Welcome, everybody. Tonight's goal is to foster discussion among faculty and attendees regarding several critical topics, including provide a high-level explanation of the etymology and symptoms that we are facing today to show how PMR is qualified to care for this patient population. Provide practical tips on how to manage this patient population as rehabilitation is pivotal to the care of those dealing with long COVID. Highlight the guidance and development by AAPMR's multidisciplinary PASC collaborative, which is fostering an ongoing patient-centered clinical exchange between post-COVID clinics nationwide for treating and learning more about long-term issues resulting from COVID-19. Having said that, I'm going to now turn it over to Dr. Bharata. Good evening, everyone. Thanks for the opportunity to be here this evening, and we look forward to speaking with you. Before I begin, if I may introduce myself and the other panelists, I'm John-Michael Bharata, a clinical assistant professor from the University of North Carolina Chapel Hill School of Medicine. On the line this evening, we also have Benjamin Abramoff from the University of Pennsylvania, Dr. Alba Azola from Johns Hopkins University, Saranda Barshikar from UT Southwestern, and Talia Fleming from JFK Johnson. We look forward to speaking with you this evening. So I will begin with an introduction to long COVID and PASC, which is a new syndrome name, and I'll be discussing that in a moment. Before we begin, I'd like to just touch on the objectives for this evening, for our discussion. We hope to provide an overview of long COVID epidemiology and symptomatology, describe an evaluation protocol and how rehabilitation principles are used in the management of the syndrome, discuss the AAPMR Long COVID Quality Improvement Collaborative, and also demonstrate how physiatrists are and will be involved across the care continuum, leading the rehabilitation care team. So let's start by reviewing some terms. You all may be familiar with the first two terms listed here. They've been in the media a lot, long COVID and long holler. But the third term may be somewhat new to you. Long COVID is a syndrome characterized by a varied but persistent set of symptoms and health effects after resolution of the initial infection, and this may last for weeks, months, or perhaps even longer. A long holler is a person that's a COVID-19 survivor with lingering effects after resolution of the infection. And post-acute sequelae of SARS-CoV-2 infection, or PASC, is a new syndrome name that was announced by the National Institutes of Health in February. Details of this diagnosis, of this syndrome, are still being defined at this time and will be the subject of a lot of future research. So PASC may overlap with other complications of COVID-19 infection, making it difficult to define. That being said, thus far, early data seems to suggest that the prevalence is highest in people who had more severe infection. So people that were hospitalized, needed ICU-level care, and who have medical comorbidities. However, there is a large and substantial risk for PASC in people who even had mild initial infection and did not need hospitalization. You can see on the right side, the diagram demonstrates some of the overlap, which illustrates the complexities associated with this particular syndrome. There may be overlap with other hospital complications for people who were admitted to the hospital, and also PICS, or post-ICU syndrome, which is a collection of physical, functional, and emotional challenges after intensive care. While the incidence of PASC is unknown, recent studies suggest that perhaps 10 to 30% of COVID-19 survivors may develop PASC. And due to the large burden of infection in our country, currently at 33 million Americans that have been infected, we can estimate that perhaps 3 to 10 million Americans may develop PASC. And these symptoms can be varied, but are often debilitating. The diagram on the bottom of this slide shows data from one of the longest U.S. cohorts, which is located in Washington State. This particular cohort analysis showed that about 30% of patients, most of whom were not hospitalized during acute illness, 30% had lingering symptoms at 3 to 9 months. I know the image on the slide is a little small, and we're going to dive into all of the most common symptoms here shortly. But I just wanted to give you an idea of the breadth of the situation. So this presents really tremendous implications for our country and its citizens. This study, published in April in Nature, analyzed the records of about 5 million Veterans Health Administration users. And it showed that people with PASC developed or had higher risks of death with increased hazard ratios. They had increased healthcare utilization with higher number of visits and also higher use of medication. These PASC patients also had increased ranges of a number of diagnoses across a variety of organ systems. So why does this occur? We don't really have a great understanding of the pathophysiology behind PASC at this time. There are two key categories, broadly speaking, of people who may have lingering symptoms. One category includes people who have end organ damage from their acute illness. And the sequelae of that is more easily understood because it seems to be directly connected with the organ damage. For people who don't have organ damage but continue to have persisting symptoms, there are a few key theories, which I've listed here. These include that there may be remnants of virus particles, essentially irritating systems in the body. There could be an autoimmune phenomenon, which essentially stimulates immune cells to attack different parts of the body. And there may be inflammation from a cytokine cascade, which can cause damage to a variety of cells or organ systems. I'd like to wrap up my part of the discussion by touching on the central role of our specialty in PASC care. We have a very important role. Physiatrists serve as a logical and appropriate choice to lead PASC programs for a variety of reasons. We are able to manage rehabilitative plans for patients with complex medical illnesses and multisystem manifestations that mirror PASC. We lead a variety of rehabilitation settings and can provide continuative care. And we also utilize a multidisciplinary and collaborative approach, thereby being able to provide comprehensive and efficient care for patients. So I will now turn it over to Dr. Azola. Thanks, my name is Alba Azola and I'm part of the faculty at Johns Hopkins Physical Medicine and Rehabilitation and I wanted to share a little bit about the clinical presentation and what you see in this patient population when they come to a post-COVID clinic. So we know, as Dr. Baratta was sharing earlier, that symptoms of PASC are those that present four weeks after the acute infection and they involve a variety of systems including musculoskeletal, respiratory, neuro, cardiac, vascular, renal, as well as cutaneous manifestations. We know that not only patients that had acute severe infection and had to be at the ICU for some time present with lingering symptoms, but also patients that were pretty mild acute disease. In this particular study, the majority of the patients were non-hospitalized and the 79 days after initial infection, there were a significant amount of the patients, about 87 percent, were still complaining of fatigue being one of the most prominent symptoms. Dyspnea, unexertion, chest tightness, myalgias, headaches, and heart palpitations were some of the other prominent ones. So in our clinic, when we have our initial evaluation, we have a template and we really want to get to know the initial acute symptoms and the onset of infection and the duration of that time. We want to know if they were hospitalized, if they used supplemental oxygen, if they spent some time in the ICU, were they actually on high flow nasal cannula, were they requiring mechanical ventilation, did they spend some time paralyzed or positioned in pronation. All those things are important to gather because they're going to lead you to think some potential complications that we have been seeing after COVID. Also, I want to highlight the importance of getting to know a little bit of the cardiac, even cardiac family history, pulmonary history, and I've seen patients, for example, that were preemies and they had never had any issues with breathing, but all of a sudden, you know, they had this new onset of this neon exertion and, you know, they had some damage to their lung tissues at a very young age. So all those things can be relevant. And then another thing that I've, that we have been noticing is other autoimmune diagnoses, patients that come in with already present Hashimoto's thyroiditis or other autoimmune disorders that can be exacerbated by COVID or even have more autoimmune disorders flourish after COVID. The other important fact is we want to ask what happened since the acute infection. Did they continue to feel the same way or the same symptoms? Was there a period that they recovered and then they all of a sudden had a new flare or onset of symptoms? What was the specific trigger for those symptoms? What are the patterns of those symptom presentation of that fatigue? For example, are they noticing that they're having major fluctuations? Are they noticing that it's pretty constant? What are their energy windows? What are those times of the day that they feel better? How can we help them manage within their symptoms, utilize those energy windows effectively? And another common symptom that we're seeing is headaches and tinnitus. And something important about the headaches and the tinnitus is to ask a little bit more about the quality of the tinnitus. Is it a ringing or is it a pulsating? We've found that we've had some patients with increased intracranial pressure and that could reveal or, you know, pulsatile tinnitus could be one of the cues, changes in position of the head, so kind of varying the pulsatile tinnitus quality. So kind of really digging into those complaints is important. We've standardized mobility and ADLs evaluations, you know, as a general PMNR physician we know how to do that very well. But it's definitely important to be able to monitor progress and use some sort of standardized evaluation. One of the most helpful tools that I found is the Promise 10 in terms of really getting insight into how much these impairments are affecting their day-to-day lives and their families' lives as well. And what is their concept of how limited they are and how much their health is impacted. Some of the patients can present with dysphagia, mainly those patients with prolonged hospitalization, prolonged intubation that are at higher risk, and we screen with an 8-10. It's not enough to just say, are you having trouble swallowing? They may say no, but if you ask them, are they cutting up their meals really small? Are they using extra liquid? Are they taking more than an hour to end the meal? So really teasing out and getting to the bottom of those symptoms. Again, we also understand that there's a significant component of depression and anxiety that comes from the impairments and we want to screen for symptoms of depression and anxiety and help them find ways to get support for those. We also screen for cognitive impairments. In our particular clinic, we have the support from neuropsychology that are performing formal cognitive evaluations in our patients, but simple memory screens are a very useful tool as well. Sleep disturbances have been reported by many, and something important to look out is for common things. So we actually perform a stop-bang questionnaire when we have patients that complain of sleep disturbances just to screen for OSA and needed referral to sleep clinic. And another one of our PM&R history typicals is the work history. You know, what are they doing for work? How is this impacting their work? Starting to plan how returning to work is going to look like, what type of accommodations they need. And another component that we found really helpful because many patients present with autonomic dysfunction symptoms is to go through a questionnaire for screening of all the different aspects of the autonomic symptoms or autonomic system. So this is a modification of the 31 questions from the Compass 31, kind of abbreviated version, but we go through asking about tolerance of standing, experiencing changes in color, flushing on their face, noticing goosebumps, changes in the way their sweat, either feeling like they're not sweating at all or excessive sweating, excessive tearing, probing about GI symptoms, the nausea, vomiting, weight loss, diarrhea, constipation. Another one that I found surprising that many people realize is urinary retention. Asking them about their bowel and bladder function can be very revealing. Also changes in vision. And for this autonomia, we're asking more about changes, for example, difficulty focusing or difficulty adjusting to changes in light. And for mobility and endurance, one of the tools that I have found helpful is the 30-second sit to stand. It depends on the patient and their level of endurance, but it can be really helpful and patients enjoy kind of tracking their progress as they kind of start working with therapies and start getting stronger. And we also on those patients that test positive on those questions for the dysautonomia screen, we'll do a 10-minute stand test in the clinic to note for any big changes on heart rate or big changes on blood pressure. But we also want to hear, you know, about the symptoms and what they're presenting with, what they're reporting during that 10-minute stand test. And neurologic exam is also extremely important. Some of the patients that we have seen, especially in the population that had prolonged ICU stay, may have focal neurological neuropathies, like from the positioning, they may have brachial plexopathies. And it's important to do a full exam to assess for those. And I will pass it along to Dr. Barshikar. Thank you. So my name is Surendra Barshikar. I'm the medical director of our Southwestern and Parkland Hospital Rehab Clinics. I'm also the vice chair of clinical operations at UD Southwestern. So, so far we have seen the basic overview, some of the intake and the history. And now we're going to talk about two of the most common symptoms that all of us seeing patients with COVID will be managing. So looking, the symptom list is exhaustive, and we don't have time to go over all. So that's why I said we are going to talk about the top four to five symptoms that all of us will be managing. So let's start with, okay, let me see if it moves. Okay, there you go. So number one symptom that most of these patients will complain is fatigue. As, as you saw mentioned by Dr. Ozola, certain, depending on the study you refer to, over three-fourths of the patients with post-acute sequelae will complain of fatigue. And the complaint of fatigue can be physical, or it could be cognitive, or it could be combined. So when, when we talk about physical, it can manifest as poor exercise tolerance, inability to perform their day-to-day activities. And these day-to-day activities could be just very simple, basic activities. I mean, some patients may really complain of just inability to move from their bed to, to going into kitchen to make a meal. So very basic. So it really depends on individual person that the level of fatigue. A phenomena of post-exertional malaise is very commonly reported. What that really means is there is either a sudden crash or body aches, severe fatigue that follows a period of activity. In such patients that you have to analyze, like ask them for their energy window. And what that means is typically patients do report that, okay, there is a period when I have energy to do things, but when I do things after that, I suddenly crash. And I really, really feel bad. I take one step ahead, like five, four steps back, something like that. So in these patients assessing sleep, mood, diet, and fluid intake is, is very important. If the, if fatigue is prolonged and if it's not getting better with conservative measures, there's certain blood work or lab work that is to be considered starting with vitamin D levels, a basic neuroendocrine screen, which could be you're starting with a thyroid assay, and then ACTH, LHFSH, and testosterone, depending on the sex. And then going into an autoimmune panel can be considered for resistant cases. After optimizing the comorbid condition, the mainstay of treatment is a graded exercise program. But this exercise program has to be very individualized and titrated based on patient symptoms. So it is really has to be symptom limited. And one important part here is to not to push patients at least initially until the patient feels comfortable and the provider or the therapist has a better understanding of patient's tolerance. Energy conservation techniques have to be discussed. And these, I think, are one of the most important measures that individuals with fatigue need to make sure they follow. Pacing and prioritizing activities throughout the day should be implemented. And the last is like medications. Medications really do not have any clear role at this time. All of us who practice brain injury medicine, we know we use other medications for say excessive daytime sleepiness or fatigue in neurorehab field. And they can be tried here again, but we don't know if it really helps or not. So at this time, it doesn't have a clear role. The next common symptom complaint is cognitive fog or mental fog. Again, this is one of the most common symptoms and over 50% of the patients will complain of a cognitive fog. And the symptoms may vary between just inability to focus or concentrate on the task versus impaired memory, mainly to short-term events, impaired receptive language. And patient may say, well, people are telling me that I ask the same questions over and over again. I do not recognize things that were told to me. And then difficulty with multitasking. And it also could manifest as like impaired executive functioning. And the presentation that these people, the patients come to you may really vary from just a subjective cognitive symptom with a negative or a normal cognitive screen and testing to basically actually objective mild cognitive impairment or individual domain impairment that is seen either in your screen or a detailed cognitive assessment. So what is the mechanism of cognitive fog? Again, not very well understood at this time, but well, question, if there is a neuroinflammation ongoing, we don't really know that. Some studies do say that there's some persistent inflammation, but it could also be secondary to deconditioning, your PTSD, dysautonomia, and post-critical illness, either like a delirium that eventually manifests into a cognitive dysfunction or just from your significant medical comorbidities. A detailed in-clinic cognitive assessment should be performed while seeing these patients for the first time in your clinic, and then appropriate referral to either speech therapy or neuropsychology should be considered. So cognitive therapy is still the mainstay of treatment after you treat the comorbid symptoms, including sleep, making sure there's enough fluid hydration, nutrition, and other medical comorbid issues. That includes like obstructive sleep apnea, all the sleep issues, and improving their fatigue and the other like chest discomfort. Some supplements that are commonly used like omega-3 and acetylcysteine, and this, this list is exhaustive. Again, we don't really know if there is any COVID-specific benefit at this time. Okay, the next group of symptoms are our psychological symptoms, and the psychological symptoms really can vary from just a little bit of an adjustment disorder. It could be anxiety, it could be depression, or it could be full-blown PTSD. We do see significant amount of PTSD in this patient, especially for the ones that had a prolonged initial hospital stay, intubation, mechanical ventilation, and who had like a severe initial hospital or multi-organ involvement. There is a study here that I've quoted, which reported that like 56% of their patients really had some kind of a psychological issue in either of the, one of these domains. So what are the main reasons people complain of psychological issues? It could be really uncertainty, fear of unknown, isolation, lack of normalcy, medical complications, and again, there is this thought whether there is a neuroinflammation relating to some obviously impaired neurotransmitters leading to psychological symptoms. Insomnia and lack of physical activity also are huge contributors. So if you think, I mean, if an individual is not sleeping well, if he is not able to physically move around, and they're limited to their room, it's pretty, I mean, it's very commonly seen that they're going to have some form of psychological issue. The mainstay of treatment initially starting would be an individual or a group counseling or psychotherapy sessions. Antidepressant use depends really on individual severity of the symptom and also patient characteristics and side effect profile. Just to mention fluoxamine, I'm just putting it here because it may be asked by some of the patients and in some of the support groups. So fluoxamine is just an SSRI. Obviously pre-COVID it was not very famous or not a very go-to med, but there was this study that I've quoted here, the second reference. So they use fluoxamine in acute COVID actually. So it's not related to post-acute or chronic sequelae. They use fluoxamine in over 150 patients in acute COVID, and they found out that patients who were on fluoxamine, really zero patients on their fluoxamine arm had deterioration. While the ones which had the placebo, six patients had clinical deterioration, and they said this was statistically significant. Again, we really don't know if there's any benefit of fluoxamine in post-acute sequelae, but if you are going to use an antidepressant, sure, why not? It really depends on side effect profile and patient characteristic and provider comfort level. Depending on the severity of the psychological symptoms, referral to psychiatry, neuropsychology should be considered if the treating provider is not equipped to manage these symptoms. So the next common symptoms are autonomic symptoms. So Dr. Azola did mention some of the common presentations that these patients may present, and this really varies because autonomic dysfunction can manifest in different systems. It could be a GI-related symptom. It could be your vascular motor symptom. It could be basic changes in your heart rate. So one of the most common symptoms that we see in our clinic is heart rate variability, and it's manifested as tachycardia with really minimal activity. And what I mean by minimal activity is like really minimal activity. Some patients really tell me, okay, I get up and try to just walk around and my heart rate races. A lot of patients nowadays have some form of a smart watch or some kind of device that is able to monitor their heart rate. So people are more and more aware of their own heart rate these days, and that's what they're really complaining. A drop in blood pressure and orthostatic intolerance and symptoms like post-orthostatic tachycardia syndrome can also be present. And obviously, the mechanism here is your deficits in the adrenergic modulation or your adrenergic parasympathetic sympathetic nervous system caused by, again, neuroinflammation. I guess we don't know the exact evidence, but this is what is taught about. People may also report persistent short of breath, chest discomfort, which may be one of the manifestation, and some present like a presyncopersyncope. The initial assessment should be a detailed history followed by some kind of questionnaire. I mean, Dr. Azula mentioned a shortened version. In our clinic, we actually do the full-blown COMPASS-31, which is a pretty long questionnaire for this. And we also do standard orthostatic vitals on every patient, which we highly recommend. And then, depending on the symptoms and your scoring, autonomic testing should be considered. For such patients who specifically present with chest discomfort, tachycardia, cardiac workup should be considered. Again, individualize. I'm not recommending cardiac workup on every patient that comes to you, but depending on individual patient, getting an EKG, a halter, or echo may be warranted. Management of these symptoms, again, vary, but the most important is starting with education, graded exercise, fluid intake and salt repletion, compression garments as needed, and pharmacological management. Beta blockers are the first-line medication that can be used, especially if there's just pure tachycardia as one of the common symptoms. And people, most patients respond pretty well with a low-dose beta blocker, and fludrocortisone or midodrine can also be considered. So, the next one or two minutes, I'm just going to talk about the basic principles of rehabilitation that we are using in these people. This, I mean, this is really new for all of us, but luckily, the symptoms that a lot of patients are presenting with are not new. And as rehabilitation physicians that have wide expertise in brain injury, spinal cord injury, debility, we are really equipped with managing their individual symptoms because we have seen these symptoms elsewhere, not as a constellation like we see here, but individual symptoms are really seen in a lot of our other diagnoses that we manage. So, Oveid et al. did lay out the basic guiding principles, our main categories for rehabilitation management, and these include general exercises that increase your cardiorespiratory work. So, our basic concepts of cardiac rehab, repetitive practice of functional activities, this is obviously our main, I mean, our expertise here, psychosocial therapies, education with emphasis on self-management, and set of specific actions tailored to patients' priorities, needs, and goals. The, like I mentioned, I mean, we know rehabilitation works, but outcomes are not very well studied, but anecdotal evidence and in talking with, I mean, patients in our program and across the nation, we have seen that a lot of these, majority of these patients are getting better. So, though we do not know outcomes, I think with all these studies that are ongoing, we soon will start knowing that these management definitely helps. So, the brief, quick example of what I mentioned earlier, a rehabilitation program really will be based on some of your existing components. For example, components of concussion clinics, and we already know how to manage persistent symptoms, and we have all the required elements. So, we know how to manage cognitive impairment. We know how to manage dissonance, vestibular dysfunction. We also know how to manage psychological symptoms. We know how to manage headache, which is another symptom, and we have knowledge of our complex medical cases, sepsis, prolonged intubation, hospitalization, critical illness, myopathy, neuropathy, and managing your sarcopenia, muscle deconditioning, cardiopulmonary deconditioning, neuropathy, delirium, autonomic deconditioning, and psychological symptoms. So, a combination of these, if you put along, and if you think, well, I think this makes up a very well program to manage your COVID patients. So, what are your main goals? The goals of your COVID program, obviously, managing symptom is one, but overall, the program should prevent further deconditioning. That's like rule number one, followed by gradual reconditioning, return to normal ADL and mobility, improving your respiratory function, improving mental health, gradual return to your work, school, or other social role, and finally, community reintegration. This here is a very busy slide, and this is where I'm going to end. The paper I quoted here, which was published earlier this year in the BMJ, have laid out a pretty nice self-explanatory guide for return to physical activity following COVID-19. This is not very specific to post-acute sequelae, but it does include all the different phases. They start with the phase one and gradually go to phase five. It's recommended by these authors to spend a minimum of seven days at each phase, and then slowly advance to the next phase, and if the symptoms worsen, go back one phase. And they have divided the graded exercise or the exertion level based on the rate of perceived exertion. We all know how to use the RPEs in our day-to-day practice, and this is how it is guided, and for all the listeners here, I've listed the source. I would recommend, highly recommend looking at this whenever you have time. I think that's all for me, and I'll give the control to Dr. Abramoff. Thank you. All right, let me unmute myself. Thank you, guys. So I'm going to talk a little bit about how our PASS clinic at Penn was developed, and I think it's kind of how a lot of us who have been starting these clinics and working in these clinics did it, by just kind of figuring it out as we go, because there was not a lot of guidance, and hopefully our experience will be helpful for you. So similar to many of you, we had an early autumn 2020, March, April, we closed all of our outpatient clinics, and then we were starting to take inpatients with these multi-system disorders following COVID who were critically ill. These were your kind of typical PICS patients, post-ICU syndrome, with multi-organ system issues, and then we started taking and noticing kind of on the outpatient side that not only were patients who were critically ill, but as all the other speakers have mentioned, even those who were not hospitalized and not critically ill initially were continuing to have persistence and symptoms, and so what were we finding, and I think this is again pretty common, they're having these multi-system deficits, as you know, has been well described, but there was a sensation that in the sense that people were being shifted from provider to provider, there was no home within the system, nobody, you know, knew kind of what the left and right hand were doing, there's no coordination between these providers, which I think our patients really felt that, you know, with a novel illness, they really wanted people who had seen other patients who had had these persistent symptoms, and they wanted, you know, the different specialists to really be talking with one another, and so that's how our clinic came into being, and we developed it in PM&R as kind of the home base to kind of go to these other symptoms specialists. I'm a spinal cord injury medicine trained physiatrist. Again, our patients have these multi-organ system issues, and we tend to have, and I tend to have, a urologist that we tend to work with closely, and a neurologist that we tend to work with closely, so we kind of use that same model in developing our post-COVID clinic, and then we had providers that we kind of picked out that worked well with us, and who had an interest in this patient population, and you'll see if you, you know, start sending these patients to different providers, some will really want to dig in, think about it, offer kind of novel thoughts and solutions, and others really kind of don't think it's a real thing, or because there's no objective clear findings on chest x-ray, that there's nothing that can be done, so we started with a team basically with us in pulmonology, and then kind of started to enter in with therapists, and neurologists, and cardiologists as the time went on, and it's continued actually to grow since that point, and even though there's no, you know, cookie cutter way to treat these patients, there are symptoms and syndromes that come up again and again, so having that structure to how we address these different symptoms turned out to be very helpful for us, so similar to other clinics as has been described, we start with a one-hour telehealth screening visit, and then based on kind of what symptoms, and how they do, how they respond to questionnaires, we filter them to different specialists, and I'm not going to go through this whole thing, and I'm happy to share these slides afterwards, but for example, if they had cognitive symptoms, they would go to, we'd recommend one of our cognitive neurologists, or seeing cognitive therapy with one of our speech language pathologists, and we build kind of the people who felt comfortable over time, so now we have two or three speech language pathologists within the system who see multiple patients with post-COVID syndrome, and then, well, we tend to offer follow-up after a few months with our patients, just to make sure that they're on the right track, they've been, when we give them these complex plans of see this person get this testing done, they have that follow-up person, that follow-up as a back, backstop, and I think the patients really appreciate that, because, you know, they feel so lost to begin with, because they have this novel illness that's not a lot still known about it, that having somebody who they can kind of go back to and bounce questions off of, and is available, I think they really appreciate. So that's how we did it. One other thing that we did to try to get a better sense of this, is we did a survey of past clinics throughout the country, and so we talked, we got survey responses from 46 different clinics in 25 states. So this is just to show you, basically, that there's many ways to do this, and people do it very differently, and I don't think we're at the state where we can say this is one, the one best way to do it. I'm sure many of the fellow panelists have, you know, a few patients at a few different specialties that see the patient the first time they come in. We are a single disciplinary clinic at first, and we kind of have triage and methods that send to the right people, and communication back and forth. So I think this is a little bit of selection bias, but most of the clinics that we spoke to were PM&R based, but pulmonology and internal medicine also have pretty significant homes as for these past clinics. Just said, a lot of people ask about behavioral health. There are many different forms for this, and there's no kind of one method. Some refer to behavioral health specialists, others directly manage as part of their post-COVID clinics, so they're prescribing the antidepressants, they're following up, they're establishing patients with therapy. We personally refer back to the primary care provider for that ongoing long longitudinal relationship. So again, many different ways that this is taken care of. And then many of the clinics, and ours included, provide different resources to the patients, educational resources, so it can be handouts, social support group resources, directed to website, whether that's Survivor Corps, which is a patient website, different CDC websites. So there's a lot of different resources that are out there, and one of the things that I think as you're developing these clinics, or if you're thinking about developing a clinic, is really trying to tap into the resources that are out there. John Hopkins has really good home exercise programs that a few of the different clinics use, and so there's different things that you can really tap into to serve your patients. So, and these clinics really sprouted out organically from COVID, so 86% of the clinics did not come from a pre-existing post-ICU clinic, they're brand new specifically for the purpose of treating long COVID patients. Most clinics do disability paperwork, and then about 44% of patients, or excuse me, 34% of patients have some sort of support group that they host, which I think is pretty interesting. A little bit of variety in terms of the length of these clinic visits, the majority, I think it's like 60 something percent, are about that one hour mark, a small percentage go longer than an hour, and then about a third are less than 45 minutes. A mix between in-person and telehealth, and many of the clinics do it based on what the patient prefers, so it's kind of split up equally between those three different types. Again, most clinics have some sort of multi-specialty component initially, about a quarter like ours do not, about half and half have some sort of formal team meetings, which I think is really admirable that that's able to be done, because I'm sure that helps the patients. The most common practice, the specialties that are involved are PM&R and pulmonology, and then many also have physical therapy, internal medicine, occupational therapy, and neuropsych, as you can see, neurology as part of their initial visits. So, there are clinics that use inclusion and exclusion criteria to see the patients. We do not, so we see anybody from Pennsylvania and New Jersey who have any type of reported history of COVID, but other clinics do use positive COVID tests needed, some have, or more of the post-hospitalization type clinics, some say you have to be greater than three months or one month since their diagnosis, and you can see the timeframes, most are between that one and three months that they are open to seeing the patients, and that makes sense, because these patients do have a good amount of natural recovery early on, so you don't want to necessarily, I mean, you can see them, but a lot of times they'll just get better on their own, and there's such a need for the long-hauler patients that you don't necessarily want to fill up your spots with those patients kind of still in that acute recovery period. This has been kind of addressed in detail by some of the other presenters, but most of the clinics do have some sort of standardized screening procedures. These are the tests that are used by the different clinics that respond to the survey, so many do screening of cardiac function with ECHOs, EKGs, pulmonary function tests are pretty common, particularly in those clinics that are run by the pulmonologist. MOCA is the most common cognitive test, PHQ, GAD are the most common psychological testing. In terms of physical testing, a six-minute walk test is used pretty frequently. It's a nice test because a lot of people know how to use it, and it's used often. I think sometimes it's not sensitive enough to see the impairment in these patients, and then a scattering of other kind of standardized screening measures, but most of the clinics did report having some obstacles. The most common were need for more established protocols, more clinical resources, whether that's more physicians or other types of healthcare workers to help staff the clinic. Financial resources did come up in terms of making sure the patients have insurance coverage for things like therapy and some of the testing that they wanted done, and then psychological and psychiatric services were also pretty commonly reported as being in need of these clinics. So how did AAPMNR and the group, the panelists, kind of work to help address some of these issues? Through AAPMNR, we've created a multidisciplinary PASC collaborative made up of established PASC clinics, and really to address some of those barriers that we identified. And again, this is kind of small font too, but there's a lot of interest in a vast array of different things this collaborative can do, and hopefully as we build and grow over time, we'll be doing more and more of these things, but the ones that kind of were highlighted at the top were development of clinical protocols, establishing best clinical practices, sharing kind of knowledge and resources, and collaborating on research and data collection efforts. But really everything that we brought up is possible. There were lots of clinics that we're interested in, and I won't go through this slide because I know we're running out of time. And then the other thing I think that's really interesting that came up is only about half the clinics had protocols, but most of the clinics that had protocols were willing to share them. So if you have an interest and you're thinking about starting one of these clinics, feel free to reach out to myself or any of the panelists, I'm sure, to see what protocols they use and how you can kind of apply it to your own clinic that you're thinking about developing. The collaborative is made up of 27 sites at this point in time. If you're interested in potentially becoming a part of the collaborative and you have a PASC clinic, please feel free to contact myself or AAPMNR and we'll help get you set up. And so right now, kind of the most pressing need based on our conversations as a collaborative was the development of specific clinical protocols for primary care providers, clinical guidance for those who are starting PASC clinics. So how do we address the patients that are sick right now? And so using our kind of expert consensus and our expert opinions and the limited research that is out there, we started a consensus process to develop guidelines. The first guideline on fatigue has officially been submitted. So hopefully those will be out soon. And it's free from looking at kind of all the different aspects from assessment to treatment. So it will be certainly on the AAPMNR's website and probably distributed to you in some other form as well. And so there's a lot of goals here. We're engaging patient groups. We have health equity as a major focus of the collaborative's efforts as well. So really looking at it from kind of all angles. So I want to make sure that we have enough time for Dr. Fleming. So I'll end it there. Please feel free to reach out to me with questions or I'm sure any of the panelists. Thank you, everyone, for joining us this evening. My name is Dr. Talia Fleming from J.S.K. Johnson Rehabilitation Institute where I'm the medical director for our COVID rehabilitation program there. So we've heard so far about the symptoms, some of the rehabilitation principles, and some of the program development of the post-COVID program. I'd like to share some of the rehabilitation across the COVID continuum and share what we know so far with the literature. So we've described already the importance of PMNR in taking care of patients with long COVID or past. And the AAPMNR has really taken a stand in terms of identifying that clinicians across the rehab system have already begun to initiate rehabilitation protocols, not only from the intensive care unit, but also to develop programs, settings, and specialized care to meet the short and long-term needs for COVID survivors. What we're also finding is that complications from COVID-19 can be reduced by delivering interdisciplinary rehabilitation really across the whole rehabilitation continuum. So not only through the acute hospital stay, but also by providing care in the inpatient rehabilitation setting, either at the IRF or at the subacute level, as well as rehabilitation care at the outpatient setting really leads towards the best outcome. So let's see what the literature says. In terms of the acute hospital stay, this study from Kim et al. and Dr. Izola from our distinguished panel is also part of this research group. They found that successful treatment takes into account not only the complexity and the severity of the disease, but also takes a look at the spectrum of interventions, starting from the intensive care and continuing all through the appropriate levels of care. This also requires a look at clinical and administrative factors in order to execute this well, as well as looking at local resources. In terms of the inpatient stay from the IRF and the SNF perspective, this particular study from GROW that was in the PM&R journal recently was a retrospective observational cohort study looking at inpatients from the IRF. What they took a look at is they stratified patients based on COVID-19 status as well as their rehabilitation impairment, and they found that COVID-19 patients had equivalent or superior improvements in functional ability in self-care domains as well as mobility domains. Those patients also had improvement in their functional change efficiency as well as their length of stay. When they compare them also to medically complex patients, patients with COVID-19 had greater functional ability in self-care as well as mobility, and COVID-19 patients had similar rates of return to the community. So this was a really important study showing the importance of inpatient rehabilitation and how it can improve outcomes in COVID-19 patients. In addition to what's already been described in terms of physical therapy, occupational therapy, and speech therapy, which we're pretty familiar with as physiatrists, some of our comfort levels also in terms of recommended rehabilitation psychology as well as neuropsychology. I wanted to bring to everyone's attention the fact that we also have other tools in our tool belt as physiatrists. So this particular study looked at specifically cardiac rehabilitation, and it was a retrospective analysis of a cohort of COVID-19 patients at a single-centered inpatient rehabilitation clinic. What they found is that there were significant enhancements that were noticed in the six-minute walk test as well as the feeling thermometer for patients who participated in cardiac rehabilitation. They found that cardiac rehab for COVID-19 patients were safe, feasible, and effective, and improvements in physical performance as well as subjective health status was found independent of whether or not the patient was on prior ventilation. The goals of pulmonary rehab, as we know, are to improve symptoms of dyspnea, relieving anxiety, reducing medical complications, and minimizing disability in patients with chronic pulmonary conditions. And we're finding that as well in pulmonary rehab, we're finding those improvements in our COVID-19 patients as well. So this particular study took a look at that, and they found that pulmonary rehabilitation should be considered when possible and safe in addition to addressing symptoms such as poor nutrition, airway management, posture, want to look at clearance, as well as oxygen supplementation and breathing exercises that we know are important in the overall rehabilitation management plan. And this study recommended that outpatient post-hospitalization pulmonary rehab should be considered in patients that have pulmonary complications after COVID-19. So altogether, we see these specific areas where physiatrists are really an integral component to the post-acute healthcare delivery for our patients. And rehabilitation professionals are experts in addressing disabling conditions and focusing on quality of life. This is what we do all the time. And so it's really important that we don't forget to look at management of COVID, not only from the medical perspective, which we're pretty familiar with, but also from a health equity perspective, especially knowing that there's certain groups with a disproportionate effect of COVID-19, be it race, ethnicity, disability status, or insurance status. So we really applaud the Academy for taking this leadership and addressing this and really prioritizing the health equity of patients and having that be a part of our conversation. So again, just want to thank the Academy. Thank you all for attending our session today. And just wanted to turn it back over to Dr. Morata. Thanks again, everyone. It's been a pleasure speaking with you all this evening. Do we have time for a few questions? Yes, there's about three or four questions in the question box. And I believe we have a hand raised. So if the faculty could stay on, I think we can get started. And I'm going to ask Dr. Morata to hand raise. So if the faculty could stay on, I think we can take a couple of these questions. So one of the questions, I'll go in the question order in the box. I haven't heard anyone mention the impact of significant COVID related to hospital bills, often $50,000 to $100,000 per patient, and subsequent economical factors, loss of jobs, savings, et cetera, affecting depression, fatigue, and cognitive issues in PASC patients. Any comments to that? Yeah, I would say that it is a major issue. And a lot of patients are really devastated on top of how they feel kind of physically. And having been through the trauma of COVID to then on top of it, lose your job, or have a job that's not understanding can be a really major issue and lead to worsening depression, anxiety, and making them feel just awful and impeding that recovery. And then they have insurance issues and can't get treatment. We try to have a social worker available to see those patients and talk with them and give them resources and address unemployment, things like that. And also accommodations, making sure they know how to go back to their work to address concerns about what is required for people with disabilities in terms of making reasonable accommodations. But it is a really challenging thing that comes up from time to time. Have any of you attempted or had success with hyperbaric oxygen therapy, specifically with patients that are struggling in multiple areas? I don't know. I don't think any of us have probably tried that. I've had patients ask me about it, but I haven't recommended it. Okay. Has there been any information regarding reproductive symptoms, especially amongst PASC females? So I can just go again. of females in our clinic irregularities. Um, and t even not related to vacci definitely report some cha But again, even pre vacci menses has been reported. actually did not have uh, three months post her inf I did not manage that mys refer the patient to um, colleagues of ours. But y are very common. Um, anot have seen is heavy menses been reported by some of not exactly know at this been a commonly reported or not. But I myself have outcome measures would yo in an outpatient telemedi if you ask, you know, fou you get probably four or I think the important thi you know, as we kind of t and uh, different guideli come out, we'll have more But it's hard to create, guidelines because people Um, and there's not any o we use hospital anxiety d I think that's relatively clinics. But we found it But there's, there's a lo All right, next question. panel. Sorry, has identifi What is the typical L. O. So, so if you mean L. O. S I'm going to answer it bo want to know about the cl these clinic visits are v the initial visit in our patient for one hour. But definitely more than one documentation way more ob templating and some of th and the symptom questione we have all of them elect send it to the patients b or if the patient does no access, they actually com as it's hopefully and do in our waiting room. That visit time. But still the are very long. Uh, and th you mean the duration, it individualized. Like I me to be very, uh, based at level. Uh, a typical regi would be somewhere around to begin with spaced once again, depending on the p then we set up most of th come and see a physiograp two months. Okay. We actu their hands raised. So dr allow you to talk if you unmute yourself and ask y my question was answered you. Okay. And then we ha with their hands raised. you very much. Um, and th presentations and for bei in the Q and A. It's so h that I have, I don't belie yet was specifically abou of viruses. For instance, and so forth. We're seein so far in preliminary stu groups as well. And we're given the history of obvi reactivation and the use antivirals to potentially something that is being u tool. Um, in the testing Um, so just curious if an doing that in order to, t diagnostic specifically f of, um, of the symptoms. Um, obviously I don't thin guidance on that. Um, I t least for me and kind of uh, there's, you know, re can be somewhat difficult also kind of looking at k latent viruses. Uh, resea able to have ways to identi Um, like for example, CMV seen kind of clear evidenc terms of covid, although you know, kind of theory some of this residual pro I'm not sure if any of th have more to contribute t We haven't been doing tit interesting thought. I wi as a long covid patient m get I shingles 10 months also had an E. B. V. Reac with body politic in our is something that might b Um, and I tell you just f with it and from, from se coming out of the support throwing it out there as patients in your care. Hey else want to follow? Okay we have, uh, we have a lo through. I think in the i we can get through two mo you have, uh, identified to answer the long covid seen are very similar to patient that I follow as Is there some overlap in and management strategies of post covid symptoms in population, concussive sy Yes. And I think that dr upon this a little bit ea brain fog is one of the p we have, um, that we see have. Um, it's definitely and one that we don't wan many specialists that do feel that there's a huge concussive symptoms as we fog that a lot of patient post covid. Um, and so ou right now is really targe sure that there's no unde or other medical conditio to it, making sure that w hygiene. That's so importa surprised at how many pati not even address that. Th I've seen every single sp one has really addressed So that's really importan that we take a look at th strategies that we are us don't have definitive evi whether or not our medicat either neurologic symptoms neurostimulants could pot of cognitive fatigue. But I think that as a special down the pipe and that's I would just add that, yo to kind of keep in mind t of post covid long covid I think there are patient with a concussive phenoty and dizziness and difficu brain fog and they don't the endurance issues and of cognitive fatigue, but you know, I can still run activities. And for those address kind of as if the getting in with our concus therapists and things lik there's others that don't symptoms. So I think most say, you know, treat it k you're seeing and kind of is presenting with becaus no kind of magic bullet t them. Okay, thank you. An are getting questions com end with one more question do our best to go back to the panelists and follow questions in here. So dr one, you would like to an study in the study in Ger cardiac symptoms. What a recommend? Like dr Abramo we need to treat the pati symptoms that they present cardiologists at my insti extensive testing on all initially and had for the normal studies return. Uh time is limit cardiac tes have chest pain or dyspnea we are doing echoes, high and um EKGs. And that's p approach that we take. Um thing is to screen and as even when you do screen t us in terms of making a c decision making or the me like that. It's fairly lo those patients. I think y to screen, but it tends n and I think with time we'l sense of kind of the util also get halters on a lot has been really interesti see a lot of kind of that and particularly not any per se, but pretty signifi with routine activities. us getting in the shower their hurry went up to th things that really seem t for them. Uh and that's w back to using tend to use patients. Um but again, I a lot to learn about this to chime in that we have with predominantly cardiac them to our cardiomyopathy been seeing significant c that are considered the l disease that was severe e sometimes present with um failure findings on M. R. hypokinesia of some of th some evidence of tissue d that were not severely af Well, thank you. On behal like to thank the panels for everybody who joined we do have some questions to follow up post meeting the recording of the sess on the online education o on friday for you to go r to claim your CME. So hav last words from the panel I just briefly saw a quest and potential into induci malaise or exacerbation o exercise. And just from o clinic, we have a group o that have specialized on and treating some of the and they have protocols t for each patient. And the be very um monitored thro of their exercise protocl had a lot of discussions exercise and just calling mean exercise for some of like sitting at the edge know, or it could be just that can be enough activi to to kind of emphasize t to kind of jump off that. the term grade exercise p I think that really you h You know, do it based on At the same time, you kno be so afraid of post exert you don't do anything bec is for some patients a uh cycle where they feel kin doing anything. So they s moving and then they get they're not exercising an go back to it, it's that finding a way to kind of at the same time, we we f and important for our pat program, we tell patients that some days are going others. So don't expect t day you're going to feel part of the process in te Okay, well thank you ever

long COVID

PASC

physiatrists

rehabilitation

symptoms

evaluation

treatment plans

post-COVID clinics

rehabilitation strategies

functional outcomes

research