Inspiratory muscle training for recovered COVID-19 patients after weaning from mechanical ventilation: A pilot control clinical study

Effectiveness of physiotherapy modalities on persisting dyspnoea in long COVID: A systematic review and meta-analysis

BACKGROUND

Dyspnoea is often found months and years later in the "long-covid" syndrome, impairing quality of life and further perpetuating anxiety and post-traumatic stress disorders. Physiotherapy was recommended as a treatment in long-covid, but there is still insufficient evidence on its effectiveness.

METHODS

We conducted a systematic literature search on MEDLINE, PEDro, WOS, Scopus, VHL and the Cochrane Library until July 2023 (PROSPERO registration number: CRD42023427464). We selected comparative trials including adults with persistent breathlessness following COVID-19, regardless of the initial severity, for whom physiotherapy was implemented as a treatment for dyspnoea. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed the study quality using the PEDro Scale.

RESULTS

19 studies that included 1292 adults fulfilled the inclusion criteria, of which 15 were randomised controlled trials and 4 non-randomised controlled trials. As for the rehabilitation modalities, 6 studies used respiratory muscle training, 6 studies used low to moderate intensity rehabilitation, 6 used high intensity rehabilitation and one used passive rehabilitation. The methods used between and within each group differed greatly, leading to an expected high heterogeneity of results. Nethertheless the random-effects model found a significant difference favouring physiotherapy (SMD -0.63, 95 CI [-1.03; -0.24], p < 0.001, I2 = 88 %). Subgroup analysis showed a significant effect in the high intensity rehabilitation group alone, with null heterogeneity.

CONCLUSION

In people suffering from dyspnoea following a SARS-CoV-2 infection, physiotherapy and especially pulmonary rehabilitation may help alleviate respiratory symptoms. Future studies will need to provide more consistent rehabilitation methods and better descriptions of them so as to reveal clear effects and avoid the confusion caused by using too many rehabilitation modalities.

A Narrative Review of Impact of Incentive Spirometer Respiratory Training in Long COVID

Long COVID refers to symptoms that appear 3 months after initial infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative virus of Coronavirus disease 2019 (COVID-19), and last for at least 2 months, not attributable to other diagnoses. This health issue significantly burdens patients' quality of life, the economy, and society. Improving the af-termath of COVID-19 is a crucial global health issue in the post-pandemic era. According to current results, it is evident that developing a simple, low-cost respiratory training method that can be easily used at home by themselves with long Coronavirus disease 2019 symptoms (long COVID) is an important and urgent issue. The incentive spirometer is widely used in physical, speech, and respiratory therapy, as well as in preventing postoperative pulmonary infections and improving sputum clearance. However, to date, the role of incentive spirometer respiratory training in long COVID symptoms is still limited. In this literature review is presented to explore the effectiveness of incentive spirometer respiratory training in alleviating symptoms among individuals recovering from long COVID. We also compile non-invasive assessment methods, with the aim to enable individuals to undergo training and assessments conveniently at home or in the community. In this review, a literature review approach was utilized to explore the effectiveness of incentive spirometer intervention in alleviating long-term COVID symptoms. This study is to synthesize the findings of articles published during January 2019 and December 2023 retrieved from PubMed/CINAHL/MEDLINE/ Google Scholar without re-strictions on study type. We ultimately identified seven articles and have summarized similar past studies. This review could contribute to improving symptoms related to long COVID by incentive spirometer respiratory training and serve as practical reference material for clinical medical staff and provide insights for healthcare policymakers in de-veloping guidelines for future research directions, clinical guidance, and educational strategies in the context of nursing care.

Tele-rehabilitation in COVID-19 survivors (TERCOV): An investigator-initiated, prospective, multi-center, real-world study

INTRODUCTION

Center-based rehabilitation is limited by COVID-19 infectivity and social distancing policy. We hypothesized that discharged patients benefit from 8-week home-based tele-rehabilitation (tele-PR) using mobile phones and low-cost instruments.

METHODS

The TERCOV (Tele-rehabilitation in COVID-19 survivors) is an investigator-initiated, prospective, multi-center, real-world study. After proper assessment, 186 discharge patients received tele-PR by smartphone, including breathing exercise, respiratory muscle training, aerobic exercise, and resistance training. Physicians, physiotherapists, and nurses provided guidance through smartphone applications. The primary outcome was six-minute walk distance (6MWD). The secondary outcomes included hand grip, short physical performance battery, maximal inspiratory pressure, maximal expiratory pressure, self-rating anxiety/depression scale (SAS/SDS), 36-item short-form health survey (SF-36) and international physical activity questionnaire.

RESULTS

Dyspnea subgroups were more functionally impaired. After tele-PR, improvements were observed in exercise capacity(∆6MWD: 16.80 m, 95% CI 1.18-32.42, p < 0.0001), limb muscle function (∆SPPB 0.25 points, 95% CI 0.05-0.46), respiratory muscle strength (∆MIP 16.50 cm H2O, 95% CI 9.22-23.78, p < 0.0001; ∆MEP: 12.09 cm H2O, 95% CI 3.48-20.70, p = 0.0002), health-related quality of life (∆SF-36 49.85, 95% CI: 21.01-78.69, p < 0.0001), physical activity(∆HEPA 13.01%, p = 0.0029). Anxiety reduced in patients with mMRC ≥ 2 (∆SAS = -4.19 points, CI -8.16 to -0.22, p = 0.03). Greater change was seen in dyspnea patients.

IMPLICATIONS ON PHYSIOTHERAPY PRACTICE

Supervised/semi-supervised tele-PR is a promising option during the pandemic. Patients with Dyspnea benefit more.

Respiratory muscle dysfunction in acute and chronic respiratory failure: how to diagnose and how to treat?

Assessing and treating respiratory muscle dysfunction is crucial for patients with both acute and chronic respiratory failure. Respiratory muscle dysfunction can contribute to the onset of respiratory failure and may also worsen due to interventions aimed at treatment. Evaluating respiratory muscle function is particularly valuable for diagnosing, phenotyping and assessing treatment efficacy in these patients. This review outlines established methods, such as measuring respiratory pressures, and explores novel techniques, including respiratory muscle neurophysiology assessments using electromyography and imaging with ultrasound.Additionally, we review various treatment strategies designed to support and alleviate the burden on overworked respiratory muscles or to enhance their capacity through training interventions. These strategies range from invasive and noninvasive mechanical ventilation approaches to specialised respiratory muscle training programmes. By summarising both established techniques and recent methodological advancements, this review aims to provide a comprehensive overview of the tools available in clinical practice for evaluating and treating respiratory muscle dysfunction. Our goal is to present a clear understanding of the current capabilities and limitations of these diagnostic and therapeutic approaches. Integrating advanced diagnostic methods and innovative treatment strategies should help improve patient management and outcomes. This comprehensive review serves as a resource for clinicians, equipping them with the necessary knowledge to effectively diagnose and treat respiratory muscle dysfunction in both acute and chronic respiratory failure scenarios.

Use of Locally Produced Novel Low-Cost 3D Printed Respiratory Muscle Strength Trainer Device (RMSTD) for Long COVID-Rehabilitation: An Innovative Case Report

Introduction. This article details the development and use of a low-cost, custom RMST device for a patient with long COVID who had received positive airway flow support during ICU treatment. By sharing our successful management of respiratory muscle weakness in a severe COVID-19 patient, we aim to contribute to the broader conversation around effective long COVID management. Case Description. A patient with respiratory muscle weakness used a hospital-made RMST device. The training involved ten short forced exhalations per cycle for five cycles, followed by five long forced exhalations held for five seconds. Additionally, the patient learned lower abdominal and box breathing techniques. The patient showed significant improvement, using the RMST device without supplemental oxygen within 24 hours and completely weaned off by day 5. By discharge, the patient could complete the RMST exercise regime and achieved 290 meters in the 6MWT. After six weeks of outpatient therapy, the patient used the RMST device at 80 cm H2O and increased their 6MWT distance to 390 meters. Device Description. The RMST device was designed for in-house production with a 3D-printed PETG cap, base, and plunger, and a standard pen spring. Its design mimicked a standard PEEP valve with a different geometry. The spring closed the valve until a pressure threshold was reached, allowing airflow. The adjustable pressure threshold ranged from -40 to +40 cm H2O, calibrated in 10 cm H2O increments by measuring displaced water column height. Discussion and Limitation. COVID-19 can cause long-term respiratory issues needing proper management and rehabilitation. Inspiratory muscle training benefits those recovering from severe COVID-19 who were weaned from mechanical ventilation. However, the device's design and production method are unsuitable for large-scale and commercial production. Rehabilitation centers should prepare for postintensive care syndrome in post-COVID-19 individuals, with interprofessional teams addressing various recovery aspects. Early medical attention and therapy can improve patients' quality of life.

Benefits of inspiratory muscle training therapy in institutionalized adult people with cerebral palsy: A double-blind randomized controlled trial

BACKGROUND

Respiratory health problems are one of the main causes of morbidity and mortality in adult people with cerebral palsy (CP). The influence of respiratory muscle training has not yet been studied in this population group. The objective of the study was to evaluate and compare the efficacy of two protocols with inspiratory muscle training (IMT), low intensity and high intensity, to improve respiratory strength and pulmonary function in adults with CP.

METHODS

The study was a controlled, randomized, double-blind trial with allocation concealment. Twenty-seven institutionalized CP patients were recruited and randomly distributed in the high-intensity training group (HIT) or low-intensity training group (LIT). Over 8 weeks, an IMT protocol was followed 5 days/week, 10 series of 1 min with 1 min rest between them. HIT trained with a load of 40% of the maximum inspiratory pressure (MIP) and LIT with 20%. Respiratory strength and pulmonary function were evaluated.

RESULTS

After IMT intervention, MIP, maximum expiratory pressure, forced expiratory volume in 1 s (FEV1) and peak expiratory flow increased in both groups; in HIT 29%, 19%, 13%, and 8%, respectively (p = 0.000, p = 0.000, p = 0.002, p = 0.001) and in LIT 17%, 7%, 3%, and 4%, respectively (p = 0.000, p = 0.000, p = 0.049, p = 0.113). All the improvements were significantly higher in HIT than in LIT.

CONCLUSION

Inspiratory muscle training improved respiratory muscle strength and pulmonary function in adults with CP. Training with a 40% MIP load improved all the evaluated parameters and was the most effective treatment for adults with CP.

Effects of respiratory muscular training in post-covid-19 patients: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Post-Covid-19 syndrome is defined as non-self-sustaining signs and/or symptoms lasting more than 12 weeks, occurring during or after a Covid-19 infection. The primary outcome was the analysis of the respiratory muscle training (RMT) result in respiratory muscle strength, (maximum inspiratory pressure (MIP) e maximum expiratory pressure (MEP)); and the secondary results were the analysis of lung function, dyspnea, quality of life (QoL), fatigue and functional performance.

METHODS

The PICO description for this research was: P: patients diagnosed with post-Covid-19; I: RMT; C: Sham or simulated inspiratory or expiratory muscle training and usual care; O: MIP, MEP, Lung Function, level of dyspnea, QoL and functional performance. On January 15, 2024, the following databases were consulted: PubMed, Lilacs, Cochrane Library, PEDro and EMBASE. Randomized clinical trials were included without restrictions on year of publication or language. The data selection and extraction steps were carried out by two independent reviewers.

RESULTS

The search in the databases resulted in a total of 14,216 studies, and after the eligibility process, 7 studies were included with a sample of 527 patients. The MIP results suffered a statistically significant increase, that is, the RMT was favorable to improve the MIP (MD = 29.55cmH2O IC 95%: 7.56cmH2O to 51.54cmH2O, p = 0,00001). For the MEP outcome, the results were statistically significant in favor of RMT (MD = 10.93cmH2O CI 95%: 3.65cmH2O to 18.21cmH2O, p = 0.00001). We also noticed a significant improvement for the group that received the RMT in the distance covered in the 6-Minute Walk Test (6MWT) MD = 40.70 m CI 95%: 18.23 m to 65.17 m%, p = 0.01).

CONCLUSION

We noticed that RMT is being used in patients with respiratory diseases, including post-Covid-19. Our systematic review observed that this training provides an increase in inspiratory and expiratory muscle strength, a reduction in dyspnea levels, and an increase in the distance covered in the 6MWT and improved QoL in post-covid patients after intervention.

Personalized Exercise Prescription in Long COVID: A Practical Toolbox for a Multidisciplinary Approach

Objective

To describe our methodology and share the practical tools we have developed to operationalize a multidisciplinary Long COVID clinic that incorporates progressive, personalized exercise prescription as a cornerstone feature.

Background

There is a lack of evidence-based guidance regarding optimal rehabilitation strategies for people with Long COVID. Existing guidelines lack precision regarding exercise dosage. As one of Australia's few established multidisciplinary Long COVID clinics, we describe our novel approach to safely incorporating exercise of both peripheral and respiratory muscles, with essential monitoring and management of post-exertional symptom exacerbation.

Methods

Working closely with primary health-care providers, our multidisciplinary team screens referrals for people aged 16 and older with Long COVID. Staff apply a three tier model of triage, dependent on the consumer's presenting problems. Exercise-based interventions necessitate detailed monitoring for post-exertional symptom exacerbation both in the clinic and at home. Personalized exercise prescription includes resistance training at a submaximal threshold (4-6 exercises, 3 days/week); whole-body endurance exercise titrated to the individual's progress, at an intensity 4-6/10 (Rate of Perceived Exertion); and for those limited by dyspnoea, high-intensity inspiratory muscle training using a threshold-based handheld device (30 repetitions per day, ≥50% of their maximum inspiratory pressure).

Discussion

We have used these approaches for the past 2 years in 250 consumers with no serious adverse events and promising consumer feedback. Our exercise prescription is less conservative than the methods advocated in international guidelines for people with Long COVID, and these more progressive tools may be valuable in other contexts.

Conclusion

In our experience, a multidisciplinary clinic-based approach to safely prescribing progressive exercise in Long COVID is feasible. Both peripheral and inspiratory muscle exercise can be effectively titrated to each individual's symptoms, and careful monitoring for post-exertional symptom exacerbation is crucial.

Impact of Inspiratory Muscle Training and Positive Expiratory Pressure on Lung Function and Extubation Success of ICU Patients: a Randomized Controlled Trial

Introduction

Preparing patients for extubation from mechanical ventilation (MV) necessitates focused respiratory muscle strengthening. This study aimed to evaluate the effect of threshold inspiratory muscle training (IMT) and positive expiratory pressure (PEP) exercises on outcomes of patients who underwent MV in intensive care unit (ICU).

Methods

This randomized controlled trial was conducted in 2023 at the ICUs of Imam Reza Hospital, Mashhad, Iran. Participants were allocated to either intervention or control group (each comprising 35 patients) through block randomization. The intervention group received standard daily chest physiotherapy as well as targeted inspiratory and expiratory muscle strengthening exercises using the threshold IMT/PEP device, administered twice daily over one week. The control group received standard daily chest physiotherapy alone. Finally, the outcomes (lung compliance, duration of intubation, extubation success rate, and diaphragmatic metrics) of the two groups were compared.

Results

70 patients with the mean age of 56.10 ± 14.15 (range: 28.00-85.00) years were randomly divided into two groups (50% male). Significant improvements were observed in the intervention group regarding pulmonary compliance values (35.62 ± 4.43 vs. 30.85 ± 6.93; p= 0.001), peak expiratory flow (PEF) (55.20 ± 10.23 vs. 47.80 ± 11.26; p = 0.002), and maximum inspiratory pressure (MIP) (33.40 ± 4.25 vs. 30.08 ± 6.08; p = 0.01) compared to the control group. Diaphragm inspiratory thickness (0.29 ± 0.03 vs. 0.26 ± 0.04; p = 0.001), diaphragm expiratory thickness (0.22 ± 0.03 vs. 0.20 ± 0.04; p = 0.006) and motion (1.61 ± .29 vs. 1.48 ± .21; p = 0.04) also exhibited significant differences between the two groups. Extubation success rate was higher in the intervention group (68.60% vs. 40%; p = 0.01). The duration of mechanical ventilation was 15.14±7.07 days in the intervention group and 17.34±7.87 days in the control group (p = 0.20). The mean extubation time was 7.00 ± 1.88 days for the intervention group and 9.00 ± 2.00 days for the control (p < 0.001).

Conclusion

Threshold IMT/PEP device exercises effectively enhance respiratory muscle strength, diaphragm thickness, and reduce ventilator dependency. These findings support their potential for inclusion in rehabilitation programs for ICU patients.

The Impact of Different Exercise Modes in Fitness and Cognitive Indicators: Hybrid versus Tele-Exercise in Patients with Long Post-COVID-19 Syndrome

The purpose of our study was to obtain evidence that an unsupervised tele-exercise program (TEgroup) via an online platform is a feasible alternative to a hybrid mode of supervised and unsupervised exercise (HEgroup) sessions for improving fitness indexes, respiratory and cognitive functions, and biomarkers of oxidative stress in patients recovering from COVID-19. Forty-nine patients with long post-COVID-19 were randomly divided into two groups (HEgroup: n = 24, age 60.0 ± 9.5 years versus TEgroup: n = 25, age 58.7 ± 9.5 years). For each patient, we collected data from body composition, oxidative stress, pulmonary function, physical fitness, and cognitive function before and after the 12-week exercise rehabilitation program (ERP). Our data showed differences in both groups before and after 12-week ERP on fitness indicators, body composition, and pulmonary function indicators. Our findings demonstrated differences between groups after 12-week ERP on adjustment in the domains of cognitive function (HEgroup increased the "visuospatial" domain: 3.2 ± 1.1 versus 3.5 ± 0.8 score, p = 0.008 and TEgroup increased the "memory" domain: 3.3 ± 1.0 versus 3.8 ± 0.5 score, p = 0.003; after 12-week ERP showed differences between groups in domain "attention" TEgroup: 4.8 ± 1.5 versus HEgroup: 3.6 ± 1.8 score, p = 0.014) and the diffusing capacity for carbon monoxide (HEgroup increased the percent of predicted values at 0.5 ± 32.3% and TEgroup at 26.0 ± 33.1%, p < 0.001). These findings may be attributed to the different ways of learning exercise programs, resulting in the recruitment of different neural circuits.

Effectiveness of Rehabilitation Interventions in Individuals With Emerging Virtual Respiratory Tract Infectious Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Assessing rehabilitation effectiveness for persistent symptoms post-infection with emerging viral respiratory diseases.

DATA SOURCES

Systematic review of seven databases (MEDLINE, EMBASE, Cochrane Library, PEDro, MedRxiv, CNKI, Wanfang) until 30 December 2023.

REVIEW METHODS

Evaluated 101 studies (9593 participants) on respiratory function, exercise capacity, and quality of life. Methodological quality was assessed using the Cochrane Collaboration's Risk of Bias tool for randomized controlled trials (RCTs), the Newcastle-Ottawa Scale (NOS) for observational studies and non-RCTs, and the NIH Quality Assessment Tools for before-after studies.

RESULTS

The most common rehabilitation program combined breathing exercises with aerobic exercise or strength training. Rehabilitation interventions significantly enhanced respiratory function, as evidenced by improvements on the Borg Scale (MD, -1.85; 95% CI, -3.00 to -0.70, low certainty), the mMRC Dyspnea Scale (MD, -0.45; 95% CI, -0.72 to -0.18, low certainty), and the Multidimensional Dyspnoea-12 Scale (MD, -4.64; 95% CI, -6.54 to -2.74, moderate certainty). Exercise capacity also improved, demonstrated by results from the Six-Minute Walk Test (MD, 38.18; 95% CI, 25.33-51.03, moderate certainty) and the Sit-to-Stand Test (MD, 3.04; 95% CI, 1.07-5.01, low certainty).

CONCLUSION

Rehabilitation interventions are promising for survivors of viral respiratory diseases, yet gaps in research remain. Future investigations should focus on personalizing rehabilitation efforts, utilizing remote technology-assisted programs, improving research quality, and identifying specific subgroups for customized rehabilitation strategies to achieve the best outcomes for survivors.

Effects of high-definition transcranial direct current stimulation combined with inspiratory muscle training for treating respiratory sequelae of long COVID: A case series

INTRODUCTION

Long COVID occurs when numerous symptoms begin 3 weeks after acute infection and last for 12 months or more. High-definition transcranial direct current stimulation (HD-tDCS) has been tested in patients with COVID-19; however, previous studies did not investigate the HD-tDCS use combined with inspiratory muscle training (IMT) for respiratory sequelae of long COVID.

CASE PRESENTATION

Six individuals (four women and two men) aged between 29 and 71 years and presenting with respiratory sequelae of long COVID were included. They were submitted to an intervention that comprised HD-tDCS combined with IMT twice a week for 5 weeks. Lung function and respiratory muscle assessments were performed at baseline and after 5 weeks of intervention.

IMPLICATIONS ON PHYSIOTHERAPY PRACTICE

HD-tDCS may enhance the IMT effects by increasing respiratory muscle strength, efficiency, and lung function of individuals with long COVID.

Quality of Life, Family Support, Spirometry, and 6-Minute Walking Distance Differences between COVID-19 and Non-COVID-19 Intensive Care Unit Patients in One Year Following Hospital Discharge

BACKGROUND

Critically ill patients after Intensive Care Unit (ICU) discharge may present disability in their cognitive and physical functions.

OBJECTIVES

To investigate the quality of life (QoL) of both COVID-19 and non-COVID-19 patients following ICU discharge, lung function, and physical performance of participants.

METHODS

This study was prospective and conducted between 2020 and 2021 in the "X" hospital. If patients were Mechanically-Ventilated (MV) > 48 h, they were included.

RESULTS

Fifty COVID-19 and seventy-two non-COVID-19 participants were included in this study. The mean (SD) of the total SF-36 scores at COVID-19 patients at hospital discharge and 3 and 12 months were 46.5 (14.5), 68.6 (17.8), and 82.3 (8.9) (p < 0.05), while non-COVID-19 participants were 48.5 (12.1), 72.2 (9.9), and 82.7 (5.4) (p < 0.05). The forced expiratory volume in one second (FEV1) and 6-minute walking distance (6MWD) were assessed at 3 and 12 months and significantly improved over 12 months.

CONCLUSION

The QoL of COVID-19 patients improved significantly over time as FEV1 and 6MWD.

Psychophysiological Adaptations to Exercise Training in COVID-19 Patients: A Systematic Review

Introduction

Many COVID-19 patients display adverse symptoms, such as reduced physical ability, poor quality of life, and impaired pulmonary function. Therefore, this systematic review is aimed at evaluating the effectiveness of physical exercise on various psychophysiological indicators among COVID-19 patients who may be at any stage of their illness (i.e., critically ill, hospitalized, postdischarge, and recovering).

Methods

A systematic search was conducted in PubMed, Scopus, ScienceDirect, Web of Science, and Google Scholar from 2019 to 2021. Twenty-seven studies, which assessed a total of 1525 patients, were included and analysed.

Results

Overall, data revealed significant improvements in the following parameters: physical function, dyspnoea, pulmonary function, quality of life (QOL), lower limb endurance and strength, anxiety, depression, physical activity level, muscle strength, oxygen saturation, fatigue, C-reactive protein (CRP), interleukin 6 (IL-6), tumour necrosis factor-alpha (TNF-α), lymphocyte, leukocytes, and a fibrin degradation product (D-dimer).

Conclusions

Physical training turns out to be an effective therapy that minimises the severity of COVID-19 in the intervention group compared to the standard treatment. Therefore, physical training could be incorporated into conventional treatment of COVID-19 patients. More randomized controlled studies with follow-up evaluations are required to evaluate the long-term advantages of physical training. Future research is essential to establish the optimal exercise intensity level and assess the musculoskeletal fitness of recovered COVID-19 patients. This trial is registered with CRD42021283087.

Feasibility, safety, and patient acceptability of electronic inspiratory muscle training in patients who require prolonged mechanical ventilation in the intensive care unit: A dual-centre observational study

BACKGROUND

Inspiratory muscle training (IMT) is an intervention that can be used to rehabilitate the respiratory muscle deconditioning experienced by patients with critical illness, requiring prolonged mechanical ventilation. Clinicians are currently using mechanical threshold IMT devices that have limited resistance ranges.

OBJECTIVES

The objective of this study was to evaluate the safety, feasibility, and acceptability of using an electronic device to facilitate IMT with participants requiring prolonged mechanical ventilation.

METHOD

A dual-centre observational cohort study, with convenience sampling, was conducted at two tertiary intensive care units. Daily training supervised by intensive care unit physiotherapists was completed with the electronic IMT device. A priori definitions for feasibility, safety, and acceptability were determined. Feasibility was defined as more than 80% of planned sessions completed. Safety was defined as no major adverse events and less than 3% minor adverse event rate, and acceptability was evaluated following the acceptability of intervention framework principles.

RESULTS

Forty participants completed 197 electronic IMT treatment sessions. Electronic IMT was feasible, with 81% of planned sessions completed. There were 10% minor adverse events and no major adverse events. All the minor adverse events were transient without clinical consequences. All the participants who recalled completing electronic IMT sessions reported that the training was acceptable. Acceptability was demonstrated; over 85% of participants reported that electronic IMT was either helpful or beneficial and that electronic IMT assisted their recovery.

CONCLUSION

Electronic IMT is feasible and acceptable to complete with critically ill participants who require prolonged mechanical ventilation. As all minor adverse events were transient without clinical consequences, electronic IMT can be considered a relatively safe intervention with patients who require prolonged mechanical ventilation.

Practical Recommendations for Exercise Training in Patients with Long COVID with or without Post-exertional Malaise: A Best Practice Proposal

People with long COVID may suffer from a wide range of ongoing symptoms including fatigue, exertional dyspnea, reduced exercise performance, and others. In particular, impaired exercise performance is a condition that can be recovered in many people through an individualized physical exercise training program. However, clinical experience has shown that the presence of post-exertional malaise (PEM) is a significant barrier to physical exercise training in people with long COVID. Currently, there is no guideline or consensus available on how to apply exercise training in this cohort. Therefore, we conducted a literature review in the PubMed library using the following search terms: "COVID", "post-COVID", "long COVID" and "exercise" searching for studies from January 2020 to January 2024. Data from 46 trials were included. Exercise training regimes were very heterogeneous and none of these studies reported on the management of PEM in the context of an exercise training program. Based on the feedback from an additional survey that was answered by 14 international experts in the field of exercise training in long COVID, combined with the authors´ own extensive practical experience, a best practice proposal for exercise training recommendations has been developed. This proposal differentiates exercise procedures according to the presence of no, mild/moderate or severe PEM in people with long COVID. These recommendations may guide allied healthcare professionals worldwide in initiating and adjusting exercise training programs for people with long COVID, stratified according to the presence and severity of PEM.

Effects of a cardiopulmonary rehabilitation protocol on functional capacity, dyspnea, fatigue, and body composition in individuals with post-COVID-19 syndrome: A randomized controlled trial

BACKGROUND AND OBJECTIVE

Reduced functional capacity, dyspnea, fatigue, and changes in body composition are common in patients with post-COVID-19 syndrome (PCS), and cardiopulmonary rehabilitation may improve these parameters. Thus, the present study verified the effects of cardiopulmonary rehabilitation (respiratory, aerobic, and resistance muscle training) on submaximal exercise tolerance, dyspnea, fatigue, and body composition.

METHODS

This controlled and randomized clinical trial applied a six-week outpatient intervention protocol in individuals over 18 years old (n = 33) with a diagnosis of COVID-19 confirmed by polymerase chain reaction. These individuals were allocated to cardiopulmonary rehabilitation (n = 17) or control groups (i.e., educational lectures; n = 16). The cardiopulmonary rehabilitation group performed respiratory, aerobic, and resistance muscle training. Submaximal exercise tolerance, dyspnea, fatigue, and body composition were assessed before and after the protocol.

RESULTS

After 6 weeks, the cardiopulmonary rehabilitation group increased the tolerance to submaximal exercise, with a difference of 100.46 m (95% confidence interval [CI]: 7.40-193 m) in the distance walked on the six-minute walk test, reduced dyspnea (-1.45, 95% CI: -1.98--0.92) in the modified Medical Research Council, and increased 0.63 kg (95% CI: 0.09-1.18 kg) of muscle mass in the upper limbs compared with the control group.

CONCLUSION

The six-week cardiopulmonary rehabilitation protocol improved functional capacity, reduced dyspnea, and increased muscle mass in the upper limbs in individuals with PCS. Thus, these results supported the protocol use in this population and encourage further studies to assess its effectiveness in a large sample.

Effects of a respiratory and neurological rehabilitation treatment plan in post Covid-19 affected university students. Randomized clinical study

BACKGROUND

COVID-19 demonstrated the possibility of neurological complications such as loss of sense of smell and taste, together with respiratory problems. Respiratory training and rehabilitation of neurological sequelae are essential to improve respiratory function and thus quality of life, and the aim of this study is to evaluate the efficacy of a pulmonary and neurological rehabilitation program.

OBJECTIVES

To apply a treatment to reduce dyspnea, increase exertional capacity, increase vital capacity and respiratory muscle strength, together with an increase in olfactory and gustatory sensitivity in post-SARS-CoV-2 patients.

METHODS

A randomised controlled experimental study was conducted in 220 patients with a medical diagnosis of COVID-19 and more than 5 months of evolution, dyspnoea or perceived fatigue, including olfactory and gustatory perception problems, of whom 200 patients completed the study. 100 patients were randomly assigned to the intervention group, consisting of an inspiratory training treatment plan (Powerbreathe Plus®) combined with aerobic exercise and olfactory gustatory treatment for 31 days, and 100 patients to the control group, for 31 days without any type of therapy.

RESULTS

The study was conducted in post-Covid-19 patients for 5 months. Two hundred patients were divided into an intervention group (n = 100) and a control group (n = 100). The comparison between the groups showed significant differences in spirometric variables; forced vital capacity (p < .001; Eta2 (0.439); Mean: 0,6135), the ratio between both FEV1/FVC (p < 0.01; Eta2 (0.728); Mean:9,313), peak inspiratory pressure (p < 0.01; Eta2 (0.906); Mean:4,526); changes were observed in dyspnoea measured with the modified Borg scale (p < 0.01; Eta2 (0.811); Mean:1,481) and the modified Medical Research Council scale (p < 0.01; Eta2 (0.881); Mean: 0.777); finally, changes were found in neurological variables, in the questions of the Singapore Smell and Taste Questionnaire, How was your sense of smell after treatment? (p < 0.01; Eta2 (0.813); Mean: 1,721) and How is your sense of taste after treatment? (p < 0.01; Eta2 (0.898); Mean: 1,088).

CONCLUSION

The implementation of a respiratory rehabilitation treatment plan with the Powerbreathe Plus® device, aerobic exercise and neurorehabilitation with olfactory and gustatory training, is a therapeutic option against respiratory and neurological sequelae in patients who have suffered such sequelae due to the SARS-CoV-2 virus. Clinicaltrials.gov: NCT05195099. First posted 18/01/2022; Last Update Posted 29/06/2022.

The effects of inspiratory muscle training on biomarkers of muscle damage in recovered COVID-19 patients after weaning from mechanical ventilation

Background: COVID-19 patients experience respiratory muscle damage, leading to reduced respiratory function and functional capacity often requiring mechanical ventilation which further increases susceptibility to muscle weakness. Inspiratory muscle training (IMT) may help mitigate this damage and improve respiratory function and functional capacity. Methods: We studied the effects of IMT on muscle damage biomarkers, respiratory function, and functional capacity in COVID-19 recovered young adults, successfully weaned from mechanical ventilation. Participants were randomly allocated to either an IMT (n = 11) or control (CON; n = 11) intervention for 4 weeks. The IMT group performed 30 dynamic inspiratory efforts twice daily, at 50% of their maximal inspiratory mouth pressure (PMmax) while the CON group performed 60 inspiratory efforts at 10% of pMmax daily. Serum was collected at baseline, week two, and week four to measure creatine kinase muscle-type (CKM), fast skeletal troponin-I (sTnI) and slow sTnI. Results: Time × group interaction effects were observed for CKM and slow sTnI, but not for fast sTnI. Both were lower at two and 4 weeks for the IMT compared to the CON group, respectively. Time × group interaction effects were observed for forced expiratory volume in 1s, forced vital capacity, PMmax and right- and left-hand grip strength. These were higher for the IMT compared to the CON group. Conclusion: Four weeks of IMT decreased muscle damage biomarkers and increased respiratory function and grip strength in recovered COVID-19 patients after weaning from mechanical ventilation.

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

OBJECTIVE

To evaluate the effectiveness of rehabilitation interventions for adults with COVID-19 and post COVID-19 condition (PCC) in all settings.

DATA SOURCES

PubMed, EMBASE, CINAHL, Scopus, Web of Science, and Physiotherapy Evidence Database were searched from inception to December 31st, 2021. PROSPERO registration number: CRD42021258553.

STUDY SELECTION

We included randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) according to the University of Alberta Evidence-based Practice Center.

DATA EXTRACTION

One author extracted data using a predetermined Excel form.

DATA SYNTHESIS

The meta-analysis indicates uncertain evidence about the effect of pulmonary rehabilitation and self-activities on exercise capacity (MD 65.06, 95% CI 42.87 to 87.25), respiratory function (forced expiratory volume in the first second [FEV1]: MD 0.16, 95% CI 0.05 to 0.28; FEV1/forced vital capacity [FVC]: MD 0.05, 95% CI 0.01 to 0.09; FVC: MD 0.19, 95% CI -0.03 to 0.42) and anxiety (MD -12.03, 95% CI -21.16 to -2.90) in mild COVID-19 and PCC patients. According to the narrative synthesis, including RCTs and NRSI, prone positioning seems to show improvements in vital parameters in severe COVID-19 post intensive care unit (ICU) discharge, pulmonary rehabilitation in activities of daily living, and qigong exercise and acupressure rehabilitation program, and "twist and raise" walking technique in reducing dyspnea and weakness in any degree of severity of COVID-19 and PCC. Functional electrical stimulation-cycling or early rehabilitation programs seem to support a faster recovery in patients with moderate COVID-19 after ICU discharge. Yoga and naturopathy, Mandala coloring, and respiratory exercise seem to reduce anxiety and depression in patients with moderate and mild COVID-19. Cognitive motor training seems to improve cognitive function in PCC patients.

CONCLUSIONS

There is very uncertain evidence about the effect of pulmonary rehabilitation on exercise capacity and respiratory function in patients with mild COVID-19 and PCC. Further high-quality research is required to improve the certainty of evidence available to support rehabilitation's crucial role in managing COVID-19.

Respiratory Muscle Strength Training in Patients Post-COVID-19: A Systematic Review

Estimates of 10-49% of patients may experience ongoing symptoms after COVID-19, including dyspnea. Respiratory muscle strength training has been used to reduce dyspnea in other respiratory diseases, thus, it may be a viable option for individuals with post-COVID-19 symptoms. The objective of this review was to evaluate the evidence for the effectiveness of respiratory muscle strength training for individuals with post-COVID-19 dyspnea. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. CINAHL, Web of Science, PubMed, EMBASE, Google Scholar, and Scopus databases were searched from 2020-2023. Eleven articles met the inclusion criteria. Pulmonary measures were improved in all but one study, and dyspnea, physical capacity and quality of life measures achieved statistical significance. Outcomes improved following respiratory muscle strength training as a standalone intervention, or with aerobic and peripheral muscle strength training.

Effects of cardiorespiratory rehabilitation program on submaximal exercise in patients with long-COVID-19 conditions: a systematic review of randomized controlled trials and recommendations for future studies

INTRODUCTION

Long-COVID-19 patients (LC19Ps) often experience cardiovascular and respiratory complications. Cardiorespiratory rehabilitation programs (CRRPs) have emerged as promising interventions to enhance exercise capacity in this population. This systematic review aimed to assess the impact of CRRPs on submaximal exercise performance, specifically the 6-minute walk test (6MWT) outcomes, in LC19Ps through an analysis of available randomized controlled trials (RCTs).

METHODS

A systematic search was conducted in PubMed/Medline and Scopus to identify relevant RCTs. Six RCTs meeting inclusion criteria were included in this review, investigating the effects of CRRPs on 6MWT outcomes in LC19Ps.

RESULTS

The findings from the included RCTs provide compelling evidence supporting the effectiveness of CRRPs in improving submaximal exercise performance in LC19Ps. These results underscore the potential of CRRPs to enhance submaximal exercise capacity and overall functional well-being in this population. However, future research is imperative to determine optimal CRRPs, including duration, intensity, and specific intervention components. Additionally, the long-term sustainability and durability of CRRP-induced improvements warrant further exploration. Future studies should prioritize patient-centric outcomes and address potential implementation barriers.

CONCLUSION

CRRPs show promise in ameliorating submaximal exercise performance among LC19Ps. Further research is needed to refine these programs and ensure their lasting impact on this patient group.

SYSTEMATIC REVIEW REGISTRATION

https://doi.org/10.17605/OSF.IO/HMN38. [Figure: see text].

Evidence-based position paper on physical and rehabilitation medicine professional practice for persons with COVID-19, including post COVID-19 condition: the European PRM position (UEMS PRM Section)

Although multiple factors still pose challenges to inpatient/outpatient rehabilitation for survivors of COVID-19, rehabilitation plays a key role for this patient population. This study aimed to improve Physical and Rehabilitation Medicine (PRM) physician's professional practice for persons with COVID-19-related functioning limitations, to promote functional recovery and reduce activity limitations and/or participation restrictions. A systematic review of the scientific literature was performed from December 2019 to August 2022, followed by production of recommendations through 5 Delphi rounds, by consensus among the delegates of all European countries represented in the Union of European Medical Specialists PRM Section. The systematic literature review is reported together with thirty-two recommendations resulting from the Delphi procedure. The PRM physician's role for persons with COVID-19-related limitations of functioning is to develop, foster, and monitor the implementation of an individual rehabilitation project tailored to the patient's age, previous medical and functional status, current comorbidities and complications, activity limitations and participation restrictions and personal and environmental factors. This is done by applying the concept of a multi-specialty integrated service model with multi-professional/interdisciplinary teams, providing care at all stages of COVID-19 illness. This evidence-based position paper represents the official position of the European Union through the UEMS PRM Section.

Cardiorespiratory dysautonomia in post-COVID-19 condition: Manifestations, mechanisms and management

A significant proportion of COVID-19 patients experience debilitating symptoms for months after the acute infection. According to recent estimates, approximately 1 out of 10 COVID-19 convalescents reports persistent health issues more than 3 months after initial recovery. This 'post-COVID-19 condition' may include a large variety of symptoms from almost all domains and organs, and for some patients it may mean prolonged sick-leave, homestay and strongly limited activities of daily life. In this narrative review, we focus on the symptoms and signs of post-COVID-19 condition in adults - particularly those associated with cardiovascular and respiratory systems, such as postural orthostatic tachycardia syndrome or airway disorders - and explore the evidence for chronic autonomic dysfunction as a potential underlying mechanism. The most plausible hypotheses regarding cellular and molecular mechanisms behind the wide spectrum of observed symptoms - such as lingering viruses, persistent inflammation, impairment in oxygen sensing systems and circulating antibodies directed to blood pressure regulatory components - are discussed. In addition, an overview of currently available pharmacological and non-pharmacological treatment options is presented.

The quality and pattern of rehabilitation interventions prescribed for post-COVID-19 infection patients: A systematic review and meta-analysis

Patients with prior COVID-19 infection may present with lasting multisystem symptoms that require intervention and includes exercise rehabilitation. The aim of this systematic review was to investigate the quality of articles, with emphasis on exercise rehabilitation, and conduct a meta-analysis on experimental and observational rehabilitation intervention studies on cardiorespiratory fitness and pulmonary function in post-COVID-19 infection patients. This systematic review used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines for evaluating rehabilitation interventions in clinical practice. A methodical search of cohort and experimental studies occurred from January 2019 up to March 2023. Thirty-two studies were included for complete analysis. The quality of the eligible studies for complete review was fair overall. The studies did not provide a detailed account of key descriptors of exercise such as volume, progression, motivational strategies, adherence and replication. There was a significant difference in the 6-minute walk test (Mean difference (MD) = 51.69 m; confidence intervals (CIs) = 36.99 to 66.38; p < 0.001, level of heterogeneity (I2) = 0), percent of predicted forced expiratory volume in one second (MD = 7.95%; CIs = 3.46 to 12.44; p = 0.0005, I2 = 65%) and percent of predicted forced vital capacity (MD = 3.49%; 95% CI = 1.25 to 5.73; p = 0.002; I2 = 37%) between the experiment and control groups. The current evidence suggests that rehabilitation interventions significantly improve cardiorespiratory fitness and pulmonary function in post-COVID-19 infection patients; however, there is a need for conceptualising high-quality and long-term rehabilitation interventions, especially exercise interventions.

[The role of the cardiopulmonary exercise test and pulmonary rehabilitation in long COVID-19]

INTRODUCTION

Long COVID refers to persistent symptoms, lasting more than 4 weeks after acute SARS-CoV-2 infection, even though the infection itself has been successfully controlled and remedied. Patient complaints are diverse, and the underlying physiopathological mechanisms are not well understood. Dyspnea and muscle fatigue are among the most commonly reported symptoms.

STATE OF THE ART

Cardiopulmonary exercise test (CPET) has been recognized as a useful tool in investigation of unexplained dyspnea. In patients with chronic lung disease, pulmonary rehabilitation is a program designed to counteract dyspnea, to increase exercise capacity and to improve quality of life.

PERSPECTIVES

Publications on CPET and pulmonary rehabilitation are needed in order to deepen comprehension and enhance management of long-COVID-19.

CONCLUSIONS

CPET reports have shown that symptoms persisting in the aftermath of acute SARS-CoV-2 infection may be related to deconditioning, a common occurrence after ICU stay, to cardiac dysautonomia subsequent to critical infections and, finally, to dysfunctional breathing subsequent to mild infections. These findings justify pulmonary rehabilitation, which has proven to be effective regardless of the severity of the initial infection, not only immediately after hospital discharge, but also at later points in time.

Meta-analysis of the impact of physical activity on the recovery of physical function in COVID-19 patients

Background

The decrease in physical function resulting from COVID-19 infection exerts a substantial negative influence on the quality of life of individuals. Physical activity plays a crucial and irreplaceable role in hastening the elimination of adverse effects on the body caused by acute and chronic diseases. Nevertheless, there have been reports of unfavorable events following physical activity post-COVID-19 infection, sparking debate regarding the efficacy of physical activity as a rehabilitation method to enhance the physical function of COVID-19 patients.

Objective

The aim of this study is to investigate the impact of physical activity on promoting the restoration of physical function among individuals with COVID-19, and to offer guidance for the advancement and consideration of physical activity in the rehabilitation treatment of COVID-19 patients.

Methods

A search was conducted on the PubMed and Web of Science core collection databases, with the search period set from January 1, 2020, to February 6, 2023. The included literature was assessed for risk of bias and methodological quality according to the Cochrane Handbook for Systematic Reviews of Interventions, utilizing Review Manager 5.1 software. The outcome measures from the included studies were analyzed, and the quality of evidence for the outcome measures was graded using the GRADE classification criteria.

Results

The effect of physical activity intervention on improving the 6-Minute Walk Test score in COVID-19 patients was better than that of conventional treatment [WMD = 69.19(95%CI = 39.38, 98.99), I2 = 57%(p = 0.03)]. The effect of physical activity on improving the 30-Second Sit-to-Stand Test score was better than that of conventional treatment [WMD = 2.98(95%CI = 1.91, 4.04), I2 = 0%(p = 0.56)]. There was no significant difference between physical activity and conventional treatment in improving Grip strength in COVID-19 patients [WMD = 2.35(95%CI = -0.49, 5.20), I2 = 0%(p = 0.80)]. The effect of physical activity on improving the Timed Up and Go test score in COVID-19 patients was better than that of conventional treatment [WMD = -1.16(95%CI = -1.98, -0.34), I2 = 4%(p = 0.35)]. The effect of physical activity on improving Forced Vital Capacity in COVID-19 patients was better than that of conventional treatment [WMD = 0.14(95%CI = 0.08, 0.21), I2 = 0%(p = 0.45)]. The effect of physical activity on improving Forced Expiratory Volume in the first second in COVID-19 patients was better than that of conventional treatment [WMD = 0.08(95%CI = 0.02, 0.15), I2 = 52%(p = 0.10)].

Conclusions

Physical activity plays a crucial role in facilitating the recovery of exercise capacity and pulmonary function in COVID-19 patients, helping to expedite the restoration of overall physical health. It is crucial for COVID-19 patients to undergo an accurate assessment of their physical condition before engaging in any physical activity.

Efficacy of Pulmonary Rehabilitation in Post-COVID-19: A Systematic Review and Meta-Analysis

BACKGROUND

This systematic review and meta-analysis examines how pulmonary rehabilitation impacts in patients suffering from subacute and long COVID-19 infections, gauging enhancements in of dyspnea, physical function, quality of life, psychological state (anxiety and depression), and fatigue.

METHODS

Three electronic databases (PubMed, Web of Science, Cochrane Library) were systematically searched for full-text articles published from inception to January 2023. Randomized, quasi-experimental, and observational studies were included, with adults diagnosed with subacute or long COVID-19 who received pulmonary rehabilitation as intervention. Outcomes related to dyspnea, physical function, quality of life, fatigue, and psychological status were included. Risk of bias was assessed with Cochrane Risk of Bias Tool for Randomized Controlled Trials and Risk of bias in non-randomized studies of intervention. The review was registered before starting in PROSPERO (CRD: 42022373075).

RESULTS

Thirty-four studies were included, involving 1970 patients with subacute and long COVID-19. The meta-analysis demonstrated moderate to large effects on dyspnea, physical function, quality of life, and depressive symptoms compared to usual care intervention. No significant differences were found in fatigue compared to usual care, nor in anxiety levels after pulmonary rehabilitation intervention.

CONCLUSIONS

Pulmonary rehabilitation has the potential to improve health outcomes in patients with subacute and long COVID-19. However, due to the high risk of bias of included studies, conclusions should be taken with caution.

Role of the Inspiratory Muscles on Functional Performance From Critical Care to Hospital Discharge and Beyond in Patients With COVID-19

OBJECTIVE

The role of inspiratory muscle performance in functional performance in patients with coronavirus disease 2019 (COVID-19) is poorly understood. The purpose of this study was to perform a longitudinal examination of inspiratory and functional performance from intensive care unit (ICU) discharge (ICUD) to hospital discharge (HD) and symptoms at HD and 1 month after HD in patients with COVID-19.

METHODS

Thirty patients (19 men, 11 women) with COVID-19 were included. Examination of inspiratory muscle performance at ICUD and HD was performed with an electronic manometer, which provided the maximal inspiratory pressure (MIP) and several other inspiratory measures. Examination of dyspnea and functional performance was performed at ICUD and HD with the Modified Borg Dyspnea Scale and the 1-minute sit-to-stand test (1MSST), respectively.

RESULTS

The mean age was 71 (SD = 11) years, the mean length of ICU stay was 9 (SD = 6) days, and the mean length of hospital stay was 26 (SD = 16) days. Most of the patients were diagnosed with severe COVID-19 (76.7%) and had a mean Charlson Comorbidity Index of 4.4 (SD = 1.9), reflecting high comorbidity. The mean MIP of the entire cohort increased minimally from ICUD to HD (from 36 [SD = 21] to 40 [SD = 20] cm H2O), reflecting predicted values for men and women at ICUD and HD of 46 (25%) to 51 (23%) and 37 (24%) to 37 (20%), respectively. The 1MSTS score increased significantly from ICUD to HD (9.9 [SD = 7.1] vs 17.7 [SD = 11.1]) for the entire cohort but remained far below population-based reference values (2.5th percentile) for the majority of patients at ICUD and HD. At ICUD, MIP was found to be a significant predictor of a favorable change in 1MSTS performance (β = 0.308; odds ratio = 1.36) at HD.

CONCLUSION

A significant reduction in inspiratory and functional performance exists in patients with COVID-19 at both ICUD and HD, with a greater MIP at ICUD being a significant predictor of a greater 1MSTS score at HD.

IMPACT

This study shows that inspiratory muscle training may be an important adjunct after COVID-19.

Can inspiratory muscle training benefit patients with COVID-19? A systematic review and meta-analysis

The possible benefits of inspiratory muscle training (IMT) on mechanical and clinical outcomes in patients with Coronavirus disease-2019 (COVID-19) remain controversial. We conducted a meta-analysis to evaluate the effect of IMT in the rehabilitation strategy of patients with COVID-19. The Pubmed, Embase, Web of Science (WOS), and Cochrane Central Register of Controlled Trials (CENTRAL) were searched to identify trials evaluating the efficacy of IMT in the treatment of patients with COVID-19. The primary outcome included change from baseline of VO2 max, maximal inspiratory pressure (PImax), 6-min walk test(6MWT), forced expiratory volume in the first second predicted (FEV1%pred), and quality of life (QOL). Six studies with 349 participants were analyzed. Significant improvements were found in change from baseline of VO2 max (MD: 4.54, 95% confidence interval [CI]: 1.79-7.30, Z = 3. 32, I2  = 0, p = 0.001), PImax (MD: 21.43, 95% CI: 1.33-41.52, Z = 2.09, I2  = 90%, p = 0.04), 6MWD (MD: 40.13, 95% CI: 24.92-55.35, Z = 5.17, I2  = 0, p < 0.00001) and FEV1%pred (MD: 8.73, 95% CI 3.07-14.39, Z = 3.02, p = 0.002) while no statistical improvements were found in QOL (SMD: 0.70, 95% CI: 0.37-1.03, Z = 4.15, I2  = 89% p = 0.32) between IMT group and control group. The application of IMT might elicit mechanical and clinical improvement in patients with COVID-19. IMT could be recommended as an effective strategy of pulmonary rehabilitation for COVID-19. However, the proper timing, optimal duration, as well as appropriate frequency and intensity of IMT remain uncertain and further studies are needed.

Dyspnea in Post-Acute COVID-19: A Multi-Parametric Cardiopulmonary Evaluation

Post-acute COVID-19 is characterized by the persistence of dyspnea, but the pathophysiology is unclear. We evaluated the prevalence of dyspnea during follow-up and factors at admission and follow-up associated with dyspnea persistence. After five months from discharge, 225 consecutive patients hospitalized for moderate to severe COVID-19 pneumonia were assessed clinically and by laboratory tests, echocardiography, six-minute walking test (6MWT), and pulmonary function tests. Fifty-one patients reported persistent dyspnea. C-reactive protein (p = 0.025, OR 1.01 (95% CI 1.00-1.02)) at admission, longer duration of hospitalization (p = 0.005, OR 1.05 (95% CI 1.01-1.10)) and higher body mass index (p = 0.001, OR 1.15 (95% CI 1.06-1.28)) were independent predictors of dyspnea. Absolute drop in SpO₂ at 6MWT (p = 0.001, OR 1.37 (95% CI 1.13-1.69)), right ventricular (RV) global longitudinal strain (p = 0.016, OR 1.12 (95% CI 1.02-1.25)) and RV global longitudinal strain/systolic pulmonary artery pressure ratio (p = 0.034, OR 0.14 (95% CI 0.02-0.86)) were independently associated with post-acute COVID-19 dyspnea. In conclusion, dyspnea is present in many patients during follow-up after hospitalization for COVID-19 pneumonia. While higher body mass index, C-reactive protein at admission, and duration of hospitalization are predictors of persistent dyspnea, desaturation at 6MWT, and echocardiographic RV dysfunction are associated with this symptom during the follow-up period.

Inspiratory Muscle Training While Hospitalized With Acute COVID-19 Respiratory Failure: A Randomized Controlled Trial

Although inspiratory muscle training (IMT) has been used in outpatient settings for patients who recovered from COVID-19 respiratory failure, little data exist to support earlier implementation in acute care hospitals. This study aimed to assess the safety and feasibility of IMT during the acute disease phase of COVID-19.

Design Setting and Patients

Sixty patients presenting with COVID-19 to a single academic medical center were randomized to control or intervention groups using systematic randomization.

Measurements

Participants in the control group had their maximal inspiratory pressure (MIP) measured at enrollment and hospital discharge. They were also asked for their rating of perceived exertion on the Revised Borg Scale for Grading Severity of Dyspnea and were scored by researchers on the Activity Measure for Post-Acute Care (AM-PAC) 6-Clicks Mobility Scale and the Intensive Care Unit Mobility Scale (IMS). Control group patients otherwise received standard care. Participants in the intervention group, in addition to the measures described previously, received inspiratory threshold trainers with the goal of doing 2 sessions daily with a physical therapist for the duration of their inpatient hospitalization. In these sessions, the patient completed 3 sets of 10 breaths with the trainer. Initial resistance was set at 30% of their MIP, with resistance increasing 1 level for the subsequent session if the patients rated their during-activity rating of perceived exertion as less than 2. Changes in functional outcome measures, amount of supplemental oxygen, hospital length of stay (LOS), discharge location, adverse events, and mortality were assessed in group comparisons.

Results

Of 60 enrolled patients, 41 (n = 19 in intervention and n = 22 in control) were included in the final data set, which required completion of the study, initial and discharge data points collected, and survival of hospitalization. Final groups were statistically similar. A total of 161 sessions of IMT were completed among the 19 patients in the intervention group. Mortality totaled 2 in the control group and 3 in the intervention group and adverse events during intervention occurred in only 3 (1.8%) sessions, all of which were minor oxygen desaturations. Sessions were unable to be completed for all potential reasons 11% of possible times. Dropout rate in the intervention group was 3 (10%). Both intervention and control groups demonstrated improved MIP, decreased supplemental oxygen requirements, improved function on the AM-PAC, and slightly decreased function on the IMS. Length of stay was shorter in the intervention group, and discharge disposition was similar between groups.

Conclusions

With a low number of recorded adverse events, similar mortality between groups, and successful completion of 161 exercise sessions, IMT may be a feasible and safe intervention for some hospitalized patients with COVID-19.

Effects of corrective and breathing exercises on respiratory function of older adults with a history of COVID-19 infection: a randomized controlled trial

BACKGROUND

Patients with a history of COVID-19 infection may suffer from different physical problems. This study aimed to investigate the effect of corrective and breathing exercises on improving respiratory function among patients with a history of COVID-19 infection.

METHODS

In this clinical trial study, thirty elderlies with a history of COVID-19 disease were divided into two groups (mean age 63.60 ± 3.56 experimental, 59.87 ± 2.99 control groups) based on the study inclusion criteria. Exercise interventions included two sections- breathing exercises and corrective exercises in the cervical and thoracic spine. The spirometry test, craniovertebral angle, and thoracic kyphosis test were used. To evaluate differences between variables, paired-samples t-test and ANCOVA were used (p-value < 0.01). Also, Eta-squared was measured to assess the effect size.

RESULTS

Results showed a significant difference between the two groups in craniovertebral angle (P = 0.001), thoracic kyphosis (P = 0.007), and respiratory capacity including Forced expiratory volume in one second (FEV1) (P = 0.002), FEV1/FVC (P = 0.003), Peripheral oxygen saturation (SPO2) (P = 0.001), while no significant differences were observed between two groups in terms of chest anthropometric indices (P > 0.01). The Eta-squared value of 0.51 for the Craniovertebral angle and the SPO2 indicates a large effect size.

CONCLUSIONS

The results showed the combination of corrective and breathing exercises could improve pulmonary function and correct cervical and thoracic posture in patients with a history of COVID-19 infection. Therefore, corrective and breathing exercises can be helpful as a complementary treatment along with pharmaceutical therapy to reduce chronic pulmonary complications in patients infected with COVID-19.

TRIAL REGISTRATION

This research was registered in the Iranian Registry of Clinical Trials (IRCT registration number: IRCT20160815029373N7, First trial registration: 23/08/2021, Registration date: 01/09/2021).

Effectiveness of a telerehabilitation intervention using ReCOVery APP of long COVID patients: a randomized, 3-month follow-up clinical trial

The main objective of this study is to analyze the clinical efficacy of telerehabilitation in the recovery of Long COVID patients through ReCOVery APP for 3 months, administered in the Primary Health Care context. The second objective is to identify significant models associated with an improvement in the study variables. An open-label randomized clinical trial was conducted using two parallel groups of a total of 100 Long COVID patients. The first group follows the treatment as usual methods established by their general practitioner (control group) and the second follows the same methods and also uses ReCOVery APP (intervention group). After the intervention, no significant differences were found in favour of the group intervention. Regarding adherence, 25% of the participants made significant use of the APP. Linear regression model establishes that the time of use of ReCOVery APP predicts an improvement in physical function (b = 0.001; p = 0.005) and community social support (b = 0.004; p = 0.021). In addition, an increase in self-efficacy and health literacy also contribute to improving cognitive function (b = 0.346; p = 0.001) and reducing the number of symptoms (b = 0.226; p = 0.002), respectively. In conclusion, the significant use of ReCOVery APP can contribute to the recovery of Long COVID patients. Trial Registration No.: ISRCTN91104012.

Study of Exercise Capacity and Quality of Life after SARS-CoV-2 Infection among the Elderly

COVID-19 significantly impacted the population by affecting physical health; social distancing and isolation influenced psychological health. This may have negative consequences, especially for older people. There is a lack of studies about the association between COVID-19 and exercise capacity among the elderly and improving quality of life after SARS-CoV-2 infection. This study aims to identify the potential sequelae of the COVID-19 disease regarding physical function and quality of life among people over 65 years old. This study recruited a total of 30 participants. A 6-minute walking test, somatic and functional measurements (including weight, height, HR, blood pressure and SpO₂%) and the World Health Organisation Quality of Life-BREF Questionnaire were used to assess aerobic capacity and quality of life. Experiencing COVID-19 can negatively impact exercise capacity. The results suggest that men may have worse sequelae than women after experiencing COVID-19. The lower values of SpO₂ in the COVID-19 group during the 6-MWT indicate a reduction in the gas diffusion capacity, which can be attributed to potential lung damage following having contracted the disease. Lockdown periods seem to have had a significant impact on the physical health, relationships and environment of the elderly people included in this study. We can conclude that physical effort may potentially impact exercise capacity and quality of life among post-COVID-19 elderly in a positive way, but further studies are needed to confirm its benefits.

Course of recovery of respiratory muscle strength and its associations with exercise capacity and handgrip strength: A prospective cohort study among survivors of critical illness

BACKGROUND

Mechanical ventilation affects the respiratory muscles, but little is known about long-term recovery of respiratory muscle weakness (RMW) and potential associations with physical functioning in survivors of critical illness. The aim of this study was to investigate the course of recovery of RMW and its association with functional outcomes in patients who received mechanical ventilation.

METHODS

We conducted a prospective cohort study with 6-month follow-up among survivors of critical illness who received ≥ 48 hours of invasive mechanical ventilation. Primary outcomes, measured at 3 timepoints, were maximal inspiratory and expiratory pressures (MIP/MEP). Secondary outcomes were functional exercise capacity (FEC) and handgrip strength (HGS). Longitudinal changes in outcomes and potential associations between MIP/MEP, predictor variables, and secondary outcomes were investigated through linear mixed model analysis.

RESULTS

A total of 59 participants (male: 64%, median age [IQR]: 62 [53-66]) were included in this study with a median (IQR) ICU and hospital length of stay of 11 (8-21) and 35 (21-52) days respectively. While all measures were well below predicted values at hospital discharge (MIP: 68.4%, MEP 76.0%, HGS 73.3% of predicted and FEC 54.8 steps/2m), significant 6-month recovery was seen for all outcomes. Multivariate analyses showed longitudinal associations between older age and decreased MIP and FEC, and longer hospital length of stay and decreased MIP and HGS outcomes. In crude models, significant, longitudinal associations were found between MIP/MEP and FEC and HGS outcomes. While these associations remained in most adjusted models, an interaction effect was observed for sex.

CONCLUSION

RMW was observed directly after hospital discharge while 6-month recovery to predicted values was noted for all outcomes. Longitudinal associations were found between MIP and MEP and more commonly used measures for physical functioning, highlighting the need for continued assessment of respiratory muscle strength in deconditioned patients who are discharged from ICU. The potential of targeted training extending beyond ICU and hospital discharge should be further explored.

Effectiveness of respiratory rehabilitation in patients with COVID-19: A meta-analysis

AIM

Examine effectiveness of respiratory rehabilitation and moderating factors on lung function and exercise capacity in post-COVID-19 patients.

DESIGN

Meta-analysis.

METHODS

R software 4.0.2 assessed the effectiveness of respiratory rehabilitation adopting the random-effects model and presenting standardised mean differences (SMDs). Heterogeneity was determined by Cochran's Q and I² . The Cochrane Risk of Bias 2.0 and MINORS evaluated quality of the included studies.

DATA SOURCES

A comprehensive search was undertaken in Cochrane, Embase, Ovid-MEDLINE, Scopus, NCBI SARS-CoV-2 Resources, ProQuest, Web of Science and CINAHL until March 2022.

RESULTS

Of the 5703 identified studies, 12 articles with 596 post-COVID-19 patients were included. Eleven of our twelve studies had moderate to high quality and one study had high risk of bias assessed with MINORS and RoB 2 tool. Overall, respiratory rehabilitation was effective in improving forced expiratory volume in 1 s (1.14; 95%CI 0.39-1.18), forced vital capacity (0.98; 95%CI 0.39-1.56), total lung capacity (0.83; 95%CI 0.22-1.44), 6-minute walk distance (1.56; 95%CI 1.10-2.02) and quality of life (0.99; 95%CI 0.38-1.60). However, no significant differences were observed for ratio of the forced expiratory volume in 1 s to the forced vital capacity of the lungs, anxiety and depression. Respiratory rehabilitation for post-COVID-19 patients was effective in those without comorbidities, performed four types of exercise programs, frequency ≥3 times/week and rehabilitation time 6 weeks.

CONCLUSIONS

Respiratory rehabilitation improved lung function, exercise capacity and quality of life in post-COVID-19 patients. The findings suggest rehabilitation programs for post-COVID-19 patients should use multiple respiratory exercise programs with frequency of ≥3 times per week for longer than 6 weeks.

IMPACT

These findings will help improve the implementation of respiratory rehabilitation programs for post-COVID-19 patients.

IMPLICATIONS FOR THE PROFESSION

Our findings can be used to develop patient-centred respiratory rehabilitation interventions by nurses and clinicians for post-COVID-19 patients.

REPORTING METHOD

PRISMA guideline was followed.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

A comprehensive examination of inspiratory muscle performance from the intensive care unit to hospital discharge in patients with COVID-19

BACKGROUND

The two most common symptoms associated with COVID-19 are dyspnea and fatigue. One possible cause of such symptoms may be inspiratory muscle weakness.

OBJECTIVES

The purpose of this study was to examine inspiratory muscle performance (IMP) from intensive care unit discharge (ICUD) to hospital discharge (HD) in patients with COVID-19 hypothesizing that IMP would be markedly depressed at both ICUD and HD.

METHODS

IMP was examined at ICUD and HD via the PrO2 device (PrO2 Health, Smithfield, RI) which provided the maximal inspiratory pressure (MIP), sustained MIP (SMIP), inspiratory duration (ID), and fatigue index test (FIT). Patient symptoms were assessed at ICUD, HD, and 1-month post-HD.

RESULTS

30 patients (19 men, 11 women) with COVID-19 were included. The mean±SD age, BMI, and length of ICU and hospital stay was 71±11 yrs, 27.9 ± 6.3 kg/m, 9 ± 6 days, and 26±16 days, respectively. The mean±SD MIP, SMIP, ID, and FIT of the entire cohort at ICUD vs HD were 36±21 vs 40±20 cm H2O, 231±157 vs 297±182 PTU, 8.8 ± 4.2 vs 9.5 ± 4.6 s, and 9.0 ± 9.4 vs 13.1 ± 12.3, respectively, with only SMIP and FIT significantly greater at HD (p=.006 and 0.03, respectively). SMIP at HD was significantly related to resting dyspnea at HD (r=-0.40; p=.02). The SMIP and FIT of men were found to increase significantly from ICUD to HD, but no measure of IMP in the women increased significantly from ICUD to HD. At least one COVID-19-related symptom was present 1 month after HD with the most persistent symptoms being fatigue, cough, and dyspnea in 47%, 40%, and 37% of the patients, respectively.

CONCLUSIONS

A significant reduction in IMP exists in patients with COVID-19 at both ICUD and HD and no measure of IMP in women was observed to increase significantly from ICUD to HD. Impaired inspiratory muscle endurance rather than strength was associated with greater dyspnea at HD.

Home-based respiratory muscle training on quality of life and exercise tolerance in long-term post-COVID-19: Randomized controlled trial

OBJECTIVE

To evaluate the effects of a home-based respiratory muscle training programme (inspiratory [IMT] or inspiratory/expiratory muscles [RMT]) supervised by telerehabilitation on quality of life and exercise tolerance in individuals with long-term post-COVID-19 symptoms. The secondary objective was to evaluate the effects of these programmes on respiratory muscle function, physical and lung function, and psychological state.

METHODS

88 individuals with long-term symptoms of fatigue and dyspnoea after COVID-19 diagnosis were randomly (1:1 ratio) assigned to IMT, IMT_sham, RMT or RMT_sham groups for an 8-week intervention (40min/day, 6 times/week). Primary outcomes were quality of life (EuroQol-5D questionnaire) and exercise tolerance (Ruffier test). Secondary outcomes were respiratory muscle function (inspiratory/expiratory muscle strength; inspiratory muscle endurance), physical function (lower and upper limb strength [1-min Sit-to-Stand and handgrip force]), lung function (forced spirometry), and psychological status (anxiety/depression levels and post-traumatic stress disorder). All outcomes were measured pre-, intermediate- (4^th week), and post-intervention.

RESULTS

At post-intervention, there was a statistically significant and large (d>0.90) improvement in quality of life, but not in exercise tolerance, in the RMT group compared with the RMT_sham group. Both of the real training groups produced a statistically significant and large increase in inspiratory muscle strength and endurance (d≥0.80) and in lower limb muscle strength (d≥0.77) compared with the 2 sham groups. Expiratory muscle strength and peak expiratory flow showed a statistically significant and large (d≥0.87) increase in the RMT group compared with the other 3 groups.

CONCLUSION

Only an 8-week supervised home-based RMT programme was effective in improving quality of life, but not exercise tolerance, in individuals with long-term post-COVID-19 symptoms. In addition, IMT and RMT programmes were effective in improving respiratory muscle function and lower limb muscle strength, but had no impact on lung function and psychological status.

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.

Dyspnoea in COVID-19 recovery beyond the intensive care unit: the potential impact of inspiratory muscle weakness

Emerging evidence confirms that dyspnoea and inspiratory muscle weakness persist for up to 6 months following mechanical ventilation with #COVID19 pneumonia. Screening for inspiratory muscle weakness should be prioritised, as it may be treatable. https://bit.ly/3CBQXO2.

The use of respiratory muscle training in patients with pulmonary dysfunction, internal diseases or central nervous system disorders: a systematic review with meta-analysis

OBJECTIVE

The aim of this systematic review with meta-analysis was to evaluate the effectiveness of RMT in internal and central nervous system disorders, on pulmonary function, exercise capacity and quality of life.

METHODS

The inclusion criteria were (1) publications designed as Randomized Controlled Trial (RCT), with (2) participants being adults with pulmonary dysfunction caused by an internal disease or central nervous system disorder, (3) an intervention defined as RMT (either IMT or EMT) and (4) with the assessment of exercise capacity, respiratory function and quality of life. For the methodological quality assessment of risk of bias, likewise statistical analysis and meta-analysis the RevMan version 5.3 software and the Cochrane Risk of Bias Tool were used. Two authors independently analysed the following databases for relevant research articles: PubMed, Scopus, Cochrane Library, Web of Science, and Embase.

RESULTS

From a total of 2200 records, the systematic review includes 29 RCT with an overall sample size of 1155 patients. Results suggest that patients with internal and central nervous system disorders who underwent RMT had better quality of life and improved significantly their performance in exercise capacity and in respiratory function assessed with FVC and MIP when compared to control conditions (i.e. no intervention, sham training, placebo or conventional treatments).

CONCLUSION

Respiratory muscle training seems to be more effective than control conditions (i.e. no intervention, sham training, placebo or conventional treatment), in patients with pulmonary dysfunction due to internal and central nervous system disorders, for quality of life, exercise capacity and respiratory function assessed with MIP and FVC, but not with FEV1.

Efficacy of home-based inspiratory muscle training in patients post-covid-19: Protocol for a randomized clinical trial

INTRODUCTION

Current evidence suggests the emergence of a novel syndrome (long COVID syndrome) due to sequels and persistent COVID-19 symptoms. Respiratory muscle training improves respiratory muscle strength, exercise capacity, diaphragm thickness, and dyspnea, especially in patients with decreased respiratory muscle strength. This study aims to evaluate the effectiveness of a protocol for home-based inspiratory muscle training to improve respiratory muscle strength, dyspnea, and quality of life of patients post-COVID-19.

METHODS AND ANALYSES

This randomized, controlled, double-blind clinical trial will be conducted at the Instituto de Medicina Tropical of Universidade Federal do Rio Grande do Norte (Brazil). Sample size will be determined using maximal inspiratory pressure after a pilot study with five patients per group (total of 10 patients). Patients included in the study will be evaluated in three moments: pre-training (initial), post-training (three weeks), and retention (24 weeks). The sample will be randomized in two groups: active (IMT using 30% of IMT and load increase of 10% of initial IMT every week. Patients will perform 30 repetitions, twice a day (morning and afternoon), for seven consecutive days, and six weeks) and SHAM (IMT without load). The following measurements will be assessed: anthropometry, respiratory muscle strength, pulmonary volume and capacity, dyspnea, perception of effort and lower limb fatigue, handgrip strength, functional capacity, anxiety, depression, and functional status. After initial evaluation, all patients will receive a POWERbreathe® (POWERbreathe®, HaB Ltd, Southam, UK) device to perform the training. Normality will be verified using Shapiro-Wilk or Kolmogorov-Smirnov, according to the number of patients included. Variables presenting nonparametric distribution will be compared using Wilcoxon (intragroup analysis) and Mann-Whitney test (intergroup analysis), whereas repeated measures two-way ANOVA will be performed in case of parametric distribution. Dunn's post hoc test will be used to identify significant differences in the two-way ANOVA test.

PRIMARY OUTCOMES

Respiratory muscle strength, dyspnea, and quality of life of post-COVID-19 patients.

SECOND OUTCOMES

Pulmonary function, dyspnea, exercise tolerance, handgrip strength, anxiety, depression, and functional status.

TRIAL REGISTRATION

Trial register number NCT05077241.

Post-Acute Sequelae of COVID-19: The Potential Role of Exercise Therapy in Treating Patients and Athletes Returning to Play

Post-acute sequelae of coronavirus disease 19 (COVID-19) (PASC) describe a wide range of symptoms and signs involving multiple organ systems occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, representing a growing health problem also in the world of sport and the athletic population. Patients with PASC have new, returning, or persisting symptoms four or more weeks after the infection. Among the most frequent symptoms, patients complain of fatigue, dyspnea, exercise intolerance, and reduced functional capacity that interfere with everyday life activity. The role of exercise programs in PASC patients will be identified, and upcoming studies will establish the magnitude of their benefits. However, the benefits of exercise to counteract these symptoms are well known, and an improvement in cardiopulmonary fitness, functional status, deconditioning, and quality of life can be obtained in these patients, as demonstrated in similar settings. Based on this background, this review aims to summarise the current evidence about the PASC syndrome and the benefit of exercise in these patients and to provide a practical guide for the exercise prescription in PASC patients to help them to resume their functional status, exercise tolerance, prior activity levels, and quality of life, also considering the athletic population and their return to play and sports competitions.

Development and Validation of a Mobile Application as an Adjuvant Treatment for People Diagnosed with Long COVID-19: Protocol for a Co-Creation Study of a Health Asset and an Analysis of Its Effectiveness and Cost-Effectiveness

OBJECTIVE

To analyse the overall effectiveness and cost-efficiency of a mobile application (APP) as a community health asset (HA) with recommendations and recovery exercises created bearing in mind the main symptoms presented by patients in order to improve their quality of life, as well as other secondary variables, such as the number and severity of ongoing symptoms, physical and cognitive functions, affective state, and sleep quality.

METHODS

The first step was to design and develop the technologic community resource, the APP, following the steps involved in the process of recommending health assets (RHA). After this, a protocol of a randomised clinical trial for analysing its effectiveness and cost-efficiency as a HA was developed. The participants will be assigned to: (1st) usual treatment by the primary care practitioner (TAU), as a control group; and (2nd) TAU + use of the APP as a HA and adjuvant treatment in their recovery + three motivational interviews (MI), as an interventional group. An evaluation will be carried out at baseline with further assessments three and six months following the end of the intervention.

DISCUSSION

Although research and care for these patients are still in their initial stages, it is necessary to equip patients and health care practitioners with tools to assist in their recovery. Furthermore, enhanced motivation can be achieved through telerehabilitation (TR).

Delayed onset phlegmasia cerulea dolens post-SARS-CoV-2 infection treated with minimally invasive clot retrieval technology

Coronavirus disease 2019 is associated with a significant venous thromboembolic risk. Phlegmasia cerulean dolens is a severe form of deep vein thrombosis that can lead to acute limb ischemia. In this report, we present a 58-year-old woman who developed a delayed-onset left lower extremity phlegmasia cerulean dolens 8 weeks after coronavirus disease 2019 onset that led to compartment syndrome and acute limb ischemia from external compression of the arterial vasculature from edematous muscle. The patient received an emergent minimally invasive percutaneous mechanical thrombectomy and four-compartment fasciotomy, resulting in adequate perfusion and ultimately made a full recovery.

Pulmonary Rehabilitation in SARS-CoV-2: A Systematic Review and Meta-Analysis of Post-Acute Patients

BACKGROUND

Pulmonary Rehabilitation (PR) was initially developed for the management of Chronic Obstructive Pulmonary Disease (COPD) and is now recognized as a core management of COVID-19 patients. This systematic review and meta-analysis examined the efficacy of PR in patients with post-acute COVID-19 infection.

METHODS

A literature search was conducted in PubMed, the Web of Science (WoS), and the Cochrane Library from their inceptions until October 2022, and randomized controlled trials and observational studies were considered. The outcomes measured included dyspnea, physical function, and quality of life.

RESULTS

Eleven studies including 677 participants with post-acute COVID-19 were included in this analysis. From a qualitative point of view and analyzing the studies separately, PR improves dyspnea, physical function, and quality of life in patients with post-acute COVID-19. However, in pooling the data of all the studies, no significant changes pre-postintervention, compared to the control, were found among the experimental studies included in the analysis in any outcome measures, due to the high heterogeneity between the studies, as well as no significant improvements being found in the observational studies. A subgroup analysis revealed significant differences in all the included outcomes. Future studies should include the same scale to assess the actual efficacy of PR.

CONCLUSION

From a qualitative analysis point of view, PR is effective in improving physical function, reducing dyspnea, and improving quality of life in patients with post-acute COVID-19. However, an exploratory meta-analysis was performed to evaluate, by subgroups, the efficacy of PR, and positive results were found in favor of PR.

The Potential of Exerkines in Women's COVID-19: A New Idea for a Better and More Accurate Understanding of the Mechanisms behind Physical Exercise

The benefits of physical exercise are well-known, but there are still many questions regarding COVID-19. Chow et al.'s 2022 study, titled Exerkines and Disease, showed that a special focus on exerkines can help to better understand the underlying mechanisms of physical exercise and disease. Exerkines are a group of promising molecules that may underlie the beneficial effects of physical exercise in diseases. The idea of exerkines is to understand the effects of physical exercise on diseases better. Exerkines have a high potential for the treatment of diseases and, considering that, there is still no study of the importance of exerkines on the most dangerous disease in the world in recent years, COVID-19. This raises the fundamental question of whether exerkines have the potential to manage COVID-19. Most of the studies focused on the general changes in physical exercise in patients with COVID-19, both during the illness and after discharge from the hospital, and did not investigate the basic differences. A unique look at the management of COVID-19 by exerkines, especially in obese and overweight women who experience high severity of COVID-19 and whose recovery period is long after discharge from the hospital, can help to understand the basic mechanisms. In this review, we explore the potential of exerkines in COVID-19 by practicing physical exercise to provide compelling practice recommendations with new insights.