Regarding COVID-19 long haulers who have symptoms consistent with severe chronic fatigue syndrome that prevents them from participating in ADLs returning to regular work. Is there an appropriate/ extrapolated way to create an impairment rating for such individuals?

The unfortunate answer is no. 

This is a timely question. There is increasing evidence that acute COVID-19 infection can result  in prolonged symptoms. These can be isolated, such as shortness of breath, or be part of a multi-symptom entity known commonly as long haul COVID. The technical terms most used are Post-Acute Sequelae of SARS-CoV-2 or Post COVID Syndrome.1

While the symptoms of the prolonged COVID state have been documented in literature, there remains much to be uncovered about this condition.2 Currently, there are no agreed upon diagnostic criteria for Post COVID Syndrome or Late Sequelae of COVID-19.6 There are also no objective tests that can reliably be used for diagnosis. In addition, there are no robust randomized controlled trials regarding treatment for this condition. Finally, there has not been enough time to understand the progression of the condition past 12 months. 

The accurate diagnosis of a condition, with reliance on as much objective evidence as possible, is the foundation of a reliable impairment calculation. Without a more in depth understanding of Post COVID Syndrome, it is not possible to apply an accurate impairment to this condition yet. Similar difficulties can be found when attempting to assign an impairment for chronic fatigue syndrome and/or fibromyalgia.3

As noted in the
6th Edition of the AMA Guides to the Evaluation of Permanent Impairment, there is no impairment class for fibromyalgia or chronic fatigue syndrome.4 Instead, the closest method of assigning an impairment for these conditions is by use of a pain related impairment. Chapter 3 of The Guides describes the difficult process of assigning a pain related impairment. Assignment is based on responses to the Pain Disability Questionnaire and the maximum impairment is 3%. While it is tempting to resort to this methodology, it should be noted that pain has not been a major presenting symptom of Post COVID Syndrome. 

Another possible surrogate impairment could be the use of a pulmonary surrogate, as described in Chapter 5 of The Guides. However, respiratory complaints are neither totally  encompassing nor a universal symptom for this condition. The same could be said for impairments related to deficits of cognition, which have also been subjectively reported.

The Social Security Administration has rules for assignment of disability, a distinct but similar entity to impairments, for chronic fatigue syndrome and fibromyalgia. However, symptoms typically need to be present for some time, there is abundant research regarding the prognosis for these conditions when compared to Post COVID Syndrome/Late Sequelae of COVID-19, and there are accepted diagnostic criteria.5

Hopefully, as research delves into this condition more, treatment and prolonged symptoms after COVID-19 infection will improve and the assignment of impairments and disability for this will be a rare necessity. 


  1. Post-acute sequelae of COVID-19 – NIH Director's Blog.
  2. Carfì A, Bernabei R, Landi F, Group GAC-P-ACS. Persistent Symptoms in Patients After Acute COVID-19. JAMA. Aug 2020;324(6):603-605. doi:10.1001/jama.2020.12603
  3. MA F, PA S-M, A M, Y S. Adjudication of fibromyalgia syndrome: challenges in the medicolegal arena. Pain research & management. Nov-Dec 2014 2014;19(6)doi:10.1155/2014/742830
  4. Rondinelli RD. Guides to the evaluation of permanent impairment. American Medical Association (AMA); 2008.
  5. ORDP O. Social Security Ruling: SSR 12-2p. Updated 2012-08-01.
  6. CDC. Late Sequelae of COVID-19. Centers for Disease Control and Prevention. Published February 11, 2020. Accessed March 11, 2021.

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