Consider the case of “Rachel,” an EMT in her 30s who was occupationally infected with COVID-19, then beset by the lingering symptoms of “long COVID.” As part of the workers’ compensation package, she was referred for a health and behavior assessment, explained Miranda Kofeldt, PhD, a licensed clinical psychologist at Ascellus Health in St. Petersburg, FL.
“She was having significant emotional distress due to a workload that grew exponentially during the pandemic,” Kofeldt said at a recent webinar on long COVID held by the Association of Occupational Health Professionals in Healthcare (AOHP).1 “She was exposed to a lot, and contracted COVID. She reported a lot of emotional drain, and the idea of going back to work after recovery was very stressful and difficult to move forward with. In addition, she had the physical deconditioning and strain that made her feel as though it was really difficult to do her normal work tasks.”
The ability to return to work is considered a benchmark for recovery, as psychological conditions like anxiety and depression can worsen in workers who remain at home indefinitely.
“The idea was to identify treatment goals relevant for her,” Kofeldt explained. “Those [included] reducing emotional distress, so you kind of have subclinical anxiety and mood concerns, and we gave her some psycho-education to help her process and understand what she’s experiencing.”
A lot of this is so-called “normalizing,” telling the patient it is not unexpected to have these feelings and that it can be a struggle to return to basic activities. “There are effective coping mechanisms and skills to use to make it through that,” she said. “We really needed to provide some support to get her back to full duty.”
Rachel feared reinfection, which is not uncommon among frontline healthcare workers.
“We realize that as these variants change, the experience of being reinfected is going up, so these are real fears that exist,” Kofeldt noted. “How do you cope with that and manage to continue your full work duties in light of the realities of the risks that you’re facing?”
Cause Still Unknown
Although it is more than two years into the pandemic, long COVID is poorly understood, and treatment often focuses on improving specific symptoms like fatigue and shortness of breath. Even definitions of the condition vary.
“The CDC definition [of long COVID is] new and returning, or ongoing health problems in people who are at least four or more weeks after the first infection with SARS-CoV-2,” Akiko Iwasaki, PhD, professor of immunobiology at Yale University, said in a recent interview.2 “The WHO definition is similar, but they usually say within three months of initial diagnosis and symptoms lasting for over two months.”
More than 200 distinct symptoms have been reported in these patients. “That includes things like memory impediments and GI symptoms,” Iwasaki explained. “There are many, many different organ systems involved. If you look at all the different surveys, fatigue is the No. 1 symptom that’s being reported, followed by cough, headache, muscle pain. Loss of taste and smell is also one of the top symptoms, as well as sore throat and shortness of breath.”
Long COVID manifests in different ways. Half of patients with severe COVID-19 may experience these lingering symptoms after discharge.
“[In contrast], people who had mild or even asymptomatic infections can develop long COVID over time within about three months of that infection,” Iwasaki said. “That tends to be between 5% to 30% [of patients]. They vary because we don’t have a universal definition of long COVID.”
Scientifically, the cause of the condition remains unknown. However, one current hypothesis is persistent virus or viral remnants in tissue, such as RNA, protein, or both, are triggering chronic inflammation in long COVID patients.
“The other hypothesis is autoimmunity,” Iwasaki said. “An acute respiratory infection can induce autoimmune conditions in some patients. Once that has developed, it’s very difficult to reverse that process. That could be happening in a subset of long COVID patients.”
There also are theories about dysregulation of the gut microbiome and reactivation of latent viruses like Epstein-Barr. “Long COVID is likely composed of multiple diseases that are under one umbrella, but it needs to be really disassociated and disentangled,” Iwasaki said. “We are basically monitoring every possible parameter in the patient so we can understand if there may be a persistent virus or RNA, or a latent virus reactivation, or autoimmunity.”
Brain imaging studies have revealed reduction in gray matter, possibly contributing to the common symptom of “brain fog.” These brain changes have been seen even in patients not severely infected enough to be hospitalized.
“What can explain these kinds of brain mass reduction?” Iwasaki asked. “It’s unclear, but I believe inflammation is involved.
Many people improve, but there are cases where some symptoms linger indefinitely. “If you follow the course of these symptoms over time, there’s a definite gradual reduction, but it’s not going to zero,” Iwasaki said. “[There is a] fraction of people who are still suffering after two years of having had COVID. How do we treat those people? Is there something that we can do to reset or reverse the disease? Again, depending on the disease etiology, the treatment will be quite different.”
Many of Iwasaki’s recommendations, including forming a task force on long COVID with representatives from multiple federal agencies, were recently adopted in a plan announced by the Biden administration. (For more information, see related story in this issue.)
“There are many agencies that are working on long COVID, but the coordination is lacking so far,” Iwasaki said. “There needs to be a consensus-based guideline for these interdisciplinary care models for clinical treatment and management of long COVID.”
Do Not Reinvent the Wheel
Meanwhile, healthcare workers with long COVID are being treated with rehabilitation approaches used for similar conditions caused by other viruses.
“Many of these cases may have a common pathway with things like chronic fatigue syndrome, post-infectious issues like Epstein-Barr virus, and mononucleosis,” Steve Wiesner, MD, Northern California Kaiser Permanente On-the-Job Medical Director for Workers’ Compensation Services, said at the AOHP webinar.
There are myriad symptoms associated with long COVID, but it is best not to overwhelm the patient with multiple diagnoses. “Let’s not forget our general rehab principles,” Wiesner said. “We take the patient where they are, we identify what their functional limitations may be, we develop an integrated rehab approach, and we support them to regain their highest level of functioning. We’ve been here before — let’s not recreate the wheel. Let’s learn from some of these challenges that long COVID is creating.”
Engaging the patient means understanding where they are, and that is essentially practicing empathy. “We should be showing empathy in trying to better understand what the patient is experiencing, putting ourselves into that situation, and then developing clear expectations and goals that are realistic for them to get them back to their highest level of functioning,” Wiesner said.
The fatigue component and any cognitive challenges experienced by the worker may call for bringing in allied health professionals and medical subspecialties.
“One of the most important areas to help engage the patient is really looking at not only managing their symptoms, but validating what those symptoms are,” Wiesner said. “[Make it] very clear to the patient that ‘I understand what you’re experiencing based on what you’ve shared with me.’”
In emphasizing you understand what the patient is describing, give specific feedback on their condition — a practice that also creates the opportunity for them to correct you if the information is inaccurate.
“You can say, for example, ‘I understand you are having fatigue and it’s at the level where you feel like you have to go to bed earlier than you want to, or you don’t get to accomplish all of your personal goals because of this level of tiredness,’” Kofeldt said. “‘You’re not having any more issues with smell. Your GI system’s been better; not quite 100%, but maybe around 80%.’ Being able to reflect that back is really helpful, and it gives them the opportunity to really feel like you’re hearing them.”
Cognitive behavioral therapy works within a causative triangle of thoughts, feelings, and behaviors, Kofeldt said, emphasizing the goal is to convince the patient to take action. This goes beyond traditional talk therapy in encouraging the patient to make behavioral changes needed to fully recover.
“I can sit and talk to them for hours about, ‘Yes, it’s scary, but your risk is really low — let’s really talk about the likelihood that X or Y will happen,’” Kofeldt explained. “Well, X already happened, and I’ve seen Y happen to a bunch of other people, and so I’m not going to change their way of thinking without them giving them the opportunity to engage in changes in their behavior that assists in supporting their self-efficacy and their ability to cope with stressful situations.”
That moves the therapy into an “exposure” realm performed in a compassionate and gradual way to boost competency. Still, some healthcare workers with long COVID feel they cannot return to work.
“From a psychological perspective, we talk about the end goal,” Kofeldt said. “‘Where do you see yourself? What do you want to get back to?’ Then, we talk about those kind of thoughts that are interfering and getting in the way. ‘How are your thoughts impacting your beliefs and your feelings about what you believe you can and cannot do?’ In this case, we’re thinking mostly of the avoidance behavior. ‘I’m avoiding going back to work, but even more than that, maybe I’m avoiding leaving my house.’”
One of the most basic and effective coping skills Kofeldt begins with is breathing exercises. “We all know breathing is essential to life, to calmness, to well-being, so that’s a key and prime example and a place to start with a psychological intervention that helps people cope with what they’re feeling,” she said.
Subclinical anxiety and depression may be present — not on the level of a medical disorder, but enough to undermine a return to work.
“The real key factor here is getting the return to work to happen,” Kofeldt said. “The longer they’re off, the longer that anxiety builds, the longer they have no evidence for their ability to handle that anxiety or depression, and the more severe it becomes. Long COVID can be three to six months down the road. That’s a long time to be off work. If they’re off three to six months, chances are pretty high they’re going to be off another three to six months. If we can get that intervention done at the four- to eight-week level, we are way more likely to get them back to work.”
As one might expect, someone with long COVID who is trying to return to work may experience many psychological factors. What healthcare workers are going back to should not be minimized, Kofeldt said.
“Those work-related psychosocial factors and stressors are really key here,” she said. “Even if you’ve worked with the same team for years in a hospital facility, people change through this. Their tolerance for stress changes, and so your workplace is going to look different.”
In addition, employees may hold legitimate concerns about returning to an environment from which COVID-19 could be brought home to children or elderly parents. Then, there is the rough tumble of the daily healthcare environment, which could include patients with negative attitudes and misinformation about COVID-19.
“Being in the hospital or emergency care settings, as in this example of a paramedic, and trying to treat people who are giving you a hard time about wearing your mask — how do you handle that?” Kofeldt asked. “Similarly, how do you handle people’s different reactions to being vaccinated vs. not?”
Guarding, self-protective behavior might manifest in the returning worker. “There are all of those anxieties about making yourself worse, feeling like your workplace isn’t supporting you in whatever restrictions that have been placed on your activity — catastrophizing,” Kofeldt said. “Those are some of the psychosocial factors.”
The EMT Recovers
Setting expectations is one thing, but managing those expectations is quite another. “There may be consequences for that individual, but that doesn’t mean that we focus only on getting them back to work,” Wiesner said. “We focus on getting them the resources to resume life at the highest level of function. That may not include, in their priorities, returning to work. If we ignore that, we’re not helping the patient.”
Rachel, the EMT in the case example, successfully completed seven cognitive behavioral therapy sessions and returned to work.
Her functional capacity was measured before and after treatment, using an assessment that looks at four major areas on a zero to 10 scale. The first area is work preparedness.
“These are things like getting up and getting ready in the morning, getting to work on time, feeling like they have the energy to do the tasks that they need to do,” Kofeldt explained. Rachel went from a four to 10 on this measure.
Similar gains were recorded in stamina and performance, and mental focus and flexibility, but Rachel struggled with interpersonal interaction and communication.
“She was really suffering there — she rated herself as a zero,” Kofeldt said. “We’re looking at not only physical deconditioning through COVID, but also emotional deconditioning. How do I interact with people, how do I get up, especially in this high-contact sort of paramedic job? How do I tell people about how to be better themselves if I don’t feel good?”
Focusing on this area and working on social skills brought the patient up to a nine, but a person does not have to be rated a nine or 10 to go back to work.
“We don’t have to be at a perfect level. We really want to have a realistic expectation,” Kofeldt said. “This individual did go back to full-duty work, with all the domains improved as she used her coping skills. As I mentioned, breathing is a big one to manage her anxiety, also being able to reframe automatic negative thoughts, identify the triggers that stressed her out, and regulate her emotions. This was really a great success story for this patient.”
REFERENCES
- Association of Occupational Health Professionals in Healthcare. Long-term COVID and return to work decision making: Medical and psychosocial consideration. April 8, 2022.
- American Medical Association. Akiko Iwasaki, PhD, on the latest long COVID-19 research. April 11, 2022.
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