I'm Dr. Michael Brode. I'm a general internist doctor and Medical Director of our Post-COVID-19 program at UT Health Austin, which is part of Dell Medical School
at the University of Texas. And so today, I really want to share
my framework for treating long COVID and share what's helping our patients
get on the path to recovery. Before talking about treatment,
the first question I always get is what test
should I get when I have long COVID? And the simple answer is
there is no test for long COVID. When we understand
the mechanism of what is causing long COVID and can send someone for a lab test
for that, that is going to be a medical breakthrough
that we don't have yet. And so there's no MRI, CT scan, or any test that we can do
to fully diagnose long COVID. At this point, it's really
whether it fits the pattern and the symptoms really start
after the COVID infection. Usually the symptoms
being chronic fatigue or neurologic, sometimes with shortness of breath
or palpitations. But for now, you know,
the fundamentals of diagnosis and testing are really making sure it's
not another cause of the symptoms. Diabetes, thyroid problems
are still common in the population. And so the testing is really a bunch of checkboxes
to make sure it's not something else or that the other chronic illnesses
that you may have are well controlled. The testing, if it all comes back normal,
it doesn't mean what you're going through is normal. It just means it's long COVID,
which we can't measure or test for. And so there's not a one size
fits all approach to testing. It's really going to be based
on your other medical problems you have, your risk
factors based on your age. And I think about it is almost a checklist
to make sure it's not something else. And a 25 year old healthy person,
that's going to be a short checklist and a 85 year old person who has heart
disease, cancer, other medical problems. That checklist is going to be
a lot longer. At the end of the day, though,
most patients are going to need some basic blood work to start,
but otherwise it's going to be really highly individualized
based on what symptoms you have. And so if that's shortness of breath,
maybe that's getting some lung function tests. If it's having palpitations
or high heart rate, maybe that's having a doctor take your
orthostatic vital signs to look for POTS. Right now, there is some
published guidance from the CDC and some doctors groups like AAPM&R
that you can suggest your doctor review because
it's going to be highly individualized. But the severe or atypical symptoms
may require some more advanced testing. But at the end of the day,
more testing is not always better. And if it's just long COVID,
most of the tests are going to come back normal. Patients in our clinic,
when they arrive, they usually have about
18 new symptoms on average. So this may take a couple of visits
to make sure the testing and take a good history
of all the symptoms. You know, what we have seen, though,
is that usually all the new symptoms start within
about 6 to 8 weeks of the COVID infection. And so there's a clear before
and after health for people who fully recovered from their COVID
infection and then develop these weird or mysterious symptoms
about six months later, that's atypical. And that would make me think the checklist
needs to be a lot longer to make sure it's not something else
before saying it's due to long COVID. Once again,
I think the fundamental part of treatment is to,
first of all, say that time is healing. We are seeing in our clinic that most,
if not all, patients are getting better. The real question is how much? And so the research shows that about 60% of
patients are fully getting better. Most patients are having the bulk of their recovery in the first year
or two year and a half. For patients who require long COVID treatment
at a specialized center, you know, what a lot of times that looks like is
if they're 20% of their baseline health. A couple of months after COVID
and a year, year and a half later, they may be at 60, 70,
80% of their health. I'll be fully honest, that's not 100%, but that is certainly better
than where they started. And I'm almost never seeing patients
get progressively worse unless they have another medical illness
that is really driving that progression. At the end of a year and a half, though,
we are seeing that the healing does continue to improve,
but unfortunately that's when it really starts to plateau
and the healing process slows. And that's why I'm having the conversation
with patients that, you know, you should be probably going to be dealing with
the symptoms in the near and medium term. We don't yet know what
the long term health effects of long COVID are going to be, but I'm optimistic
because I'm seeing a lot of patients get better. Also, the bad news is that
although many of the symptoms go away, the most common symptoms of long COVID,
the fatigue, brain fog and post exertional malaise,
meaning you do an activity that should not be tiring
and it just wears you out and it makes your symptoms worse. Those three symptoms
are the last ones to go away. When that wall, that post
exertional malaise goes away, that everything gets better, which really makes me
think it's fundamental to long COVID. Getting into the treatment directly,
I really think about it in four steps. The first being managing that energy
and avoiding hitting that wall of post exertional malaise. The next focused on
intentional rehabilitation that's building on your strengths,
accommodating your deficits. The next gets a little bit
into the more medical management using medications and evidence
based treatments to treat symptoms. And then the last step,
which I hope would be the first step one day, is really looking at the targeted therapies
that treat long COVID directly. But unfortunately, at this time,
all of those are purely experimental and we don't know
if they work for everyone yet. I think the most fundamental
and first step of treating COVID is really managing energy and the part
I really have to tell everyone is that wall of post exertional malaise is real
and there's no way around it. That is the illness for most people. The best advice I give
people is don't push through. You've got to recognize
when your body is sending you the signals that you are running out
of energy and approaching that wall. For some people, that's feeling short of breath, having a higher heart
rate, feeling achy or just, you know, not feeling with it and not being able
to concentrate, that battery is limited. I really encourage people
to be intentional about how they use that battery
throughout the day, take breaks to be able to recharge it
and get good sleep at night. So it's as full as it can be
for the next day. And what we've really seen with long COVID
is that both physical, mental or even emotional exertion
can drain that battery. So it's very important
how you use the battery for all those activities
and even to passive activities like watching TV or scrolling through
the phone can also drain that battery, whether you intend to use it
that way or not. What I see a lot of patients come in
and tell me is that they have good days and bad days,
and sometimes that's true that they can randomly have,
you know, changes in their illness. But what a lot of patients are actually
happening is they're in this pattern of, you know, they're not feeling well,
they're fatigued, they're at home, and then they wake up one day and they go out and do all the activities
that they want to do because they feel better
and they crash into that wall. And so they're in this cycle
where they crash experience, post
exertional malaise are at home recovering. And then as soon as they feel good again,
they crash, recover, crash, recover. As soon as you stop crashing into the wall
and making yourself feel worse, you start to feel better. And once again, with that battery,
it really becomes important about how you spend it. And so I think about it in the four P’s
that's prioritizing the activities that you need to do, pacing yourself
through those activities, really planning ahead and building
in time for rest and positioning yourself throughout those activities so that it's
not going to overexert yourself. And within that, as soon as people stop
having these large up and down swings of energy and can kind of live
in this zone and moderate it, they can't do all the activities
that they used to do before. But if they manage their energy well, they're usually very pleasantly surprised
how much they can do. If they're intentional and plan
accordingly. I also recognize, unfortunately,
that for people who have to put food on the table for their families,
that their job and employment is usually the biggest drain
on their battery. Long COVID is considered a disability
under the Adults with Disabilities Act. So fundamentally,
I do think it is important talking with your employer
and getting the protections you need to be able to fulfill your work
duties, maybe that is reduced hours, maybe that is getting
some work accommodations. And it is very clear to us once again
that physical and mental labor can be just as taxing
throughout the work day. So the next step in treatment
after really managing that energy is what I call
intentional rehabilitation. And it's once again recognizing that physical, mental
and emotional exertion drains the battery. The intentional rehabilitation
is all about managing that battery better, building on your strengths,
accommodating your deficits with the hope of pushing that wall further
away. I'll be honest, it doesn't cure
long COVID, but usually under professional guidance, people can really build
on their strengths and feel a lot better. And that can either be physical therapy,
cognitive therapy, or mental health counseling
to focus on all of those things. It's hard to do all at once,
but I do recommend people pick and choose what is most important to them or what is bothering them
the most, and focus on that and then move to the next thing
once they've improved a little bit. Looking at, you know, physical
rehabilitation or physical therapy and what I recommend for that is unfortunately, people
get in this cycle of deconditioning, you know, where they have long COVID,
they're tired, they're not doing much. They start to lose muscle mass, get out of shape,
and it starts to snowball and get worse. And you need to break that cycle, but
at the same time, avoid hitting that wall. And so exercise, if done incorrectly,
will make you feel worse. You will hit the wall. But if you don't do anything,
you'll get into that cycle. And so you need to find this perfect
balance of doing enough that rehabilitates you aerobically and cardiovascularly,
but not too much. And for some days, you know,
that's almost like walking a tightrope that swinging in the wind. But if done well,
it can be really effective at pushing that wall farther away
and a physical therapist or someone trained and helping
you find an individualized program to meet those rehabilitation needs
can be really powerful, especially if you're having trouble
doing any physical activities at all. What we found from patients telling me
is that doing that rehabilitation, that low impact exercises
can be really helpful in avoiding changes in position
because they're big stress on the body. Also, kind of dehydration and heat
can be a stress. So you really want to do any sort
of exercises under the right conditions. The next one is, you know,
cognitive therapy or mental activities, and that is really focused
on accommodating your deficit. So how to direct your attention,
you know, break problems into smaller tasks, write lists,
intentionally encode memories, and professionals like speech, language,
pathology, neuropsychology. They can help teach those techniques
and find exactly what your deficits are. Mental health counseling can really help
with anxiety, stress, or dealing with the grief from going through what
for many people is a disabling illness. And you know that uncontrolled mental
health symptoms are a passive drain on the battery. And I do think that is always
going to be a foundation for recovery,
making sure that's taken care of. The third step in treatment is what I call
symptomatic management, and that's really using evidence
based treatments or medication to treat specific symptoms. And now medications not be for everyone,
but we do have evidence based medications that treat the common symptoms of COVID,
including fatigue, insomnia, migraines, nerve pain. And what we do is they don't cure
long COVID, but for some people they can be really impactful and help them
get back their functioning day to day. And so that's going to be
highly individualized. We try to choose medications
that maybe treat one or two of the most disabling symptoms people have or using treatments like acupuncture,
which have evidence for chronic pain to treat those specific symptoms
and they can be highly impactful. That's a little bit of trial and error. Everybody's different in how they react to
medication and what doses work the best. If your doctor is recommending
a medication, you always ask what the side effects are,
especially avoiding medications that can cause fatigue or sedation
as a side effect. If you read the back of the label,
everything all label is going to say Fatigue is a side effect
and they have to write that. But your doctor is definitely going
to know which medications commonly have those side effects,
and it's worth that conversation. Fourth step in treatment is targeted
long-covid therapies. And once again, I hope one day this is
going to be the first step in treatment. But right now all of these targeted
therapies remain experimental. And what that means is
we cannot say they work or not because there's no evidence
to support them. And so the research in long COVID
can vary widely. The gold standard are randomized
controlled trials from reputable institutions,
but the long COVID research can also vary to the opposite end,
where that is junk science. And they're trying to sell something. Right now, though, most of the research
is at the point where they're just small trials
where they don't have a comparison. So it's hard to say
if those preliminary research is going to work for every single patient
with long COVID, because the disease can look different
in a lot of people or a lot of the recommendations
for treatments actually
haven't been studied in long COVID. They've just been used in illnesses
that look similar to long COVID, but haven't been studied
directly in that population. Right now a lot of the treatments are promising, but we can't say whether
they're going to work for everyone. And it's a little bit experimental
or trial and error. And I do think there's a lot of important
voices out there, especially on online communities, that can be powerful
about what other people have tried. But I do always give a warning. The loudest voice is not always
the correct voice and really have to think about what fits you and your personality
before trying an experimental medication. There are categories
that are being proposed for targeted treatments for long COVID. I think about them in three
big categories. The first theory is that
there are viral fragments in the body, and so treatments
about eradicating the viral fragments, whether that's antivirals
or taking the vaccine multiple times to try to get rid of the viral
fragments is one category. The second is treating
the chronic inflammation from the virus. This may include immunologic therapies
that are used in other autoimmune disorders like rheumatoid arthritis,
using medications like IVIG. And there's been a lot of interest
in using low dose naltrexone, which may decrease neurologic and systemic
inflammation and help symptoms. Another theory on that inflammation
is potentially using antidepressants to help
with the neurotransmitters like serotonin. The last category is really treatments to improve blood
flow and oxygen utilization. There is some research
that shows that, you know, the oxygen utilization in long
COVID is not efficient, as it used to be. And so some people have put forward therapies like hyperbaric oxygen
or mitochondrial supplements to try to improve people's energy
and help the fatigue. So if you are interested in trying
one of the more targeted therapies, I do highly recommend
that you participate in a clinical trial so we can really know in a rigorous way
whether these treatments work and give back to the Long-covid community. So research opportunities
unfortunately, are pretty rare right now. So it's going to be important
to have an in-depth conversation with your doctor
if you want to try one of these treatments about what is safe, what doesn't interact
with your other medications, and what the current research says
is most promising. And that's going to be
really individualized with your health care provider. Unfortunately, though,
many of the experimental medications that are used off label
probably will not be covered by insurance
because of their experimental nature. And so that could lead to significant
out-of-pocket costs to try these things. I will say the last note
about the targeted therapies is talking about supplements. And I'm not here to say that supplements
are either good or bad. The thing with supplements
or natural treatments, though, is that they are less regulated
than traditional prescription medications. So they're allowed to make claims
that may not be backed by science and they're allowed to market
what they want. And so they have a little bit of leeway making promises that may not be evidence
based. And honestly, if all of these things were
miracle cures, we'd all be taking them. But what I do suggest,
if you're interested for supplements or any other of these treatments,
is just trying one at a time and deciding beforehand what the expected effect
of taking that medication is going to be, how long you're going to have to take the medication to see that effect
and really judge it at that time point. If it works, keep taking it. If it doesn't work, stop taking it. I really recommend people
avoid starting ten things at once because then
it becomes impossible to determine which one of those was helpful and
which one of those may have side effects. Our approach to treating COVID
is really in those four steps. The first is that time
and energy management can really make a huge difference in people's lives,
especially if they're able to manage that battery well and avoid hitting
that wall of post exertional malaise. The next is being involved in intentional
rehabilitation, physical cognitive or emotional rehabilitation
to make sure you're using the battery the best you can. It all builds on each other. If those steps aren't getting to where you want to be moving into more
of the medical parts, prescription medication or other medical treatments
to help treat the symptoms. And then lastly,
using more of the targeted therapies, which we encourage
being part of a clinical trial, but really having an individualized
conversation with your doctor. If those aren't available to you
immediately. So thank you so much for listening.
