Long COVID

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

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 [2]:

  • 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.

The long term sequelae of COVID-19 awaits consensus definition, and a variety of nomenclature has been used to describe the long term signs and symptoms of COVID-19. This includes the patient directed terms "Long Covid" [3][4][5][6][7][8], "Long-Haul Covid" [4][9] and "Long Haulers" [10][11], plus other terms including "Post-COVID-19 syndrome" [2][12], "Post-COVID Syndrome" [13], "Post-Acute COVID-19" [14], and "Post-Acute COVID-19 syndrome"[15]. For the purposes of consistency, this page will refer to the long term consequences of COVID-19 as "Long Covid" and to "People living with COVID-19". We will refer to "Long Covid" because this term acknowledges that 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 peoples experiences, draws attention to morbidity, and centres people with disability [3]. We will refer to "People living with COVID-19" to align with existing person first language [16] and applying knowledge from other health care conditions with experiences of stigma [17].

What is Long Covid?[edit | edit source]

Long Covid has been preliminarily defined by The National Institute for Health and Care Excellence (NICE), the Scottish Intercollegiate Guidelines Network, and the Royal College of General Practitioners, 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) [18].

The rapid and dynamic review of Long Covid evidence by the National Institute for Health and Care Excellence (NICE) suggests that Long Covid may be made up of 4 phenotypes [16]:

  • post-intensive care
  • post-viral fatigue
  • permanent organ damage
  • long-term COVID

Consensus has not yet been reached on a Long Covid case definition [6][19][20], however attempts have been made to characterise Long Covid as prolonged with multi-system involvement and significant disability [19].

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 [18][19][21][22][23]. Long Covid can include a range of 205 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 [19]. A list of common Long Covid symptoms is provided by The National Institute for Health and Care Excellence (NICE) [24].

The most common Long Covid symptom is fatigue [19][25][26][27][28][29][30][31]. The most frequently reported Long Covid symptoms after 6 months include fatigue, post-exertion malaise, and cognitive dysfunction [19]. The multidimensional, episodic and often unpredictable nature of Long Covid has been described as "relapsing and remitting" [22], 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 [19]. 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 [19].

Long Covid Prevalence[edit | edit source]

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 [32] 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 [7].

Pathological Process[edit | edit source]

The aetiology and pathophysiological causes of Long Covid symptoms remains unknown, due to insufficient evidence. Initial hypothesis include: viral persistence [33][34][35][36], continued hyperactive immune response [37][38], cellular metabolic dysfunction [39], auto-antibodies [40], and organ impairment [27]. More research is required.

Long Covid Management[edit | edit source]

The National Institute for Health and Care Excellence (NICE) published a rapid guideline on managing Long Covid [18], 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 [41].

Outcome Measures[edit | edit source]

The National Institute for Health Research (NIHR) [16] has encouraged the use of the International Classification of Functioning Disability and Health (ICF) [42][43] to provide a framework and standard language for the description of health and health-related state, due to current insufficient evidence to provide guidance. The ICF has been operationalised into the ICF Browser [44], ICF Checklist [45], and World Health Organization Disability Assessment Schedule (WHODAS) 2.0 [46].

Some studies have performed a level of functional assessment, including the new "Post-COVID-19 Functional Status Assessment" (PCFS) [47][48][49], sit-to-stand tests [49][50] , gait speed tests [49][51][52][53][54], modified Rankin Score [55], and SF-36 questionnaire [50].

Management / Interventions[edit | edit source]

There is currently insufficient evidence on safe and effective interventions for management of Long Covid symptoms and impairments.

The National Institute for Health and Care Excellence (NICE) has cautioned against the use of graded exercise therapy (GET) for managing post-viral fatigue [56], in responce to draft guidance updates on the management of Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME/CFS) [57][58]. Substantial concerns exist regarding the potential for harm in respect to GET as an intervention for ME/CFS [59]. Post-exertion malaise is a symptom experienced by people living with ME/CFS [60], and is characterised as the worsening of symptoms by exertion including physical, cognitive and emotional activities [61][62][63], which would prohibit exercise interventions. Among a sample of 3,762 people living with Long Covid, post-exertion malaise was reported by 72.2% [19].

Risk stratification to exercise as a rehabilitation intervention, has been advocated by groups representing people living with Long Covid, to assess and exclude post-exertion malaise [64][65], plus screening for potential cardiac involvement [66] due to 32% prevalence of cardiac impairment among a young and low-risk population of people living with Long Covid and persistent symptoms [27].

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 [67][68]. Useful resources on pacing are provided below:

  • Royal College of Occupational Therapy (RCOT): "Post viral fatigue and energy conservation" [69].
  • Royal College of Occupational Therapy (RCOT): "How to manage post-viral fatigue after COVID-19 - Practical advice for people who have been treated in hospital" [70].
  • Royal College of Occupational Therapy (RCOT): "How to manage post-viral fatigue after COVID-19 - Practical advice for people who have recovered at home"[71]
  • Royal College of Occupational Therapy (RCOT): "How to conserve your energy" [72].
  • Workwell Foundation & Dialogues ME/CFS: "Activity and Energy Management – Pacing" [73].
  • PhysioForME: "Pacing" [74]
  • ME Action: "Pacing and management guide for ME/CFS" [75]
  • Action for ME: "Pacing for people with M.E. A detailed guide to managing energy, rest and activity for adults with mild/moderate M.E."[76].
  • Emerge Australia: "Pacing" [77].

Differential Diagnosis[edit | edit source]

add text here relating to the differential diagnosis of this condition

Resources[edit | edit source]

add appropriate resources here

References[edit | edit source]

  1. ↑ https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance/naming-the-coronavirus-disease-(covid-2019)-and-the-virus-that-causes-it
  2. ↑ 2.0 2.1 https://www.nice.org.uk/guidance/gid-ng10179/documents/final-scope
  3. ↑ 3.0 3.1 https://blogs.bmj.com/bmj/2020/10/01/why-we-need-to-keep-using-the-patient-made-term-long-covid/
  4. ↑ 4.0 4.1 https://www.sciencedirect.com/science/article/pii/S0277953620306456
  5. ↑ https://www.nature.com/articles/d41586-020-02796-2
  6. ↑ 6.0 6.1 https://www.bmj.com/content/371/bmj.m4938
  7. ↑ 7.0 7.1 https://www.ons.gov.uk/news/statementsandletters/theprevalenceoflongcovidsymptomsandcovid19complications
  8. ↑ https://www.nature.com/articles/d41586-020-02796-2
  9. ↑ https://n.neurology.org/content/95/13/559.long
  10. ↑ https://www.nature.com/articles/d41586-020-02598-6
  11. ↑ https://onlinelibrary.wiley.com/doi/10.1002/jmv.26624
  12. ↑ https://openres.ersjournals.com/content/6/4/00542-2020
  13. ↑ https://www.england.nhs.uk/coronavirus/publication/national-guidance-for-post-covid-syndrome-assessment-clinics/
  14. ↑ https://www.bmj.com/content/370/bmj.m3026
  15. ↑ https://www.england.nhs.uk/coronavirus/publication/national-guidance-for-post-covid-syndrome-assessment-clinics/
  16. ↑ 16.0 16.1 16.2 https://evidence.nihr.ac.uk/themedreview/living-with-covid19/
  17. ↑ https://www.nhivna.org/file/5dcbdcb83254e/BP-19-2.pdf
  18. ↑ 18.0 18.1 18.2 https://www.nice.org.uk/guidance/ng188
  19. ↑ 19.0 19.1 19.2 19.3 19.4 19.5 19.6 19.7 19.8 https://www.medrxiv.org/content/10.1101/2020.12.24.20248802v2.full.pdf
  20. ↑ https://www.medrxiv.org/content/10.1101/2020.12.08.20246025v1
  21. ↑ https://jamanetwork.com/journals/jama/fullarticle/2768351
  22. ↑ 22.0 22.1 https://patientresearchcovid19.com/research/report-1/
  23. ↑ https://www.journalofinfection.com/article/S0163-4453(20)30762-3/fulltext
  24. ↑ https://www.nice.org.uk/guidance/ng188/chapter/common-symptoms-of-ongoing-symptomatic-covid-19-and-post-covid-19-syndrome#common-symptoms-of-ongoing-symptomatic-covid-19-and-post-covid-19-syndrome
  25. ↑ https://www.medrxiv.org/content/10.1101/2020.11.04.20226126v1
  26. ↑ https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/late-sequelae.html
  27. ↑ 27.0 27.1 27.2 https://www.medrxiv.org/content/10.1101/2020.10.14.20212555v1
  28. ↑ https://www.cdc.gov/mmwr/volumes/69/wr/mm6930e1.htm
  29. ↑ https://www.acpjournals.org/doi/10.7326/M20-5926
  30. ↑ https://www.medrxiv.org/content/10.1101/2020.10.19.20214494v2
  31. ↑ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0240784
  32. ↑ https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/coronaviruscovid19infectionsurveypilot/previousReleases
  33. ↑ https://www.nature.com/articles/s41423-020-00550-2
  34. ↑ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7654855/
  35. ↑ https://www.biorxiv.org/content/10.1101/2020.11.18.388819v1.full
  36. ↑ https://www.thelancet.com/journals/ebiom/article/PIIS2352-3964(20)30480-1/fulltext
  37. ↑ https://www.ijidonline.com/article/S1201-9712(20)30732-3/fulltext
  38. ↑ https://www.medrxiv.org/content/10.1101/2020.10.21.20216192v2
  39. ↑ https://www.sciencedirect.com/science/article/pii/S0306987720314742?via%3Dihub
  40. ↑ https://ard.bmj.com/content/79/12/1661
  41. ↑ https://www.bmj.com/content/370/bmj.m2912
  42. ↑ https://www.who.int/classifications/international-classification-of-functioning-disability-and-health
  43. ↑ https://physio-pedia.com/International_Classification_of_Functioning,_Disability_and_Health_(ICF)?utm_source=physiopedia&utm_medium=search&utm_campaign=ongoing_internal
  44. ↑ https://apps.who.int/classifications/icfbrowser/
  45. ↑ https://www.who.int/docs/default-source/classification/icf/icfchecklist.pdf?sfvrsn=b7ff99e9_4
  46. ↑ https://www.who.int/standards/classifications/international-classification-of-functioning-disability-and-health/who-disability-assessment-schedule
  47. ↑ https://erj.ersjournals.com/content/56/1/2001494
  48. ↑ https://www.medrxiv.org/content/10.1101/2020.08.26.20182618v1
  49. ↑ 49.0 49.1 49.2 https://openres.ersjournals.com/content/early/2020/10/15/23120541.00655-2020
  50. ↑ 50.0 50.1 https://www.medrxiv.org/content/10.1101/2020.08.12.20173526v1
  51. ↑ https://www.medrxiv.org/content/10.1101/2020.10.15.20205054v1
  52. ↑ https://www.resmedjournal.com/article/S0954-6111(20)30337-1/fulltext
  53. ↑ https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-020-01429-6
  54. ↑ https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-020-01546-2
  55. ↑ https://www.medrxiv.org/content/10.1101/2020.10.16.20211029v1
  56. ↑ https://www.bmj.com/content/370/bmj.m2912
  57. ↑ 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
  58. ↑ https://www.nice.org.uk/guidance/indevelopment/gid-ng10091
  59. ↑ https://www.dialogues-mecfs.co.uk/films/graded-exercise-therapy/
  60. ↑ https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2796.2011.02428.x
  61. ↑ https://www.frontiersin.org/articles/10.3389/fneur.2020.01025/full
  62. ↑ https://meassociation.org.uk/wp-content/uploads/MEA-Research-Review-Assessing-PEM-in-MECFS-25.03.19.pdf?fbclid=IwAR1iT9TOYyOfdofaTsflQRdxkg_VEjY-0wFMOCLJJ9l8ZGQ1dgL3EI-MCeA.
  63. ↑ https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0197811
  64. ↑ https://www.mdpi.com/2075-4418/9/1/26
  65. ↑ https://www.frontiersin.org/articles/10.3389/fped.2018.00330/full
  66. ↑ https://www.sciencedirect.com/science/article/abs/pii/S1936878X20309098
  67. ↑ https://www.physiosforme.com/heart-rate-monitoring
  68. ↑ https://www.physiosforme.com/post/new-podcast-heart-rate-monitoring
  69. ↑ https://www.rcot.co.uk/recovering-covid-19-post-viral-fatigue-and-conserving-energy
  70. ↑ https://www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19
  71. ↑ https://www.rcot.co.uk/how-manage-post-viral-fatigue-after-covid-19-0
  72. ↑ https://www.rcot.co.uk/conserving-energy
  73. ↑ https://www.dialogues-mecfs.co.uk/films/pacing/
  74. ↑ https://www.physiosforme.com/pacing
  75. ↑ https://www.meaction.net/wp-content/uploads/2020/10/Pacing-and-Management-Guide-for-ME_CFS-8.pdf
  76. ↑ https://www.actionforme.org.uk/uploads/pdfs/Pacing-for-people-with-me-booklet-Feb-2020.pdf
  77. ↑ https://www.emerge.org.au/Handlers/Download.ashx?IDMF=2a2287ee-b84d-428f-b72e-00da812ddd7c

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