Reconceptualizing rehabilitation research via an enactive framework and a radically interdisciplinary cross-analysis: a study protocol on fatigue in post COVID-19 condition (PCC)

Authors

  • Richard Levi Department of Rehabilitation Medicine and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  • Ulrika Birberg Thornberg Department of Rehabilitation Medicine and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  • Ida Blystad Department of Radiology Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden; Centre for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden
  • Anestis Divanoglou Department of Rehabilitation Medicine and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
  • David Engblom Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
  • Felipe Leon Centre of Philosophy, School of Arts and Humanities, University of Lisbon, Lisboa, Portugal
  • Sofia Morberg Jämterud Department of Thematic Studies: Technology and Social Change and the Centre for Medical Humanities and Bioethics, Linköping University, Linköping, Sweden
  • Kristin Zeiler Centre for Medical Image Science and Visualization (CMIV), Linköping University, Linköping, Sweden; Department of Thematic Studies: Technology and Social Change and the Centre for Medical Humanities and Bioethics, Linköping University, Linköping, Sweden

DOI:

https://doi.org/10.2340/jrm.v57.42254

Keywords:

fatigue, interdisciplinary study, models, biopsychosocial, neurological rehabilitation, post-acute COVID-19 syndrome

Abstract

Objective: To present a radically interdisciplinary research approach to ill-defined symptoms, with a focus on fatigue as a major symptom of post COVID-19 condition, where multiple and, to date, rarely combined approaches may yield a fuller understanding of these symptoms.

Design: Protocol for a mixed-methods study comprising an interdisciplinary cross-analysis.

Patients: 35 persons with post COVID-19 condition and severe fatigue were included, and 35 age-, sex-, and educationally matched controls who recovered from COVID-19 without post COVID-19 condition.

Methods: Participants were assessed by a multidisciplinary research team as follows: physician assessment; blood and urinalysis; spirometry and physical performance tests; neuropsychological tests; structural and functional magnetic resonance imaging; extended immunological tests (cytokines); and qualitative phenomenological analysis of interviews. Data will be analysed in accordance with established methods in each of these research fields and by a cross-analysis methodology developed from within an enactive framework. This framework encompasses a focus on neuroscientific, physiological, and experiential aspects of the person as a living being in their sociocultural world.

Conclusion: The biopsychosocial model needs to be implemented in research according to methods that allow radically different research paradigms, typically seen as incommensurable, to inform each other in a non-reductionist manner. One application of such an approach is therefore described.

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References

Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977; 196: 129–136.

https://doi.org/10.1126/science.847460 DOI: https://doi.org/10.1126/science.847460

Bolton D, Gillett G. The biopsychosocial model of health and disease: new philosophical and scientific developments. London: Palgrave Macmillan; 2019. DOI: https://doi.org/10.1007/978-3-030-11899-0

https://doi.org/10.1007/9783030118990

Cormack B, Stilwell P, Coninx S, Gibson J. The biopsychosocial model is lost in translation: from misrepresentation to an enactive modernization. Physiother Theory Pract 2023; 39: 2273–2288.

https://doi.org/10.1080/09593985.2022.2080130 DOI: https://doi.org/10.1080/09593985.2022.2080130

de Haan S. Bio-psycho-social interaction: an enactive perspective. Int Rev Psychiatry 2021; 33: 471–477.

https://doi.org/10.1080/09540261.2020.1830753 DOI: https://doi.org/10.1080/09540261.2020.1830753

Van Oudenhove L, Cuypers S. The relevance of the philosophical “mind–body problem” for the status of psychosomatic medicine: a conceptual analysis of the biopsychosocial model. Med Health Care Philos 2014; 17: 201–213.

https://doi.org/10.1007/s11019-013-9521-1 DOI: https://doi.org/10.1007/s11019-013-9521-1

Varela FJ, Thompson E, Rosch E, Kabat-Zinn J. The embodied mind: cognitive science and human experience. Revised ed. Cambridge, MA: MIT Press; 2017. DOI: https://doi.org/10.7551/mitpress/9780262529365.001.0001

https://doi.org/10.7551/mitpress/9739.001.0001

Newen A, Bruin Ld, Gallagher S. The Oxford handbook of 4E cognition. Oxford: Oxford University Press; 2018 DOI: https://doi.org/10.1093/oxfordhb/9780198735410.001.0001

Vaz DV, Stilwell P, Coninx S, Low M, Liebenson C. Affordance-based practice: an ecological-enactive approach to chronic musculoskeletal pain management. Braz J Phys Ther 2023; 27: 100554.

https://doi.org/10.1016/j.bjpt.2023.100554 DOI: https://doi.org/10.1016/j.bjpt.2023.100554

Gallagher S. The self and its disorders. Oxford: Oxford University Press; 2024 DOI: https://doi.org/10.1093/oso/9780198873068.001.0001

Colombetti G. Enacting affectivity. Oxford: Oxford University Press; 2018.

https://doi.org/10.1093/oxfordhb/9780198735410.013.31 DOI: https://doi.org/10.1093/oxfordhb/9780198735410.013.31

Fuchs T. Ecology of the brain: the phenomenology and biology of the embodied mind. First ed. Oxford: Oxford University Press; 2017 DOI: https://doi.org/10.1093/med/9780199646883.001.0001

Husserl E. Collected works. Vol. 3: Ideas pertaining to a pure phenomenology and to a phenomenological philosophy, second book: studies in the phenomenology of constitution. The Hague: Nijhoff; 1989

Merleau-Ponty M. Phenomenology of perception. London: Routledge; 2014 DOI: https://doi.org/10.4324/9780203720714

Slatman J. Our strange body: philosophical reflections on identity and medical interventions. 1st ed. Amsterdam: Amsterdam University Press; 2014 DOI: https://doi.org/10.1017/9789048523146

Leder D. The absent body. Chicago: University of Chicago Press; 1990

Fuchs T. The circularity of the embodied mind. Front Psychol 2020; 11: 1707.

https://doi.org/10.3389/fpsyg.2020.01707 DOI: https://doi.org/10.3389/fpsyg.2020.01707

Smets EMA, Garssen B, Bonke B, De Haes JCJM. The Multidimensional Fatigue Inventory (MFI) psychometric qualities of an instrument to assess fatigue. J Psychosom Res 1995; 39: 315–325.

https://doi.org/10.1016/0022-3999(94)00125-O DOI: https://doi.org/10.1016/0022-3999(94)00125-O

Hinz A, Fleischer M, Brähler E, Wirtz H, Bosse-Henck A. Fatigue in patients with sarcoidosis, compared with the general population. Gen Hosp Psychiatry 2011; 33: 462–468.

https://doi.org/10.1016/j.genhosppsych.2011.05.009 DOI: https://doi.org/10.1016/j.genhosppsych.2011.05.009

Westenberger A, Nöhre M, Brähler E, Morfeld M, de Zwaan M. Psychometric properties, factor structure, and German population norms of the multidimensional fatigue inventory (MFI-20). Front Psychiatry 2022; 13: 1062426.

https://doi.org/10.3389/fpsyt.2022.1062426 DOI: https://doi.org/10.3389/fpsyt.2022.1062426

Wahlgren C, Forsberg G, Divanoglou A, Östholm Balkhed Å, Niward K, Berg S, et al. Two-year follow-up of patients with post-COVID-19 condition in Sweden: a prospective cohort study. Lancet Reg Health Eur 2023; 28: 100595.

https://doi.org/10.1016/j.lanepe.2023.100595 DOI: https://doi.org/10.1016/j.lanepe.2023.100595

van Dixhoorn J, Folgering H. The Nijmegen Questionnaire and dysfunctional breathing. ERJ Open Res 2015; 1.

https://doi.org/10.1183/23120541.00001-2015 DOI: https://doi.org/10.1183/23120541.00001-2015

Grimby G, Frändin K. On the use of a six-level scale for physical activity. Scand J Med Sci Sports 2018; 28: 819–825.

https://doi.org/10.1111/sms.12991 DOI: https://doi.org/10.1111/sms.12991

Evans JA, Whitelaw WA. The assessment of maximal respiratory mouth pressures in adults. Respir Care 2009; 54: 1348–1359

Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med 1998; 158: 1384–1387.

https://doi.org/10.1164/ajrccm.158.5.9710086 DOI: https://doi.org/10.1164/ajrccm.158.5.9710086

Strassmann A, Steurer-Stey C, Lana KD, Zoller M, Turk AJ, Suter P, et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health 2013; 58: 949–953.

https://doi.org/10.1007/s00038-013-0504-z DOI: https://doi.org/10.1007/s00038-013-0504-z

Ruff RM, Allen CC. Ruff 2 & 7: Selective Attention Test: professional manual. Lutz, FL: Psychological Assessment Resources; 1996

Conners CK. Conners continuous performance test, 3rd ed. (Conners CPT 3) & Connors continuous auditory test of attention (Conners CATA): Technical manual. London: MHS; 2014

Wechsler D. Wechsler adult intelligence scale. 4th ed. San Antonio, TX: Psychological Corporation; 2008 DOI: https://doi.org/10.1037/t15169-000

Schmidt M. Rey auditory verbal learning test. Los Angeles: Western Psychological Services; 1996

Tombaugh TN. Trail Making Test A and B: normative data stratified by age and education. Arch Clin Neuropsychol 2004; 19: 203–214.

https://doi.org/10.1016/s0887-6177(03)00039-8 DOI: https://doi.org/10.1016/S0887-6177(03)00039-8

Delis D. Delis-Kaplan Executive Function System. San Antonio, TX: Psychological Corporation; 2001 DOI: https://doi.org/10.1037/t15082-000

Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983; 67: 361–370.

https://doi.org/10.1111/j.1600-0447.1983.tb09716.x DOI: https://doi.org/10.1111/j.1600-0447.1983.tb09716.x

Bastien CH, Vallières A, Morin CM. Validation of the Insomnia Severity Index as an outcome measure for insomnia research. Sleep Med 2001; 2: 297–307.

https://doi.org/10.1016/s1389-9457(00)00065-4 DOI: https://doi.org/10.1016/S1389-9457(00)00065-4

Díez-Cirarda M, Yus M, Gómez-Ruiz N, Polidura C, Gil-Martínez L, Delgado-Alonso C, et al. Multimodal neuroimaging in post-COVID syndrome and correlation with cognition. Brain 2023; 146: 2142–2152.

https://doi.org/10.1093/brain/awac384 DOI: https://doi.org/10.1093/brain/awac384

Bungenberg J, Hohenfeld C, Costa AS, Heine J, Schwichtenberg K, Hartung T, et al. Characteristic functional connectome related to Post-COVID-19 syndrome. Sci Rep 2024; 14: 4997.

https://doi.org/10.1038/s41598-024-54554-3 DOI: https://doi.org/10.1038/s41598-024-54554-3

Boito D, Eklund A, Tisell A, Levi R, Özarslan E, Blystad I. MRI with generalized diffusion encoding reveals damaged white matter in patients previously hospitalized for COVID-19 and with persisting symptoms at follow-up. Brain Commun 2023; 5: fcad284.

https://doi.org/10.1093/braincomms/fcad284 DOI: https://doi.org/10.1093/braincomms/fcad284

Hagiwara A, Warntjes M, Hori M, Andica C, Nakazawa M, Kumamaru KK, et al. SyMRI of the brain: rapid quantification of relaxation rates and proton density, with synthetic MRI, automatic brain segmentation, and myelin measurement. Invest Radiol 2017; 52: 647–657.

https://doi.org/10.1097/rli.0000000000000365 DOI: https://doi.org/10.1097/RLI.0000000000000365

Cervia-Hasler C, Brüningk SC, Hoch T, Fan B, Muzio G, Thompson RC, et al. Persistent complement dysregulation with signs of thromboinflammation in active long Covid. Science 2024; 383: eadg7942.

https://doi.org/10.1126/science.adg7942 DOI: https://doi.org/10.1126/science.adg7942

Fernández-Castañeda A, Lu P, Geraghty AC, Song E, Lee MH, Wood J, et al. Mild respiratory COVID can cause multi-lineage neural cell and myelin dysregulation. Cell 2022; 185: 2452–2468.e2416.

https://doi.org/10.1016/j.cell.2022.06.008 DOI: https://doi.org/10.1016/j.cell.2022.06.008

Iosef C, Knauer MJ, Nicholson M, Van Nynatten LR, Cepinskas G, Draghici S, et al. Plasma proteome of long-COVID patients indicates HIF-mediated vasculo-proliferative disease with impact on brain and heart function. J Transl Med 2023; 21: 377.

https://doi.org/10.1186/s12967-023-04149-9 DOI: https://doi.org/10.1186/s12967-023-04149-9

Klein J, Wood J, Jaycox JR, Dhodapkar RM, Lu P, Gehlhausen JR, et al. Distinguishing features of long COVID identified through immune profiling. Nature 2023; 623: 139–148.

https://doi.org/10.1038/s41586-023-06651-y DOI: https://doi.org/10.1038/s41586-023-06651-y

Lai YJ, Liu SH, Manachevakul S, Lee TA, Kuo CT, Bello D. Biomarkers in long COVID-19: a systematic review. Front Med (Lausanne) 2023; 10: 1085988.

https://doi.org/10.3389/fmed.2023.1085988 DOI: https://doi.org/10.3389/fmed.2023.1085988

Liew F, Efstathiou C, Fontanella S, Richardson M, Saunders R, Swieboda D, et al. Large-scale phenotyping of patients with long COVID post-hospitalization reveals mechanistic subtypes of disease. Nat Immunol 2024; 25: 607–621. DOI: https://doi.org/10.1183/13993003.congress-2023.PA4070

https://doi.org/10.1038/s41590-024-01778-0 DOI: https://doi.org/10.1038/s41590-024-01778-0

Mahdi A, Zhao A, Fredengren E, Fedorowski A, Braunschweig F, Nygren-Bonnier M, et al. Dysregulations in hemostasis, metabolism, immune response, and angiogenesis in post-acute COVID-19 syndrome with and without postural orthostatic tachycardia syndrome: a multi-omic profiling study. Sci Rep 2023; 13: 20230.

https://doi.org/10.1038/s41598-023-47539-1 DOI: https://doi.org/10.1038/s41598-023-47539-1

Patel MA, Knauer MJ, Nicholson M, Daley M, Van Nynatten LR, Cepinskas G, et al. Organ and cell-specific biomarkers of long-COVID identified with targeted proteomics and machine learning. Mol Med 2023; 29: 26.

https://doi.org/10.1186/s10020-023-00610-z DOI: https://doi.org/10.1186/s10020-023-00610-z

Phetsouphanh C, Darley DR, Wilson DB, Howe A, Munier CML, Patel SK, et al. Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection. Nat Immunol 2022; 23: 210–216.

https://doi.org/10.1038/s41590-021-01113-x DOI: https://doi.org/10.1038/s41590-021-01113-x

Woodruff MC, Bonham KS, Anam FA, Walker TA, Faliti CE, Ishii Y, et al. Chronic inflammation, neutrophil activity, and autoreactivity splits long COVID. Nat Commun 2023; 14: 4201.

https://doi.org/10.1038/s41467-023-40012-7 DOI: https://doi.org/10.1038/s41467-023-40012-7

Gallagher S. Phenomenology and non-reductionist cognitive science. Dordrecht: Springer Netherlands; 2009: p. 21–34.

https://doi.org/10.1007/978-90-481-2646-0_2 DOI: https://doi.org/10.1007/978-90-481-2646-0_2

Køster A, Fernandez AV. Investigating modes of being in the world: an introduction to phenomenologically grounded qualitative research. Phenomenol Cogn Sci 2023; 22: 149–169.

https://doi.org/10.1007/s11097-020-09723-w DOI: https://doi.org/10.1007/s11097-020-09723-w

Zeiler K, Käll LF. Feminist phenomenology and medicine. 1st ed. Albany: State University of New York Press; 2014 DOI: https://doi.org/10.2307/jj.18253445

De Boer M, Zeiler K. Qualitative critical phenomenology. Phenomenology and the Cognitive Sciences 2024. Accepted for publication DOI: https://doi.org/10.1007/s11097-024-10034-7

Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101.

https://doi.org/10.1191/1478088706qp063oa DOI: https://doi.org/10.1191/1478088706qp063oa

Coninx S, Stilwell P. Pain and the field of affordances: an enactive approach to acute and chronic pain. Synthese 2021; 199: 7835–7863.

https://doi.org/10.1007/s11229-021-03142-3 DOI: https://doi.org/10.1007/s11229-021-03142-3

Gallagher S. Integration and causality in enactive approaches to psychiatry. Front Psychiatry 2022; 13: 870122.

https://doi.org/10.3389/fpsyt.2022.870122 DOI: https://doi.org/10.3389/fpsyt.2022.870122

Published

2025-04-06

How to Cite

Levi, R., Birberg Thornberg, U., Blystad, I., Divanoglou, A., Engblom, D., Leon, F., … Zeiler, K. (2025). Reconceptualizing rehabilitation research via an enactive framework and a radically interdisciplinary cross-analysis: a study protocol on fatigue in post COVID-19 condition (PCC). Journal of Rehabilitation Medicine, 57, jrm42254. https://doi.org/10.2340/jrm.v57.42254

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