The ‘long tail’ of persistent COVID-19 symptoms
We’re all aware that COVID-19 is a new illness that is having widespread impacts on health, wellbeing and the economy, on a scale that has never been seen in living memory. We are repeatedly reminded that it is a new disease, which we are still learning about and we are still far from understanding the long term impacts of the illness.
Earlier in the pandemic the emphasis was on COVID-19 being a respiratory condition, but it has since emerged that it is a microvascular disorder that can affect any organ including the lungs, heart, kidney and liver, and understanding this has improved survival rates.
A growing list of symptoms
In keeping with the fact that it is a multi-system disease there have been a wide variety of presentations of COVID-19 19 from skin rashes to abdominal pain, ‘COVID-19 toes’ to joint aches, besides the Public Health England (PHE) list of coronavirus symptoms of cough, high temperature and anosmia.
Initially, government and healthcare’s focus was on treating patients and preventing disease spread. However, there is increasing evidence of a ‘long tail’ of COVID-19 related illnesses that require a holistic rehabilitative approach to enable people to return to their baseline levels of activity (and return to the workforce).
The severity of the initial symptoms does not necessarily seem to correlate with prolonged recovery, as many individuals reporting a prolonged and debilitating course of their illness were never admitted to hospital.
Research has shown that the most commonly reported persistent symptoms include fatigue, shortness of breath with exertion, chest tightness, cough, skin rash, high temperatures and neurological disturbances. The COVID-19 Symptom Tracking App developed by King’s College hospital, which has collected data from almost 4 million people, reports that 10% of people with COVID-19 had symptoms at 25 days and 5% were still symptomatic a month later.
The path towards recovery
Some individuals have reported a relapsing and remitting course of their illness, where symptoms seem to recur every 3rd or 4th day in a cyclical pattern, usually reducing in intensity as they recover. It is unclear if some of these recurrences represent re-activation viraemias or are a consequence of immune response.
Fatigue can vary from mild disturbance in usual activity levels to much more debilitating exhaustion, where even simple task, such as dressing, become challenging. As well as physical activity, mental activity can be affected by fatigue causing a loss of concentration, reduced ability to process information and poor short term memory.
A gradual approach is needed to return to activity following COVID-19 infection and the following tips may be helpful:
- Find your baseline activity levels which you are comfortable with and if you can maintain this with no increase in fatigue for 5-7 days then increase your activity by 20%
- Pace and plan activities with rest breaks. Initially you may find you need shorter active periods followed by longer rest breaks
- Consider adding active rest breaks such as meditation or breathing exercises
- Try to avoid ‘boom and bust’ – many individuals may experience a ‘good day’ and feel they have the energy to do a lot more and subsequently experience a crash in their energy levels. Plan and pace activities and increase them gradually, even if you feel a sudden surge in energy
- Maintain a regular routine and schedule in fixed timings for naps if needed rather than spending long periods in bed as this can disrupt your sleep cycle
- Keeping a diary of exercise/activity, sleep and fatigue may help plan your rehabilitation approach
Unfortunately, there is some challenge in attributing all ‘long tail’ symptoms to COVID-19 in those individuals whose symptoms first occurred during a time in the pandemic, when testing was not widely available.
Although COVID-19 testing is now readily available, concerns remain around the current limited sensitivity and specificity of COVID-19 PCR swab tests, due to the timing and technique in collecting the swab samples.
The antibody tests have been found to be highly specific, but there is some reduction in their sensitivity over time elapsed since symptoms and we do not know what proportion of COVID-19 patients seroconvert and produce IgG antibodies after infection. Further uncertainty exists around the level and duration of immunity (and carrier risk) after COVID-19 recovery.
COVID-19 has so far taught us that there is an interaction between biology, genetics, physiology and even socio-economic factors, that all affect the severity of illness and recovery from COVID-19. Any rehabilitative approach needs to be tailored to an individual’s needs and encompass both psychological and medical support.
If you feel that you may be struggling with protracted symptoms of COVID-19 speak to your GP or book an appointment to discuss further assessment and how best you can be supported. If you have an employee who may require support or guidance, please visit our occupational health pages for further information about the support available.
Dr. Sidra Malik BMBS MRCGP DRCOG DFSRH