What interventions or best practice are there to support people with Long COVID, or similar post-viral conditions or conditions characterised by fatigue, to return to normal activities: a rapid review
Authors: Spencer Llinos Haf , Hendry Annie , Makanjuola Abraham , Anthony Bethany F , Davies Jacob , Pisavadia Kalpa , Hughes Dyfrig , Fitzsimmons Deb , Wilkinson Clare , Edwards Rhiannon Tudor , Lewis Ruth , Cooper Alison , Edwards Adrian 
Published: January 2023

AbstractPrevious research has categorised symptoms of COVID-19 / Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life. Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities.Evidence was included from guidelines, systematic reviews (SR), and primary studies. The primary studies focussed on Long COVID (LC) indicated that there should be a needs-based focus to care for those with LC. Consideration should be given to individuals living with LC in the same way as people with disabilities are accommodated in terms of workplace adjustment. Two SRs indicated that non-pharmaceutical interventions (NPIs) for patients with LC or chronic fatigue syndrome could help improve function for activities of daily life. However, the third, most recent SR, concluded that there is a lack of robust evidence for NPIs. LC fatigue management methods may be beneficial under certain conditions. One SR reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life. One primary study, on individuals with CFS, described a written self-management programme. Following this intervention there was an 18% increase in the number of patients in employment.Policy and practice implications: Long COVID is still being established as a post-viral condition with many symptoms. Patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy may be considered in the same way as for other debilitating conditions. Return-to-work accommodations are needed for all workers unable to return to full-time employment. Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities.Funding statementThe Bangor Institute for Health and Medical Research was funded for this work by the Wales COVID-19 Evidence Centre, itself funded by Health & Care Research Wales on behalf of Welsh Government.Rapid Review DetailsReview conducted byBangor Institute for Health and Medical Research (BIHMR), Bangor University.Review Team▪Dr Llinos Haf Spencer,l.spencer@bangor.ac.uk▪Dr Annie Hendry,a.hendry@bangor.ac.uk▪Mr Abraham Makanjuola,a.makanjuola@bangor.ac.uk▪Ms Bethany Fern Anthony,b.anthony@bangor.ac.uk▪Mr Jacob Davies,jacob.davies@bangor.ac.uk▪Ms Kalpa Pisavadia,kalpa.pisavadia@bangor.ac.uk▪Professor Dyfrig Hughes,d.a.hughes@bangor.ac.uk▪Professor Deb Fitzsimmons,d.fitzsimmons@bangor.ac.uk▪Professor Clare Wilkinson,c.wilkinson@bangor.ac.uk▪Professor Rhiannon Tudor Edwards,r.t.edwards@bangor.ac.ukReview submitted to the WCEC on11 January 2023Stakeholder consultation meeting8thNovember 2022Rapid Review report issued by the WCEC inJanuary 2022WCEC TeamAdrian Edwards, Ruth Lewis, Alison Cooper and Micaela Gal involved in drafting the Topline Summary and editing.This review should be cited asRR00042_ Wales COVID-19 Evidence CentreDisclaimerThe views expressed in this publication are those of the authors, not necessarily Health and Care Research Wales. The WCEC and authors of this work declare that they have no conflict of interest.TOPLINE SUMMARYWhat is a Rapid Review?Our rapid reviews (RR) use a variation of the systematic review (SR) approach, abbreviating or omitting some components to generate the evidence to inform stakeholders promptly whilst maintaining attention to bias. They follow the methodological recommendations and minimum standards for conducting and reporting RR, including a structured protocol, systematic search, screening, data extraction, critical appraisal, and evidence synthesis to answer a specific question and identify key research gaps. They take 1 to 2 months, depending on the breadth and complexity of the research topic/question(s), extent of the evidence base, and type of analysis required for synthesis.Who is this summary for?Policymakers in Welsh Government to plan and deliver services for individuals with Long COVID as they re-enter training, education, employment, and informal caring responsibilities.Background / Aim of Rapid ReviewPrevious research has categorised symptoms of COVID-19/Long COVID into 12 thematic areas including: fever, myalgia, fatigue, impaired cognitive function, and that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life (Amdal et al., 2021; de Oliveira Almeida et al., 2022). NICE guidelines highlight the impact of the condition on quality of life and the challenge of determining best practice based on the current evidence (National Institute for Health and Care Excellence et al., 2022). Treatments for other post-viral syndromes may also apply to people living with Long COVID (Wong and Weitzer, 2021). Our aim was to review the evidence for interventions or best practice to support people with Long COVID, or similar post-viral conditions characterised by fatigue, to return to normal activities (including return to the workforce, education, childcare, or housework).Key FindingsEvidence was included from guidelines (n=3), systematic reviews (SRs) (n=3), and primary studies (n=4).Extent of the evidence base▪Two SRs included non-pharmacological interventions for Long COVID or post-viral syndromes, including Long COVID (Chandan et al., 2022; Fowler-Davis et al., 2021). The remaining SR focused on interventions for Chronic Fatigue Syndrome (CFS).▪The four primary studies were conducted in the UK, USA, Norway, and Turkey. The SRs included studies from across Europe, Asia, Africa, and Australasia.▪Included SRs and primary studies evaluated non-pharmaceutical interventions, including fatigue management, exercise therapy, Cognitive Behavioural Therapy (CBT), workplace support, self-management, sleep therapy, music therapy, and counselling.▪Two relevant guidelines were identified for Long COVID and one for ME/CFS. The Long COVID guideline was aimed at employers, and the ME/CFS guideline was aimed at service providers and users.Recency of the evidence base▪Included papers were from 2014 to 2022.Evidence of effectiveness▪The primary studies focussed on Long COVID indicated that there should be a needs-based focus to care for those with Long COVID (Lunt et al., 2022; Skilbeck, 2022; Wong et al., 2022). Consideration should be given to individuals living with Long COVID in the same way as people with disabilities are accommodated in terms of workplace adjustment (e.g. part-time hours, working from home, or hybrid working).▪Two SRs indicated that non-pharmaceutical interventions for patients with Long COVID or CFS could help improve function for activities of daily life (Fowler-Davis et al., 2021; Larun et al., 2019). However, the third and most recent SR concluded that there is a lack of robust evidence for non-pharmaceutical interventions (Chandan et al., 2022).▪Long COVID fatigue management by exercise therapy, electrical nerve stimulation, sleep and touch therapy, and behavioural self-management may be beneficial when: physical and psychological support is delivered in groups, people can plan their functional response to fatigue, strengthening rather than endurance is used to prevent deconditioning, fatigue is regarded in the context of an individual’s lifestyle and home-based activities are used (Fowler-Davis et al 2021).▪One SR (Chandan et al 2022) reported work capability as an outcome however they did not find any studies which evaluated the impact of interventions on return to work/ normal life.▪One primary study concentrated on individuals with CFS (Nyland et al., 2014). Nyland et al. (2014) described a written self-management programme featuring active coping (with CFS) strategies for daily life. Following this intervention, there was an 18% increase in the number of patients in employment (from baseline to follow-up) (Nyland et al., 2014).Best quality evidence▪The three SRs (Chandan et al., 2022; Fowler-Davis et al., 2021; Larun et al., 2019) were of high quality, as was one of the cohort studies (Lunt et al., 2022).Policy Implications▪Long COVID is still being established as a post-viral condition with many symptoms. The Welsh Government may seek to consider patient-centred treatment options such as occupational therapy, self-management therapy and talking therapy (such as Cognitive Behavioural Therapy) in the same way as for other debilitating conditions including ME/CFS.▪Return-to-work accommodations are needed for all workers unable to return to full-time employment.▪Due to the nature of the studies included, there was little reported evidence of effectiveness of getting individuals back into their normal activities.Strength of EvidenceConfidence in the findings is low. Only four primary studies reported outcomes relating to work capacity and return to normal activities such as childcare and housework.