Long COVID: The Winding Road Back
Helping stricken healthcare workers return to duty
By Gary Evans, Medical Writer
Clinical experts working with healthcare workers who have acquired long COVID say it can be a hard road returning to work, but rehabilitation models used for other chronic conditions are proving helpful.
“Many of these cases, in some ways, may have a common pathway with things like chronic fatigue syndrome, post-infectious issues like Epstein-Barr virus, and mononucleosis,” said Steve Wiesner, MD, Northern California Kaiser Permanente on-the-job medical director for workers’ compensation services, in Oakland, CA.
There are myriad symptoms associated with long COVID — loss of smell, shortness of breath, and brain fog — but it is best not to overwhelm the patient with multiple diagnoses, Wiesner said.
“Giving lots of diagnoses may not actually be in the patient’s best interest,” he said. “Let’s not forget our general rehab principles. 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 being able to understand where they are, and that essentially is practicing empathy, he said.
“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,” he said. “So making it very clear to the patient that I understand what you’re experiencing based on what you’ve shared with me.”
In emphasizing understanding 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 not correct, said Miranda Kofeldt, PhD, a licensed clinical psychologist at Ascellus Health in St. Petersburg, FL.
Kofeldt and Wiesner spoke recently at a webinar on long COVID held by the Association of Occupational Health Professionals in Healthcare (AOHP).
“You can say, ‘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 [gastrointestinal] 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.”
Goal: PT Action
Cognitive behavioral therapy works within a causative triangle of thoughts, feelings, and behaviors, Kofeldt said, emphasizing that the goal is get 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,’” she said. “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 done in a compassionate and gradual way to boost their competency. Some healthcare workers with long COVID feel they can’t go back to work again and fear getting infected again if they do. “From a psychological perspective, we talk about the end goal,” she said. “Where do you see yourself? What do you want to get back to? And 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? And 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 that Kofeldt begins with is breathing exercises.
“We all know breathing is essential to life, to calmness, to well-being, and 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,” she 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. So 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, psychological factors may be multiple in someone with long COVID who is trying to return to work, Kofeldt said. Returning to work after recovering from the chronic effects of COVID-19 can be particularly stressful, and generally is more difficult the longer the healthcare worker is out, she 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.”
Guarding, self-protective behavior, and fear of reinfection may manifest in the returning worker.
“All of those anxieties about making yourself worse, feeling like your workplace isn’t supporting you in whatever restrictions that’s been placed on your activity — catastrophizing,” Kofeldt said. “Those are some of the psychosocial factors.”
Clinical experts working with healthcare professionals who have acquired long COVID say it can be a hard road returning to work, but rehabilitation models used for other chronic conditions are proving helpful.
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