Critically appraised paper: In people reporting dyspnoea following COVID-19 hospitalisation, additional telerehabilitation is more effective at improving exercise capacity, muscle strength and the physical component of quality of life than education alone [commentary]

Commentary

Despite COVID-19 leaving millions of people with rehabilitation needs, services have been reliant on general rehabilitation principles, clinical expertise and consensus guidance based on evidence from other conditions.¹ This trial provides evidence of the effects of rehabilitation for patients admitted to hospital with COVID-19 who had moderate breathlessness at discharge.

The group-level differences in the primary outcome of functional exercise capacity at 6 and 28 weeks were striking. They were twice the minimum clinically important difference, meaning that most participants perceived the change, reflected in their quality of life scores. They also far exceeded changes after a similar intervention following admission for exacerbation of chronic respiratory disease.² This may be related to differences in pre-admission function and the potential recovery trajectory.

The primary finding is also impressive, given the delivery model with minimal therapist contact and supervision. The COVID-19 pandemic has led to rapid growth in digital healthcare interventions, making efficient use of therapist time and promoting patient self-management and empowerment. However, such interventions can introduce inequality due to costs and digital capability (hardware ownership, literacy, etc). Patient choice and preference should guide use, and communication to understand each patient’s goals, motivations and challenges remains important.

Although not widely recognised early in the pandemic, ‘Long COVID’ is now understood as a key consideration in post-viral disease. It may explain some of the adverse events, discontinuations and re-hospitalisations observed in this trial, which were higher in the intervention group but were not attributed to the intervention. Clinicians should vigilantly screen for oxygen desaturation, post-exertional symptom exacerbation, cardiac impairment and autonomic dysfunction during and after rehabilitation interventions. Given the multi-dimensional, episodic and unpredictable nature of Long COVID, pacing (activity management) and symptom-titrated activities are advocated, whereas graded or fixed incremental exercise prescriptions are not.³