A mixed-methods systematic review of post-viral fatigue interventions: Are there lessons for long Covid?, 2021, Fowler-Davis et al

Abstract

Objectives
Fatigue syndromes have been widely observed following post-viral infection and are being recognised because of Covid19. Interventions used to treat and manage fatigue have been widely researched and this study aims to synthesise the literature associated with fatigue interventions to investigate the outcomes that may be applicable to ‘long Covid’.

Method
The study was registered with PROSPERO (CRD42020214209) in October 2020 and five electronic databases were searched. Papers were screened, critically appraised and data extracted from studies that reported outcomes of fatigue interventions for post-viral syndromes. The narrative synthesis includes statistical analysis associated with effectiveness and then identifies the characteristics of the interventions, including identification of transferable learning for the treatment of fatigue in long Covid. An expert panel supported critical appraisal and data synthesis.

Results
Over 7,000 research papers revealed a diverse range of interventions and fatigue outcome measures. Forty papers were selected for data extraction after final screening. The effectiveness of all interventions was assessed according to mean differences (MD) in measured fatigue severity between each experimental group and a control following the intervention, as well as standardised mean differences as an overall measure of effect size. Analyses identified a range of effects–from most effective MD -39.0 [95% CI -51.8 to -26.2] to least effective MD 42.28 [95% CI 33.23 to 51.34]–across a range of interventions implemented with people suffering varying levels of fatigue severity. Interventions were multimodal with a range of supportive therapeutic methods and varied in intensity and requirements of the participants. Those in western medical systems tended to be based on self- management and education principles (i.e., group cognitive behavioural therapy (CBT).

Conclusion
Findings suggest that the research is highly focussed on a narrow participant demographic and relatively few methods are effective in managing fatigue symptoms. Selected literature reported complex interventions using self-rating fatigue scales that report effect. Synthesis suggests that long Covid fatigue management may be beneficial when a) physical and psychological support, is delivered in groups where people can plan their functional response to fatigue; and b) where strengthening rather than endurance is used to prevent deconditioning; and c) where fatigue is regarded in the context of an individual’s lifestyle and home-based activities are used.

Open access, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0259533

 

The inability to grasp the most basic things about this are infuriating. It's as if learning from experience is impossible without a theoretical understanding, zero attention to the details that actually matter.

The conclusions are as weak as the effort that went into this.

 

By "substantiated by a programme of research", this review's authors mean that the 2007 guideline's GET/CBT recommendation was based on minimal research (not cited here), and that all the evidence cited here in support of NICE's 2007 recommendations (items 12-14) was published only years later (item 14 is PACE). I couldn't see any reference in this review to NICE's current evidence reviews explaining why publications 12-14 do not actually "substatiate" the 2007 guideline (only the claim that NICE reacted to "wide-spread reaction from patients"), nor citations for any of the other research criticising PACE. These are such striking omissions in a review article that I might at one time have wondered how it got past peer review.

The review's authors also state without any qualification or comment that use of GRADE means NICE recommendations "were deemed problematic". (Reference 16 is of course Turner-Stokes & Wade in the BMJ in December.) NICE has been using GRADE since 2009. Turner-Stokes & Wade were careful to limit their criticism of GRADE to "complex conditions", although they did not define the phrase. One would expect authors of a "systematic review" to take at least a passing interest in whether they are arguing that GRADE (and therefore almost the entire edifice of NICE guidelines) is wholly worthless, or only worthless in relation to certain conditions. Instead the review dismisses NICE as "problematic" with all the attention to detail of a Twitter pile-on.

Reviews like this one are a reminder of the need for more structured research into pacing. I resent spending scarce resources on research which can only show what decades of patient experience have long since proven, but while we are trying desperately to teach clinicians that the plural of anecdote is not data, we have little choice I think but to apply even stricter standards to our hard-won lived experience.