General rehabilitation for the Post-COVID-19 condition: A narrative review

Abstract

COVID-19 significantly impacts the acute phase or the period after being infected by severe acute respiratory syndrome coronavirus-2. Studies have shown it has affected multiorgan and needs continuous care by a multidisciplinary team. Nowadays, guidance is required to assist the recovery process of survivors who reported at least one symptom as a residual effect. This study aims to describe the rehabilitation management of post-COVID-19 conditions. As the number of survivors seems to be increasing, it is expected that COVID-19 survivors will recover through a holistic approach by all physicians. Comprehensive rehabilitation for long COVID or COVID-19-related illnesses includes exercising, nutrition, education, managing voice, breathlessness, neurocognitive problems, mental health, feeding problems, and daily activities. Specific recommendations have already been published to support rehabilitation for survivors in every targeted organ. Supportive care, especially rehabilitation programs, is recently an urgent knowledge in this pandemic.

COVID-19 (Coronavirus-19) is a highly contagious respiratory disease that eventually becomes a pandemic and has significantly impacted the world.[1] The respiratory system, especially the lungs, is the most common site of the infection.[2]

Due to the advancing studies following the disease, the definition of long COVID kept developing, such as long-haul COVID or postacute sequelae of severe acute respiratory syndrome coronavirus-2 infection (PASC).[3,4,5,6] Fatigue, shortness of breath, and cognitive dysfunction are common symptoms and impact daily functioning. Symptoms may be new-onset, following initial recovery from an acute COVID-19 episode, or persist from the initial illness. Symptoms may also fluctuate or relapse over time.[7]

Studies show that approximately 10% of people experience prolonged illness after being infected with COVID-19.[5] The disease is recently predicted with significant morbidity for 3–6 months (intermediate phase) and requires routine medical and rehabilitation services for 12 months or longer (chronic phase).[1,8]

At 6 months after acute COVID-19, the most common pulmonary impairment is decreased lung diffusing capacity for carbon monoxide (about 33% of patients), followed by decreased total lung capacity (approximately 17%).[9]

There is a strong need for COVID-19 survivors to be given a rehabilitative program.[1] Their wellness can be achieved through multidisciplinary team rehabilitation and community-based rehabilitation services, including patient self-management and peer support.[1,5,10] Thus, this article aimed to describe recommendations and the most effective management of post-COVID-19 conditions.

Rehabilitation for Post-COVID-19 Condition

Since the COVID-19 pandemic emerged, continuous rehabilitation and management have already been introduced in the critical care setting or soon after the acute phase. The National Institute for Health and Care Excellence recommends starting progressive rehabilitation programs within the first 30 days (postacute phase) to maximize recovery. The management for rehabilitation in COVID-19 is shown in Table 1.[1,2,4,5,9,11,12]

Table 1.

Management of post COVID syndrome conditions[2,4,5]

Symptoms	Suggestion activities[1,11,12]
Chronic fatigue,[9] deconditioning	Physical exercise
	Adjust patients’ expectations and ease back into activities. Principal for starting an exercise: start low, go slow
	Energy conservation and fatigue management using pace, prioritize, and plan
	Allow others to assist the patients
Chest pain Palpitation	Specialty guidance should be sought based on the patient’s initial examination and symptoms, and additional investigations may include a specialist blood panel, echocardiography, ECG*, 24 h ECG, cardiopulmonary exercise tests, and/or cardiac MRI* Depending on symptoms and complications, a rest period following infection will reduce the risk of postinfection cardiac failure secondary to myocarditis
Persistent dyspnea/shortness of breath[9] Persistent oxygen requirement	Positioning
	Lying proning
	High side-lying
	Forward lean sitting (with/without a table in front)
	Forward lean standing
	Standing with back support
	Breathing techniques
	Controlled breathing
	Paced breathing
	When it is generally safe, an initial assessment is recommended as soon as possible, depending on the severity of dysfunction, normocapnic respiratory failure, and the patients’ physical and mental status
	Low-intensity exercise (3 METs* or similar) should be tried first, especially for patients who require oxygen therapy, while vital signs are monitored (heart rate, pulse oximetry, and blood pressure). The amount of activity they do should be gradually increased based on their symptoms
Chronic cough	Instead of inhaling by mouth, try breathing through the nose
	Try the “cough-stopping exercise.” Close the lips and cover them with a palm as soon as the patient feels the urge to cough (smother the cough). Simultaneously, force the patients to swallow. Take a breather and a break. When they begin to breathe again, gently inhale and exhale through the nose
	If the patients cough at night due to gastric reflux, try lying on their side or using pillows to prop themself up
Hoarseness	Keep talking if it is comfortable
	Do not strain the voice
	Take rests
	Try humming
	Use other ways of communicating
	Sip water throughout the day
Neurocognitive deficits (brain fog)	Brain exercises, such as new hobbies or activities, puzzles, word and number games, memory exercises, and reading
	Prompt patients with lists, notes, and alerts, such as phone alarms
	Break down activities, take frequent breaks
	Minimize distractions
	Complete activities fatigue when less
	Referral to psychological services and considering trauma-focused cognitive behavioral therapy, cognitive processing therapy, or eye movement desensitization and reprocessing is appropriate for moderate to severe acute stress disorder symptoms.
	Severe symptoms have the potential to cause considerable or life-altering disability. For patients with moderate-to-severe
	neurological symptoms, inpatient multimodal rehabilitation is advised to maximize recovery
Mood changes, anxiety/depression, sleep disruption	Get enough quality sleep
	Eating sufficiently and healthily
	Be physically active
	Staying socially connected
	Do relaxing activities
	Gradually enhance patients’ participation in their regular activities or hobbies
Feeding problem (difficulty in swallowing and drinking)	Sit upright whenever the patients eat or drink
	Remain upright
	Try foods of different consistencies
	Concentrate when the patients eat or drink
	Take the time when eating
	Make sure the mouth is clear
	Eat smaller meals throughout the day
	If the patients cough or choke or their breathing becomes difficult when eating and drinking, take a break to recover

*ECG: Electrocardiogram, METs: Metabolic equivalent tasks, MRI: Magnetic resonance imaging

World Health Organization also provides a supportive rehabilitation guideline for COVID-19 survivors. It is shown in Figure 1 below. There are several main components in supportive care for them. Table 1 also describes specifically each of the components.[11,12]

Figure 1.

Components of supportive care for COVID-19-related Illness.[11,12] 3P: Pace, plan, prioritize

Many COVID-19 survivors feel doubtful about returning to their daily activities since they still have some residual symptoms. Thus, physicians take a significant role in encouraging and educating the survivors to start their initial recovery. A staged strategy can be utilized to improve physical activity levels to baseline or beyond once a patient has been symptom-free for at least 7 days. Patients should be risk-stratified before the next phase of recovery management if there are still several symptoms, such as cardiac, psychological, or other enduring symptoms post-COVID-19. Further examinations are sometimes needed to complement the assessment, such as an electrocardiogram, laboratory blood panel, or cardiopulmonary exercise testing. A special precaution is made for myocarditis cases. If COVID-19 patients are confirmed to have myocarditis, they are restricted to exercise for 3 up to 6 months and need periodic assessment.[13]

After the acute phase of COVID-19, patients might experience worsening of fatigue and other symptoms (described as “crashing“ or “relapse“) after minimal exertion. Recently, it has been known in terms of postexertional malaise. Typically, the exacerbation occurs hours or days after the physical or mental activity. It takes 24 h or longer to recover. It can affect your energy levels, concentration, sleep, and memory and cause muscle/joint pains and flu-like symptoms. Thus, it is recommended to have gradual exercise before ultimately returning to normal activities. Five steps below, described in Table 2, can be implemented to guide the preparation before the patients are entirely back to their previous activities.[12]

Table 2.

Five steps before returning to the previous exercises and sports participation for COVID-19 survivors[12]

Phases	Exercises
Phase 1. Very low-intensity activity	Examples: Gentle walking, stretching, balance, and controlled breathing exercises. If the RPE* score for any of these is >1, do not do them in this phase
	Stretching can be done in a sitting or standing position. Perform gently, and hold each one for 15-20 s
Phase 2. Low-intensity activity	Examples: Walking, light household/garden tasks. If the RPE score for any of these is >3, do not do them in this phase
	If patients can tolerate RPE scores of 2-3, gradually increase the exercise time by 10-15 min per day
	Before moving on to the next level, spend at least 7 days in this phase without PEM* Do not forget to have a stretching
Phase 3. Moderate-intensity activity	Examples: Brisk walking, going up and down stairs, jogging, introducing inclines, resistance exercises, bicep curl, arm raises to the side, wall push-off, sit to stand, knee straightening, squats, heel raises
	If the RPE score for any of these is >5, do not do them in this phase
Phase 4. Prereturn to the baseline exercises	Some examples: Running, cycling, swimming, and dance classes. If the RPE score for these exercises is >7, do not do them in this phase
Phase 5. Return to the baseline exercises	Now patients can return to complete their pre-COVID-19 regular exercise/sports/activity

*RPE: Rating of perceived exertion[12], PEM: Postexertional malaise[12]

Exercise for survivors also should be started with a warm-up and closed by cooling down exercise. Fitness and strengthening exercises are the main exercises for both arms and legs. For warm-up exercises, patients can do shoulder shrugs, shoulder circles, side bends, knee lifts, ankle taps, or ankle circles. To cool down the body, patients can walk at a slower pace, gently march on the spot for approximately 2 min, or repeat the warm-up exercises to move the joints while sitting or standing. The fitness exercise can march on the site, take step-ups, walk, jog, or cycling, while the strengthening exercise is mainly included in phase three.[11,12]

Finally, physicians should provide a prudent approach for the survivors. The supportive care, especially the exercise program, should be gradual, individualized, and based on subjective activity tolerance.

Interdisciplinary Management in COVID-19

Several studies have promoted comprehensive care for post-COVID patients, including referral pathways, initial assessment after being referred, subsequent care, and disposition intervention. The primary goals of that comprehensive care are to (a) provide a comprehensive evaluation of post-COVID-19 complications, (b) characterize and mitigate pulmonary sequelae of COVID-19, and (c) address persistent symptoms experienced by post-COVID-19 survivors. A multidisciplinary care program should include coordination with primary care, access to rehabilitation services, social work and welfare support, pharmacy, subspecialty care through direct inclusion or targeted referrals, and structured peer support programs with trained moderators.[13,14] Various assessments are needed to examine patient's condition either before or after discharge. Outpatient should be assessed after the referral to the rehabilitation. In the Table 3 below, we summarize the assessment section.[4,5,13,14,15,16]

Table 3.

Assessments before discharging the patients and after the referral to rehabilitation[4,5,13,14,15,16]

Period	Assessment
Before the patient is discharged	Respiratory and functional assessment should be performed using mobile or pulse oximetry, physical and occupational therapy, and swallow evaluation
	It is urgently needed for the survivors to have an evaluation and to meet their clinical needs
	Clinicians should also be flexible in their approaches, such as telemedicine or an applied hybrid model that accommodates virtual and in-person clinics. Health care providers should arrange home services and identify the COVID-19 survivors who need to be referred[13,15]
Follow-up in primary care	Collect a detailed history and physical examination and perform functional, mental health, and cognitive impairment assessments[4,16]
	Assess the pulmonary or cardiovascular system symptoms such as dyspnea or persistent oxygen requirement at 4 up to 6 weeks and 12 weeks postdischarge
	Current guidelines recommend that follow-up begins 4-8 weeks after discharge or acute illness for those not hospitalized and continues for 3 months as needed[4]
After being referred to rehabilitation[5,14]	Pulmonary and extrapulmonary consultation Subjective examination
	Repeated imaging status and selected laboratory test
	PFTs*
	6MWT*
	Neurocognitive and mental health screening
	If the symptoms are resolved, and the PFTs are normal, they can transition to primary care, but if the symptoms persist or the PFTs value is abnormal, they must continue the comprehensive care[14]

*PFTs: Pulmonary functional tests,[14] 6MWT: 6-min walk test[14]

Rehabilitation takes a leading role in the subsequent care in pulmonary rehabilitation and physical/occupational therapy of outpatient care.[5,14] Physiatrist also needs to conduct programs during acute and postacute phases. Comprehensive management is urgently required to facilitate physical, cognitive, psychosocial, and vocational rehabilitation due to the complexity of PASC. They should examine neurological and musculoskeletal complications. Specifically, physical therapy needs to teach the survivors or caregivers compensatory strategies to adapt and improve functioning until tolerated and can be titrated to the optimum. Occupational therapy plays a role in evaluating and managing cognitive impairment, encouraging active engagement in meaningful activities, resumption of productive life, and returning to social participation.[6,14]

Conclusion

A rehabilitation program for long COVID aims to recover physical function optimally. Post-COVID-19 condition becomes increasingly common as the pandemic evolves. It has many symptoms and involves multi-organ. To handle COVID-19 survivors, a thorough and multidisciplinary strategy is required, incorporating primary care physicians for initial evaluation and appropriate referrals. Every supportive program is individualized, comprehensive, and should be safe for the survivors. Thus, we encourage health-care professionals to recognize the implications of long-term rehabilitation of post-COVID-19 conditions effectively.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.