18 - Louise Cummings - Cognitive & Linguistic Difficulties in Long Covid

Episode 18 of the Long Covid Podcast is a chat with Louise Cummings, Professor of Clinical Linguistics at Hong Kong Polytechnic University & also a speech & language therapist.

We talk about the work she has been doing around the cognitive & linguistic difficulties a lot people with Long Covid have been experiencing. She is able to explain some of her interim results, as well as how she is going about assessing people.

Routledge: Cognitive-linguistic difficulties in adults with Long COVID

Routledge: Communication-related quality of life in adults with Long COVID

Routledge: Case studies of adults with COVID-19 infection

Springer: Cognitive-linguistic difficulties in COVID -19

Journal article: Pragmatic impairment in COVID-19

Journal article: Cognitive-linguistic difficulties in COVID-19: A longitudinal case study

Journal article: COVID-19 and language: A case study

Cambri

For more information about Long Covid Breathing courses & workshops, please check out LongCovidBreathing.com

(music credit - Brock Hewitt, Rule of Life)

Transcript

Jackie Baxter  
Welcome to this episode of the long COVID Podcast. I'm very excited to have Louise Cummings with me today to talk about some of the work that she has been doing with people with long COVID. So, welcome to the podcast.

Louise Cummings  
Thank you, Jackie. It's lovely to be here.

Jackie Baxter  
So to start with, would you be able to introduce yourself? So who are you and what is it that you do?

Louise Cummings  
Okay, so I'm a Professor of Clinical linguistics at the Hong Kong Polytechnic University. I'm also UK trained speech and language therapist. So my academic role at the university is one to conduct research and do teaching in both academic linguistics and in clinical work as well. 

Jackie Baxter  
Awesome. Are you actually in Hong Kong at the moment? 

Louise Cummings  
I am in Hong Kong? Yes, I am. Yeah, I'm in Hong Kong. So we're eight hours ahead of the UK.

Jackie Baxter  
Right. So it's sort of evening for you then? 

Louise Cummings  
early evening. That is really exciting. 

Jackie Baxter  
I spoke to someone in America a few weeks ago. 

Louise Cummings  
Oh, okay. So it's quite global then 

Jackie Baxter  
We are branching out. This is very cool. So when was it that you became aware of this cognitive sort of effect of long COVID?

Louise Cummings  
Okay, well, I was in the UK at the beginning of the pandemic, and January 2020, I had actually flown over to the UK to do a month long period of research. And at the time, I was studying adults with neurodegenerative disorders. So conditions like Parkinson's disease, and I was visiting these clients in their homes, so I was doing quite a lot of home visits. 

And you know, I became aware just before I flew to the UK, I became aware that things were not going well in mainland China, obviously. And as I was in the UK working, it was clear the situation was getting more and more serious. And I continued my work there for as long as I could, then it became clear that it was going to be difficult to return to Hong Kong sort of immediately, and I was given permission to stay on in the UK. And they stayed there for five months, actually. 

So I was in the UK when things became very severe during the first wave of the pandemic. And, you know, once we sort of got into May, June time, it became apparent that people who had been unwell, back in March and April, were, you know, reporting that they weren't making a good recovery. And one of the symptoms that was coming through quite commonly, in their reports about their illness, was that they were experiencing this brainfog. 

This really quite struck me because you know, by this stage, even people were sort of maybe three, four, in some cases, five months on from their initial infections, and that they, you know, were so consistently reporting this brainfog as one of their symptoms. So I thought there's something interesting here, there's something going on here. This is being reported too consistently for it just to be sort of a very rare feature of the disorder. And at that point, I started to reach out to people with long COVID via Facebook groups, and that's how I really got interested in it. 

Jackie Baxter  
Yeah, it's kind of hard to remember now, isn't it so many months on, but right back at the start of the pandemic, I think everybody who hadn't sort of recovered straightaway, thought that they were the only one, to start with. And then you know, these support group started popping up. And there was the odd news article. And I think at the time, everything was so bad for so many people, that the focus was much more on the death toll and hospitalizations, wasn't it, not the people that were staying at home?

Louise Cummings  
And I think as well, what was happening is, that even the people who weren't seriously ill enough to have to go to hospital, were at home with their illnesses, they were so overwhelmed with just dealing with the physical aspects of the breathing difficulties, and all the other very unpleasant physical symptoms, that they weren't actually aware at that stage that they were having these cognitive linguistic issues. And it was only as some of the physical symptoms began to settle down a bit, that they became aware that they were really struggling with cognitive issues that, you know, were not part of how they were functioning and operating before their illness. 

So, you know, we have a wide range of different symptoms, Jackie, from, you know, memory was obviously a very prominent one that people were reporting quite often, but word finding difficulty, problems following conversation, issues with reading and writing, a real range of sort of language and cognitive issues that were quite severe enough to prevent return to work, in many cases. These were not mild difficulties.

Jackie Baxter  
Yeah, absolutely. I mean, I've heard people say things that they don't trust themselves to drive because the things that you take for granted, you check your mirrors and things like that, that they weren't actually thinking that they could do that. Even if they had the energy to get into the car in the first place, of course

Louise Cummings  
That's right. Those sorts of quick reflexive judgments that we all make were becoming a real labor and were quite challenging for people.

Jackie Baxter  
Yeah, I mean, it's quite a scary thing to think of, I've not really experienced the cognitive side of this. And I guess I just have to be grateful for that. Because it does, it sounds really scary, the not being able to find the words that you know that you have, and things like that,

Louise Cummings  
yes, and I mean, these symptoms were occurring in people, I was seeing a lot of medical and health professionals. So these were high functioning people prior to their illness. And, you know, they were struggling to do things that wouldn't have cost them a second thought before. And as I say these difficulties were severe enough to put them out of work. So even if they felt physically sufficiently recovered to return, it was the cognitive linguistic issues that were preventing a return to work for many of them.

Jackie Baxter  
Yeah, as I say, it's not a side that I have any personal experience of really, this is really interesting. So would you be able to talk through what your study involves or involved? Are you still going with it?

Louise Cummings  
Yes, I'm still working on it. I'm sort of in the second phase of it, I've completed the first phase, which was a study of 142 people, not all of them with long COVID, because I had to obviously include a number of control participants in there who obviously have not had COVID infection. 

So what I was interested in was, obviously trying to find some way of assessing these cognitive linguistic issues. Because I knew very much that if I stuck with the standardized assessments that were used by Speech and Language Therapists, I was unlikely to be able to tap in to some of the issues that were proving problematic. 

So I developed a number of what are called discourse production tasks. This is where you're asking people to, you're maybe showing them a picture and asking you to give a description of the picture, or showing them a sequence of pictures and asking them to tell a story on the basis of the sequence. Or maybe, you know, showing them a picture book of a well known fictional narrative, something like the Cinderella story and asking them them to tell the story back to you. 

Like these might sound quite straightforward, simple tasks. You know, we think of stories as something we tell young children, and then automatically assume that they're cognitively and linguistically quite simple tasks to undertake, but they're not, they actually involve quite a number of high level cognitive linguistic processes. So I wanted to place emphasis on those discourse production tasks, because I felt that those would be most likely to reveal where the problems lay. And that has actually been the case. 

So I undertook, as I said, the first phase of the study to 142 participants. That data is undergoing statistical analysis at the minute, but it is very clear that those tasks are revealing quite a number of difficulties for the long COVID participants that are not being finding the healthy participants in the study. 

So what I'm moving on to do in terms of the second phase, is a number of the people that took part in first study, I'm leaving a six month period between their first assessment and then I'm doing a follow up assessment to see if there's been any change in the six months since they were first assessed by me, just to see what's going on, you know. These are symptoms that are not, you know, improving quickly in people and you maybe know this yourself from long COVID, that these symptoms can really linger well beyond what we're used to with other infections, and it will be interesting to see what has happened in the intervening six months for these participants

Jackie Baxter  
Yeah, absolutely. I mean, just going with people that I send commenting in support groups, and people are saying that, you know, 18 months on their brain fog is still as bad as it was. But there's also some people that have said that it's improved. So it'll be really interesting.

Louise Cummings  
Well, it is, it's it's a new area of work. You know, we're trying to find our way around just but you know, the thing we need to do is gather data, we're not going to make any progress in understanding these cognitive linguistic difficulties if we don't get an intellect the data, and try and to see what's going on. Yeah,

Jackie Baxter  
Yeah, that's true. Yeah. You've got to start somewhere, haven't you? 

Louise Cummings  
Yeah, absolutely. 

Jackie Baxter  
Yeah, I'm sure somebody else. I can't remember who it was. But it was somebody who was doing research, and they were talking about how one study is not going to answer everything, but it's going to add maybe a piece to the puzzle, which I quite liked.

Louise Cummings  
Exactly. And I mean, there have been other studies, much larger studies that have looked at cognitive issues, but I'm also looking at the language aspect. So you know, cognition and language operate hand in hand. And you can examine a range of cognitive skills without necessarily thinking about their impact on language, but I'm interested on what those cognitive issues are doing to someone's ability to use and comprehend language. So I think that's sort of where the novel aspect of my work comes in.

Jackie Baxter  
Yes, I guess you add your own specialties to it, don't you? 

Louise Cummings  
Yeah. Your own disciplinary knowledge, so language is my background. So I wanted to reflect what are the linguistic difficulties for these participants? 

Jackie Baxter  
Sure. Yeah. So you mentioned that you'd already been doing research with - was it Parkinson's, wasn't it? I think you mentioned

Louise Cummings  
Yeah, just just adults, in general, with neurodegenerative disorders. Parkinson's disease is just one of them.

Jackie Baxter  
So did that help you to get your long COVID related study off the ground, because you'd already been doing that?

Louise Cummings  
It very much did, because I'd already worked up a good test protocol. And that protocol was again sufficiently sensitive to pick up quite early changes in language in adults with conditions like Parkinson's disease. So when neurodegeneration sets in, and affects language, it might help to think of language as different levels. 

So we have you know, the phonetic and the phonological level. And we work our way right through grammar, and the morphological structure of words. And then if we go up several levels, we get to the highest language levels, and these are things like pragmatics and discourse. So pragmatics is the ability to comprehend and use language in an appropriate way in context. And the pragmatic level of language is much more interwoven with our cognitive skills than some of the lower language levels. 

So this is why I was focusing on pragmatic and discourse skills when I was looking at the adults who had neurodegenerative disorders, because when there's early stage cognitive impairment in these adults, it's going to be at the pragmatic and discourse level that it becomes most evident. It's usually much later into the disease, diseases like Alzheimer's, for example, before more structural levels of language like syntax, and morphology begin to break down. 

So I knew from studying the adults with neurodegenerative disorders, which areas of language to go to in the first instance, and which areas of language were most likely to repeat these subtle cognitive deficits. So I was able to take that test protocol that I had developed with the adults who have neurodegenerative conditions, and basically carry that over to the work with adults with long COVID. 

Jackie Baxter  
Right. So you were able to tailor it much more effectively. 

Louise Cummings  
Yes, absolutely. And I also knew, one of the disorders that speech therapists assess and treat most often than adults is a condition called Aphasia, a language disorder, usually as a result of a stroke, or a traumatic brain injury, but most often a stroke. So that disorder does affect linguistic structures. So there's a breakdown in the grammar of language, there's a breakdown in the ability to retrieve words from your mental lexicon, and fit words into sentences. So that language disorder is an impairment of the structural levels of syntax, morphology, those levels. 

But the problems with the long COVID People are quite different from these difficulties in Aphasia. So I also knew that we needed a different type of assessment, and that we weren't really going to be able to tap in properly to the difficulties of the long COVID adults, unless we developed a different way of assessing them. So I knew to keep away from the types of assessments that clinicians would use with adults who have Aphasia, for example,

Jackie Baxter  
that's a really good point, isn't it? Because we think about the physical symptoms, and everybody's tests are coming back negative. And you think, well, obviously, we are not fine. But they're just not using the right tests just yet. 

Louise Cummings  
You're not using the right tests? Yeah. 

Jackie Baxter  
So I guess that's what you're trying to do by developing your own way of testing, is to test for the right things?

Speaker 2  
Yes. I mean, if you don't test, you know, speech therapists have known for a very long time, that if you don't test in the right way, you're not going to find the difficulties that somebody is experiencing. So you know, don't employ an assessment that works on clients with Aphasia with somebody who has the type of cognitive linguistic difficulties people with long COVID are having. You're not going to reveal or expose the problems if you're using the wrong type of assessment.

Jackie Baxter  
Yeah, it sounds really obvious when you say it like that. 

Louise Cummings  
Yeah. Well, you know what, a lot of the participants in my study were really quite frustrated that you know, they'd maybe been for assessments with neurologists and with other types of clinicians, and had maybe undertaken cognitive assessment, had been given a completely clean bill of health, but they knew they weren't well. They knew that this wasn't actually picking up on the difficulties that they were experiencing. 

So I think there's a lesson for all clinicians in long COVID, that if you don't employ the right type of assessment, you're not going to establish what the difficulties are. 

Jackie Baxter  
Yeah, exactly. 

Louise Cummings  
It sounds like common sense. But sometimes we need to be reminded, we've got to assess in a very smart way.

Jackie Baxter  
I think it's one of those things that's really obvious once it's pointed out to you, but you sort of think why didn't I think of that? I get the same thing when I'm teaching. You say something and sounds like Oh, duh!

Unknown Speaker  
Yeah, exactly. 

Jackie Baxter  
Sometimes it takes someone to point out to you. 

Louise Cummings  
Exactly. That's right. So you know, we will get better at this. Jackie, as we have more experience of working with long COVID. But I mean, clearly, the physical medical tests as well need to become more sensitive. Because, you know, just sending people for MRI scans, or chest X rays, or ECGs, all of which are showing nothing abnormal whatsoever, is not working.

Jackie Baxter  
Yeah, exactly. And the whole load of negative tests is not really that reassuring when you know that you're ...

Louise Cummings  
know that you're not well. Exactly. 

Jackie Baxter  
So how did you go about recruiting for your participants? Were you specifically looking for people with long COVID who did have cognitive difficulties? Or was it just more of random?

Louise Cummings  
Okay, so I initially reached out to people who were, you know, beginning to write and maybe blog a bit about long COVID. And once I established a few contacts there, they then you know, maybe took part in the study themselves, and then went back on to the long COVID Facebook groups or maybe put posts encouraging other people. So it was really largely through word of mouth, you know, people having taken part in the study, had a good experience of it, and then encouraged other people through the Facebook groups and other forms of social media to also take part. 

So I created it - there actually six groups, different groups in the first phase of the study. So we had the people with long COVID, who were experiencing brain fog, then people who had had COVID, but we're not having any cognitive linguistic problems, so didn't have any brain fog. Then obviously, a group of healthy participants who had not had COVID infection. But then a number of people who spoke English as a second language, they also came forward. So you know, I didn't want to exclude them from the survey. So I then formed a couple of additional groups for people who were speakers of English as a second language. 

And then the sixth group in the study, were people with ME, or chronic fatigue syndrome, because I was quite interested in the relationship between fatigue in long COVID and these linguistic difficulties, because fatigue is a well recognized performance limitation on language and cognition anyway. So I wanted to know, Well, were these linguistic and cognitive issues a direct consequence of the fatigue that most people with long COVID were experiencing. So that's why I wanted to include a group of ME participants as well. 

So it was one of the studies that really grew organically, starting out with quite small numbers of people. And then through word of mouth, more and more people, you know, approached me about taking part in the study, and that's how it grew up to 14w. I know 142 doesn't sound like huge numbers. But when you're doing quite detailed linguistic analysis of the data, you can't afford to work with hundreds of participants, you need to keep it manageable. 

Jackie Baxter  
Yes, that's true, 500 participants would be quite a lot. 

Louise Cummings  
You can't do this sort of linguistic analysis with 500 people, not unless you have a very large research team.

Jackie Baxter  
Yes, that's true. So I think you said your data's going through analysis at the moment, but have you been able to get any findings from it sort of initially?

Louise Cummings  
Yes, I have. So these are the areas which are coming across quite strongly as problematic for the people with long COVID. So they're having difficulty with immediate and delayed recall of verbal material. So this is where I'll tell them as a 100 word story and ask them to recall it immediately. And then delayed recall allows them to recall it at the end of the test session. And scores on those tasks are well down in the long COVID people. 

Then something called verbal fluency. Now, there's two types of tests which are involved in verbal fluency. One is letter fluency where you're asking people to generate words beginning with a certain letter like F or A. That's letter fluency, but then category fluency as well where you're asking participants to generate names of animals or vegetables. So those verbal fluency scores are considerably reduced in the long COVID participants as well. 

And then the third big area of deficit is something I'm calling discourse informativeness. So for the discourse production tasks that I was talking to you earlier about, where people were being asked to describe pictures or tell a story, the informativeness of that discourse is quite markedly reduced in the people with long COVID. And that is a direct consequence of the cognitive difficulties that they're experiencing. 

So if you think about storytelling, what makes a good story or what makes a good storyteller, it's the person who can work out the motivations of the characters in a story, can work out what events to report and what order to report them, so that a listener can actually assimilate information that they're being told in the story. 

So there's quite a number of very high level cognitive, linguistic processes going on there. And they all have to be very sharp and well integrated for storytelling to be informative. And the long COVID people are really struggling with those higher level cognitive and language skills. And you see that in reduced informativeness scores on those discourse production tasks.

Jackie Baxter  
Yeah, that is really interesting, isn't it? I mean, I've had the odd conversation with people when their brain fog will sort of strike, and there'll be in the middle of answering a question, they'll forget what the question is halfway through answering 

Louise Cummings  
Yep, that's correct, 

Jackie Baxter  
I guess, if you haven't experienced it, it's quite hard to kind of understand.

Louise Cummings  
And I mean, I think it was quite reassuring, actually, for a number of the participants in the study to see these tests reflecting these difficulties, because this was the first time that they'd had any assessment which actually showed and pinpointed where the difficulties lay. 

So the discourse production tasks are much more like the sort of cognitive linguistic skills that you would use in daily life, you know. We seldom are in a situation where we can just focus on one type of stimuli. We're dealing with competing stimuli all the time trying to, you know, focus our attention on some things and blank out other things. 

And the storytelling tasks are good at mimicking the cognitive demands of everyday life, where you're having to, you know, direct attention towards some things, direct attention away from other things. You're having to juggle a whole lot of stimuli at one time. So those tasks, the discourse, production tasks, I think, are a more faithful representation of the types of skills that people are using in their daily lives, and indeed, for the long COVID people that they are struggling with.

Jackie Baxter  
Yeah, absolutely. That sort of idea of finally having something to show. I think a lot of people have been struggling with the negative tests, and you know, oh, yeah, you're fine. When you know that you're not. So I think that's, that's actually quite - I was gonna say, encouraging. I'm not sure if that's the right word to have somebody be told that they're not cognitively functioning properly. But, you know, when you know that you're not, having something to reflect that,

Louise Cummings  
yes, do you do there comes a point where, you know, you don't need another test telling you that you're fine. When you know that you're not fine. And you know, these tests are at least sensitive enough to pick up where the difficulties lie. And people find that I think, reassuring, just to get some confirmation of what they know that they're experiencing.

Jackie Baxter  
Yeah, definitely. So have you got any idea of why? I don't know if that's a question you can answer.

Louise Cummings  
We don't really know. I mean, I don't work with sort of the physiological aspects of it. But it's, you know, clearly the immune system has been sent into a total spiral with this new virus, it hasn't known what to do with it. And it has really, you know, been, I think, firing out quite a number of aberrant signals, chemical signals. And you know, the nervous system, just like every other system and organ in the body, has been affected by the immune system's response to this virus. And it's taking just an unusually long period of time for it to settle back down. 

And I do think these difficulties will improve over time and quite a number of the participants have reported improvements. It wasn't uncommon, for example, for people to say, Well, if you'd seen me three months ago, or if you'd seen me five months ago, I was much worse than I am at the minute. That was commonly said to me. So the difficulties do settle down over time, but it's just very, very protracted and much more so than we would be used to seeing with other infectious diseases, for example,

Jackie Baxter  
yeah, absolutely. You know, for anybody listening who is thinking, Oh, I have brain fog, and it's really difficult. Is there anything that they could do to help that recovery? Or is it just a case of time?

Louise Cummings  
Well, time is certainly important. But I think the concept of pacing that the long COVID people are doing physical pacing. I think we need to do cognitive pacing, as well. And I encourage everybody to prioritize their physical recovery from this infection. So to rest as much as possible, to pace their activities as much as possible. People think Oh I am resting, I'm laying on the settee listening to music, or I'm laying on the settee watching the television. 

Don't listen to music, and don't watch the television. Because your brain is having to undertake a vast amount of work to process all that stimulation and information coming from the TV screen. So you know, cognitive pacing, we need to start thinking about cognitive work as involving an expenditure of energy, in the same way that we think of walking up and down the stairs and you know, involves an expenditure of energy. 

So people need to, when they're thinking about cognitive pacing, they need to close down to a lot of stimulation. You know, they maybe consider watching the TV as a form of relaxation and rest. It's actually not for someone with long COVID. You are much better just to close down, than something like listening to music and watching the TV. Some cognitive pacing I think is the way forward for these people. And if done properly, I think it does produce good results.

Jackie Baxter  
Yeah, I mean, that's something that I've never thought about until I was ill, you know how reading a book is really tiring. Looking at a screen is really tiring, answering your emails.

Louise Cummings  
Yes, you can't afford to do these things. These are things that are really working your brain more than it needs to be worked when you're trying to recover from this. 

Jackie Baxter  
Yeah, I guess you never really think about it until suddenly you do. 

Louise Cummings  
Yeah. Yeah. So cognitive pacing to match the physical pacing that the long COVID People are already very familiar with, and know that they should be doing.

Jackie Baxter  
Yes, yeah, it's difficult to do. But I think everybody's kind of heard of it at least

Louise Cummings  
they've heard of it. Yes. Even if they're not practicing it fully, but at least they know it exists. And they know that this is something that can help.

Jackie Baxter  
Yeah, definitely. I was quite interested when you said that you had a cohort of ME and chronic fatigue people, because we do know that there are quite a lot of kind of links and crossover of symptoms between the two. How did the results from those two cohorts compare? 

Louise Cummings  
Okay, this is quite interesting, because the people with ME, were very similar to healthy participants in all but one of the tests that I was using, which is the letter fluency tasks, where people are being asked to produce words beginning with a certain letter. They displayed a significantly reduced performance on that single task relative to the healthy participants. But in all the other tasks, they match the performance of the healthy participants. 

But I do have to emphasize there was quite a small group of ME participants in my study. So maybe if I'd have a larger group, we could have come up with a different result there. But at the minute, they are similar to the healthy participants in all but one of those tests. But the ME people were markedly better than the people with long COVID. 

So that led me to conclude again, I have to be cautious here because it was a small group of ME participants, that led me to conclude that maybe fatigue is not playing as a significant role in the long COVID cognitive linguistic issues, that I thought was maybe the case before I started the study

Jackie Baxter  
Right, so it's a different side of it, I guess,

Louise Cummings  
yes. You know, where I would like to continue to do work with the ME people and get a bigger group and to get more data. But at the minute, their performance, the ME people, are more like the healthy participants than they are like the COVID participants in the study. 

Jackie Baxter  
That is interesting. So you mentioned that you were doing a sort of a six month follow up. Have you done that bit yet? Or is that still ongoing?

Louise Cummings  
I'm just in the process of starting that now. So I've gone back to quite a number of the participants that I worked with previously, and have asked them if they would like to be assessed again six months on. And I'm just you know, getting responses to that at the minute, so that study will you know, that'll take a while to work through as well, because it'll be early 2022 before I'm really getting the data from those people six months on,

Jackie Baxter  
of course. Are you going to be using the same tests? 

Louise Cummings  
I'm going to be using a set of matched materials. I'm not going to use exactly the same, because obviously everybody knows now that they're being asked to tell the Cinderella story. So and once you've got a story like that primed, you're not going to get an accurate result on that. So I will be using a similar set of materials, and they happen quite closely matched to the ones that were used before to ensure comparability, but they will be different. 

Jackie Baxter  
Sure, so you'll be able to compare 

Louise Cummings  
Exactly, exactly without people, you know, being able to remember oh, well, I was assessed on X Y&Z at the first assessment

Jackie Baxter  
Yes. Oh, I wrote down the story afterwards, so I can remember it. 

Louise Cummings  
Yes. So, you know, I've used the second set of test materials with a number of people so far, and I think they're quite robust in what they're revealing. So I think they should be quite okay.

Jackie Baxter  
Yeah. Well, that'd be really interesting to hear what your results are after that. We'll have to get you back on in six months time. Yeah.

Louise Cummings  
In six months. Yeah. So I'll talk again, exactly

Jackie Baxter  
I think yeah, I mean, I've definitely noticed with some of the other people I've spoken to about research, you know, a lot of them are just getting off the ground. So I think, well, it's a really interesting study. But it would be really nice to hear about what actually happens with it.

Louise Cummings  
Yes, well so little research is longitudinal in nature, where we follow people through. And it's simply because it takes a lot of manpower to do that type of study. So we tend to assess people at one point in time and leave it there. But for a condition like long COVID, where we really are talking about, you know, a condition that looks as if it's gonna run and run for many, many months, we do need to look at people longitudinally rather than just at a single point in time.

Jackie Baxter  
Exactly. Because things change day to day, let alone in six months time. So yeah,

Louise Cummings  
Absolutely. 

Jackie Baxter  
So what's up next, you talked about your six month follow-ups and things that you're starting off on, but what else for the future or publication or anything? 

Louise Cummings  
Well, yes, there are publications out at the minute. To date, I've been working on a number of case studies. So a number of journal articles and book chapters, a few of those are already out, some of those are in development at the minute. And in 2022, I will be bringing a book, an edited volume actually, on COVID-19 in speech language pathology, so there will be work in volume by me. But then there will also be contributions from quite a number of other authors. So we've got people from the US, we've got people from Italy, New Zealand, Australia, got a contributor from Taiwan. And we will all be writing on different aspects of COVID-19 and its impact on language, cognitive skills, swallowing, because we also need to remember that some severely ill people with COVID can end up with swallowing problems as a result of severe COVID illness. So there will be contributions from quite a number of authors, these are academics from different countries around the world.

Jackie Baxter  
Wow, that's really interesting. I can put links to some of them into the show notes. So people can [follow up]

Speaker 2  
you can, that's no problem at all. Yes, you can do that. I can send you those links. I think that would be useful for your listeners to be able to access some of that work.

Jackie Baxter  
Yeah, absolutely. Yeah, it'd be nice for them to be able to follow up and have a read of that, if they're interested. That'd be great. Fantastic.

Louise Cummings  
You know, if you want me to come back at a later point in time to to do an update, once they see what the second phase of the study is, like, I'm more than happy to do that.

Jackie Baxter  
That would be really interesting to follow up after that. Because like you say, it gives that sense of what happens over time, 

Louise Cummings  
it's very easy to think just in terms of sort of two and three weeks, they need to be able to take the long term view and I think it's important for people to see that recovery as possible. And you know, it's going to take a bit longer, but it is possible in the longer term.

Jackie Baxter  
Exactly. Because when you lose that hope then it just gets really difficult, doesn't it? Yeah,

Louise Cummings  
it does. It does. 

Jackie Baxter  
Fantastic. Well, thank you so much for your time today. It's been really, really interesting and really awesome to talk to you. So thank you so much.

Louise Cummings  
You're welcome, Jackie. Thank you for having me.

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