post covid syndrome long covid & workers …
TRANSCRIPT
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POST COVID SYNDROMELONG COVID & WORKERS COMPENSATION
Greg Vanichkachorn MD, MPH, FACOEMMayo Clinic
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LEARNING OBJECTIVESUPON CONCLUSION OF THIS PROGRAM, PARTICIPANTS SHOULD BE ABLE TO:
1. Recognize the true presentation of Post COVID Syndrome.
2. Understand the basic elements of care.
3. Prepare for the challenges ahead in workers compensation
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VIGNETTE
35 yo paramedic
COVID-19 3 months ago, with stroke
Sudden syncope, fatigue, dyspnea
Labile vital signs, constipation
Non supportive supervisor
Failed return to work
Worker’s compensation
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MAYO CLINIC POST COVID RECOVERY
COVID Activity Rehabilitation Program CARP April/May start Based on PICU work Formalized June 2020 300-400 patients
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WHAT IS POST COVID SYNDROME?
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Post COVID-19 Syndrome (long haul syndrome): Initial Cohort Characteristics from the Mayo Clinic
July 2021, Mayo Clinic Proceedings
1st 100 patients in CARP
Define characteristics
Identify risk factors
Diagnostic nuances
Describe treatment program
Understand functional implications
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WHAT IS POST COVID SYNDROME?-No universal definition
-Long haul COVID vs PASC vs PCS
-Mayo Clinic Working Case Definition
Positive PCR, antigen, or antibody test
> 4 weeks from acute infection start (symptoms or test)
Symptoms consistent with PCS
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Carfì A, Bernabei R, Landi F, Group GAC-P-ACS. Persistent Symptoms in Patients After Acute COVID-19. JAMA. Aug 2020;324(6):603-605. doi:10.1001/jama.2020.12603
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CARP POPULATION
Fatigue 80%
Respiratory 59%
Neurologic 59%
Cognitive impairment 45%
Sleep disturbance 30%
Mental health sx 26%
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CARP POPULATION
UNIQUE SX
Tinnitus
Loss of taste and smell
Hair shedding
Syncope
Sinus pressure
Eye changes
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RISK AND EPIDEMIOLOGY
75% not hospitalized
22% pre-existing respiratory/cardiac dx
34% pre-existing depression/anxiety
4% pre-existing chronic fatigue/fibromyalgia
Average age 45.4
68% female
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CARP POPULATION FUNCTION
34% impaired ADLS
82% impaired IADLS
63% returned to work in some form
46% (29/63) were back at baseline work
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PROGNOSISFollow up of hospitalized patients, discharged Jan – May 2020
6 and 12 months
1276 participants
At least one sx: 68% and 49% at 6 and 12 months
Anxiety/depression: 23% and 26%
No difference in 6MWD
88% had returned to work in 12 months
Only 16 received rehabilitation
Huang L, Yao Q, Gu X, et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. The Lancet. 08/28/2021 2021;398(10302):747-758. doi:10.1016/s0140-6736(21)01755-4
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TREATMENT
Post Acute Monitoring
Psychosocial support
Rehabilitation
Management of dysautonomia
Cognitive rehabilitation
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POST ACUTE MANAGEMENT-Rule out other serious conditions
-31% of ICU patients – thromboembolic event
-60% myocardial inflammation at 70 days
-1250 discharged patients Within 60 days 10.4% ICU patients died 6.7% general ward patients died 15% readmitted
-FA K, MJHA K, NJM vdM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thrombosis research. 2020 Jul 2020;191doi:10.1016/j.thromres.2020.04.013-Puntmann VO, Carerj ML, Wieters I, et al. Outcomes of Cardiovascular Magnetic Resonance Imaging in Patients Recently Recovered From Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11):1265-1273.-Chopra V, Flanders SA, O'Malley M, Malani AN, Prescott HC. Sixty-Day Outcomes Among Patients Hospitalized With COVID-19. https://doiorg/107326/M20-5661. 2020.
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POST ACUTE MANAGEMENT
-Important history elements Post exertional malaise? Pre infection function Abilities with ADLS/IADLS Work ability Sleep Mood and anxiety PHQ9, GAD-7, WLQ-5
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POST ACUTE MANAGEMENT
-Initial diagnostics CBC CMP Thyroid panel IL-6 Vitamin-D Vitamin-B12 Ferritin
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TREATMENT: PSYCHOSOCIAL ASSESSMENT-Patients Feel “abandoned”
-Guilt/self doubt
-Clinical depression/anxiety/PTSD
-12.9% reported needing psychological support
-Empathize, not medicalize or catastrophize
Z L, C Z, C D, et al. Rehabilitation needs of the first cohort of post-acute COVID-19 patients in Hubei, China. European journal of physical and rehabilitation medicine. 2020;56(3).KT H, R T, GBJ A, et al. Non-Invasive and Minimally Invasive Management of Low Back Disorders. Journal of occupational and environmental medicine. 2020 Mar 2020;62(3)doi:10.1097/JOM.0000000000001812
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TREATMENT: PSYCHOSOCIAL SUPPORT
Frequent interaction (Q2 weeks, EMR messaging)
Employee Assistance Programs
Psychological therapy
Psychiatry
Support Groups
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TREATMENT: REHABILITATION -SARS/MERS 19-33% reduction of 6MWT 78.6% decreasedV02 max
-COVID-19 41% reduced exercise capacity
-S R, A W, L P. Systematic Review of Changes and Recovery in Physical Function and Fitness After Severe Acute Respiratory Syndrome-Related Coronavirus Infection: Implications for COVID-19 Rehabilitation. Physical therapy. 2020;100(10).-George PM, Barratt SL, Condliffe R, et al. Respiratory follow-up of patients with COVID-19 pneumonia. Thorax. Aug 2020;doi:10.1136/thoraxjnl-2020-215314
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TREATMENT: REHABILITATION-Post Exertional Malaise in Chronic fatigue and fibromyalgia
-After physical stress: 30% reported fatigue, flu like sx, muscle pain
-Comparison of treatment modalities: Graded exercise – negative effect in 54-74% Cognitive behavioral therapy – positive effect in 8-35% Paced activity – positive effect in 44-82%
-K G, M H, S K. Myalgic encephalomyelitis/chronic fatigue syndrome patients' reports of symptom changes following cognitive behavioural therapy, graded exercise therapy and pacing treatments: Analysis of a primary survey compared with secondary surveys. Journal of health psychology. 2019;24(10).-Chu L, Valencia IJ, Garvert DW, Montoya JG. Deconstructing post-exertional malaise in myalgic encephalomyelitis/ chronic fatigue syndrome: A patient-centered, cross-sectional survey. PLoS One. 2018;13(6):e0197811.
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TREATMENT: REHABILITATION-Rehabilitation ≠ exercise
• Focus on daily function/activities in addition to rehab• Low level but consistent activity• Not simply “stop when it hurts”• Gradual increases (i.e., 10 min to 13 min of walking)
-Use Adaptive Paced Therapy
• PT/OT
-Mayo Clinic Work Rehabilitation Center
-Chu L, Valencia IJ, Garvert DW, Montoya JG. Deconstructing post-exertional malaise in myalgic encephalomyelitis/ chronic fatigue syndrome: A patient-centered, cross-sectional survey. PLoS One. 2018;13(6):e0197811.D A, AM K, P K, S W, L M. Survey of activity pacing across healthcare professionals informs a new activity pacing framework for chronic pain/fatigue. Musculoskeletal care. 2019;17(4).
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THERAPY SPECIFICS
-Gauge condition: 6MWT, 1MSTS
-Borg Ratings of Perceived Exertion and Dyspnea
-Vitals after exercise
-Diaphragmatic breathing
-Strength training first
-Supine exercises are better tolerated
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THERAPY SPECIFICS
-Borg scale limit: 13 – somewhat hard 11 if significant symptoms
-Dyspnea scale limit: 3 – moderate
-Keep O2 sats above 90% Relaxed breathing if falls below
60 - 70% max heart rate during peak exercise
50 - 60% max heart rate during normal daily activity
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TREATMENT: DYSAUTONOMIA
Balance issues/Dizziness Tachycardia Pain
Brain fog Shortness of breath
Exercise intolerance
Sleeping problems Mood swings Etc…..
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TREATMENT: DYSAUTONOMIA
-Autonomic dysfunction was seen in SARS
-POTS preceded by viral illness in 21-40%
-Case reports of POTS in COVID-19
-Miglis MG, Prieto T, Shaik R, Muppidi S, Sinn DI, Jaradeh S. A case report of postural tachycardia syndrome after COVID-19. Clin Auton Res. 10 2020;30(5):449-451. doi:10.1007/s10286-020-00727-9-K K, S J, A K, BP G. New-onset Postural Orthostatic Tachycardia Syndrome Following Coronavirus Disease 2019 Infection. The Journal of innovations in cardiac rhythm management. 2020;11(11).
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TREATMENT: DYSAUTONOMIA -Mayo Clinic study of 27 patients
-Abnormalities on testing Sudomotor function 36% Cardiovagal function 27% Cardiovascular adrenergic function 7%
-Diagnoses 22% met criteria for POTS Autoimmune autonomic ganglionopathy Inappropriate sinus tachycardia Vasodepressor syncope
Shouman K, Vanichkachorn G, Cheshire WP, et al. Autonomic dysfunction following COVID-19 infection: an early experience. Clin Auton Res. 2021;31(3):385-394.
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TREATMENT: DYSAUTONOMIA
Autonomic Reflex TestTilt TableQSARTThermoregulatory sweat testEpidermal nerve fiber biopsy
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TREATMENT: DYSAUTONOMIA
-Neurology consult
-Hydration (3L/day)
-Salt Intake (8-12 grams sodium)
-Compression stockings (30-40 mmHg and waist high)
-Abdominal biners, 10 mmHg
-Leg tensing, crossing, weight shifting
-Education***
-Medications
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TREATMENT: DYSAUTONOMIA
-Metoprolol
-Propranolol
-Midodrine
-Fludrocortisone
-Methyldopa
-Pyridostigmine
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TREATMENT: BRAIN REHABILITATION-Brain Rehabilitation ClinicNeuromuscular retrainingNeuropsychometric testingHeadache management Sleep improvement Speech therapy
-L M, H J, M W, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China. JAMA neurology. 2020;77(6).
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EARLY OUTCOMES
-20% made a full recovery Started with very limited function Return to normal function Full duty work Recovered by 4 months after acute infection start Earlier start of treatment Less cognitive complaints than rest of population Observations, NOT inferences
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NO STANDARD OBJECTIVE CRITERIA
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DIAGNOSTICS
First 100 patients
Tests performed Abnormal tests29 echocardiograms 13.8% (n=4)28 pulmonary function tests 25.0% (n=7)35 chest x-rays 2.9% (n=1)21 autonomic reflex test (tilt and QSART) 57.1% (n=12)
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DIAGNOSTICSNO SPECIFIC PATTERNCBC
CMP
Thyroid Panels
Vitamin D
Vitamin B-12
Cytomegalovirus
Epstein Barr Virus
IL-6
D-Dimer
Ferritin
CRP/ESR
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NO STANDARD SUBJECTIVE CRITERIA
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NO DIAGNOSTIC CRITERIABudapest Criteria for Complex Regional Pain Syndrome -We have nothing like this
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NO CLEAR PHYSIOLOGIC BASIS
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WHY IS THIS HAPPENING?
-Possible hyper-inflammatory/auto-immune state
-Evidence of early cytokine storm
-Abnormal function of CD8+ cells
-Increased IL-6 in CSF
-Accumulation of immune cells in brain perivascular/parenchyma on autopsy
-Genetic difference due to ACE2 receptor/TMPRSS2 variations
-Autoantibodies against ACE2
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NOT RARE
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THE RISE OF WORK-RELATED INFECTIONS
Presumed to be work related in many states
Burden on employer and insurer to prove otherwise
17 states provided workers comp coverage
9 states had presumption coverage
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39 MILLION COVID-19 CASES
3.9 million Post COVID Syndrome cases
1,170,000 unable to RTW
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VIGNETTE COMPLETION
Labs all normal
Holter monitor – no arrhythmia
Cardiac MRI – no signs of myocarditis
Thoracic echocardiogram – no motion abnormalities, EF 50%
6-hour blood pressure monitor – no hypertension/hypotension
Autonomic reflex screen – no dysautonomia
Overnight EEG – no seizure activity
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VIGNETTE COMPLETION
Anorectal manometry – rectal evacuation disorder Treated with pelvic floor dysfunction therapy
Polysomnogram – Mild obstructive sleep apnea CPAP treatment
SYMPTOMS RESOLVED
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VIGNETTE COMPLETION
No additional episodes for 4 months
Unable to return to safety sensitive work
Return to private driving after 3 months
Transitioning to new work role
Long term disability
ALL COVERED BY WORKERS COMPENSATION
How is OSA and pelvic floor dysfunction related to COVID? Who knows?
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UNEXPLAINABLE ≠ NON-EXISTENT
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Greg Vanichkachorn MD, MPHSenior Associate ConsultantOccupational and Aerospace Medicine