key: cord-283719-zmizyx7e
authors: Cheng, Yuan-Yang; Chen, Chin-Ming; Huang, Wei-Chun; Chiang, Shang-Lin; Hsieh, Pei-Chun; Lin, Ko-Long; Chen, Yi-Jen; Fu, Tieh-Cheng; Huang, Shu-Chun; Chen, Ssu-Yuan; Chen, Chia-Hsin; Chen, Shyh-Ming; Chen, Hsin-Shui; Chou, Li-Wei; Chou, Chen-Liang; Li, Min-Hui; Tsai, Sen-Wei; Wang, Lin-Yi; Wang, Yu-Lin; Chou, Willy
title: Rehabilitation Programs for Patients with COronaVIrus Disease 2019: Consensus Statements of Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation
date: 2020-08-17
journal: J Formos Med Assoc
DOI: 10.1016/j.jfma.2020.08.015
sha: 
doc_id: 283719
cord_uid: zmizyx7e

Abstract The COronaVIrus Disease 2019 (COVID-19), which developed into a pandemic in 2020, has become a major healthcare challenge for governments and healthcare workers worldwide. Despite several medical treatment protocols having been established, a comprehensive rehabilitation program that can promote functional recovery is still frequently ignored. An online consensus meeting of an expert panel comprising members of the Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation was held to provide recommendations for rehabilitation protocols in each of the five COVID-19 stages, namely (1) outpatients with mild disease and no risk factors, (2) outpatients with mild disease and epidemiological risk factors, (3) hospitalized patients with moderate to severe disease, (4) ventilator-supported patients with clear cognitive function, and (5) ventilator-supported patients with impaired cognitive function. Apart from medications and life support care, a proper rehabilitation protocol that facilitates recovery from COVID-19 needs to be established and emphasized in clinical practice.

Since the end of 2019, COronaVIrus Disease 2019 (COVID-19), a novel infectious disease emerging from Wuhan, China, has continued to spread rapidly, causing an ongoing global outbreak. Patients may exhibit dyspnea, hypoxia, remarkable pneumonia, acute respiratory distress syndrome (ARDS), or even multiple organ failure. 1, 2 In addition to the possible sequelae of pulmonary fibrosis, 3 which could impair the survivors' ventilation and oxygenation, many other organs could be affected, especially the cardiovascular system. 4 Common complications of the cardiovascular system may include arrhythmia, myocarditis, acute coronary syndrome, venous thromboembolism, cardiogenic shock, and heart failure. 5 Furthermore, prolonged inactivity can also affect exercise capacity significantly. Apart from medical treatment and supportive therapy, rehabilitation plays a vital role throughout the entire disease course. An appropriate rehabilitation program could help patients with mild disease maintain exercise capacity and activities of daily living. For patients with advanced disease severity, a well-designed rehabilitation program is even more crucial to improve pulmonary secretion clearance, ameliorates side-effects related to a prolonged bedridden state, and even prevents intensive care unit-acquired weakness. This expert consensus provides recommendations for rehabilitating patients with varying degrees of COVID-19 severity.

Although rehabilitation has multiple benefits for patients, the disease remains highly contagious and poses a substantial threat to medical providers. Hence, proper protective personal equipment (PPE) should be used when caring for patients with COVID-19, 6 J o u r n a l P r e -p r o o f

Considering that COVID-19 can cause significant morbidity and mortality based on certain risk factors, such risk factors need to be identified in order to establish individualized rehabilitation programs. Data from 44,672 laboratory-confirmed cases of COVID-19 in China have shown that disease severity can be categorized as mild, severe, and critical. 1 Approximately 81% of infected patients were categorized as mild and presented without or with mild pneumonia, while approximately 14% were categorized as severe and presented with dyspnea, blood oxygen saturation ≤ 93%, partial pressure of arterial oxygen to fraction of inspired oxygen (P/F) ratio < 300, or lung infiltrates > 50% within 24 to 48 hours. The remaining 5% were classified as critical and presented with respiratory failure, septic shock, or multiple organ dysfunction, which resulted in a high mortality rate of 49%. Those with preexisting comorbid conditions, including cardiovascular disease (CVD) (10.5%), diabetes (7.3%), chronic respiratory disease (6.3%), hypertension (6.0%), and cancer (5.6%), displayed a higher case-fatality rate (CFR). Patients without underlying medical conditions had an overall CFR of 0.9%. A recent meta-analysis that assessed the risk for severe infection in 46,248 patients 7 found that those with CVD [odds ratio (OR) = 3.42] had the highest risk for severe infection, followed by respiratory system disease (OR = 2.46) and hypertension (OR = 2.36). Moreover, another study outside China showed that older age (OR = 1.06), male gender (OR = 3.68), and hypertension (OR = 2.71) were independently associated with severe disease at admission. 8 Altogether, potentially significant risk factors for severe COVID-19 that should be identified and considered when designing rehabilitation programs include old age, male gender, hypertension, diabetes, respiratory disease, and CVD.

The World Health Organization (WHO) had categorized clinical syndromes associated with COVID-19 as mild illness, pneumonia, severe pneumonia, ARDS, sepsis and septic J o u r n a l P r e -p r o o f 5 shock. 9 However, this expert consensus categorized patients with COVID-19 differently such that outpatients with various risk factors or inpatients with disparate cognitive status should receive distinct rehabilitation programs. Therefore, the current expert consensus categorized patients with COVID-19 into the following five groups: (1) outpatients with mild disease and no risk factors, (2) outpatients with mild disease and epidemiological risk factors, J o u r n a l P r e -p r o o f

Majority of the patients with COVID-19 had mild disease. 1 Those with mild disease and no risk factors were allocated to home care, with rehabilitation recommendations similar to those of the American College of Sports Medicine (ACSM) general principles of exercise prescription, 10 though infection control is essential. 11, 12 While home-based rehabilitation is recommended for this group of patients, hospital-based rehabilitation may be started only when patients have been (1) at least 10 days since symptom onset (2) at least 24 hours since resolution of fever without taking antipyretic drugs and (3) without other COVID-19 related symptoms, according to the recommendation for discontinuation of home isolation from Center for Disease Control and Prevention of United States. 13 The objective of rehabilitation is primarily preventing complications of inactivity through conditioning exercises.

Conditioning exercises should include at least three components, namely warm-up, exercise, cool-down and stretching. 10 A proper warm-up generally includes light intensity endurance activities for at least 5-10 minutes. Exercises include both aerobic exercise and resistance training. Aerobic training involves the activation of large muscle groups in a rhythmic movement (e.g., treadmill walking, bicycling, or upper limb ergometer trainings).

Training frequency, intensity, and duration should be as follows:

-Frequency: 5 days or more per week -Intensity: maintaining a heart rate reserve of 40%-59% during exercise, while the heart rate reserve refers to the difference between the predicted maximum heart rate and the resting heart rate 14 (1) Hypertension: Post-exercise blood pressure (BP) reduction should be considered especially among older patients receiving anti-hypertensive medicine such as α-blockers and vasodilators. Therefore, exercise termination should be gradual, while the cool-down phase should be extended and monitored carefully until BP and heart rate return to resting levels.

Avoid the Valsalva maneuver or breath holding during resistance training and static stretching to avoid excessive BP elevation.

(2) CVD: Exercise training is safe and effective for most patients with CVD. Patient whose angina threshold heart rate had been previously determined by a formal cardiopulmonary exercise test should adjust their exercise intensity to the upper limit of heart rate 10 beats/min below the angina threshold. 21 Patients who had not undergone formal exercise testing can exercise at a rated perceived exertion of 4-6 on a 0-10 scale. 21 However, a formal exercise test should still be considered in patients with advanced CVD with proper clinical disinfection following CDC 11 (3) Pulmonary disease: Patients with previous chronic pulmonary diseases could develop much more airway secretions than those without. Airway clearance techniques, which will be described in detail in the next section, should include flutter breathing, autogenic drainage, and cough techniques, such as huff coughing and controlled coughing.

Specific exercises, such as Yoga, Tai-chi, Pilates, and trunk core muscle training, can help stabilize the trunk and promote efficient breathing. 24 Inspiratory muscle training, with a threshold loading starting at 30% of the maximal inspiratory pressure (MIP), is recommended given evidence suggesting its benefits in reducing dyspnea and improving, exercise capacity and quality of life for patients with COPD. 25 During conditioning exercises, intensity should be set at a rated perceived exertion of 4-6 on a 0-10 scale. Exercise in cold environments or those with allergens or pollutants should be limited to avoid triggering bronchoconstriction among susceptible individuals. 

Approximately 14% of patients with COVID-19 developed moderate to severe disease that required hospitalization and aggressive treatment. 1 These individuals usually present with fever, cough, dyspnea, tachycardia, tachypnea, and various degrees of oxygen desaturation necessitating support. 2 Studies have shown that early rehabilitation interventions for community-acquired pneumonia and interstitial pneumonia within 2 days of admission reduced in-hospital mortality. 26, 27 The two primary objectives of rehabilitation in this stage are promoting airway clearance and preventing complications of acute illness-related immobilization.

About 33.7% of COVID-19 patients could have copious sputum production. 28 Incorporating chest physiotherapy into the medical treatment of patients with lung consolidation plays an important role in helping patients with airway secretions. Proper chest physiotherapy could promote effective expectoration, enhance mucociliary clearance of secretions to the upper airways, and improve cough effectiveness. 29 Chest physiotherapy strategies that promote airway clearance include the following: Another important issue in the rehabilitation of patients with moderate to severe disease is preventing deconditioning due to acute illness. Immobilization has been shown to speed functional decline with reduced muscle strength and cardiorespiratory fitness, particularly among elderly individuals and those with comorbidities. 1, 35 Therefore, once medical condition stabilized, early mobilization should be encouraged. 36 Rehabilitation interventions for such patients should include the following:

(1) Active or active-assisted range of motion (ROM) exercise: Patients with moderate to severe disease who are able to actively move their extremities are encouraged to engage in active or active-assisted ROM exercises to maintain or improve joint integrity and prevent joint contracture and soft-tissue shortening. 37 (2) Mobilization and progressive off-bed activities: early mobilization with progressive mobility training, including off-bed transferring, unsupported sitting, standing, level-surface ambulation, and stair climbing, tailored to the patient's general condition should be carried out once medically stabilized. Proper walking aid may be used to assist in energy conservation to reduce distress during the activity. The following are the key points and strategies for the rehabilitation of ventilated patients with clear cognitive status:

(1) Activities:

In-bed cycling in patients with critical illness has been shown to be a safe and feasible procedure for preserving muscle function 41 and muscle fiber cross-sectional area, 42 as well as fostering positive mental effect, including the feeling of control, safety, and hope, during the critical stages of the illness. 43 Low resistance levels (i.e., approximately 0.5 Nm), are recommended with patient self-selected pedaling rate for 30 minutes daily. 41

Upper-limb resistance training using elastic bands and pulleys can also be utilized. Patients who have stable clinical status can commence out-of-bed mobility depending on their tolerance, which may include sitting on the edge of the bed, moving from bed to chair, standing next to the bed, stepping on the spot, and walking with ambulatory assistive devices. 44 (2) Breathing exercises:

Inspiratory muscle training, which strengthens the inspiratory muscles through the application of resistance during inspiration, can also be used for intubated patients or those with a tracheostomy. Using a threshold training device, with the threshold set at 50% of the MIP, five sets of six breaths performed once per day are recommended. 45 Patients can also be educated on diaphragmatic breathing, which involves the negative pressure generated by the diaphragm instead of the accessory respiratory muscles.

Finally, chest expansion and mobilization are important for increasing chest wall mobility and improving thoracic compliance during mechanical ventilation. J o u r n a l P r e -p r o o f

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The authors would like to thank Dr. Kai-Hua Chen, the Secretary-General of Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation, for holding discussion meetings, recording the details of the meetings, and miscellaneous tasks related to the publishing of this expert consensus.J o u r n a l P r e -p r o o f