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12 October 2022: Review Articles

Effects of Physiotherapy on Rehabilitation and Quality of Life in Patients Hospitalized for COVID-19: A Review of Findings from Key Studies Published 2020–2022

Samire Beqaj 12ABCDEF* , Amra Mačak Hadžiomerović 1ABEF , Arzija Pašalić 1DEF , Amila Jaganjac 1DEF

DOI: 10.12659/MSM.938141

Med Sci Monit 2022; 28:e938141

Table 1 Characteristics of the reviewed intervention studies.

StudyType of studySubjectsN%FSettingIntervention, duration and frequency
Ahmed et al, 2021 []53 Prospective intervention studyPatients currently admitted to rehabilitation center. previously hospitalized during their active COVID-19 disease, divided in 2 subgroups, those who used ventilatory support (group 1, 10 subjects), and who did not use ventilatory support (group 2, 10 subjects)2035Outpatient department at Bin Inam Rehabilitation Center. Faisalābad, Punjab, PakistanAerobic training: 5 weeks (3 sessions/week, 15 sessions in total) of upper or lower limb ergometry, elliptical or treadmill. The intensity defined by:Based on American College of Sports Medicine guidelines, the duration was increased daily by increasing the work rate and carefully monitoring the heart rate and rate of perceived exertion to achieve the 60-min session on the final day intervention.Breathing exercise training: Buteyko Breathing Technique consisting of ‘Slow and Reduced breathing’ in combination with ‘control pauses’ and ‘extended pauses’ under an on-site physiotherapist’s supervision
Chikhanie et al, 2021 []54 Part of an ongoing cohort of pulmonary rehabilitation 2019–2022Post-ICU COVID-19 and non-COVID-19 patients admitted to pulmonary rehabilitation2133Pulmonary rehabilitation center Dieulefit Sant’e in Dieulefit, France (No information on whether it is inpatient or outpatient)Pulmonary rehabilitation: respiratory exercises, muscle strengthening, balance and walking when possible, cycling and gymnastics according to current American Thoracic Society/European Respiratory Society recommendations.Duration of pulmonary rehabilitation: 27.6±14.2
Everaerts et al, 2021 []55 Prospective intervention studyDischarged COVID-19 adult patients admitted to an outpatient multidisciplinary rehabilitation program2232Multidisciplinary rehabilitation program for outpatient adult patients with COVID-19 at KU Leuven University Hospitals Leuven, Leuven, BelgiumRehabilitation program for 3 months (1.5 hours per session/3 times a week).Endurance training: treadmill, cycle ergometer, arm ergometer and stair climbing or step.The program started at 60–75% of maximal individual performance.If the patient was not able to cycle ≥10 min on 80% of his maximal work load during Cardiopulmonary Exercise Testing (CPET), interval training was implemented.Progressive overload was obtained by increasing both intensity and duration, targeting symptom score 4–6/10 on Modified Borg dyspnea and fatigue scale.Strength training: leg and chest press
Gloeckl et al, 2021 []56 Prospective observational cohort studyPatients in the post-acute phase of a mild/moderate or severe/critical course of COVID-19 admitted to a pulmonary rehabilitation program5056Inpatient pulmonary rehabilitation at the Schoen Klinik Berchtesgadener Land, Schoenau am Koenigssee, Germany3-week inpatient pulmonary rehabilitation program.Cycle endurance training: 10–20 min per session at 60–70% of peak work rate, 5 days per week.Strength training using resistance training machines, ~30 min per session, 5 days per week, 3 sets of 15–20 repetitions of leg press, knee extension, pull-down and push-down, butterfly forward/backward, rowing, back extension and abdominal trainer.Individually tailored respiratory/chest physiotherapy, 30 min, 2–4 times per week using techniques for breathing retraining, cough techniques, mucus clearance, connective tissue massage, energy conservation techniques, etc.Activities of daily living training (callisthenics), 30 min, 4–5 times per week, as well as Nordic walking or aqua fitness, 30 min, twice per week.Relaxation techniques QiGong or progressive muscle relaxation (Jacobson technique), 30 min, twice per week.Patient education.Occupational therapy.Psychological support.Nutritional counseling
Hermann et al, 2020 []57 Retrospective cohort studyPatients referred from acute care hospitals after severe COVID-19 to inpatient rehabilitation, grouped into previously ventilated and non-ventilated patients2850Zurich RehaCenter, Klinik Wald, SwitzerlandCardiopulmonary rehabilitation program, adapted to the severity of the disease, duration 2–4 weeks (5–6 days per week, 25–30 therapy sessions in total).Aerobic exercise: primarily supervised indoor and outdoor walking or stationary cycling.Strength training: 3×20 repetitions with the maximum tolerated load. The intensity of the monitored endurance training sessions was adjusted continuously to achieve the maximum tolerated exercise load during each training session.Respiratory physiotherapy: teaching breath control (pursed lip breathing, secretion mobilization, and diaphragmatic breathing), energy saving techniques, and controlled coughing exercises.Educational sessions: self-management, coping skills and nutrition interventions, self-medication, management of infections and exacerbations, dyspnea, use of oxygen, and activities of daily living
Puchner et al, 2021 []58 Prospective observational studyPost-acute COVID-19 patients enrolled into specific rehabilitation program, previously hospitalized due to COVID-19 in two tertiary care centers, Innsbruck and Zams, Tyrol, Austria.2330Inpatient Clinic for Rehabilitation Münster, AustriaIndividualized, multiprofessional rehabilitation training, duration at least 3 weeks (mean=24±5 days) (25 min per session):Endurance training: 20 minutes at resistance of 50% of individual Pmax. The interval approach consisting of an eight-minute warm-up with 30% of individual Pmax, 12 interval bouts with 100% of Pmax for 30 seconds followed by an active recovery phase for another 30 seconds with 0–20% of Pmax and a six-minute cool-down phase with 20% of Pmax. The subjective feeling of physical effort and adjustment to intensity was done twice during training session using BORG RPE-Scale (6–20).Strength training: strength-training devices, as well as using body weight, elastic bands, dumbbells.Breathing therapyRespiratory muscle trainingMobilization and breathing perception therapy (general mobilization, thorax mobilization, and breath perception training).Speech therapyOccupational therapyPsychological therapyNutritional counseling (50 min per session)
Spielmanns et al, 2021a []59 Prospective observational studyPatients overcoming the acute phase of COVID-19 infection, referred from acute hospitals for inpatient pulmonary rehabilitation after hospitalization9942.4Zurich RehaCenter, Klinik Wald, Switzerland3-week inpatient pulmonary rehabilitation program (5–6 times/week, max 4 exercise sessions/day, 25–30 sessions in total).Endurance training: individualized exercise including cycling and treadmill, gymnastics (3 levels), in-and outdoor walking (3 levels).Strength training: 3 series of 8–12 repetitions per exercise, 3–5 exercises for large muscle groups, the intensity goal of 4–5/10 on Modified Borg dyspnea and fatigue scale, adapted to the patients’ functional performance and physical limitations.Respiratory physiotherapy: teaching breath control (pursed lip breathing, secretion mobilization, and diaphragmatic breathing), energy saving techniques, and controlled coughing exercises.Educational sessions: self-management, coping skills, self-medication, management of infections and exacerbations, dyspnea, use of oxygen, and nutrition interventions
Spielmanns et al, 2021b []60 Prospective observational studyPatients overcoming the acute phase of COVID-19 infection, referred from acute hospitals for inpatient pulmonary rehabilitation after hospitalization18333Zurich RehaCenter, Klinik Wald, Switzerland3-week inpatient pulmonary rehabilitation program (5–6 times/week, 4 exercise sessions/day, 25–30 sessions in total).Endurance training: individualized exercise including cycling and treadmill, gymnastics (3 levels), in- and outdoor walking (3 levels).Strength training: individually, according to recentAmerican Thoracic Society/European Respiratory Society recommendations, the intensity goal of 4–5/10 on Modified Borg dyspnea and fatigue scale, adapted to the patients’ functional performance and physical limitations.Educational sessions: self-management, coping skills, self-medication, management of infections and exacerbations, dyspnea, use of oxygen, and nutrition interventions
Udina et al, 2021 []61 Prospective cohort studyPost-acute care and post-COVID-19 patients included in a rehabilitation protocol3357.6/Multi-component therapeutic exercise intervention (mean=8.2±1.7 days, 7 days/week, 30 min/session).Endurance training: up to 15-min aerobic training with a cycle ergometer, steps or walking.Strength training: 1–2 sets with 8–10 repetitions each, intensity between 30–80% of the Repetition Maximum.Balance training: walking with obstacles, changing directions or on unstable surfaces.Recommendations to decrease daily sedentary behavior
Zampogna et al, 2021 []62 Retrospective data analysisPost-COVID-19 patients, consecutively admitted to an inpatient pulmonary rehabilitation program14032.2ICS Maugeri hospitals in Italy (Bari, Lumezzane, Tra-date, Pavia, and Veruno) and referral institutions for pulmonary rehabilitation, diagnosis, and care for post-acute and chronic subjectsAn Italian Position Paper based multidisciplinary program was applied in all centers involved. Intervention type, intensity, timing and modality were tailored to the individual patient starting from 1, 20-min daily session up to 2–3, 30-min daily sessions.Patients were allocated either to individual (level A if SPPB < 6 with a physiotherapist/patient ratio 1: 1) or group (level B if SPPB ≥6 with a physiotherapist/patient ratio 1: 4–5) sessions.The level A program: one or more of mobilization, active exercises and free walking, peripheral limb muscle activities, shoulder, and full arm circling.The level B program: one or more of callisthenic, strengthening, balance exercise, paced walking, and cycle ergometer at low-intensity exercises (
Ahmed et al, 2021 []53 Prospective intervention studyPatients currently admitted to rehabilitation center. previously hospitalized during their active COVID-19 disease, divided in 2 subgroups, those who used ventilatory support (group 1, 10 subjects), and who did not use ventilatory support (group 2, 10 subjects)Physical function:Quality of Life:Significant improvement in both subgroups (ventilated and non-ventilated) in measures of endurance, dyspnea and quality of life (Time effect
Chikhanie et al, 2021 []54 Part of an ongoing cohort of pulmonary rehabilitation 2019–2022Post-ICU COVID-19 and non-COVID-19 patients admitted to pulmonary rehabilitationPhysical function:Pulmonary function:Quality of life:Severe limitations in 6-min walking distance in both COVID-19 and non-COVID-19 groups at the start of pulmonary rehabilitation.Significantly greater 6MWD improvement (
Everaerts et al, 2021 []55 Prospective intervention studyDischarged COVID-19 adult patients admitted to an outpatient multidisciplinary rehabilitation program2232Physical function:Pulmonary function:16 (out of 22) patients completed the 3-month evaluation.At 6 weeks 6MWD improved with 86 (53–175) m.All patients went from interval to endurance training before week 6.At the 3-month evaluation all physical variables showed significantly better values (
Gloeckl et al, 2021 []56 Prospective observational cohort studyPatients in the post-acute phase of a mild/moderate or severe/critical course of COVID-19 admitted to a pulmonary rehabilitation program5056Both mild and severe subgroupsPhysical function:Pulmonary function:Quality of life:The subgroup of severe patientsPhysical function:Parameters assessed in both subgroups: Reduced performance at admission on 6MWT (mild: median 509 m, interquartile range (IQR) 426–539 m; severe: 344 m, 244–392 m), an impaired FVC (mild: 80%, 59–91%; severe: 75%, 60–91%) and a low SF-36 mental health score (mild: 49 points, 37–54 points; severe: 39 points, 30–53 points).At discharge, patients in both subgroups improved in 6MWT (mild/moderate: +48 m, 35–113 m; severe/critical: +124 m, 75–145 m; both
Hermann et al, 2020 []57 Retrospective cohort studyPatients referred from acute care hospitals after severe COVID-19 to inpatient rehabilitation, grouped into previously ventilated and non-ventilated patients2850Physical function:Quality of life:Significant enhancements observed in 6MWD (+130 m) and FT (+40 points) for total sample (
Puchner et al, 2021 []58 Prospective observational studyPost-acute COVID-19 patients enrolled into specific rehabilitation program, previously hospitalized due to COVID-19 in two tertiary care centers, Innsbruck and Zams, Tyrol, Austria.2330Physical function:Pulmonary function:Initially, 87% had pulmonary and 85% neuropsychological dysfunction.At the end of rehabilitation significant increase in FVC, FEV1, TLC, DLCO (
Spielmanns et al, 2021a []59 Prospective observational studyPatients overcoming the acute phase of COVID-19 infection, referred from acute hospitals for inpatient pulmonary rehabilitation after hospitalization9942.4Physical function:Quality of life:The data of the post-COVID-19 patients (PG) were prospectively analyzed and were compared to the cohort of rehabilitation participants with different pulmonary diseases (LG) of the year 2019.No significant differences between the groups according to age and sex.The improvements in the 6MWD were on average 180 (±101) m for PG and 102 (±89) m for LG (
Spielmanns et al, 2021b []60 Prospective observational studyPatients overcoming the acute phase of COVID-19 infection, referred from acute hospitals for inpatient pulmonary rehabilitation after hospitalization18333Within 2 days after admissionPhysical function:Quality of life:At admission and before dischargePhysical function:Pulmonary function:Quality of lifeSignificant improvement in 6MWT, FIM total, FIM motoric, and FT after the intervention (P83% were identified as the strongest predictor for reaching predicted 6-MWD
Udina et al, 2021 []61 Prospective cohort studyPost-acute care and post-COVID-19 patients included in a rehabilitation protocol3357.6Pre-COVIDPhysical function:All outcomes improved significantly in the total sample (
Zampogna et al, 2021 []62 Retrospective data analysisPost-COVID-19 patients, consecutively admitted to an inpatient pulmonary rehabilitation program14032.2Physical function:After the program: Improvement in BI from 55.0 (30.0–90.0) to 95.0 (65.0–100.0) (=0.00) and all components of SPPB (ability to stand, walk and rise from a chair) (
6MWT – Six Minute Walking Test; BI – Barthel Index; FVC – forced vital capacity; FEV1 – forced vital capacity in one second; MIP – maximum inspiratory pressure; MEP – maximum expiratory pressure; SF-36 – 36-Item Short Form Survey; GAD-7 – Generalized Anxiety Disorder-7; PHQ-9 – Patient Health Questionnaire; ESWT – Endurance Shuttle Walk Test; FIM – Functional Independence Measure; CRQ – Chronic Respiratory Questionnaire; HADS – Hospital Anxiety and Depression Scale; TLC – total lung capacity; RV – residual volume; DLCO – diffusion capacity for carbon monoxide; FT – feeling thermometer; SPPB – Short Physical Performance Battery.

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Medical Science Monitor eISSN: 1643-3750
Medical Science Monitor eISSN: 1643-3750