Managing COVID-19 Long-haul Illnesses


Currently, the medical and public health communities don't have a good handle on COVID-19, let alone how to define its long-term, chronic phase. "We don't have a huge body of evidence at this point," says Mehta, a researcher at John's Hopkins. Outside of a few small studies from the United Kingdom, most evidence of Long COVID has been reported anecdotally through grassroots efforts like the Body Politic COVID-19 Support GroupSurvivor CorpsPatient-Led Research for COVID-19, and Long Haul COVID Fighters. Until recently, there hasn't been many resources devoted to long-haulers. Now, a year into the pandemic, as more individuals continue to struggle with the long-term effects of the disease, the focus is shifting. More research is forthcoming, including a new initiative from the National Institutes of Health and studies at institutions including Johns Hopkins and Mount Sinai focused on their clinic patients.

Image of virus and cells
Johns Hopkins responds to COVID-19

Coverage of how the COVID-19 pandemic is affecting operations at JHU and how Hopkins experts and scientists are responding to the outbreak

The Johns Hopkins COVID Long Study, on the other hand, will be one of the largest studies to date. By casting a wide net, researchers hope to reach a much larger and more representative sample of individuals who have been infected with SARS-CoV-2 in the United States in order to understand the full spectrum of the disease—why people have different responses to the virus, how many people have symptoms that clear, how many people have longer-term symptoms, and how many have no symptoms at all.

In particular, they hope to get a better picture of those with Long COVID. "We're going to learn much more about the set of symptoms that comes with Long COVID," says Lau. "There may be a wide variety of symptoms and not everyone will present the same way. There may also be several different underlying pathways involved in the development and persistence of the symptoms." Understanding the prevalence, symptoms, and trajectory of Long COVID not only helps with developing better treatment plans, but it also gives public health departments, government officials, and the medical systems data to help with health planning and policy decisions.

"This is just one attempt to try to understand those people who have long-term symptoms, and if we can understand what's going on, perhaps we can help address it. Similar to what we tried to do in the early stages of understanding what kind of treatments people needed in the hospital," says Duggal. "It's just trying to inform us more so that we can help those people who are affected."

What tests are required?

Blood tests should be ordered selectively and for specific clinical indications after a careful history and examination (see infographic); the patient may not need any. Anaemia should be excluded in the breathless patient. Lymphopenia is a feature of severe, acute covid-19. Elevated biomarkers may include C reactive protein (for example, acute infection), white cell count (infection or inflammatory response), natriuretic peptides (for example, heart failure), ferritin (inflammation and continuing prothrombotic state), troponin (acute coronary syndrome or myocarditis) and D-dimer (thromboembolic disease). Troponin and D-dimer tests may be falsely positive, but a negative result can reduce clinical uncertainty. Further research is likely to refine the indications for, and interpretation of, diagnostic and monitoring tests in follow-up of covid-19.

For patients who were not admitted to intensive care, British Thoracic Society guidance on follow-up of covid-19 patients who have had a significant respiratory illness proposes community follow-up with a chest x ray at 12 weeks and referral for new, persistent, or progressive symptoms.26 For those with evidence of lung damage (such as persistent abnormal chest x ray and oximeter readings), referral to a respiratory service is recommended; subsequent early referral to pulmonary rehabilitation probably aids recovery.

Figure1

<h5 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 5px; border-top: 0px; border-right: 0px; border-bottom: none; border-left: 0px; border-image: initial; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-weight: inherit; font-stretch: inherit; line-height: 3rem; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 2.2rem; vertical-align: baseline; color: rgb(28, 73, 125); background-color: rgb(255, 255, 255);">Supporting Recovery</h5> <p id="p-24" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 1.5; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51); background-color: rgb(255, 255, 255);">After excluding serious ongoing complications or comorbidities, and until the results of long term follow-up studies are available, patients should be managed pragmatically and symptomatically with an emphasis on holistic support while avoiding over-investigation.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-2" id="xref-ref-2-3" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">2</a>&nbsp;Fever, for example, may be treated symptomatically with paracetamol or non-steroidal anti-inflammatory drugs. Monitoring functional status in post-acute coivd-19 patients is not yet an exact science. A post-covid-19 functional status scale has been developed pragmatically but not formally validated<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-27" id="xref-ref-27-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">27</a>—a simplified version of this is reproduced in the supplementary material.</p> <p id="p-25" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 1.5; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51); background-color: rgb(255, 255, 255);">Referral to a specialist rehabilitation service does not seem to be needed for most patients, who can expect a gradual, if sometimes protracted, improvement in energy levels and breathlessness, aided by careful pacing, prioritisation, and modest goal setting. In our experience, most but not all patients who were not admitted to hospital recover well with four to six weeks of light aerobic exercise (such as walking or Pilates), gradually increasing in intensity as tolerated. Those returning to employment may need support to negotiate a phased return. Box 5 links to patient resources, including a comprehensive patient guide from Homerton University Hospital.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-28" id="xref-ref-28-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">28</a></p> <div class="subsection" id="sec-7" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51); background-color: rgb(255, 255, 255);"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Respiratory symptoms and support</h3> <div class="subsection" id="sec-8" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Cough</h4> <p id="p-26" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">The British Thoracic Society defines chronic cough as one that persists beyond eight weeks.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-26" id="xref-ref-26-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">26</a>&nbsp;Up to that time, and unless there are signs of super-infection or other complications such as painful pleural inflammation, cough seems to be best managed with simple breathing control exercises&nbsp;and medication where indicated (such as proton pump inhibitors if reflux is suspected).</p> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 3rem; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 1.9rem; vertical-align: baseline; color: rgb(51, 51, 51);">Breathing techniques</h3> <p id="p-27" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 1.5; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51);">About 80% of the work of breathing is done by the diaphragm. After illness or general deconditioning, the breathing pattern may be altered, with reduced diaphragmatic movement and greater use of neck and shoulder accessory muscles. This results in shallow breathing, increasing fatigue and breathlessness, and higher energy expenditure. The “breathing control” technique is aimed at normalising breathing patterns and increasing the efficiency of the respiratory muscles (including the diaphragm) resulting in less energy expenditure, less airway irritation, reduced fatigue, and improvement in breathlessness.</p> <p id="p-28" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 1.5; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51);">The patient should sit in a supported position and breathe in and out slowly, preferably in through the nose and out through the mouth, while relaxing the chest and shoulders and allowing the tummy to rise. They should aim for an inspiration to expiration ratio of 1:2. This technique can be used frequently throughout the day, in 5-10 minute bursts (or longer if helpful).</p> <p id="p-29" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: 1.5; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; color: rgb(51, 51, 51);">Other breathing techniques—such as diaphragmatic breathing, slow deep breathing, pursed lip breathing, yoga techniques, Buteyko—are used in strategies to manage patients’ breathing patterns and breathlessness but require specialist advice to identify which technique best suits each patient.</p> <div class="section other2" id="sec-6" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-variant-numeric: inherit; font-variant-east-asian: inherit; font-stretch: inherit; line-height: inherit; font-family: interfaceregular, &quot;Helvetica Neue&quot;, Helvetica, Arial, sans-serif; font-size: 16px; vertical-align: baseline; clear: both; color: rgb(51, 51, 51); background-color: rgb(255, 255, 255);"> <div class="subsection" id="sec-7" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <div class="subsection" id="sec-9" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Breathlessness</h4> <p id="p-30" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">A degree of breathlessness is common after acute covid-19. Severe breathlessness, which is rare in patients who were not hospitalised, may require urgent referral. Breathlessness tends to improve with breathing exercises (<a class="xref-boxed-text" href="https://www.bmj.com/content/370/bmj.m3026#boxed-text-3" id="xref-boxed-text-3-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">box 2</a>). Pulse oximeters may be extremely useful for assessing and monitoring respiratory symptoms after covid-19, and we could find no evidence that their use in the home leads to increased anxiety (<a class="xref-boxed-text" href="https://www.bmj.com/content/370/bmj.m3026#boxed-text-4" id="xref-boxed-text-4-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">box 3</a>).</p> <div class="boxed-text" id="boxed-text-4" style="box-sizing: border-box; margin: 15px 0px; padding: 15px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; background-color: rgb(238, 238, 238);"><span class="boxed-text-label" style="border:0px; box-sizing:border-box; font-family:inherit; font-stretch:inherit; font-style:inherit; font-variant:inherit; font-weight:inherit; line-height:inherit; margin:0px; padding:0px; vertical-align:baseline">Box 3</span> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Use of pulse oximetry in post-acute covid-19</h3> <p id="p-31" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Hypoxia may reflect impaired oxygen diffusion and is a recognised feature of covid-19. It may be asymptomatic (so called silent hypoxia<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-29" id="xref-ref-29-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">29</a>) or symptomatic (reflecting increased work of breathing, or secondary pathology such as a bacterial pneumonia or thromboembolism). Oxygen saturation probes (pulse oximeters) have been used as part of a package of care for patients with covid-19 and are recommended as part of the assessment of acute covid-19 in national and local guidelines.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-30" id="xref-ref-30-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">30</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-31" id="xref-ref-31-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">31</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-32" id="xref-ref-32-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">32</a></p> <p id="p-32" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Self monitoring of oxygen saturations over three to five days may be useful in the assessment and reassurance of patients with persistent dyspnoea in the post-acute phase, especially those in whom baseline saturations are normal and no other cause for dyspnoea is found on thorough evaluation. An exertional desaturation test should be performed as part of baseline assessment for patients whose resting pulse oximeter reading is 96% or above but whose symptoms suggest exertional desaturation (such as light-headedness or severe breathlessness on exercise). In the absence of contraindications, such patients should be invited to repeat the oximeter reading after 40 steps on a flat surface (if self testing remotely) and then after spending one minute doing sit-to-stand as fast as they can (if supervised on site).<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-33" id="xref-ref-33-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">33</a>&nbsp;A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-33" id="xref-ref-33-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">33</a></p> <p id="p-33" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Patients should be provided with a pulse oximeter and an observations diary and given instructions for how to self monitor.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-34" id="xref-ref-34-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">34</a>&nbsp;Typically, this would be a daily reading taken on a clean, warm finger without nail polish, after resting for 20 minutes; the device should be left to stabilise and the highest reading obtained should be recorded. While the range of commercially available oxygen saturation probes from healthcare suppliers and pharmacies seem to work within normal ranges (92% and above), smartphone apps that purport to measure oxygen saturations using the phone camera and torch should not be used.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-35" id="xref-ref-35-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">35</a></p> <p id="p-34" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">British Thoracic Society guidelines define the target range for oxygen saturation as 94-98% and a level of 92% or below as requiring supplementary oxygen (unless the patient is in chronic respiratory failure).<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-36" id="xref-ref-36-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">36</a>&nbsp;In the context of a normal assessment (history, examination, and appropriate investigations) without red flags, an oxygen saturation of 96% or above and the absence of desaturation on exertional tests is very reassuring. Further investigation or referral in the first six weeks after covid-19 in such patients is rarely indicated, though regular support by telephone or video is likely to be appreciated. Oximeter readings persistently in the 94-95% range or below (indicating substantially farther down the oxygen-haemoglobin desaturation curve<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-37" id="xref-ref-37-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">37</a>) require assessment and investigation. The patient should be provided with safety-netting advice (such as contacting their general practice or NHS111) in the event of recurrent low saturation readings. Appropriate adjustments should be made for patients with lung disease and known hypoxia—in whom the range of 88-92% is considered acceptable.</p> <a href="https://www.bmj.com/content/370/bmj.m3026#xref-boxed-text-4-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">RETURN TO TEXT</a></div> <p id="p-35" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Recovery after any severe debilitating illness may be prolonged.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-38" id="xref-ref-38-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">38</a>&nbsp;Survivors of covid-19 acute respiratory distress syndrome are at risk of long term impairment of lung function.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-39" id="xref-ref-39-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">39</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-40" id="xref-ref-40-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">40</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-41" id="xref-ref-41-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">41</a>&nbsp;Serious interstitial lung disease seems to be rare in patients who are not hypoxic, though data on long term outcomes are not yet available.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-42" id="xref-ref-42-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">42</a></p> </div> <div class="subsection" id="sec-10" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Pulmonary rehabilitation</h4> <p id="p-36" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Many patients are still recovering spontaneously in the first six weeks after acute covid-19 and do not generally require fast-track entry into a pulmonary rehabilitation programme. Those who have had significant respiratory illness may benefit from pulmonary rehabilitation, defined as “a multidisciplinary intervention based on personalised evaluation and treatment which includes, but is not limited to, exercise training, education, and behavioural modification designed to improve the physical and psychological condition of people with respiratory disease.”<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a>&nbsp;In the context of covid-19, rehabilitation is being delivered by various virtual models, including video linked classes and home education booklets with additional telephone support. We describe one such programme in the supplementary material on bmj.com.</p> </div> </div> <div class="subsection" id="sec-11" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Fatigue</h3> <p id="p-37" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">The profound and prolonged nature of fatigue in some post-acute covid-19 patients shares features with chronic fatigue syndrome described after other serious infections including SARS, MERS, and community acquired pneumonia.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-19" id="xref-ref-19-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">19</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-20" id="xref-ref-20-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">20</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-22" id="xref-ref-22-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">22</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-44" id="xref-ref-44-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">44</a>&nbsp;We found no published research evidence on the efficacy of either pharmacological or non-pharmacological interventions on fatigue after covid-19. Patient resources on fatigue management<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-45" id="xref-ref-45-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">45</a>&nbsp;and guidance for clinicians on return to exercise<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a>&nbsp;and graded return to performance for athletes (<a class="xref-boxed-text" href="https://www.bmj.com/content/370/bmj.m3026#boxed-text-5" id="xref-boxed-text-5-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">box 4</a>)&nbsp;<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-46" id="xref-ref-46-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">46</a>&nbsp;in covid-19 are currently all based on indirect evidence.</p> <div class="boxed-text" id="boxed-text-5" style="box-sizing: border-box; margin: 15px 0px; padding: 15px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; background-color: rgb(238, 238, 238);"><span class="boxed-text-label" style="border:0px; box-sizing:border-box; font-family:inherit; font-stretch:inherit; font-style:inherit; font-variant:inherit; font-weight:inherit; line-height:inherit; margin:0px; padding:0px; vertical-align:baseline">Box 4</span> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">The sportsperson returning to exercise (summarised from Stanford-Hall statement<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-3" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a>)</h3> <ul class="list-unord " id="list-3" style="box-sizing: border-box; margin: 15px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; list-style-position: initial; list-style-image: initial;"> <li id="list-item-7" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-38" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">After recovery from mild illness: 1 week of low level stretching and strengthening before targeted cardiovascular sessions</p> </li> <li id="list-item-8" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-39" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Very mild symptoms: limit activity to slow walking or equivalent. Increase rest periods if symptoms worsen. Avoid high-intensity training</p> </li> <li id="list-item-9" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-40" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Persistent symptoms (such as fatigue, cough, breathlessness, fever): limit activity to 60% maximum heart rate until 2-3 weeks after symptoms resolve</p> </li> <li id="list-item-10" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-41" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Patients who had lymphopenia or required oxygen need respiratory assessment before resuming exercise</p> </li> <li id="list-item-11" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-42" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Patients who had cardiac involvement need cardiac assessment before resuming</p> </li> </ul> <a href="https://www.bmj.com/content/370/bmj.m3026#xref-boxed-text-5-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">RETURN TO TEXT</a></div> <p id="p-43" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">There is much debate and controversy about the role of graded exercise in chronic fatigue generally (see patient responses to a recent Cochrane review<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-47" id="xref-ref-47-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">47</a>) and in covid-19 in particular (see a recent statement from the National Institute for Health and Care Excellence (NICE)<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-48" id="xref-ref-48-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">48</a>). Pending direct evidence from research studies, we suggest that exercise in such patients should be undertaken cautiously and cut back if the patient develops fever, breathlessness, severe fatigue, or muscle aches. Understanding, support, and reassurance from the primary care clinician are a crucial component of management.</p> </div> <div class="subsection" id="sec-12" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Cardiopulmonary complications, assessment and management</h3> <p id="p-44" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Perhaps 20% of patients admitted with covid-19 have clinically significant cardiac involvement<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-49" id="xref-ref-49-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">49</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-50" id="xref-ref-50-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">50</a>; occult involvement may be even commoner.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-51" id="xref-ref-51-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">51</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-52" id="xref-ref-52-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">52</a>&nbsp;Cardiopulmonary complications include myocarditis, pericarditis, myocardial infarction, dysrhythmias, and pulmonary embolus; they may present several weeks after acute covid-19. They are commoner in patients with pre-existing cardiovascular disease,<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-49" id="xref-ref-49-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">49</a>&nbsp;but they have also been described in young, previously active patients.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-4" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-53" id="xref-ref-53-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">53</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-54" id="xref-ref-54-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">54</a>&nbsp;Various pathophysiological mechanisms have been proposed, including viral infiltration, inflammation and microthrombi, and down-regulation of ACE-2 receptors.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-51" id="xref-ref-51-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">51</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-53" id="xref-ref-53-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">53</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-54" id="xref-ref-54-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">54</a></p> <div class="subsection" id="sec-13" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Chest pain</h4> <p id="p-45" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Chest pain is common in post-acute covid-19. The clinical priority is to separate musculoskeletal and other non-specific chest pain (for example, the symptom described by a large patient-led survey as “lung burn”<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-4" id="xref-ref-4-4" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">4</a>) from serious cardiovascular conditions. Clinical assessment of the post-acute covid-19 patient with chest pain should follow similar principles to that for any chest pain: a careful history, taking account of past medical history and risk factors, a physical examination, backed up as indicated by investigations (infographic).<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-5" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a>&nbsp;Where the diagnosis is uncertain, or the patient is acutely unwell, urgent cardiology referral may be needed for specialist assessment and investigations (including echocardiography, computed tomography of the chest, or cardiac magnetic resonance imaging).</p> </div> <div class="subsection" id="sec-14" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Thromboembolism</h4> <p id="p-46" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Covid-19 is an inflammatory and hypercoagulable state,<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-50" id="xref-ref-50-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">50</a>&nbsp;with an increased risk of thromboembolic events.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-55" id="xref-ref-55-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">55</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-56" id="xref-ref-56-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">56</a>&nbsp;Many hospitalised patients receive prophylactic anticoagulation. Recommendations for anticoagulation after discharge vary, but higher risk patients are typically discharged from hospital with 10 days of extended thromboprophylaxis.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-57" id="xref-ref-57-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">57</a>&nbsp;If the patient has been diagnosed with a thrombotic episode, anticoagulation and further investigation and monitoring should follow standard guidelines.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-58" id="xref-ref-58-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">58</a>&nbsp;It is not known how long patients remain hypercoagulable following acute covid-19.</p> </div> <div class="subsection" id="sec-15" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Ventricular dysfunction</h4> <p id="p-47" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Left ventricular systolic dysfunction and heart failure after covid-19 can be managed according to standard guidelines.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-59" id="xref-ref-59-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">59</a>&nbsp;Intense cardiovascular exercise must be avoided for three months in all patients after myocarditis or pericarditis; athletes are advised to take three to six months of complete rest from cardiovascular training followed by specialist follow-up, with return to sport guided by functional status, biomarkers, absence of dysrhythmias, and evidence of normal left ventricular systolic function.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-60" id="xref-ref-60-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">60</a></p> </div> </div> <div class="subsection" id="sec-16" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Neurological sequelae</h3> <p id="p-48" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Ischaemic stroke, seizures, encephalitis, and cranial neuropathies have been described after covid-19, but these all seem to be rare.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-61" id="xref-ref-61-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">61</a>&nbsp;A patient suspected of these serious complications should be referred to a neurologist. Common non-specific neurological symptoms, which seem to co-occur with fatigue and breathlessness, include headaches, dizziness, and cognitive blunting (“brain fog”).<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-4" id="xref-ref-4-5" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">4</a>&nbsp;Until evidence based guidance appears on how to manage or when to refer such symptoms, we recommend supportive management and symptom monitoring in primary care.</p> </div> <div class="subsection" id="sec-17" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">The older patient</h3> <p id="p-49" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Covid-19 tends to affect older patients more severely.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-62" id="xref-ref-62-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">62</a>&nbsp;Those who survive are at high risk of sarcopenia, malnutrition, depression, and delirium.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-2" id="xref-ref-2-4" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">2</a>&nbsp;Post-covid-19 chronic pain may affect patients of any age but seems to be commoner in elderly patients.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-63" id="xref-ref-63-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">63</a>&nbsp;Physical symptoms add to the psychosocial impact of disrupted access to health care (such as arrangements for obtaining regular medication), core personal routines (such as walking to local shops), social interactions (such as meeting friends), and lay and professional support networks.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-64" id="xref-ref-64-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">64</a>&nbsp;Support should be personalised with input from the multi-professional team (for example, general practitioner, district nurse, social worker, rehabilitation teams, and occupational therapist as needed).</p> </div> <div class="subsection" id="sec-18" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Mental health and wellbeing</h3> <p id="p-50" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Most publications on covid-19 and mental health have emphasised individual reactions to the pandemic such as anxiety, stress, and conditions related to broken routines, loneliness, and social isolation in uninfected individuals<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-65" id="xref-ref-65-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">65</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-66" id="xref-ref-66-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">66</a>; the World Health Organisation has issued guidance on these.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-67" id="xref-ref-67-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">67</a>&nbsp;Lay accounts suggest that post-acute covid-19 is often associated with low mood, hopelessness, heightened anxiety, and difficulty sleeping.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-6" id="xref-ref-6-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">6</a>&nbsp;Post-traumatic stress disorder may occur, especially in healthcare workers and others with caring responsibilities.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-15" id="xref-ref-15-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">15</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-16" id="xref-ref-16-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">16</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-43" id="xref-ref-43-6" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">43</a></p> <p id="p-51" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">While a minority of patients may benefit from referral to mental health services, it is important not to pathologise the majority. Physical manifestations of covid-19 may distort responses to assessment tools (such as the PHQ9) designed to measure anxiety and depression in a physically healthy population, though these complications may occur. Patient organisations emphasise wellbeing, mindfulness, social connection, self care (including diet and hydration), peer support, and symptom control. Mental illness is strongly associated with social determinants such as poverty, discrimination, and social exclusion; mental health and wellbeing are enhanced by increased social solidarity, informal social support, mutual aid, and other community based and collective measures.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-68" id="xref-ref-68-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">68</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-69" id="xref-ref-69-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">69</a>&nbsp;Given how pervasive and unequal the impact of covid-19 has been,<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-70" id="xref-ref-70-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">70</a><a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-71" id="xref-ref-71-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">71</a>&nbsp;community level, cross-sector collaborations may be needed to develop locally relevant solutions. A recent report from general practice in a deprived area of Glasgow describes the importance of accessible, relationship-based care for patients with complex needs, and of system-level interventions such as attached financial advisers and outreach mental health services.<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-69" id="xref-ref-69-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">69</a></p> </div> <div class="subsection" id="sec-19" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Social and cultural considerations</h3> <p id="p-52" style="box-sizing: border-box; margin: 0px 0px 15px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline;">Covid-19 is more common and has a worse prognosis in the acute phase in people who are poor, elderly, and from certain minority ethnic groups (notably black, south Asian, and Jewish<a class="xref-bibr" href="https://www.bmj.com/content/370/bmj.m3026#ref-70" id="xref-ref-70-2" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px 5px 0px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; font-size: 10px; vertical-align: 0.4em; word-break: break-all;">70</a>). It is too early to say whether these sociodemographic patterns persist in post-acute covid-19. Our own experience suggests that patients with post-acute covid-19 are from diverse social and cultural backgrounds. Many have comorbidities including diabetes, hypertension, kidney disease, or ischaemic heart disease. Some have experienced family bereavements as well as job losses and consequent financial stress and food poverty. Strain on many carers has been high. For an important few, lockdown has worsened safeguarding concerns such as the risk of child or intimate partner abuse. A detailed discussion of all these issues is beyond the scope of this article, but there are strong arguments for working with other agencies to develop local, system-level solutions.&nbsp;<a class="xref-boxed-text" href="https://www.bmj.com/content/370/bmj.m3026#boxed-text-6" id="xref-boxed-text-6-1" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: bold; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">Box 5</a>&nbsp;provides some links to covid-19 advice from specialist social care, lay care, and faith organisations.</p> <div class="boxed-text" id="boxed-text-6" style="box-sizing: border-box; margin: 15px 0px; padding: 15px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; background-color: rgb(238, 238, 238);"><span class="boxed-text-label" style="border:0px; box-sizing:border-box; font-family:inherit; font-stretch:inherit; font-style:inherit; font-variant:inherit; font-weight:inherit; line-height:inherit; margin:0px; padding:0px; vertical-align:baseline">Box 5</span> <h3 style="box-sizing: border-box; margin: 0px; padding: 0px 0px 10px; border: 0px; font-style: inherit; font-variant: inherit; font-stretch: inherit; line-height: 3rem; font-family: inherit; font-size: 1.9rem; vertical-align: baseline;">Additional resources for patients and professionals</h3> <div class="subsection" id="sec-20" style="box-sizing: border-box; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <h4 style="box-sizing: border-box; margin: 0px 0px 10px; padding: 0px; border: 0px; font-variant: inherit; font-stretch: inherit; line-height: 2.2rem; font-family: inherit; font-size: 1.6rem; vertical-align: baseline;">Advice for patients</h4> <ul class="list-unord " id="list-4" style="box-sizing: border-box; margin: 15px 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; list-style-position: initial; list-style-image: initial;"> <li id="list-item-12" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-53" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Homerton University Hospital. ACERS: Post COVID-19 patient information pack.&nbsp;<a href="https://www.hackneycitizen.co.uk/wp-content/uploads/Post-COVID-19-information-pack-5.pdf" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.hackneycitizen.co.uk/wp-content/uploads/Post-COVID-19-information-pack-5.pdf</a></p> </li> <li id="list-item-13" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-54" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Royal College of Occupational Therapists. How to conserve your energy: Practical advice for people during and after having COVID-19.&nbsp;<a href="https://www.rcot.co.uk/conserving-energy" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.rcot.co.uk/conserving-energy</a></p> </li> <li id="list-item-14" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-55" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Chartered Society of Physiotherapy. Covid-19: The road to recovery activity planner.&nbsp;<a href="https://www.csp.org.uk/system/files/documents/2020-06/001751_covid19-the_road_to_recovery_activity_planner_v3.pdf" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.csp.org.uk/system/files/documents/2020-06/001751_covid19-the_road_to_recovery_activity_planner_v3.pdf</a></p> </li> <li id="list-item-15" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-56" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Mental Health Foundation. How to look after your mental health during the coronavirus outbreak.&nbsp;<a href="https://www.mentalhealth.org.uk/coronavirus" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.mentalhealth.org.uk/coronavirus</a></p> </li> <li id="list-item-16" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-57" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Mind. Coronavirus and your mental health.&nbsp;<a href="https://www.mind.org.uk/information-support/coronavirus/" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.mind.org.uk/information-support/coronavirus/</a></p> </li> <li id="list-item-17" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-58" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Asthma UK and British Lung Foundation. Post-COVID HUB.&nbsp;<a href="https://www.post-covid.org.uk/" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.post-covid.org.uk/</a></p> </li> <li id="list-item-18" style="box-sizing: border-box; margin: 0px 0px 15px 10px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline;"> <p id="p-59" style="box-sizing: border-box; margin: 0px 0px 20px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: 1.5; font-family: inherit; vertical-align: baseline; display: inline;">Facebook. Long Covid Support Group.&nbsp;<a href="https://www.facebook.com/groups/longcovid" style="box-sizing: border-box; background: transparent; color: rgb(42, 110, 187); text-decoration-line: none; margin: 0px; padding: 0px; border: 0px; font-style: inherit; font-variant: inherit; font-weight: inherit; font-stretch: inherit; line-height: inherit; font-family: inherit; vertical-align: baseline; word-break: break-all;">https://www.facebook.com/groups/longcovid</a></p> </li> </ul> </div> </div> </div> </div> </div> </div>