“What we do know is that we still have a lot to learn.” Doctors and scientists respond with this cautious understatement when it comes to addressing the avenues of treatment for the long Covid. “The pathophysiological mechanisms that could explain the persistent symptoms after infection with Covid-19 are still very poorly understood”, summarizes Dominique Le Guludec, the president of the High Authority for Health (HAS). In other words, specialists have not yet been able to determine how Sars-CoV-2 leads some patients to suffer for weeks or even months from disorders, most often pulmonary, neuropsychiatric, cardiovascular or gastrointestinal. manifesting through a galaxy of persistent symptoms: exhaustion, headaches, loss of balance and concentration, depression, anxiety, insomnia, ageusia, diarrhea, shortness of breath… The list is still long (more than 200).
Studies on the subject are lacking, but several hypotheses are emerging. These symptoms could be related to inflammatory reactions, such as suggests a study published on January 1 in CELLas well as autoimmune phenomena, or even the persistence of the virus in the body, suggests another study published in Nature, or even microthrombi, damage to the blood vessels. “Functional (somatic) disorders and the pandemic context are also among the hypotheses which would explain the persistence of symptoms, or their aggravation”, adds Dr. Olivier Robineau, specialist in infectious diseases. “But until we have identified the underlying mechanisms, we can only offer symptomatic treatments (which act on the symptoms), but not specific treatments (which cure the disease), underlines Mathieu Molimard, head of department of medical pharmacology at the Bordeaux University Hospital If the loss of smell is explained by damage to the nerves, olfactory rehabilitation must be practiced, if the exhaustion is caused by inflammatory mechanisms, such as the persistence of cytokines, it is need to prescribe anti-inflammatories, etc.
The long Covid is not a disease, but solutions exist
This vagueness explains why “long Covid” is not defined as a disease. The term is also debated. Shouldn’t we rather speak of “long Covids”, or “post-Covid syndrome”, or even “persistent symptoms after infection”? The other difficulty concerns the duration. Symptoms persist for a few weeks in some patients, while others are still on sick leave more than a year after infection, unable to return to work or lead a normal life… So where should the closed off ? “There are probably two types of patients: those for whom the symptoms of the initial disease will persist for four to twelve weeks with a slow but real recovery kinetics, what we call “long Covid” and patients who have developed symptoms during or after the infection which persist for more than twelve weeks and which cannot be explained by another diagnosis, the so-called “post-Covid”, an often fluctuating evolution, a very slow improvement and risks of fixed sequelae “, tells us the Directorate General of Health. According to these criteria, the WHO estimates the frequency of “long Covid” at 25% and the frequency of “post-Covid” at 10%.
Pending a better understanding of the phenomenon, and because it is necessary to respond to the suffering of patients, doctors are developing treatment strategies. In Tourcoing, a long Covid center has been set up. Dr. Olivier Robineau, specialist in infectious diseases, welcomes patients there. He first listens to them for a long time, and determines if their symptoms cannot be explained by another disease – “This is the case for around 15% of them”, he specifies, before, if necessary , to prescribe additional examinations. Otherwise, he details the current state of science, then offers them treatments: psychological consultations, physiotherapy sessions for rehabilitation of effort and breathing, painkillers. “The ideal would be to be able to organize a whole day with multidisciplinary consultations, then, depending on the results, to redirect them to city medicine, with a network of practitioners whom we are also starting to train through webinars” , he explains.
Infectiology, physical rehabilitation and psychiatry
This idea has already been put into practice at the Hôtel-Dieu hospital (Paris, AP-HP), via the CASPER protocol: patients whose files are retained spend half a day on site. They benefit from three consultations: with an infectiologist or an internal doctor who checks whether other diagnoses explain their symptoms and looks for organic sequelae of Covid, a sports doctor or a teacher in adapted physical activity (EAPA) who assesses their physical abilities – balance, coordination, muscle strength – and, finally, a psychiatrist.
“We are carrying out a general assessment of the psychological impact of persistent symptoms, which can include depression or anxiety for example, and whether they need to be treated, explains psychiatrist Clément Gouraud. We are also trying to identify the possible presence of cognitive brakes to the implementation of an adapted rehabilitation, in a patient support approach”. In other words, psychiatrists explain to patients how their own perception of their state of health can influence the evolution of their symptoms and how vicious circle mechanisms can take place. An approach encouraged by Dominique Le Guludec: “It does not matter if the Covid is the cause of depression and anxiety or if these are the consequences of persistent symptoms, the important thing is to recognize the suffering, to accompany it and make it better.”
Same on the muscular level. If sports doctors and EAPAs take into consideration the hypothesis that persistent muscle pain and fatigue can be caused by Covid, they also explain to patients that the months of inactivity after infection induce muscle reduction and a loss of habit to the effort, which must then be gradually reintroduced. But every doctor, whatever his specialty, walks on eggshells, because many patients have come up against a medical body that has too often “psychologized” their symptoms. “Faced with the proposal of psychological participation by members of the medical profession, some patients experienced a strong feeling of non-recognition of the symptoms and their impact”, analyzes Clément Gouraud.
A long-term fight
Once this day has been completed at the Hôtel-Dieu, most patients are redirected to appropriate structures, depending on the needs. But 10 to 15% of the people assessed join a personalized program for return to effort, muscle and joint work, etc. Two to three weekly sessions take place in the hospital, for six to nine weeks, supervised by EAPAs. The patients interviewed on site are unanimous: the team’s attentiveness is excellent and the results extremely encouraging. One of them wonders, however: “what will happen next?”.
“At the end of the program, we must direct patients to an appropriate structure, close to their home and which offers them an activity which attracts them with trained educators, specifies Pr. Patricia Thoreux, surgeon and head of this service of the Hôtel-Dieu. There are in particular structures labeled by the Ministry of Sports throughout France (Maisons Sport Santé) or in Ile de France with the Label Prescriforme (Regional Health Agency)”. Sports clubs and associations that have educators trained in patient care are also certified. Be that as it may, “Patients must have a mind of steel”, believes Olivier Robineau. And arm yourself with patience, while waiting for researchers and doctors to better understand the persistent post-Covid symptoms.