Return-to-Work Following Occupational Rehabilitation for Long COVID: A Cohort Study, 2022, Brehon et al

Background:

Emerging evidence suggests that globally, between 30-50% of those who are infected with Coronavirus Disease 2019 (COVID-19) experience Long COVID (LC) symptoms. These symptoms create challenges with return-to-work (RTW) in a high proportion of individuals with LC. In order to tailor rehabilitation programs to LC sequelae and help improve RTW outcomes, more research on LC rehabilitation program outcomes is needed.

Objective:

This study described characteristics and outcomes of workers who participated in a LC occupational rehabilitation program.

Methods:

A historical cohort study was conducted. Descriptive variables included demographic and occupational factors as well as patient-reported outcome measures (i.e., the Fatigue Severity Scale (FSS), Post-COVID Functional Scale (PCFS), Short Form Health Survey (SF-36), Pain Disability Index (PDI), Pain Visual Analogue Scale (VAS), Patient Health Questionnaire (PHQ-9), Generalized Anxiety Disorder Questionnaire (GAD-7), and post-traumatic stress disorder checklist (PCL-5)). The main outcome variable was return-to-work status. Descriptive statistics were calculated. Logistic regression examined predictors of return-to-work.

Results:

The sample consisted of 81 workers. Most workers were female (n=52) and from health-related occupations (n=43). Only 43 individuals returned to work at program discharge, with 93% of these returning to modified duties. Although there were statistically significant improvements on the pain VAS (11.1 + 25.6 (t(31) = 2.5, P=.02)), the PDI (9.4 + 12.5 (t(32) = 4.3, P<.001)), the FSS (3.9 + 8.7 (t(38) = 2.8, P=.009)), the SF-36’s PCS (4.8 + 8.7 (t(38) = -3.5, P=.001)), the PHQ-9 (3.7 + 4.0 (t(31) = 5.2, P<.001)), and the GAD-7 (1.8 + 4.4 (t(22) = 1.8, P=.03)), there were no significant improvements in the PCFS, overall mental component score of the SF-36, or on the PCL-5. Availability of modified duties (OR 3.38, 95% CI: 1.26-9.10) and shorter time between accident and intake (OR 0.99, 95% CI: 0.99-1.00) predicted return-to-work even when controlling for age and gender.

Conclusions:

Findings suggest that modified duties and earlier, timely rehabilitation are essential for successful return-to-work in people with LC. Additional research is needed, including larger observational cohorts as well as randomized controlled trials, to evaluate effectiveness of LC rehabilitation.

Open access, https://preprints.jmir.org/preprint/39883/accepted

 

I am kind of sick of the word "rehabilitation" being thrown around Long Covid. What is that even supposed to mean?
They are putting the cart before the horse.

 

Not that this is a good study, but it actually suggests that rehabilitation is not useful. We are still seeing the mutually exclusive messaging that most people recover but also look at how a few people got "helped" by our rehabilitation healing presence, or something. How can it be "essential" given so many are still ill? And that most recover over time anyway, which would obviously explain most if not all improvement over time.

I'm not sure they could possibly even define what they are "rehabilitating". When it's nerve damage it's clear enough. If it's the heart muscle or lungs or whatever, that's what's being worked on.

What is even being worked on in a generic rehabilitation program? Everyone says there is a "need" for rehabilitation but no one can actually say out loud what that need actually is. Clearly the "need" expressed here is not being able to work. And the goal is to return them to work. But without considering why they can't work, let alone addressing this. It's just generic "let's get you moving and motivated", which was never the problem, or even a problem, it's a consequence of.

And to have nothing but entry-level studies with no controls, small numbers and very little details a full 2.5 years into the widespread ramping up of hundreds of such clinics and programs that have seen tens of thousands of patients by now, really shows that no one actually wants to know whether it works or not, they just want the blessing to keep going, to keep being a "healing presence" or whatever. No one is testing whether it doesn't work, only that it does. Alternative medicine.

What a mess.

 

Rehabilitation is just a euphemism for exercise and CBT and relies on the BPS model. Not surprisingly its failing Long haulers too and I wonder how many of those drop outs got worse?! Its a travesty these studies are getting past ethics reviews given all the guidance put out about Long Covid early on.

 

I suspect returning to work can not be reliably measurable in the current time scale of Covid-19 and the resultant Long Covid.

I am not objecting to the idea of support to get people back to work or phased return to work, though I suspect simplistic blanket rehabilitation given our current knowledge is unlikely to have any long term benefit and for some may even be harmful. The limited data from the British ME/CFS services, then providing GET/CBT, suggested such intervention ultimately resulted in patients working fewer hours and claiming more benefit. I would argue for ME like Long Covid the timescale used to look at ability to work needs to be on a much longer time scale. This is particularly so at the mild and moderate end of the spectrum. My personal ME experience was struggling partially successfully to maintain full time employment for a number of years post onset, then going half time for another four or five years with better success until a major relapse some eight years post onset forced ill health retirement.

I suspect the only option to allow people to continue working as long as possible, is not just a phased return to work, but a much more flexible ongoing working environment and benefits/insurance/pension system that would allow people to decease or increase their working hours or even to drop in or out of work altogether in response to fluctuations in their condition.

[edited to add a crucial ‘not’ into the first sentence]

 

This bit is telling to me: "there were no significant improvements in the PCFS, overall mental component score of the SF-36, or on the PCL-5".

This tells me that symptoms weren't much improved and people were still struggling, but if they had suitable accommodations at work and were pacing, they could do a little bit more.

It also shows, to me, that when you help people meet their needs with accommodations, things get easier for them, even if they don't get better.

So this flies in the face of the "no accommodations, ever" mantra that was popular among some researchers and clinicians for so long. Rather than making us dependent, as they claimed, accommodations can make us more independent.

 

but is it sustainable?

 

Except that their conclusion in their abstract then says 'timely rehabilitation is important'.

There is a big issue with how people are allowed to write such statements without evidence - if you couldn't read the results and conclude that to write a marketing statement accurately then you shouldn't be allowed to do so for your abstract surely?

 

The LC recovery team said 'recovery' doesn't mean recovery to previous health.

When I queried what rehabilitation meant, I was provided with the following.

https://app.magicapp.org/#/guideline/EQpzKn/section/jNk6gL

https://www.who.int/health-topics/rehabilitation#tab=tab_1

 

when you look at the definition of the word it says 'restore' which is even more specific. ie restore to normal health or normal life

I think they know exactly what they are doing with using the terms rehab instead of adjustments or support. I think it is the usual minimise and pretend recovery is likely just as was done for ME.

To use those terms in the context of workplace is very divisive. Nothing wrong with adjustment - other than it infers the place with accommodate your needs rather than them changing the person 'to fit' as a promise

 

Also a very important point. I venture that even if it is sustainable, you might see a better response if people were able to stay at home and have adaptations made there instead. Because the act of going to/doing work is probably a net energy drain anyway.

 

Worrying that the focus might be 'getting them there' and then job done - whereas the real focus at this point in long covid needs to be on monitoring those who do 'get there' over the course of 5yrs.

Noone seems to be noting that homeworking and reduced hours meaning that someone isn't deteriorated life-long is better than 1yr of 'more presenteeism' and then dependent on care the rest of their life.

THAT has been the big issue with ME and I find it offensive that lesson hasn't even been learned - which is why putting aside 'us' (a big reason), there is a massive need for a public inquiry. I'd want to think there were quicker routes on that but struggle to see how they mightn't get warped or would be certain to be trustworthy if it is a pick and choose scenario given how the illness works.

If ME should have taught everyone one thing it is to stop being short-termist and to ensure independence in assessment and find a way of patient voice not getting sullied in data collection process.

And THAT is why 'rehab' getting into the Occupational health and occupational therapist territory and trying to take over from disease-specialist centres is ridiculous. They should be under the 'do no harm'. And people need to be reminded that very much isn't something that doesn't count and you are no longer accountable for if you get them out of the door and off the books first. Or say 'that bit isn't my problem'.

SIlo'd NHS departments with noone as an expert in the condition is the driver here - the symptom-based nonsense, where everything 'could have been caused by something that is not my job' creates a 'don't look too closely' situation. I take putting long covid people under rehab as a big sign of intention - and that 'good intention' nonsense being my most hated phrase (and I have a lot of them) I think it's time people call BS on anyone saying that who at the same point isn't interested in 'hearing the consequences of their actions', because how can you have one if you don't care about the other?

 

The main point exactly.

 

The results of the study are in line with what I'd expect due to natural recovery. While I'm very glad the authors took a biomedical approach to rehab and respected PEM, I wish they would have mentioned that their results could be explained by the natural course of the illness, and then saying research into treatments, in addition to just symptom management, is needed.

Edit: Clarify.