Joint Statement on the Role of Respiratory Rehabilitation in the COVID-19 Crisis: The Italian Position Paper

Professional practice, competence, and education related to COVID-19: A mixed-methods light study of physiotherapists' experiences

BACKGROUND

Coronavirus Disease 2019 (COVID-19) became a significant challenge for the work and personal experience of physiotherapists (PTs).

OBJECTIVE

To investigate how the work activities of PTs in a region in Italy have changed, describe the reasons for change, perceived competence, and effectiveness of professional education, and explore their personal experience.

METHODS

We adopted a monocentric convergent mixed-methods light-questionnaire variant study. The questionnaire contains both closed-ended and open-ended questions. Quantitative and qualitative data were combined to interpret the results.

RESULTS

Among 78 respondents (response rate 24.4%), 87.2% worked during the pandemic, 52.9% treated patients with COVID-19, and 45.6% changed their working activities. Professional competence was perceived as low in intensive and sub-intensive care settings. The major critical aspect of professional education was respiratory rehabilitation. Life-learning education was judged as effective, even if mainly focused on safety. Nine themes emerged from the analysis of the PTs' experiences: 1) Physiotherapy during COVID-19; 2) Fear and negative feelings; 3) Positive aspects; 4) Organization and management; 5) Prevention measures; 6) Patients; 7) Change; 8) Information; and 9) Professional education.

CONCLUSIONS

PTs who have direct experience with patients with COVID-19 showed great resilience. They overcame the first phase of disorientation and fear, despite a specific lack of competence in the respiratory field.

Arm cycle ergometry in critically ill patients: A systematic review

BACKGROUND

Intensive care unit (ICU) survivors face functional limitations due to ICU-acquired weakness. Arm cycle ergometry (ACE) introduced in the ICU may improve physical function. To our knowledge, there is limited evidence on the effectiveness of ACE and physical function outcomes in critically ill patients.

OBJECTIVE

The objective of this systematic review was to examine the impact of ICU-based ACE on physical function, safety, and other clinical outcomes.

REVIEW METHOD USED

Systematic Review.

DATA SOURCES

A search of seven databases was conducted from the inception to January 1, 2023: Medline Ahead of Print, Ovid MEDLINE(R), Allied and Complementary Medicine Database (AMED), Embase, Cochrane Central, Physiotherapy Evidence Database, and Cumulative Index to Nursing and Allied Health Literature (CINAHL).

REVIEW METHODS

We included two arm studies of critically ill adults admitted to the ICU who received ACE and any comparator for our primary outcome, physical function. Our secondary outcomes included severe events. We included safety studies with or without a comparator group. Screening, data abstraction, and risk-of-bias assessments were completed independently, in duplicate. We used the Grading of Recommendations, Assessment, Development, and Evaluation approach to assess the overall certainty of evidence.

RESULTS

We screened 651 citations and included eight studies that enrolled 183 patients. Due to heterogeneity, meta-analysis was not performed. For our primary outcome, one randomised controlled trial found significant improvements in physical function, measured by the Barthel Index with ACE, whereas a nonrandomised study showed no difference. Out of the six studies reporting safety, none reported any severe safety events. The overall certainty of evidence was very low.

CONCLUSION

ACE initiated in the ICU is a likely safe intervention. Based on the limited ACE studies and heterogeneity between studies, further research with more rigorous studies evaluating important outcomes for patients is needed.

Pulmonary rehabilitation and risk of fall in elderly with chronic obstructive pulmonary disease

BACKGROUND

Few data are available on the effects of pulmonary rehabilitation (PR) on risk of fall in over 80 individuals with chronic obstructive pulmonary disease (COPD). We investigated the effectiveness of PR on the risk of fall in older as compared to younger than 80 individuals.

METHODS

Parallel-group retrospective exploratory study of individuals undergone in-hospital PR. The risk of fall was defined as a gait speed ≤0.8 m/s (primary outcome). Outcome measures (exercise capacity, physical performance, symptoms, and health status) were also assessed.

RESULTS

As compared to younger, individuals over 80 suffered from more severe symptoms, a reduction in physical performance and in exercise capacity and greater risk of fall (P=0.0001). The proportion of participants at risk of fall increased with age, and after PR decreased significantly without any significant difference between age groups. However, 53.4% of older individuals were still at risk of fall, as compared to 17.5% of those under 80 (P=0.0001). After PR, both populations had improved outcomes measures, without any significant between group differences.

CONCLUSIONS

In individuals with COPD pulmonary rehabilitation reduced the risk of fall, while improving outcome measures independent of age, however, more than 50% of those over 80 were still at risk of fall. The pulmonary rehabilitation programs for individuals over 80 should include strategies effective in reducing the risk of fall.

Recovery of activities of daily living in COVID-19 patients requiring intensive care unit or medical care unit: an observational study on the role of rehabilitation in the subacute phase

Purpose

This study aims to describe the functional status of a cohort of subacute COVID-19 patients treated in a dedicated rehabilitation unit and to compare functional outcomes between patients previously hospitalized in the intensive care unit (ICU group) and patients assisted in the medical care unit (MCU group).

Materials and methods

Clinical and functional evaluations were performed at admission and discharge. The functional status was assessed using Barthel index (BI), functional ambulation categories (FAC), trunk control test (TCT), and dysphagia outcome and severity score (DOSS). All patients received multidisciplinary tailored rehabilitation.

Results

We evaluated 171 patients (with a mean age of 67.7 ± 11.9 years, 117 were males), 110 coming from the ICU (with a mean age of 63.24 ± 10.9 years), and 61 coming from the MCU (with a mean age of 75.75 ± 9.09 years). The ICU group showed a worse functional status at admission compared with the MCU group [BI 2.5 (0-20) vs. 20 (10-60), FAC 0 (0-0) vs. 0 (0-2), TCT 61 (42-100) vs. 100 (61-100), DOSS 5 (1-7) vs. 7 (7-7)] and had significantly longer hospital stay. At discharge, all functional scales were improved with no statistically significant differences between the two groups.

Conclusion

Early rehabilitation of COVID-19 survivors improves functional recovery closing the initial gap between the ICU and MCU groups. In addition, it is effective to improve the functional outcome reducing the costs for longer-term assistance of COVID-19 patients.

Rapid Recovery in a Patient with Severe COVID-19 after a Low-Load, High-Frequency Rehabilitation Program Using an Ergometer in the Supine Position

BACKGROUND

Rehabilitation therapy for patients with severe coronavirus disease 2019 (COVID-19) is crucial; however, studies regarding rehabilitation strategies for intensive care unit (ICU) patients with COVID-19 are limited. We report a case of severe COVID-19 in an ICU patient whose physical function and basic movement ability rapidly improved after the initiation of active aerobic exercise in the supine position.

CASE

A 70-year-old man with hypertension and obesity was admitted to the ICU and managed with a ventilator because of severe COVID-19. Physical therapy started on postadmission day 34. Problems encountered during physical therapy included low saturation of percutaneous oxygen (SpO2; <90%), dyspnea with a light exercise load, advancing muscle weakness, and endurance decline. The rehabilitation program included getting out of bed and resistance training of the upper and lower limbs twice daily while maintaining SpO2 at ≥90%. After ventilator weaning, we initiated aerobic training using a supine ergometer with varying load volume. On discharge from the ICU on postadmission day 45, the patient's physical function (handgrip strength, Medical Research Council score, and Borg scale) and basic movement ability (Functional Status Score for ICU) rapidly improved.

CONCLUSION

Rehabilitation therapy involving aerobic cycling training based on a quantitative load setting may be effective in treating COVID-19.

Inpatient rehabilitation of a person with Guillain-Barré syndrome associated with COVID-19 infection: An expert interdisciplinary approach to a case study

BACKGROUND AND PURPOSE

Several cases of Guillain-Barré Syndrome (GBS) associated with a COVID-19 infection have been recently reported. Rehabilitation might be a key player in the recovery of these highly complex patients however, results are yet unknown. This case report aimed to describe the effects of an inpatient rehabilitation program, with an interdisciplinary team approach, in a patient with GBS in the context of a COVID-19 infection.

CASE DESCRIPTION

A 58-year-old man with GBS after COVID-19 started an inpatient rehabilitation program focused on reducing dyspnea and fatigue symptoms; improving muscle strength, balance, aerobic and functional training; practicing activities of daily living and energy conservation techniques; swallowing training; emotional support and patient and family education about daily routines. An expert interdisciplinary team delivered the intervention, approximately 5 h/day, 5 days/week for 6 weeks.

OUTCOMES

Improvements were observed in dyspnea, fatigue, nocturnal ventilation, muscle strength, balance, walking capacity, functional status, and swallowing function.

CONCLUSION

This clinical case report illustrates the impact of a tailored and interdisciplinary rehabilitation program, on promoting recovery in multiple health domains of a patient with GBS associated with COVID-19 infection. Our experience might be useful to guide other inpatient rehabilitation programs to successfully manage these highly complex patients.

Comprehensive analysis of research related to rehabilitation and COVID-19, hotspots, mapping, thematic evolution, trending topics, and future directions

BACKGROUND

This study conducted a comprehensive analysis of research pertaining to the intersection of rehabilitation and COVID-19 (COV-REH). The main aim of this study is to analyze the thematic progression and hotspots, detect emerging topics, and suggest possible future research directions in the COV-REH.

METHODS

Appropriate keywords were selected based on the Medical Subject Headings (MeSH) PubMed database and the Scopus database were used to retrieve a total of 3746 original studies conducted in the English language. The data extraction was performed on June 30, 2023. VOSviewer and Bibliometrix utilize CVS and BibTex files to facilitate the performance analysis and generate visual maps. The performance indicators reported for the research components of the COV-REH were compiled using the Scopus Analytics tool.

RESULTS

From 2003 to 2023, 3470 authors from 160 organizations in 119 countries generated 3764 original research documents, with an annual growth of 53.73%. 1467 sources identified these scholarly works. Vitacca, M. (Italy), Harvard University (USA), and the USA published the most articles. This study included 54.1% of medical scholars. Telerehabilitation, exercise, quality of life, case reports, anxiety, and pulmonary rehabilitation were the primary themes of the COV-REH. One component of "telerehabilitation" is now the cardiac rehabilitation cluster. The trending topics in COV-REH are "symptoms," "protocol," and "community-based rehabilitation".

CONCLUSIONS

This study proposed several significant research directions based on the current thematic map and its evolution. Given that COV-REH investigations have been determined to be multidisciplinary, this study contributes conceptually to several fields and has wide-ranging implications for practitioners and policymakers.

Clinical Variables Related to Functional Capacity and Exertional Desaturation in Patients with COVID-19

Impaired functional capacity is one of the most commonly reported consequences among post-COVID-19 patients. This study aimed to analyse the clinical variables related to functional capacity and exertional desaturation in post-COVID-19 patients at the time of hospital discharge. A cross-sectional study was conducted on patients recovering from COVID-19 pneumonia. The main outcomes measures were functional capacity, assessed using the 1 min sit-to-stand test (1 min STST), and exertional desaturation, defined as a drop of ≥4% in the arterial oxygen saturation. Factors used to characterise the participant outcomes included the use of a high-flow nasal cannula (HFNC), prolonged hospitalisation, occurrence of pulmonary embolism during hospitalisation, and underlying comorbidities. A total of 381 participants (mean age = 53.7 ± 13.2 years, 65.6% men) were included. Participants completed a mean of 16.9 ± 6.2 repetitions in the 1 min STST. Exertional desaturation was observed in 51% of the patients. Higher odds of exertional desaturation were found in the participants who used a HFNC (OR = 3.6; 95%CI: 1.6 to 7.8), were admitted in the hospital >10 days (OR = 4.2; 95%CI: 2.6 to 6.8), and had a pulmonary embolism (OR = 3.5; 95%CI: 2.2. to 5.3). Use of a HFNC (β = -3.4; 95%CI: -5.3 to -1.44), a hospital stay >10 days (β = -2.2; 95%CI: -3.4 to -0.9), and a history of pulmonary embolism (β = -1.4; 95%CI: -2.6 to -0.2) were also negatively associated with the 1 min STST. Most post-COVID-19 patients exhibited reduced functional capacity at the time of hospital discharge, and approximately half had exertional desaturation after the 1 min STST. The use of a HFNC, prolonged hospitalisation and pulmonary embolism were the main clinical variables associated with worse a 1 min STST performance and a higher likelihood of exertional desaturation.

Effect of Pulmonary Rehabilitation on COPD Assessment Test Items in Individuals Classified as GOLD Group E

BACKGROUND

A new Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification has been proposed, based also on COPD Assessment Test (CAT).

OBJECTIVES

The aim of this large, multicenter, retrospective study was to determine the impact of pulmonary rehabilitation (PR) on CAT items in individuals with COPD, GOLD group E, recovering from an exacerbation (ECOPD). As secondary aims, we evaluated whether gender, associated chronic respiratory failure (CRF), and age might influence results.

METHODS

Data of 2,213 individuals with available paired pre- and post-PR CAT were analyzed. Other common outcome measures were also assessed.

RESULTS

After PR, total CAT improved from 20.8 ± 7.8 to 12.4 ± 6.9 (p = 0.000), and 1,911 individuals (86.4%) reached the minimal clinically important difference (MCID). All CAT items improved significantly without any significant difference among them. However, item "confidence with disease" improved significantly more in males than in females (p = 0.009). Total CAT and six out of eight items improved significantly more in individuals with CRF than in those without (all p < 0.001). Total CAT and three items improved significantly more in younger than in older individuals (p = 0.023). Only presence of CRF was significantly associated with the probability of improving total CAT more than the MCID.

CONCLUSION

In individuals with COPD, GOLD group E, recovering from ECOPD, PR improves all CAT items; however, gender, associated CRF and age may influence the effect size, suggesting the need to evaluate all items in addition to total CAT score.

Multidisciplinary inpatient rehabilitation for older adults with COVID-19: a systematic review and meta-analysis of clinical and process outcomes

BACKGROUND

Older adults are at increased risk for disease severity and poorer prognosis following COVID-19 infection. The aim of this systematic review and meta-analysis is to explore the impact of multidisciplinary rehabilitation in the acute or post-acute hospital setting for older adults with COVID-19.

METHODS

The Cochrane library, EMBASE, Cinahl and Medline (via EBSCO), PubMed, and Web of Science were systematically searched in June 2022 and a repeat search was completed in March 2023. Screening, data extraction and quality appraisal were conducted independently by two reviewers. Studies reporting outcomes for older adults following multidisciplinary rehabilitation (provided by two or more Health and Social Care Professionals) were included. Both observational and experimental study designs were included. The primary outcome was functional ability. Secondary outcomes included discharge disposition, acute hospital and rehabilitation unit length of stay, mortality, primary and secondary healthcare utilisation, and long-term effects of COVID-19.

RESULTS

Twelve studies met the inclusion criteria, comprising a total of 570 older adults. Where reported, older adults stayed in the acute hospital for a mean of 18 days (95%CI, 13.35- 23.13 days) and in rehabilitation units for 19 days (95%CI, 15.88-21.79 days). There was a significant improvement in functional ability among older adults with COVID-19 who received multidisciplinary rehabilitation (REM, SMD = 1.46, 95% CI 0.94 to 1.98). The proportion of older adults who were discharged directly home following rehabilitation ranged from 62 to 97%. Two studies reported a 2% inpatient mortality rate of older persons during rehabilitative care. No study followed up patients after the point of discharge and no study reported on long term effects of COVID-19.

CONCLUSIONS

Multidisciplinary rehabilitation may result in improved functional outcomes on discharge from rehabilitation units/centres for older adults with COVID-19. Findings also highlight the need for further research into the long-term effect of rehabilitation for older adults following COVID-19. Future research should comprehensively describe multidisciplinary rehabilitation in terms of disciplines involved and the intervention provided.

Year in Review: Long COVID and Pulmonary Rehabilitation

There have been an estimated 100 million people diagnosed with COVID-19 in the United States, with a majority of patients reporting persistent symptoms expressed as long COVID. The 2 most frequently reported long COVID symptoms are shortness of breath and fatigue. Exercise training during pulmonary rehabilitation (PR) is a successful strategy for improving the lives of people with persistent respiratory symptoms caused by a variety of lung diseases. This narrative review assessed the impact of exercise interventions on functional exercise capacity measures and related symptoms (dyspnea, fatigue) in people with long COVID over the last year. Articles were accessed through electronic databases including PubMed, Embase, CINAHL Plus with full text (EBSCO), and LitCovid. Findings for this Year in Review revealed that exercise interventions and PR show promise for improving functional exercise capacity, dyspnea, and fatigue in people with long COVID. This review supports the need for more rigorous scientific studies on the benefits of structured PR in people with long COVID who have respiratory-related symptoms.

Effectiveness of Respiratory Rehabilitation in COVID-19's Post-Acute Phase: A Systematic Review

BACKGROUND

The COVID-19 pandemic, caused by the new grave and acute respiratory syndrome Coronavirus-2 (SARS-CoV-2), generated an unprecedented danger to public health. This condition may impact survivors' quality of life and includes extensive pulmonary and respiratory outcomes. Respiratory rehabilitation is known for its effects in improving dyspnea, alleviating anxiety and depression, reducing complications, preventing and ameliorating dysfunctions, reducing morbidity, preserving functions and improving subjects' quality of life. For this reason, respiratory rehabilitation may be recommended for this category of patients.

OBJECTIVE

Our objective was to evaluate the effectiveness and benefits produced by the adoption of pulmonary rehabilitation (PR) programs in COVID-19's post-acute phase.

MATERIAL AND METHODS

A search of relevant publications was conducted using the following electronic databases: PubMed, Scopus, PEDro, and Cochrane Library. A single reviser selected pertinent articles that studied the effects of pulmonary rehabilitation during COVID-19's post-acute phase in improving the respiratory function, physical performance, autonomy and quality of life (QoL).

RESULTS

After an initial selection, 18 studies were included in this systematic review, of which 14 concern respiratory rehabilitation delivered in conventional form and 4 concern respiratory rehabilitation provided in telehealth.

CONCLUSIONS

Pulmonary rehabilitation combining different types of training-breathing, aerobic, fitness and strength-and not bypassing the neuropsychological aspects revealed itself to be capable of improving pulmonary and muscular functions, general health and quality of life in post-acute COVID-19 patients, besides increasing workout capacity and muscle strength, improving fatigue states and reducing anxiety and depression.

Numerical simulation of pneumatic throttle check valve using computational fluid dynamics (CFD)

The article presents a numerical CFD simulation of a throttle-check valve used in an innovative control system for two pneumatic drives. This type of control is used in an innovative rehabilitation device for lower limbs. In order to determine the boundary conditions, experimental tests were carried out. The throttle valves on the test stand were scaled and the air flow rate values were read for different valve opening heights. The purpose of this article is to present a CFD simulation of a pre-adjusted check valve throttle. Numerical simulation (CFD) makes it possible to study the flow phenomena inside a pneumatic throttle-check valve, with different sizes of flow gaps. The obtained results made it possible to determine the distribution of physical quantities of static pressure, the velocity of the medium flowing through the valve, or the vector velocity distribution. The throttle valve assembly has been scaled for a suitable degree of synchronization of the movement of the piston actuators independently of the different external loads acting on each of them. The authors investigated airflow phenomena for different valve opening heights. The simulation provided information on the occurrence of supersonic and subsonic flow velocities at specific valve opening heights.

Systematic review of post-COVID-19 syndrome rehabilitation guidelines

Introduction

Post-COVID-19 syndrome is associated with significant health and potential socioeconomic burden. Due to its novel nature, there is a lack of clarity over best practice for the rehabilitation of patients with ongoing or new symptoms following acute COVID-19 infection. We conducted a systematic review of clinical and service guidelines for post-COVID-19 syndrome rehabilitation.

Methods

This review was registered on PROSPERO and is reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We included guidelines formally published or endorsed by a recognised professional body, covering rehabilitation of people with symptoms following resolution of acute COVID-19 infection. We searched Medline, Embase, PsycINFO, CINAHL, Web of Science, NHS Evidence, MedRxiv, PsyArXiv and Google for terms related to COVID-19, rehabilitation and guideline. Two reviewers independently screened articles for inclusion, data extracted and quality assessed using the AGREE II and AGREE-REX tools for clinical guidelines and the AGREE-HS tool for service guidelines. We included guidelines of sufficient quality in a narrative synthesis.

Results

We identified 12 790 articles, of which 37 guidelines (19 clinical only, 7 service only and 11 combined clinical and service) were included. Guidelines covered a range of countries, rehabilitation types, populations and rehabilitation settings. Synthesis of clinical guidelines (n=4) was structured following the patient pathway, from identification, to assessment, treatment and discharge, with consideration of specific patient groups. Synthesis of service guidelines (n=8) was structured according to the Donabedian framework.

Discussion

Though the available post-COVID-19 syndrome rehabilitation guidelines were generally of poor quality, there was a high degree of consensus regarding the breadth of symptoms, the need for holistic assessment by a broad multidisciplinary team and person-centred care. There was less clarity on management options, measuring outcomes and discharge criteria.

PROSPERO registration number

CRD42021236049.

Clusters of individuals recovering from an exacerbation of chronic obstructive pulmonary disease and response to in-hospital pulmonary rehabilitation

INTRODUCTION AND OBJECTIVES

Due to the present low availability of pulmonary rehabilitation (PR) for individuals recovering from a COPD exacerbation (ECOPD), we need admission priority criteria. We tested the hypothesis that these individuals might be clustered according to baseline characteristics to identify subpopulations with different responses to PR.

METHODS

Multicentric retrospective analysis of individuals undergone in-hospital PR. Baseline characteristics and outcome measures (six-minute walking test - 6MWT, Medical Research Council scale for dyspnoea -MRC, COPD assessment test -CAT) were used for clustering analysis.

RESULTS

Data analysis of 1159 individuals showed that after program, the proportion of individuals reaching the minimal clinically important difference (MCID) was 85.0%, 86.3%, and 65.6% for CAT, MRC, and 6MWT respectively. Three clusters were found (C1-severe: 10.9%; C2-intermediate: 74.4%; C3-mild: 14.7% of cases respectively). Cluster C1-severe showed the worst conditions with the largest post PR improvements in outcome measures; C3-mild showed the least severe baseline conditions, but the smallest improvements. The proportion of participants reaching the MCID in ALL three outcome measures was significantly different among clusters, with C1-severe having the highest proportion of full success (69.0%) as compared to C2-intermediate (48.3%) and C3-mild (37.4%). Participants in C2-intermediate and C1-severe had 1.7- and 4.6-fold increases in the probability to reach the MCID in all three outcomes as compared to those in C3-mild (OR = 1.72, 95% confidence interval [95% CI] = 1.2 - 2.49, p = 0.0035 and OR = 4.57, 95% CI = 2.68 - 7.91, p < 0.0001 respectively).

CONCLUSIONS

Clustering analysis can identify subpopulations of individuals recovering from ECOPD associated with different responses to PR. Our results may help in defining priority criteria based on the probability of success of PR.

Effects of physical rehabilitation interventions in COVID-19 patients following discharge from hospital: A systematic review

BACKGROUND

Hospitalized patients recovering from coronavirus disease 2019 (COVID-19) may experience disability and suffer from significant physical and mental impairment requiring physical rehabilitation following their discharge. However, to date, no attempt has been made to collate and synthesize literature in this area.

OBJECTIVE

This systematic review examines the outcomes of different physical rehabilitation interventions tested in COVID-19 patients who were discharged from hospital.

SEARCH STRATEGY

A systematic search of MEDLINE/PubMed, CINAHL, Scopus and medRxiv was conducted to identify articles published up to March 2022.

INCLUSION CRITERIA

This systematic review included studies of outpatient rehabilitation programs for people recovering from COVID-19 who received physical activity, exercise, or breathing training to enhance or restore functional capacity, pulmonary function, quality of life, and mental health or function.

DATA EXTRACTION AND ANALYSIS

Selection of included articles, data extraction, and methodological quality assessments were conducted by two review authors respectively, and consensus was reached through discussion and consultation with a third reviewer. Finally, we review the outcomes of studies based on four categories including: (1) functional capacity, (2) pulmonary function, (3) quality of life, and (4) mental health status.

RESULTS

A total of 7534 titles and abstracts were screened; 10 cohort studies, 4 randomized controlled trials and 13 other prospective studies involving 1583 patients were included in our review. Early physical rehabilitation interventions applied in COVID-19 patients who were discharged from the hospital improved multiple parameters related to functional capacity, pulmonary function, quality of life and mental health status.

CONCLUSION

Physical rehabilitation interventions may be safe, feasible and effective in COVID-19 patients discharged from the hospital, and can improve a variety of clinically relevant outcomes. Further studies are warranted to determine the underlying mechanisms. Please cite this article as: Rahmati M, Shamsi MM, Woo W, Koyanagi A, Lee SW, Yon DK, Shin JI, Smith L. Effects of physical rehabilitation interventions in COVID-19 patients following discharge from hospital: A systematic review. J Integr Med. 2023; Epub ahead of print.

Singing Interventions in Pulmonary Rehabilitation: A Scoping Review

(1) Background: Individuals with pulmonary disease need intensive and consistent rehabilitation due to their high risk for serious illness and long-term complications. The purpose of this scoping review was to provide a comprehensive analysis of relevant research regarding the use of singing in pulmonary rehabilitation. (2) Methods: A systematic literature search was performed using the PsycINFO, CINAHL, PubMed, and Web of Science databases. A search for studies that employed singing in pulmonary rehabilitation for patients with pulmonary disease was conducted. (3) Results: Studies that met the selection criteria were summarized and analyzed. Twenty-seven studies were included in the final analysis. Results showed that research using singing in pulmonary rehabilitation generally employed an intervention with structured tasks and additional home practice or socialization time. However, the singing procedure in each intervention was not always specifically described and the findings were inconsistent. (4) Conclusions: Programmed singing interventions can support lung health and be an effective component of pulmonary rehabilitation. The therapeutic singing method in relation to respiratory exercises should be integrated into the main activity in the intervention. Overall, singing has physical and psychosocial effects, leading to improvements in symptoms, but more research is necessary to ensure that the respiratory needs of people with pulmonary disease are adequately met.

Safety and efficacy of pulmonary physiotherapy in hospitalized patients with severe COVID-19 pneumonia (PPTCOVID study): A prospective, randomised, single-blind, controlled trial

BACKGROUND

Pulmonary physiotherapy (PPT) is an important treatment in the management of patients with different types of pulmonary disorders. We aimed to evaluate safety and efficacy of PPT in hospitalized patients with severe COVID-19 pneumonia.

METHODS

In this randomised, single-blind, controlled trial, we enrolled hospitalized, non-intubated patients (18 to 75 years with oxygen saturation (Spo2) in free-air breathing ≤90%) with COVID-19 pneumonia at a referral hospital. Participants were randomly assigned (1:1) to receive PPT (six sessions PPT with breathing exercises and airway clearance techniques) or basic care. The primary outcomes were venous blood O2 (pO2) and CO2 (pCO2) pressures, Spo2, and three-minute walking test (3MWT) that were assessed before and end of sixth session. Secondary outcomes included level of dyspnea, venous blood PH, one-month mortality, three-month mortality and short form-36 (SF-36) after one and three months. The assessor was blinded to the assignment. This trial is registered with ClinicalTrials.gov (NCT04357340).

FINDINGS

In April-May 2020, 40 participants were randomly assigned to PPT or basic care groups. While at the end of intervention, pO2 (adjusted mean difference to baseline measure (AMD) 6.43 mmHg [95%CI 2.8, 10.07], P<0.01), Spo2 (AMD 4.43% [95%CI 2.04, 6.83], P = 0.0011), and 3MTW (AMD 91.44 m [95%CI 68.88, 113.99], P<0.01) were higher in PPT group and basic care group, pCO2 was not improved (AMD -2.1 mmHg [95%CI-6.36, 2.21], P = 0.33). Based on the logistic model adjusted to baseline Spo2, the risks of mortality were reduced 81% ([95%CI: 97% reduction to 30% increase], P = .09) and 84% ([95%CI 74% reduction to 5% increase], P = .06) at one-month and three-month, respectively. There were no significant differences in most SF-36 domains scores after one and three months. No serious adverse event was observed during PPT sessions.

CONCLUSION

Early PPT can be considered a safe and relatively effective therapeutic choice for patients with severe COVID-19.

Cognitive Deficits among Individuals Admitted to a Post-Acute Pneumological Rehabilitation Unit in Southern Italy after COVID-19 Infection

(1) Background: We investigated the differences in the neuropsychological profile as well as the pneumological and motor functions in two groups of patients admitted to rehabilitation who received different respiratory support during their COVID-19 infection. (2) Methods: Group-1 (n = 18; 15 male, median age 67.5) consisted of patients who received non-invasive mechanical ventilation; Group-2 (n = 19; 16 male, median age 63) consisted of patients who received invasive mechanical ventilation. All patients underwent a neuropsychological assessment including Mini-Mental State Examination (MMSE), Frontal Assessment Battery (FAB), and the Repeatable Battery for the Assessment of Neuropsychological Status (R-BANS) to evaluate the patients' cognition. Depression and anxiety were also measured at admission and discharge to rehabilitation. (3) Results: At admission, patients impaired at MMSE were 44% in Group-1 and 5% in Group-2, while patients impaired at FAB were 88% in Group-1 and 26% in Group-2. Wilcoxon's effect size revealed meaningful differences between groups for FAB, R-BANS global score, immediate and delayed memory, and attention-coding task, with Group-2 performing better than Group-1 across all measures. At discharge, 52% of the 25 patients re-assessed still had mild to moderate cognitive deficits, while 19% had depression and 35% had anxiety. (4) Conclusions: Patients who received oxygen therapy experienced higher levels of acute and chronic stress compared to those who benefitted from invasive mechanical ventilation. Despite patients showing a meaningful improvement at discharge, cognitive impairment persisted in a great number of patients; therefore, long-term neuropsychological follow-up and treatment for COVID-19 patients are recommended.

Assessment of Functional Status and Rehabilitation Intervention in Patients with Coronavirus Disease (COVID-19)

Aim: To assess the functional status of patients and to investigate the effectiveness of rehabilitation intervention in coronavirus disease (COVID-19). Materials and Methods: There were 21 patients with clinically-laboratory confirmed coronavirus disease (COVID-19), who participated in the study. Among the examined patients there were 16 (76.2%) women and 5 (23.8%) men. The average age of the patients was 58}5.08 years. The rehabilitation cycle included an initial and final assessment of the patients’ functional status, after which a rehabilitation intervention was carried out, which consisted of breathing exercises and motor activity. Results: The initial assessment of the patients’ functional status in physical exertion during the 1st day showed that the heart rate (HR) was 127.09}0.55 bpm, the respiratory rate (RR) was 28.05}0.39/min, SpO2 was 85.95}0.38 %, systolic arterial pressure (APs) – 145.09}1.48 mmHg, diastolic arterial pressure (APd) – 84.33}0.86 mmHg. Up to the 5th day of the rehabilitation cycle, heart rate decreased at 25.9%, RR – at 16.8%, SpO2 increased at 6.8%, АPs decreased by 14.3%, АPd decreased at – 9.3% (p<0.001). The SpO2 saturation index after respiratory gymnastics increased significantly starting from the first up to the 5th day of rehabilitation from 92.29}0.44% to 97.62}0.29% (р<0.001). Subjective indices under the influence of rehabilitation intervention had reliable dynamics with a tendency to the decrease of manifestations of shortness of breath according to the Modified Borg scale (MBS) at 63.6% (р<0.001), leveling of general fatigue according to the Borg CR10 scale – at 63.4% (р<0.001), an increase in the patient’s mobility index – at 66.4% (р<0.001), an increase in tolerance to the physical exertion for 6-minute walking distance 6MWD – at 93.4% (р<0.001). Conclusions: Thus, rehabilitation assessment and intervention is an extremely important stage in the treatment of patients with the coronavirus disease (COVID-19), which provides an opportunity to improve the functional status of patients by physically influencing the pathogenetic mechanisms of the disease.

Impact of Physical Activity on COVID-19

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic, which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is seriously endangering human health worldwide. This study finds effective intervention modalities of physical activity on COVID-19 through a narrative review.

METHODS

In this study, 41 papers were selected for a narrative literature review after a comprehensive database search from 20 December 2019, to 30 August 2022.

RESULTS

41 articles meet the established criteria, and in this review, we comprehensively describe recent studies on exercise and COVID-19, including the impact and recommendations of exercise on COVID-19 prevention, patients with COVID-19, and noninfected populations.

CONCLUSIONS

The literature suggests that physical activity (PA) contributes to the prevention and treatment of COVID-19, can promote recovery of physical function, alleviate post-acute COVID-19 syndrome, and improve patients' psychological well-being. It is recommended to develop appropriate exercise prescriptions for different populations under the guidance of a physician.

Physiotherapy practice for hospitalized patients with COVID-19

OBJECTIVE

To identify the indications for physiotherapy and to evaluate physiotherapy practices in patients with COVID-19 admitted to the ICU (on mechanical ventilation) or to the ward (spontaneously breathing).

METHODS

An online, 50-item survey was completed by physiotherapists who had been treating hospitalized patients with COVID-19 in Brazil.

RESULTS

Of the 644 physiotherapists who initiated the survey, 488 (76%) completed it. The main reasons for indications for physiotherapy in both settings reported as "very frequently" and "frequently" both in the ICU and the ward by most respondents were oxygenation improvement (> 95%) and prevention of general complications (> 83%). Physical deconditioning was considered an infrequent indication. When compared with mobilization strategies, the use of respiratory interventions showed great variability in both work settings, and techniques considered effective were underutilized. The most frequently used respiratory techniques in the ICU were positioning (86%), alveolar recruitment (73%), and hard/brief expiratory rib cage compression (46%), whereas those in the ward were active prone positioning (90%), breathing exercises (88%), and directed/assisted cough (75%). The mobilization interventions reported by more than 75% of the respondents were sitting on the edge of the bed, active and resistive range of motion exercises, standing, ambulation, and stepping in place.

CONCLUSIONS

The least common reason for indications for physiotherapy was avoidance of deconditioning, whereas oxygenation improvement was the most frequent one. Great variability in respiratory interventions was observed when compared with mobilization therapies, and there is a clear need to standardize respiratory physiotherapy treatment for hospitalized patients with COVID-19.

Effects of early rehabilitation on motor function, dyspnoea intensity, respiratory muscle performance and handgrip strength in patients with COVID-19: an observational study

Background/Aims

Although an increasing volume of research is emerging, rehabilitative treatment of patients with COVID-19 still continues to be a matter of great importance that must be explored further. The purpose of the present study was to describe the effects of inpatient rehabilitation in acute patients treated in a sub-intensive hospital setting during the COVID-19 pandemic.

Methods

A retrospective analysis was conducted based on the prospectively collected data of 192 patients with COVID-19 undergoing a physiotherapeutic regimen during their hospitalisation. Patients were admitted because of COVID-19-related pneumonia from the periods of 25 March–12 June 2020 and 2 November 2020–9 June 2021. This study investigated dyspnoea intensity using the modified Borg scale, motor function through the 1-minute sit-to-stand test, and daily walked distance. In a subset of 57 patients, handgrip strength and respiratory muscle function was also evaluated. Measurements were taken at baseline and discharge.

Results

Patients were classified according to the severity of their ratio of arterial oxygen partial pressure to fractional inspired oxygen (mean 225 ± 82 mmHg). At discharge to home or to another hospital facility, patients performed a mean of 12 repetitions (1-minute sit-to-stand test); dyspnoea intensity was 1.4 (modified Borg scale), and they were able to walk a mean distance of 266.7 metres. The mean handgrip strength of the dominant hand was 29.3 kg, the maximal inspiratory pressure was 43.5 cmH2O, and the maximal expiratory pressure was 59.1 cmH2O. Overall, significant differences before and after treatment were detected for all clinical variables. Dyspnoea improved by 0.7 points; walked distance by 200 metres; the number of repetitions at the 1-minute sit-to-stand test by 5.6; the handgrip strength by 1.2 kg (right hand) and 1.7 kg (left hand); maximal inspiratory pressure by 7.7 cmH2O; and maximal expiratory pressure by 9.5 cmH2O.

Conclusions

Patients obtained significant improvements in functional capacity, dyspnoea perception, handgrip strength and respiratory muscle function. In addition, the treatment was feasible and well tolerated by patients, and no adverse related events were observed in a sub-intensive care setting.

The effect of exercise rehabilitation on COVID-19 outcomes: a systematic review of observational and intervention studies

Purpose

Methods

Results

Conclusion

In-Patient Trajectories and Effects of Training in Survivors of COVID-19-Associated Acute Respiratory Failure

BACKGROUND

Pulmonary rehabilitation (PR) is useful in survivors of COVID-19-associated acute respiratory failure (ARF). The aim of this retrospective study on in-patient PR was to report rehabilitative trajectories and effects of cycle training.

METHODS

According to the Short Physical Performance Battery (SPPB) score at admission (T0), participants were allocated to stage 1 (SPPB < 6), stage 2 (SPPB ≥ 6 and < 10), or stage 3 (SPPB ≥ 10) and performed increasing level of activities from passive exercises to free walking, balance exercises, strength exercises, and tailored cycle-ergometer endurance training. The primary outcome was SPPB. 6-min walk distance (6MWD), Medical Research Council score, Barthel dyspnea index, and rate of subjects able to cycling were also assessed.

RESULTS

Data of 123 participants were analyzed. At T0, 44 (35.8%), 50 (40.6%), and 29 (23.6%) participants were allocated to stages 1-3, respectively. At discharge, participants showed significant improvements in SPPB, independent of the initial stage, 81 (65.8%) improving more than its minimal clinically important difference. At T1, the proportion of participants in stages 1 and 2 decreased, whereas significantly increased in stage 3 (P = .003), (being 9.8%, 33.3%, and 56.9% for stages 1-3, respectively; P <.001). Sixty-nine of 123 participants (56.1%) underwent cycle exercise training. In participants able to perform it, 6MWD improved by 115 (65-240) m and 60 (40-118) m in participants with and without exercise-induced desaturation, respectively, with significant difference between groups (P = .044).

CONCLUSIONS

In-patient PR could be tailored and progressively increased to survivors of COVID-19-associated ARF; cycle training was feasible in half of the participants. Benefits were independent of initial stage of physical performance and allowed participants to move from lower to higher levels of activities.

Adapted physical activity in subjects and athletes recovering from covid-19: a position statement of the Società Italiana Scienze Motorie e Sportive

Coronavirus disease 2019 (COVID-19) is a worldwide pandemic illness that is impacting the cardiovascular, pulmonary, musculoskeletal, and cognitive function of a large spectrum of the worldwide population. The available pharmacological countermeasures of these long-term effects of COVID-19 are minimal, while myriads of non-specific non-pharmacological treatments are emerging in the literature. In this complicated scenario, particular emphasis should be dedicated to specific exercise interventions tailored for subjects and athletes recovering from COVID-19. Specific guidelines on adapted physical activity in this critical population are unavailable so far, therefore, in this position statement of the Società Italiana di Scienze Motorie e Sportive (SISMeS) the members of the steering committee of the research group Attività Motoria Adattata, Alimentazione, Salute e Fitness have indicated the adapted physical activity approaches to counteract the long-term effects of the COVID-19, both in good health people and athletes.

Efficacy and safety of HD-tDCS and respiratory rehabilitation for critically ill patients with COVID-19 The HD-RECOVERY randomized clinical trial

Background and purpose

Acute Respiratory Distress Syndrome (ADRS) due to coronavirus disease 2019 (COVID-19) has been associated with muscle fatigue, corticospinal pathways dysfunction, and mortality. High-Definition transcranial Direct Current Stimulation (HD-tDCS) may be used to attenuate clinical impairment in these patients. The HD-RECOVERY randomized clinical trial was conducted to evaluate the efficacy and safety of HD-tDCS with respiratory rehabilitation in patients with moderate to severe ARDS due to COVID-19.

Methods

Fifty-six critically ill patients were randomized 1:1 to active (n = 28) or sham (n = 28) HD-tDCS (twice a day, 30-min, 3-mA) plus respiratory rehabilitation for up to 10 days or until intensive care unit discharge. The primary outcome was ventilator-free days during the first 28 days, defined as the number of days free from mechanical ventilation. Furthermore, secondary outcomes such as delirium, organ failure, hospital length of stay and adverse effects were investigated.

Results

Active HD-tDCS induced more ventilator-free days compared to sham HD-tDCS. Patients in the active group vs in the sham group experienced lower organ dysfunction, delirium, and length of stay rates over time. In addition, positive clinical response was higher in the active vs sham group. There was no significant difference in the prespecified secondary outcomes at 5 days. Adverse events were similar between groups.

Conclusions

Among patients with COVID-19 and moderate to severe ARDS, use of active HD-tDCS compared with sham HD-tDCS plus respiratory rehabilitation resulted in a statistically significant increase in the number of ventilator-free days over 28 days. HD-tDCS combined with concurrent rehabilitation therapy is a safe, feasible, potentially add-on intervention, and further trials should examine HD-tDCS efficacy in a larger sample of patients with COVID-19 and severe hypoxemia.

Rehabilitation at the Time of Pandemic: Patient Journey Recommendations

Purpose

The World Health Organization (WHO) declared severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) a pandemic in March 2020, causing almost 3.5 million coronavirus disease (COVID-19) related deaths worldwide. The COVID-19 pandemic has imposed a significant burden on healthcare systems, economies, and social systems in many countries around the world. The access and delivery of rehabilitation care were severely disrupted, and patients have faced several challenges during the COVID-19 outbreak. These challenges include addressing new functional impairments faced by survivors of COVID-19 and infection prevention to avoid the virus spread to healthcare workers and other patients not infected with COVID-19. In this scoping review, we aim to develop rehabilitation recommendations during the COVID-19 pandemic across the continuum of rehabilitation care.

Materials and Methods

Established frameworks were used to guide the scoping review methodology. Medline, Embase, Pubmed, CINAHL databases from inception to August 1, 2020, and prominent rehabilitation organizations' websites were searched.

Study Selection

We included articles and reports if they were focused on rehabilitation recommendations for COVID-19 survivors or the general population at the time of the COVID-19 pandemic.

Data Extraction

Two of our team members used the pre-tested data extraction form to extract data from included full-text articles. The strength and the quality of the extracted recommendations were evaluated by two reviewers using the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach.

Results

We retrieved 6,468 citations, of which 2,086 were eligible after removing duplicates. We excluded 1,980 citations based on the title and the abstract. Of the screened full-text articles, we included 106 studies. We present recommendations based on the patient journey at the time of the pandemic. We assessed the evidence to be of overall fair quality and strong for the recommendations.

Conclusion

We have combined the latest research results and accumulated expert opinions on rehabilitation to develop acute and post-acute rehabilitation recommendations in response to the global COVID-19 pandemic. Further updates are warranted in order to incorporate the emerging evidence into rehabilitation guidelines.

Time to active sitting position: One-year findings from a temporary COVID-19 intensive care unit

Objective

To investigate the association between time to active sitting position and clinical features in people with COVID-19 admitted to intensive care unit (ICU) and referred to physiotherapists.

Method

Prospective study conducted in the largest temporary ICU in Lombardy (Italy) between April 2020 and June 2021. All individuals with COVID-19 who received physiotherapy were included. Multivariable Cox proportional hazard model was fitted to explore the statistical association between active sitting position and characteristics of patients referred to physiotherapists, also accounting for the different multidisciplinary teams responsible for patients.

Results

284 individuals over 478 (59.4%) had access to physiotherapy, which was performed for a median of 8 days, without difference between multidisciplinary teams (P = 0.446). The active sitting position was reached after a median of 18 (IQR: 10.0–32.0) days. Sex was the only characteristic associated with the time to active sitting position, with males showing a reduced hazard by a factor of 0.65 (95% CI: 0.48–0.87; P = 0.0042) compared to females. At ICU discharge, nearly 50% individuals increased Manchester Mobility Score by 3 points. During physiotherapy no major adverse event was recorded.

Conclusion

Individuals with COVID-19 take long time to reach active sitting position in ICU, with males requiring longer rehabilitation than females.

The future of post-COVID-19 rehabilitation

Tras un año y medio de la pandemia, en el que los esfuerzos se han basado fundamentalmente en evitar el colapso de los hospitales y el desarrollo de vacunas innovadoras en tiempo récord, ha aparecido una consecuencia preocupante:  las secuelas clínicas entre los supervivientes de esta enfermedad. A partir del abrumador número de personas infectadas (más de 430 millones de personas hasta febrero de 2022), era posible predecir que un porcentaje significativo de ellas iba a desarrollar secuelas, lo que les dificultaría reintegrarse al trabajo, con sus familias y a la sociedad.  Por supuesto, no todas las personas infectadas presentaron secuelas; sin embargo, las probabilidades son significativamente mayores para los afectados por las formas más graves de la enfermedad, como los que sufrieron el síndrome de dificultad respiratoria aguda (SDRA), y particularmente aquellos con comorbilidades, así como los adultos mayores. En los últimos meses, este tema ha sido tan importante que ha aparecido un nuevo concepto relacionado con la persistencia de los síntomas durante más de tres meses: COVID persistente, o "COVID largo". Esta nueva condición nos permite pensar en el COVID persistente como una enfermedad crónica; por lo tanto, la rehabilitación adquiere un papel aún más preponderante por la duración de las secuelas y por los diferentes sistemas involucrados.

Outpatient Pulmonary Rehabilitation in Patients with Long COVID Improves Exercise Capacity, Functional Status, Dyspnea, Fatigue, and Quality of Life

BACKGROUND

COVID-19 survivors face the risk of long-term sequelae including fatigue, breathlessness, and functional limitations. Pulmonary rehabilitation has been recommended, although formal studies quantifying the effect of rehabilitation in COVID-19 patients are lacking.

METHODS

We conducted a prospective observational cohort study including consecutive patients admitted to an outpatient pulmonary rehabilitation center due to persistent symptoms after COVID-19. The primary endpoint was change in 6-min walk distance (6MWD) after undergoing a 6-week interdisciplinary individualized pulmonary rehabilitation program. Secondary endpoints included change in the post-COVID-19 functional status (PCFS) scale, Borg dyspnea scale, Fatigue Assessment Scale, and quality of life. Further, changes in pulmonary function tests were explored.

RESULTS

Of 64 patients undergoing rehabilitation, 58 patients (mean age 47 years, 43% women, 38% severe/critical COVID-19) were included in the per-protocol-analysis. At baseline (i.e., in mean 4.4 months after infection onset), mean 6MWD was 584.1 m (±95.0), and functional impairment was graded in median at 2 (IQR, 2-3) on the PCFS. On average, patients improved their 6MWD by 62.9 m (±48.2, p < 0.001) and reported an improvement of 1 grade on the PCFS scale. Accordingly, we observed significant improvements across secondary endpoints including presence of dyspnea (p < 0.001), fatigue (p < 0.001), and quality of life (p < 0.001). Also, pulmonary function parameters (forced expiratory volume in 1 s, lung diffusion capacity, inspiratory muscle pressure) significantly increased during rehabilitation.

CONCLUSION

In patients with long COVID, exercise capacity, functional status, dyspnea, fatigue, and quality of life improved after 6 weeks of personalized interdisciplinary pulmonary rehabilitation. Future studies are needed to establish the optimal protocol, duration, and long-term benefits as well as cost-effectiveness of rehabilitation.

COVID-19 Post-Acute Sequela Rehabilitation: A look to the future through the lens of COPD and Pulmonary Rehabilitation

Post–COVID-19 condition is characterized by a myriad of persistent symptoms experienced up to 60 days after the acute infection, not only in those hospitalized, but also in patients with mild to moderate acute symptoms. The overwhelming evidence on multisystem involvement in post–COVID-19 condition brings to attention the need for integrated delivery models to address health care needs of this population. The World Health Organization recently highlighted critical gaps in adequately providing the level of integrative care required to address the multisystem needs of this population in current health care delivery models and recommended development of new innovative models of delivery. This article presents a novel approach to addressing these gaps from a rehabilitation perspective.

Safety and feasibility of physiotherapy in ICU-admitted severe COVID-19 patients: an observational study

Early physiotherapy could play an important role in the management of severe COVID-19 subjects with consequences of prolonged ICU stay, although its effectiveness is still unclear. Aim of this study is to describe physiotherapy performed in severe COVID-19 patients and to evaluate its safety and feasibility. Consecutive adults with confirmed SARS-CoV-2 infection, admitted to the ICU, needing invasive mechanical ventilation for >24 hours and receiving early physiotherapy, have been enrolled. Adverse events occurred during physiotherapy sessions and timing and type of physiotherapy delivered were analysed, to identify the interventions most frequently performed and to determine the time taken to first mobilize, stand and walk. Functional and clinical assessment of patients was also performed at hospital discharge. Eighty-four severe COVID-19 subjects were enrolled. Few minor adverse events were recorded. Active mobilization was promoted over passive mobilization and independence in daily life activities was supported. Time interval from patients' intubation to the first physiotherapy treatment was 13 days and to walking was 27 days. Forty-eight (57.1%) subjects returned at home, whereas 29 (34.5%) were discharged to in-patient rehabilitation. Patients with tracheostomy experienced a delay in time from ICU admission until sit out of bed and ambulation, if compared with subjects without tracheostomy, although no differences were found in 6MWT and 1m-STST performances. This study reporting early physiotherapy during pandemic suggests that this intervention is feasible and safe for severe COVID-19 subjects, as well as healthcare workers, although delayed compared to other critically ill patients.

Cardiac Rehabilitation in Patients with Peripheral Artery Disease-A Literature Review in COVID-19 Era

Cardiac rehabilitation (CR) is an integral part of the management of various cardiovascular disease such as coronary artery disease (CAD), peripheral artery disease (PAD), or chronic heart failure (CHF), with proven morbidity and mortality benefits. This article aims to review and summarize the scientific literature related to cardiac rehabilitation programs for patients with PAD and how they were adapted during the COVID-19 pandemic. The implementation of CR programs has been problematic since the COVID-19 pandemic due to social distancing and work-related restrictions. One of the main challenges for physicians and health systems alike has been the management of PAD patients. COVID-19 predisposes to coagulation disorders that can lead to severe thrombotic events. Home-based walking exercises are more accessible and easier to accept than supervised exercise programs. Cycling or other forms of exercise are more entertaining or challenging alternatives to exercise therapy. Besides treadmill exercises, upper- and lower-extremity ergometry also has great functional benefits, especially regarding walking endurance. Supervised exercise therapy has a positive impact on both functional capacity and also on the quality of life of such patients. The most effective manner to acquire this seems to be by combining revascularization therapy and supervised exercise. Rehabilitation programs proved to be a mandatory part of the integrative approach in these cases, increasing quality of life, and decreasing stress levels, depression, and anxiety.

ERS International Congress 2021: Highlights from the Allied Respiratory Professionals assembly

This paper provides an overview of some of the most memorable sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the 2021 European Respiratory Society International Congress, which was held online for the second consecutive year due to the COVID-19 pandemic. Early Career Members from Assembly 9 summarised the content of the sessions (three oral communication sessions, two symposia and one Expert View) with the support of the chairs from the four Assembly groups: Respiratory Function Technologists and Scientists (Group 9.01); Physiotherapists (Group 9.02); Nurses (Group 9.03); and Psychologists and Behavioural Scientists (Group 9.04). The sessions covered the following topics: impact of COVID-19 on lung function and healthcare services, and the importance of quality assurance and technology in lung function assessment; diagnosis and management of sarcopenia in patients with chronic respiratory disease; maintenance of the effects of pulmonary rehabilitation; solutions outside the hospital for the management of patients with COVID-19 in need of health care; the nursing perspective during the COVID-19 pandemic; and psychological and behavioural issues in respiratory care. This highlights article provides valuable insight into the latest scientific data and emerging areas affecting clinical practice of allied respiratory professionals.

This article provides an overview of outstanding sessions that were (co)organised by @ERS_Assembly9 during #ERSCongress 2021https://bit.ly/332uZWy

The Effects of Early Rehabilitation in the Intensive Care Unit for Patients with Severe COVID-19 Pneumonia: A Retrospective Cohort Study

This retrospective cohort study aimed to examine the rehabilitation effect of patients with coronavirus disease 2019 (COVID-19) in the intensive care unit (ICU) under mechanical ventilation and included ICU patients from a university hospital who received rehabilitation under ventilator control until 31 May 2021. Seven patients were included, and three of them died; thus, the results of the four survivors were examined. The rehabilitation program comprised the extremity range-of-motion training and sitting on the bed’s edge. The Sequential Organ Failure Assessment score (median (25–75th percentiles)) at admission was 7.5 (5.75–8.5), and the activities of daily living (ADLs) were bedridden, the lowest in the Functional Independence Measure (FIM) and Barthel Index (BI) surveys. Data on the mean time to extubation, ICU length of stay, and ADLs improvement (FIM and BI) during ICU admission were obtained. Inferential analyses were not performed considering the small sample size. The mean time to extubation was 4.9 ± 1.1 days, and the ICU length of stay was 11.8 ± 5.0 days. ΔFIM was 36.5 (28.0–40.5), and the ΔBI was 22.5 (3.75–40.0). Moreover, no serious adverse events occurred in the patients during rehabilitation. Early mobilization of patients with COVID-19 may be useful in ADLs improvement during ICU stay.

Delivery of Acute Rehabilitation to a Postcoronary Artery Bypass Graft COVID-19 Patient in a Pandemic Environment

During the first wave of the coronavirus disease (COVID-19) pandemic, a 57-year-old COVID-19 male patient was diagnosed with non-ST-elevation myocardial infarction and required urgent coronary artery bypass graft. In-patient cardiac rehabilitation following cardiac surgery was inevitable to limit or prevent various postoperative complications. A routine rehabilitation program was not feasible because of the strict COVID-19 isolation procedures, the high risk of cross infections, and the lack of various resources. Moreover, the detrimental effects of COVID-19 infection on multiple body systems reduced his exercise tolerance, limiting his engagement in physical activity. This case report highlights the various challenges encountered during the rehabilitation of these patients and strategies adopted to overcome them, illustrating the feasibility of a modified rehabilitation program to ensure early functional recovery.

Estimating the effects of lockdown timing on COVID-19 cases and deaths in England: A counterfactual modelling study

BACKGROUND

During the first wave of the COVID-19 pandemic, the United Kingdom experienced one of the highest per-capita death tolls worldwide. It is debated whether this may partly be explained by the relatively late initiation of voluntary social distancing and mandatory lockdown measures. In this study, we used simulations to estimate the number of cases and deaths that would have occurred in England by 1 June 2020 if these interventions had been implemented one or two weeks earlier, and the impact on the required duration of lockdown.

METHODS

Using official reported data on the number of Pillar 1 lab-confirmed cases of COVID-19 and associated deaths occurring in England from 3 March to 1 June, we modelled: the natural (i.e. observed) growth of cases, and the counterfactual (i.e. hypothetical) growth of cases that would have occurred had measures been implemented one or two weeks earlier. Under each counterfactual condition, we estimated the expected number of deaths and the time required to reach the incidence observed under natural growth on 1 June.

RESULTS

Introducing measures one week earlier would have reduced by 74% the number of confirmed COVID-19 cases in England by 1 June, resulting in approximately 21,000 fewer hospital deaths and 34,000 fewer total deaths; the required time spent in full lockdown could also have been halved, from 69 to 35 days. Acting two weeks earlier would have reduced cases by 93%, resulting in between 26,000 and 43,000 fewer deaths.

CONCLUSIONS

Our modelling supports the claim that the relatively late introduction of social distancing and lockdown measures likely increased the scale, severity, and duration of the first wave of COVID-19 in England. Our results highlight the importance of acting swiftly to minimise the spread of an infectious disease when case numbers are increasing exponentially.

Respiratory rehabilitation for patients with COVID-19 infection and chronic respiratory failure: a real-life retrospective study by a Lombard network

The Lombardy region has been one of the areas most affected by the COVID-19 pandemic since the first months of 2020, providing real-life experiences in the acute phase. It is unclear how the respiratory rehabilitation network responded to this emergency. The aims of this retrospective study were: i) to analyze clinical, functional, and disability data at admission; ii) describe assessment tools and rehabilitative programs; iii) evaluate improvement after rehabilitation. The study was conducted on data collected from ten pulmonary rehabilitation centers in Lombardy, between the period of March 1st 2020 to March 1st 2021, in patients with respiratory failure recovering from COVID-19 both at admission and discharge. The study included demographics, comorbidities, nutritional status, risk of falls, disability status (Barthel index; Short Physical Performance Battery (SPPB); 6 minutes walking test (6MWT), symptoms (dyspnoea with Barthel Dyspnoea and MRC Dyspnoea Scale), length of stay, discharge destination, need for mechanical ventilation, respiratory function, assessment/outcomes indices, and prescribed rehabilitative programs. 413 patients were analyzed. Length of stay in acute and rehabilitative units was less than 30 days. Fifty % of patients used non-invasive ventilation during their stay. Functional status was mildly compromised for forced volumes and oxygenation, while severely compromised for diffusion capacity. Independency was low while physical performance status very low.  At discharge, 318 (77%) patients were sent home, 83 (20.1%) were transferred to an acute unit and 12 (2.9%) passed away. Barthel Index and 6MWT were the most used, while MRC score was the least used outcome parameter. The 5 main rehabilitative activities were walking (90.8 %), transfer from bed to armchair (77.5%), limb mobilization in bed (76%), balance (71.2%), and cycle-ergometer or treadmill (43.1%). A huge difference was found in admission, discharge, and delta change among different rehabilitative centers. When available, all outcomes showed a significant improvement. With the limitation of a retrospective study with a clear amount of missing data, COVID-19 subjects admitted to rehabilitative centers presented a reduced physical performance, symptoms of dyspnoea, and severe disability. The 6MWT and Barthel index were the most used measurement.

Role of Exercise Intensity on Th1/Th2 Immune Modulations During the COVID-19 Pandemic

The COVID-19 pandemic has led to several pioneering scientific discoveries resulting in no effective solutions with the exception of vaccination. Moderate exercise is a significant non-pharmacological strategy, to reduce the infection-related burden of COVID-19, especially in patients who are obese, elderly, and with additional comorbidities. The imbalance of T helper type 1 (Th1) or T helper type 2 (Th2) cells has been well documented among populations who have suffered as a result of the COVID-19 pandemic, and who are at maximum risk of infection and mortality. Moderate and low intensity exercise can benefit persons at risk from the disease and survivors by favorable modulation in Th1/Th2 ratios. Moreover, in COVID-19 patients, mild to moderate intensity aerobic exercise also increases immune system function but high intensity aerobic exercise may have adverse effects on immune responses. In addition, sustained hypoxia in COVID-19 patients has been reported to cause organ failure and cell death. Hypoxic conditions have also been highlighted to be triggered in COVID-19-susceptible individuals and COVID-19 survivors. This suggests that hypoxia inducible factor (HIF 1α) might be an important focus for researchers investigating effective strategies to minimize the effects of the pandemic. Intermittent hypoxic preconditioning (IHP) is a method of exposing subjects to short bouts of moderate hypoxia interspersed with brief periods of normal oxygen concentrations (recovery). This methodology inhibits the production of pro-inflammatory factors, activates HIF-1α to activate target genes, and subsequently leads to a higher production of red blood cells and hemoglobin. This increases angiogenesis and increases oxygen transport capacity. These factors can help alleviate virus induced cardiopulmonary hemodynamic disorders and endothelial dysfunction. Therefore, during the COVID-19 pandemic we propose that populations should engage in low to moderate exercise individually designed, prescribed and specific, that utilizes IHP including pranayama (yoga), swimming and high-altitude hiking exercise. This would be beneficial in affecting HIF-1α to combat the disease and its severity. Therefore, the promotion of certain exercises should be considered by all sections of the population. However, exercise recommendations and prescription for COVID-19 patients should be structured to match individual levels of capability and adaptability.

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.

Characteristics of COVID-19 Pneumonia Survivors With Resting Normoxemia and Exercise-Induced Desaturation

BACKGROUND

Survivors of coronavirus disease 2019 (COVID-19) associated pneumonia may show exercise-induced desaturation. We wondered whether these individuals show physiologic and symptom characteristics similar to individuals with chronic respiratory diseases with exercise-induced desaturation, namely COPD or interstitial lung diseases (ILD). We evaluated lung function, exercise capacity, and symptoms in these individuals compared with individuals with COPD or ILD and exercise-induced desaturation.

METHODS

Survivors of COVID-19 associated pneumonia (study individuals), normoxemic at rest with exercise-induced desaturation, underwent assessment of dyspnea, dynamic lung volumes, carbon monoxide diffusion capacity, and the 6-min walk test. Data of individuals with COPD or with ILD and exercise-induced desaturation were also retrospectively analyzed.

RESULTS

FVC was lower in individuals with COVID-19 or ILD than in those with COPD. Individuals who had COVID-19 walked < 70% of predicted and, as a whole, had a 6-min walk test performance similar to individuals with ILD but walked significantly less, showed more severe leg fatigue and dyspnea during exercise, and more exercise-induced desaturation than individuals with COPD.

CONCLUSIONS

Survivors of COVID-19 associated pneumonia, who were normoxemic at rest with exercise-induced desaturation, had alterations in lung function, exercise capacity, and symptoms similar to individuals with ILD but more severe than individuals with COPD and exercise-induced desaturation.

The vital role of physiotherapy during COVID-19: A systematic review

BACKGROUND

The current COVID-19 pandemic has changed the entire world population's physical and mental wellbeing irrespective of the person being infected or not. Flourishing numbers of new research recommends physiotherapy for the management of COVID-19 patients. However, there are cavities in the study in the recommendation of physiotherapy specific to the current pandemic.

OBJECTIVE

This review aimed to synthesize physiotherapy-related articles to COVID-19 and summarize their efficacious highlights.

METHODS

For the literature search PubMed, PEDro, DOAJ and The Cochrane Database of Systematic Reviews were used. The keywords included "Physiotherapy", "COVID-19", and "Coronavirus". The Boolean search was applied as required. Selection criteria included studies that included physiotherapy intervention as a tool for recovery of COVID-19. Exclusion criteria included animal studies, non-COVID-19 studies and physiotherapy as an adjunct treatment. The study evaluated evidence of all full-text articles in English from December 2019 to August 2020.

RESULTS

Of the retrieved 577 articles, 390 articles were excluded at the title and abstract screening. 167 articles underwent full-text screening and further narrowed to 11 studies matching the expected criteria. 156 studies were excluded for various reasons.

CONCLUSION

The current study findings support that physiotherapy interventions facilitate recovery in COVID-19 patients and act as a protective barrier. Further results include a reduced length of stay in intensive care and reduced treatment cost since this outbreak has brought a significant economic burden to many countries.

The effects of respiratory exercises on partial pressures of gases and anxiety in the acute phase of COVID-19 infection

INTRODUCTION

Respiratory exercise in post-COVID-19 significantly improves pulmonary function, exercise capacity and quality of life. Our study aimed to investigate the effect of respiratory exercise on partial pressures of oxygen, carbon dioxide and oxygen saturation in arterial blood and anxiety assessed by the GAD-7 scale in the acute phase of COVID-19 infection.

METHODS

The study was conducted at the Clinical Center, Kragujevac, from June to July 2020. The study was a prospective clinical trial and included 62 patients with the acute-phase of COVID-19 infection (61.3% males, mean age 60.82 ± 11.72). The duration of the comprehensive pulmonary rehabilitation program was 14 days ± 2.28 days. Oxygen saturation and heart rate were determined by using the pulse oximeter, oxygen flow, and arterial blood gas analysis values by using the gas analyzer. The anxiety assessment was measured using the Generalized Anxiety Disorder (GAD-7).

RESULTS

The values of oxygen saturation significantly differed before and after the respiratory exercise sessions (95.77 vs 98.02, respectively; p < .001). After the respiratory exercise program, significantly lower values of the GAD-7 scale were observed compared to the values before the respiratory exercise program (p = .049). A significant negative correlation was observed between oxygen saturation after respiratory exercise and age and presence of chronic obstructive pulmonary disease (ρ = -0.329; p = .013; ρ = -0.334; p = .009, respectively). GAD-7 score after respiratory exercise negatively correlated with chronic obstructive pulmonary disease and malignancy (ρ = -0.285; p = .025; ρ = -0.350; p = .005, respectively).

CONCLUSION

The respiratory exercise program significantly improves oxygen saturation and anxiety levels in COVID-19 patients.