COVID-19: Achieving Maximum Medical Improvement and Assessing Permanent Impairment
James B. Talmage
Search for other papers by James B. Talmage in
Current site
Google Scholar
PubMed
Close
,
Mark H. Hyman
Search for other papers by Mark H. Hyman in
Current site
Google Scholar
PubMed
Close
,
Christopher R. Brigham
Search for other papers by Christopher R. Brigham in
Current site
Google Scholar
PubMed
Close
,
Sarah H. Gulick
Search for other papers by Sarah H. Gulick in
Current site
Google Scholar
PubMed
Close
, and
Leslie Burton
Search for other papers by Leslie Burton in
Current site
Google Scholar
PubMed
Close
Free access

Abstract

Patients with coronavirus disease 2019 (COVID-19) may have persistent symptoms beyond the normally expected illness resolution. This disease was not diagnosed before late 2019, and therefore, we have more limited experience in understanding all of its outcomes. Thus, clinical, functional, and permanent impairment assessment is challenging. Symptoms including fatigue, dyspnea, and cognitive difficulties have been referred to as “post-acute COVID,” “long COVID,” or “long haulers.”

Patients who present for assessment of causation, maximum medical improvement (MMI), and permanent impairment can be challenging. For some examinees, after 6 to 12 months without outgoing improvement and with appropriate investigation, treatment, and rehabilitation, the examinee can be considered at MMI. However, because this disorder is new and appropriate treatment may be unclear, the time to achieve MMI is less certain. Physicians may use approaches in the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides), to help define MMI. As science evolves, so will our understanding of how to evaluate chronic problems associated with COVID-19.

EDITORIAL COMMENT

Although this article's focus is on COVID-19 and MMI, it is also imperative to assess causation. For guidance on causation and COVID-19, refer to the July/Aug 2020 issue of the AMA Guides Newsletter.

Introduction

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It was declared a pandemic in 2020 and continues into 2021, and it has affected the work performed in assessing permanent impairment. The SARS-CoV-2 virus is similar in its RNA genetic sequences and physical structure to coronaviruses that have caused prior epidemics, such as SARS in 2003 and Middle East respiratory syndrome (MERS) in 2012 to 2015. As of February 7, 2021, it is predicted that by June 1, 2021, there will be more than 630,000 deaths in the United States caused by SARS-CoV-2 since the start of the pandemic.1

Patients have suffered a variety of illnesses with all degrees of severity from this virus. A review of published studies found a large variance of asymptomatic infections from 18% to 81%. Many patients remained asymptomatic, but all could potentially transmit the infection to others.2

This article focuses on healthcare professionals’ needs in caring for patients who are recovering from illness and who have an accepted COVID-19 workers’ compensation claim. It also guides evaluating physicians who need to address clinical assessment, maximum medical improvement (MMI), and permanent impairment associated with COVID-19.

Both treating and evaluating physicians may encounter individuals who present with persistent symptoms like fatigue, shortness of breath with exercise, cognitive impairment (“brain fog”), and anxiety. These patients with “post-acute COVID-19 syndrome” are euphemistically termed “long COVID” or “long haulers.” The science on evaluation and treatment of these patients is evolving, and this article provides preliminary advice.

Maximum Medical Improvement (MMI)

MMI is defined in the sixth edition of the AMA Guides to the Evaluation of Permanent Impairment (AMA Guides) as the “point at which a condition has stabilized and is unlikely to change (improve or worsen) substantially in the next year, with or without treatment” (6th ed, 612). The sixth edition also states, “[o]nly permanent impairment may be rated according to the Guides, and only after the status of ‘Maximum Medical Improvement’ (MMI) is determined,” as explained in Section 2.5e. “Impairment should not be considered permanent until a reasonable time has passed for the healing or recovery to occur” (6th ed, 24). Because this disorder is new and appropriate treatment may be unclear, the time to achieve MMI is uncertain.

Clinical Course

Data from a COVID Symptom Study tracking application (app) indicated that by 2 weeks after the first onset of symptoms, 90% of patients have recovered.3 Many of the remaining 10% recover fully over the next 2 to 3 months. Currently available studies that evaluated patients with disease severe enough for hospitalization reported higher rates of residual problems. A US study found 65% of patients had returned to their pre-infection state of health after 14 to 21 days.4

The National Institutes of Health COVID-19 Treatment Guidelines state that there “have been an increasing number of reports of patients who experience persistent symptoms after recovering from acute COVID-19.”5 At this time, there is limited information on the prevalence, duration, underlying causes, and effective management strategies for these lingering signs and symptoms.6 Some of the symptoms overlap with the post-intensive care syndrome that has been described in patients without COVID-19, but prolonged symptoms and disabilities after COVID-19 have also been reported in patients with milder illness, including outpatients.7 Some of the persistent symptoms that have been reported include fatigue, joint pain, chest pain, palpitations, shortness of breath, and worsened quality of life.8 In addition, psychological distress and its correlates have been reported among COVID-19 survivors during early convalescence across age groups.9

One study from China found that pulmonary function was still impaired 1 month after hospital discharge.10 Based on currently available studies and their data, hospitalized patients are more likely to have chronic problems than nonhospitalized patients with less severe disease.

Another study found that between 22% and 56% of patients surviving COVID-19 had a spirometry-measured diffusing capacity for carbon monoxide (DLco) < 80% of predicted 6 months later. The more severely ill patients had a greater likelihood of spirometry-documented impairment.11

A study from the United Kingdom reported that among 100 hospitalized patients (32 received care in the intensive care unit [ICU] and 68 received care in hospital wards only), 72% of the ICU patients and 60% of the ward patients experienced fatigue and breathlessness at 4 to 8 weeks after hospital discharge. The authors of the study suggest that posthospital rehabilitation might be necessary for some of these patients.8

In Ireland, a study of 487 patients assessed a median of 75 days after diagnosis suggested that clinically relevant pulmonary fibrosis is an uncommon complication. However, 62% of patients reported not returning to full health, with fatigue being a common complaint.13

An Italian study assessing 143 patients a mean of 60 days after the onset of COVID-19 symptoms revealed only 12.6% were completely free of any symptoms related to COVID-19, and 55% had three or more symptoms. Worsened quality of life was observed among 44.1% of patients. Fatigue and dyspnea were the most common complaints.14

Neurologic and psychiatric symptoms have also been reported among patients who have recovered from acute COVID-19. High rates of anxiety and depression have been reported in some patients using self-report scales for psychiatric distress. Younger patients experienced more psychiatric symptoms than patients older than age 60.12

Patients might continue to experience headaches, vision changes, hearing loss, loss of taste or smell, impaired mobility, numbness in extremities, tremors, myalgia, memory loss, cognitive impairment, and mood changes for up to 3 months after diagnosis of COVID-19.15,16 Huang reported on the persistence of these and other symptoms at 6 months post-hospitalization. At 6 months, 63% of the patients reported fatigue or muscle weakness; 26% reported difficulty sleeping; 22% reported hair loss; 11% reported difficulty with smell; 9% reported difficulty with sleep; and 7% reported trouble with mobility.11 More research is needed to better understand the pathophysiology and clinical course of these post-infection sequelae and identify management strategies for patients.

One Approach to Persisting Symptoms of Fatigue and Dyspnea on Exertion

For all persistent complaints after a COVID-19 illness, reviewing the medical records before this illness is necessary to establish the patient's pre-COVID-19 status and whether the condition or symptoms now present were already present. No medication approved for current claims related to COVID-19 has been shown to hasten recovery in those living at home while recovering from COVID-19. In those patients with mild illness who recovered at home without hospitalization, typically by 2 to 3 weeks after resolution of fever, they should be recovered enough to resume sedentary or light work based on Dictionary of Occupational Titles criteria. For those with moderate illness hospitalized for hypoxia, but who did not require ICU admission or mechanical ventilation, 4 to 6 weeks of recovery might be required before returning to sedentary or light work.17 For those with persisting symptoms of fatigue or dyspnea on exertion, and for those with documented lower respiratory tract infection (pneumonia on imaging), a testing-based evaluation might help.

The British Medical Journal (BMJ) published the open-access article, “Management of post-acute COVID-19 in primary care,” which focused on a central theme that evaluating and managing these patients is the task of a primary care physician (PCP).18 An initial evaluation would screen out patients who need a referral to specific specialists (eg, cardiologist, neurologist, and so on) from those who can then continue to be under the care of the PCP to support the patient through recovery. Patients who should be referred include those with increasingly worsening breathlessness, chest pain possibly consistent with cardiac ischemia, and resting oxygen saturation of less than 96% on pulse oximetry.

Clinical Assessment

The physician assessment should include:

  • A history and physical examination to document symptoms, symptom severity, and the patient's current status. Vital signs should COVID-19: Achieving Maximum Medical Improvement and Assessing Permanent Impairment, continued include pulse oximetry for oxygen-saturation percentage at rest and, with complaints of dizziness or light-headedness, sitting and standing pulse rate, and blood pressure screening for postural orthostatic tachycardia syndrome (POTS).

  • Review of any medical records and testing obtained during the illness and from before the illness.

  • A complete blood count (CBC) screening for anemia.

  • Electrolytes, serum creatinine, and urinalysis to assess kidney function.

  • Liver function tests (eg, bilirubin, aspartate transaminase [AST], alanine aminotransferase [ALT]) to assess liver function.

  • C-reactive protein and ferritin tests to rule out persisting hyperinflammatory state.

  • D-dimer test to rule out persisting hypercoagulable state.

  • Troponin and brain natriuretic peptide (BNP) tests, and a 12-lead electrocardiogram (ECG) to help rule out acute coronary artery syndrome, heart failure, and prior myocardial infarction, as appropriate.

If this comprehensive screening suggests the active phase of the disease is over and shows no worrisome findings requiring specialist evaluation, the recommendation is to screen for safe participation in an exercise program. Table 1 summarizes tests that may be used to assess permanent impairment.

TABLE 1.

Tests That May Be Used to Assess Permanent Impairment in COVID-19 Survivors

Symptom Tests Potential Treatment
Any History and physical examination

Review of pre-illness medical records

Vital signs with pulse oximetry at rest CBC

Electrolytes, creatinine, and urinalysis

Bilirubin, AST, ALT

C-reactive protein, ferritin

D-dimer

Troponin, BMP, 12-lead ECG
Dizziness, light-headedness Sitting and standing pulse rate and blood pressure Midodrine (eg, fludrocortisone)
Chest pain suggesting angina, regional wall motion abnormality on ECHO suggesting prior infarction Cardiac stress ECHO, preferably with metabolic testing Cardiac rehabilitation or potential percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)
Dyspnea on exertion, non-anginal chest pain, fatigue, no desaturation on 100-foot walk Full spirometry (with DLco) and cardiac stress ECHO, preferably with metabolic testing If clinically stable with no documented heart involvement or pulmonary hypertension, exercise rehabilitation by physical therapy
Non-specific fatigue, muscle soreness, anxiety, or depression Fear-Avoidance Belief Questionnaire

Injustice Experience Questionnaire

Modified Somatic Perceptions Questionnaire

Beck Depression Inventory

GAD-2 or GAD-7
Psychiatric referral
Montreal Cognitive Assessment Mental Status Exam

Montreal Cognitive Assessment
Neuropsychologist referral

Pulmonary Assessment

An exertional desaturation test is part of a baseline assessment for patients whose resting pulse-oximeter reading is at 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 or after doing a 1-minute sit-to-stand test as fast as they can. A fall of 3% in the saturation reading on mild exertion is abnormal and requires investigation.19

An easy way to perform a screening test is to recall that 40 steps with a 30-inch (2.5-foot) step length is 100 feet. Suppose the medical office has a hallway with 12-inch vinyl tile flooring, and if the patient walks 50 tiles (50 feet) away from the examiner, turns around, and then walks 50 feet back to the examiner while wearing a pulse oximeter on a finger, the pulse rate and oxygen saturation can be read from the pulse oximeter; first while standing and about to walk and then again after the 100-foot walk. Respiratory rate immediately before and after the walk should also be recorded.

Individuals with an oxygen saturation on room air at rest of 93% to 95% should have the results of full pulmonary function testing and an echocardiogram (ECHO) reviewed before attempting an exercise stress test. Many of these can be referred for specialist evaluation based on the predominant abnormality on these two tests. If these patients are given the 100-foot walk test and desaturate further (ie, a 3% drop from baseline), a prescription for home oxygen while awaiting the cardiologist or pulmonologist referral may be considered.

If no desaturation or inappropriate tachycardia (heart rate greater than 100 beats per minute) occurs during a self-paced 100-foot walk, the examiner might feel comfortable continuing the exercise test by asking the patient to continue to walk the 100-foot laps, self-paced, until 6 minutes have elapsed. The total distance covered in 6 minutes of walking can be recorded and compared to established norms, as this is the well-researched “6-minute walk test.”20

Patients post-COVID-19 without other known causes of exertional dyspnea (eg, anemia, heart disease, and so on) who are intolerant of the 100-foot exercise test may need to be evaluated further by a cardiologist or pulmonologist before exercise rehabilitation. After an appropriate evaluation, patients with documented cardiac disease and/or pulmonary disease might be referred to a formal “cardiac rehabilitation program” or “pulmonary rehabilitation program.” In these programs, progressive increases in exercise stress are monitored by nurses or therapists trained in exercise rehabilitation. These individuals will not have attained MMI before completing such a rehabilitation program.

If the testing described earlier establishes mild desaturation as exclusively pulmonary with no documented cardiac complication, and if a referral to a pulmonologist is not necessary or cannot be accomplished easily, the PCP should consider making a direct referral to a pulmonary rehabilitation program. Depending on the degree of desaturation, it may be necessary to prescribe oxygen. Permanent pulmonary disease has been documented in COVID-19 patients.21

Many medical offices perform simple spirometry testing. However, as opposed to impairment evaluation for asthma or chronic obstructive pulmonary disease (COPD), impairment evaluation for post-COVID-19 patients generally requires the performance of the DLco or DCO. A full pulmonary function test, with and without bronchodilators, is recommended. Obtaining a recent CBC permits the testing site to correct the DLco for anemia, if present. The DLco is the most likely pulmonary function test to be abnormal in a post-COVID-19 patient.11 If the DLco is abnormal, the treating physician can consider referring the patient to a pulmonologist, and a formal pulmonary rehabilitation program will likely be required.

Permanent impairment is rated using Table 5-4, Criteria for Rating Permanent Impairment due to Pulmonary Dysfunction (6th ed, 88; 5th ed, 107). The DLco may well be the most abnormal test, and thus the basis for a class assignment. Permanent impairment should not be rated based on pre-rehabilitation program spirometry, as it is hoped the patient's pulmonary function test values will improve with time and treatment. Thus, pulmonary function testing might need to be obtained twice: once to prove persisting disease and justify referral to a pulmonologist or pulmonary rehabilitation, and then a second time after rehabilitation (treatment) to assess impairment at MMI.

Cardiovascular Assessment

Another potential cause of exertional desaturation is cardiac conditions. Chest pain suggestive of angina during a 100-foot walk warrants a usually prompt referral to a cardiologist, as should a history of possible anginal chest pain on home activity.

The SARS-CoV-2 virus is known to involve the heart. Diffuse myocarditis or myocardial fibrosis has been reported.22,23 Heart involvement is assessed with the basic tests for troponin and BNP levels, an ECHO, and ECG.

In patients who desaturate during the exercise test, an ECHO should be obtained. An ECHO can help screen for left ventricular (LV) systolic dysfunction and/or diastolic dysfunction and pulmonary hypertension. Just as radiologists give better interpretations if given significant clinical information, when requesting an ECHO, it is wise to alert the interpreting cardiologist that the patient “had COVID, desaturates with exercise” or “had COVID, evaluate left and right heart function and for pulmonary hypertension.”

Patients with an ECHO or stress ECHO who have regional LV wall abnormalities might have had a myocardial infarction. This finding may precipitate a referral to a cardiologist and subsequent enrollment in a formal cardiac rehabilitation program. A subsequent exercise stress ECHO after completion of cardiac rehabilitation can be used to assess permanent impairment using Table 4-6, Criteria for Rating Impairment Due to Coronary Artery Disease (6th ed, 55; 5th ed, 36) to rate the permanent cardiac impairment.

LV systolic function is easily screened using ECHO. This test measures the ejection fraction; it is normally greater than 50%. Multiple indices of LV diastolic function are present on transthoracic ECHOs. The interpreting cardiologist will identify the status of LV systolic and diastolic function.

Diffuse myocardial injury without regional wall motion (discrete infarct) can occur in COVID-19.22,24,25 The ECHO provides objective evidence of cardiac involvement that may justify a referral to a cardiologist and subsequent placement in a formal cardiac rehabilitation program. The LV ejection fraction (evaluating the ventricular systolic function) and a BNP test are used to rate permanent impairment using Table 4-7, Criteria for Rating Impairment due to Cardiomyopathies (6th ed, 59; 5th ed, 47).

LV diastolic dysfunction is also ratable in this table by “E” and “A,” which are not defined in the table except as “wave forms” on the ECHO. The E/A ratio is a marker of LV function. It represents the ratio of the peak velocity of blood flow during LV relaxation in early diastole (the E wave) to the peak velocity flow in late diastole caused by atrial contraction (the A wave). Typically, the interpreting cardiologist will consider other measurements of LV diastolic function, so the cardiologist's statement about LV diastolic function being normal or mildly abnormal should usually be accepted.26

Pulmonary hypertension from loss of lung tissue with pulmonary infarcts or pulmonary fibrosis, which is detected on ECHO by estimating peak pulmonary artery systolic pressure, whose measurement plus blood BNP level and VO2 max on an exercise stress ECHO would objectively document the potential need for referral to a cardiologist and would permit permanent impairment rating by Table 4-14, Criteria for Rating Impairment due to Diseases of the Pulmonary Artery (6th ed, 72; 5th ed, 79).

On ECHOs, the estimated pulmonary artery systolic pressure is calculated by the Bernoulli equation (not measured) from the tricuspid valve regurgitation velocity (meters/second) and estimated right atrial pressure.27 The pulmonary artery systolic pressure is more accurately measured by right heart cardiac catheterization, but right heart catheterization is not commonly performed.

Normal pulmonary artery systolic pressure measured by right heart cardiac catheterization had been defined as less than 35 mmHg in adults younger than 60 or less than or equal to 40 mmHg in adults older than 60. These pressures were accepted at the time of writing of the sixth edition of the AMA Guides and Table 4-14. However, lower mean pulmonary artery pressures are now recognized as abnormal. The Sixth World Task Force on Pulmonary Hypertension has recommended greater than or equal to 25 mmHg as abnormal pulmonary artery systolic pressure, or 20 to 25 mmHg with other criteria present (eg, abnormal pulmonary arterial wedge pressure and/or pulmonary vascular resistance, and perhaps the presence of right ventricular hypertrophy).28 The examiner may choose to recognize scientific progress and rate those with an ECHO-estimated pulmonary artery pressure of 25 mmHg or greater as class 1 or mild impairment, but would need to fully discuss the rationale for this in the report.

The possibility of acute illness myopathy should be considered for those with significant exercise intolerance with no desaturation on the office-based exercise during the “100-foot walk” test, and not having anemia or explanatory systemic disease. Being hospitalized or bed-confined for a few weeks frequently leads to muscle catabolism (ie, the body digesting muscle for energy when nutrition is poor). People with significant deconditioning can have an elevated heart rate with trivial exercise. Thus, determining the patient's pre-COVID-19 weight from medical records and current post-COVID-19 weight might establish the need for nutritional counseling and between-meals calorie and protein, vitamin, or mineral supplementation. Recovery of lean body mass to the ideal body mass index (BMI) might be a criterion for declaring when a patient is at MMI.

Screening with pulmonary function testing and echocardiography can direct referral to the appropriate specialist (eg, pulmonologist or cardiologist), if needed. This testing can also reassure PCPs that they can manage their patients without a referral. Repeat testing at MMI would permit impairment rating. For cases that appear more difficult to interpret results, cardiopulmonary exercise testing is the gold standard of testing. Table 2 summarizes cardiopulmonary test results that may be used in specific tables from the AMA Guides.

Table 2.

Cardiopulmonary Tests Results and AMA Guides Tables

Condition/Test AMA Guides, Sixth Edition AMA Guides, Fifth Edition
Post-pneumonia or post-pulmonary embolism dyspnea

Spirometry (FEV1, FVC, DLco), 6-minute walk to check for desaturation, and possibly VO2 max achieved on exercise stress test
Table 5-4, p 88 Table 5-12, p 107
Myocardial infarction

Coronary angiogram, VO2 max or metabolic equivalents of task (METs) achieved on exercise stress test, or stress ECHO or myocardial nuclear perfusion scan
Table 4-6, p 55 Table 3-6a, p 36
Myocarditis or post-viral cardiomyopathy

Systolic dysfunction ejection fraction by ECHO or cardiac catheterization, blood BNP test, VO2 max or METs achieved on exercise stress test
Table 4-7, p 59 Table 3-9, p 47

Note: Does not consider many test results; uses dietary restrictions, medications, and congestive heart failure signs instead
Myocarditis or post-viral cardiomyopathy

Diastolic dysfunction includes above plus “E” and “A” or “E/A ratio” by ECHO
Table 4-7, p 59 Tests not specifically mentioned, use Table 3-9, p 47
Pulmonary hypertension

ECHO estimate or right heart catheterization measurement of pulmonary artery systolic pressure, BNP blood test, VO2 max, or METs achieved on exercise stress test
Table 4-14, p 72

Note: The definition of “mild” has changed since the sixth edition was written
Table 4-6, p 79

Note: The definition of “mild” has changed since the fifth edition was written

Physical Therapy Reconditioning

In the absence of serious detected cardiac or pulmonary disease, it should be safe to refer deconditioned post-COVID-19 patients to a physical therapy reconditioning program.29 Therapists measure and provide baseline function; set goals; plan, formulate, and implement a rehabilitation program; and monitor progress toward outcome goals.

Therapists measure baseline functional ability through a variety of standardized protocols. Some of these tools may include:

  • Patient Specific Functional Scale

  • Activities-Specific Balance Confidence Scale

  • Patient Health Questionnaire-9 (PHQ-9)

  • Timed Up and Go Test (TUG)

  • Chair rise test

  • 6-minute or 2-minute walk test

  • Berg Balance Scale or Tinetti Assessment for baseline measures of strength, endurance, and balance

Each of the standard testing protocols is closely supervised for fall safety, as well as oxygen saturation and heart rate for medical safety. The results of the baseline measures are then incorporated into a comprehensive treatment program to improve functional ability. Monitoring vital signs (eg, heart rate, blood pressure, and pulse oximetry) during each session and using the Borg Rating of Perceived Exertion scale provides an immediate patient response to a rehabilitation program of aerobic conditioning, strengthening, balance, and work-simulation tasks.

Patient education in sleep hygiene, relaxation training, and activities of daily living (ADLs), combined with a home exercise program of flexibility, strengthening, and conditioning activities, augment the efforts completed during a patient's “in-facility” episode of care. Patients in a clinical therapy program typically achieve better outcomes than patients do in unsupervised home exercise. This might be partially due to therapist-delivered cognitive behavioral therapy in the therapy setting. Physical therapists and occupational therapists who offer progressive exercise rehabilitation would also serve as a “cognitive-behavioral therapist” to gradually increase workload while providing reassurance (cognitive restructuring) about the safety and value of exercise.

Other Organ System Assessment

COVID-19 can affect many organ systems. Impairment may result from acute complications or long-term sequelae. Therefore, the evaluator may need to use multiple chapters and approaches to define impairment. Table 3 presents examples of conditions and corresponding criteria.

Table 3.

Conditions, AMA Guides Chapters and Tables

Condition/Test AMA Guides, Sixth Edition AMA Guides, Fifth Edition
Cardiovascular System Chapter 4 Chapter 3
Myocardial infarction Table 4-6, p 55 Table 3-6a, p 36
Myocarditis or post-viral cardiomyopathy Table 4-7, p 59 Table 3-9, p 47
Pulmonary hypertension/emboli Table 4-14, p 72 Table 4-6, p 79
Arrhythmia Table 4-6, p 55 Table 3-11, p 56
Deep vein thrombosis Table 4-12, p 69 Table 4-5, p 76
Pulmonary System Chapter 5 Chapter 5
Chronic pulmonary disease Table 5-4, p 88 Table 5-12, p 107
Digestive System Chapter 6 Chapter 6
Liver dysfunction Table 6-8, p 119 Table 6-7, p 133
Urinary and Reproductive Systems Chapter 7 Chapter 7
Chronic renal disease Table 7-2, p 134 Table 7-1, p 146
Skin Chapter 8 Chapter 8
Hair loss Table 8-2, p 166 Table 8-1, p 174
Hematopoietic System Chapter 9 Chapter 9
Thrombotic disorders Table 9-12, p 208 Section 9.6, p 206
Endocrine Chapter 10 Chapter 10
Diabetes (aggravation) Table 10-10, p 234 Table 10-8, p 231
Ear, Nose, Throat, and Related Structures Chapter 11 Chapter 11
Loss of sense of smell or taste Section 11.4c, p 270 Section 11.4c, p 262
Visual System Chapter 12 Chapter 12
Vision loss secondary to hypercoagulable state or cerebrovascular accident Per applicable vision tables Per applicable vision tables
Central and Peripheral Nervous System Chapter 13 Chapter 13
Loss of sense of smell Section 13.4a, p 327
Loss of sense of taste Table 13-12, 332
Cerebrovascular (vascular, encephalopathy) Tables 13-4, p 327; 13-5, p 328; 13-6, p 329; 13-8, p 331; 13-9, p 332; 13-10, p 334 Tables 13-2, p 309; 13-3, p 312; 13-4, p 317; 13-5, p 320; 13-6, p 320; 13-7, p 323; 13-8, p 325
Insomnia Table 13-6, p 329 Table 13-4, p 317
Upper extremity CNS dysfunction (myopathy) Table 13-11, p 334 Tables 13-16, p 338; 13-17, p 340
Station and gait disorders (myopathy) Table 13-12, p 336 Table 13-15, p 336
Headache Table 13-18, p 342 or Chapter 3 Chapter 18
Mental and Behavioral Disorder Chapter 14 Chapter 14
Post-traumatic stress disorder, anxiety, depression Tables 14-9, p 357; 14-10, p 358; 14-17, p 360 Table 14-1, p 363

Persisting Symptoms of Fatigue, Muscle Soreness, Anxiety, or Depression

Some “long COVID” patients have mental symptoms as their primary persisting complaints. Mental factors (eg, underlying personality, life experiences, defense mechanism[s], mental disorders, and so on) contribute to symptom presentation; thus, referral for cognitive-behavioral therapy might be needed.

Symptoms can be assessed with multiple validated, public-domain screening questionnaires that were developed for chronic musculoskeletal complaints, such as:

These screening questionnaires do not prove a diagnosis or permit a permanent impairment rating. They can suggest that a post-COVID-19 patient might have a mental disorder delaying or preventing recovery (ie, MMI) and return to work. Referral for psychological or psychiatric evaluation and potential treatment in these circumstances would be medically reasonable.

Persisting Complaints of Cognitive Dysfunction (“Brain Fog”)

Neurological deficits have been documented to occur during COVID-19 illness.31 Some “long COVID” patients complain of persistent cognitive difficulties. The medical records generated during the illness should be compared to patients’ pre-COVID-19 medical records.

Gross screening for cognitive impairment can be achieved with in-office simple mental examinations such as the following:

Values greater than or equal to 26 out of 30 is considered normal, but age and educational achievement may suggest a higher “normal” score should be required. If these tests are normal, but the complaints are significant with no history of improvement, referral to a neuropsychologist might be indicated for formal neuropsychological testing.

An adequate neuropsychological evaluation should include measures of effort, motivation, neurologic, neurocognitive, and personality or psychological testing. Research has shown that malingering measures of psychological problems do not indicate malingering of cognitive problems, and vice versa. Therefore, recommended measures of effort in both the cognitive and psychological domains are recommended. Tests that include measures of psychological malingering:

These two scales are of the most widely used measures of psychological malingering. They include scales of overreporting and underreporting of psychological symptoms and personality functioning.

There are also stand-alone measures for psychological malingering, such as the following:

Two widely used measures of cognitive malingering include:

Several neuropsychological testing batteries assess neurological and cognitive functioning, such as:

All of these tests have their advantages and disadvantages. The AMA Guides state neuropsychological test batteries “should include instruments that include 2 symptom validity tests” (6th ed, 351; 5th ed, 306).

Programs exist for cognitive rehabilitation for those with an objectively documented cognitive impairment. These programs have published data on outcomes for traumatic brain injury and stroke. However, there are no published data on outcomes for post-COVID-19 patients in these programs. If present, after sufficient recovery time (typically longer than 6 months) and treatment, permanent impairment could be rated (6th ed, 331; 5th ed, 320).

What-If Option

There will be patients with believable, consistent “long COVID” complaints. However, there is no objective impairment (0%) per criteria in the AMA Guides using the test results and tables discussed previously. This does not necessarily reflect a lack of disease; rather, this disease is new, and we do not fully understand the pathophysiology. As we understand the underlying clinical issues, we may develop new approaches and criteria to define impairment.

In many of these cases, the pre-COVID-19 medical records will not contain the same test results, so there is no method to determine whether the function of the heart, lung, liver, kidney, brain, and so on, was better pre-COVID-19 than the “normal” value(s) measured post-COVID-19. For cases in which the complaints are both consistent and persistent with no clear evidence of symptom exaggeration, Section 2.5e, Maximum Medical Improvement, in the sixth edition of the AMA Guides states:

In certain instances, the treatment of an illness may result in apparent total remission of the person's signs and symptoms. However, if the examiner concludes … the patient has actually not regained his or her previous function, and if the Guides has not provided specific criteria to rate such impairment, the physician may choose to increase the impairment estimate by a small percentage (eg, 1% to 3%). Such a discretionary impairment is provided only once (6th ed, 26).

The fifth edition has a similar statement in Section 2.5g, Adjustments for Effects of Treatment or Lack of Treatment (5th ed, 20).

Patients with symptoms suggesting the involvement of more than one organ system, yet with normal testing (no impairment) by specific chapters and criteria, are logically more impaired than those with symptoms suggesting impairment in only one organ system. From the permitted range of 1% to 3% whole person impairment, the examiner would choose a percentage based on the severity of the disruption to ADLs and the number of symptom-suggested organ systems involved. The rationale for assigning a “non-zero” impairment should be explicitly and clearly stated in the impairment rating physician's medical record.

Additional sources for recommendations in the evolving literature include:

  • Barker-Davies RM, O’Sulivan O, Senaratne KPP, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020 Aug;54(16): 949–959.

  • Carfì A, Bernabei R, Landi F, et al. Persistent symptoms in patients after acute COVID-19. JAMA. 2020 Aug 11;324(6): 603–605.

  • Ceravolo MG, Arienti C, De Sire A, et al. Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Eur J Phys Rehabil Med. 2020 Oct;56(5): 642–651.

  • Hermann M, Pekacka-Egli AM, Witassek F, et al. Feasibility and efficacy of cardiopulmonary rehabilitation following COVID-19. Am J Phys Med Rehabil. 2020;99(10): 865–869.

  • Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397: 220–232.

  • Lutchmansingh DD, Knauert MP, Antin-Ozerkis DE, et al. A clinic blueprint for post-coronavirus disease 2019 recovery: learning from the past, looking to the future. Chest. 2020;159(3):949–958.

  • Simpson R, Robinson L. Rehabilitation following critical illness in people with COVID-19 infection. Am J Phys Med Rehabil. 2020 Jun;99(6): 470–474.

  • Wade DT. Rehabilitation after COVID-19: an evidence-based approach. Clin Med (Lond). 2020 Jul;20(4): 359–365.

  • Wang TJ, Chau B, Kui M, et al. PM&R and pulmonary rehabilitation for COVID-19. Am J Phys Med Rehabil. 2020;99(9): 769–774.

Conclusion

Patients with persistent symptoms after COVID-19 are unique, as this disease had not been diagnosed before late 2019. Many patients with accepted causation of this infection by workplace exposure will present for evaluation for MMI and permanent impairment. Evidence will emerge to further guide physicians in evaluating and treating these patients. After 6 to 12 months, without ongoing improvement, and after appropriate rehabilitation, the patient recovering from COVID-19 with persisting symptoms may be considered to be at “maximal medical improvement” and permanent impairment may be rated.

References

  • 1.

    Institute for Health Metrics and Evaluation. COVID-19 projections. Accessed Feb 2, 2021. https://COVID19.healthdata.org/united-states-of-america?view=total-deaths&tab=trend.

    • Search Google Scholar
    • Export Citation
  • 2.

    Nikolai, LA, Meyer, CG, Kremsner, PG, et al.Asymptomatic SARS Coronavirus 2 infection: invisible yet invincible. Int J Infect Dis. 2020 Nov;100: 112116.

    • Search Google Scholar
    • Export Citation
  • 3.

    COVID Symptom Study. How long does COVID last? Accessed Feb 2, 2021. https://covid.joinzoe.com/post/covid-long-term?fbclid=IwAR1RxIcmmdL-EFjh_aI-.

    • Search Google Scholar
    • Export Citation
  • 4.

    Tenforde, MW, Kim, SS, Lindsell, CJ, et al.Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network—United States, March–June 2020. Morb Mortal Wkly Rep. 2020;69: 993998.

    • Search Google Scholar
    • Export Citation
  • 5.

    National Institutes of Health. Clinical spectrum of SARSCoV-2 infection. Accessed Feb 2, 2021. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum.

    • Search Google Scholar
    • Export Citation
  • 6.

    Marshall, M. The lasting misery of coronavirus long-haulers. Nature. 2020 Sep;585(7825): 339341.

  • 7.

    Rawal, G, Yadav, S, Kumar, R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017 Jun; 5(2): 9092.

  • 8.

    Halpin, SJ, McIvor, C, Whyatt, G, et al.Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2021 Feb;93(2): 10131022.

    • Search Google Scholar
    • Export Citation
  • 9.

    Cai, X, Hu, X, Ekumi, IO, et al.Psychological distress and its correlates among COVID-19 survivors during early convalescence across age groups. Am J Geriatr Psychiatry. 2020 Oct;28(10): 10301039.

    • Search Google Scholar
    • Export Citation
  • 10.

    Huang, Y, Tan, C, Wu, J, et al.Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase. Respir Res. 2020;21: 163.

    • Search Google Scholar
    • Export Citation
  • 11.

    Huang, C, Huang, L, Wang, Y, et al.6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397: 220232.

    • Search Google Scholar
    • Export Citation
  • 12.

    Mazza, MG, De Lorenzo, R, Conte, C, et al.Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors. Brain Behav Immun. 2020 Oct;89: 594600.

    • Search Google Scholar
    • Export Citation
  • 13.

    Townsend, L, Dowds, J, O’Brien, K, et al.Persistent poor health post-COVID-19 is not associated with respiratory complications or initial disease severity. Ann Am Thorac Soc. 2021 Jan 8. doi: https://doi.org/10.1513/AnnalsATS.202009-1175OC.

    • Search Google Scholar
    • Export Citation
  • 14.

    Carfi, A, Bernabei, R, Landi, F, et al.Persistent symptoms in patients after acute COVID-19. JAMA. 2020 Aug 11;324(6): 603605.

  • 15.

    Heneka, MT, Golenbock, D, Latz, E, et al.Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. J Med Virol. 2021 Feb;93(2): 10131022.

    • Search Google Scholar
    • Export Citation
  • 16.

    Lu, Y, Li, X, Geng, D, et al.Cerebral micro-structural changes in COVID-19 patients: an MRI-based 3-month follow-up study. EClinicalMedicine. Aug 3, 2020. Accessed Feb 2, 2021. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30228-5/fulltext.

    • Search Google Scholar
    • Export Citation
  • 17.

    Hyman, MH, Talmage, JN, Hegmann, KT. Evaluating COVID-19 injury claims with a focus on workers’ compensation. J Occup Environ Med. 2020 Sep;62(9): 692699.

    • Search Google Scholar
    • Export Citation
  • 18.

    Greenhalgh, T, Knight, M, A’Court, C, et al.Management of post-acute COVID-19 in primary care. BMJ. 2020; 370:m3026.

  • 19.

    Greenhalgh, T, Javid, B, Knight, M, et al.What is the efficacy and safety of rapid exercise tests for exertional desaturation in COVID-19? The Center for Evidence-Based Medicine. Accessed Feb 2, 2021. https://www.cebm.net/COVID-19/what-is-the-efficacy-and-safety-of-rapid-exercise-tests-forexertional-desaturation-in-COVID-19.

    • Search Google Scholar
    • Export Citation
  • 20.

    Casanova, C, Celli, BR, Barria, P, et al.The 6-min walk distance in healthy subjects: reference standards from seven countries. Eur Respir J. 2011;37: 150156.

    • Search Google Scholar
    • Export Citation
  • 21.

    Schaller, T, Hirschbühl, K, Burkhardt, K, et al.Postmortem examination of patients with COVID-19. JAMA. 2020;323(24): 25182520.

  • 22.

    Freaney, PM, Shah, SJ, Khan, SS. COVID-19 and heart failure with preserved ejection fraction. JAMA. 2020;324(15): 14991500.

  • 23.

    Linder, D, Fitzek, A, Bräauninger, H, et al.Association of cardiac infection with SARS-CoV-2 in confirmed COVID-19 autopsy cases. JAMA Cardiol. 2020;5(11): 12811285.

    • Search Google Scholar
    • Export Citation
  • 24.

    Puntmann, VO, Carerj, ML, Wieters, I, et al.Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11): 12651273.

    • Search Google Scholar
    • Export Citation
  • 25.

    Szekely, Y, Lichter, Y, Taieb, P, et al.Spectrum of cardiac manifestations in COVID-19. Circulation. 2020;142: 342353.

  • 26.

    D’Andrea, A, Vriz, O, Ferrara, F, et al.Reference ranges and physiologic variations of Left E/e’ ratio in healthy adults: clinical and echocardiographic correlates. J Cardiovasc Echogr. 2018 Apr-Jun;28(2): 101108.

    • Search Google Scholar
    • Export Citation
  • 27.

    Augustine, DX, Coates-Bradshaw, LD, Willis, J, et al.Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2018 Sep;5(3): G11G24.

    • Search Google Scholar
    • Export Citation
  • 28.

    Simonneau, G, Montani, D, Celermajer, DS, et al.Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019 Jan;53(1): 1801913.

    • Search Google Scholar
    • Export Citation
  • 29.

    Larun, L, Brurberg, KG, Odgaard-Jensen, J, et al.Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2019 Oct 2;10(10): CD003200.

    • Search Google Scholar
    • Export Citation
  • 30.

    George, SZ, Fritz, JM, Childs, JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38(2): 5058.

    • Search Google Scholar
    • Export Citation
  • 31.

    Zubair, AS, McAlpine, LS, Gardin, T, et al.Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of coronavirus disease 2019: a review. JAMA Neurol. 2020;77(8): 10181027.

    • Search Google Scholar
    • Export Citation
  • 1.

    Institute for Health Metrics and Evaluation. COVID-19 projections. Accessed Feb 2, 2021. https://COVID19.healthdata.org/united-states-of-america?view=total-deaths&tab=trend.

    • Search Google Scholar
    • Export Citation
  • 2.

    Nikolai, LA, Meyer, CG, Kremsner, PG, et al.Asymptomatic SARS Coronavirus 2 infection: invisible yet invincible. Int J Infect Dis. 2020 Nov;100: 112116.

    • Search Google Scholar
    • Export Citation
  • 3.

    COVID Symptom Study. How long does COVID last? Accessed Feb 2, 2021. https://covid.joinzoe.com/post/covid-long-term?fbclid=IwAR1RxIcmmdL-EFjh_aI-.

    • Search Google Scholar
    • Export Citation
  • 4.

    Tenforde, MW, Kim, SS, Lindsell, CJ, et al.Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network—United States, March–June 2020. Morb Mortal Wkly Rep. 2020;69: 993998.

    • Search Google Scholar
    • Export Citation
  • 5.

    National Institutes of Health. Clinical spectrum of SARSCoV-2 infection. Accessed Feb 2, 2021. https://www.covid19treatmentguidelines.nih.gov/overview/clinical-spectrum.

    • Search Google Scholar
    • Export Citation
  • 6.

    Marshall, M. The lasting misery of coronavirus long-haulers. Nature. 2020 Sep;585(7825): 339341.

  • 7.

    Rawal, G, Yadav, S, Kumar, R. Post-intensive care syndrome: an overview. J Transl Int Med. 2017 Jun; 5(2): 9092.

  • 8.

    Halpin, SJ, McIvor, C, Whyatt, G, et al.Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2021 Feb;93(2): 10131022.

    • Search Google Scholar
    • Export Citation
  • 9.

    Cai, X, Hu, X, Ekumi, IO, et al.Psychological distress and its correlates among COVID-19 survivors during early convalescence across age groups. Am J Geriatr Psychiatry. 2020 Oct;28(10): 10301039.

    • Search Google Scholar
    • Export Citation
  • 10.

    Huang, Y, Tan, C, Wu, J, et al.Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase. Respir Res. 2020;21: 163.

    • Search Google Scholar
    • Export Citation
  • 11.

    Huang, C, Huang, L, Wang, Y, et al.6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397: 220232.

    • Search Google Scholar
    • Export Citation
  • 12.

    Mazza, MG, De Lorenzo, R, Conte, C, et al.Anxiety and depression in COVID-19 survivors: role of inflammatory and clinical predictors. Brain Behav Immun. 2020 Oct;89: 594600.

    • Search Google Scholar
    • Export Citation
  • 13.

    Townsend, L, Dowds, J, O’Brien, K, et al.Persistent poor health post-COVID-19 is not associated with respiratory complications or initial disease severity. Ann Am Thorac Soc. 2021 Jan 8. doi: https://doi.org/10.1513/AnnalsATS.202009-1175OC.

    • Search Google Scholar
    • Export Citation
  • 14.

    Carfi, A, Bernabei, R, Landi, F, et al.Persistent symptoms in patients after acute COVID-19. JAMA. 2020 Aug 11;324(6): 603605.

  • 15.

    Heneka, MT, Golenbock, D, Latz, E, et al.Immediate and long-term consequences of COVID-19 infections for the development of neurological disease. J Med Virol. 2021 Feb;93(2): 10131022.

    • Search Google Scholar
    • Export Citation
  • 16.

    Lu, Y, Li, X, Geng, D, et al.Cerebral micro-structural changes in COVID-19 patients: an MRI-based 3-month follow-up study. EClinicalMedicine. Aug 3, 2020. Accessed Feb 2, 2021. https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(20)30228-5/fulltext.

    • Search Google Scholar
    • Export Citation
  • 17.

    Hyman, MH, Talmage, JN, Hegmann, KT. Evaluating COVID-19 injury claims with a focus on workers’ compensation. J Occup Environ Med. 2020 Sep;62(9): 692699.

    • Search Google Scholar
    • Export Citation
  • 18.

    Greenhalgh, T, Knight, M, A’Court, C, et al.Management of post-acute COVID-19 in primary care. BMJ. 2020; 370:m3026.

  • 19.

    Greenhalgh, T, Javid, B, Knight, M, et al.What is the efficacy and safety of rapid exercise tests for exertional desaturation in COVID-19? The Center for Evidence-Based Medicine. Accessed Feb 2, 2021. https://www.cebm.net/COVID-19/what-is-the-efficacy-and-safety-of-rapid-exercise-tests-forexertional-desaturation-in-COVID-19.

    • Search Google Scholar
    • Export Citation
  • 20.

    Casanova, C, Celli, BR, Barria, P, et al.The 6-min walk distance in healthy subjects: reference standards from seven countries. Eur Respir J. 2011;37: 150156.

    • Search Google Scholar
    • Export Citation
  • 21.

    Schaller, T, Hirschbühl, K, Burkhardt, K, et al.Postmortem examination of patients with COVID-19. JAMA. 2020;323(24): 25182520.

  • 22.

    Freaney, PM, Shah, SJ, Khan, SS. COVID-19 and heart failure with preserved ejection fraction. JAMA. 2020;324(15): 14991500.

  • 23.

    Linder, D, Fitzek, A, Bräauninger, H, et al.Association of cardiac infection with SARS-CoV-2 in confirmed COVID-19 autopsy cases. JAMA Cardiol. 2020;5(11): 12811285.

    • Search Google Scholar
    • Export Citation
  • 24.

    Puntmann, VO, Carerj, ML, Wieters, I, et al.Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19). JAMA Cardiol. 2020;5(11): 12651273.

    • Search Google Scholar
    • Export Citation
  • 25.

    Szekely, Y, Lichter, Y, Taieb, P, et al.Spectrum of cardiac manifestations in COVID-19. Circulation. 2020;142: 342353.

  • 26.

    D’Andrea, A, Vriz, O, Ferrara, F, et al.Reference ranges and physiologic variations of Left E/e’ ratio in healthy adults: clinical and echocardiographic correlates. J Cardiovasc Echogr. 2018 Apr-Jun;28(2): 101108.

    • Search Google Scholar
    • Export Citation
  • 27.

    Augustine, DX, Coates-Bradshaw, LD, Willis, J, et al.Echocardiographic assessment of pulmonary hypertension: a guideline protocol from the British Society of Echocardiography. Echo Res Pract. 2018 Sep;5(3): G11G24.

    • Search Google Scholar
    • Export Citation
  • 28.

    Simonneau, G, Montani, D, Celermajer, DS, et al.Haemodynamic definitions and updated clinical classification of pulmonary hypertension. Eur Respir J. 2019 Jan;53(1): 1801913.

    • Search Google Scholar
    • Export Citation
  • 29.

    Larun, L, Brurberg, KG, Odgaard-Jensen, J, et al.Exercise therapy for chronic fatigue syndrome. Cochrane Database Syst Rev. 2019 Oct 2;10(10): CD003200.

    • Search Google Scholar
    • Export Citation
  • 30.

    George, SZ, Fritz, JM, Childs, JD. Investigation of elevated fear-avoidance beliefs for patients with low back pain: a secondary analysis involving patients enrolled in physical therapy clinical trials. J Orthop Sports Phys Ther. 2008;38(2): 5058.

    • Search Google Scholar
    • Export Citation
  • 31.

    Zubair, AS, McAlpine, LS, Gardin, T, et al.Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of coronavirus disease 2019: a review. JAMA Neurol. 2020;77(8): 10181027.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 2656 2656 2032
PDF Downloads 0 0 0
Save