More than “Brain Fog”: Cognitive Dysfunction and the Role of Occupational Therapy in Long COVID, 2025, Skiffington and Breen

Skiffington, Helen OT, BSc Hons1,2; Breen, Ciara MSc, HCM3,4,

Abstract
Long COVID is a disabling condition which affects occupational performance and quality of life. It interferes with activities of daily living, work, and many meaningful life roles.

Cognitive dysfunction is a frequently reported symptom, yet it is commonly overlooked. It is important that cognitive activity is considered when working with people with long COVID, particularly when identifying triggers of post exertional symptom exacerbation.

There are many potential mechanisms that could be driving cognitive dysfunction in long COVID including neuroinflammation, viral persistence, vascular damage, and orthostatic intolerance. It is important to consider these to help guide intervention. The purpose of this clinical perspective is to highlight the debilitating impact of cognitive dysfunction in those with long COVID and share the key role of occupational therapists in this area.

Cognitive dysfunction may be missed on standardized assessments as they may not be sensitive enough due to the episodic nature of symptoms. Occupational therapists can play a key role in this area as they are experts in assessing occupational performance and in providing safe cognitive assessment and rehabilitation.

https://journals.lww.com/cptj/fullt..._brain_fog___cognitive_dysfunction_and.7.aspx

 

A lot of good stuff in this paper, I think. Especially this paragraph:

and I like that they seem to be aware that strategies to counteract cognitive overexertion through pacing, planning, prioritising etc aren't risk-free because they can themselves cause cognitive overexertion.

 

But is is still an advert for unevidenced therapping, even if only occupational therapping.

 

But seeming sensible isn't evidence is it.

No doubt most people with ME/CFS would prefer to have this author looking after them than a multidisciplinary team of physics and psychologists but the tone is still that 'we know what is best'. And nobody knows if it is actually beneficial.

Which again sounds sensible, but how do they know what to advise. And how do they know that what they teach the next lot to do will be understood by the next lot, and the lot after, or used even sensibly? If it all depends on common sense what is there to teach?

An OT or nurse may well be the best person to fulfil a supportive role of this sort but whenever I read words like 'cognitive' I see theories about dysregulation and all sorts of mumbo-jumbo not very far round the corner. It might be better to say that with experience of seeing lots of people having trouble thinking straight you can probably help others a bit in terms of support. That's all.

 

There are some good, insightful parts:

But that's followed by:

In terms of education, the best they can do is advise patients to learn their own limits and trust their own instincts. Interventions for cognitive difficulties? There aren't any that could be formalised as advice or training.

OTs can play a important role, especially in employment, education, and housing contexts. They may be the only professionals who really understand the challenges. Why not train them to be really good at those interventions, instead of giving the impression they can somehow do something about cognitive dysfunction?

 

That made me grin. Is there anybody in the Western world who doesn't use an electric kettle? They've been in every home, workplace and hotel room for over half a century.

But most will already have worked this out by the time they've spent months going back and forth to the GP, then waited more months for an OT appointment. The time span from initially getting ill to seeing an OT could easily be a year.

I suspect you didn't mean it in the strict sense, but scheduling things is a GET-like approach that patients should be warned to avoid, not encouraged to do. It puts a corrosive pressure on them to attempt things when they're not well enough, and they'll already have plenty of that.

Yeah, I agree on the pamphlet/phone line. If long Covid is like ME/CFS, the only person who can really know how to manage their pacing is the patient themselves. Their OT could usefully remind them not to gaslight themselves, but most of their role is assessing them for aids, adaptations and housing, and acting as liaison between work or education and the health, social care and benefits services.

At the moment, other than timely and accurate diagnosis, OTs who actually understand LC and ME/CFS have the potential to make more difference to our lives than anyone else. Partly because they can remove so much of the friction from interactions between services, but mostly because other professionals tend to believe what they say. They have credibility that's often denied to patients. This crucial role in helping people navigate the transition to a very different life is what I'd like see the profession put the emphasis on, rather than encouraging OTs to spend their contact time doing what Jonathan calls therapping.

 

To me it seems like a mixture of sensible advice, unnecessary rehabbing, and muddle-headed Twitter-science about neuroinflammation & so forth, e.g.:

As for the specific examples that are mentioned - smartphone apps, diaries, heart-rate monitoring - some patients do report finding these useful but it's not as if they can really be recommended as there's no hard evidence for any particular intervention. Helping a patient adapt to their illness in common-sense, practical ways & advocating for occupational adjustments & adaptations is welcome but I don't see why pwME need therapists to co-create specific "cognitive pacing" plans with them. Patient education sessions, diary-use reviews? If there's one thing pwME don't need it's micromanagement of their lives.

Americans!

 

Really? Bloody hell.

And also: WHY!!

 

'When cognitive dysfunction and PEM/PESE are experienced by the same individual, as is common, 59,61 we propose that education about PEM/PESE and the importance of pacing to avoid PEM/PESE may yield the greatest initial gain by interrupting the cycle of further neuroinflammation and neuroimmune activation.'

That to me is a very big wavy red flag. No way should an OT be talking this sort of bullshit to patients. This is where I get off the bus. - as in the bit in the abstract:

It is not legitimate to consider these to help guide intervention unless you actually have some facts.

 

I don't have too much counter space

 

they don't in spain (the spanish that is).
They often make a cup of tea by putting a tea bag in a mug of water and then putting it in the microwave.

eta:
I bought a spanish friend an electric kettle as a wedding present. It was well received.

 

I think that can be said of most europeans in student accomodations.