CRAJ Spring 2024

Spring 2024 (Volume 34, Number 1)

Long COVID: What We Know and the Way Forward

By Mark Bonta, MD, FRCPC

What exactly is Long COVID or the Post-COVID condition? Not only have we failed to standardize the name that describes the constellation of symptoms that develop or linger after a COVID-19 infection, but diagnostic criteria vary worldwide.¹ In Canada, we describe the “Post-COVID-19 condition”, with 18 symptoms in patients who may have had COVID-19 (formal testing is not required).² Regardless of the name, similarities include fatigue, multisystem physical symptoms, mental health symptoms, and sleep impairment.^3,4

Interestingly, this complex of disabling physical and mental symptoms has existed for decades prior to COVID-19. From Post-Ebola Syndrome (West Africa)⁵ to Chronic Fatigue Syndrome (North America), these conditions describe people with Medically Unexplained Physical Symptoms (MUPS). Central sensitization, the purported mechanism responsible for chronic pain, has gained traction as a likely etiology, in part, for MUPS.⁶ Somatic Symptom Disorder, used by psychiatrists, is an umbrella term for physical symptoms that impair function in other facets of life. Somatic Symptom Disorders include conditions with known pathophysiology, while also including MUPS patients.⁷ Simple scoring systems can be used to quantify the degree of impairment experienced by the patient and allow one to monitor their somatic symptom burden over time, useful for trending longitudinal changes. The Symptom Severity Scale (SSS)⁸ used in fibromyalgia research is an example.

A 2018 survey of Canadian rheumatologists identified that half of them would potentially refuse consultations for fibromyalgia.⁹ The terms "difficult patients" and "heartsink" have been coined and have become synonymous with MUPS. Studies have highlighted a gender bias in treating pain. The list goes on, and all the while we wait with bated breath for a Long COVID clinic to open and accept all our referrals, solving our problems. We need to set aside our biases and preferences and recognize that we do have tools to help these patients.

Collectively, we must appreciate the impact that MUPS has across multiple domains, such as societal burden, strain on the healthcare system, economic impact, and family strain, and start helping the 1.5 million Canadians (at last count) living with MUPS,¹⁰ instead of shrugging our shoulders and saying, "there’s nothing objectively wrong with you" and referring onwards.

First, we can sit down, listen to our patients, and empathize with them.¹¹ As we recognize with someone who presents debilitated from acute polyarthritis due to rheumatoid arthritis, our patients with MUPS are also suffering. Empathize with them. Remind them they are not alone, as many other Canadians are experiencing similar symptoms. Wonderful resources (CANCOV Database, www.DrRicArseneau.ca) abound that provide evidence-based interventions, along with a host of patient-specific information resources.

Secondly, we can use our diagnostic acumen to ensure that a medical condition with known pathophysiology is not at play. By trusting our medical judgment and intuition, we can recognize when to shift our questioning to features of central sensitivity syndromes and minimize over-investigating. Moreover, we can modify our history-taking to include features associated with the development of MUPS¹² (i.e., physical trauma, sexual trauma) and screen our patients for mental health conditions which are far more prevalent than in those without MUPS.¹³

Third, we can advocate for our patients to have access to a clinical milieu purposed to suit their needs. Interprofessional management, with close collaboration between experts in both mental and physical health working together instead of in silos, is something that we can all advocate for.

Finally, we can draw on the chronic pain literature to acknowledge the mind-body duality and apply evidence-based strategies to improve physical function and quality of life.¹⁴ Prescribing Cognitive Behavioural Therapy (CBT), mindfulness-based relaxation, diaphragmatic breathing, and psychosocial counselling are evidence-based.¹⁵ Working with our patients and empowering them to take ownership over their symptoms and commit to a longitudinal journey of self-management can go a long way.

In the perpetual evolution of medicine, novel avenues for treatment, healing, and potential cures continually emerge, demanding our unwavering attention. It is incumbent upon us, as physicians, to vigilantly assess these advancements and adapt our approaches accordingly. Such a task requires a collective commitment from us, our patients, and healthcare administrators alike. We must uphold and enrich the sanctity and depth inherent in clinical practice. Through generous listening, we nurture genuine, reciprocal relationships, fostering a shared sense of purpose between clinicians and patients that transcends the confines of standardized guidelines or algorithms.

Mark Bonta, MD, FRCPC
Staff Internist, Collingwood, Ontario
ECHO Ontario – Integrated Mental & Physical Health (Lead Internist)
UHN (Toronto General Hospital) Telemedicine Interprofessional Clinic (Lead Internist)

References:

1. Soriano JB, Murthy S, Marshall JC, et al. WHO Clinical Case Definition Working Group on Post-COVID-19 Condition. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022 Apr; 22(4):e102-e107. doi: 10.1016/S1473-3099(21)00703-9. Epub 2021 Dec 21. PMID: 34951953; PMCID: PMC8691845.

2. Government of Canada. Post-COVID-19 Condition in Canada: What we know, what we don’t know, and a framework for action. December 2022. Available at https://science.gc.ca/site/science/en/office-chief-science-advisor/initiatives-covid-19/post-covid-19-condition-canada-what-we-know-what-we-dont-know-and-framework-action. Accessed March 2, 2024.

3. Davis HE, McCorkell L, Vogel JM, et al. Long COVID: major findings, mechanisms and recommendations. Nat Rev Microbiol. 2023 Jun;21(6): 408. doi: 10.1038/s41579-023-00896-0.

4. Reid KJ, Ingram LT, Jimenez M, et al. Impact of sleep disruption on cognitive function in patients with post-acute sequelae of SARS-CoV-2 infection: initial findings from a Neuro-COVID-19 clinic. Sleep Adv. 2024 Jan 12; 5(1):zpae002. doi: 10.1093/sleepadvances/zpae002. PMID: 38370438; PMCID: PMC10873785.

5. Wojda TR, Valenza PL, Cornejo K, et al. The Ebola Outbreak of 2014-2015: From Coordinated Multilateral Action to Effective Disease Containment, Vaccine Development, and Beyond. J Glob Infect Dis. 2015 Oct-Dec; 7(4):127-38. doi: 10.4103/0974-777X.170495. PMID: 26752867; PMCID: PMC4693303. 6. Clauw DJ, Calabrese L. Rheumatology and Long COVID: lessons from the study of fibromyalgia. Ann Rheum Dis. 2024 Jan 11; 83(2):136-138. doi: 10.1136/ard-2023-224250. PMID: 37230736; PMCID: PMC10850638.

7. D'Souza RS, Hooten WM. Somatic Symptom Disorder. [Updated 2023 Mar 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532253/.

8. Zhang Y, Baumeister D, Spanidis M, et al. How symptoms of simple acute infections affect the SSS-8 and SSD-12 as screening instruments for somatic symptom disorder in the primary care setting. Front Psychiatry. 2023 Apr 17;14:1114782. doi: 10.3389/fpsyt.2023.1114782. PMID: 37139311; PMCID: PMC10149793.

9. Agarwal A, Oparin Y, Glick L, et al. Attitudes Toward and Management of Fibromyalgia: A National Survey of Canadian Rheumatologists and Critical Appraisal of Guidelines. J Clin Rheumatol. 2018 Aug;24(5):243-249. doi: 10.1097/RHU.0000000000000679. PMID: 29280818.

10. Statistics Canada. Medically unexplained physical symptoms (MUPS) among adults in Canada: Comorbidity, health care use and employment. March 2017. Available at https://www150.statcan.gc.ca/n1/pub/82-003-x/2017003/article/14780-eng.htm. Accessed March 2, 2024.

11. Bradshaw J, Siddiqui N, Greenfield D, et al. Kindness, Listening, and Connection: Patient and Clinician Key Requirements for Emotional Support in Chronic and Complex Care. J Patient Exp. 2022 Apr 12;9:23743735221092627. doi: 10.1177/23743735221092627. PMID: 35434291; PMCID: PMC9008851.

12. Greenman PS, Renzi A, Monaco S, et al. How Does Trauma Make You Sick? The Role of Attachment in Explaining Somatic Symptoms of Survivors of Childhood Trauma. Healthcare (Basel). 2024 Jan 15; 12(2):203. doi: 10.3390/healthcare12020203. PMID: 38255090; PMCID: PMC10815910.

13. Deumer US, Varesi A, Floris V, et al. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS): An Overview. J Clin Med. 2021 Oct 19;10(20):4786. doi: 10.3390/jcm10204786. PMID: 34682909; PMCID: PMC8538807.

14. Sanabria-Mazo JP, Colomer-Carbonell A, Fernández-Vázquez Ó, et al. A systematic review of cognitive behavioral therapy-based interventions for comorbid chronic pain and clinically relevant psychological distress. Front Psychol. 2023 Dec 22; 14:1200685. doi: 10.3389/fpsyg.2023.1200685. PMID: 38187407; PMCID: PMC10766814.

15. Nakao M, Shirotsuki K, Sugaya N. Cognitive-behavioral therapy for management of mental health and stress-related disorders: Recent advances in techniques and technologies. Biopsychosoc Med. 2021 Oct 3; 15(1):16. doi: 10.1186/s13030-021-00219-w. PMID: 34602086; PMCID: PMC8489050.