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Scott Webb: COVID-19 is a virus that can potentially cause long-term functional impairments. Common early symptoms include fever, cough, loss of smell or taste, shortness of breath, muscle aches, nasal congestion, headache, and fatigue. For most people with COVID-19, these symptoms usually last up to two to three weeks and resolve either spontaneously or with medical treatment.

Sometimes symptoms can be more serious or last even longer. Individuals who experienced long-term symptoms are identified as COVID-19 long haulers. We treat COVID-19 long-haulers with a comprehensive multidisciplinary approach with a physiatrist and with physical therapy, occupational therapy and speech therapy, other specialists that may be involved including a neuropsychologist, pulmonologist and ENT.

And joining me today to discuss the symptoms and treatment options for COVID-19 long-haulers is Dr. Nina Bhupathiraju. She's a physiatrist with Franciscan Physician Network and she's board-certified in brain injury medicine, as well as physical medicine and rehabilitation.

This is the Franciscan Health Doc Pod. I'm Scott Webb. Doctor, thanks so much for your time today. You know, we've all learned a lot of new terminology in the past year. Things like social distancing, which we never really heard before and never used certainly as much as we have in the past year. And another one that I'm trying to get caught up to speed on is COVID-19 long-haulers. What is a COVID-19 long-hauler?

Dr. Nina Bhupathiraju: The COVID-19 long-haulers are being identified as these patients who have persistent symptoms following a diagnosis of COVID-19. Initially, it was identified as this respiratory illness and typically respiratory illnesses have a short, concentrated recovery course that we can usually track pretty well.

In these patient population, we're finding that symptoms can sometimes persist for after two weeks. And if they still don't resolve, we've had patients that have symptoms a little longer up to 10 months. So it's really anyone that has symptoms longer than two weeks, two to four weeks, we're identifying as COVID long-haulers.

Scott Webb: So when we talk about, because you know, this is the sort of the allergy season for a lot of people and one of the difficulties with COVID-19 all along has been that it mimics these very similar symptoms to that of cold and flu. So is that one of the difficulties in diagnosing COVID 19 and now treating or diagnosing people as long-haulers? Is that one of the difficulties that now we're into allergy season when people may have issues anyway?

Dr. Nina Bhupathiraju: This absolutely is going to be more of a concern now. The COVID long-haulers really didn't really get identified until about May, really in New York, when they started noticing that more patients were having these lingering symptoms. We had that initial peak here in the United States, in New York.

So that's when they first were identified. And now, obviously with numbers kind of tapering down, now entering the new season of this allergy season, we're really looking at patients who've had a positive diagnosis of COVID-19 and whether that was a severe illness or mild illness, it doesn't really seem to matter.

These are patients who have recovered at home as well. So when we look at other patients who are complaining of maybe fatigue, myalgias, body aches, fevers, and chills, and we've ruled out everything else like the flu, like allergies and we feel like these are not related to that, we can treat them as COVID long-haulers.

We have patients that, you know, when you have allergies, definitely have more of a fatigue. You feel drowsy. This could just be from the allergy itself or from medications you're using. But if it doesn't seem to have come from really anything related to COVID, then obviously we wouldn't treat it as such.

When you have something like the flu as well, traditionally you would have this very identifiable course of recovery in usually about two to three weeks. And you don't typically have residual symptoms lasting beyond that. So we'd kind of wait for these symptoms to resolve, see how you're doing after a few weeks. Now, it's two months in and we're still having these symptoms and I think it's worth it to even look into, "Hey, is this related to COVID-19? Is this a long-hauler type symptom?"

So I think it will get difficult as we see more of that in the allergy season. But we've identified the course of recovery and typical symptoms with these other disease processes, such as a flu and allergies. These are definitely different and unique. So I don't think it'll be too much of a challenge to identify those.

Scott Webb: Yeah. That's great. And it sounds like you do have a real good handle on things. And so I want to talk about the long-hauler program. And I know you're treating with a comprehensive multidisciplinary approach, a psychiatrist, physical therapy, occupational therapy, and so on. So I want to have you tell listeners about the COVID-19 long-hauler program.

Dr. Nina Bhupathiraju: Absolutely. So we have a program just in general, as a physiatrist, we look at treating disease processes whether it be neurological, musculoskeletal. We want to treat these in a multi-disciplinary approach. That's just really how our background is and how we think about recovery from any disease process.

When we started seeing that these patients were having lingering symptoms, we just really wanted to see how we could treat that in our program. Well, we look at the symptoms they describe, this can be anything from vestibular, so dizziness, balance issues, and then they sometimes complain of vision issues. And one of the big ones has been this brain fog, memory issues. That is something that definitely we can treat in a good comprehensive therapy program.

What we've have set up here is therapy involving physical therapy, which traditionally people know is, you know, the musculoskeletal side of things, but also the balance part, the vertigo type symptoms, the deconditioning type. The lack of endurance patients are describing, more of a respiratory-based program. Occupational therapy helps with more of the visual deficits that patients are describing. And the speech therapy part is this cognitive part, the memory part and this pacing.

So in that approach, I think we can definitely help these patients just regain more of their function, quality of life. Then now, obviously with this complexity of disease, there are so many other symptoms patients are describing and we're learning more as we see more patients. These can be more chronic fatigue related to a thyroid deficiency or other hormonal imbalances, dietary concerns. So we address those and reach out to endocrinologist if needed. We reach out to our dietary department to help with certain diets, reducing this further inflammation in the body.

We have neuro-optometrists that also been helping our patients, which has been really interesting. Patients have been complaining of vague vision symptoms, visual deficits. We send them to occupational therapy for a basic visual assessment and, in turn, maybe to neuro-optometrist. We've actually identified some objective findings that seem to correlate to a brain dysfunction.

So if we can continue to reach out to these other services and treat patients under this comprehensive multidisciplinary approach, we feel it's the best way for these patients to recover, get back to work, enjoy their normal activities and just regain some independence again.

Scott Webb: I've heard recently, people have been talking about that lingering fogginess. What do you attribute that to?

Dr. Nina Bhupathiraju: There's a few things. So traditionally there's this term, chronic fatigue syndrome, which has been around even before COVID-19, which describes this as a disease process usually triggered by a viral infection. So that's been around for decades and this is kind of how we're treating it.

So in these lingering symptoms, when people complain of fatigue, we really want to see what this means. Is this a mental fatigue? Like, "Hey, I can't concentrate at work." Is this a fatigue related now to a hormonal imbalance? Is this fatigue related to, you know, vision? Is it related to really shortness of breath? Just to recap, this is a primarily respiratory disease or at least that's how it starts.

So, as we've seen more patients, we've kind of been asking more of these questions because patients also have trouble describing this. So it's really hard to identify it, but I feel like we're just doing a better job. So we're asking, "Hey, what is your fatigue? Is it 'I cannot walk from the bathroom to the kitchen'? Is the fatigue 'I can't concentrate at work'? What do you mean by this fatigue?" So as we kind of ask those more pointed questions, it's been really great to target that approach and it's really helped us.

So we had a patient recently who said, "Yeah, I traditionally use my albuterol inhaler maybe once or twice a month before all this. I was diagnosed with COVID-19, recovered at home." And now, I asked her how often she's using her albuterol inhaler, she said eight times a day. So clearly, this fatigue is related to a respiratory problem. So she was subsequently sent to her pulmonologists, changed her inhaler regimen, you know, had some more respiratory workup and she might need more of a respiratory-based program.

For another patient, the fatigue was a mental fatigue. It's "I cannot focus at work. The multitasking is hard. I get home and I'm worn out. I'm trying to help kids with virtual school. I'm trying to help get back to work." So that patient might benefit more from pacing from a neuroscience education, more from a neurostimulant at work, working on their sleep-wake cycle. So it's really identifying what's going on.

There has been a lot of studies of patients having a thyroid deficiency or just abnormalities from this. So then that's an endocrinologist who can help out, make sure hormonally everything is back in check so that hopefully we can identify that as well and improve.

Scott Webb: Yeah. And asking those pointed questions really helps you narrow down, identify, diagnose properly, which it's all really amazing. Before we move on, I wanted to ask you, who's more likely to be a long-hauler? Is it men or women?

Dr. Nina Bhupathiraju: So right now, you know, we look at just identifying the long-haulers. Initially, the forums and the questionnaires that were coming out were just symptom identification. You know, "Do you have any body aches? What are you really describing?" It turned out that it was about 2:1 ratio in some studies that I saw too, that was more females to males that we're describing these symptoms, or at least more likely to identify them and present to their primary care physician with these issues.

It's still too early to say who really identifies that way. Is it just underreporting from some patient population? Again, for us in the medical world, we're identifying it more, but it's not really something that patients have seen in the real world. So I don't know if men may be just not prone to identifying it.

Traditionally, what we've seen so far is, yes, women are more likely to report these symptoms, but I don't know if they're just more prone to having that or just that they're more reporting it more, so it’s hard to say right now.

Scott Webb: Yeah, I'm sure it is. And you know, that's one of the sort of fascinating things in a way about COVID-19 is, you know, how far we've come, how much we've learned and how much more there is yet to be learned and really kind of interesting and fascinating I'm sure for medical professionals, doctors, and scientists, and so on. Doctor, as we get close to wrapping up, this has been a great conversation, tell us about the day rehab program.

Dr. Nina Bhupathiraju: Yeah. How this actually started was we were a really well-run system with our day rehab program here at Franciscan, meaning if you see any more than one discipline of therapy, whether it's physical therapy, occupational therapy or speech therapy, you're identified as a day rehab patient.

We really want to say, you know, not every patient is appropriate for inpatient rehab hospitalization, but there is a portion of the population that don't require hospitalization that still require a comprehensive rehab approach to their care and recovery. So we have a program for our patients with strokes, we have a Parkinson's day rehab program, amputee day rehab program.

When we were looking at New York and when they started identifying, especially at Mount Sinai hospital, identifying these COVID long-hauler patients, we looked at how they were treating them and we realized we had that infrastructure here already.

So we've incorporated that to our COVID-19 long-hauler patients. Obviously, there are some fine tuning that comes with that. But the day rehab program really entails PT, OT, and speech therapies, along with a neuropsychologist. We have case manager and that's under physician oversight. So we frequently meet with therapists to help with these patients that are in the program and to see what barriers they have to their recovery, that we can identify earlier and take care of, and just treating that multidisciplinary approach.

Scott Webb: Yeah. And as always, Franciscan is on top of their game and, you know, always on the cutting edge. And great that you already had a lot of these resources and you could say, "Well, wait. We're already kind of doing this. Why don't we, yeah, move this over to COVID-19 and do it there as well?" So, really great stuff, yeah. Doctor, as we close here, anything else you want to tell people about COVID-19 long-haulers? How long before, if people are experiencing symptoms, they might want to be checked out, be tested in case they are in fact a long-hauler? Anything else you want people to know?

Dr. Nina Bhupathiraju: Right now, we're just learning more. It's really interesting to see how patient presents, how we can help them out. And so, as patients are learning, we are too. I think really, if you have lingering symptoms that are affecting your quality of life and function, whether it be emotional, mental, psychological, physical, neurological, there's definitely a reason to see your primary care physician and to seek help.

At Franciscan, we've discussed this with our primary care physician team to really help get our patients in the program earlier. If they have any patient with lingering symptoms, that's really affecting their quality of life, we think that we can help them.

Sometimes they may not need therapy. They might just need a better sleep-wake cycle, adjustment. They might just need a little help with coping and behavioral health. They might not need all the resources that we have, but our goal is to help with function and return to quality of life. So there's a way we can do that. And that's what patients are seeking. I think it's definitely worth it to investigate that further on their end.

Scott Webb: Yeah, that sounds right. Sounds like great advice. And it's always a great thing to do. Start out with your primary and this multidisciplinary approach and all that you offer, including the day rehab program. Really amazing stuff. Doctor, thanks so much for your time today. You stay well.

Dr. Nina Bhupathiraju: Thank you very much. Appreciate it.

Scott Webb: And we hope you found this podcast to be helpful and informative. This is the Franciscan Health Doc Pod. I'm Scott Webb. Stay well, and we'll talk again next time.