A safe and effective micro‑choice based rehabilitation for patients with long COVID: results from a quasi‑experimental study 2023, Frisk et al

The rehabilitation program is described in the protocol paper:
Evaluation of Novel Concentrated Interdisciplinary Group Rehabilitation for Patients With Chronic Illnesses: Protocol for a Nonrandomized Clinical Intervention Study

Abstract
Background:An aging population with a growing burden of chronic complex illnesses will seriously challenge the public health care system. Consequently, novel and efficacious treatment approaches are highly warranted. Based on our experiences with concentrated treatment formats for other health challenges, we developed a highly concentrated interdisciplinary group rehabilitation approach for chronic illnesses.

Objective:We aim to explore the acceptability of the intervention and describe potential changes in functional impairment at follow-up.

Methods:The cornerstones of the intervention are as follows: (1) prepare the patient for change prior to treatment, (2) focus on health promoting microchoices instead of symptoms, and (3) expect the patient to integrate the changes in everyday living with limited hands-on follow-up. The intervention will be delivered to patients with highly diverse primary symptoms, namely patients with low back pain, post–COVID-19 symptoms, anxiety and depression, and type 2 diabetes.

Results:Recruitment started between August 2020 and January 2021 (according to the illness category). For initial 3-month results, recruitment is expected to be completed by the end of 2021.

Conclusions:If successful, this study may have a substantial impact on the treatment of low back pain, post–COVID-19 symptoms, anxiety and depression, and type 2 diabetes, which together constitute a major socioeconomic cost. Further, the study may widen the evidence base for the use of the concentrated treatment format in a diverse group of medical conditions.

 

So the aim seems to be to get people to focus on changing activity patterns not on symptoms, and to see any improvement in symptoms as a bonus, not as the main aim. Given that, I assume the questionnaire results, particularly on CFQ, are simply about getting patients to recalibrate how they interpret their fatigue.

Note they were only included if they were assessed as ready and willing to change.

And of course there's no control group.

 

My bolding.

PEM doesn't seem to have been assessed, but since they did quite a lot of physical testing initially - CPET, stair climbing and sit to stand test I think they must have been relatively mildly affected or they wouldn't have been able to do these.

 

I thought the exactly the same.

Yes, it really is. Not sure if the researchers are stupid (with respect to this work) or they just think the readers of their paper are. Clearly the researchers think all their participants are - that it has not occurred to people to do a bit more, and push through the pain/fatigue.

• Self-selection of participants, as Trish said, people who are ready and able to do more.
• Natural improvement over time, and no controls.
• "sustaining over time" 3 months is too short a time for assessment in Long Covid with PEM. The effects of increases of activity accumulate over time.
• Chalder Fatigue Questionnaire is notorious for over-stating improvement from baseline, and not acknowledging worsening due to the ceiling effect.

 

The training included:

• Patient training
• Individually tailored exercise on breaking inflexible patterns
• Physical activity/exercise training
• Brief mindfulness sessions

3 days from 8.30 am to 16.00 pm, including exercise. That must surely have had a major impact on what sort of participants signed up. It's sounding a lot like the Lightning Process, perhaps without the high price tag. No coincidence that this is Norwegian research I think.

"To what extent did you allow the symptoms to decide today?"
That could be incredibly harmful to people who are not able to improve.

I think the question has to be asked - is the psychological and potentially physical harm done to people who could not improve outweighed by the improvements in functionality over time of people who probably would have improved on their own anyway?

 

I thought of LP too. I didn't see any mention of PEM.

 

78 people started the training; 2 didn't complete it, supposedly due to some other illness.
5 more people dropped out, 4 because they didn't want to continue and 1 due to some new disease.

That left 71.

So, there isn't data for all 71 participants for all outcomes.

Table 2 shows the numbers of participants at baseline and at three months. There are huge drops in the numbers of participants at 3 months, and no consistency in how many people are included at baseline. It really is very shoddy, especially given there are no controls. How is it reasonable to include the data from people at baseline who weren't even able to complete the training due to illness? - it artificially depresses the baseline.
e.g. numbers of participants:
CFQ - at baseline 77; at 7 days 74; at 3 months 71
Sick leave - at baseline on sick leave 39 out of 62 (63%); at 3 months 23 out of 55 (43%)
VO2 peak - at baseline 77; at 3 months 67
Dyspnea 12 - at baseline 68; at 3 months 71

Re the sick leave, sick leave was measured for employed participants only. They say that 63% of the 62 employed participants at baseline were on sick leave (therefore 23 people were employed and weren't on sick leave at baseline), but only 43% of participants were on sick leave at 3 months. Given that only 55 participants were assessed for sick leave at 3 months, that suggests that 32 people were employed and not on sick leave at 3 months. That's 9 people out of 78 who went from on sick leave to not on sick leave between having the course and the 3 month followup.

The discussion says

I don't think a rapid return to work fairly describes what we have seen here, at least not due to the 3-day course.

If we look at Figure 2 which gives the waterfall diagram for this 'quasiexperiment', 16 people out of the 120 assessed for eligibility are reported as improving between the assessment for eligibility and the baseline measures to the point where they became ineligible. Between the baseline and the course, which surely was not very long, another 3 out of 83 improved to the point where they became ineligible. Clearly, people were improving all the time, including before they attended the 3 day course.

Also, sick leave was self-reported by people who had had 3 days of being told that they should not let their symptoms dictate what they did - they would have got that message that people who took sick leave were not taking charge of their illness. That probably affected reporting rates.

Re the VO2 peak, the average VO2 peak for sedentary men is reported from google as 35 to 40ml/kg and just 27 to 30 for average sedentary females. Even with all those drop outs (77 to 67), there wasn't much of a change in VO2 peak/kg: from 30.8 to 31.5. It's worth noting that the VO2 peaks actually were pretty good, even at baseline, especially given 82% of the participants were female. Table 3 gives the data expressed as a percentage of expected value - from 92% of predicted to 95% of predicted.

Re fatigue, 99% of the participants reported fatigue at baseline. At 3 months, 77% still reported fatigue, 18% of them reporting severe fatigue, even with the problems with the CFQ.

(I'm tired, so I'm not going to check I have all the numbers right, but will just post this.)

 

Sick leave is a fuzzy area if you’re on a phased return you’re not working your full time hours but are partially off sick, after 3 months could still be trying to return to full time.

Or still being in employment unless it means return to previous role/hours could mean people have formally reduced working hours by a change in contract, so aren’t technically off sick but are affected in terms of finances etc.

 

Forskning.no wrote about this study today, but unfortunately only mentions the lack of a control group/short timeframe as problems (rest is all very positive). They are going to do another study with one year follow up (not clear to me if it's a new cohort or a longer follow up of the patients in this study).

I think this sentence: "There are various treatment plans for people with long covid, while research is being done on what works best." really should say we don't know what works at all, not that we don't know "what works best".

Kan long covid behandles på tre dager i Hardanger?
Can long covid be treated in three days in Hardanger?

 

My response to that cannot be written here. But it really shows that these people have no idea what they are talking about. Relax? Tired?

I know we've said it all before, but it's the sheer arrogance these people have, to think that we have not tried to ignore the symptoms and keep going. Eventually we learn - there are consequences. But even then, many of us keep trying to ignore the symptoms in order to do something we really want to do, and the consequences keep coming.