The need for exercise sciences and an integrated response to COVID-19: A position statement from the international HL-PIVOT network

The lifestyle health index in the context of COVID-19 mortality and vaccination in the United States: A syndemic not to be repeated

Public health, personal/community health behaviors, health care delivery, and the scientific community have all been impacted by the COVID-19 pandemic and are consequently poised to consider substantial paradigm shifts that will enhance disease prevention and public health resilience. The current analysis compares the newly developed Lifestyle Health Index (LHI) to U.S. county-level COVID-19 vaccination, infection, and mortality rates. We linked Centers of Disease Control PLACES, the U.S. Community Profile Report, and Nationhood lab databases through common zip-code identifiers to determine the association between county-level LHI scores and COVID-19 outcomes and vaccination status against the backdrop of U.S. regions with distinct cultural phenotypes. There was a statistically significant relationship between a poor LHI, lower COVID-19 vaccination rates and higher COVID-19 infection and mortality rates. There were clear differences in outcomes across the U.S. regions, suggesting distinct regional cultural characteristics may significantly influence health behaviors and outcomes. In the U.S., a syndemic comprising unhealthy lifestyle, chronic disease, and COVID-19 resulted in unnecessary hospitalizations and deaths. Politicization of the pandemic, socioeconomic inequity and regional cultural values meaningfully contributed to the uneven distribution of poor outcomes during this syndemic. Components of the syndemic were avoidable and should not be repeated. Condensed Abstract: The unhealthy lifestyle - chronic disease - COVID-19 U.S. syndemic resulted in unnecessary hospitalizations and deaths. Politicization of the pandemic, socioeconomic inequity and regional cultural values meaningfully contributed to the uneven distribution of poor outcomes during this syndemic. Components of the syndemic were avoidable and should not be repeated.

Telerehabilitation improves cardiorespiratory and muscular fitness and body composition in older people with post-COVID-19 syndrome

BACKGROUND

The effects of post-coronavirus disease 2019 (COVID-19) syndrome on the cardiorespiratory and muscular fitness in older people are of utmost relevance. This study aimed to evaluate the effects of a 12-week telerehabilitation programme on cardiorespiratory and muscular fitness and body composition in older patients with post-COVID-19 syndrome.

METHODS

One hundred twenty older patients with post-COVID-19 syndrome were randomly assigned to one of two groups: patients who carried out the telerehabilitation programme (n = 60; age: 65.0 ± 5.2; female: 14.2%) and a control group (n = 60; age: 64.3 ± 5.0; female: 24.5%). An incremental cardiopulmonary exercise testing, isokinetic strength test, and bioelectrical impedance analysis were performed to compare cardiorespiratory and muscle strength responses and body composition between telerehabilitation and control groups.

RESULTS

A significant increase in the cardiopulmonary exercise testing duration was found in the telerehabilitation group compared to the control group (mean difference = 88.9 s, P = 0.001). Peak oxygen uptake increased in the telerehabilitation group (mean difference = 3.0 mL·kg-1·min-1, P < 0.001) and control group (mean difference = 1.9 mL·kg-1·min-1, P < 0.001). Power output in cycle ergometer (mean difference = 25.9 watts, P < 0.001), fat free mass (mean difference = 2.1 kg, P = 0.004), soft lean mass (mean difference = 2.1 kg, P = 0.003), and skeletal muscle mass (mean difference = 1.4 kg, P = 0.003) only increased in the telerehabilitation group. A significant increase in the power output was observed in the telerehabilitation group compared with the control group in both lower limbs after isokinetic strength test of the leg extension at a speed of 60° (right: mean difference = 18.7 watts, P = 0.012; left: mean difference = 15.3 watts, P = 0.010). The peak torque of right leg extension increased only in the telerehabilitation group after isokinetic strength test at a speed of 60° (mean difference = 13.1 N·m, P < 0.001). A significant increase in the power output was observed in the telerehabilitation group compared with the control group in the left leg extension after isokinetic strength test at a speed of 180° (mean difference = 30.2 watts, P = 0.003).

CONCLUSIONS

The telerehabilitation programme improved cardiorespiratory and muscular fitness, and body composition in older patients with post-COVID-19 syndrome to a greater extent than a control group. The telerehabilitation programmes may be an alternative to improve the sequelae of post-COVID-19 syndrome in older patients.

Developing effective strategies to optimize physical activity and cardiorespiratory fitness in the long Covid population- The need for caution and objective assessment

The Post Covid-19 Condition (commonly known as Long Covid) has been defined by the World Health Organisation as occurring in individuals with a history of probable or confirmed SARS CoV 2 infection, usually within 3 months from the onset of acute Covid-19 infection with symptoms that last for at least two months which cannot be explained by an alternative diagnosis. Long Covid is associated with over two hundred recognised symptoms and affects tens of millions of people worldwide. Widely reported reductions in quality of life(QoL) and functional status are caused by extremely sensitive and cyclical symptom profiles that are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli. This manifestation prevents millions of people from engaging in routine activities of daily living (ADLs) and has important health and well-being, social and economic impacts. Post-exertional symptom exacerbation (PESE) (also known as post-exertional malaise) is an exacerbation in the severity of fatigue and other symptoms following physical, emotional, orthostatic and cognitive tasks. Typically, this will occur 24-72 h after "over-exertion" and can persist for several days and even weeks. It is a hallmark symptom of Long Covid with a reported prevalence of 86%. The debilitating nature of PESE prevents patients from engaging in physical activity which impacts functional status and QoL. In this review, the authors present an update to the literature relating to PESE in Long Covid and make the case for evidence-based guidelines that support the design and implementation of safe rehabilitation approaches for people with Long Covid. This review also considers the role of objective monitoring to quantify a patient's response to external stimuli which can be used to support the safe management of Long Covid and inform decisions relating to engagement with any stimuli that could prompt an exacerbation of symptoms.

Using cardiorespiratory fitness assessment to identify pathophysiology in long COVID - Best practice approaches

Cardio-respiratory fitness (CRF) is well-established in the clinical domains as an integrative measure of the body's physiological capability and capacity to transport and utilise oxygen during controlled bouts of physical exertion. Long COVID is associated with >200 different symptoms and is estimated to affect ∼150 million people worldwide. The most widely reported impact is reduced quality of life and functional status due to highly sensitive and cyclical symptoms that manifest and are augmented following exposure to physical, emotional, orthostatic, and cognitive stimuli, more commonly known as post-exertional symptom exacerbation (PESE) which prevents millions from engaging in routine daily activities. The use of cardiopulmonary exercise testing (CPET) is commonplace in the assessment of integrated physiology; CPET will undoubtedly play an integral role in furthering the pathophysiology and mechanistic knowledge that will inform bespoke Long COVID treatment and management strategies. An inherent risk of previous attempts to utilise CPET protocols in patients with chronic disease is that these are compounded by PESE and have induced a worsening of symptoms for patients that can last for days or weeks. To do this effectively and to meet the global need, the complex multi-system pathophysiology of Long COVID must be considered to ensure the design and implementation of research that is both safe for participants and capable of advancing mechanistic understanding.

The physiologic benefits of optimizing cardiorespiratory fitness and physical activity - From the cell to systems level in a post-pandemic world

Cardiovascular (CV) disease (CVD) is a leading cause of premature death and hospitalization which places a significant strain on health services and economies around the World. Evidence from decades of empirical and observational research demonstrates clear associations between physical activity (PA) and cardiorespiratory fitness (CRF) which can offset the risk of mortality and increase life expectancy and the quality of life in patients. Whilst well documented, the narrative of increased CRF remained pertinent during the coronavirus disease 2019 (COVID-19) pandemic, where individuals with lower levels of CRF had more than double the risk of dying from COVID-19 compared to those with a moderate or high CRF. The need to better understand the mechanisms associated with COVID-19 and those that continue to be affected with persistent symptoms following infection (Long COVID), and CV health is key if we are to be able to effectively target the use of CRF and PA to improve the lives of those suffering its afflictions. Whilst there is a long way to go to optimise PA and CRF for improved health at a population level, particularly in a post-pandemic world, increasing the understanding using a cellular-to-systems approach, we hope to provide further insight into the benefits of engaging in PA.

Long COVID quality of life and healthcare experiences in the UK: a mixed method online survey

PURPOSE

The complexity of long COVID and its diverse symptom profile contributes to unprecedented challenges for patients, clinicians, and healthcare services. The threat of long COVID remains ignored by Governments, the media and public health messaging, and patients' experiences must be heard through understanding of the lived experience. This study aimed to understand the lived experience of those living with long COVID.

METHODS

An online web-based survey was designed using Patient and Public Involvement and Engagement (PPIE) to increase understanding of the lived experiences of long COVID, and was distributed through PPIE groups, social media, and word of mouth. The survey used closed and open questions relating to demographics, pre- and post-COVID-19 health quality of life, daily activities and long COVID experiences.

RESULTS

Within our sample of 132 people living with long COVID, the findings highlight that individuals are being severely impacted by their symptoms and are unable to or limited in participating in their daily activities, reducing quality of life. Long COVID places strain on relationships, the ability to live life fully and is detrimental to mental health. Varying health care experiences are described by participants, with reports of medical gaslighting and inadequate support received.

CONCLUSIONS

Long COVID has a severe impact on the ability to live life fully, and strains mental health. The appropriate mechanisms and support services are needed to support those living with long COVID and manage symptoms.

Effect of different types of supervised exercise programs on cardiorespiratory and muscular fitness, pain, fatigue, mental health and inflammatory and oxidative stress biomarkers in older patients with post-COVID-19 sequelae "EJerSA-COVID-19": a randomized controlled trial

BACKGROUND

Many patients with COVID-19 present the so-called post-acute sequelae of COVID-19 such as fatigue, post-stress discomfort, dyspnea, headache, pain mental impairment, incapacity to perform daily physical tasks ant exercise intolerance. This study aims to investigate the effects of different exercise programs on physical and mental fitness, physical condition and biomarkers of the immune system and oxidative stress in older patients with post-COVID-19 sequelae.

METHODS

The sample will be made up of 120 eligible participants, over the age of 60 years who have had COVID-19 disease and are survivors and present persistent COVID-19 symptomatology diagnosed by the corresponding physician. The participants will be randomly assigned to the experimental groups: supervised endurance group (SEG, n = 30), supervised strength group (SSG, n = 30), supervised concurrent group (SCG, n = 30), which will perform the corresponding exercise program 3 days a week compared to the control group (CG, n = 30), which will not carry out a supervised exercise program. The design of this project will include measurements of four relevant dimensions; 1) Cardiorespiratory fitness; 2) Muscle fitness; 3) Pain and mental health; and 4) Biomarkers of inflammation and oxidative stress.

CONCLUSIONS

The results of this study will provide insights into the effects of different exercise programs on physical and mental fitness, physical condition and biomarkers of the immune system and oxidative stress in older patients with post-COVID-19 sequelae. These findings may be the basis for the formulation of health plans and rehabilitation programs that allow healthy aging and a reduction in the associated morbidity in patients with post-COVID-19 sequelae.

TRIAL REGISTRATION

NCT05848518. Registered on May 8, 2023.

Effectiveness of a respiratory rehabilitation program including an inspiration training device versus traditional respiratory rehabilitation: a randomized controlled trial

Background

In the context of COVID-19, respiratory training is vital for the care and recuperation of individuals. Both exercise-based and instrumental respiratory training have been employed as interventions to enhance respiratory function, providing relief from symptoms in those impacted by the virus. The aim of this study was to evaluate the efficacy of two different respiratory rehabilitation programs.

Methods

A total of 200 participants affected with COVID-19 respiratory sequels were recruited, with a block randomization regarding sex to ensure equal and appropriate applicability of the results. An experimental controlled and randomized study was conducted, with participants engaging in a 31 days respiratory rehabilitation program, (a) experimental group, inspiratory training device combined with aerobic exercise and (b) traditional respiratory exercises combined with aerobic exercise.

Results

Both groups improved in cardiorespiratory parameters, with a decrease in systolic and diastolic pressure, dyspnea and lower limbs fatigue, and increased oxygen saturation, 6 min walking distance, diaphragmatic thickness, forced vital capacity, forced expiratory volume during the first second, peak expiratory flow rate, forced inspiratory vital capacity and maximal inspiratory pressure. Comparison between groups showed statistically significant differences in all variables except for oxygen saturation, 6 min walking distance and diaphragmatic thickness. The results of this study support the use of specific inspiration training devices for respiratory rehabilitation in COVID-19 sequels.

Physical activity status prevents symptoms of long covid: Sulcovid-19 survey

BACKGROUND

Physical activity is indicated as a treatment for Long COVID, but prevention is unknown. This study aimed to investigate the relationship between physical activity (PA) before and after acute SARS-Cov-2 infection and the presence of Long COVID symptoms in adults.

METHODS

We used data from the Sulcovid-19, a longitudinal study carried out with individuals who were infected by SARS-Cov-2 between December/2020 and March/2021. Participants were asked about 19 symptoms commonly associated with long COVID. Three PA variables were built, as follows: (1) remained inactive; (2) became inactive; (3) remained active.

RESULTS

2.919 people were interviewed. The prevalence of individuals who had at least one symptom of Long COVID is 48.3% (95%CI 46.5-51.1). Our results showed that 71.8% (95%CI 70.1-73.4) of the individuals remained inactive, 14.9% (95%CI 13.6-16.2) became inactive and 13.3% (95% CI 12.1-14.6) remained active. The likelihood of experiencing long COVID symptoms was reduced in the musculoskeletal (PR 0.70; 95%CI 0.49-0.99), neurological (PR 0.61; 95%CI 0.43-0.88), and respiratory (PR 0.58; 95%CI 0.35-0.96) systems in those who remained active. In addition, the likelihood of experiencing Long COVID symptoms was 7% less in those who remained active.

CONCLUSIONS

Continuous PA practice showed important protection effect for Long COVID symptoms in adults.

Clinical manifestations of pain in patients suffering from COVID-19 infected with Delta variant of SARS-Cov-2

Background

Although respiratory presentations of COVID-19 predominate, the extra pulmonary involvement such as muscle pain, joint pain, headache, back pain, abdominal pain, and sore throat are usually included in the clinical picture of the disease and it can be considered as an early symptom in COVID-19 patients. The objective of the present study was to determine the frequency, localization, and intensity of pain in COVID-19 patients hospitalized in Imam Khomeini hospital of Ardabil, Iran.

Methods and materials

A prospective study was conducted on 388 COVID-19 patients who were admitted to Ardabil, Iran's Imam Khomeini Central Hospital between March and June 2020. Demographic characteristics of patients and general clinical manifestations of pain at the first admission to the hospital, localization, severity, and continuity of pain were evaluated by using a questionnaire and the Visual Analog Scale (VAS).

Findings

For the 388 (51.3% female, age 47.25 + 15.55 and 48.7% male, age 50.12 + 15.26 years old) Delta COVID-19 patients, the median duration from illness onset to hospitalization was 5 days. Patients' complaints included 89.7% fatigue, 85.56% cough, 67.8% fever, 64.17% loss of taste, 63.91% loss of smell, 37.9% diarrhea, and 11.85% skin lesions, respectively. Pain including muscle, joint, bone and low back pain was the chief complaint in both sexes. Pain complaints had started on average 5 days before admission. The distribution of pain was 313 (80.41%) muscle pain, 264 (70.61%) joint pain, 299 (77.1%) headache, 208 (53.6%) low back pain, 312 (80.41%) sore throat, and 157 (40.46%) abdominal pain. Out of 388 patients, 292 (75.25%) had diffuse pain.

Conclusions

Acute pain including myalgia, sore throat, arthralgia, headache, and low back pain were the most common symptoms of COVID-19 patients. Viral diseases such as COVID-19 may trigger the immune system to release cytokines that lead to muscle pain. Patients presenting to healthcare centers with complaints of pain should be evaluated for suspected COVID-19 infection.

Exploring the Impact of COVID-19 on Physical Activity One Month after Infection and Its Potential Determinants: Re-Infections, Pre-Illness Vaccination Profiles/Types, and Beyond

This study investigated changes in physical activity (PA) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection while considering age, PA level, underlying medical conditions (UMCs), vaccination profiles/types, re-infections, disease severity, and treatment. Data were collected from 5829 respondents by using a validated web-based questionnaire. The findings showed that there was a significant overall decrease in PA (-16.2%), including in daily occupation (-11.9%), transportation (-13.5%), leisure-time (-16.4%), and sporting (-27.6%) activities. Age, PA level, UMCs, vaccination profiles/types, disease severity, and treatment played a role in determining PA in individuals' post-acute SARS-CoV-2 infections. Re-infections did not impact the decline in PA. Unvaccinated individuals experienced a significant decline in PA (-13.7%). Younger (-22.4%) and older adults (-22.5%), those with higher PA levels (-20.6%), those with 2-5 UMCs (-23.1%), those who were vaccinated (-16.9%) or partially vaccinated (-19.1%), those with mRNA-type vaccines only (-17.1%), those with recurrent (-19.4%)-to-persistent (-54.2%) symptoms, and those that required hospital (-51.8%) or intensive care unit (-67.0%) admission during their infections had more pronounced declines in PA. These findings emphasize the complex relationship between post-acute SARS-CoV-2 infection and PA and highlight the need for targeted interventions, further research, and multidisciplinary care to promote PA resumption and mitigate long-term effects on global public health.

Forming a consensus opinion to inform long COVID support mechanisms and interventions: a modified Delphi approach

Background

Current approaches to support patients living with post-COVID condition, also known as Long COVID, are highly disparate with limited success in managing or resolving a well-documented and long-standing symptom burden. With approximately 2.1 million people living with the condition in the UK alone and millions more worldwide, there is a desperate need to devise support strategies and interventions for patients.

Methods

A three-round Delphi consensus methodology was distributed internationally using an online survey and was completed by healthcare professionals (including clinicians, physiotherapists, and general practitioners), people with long COVID, and long COVID academic researchers (round 1 n = 273, round 2 n = 186, round 3 n = 138). Across the three rounds, respondents were located predominantly in the United Kingdom (UK), with 17.3-15.2% (round 1, n = 47; round 2 n = 32, round 2 n = 21) of respondents located elsewhere (United States of America (USA), Austria, Malta, United Arab Emirates (UAE), Finland, Norway, Malta, Netherlands, Iceland, Canada, Tunisie, Brazil, Hungary, Greece, France, Austrailia, South Africa, Serbia, and India). Respondents were given ∼5 weeks to complete the survey following enrolment, with round one taking place from 02/15/2022 to 03/28/22, round two; 05/09/2022 to 06/26/2022, and round 3; 07/14/2022 to 08/09/2022. A 5-point Likert scale of agreement was used and the opportunity to include free text responses was provided in the first round.

Findings

Fifty-five statements reached consensus (defined as >80% agree and strongly agree), across the domains of i) long COVID as a condition, ii) current support and care available for long COVID, iii) clinical assessments for long COVID, and iv) support mechanisms and rehabilitation interventions for long COVID, further sub-categorised by consideration, inclusion, and focus. Consensus reached proposes that long COVID requires specialised, comprehensive support mechanisms and that interventions should form a personalised care plan guided by the needs of the patients. Supportive approaches should focus on individual symptoms, including but not limited to fatigue, cognitive dysfunction, and dyspnoea, utilising pacing, fatigue management, and support returning to daily activities. The mental impact of living with long COVID, tolerance to physical activity, emotional distress and well-being, and research of pre-existing conditions with similar symptoms, such as myalgic encephalomyelitis, should also be considered when supporting people with long COVID.

Interpretation

We provide an outline that achieved consensus with stakeholders that could be used to inform the design and implementation of bespoke long COVID support mechanisms.

Funding

None.

Lived experience of patients with Long COVID: a qualitative study in the UK

BACKGROUND

Long COVID is a rapidly evolving global health crisis requiring interdisciplinary support strategies that incorporate the lived experience of patients. Currently, there is a paucity of research documenting the day-to-day experiences of patients living with Long COVID.

OBJECTIVE

To explore the lived experience of Long COVID patients.

STUDY DESIGN

Longitudinal, observation study.

SETTING

An inductive, data-driven, qualitative approach was used to evaluate hand-written diaries obtained from individuals who had been referred to a Derbyshire Long COVID clinic.

PARTICIPANTS

12 participants (11 females, age 49±10 years, 11 Caucasians) were recruited. Participants were included if they had a previous confirmed or suspected COVID-19 infection with ongoing recovery, >18 years old, understood the study requirements and provided informed consent.

METHOD

Participants were directed to complete self-report diaries over 16 weeks. Responses were transcribed verbatim and analysed using thematic analysis.

RESULTS

Three key themes were highlighted: (1) understanding who helps patients manage symptoms, (2) daily activities and the impact on quality of life and health status and (3) the effect of turbulent and episodic symptom profiles on personal identity and recovery.

CONCLUSIONS

The novel challenges presented by Long COVID are complex with varying inter-related factors that are broadly impacting functional status and quality of life. Support mechanisms must incorporate the lived experiences and foster true collaborations between health professionals, patients and researchers to improve patient outcomes.

TRIAL REGISTRATION NUMBER

NCT04649957.

Aged brain and neuroimmune responses to COVID-19: post-acute sequelae and modulatory effects of behavioral and nutritional interventions

Advanced age is one of the significant risk determinants for coronavirus disease 2019 (COVID-19)-related mortality and for long COVID complications. The contributing factors may include the age-related dynamical remodeling of the immune system, known as immunosenescence and chronic low-grade systemic inflammation. Both of these factors may induce an inflammatory milieu in the aged brain and drive the changes in the microenvironment of neurons and microglia, which are characterized by a general condition of chronic inflammation, so-called neuroinflammation. Emerging evidence reveals that the immune privilege in the aging brain may be compromised. Resident brain cells, such as astrocytes, neurons, oligodendrocytes and microglia, but also infiltrating immune cells, such as monocytes, T cells and macrophages participate in the complex intercellular networks and multiple reciprocal interactions. Especially changes in microglia playing a regulatory role in inflammation, contribute to disturbing of the brain homeostasis and to impairments of the neuroimmune responses. Neuroinflammation may trigger structural damage, diminish regeneration, induce neuronal cell death, modulate synaptic remodeling and in this manner negatively interfere with the brain functions.In this review article, we give insights into neuroimmune interactions in the aged brain and highlight the impact of COVID-19 on the functional systems already modulated by immunosenescence and neuroinflammation. We discuss the potential ways of these interactions with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and review proposed neuroimmune mechanisms and biological factors that may contribute to the development of persisting long COVID conditions. We summarize the potential mechanisms responsible for long COVID, including inflammation, autoimmunity, direct virus-mediated cytotoxicity, hypercoagulation, mitochondrial failure, dysbiosis, and the reactivation of other persisting viruses, such as the Cytomegalovirus (CMV). Finally, we discuss the effects of various interventional options that can decrease the propagation of biological, physiological, and psychosocial stressors that are responsible for neuroimmune activation and which may inhibit the triggering of unbalanced inflammatory responses. We highlight the modulatory effects of bioactive nutritional compounds along with the multimodal benefits of behavioral interventions and moderate exercise, which can be applied as postinfectious interventions in order to improve brain health.

Implementation of a rehabilitation program in a virtual reality for post-Covid-19 patients - preliminary results

This study aims to present the preliminary results of a novel rehabilitation program for post-COVID-19 patients that incorporates virtual reality (VR). The study included 20 patients who had previously been affected by SARS-CoV-2 and participated in inpatient pulmonary rehabilitation. These patients were randomly divided into either a VR group or a control group. The both the VR group and the control group participated in the same rehabilitation program, which consisted of exercise capacity training on a cycle ergometer, breathing exercises, resistance and general fitness training, and relaxation. Each training component was performed once a day. The groups that participated differed based on the training settings they received on the cycle ergometer and relaxation training. The study assessed exercise tolerance (6MWT), lung function (FEV1, FVC, TLC, FEV1%VC), stress levels (PSS-10), quality of life (WHOQOL-BREF), likewise anxiety and depression symptoms (HADS). The results showed that the VR group had a statistically significant improvement in all of the functional capacity tests compared to the control group. The VR group also had a statistically significant improvement in quality of life compared to the control group. These results suggest that the inclusion of VR in rehabilitation programs may be beneficial for post-COVID-19 patients.

Cardiovascular services in Covid-19 - Impact of the pandemic and lessons learned

The coronavirus disease 2019 (COVID-19) pandemic immediately and perhaps irrevocably impacted society at large, the provision of cardiovascular (CV) care, the function and staffing of hospitals, and CV clinicians. Initially many clinicians at all career stages rose to the challenges, and support and accolades were the initial societal response. Politicization of the public health response as well as widespread misinformation and disinformation all negatively impacted CV clinicians' roles as well diminished and, in some cases, eliminated their public and self-esteem. Unabated stress, disrespect, and a likely lack of emotional and physical respite may all have contributed to the Great Resignation. Insights gained from review of the COVID-19 pandemic may help inform changes to foster system resiliency and prepare for an improved response to the inevitable next stressor.

Cardiorespiratory fitness as a vital sign of CVD risk in the COVID-19 era

The severe health consequences of the corona virus disease 2019 (COVID-19) pandemic have been exacerbated by the prevalence of cardiovascular disease (CVD) risk factors, such as physical inactivity, obesity, hypertension, and diabetes. Further, policy decisions during the pandemic augmented unhealthy lifestyle behaviors and health inequalities, likely increasing the global disease burden. Cardiorespiratory fitness (CRF) is a well-established biomarker associated with CVD risk. Emerging data demonstrate that high CRF offers some protection against severe outcomes from COVID-19 infection, highlighting the importance of CRF for population health and the potential for limiting the severity of future pandemics. CRF is best assessed by cardiopulmonary exercise testing (CPET), which will be an important tool for understanding the prolonged pathophysiology of COVID-19, the emergence of long-COVID, and the lasting effects of COVID-19 on CVD risk. Utilization of CRF and CPET within clinical settings should become commonplace because of lessons learned from the COVID-19 pandemic.

The acute and chronic implications of the COVID-19 virus on the cardiovascular system in adults: A systematic review

Despite coronavirus disease 2019 (COVID-19) primarily being identified as a respiratory illness, some patients who seemingly recovered from initial infection, developed chronic multi-system complications such as cardiovascular (CV), pulmonary and neurological issues leading to multiple organ injuries. However, to date, there is a dearth of understanding of the acute and chronic implications of a COVID-19 infection on the CV system in adults. A systematic review of the literature was conducted according to PRISMA guidelines and prospectively registered via Prospero (ID: CRD42022360444). The MEDLINE Ovid, Cochrane Library and PubMed databases were searched from inception to August 2022. The search strategy keywords and MeSH terms used included: 1) COVID; 2) coronavirus; 3) long COVID; 4) cardiovascular; and 5) cardiovascular disease. Reference lists of all relevant systematic reviews identified were searched for additional studies. A total of 11,332 records were retrieved from database searches, of which 310 records were duplicates. A further 9887 were eliminated following screening of titles and abstracts. After full-text screening of 1135 articles, 9 manuscripts were included for review. The evidence of CV implications post-COVID-19 infection is clear, and this must be addressed with appropriate management strategies that recognise the acute and chronic nature of cardiac injury in COVID-19 patients. Efficacious management strategies will be needed to address long standing issues and morbidity.

Healthy living behaviors in youth: a comparative study in Brazil, Colombia and Mexico

The physical, mental and social well being, refers to a new concept of health, far from a conceptualisations of absence of disease Additional challenges emerge as individuals face deep social inequities depending on their ethnicity, rural residence or low educational level, as these translate to poor access to health services and more difficulties to adhere to healthy living behaviors. The objective of this study was to assess the perception that adolescents and young adults in Latinamerica have of the importance of healthy living behaviors (HLB) in the physical, emotional and lifestyle spheres. The approach is considered quantitative and descriptive with a cross sectional design. The sampling consisted of 192 young adults in Brazil, Colombia and Mexico. The results show that participants prioritize higher emotional wellbeing. They state that the health crisis changed the perception, as now the value more the emotional side of health, and understand the status of a combination of the different aspects of wellness. The Latinamerican context poses a challenge in designing strategies with a holistic health perspective, with complexities in the economic and sociocultural domains.

Post pandemic research priorities: A consensus statement from the HL-PIVOT

We have been amid unhealthy living and related chronic disease pandemics for several decades. These longstanding crises have troublingly synergized with the coronavirus disease 2019 (COVID-19) pandemic. The need to establish research priorities in response to COVID-19 can be used to address broad health and wellbeing, social and economic impacts for the future is emerging. Accordingly, this paper sets out a series of research priorities that could inform interdisciplinary collaboration between clinical sciences, public health, business, technology, economics, healthcare providers, and the exercise science/sports medicine communities, among others. A five-step methodology was used to generate and evaluate the research priorities with a focus on broad health and well-being impacts. The methodology was deployed by an international and interdisciplinary team from the Healthy Living for Pandemic Event Protection (HL- PIVOT) network. This team were all engaged in responding to the Pandemic either on the 'front-line' and/or in leadership positions ensuring the currency and authenticity of the process. Eight research priorities were identified clustered into two groups: i) Societal & Environmental, and ii) Clinical. Our eight research priorities are presented with insight from previously published research priorities from other groups.

Management of Long COVID—The CoviMouv' Pilot Study: Importance of Adapted Physical Activity for Prolonged Symptoms Following SARS-CoV2 Infection

Context

After a COVID-19 infection, some patients have persistent symptoms, the most common is fatigue. To prevent it from becoming chronic (post-COVID-19 syndrome), early management before 3 months could be useful. Exercise and education are recommended.

Objective

To assess fatigue in patients with prolonged symptoms after COVID-19 infection and who received a mixed program of remote adapted physical activity and therapeutic education. The secondary objective was to evaluate the efficacy and safety of this training method thanks to aerobic and anaerobic parameters.

Methods

“CoviMouv': From Coaching in Visual to Mouv in real” is a nonrandomized controlled pilot study. Patients in telerehabilitation followed 12 remote exercise sessions and 3 therapeutic education workshops. Patients on traditional rehabilitation followed their program with a community-based physiotherapist.

Results

Fatigue was reduced after the one-month intervention in both groups (p = 0.010). The majority of aerobic parameters were significantly improved, e.g., maximal oxygen uptake (p = 0.005), walking distance (p = 0.019) or hyperventilation values (p = 0.035). The anaerobic parameter was not improved (p = 0.400). No adverse event was declared.

Discussion

Telerehabilitation is a good alternative when a face-to-face program is not possible. This care at an early stage of the disease could help prevent the chronicity of post-COVID-19 symptoms and the installation of vicious circles of physical deconditioning. A larger study would be necessary.

Effect Of Surgical And N95 Facial Masks On Exercise Tolerance, Heart Rate, Respiratory Rate And Blood Oxygen Saturation

Background — Although wearing masks is inevitable these days, the effects of wearing them on physiologic parameters have not been reported. This study aimed to assess the effects of wearing no mask, a three-layer standard surgical mask, and wearing an N95 mask on blood oxygen saturation, aerobic tolerance, and performance during exercise. Methods — Twenty-one participants were enrolled in the study. Each participant was monitored with electrocardiography (ECG) while performing an exercise tolerance test using the Bruce treadmill protocol. Testing was conducted three times on different dates. Participants did not use any mask in the first test but did wear surgical and N95 masks during the second and third tests respectively. Respiratory rate (RR) was assessed for 10 seconds and then multiplied by 6. Heart rate (HR) was monitored by ECG, and oxygen saturation levels were monitored (O2Sat) via digital pulse-oximetry. Assessments were done before warm-up, at the middle and end of each Bruce stage, and as well at 1, 2, and 5 minutes into recovery (masks were worn during recovery). Results — HR, RR, and O2Sat measured data were all significantly different between the three trials at end-stage 3 of Bruce treadmill protocol (p<0.05). Although HR was still higher through the recovery period in the N95 trial in comparison with other trials (p<0.05), RR and O2Sat measured data were not different in the recovery phase. Conclusion — HR, RR, O2Sat and exercise tolerance are significantly affected by wearing surgical and N95 masks.

The Impact of Post-traumatic Stress of SARS-CoV-2 Affliction on Psychological and Mental Health of Student Survivors: Cross Sectional Study

Background

COVID-19 survivor's population is often associated with a long term impact on mental and psychological health. Recent included studies have also stated affliction of mental health due to fear of virus and preventive policies among the college students.

Objectives

The research was conducted to find the psychological and mental impacts of SARS-CoV-2 affliction among the students' survivors in the university.

Methods

The study design of the experiment was cross-sectional, sampling technique was non probability and sampling method being applied was convenience sampling. IBM Statistical Package for the Social Sciences version 20 was used for analyses. Descriptive data was examined and results were showed as mean and standard deviations, percentages, frequencies for continuous variables of IES-R scale (Intrusion, Avoidance, and Hyperarousal) using the total sample of n = 34.

Results

Out of 34 only 24 student survivors responded to the online survey post COVID-19 recovery, with an overall participation level of 71%. Grading was given for the total IES-R score which was subdivided into a predefined range. Out of 24 participants, 9 (38%) participants showed the symptoms of mild (n = 2)-severe (n = 7) psychological impacts. On correlation of factors total IES-R score and taste and sense of smell were moderately correlated. The ordinal regression for complete loss of sense of taste and smell was also significant.

Conclusion

The results from IES-R evaluation clearly outlines the presence of psychological sequels post recovery of COVID-19 episodes among the young college survivors. Complete loss of sense of smell and taste may be an indicator of psychological sequelae as compared to reduce sense of smell.

Impact of Exercise on Susceptibility and Severity of COVID-19 in Patients with Cancer: A Retrospective Study

BACKGROUND

Modifiable lifestyle-related factors heighten the risk and severity of coronavirus disease 2019 (COVID-19) in patients with cancer. Whether exercise lowers susceptibility or severity is not known.

METHODS

We identified 944 cancer patients from Memorial Sloan Kettering Cancer Center (mean age: 64; 85% female; 78% White) completing an exercise survey before receiving a confirmed positive or negative SARS-CoV-2 test. Exercise was defined as reporting moderate-intensity ≥5 days per week, ≥30 minutes/session or strenuous-intensity ≥3 days per week, ≥20 minutes/session. Multivariable logistic regression was used to determine the relationship between exercise and COVID-19 susceptibility and severity (i.e., composite of hospital admission or death events) with adjustment for clinical-epidemiologic covariates.

RESULTS

Twenty-four percent (230/944) of the overall cohort were diagnosed with COVID-19 and 35% (333/944) were exercisers. During a median follow-up of 10 months, 26% (156/611) of nonexercising patients were diagnosed with COVID-19 compared with 22% (74/333) of exercising patients. The adjusted OR for risk of COVID-19 was 0.65 [95% confidence interval (CI), 0.44-0.96, P = 0.03] for exercisers compared with nonexercisers. A total of 20% (47/230) of COVID-19 positive patients were hospitalized or died. No difference in the risk of severe COVID-19 as a function of exercise status was observed (P > 0.9).

CONCLUSIONS

Exercise may reduce the risk of COVID-19 infection in patients with a history of cancer, but not its severity.

IMPACT

This study provides the first data showing that exercise might lower the risk of COVID-19 in cancer patients, but further research is required.

COVID-19 patients require multi-disciplinary rehabilitation approaches to address persisting symptom profiles and restore pre-COVID quality of life

BACKGROUND

Long-COVID diagnosis is prominent, and our attention must support those experiencing debilitating and long-standing symptoms. To establish patient pathways, we must consider the societal and economic impacts of sustained COVID-19. Accordingly, we sought to determine the pertinent areas impacting quality of life (QoL) following a COVID-19 infection.

RESEARCH METHODS

Three hundred and eighty-one participants completed a web-based survey (83% female, 17% male) consisting of 70 questions across 7 sections (demographics, COVID-19 symptoms; QoL; sleep quality; breathlessness; physical activity and mental health). Mean age, height, body mass and body mass index (BMI) were 42 ± 12 years, 167.6 ± 10.4 cm, 81.2 ± 22.2 kg, and 29.1 ± 8.4 kg.m², respectively.

RESULTS

Participant health was reduced because of COVID-19 symptoms ("Good health" to "Poor health" [P<0.001]). Survey respondents who work reported ongoing issues with performing moderate (83%) and vigorous (79%) work-related activities.

CONCLUSIONS

COVID-19 patients report reduced capacity to participate in activities associated with daily life, including employment activities. Bespoke COVID-19 support pathways must consider multi-disciplinary approaches that address the holistic needs of patients to restore pre-pandemic quality of life and address experienced health and wellbeing challenges.

An Evolving Approach to Assessing Cardiorespiratory Fitness, Muscle Function and Bone and Joint Health in the COVID-19 Era

Cardiorespiratory fitness (CRF) is now an established vital sign. CRF, along with muscle function and bone and joint health is related to functional independence and a higher quality of life. Wasserman and colleagues proposed a gear model illustrating the integrated role of the respiratory, cardiovascular, and skeletal muscle systems during aerobic exercise; in 2015, a revision to the original model was proposed. Our understanding of the effects and challenges associated with the coronavirus disease 2019 (COVID-19) are rapidly evolving. Initial evidence indicates higher levels of CRF, and muscle function protect individuals infected with COVID-19 from a complicated medical course. Moreover, for those individuals infected with COVID-19, there are initial signs of a reduction in CRF following the initial phase of recovery. We are also gaining an understanding of long COVID syndrome, where individuals who have recovered from the acute phase of viral infection present with lasting symptoms, which include but are not limited to reduced CRF, shortness of breath, and fatigue. Clearly, these individuals will require rehabilitation to restore and/or improve CRF, muscle function, bone and joint health, functional capacity (ie, the ability to perform activities of daily living), and quality of life. The importance of assessing the synergistic function of systems essential to performing activities that require physical exertion is a health care imperative. This graphical narrative provides an update to the gear model initially proposed by Wasserman and updated to a gear and circuit in 2015. External CRF, muscle function, and bone and joint health influencers and an approach to clinical assessment are also introduced.

The Aftermath of the COVID-19 Crisis in Saudi Arabia: Respiratory Rehabilitation Recommendations by Physical Therapists

Since late 2019, the number of COVID-19 patients has gradually increased in certain regions as consecutive waves of infections hit countries. Whenever this wave hits the corresponding areas, the entire healthcare system must respond quickly to curb the diseases, morbidities, and mortalities in intensive care settings. The healthcare team involved in COVID-19 patients' care must work tirelessly without having breaks. Our understanding of COVID-19 is limited as new challenges emerge with new COVID-19 variants appearing in different world regions. Though medical therapies are finding solutions to deal with the disease, there are few recommendations for respiratory rehabilitation therapies. A group of respiratory rehabilitation care professionals in Saudi Arabia and international experts have agreed with the World Health bodies such as the World Health Organization (WHO) on the treatment and rehabilitation of patients with COVID-19. Professionals participating in COVID-19 patient treatment, rehabilitation, and recovery formulated respiratory rehabilitation guidelines based on the DELPHI Method, combining scientific research and personal practical experience. As a result, it is envisaged that the number of individuals in the region suffering from respiratory ailments due to post-COVID-19 will decrease. This narrative review and clinical expertise guidelines may give physiotherapists acceptable and standard clinical guideline protocols for treating COVID-19 patients.

A mixed-methods systematic review of post-viral fatigue interventions: Are there lessons for long Covid?

OBJECTIVES

Fatigue syndromes have been widely observed following post-viral infection and are being recognised because of Covid19. Interventions used to treat and manage fatigue have been widely researched and this study aims to synthesise the literature associated with fatigue interventions to investigate the outcomes that may be applicable to 'long Covid'.

METHOD

The study was registered with PROSPERO (CRD42020214209) in October 2020 and five electronic databases were searched. Papers were screened, critically appraised and data extracted from studies that reported outcomes of fatigue interventions for post-viral syndromes. The narrative synthesis includes statistical analysis associated with effectiveness and then identifies the characteristics of the interventions, including identification of transferable learning for the treatment of fatigue in long Covid. An expert panel supported critical appraisal and data synthesis.

RESULTS

Over 7,000 research papers revealed a diverse range of interventions and fatigue outcome measures. Forty papers were selected for data extraction after final screening. The effectiveness of all interventions was assessed according to mean differences (MD) in measured fatigue severity between each experimental group and a control following the intervention, as well as standardised mean differences as an overall measure of effect size. Analyses identified a range of effects-from most effective MD -39.0 [95% CI -51.8 to -26.2] to least effective MD 42.28 [95% CI 33.23 to 51.34]-across a range of interventions implemented with people suffering varying levels of fatigue severity. Interventions were multimodal with a range of supportive therapeutic methods and varied in intensity and requirements of the participants. Those in western medical systems tended to be based on self- management and education principles (i.e., group cognitive behavioural therapy (CBT).

CONCLUSION

Findings suggest that the research is highly focussed on a narrow participant demographic and relatively few methods are effective in managing fatigue symptoms. Selected literature reported complex interventions using self-rating fatigue scales that report effect. Synthesis suggests that long Covid fatigue management may be beneficial when a) physical and psychological support, is delivered in groups where people can plan their functional response to fatigue; and b) where strengthening rather than endurance is used to prevent deconditioning; and c) where fatigue is regarded in the context of an individual's lifestyle and home-based activities are used.

Rehabilitation and In-Hospital Mortality in COVID-19 patients

BACKGROUND

COVID-19 guidelines endorse early rehabilitation to improve outcomes in hospitalized patients, but the evidence-base to support this recommendation is lacking. We examined the association between early rehabilitation and in-hospital deaths in COVID-19 patients.

METHODS

Single center retrospective study involving 990 COVID-19 patients (42·4% women, mean age 67.8 years) admitted between March 1, 2020 and May 31, 2020 to a community hospital. Association of rehabilitation during hospitalization with in-hospital mortality was examined using logistic regression analysis adjusted for demographics, length of stay, body mass index, comorbid illnesses, functional status as well as for COVID-19 presentations, treatments, and complications.

RESULTS

Over the 3-month study period, 475 (48·0%) in-patients were referred for rehabilitation. Patients who received rehabilitation were older (73·7 ± 14·0 vs. 62·3 ± 17·2). There were 61 hospital deaths (12·8%) in the rehabilitation group and 165 (32·0%) in the non-rehabilitation group. Receiving rehabilitation was associated with an 89% lower in-hospital mortality (OR 0·11, 95% CI 0·06-0·19) after adjusting for multiple confounders and COVID-19 disease markers. In sensitivity analyses, the results were significant in sub-populations defined by age group, sex, race, length of hospitalization, or pulmonary presentations. Each additional rehabilitation session was associated with a 29% lower risk of in-hospital mortality (OR per session 0·71, 95% CI 0·64-0·79) in the fully adjusted model.

CONCLUSION

Among hospitalized COVID-19 patients, receiving early rehabilitation was associated with lower in-hospital mortality. Our findings support implementation of rehabilitation services for COVID-19 patients in acute care settings, but further research from randomized clinical trials is needed.

Post-COVID-19 Syndrome and the Potential Benefits of Exercise

The coronavirus disease (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection, is leading to unknown and unusual health conditions that are challenging to manage. Post-COVID-19 syndrome is one of those challenges, having become increasingly common as the pandemic evolves. The latest estimates suggest that 10 to 20% of the SARS-CoV-2 patients who undergo an acute symptomatic phase are experiencing effects of the disease beyond 12 weeks after diagnosis. Although research is beginning to examine this new condition, there are still serious concerns about the diagnostic identification, which limits the best therapeutic approach. Exercise programs and physical activity levels are well-known modulators of the clinical manifestations and prognosis in many chronic diseases. This narrative review summarizes the up-to-date evidence on post-COVID-19 syndrome to contribute to a better knowledge of the disease and explains how regular exercise may improve many of these symptoms and could reduce the long-term effects of COVID-19.

Exercise and sports after COVID-19-Guidance from a clinical perspective

SARS-CoV-2 infection has emerged as not only a pulmonary but also potentially multi-organ disease, which may cause long-term structural damage of different organ systems including the lung, heart, vasculature, brain, liver, kidney, or intestine. As a result, the current SARS-CoV-2/COVID-19 pandemic will eventually yield substantially increased numbers of chronically diseased patients worldwide, particularly suffering from pulmonary fibrosis, post-myocarditis, chronic heart failure, or chronic kidney disease. Exercise recommendations for rehabilitation are complex in these patients and should follow current guidelines including standards for pre-exercise medical examinations and individually tailored exercise prescription. It is of utmost importance to start exercise training at an early stage after COVID-19 infection, but at the same time paying attention to the physical barriers to ensure safe return to exercise. For exercise recommendations beyond rehabilitation programs particularly for leisure time and elite athletes, more precise advice is required including assessment of sports eligibility and specific return-to-sports exercise programs. Because of the current uncertainty of long-term course of SARS-CoV-2 infection or COVID disease, long-term follow-up seems to be necessary.

The Influence of the COVID-19 Pandemic on Physical Activity and New Incidence of Frailty among Initially Non-Frail Older Adults in Japan: A Follow-Up Online Survey

OBJECTIVES

The objective of this study was to investigate the influence of the COVID-19 pandemic on physical activity (PA) and the incidence of frailty among initially non-frail older adults in Japan.

DESIGN

A follow-up online survey.

SETTING AND SUBJECTS

Among the 1,600 baseline online survey participants, 388 adults were already frail, and 275 older adults did not respond to the follow-up survey. Thus, the final number of participants in this study was 937 (follow-up rate: 77.3%).

METHODS

We assessed the total PA time at four time points according to the COVID-19 waves in Japan: January 2020 (before the pandemic), April 2020 (during the first wave), August 2020 (during the second wave), and January 2021 (during the third wave). We then investigated the incidence of frailty during a one-year follow-up period (during the pandemic).

RESULTS

The total PA time during the first, second, and third waves of the pandemic decreased from the pre-pandemic PA time by 33.3%, 28.3%, and 40.0%, respectively. In particular, the total PA time of older adults who were living alone and socially inactive decreased significantly: 42.9% (first wave), 50.0% (second wave), and 61.9% (third wave) less than before the pandemic, respectively. Additionally, they were at a significantly higher risk of incident frailty than those who were not living alone and were socially active (adjusted odds ratio: 2.04 [95% confidence interval: 1.01-4.10]).

CONCLUSION

Our findings suggest that older adults who live alone and are socially inactive are more likely to experience incident frailty/disability due to decreased PA during the pandemic. Understanding this mechanism may be crucial for maintaining the health status of older adults.