Physiotherapy interventions in post- and long-COVID-19: a scoping review protocol

Abstract

Introduction

Post- or long-COVID-19 conditions manifest with a spectrum of symptoms reminiscent of pulmonary, musculoskeletal, psychological and neurological disorders. Individuals with post- or long-COVID-19 syndrome often present with myalgia, pulmonary problems and fatigue, which significantly impact their daily functioning. Physiotherapy interventions are an accepted medical remedy for these symptoms. This scoping review aims to outline the evidence of physiotherapy interventions documented in the scientific literature, specifically focusing on hands-on therapy.

Methods and analysis

This scoping review conforms to the methodological framework established by the Joanna Briggs Institute (JBI). The procedure for drafting a scoping review involves several steps, starting with defining the research question and the inclusion and exclusion criteria. Eligible studies are those analysing physiotherapy treatment parameters for direct patient interaction in post- and long-COVID-19 patients. Telemedicine and entirely home-based workouts will be excluded aligning with the context of outpatient physiotherapy in Germany. The literature search will be conducted in PubMed, EBSCO research, Scopus, Web of Science, Embase, PEDRO, Cochrane and WISO databases by two independent researchers. Screening, data extraction and a critical appraisal will be performed by these researchers using assessment tools provided by the JBI. Extracted data will encompass demographic characteristics, definitions of post- or long-COVID-19 conditions, descriptions of interventions, their treatment parameters and treatment outcome. Subsequently, findings will be disseminated through a scoping review article or conference presentation.

Ethics and dissemination

Given that this review does not involve human participants, ethical committee approval is deemed unnecessary. The results will be published in peer-reviewed journals and presented at academic and physiotherapeutic conferences.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• There will be no librarian supporting the literature research.

• The scoping review covers only English and German language publications.

• First known literature review focusing on physiotherapy treatment parameters in post- or long-COVID-19 condition.

• No manual search was conducted.

• A quality assessment will be included in the review.

Introduction

The manifestation of post- or long-COVID-19 condition follows an acute COVID-19 infection. The prevalence of the post- and long-COVID-19 condition varies from 10% to 35% in patients developing subacute or chronic symptoms.^{1 2} This phenomenon has been previously observed in the aftermath of other infectious diseases, for example, with the development of postviral fatigue (ICD-10 code G93.3).³ Patients with post- or long-COVID-19 present diverse symptom complexes akin to those observed in patients with pulmonary, musculoskeletal, psychological and neurological disorders.² Affected individuals frequently report myalgia, pulmonary complications, fatigue and significant limitations in daily living.^{2 4 5} Synonyms such as ‘post-acute COVID’, ‘long-haul COVID’ and ‘post-acute sequelae of SARS-CoV-2 infection’ are used for post- or long-COVID-19. The WHO introduced the ICD-10-CM-Code ‘U09.9 Post COVID-19 condition, unspecified’, defining it as a ‘continuation or development of new symptoms 3 months after the initial SARS-CoV-19 infection, with these symptoms lasting for at least 2 months with no other explanation’. The term Long-COVID is used interchangeably with Post-COVID.^{6 7} Post-COVID-19 is defined as the persistence of symptoms for a minimum of 2 months over a 12-month period.⁷ Given the interchangeable use of the terms post- and long-COVID-19 in common discourse,⁷ both terms and their definitions will be considered in this project. Physiotherapy is recommended in the interprofessional treatment of long-COVID-19, because most of the symptoms can be addressed by physiotherapeutic interventions.^{2 8} Positive effects of physiotherapy interventions in the context of other diagnoses have been reported for some of these symptoms, for example, chronic obstructive pulmonary disease or fibromyalgia.⁹,¹¹ Physiotherapy interventions are recommended in medical guidelines or statements for treatment in patients with post- or long-COVID-19 condition.¹²,¹⁵

In Germany, physiotherapy is an accepted intervention prescribed by physicians and partially funded by health insurers. The prevalence of post- and long-COVID-19 conditions has heightened the demand for physiotherapy in Germany. The therapeutic intervention index (Heilmittelkatalog. https://heilmittelkatalog.de; accessed 31 Jan 2023) in Germany has been adjusted to include physiotherapy in the treatment of post- and long-COVID-19 syndrome. Notably, the prescription of physiotherapy for patients with post- and long-COVID-19 is not deducted from physicians’ budgets, making the prescription process less bureaucratic. Data from the Scientific Institute of German Health Insurance indicate a surge in the number of patients with post- and long-COVID-19 conditions receiving physiotherapy prescriptions, which escalated from 218 in 2020 to 6928 in 2022. The number of physiotherapy prescriptions also increased from 377 in 2020 to 10 718 in 2022, including a broad spectrum of physiotherapy interventions, such as exercise therapy, massage and electrotherapy (Wissenschaftliches Institut der AOK (WIDO)) provided the information on the request of the authors).

Given the novelty of the post- or long-COVID-19 conditions, this study was inspired by outpatient physiotherapists, who reported a lack of adequate information regarding treatment options for this syndrome. Schreiber et al confirmed this impression, revealing that 65% of participating physiotherapists felt insufficiently informed about post- and long-COVID-19 rehabilitation.¹⁶

Studies and reviews highlight the positive effects of exercise programmes.¹⁷,²¹ Implications such as ‘a slow progressive approach’¹⁷ have been emphasised.^{17 22} Other authors have underlined the need for ‘robust study design and knowledge sharing’.^{23 24} Due to the absence of ‘validated treatment options’,²³ physicians’ treatments often take on an experimental design, and adverse events are less frequently reported.^{17 23} This scenario extends to other healthcare professionals, including physiotherapists.

This scoping review will be conducted to collect evidence for physiotherapy interventions from the scientific literature, placing a focus on those applicable in hands-on therapy. This protocol presents the planned methodology for conducting this scoping review.

Methods and analysis

This scoping review was registered retrospectively on Open Science Framework (registry number osf.io/5k3tA). Two research associates who have extensive experience in rehabilitation research will conduct this scoping review independently. The PRISMA checklist for scoping reviews can be found in the online supplemental file 1.

This scoping review will be carried out using the guideline established by the Joanna Briggs Institute (JBI).²⁵ The methodological framework for conducting a scoping review entails several sequential steps, starting with defining the research question, defining the inclusion and exclusion criteria and completing the literature search. Iterative loops will be performed to ensure the comprehensive coverage of all relevant aspects.²⁶

Patient and public involvement

No patients were involved in this project.

Research question

The primary research question guiding this review is ‘What kind of physiotherapeutic interventions are used in both outpatient and inpatient settings for Post- and Long-COVID-19 patients?’. This question is divided into several sub-questions, as shown in table 1.

Table 1. Scoping review research sub-questions.

Perspective	Research questions
Descriptive	How many studies were published between January 2020 and February 2023 on physiotherapy interventions in patients with post- or long-COVID-19 syndrome?
Methods	Which research methods were used in the published literature (qualitative/quantitative)? What population characteristics are described in the published literature? What definitions of post- and long-COVID-19 are used in the published literature?
Physiotherapy interventions	What types of physiotherapy interventions are reported in the published literature? What is the reported frequency of the physiotherapeutic interventions? What is the reported intensity of the physiotherapeutic interventions?
Physiotherapy and post-/long-COVID-19	What is the impact of physiotherapy on post- or long-COVID-19 symptoms? Are adverse events reported for physiotherapeutic interventions in patients with post- or long-COVID-19 syndrome? Are negative influences reported for parallel, applied physiotherapeutic interventions in patients with post- or long-COVID-19 syndrome? Are differences reported in inpatient and outpatient interventions?

Inclusion and exclusion criteria

The selected articles for inclusion must adhere to the criteria outlined in table 2. The articles needed to describe randomised controlled trials, observational studies, case reports, systematic reviews or meta-analyses investigating physiotherapy treatment parameters in the context of the post- or long-COVID-19 conditions. Overview articles or articles describing the treatment of an acute COVID-19 infection will be excluded. This study examines fundamental treatment modalities for physiotherapists engaging in direct patient care. To date, telemedicine approaches are not widely established in physiotherapy care in Germany. Therefore, these approaches were excluded from this study. Home exercise programmes can be recommended by physiotherapists but are not obligatory. For this reason, this scoping review exclusively directs a focus towards direct interventions, such as hands-on techniques.

Table 2. Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Long-COVID-19Post-COVID-19Post-acute COVIDPatients aged above 18 yearsPhysiotherapy interventionsPhysiotherapy interventions with additional home exercise workoutRandomised controlled trials, observational studies, case reports, systematic reviews and meta-analyses, umbrella reviews, rapid reviewsGerman or English languagePublication date between January 2020 and February 2023	Acute COVID-19Non-COVID-19Other infectious diseasesNon-systematic reviewsStudy protocolsEditorials, lettersNarrative reviewsPatients aged under 18 yearsTelemedicineSolely home-based workouts

Literature search

The literature search will be carried out by two independent researchers, without the involvement of a professional librarian.

1. The following databases will be searched: PubMed, EBSCO, Scopus, Web of Science, Embase, PEDRO, Cochrane and WISO.

2. Search terms will primarily be chosen on the basis of predictor variables (or the independent/predictor variables). Relevant keywords will be identified with thesauruses deposited within each of the databases used for optimisation. The strategies for the literature search concerning search terms and Medical Subject Headings (MeSH) are shown in tables3 4, respectively.

Table 3. Search terms.

Domain	Search terms
Population	Long-COVID, post-COVID-19,post-acute COVID
Physiotherapy intervention	Physiotherapy, aerobic exercise, physical activity, resistance training, passive mobilisation, active mobilization, manual therapy, massage therapy, lymphatic drainage, electrotherapy, ultrasound, respiratory therapy, proprioceptive neuromuscular facilitation (PNF), Vojta, Bobath, pressure ulcer management, prevention
Outcome	Physical fitness, fatigue, general health, pain, return to work, physical health, mental health, mobility, vital capacity, fatigue, dyspnoea, myalgia, arthralgia, functional capacity, health-related quality of life, stress, range of movement, patient-reported outcome measures
Study design	Randomised control trialObservational studiesCase reportsSystematic reviewsMeta-analyses

Table 4. Search strategy for PubMed.

Number	Strategy/Medical Subject Headings (MeSH)
1	”Post-acute COVID-19 syndrome”
2	“Physical therapy modalities“ OR “Physical therapy specialty“ OR ”Exercise therapy” OR “Exercise movement techniques” OR “Physical fitness“ OR “Musculoskeletal manipulation” OR “Relaxation” OR “Stress, physiological” OR “Immobilisation” OR “Prevention & control” OR “Manual lymphatic drainage“ OR “Electric stimulation therapy“ OR “Ultrasonic therapy“ OR “Respiratory therapy“ OR “Breathing exercises“
3	“Physical fitness“ OR “Fatigue“ OR “Mental health” OR “Return to work“ OR “Pain management” OR “Vital capacity“ OR “Myalgia“ OR “Arthralgia” OR “Quality of life“ OR “Patient-reported outcome measures“ OR “Health” OR “Health status”
4	“Randomised controlled trial” OR “Observational study” OR “Case reports” OR “Systematic review” OR “Meta-analysis”
5	1 AND 2
6	3 AND 5
7	4 AND 6

Study selection

Following database searches, relevant studies will be selected by the two independent researchers. Therefore, a screening of titles and abstracts by each researcher will be conducted. Subsequently, both researchers will compare their results and resolve any differences through discussion. The selection procedure will be conducted in accordance with the guidelines provided by the JBI.²⁵ The study selection process will be charted.

Data extraction

After selecting and screening the included studies, the data will be extracted by the two independent researchers. A matrix will be used incorporating key information, as recommended by the JBI.²⁵ This matrix will encompass items such as population characteristics, definitions of post- and long-COVID-19 syndrome, interventions applied, treatment parameters, treatment outcomes and adverse events. Additionally, definitions of the post- and long-COVID-19 conditions will be considered during data extraction.

Critical appraisal

The selected studies will be critically appraised by the two independent researchers with many years of experience in rehabilitation research by using the JBI critical appraisal tools.²⁶ In preparation for the quality assessment, the JBI critical assessment tools and their notes will be studied and discussed until a consensus is reached. The quality assessment will be carried out to evaluate methodological quality with regard to the data to be extracted from the included articles. If predominantly methodological ambiguities regarding the data to be extracted are noted, that is, treatment parameters, a manuscript will be excluded. The protocol specifies that the selected studies be screened for the physiotherapy treatment parameters and physiotherapy interventions. As soon as the screening yields positive results, the studies will be evaluated qualitatively. Each researcher will individually complete the quality assessment for the selected studies. Afterwards, both reviewers will compare their results in terms of study quality. If differences are detected, the study in question will be discussed until a consensus is reached. The quality assessment results for the individual studies will be taken into account when presenting results.