Monthly Archives: December 2021

6th December – 12th December

• Hours: 15

Main Theme Addressed During Phone Calls

• Fatigue as a catalyst for breathlessness and other ‘typical’ long covid symptoms.
  • A number of participants this week noted that some of their ‘long COVID’ symptoms are worse on days where they feel particularly fatigued. For example, one participant notes that their breathlessness is more noticeable and another experiences heart palpitations. A 2021 study on long COVID symptoms noted that, ‘…in many [people] the breathlessness was an expression of fatigue, deconditioning and/ or breathing pattern disorders rather than the result of ongoing parenchymal lung pathology.’ (Taylor, et al., p.389). Naturally, if people have had a prolonged period of sedentary behaviour due to being ill with COVID-19 they may experience decreased muscle strength, reduced exercise capacity and MSK pain. (Demeco, et al., 2020). As a result, tasks that previously were deemed easy or tolerable by the participants can be much more fatiguing and exacerbate symptoms such as breathlessness. Therefore, one of the most important skills for participants to learn is correct pacing, planning and prioritising of daily and weekly tasks in order to reduce the likelihood of symptom flare-ups. Participants are currently using an activity diary to plan their days and weeks and those who have identified a link between their fatigue and ‘long COVID’ symptoms are now starting to adjust their weekly schedule to make tasks more manageable. I have also signposted participants to physiotherapy for BPD if they are struggling with breathlessness as it could also be a sign of disordered breathing patterns. This website has self help videos and also an information leaflet specifically for those suffering with breathlessness post-covid infection.
• Pacing physically involves slowing down.
  • One participant had previously completed the HOPE programme – a programme aimed at helping individuals living with a chronic illness. She explained that the programme helped her to take control over her days by planning, pacing and prioritising effectively. However, the participant was still noting that her fatigue and breathlessness can be pronounced in the evenings/towards the end of the week. Furthermore, she still experiences breathlessness doing ‘small things’ around the house. On further questioning it appeared that the patient was pacing correctly For example, she breaks her work day into 2 x 3 hour working blocks and she takes rest periods after completing any task during her day. However, when I asked her how quickly she completes these small tasks she admitted that she tends to rush around when doing things.
  • At this point I compared her goal of wanting reduced breathlessness and fatigue to someone running a marathon. Runners have different pacing strategies depending on what race they are running, i.e. a runner’s 5km pace will be much quicker than their marathon pace. If a runner attempted to complete a marathon at their 5km pace they would ‘burn out’ and not complete the race. The participant resonated with this analogy and iterated that she has been completing daily tasks too quickly. As a result she is burning out, which ultimately leads to increased breathlessness and fatigue. Therefore, over the next week the participant has agreed that she will view her days and weeks as a marathon and not a sprint. She notes that she is physically going to slow down when completing any task to see if this makes a difference to her symptoms.

GP Study Day 8th December

• Presented the COVID-19 Rehabilitation Programme to local GP’s.
  • Aim = for GP’s to link up with the programme in order for them to refer patients.
  • Outcome = GP’s happy to signpost patients; however, noted that self-referral is better for patient outcomes. Jokingly some of the GP’s passed a comment about self-referral is less admin for them. However, on a serious note they stated that they would much rather signpost patients to us as self-referral is better for patient outcomes. On further reading, I found this really comprehensive article on referral pathways for MSK conditions and the benefits are quite vast for both the patients and the healthcare system. I initially felt quite frustrated with the response by the GP’s as the aim was for them to provide us with clinical referrals. However, on reflection I can see why self-referral is not only a better option for themselves but for patients. In the grand scheme of things the NHS is under a lot of pressure post-pandemic and by having a referral system we will be alleviating time pressures GP’s face every day. Equally, self referral means that participants can be seen faster as opposed to waiting for the referral to be submitted and thus feel more satisfied with their care.

Strength Class

• (30 secs on (60 secs if singe leg), 30 seconds off (2:1) x 2, followed by a 60 second rest) x 5
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Analysis & Evaluation 

• This week has been a turning point for some participants.
  • 3 participants have noticed improvements, physically and emotionally. Equally, those who have been struggling are starting to see what triggers their symptom flares and are beginning to make adjustments based on their findings. I also think I my patient communication is improving as I am finding different ways of explaining/coaching skills or tasks on a level that may be more relatable/understandable.
• However, 1 participant is experiencing symptoms that warrant further investigation – night sweats that are disrupting sleep and a circulation concern.
  • This participant has experienced night terrors in the recent past which are reducing; however, his night sweats have not diminished and they are resulting in a broken nights sleep which will not be conducive to managing fatigue. He also reported that his feet and ankles are swollen. I followed the NHS advice on oedema and encouraged the participant to book an appointment with his GP if it does not settle, gets worse or he develops any symptoms identified on the NHS website as emergent.
  • I feel like I handled this situation well by firstly checking for any signs and symptoms of a DVT and other red flags. Equally, night terrors and night sweats are likely outside of my scope of practice. Night sweats combined with night terrors could be a sign of more complex EWB needs, such as PTSD (Jimeno-Almazán., et al. 2021). PTSD is something that would require specialised support that is not offered within this programme.

Conclusion 

• Next week I will be following up the results from the participant who will be adjusting her pacing strategy. I am hoping that she will report increased energy levels and reduced fatigue. I will also be following up with the participant who I have asked to get in touch with his GP. However, I am aware that it is currently quite difficult to ascertain an appointment with a GP if not emergent. Therefore, next week I will also be ensuring the participant is accessing the EWB content of the programme too.

Revisiting Reflection

• The participant who was adjusting her pacing strategy made some real progress over the week. She explained, she was able to get much more done and although having to consciously think about slowing down it has helped her enjoy tasks that she previously felt too tired to do e.g. Horse riding.
• The participant who I suggested should put and e-consult in has yet to do so but there has been no improvement in his symptoms. His night terrors and nights sweat have stopped which has resulted in better sleep. Therefore, the participant notes his fatigue is substantially less. The participant has stated he will put an e-consult in this week so I will need to continue to follow up on this.

References

• Jimeno-Almazán, A., Pallarés, J. G., Buendía-Romero, Á., Martínez-Cava, A., Franco-López, F., Sánchez-Alcaraz Martínez, B. J., Bernal-Morel, E., & Courel-Ibáñez, J. (2021). Post-COVID-19 Syndrome and the Potential Benefits of Exercise. International journal of environmental research and public health, 18(10), 5329. https://doi.org/10.3390/ijerph18105329.
• Taylor, R. R., Trivedi, B., Patel, N., Singh, R., Ricketts, W. M., Elliott, K., Yarwood, M., White, V., Hylton, H., Allen, R., Thomas, G., Kapil, V., McGuckin, R., & Pfeffer, P. E. (2021). Post-COVID symptoms reported at asynchronous virtual review and stratified follow-up after COVID-19 pneumonia. Clinical medicine (London, England), 21(4), e384–e391. Advance online publication. https://doi.org/10.7861/clinmed.2021-0037.
• Demeco, A., Marotta, N., Barletta, M., Pino, I., Marinaro, C., Petraroli, A., Moggio, L., & Ammendolia, A. (2020). Rehabilitation of patients post-COVID-19 infection: a literature review. The Journal of international medical research, 48(8), 300060520948382. https://doi.org/10.1177/0300060520948382

29th November – 5th December

• Hours: 15

Main Theme Addressed During Phone Calls

• Emotional Wellbeing (EWB) and its impact on recovery
  •  A number of patients reported a sense of worry and anxiety post-covid. For example, ‘how will I earn money if I am off work?’ ‘I don’t look sick so people will think I am lazy if I say no to things.’ During the phone calls I iterated that it is normal to experience worry and anxiety; however, when it becomes all-consuming or intrusive then this is something that needs to be addressed. I iterated that worrying will contribute to fatigue, particularly brain fog , as the mind is constantly wired. I didn’t actually give this advice based on evidence it just, at the time, felt like a caring but logical piece of information to highlight.
  • However, afterwards I paused to reflect. Many of the patients I have worked with have previously been given advise from GP’s to manage their condition as though they have chronic fatigue syndrome (CFS). Literature has also made links between long covid and CFS for example, a review by Wong and Weitzer highlighted the similarity of both CFS and long covid symptoms (2021).  And, there is evidence that links neuroticism and maladaptive perfectionism to fatigue and/or CFS (Deary and Chalder, 2010; Valero. et al., 2013). Therefore, helping to manage levels of worry, anxiety and internal pressures patients may place on themselves may be a crucial aspect of their rehabilitation.

Case Study for MDT meeting Tuesday 7th December

• This week. I also gathered information on a particular case to present for the MDT as I was looking for further guidance on appropriate management.
• The participants main complaint = Proximal Weakness (Shoulders and Thighs).
• Symptoms = Extreme fatigue in shoulders after ADL’s, such as brushing teeth, combing hair, typing, writing, driving, and eating. Walking any incline was once difficult but there has been some improvement. Fasciculations in thighs are not as frequent as they were in early recovery, but he may still experience them after exercise.
• Impact = The patient returned to work after COVID-19; however, 5-6 months ago his shoulders deteriorated to such a degree that he could no longer work. The patient is a doctor at the local hospital. His shoulders have not improved since the deterioration.
• Medical Interventions = Blood tests, nerve conduction studies and an EMG. All results were normal.
• Pattern = After a night’s rest both shoulders and thighs feel completely normal. However, as soon as he does something minimal, such as brush his teeth, he feels the fatigue in his shoulders. If he pushes them too far, e.g., a long drive, the fatigue he feels will not resolve unless he rests for an extended period, e.g., a night’s sleep.
• Currently on Week 2 of the programme. Each exercise session to date has made him ‘more aware of fatigue than usual’ the next day. However, after 2 days he returns to his current baseline. Rated week 1 cardio class 9/10 in terms of muscular fatigue and he struggled to perform the shoulder stretch during the cool down.
• Management suggestions from MDT:
  • Focus on improving grip strength as an indirect shoulder strengthening exercise.
  • Closely monitor for signs and symptoms of PoTS. Consider measuring SpO2 whilst exercising.
  • Discussion was had around coat hanger syndrome; however, the patient does not experience any pain and this would not explain the weakness in the thighs.
• I initially thought the participant was presenting with polymyositis; however, this would have been ruled out with his blood tests and EMG. The conclusion from this meeting was to continue managing symptoms and monitor closely for any deterioration. My current line of thinking is to work on strengthening all the surrounding musculature e.g. triceps, biceps, glutes and calves. If they are able to get stronger they may offload the shoulders and thighs and provide some relief to the participant.

Mobility Class

• (6o secs on, 30 seconds off (2:1) x 2, followed by a 60 second rest) x 5
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Analysis & Evaluation 

• I felt I provided suitable advice this week, particularly around the topic of worrying. However, I feel that this is an area I could improve on further and find some additional strategies for patients to utilise. Currently, I advise patients to reflect on unhelpful thinking and identify ways they could change their thinking to be more helpful. For example, rather than ‘I can’t do this – I will never be normal again’ try ‘Recovery takes time and I am making small improvements that show my body is healing itself. I also advised them on creating a time and space for worry so it does not interfere with their day; however, many struggle with being able to compartmentalise in this way.
• It wasn’t great that the MDT meeting didn’t provide any clear cut answers. However, it is good to know that my current approach is acceptable and I haven’t missed any red flags

Conclusion 

• Currently the exercise class is still virtual; however, when the course transitions to an in-person setting I will provide exercises to the participant struggling with proximal weakness as mentioned previously to see if this makes a difference.
• Furthermore, it may be helpful to have more tools at my disposal to help those with worry and anxiety. I may need to accept that an onward referral is required as their needs may be more complex than the support I can offer. However; waiting lists and accessibility can be an issue for EWB services, so it is important that I can offer some strategies in the interim or at least signpost individuals who could benefit from some extra help and support.

Revisiting Reflection

References

• Wong, T. L., & Weitzer, D. J. (2021). Long COVID and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)-A Systemic Review and Comparison of Clinical Presentation and Symptomatology. Medicina (Kaunas, Lithuania), 57(5), 418. https://doi.org/10.3390/medicina57050418
• Vincent Deary & Trudie Chalder (2010). Personality and perfectionism in chronic fatigue syndrome: A closer look, Psychology & Health, 25:4, 465-475, DOI: 10.1080/08870440802403863

• Valero, S., Sáez-Francàs, N., Calvo, N., Alegre, J., & Casas, M. (2013). The role of neuroticism, perfectionism and depression in chronic fatigue syndrome. A structural equation modeling approach. Comprehensive psychiatry, 54 7, 1061-7 .

22nd November – 28th November

• Hours: 15

Main Symptoms

• Fatigue
• Muscle Pain and/or Weakness
• Brain Fog
• Headaches
• Breathlessness
• Low Mood

The majority of patient symptoms align with current literature publish on long-covid. However, one study acknowledged that there are likely over 200 symptoms of long-covid (Davis, et al, 2021). Although fatigue, post-exertional malaise and cognitive dysfunction seem the most common according to this study. The NHS also have a comprehensive list of symptoms that people may experience – many of which resonate with the participants.

Initial Phone Calls

• Participants that I spoke to after the class were all quite shocked at how challenging they found the exercise class. The main reason behind this was a thought process similar to, ‘this is much less than I used to be able to do’ and ‘it shows I have a long journey ahead of me.’ Therefore, I spent a lot of time discussing how to reframe this style of thinking and celebrating the achievement of completing the exercise. For example, one participant had not tried any formal exercise since her COVID diagnosis 18 months ago. She completed the whole session and it did not exacerbate her fatigue. However, she stated that she was previously very active and would spend up to 2 hours in the gym most evenings. As a result she was deflated by how breathless she got during the session.
• I supported the participant by celebrating the successful introduction of formal exercise and there being no exacerbation of symptoms. This highlights that she is capable of doing more than what she thought. I also asked her to think of reframing her thinking style. I stated that if she is always comparing herself to pre-covid levels, any progress she makes during her recovery won’t be acknowledged or celebrated.  She agreed that she needs to work on being kinder to herself and reflect on how far she has come already rather than how far she has to go, as the former is a much better motivator.
• It is expected that COVID-19 will result in a reduced tolerance to exercise (Jimeno-Almazán, et al, 2021) due to fatigue and deconditioning; however, exercise may play a role in helping to diminish these symptoms when properly delivered. Sharing this information with participant, I think, is important as it can help to set realistic expectations and encourage adherence to the programme early on. Many of them appreciate the information shared and tend to report that they know they have to take it slowly but they are just impatient.

Cardio Class

• (30 seconds on to 30 seconds off (1:1) x 2, followed by a 60 second rest) x 3
• The class is always symptom-led as opposed to graded exercise therapy. Participants are free to rest when needed. They can end the class early if they have reached their limit and they can reduce the amount of sets they do if necessary.

Analysis & Evaluation 

• Week 1 is quite a challenging week. I am a relative stranger to the participants so it can be difficult for them to open up or accept advice at such an early stage. However, I know that I play a crucial role in their adherence and; therefore, their chances of success on the programme. So, in a stage in early as this I work hard to get to know the individuals and build a rapport with participants as this is instrumental to adherence (Barrow and Walker, 2013). Although there are a few participants that remained quite closed during the phone calls, the majority started to open up and share personal information about how COVID has impacted them.
• One participant really didn’t respond well to exercise. The warm-up resulted in a coughing fit and the participant did very little of the exercise class (See participant update – week 5). She was very emotional on the phone and although I suggested a visit to the GP she seems to have a fractured relationship with them and did not take this advise on board.
• It seems that improving emotional wellbeing (EWB) will need to be the focus for many participants of the programme. However, one participant noted quite a substantial increase in their psychological wellbeing just from meeting other people, albeit virtually, with long covid and having a programme to help her get better. She noted that she was putting herself first for a change and it was nice not to feel alone in her recovery. Although there are both benefits and draw backs to group rehabilitation, I think this participant is likely going to respond well to the group setting. However, one of the drawbacks to group rehabilitation is, ‘what happens when the group programme doesn’t run anymore?’ Therefore, I will be mindful to really encourage independence, when using the gym and designing their own workouts as this should hopefully instil them with confidence that they can continue with their rehab independently.
• The participant that experienced a coughing fit on exertion needs to have seated alternatives to reduce intensity even further. Reassessment of suitability for the programme may need to be considered if this doesn’t help.
• It will always be easier to build a rapport with some individuals over others. However, I need to work on developing some more skills that allow me to build rapport with individuals that are a bit more closed.

Conclusion 

• There is EWB training next week which I will attend to ensure I am prepared to help my participants who are struggling in this area. Being up-skilled in this area may also help me build rapport quickly.

Revisiting Reflection

• My EWB training focused on how to deal with patients who need to ‘offload’ where you typically wouldn’t know how to respond. The advice given was to always repeat back what the person has said to show you have actively listened and also to thank the participant for sharing such personal/emotional information with you. I used this technique for a participant that I was finding difficult to build a rapport with. Although not a resounding success, with the addition of some open questions, it encouraged the participant to share more. This ultimately gave me the opportunity to acknowledge what they were saying by repeating what they had said back to them.
• Sometimes I am really quick to try and give an answer or try and offer some advice – it is likely a natural instinct when you are in the position of rehabilitation – however; I need to remember I don’t have all the answers and some EWB matters are not something for me to fix but to acknowledge and onward refer if necessary.

References 

• Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., Low, R. J., Re’em, Y., Redfield, S., Austin, J. P., & Akrami, A. (2021). Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine, 38, 101019. https://doi.org/10.1016/j.eclinm.2021.101019
• Jimeno-Almazán, A., Pallarés, J. G., Buendía-Romero, Á., Martínez-Cava, A., Franco-López, F., Sánchez-Alcaraz Martínez, B. J., Bernal-Morel, E., & Courel-Ibáñez, J. (2021). Post-COVID-19 Syndrome and the Potential Benefits of Exercise. International journal of environmental research and public health, 18(10), 5329. https://doi.org/10.3390/ijerph18105329
• Monna Arvinen-Barrow, & Natalie Walker. (2013). The Psychology of Sport Injury and Rehabilitation. Routledge.Monna Arvinen-Barrow, & Natalie Walker. (2013). The Psychology of Sport Injury and Rehabilitation. (pp.40-53). Routledge.