Perspectives of Rehabilitation Professionals on Long COVID Interventions to Facilitate Return-to-Work 2025 Janaudis-Ferreira et al

Background.
The severe functional impact of long COVID presents a significant challenge for clients seeking to return to work. Despite emerging clinical management guidelines, long COVID remains a concern in the rehabilitation field. There is a need to establish optimal practices for sustainable rehabilitation paths that enhance the recovery of clients with long COVID, all while understanding the challenges faced by rehabilitation professionals working with this population.

Purpose.
This study aimed to explore the perspectives of rehabilitation professionals intervening in long COVID rehabilitation with the goal of returning to work.

Methods.
A qualitative study was conducted involving online semi-structured interviews with rehabilitation professionals in Quebec from public and private sectors across various regions who had experience treating individuals with long COVID. Thematic analysis was employed for data analysis.

Findings.
Nine rehabilitation professionals participated in the study, yielding five themes: (a) reassessment of RTW goals; (b) education and self-management as primary interventions; (c) gradually reintegrating daily activities and life habits; (d) progression of interventions and dealing with post-exertional malaise (PEM); and (e) challenges in long COVID rehabilitation.

Conclusion.
Education, gradual activation and self-management appear as central components in supporting patient recovery, however, achieving return to work remains challenging without proper accommodations.

Open access

 

Furthermore, post-exertional malaise (PEM), affects the majority of individuals with long COVID (Twomey et al., 2022). PEM is a worsening of symptoms and reduction in function following physical, emotional, or cognitive activities (Twomey et al., 2022). The effort exerted to engage in these activities leads to a malaise characterized by fatigue post-exertion (Twomey et al., 2022). This malaise can vary in length of time: from hours to days to weeks, depending on the individual (Provincial Health Services Authority, 2022), and may impact individuals’ daily activities, family, and societal roles (Twomey et al., 2022).

 

Progression of Interventions and Dealing With PEM

Progressing interventions and dealing with PEM go hand in hand when working with the long COVID population in that the presence or absence of a PEM can dictate whether or not progressing interventions is warranted. “Once the symptoms have stabilized, i.e., once there's a reduction in post-exertional malaise, and a faster recovery from post-exertional malaise, that's when we can make gradual progress.” (RP #4).

Furthermore, many rehabilitation professionals mentioned that increasing exertion levels is done on a trial-and-error basis, by adding and removing activities on a day-to-day basis, and that it is best to wait between two and seven days after slightly increasing exertion levels or integrating a new activity prior to increasing further. “So I prefer to go really, really gradually in increasing the exercises and then really wait for a good week, for example, to see how it went. Then maybe we can think about increasing it again.” (RP #5).

Rehabilitation professionals emphasize that when gradually increasing exertion levels, the focus should be on elevating duration and frequency before increasing intensity. “[…] to increase first the duration really just a few minutes more. Then, maybe the frequency, so doing it more often. And the intensity would be the last one.” (RP #3).

Many added that gradual activation typically involves incorporating activities that are part of one's daily routine rather than focusing on specific isolated exercises. It is therefore important to acknowledge that this is done on a case-by-case basis, contingent on the capacities of the client and the activities they wish to reintegrate. When PEM does occur, rehabilitation professionals state that they work with clients to implement strategies to recognize these symptom exacerbations when they happen and identify the triggers and warning signs. This is primarily achieved through education, which can be supported by encouraging the client to keep a logbook or activity journal to constantly track how specific activities make them feel. “So we use a symptom journal. I’ll ask the client to fill in a symptom journal so that we can really keep track of what's going on, and so that they too can better understand what they’re feeling, and when they need to take action.” (RP #5).

 

Imagine having your activity micromanaged in this way by people who think you can exercise your way out of a disease.

 

I would love to see the evidence that shows that this is a safe and effective approach for pwPEM.

How to make pwPEM crash hard 101.

Why can’t they understand that maybe their tools are useless or even harmfull? Find the right tools for the patient, don’t just use your favourites for everyone.

I’m so tired of these «we’re important» papers.

 

Lots of words to reframe being completely ineffectual while people are left to fend for themselves with nothing better on the horizon. What is even the point of those professionals when they clearly describe being completely useless to this process and having zero difference in outcome?

And they keep including education while clearly showing they learned little of value. All of this was literally the entire controversy for decades, the health care industry has not added one bit of useful information of their own. They are still following the mindless formula: rehabilitate people, they will be rehabilitated.

We need effective treatments. Those don't exist in a rehabilitation framework. Do the freaking work. This is literally what patients are criticizing when they say there are no treatments, no effective health care, no useful support.

At least from the comments they mostly seem compassionate and to have learned enough about how immensely disabling it all is. But none of this changes the fact that it's not effective at anything. They still only get it as far as it affects what they do in their day job, they still completely miss the forest for the trees.

Really what is the point of this when they literally admit it's not effective but can't see anything wrong with not having anything else, or even continuing with something that is, again as they recognize, ineffective? Completely myopic way of doing things.

It's just completely absurd reading this while we are still having to deal with crap like Cochrane, the NICE guideline being rejected, the Oslo gang, and so on. It's completely independent realities coexisting on top of each other, both leading to the same failure.

And of course zero mention of ME/CFS. They talk about PEM without any hint of recognition that it's been known and described for decades and the subject of immense controversy over literally everything they describe here.

It's pretty much literally this.

How to get rich:

1. Make money
2. Keep making money until you have lots of money
3. You are now rich, congrats!

 

This is such a correlation / causation mixup.

Once the symptoms have stabilised and there’s a reduction in post-exertional malaise, that means the patient is literally already doing better likely a sign they might be on course to recovery, that’s not when you can “start making gradual progress” with your magic.

When people start following a positive course they are probably more likely to continue on that course.

 

@Yann04 you could also argue that if the patients are getting better (i.e. less symptoms), then why change the approach? Why not let them continue what they are currently doing and maybe their baseline will increase over time?

 

Exactly that. Pacing = reducing PEM symptoms as much as you can.

But PEM-free isn't the same as well. And all it takes for someone who still has underlying symptoms is for a delivery to get lost in the post, or their broadband router to go down, to put them right back into PEM by the time they've done the unplanned admin.

ETA: the article also shows no understanding that, like the money markets, PEM thresholds can go down as well as up.

 

Same ideas as "you are not in traffic, you are traffic".

The increased activity itself is the improvement. It does not lead to it, it is it. They never seem to get that, even though almost every single medical professional is able to work it out if a few labels are changed, if the same argument were applied to something they dismiss, like homeopathy.

 

Basically some people are recovering naturally, adjusting their activity levels naturally and these "rehabilitation specialists" are thinking they're making a difference when they're largely bystanders.

 

This makes me believe that they’ve never encountered a severe or even moderate patient. If they have, there’s no excuse for this paper.

 

"We need effective treatments. Those don't exist in a rehabilitation framework. Do the freaking work. This is literally what patients are criticizing when they say there are no treatments, no effective health care, no useful support."

And so we have PROMs to encapsulate this and retain rehab roles .
What could go wrong ? ( Rhetorical)

 

So much this

 

Just do it right. Stop doing it wrong. Duh!

Like the whole ideology, they are confusing the outcome for the process and the process for the outcome. All laid out with the same intellectual depth as your average self-help book:

1. Do good things
2. Don't do bad things
3. Don't not do good things

 

Here it's even worse, they notice that they're not making a difference, but still find nothing wrong with the idea that they are critical to the process. Even though because of the way such services are set up, they will never be able to see more than 1% of patients, and more people are developing this type of illness every year than they are able to treat, but because of natural recoveries and people adjusting to a lower quality of life, they are completely blind to it.

It's like the dude who was in charge of the Toronto SARS survivors. They did very intensive long-term rehabilitation. None of the patients returned to normal health. He still would do it all over again the same way, still thinks it was worth doing it like that and no other way. It's completely baffling, and all really explains why medicine is very good at keeping people alive, it's unambiguous and permanent, but can't tell their own ass from a hole in the ground when it comes to non-binary outcomes. They just make them seem to be binary.