The National Institute for Health and Care Excellence (NICE) <ref name=":4" />.   
Long COVID usually presents as clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. <ref name=":23" /><ref name=":4" /><ref name=":5">Davis HE, Assaf GS, McCorkell L, Wei H, Low RJ, Re’em Y, Redfield S, Austin JP, Akrami A. [https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.full.pdf Characterizing Long COVID in an International Cohort: 7 Months of Symptoms and Their Impact]. medRxiv. 2020 Jan 1.</ref><ref name=":18">Carfì A, Bernabei R, Landi F. [https://jamanetwork.com/journals/jama/fullarticle/2768351 Persistent symptoms in patients after acute COVID-19]. Jama. 2020 Aug 11;324(6):603-5.</ref><ref name=":6">Assaf G, Davis H, McCorkell L. [https://patientresearchcovid19.com/research/report-1/ Report: What Does COVID-19 Recovery Actually Look Like? An analysis of the prolonged COVID-19 symptoms survey by Patient-Led Research Team]. Patient-Led Research [online]. Patient-Led Research. 2020.</ref><ref>Salmon-Ceron D, Slama D, Broucker TD. [https://www.journalofinfection.com/article/S0163-4453(20)30762-3/fulltext Clinical, virological and imaging profile in patients with prolonged forms of COVID-19: A cross-sectional study]. J Infect. 2020.</ref><ref name=":14">Chaolin Huang, Lixue Huang, Yeming Wang, Xia Li, Lili Ren, Xiaoying Gu, Liang Kang, Li Guo, Min Liu, Xing Zhou, Jianfeng Luo, Zhenghui Huang, Shengjin Tu, Yue Zhao, Li Chen, Decui Xu, Yanping Li, Caihong Li, Lu Peng, Yong Li, Wuxiang Xie, Dan Cui, Lianhan Shang, Guohui Fan, Jiuyang Xu, Geng Wang, Ying Wang, Jingchuan Zhong, Prof Chen Wang, Prof Jianwei Wang, Dingyu Zhang, Prof Bin Cao. [https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)32656-8/fulltext 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study]. The Lancet, 2021. </ref> including, but not limited to: pulmonary, cardiovascular, gastrointestinal, reproductive, genitourinary, endocrine, renal, dermatologic, musculoskeletal, neurological, neuropsychiatric, immunological, ophthalmic, and audiological.<ref name=":5" /> A list of common Long COVID symptoms is provided by The National Institute for Health and Care Excellence (NICE) <ref name=":4" />.   


The most common Long Covid symptom is fatigue.<ref name=":5" /><ref name=":18" /><ref>Tabacof L, Tosto-Mancuso J, Wood J, Cortes M, Kontorovich A, McCarthy D, Rizk D, Nasr L, Breyman E, Mohammadi N, Kellner C. [https://www.medrxiv.org/content/10.1101/2020.11.04.20226126v1 Post-acute COVID-19 syndrome negatively impacts health and wellbeing despite less severe acute infection]. medRxiv. 2020 Jan 1.</ref><ref>Centers for Disease Control and Prevention. [https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae.html Late Sequelae of COVID-19]. 2020 November 13 [Accessed 8 January 2021].</ref><ref name=":9">A.Dennis, M.Wamil, J.Alberts, J.Oben, DJ.Cuthbertson, D.Wootton, M.Crooks, M.Gabbay, M.Brady, L.Hishmeh, E.Attree, M.Heightman, R.Banerjee, A.Banerjee.[https://bmjopen.bmj.com/content/11/3/e048391.citation-tools Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study]. BMJ Open 2021;11:e048391. doi: 10.1136/bmjopen-2020-048391</ref><ref>Tenforde MW, Kim SS, Lindsell CJ, Rose EB, Shapiro NI, Files DC, Gibbs KW, Erickson HL, Steingrub JS, Smithline HA, Gong MN. [https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network—United States, March–June 2020]. Morbidity and Mortality Weekly Report. 2020 Jul 31;69(30):993.</ref><ref>Nehme M, Braillard O, Alcoba G, Aebischer Perone S, Courvoisier D, Chappuis F, Guessous I. [https://www.acpjournals.org/doi/10.7326/M20-5926 COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient Settings]. Annals of internal medicine. 2020 Dec 8.</ref><ref>Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E. [https://www.nature.com/articles/s41591-021-01292-y?utm_medium=affiliate&utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID9237743&utm_content=deeplink&fbclid=IwAR1OaqtjXjqc6sFYJ7du39yAH_1zmutyXDK8K1qc4RQrBCIwqmOO0iL98HE Attributes and predictors of Long-COVID]. Nature Medicine, 2021. </ref><ref name=":25">Townsend L, Dyer AH, Jones K, Dunne J, Mooney A, Gaffney F, O'Connor L, Leavy D, O'Brien K, Dowds J, Sugrue JA. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240784 Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection]. Plos one. 2020 Nov 9;15(11):e0240784.</ref><ref>S.Lopez-Leon, T.Wegman-Ostrosky, C.Perelman, R.Sepulveda, P.Rebolledo, A.Cuapio, S.Villapol. [https://www.medrxiv.org/content/10.1101/2021.01.27.21250617v1 More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis]. MedRxiv, 2021.  
The most common Long Covid symptom is fatigue.<ref name=":5" /><ref name=":18" /><ref>Tabacof L, Tosto-Mancuso J, Wood J, Cortes M, Kontorovich A, McCarthy D, Rizk D, Nasr L, Breyman E, Mohammadi N, Kellner C. [https://www.medrxiv.org/content/10.1101/2020.11.04.20226126v1 Post-acute COVID-19 syndrome negatively impacts health and wellbeing despite less severe acute infection]. medRxiv. 2020 Jan 1.</ref><ref>Centers for Disease Control and Prevention. [https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae.html Late Sequelae of COVID-19]. 2020 November 13 [Accessed 8 January 2021].</ref><ref name=":9">A.Dennis, M.Wamil, J.Alberts, J.Oben, DJ.Cuthbertson, D.Wootton, M.Crooks, M.Gabbay, M.Brady, L.Hishmeh, E.Attree, M.Heightman, R.Banerjee, A.Banerjee.[https://bmjopen.bmj.com/content/11/3/e048391.citation-tools Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study]. BMJ Open 2021;11:e048391. doi: 10.1136/bmjopen-2020-048391</ref><ref>Tenforde MW, Kim SS, Lindsell CJ, Rose EB, Shapiro NI, Files DC, Gibbs KW, Erickson HL, Steingrub JS, Smithline HA, Gong MN. [https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network—United States, March–June 2020]. Morbidity and Mortality Weekly Report. 2020 Jul 31;69(30):993.</ref><ref>Nehme M, Braillard O, Alcoba G, Aebischer Perone S, Courvoisier D, Chappuis F, Guessous I. [https://www.acpjournals.org/doi/10.7326/M20-5926 COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient Settings]. Annals of internal medicine. 2020 Dec 8.</ref><ref>Sudre CH, Murray B, Varsavsky T, Graham MS, Penfold RS, Bowyer RC, Pujol JC, Klaser K, Antonelli M, Canas LS, Molteni E. [https://www.nature.com/articles/s41591-021-01292-y?utm_medium=affiliate&utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID9237743&utm_content=deeplink&fbclid=IwAR1OaqtjXjqc6sFYJ7du39yAH_1zmutyXDK8K1qc4RQrBCIwqmOO0iL98HE Attributes and predictors of Long-COVID]. Nature Medicine, 2021. </ref><ref name=":25">Townsend L, Dyer AH, Jones K, Dunne J, Mooney A, Gaffney F, O'Connor L, Leavy D, O'Brien K, Dowds J, Sugrue JA. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240784 Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection]. Plos one. 2020 Nov 9;15(11):e0240784.</ref><ref>S.Lopez-Leon, T.Wegman-Ostrosky, C.Perelman, R.Sepulveda, P.Rebolledo, A.Cuapio, S.Villapol. [https://www.medrxiv.org/content/10.1101/2021.01.27.21250617v1 More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis]. MedRxiv, 2021.  
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</ref><ref name=":24">D Menges; T.Ballouz; A.Anagnostopoulos; HE.Aschmann; A.Domenghino; JS.Fehr; MA.Puhan. [https://www.medrxiv.org/content/10.1101/2021.02.27.21252572v1 Estimating the burden of post-COVID-19 syndrome in a population-based cohort study of SARS-CoV-2 infected individuals: Implications for healthcare service planning]. MedRxiv, 2021. <nowiki>https://doi.org/10.1101/2021.02.27.21252572</nowiki>
</ref><ref name=":24">D Menges; T.Ballouz; A.Anagnostopoulos; HE.Aschmann; A.Domenghino; JS.Fehr; MA.Puhan. [https://www.medrxiv.org/content/10.1101/2021.02.27.21252572v1 Estimating the burden of post-COVID-19 syndrome in a population-based cohort study of SARS-CoV-2 infected individuals: Implications for healthcare service planning]. MedRxiv, 2021. <nowiki>https://doi.org/10.1101/2021.02.27.21252572</nowiki>
</ref><ref>B.Osikomaiya, O.Erinoso, KO.Wright, AO.Odusola, B.Thomas, O.Adeyemi, A.Bowale, O.Adejumo, A.Falana, I.Abdus-salam, O.Ogboye, A.Osibogun, A.Abayomi. [https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05716-x ‘Long COVID’: persistent COVID-19 symptoms in survivors managed in Lagos State, Nigeria]. BMC Infectious Diseases, 2021.  
</ref><ref>B.Osikomaiya, O.Erinoso, KO.Wright, AO.Odusola, B.Thomas, O.Adeyemi, A.Bowale, O.Adejumo, A.Falana, I.Abdus-salam, O.Ogboye, A.Osibogun, A.Abayomi. [https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-020-05716-x ‘Long COVID’: persistent COVID-19 symptoms in survivors managed in Lagos State, Nigeria]. BMC Infectious Diseases, 2021.  
</ref> The most frequently reported Long COVID symptoms after 6 months include fatigue, post-exertion malaise, and cognitive dysfunction <ref name=":5" />.  Researchers and patients have distinguished more than 200 symptoms associated with long COVID.  Mental health symptoms associated with long COVID include anxiety (28% increase), increased presence of depression(13% increase), PTSD(20% increase), suicide ideation (10% increase) and decreased life satisfaction and daily functioning.<ref>Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA. [https://jamanetwork.com/journals/jama/fullarticle/2805540 Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection.] JAMA. 2023</ref>
</ref> The most frequently reported Long COVID symptoms after 6 months include fatigue, post-exertion malaise, and cognitive dysfunction <ref name=":5" />.  Mental health symptoms associated with long COVID include anxiety (28% increase), increased presence of depression(13% increase), PTSD(20% increase), suicide ideation (10% increase) and decreased life satisfaction and daily functioning.  Researchers and patients have distinguished more than 200 symptoms associated with long COVID. <ref name=":2">Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, McCorkell L, Nadkarni GN, Parthasarathy S, Singh U, Walker TA. [https://jamanetwork.com/journals/jama/fullarticle/2805540 Development of a Definition of Postacute Sequelae of SARS-CoV-2 Infection.] JAMA. 2023</ref>


The multidimensional, episodic and often unpredictable nature of Long COVID has been described as "relapsing and remitting"<ref name=":6" />, whereby 86% of people with Long COVID report relapses over 7 months, with physical activity, stress, exercise and mental activity being the most common triggers of relapses.<ref name=":5" /> The trajectory of Long COVID is heterogenous with some improving over time, some worsening and others stable, with many experiencing ongoing fluctuating symptoms after 6 months<ref name=":5" />.<ref name=":27">J.Scott, L.Sigfrid, T.Drake, E.Pauley, E.Jesudason, WS.Lim, D.Munblit, C.Hastie, E.Harrison, A.Docherty, P.Olliaro, P.Openshaw, K.Baillie, C.Semple for ISARIC4C Investigators. [https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/968923/s1138-isaric4c-long-covid-preliminary-results.pdf Symptoms and quality of life following hospitalisation for COVID-19 (Post COVID-19 Syndrome/Long COVID) in the ISARIC WHO Clinical Characterisation Protocol UK: preliminary results]. 2021.</ref> Furthermore, outcomes were worse in working age females than males, with females under 50 being over five times more likely to report incomplete recovery, over five times more likely to report a new disability, more likely to have severe fatigue, and more than six times more likely to report increased breathless than males under 50.<ref name=":27" /> It is estimated that 30% of people not hospitalised with "mild" acute symptoms, continue to have symptoms 9 months after infection.<ref name=":22" /> Preliminary evidence suggests children also experience Long COVID symptoms similar to adults.<ref>D.Buonsenso, D.Munblit, C.De Rose, D.Sinatti, A.Ricchiuto, A.Carfi, P.Valentini. [https://www.medrxiv.org/content/10.1101/2021.01.23.21250375v1 Preliminary Evidence on Long COVID in children]. MedRxiv, 2021. <nowiki>https://doi.org/10.1101/2021.01.23.21250375</nowiki>
The multidimensional, episodic and often unpredictable nature of Long COVID has been described as "relapsing and remitting"<ref name=":6" />, whereby 86% of people with Long COVID report relapses over 7 months, with physical activity, stress, exercise and mental activity being the most common triggers of relapses.<ref name=":5" /> The trajectory of Long COVID is heterogenous with some improving over time, some worsening and others stable, with many experiencing ongoing fluctuating symptoms after 6 months<ref name=":5" />.<ref name=":27">J.Scott, L.Sigfrid, T.Drake, E.Pauley, E.Jesudason, WS.Lim, D.Munblit, C.Hastie, E.Harrison, A.Docherty, P.Olliaro, P.Openshaw, K.Baillie, C.Semple for ISARIC4C Investigators. [https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/968923/s1138-isaric4c-long-covid-preliminary-results.pdf Symptoms and quality of life following hospitalisation for COVID-19 (Post COVID-19 Syndrome/Long COVID) in the ISARIC WHO Clinical Characterisation Protocol UK: preliminary results]. 2021.</ref> Furthermore, outcomes were worse in working age females than males, with females under 50 being over five times more likely to report incomplete recovery, over five times more likely to report a new disability, more likely to have severe fatigue, and more than six times more likely to report increased breathless than males under 50.<ref name=":27" /> It is estimated that 30% of people not hospitalised with "mild" acute symptoms, continue to have symptoms 9 months after infection.<ref name=":22" /> Preliminary evidence suggests children also experience Long COVID symptoms similar to adults.<ref>D.Buonsenso, D.Munblit, C.De Rose, D.Sinatti, A.Ricchiuto, A.Carfi, P.Valentini. [https://www.medrxiv.org/content/10.1101/2021.01.23.21250375v1 Preliminary Evidence on Long COVID in children]. MedRxiv, 2021. <nowiki>https://doi.org/10.1101/2021.01.23.21250375</nowiki>
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== Long COVID Prevalence ==
== Long COVID Prevalence ==
Estimating the prevalence of Long COVID symptoms poses several challenges due to current lack of consensus definition and limited data collection in national surveys. The COVID-19 Infection Survey<ref>Office for National Statistics. [https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/previousReleases Coronavirus (COVID-19) Infection Survey, UK Statistical bulletins]. [Accessed 8 January 2021]</ref> is a nationally representative sample of the UK community population, from which it is has been estimated that around 1 in 5 people exhibit Long COVID symptoms for 5 weeks or longer, and around 1 in 10 exhibit Long COVID symptoms for 12 weeks or longer <ref name=":7">Office for National Statistics. [https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications The prevalence of long COVID symptoms and COVID-19 complications]. 2020 December 16 [Accessed 7 January 2021].</ref><ref>Office for National Statistics. [https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/adhocs/12788updatedestimatesoftheprevalenceoflongcovidsymptoms Updated estimates of the prevalence of long COVID symptoms]. Released 21 January 2021. Accessed 21 January 2021.  
The COVID-19 Infection Survey<ref>Office for National Statistics. [https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/previousReleases Coronavirus (COVID-19) Infection Survey, UK Statistical bulletins]. [Accessed 8 January 2021]</ref> is a nationally representative sample of the UK community population, from which it is has been estimated that around 1 in 5 people exhibit Long COVID symptoms for 5 weeks or longer, and around 1 in 10 exhibit Long COVID symptoms for 12 weeks or longer <ref name=":7">Office for National Statistics. [https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications The prevalence of long COVID symptoms and COVID-19 complications]. 2020 December 16 [Accessed 7 January 2021].</ref><ref>Office for National Statistics. [https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/adhocs/12788updatedestimatesoftheprevalenceoflongcovidsymptoms Updated estimates of the prevalence of long COVID symptoms]. Released 21 January 2021. Accessed 21 January 2021.  
</ref>. The [https://www.corona-immunitas.ch/en/program/studies/e7-zurich-coronavirus-cohort-study/ Zurich Coronavirus Cohort Study]<ref name=":24" /> recruited 437 SARS-CoV-2 positive individuals. Symptoms at diagnosis were reported by 90% of participants, of which 16%, 40%, 30% & 13% reported mild, moderate, severe and very severe symptoms respectively. Within two weeks of infection, 20% were hospitalised. At 6 months, 26% reported not having returned to normal health state; 31% among males and 21% among females. Furthermore, 23% among the non-hospitalised and 39% among the hospitalised reported not having fully recovered. The World Health Organization regional office for Europe Policy Brief on Long COVID, provides a selected evidence summary on Long COVID prevalence among both people non-hospitalised and hospitalsed.<ref name=":23" />   
</ref>.  
 
Researchers have determined that long COVID was more severe and common in individuals infected before the Omicron variant in 202 and those who were unvaccinated. Additionally, reinfections were related to higher long COVID severity and frequency compared to people who were only infected once.<ref name=":2" />   


== Pathological Process  ==
== Pathological Process  ==
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== Long COVID Management  ==
== Long COVID Management  ==


The National Institute for Health and Care Excellence (NICE) published a rapid guideline on managing Long COVID<ref name=":4" />, which covers identifying, assessing and managing Long COVID across all health care settings for adults, children and young people who have ongoing symptoms 4 weeks or more after the start of acute COVID-19. The novel nature of Long COVID has resulted in urgent calls for more research to fill existing gaps in knowledge <ref name=":13">Torjesen I. [https://www.bmj.com/content/370/bmj.m2912 NICE cautions against using graded exercise therapy for patients recovering from covid-19]. 2020 July 21 [Accessed 8 January 2021].</ref>. Co-designed quality standards for Long COVID services are proposed with potential patient care pathway model, highlighting equity and ease of access, minimal patient care burden, clinical responsibility, a multidisciplinary and evidence-based approach, and patient involvement.<ref>E.Ladds, A.Rushforth, S.Wieringa, S.Taylor, C.Rayner, L.Husain, T.Greenhalgh. [https://www.rcpjournals.org/content/clinmedicine/21/1/59 Developing services for long COVID: lessons from a study of wounded healers]. Clinical Medicine 2021 Vol 21, No 1: 59–65. DOI: <nowiki>https://doi.org/10.7861/clinmed.2020-0962</nowiki></ref> A multi-disciplinary approach assessment and management of Long COVID is essential.<ref name=":23" /> Encompassing a disability model could improve clinicians’ responses to Long COVID.<ref>VV.Altiery De Jesús, N.Alwan, F.Callard, Z.Berger. [https://osf.io/tfbnd/ Listening to Long COVID: Epistemic Injustice and COVID-19 morbidity]. OSFPrePrints, 2021. </ref><br>
The National Institute for Health and Care Excellence (NICE) published a rapid guideline on managing Long COVID<ref name=":4" />, which covers identifying, assessing and managing Long COVID across all health care settings for adults, children and young people who have ongoing symptoms 4 weeks or more after the start of acute COVID-19. Co-designed quality standards for Long COVID services are proposed with potential patient care pathway model, highlighting equity and ease of access, minimal patient care burden, clinical responsibility, a multidisciplinary and evidence-based approach, and patient involvement.<ref>E.Ladds, A.Rushforth, S.Wieringa, S.Taylor, C.Rayner, L.Husain, T.Greenhalgh. [https://www.rcpjournals.org/content/clinmedicine/21/1/59 Developing services for long COVID: lessons from a study of wounded healers]. Clinical Medicine 2021 Vol 21, No 1: 59–65. DOI: <nowiki>https://doi.org/10.7861/clinmed.2020-0962</nowiki></ref> A multi-disciplinary approach assessment and management of Long COVID is essential.<ref name=":23" /> Encompassing a disability model could improve clinicians’ responses to Long COVID.<ref>VV.Altiery De Jesús, N.Alwan, F.Callard, Z.Berger. [https://osf.io/tfbnd/ Listening to Long COVID: Epistemic Injustice and COVID-19 morbidity]. OSFPrePrints, 2021. </ref><br>
== Outcome Measures ==
== Outcome Measures ==
The National Institute for Health Research (NIHR)  has encouraged the use of the [https://www.who.int/classifications/international-classification-of-functioning-disability-and-health International Classification of Functioning Disability and Health (ICF)] to provide a framework and standard language for the description of health and health-related state, due to current insufficient evidence to provide guidance.<ref name=":8">National Institute of Health Research. [https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ Living with Covid19]. 2020 October 15 [Accessed 7 January 2021].</ref> The ICF has been operationalised into the [https://apps.who.int/classifications/icfbrowser/ ICF Browser], [https://www.who.int/docs/default-source/classification/icf/icfchecklist.pdf?sfvrsn=b7ff99e9_4 ICF Checklist], and [https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule World Health Organization Disability Assessment Schedule (WHODAS) 2.0].     
The National Institute for Health Research (NIHR)  has encouraged the use of the [https://www.who.int/classifications/international-classification-of-functioning-disability-and-health International Classification of Functioning Disability and Health (ICF)] to provide a framework and standard language for the description of health and health-related state, due to current insufficient evidence to provide guidance.<ref name=":8">National Institute of Health Research. [https://evidence.nihr.ac.uk/themedreview/living-with-covid19/ Living with Covid19]. 2020 October 15 [Accessed 7 January 2021].</ref> The ICF has been operationalised into the [https://apps.who.int/classifications/icfbrowser/ ICF Browser], [https://www.who.int/docs/default-source/classification/icf/icfchecklist.pdf?sfvrsn=b7ff99e9_4 ICF Checklist], and [https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule World Health Organization Disability Assessment Schedule (WHODAS) 2.0].     
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* [https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule WHODAS 2.0] <ref name=":21" />     
* [https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule WHODAS 2.0] <ref name=":21" />     
* [https://www.washingtongroup-disability.com/ Washington Group on disability statistics] <ref name=":21" /><ref name=":27" />.     
* [https://www.washingtongroup-disability.com/ Washington Group on disability statistics] <ref name=":21" /><ref name=":27" />.     
It may be suitable to assess for post-exertion malaise<ref name=":15" /> using measurement tools such as the DePaul Symptom Questionnaire<ref name=":16" />. People living with Long COVID report post-exertion malaise,<ref name=":5" /> and the presence of this symptom would suggest exercise is not a safe rehabilitation intervention.<ref name=":17" />  
It may be suitable to assess for post-exertion malaise<ref name=":15" /> using measurement tools such as the DePaul Symptom Questionnaire<ref name=":16" />. People living with Long COVID report post-exertion malaise,<ref name=":5" /> and the presence of this symptom would suggest exercise is not a safe rehabilitation intervention.<ref name=":17" />
 
The World Health Organization (WHO) invites clinicians and patients to collect information on COVID-19 in a systematic way and contribute clinical data to the WHO Clinical Platform to expand knowledge on Long COVID (here termed by WHO "Post-COVID-19 condition"), and support patient care and public health interventions. WHO’s Post COVID [https://www.who.int/publications/i/item/global-covid-19-clinical-platform-case-report-form-(crf)-for-post-covid-conditions-(post-covid-19-crf-)?fbclid=IwAR10sOePi5VdB15HI62GVi82c3r1V3yP2ovUz_1I58lyVBD8SxneDdJo6yk case report form (CRF)] has been designed to report standardised clinical data from individuals after hospital discharge or after the acute illness to examine the medium- and long-term consequences of COVID-19. The forms will be available in multiple languages. The CRF includes questions on functioning and disability (section 2.5) adopted from WHODAS 2.0 12-item self-report questionnaire.   
 
== Management / Interventions  ==
== Management / Interventions  ==


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</ref>   
</ref>   


The National Institute for Health and Care Excellence (NICE) has cautioned against the use of graded exercise therapy (GET) for managing post-viral fatigue<ref name=":13" />, in response to draft guidance updates on the management of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS).<ref name=":17">NICE. [https://www.nice.org.uk/news/article/nice-draft-guidance-addresses-the-continuing-debate-about-the-best-approach-to-the-diagnosis-and-management-of-me-cfs NICE draft guidance addresses the continuing debate about the best approach to the diagnosis and management of ME/CFS]. 2020 November 10 [Accessed 8 January 2020].</ref><ref>National Institute for Health and Care Excellence (NICE). [https://www.nice.org.uk/guidance/indevelopment/gid-ng10091 <nowiki>Myalgic encephalomyelitis (or encephalopathy) /chronic fatigue syndrome: diagnosis and management, In development [GID-NG10091]</nowiki>]                                    Expected publication date: <time>21 April 2021 [Accessed 8 January 2021].</time>               
The National Institute for Health and Care Excellence (NICE) has cautioned against the use of graded exercise therapy (GET) for managing post-viral fatigue<ref name=":13">Torjesen I. [https://www.bmj.com/content/370/bmj.m2912 NICE cautions against using graded exercise therapy for patients recovering from covid-19]. 2020 July 21 [Accessed 8 January 2021].</ref>, in response to draft guidance updates on the management of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS).<ref name=":17">NICE. [https://www.nice.org.uk/news/article/nice-draft-guidance-addresses-the-continuing-debate-about-the-best-approach-to-the-diagnosis-and-management-of-me-cfs NICE draft guidance addresses the continuing debate about the best approach to the diagnosis and management of ME/CFS]. 2020 November 10 [Accessed 8 January 2020].</ref><ref>National Institute for Health and Care Excellence (NICE). [https://www.nice.org.uk/guidance/indevelopment/gid-ng10091 <nowiki>Myalgic encephalomyelitis (or encephalopathy) /chronic fatigue syndrome: diagnosis and management, In development [GID-NG10091]</nowiki>]                                    Expected publication date: <time>21 April 2021 [Accessed 8 January 2021].</time>               
</ref> Substantial concerns exist regarding the potential for harm in respect to GET as an intervention for ME/CFS.<ref>Dialogues for a Neglected Illness (Dialogues for ME/CFS). [https://www.dialogues-mecfs.co.uk/films/graded-exercise-therapy/ Graded Exercise Therapy]. [Accessed 8 January 2021]</ref> Post-exertion malaise is a symptom experienced by people living with ME/CFS, <ref>Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, Staines D, Powles AP, Speight N, Vallings R, Bateman L. [https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2011.02428.x Myalgic encephalomyelitis: international consensus criteria]. Journal of internal medicine. 2011 Oct;270(4):327-38.</ref> and is characterised as the worsening of symptoms by exertion including physical, cognitive and emotional activities,<ref>Stussman B, Williams A, Snow J, Gavin A, Scott R, Nath A, Walitt B. [https://www.frontiersin.org/articles/10.3389/fneur.2020.01025/full Characterization of Post–exertional Malaise in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome]. Frontiers in Neurology. 2020 Sep 18;11:1025.</ref><ref>Stephens C. [https://meassociation.org.uk/wp-content/uploads/MEA-Research-Review-Assessing-PEM-in-MECFS-25.03.19.pdf?fbclid=IwAR1iT9TOYyOfdofaTsflQRdxkg_VEjY-0wFMOCLJJ9l8ZGQ1dgL3EI-MCeA MEA Summary Review: Assessing PEM (Post-exertional malaise)]. The ME Association. 2019 March 25 [Accessed 8 January 2021].</ref><ref>Chu L, Valencia IJ, Garvert DW, Montoya JG. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197811 Deconstructing post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome: A patient-centered, cross-sectional survey]. PloS one. 2018 Jun 1;13(6):e0197811.</ref> which would prohibit exercise interventions. Among a sample of 3,762 people living with Long COVID, post-exertion malaise was reported by 72.2%, plus exercise is a common trigger for symptom relapses<ref name=":5" /><ref name=":26" /> warranting caution with exercise as a rehabilitation intervention for Long COVID and people living with COVID-19.   
</ref> Substantial concerns exist regarding the potential for harm in respect to GET as an intervention for ME/CFS.<ref>Dialogues for a Neglected Illness (Dialogues for ME/CFS). [https://www.dialogues-mecfs.co.uk/films/graded-exercise-therapy/ Graded Exercise Therapy]. [Accessed 8 January 2021]</ref> Post-exertion malaise is a symptom experienced by people living with ME/CFS, <ref>Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, Staines D, Powles AP, Speight N, Vallings R, Bateman L. [https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2011.02428.x Myalgic encephalomyelitis: international consensus criteria]. Journal of internal medicine. 2011 Oct;270(4):327-38.</ref> and is characterised as the worsening of symptoms by exertion including physical, cognitive and emotional activities,<ref>Stussman B, Williams A, Snow J, Gavin A, Scott R, Nath A, Walitt B. [https://www.frontiersin.org/articles/10.3389/fneur.2020.01025/full Characterization of Post–exertional Malaise in Patients With Myalgic Encephalomyelitis/Chronic Fatigue Syndrome]. Frontiers in Neurology. 2020 Sep 18;11:1025.</ref><ref>Stephens C. [https://meassociation.org.uk/wp-content/uploads/MEA-Research-Review-Assessing-PEM-in-MECFS-25.03.19.pdf?fbclid=IwAR1iT9TOYyOfdofaTsflQRdxkg_VEjY-0wFMOCLJJ9l8ZGQ1dgL3EI-MCeA MEA Summary Review: Assessing PEM (Post-exertional malaise)]. The ME Association. 2019 March 25 [Accessed 8 January 2021].</ref><ref>Chu L, Valencia IJ, Garvert DW, Montoya JG. [https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197811 Deconstructing post-exertional malaise in myalgic encephalomyelitis/chronic fatigue syndrome: A patient-centered, cross-sectional survey]. PloS one. 2018 Jun 1;13(6):e0197811.</ref> which would prohibit exercise interventions. Among a sample of 3,762 people living with Long COVID, post-exertion malaise was reported by 72.2%, plus exercise is a common trigger for symptom relapses<ref name=":5" /><ref name=":26">N.Ziauddeen, D.Gurdasani, ME.O’Hara, C.Hastie, P.Roderick, G.Yao, NA.Alwan. [https://www.medrxiv.org/content/10.1101/2021.03.21.21253968v1.full.pdf?fbclid=IwAR0pV8LBthvrj_USuO3wYe63pOUvIDIRsjKuBLvbh-pBsSTHQGE1P4MZGRM Characteristics of Long Covid: findings from a social media survey]. MedRxiv, 2021. </ref> warranting caution with exercise as a rehabilitation intervention for Long COVID and people living with COVID-19.   


Groups representing people living with Long COVID have advocated for a risk stratification approach to exercise as a rehabilitation intervention. A focus is needed on assessing and excluding post-exertion malaise<ref name=":15">Holtzman CS, Bhatia S, Cotler J, Jason LA. [https://www.mdpi.com/2075-4418/9/1/26 Assessment of post-exertional malaise (PEM) in patients with myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS): a patient-driven survey]. Diagnostics. 2019 Mar;9(1):26.</ref><ref name=":16">Jason LA, Sunnquist M. [https://www.frontiersin.org/articles/10.3389/fped.2018.00330/full The Development of the DePaul Symptom Questionnaire: Original, Expanded, Brief, and Pediatric Versions]. Frontiers in pediatrics. 2018 Nov 6;6:330.</ref>, plus screening for potential cardiac involvement<ref>Phelan D, Kim JH, Elliott MD, Wasfy MM, Cremer P, Johri AM et al. [https://www.sciencedirect.com/science/article/abs/pii/S1936878X20309098 Screening of Potential Cardiac Involvemenappt in Competitive Athletes Recovering from COVID-19: An Expert Consensus Statement]. JACC: Cardiovascular Imaging. 2020;13(12):2635-2652.</ref> due to 32% prevalence of cardiac impairment among a young and low-risk population of people living with Long COVID and persistent symptoms.<ref name=":9" />  
Groups representing people living with Long COVID have advocated for a risk stratification approach to exercise as a rehabilitation intervention. A focus is needed on assessing and excluding post-exertion malaise<ref name=":15">Holtzman CS, Bhatia S, Cotler J, Jason LA. [https://www.mdpi.com/2075-4418/9/1/26 Assessment of post-exertional malaise (PEM) in patients with myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS): a patient-driven survey]. Diagnostics. 2019 Mar;9(1):26.</ref><ref name=":16">Jason LA, Sunnquist M. [https://www.frontiersin.org/articles/10.3389/fped.2018.00330/full The Development of the DePaul Symptom Questionnaire: Original, Expanded, Brief, and Pediatric Versions]. Frontiers in pediatrics. 2018 Nov 6;6:330.</ref>, plus screening for potential cardiac involvement<ref>Phelan D, Kim JH, Elliott MD, Wasfy MM, Cremer P, Johri AM et al. [https://www.sciencedirect.com/science/article/abs/pii/S1936878X20309098 Screening of Potential Cardiac Involvemenappt in Competitive Athletes Recovering from COVID-19: An Expert Consensus Statement]. JACC: Cardiovascular Imaging. 2020;13(12):2635-2652.</ref> due to 32% prevalence of cardiac impairment among a young and low-risk population of people living with Long COVID and persistent symptoms.<ref name=":9" />  


The National Health Service (NHS) provides free online self-management rehabilitation for people recovering from COVID-19 called "[https://www.yourcovidrecovery.nhs.uk/ Your COVID Recovery]".   
Activity management or [https://longcovid.physio/pacing pacing] is likely to be a safe and effective intervention for managing fatigue and post-exertion malaise. [https://longcovid.physio/heart-rate-monitoring Heart rate monitoring] is likely to be a safe and effective intervention for managing fatigue and post exertion malaise. Useful resources on pacing and heart rate monitoring are provided below:    
 
*World Physiotherapy response to COVID-19: [https://world.physio/sites/default/files/2021-06/Briefing-Paper-9-Long-Covid-FINAL-2021.pdf Safe Rehabilitation Approaches for People Living with Long Covid: Physical Activity and exercise]. June 2021
Mount Sinai Long COVID Recovery programme provides free online breath-work for Long COVID called "[https://stasisperformance.com/covid19?fbclid=IwAR3eOToRmhIlIacQcODGM81CwS4wEAJTkypY80uCe1NUFo9HfOmy1eJTd9g STASIS]".     
 
The National Institute for Health Research (NIHR) recently funded a research award for the Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN) study.<ref>National Institute for Health Research (NIHR). [https://www.fundingawards.nihr.ac.uk/award/NIHR132046 Rehabilitation Exercise and psycholoGical support After covid-19 InfectioN (REGAIN)]. [Accessed 8 January 2021]</ref>   
 
Activity management or [https://longcovid.physio/pacing pacing] is likely to be a safe and effective intervention for managing fatigue and post-exertion malaise. [https://longcovid.physio/heart-rate-monitoring Heart rate monitoring] is likely to be a safe and effective intervention for managing fatigue and post exertion malaise. Useful resources on pacing and heart rate monitoring are provided below:
* World Physiotherapy response to COVID-19: [https://world.physio/sites/default/files/2021-06/Briefing-Paper-9-Long-Covid-FINAL-2021.pdf Safe Rehabilitation Approaches for People Living with Long Covid: Physical Activity and exercise]. June 2021
* Royal College of Occupational Therapy (RCOT): "[https://www.rcot.co.uk/recovering-covid-19-post-viral-fatigue-and-conserving-energy Post viral fatigue and energy conservation]"
* Royal College of Occupational Therapy (RCOT): "[https://www.rcot.co.uk/recovering-covid-19-post-viral-fatigue-and-conserving-energy Post viral fatigue and energy conservation]"
* Royal College of Occupational Therapy (RCOT): "[https://www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19 How to manage post-viral fatigue after COVID-19 - Practical advice for people who have been treated in hospital]"
* Royal College of Occupational Therapy (RCOT): "[https://www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19 How to manage post-viral fatigue after COVID-19 - Practical advice for people who have been treated in hospital]"
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* PhysioForME: "[https://www.physiosforme.com/post/new-podcast-heart-rate-monitoring Heart Rate Monitoring Podcast]"  
* PhysioForME: "[https://www.physiosforme.com/post/new-podcast-heart-rate-monitoring Heart Rate Monitoring Podcast]"  
* ME Association: "[https://meassociation.org.uk/wp-content/uploads/MEA-Research-Review-Assessing-PEM-in-MECFS-25.03.19.pdf Assessing Post Exertion Malaise (PEM)]" page 6  
* ME Association: "[https://meassociation.org.uk/wp-content/uploads/MEA-Research-Review-Assessing-PEM-in-MECFS-25.03.19.pdf Assessing Post Exertion Malaise (PEM)]" page 6  
* National Health Service (NHS) provides free online self-management rehabilitation for people recovering from COVID-19 called "[https://www.yourcovidrecovery.nhs.uk/ Your COVID Recovery]"
* Mount Sinai Long COVID Recovery programme provides free online breath-work for Long COVID called "[https://stasisperformance.com/covid19?fbclid=IwAR3eOToRmhIlIacQcODGM81CwS4wEAJTkypY80uCe1NUFo9HfOmy1eJTd9g STASIS]".


== Peer Support  ==
== Peer Support  ==
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* [https://twitter.com/LongCovidOT Long COVID OT] (Occupational Therapy) - [https://www.facebook.com/groups/685453145469418 Facebook]  
* [https://twitter.com/LongCovidOT Long COVID OT] (Occupational Therapy) - [https://www.facebook.com/groups/685453145469418 Facebook]  
* [https://twitter.com/longcovacademia Long COVID in Academia]  
* [https://twitter.com/longcovacademia Long COVID in Academia]  
*
* For a successful rehabilitation, a multidisciplinary team approach is essential where a rehabilitation physician (physiatrist) works in collaboration with a group of physicians from multiple specialties (critical care experts, pulmonologists, neurologists, cardiologists, rheumatologists, ''etc.''), nursing professionals, pharmacists, occupational therapists, physiotherapists, social workers, mental health experts, community workers, and other health care professionals
*
*
* For a successful rehabilitation, a multidisciplinary team approach is essential where a rehabilitation physician (physiatrist) works in collaboration with a group of physicians from multiple specialties (critical care experts, pulmonologists, neurologists, cardiologists, rheumatologists, ''etc.''), nursing professionals, pharmacists, occupational therapists, physiotherapists, social workers, mental health experts, community workers, and other health care professionals  


== Video Resources for Patients ==
== Video Resources for Patients ==

Revision as of 23:20, 12 June 2023

Original Editor - Darren Brown Top Contributors - Darren Brown, Jess Bell, Olajumoke Ogunleye, Robin Tacchetti, Kim Jackson, Shwe Shwe U Marma, Tarina van der Stockt, Lucinda hampton, Candace Goh and Chelsea Mclene 

This article and the related course is currently under construction and may only be partially complete. Please come back soon to see the finished work! (12/06/2023)

Introduction[edit | edit source]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the virus that causes coronavirus disease (COVID-19) [1]. The effects of COVID-19 have been characterised across different time points:

  • Acute COVID-19 infection with signs and symptoms of COVID-19 for up to 4 weeks.
  • Ongoing symptomatic COVID-19 with signs and symptoms of COVID-19 from 4 weeks up to 12 weeks.
  • Long term consequences of COVID-19 which usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body for more than 12 weeks.[2]

** Long COVID acknowledges that the disease cause and course are as yet unknown, makes clear that “mild” COVID-19 is not necessarily mild, avoids “chronic,” “post” and “syndrome” that may delegitimise people's experiences, draws attention to morbidity, and centres people with disability [3].

What is Long COVID?[edit | edit source]

Long Covid has been preliminarily defined by as the presence of signs and symptoms that develop during or following an infection consistent with COVID-19 which continue for 12-weeks or more and are not explained by an alternative diagnosis. This includes both ongoing symptomatic COVID-19 (from 4 to 12 weeks) and "Post-COVID Syndrome" (12-weeks or more).[4]

Long COVID affects people who have been hospitalised with acute COVID-19 and those who managed in a community setting. There is growing evidence to suggest that individuals who have suffered from both mild or severe COVID-19 can experience prolonged symptoms or develop Long COVID.[5][6][7][8][9][10][11][12][13]. Long COVID is both common and debilitating.[14]

As of October 2021, the World Health Organization (WHO) has developed a case definition of post COVID-19 condition.

"Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS- CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others* and generally have an impact on everyday functioning. Symptoms may be new onset following initial recovery from an acute COVID-19 episode or persist from the initial illness. Symptoms may also fluctuate or relapse over time."[15]

Long COVID Symptoms[edit | edit source]

Long COVID usually presents as clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. [14][4][16][17][18][19][20] including, but not limited to: pulmonary, cardiovascular, gastrointestinal, reproductive, genitourinary, endocrine, renal, dermatologic, musculoskeletal, neurological, neuropsychiatric, immunological, ophthalmic, and audiological.[16] A list of common Long COVID symptoms is provided by The National Institute for Health and Care Excellence (NICE) [4].

The most common Long Covid symptom is fatigue.[16][17][21][22][13][23][24][25][9][26][27][28][29][30][31][11][32][33] The most frequently reported Long COVID symptoms after 6 months include fatigue, post-exertion malaise, and cognitive dysfunction [16]. Mental health symptoms associated with long COVID include anxiety (28% increase), increased presence of depression(13% increase), PTSD(20% increase), suicide ideation (10% increase) and decreased life satisfaction and daily functioning. Researchers and patients have distinguished more than 200 symptoms associated with long COVID. [34]

The multidimensional, episodic and often unpredictable nature of Long COVID has been described as "relapsing and remitting"[18], whereby 86% of people with Long COVID report relapses over 7 months, with physical activity, stress, exercise and mental activity being the most common triggers of relapses.[16] The trajectory of Long COVID is heterogenous with some improving over time, some worsening and others stable, with many experiencing ongoing fluctuating symptoms after 6 months[16].[35] Furthermore, outcomes were worse in working age females than males, with females under 50 being over five times more likely to report incomplete recovery, over five times more likely to report a new disability, more likely to have severe fatigue, and more than six times more likely to report increased breathless than males under 50.[35] It is estimated that 30% of people not hospitalised with "mild" acute symptoms, continue to have symptoms 9 months after infection.[11] Preliminary evidence suggests children also experience Long COVID symptoms similar to adults.[36]

[37]

Long COVID Prevalence[edit | edit source]

The COVID-19 Infection Survey[38] is a nationally representative sample of the UK community population, from which it is has been estimated that around 1 in 5 people exhibit Long COVID symptoms for 5 weeks or longer, and around 1 in 10 exhibit Long COVID symptoms for 12 weeks or longer [39][40].

Researchers have determined that long COVID was more severe and common in individuals infected before the Omicron variant in 202 and those who were unvaccinated. Additionally, reinfections were related to higher long COVID severity and frequency compared to people who were only infected once.[34]

Pathological Process[edit | edit source]

The aetiology and pathophysiological causes of Long COVID symptoms remains unknown. Initial hypothesis include: viral persistence [41][42][43][44], continued hyperactive immune response[45][46][47], cellular metabolic dysfunction[48], auto-antibodies[49][50], neurological dysfunction[51][52][53][54], neuroimmunology[55], neurological inflammation[56], and organ impairment[13] including cardiac impairment [13][57][58][59][60][61]. Musculoskeletal short- and long-term consequences of COVID-19 are also discussed.[62] More research is required to understand the mechanisms by which Long COVID develops.[14]

Long COVID Management[edit | edit source]

The National Institute for Health and Care Excellence (NICE) published a rapid guideline on managing Long COVID[4], which covers identifying, assessing and managing Long COVID across all health care settings for adults, children and young people who have ongoing symptoms 4 weeks or more after the start of acute COVID-19. Co-designed quality standards for Long COVID services are proposed with potential patient care pathway model, highlighting equity and ease of access, minimal patient care burden, clinical responsibility, a multidisciplinary and evidence-based approach, and patient involvement.[63] A multi-disciplinary approach assessment and management of Long COVID is essential.[14] Encompassing a disability model could improve clinicians’ responses to Long COVID.[64]

Outcome Measures[edit | edit source]

The National Institute for Health Research (NIHR) has encouraged the use of the International Classification of Functioning Disability and Health (ICF) to provide a framework and standard language for the description of health and health-related state, due to current insufficient evidence to provide guidance.[65] The ICF has been operationalised into the ICF Browser, ICF Checklist, and World Health Organization Disability Assessment Schedule (WHODAS) 2.0.

Some studies have performed a level of functional assessment, including:

It may be suitable to assess for post-exertion malaise[81] using measurement tools such as the DePaul Symptom Questionnaire[82]. People living with Long COVID report post-exertion malaise,[16] and the presence of this symptom would suggest exercise is not a safe rehabilitation intervention.[83]

Management / Interventions[edit | edit source]

There is currently insufficient evidence on safe and effective interventions for management of Long COVID symptoms and impairments or disability. The World Health Organization has called on countries to offer people living with Long COVID more rehabilitation.[84]

The National Institute for Health and Care Excellence (NICE) has cautioned against the use of graded exercise therapy (GET) for managing post-viral fatigue[85], in response to draft guidance updates on the management of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS).[83][86] Substantial concerns exist regarding the potential for harm in respect to GET as an intervention for ME/CFS.[87] Post-exertion malaise is a symptom experienced by people living with ME/CFS, [88] and is characterised as the worsening of symptoms by exertion including physical, cognitive and emotional activities,[89][90][91] which would prohibit exercise interventions. Among a sample of 3,762 people living with Long COVID, post-exertion malaise was reported by 72.2%, plus exercise is a common trigger for symptom relapses[16][92] warranting caution with exercise as a rehabilitation intervention for Long COVID and people living with COVID-19.

Groups representing people living with Long COVID have advocated for a risk stratification approach to exercise as a rehabilitation intervention. A focus is needed on assessing and excluding post-exertion malaise[81][82], plus screening for potential cardiac involvement[93] due to 32% prevalence of cardiac impairment among a young and low-risk population of people living with Long COVID and persistent symptoms.[13]

Activity management or pacing is likely to be a safe and effective intervention for managing fatigue and post-exertion malaise. Heart rate monitoring is likely to be a safe and effective intervention for managing fatigue and post exertion malaise. Useful resources on pacing and heart rate monitoring are provided below:

Peer Support[edit | edit source]

Peer support involves people sharing knowledge, experience, or practical help with each other, often when living with the same or similar health conditions. Many online Long COVID peer support groups have been established for people living with Long COVID. These are safe spaces for people living with Long COVID to access peer support. Mutual respect and confidentiality is, therefore, requested in these groups. Many of these groups have outputs to share valuable information with allies. Long COVID Physio published blogs with JOSPT highlighting the value of peer support. Long COVID groups include:

Video Resources for Patients[edit | edit source]

[94]
[95]

References[edit | edit source]

  1. ↑ World Health Organization. Naming the coronavirus disease (COVID-19) and the virus that causes it. [Accessed 7 January 2021]
  2. ↑ National Institute for Health and Care Excellence (NICE), COVID-19 guideline scope: management of the long-term effects of COVID-19. 2020 [Accessed 7 January 2021].
  3. ↑ Perego E, Callard F, Stras L, Melville-Johannesson B, Pope R, Alwan N. Why we need to keep using the patient made term “Long Covid. BMJ Opinion. 2020 Oct 1 [Accessed 7 January 2021].
  4. ↑ 4.0 4.1 4.2 4.3 National Institute for Health and Care Excellence (NICE). COVID-19 Rapid Guideline: Managing The Long-term Effects of COVID-19. 2020 December 18 [Accessed 8 January 2021].
  5. ↑ Public Health England. COVID-19: epidemiology, virology and clinical features. February 18, 2021.
  6. ↑ L.Townsend, J.Dowds, K.O'Brien, G.Sheill, AH.Dyer, B.O'Kelly, JP.Hynes, A.Mooney, J.Dunne, CN.Cheallaigh, C.O'Farrelly, NM.Bourke, N.Conlon, I.Martin-Loeches, C.Bergin, P.Nadarajan,C.Bannan. Persistent Poor Health Post-COVID-19 Is Not Associated with Respiratory Complications or Initial Disease Severity. Annals of the American Thoracic Society, 2021.
  7. ↑ EL.Graham, JR.Clark, ZS.Orban, PH.Lim, AL.Szymanski, C.Taylor, RM.DiBiase, DT.Jia, R.Balabanov, SU.Ho, A.Batra, EM.Liotta, IJ.Koralnik.Persistent neurologic symptoms and cognitive dysfunction in non‐hospitalized Covid‐19 “long haulers”. Annals of Clinical and Translational Neurology, 2021.
  8. ↑ P.Brodin. Immune determinants of COVID-19 disease presentation and severity. Nature Medicine, 2021;27:28–33.
  9. ↑ 9.0 9.1 Townsend L, Dyer AH, Jones K, Dunne J, Mooney A, Gaffney F, O'Connor L, Leavy D, O'Brien K, Dowds J, Sugrue JA. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection. Plos one. 2020 Nov 9;15(11):e0240784.
  10. ↑ M.Augustin, P.Schommers, M.Stecher, F.Dewald, L.Gieselmann, H.Gruell, C.Horn, K.Vanshylla, V.Di Cristanziano, L.Osebold, M.Roventa, T.Riaz, N.Tschernoster, J.Altmueller, L.Rose, S.Salomon, V.Priesner, JC.Luers, C.Albus, S.Rosenkranz, B.Gathof, G.Fätkenheuer, M.Hallek, F.Klein, I.Suárez, C.Lehmann. Recovered not restored: Long-term health consequences after mild COVID-19 in non-hospitalized patients. MedRxiv, 2021.
  11. ↑ 11.0 11.1 11.2 JK.Logue, NM.Franko, DJ.McCulloch, D.McDonald, A.Magedson,CR.Wolf, HY.Chu. Sequelae in Adults at 6 Months After COVID-19 Infection. JAMA Netw Open. 2021;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830
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  13. ↑ 13.0 13.1 13.2 13.3 13.4 A.Dennis, M.Wamil, J.Alberts, J.Oben, DJ.Cuthbertson, D.Wootton, M.Crooks, M.Gabbay, M.Brady, L.Hishmeh, E.Attree, M.Heightman, R.Banerjee, A.Banerjee.Multiorgan impairment in low-risk individuals with post-COVID-19 syndrome: a prospective, community-based study. BMJ Open 2021;11:e048391. doi: 10.1136/bmjopen-2020-048391
  14. ↑ 14.0 14.1 14.2 14.3 14.4 S.Rajan, K.Khunti, N.Alwan, C.Steves, T.Greenhalgh, N.MacDermott, A.Sagan, M.McKee. In the wake of the pandemic: preparing for Long COVID. World Health Organization regional office for Europe, 2021. Policy Brief 39.
  15. ↑ WHO Diaz JV, Soriano JB. A Delphi consensus to advance on a Clinical Case Definition for Post COVID-19 condition: A WHO protocol. 6.10.2021 Available: https://apps.who.int/iris/bitstream/handle/10665/345824/WHO-2019-nCoV-Post-COVID-19-condition-Clinical-case-definition-2021.1-eng.pdf (accessed11.10.2021)
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