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

Andy

Andy

Senior Member (Voting rights)
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
 
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.
 
Lack of a control group makes the outcomes meaningless, but at least the rehab described is not as bad as I suspected:

The multidisciplinary program consists of occupational, physical, and exercise therapy along with psychology, nursing, and medical interventions, as needed. The program provides psychoeducational approaches for management of LC symptoms, guidance on pacing and energy conservation, as well as breathing strategies. Some activity or exercise interventions are also prescribed as tolerated by the workers and in a manner that avoids the post-exertional malaise that is common to the LC population.
...
A primary goal of the program is RTW, thus advice about work activity, exploration of modified duties, and negotiation with employers about appropriate duties are also performed.
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Reading further, there is such a high proportion of missing data and their own analysis showed that 'those with incomplete data had a lower likelihood of returning to work.'
The stand out figure in my view is that only 3 out of the 81 returned to normal duties. All the rest who returned to work were on modified duties, and the biggest predictor of return to work was availablity of modified duties.

Also 'Workers with longer time between symptom onset and program admission also had lower likelihood of successful RTW.'
They interpret this as meaning patients need to be put on a rehab program earlier. My interpretation is that recovery/improvement is more likely in the earlier stages of post viral illness. Catching them earlier just means you will include more who would recover anyway.

They refer to the recent dreadful Chalder ME/CFS study:
To our knowledge, this is the first study examining predictors of RTW among workers with LC, likely because of the novelty of the condition. However, previous research has examined RTW in individuals with chronic fatigue syndrome, which has been found to have overlapping clinical presentation with LC [42]. In a longitudinal study (n=508) exploring socio-demographic, work, and clinical characteristics associated with occupational status among individuals with chronic fatigue syndrome, those who RTW were functioning better (as measured by the SF-36) and were younger in age [43]. Individuals who reported more fatigue (measured by the Chalder Fatigue Questionnaire) and/or met the criteria for anxiety and depression (measured by the Hospital Anxiety and Depression Scale) were more likely to have stopped working between baseline and follow-up [43]. These findings suggest that levels of fatigue, age, function, anxiety, and depression may be important variables to consider in future studies analyzing prognostic factors of RTW among individuals living with LC
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Reference:
43. Stevelink SAM, Mark KM, Fear NT, Hotopf M, Chalder T. Chronic fatigue syndrome and occupational status: a retrospective longitudinal study. Occupational Medicine; 2022;72(3):177–83.
Thread on that study here:
https://www.s4me.info/threads/facto...-stevelink-n-t-fear-m-hotopf-t-chalder.10645/

So basically they have shown their rehab program was useless at returning people to their old unmodified jobs, with only 3 out of 81 doing so.
 
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]
 
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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.
 
rvallee said:
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.
Click to expand...

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?
 
marcjr said:
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.
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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.

Definition

Rehabilitation: a set of interventions designed to optimise functioning, health and wellbeing, and reduce disability in people with health conditions in interaction with their environment. In the context of ongoing COVID-19 symptoms, this may include providing information, education, supported self-management, peer support, symptom management strategies and physical rehabilitation. (Informed by the World Health Organization's fact sheet on rehabilitation.)
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https://app.magicapp.org/#/guideline/EQpzKn/section/jNk6gL

Rehabilitation
10 November 2021

Key facts
  • Rehabilitation is an essential part of universal health coverage along with promotion of good health, prevention of disease, treatment and palliative care.
  • Rehabilitation helps a child, adult or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation and meaningful life roles such as taking care of family.
  • Globally, an estimated 2.4 billion people are currently living with a health condition that benefits from rehabilitation.
  • The need for rehabilitation worldwide is predicted to increase due to changes in the health and characteristics of the population. For example, people are living longer, but with more chronic disease and disability.
  • Currently, the need for rehabilitation is largely unmet. In some low- and middle-income countries, more than 50% of people do not receive the rehabilitation services they require. Rehabilitation services are also amongst the health services most severely disrupted by the COVID-19 pandemic.
What is rehabilitation?
Rehabilitation is defined as “a set of interventions designed to optimize functioning and reduce disability in individuals with health conditions in interaction with their environment”.

Put simply, rehabilitation helps a child, adult or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation and meaningful life roles such as taking care of family. It does so by addressing underlying conditions (such as pain) and improving the way an individual functions in everyday life, supporting them to overcome difficulties with thinking, seeing, hearing, communicating, eating or moving around.

Anybody may need rehabilitation at some point in their lives, following an injury, surgery, disease or illness, or because their functioning has declined with age.

Some examples of rehabilitation include:

  • Exercises to improve a person’s speech, language and communication after a brain injury.
  • Modifying an older person’s home environment to improve their safety and independence at home and to reduce their risk of falls.
  • Exercise training and education on healthy living for a person with a heart disease.
  • Making, fitting and educating an individual to use a prosthesis after a leg amputation.
  • Positioning and splinting techniques to assist with skin healing, reduce swelling, and to regain movement after burn surgery.
  • Prescribing medicine to reduce muscle stiffness for a child with cerebral palsy.
  • Psychological support for a person with depression.
  • Training in the use of a white cane, for a person with vision loss.
Rehabilitation is highly person-centered, meaning that the interventions and approach selected for each individual depends on their goals and preferences. Rehabilitation can be provided in many different settings, from inpatient or outpatient hospital settings, to private clinics, or community settings such as an individual’s home.

The rehabilitation workforce is made up of different health workers, including but not limited to physiotherapists, occupational therapists, speech and language therapists and audiologists, orthotists and prosthetists, clinical psychologists, physical medicine and rehabilitation doctors, and rehabilitation nurses.

The benefits of rehabilitation
Rehabilitation can reduce the impact of a broad range of health conditions, including diseases (acute or chronic), illnesses or injuries. It can also complement other health interventions, such as medical and surgical interventions, helping to achieve the best outcome possible. For example, rehabilitation can help to reduce, manage or prevent complications associated with many health conditions, such as spinal cord injury, stroke, or a fracture.

Rehabilitation helps to minimize or slow down the disabling effects of chronic health conditions, such as cardiovascular disease, cancer and diabetes by equipping people with self-management strategies and the assistive products they require, or by addressing pain or other complications.

Rehabilitation is an investment, with cost benefits for both the individuals and society. It can help to avoid costly hospitalization, reduce hospital length of stay, and prevent re-admissions. Rehabilitation also enables individuals to participate in education and gainful employment, remain independent at home, and minimize the need for financial or caregiver support.

Rehabilitation is an important part of universal health coverage and is a key strategy for achieving Sustainable Development Goal 3 – “Ensure healthy lives and promote well-being for all at all ages”.

Misconceptions about rehabilitation
Rehabilitation is not only for people with long-term or physical impairments. Rather, rehabilitation is a core health service for anyone with an acute or chronic health condition, impairment or injury that limits functioning, and as such should be available for anyone who needs it.

Rehabilitation is not a luxury health service that is available only for those who can afford it. Nor is it an optional service to try only when other interventions to prevent or cure a health condition fail.

For the full extent of the social, economic and health benefits of rehabilitation to be realized, timely, high quality and affordable rehabilitation interventions should be available to all. In many cases, this means starting rehabilitation as soon as a health condition is noted and continuing to deliver rehabilitation alongside other health interventions.

Unmet global need for rehabilitation
Globally, about 2.4 billion people are currently living with a health condition that benefits from rehabilitation. With changes taking place in the health and characteristics of the population worldwide, this estimated need for rehabilitation is only going to increase in the coming years.

People are living longer, with the number of people over 60 years of age predicted to double by 2050, and more people are living with chronic diseases such as diabetes, stroke and cancer. At the same time, the ongoing incidence of injury (such as a burn) and child developmental conditions (such as cerebral palsy) persist. These health conditions can impact an individual’s functioning and are linked to increased levels of disability, for which rehabilitation can be beneficial.

In many parts of the world, this increasing need for rehabilitation is going largely unmet. More than half of people living in some low- and middle-income countries who require rehabilitation services do not receive them. Rehabilitation services are consistently amongst the health services most severely disrupted by the COVID-19 pandemic.

Global rehabilitation needs continue to be unmet due to multiple factors, including:

  • Lack of prioritization, funding, policies and plans for rehabilitation at a national level.
  • Lack of available rehabilitation services outside urban areas, and long waiting times.
  • High out-of-pocket expenses and non-existent or inadequate means of funding.
  • Lack of trained rehabilitation professionals, with less than 10 skilled practitioners per 1 million population in many low- and middle-income settings.
  • Lack of resources, including assistive technology, equipment and consumables.
  • The need for more research and data on rehabilitation.
  • Ineffective and under-utilized referral pathways to rehabilitation.
Rehabilitation in emergencies
Natural hazards such as earthquakes or disease outbreaks and human induced hazards including conflict, terrorism or industrial accidents can generate overwhelming rehabilitation needs as a result of injury or illness. They also simultaneously disrupt existing services and have the greatest impact on the most vulnerable populations and the weakest health systems.

While the important role of rehabilitation in emergencies is recognized in clinical and humanitarian guidelines, it is rarely considered as part of health system preparedness and early response. The result is that pre-existing limitations in rehabilitation services are magnified, health service delivery is less efficient, and people directly affected are at risk of increased impairment and disability.

WHO response
For rehabilitation to reach its full potential, efforts should be directed towards strengthening the health system as a whole and making rehabilitation part of health care at all levels of the health system, and as part of universal health coverage.

In 2017, WHO launched the Rehabilitation 2030 initiative, which emphasizes the need for health system strengthening, and calls for all stakeholders worldwide to come together to work on different priority areas, including: improving leadership and governance; developing a strong multidisciplinary rehabilitation workforce; expanding financing for rehabilitation; and improving data collection and research on rehabilitation.

WHO is responding to the identified challenges and promoting health system strengthening for rehabilitation through:

  • Providing technical support and building capacity at country level
  • Increasing leadership, prioritization and resource mobilization
  • Developing norms, standards and technical guidance
  • Shaping the research agenda and monitoring progress
Related links
WHO's work on rehabilitation
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https://www.who.int/health-topics/rehabilitation#tab=tab_1
 
livinglighter said:
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
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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
 
adambeyoncelowe said:
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.
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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?
 
bobbler said:
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.
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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.
 
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