Long-Term Health Effects of COVID-19 Disability and Function Following SARS-CoV-2 Infection (2024) / Chapter Skim
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3 Selected Long-Term Health Effects Stemming from COVID-19 and Functional Implications
Pages 55-148

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From page 55...
... Although a great number of Long COVID health effects could impact function, the committee thinks it will be useful for SSA to become familiar with these three, as they are particularly challenging to treat because of their multisystem nature. (See Chapter 5 for an overview of similar multisystem chronic conditions.)
From page 56...
... In an effort to be inclusive, the committee includes at the end of this chapter annex tables organized by body system of selected health effects associated with Long COVID, along with their potential functional impacts and selected management guidelines. OVERVIEW OF HEALTH EFFECTS ASSOCIATED WITH LONG COVID Epidemiology of the Long-Term Health Effects of SARS-CoV-2 Infection Data from the U.S.
From page 57...
... ; methods used to account for the effect of baseline health in ascertaining whether the emergence of specific health effects following infection represents new disease; specification of outcomes; and other methodological differences. Because of the considerable variation in estimates of the long-term health effects seen in Long COVID, the committee presents average estimates for different body systems based on the published literature.
From page 58...
... . As described in Chapter 1, the International Classification of Functioning, Disability and Health model of disability identifies three domains of functioning: body functions and structures (i.e., physiological functions of the body, including psychological functions, and functioning of body structures)
From page 59...
... Annex Tables 3-1 through 3-11 at the end of this chapter list selected health conditions associated with Long COVID in adults, organized by body system. Annex Table 3-12 lists selected health effects that are not organ system–specific, including chronic fatigue and PEM, ME/CFS, and fever.
From page 60...
... Clustering of Health Effects Given the vast number of symptoms and health effects associated with Long COVID, several research groups have attempted to cluster patients with similar effects to better understand the disease (see Table 3-1)
From page 61...
... central neurological, and type variant in unvaccinated 9,804 UK-based data, additional testing (3) multi-organ systemic people, alpha variant in adults using data from inflammatory unvaccinated people, and delta Covid Symptom Study variant in vaccinated people.
From page 62...
... cardiovascular symptoms with work absence individuals, 77% common self-reported chest pain, shortness of breath, mild initial illness symptoms and palpitations, hierarchical clustering (3) significantly fewer symptoms than clusters 1 and 2 Kisiel et al.
From page 63...
... brain fog and PEM, found most representative Long 85 enrolling sites (3) brain fog, PEM, and fatigue, COVID symptoms to be smell/ in 33 states plus (4)
From page 64...
... SELECTED MULTISYSTEM HEALTH EFFECTS ASSOCIATED WITH LONG COVID Three health effects associated with Long COVID that have a significant effect on functioning and are particularly challenging to manage -- chronic fatigue and PEM, PCCI, and autonomic dysfunction -- are reviewed in this section. There is significant overlap among the symptoms associated with these conditions.
From page 65...
... The health system barriers include limited or inequitable access to CPET, with even fewer trained clinicians who can apply and interpret 2-day CPET to diagnose PEM. Patient-level barriers include prolonged recovery from testing and the prohibitive cost of testing without adequate insurance coverage.
From page 66...
... Nevertheless, additional research is needed to compare 2-day CPET results in Long COVID versus ME/CFS. Functional Impacts Chronic fatigue symptoms in Long COVID impact a person's ability to work and perform activities of daily living, which makes clinical care and rehabilitation a priority for these patients (Walker et al., 2023)
From page 67...
... . Similarly, another population-based longitudinal study conducted in Switzerland describing the long-term trajectory of post-COVID symptoms in adults at 1, 2, 6, 9, 12, 18, and 24 months after SARS-CoV-2 infection found that PEM was more likely in those who had worsening of or no change in their perceived health status compared with those who reported improvement or showed continued recovery (Ballouz et al., 2023)
From page 68...
... . Post-COVID-19 Cognitive Impairment Cognitive impairment has emerged as one of the most commonly reported health effects associated with Long COVID, potentially portending significant consequences for patient functioning and quality of life.
From page 69...
... . Finally, preexisting conditions, including headaches (Jacobs et al., 2023)
From page 70...
... As noted above, some individuals with Long COVID may report brain fog or other cognitive concerns and experience functional impairment, while not necessarily meeting the clinical diagnostic threshold for cognitive impairment (Davis et al., 2023)
From page 71...
... Finally, it is important to note that other conditions can mimic the symptoms of PCCI. For example, depression may increase one's perception of brain fog and contribute to poor attention and concentration (Cristillo et al., 2022)
From page 72...
... Several instruments (e.g., Instrumental Activities of Daily Living scale) can be used to gauge how PCCI may be impacting daily tasks, such as managing finances, following instructions, or planning activities.
From page 73...
... , but autonomic symptoms arise upon assuming an upright posture and are relieved by being supine, then the diagnosis of orthostatic intolerance can be given. Some symptoms of autonomic dysfunction, such as lightheadedness, improve quickly upon lying down, but other symptoms, such as fatigue and brain fog, can persist for hours or days at a time and can impact activities of daily living (Fedorowski, 2019; Vernino et al., 2021)
From page 74...
... . One study found orthostatic hypotension in 14 percent of subjects with Long COVID symptoms (Buoite Stella et al., 2022)
From page 75...
... Two forms of standing tests are used to diagnose POTS in Long COVID patients. These tests assess heart rate and blood pressure changes upon assuming an upright position, providing insight into autonomic dysfunction and orthostatic intolerance.
From page 76...
... . Functional Impacts Symptoms resulting from autonomic dysfunction following SARSCoV-2 infection have a substantial impact on individuals' functioning and quality of life in the short, medium, and long terms (Carmona-Torre et al., 2022)
From page 77...
... . The course of recovery for symptoms associated with autonomic dysfunction in Long COVID entails remitting and relapsing as a result of various factors, such as comorbid conditions, stress, and overexertion (Barizien et al., 2021; Seeley et al., 2023)
From page 78...
... . Nonetheless, persistent health effects following SARS-CoV-2 infection have been reported in children, with multisystem inflammatory syndrome in children (MIS-C)
From page 79...
... Pediatric Long COVID is a separate entity from MIS-C. The true prevalence of Long COVID symptoms and health effects remains unclear for multiple reasons and varies widely in the literature, including limited studies and heterogeneous samples (Pellegrino et al., 2022)
From page 80...
... ; this issue has not been explicitly studied in children with Long COVID. POTS and other forms of autonomic dysfunction have also been reported in children with Long COVID (Morrow et al., 2022)
From page 81...
... Weight loss Lack of appetite Mental Health Anxiety Depression/low mood Increased somatic symptoms School avoidance Regression of academic or social milestones No specific organ system Fatigue (general) ; Post-exertional malaise Exercise intolerance Sleep disturbances Fever SOURCES: Behnood et al., 2022; Borch et al., 2022; Drogalis-Kim et al., 2022; Funk et al., 2022; Jiang et al., 2023; Kompaniyets et al., 2022; Kostev et al., 2022; Leftin Dobkin et al., 2021; Lopez-Leon et al., 2022; Malone et al., 2022; Mariani et al., 2023; Morrow et al., 2022; Pellegrino et al., 2022; Radtke et al., 2021; Riera-Canales and Llanos-Chea, 2023; Roessler et al., 2022; Sansone et al., 2023.
From page 82...
... Children with Long COVID may experience new or worsening mental health conditions, such as anxiety and depression. One study with 236 pediatric Long COVID patients found that irritability, mood changes, and anxiety or depression were found in 24.3 percent, 23.3 percent, and 13.1 percent of the cohort, respectively, suggesting a high prevalence of persistent psychiatric symptoms (Roge et al., 2021)
From page 83...
... Compared with adults, children are healthier, with fewer preexisting chronic health conditions. Conditions that may increase the risk of Long COVID in adults, such as type 2 diabetes, are rarely seen in pediatrics, and Long COVID may therefore represent a large change from baseline for previously healthy children (Malone et al., 2022)
From page 84...
... , and (vi) health and physical well-being."3 SELECTED GUIDANCE STATEMENTS SPECIFIC TO LONG COVID In addition to the diagnosis and management guidelines included in Annex Tables 3-1 through 3-12, selected guidance statements specific to Long COVID are listed in Table 3-3.
From page 85...
... Disciplinary Collaborative consensus guidance statement 2021 (2022) Writing Group on the assessment and treatment of cognitive symptoms in patients with post-acute sequelae of SARS CoV-2 infection (PASC)
From page 86...
... treatment of neurologic sequelae in patients with post acute sequelae of SARS-CoV-2 infection (PASC) AAPMR PASC Multi- Multidisciplinary collaborative November 8, Cheng Disciplinary Collaborative consensus guidance statement 2023 et al.
From page 87...
... . OVERVIEW OF BODY SYSTEMS POTENTIALLY AFFECTED IN LONG COVID In addition to the information in Annex Tables 3-1 through 3-12 on selected health effects associated with Long COVID, the following narratives, organized by body system, provide a high-level overview of diagnostic, management, and other information potentially relevant to adults with Long COVID.
From page 88...
... Cardiovascular System Cardiovascular symptoms and conditions are common following acute SARS-CoV-2 infection, and can include cardiopulmonary symptoms (e.g., chest pain, dyspnea, or palpitations) , cardio-neuro symptoms, cardiac inflammatory diseases (e.g., myocarditis and pericarditis)
From page 89...
... . Additionally, studies have found visual and auditory disturbances, such as blurry vision, tinnitus, or hearing loss, in some Long COVID patients.
From page 90...
... Of note, lower levels of serum cortisol have been described in patients with Long COVID compared with non–Long COVID healthy controls (Klein et al., 2023)
From page 91...
... . Notably, these abnormalities are not diagnostic of Long COVID, but are observations that support immune dysregulation among Long COVID patients.
From page 92...
... It is therefore important to monitor kidney function in Long COVID patients who are at higher risk of kidney disease. Diagnosis involves a combination of medical history, physical examination, laboratory tests, and imaging studies, as used in the general population.
From page 93...
... Health effects associated with Long COVID may manifest as impairments in body structures and
From page 94...
... In addition, individuals with Long COVID may experience multiple and potentially overlapping symptoms and conditions, including chronic fatigue and PEM, PCCI, and autonomic dysfunction. Some health effects can be sufficiently severe to interfere with an individual's day-to-day functioning, including participation and performance in work and school activities.
From page 95...
... 2023. Recovery and symptom trajectories up to two years after SARS-CoV-2 infection: Population based, longitudinal cohort study.
From page 96...
... 2021. Myalgic encephalomy elitis/chronic fatigue syndrome: Essentials of diagnosis and management.
From page 97...
... 2022. Long COVID symptoms and duration in SARS-CoV-2 positive children -- A nationwide cohort study.
From page 98...
... 2023. Profiling post-COVID-19 condition across different variants of SARS-CoV-2: A prospective longitudinal study in unvaccinated wild-type, unvaccinated Alpha-variant, and vaccinated Delta-variant populations.
From page 99...
... 2023. Exploring the influence of pre-existing conditions and infection factors on pediatric long COVID symptoms and quality of life.
From page 100...
... 2010. Conceptual model for physical therapist management of chronic fatigue syndrome/myalgic encepha lomyelitis.
From page 101...
... 2020. 2020 focused updates to the asthma management guidelines: A report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group.
From page 102...
... 2022. Long COVID classification: Findings from a clustering analysis in the Predi-COVID cohort study.
From page 103...
... 2022. Deep dive into the long haul: Analysis of symptom clusters and risk factors for post-acute sequelae of COVID-19 to inform clinical care.
From page 104...
... 2021. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC)
From page 105...
... 2022. Comprehensive clinical characterisation of brain fog in adults reporting long COVID symptoms.
From page 106...
... 2020. Characteristics and outcomes of pregnant women admitted to hospital with confirmed SARS-CoV-2 infection in UK: National population based cohort study.
From page 107...
... 2023. Risks of neurological and psychiatric sequelae 2 years after hospitalisation or intensive care admission with COVID-19 compared to admissions for other causes.
From page 108...
... Whiteson 2022. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of breathing discomfort and respiratory sequelae in patients with post acute sequelae of SARS-CoV-2 infection (PASC)
From page 109...
... 2023. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of neu rologic sequelae in patients with post-acute sequelae of SARS-CoV-2 infection (PASC)
From page 110...
... 2022. Intensive care unit-acquired weakness and hospital functional mobility outcomes follow ing invasive mechanical ventilation in patients with COVID-19: A single-centre prospec tive cohort study.
From page 111...
... 2022. Prevalence and corre lates of long COVID symptoms among us adults.
From page 112...
... 112 LONG-TERM HEALTH EFFECTS OF COVID-19 Pringsheim, T., G
From page 113...
... 2019. Long term follow up of young people with chronic fatigue syndrome at tending a pediatric outpatient service.
From page 114...
... 2023. High incidence of autonomic dysfunction and postural orthostatic tachycardia syndrome in patients with long COVID: Implications for management and health care planning.
From page 115...
... 2022. Hormonal trends in patients suffering from long COVID symptoms.
From page 116...
... 2021. Pre-existing health conditions and severe COVID-19 outcomes: An umbrella review ap proach and meta-analysis of global evidence.
From page 117...
... : State of the science and clinical care from a 2019 Na tional Institutes of Health Expert Consensus Meeting -- Part 1. Autonomic Neuroscience 235:102828.
From page 118...
... 2023. Epidemiology, symptomatology, and risk factors for long COVID symptoms: Population-based, multicenter study.
From page 119...
... 2023. Data-driven analysis to understand long COVID using electronic health records from the recover initiative.
From page 120...
... •  Idiopathic pulmonary fibrosis in adults: Diagnosis and management (NICE, 2017) Hypoxemia Standing; walking; N/A None strenuous physical activity; lifting; carrying; pushing/pulling; overhead reaching; climbing; low work; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace Pneumonitis Walking, strenuous •  Diagnosis of None physical activity, lifting, hypersensitivity carrying, pushing/pulling, pneumonitis in adults: An overhead reaching, official ATS/JRS/ALAT climbing, low work clinical practice guideline (Raghu et al., 2020)
From page 121...
... reaching, climbing, low work, speaking SOURCES: Maley et al., 2022; Zang et al., 2023.
From page 122...
... Pulmonary Walking, strenuous • American Society 7.08 embolism physical activity, of Hematology lifting, carrying, 2020 guidelines for pushing/pulling, management of venous overhead reaching, thromboembolism: climbing, low work Treatment of deep vein thrombosis and pulmonary embolism (Ortel et al., 2020)
From page 123...
... Vasculitis Strenuous physical • Vasculitis clinical practice 14.03 activity, lifting, guidelines (ACR, 2021) carrying, pushing/ pulling, reaching, overhead reaching Cardiac Walking, strenuous • Management of acute None inflammatory physical activity, myocarditis and disease lifting, carrying, chronic inflammatory (myocarditis and/ pushing/pulling, cardiomyopathy: An Expert or pericarditis)
From page 124...
... lifting; carrying; pushing/ (Rogers et al., 2023) pulling; reaching; climbing; low work; near visual acuity; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace; problem solving Encephalitis/ Sitting; standing; walking; • Autoimmune None Encephalopathy strenuous physical activity; encephalitis (Gole and lifting; carrying; pushing/ Anand, 2023)
From page 125...
... Neurocognitive Speaking; understanding, •  Multi-disciplinary None disorders/post- remembering, and applying collaborative consensus COVID cognitive information; concentrating, guidance statement impairment persisting, or maintaining on the assessment and pace; problem solving; treatment of cognitive adapting or managing symptoms in patients oneself; interacting with with post-acute others sequelae of SARS CoV-2 infection (PASC)
From page 126...
... 126 LONG-TERM HEALTH EFFECTS OF COVID-19 ANNEX TABLE 3-3 Continued Potential Social Security Potential Functional Selected Diagnostic and Administration Health Effects Limitations Management Guidelines Listings Abnormal Standing, walking, •  Evidence-based 12.07 movements/ strenuous physical guideline update: Tremors activity, lifting, carrying, Treatment of essential reaching, gross and fine tremor: Report of the manipulation, foot/leg Quality Standards controls, climbing, low Subcommittee of the work, speaking American Academy of Neurology (Zesiewicz et al., 2011) •  Differentiation and diagnosis of tremor (Crawford and Zimmerman, 2011)
From page 127...
... Stroke Sitting; standing; walking; • Guidelines for the 11.04 strenuous physical activity; early management of lifting; carrying; pushing/ patients with acute pulling; reaching; gross ischemic stroke: 2019 and fine manipulation; update to the 2018 foot/leg controls; climbing; guidelines for the low work; vision; hearing; early management speaking; understanding, of acute ischemic remembering, and applying stroke: A guideline information; concentrating, for healthcare persisting, or maintaining professionals from pace; problem solving; the American Heart adapting or managing Association/American oneself; interacting with Stroke Association others (Powers et al., 2019) •  Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association (Winstein et al., 2016)
From page 128...
... Pain Standing; walking; •  Clinical guidelines None strenuous physical activity; (AAPM, 2023) lifting; carrying; pushing/ pulling; climbing; low work; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace
From page 129...
... information; concentrating, persisting, or maintaining pace Transverse Sitting, standing, walking, • Transverse myelitis 11.08 myelitis or other strenuous physical activity, (Simone and Emmady, demyelinating lifting, carrying, pushing/ 2020 disease pulling, reaching, gross and fine manipulation, foot/leg controls, climbing, low work, vision Raynaud's Fine manipulation •  Raynaud's 114.04 phenomenon (NIAMSD, 2021) Paresthesia Fine manipulation, foot/leg • A comprehensive None controls algorithm for management of neuropathic pain (Bates et al., 2019)
From page 130...
... Visual, ocular Near or far visual • Clinical management guidelines 2.02, 2.03, 2.04 symptoms acuity, peripheral (The College of Optometrists, (changes in vision 2022) vision/dry eye)
From page 131...
... Myalgia Standing, walking, strenuous •  Nonpharmacologic None physical activity, lifting, and pharmacologic pushing/pulling, reaching, management of acute gross and fine manipulation, pain from non-low back, climbing, low work musculoskeletal injuries in adults: A clinical guideline from the American College of Physicians and American Academy of Family Physicians (Qaseem et al., 2020) continued
From page 132...
... 132 LONG-TERM HEALTH EFFECTS OF COVID-19 ANNEX TABLE 3-5 Continued Potential Social Security Health Potential Functional Selected Diagnostic and Administration Effects Limitations Management Guidelines Listings Arthralgia Standing, walking, strenuous • 2019 American College of None physical activity, lifting, Rheumatology/Arthritis pushing/pulling, reaching, Foundation guideline gross and fine manipulation, for the management of climbing, low work osteoarthritis of the hand, hip, and knee (Kolasinski et al., 2020) Arthritis Sitting, standing, walking, • American College of 14.09 strenuous physical activity, Rheumatology guideline lifting, pushing/pulling, for the treatment of reaching, gross and fine rheumatoid arthritis manipulation, climbing, low (Fraenkel et al., 2021)
From page 133...
... vision; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace Diabetes type 2 Standing; walking; • Classification and diagnosis of None (diabetes strenuous physical diabetes: Standards of care in complications activity; lifting; pushing/ diabetes -- 2023 (ElSayed et al., are included pulling; reaching; gross 2023) under organ and fine manipulation; specific climbing; low work; listings)
From page 134...
... climbing; low work; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace; problem solving; interacting with others Reproductive Low testosterone: • Sex hormones in SARS-CoV-2 None hormone Understanding, susceptibility: Key players or dysfunction remembering, and confounders?
From page 135...
... erythematosus, low work; vision; hearing; myositis, systemic speaking; understanding, sclerosis, Sjögren's remembering, and applying syndrome, mixed information; concentrating, connective tissue persisting, or maintaining disease, and pace; problem solving; inflammatory interacting with others; bowel disease) adapting or managing oneself NOTE: Myositis and rheumatoid arthritis are discussed in Annex Table 3-5 (musculoskeletal conditions)
From page 136...
... Irritable bowel Strenuous physical • ACG clinical guideline: None syndrome/ activity; lifting; carrying; Management of irritable motility disorders pushing/pulling; bowel syndrome (Lacy reaching; gross and fine et al., 2021) manipulation; foot/leg controls; climbing; low work; vision; hearing; speaking; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace; problem solving; interacting with others; adapting or managing oneself Gut dysbiosis N/A N/A None
From page 137...
... Chronic liver Standing, walking, • EASL clinical practice 5.05 disease strenuous physical activity guidelines for the management of patients with decompensated cirrhosis (Angeli et al., 2018) Cholangitis N/A • Tokyo guidelines 2018: None Diagnostic criteria and severity grading of acute cholangitis (with videos)
From page 138...
... Nausea or Strenuous physical • AGA clinical practice None vomiting activity, climbing update on management of medically refractory gastroparesis: Expert review (Lacy et al., 2022)
From page 139...
... Oligospermia N/A •  Diagnosis and None treatment of infertility in men: AUA/ASRM guideline part I (Schlegel et al., 2020) Orchitis/ Standing, walking, •  Sexually transmitted None epididymitis strenuous physical activity, infections treatment (with moderate lifting, carrying, pushing/ guidelines, 2021 (CDC, to severe pain)
From page 140...
... work; understanding, remembering, and applying information; concentrating, persisting, or maintaining pace; problem solving Overactive Sitting; standing; walking; •  Diagnosis and None bladder strenuous physical activity; treatment of overactive syndrome lifting; carrying; pushing/ bladder (non pulling; climbing; low neurogenic) in adults: work; concentrating, AUA/SUFU guideline persisting, or maintaining amendment 2019 pace; adapting or (Lightner et al., 2019)
From page 141...
... Retiform Sitting, strenuous •  Retiform purpura: A 8.05 purpura physical activity, lifting, diagnostic approach carrying, pushing/pulling, (Georgesen et al., 2020) reaching, gross and fine manipulation, foot/leg controls, low work Chronic Sitting, strenuous • The diagnosis and None urticaria physical activity, lifting, management of acute and carrying, pushing/pulling, chronic urticaria: 2014 reaching, gross and fine update (Bernstein et al., manipulation, foot/leg 2014)
From page 142...
... None hyperactivity persisting, or maintaining disorder pace; interacting with others; adapting or managing oneself Anxiety/panic Speaking; concentrating, • DSM-5-TR (APA, 2022) 12.06 disorders persisting, or maintaining pace; interacting with others; adapting or managing oneself Depression Speaking; concentrating, • DSM-5-TR (APA, 2022)
From page 143...
... None physical activity; climbing; concentrating, persisting, or maintaining pace; interacting with others; adapting or managing oneself Obsessive Concentrating, persisting, • DSM-5-TR (APA, 2022) None compulsive or maintaining pace; disorder interacting with others; adapting or managing oneself Disordered sleep Understanding, • DSM-5-TR (APA, 2022)
From page 144...
... Myalgic Sitting; standing; walking; •  Beyond myalgic None encephalitis/ strenuous physical activity; encephalomyelitis/ chronic fatigue lifting; carrying; pushing/ chronic fatigue syndrome pulling; reaching; gross syndrome: Redefining and fine manipulation; an illness (IOM, 2015) foot/leg controls; climbing; •  Myalgic low work; vision; hearing; encephalomyelitis/ speaking; understanding, chronic fatigue remembering, and applying syndrome: Essentials information; concentrating, of diagnosis and persisting, or maintaining management (Bateman pace; problem solving; et al., 2021)
From page 145...
... can affect an individual's ability to walk. Strenuous physical Strenuous physical activity captures activities that require exertion activity and stamina -- for example, running, jumping, swimming, throwing, catching, and the like.
From page 146...
... . Overhead reaching requires neck extension and may require standing.
From page 147...
... From a functional perspective, lying on the ground has more in common with other low work activities in that it includes the need to get up and down from the ground and potentially squirming around to do work while on the ground. These are difficult tasks that are equivalent to the other low work activities.
From page 148...
... psychologically based symptoms; distinguishing between acceptable and unacceptable work performance; setting realistic goals; making plans for [oneself] independently of others; maintaining personal hygiene and [appropriate attire]


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