Addressing Post-COVID Symptoms: A Guide for Primary Care Physicians, 2021, Vance et al

Abstract

Background: Post-COVID symptoms, defined as symptoms lasting >4 weeks postinfection, have been identified not only among those patients who were hospitalized with severe symptoms but also among those who were asymptomatic or with only mild symptoms. Primary care providers (PCPs) will often be the first point of contact for patients experiencing potential complications of post-COVID symptoms. The aim of this article is to present a post-COVID management tool for PCPs to use as a quick reference and guide to the initial workup and management of the most common post-COVID symptoms.

Methods: Published guidance, recent literature, and expert specialist opinion were used to create the structure outlining the outpatient evaluation and treatment for post-COVID symptoms.

Results: A quick-reference guide for management of post-COVID symptoms was created for PCPs. Educational materials were created for clinicians to share with patients. Our article reviews several common complaints including respiratory, cognitive, and neurological symptoms, chronic fatigue, dysautonomia, and anosmia and presents recommendations for management.

Conclusions: Data on long-term effects of COVID-19 are still emerging, and rapid dissemination of this data to front-line PCPs is crucial. This table was our effort to make the currently available evidence accessible for our PCPs in a simple, easy-to-use format.

Open access, https://www.jabfm.org/content/34/6/1229

 

Has anyone looked at this document? If so, what did you think about this overall? And also re the discussion on cognitive issues. Quite an emphasis on non-specific factors that support the psychosocial interpretations doctors are telling Long COVID patients.

While the outcomes literature continues to evolve, these nondisease-specific factors are most likely to be a primary contributor to cognitive symptom experience in cases where patients had an uncomplicated medical course but are reporting significant cognitive changes (Figure 2).
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And here's Figure 2.

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Somatic sensitivities - sounds likes a sanitised word for Somatic Symptoms and Related Disorders as per DSM 5. Otherwise know as Functional Neurological Disorders, somatic symptom disorder, illness anxiety disorder, fictitious illness etc

And lots of psycho-social model thinking.

 

I read through this very long and comprehensive guide for Primary Care Physicians (PCP) in the USA

Most was pretty normal/standard treatment within the US context, not necessarily standard practice in other countries due to resource constrictions (public imaging services) and medication might require specialist approval (like in NZ, a psychiatrist would need to approve some meds for funding as would be considered to be outside a GP’s professional expertise)

They admit there is limited evidence for the treatment Post Covid Symptoms so have done an extensive literature review and used expert consensus from various disciplines.

Some useful directions for PCP’s was to 1) evaluate all aetiologies (causes for symptoms) 2) validate symptoms and 3) provide support as needed
4) offer encouragement that many will recover but in a prolonged fashion and to give no expectation on rate of recovery.

There is a comprehensive table showing this work up and treatment guidance in line with standard medical practice.

Of Note: There is no specific mention of ME at all. There are specific sections that talk to the core symptoms of ME and associated comorbidities eg. Dysautomnia and POTS, Anxiety and Depression Disorders - they referenced a Spanish paper reviewing ME which put it at 28% in 2009.

1) Fatigue - recommendation to pace, plan day, breakdown tasks (3P’s) and using a AVS (analogue visual scale) to rate fatigue.

Important statement in preamble - “Another proposed framework suggests that fatigue is dependent on both conditional (task, environment, physical and mental capacity of individuals) and physiologic (central and psychological) factors. In the absence of evidence addressing specific treatments for COVID-related fatigue, clinicians can apply their normal approach for managing chronic fatigue due to other conditions. Graded or paced exercise of low impact and short duration may be recommended. Exercise should be undertaken cautiously and reduced if exacerbations in other symptoms such as breathlessness or myalgia occur. In severe cases, stimulants may be considered, but patients should be monitored carefully for adverse reactions, particularly if cardiovascular complications are present. In all cases, patients should be provided empathy and reassurance.”

They had recommendations to return to activity and exercise but forgot to put in main table that stated “stop if develop new symptoms of dizziness, chest pain, breathlessness and palpitations” no mention of PEM but in additional material it states if you have excessive fatigue to contact PCP. They did advise resting pacing and gradual return to activities if symptoms not exacerbated but to refer on to a Post Covid Clinic for further assessment

2) Brain Fog - They say this is most common following a complex medical course to the covid infection (so requiring oxygen, meds, intubation, circulatory support etc.), so not asymptomatic infection.

“While the outcomes literature continues to evolve, these nondisease-specific factors are most likely to be a primary contributor to cognitive symptom experience in cases where patients had an uncomplicated medical course but are reporting significant cognitive changes (Figure 2). This is supported by findings of only mild cognitive change for most recovered patients, with those changes associated with degree of inflammation, when controlling for factors such as mental health disorders, need for psychotropic medications, and history of substance abuse.19 The threshold for referral for psychotherapy should be low, given the impact mood and distress can have on functional cognition”

Otherwise standard advice on education on the mind-body connection, i.e. stress/anxiety can worsen cognitive performance (true). The PCP to state that they would expect this to improve but no guarantees. The PCP should optimise other impacts on cognitive function eg. mood, pain and medication that causes cognitive side effects.(all sound advice).

But then they suggested the PCP keep in mind these factors and to have it on hand to refer too, perhaps to explore and pass on their opinion in referral letters (These are the factors in the above diagram).

It was unclear what psychotherapy they recommended, (hopefully it was supportive and non judgemental but would usually involve some sort of psychological/psychotherapeutic assessment of the person and social supports). But very unclear what would happen, I guess that depends on what sort of clinician/therapist was available and what they are trained in.