All right, everyone Hello, and welcome to our next installment of research briefs. Where MD guidelines has partnered with the American College of occupational and environmental health. Environmental medicine to bring you a webinar about long. I'm Carrie Weissman, assistant director of epidemiology guidelines and we're going to be a moderator for today. We're thrilled that you can join us and we have a lot of conference cover, so I'm going to go ahead and jump right in. A few housekeeping slides, all participants will be needed for the webinar. If you're requesting CME or CCM, and you cannot attend to the zoom. I called into the phone these emails to confirm your attendance, our slides and resources and recording links will be sent out after the webinar. At any time, if you have any questions, please feel free to put them into the chat box. Put them into the QA so all the panelists can see them and consider them for the question and answer piece at the end. You can also do chat messages to all panelists or all panelists and attendees. These are the objectives we're going to address today. We're going to focus on the occupational health side of long period, including evidence based guidelines and strategies. Support return to work. These are our speakers for today. So first, I'm going to be Dr. Greg Beneschke, who is an occupational and aerospace medicine physician at Mayo Clinic in Minnesota. Dr. Kurt Hegman is the director of the Rocky Mountain Center for Occupational and Environmental Health at the University of Utah School of Medicine. He's also the editor-in-chief of the ACOM guidelines. Dr. Lasker-Tay is a senior VP of behavioral health at Axon Medical and the president of Dr. Lasker-Tay and Associates, he's out in Tennessee. Our last speaker is Dr. Jeremy House, he's an assistant professor here at the University of Colorado and a physical medicine and rehab physician at CU hospital. These are our disclosures, which include working with ACOM, offering some of the guidelines and consulting with health groups. So we're diving right into long COVID. Long COVID actually started as a patient-led hashtag back in 2020 out of Italy. It is thought to be the first disease named by Twitter. So now it's been widely accepted as a serious illness, despite the lack of a thorough scientific basis. So this is kind of a first for all of us. The Center for Disease Control and Prevention definition of long COVID is a little bit different than the World Health Organization, and that's been a challenge as we try to distinguish long COVID after COVID infections. It's now also called the post-acute sequela of SARS-CoV-2 infections or PAS. And you can see, this is a list of the symptoms that CDC has defined as part of long COVID, but this is a growing and evolving list. So a lot of impact from long COVID, and so while studies continue to be published, some estimate that 30 to 50% of COVID survivors have one or more symptoms after three to six months. Over in the UK, they found a survey that 46% of employers had at least one employee dealing with long COVID. And those with long COVID might need work accommodation, such as reduced work schedules or time away from work. A report from the Brookings Institute in Washington, D.C. estimates that long COVID could be a significant contributor to America's great resignation, with 1.1 million people out of work before COVID and another 2.1 million utilizing reduced work hours. So we see this as a growing problem in the future, and we're interested to dive right into the treatment here, so I'm going to go ahead and hand it over to Dr. Boone. All right, everyone. Thank you so much for juggling with the sound issues there. I'm hoping that everybody can hear me okay with my microphone. Someone just give me a shout out in the chat, please. All right, good. Yeah, that my wife says that definitely doesn't have a hard time hearing my voice. So, well, welcome, everybody. My name is Greg Van Nish Kishore, and I'm going to be talking a little bit about what we see on the front lines when it comes to treating long haul COVID. Now, to start off my section, I have to address the elephant in the room, and that elephant is the question of how in the world an occupational and aerospace medicine physician became the face and leader of long haul COVID at Mayo Clinic. It's a just question, really. And part of it's timing. At the time of the pandemic, our team had already been working with our post-ICU team to help patients who were coming out of the ICU get back on their feet and get back to work, and it was only a matter of time that we started seeing patients coming out of the ICU after having COVID-19. And pretty much from the get-go, we started seeing that these individuals were going to have a different recovery. You know, they had prolonged symptoms like fatigue and shortness of breath. And as more and more patients presented needing care, we came up with a program first informally and then formally as the COVID Activity Rehabilitation Program. And we've been doing that since about June of 2020. Since that time period, we've had a chance to visit with about 600 patients from across the world with long haul COVID. Now, it wasn't just sheer luck of timing, though, that has kept occupational medicine at the forefront of long haul COVID at Mayo. In fact, when you start to think about what really long haul COVID is, the relationship between occupational medicine and this condition actually makes a lot of sense. Most people, when they think of long haul COVID, they think of fatigue and shortness of breath, the symptoms. But as you can see from this diagram, there are so many other factors that come into play that really can change what a person feels and experiences as part of a long haul COVID condition. And by the way, we call it post-COVID syndrome here. But these are factors like being out of work, financial stress, and lack of social support. And if this paradigm looks familiar, that's by design. It's because the same exact paradigm can be applied to work-related conditions. Thanks to our training and our clinical experience, occupational medicine providers are very used to navigating through all of these psychosocial factors that affect the experience of a health condition. And this is really an underrated and important skill set when it comes to long haul COVID. In my experience, what I have seen a lot of out there is that there are many experts who are treating long haul COVID, but purely from the lens of their expertise. So, for example, neurologists helping with headaches and cardiologists helping with things like myocarditis. And of course, that help is very important. But what is also more important is patients really need someone to help synthesize all of that information together to develop a coordinated, multidisciplinary, and real-world plan that can help them get back on their feet. And because of that need, that's where occupational medicine really has been able to take a foothold here and why I think this condition is going to be a very important part of our specialty going forward. All right, so let's talk a little bit about what we actually see. So you heard a little bit about some of the symptoms there as Kerry was introducing the subject, but here's a list of the most common symptoms that we see in our CARB clinic at Mayo. This comes from the first 100 patients that came through our program. Right at the very top, you see fatigue and respiratory complaints, and that's what most people think about when they think of long haul COVID. It is important to note that the fatigue is quite profound. It's not like fatigue that's associated with a poor night of sleep or even things like having influenza. But it's very common for patients to say something like they went to take their trash out and then they had to take a nap for three to four hours afterwards, or maybe go for a walk and then have symptoms that are worse for days afterwards. The respiratory problems, that can be both with exertion and at rest. Now, while those are the most common symptoms, there are also a lot of other things that we see quite frequently. In fact, neurological complaints are equal to respiratory complaints, and that includes things like headaches. I will note that subjective cognitive impairment, and highlighting the word subjective right now, is present in about 45% of our patients, and this is typically known as brain fog. Patients will describe it as troubles with word finding, multitasking, and short-term memory. I find this is very important because of all the symptoms that we see associated with long COVID, this tends to be the most stressful because it causes problems at work. Now, in addition to these common symptoms, we also see some unique but not rare symptoms associated with long haul COVID. Things like tinnitus, prolonged troubles with taste and smell, and even visual changes. So, the takeaway point for these two slides is that long COVID is more than just shortness of breath and fatigue. It seems like every day we are learning more about the symptoms that can be associated with this condition. Now, symptoms are only half of the battle when it comes to long haul COVID. The other half is how those symptoms affect a person's ability to live their lives. Being an occupational medicine clinic, we have focused heavily on functions from the very beginning, and when we look back at our patients, over 34% of them reported some troubles with the basic ADLs at their time of presentation to our clinic. So, that's things like taking a shower or putting on their clothes. 82% reported troubles with the more routine things of life like driving, grocery shopping, and of course, work. Now, 63% had been able to return to work in some form by the time they presented to our clinic, and that may sound promising, but it's important to note that the average time between infection and presentation to our clinic was three months. So, another way to look at this is that at three months after an infection start, only a little bit more than half of patients were back at work, and about half of those were back at baseline work. All right. So, now just going briefly to the treatment that we do here at Mayo, this is an overview of how we look at the different phases of treatment. So, first is the post-acute phase, which occurs between zero to four weeks. Then we have an early post-COVID syndrome or PASC phase, which is between five and 12 weeks, and that's where our program focuses in on. After that is finally the true long-haul COVID phase, which is three months out after infection, and each one of these phases has different purposes, but again, we focus primarily in this five to 12-week window. The philosophy of this program is that if we can help intervene in patients early on, maybe we can stop them from going down the pathway of getting into the long, long-haul COVID state, and we can get them back on their feet and back to work more quickly. And zooming into that window, here is how our program is structured overall, and I'm just going to review these in brief because this really is a talk in itself. So, first thing we do for patients is making sure that nothing else is going on that could affect their well-being. Now, there are other things that can happen besides COVID when someone gets COVID-19 infection, things like opportunistic infections or pulmonary embolism, so we start with a general evaluation. After that comes what I think is probably one of the most important things, and that's psychosocial support. By the time that patients come to visit with our clinic, they've often been told very non-helpful things, like this is all in their head or they're just experiencing anxiety and depression, and this leads to a lot of self-doubt and guilt and, frankly, people questioning their sanity. So, one of the first things that we do is just making sure that we listen to patients and provide them some validation of what they're going through. After that, we'll start a targeted evaluation, as clinically indicated. So, for example, if someone has heart symptoms, we might do a cardiac workout with an echocardiogram or a cardiac MRI, checking for things like myocarditis or ventricular dysfunction. The important thing to note about these pink boxes is that they're not mandatory. We only go down these pathways if there's some sort of clinical indication that something may be amiss. Once we have identified any conditions that may be going on, we help manage those symptoms or conditions in the same fashion that we would manage them if someone didn't have long-haul COVID. So, for example, if someone has sleep apnea, we will initiate CPAP and get sleep medicine on board. Once we have all of that in place, then comes the next most important thing, which is rehabilitation. Many patients after long-haul COVID, or sorry, excuse me, many patients after their COVID infection, they are sick of being sick, and they try to get back to their normal lives as quickly as possible. But oftentimes, this results in worsening of their symptoms because they try to push themselves too hard. That requires rest, and that leads to further deconditioning, and patients can get themselves into this vicious cycle. So we try to break that early on by having patients visit with our physical and occupational therapy team and our work rehab group. And as you can imagine, that is a team that is very used to helping juggle numerous psychosocial factors that can affect a health condition. Now, I just want to highlight two areas of the treatment here before I finish up my section. The first involves diagnostics, and we're going to be talking about this quite a bit throughout the webinar. But a good thing to note here is that when we first started working with patients, we pretty much did any test that we thought could be helpful. Echocardiograms, pulmonary function tests, brain MRIs, and so forth. And when we went back to look at how helpful all that testing was in the first 100 patients, what we found was it's not very helpful at all. So for example, of the 29 echocardiograms, we did only four were abnormal, and they were mildly abnormal. Chest X-rays of the 35 we did, only one was abnormal, and that just showed some quote-unquote resolving pneumonia. Interestingly, the test that was most frequently abnormal was our autonomic reflex test for autonomic dysfunction, think like POTS. So with that information, we have actually pared down our initial diagnostics to a minimal panel of blood work that you can see here. And the takeaway from all of this is that less is more when it comes to diagnosis and evaluations in long-haul COVID. This is especially true for patients in this condition because many patients of long-haul COVID right now have very nebulous insurance coverage. So the last thing we want to do for someone who's been out of work for three months is to give them a $3,000 medical bill that was unnecessary. And for my final clinical pearl, this I want to talk about is return to work strategies. Now, as far as I know, we're the only long-haul COVID clinic that specializes in occupational medicine. And so with that, we've come up with a couple of different strategies that I think are worth highlighting. So first up, we like to interact with our patients about every two to four weeks to provide them updates regularly about their work status. One of the worst things that can happen is someone giving a patient a work status form and saying, we'll see you back in about three months. Because, well, a lot of things can fall off the bus there in about three months. So again, we see a person about every two to four weeks. And I remind patients that they don't have to wait until their scheduled appointments to ask for adjustments in their restrictions. So I tell patients, if something goes wrong or you need to adjust something or you're feeling great, just give me a call and we can talk through a new work restriction. Another thing that we have found to be helpful is titration. Many patients are fearful that when they go back to work, they're going to have to hit the ground running at 100%. We hardly ever actually do that now. Instead, what we typically will promote is a titrated return to work. So for example, one of the most common restrictions I start with is going back to work four hours every other day for a max of three shifts per week. And let's try that for about two to four weeks. A unique feature that has come out of the pandemic is more people are working from home. So we've been able to capitalize on that, sometimes recommending that patients work from home initially, say working four hours total throughout the day. And spending that time on sedentary work like catching up on training and emails. From there, we make slow transitions, for example, going from four to six hour shifts. One area that I personally focus on is trying to build confidence in patients that they can manage themselves, their pacing and their condition. So when I sense that is occurring, then I allow patients to self-pace a little bit, say eight to 12 hours as tolerated. And I find that it is very helpful for patients believing that, yes, I can go back to work without everything getting worse. And then finally is quality relief. If someone is working four hours every other day, that's great. But if they have to go back to work, let's say on a production line, like building cars or in a pork processing facility, where if they can't keep up with the pace, everything falls off. That is not very conducive to getting a person back to work. So what I'll sometimes write is, for example, no volume sensitive work. And if I really want to spell it out clearly, I'll even put that the purpose of initial work hours are just to reintegrate the employee back to the work environment. Just having that little bit of written support can help employees be able to navigate the return to work process with their supervisors and coworkers. And with that, I will go ahead and end my section and pass it off to my colleagues here. Okay, and this is Kurt Hegman. Hopefully, you can hear me. All right, very good. Thank you very much. I appreciate Dr. V's wonderful discussion and Mayo's leadership in this area. I'm Kurt Hegman. I direct the Rocky Mountain Center for Occupational Environmental Health and lead the college's guidelines efforts. So what you'll see is going to be, I think, what Dr. V said. And let me hit the arrow, the other arrow. There we go. And so the first area that we have guidance that we've crafted, and I will cut to the chase, all of these things, unfortunately, still have insufficient evidence. What that means is we are still waiting for moderate and high quality randomized controlled trials to actually answer these questions. However, that said, based in part on prior experience and other conditions, we are able to craft guidance that's expert opinion. And that's what I'm going to show you. So the first item to talk about is going to be pulmonary rehabilitation. And for this area, the goal is to target dyspnea exertional tolerance, and especially function. And I think Dr. V hit that very well. And I think that's also one of the reasons why occupational medicine, occupational oriented physicians, and other clinicians are going to be very well suited for helping people in these areas. Because we're ultimately looking at targeting significant gaps between current function and what the job demands are. And those can often be objectively measured. There is recommendation included for earlier exercise, but one has to do it on an incremental graded basis and not overdo it. As Dr. V hinted at, the typical person wanting to suddenly go for a long walk after not doing anything is of course not a good prescription for a good outcome. Because of the history of heart issues, we also have to be careful about monitoring the cardiac status. Testing is generally indicated just to ensure that there isn't a problem. And also some, at least some monitoring during the rehabilitative process, especially for more severely affected individuals to make sure that they do not have dysrhythmias and other signs of cardiomyopathy. Individualized evaluation and individualized treatment are recommended because there are so many factors involved with these cases, including severity of the case, severity of the impairments, duration, and so forth. So testing is again indicated both from a cardiac and pulmonary standpoint, generally at baseline on the more severely affected individuals and or those that Dr. V was pointing out fall out with a longer case rather than a faster recovery type of situation. In the area of pulmonary rehabilitation, prior evidence and prior programs use an interdisciplinary approach. Common elements include education, exercise training, and behavior change issues with speed of process tailored to include cardiac involvement. Examples of what have been published are these two examples here. If you think about 3METS, 3METS is not that high, but 3METS is one example and another is 58% of the VO2 max, which of course one has to be careful of prior VO2 max measures if somebody has that, for example, a firefighter, because it may be markedly debilitated in the post-operative period. Because it may be markedly debilitated in the post-COVID scenario. Duration is typically at least four weeks for this sort of thing. It could be shorter in milder cases, could also be longer. And again, as I mentioned before, the quality of evidence for pulmonary rehabilitation is currently sparse. Where we have evidence that's previously published moderate to high quality would be in outcomes such as pneumonia and interstitial fibrosis. Cardiac rehabilitation is the next one. And again, the goal is to target the dysfunction, usually dyspnea-related, tolerance-related, exercise tolerance-related issues. Again, gaps between their current function and what they need to do job demands is really a critical issue. Some of these, again, can be clearly measured. Six-minute walk tests and so forth, how much walking do they have to do on the job, how much standing and so forth. In the occupational world, we are used to looking at job descriptions, but we hopefully are also looking at working with the supervisor and the HR and so forth to get data to use to actually target and ultimately measure in the rehabilitation process to assure that the gaps become minimal so that return to work is much more easily facilitated. Generally, it's been recommended to be pretty careful in the two to three-week post-COVID timeframe because of the cardiomyopathy issues. At the same time, doing nothing usually is not a good thing either because that also has its own cardiac complications. Again, testing and monitoring for cardiac issues is indicated. The program for cardiac rehabilitation is, again, advised to be individualized, again, because of the number of different variables which may come into play for different individuals. The typical program is, again, based on prior experience, interdisciplinary, including education, exercise training, strength resistance training, psychological factors, and behavior change issues. The involvement of the cardiac system and monitoring for dysrhythmias and other similar issues should be monitored, and that also helps to inform the speed of the program and its implementation rate. Once again, the typical duration of most of these programs is in the area of four weeks, and again, it could be shorter than that or it certainly could be longer depending on that individual's circumstances. Again, the level of evidence is unfortunately low quality, although we do expect to have many RCTs eventually published on these things. There are protocols published online. Exercise therapy is another significant intervention dealing with targeting hospital and activity-related deconditioning. Again, looking at targeting gaps between function and job demands, and there are, once again, quantitative measures, and some of these are pretty low-tech that can be used and certainly can be used in a clinic setting. Six-minute walk tests, sit-to-stand, leg strength tests, many of these things can be done with different patients, but widely implemented and easy to do and easy to track progress as things progress. Again, cardiac monitoring is advised. These programs are usually multidisciplinary. Physical therapy, occupational therapy, as Dr. V noted, medical involvement, psychology. Once again, tracking their progress and looking at filling the gaps of the aerobic and strength demands as needed to accomplish daily activities of living as well as job demands. Again, there are no quality trials, and we do monitor for that, and we are eagerly waiting those to be published. Memory and cognition. Typically, we're dealing with higher cortical deficits other than those who sustained, unfortunately, a stroke, and ongoing cognitive dysfunction is an indication, especially if it's not undergoing rapid resolution, with the goal for these types of interventions to target gaps between their functions at current and the job demands. Ideally, objectively measured, although a lot of this is now in the subjective questionnaire side of things. Cognitive programs typically are also multidisciplinary using psychology, neuropsychology, and speech pathology, with intensity also geared towards severity and the gaps to fill between current abilities and the ultimate goals for recovery. And yet again, we're waiting for quality evidence. Other things to just be aware of in terms of the guidelines are we have detailed guidance available on anxiety, depression, and PTSD, as well as strength pain related issues and other body part guidelines. And with that, I think we're ready to pass the baton to Dr. Kertay. Thank you, Dr. Hegman. Let me go ahead and... You're going to have to stop sharing your screen, I think. Yep, there we go. Now I can share mine. All righty. So you all are about to see that I have way too much stuff on these slides, so I'm going to hit the high points, but I wanted it on the slides for your reference. And I want to start with kind of taking off on something that Dr. Banish-Kishoren said about people being told unhelpfully that they are just anxious. I wish we could just strike the word just from our vocabulary when we're talking about these patients. They are often anxious. It has nothing to do with just being anxious. And we'll talk a little bit, I want to talk a little bit more about why that makes sense to consider that. So we know from large studies early on across cultures, across lots of settings, we know that there is a much higher level of mental distress being reported post-COVID. I'm going to argue that that's not terribly surprising for a number of reasons, but we have definitely seen it. And Ali and Zee, in a follow-up in 2022, looked at a huge number of VA cases and found these significantly elevated incidents of both depressive and anxiety disorders. To some extent, increased trauma-related or adjustment-related disorders. Interestingly enough, we see in these large studies that it is actually dose-dependent, it is actually dose-dependent. So the people who were ventilated have the highest incidents, people who are hospitalized or in intensive care have less, hospitalized without intensive care is less, and people who were not hospitalized have the smallest numbers. And that's pretty true across it. For the trauma-related disorders in these samples in particular, they washed out when you accounted for levels of intervention. So the people who were ventilated were much more likely to have trauma responses. Totally unsurprising. We would expect to see that. In general, post-COVID stress is high overall, and this is being interpreted in different ways. Again, not surprising to anyone that stress is high in these folks. And in fact, in all of us, we've all been stressed. I don't know about you, but for most of two years, I didn't go anywhere. And it's interesting, some of these studies conclude that treatment is necessary for that symptoms. And I think that we're probably over-treating things that are not diagnosable conditions. But that's another conversation that we have. We have seen that younger workers are most at risk to report COVID-related stress, which is interesting. And I thought this was a really interesting quote. And I think it's a really important observation that a lot of the anxious and depressive symptoms related to the lockdown are really associated with people's intolerance of uncertainty. I'm going to make this point again in a minute, but human beings hate ambiguity and uncertainty. And it stresses us when that happens. There has been a proposal for something called a COVID stress syndrome, multifaceted. There's a scale that Taylor developed. I have significant questions about whether this belongs as its own unique stress syndrome. But this, I think, is an important quote here that this footprint is much larger than even the medical footprint of COVID and post-COVID. Interestingly enough, people emotionally affected by far were not actually infected with the disease. So we're seeing stress responses in anxiety and depression in people who were not sick. And so not surprising that if you were sick and have extended symptoms that you would continue to be anxious. Makes perfect sense. Some risk factors that go with this. Women are more likely to report post-COVID anxiety and depression, age. Healthcare workers are particularly vulnerable. I think an interesting observation that's early is that individuals diagnosed with OCD are, whether they were infected or not, are more likely to report post-COVID related anxiety and depression. We've seen increased substance abuse. The impact on disability has been, it's a little early to tell. We have seen significant increases in loss ratios in life insurers. Unsurprising because we had a significant amount of excess death. It looks like there's a trend to increased incidence of disability claims. But it's really early to tell. And it's not as big as we thought it was. And that's been an important thing to watch. I get information because I've spent a lot of time working in the field. And so I continue to monitor that. But in publicly available data. But it does look like we're seeing claims for disability go up. And that means that we have to really have a clear evaluation of function. I don't really care what the diagnosis is. I care about can we quantify what a person can and can't do in that setting. And that's a really important thing. I think we have to watch for. Now I want to say some things about methodology because there are some really problematic issues related to incidence and prevalence studies. There are bias problems there. Here's some references for you. There are bias problems. There's a lack of standardized assessment protocols. A lot of these studies have not had control groups involved. That's one of the things that's interesting about the VA studies because they had 70, in the original study, they had 76,000, I think, COVID cases associated with the VA and over 4 million cases that did not have COVID. That's a pretty big comparison group. So, you know, I tend to lend credence to those. The pandemic itself actually had an impact. So I put this slide in here for, you know, the trend of serious mental illness in the past year from SAMHSA. I want to note two things about this. One is that mental health difficulties were on an upward trend long before COVID. And it appears to have been exacerbated by COVID, but that trend has continued. But secondly, it's really interesting that SAMHSA, in a very long explanation, that's an appendix to their report, indicated why they did not connect the dot between 2019 and 2020. And the reason is that in 2020, because they normally do all of these evaluations and interviews face-to-face, they had to do all of these by telepresence. And the methodology they felt was changed significantly enough that they were not comfortable making a statistical connection. So it just goes to kind of underline the kinds of methodological problems that we're having. We have to ask ourselves when we're looking at these studies, you know, how is the information gathered? Was there any assessment of premorbid function? And if so, how? So quite a number of these studies looked at if hospital records or medical records prior to the event did not have reference to anxiety or depression, but did have afterwards, then it's presumed that this anxiety or depression is caused by COVID, by the infection. Well, okay, but again, if I'm sick with an illness that is unique, that no one knows what to do with, and I'm continuing to have symptoms, I'm probably going to report anxiety. If anxiety is turned into a diagnosis in a medical record, which is frequent, then are we really comparing apples to apples? So I think we have to ask all of those questions. And it's, you know, this is, you know, we're all sort of waiting for those, you know, for randomized controlled trials and better studies. In the meantime, we have to do the best that we can, right? But I think it's important to ask these kinds of questions. You know, this has got Dr. Kertay's pot shot analysis of the moment, but I want to do this. I got interested because I noticed that a lot of the studies that were assessing depression post-COVID were using the PHQ-2. And so I found sensitivity and specificity for the PHQ-9. The PHQ-2 is lower, but I couldn't find something that I could rely on. So if you take point prevalence of 8% in any two week period, this is 2019 numbers, you'd use this sensitivity and specificity of the PHQ-9. The thing I want you to notice is that of the positives on those screening measures, 61% of them are false positives. So over half, and that's just based on incidence and sensitivity and specificity. So a majority of these are false positives for a diagnosis. Any study, in my opinion, that uses screening measures and then diagnoses a condition is fatally flawed for any number of reasons. Again, when I'm faced with a patient who reports feeling depressed, I don't really care. I'm going to do a careful analysis. I'm going to do a careful diagnostic interview, and I'm going to treat them appropriately. So I don't want to say that these people aren't sick, but when we look at epidemiology, we have to ask ourselves these questions like, and what I worry about is this kind of tsunami of people who begin to be diagnosed and treated as if they have psychiatric conditions, when psychosocial support and stress reduction might be the best approach. You know, from my perspective, this is a frightening disease. We didn't know what was happening. People hate ambiguity, and the information that was out there became politicized in very short order, focused around clickbait. And so I think the most sensible approach is when we see people who are distressed following COVID, our best bet is to treat them as if they have an adjustment disorder with anxious distress, give them the support that they need, and for sure, don't tell them that they are just anxious. So my recommendations, interpret studies with careful attention to the methodology, you know, that part of the research studies that we all like to ignore until we became epidemiology geeks. You know, make sure that you do things to enhance the accuracy of an interview. If you are seeing someone who says they're depressed and they've never been depressed before, that's worth a really careful inquiry about their history, because often that turns out not to be true. And I think when there is a diagnosed condition, it is incumbent on us to provide evidence-based treatment, for other conditions, I think it's important to reassure people with, and this is a really important point, credible explanations that take their experience into account, right? Again, it's not just anxious, it's like, well, of course you're anxious, here's what happened, and here's what you're experiencing now. That approach, I think, will be the most helpful. When it comes to activity restriction, whether it's activity restrictions or return to work, I do think that it's terribly important to distinguish between an individual's capacity and their perceived tolerance, right? Just because I feel more anxious about going back to work doesn't mean that my anxiety should prevent me from going back to work. In fact, we don't prescribe avoidance for anxiety, right? We prescribe exposure. So helping people to get back to functioning is where we wanna go. And with that, I will turn it over to Dr. Nijhuis. Hi, everybody. I'm gonna take over sharing here. Hopefully you all can still hear me okay. And then I'm gonna slide this over so I can control the slideshow. So in general, I'm gonna be talking about the kind of neuro pieces. They've already introduced me as one of the physical medicine and rehab doctors. All this talk of function is definitely exciting, and I appreciate all of that as well, being a rehab doc myself. I was tasked with kind of looking at what's out there and what we're working on, and so we can go through those areas. I totally wanna echo some of the presenters here in talking about reported symptoms and what things actually are and how things look. I'm definitely gonna go through some of those reported symptomatology, because I think those are what patients are presenting to us with, and what we can kind of do to help try and target and help out with that. So this data was pulled from the Patient-Led Research Collaborative. That was built out of a patient advocacy group called BodyPolitik, and they did a survey very early on of kind of what people were having in terms of symptoms way back towards the beginning of the pandemic to see what people are actually talking about. The top 10 things that they actually reported overall kind of fall in those areas that we're talking about right now. So there's shortness of breath, chest tightness, fatigue, mild, moderate, different degrees of body ache, dry cough, exertional fatigue, headache, and a whole bunch of other symptoms, including the brain fog area here. And you can see what those look like over the weeks following the initial presentation, and then the Y-axis is the percent affected. The different colors relate to the different areas here, and hopefully you're on a bigger screen and can see those. Jumping into the actual specific neurologic symptoms that people report or present with or the patient advocacy groups are discussing, that looks more like this. And these are those neurosymptoms. So there's brain fog, which we've already kind of highlighted a little bit today, trouble sleeping, dizziness, lightheaded, problems with equilibrium, headache level, anxiety, which the last presenter was talking about, changes in sense of smell, taste, headache, temperature regulation issues, body position, sense, short-term memory loss, and all of those kinds of things. And this is what the patient-led groups are kind of having discussed and report in their things. And those are the different areas that patients are actually presenting with to the clinics that we're all a part of. I highlight this, and then if you're a tech savvy, you can use these QR codes to go to those actual data sites if you want. I am involved with the PMNR collaborative multidisciplinary consensus guidance statements that are getting generated as well. We've done ones that are published out there so far on fatigue, cognition, and then we have several that are about to come out on autonomic dysfunction, pediatric cases of COVID, and then a breathing and pulmonary-based guidance statement as well. So you can reference those in addition to the ones that this group is already putting out, which is very strong work as well. These are the areas that we're seeing in our clinic and that we're talking about in this group. Going into issues with sleep, dysphagia, dysautonomia, critical illness, demyelinating symptoms, spinal cord and brain injury strokes, cranial nerve dysfunction. That includes the taste and smell, spasticity, tone, balance, vestibular disequilibrium type things, headache, neuropathic pain and paresthesias, vision changes, potential neurotransmitter issues, dysarthria, different movement disorders and myopathies. And you can see that this is what people are coming to us with, and we're still trying to sort out which of these are COVID related, which of these are normal occurrences of other neurologic conditions or neuromuscular conditions that occur normally in the population that we're currently attributing to COVID because someone had COVID a few months ago. We don't have, like the other presenters have mentioned, a whole lot of placebo, randomized controlled trials to really say X, Y or Z works or this works versus another. I will say that the one that, like I said, the guidance statement that's gonna be released here in a couple of weeks is more on the dysautonomic regulation. The things that we're seeing with that tend to be more driven by postural hypotension, issues with balance and fatigue in terms of transitioning from a supine to standing upright position. And using some of those similar interventions we use for traditional POTS patients has shown to be helpful in a lot of the clinics across the country that we've polled and worked with and tried to build this statement around. Some of those things that we use to try and to intervene there. And I heard a lot of the presenters use the word exercise and sometimes that's a tricky word in some of these patient populations, right? If you look at any of the chronic fatigue guidelines, for example, chronic fatigue syndrome, exercise is kind of this, I don't know, apropos word that doesn't always get brandish about is the next right step. Really the way I try to present it is more return to activity or increasing the current activity level from wherever it's at. And taking that exercise terminology out and really trying to focus in on what's the activity, what's the function, how are we actually addressing that person, helping them improve in those activities of daily living and that eventual return to work if that's appropriate. And so doing things in that dysautonomic POTS style where you start recumbent, you start submaximal, you start with minimal weight training, isometric exercises, isotonic exercises where you're below the aerobic threshold to really get that person's heart rate and pulmonary work up, but you're still working on strengthening that muscle tissue. Doing some more recumbent based exercise if it's aerobic before you go to upright has been shown to really benefit these patients. And then also working on the nutrition, oral hydration and making sure they're having a healthy balanced diet to work through all these processes. In addition to all the mental health pieces that go along with it, counseling expectations, how long is this recovery gonna take and really trying to create that system of care around that person to help them improve and get better. I know we're getting close to the end of the time here. So I'm gonna jump through these last few quickly, but I did wanna also let you all know that this is something that is being talked about at a governmental level, at least here at the United States. Earlier this week, the White House put in some executive orders where there needs to be a whole government response for long COVID or post-acute sequelae of COVID. And so they're working on pulling that out. That hit the news press back on April 5th, just a few days ago. And then there's even earlier this week as well, new legislation being introduced at the legislative level in the, I believe it was the House that put in and proposed some bills to actually support funding and help out our clinics that are working on this and our providers that are working on this and the patients that are suffering from this. And I think that's great to finally see that there might be some movement at a wider perspective on this that's outside of just the medical sphere. And I think that's very exciting. I'm gonna switch over to the moderator questions here to make sure we honor everyone's time. All right. Can you guys hear me this time better? Yes. All right. So I am going to take the first stab at a question as the moderator. I would like to ask all of you guys, jump in whoever feels so inclined. Can you recommend any strategies for employers to be supporting return to work efforts? Okay, I'll go first here, sorry about that. So, you know, one thing that I get, my patients get told quite a bit is, okay, we're sorry for what you're feeling, but please don't come back until you're 100%, which is quite difficult, really, because I don't know if I've ever started work at 100% in my life. So this goes with the idea of if that, of the temporary alternative duties and possible jobs that can be used to help patients slowly recover and get back to the work site. That is something that we have found to be very helpful, something we also do here at Mayo as well, too. So if there's any possibilities to do that, that's great. I know it's easier said than done. I think that's probably the number one problem that I've observed is employees who believe they have to be 100% or employers who will just say that folks have to be at 100%, which is just not particularly helpful, nor is it realistic. And unfortunately, it further delays people being back in the workplace, which just increases the odds of them staying out of work. So that's a, working with the employer, I think is a huge barrier. And if I could add just one more piece in there, something that is often overlooked is the culture of recovery. Remember this, that we're dealing with a condition where it's highly political and there are folks out there who still don't believe COVID-19 exists. So you can imagine that trying to convince someone that you have long haul COVID is even worse. So again, easier said than done, but we need to start addressing this culture at work where an employee, they don't need to just only have work accommodation, but need to be supported by their supervisors and their coworkers as they try to get back on their feet. All right, Dr. Heckman, I have a question for you. Do you, from all the studies that you guys have been reading for the guideline, do we understand why COVID patients are having cardiac abnormalities? That's an interesting question. I would say there's hints of what's going on and certainly there's more than one issue, but the inflammatory processes and then some of this is related to, of course, thromboses and then cardiac events, but some of it just seems to be inflammatory mediated as the best guess of pathophysiology from what I've been seeing. But we've got other experts and they may be seeing a different database of studies. I can help tackle this. We have a cardiologist that's involved with our clinic out here in Colorado and she's excellent. And there are definitely those case reports of the pericarditis and those things, but those seem to be more less frequent than anything else. There also is this component, and maybe it's the rehab doc and me thinking about this, but when people go through COVID, whether it's ICU where they had the extended stay at home, their activity level inherently drops from wherever it was before. And that is a deconditioning piece. And that's not just a musculoskeletal deconditioning, that's also cardiopulmonary. And what we're seeing is sometimes even those really high level weekend athletes, the people that were doing the bike races and running and all of those kinds of things, they didn't move around for potentially weeks. And now they're trying to get back into it and it's not the same. And how much of that is deconditioning? How much of that is COVID? How much of that is a change in activity status or loss of muscle strength or mass? I don't think anyone necessarily knows, but it all kind of goes together and you kind of need to rule out some of those cardiac pieces when appropriate, but it might just be just generalized deconditioning for whoever that person was and where they were operating before. Thank you. Another question, maybe Dr. Korteh can weigh in on this one. How can you address the fear for return to work, especially with COVID being political and kind of everywhere? Do you have strategies for that? Well, I mean, this is gonna sound like one of those non-answer answers. The first place to start is a conversation with the person about what their fears are. Is it a fear of being re-exposed? Well, that's a different sort of, then you put measures in place to help that feel protective. If the fear is of what my coworkers are gonna say, then you need to help somebody develop strategies around that. I think the most important thing, and this has been made, I've seen in the comments, people have made this, anxiety, avoidance is self-reinforcing in anxiety. So when somebody is afraid, I talk to them about that. I understand that you're afraid. And just like mom told you to get back up on the horse when you fell off, we need to find a way to help you do that. This is where either a therapist or a coach can really be helpful, or a physician who is not simply writing people out of work, but saying, listen, this is gonna be better for you. As we help you be successful, it's going to be helpful, and you're more likely to get better faster, which we know is true. I apologize to everyone. I know it's a non-answer, but it's the best I've got. And then I guess one last quick question. I know, Dr. Niehaus, that you mentioned at the end of your presentation with policies coming up. Do you guys see any big rulings coming down in like work comp or federal level or state level, or even with employers trying to, insurance companies trying to make rulings on any of these? That's kind of a tough one. I know that in discussions that a lot of people just don't know what's coming, and everybody wants to do the right thing and help people out and get policies to help people, but there's so much unknown right now. I could add a little bit. I think work comp, of course, is a state-by-state situation. A lot of people don't know what's going on. A lot of people don't know what's going on. And I think that's a big part of it. I think that's a big part of it. Work comp, of course, is a state-by-state situation. About half of the states roughly have presumptive laws under work comp for COVID. However, that gets into the weeds right away of what are they doing to accept and deny the claims and the deal with how much rehabilitation, how far. And also the related issue that, in general, mental health has been issued. So there's a lot of challenges there. State-wise, excuse me, federal-wise, OSHA is certainly being involved in rulemaking and so forth. But where they go, they don't tell you until they actually publish it. Sounds like we're all gonna be staying tuned. Thank everybody for coming to the webinar. The speakers were phenomenal. If you are requesting continuing education credit, here's your instructions to make sure that you get us our information, a recording, and the slides will be sent out afterwards. If you have any questions, please feel free to reach out to either ACOM or MD Guidelines. Thank you all again so much for attending. Thanks, everyone. Thank you.

long COVID

return to work strategies

accommodations

occupational health

evidence-based guidelines

collaborative approach

multidisciplinary team

symptoms management

gradual return to work programs

government initiatives