Effectiveness of Rehabilitation Interventions on Adults With COVID-19 and Post-COVID-19 Condition. A Systematic Review With Meta-analysis

ARACOV-02. Specialized nutritional intervention and telerehabilitation in patients with long COVID: Protocol of a randomized controlled trial

BACKGROUND

It is estimated that at least 10% of the population infected with SARS-CoV-2 develop Post COVID Condition, which is characterized by a diverse array of symptoms including dyspnea, fatigue, anxiety, depression, and deterioration in quality of life. The SARS-CoV-2 virus can trigger an excessive immune response, characterized by the release of pro-inflammatory cytokines including IL-6, IL-1, TNFα and reactive oxygen species. Specialized Pro Resolving Mediators (SPMs) (17-HAD, 14-HAD and 18_HEPE) that could be useful in Post COVID Condition modulating the inflammatory response. The objective is to determine the change in quality of life, inflammatory profile, functional capacity and emotional variables in a group taking a nutritional supplement (SPMs) plus a telerehabilitation programme.

METHODS

ARACOV-2 study is a double-blind, parallel-group, randomized control trial with two parallel interventions: Nutritional supplement and telerehabilitation vs placebo supplement and telerehabilitation. The primary endpoint will be quality of life (EQ-5L-5D). The intervention will last 12 weeks with a daily intake of omega-3 or placebo and a daily supervised rehabilitation programme using telerehabilitation.

DISCUSSION

This study suggests that SPMs supplementation combined with telerehabilitation may improve inflammation and symptoms like fatigue in Post COVID Condition patients. Both interventions have anti-inflammatory potential, and their combined use could enhance physical and mental health outcomes. This approach offers a promising strategy for managing Post COVID Condition symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT06063031.

Efficacy of early pulmonary rehabilitation in severe and critically ill COVID-19 patients: a retrospective cohort study

BACKGROUND

Respiratory sequelae, induced by lung injury, reduced muscle strength, and nutritional disturbance, are common in hospitalized patients with coronavirus disease 2019 (COVID-19). Therefore, optimal treatment is essential for reducing the mortality in severe forms of the disease and critically ill patients. Pulmonary rehabilitation (PR) has been used in many chronic respiratory diseases, but the role of early PR in severe and critically ill COVID-19 patients remains to be fully understood.

METHODS

Hospitalized severe to critically ill COVID-19 patients were recruited from Beijing Chaoyang Hospital between December 1, 2022, and June 30, 2023. In all, we recruited 272 patients, with 39 in the PR group and 233 in the control group. The PR intervention consisted of the prone position, airway clearance therapy (ACT), and resistance respiratory training (RRT). The primary outcome was the composite disease progression outcome rate, defined as death or intensive care unit (ICU) admission. Adverse events (AEs) and serious adverse events (SAEs) were recorded in the PR group. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) was used to balance confounding bias, generating weighting cohort and matched cohort.

RESULTS

The rate of the primary outcome was lower in the PR group (28.2% [11/39] in the PR group vs. 48.9% [114/233] in the control group). Significant differences were observed in both the original and weighting cohorts. Subgroup analyses showed that receiving ≥ 2 types of PR, receiving RRT, length from admission to intervention ≤ 4 days, and baseline P/F ≤ 150 mmHg were associated with lower rates of progression. Total rates of 2.6% (1/39) for AEs and 10.26% (4/39) for SAEs were reported.

CONCLUSIONS

Early pulmonary rehabilitation may prevent disease progression and reduce mortality in patients with severe COVID-19. These findings may be helpful for formulating an optimal rehabilitation strategy.

Long COVID: Pathophysiology, current concepts, and future directions

Long COVID, an umbrella term referring to a variety of symptoms and clinical presentations that emerges in a subset of patients after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, has a significant effect on quality of life and places a substantial burden on health care systems worldwide, straining financial and human resources. The pathophysiology of long COVID remains incompletely understood, though several hypotheses have been proposed to explain different aspects of this complex condition. SARS-CoV-2 persistence, direct organ damage, innate and adaptive immune system perturbation, autoimmunity, latent virus reactivation, endothelial dysfunction, and microbiome disturbances are among the most relevant avenues for elucidating the evolution, complexity, and mechanisms of long COVID. Active investigation regarding potential biomarkers for long COVID and its associated disease endotypes highlights the role of inflammatory mediators, immunophenotyping, and multiomics approaches. Further advances in understanding long COVID are needed to inform current and future therapeutics.

Effect of pulmonary rehabilitation for patients with long COVID-19: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Pulmonary rehabilitation (PR) has demonstrated efficacy in managing long COVID-19, underscoring the need to refine and tailor PR strategies for optimal patient outcomes.

OBJECTIVES

To evaluate the impact of PR on patients with long COVID-19 and to compare the efficacy of different types and durations of PR interventions.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES AND METHODS

We systematically searched randomized controlled trials (RCTs) of the effectiveness of PR in long COVID-19 patients published before April 2024. The primary outcomes were physical capacity assessed by the 6-minute walking test (6MWT), lung function measured by forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC), health-related quality of life (HRQoL), and fatigue. Secondary outcomes were thirty-second sit-to-stand test (30STST), handgrip strength tests, maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP), dyspnea, depression, anxiety, perceived effort, and adverse events.

RESULTS

A total of 37 studies with 3363 patients were included. Compared to controls, PR improved physical capacity (6MWT, 30STST, handgrip), lung function (FEV1, FVC, MIP, MEP), HRQoL, fatigue, dyspnea, and anxiety but did not reach statistical significance for depression. Subgroup analyses of PR duration indicated that programs of ⩽4 weeks improved 6MWT; those between 4 and 8 weeks significantly improved 6MWT, lung function (FEV1, FVC), HRQoL, and reduced fatigue; and programs over 8 weeks improved HRQoL and reduced fatigue. Exercise type analysis revealed that breathing exercises improved 6MWT, lung function (FEV1, FVC), and HRQoL; multicomponent exercises enhanced 6MWT performance and reduced fatigue; the combination of both types improved 6MWT, FEV1 (L), FVC (%pred), HRQoL, and reduced fatigue.

CONCLUSION

PR improves physical capacity, lung function, and quality of life and alleviates dyspnea, fatigue, and anxiety in long COVID-19 patients. A 4- to 8-week PR program and a combination of both breath exercises and multicomponent training is most effective for managing long-term COVID-19 syndromes.

TRIAL REGISTRATION

PROSPERO ID: CRD42024455008.

Cost-Utility Analysis of Supervised Inspiratory Muscle Training Added to Post-COVID Rehabilitation Program in the Public Health System of Brazil

OBJECTIVES

This study aims to provide model-based cost-utility estimates for the addition of inspiratory muscle training (IMT) in COVID-19 pulmonary rehabilitation (PR).

METHODS

A cohort model comparing IMT with PR (intervention group) to IMT with only PR (control group) was used. The payer perspective from the Unified Health System in Brazil was adopted. Effectiveness parameters: Effectiveness was measured in quality-adjusted life years (QALYs). Probabilistic sensitivity analyses were performed using 1000 Monte Carlo simulations. A beta probability distribution was assumed for utilities, and a gamma distribution was applied to the costs. A cost-effectiveness threshold of BRL 40.000/QALYs was applied.

RESULTS

As the threshold of BRL 40.000/QALYs, we obtained 512 (51.2%) simulations that can be considered cost-effective to IMT added in PR programs. IMT added in PR treatment was more expensive (USD 317.73 versus USD 293.93) and more effective (incremental utility of 0.03 to INT group) than PR alone. The incremental cost-effectiveness ratio (ICER) was 793.93 USD/QALY.

CONCLUSIONS

IMT added to PR is a cost-effective alternative compared with PR for post-COVID-19 patients. This strategy may result in net cost savings and improvements in the QALYs for these patients.

Effectiveness of a Person-Centered Interdisciplinary Rehabilitation Treatment of Post-COVID-19 Condition: Protocol for a Single-Case Experimental Design Study

BACKGROUND

Patients with post-COVID-19 condition (PCC) experience a wide range of complaints (physical, cognitive, and mental), sometimes with high levels of disability in daily activities. Evidence of effective interdisciplinary rehabilitation treatment is lacking. A person-centered, biopsychosocial, interdisciplinary rehabilitation program, adapted to expert opinions and the patient's needs, was therefore developed.

OBJECTIVE

This study aims to present a study protocol for a clinical trial to evaluate the effect of a new, person-centered, interdisciplinary rehabilitation treatment for PCC. It is aimed at improving participation in society and health-related quality of life in patients with PCC who perceive a high level of disability in daily activities or participation.

METHODS

A total of 20 Dutch adults, aged 18 years or older, with high levels of disability in daily activities and participation in society will be included in this replicated and randomized single-case experimental design study, from October 2023 onward. The replicated and randomized single-case experimental design consists of 3 phases. The baseline phase is the observational period, in which no specific treatment will be given. In the intervention phase, patients will receive the new outpatient treatment 3 times a week for 12 weeks, followed by a 12-week follow-up phase. During the intervention phase, the treatment will be personalized according to the patient's physical, mental, and cognitive symptoms and goals. The treatment team can consist of a rehabilitation physician, physiotherapist, occupational therapist, speech therapist, and psychologist. The primary outcomes of the study are daily diaries, which consist of 8 questions selected from validated questionnaires (Utrecht Scale for Evaluation of Rehabilitation-Participation, EQ-5D-5L, and the Hospital Anxiety and Depression Scale). The other primary outcome measurements are participation in society (Utrecht Scale for Evaluation of Rehabilitation-Participation) and health-related quality of life (EQ-5D-5L). The secondary outcomes are physical tests and validated questionnaires aimed at physical, mental, and cognitive complaints. Effect evaluation based on daily assessments will include visual analysis, calculation of effect sizes (Nonoverlap of All Pairs), randomization tests, and multilevel analysis. In addition, other analyses will be based on ANOVA or a 2-tailed Student t test.

RESULTS

Data collection for this study started in October 2023 and is planned to be completed in July 2024. The results will be published in peer-reviewed journals and presented at international conferences.

CONCLUSIONS

This is the first study investigating the effect of an interdisciplinary rehabilitation treatment with a person-centered, biopsychosocial approach in patients with PCC. Our findings will help to improve the treatment and support of patients with PCC.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00032636; https://drks.de/search/en/trial/DRKS00032636.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/63951.

Effectiveness of telerehabilitation versus face-to-face pulmonary rehabilitation on physical function and quality of life in people with post COVID-19 condition: a systematic review and network meta-analysis

INTRODUCTION

Post COVID-19 condition (PCC) is characterized by the persistence of symptoms associated with COVID-19 infection for more than 12 weeks, with worsening quality of life and physical function deconditioning being among the most commonly reported persistent symptoms. Pulmonary rehabilitation has emerged as a safe and viable option for these patients. Administered either face-to-face (FTF) or telemedicine (TL), it has been shown to improve symptoms associated with PCC. However, little is known about which approach is best for this population. Therefore, we conducted a systematic review and network meta-analysis on the efficacy of FTF versus TL compared to usual care in improving physical function and quality of life (physical and mental) in patients with PCC.

EVIDENCE ACQUISITION

A systematic search of PubMed, Cochrane Library, and Web of Science was performed from 2020 to January 5th, 2024. Two independent reviewers performed study selection, data extraction, and risk of bias assessment; this selection included only randomized controlled trials. A network meta-analysis was performed to compare the effects of FTF and TL with usual care. Multivariate and univariate analysis were performed to evaluate the best intervention.

EVIDENCE SYNTHESIS

Data were extracted from 10 studies, five of which were treated with FTF and five of which were TL, involving 765 adults with PCC, ranging in age from 22 to 66 years. Interventions consisted of isolated or combined exercises (aerobic, resistance, breathing) and lasted between three and ten weeks in most of the included studies. Multivariate analysis found that FTF produced significant differences compared to TL or usual care with moderate quality of evidence. Univariate analysis found that significant differences were only found for physical function and mental domain of quality of life for TL vs. usual care, with moderate quality of evidence.

CONCLUSIONS

This study supports the use of FTF as a therapy to improve physical function and quality of life in patients with PCC. However, in the absence of differences between FTF and TL in the univariate model for any of the outcomes studied, the choice of the form of pulmonary rehabilitation administration should be individualized. Future studies should compare FTF with TL directly to clarify which is the best approach.

Effects of rehabilitation interventions for old adults with long COVID: A systematic review and meta-analysis of randomised controlled trials

BACKGROUND

There is limited evidence on the effectiveness of the existing rehabilitation interventions for old adults with long coronavirus disease (COVID), which is of particular concern among old adults.

METHODS

We systematically searched studies published in PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases from their inception to 15 November 2023. Randomised controlled trials (RCTs) compared rehabilitation interventions with other controls in old adults (mean/median age of 60 or older) with long COVID were included. We performed a meta-analysis to compare the effects of the rehabilitation interventions with the common control group. Mean difference (MD) or standardised mean difference (SMD) with its 95% confidence intervals (CI) were used as summary statistics. Moreover, subgroup analyses based on the intervention programmes, the severity of acute infection, and the age of participants were carried out.

RESULTS

A total of 11 RCTs involving 832 participants (64.37 ± 7.94 years, 52.2% were men) were included in the analysis. Compared with the control groups, rehabilitation interventions significantly improved 6-minute walking test (6 MWT; MD = 15.77 metres (m), 95% CI = 5.40, 26.13, P < 0.01), 30-second sit-to-stand test (MD = 4.11 number of stands (n), 95% CI = 2.46, 5.76, P < 0.001), all aspects of quality of life, independence in activities of daily living (SMD = 0.31, 95% CI = 0.14, 0.48, P < 0.001), and relieved fatigue (SMD = -0.66, 95% CI = -1.13, -0.19, P < 0.01), depression (SMD = -0.89, 95% CI = -1.76, -0.02, P < 0.05) and anxiety (SMD = -0.81, 95% CI = -1.58, -0.05, P < 0.05). However, the improvement of hand grip strength and pulmonary function was not statistically significant (P > 0.05). Subgroup analyses showed that improvements in 6 MWT, fatigue, anxiety, and depression were more pronounced in old patients who received exercise training, while those who received respiratory rehabilitation had more pronounced improvements in pulmonary function and quality of life.

CONCLUSIONS

Old adults with long COVID who underwent rehabilitation interventions experienced significant improvement in functional capacity, fatigue, quality of life, independence in activities of daily living, and mental health outcomes compared with usual/standard care. These findings suggest that screening, management, and rehabilitation interventions for long COVID in older adults should be strengthened to improve their complete health status and functional status, thereby reducing the long-term disease burden caused by long COVID and fostering healthy aging during the post-pandemic era.

Individually tailored exercise in patients with postural orthostatic tachycardia syndrome related to post-COVID-19 condition - a feasibility study

Postural orthostatic tachycardia syndrome (POTS) occurs in approximately 30% of people with highly symptomatic post-COVID-19 condition (PCC). It involves several symptoms that limit physical and psychological functions and cause reduced quality of life. Evidence for different treatments of POTS and PCC is limited, and this study aimed to evaluate the feasibility of individually tailored physical exercise. The secondary aim of the study was to evaluate the preliminary effectiveness of this intervention. Twenty-six participants (81% female, median age 41 years) were enrolled and performed individually tailored endurance and strength training, with progression, for twelve weeks. During the intervention period, the participants had weekly support from a physiotherapist. Feasibility was evaluated with good compliance, with 76% adherence to exercise prescription and 96% completing the study protocol. The treatment was safe, and the evaluation methods (questionnaires, physical assessments, and accelerometer monitoring) were judged to be feasible. After the intervention, improvements in symptom burden as well as in psychological and physical functions were observed. In conclusion, future randomized controlled trials can be performed with only minor adjustments and could include questionnaires, physical assessment and accelerometer monitoring, which were demonstrated as feasible by this study.

Developing Physiotherapy in Primary Health Care: A First Snapshot from the Italian Metropolitan City of Milan

INTRODUCTION

Since the COVID-19 pandemic, the Italian National Health Service (NHS) has been undergoing a structural reform shifting focus from hospital-centered care to smaller, intermediate, or primary health facilities closer to the community (e.g., community hospitals and community houses). This reorganization should include rehabilitation and physiotherapy, but the actual spread of these services is still unclear.

OBJECTIVE

This study explored the number and characteristics of community-based physiotherapy services in the Metropolitan City of Milan (Italy).

METHODS

Between April and May 2024, we distributed a structured, anonymous online survey about community physiotherapy services and users to all Directors of the Health and Social Care Professions Departments (DAPSS) in the Metropolitan City of Milan. We used descriptive statistics to analyze the number of community houses offering physiotherapy services, the specific intervention areas, and access modalities.

RESULTS

Six out of seven DAPSS Directors completed the survey (87%). Thirty-seven community houses were reported in the area, with fourteen of these offering physiotherapy services. In most of them, physiotherapy was a primary reason for access following a general practitioner's prescription. Five out of six responders reported that rehabilitation needs were mainly assessed by specialists in Physical and Rehabilitation Medicine, with physiotherapists involved in the assessment process in two cases. Physiotherapists primarily handled the intervention phase, dealing mainly with orthopedic and neurological conditions. DAPSS Directors noted that additional physiotherapy initiatives focusing on prevention will be implemented.

CONCLUSIONS

Physiotherapy services are becoming available in the Metropolitan City of Milan. However, more efforts are needed to facilitate access and ensure tailored assessment and effective interventions, particularly in preventive care. Future investigations should help to better define the number and the characteristics of the patients who can most benefit from this type of care, the number of sessions they need, and with what types of intervention; it would be also necessary to better define the communication network in the area that allows doctors, health professionals, and patients to be informed about this possibility.

Long COVID management: a mini review of current recommendations and underutilized modalities

Long COVID is a condition that develops in a subset of patients after COVID-19 infection comprising of symptoms of varying severity encompassing multiple organ systems. Currently, long COVID is without consensus on a formal definition, identifiable biomarkers, and validated treatment. Long COVID is expected to be a long-term chronic condition for a subset of patients and is associated with suffering and incapacity. There is an urgent need for clear management guidelines for the primary care provider, who is essential in bridging the gap with more specialized care to improve quality of life and functionality in their patients living with long COVID. The purpose of this mini review is to provide primary care providers with the latest highlights from existing literature regarding the most common long COVID symptoms and current management recommendations. This review also highlights the underutilized interventions of stellate ganglion blocks and low-dose naltrexone, both with well-established safety profiles demonstrated to improve quality of life and functionality for patients suffering with some symptoms of long COVID, and encourages prompt referral to interventional pain management.

Evaluating qigong as integrative support for COVID-19 and Long-COVID-19 rehabilitation: a systematic review

Introduction

Amidst the ongoing global impact of COVID-19 on public health, there is an increasing focus on holistic strategies encompassing integrative therapies and rehabilitation techniques, particularly in addressing the challenges posed by Long-COVID-19. This review investigates the potential of Qigong, an ancient Chinese practice characterized by gentle movements, controlled breathing, and meditative elements, within the context of COVID-19.

Methods

A systematic search of PubMed, EMBASE, Web of Science, Scopus, and Google Scholar was conducted to identify pertinent clinical studies.

Results

Following thorough database scrutiny, nine studies were identified as meeting the eligibility criteria. Across the spectrum of COVID-19 severity, individuals engaging in qigong practice exhibited notable enhancements in both physical and psychological wellbeing, evidenced by ameliorated respiratory symptoms, reduced anxiety levels, enhanced sleep quality, bolstered mental wellbeing, and augmented health-related quality of life. Moreover, qigong training, whether employed independently or in conjunction with other therapies, demonstrated beneficial effects on Long-COVID-19 symptoms, encompassing persistent respiratory issues, dizziness, sleep disturbances, and compromised health-related quality of life.

Discussion

This review underscores the necessity for further investigation to quantify and standardize the contribution of Qigong to COVID-19 recovery and rehabilitation. Such endeavors aim to integrate this accessible and low-impact practice into public health strategies and comprehensive treatment regimens.

Systematic review registration

The review protocol was registered in the Open Science Framework under the following doi: 10.17605/OSF.IO/7K5X6 (URL: https://osf.io/7k5x6).

Rehabilitation and COVID-19: systematic review by Cochrane Rehabilitation

INTRODUCTION

Until the last update in February 2022, the Cochrane Rehabilitation COVID-19 Evidence-based Response (REH-COVER) action identified an increasing volume of evidence for the rehabilitation management of COVID-19. Therefore, our aim was to identify the best available evidence on the effectiveness of interventions for rehabilitation for COVID-19-related limitations of functioning of rehabilitation interest in adults with COVID-19 or post COVID-19 condition (PCC).

EVIDENCE ACQUISITION

We ran the searches on February 17th, 2023, in the following databases: PubMed, EMBASE, CENTRAL, CINHAL, and the Cochrane COVID-19 Study Register, applying a publication date restriction to retrieve only papers published in 2022. To retrieve papers published before 2022, we screened the reference lists of previous publications included in the REH-COVER action, covering papers from early 2020 to the end of 2022. This current review includes only randomised controlled trials and concludes the rapid living systematic reviews of the Cochrane Rehabilitation REH-COVER action. The risk of bias and certainty of evidence were evaluated in all studies using the Cochrane Risk of Bias tool and GRADE, respectively. We conducted a narrative synthesis of the evidence. PROSPERO registration number: CRD42022374244.

EVIDENCE SYNTHESIS

After duplicate removal, we identified 18,950 individual records and 53 RCTs met the inclusion criteria. Our findings suggest that the effect of breathing and strengthening exercise programs on dyspnea and physical exercise capacity compared to no treatment in non-severe COVID-19 patients is uncertain. Multicomponent telerehabilitation may slightly increase physical exercise capacity compared to educational intervention in adults with PCC. There is, however, uncertainty about its effect on lung function and physical exercise capacity when compared to no treatment. Finally, the effect of inspiratory muscle training on maximal inspiratory pressure compared to no treatment in adults with PCC is uncertain.

CONCLUSIONS

Interventions that are part of comprehensive pulmonary rehabilitation approaches may benefit dyspnea and exercise tolerance in adults with COVID-19 and PCC. The available evidence has several methodological limitations that limit the certainty of evidence and the clinical relevance of findings. Therefore, we cannot provide robust suggestions for practice. While high-quality RCTs are being conducted, clinicians should consider using high-quality evidence from other pulmonary conditions to rehabilitate patients with COVID-19 or PCC using context-specific interventions.

[Post COVID care needs rehabilitation]

Fast drei Jahre nach dem Ausbruch der COVID-19-Pandemie zählt die Weltgesundheitsorganisation rund 7 Millionen Tote aufgrund von COVID-19 und knapp 771 Millionen bestätigte Infektionen mit SARS-CoV-2 1. Die weltweite Übersterblichkeit in den ersten zwei Jahren der Pandemie wird sogar zwei- bis dreimal höher geschätzt, teilweise bedingt durch überlastete Gesundheitssysteme 2.