How can we help employees who are still suffering many months later, asks Stephanie Foster
COVID-19 has had a significant impact on all areas of our lives, with the socio-economic impact likely to be felt for many years to come. The rapidly changing situation regarding testing, clinical vulnerability and vaccination has kept OH Practitioners on their toes, and it has been heart-warming to observe the sharing of knowledge and best practise within the OH community as a result. While we know that most people who get the disease will experience mild to moderate symptoms and make a functional recovery, there are a number of individuals who are experiencing long term health issues affecting their attendance at work. Increasingly they are being referred to OH for our advice on their fitness for work and the need for workplace adjustments. Our latest challenge is providing evidence-based advice when our understanding and knowledge of this new condition is constantly evolving.
As already highlighted, most individuals who develop symptomatic COVID 19 will make a functional recovery within 2-4 weeks. Approximately 20% may experience a slightly longer recovery period, experiencing issues with post viral fatigue and cough, that gradually resolves with rest and graded exercise within 12 weeks.1,2 However there are estimates of between 1 – 10 % of patients, who appear to be experiencing much longer term symptoms.2,3,4 Certainly, I have started to see clients in my clinics who, 6-10 months on from their initial infection, continue to experience significant health issues. The term Long COVID was initially conceptualised by patients, who found each other through social media and lobbied for recognition, further research and support due to their ongoing symptoms. The term was eventually adopted by the media and clinicians to define a range of symptoms commonly being experienced by patients 12 weeks post infection.5 While NICE acknowledges the term, it uses definitions on page 8, which would probably be best practice for OH to adopt.
We know that critical illness such as sepsis and other conditions that may require ITU care, can result in a range of long-term symptoms, commonly given an umbrella term of Post Sepsis Syndrome (PSS) or Post Intensive Care Syndrome (PICS).7.8 The World Health Organisation, Sepsis charities and researchers in several countries have highlighted the similarities between the range of symptoms of these 2 syndromes and the long-term symptoms being reported post COVID. Some have even gone as far as suggesting that Post COVID-19 Syndrome is in fact a result of viral sepsis1,9.10. The UK Sepsis Trust highlights on its website, that symptoms such as breathlessness and fatigue tend to gradually improve over a 6-to-18 month period7. Although others are reticent to attribute Post COVID symptoms to a single cause11. Only time will reveal if recovery follows the same path for sepsis caused by other infections, or if there are additional unique health issues experienced due to COVID -19, but it gives us a base from which to start. One small study highlighted that 55% of post COVID patients had three or more symptoms, with the most common being extreme fatigue, breathlessness, joint and chest pain12. In addition, symptoms do not appear to be dependent on the severity of the initial infection and can be relapsing and remitting in nature2. Due to the aggressive inflammatory response and increased risk of blood clots that the infection can cause, there have been cases of associated coronary heart disease, heart attack, stroke, Pulmonary Embolism (PE), kidney disease and new onset of diabetes, although these complications are rare2,13.
Signs and symptoms of COVID‑19 for up to 4 weeks.
Ongoing symptomatic COVID-19
Signs and symptoms of COVID‑19 from 4 weeks up to 12 weeks.
Signs and symptoms that develop during or after an infection consistent with COVID‑19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. Post‑COVID‑19 syndrome may be considered before 12 weeks while the possibility of an alternative underlying disease is also being assessed.
In addition to the clinical case definitions, the term ‘long COVID’ is commonly used to describe signs and symptoms that continue or develop after acute COVID‑19. It includes both ongoing symptomatic COVID‑19 (from 4 to 12 weeks) and post‑COVID‑19 syndrome (12 weeks or more).
These definitions are irrespective of if the individual had a positive or negative COVID -19 test.
Source: NHS England. National guidance for post-covid syndrome assessment clinics.6
SEPSIS VS COVID-19 RECOVERY
Post Sepsis Syndrome
Source: Sepsis Trust7
Post COVID-19 Syndrome
Source: NHS.co.uk14, NICE6 and WHO1
Although advising on this new disease is daunting, we have the existing knowledge and skills to be able to support employees and management. We already assess the functional impact of the symptoms outlined above and offer advice regarding their impact on workability and appropriate adjustments. This is because these symptoms are not unique to COVID 19. We can utilize the knowledge we have gained regarding conditions such as multiple sclerosis, fibromyalgia, chronic respiratory disease, cancer, stroke and traumatic head injury to inform our practise. Going back to basics and carrying out a good functional assessment, looking at the impact on activities of daily living, is a cornerstone of OH practise. The World Health Organisation (WHO) in their training package on COVID-19 rehabilitation, repeatedly advocates the use of well validated assessment tools to assess and monitor progress.1 The concept of fatigue and how it impacts on daily life is hard to describe. Therefore, assessment tools such as the Chandler Fatigue Scale (CFQ11)15,16 and the Fatigue Assessment Scale (FAS)17, can help us to assess the impact the fatigue is having on both physical and mental functioning, in a reliable and reproducible manner. The Medical Research Council (MRC) dyspnoea scale18 has long been used for grading the effect of breathlessness on daily activities, with a level 3 score being used as a criteria for further investigation and respiratory rehabilitation.19 Other specific assessment tools have been developed by various multidisciplinary COVID rehabilitation clinics and are included in the appendix of the NHS England guidance for post-covid syndrome assessment clinics.20
It is estimated that approximately 15 – 20% of people who develop COVID-19 symptoms will require hospital treatment, while 5% are likely to need intensive care13. This cohort of patients is the group that multidisciplinary rehabilitation services are predominantly targeted at. However, as many individual’s with post COVID symptoms will not have been hospitalised or have had limited contact with primary care services, we may provide their first in depth interaction with a health care professional. This gives us chance to really add value by helping them to learn to mitigate the impact of their symptoms and aid rehabilitation, by highlighting available techniques, signposting them to patient education materials and referring them to rehabilitation services or primary care, as appropriate.
For example, highlighting the importance of avoiding over exertion resulting in prolonged periods of rest (Boom and Bust type scenario), as this is not thought to be helpful. Instead taking the 3 Ps approach, planning activity to be as efficient as possible e.g., using equipment to reduce the effort required to carry out a task, does it need to be done today, can it be delegated. Prioritising the most important or demanding tasks to when the individual feels the most refreshed. Pacing activity to available energy, i.e., carrying out short periods of activity but taking a rest, or alternating to less demanding tasks, before exhaustion hits. Many people are trying to speed their recovery up by pushing their activity. I have been using the analogy of a broken bone: it takes time for the body to heal, and effort and will are not necessarily going to speed recovery. Instead, adopting a graded approach to gradually increasing activity is likely to be of more benefit.2,21
Experiencing breathlessness can understandably cause anxiety. However, as with back pain, there are suggestions that fear avoidance behaviour can prolong recovery.2,21 Using breathing exercises and posture can reduce the effort required and make breathing easier. Deep breathing and pursed lip exercises can help with anxiety, paced breathing can help meet the demands of exertion, while controlled breathing techniques may reduce breathlessness. However, as with back pain, there are some potential red flags due to the increased risk of cardiac conditions and PE. If patients feel severe shortness of breath that does not improve with positions and breathing techniques, then further medical assistance should be sought. I am not advocating we as OH professionals teach these techniques, as for most of us this will be outside our area of expertise. However, having an awareness of them can be helpful. The WHO have created a free online E training package on post COVID rehabilitation and an associated patient guide which covers these techniques in more detail.2 There is also the NHS ‘your COVID recovery’ website, which is a good resource to direct employees to.21
Managers and HR are looking to Occupational Health for guidance in order to help them manage their workforce. Indeed, some in the HR sphere have already identified the significant impact Long COVID is likely to have on a large cohort of the workforce, and that they need to start taking into consideration how they might need to review sickness absence policies on rehabilitation, phased return to work and redeployment, to accommodate this.22
Adjustments to consider
Fatigue and breathlessness
- Phased return may need to be extended if fatigue I s a limiting factor.
- 3 Ps- Planning, Prioritising and Pacing activity.
- Equipment to reduce effort required. E.g., trolly
- In order to avoid a boom and bust type scenario.
- Flexible working, to facilitate rest breaks, working when feels most refreshed.
- Homeworking, so energy is not expended on the commute.
- Reduced workload or targets
- Off peak travel / reduced travel around site
- Preferred parking
- Redeployment to a less demanding role
- Consider impact if a safety critical role
Cognitive issues might include difficulty: filtering out background noise, being easily distracted, moving from one task to another, processing information quickly or with a poor short-term memory.
- Do not disturb sign / out of office for dedicated periods when need to focus.
- Quiet place to work or use of earphones.
- Digital reminders
- Doing one thing at a time
- Flow charts
- Write notes or use a digital recorder rather than hold something in the mind.
From an OH perspective, although this is a new condition, collectively we have a wealth of knowledge and experience on which to draw. Hopefully, ongoing studies that are tracking patient’s symptoms, treatment and progress will advise our practise in the future. However historically, when there is no definitive answer, we have as a specialism discussed and debated to come to a consensus opinion. I hope at least, this article can perhaps be a starting point for that discussion.
- World Health Organisation (2020). Course 6: Clinical management of patients with COVID-19 – Rehabilitation of patients with COVID-19. Accessed at: https://openwho.org/courses/clinical-management-COVID-19-rehabilitation. [Accessed 12.02.2021]
- SAGE (2021). Independent SAGE report on Long COVID. Available at:https://www.independentsage.org/wp-content/uploads/2021/01/Long-COVID_FINAL.pdf [Accessed 17.02.2021]
- COVID Symptom Study, Kings College London (June 2020). How long does COVID 19 last? Available at: https://covid.joinzoe.com/post/covid-long-term?fbclid=IwAR1RxIcmmdL-EFjh_aI-. [Accessed 13.02.2021]
- Sudre CH, Murray B, Varsavsky T, et al. (2020). Attributes and predictors of long-covid: analysis of covid cases and their symptoms collected by the Covid Symptoms Study app. MedRxiv [preprint]. Accessed at: https://www.medrxiv.org/content/10.1101/2020.10.19.20214494v1 [Accessed 13.02.2021]
- Perego E, Callard F, Stras L et al. Why the Patient-Made Term ‘Long Covid’ is needed. Wellcome Open Res 2020, 5:224. Available at: https://doi.org/10.12688/wellcomeopenres.16307.1 [Accessed 12.02.2021]
- NICE, (December 2020). Guidance: COVID-19 rapid guideline: managing the long-term effects of COVID-19. Available at: Overview | COVID-19 rapid guideline: managing the long-term effects of COVID-19 | Guidance | NICE. [Accessed 12.02.2021]
- The UK Sepsis Trust. [Online] Post Sepsis Syndrome Available at: https://sepsistrust.org/get-support/support-for-survivors/post-sepsis-syndrome/ [Accessed 20.02.2021]
- Society of Critical Care Medicine (2013( [Online] Post Intensive Care Syndrome. Available at: SCCM | Post-intensive Care Syndrome (PICS) [Accessed 20.02.2021]
- Prescott HC, Girard TD. (2020) Recovery From Severe COVID-19: Leveraging the Lessons of Survival From Sepsis. JAMA. 2020;324(8):739–740. doi:10.1001/jama.2020.14103
- Sepsis Organisation [Online] Post Sepsis Syndrome. Available at: https://www.sepsis.org/sepsis-basics/post-sepsis-syndrome/ [Accessed 20.02.2021]
- Mahase E, (2020). Long Covid could be four different syndromes, review suggests BMJ;371:m3981. Available at: https://www.bmj.com/content/371/bmj.m3981 [Accessed 12.02.2021]
- Carfì A, Bernabei R, Landi F,Gemelli. (2020) Against COVID-19 Post-Acute Care Study Group. Persistent symptoms in patients after acute covid-19. JAMA2020;9. doi:10.1001/jama.2020.12603. pmid:32644129
- Public Health England (10.02.2021) Guidance: COVID-19: epidemiology, virology and clinical features. Available at: https://www.gov.uk/government/publications/wuhan-novel-coronavirus-background-information/wuhan-novel-coronavirus-epidemiology-virology-and-clinical-features. [Accessed 12.02.2021]
- NHS, (February 2021)Long-term effects of coronavirus (long COVID) – NHS (www.nhs.uk) [Accessed 12.02.2021]
- Chalder Fatigue Scale: Available at: http://www.goodmedicine.org.uk/files/assessment,%20chalder%20fatigue%20scale.pdf [Accessed 20.02.2021]
- Craig Jackson, The Chalder Fatigue Scale (CFQ 11), Occupational Medicine, Volume 65, Issue 1, January 2015, Page 86, https://doi.org/10.1093/occmed/kqu168 [Accessed 20.02.2021]
- WASOG [Online] Fatigue Assessment Scale (FAS). Available at: https://www.wasog.org/education-research/questionnaires.html [Accessed 20.02.2021]
- Medical Research Council [Online] MRC Dyspnoea Scale. Available at: https://www.pcrs-uk.org/mrc-dyspnoea-scale [Accessed 20.02.2021]
- Bestall JC, Paul EA, Garrod R, et al. (1999). Usefulness of the Medical Research Council (MRC) dyspnoea scale as a measure of disability in patients with chronic obstructive pulmonary disease Thorax 1999;54:581-586. Available at: https://thorax.bmj.com/content/54/7/581.info [Accessed 20.02.2021]
- NHS England. National guidance for post-covid syndrome assessment clinics. Nov 2020. Available at: https://www.england.nhs.uk/coronavirus/publication/national-guidance-for-post-covid-syndrome-assessment-clinics/ [Accessed 13.02.2021]
- NHS, (2020) [Online] Your Covid Recovery. Available at: https://www.yourcovidrecovery.nhs.uk/what-is-covid-19/. [Accessed 12.02.2021]
- https://www.peoplemanagement.co.uk/long-reads/articles/should-hr-worried-long-covid#gref [Accessed 12.02.2021]