Impact of fatigue as the primary determinant of functional limitations among patients with post-COVD-19 syndrome, 2023, Walker et al

Impact of fatigue as the primary determinant of functional limitations among patients with post-COVID-19 syndrome: a cross-sectional observational study
Sarah Walker; Henry Goodfellow; Patra Pookarnjanamorakot; Elizabeth Murray; Julia Bindman; Ann Blandford; Katherine Bradbury; Belinda Cooper; Fiona L Hamilton; John R Hurst; Hannah Hylton; Stuart Linke; Paul Pfeffer; William Ricketts; Chris Robson; Fiona A Stevenson; David Sunkersing; Jiunn Wang; Manuel Gomes; William Henley; Living With Covid Recovery Collaboration

Objectives
To describe self-reported characteristics and symptoms of treatment-seeking patients with post-COVID-19 syndrome (PCS). To assess the impact of symptoms on health-related quality of life (HRQoL) and patients’ ability to work and undertake activities of daily living.

Design
Cross-sectional single-arm service evaluation of real-time user data. Setting 31 post-COVID-19 clinics in the UK. Participants 3754 adults diagnosed with PCS in primary or secondary care deemed suitable for rehabilitation. Intervention Patients using the Living With Covid Recovery digital health intervention registered between 30 November 2020 and 23 March 2022.

Primary and secondary outcome measures
The primary outcome was the baseline Work and Social Adjustment Scale (WSAS). WSAS measures the functional limitations of the patient; scores of ≥20 indicate moderately severe limitations. Other symptoms explored included fatigue (Functional Assessment of Chronic Illness Therapy–Fatigue), depression (Patient Health Questionnaire–Eight Item Depression Scale), anxiety (Generalised Anxiety Disorder Scale, Seven-Item), breathlessness (Medical Research Council Dyspnoea Scale and Dyspnoea-12), cognitive impairment (Perceived Deficits Questionnaire, Five-Item Version) and HRQoL (EQ-5D). Symptoms and demographic characteristics associated with more severe functional limitations were identified using logistic regression analysis.

Results
3541 (94%) patients were of working age (18-65); mean age (SD) 48 (12) years; 1282 (71%) were female and 89% were white. 51% reported losing ≥1 days from work in the previous 4 weeks; 20% reported being unable to work at all. Mean WSAS score at baseline was 21 (SD 10) with 53% scoring ≥20. Factors associated with WSAS scores of ≥20 were high levels of fatigue, depression and cognitive impairment. Fatigue was found to be the main symptom contributing to a high WSAS score.

Conclusion
A high proportion of this PCS treatment-seeking population was of working age with over half reporting moderately severe or worse functional limitation. There were substantial impacts on ability to work and activities of daily living in people with PCS. Clinical care and rehabilitation should address the management of fatigue as the dominant symptom explaining variation in functionality.

Link | PDF (BMJ Open)

 

No mention at all of PEM/PESE or of ME/CFS in the paper that I could find.

The bolded sentence seems strangely worded to me.

"This study has implications for the targeting of limited resources to effectively address functional limitations from PCS. Of particular concern is the large proportion of working age women in our study population, people who contribute substantially to the healthcare, social care and informal care sectors52 at a time when these sectors are already under duress.53 PCS is clearly a multifactorial disease affecting physical and mental well-being, but post-COVID-19 assessment services should consider focusing on assessing and treating fatigue to maximise the recovery and return to work in this large cohort of patients. Further work is needed to explore the recovery trajectories of this cohort over time and whether fatigue continues to predict functional impairment and low HRQoL over time."

And the conclusion provides an accidental damning assessment of the current, pre-covid, fatigue clinics.

"Conclusion
In this first UK national study reporting clinical symptoms from patients referred for assessment and treatment of PCS, we demonstrate high levels of functional impairment and low HRQoL. Fatigue appears to be the symptom most strongly associated with functional impairment. Currently, clinical services lack evidence-based approaches in treating patients experiencing fatigue related to PCS with no standard rehabilitation pathway.11–14 This requires further targeted research. Our future work to explore the recovery trajectory of patients using the LWCR DHI may help to establish the extent to which WSAS and other PROMs are sensitive to changes in the health of a patient with PCS. This work can contribute to the identification of PROMs best suited for use in assessing, managing and treating patients with PCS, both digitally and in face-to-face appointments."

 

From my quick scan of the references, this paper was the closest that the authors came to referencing anything remotely like ME/CFS, and it's the latest garbage from the COFFI crew, Jama - Prevalence and Characteristics with Post-COVID-19 Condition Among Non-hospitalized Adolescents... - Selvakumar, Wyller et al, 2023

I obviously can't prove that they deliberately steered away from drawing any sort of connection with ME/CFS, but given the total lack of cross-referencing to what is on offer within the NHS for post-infectious fatigue (no matter how bad we consider those services to actually be) it does seem suspicious, especially as there are copious cross-references to cancer related fatigue.

 

They actually cover this point somewhat
"This study enforces the recommendation for the use of a consistent set of outcome measures in studies in COVID-19. One such list of recommended variables is the International Consortium for Health Outcomes Measurement (ICHOM) set of patient-centred outcome measures for COVID-19, which recommends that research assesses functional status, quality of life and social functioning in addition to the typically reported measures of clinical outcomes, mental functioning and symptom reporting.48 49 Additionally, consideration should be given to the interpretation of fatigue in patients with PCS, as advised by Sandler et al.10 Patients may report fatigue when experiencing weakness, dyspnoea, cognitive dysfunction, somnolence or low mood."

Reference 10 is to that COFFI paper I link to above.

 

Recommendation to solve the problem: solve the problem. They recommend the current thing. The thing that failed for decades. Which no one can do because it's not a thing. And their genius idea is to recommend it again. I guess this time they mean it so it must work.

It makes no sense to speak of an outcome, fatigue is a consequence, as a determinant. This is simply not caring about how things even possibly can affect one another. Weak.