Abstract
Prolonged symptoms from the novel coronavirus disease 2019 (COVID-19), otherwise known as long COVID, postacute sequelae of COVID-19 (PASC), or post-COVID syndrome, are affecting an increasingly high number of patients after severe, moderate, and mild acute COVID-19 infections. Using evidence-based practice strategies, this case report describes occupational therapy evaluation and treatment approaches, plan of care, and associated outcomes for one client experiencing long COVID symptoms in the outpatient setting.
Occupational therapy evaluation and treatment approaches, plan of care, and associated outcomes are described for a client experiencing long-haul COVID symptoms in the outpatient setting.
After nearly a year of adjusting to the clinical challenges of the coronavirus disease 2019 (COVID-19) pandemic and rapidly trying to evaluate best practices for acute symptom management, researchers began to expand their investigations to explore the range of post viral sequelae affecting patients’ long-term recovery from COVID-19. Prolonged symptoms from COVID-19, otherwise known as long COVID, postacute sequelae of COVID-19 (PASC), or post-COVID syndrome, most often involve generalized fatigue, poor attention and memory, difficulty thinking (also referred to as brain fog), cough, shortness of breath, chest pain, depression, muscle and joint pain, headaches, sleep symptoms, sensorimotor deficits, and heart palpitations (National Institute for Health and Care Excellence [NICE], 2020). Long haulers, a term used to describe people with PASC, have reported more than 250 symptoms having onset during or immediately after the acute viral infection (Davis et al., 2020). Long COVID, defined as symptoms lasting beyond 12 wk from the initial infection, have the potential to remit and relapse, most often triggered by intense exercise, physical or mental activity, and stress (Davis et al., 2020). Notably, postacute COVID-19 symptoms appear to be multisystem, nonspecific, and unassociated with the severity of acute COVID-19 infection (Greenhalgh, Knight, et al., 2020; Townsend et al., 2020). Persisting symptoms have been found to have a significant impact on long haulers as they struggle to return to work and family roles, often with secondary financial consequences (Davis et al., 2020).
Guidelines from NICE (2020) recommend a holistic, person-centered approach to the assessment and clinical management of long COVID, with consideration of how persistent symptoms affect a person’s life and daily activities, including work, education, mobility, independence, and psychological well-being. People presenting to primary care with new or ongoing symptoms of COVID-19 4 wk beyond the acute infection require medical assessment for potential acute or unrelated etiology. Once other diagnoses are ruled out, NICE guidelines recommend referral to integrated, multidisciplinary rehabilitation services for individualized interventions to promote symptom self-management and minimize impact on functional performance.
Occupational therapy practitioners are essential health care providers who offer screening, evaluation, and treatment services throughout the continuum of care. This case report describes a woman’s experiences after contracting COVID-19 and provides an overview of the outpatient occupational therapy services provided, addressing the persistent functional limitations affecting her daily roles, routines, interests, and occupations.
Brenda
Brenda is a 32-yr-old Hispanic woman with no significant medical history who lives in a multigenerational household with six other family members. She is a registered nurse and works in a cardiac surgery intensive care unit (ICU) at her community hospital. She enjoys spending time with family, engages in a daily yoga practice, and paddleboards on the weekends.
While working at a local restaurant, Brenda’s sister contracted COVID-19, and within 7 days Brenda and her mother, father, and aunt all tested positive for COVID-19. Brenda’s acute infection was considered mild, and she had symptoms of fever, body aches, headache, generalized fatigue, loss of appetite, mild shortness of breath, and loss of taste and smell.
While at home, Brenda took responsibility for care of her other family members, despite being ill herself. Her efforts were successful, and her parents avoided hospitalization. Unfortunately, Brenda’s aunt was admitted to the hospital after developing acute respiratory distress syndrome while at home and died after 4 wk in the ICU.
Medical Examination and Diagnostic Testing
Four weeks after her COVID-19 diagnosis, Brenda continued to experience shortness of breath and tachycardia while performing instrumental activities of daily living (IADLs) such as cleaning the bathroom and carrying groceries into the house. This prompted Brenda to visit her primary care physician (PCP). The PCP initiated a medical evaluation to investigate underlying causes of Brenda’s symptoms and extended her medical leave from work. Her laboratory testing, thyroid function, echocardiogram, electrocardiogram, remote cardiac monitoring study, chest imaging, pulmonary function tests, and clinical examination were unremarkable. Brenda’s PCP referred her to outpatient occupational therapy to improve her symptom management and facilitate her eventual return to work.
Occupational Profile
Upon initial evaluation, the occupational therapist completed an occupational profile with Brenda to identify strengths and barriers to engagement in occupation and role fulfillment (American Occupational Therapy Association, 2021). Brenda described success with basic activities of daily living (ADLs), functional mobility within the home and short community distances, driving, and paying her bills. She reported difficulty performing household chores, including vacuuming, laundry, cleaning the bathroom, and cooking. She was unable to engage in her normal daily yoga practice because of fatigue, breathlessness, and intermittent dizziness. Her main concern was whether she could return to her critical responsibilities as an ICU nurse. She identified symptoms of brain fog (specifically, poor concentration, memory, and planning), intermittent exertional dyspnea, occasional heart palpitations, dizziness, and disrupted sleep patterns. In addition, she described a pervasive, generalized fatigue that could keep her in bed for 2 or 3 days at a time. She acknowledged feelings of anxiety and hopelessness as she considered returning to work while still learning to cope with the unpredictable and fluctuating nature of her symptoms and their impact on her daily life. Table 1 lists the International Classification of Diseases, Tenth Revision, Clinical Modification diagnostic codes included in Brenda’s plan of care (U.S. Department of Health and Human Services, 2021).
ICD–10–CM Diagnosis and Billing Codes Commonly Used With Post-COVID Patients (U.S. Department of Health and Human Services, 2021)
Note. COVID = coronavirus disease; ICD–10–CM = International Classification of Diseases, Tenth Revision, Clinical Modification.
Assessment Results
On the basis of the client’s priorities, medical history, and occupational profile, the occupational therapist chose assessment tools to further examine ADL and IADL performance, cardiopulmonary endurance, and functional cognition affecting occupational performance (Table 2). To assess role attainment, Brenda completed the Role Checklist (Scott, 2019) and identified feeling disengaged from her roles as a nurse, daughter, homemaker, and yogi. Brenda was intermittently tearful and frustrated throughout the evaluation, stating, “I should be able to do these things” and “How am I ever going to be able to go back to work full time?”
Assessment Results at Evaluation, Reassessment, and Discharge
Note. AM-PAC = Activity Measure for Post-Acute Care; IADL = instrumental activities of daily living.
Occupational Therapy Plan of Care
Brenda and her occupational therapist agreed on a plan of care that blended in-person clinic visits and remote telehealth services; one visit per week for 12 wk was set as the frequency and duration, respectively, for outpatient occupational therapy services. The long-term goals emphasized improved activity tolerance for daily activities (including home maintenance), participation in a modified physical fitness routine (including yoga), development and implementation of sleep hygiene strategies, self-management of fatigue, consistent use of coping mechanisms for anxiety and depression, routine building, and return to work.
Client Factors and Analysis of Performance
Activity Intolerance, Exertional Dyspnea, and Dizziness
During the initial evaluation, Brenda completed the 1-min sit-to-stand test (Greenhalgh, Javid, et al., 2020), a measure of cardiopulmonary endurance during continuous, self-paced functional activity. During the sit-to-stand test, the occupational therapist monitored Brenda’s repetitions, peripheral pulse rate, pulse oximetry, posttest vital sign recovery time, and posttest assessment of perceived breathlessness using the Modified Borg Dyspnea Scale (Borg et al., 2010). Brenda’s symptomatic breathlessness correlated with her elevated heart rate during exertion (Table 3). Her oxygen saturation stayed at or above 92%, ruling out exertional hypoxia (Greenhalgh, Javid, et al., 2020). Therefore, the primary treatment approach focused on gradual cardiovascular endurance training and task modification within the context of her daily routines (Wilcox et al., 2021). Careful consideration was given to progressing Brenda’s endurance training activities, aiming to build consistency in her daily energy reserves and performance capacity, as opposed to short-term intensity gains followed by days of prolonged rest and inactivity (NICE, 2020). In addition, the clinician challenged Brenda to reconsider her definition of exercise to include higher intensity daily activities that resulted in equivalent physiologic responses to her traditional workout routines (Humphreys et al., 2021).
Functional Endurance Assessment Results of the 1-Minute Sit-to-Stand Test
Note. The 1-min stand test was conducted at 1, 8, and 12 wk. Pre- and postactivity measures were recorded. BPM = beats per minute; mBorg = Modified Borg Dyspnea Scale; SpO2 = peripheral oxygen saturation.
Asks the client to rate the difficulty of their breathing on a scale ranging from 1 (no difficulty) to 10 (maximal difficulty).
Notably, Brenda was observed to frequently hold her breath while performing tasks that challenged her upper body strength and endurance. After ruling out orthostatic blood pressure abnormalities, it was determined that breath-holding maneuvers were the likely source of Brenda’s sudden episodes of dizziness, which commonly occurred while cleaning the house and practicing yoga. Once the task demands triggering her dizziness were identified, the subsequent focus became Brenda’s recognition of performance patterns within the context of her daily activity routines as a prerequisite for behavior change. In the days between therapy sessions, Brenda recorded her episodes of dizziness and the context in which they occurred, paying attention to the task demands identified in the therapy session.
A graded approach was used to remediate Brenda’s breath control, applying a pursed-lip breathing (PLB) technique to prevent breath holding during activity. PLB techniques were first introduced as a preparatory exercise in various body positions; followed by integration into low-complexity exercises and activities, such as the upper extremity cycle ergometer; and finally practiced during task-specific training related to home management and community-based activity routines, including walking and carrying a 1.8 kg (4-lb) laundry basket, vacuuming or mopping, reaching for items on a high shelf slightly out of reach, and bending over to assume a quadruped position to use a dustpan or wipe up spilled juice from the floor (Migliore, 2004). In addition, individualized work simplification and energy conservation strategies were implemented during task-specific training to promote carryover to home IADL engagement. Brenda was initially prescribed a home program of quiet PLB exercises that grew in complexity each week as she learned to integrate her breath control skills into a modified sequence of yoga poses, in turn building confidence as she returned to her preferred fitness hobby and leisure routine.
Time Use and Occupational Balance
Analysis of Brenda’s current time use and daily routines revealed inconsistent sleep–wake cycles; minimal outdoor activity; limited community participation; and variable engagement in leisure, social, and restorative occupations. Although Brenda had previously followed a rigid weekly routine to accommodate her demanding work schedule, she now found it difficult to finish a day’s worth of tasks over the course of a full week. Brenda often reflected on her ability to overcome the exhaustion she had experienced while taking care of her parents during her acute COVID-19 infection, contrasting her previous capacity to push her body to its limits with her current difficulty to build consistency in caring for herself.
In Wk 3 of her outpatient program, Brenda joined her girlfriends on a 3.2-km (2-mi) hike in an attempt to jump-start her fitness routine. Initially, she was thrilled to feel like herself again, reconnecting with friends and spending time outdoors. Unfortunately, the abrupt increase in physical and mental energy expenditure left Brenda in bed for the following 4 days, feeling exhausted, with body aches, worsening shortness of breath, and heart palpitations every time she walked to the bathroom. During the following week’s telehealth therapy session, Brenda expressed frustration with her “set back” as she struggled to understand her body. Recognizing that Brenda’s relapse followed a sudden return to high-intensity activity, the occupational therapist facilitated Brenda’s analysis of the ways in which the hike with friends had stressed her body, inadvertently resulting in postexertional malaise (Humphreys et al., 2021). Despite her disappointment, Brenda left the therapy session feeling empowered that, armed with this new insight, she was better equipped to prevent future relapses.
In the setting of her fragile energy reserves, Brenda and her occupational therapist shifted to generalizing energy conservation principles to her expenditure over the course of a day and week, in addition to the task-specific modifications and pacing strategies she had grown familiar with from earlier sessions (Royal College of Occupational Therapists, 2020). Recognizing the value of planning and practice from her earlier lessons in symptom management, Brenda was easily engaged in daily routine modification activities to strategically schedule a well-balanced sequence of important activities across the days of her week. For Brenda, allocating her energy required consideration of both the physical and the mental stress a task demanded, and she aimed to plan her week with a blend of low- and high-energy tasks across each day. Attention was given to ensure time was allotted to rest and recharge through restorative occupations. Collaboratively, Brenda and her therapist decided to rebuild her daily routine starting with sleep, more specifically her bedtime and wake-up routines, ensuring that rest remained a top priority. Together, they planned the first and last 2 hr of Brenda’s day, structuring a sequence of tasks aimed to prepare her body and mind to start and end each day, followed by blocks of time for meals, a modified yoga practice, and social engagement with family.
Symptom Self-Management
An occupation-based approach to symptom self-management training sought to provide Brenda with the tools needed to cope with the ongoing cognitive and physical fatigue through lifestyle modification and daily routine management. To promote symptom self-management, Brenda was encouraged to complete a daily diary to record activity patterns, symptom experiences, and sleep routines. The diary created a place for Brenda to reflect on how her daily performance patterns influenced her symptom severity. In addition, the daily practice strengthened Brenda’s ability to self-monitor performance patterns and recognize routines that optimize symptom control, serving as a tool to guide future energy allocation. Brenda often analogized her daily diary entry to writing an end-of-shift note in her patients’ medical charts, expanding on the prompts provided by her therapist to include objective data collected by her fitness tracker, such as average heart rate, step count, and minutes of exercise. During her weekly therapy sessions, Brenda reflected on her diary entries, areas of strength, and opportunities for growth.
The daily diary was also used to track and monitor coping behaviors in response to anxiety. Brenda often mentioned feelings of stress and guilt with regard to the recent passing of her aunt and her parents’ illness. Coping skills were discussed during a telehealth treatment session with Brenda, and the Brief COPE (Carver, 1997) was used to identify her preferred positive and negative coping mechanisms. The daily diary entries prompted Brenda to report her use of coping mechanisms from the previous day and build action plans to promote the use of healthy coping strategies.
Functional Cognition Using a Multicontext Approach
By Wk 8, Brenda had demonstrated improvements in her symptom severity, functional independence, and physical and cognitive performance capacities (see Table 2, “Discharge” column). Brenda reported improvements in her brain fog and overall energy levels as she reestablished her daily activity routines and sleep schedule.
In anticipation of Brenda’s return to work, her therapist used a multicontext approach to cognitive rehabilitation, integrating metacognitive strategy interventions to address her ongoing challenges with functional cognition during complex activity performance across a range of environments and relevant scenarios (Toglia & Foster, 2021).
Brenda’s therapist designed work training activities specific to Brenda’s responsibilities as an ICU nurse, blending the higher complexity physical and cognitive demands she would encounter upon her return to the ICU. Recognizing the small margin for error in Brenda’s work, it was critical that she develop, practice, and generalize metacognitive strategies to support her performance across her standard work activities.
Functional training activities were used to assess and challenge Brenda’s ability to initiate and translate metacognitive strategies across a range of work tasks, under variable conditions and contexts. Brenda and her therapist determined three scenarios that consistently contributed to a higher frequency of task errors during work-related training activities in the therapy clinic. Contexts and task demands that had a negative impact on Brenda’s performance were as follows:
Tasks completed under time constraints in which Brenda felt rushed to finish before moving on to another unrelated task (e.g., rushing to quickly enter vital signs into a patient’s electronic health record before promptly reporting to another patient’s bedside to assist the medical team with a procedure). Executing a computer-based task too quickly, without pausing to briefly review the data entry for potential errors, increased the frequency of her documentation errors during clinic-based work training activities.
Delayed recall of information received while performing an unrelated, complex psychomotor tasks. For example, during work training activities, Brenda often forgot or inaccurately recalled verbal updates she received while engaged in care delivery tasks, such as forgetting to provide a patient with pain medication in preparation for a scheduled therapy session after receiving the communication while simultaneously assisting another patient with toileting and passive repositioning in bed. Collaboratively with her therapist, Brenda developed and practiced strategies for clearly communicating with other care providers that she was not available for care coordination conversations while present at the bedside caring for patients.
Cognitive fatigue, which consistently increased the frequency of performance errors and Brenda’s ability to detect and correct them. Brenda had grown particularly sensitive to the abundance of auditory and visual alarms present in her workspaces and benefited from modulating unnecessary sensory stimuli in her environment. With the support of the medical team and nursing management, Brenda was able to adjust the bedside monitor and device alarms to signal her attention based on settings individualized to her patient, as opposed to the default device settings programmed by the manufacturer. In addition, Brenda felt that it was important to create time to recharge her energy throughout the day and made the effort to take her breaks and mealtimes outdoors on the patio.
After her 11th visit and fourth session of work-related training activities using a multicontext approach, Brenda identified task challenges before initiating an activity, initiated strategy use to prevent errors, recognized and corrected errors during performance, self-monitored her symptoms and task performance, effectively managed incoming interruptions, and regulated her emotions while communicating her need for assistance when tasks exceeded her available capacity (Toglia & Foster, 2021).
Outcomes
Four months after her acute COVID-19 infection, Brenda successfully returned to work in the cardiac ICU to continue her long-haul recovery from PASC.
Implications for Occupational Therapy Practice
The case of Brenda is just one example of how occupational therapy can have a lasting impact on the quality of life and symptom self-management skills of long haulers to promote independence in the home, community, and workplace. Long haulers are experiencing profound and persistent physical, cognitive, psychological, and emotional symptoms that have a significant impact on return to work and reengagement in meaningful occupations, roles, and routines. Without extensive research to direct care delivery, best practice guidelines recommend referral to occupational therapy for rehabilitation that aims to balance ongoing symptom burden with returning people to their normal daily lives (NICE, 2020). Occupational therapy practitioners are uniquely qualified to guide clients through recovery from PASC, armed with their expertise in health promotion, activity analysis, energy conservation, lifestyle modification, functional cognition, and the secondary consequences of occupational disengagement on a person’s identity and well-being.
Conclusion
As clinical investigation into PASC continues, recognizing occupational therapy’s distinct value in the evaluation and treatment of long haulers is essential (Ladds et al., 2020). The occupational therapy profession has the potential to make a distinct and substantial impact toward a global recovery from the COVID-19 pandemic at the individual, organizational, and policy levels.
Footnotes
Acknowledgments
The authors thank the USC occupational therapy faculty practice and Keck hospital COVID-19 team clinicians for their collaborative efforts throughout the pandemic. We would also like to acknowledge and thank every occupational therapy practitioner who was affected by the COVID-19 pandemic yet continued to provide quality care to improve the function of our clients across the continuum of care.