key: cord-0780158-j2e39pqy
authors: Webber, Sandra C; Tittlemier, Brenda J; Loewen, Hal J
title: Apparent Discordance between the Epidemiology of COVID-19 and Recommended Outcomes and Treatments: A Scoping Review
date: 2021-06-21
journal: Phys Ther
DOI: 10.1093/ptj/pzab155
sha: b4e01e20c1fbed4d1c86a36e3d0676c41cc812af
doc_id: 780158
cord_uid: j2e39pqy

OBJECTIVE: Many survivors of COVID-19 experience ongoing signs and symptoms affecting multiple body systems that impair function and negatively affect participation and quality of life. The purpose of this review was to identify and synthesize outpatient rehabilitation assessment and treatment recommendations for adults in postacute COVID-19 stages. METHODS: MEDLINE (Ovid), EMBASE (Ovid), Central, CINAHL, and Scopus were searched from January 1, 2020, to December 7, 2020. Teams of 2 reviewers independently assessed study eligibility and extracted data. All study designs that included rehabilitation recommendations were included. Study design, country, study population, purpose, and rehabilitation recommendations were recorded. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was used to evaluate the quality of consensus guidelines. RESULTS: Forty-eight articles fit the inclusion and exclusion criteria (11 systematic reviews, 1 scoping review, 6 original research studies, 4 consensus guidelines, 26 narrative reviews, and editorials/commentaries). Recommended outcomes included exercise tolerance, respiratory function, muscle strength, and activities of daily living (ADL) or functional independence. Recommended treatments included respiratory rehabilitation, exercise therapy, education, psychological support, ADL and gait training, traditional Chinese medicine, and cognitive and vocational rehabilitation. CONCLUSION: There were incongruities between what is known about postacute COVID-19 and what was recommended in the literature. Given the relatively large proportion of survivors who experience ongoing symptomatic COVID-19 or post–COVID-19 syndrome, it is important to quickly develop tools for self-management and access to rehabilitation specialists in multidisciplinary teams. IMPACT: Physical therapists, occupational therapists, and respiratory therapists have an important role to play. Clinicians should focus on epidemiological evidence and emerging information on late sequelae of COVID-19 to inform rehabilitation programming and future research.

Impact. Physical therapists, occupational therapists, and respiratory therapists have an important role to play. Clinicians should focus on epidemiological evidence and emerging information on late sequelae of COVID-19 to inform rehabilitation programming and future research.

As of April 1, 2021, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) associated with the COVID-19 pandemic has infected more than 128 million people world-wide and claimed the lives of more than 2.8 million. 1 The clinical presentation of patients with COVID-19 ranges from asymptomatic to critically ill. 2 Patients with mild illness may experience a myriad of symptoms including fever, cough, fatigue, muscle pain, and gastrointestinal complaints. 2 At the other end of the spectrum, those with severe and critical levels of illness demonstrate low oxygen saturation, high respiratory rates, lung infiltrates, septic shock, and/or multiple organ dysfunction. 2 COVID-19 is a multi-system disease that affects the respiratory, neurological, cardiovascular, musculoskeletal, renal, hepatic, and immune systems. [3] [4] [5] [6] Adults with chronic medical conditions such as cardiovascular disease (including hypertension), chronic lung disease, diabetes, cerebrovascular disease, obesity, cancer and chronic kidney disease are at greater risk of being severely affected in the acute stages of COVID-19. 7, 8 Patients who require treatment in the intensive care unit (ICU) are also at risk of developing post-traumatic stress disorder (PTSD) and post-intensive care syndrome (PICS). 9 It is becoming increasingly apparent that many patients, including those who experienced relatively mild disease, experience persistent signs and symptoms and/or new signs and symptoms beyond the initial period of acute infection and illness associated with COVID-19. 10 19. 13 The guideline includes definitions for timeframes associated with the recovery. The acute signs and symptoms of COVID-19 typically last for up to 4 weeks. "Ongoing symptomatic COVID-19" describes the condition when symptoms last from 4 to 12 weeks, and "post-COVID- 19 syndrome" occurs when symptoms persist for more than 12 weeks and cannot explained by an alternative diagnosis. "Long COVID" is used to describe both post-acute stages, ie, ongoing symptomatic COVID-19 and post-COVID-19 syndrome. 13 Symptoms reported by patients experiencing post-acute COVID-19 are highly variable and relatively little related research exists to date. One study conducted in Italy in April to May 2020

reported that 87% of patients experienced continuing symptoms approximately two months after the onset of COVID-19, and 55% of the sample had three or more persistent symptoms. 10 This study enrolled 143 patients with a mean age of 56.5 years, and mean length of hospital stay 13.5 days (77 patients received oxygen therapy, and 7 required invasive ventilation). The most common continuing symptoms were fatigue (53%) and dyspnea (43%). Another study conducted in France that included 120 patients 111 days following hospital admission (96 ward patients, 24

ICU patients) reported ongoing fatigue (55%), dyspnea (42%), loss of memory (34%), problems with concentration (28%) and sleep disorders (31%). 11 A study conducted in the United Kingdom (n = 100, mean 48 days post hospital discharge) reported similar results. 12 Other common persistent and/or new symptoms include gastrointestinal illnesses, cardiovascular symptoms (eg, chest tightness, palpitations), muscle and joint pain, and dizziness. 13 While studies such as these provide important information about the course of disease after discharge from hospital, severity of disease does not predict the development of post-acute COVID-19 and a large number of people who had relatively mild disease are also affected. 13 The recently released NICE guidelines suggest clinician-supported self-management and individually-prescribed multidisciplinary rehabilitation as the foundation for treatment of individuals post-acute COVID-19. 13 The guidelines advocate for including physical therapists, occupational therapists, rehabilitation medicine specialists, and clinical psychologists on the healthcare teams treating these patients. 13, 14 They also recommend that experts "share knowledge, skills and training between services to help practitioners in the community provide assessments and interventions". 13 15 We also considered refinements to scoping review methodology as discussed by

Levac et al. 16 The PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist guided reporting. 17

We developed a protocol outlining the methodology for our scoping review entitled, "A scoping review of rehabilitation recommendations for people post-acute COVID-19. December 2020 respectively, because they did not provide results nor offer any rehabilitation treatment recommendations. Three teams of two trained reviewers used Rayyan (https://www.rayyan.ai/) to independently conduct level one and level two screening. Conflicts in either level one or two screening were resolved by consensus or by a third reviewer.

[H3]Data charting A data extraction form was developed a priori in Excel which included content fields specific to article title and authors, date of publication, target discipline for recommendations, country of publication (corresponding author), purpose of the paper, study design and general process for developing recommendations, patients targeted, and recommendations related to assessment (including outcome measures) and specific treatment techniques. The data extraction form was pilot tested on 7 articles and data extracted were reviewed with the entire extraction team to

ensure consistency with this process. The first author checked the accuracy of extracted data against the full text of these 7 articles. We found no major discrepancies between reviewers during this exercise, so extraction continued with 3 teams of 2 independent reviewers completing data extraction. When articles included information about both acute and post-acute care, we only extracted details relevant to rehabilitation assessment and treatment in the outpatient and/or community setting. Similarly, some articles included multiple purpose or objective statements, but only those relevant to post-acute care were extracted in our study. We classified review articles as commentaries if they did not provide details about how the literature search was conducted.

[H2]Quality Assessment of Recommendations

The Appraisal of Guidelines for Research and Evaluation Instrument (AGREE II) 19 was used to evaluate the quality and transparency of development of guidelines and recommendations in the included studies because the AGREE II is easy to utilize, valid and reliable. 20, 21 We utilized select questions from the AGREE II because we anticipated that several sources of recommendations would not be traditional clinical practice guidelines due to the urgency to provide information to rehabilitation professionals quickly in the time of the pandemic. As such, we felt that many of the AGREE II questions would not be relevant to the sources we would find. The two lead researchers on the project independently reviewed all questions contained in the AGREE II and selected those thought to be most relevant to our sources and most appropriate to provide information about the quality of the recommendations. The researchers met, discussed their selection of questions, and agreed on a final set of questions. Three teams of 2 independent reviewers completed the quality appraisal, and the results of the quality appraisal of the guidelines and recommendations were also included on the data extraction form. Conflicts were [H2]Synthesis of results

Descriptive statistics were used to detail the characteristics of the literature, ie, the number of included studies, the types of study designs, and the countries of origin. We utilized narrative

synthesis to describe the rehabilitation assessment and treatment recommendations for people who required rehabilitation post-acute COVID-19. A narrative synthesis is a systematic and transparent data analysis approach that examines and summarizes text to explain the findings of studies included in a review. 23 The collating and summarizing phase was an iterative process and the two lead researchers met virtually to discuss and ensure consensus with the findings.

[H1]Results

The literature search yielded 20,442 citations that were filtered through removal of duplicates and screening with our inclusion and exclusion criteria ( Figure) . The most frequent reason for excluding articles at the full-text stage occurred because the paper described only a general role for rehabilitation with post-acute COVID-19 patients and did not provide specific recommendations for assessment and treatment. We extracted data relevant to our research questions from 48 full-text articles that met eligibility criteria. Many of these papers did not define the post-acute period in terms of the number of weeks since the onset of COVID-19, however, we included information if it pertained to an outpatient setting and/or was reported as being suitable for patients who had been discharged from hospital after admission related to COVID-19.

Eleven papers were systematic reviews, 24-34 1 was a scoping review, 35 43, 61 Turkey (n = 2), 54,55 Australia (n = 1), 40 Bangladesh (n = 1), 35 Brazil (n = 1), 4 Morocco (n = 1), 52 Nigeria (n = 1), 46 Russia (n = 1), 38 and Singapore (n = 1). 39 A number of studies reviewed included recommendations for both acute and post-acute stages of COVID-19.

We focused data extraction on details that pertained to post-acute patients which included both ongoing symptomatic COVID-19 and post-COVID-19 syndrome. 13 Details of the original research articles and the consensus guidelines are included in Tables 1 and 2, respectively. Table   3 summarizes findings of our critical appraisal for the four consensus guidelines. Details of the systematic/scoping reviews, narrative reviews, and editorials/commentary pieces are included in

Supplementary Tables 1 to 3, respectively.

Findings of the scoping review are presented below according to the research questions.

[H3]Question 1. What processes were used to develop the rehabilitation recommendations?

Many papers included in the review were narrative reviews and editorials/commentaries (n = 26) which based recommendations on previous literature and expert opinions (see Suppl. Tab. 2 and 3). None of the systematic reviews (n = 11, Suppl. Tab. 1) included a meta-analysis as results

were not amenable to this type of analysis. The original research articles included three case reports, [38] [39] [40] one prospective cohort study, 41 one observational cohort study 36 and one open randomized controlled trial (RCT) 37 (Tab. 1). While we did conduct a critical appraisal of all included studies as described in our methods, most studies scored very poorly as they were not designed to provide systematically and rigorously developed guidelines per se. Critical appraisal of the four consensus guidelines included in the review demonstrated variable results (Tab. 3).

All four studies [42] [43] [44] [45] were authored by teams that included expertise from relevant healthcare fields, provided details of the recommendation development processes and how the processes influenced resultant recommendations, and clearly presented the recommendations in the publication. None of the guideline groups sought the views of the target population of people

with post-acute COVID-19 and only one study 45 reported that recommendations were externally reviewed prior to journal submission.

[H3]Question 2. What outcomes and outcome measures are recommended for patients experiencing post-acute signs and symptoms related to COVID-19? Table 4 ADLs, whereas 0 to 4 outcome measures were suggested for other outcomes. The 6-minute walk test (6-MWT) was recommended in 10 papers, assessment using spirometry and pulmonary function tests were recommended by eight authors, and careful monitoring of peripheral capillary oxygen saturation (SpO2) was specified in 6 papers.

[H3]Question 3. What rehabilitation treatments are recommended for these patients? Table 5 provides details about recommended rehabilitation treatments identified in the included studies. Overall, eight categories of treatment priorities were recognized. Most frequently authors reported on the need to provide respiratory rehabilitation (n = 25) and exercise therapy (n = 25)

to patients experiencing post-acute COVID-19. Papers also discussed the importance of education (n = 13), psychological support (n = 13), ADL/gait training (n = 11), Traditional

Chinese Medicine (n = 5), cognitive rehabilitation (n = 3) and vocational rehabilitation (n = 2).

While several papers provided recommendations for the general types of treatment that should be included in rehabilitation, many did not elaborate on specific components of treatment or specific prescriptions for treatment delivery.

The two treatment areas that received the most detailed recommendations were aerobic exercise and resistance exercise. Nine papers provided guidance on aerobic exercise prescription (Tab. 5).

In general, the recommendations for aerobic exercise were consistent among studies with the following guidelines for patients experiencing post-acute signs and symptoms related to COVID-

Type of activitywalking, jogging and/or swimming 32, 35, 40, 45, 47, 67 Intensitylight aerobic exercise, gradually increasing as tolerated 47 Duration -5 to 30 min/session as tolerated, increasing time gradually 32, 35, 40, 45, 67 Frequency -3 to 6 times/week 32, 35, 40, 45, 67 Of note, Torjesen 65 reported that the National Institute for Health and Care Excellence (NICE)

has cautioned healthcare practitioners about using graded exercise therapy to treat post-viral fatigue in people recovering from COVID-19. This area requires further study as patients recovering from COVID-19 may not respond similarly to those with chronic fatigue syndrome.

In their consensus statement targeting active individuals (eg, military personnel and athletes),

Barker-Davies et al 42 recommend that people perform low-level stretching and low intensity resistance exercises for one week prior to beginning specific aerobic exercise sessions.

Ten papers provided guidance on prescribing resistance exercise (Tab. 5). These recommendations included:

Type of activityprogressive resistance training for large muscle groups 32, 40, 45, 57, 67, 68 ; using body weight, resistance bands, and/or dumbbells 40, 68 ; using neuromuscular electrical stimulation 6, 63 Intensityincrease training load 5% to 10% per week 32 post-acute COVID-19 are fatigue and dyspnea. [10] [11] [12] [13] The next most common symptoms vary by report and include "brain fog", 13 psychological distress, 12 memory loss, 11 Previous studies in patients experiencing long-term effects from SARS and MERS indicated that the respiratory impairment was usually primarily restrictive in nature, 70, 74 and preliminary information suggests this is true regarding the pulmonary effects of COVID-19 as well. 75 Respiratory rehabilitation programs that include aerobic, resistance, and breathing exercises, as Knowledge and literature about COVID-19 is changing quickly which makes it difficult for scoping reviews such as this to stay current. We did not search for information on the websites of national professional organizations for physical therapy, occupational therapy or respiratory therapy and therefore did not capture assessment and treatment recommendations offered through these outlets.

Our results provide a summary of recommendations as they are currently available, however, most of these recommendations do not come from original research studies and may not be supported by strong evidence. The main recommendations for treatment focus on respiratory rehabilitation and exercise, both of which were supported in consensus guidelines [42] [43] [44] [45] and original research

studies. 37, 39, 40 Some findings reported in original research studies were repeated in the narrative and systematic reviews that we included. It was not our purpose to investigate modes for treatment delivery, however, there is a body of emerging literature regarding benefits and short-comings related to using tele-rehabilitation. 86 Methodological strengths of this review include the comprehensive literature search developed by a health sciences librarian and the fact that teams of two researchers independently carried out all stages of screening, critical appraisal and data extraction for included studies (with a third team member available to reach a majority decision when required).

The emergence of this new set of patients with ongoing symptomatic COVID-19 or post-COVID-19 syndrome demands that governments and health authorities organize services to provide tools for self-management, the option of supported self-management, and access to rehabilitation specialists as well as integrated multidisciplinary rehabilitation programs to address patients' ongoing and varied needs. 13 Current data suggest that approximately one-third of survivors of COVID-19 continue to experience symptoms more than 7 weeks after hospital discharge, and it is difficult to track the prevalence in those who recovered from the initial infection without requiring hospitalization. [10] [11] [12] 83 Physical therapists, occupational therapists and respiratory therapists will be essential in providing rehabilitation services. To date, much of the 

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest. Seven teams appraised evidence of rehabilitation needs post-COVID gathered from PubMed, Google Scholar and COVID-19 repositories. A writing committee prepared consensus statements and applied Oxford levels of evidence to each recommendation. Authors reported their level of agreement with each recommendation and attended an agreement meeting where recommendations were modified until high agreement was achieved.

COVID-19 pathology is reviewed, and 36 rehabilitation assessment and treatment recommendations are presented under the following headings: general rehabilitation (5), pulmonary (3), cardiac (6), exercise (5), psychological (4), musculoskeletal (4), neurological (5), medical sequelae (4). Each recommendation is presented with level of evidence and level of agreement data. The Convergence of Opinion on Recommendations and Evidence (CORE) process was used with a multinational task force. Seventy-six experts (primarily physiotherapists and pulmonologists) completed 13 multiple choice questions (developed through small team of experts and after seeking global input online). Agreement of directionality was tabulated for each question and 70% agreement was required to make consensus recommendations. More than 705 agreement was reached on all questions in the first round. Breathing exercises (+/-pursed lip breathing, +/-diaphragmatic breathing) 32, 35, 37, 39, 40, 45, 47, 56, 57, 67, 68 Sputum expectoration exercises/coughing 32, 35, 37, 38, 45, 52, 53, 57, 67 3 × 10 active coughs, 37 high frequency chest oscillation using vibrationcompression therapy with 13 Hz frequency for 30 min 38 Respiratory muscle training 32, 37, 38, 44, 52, 67, 68 Commercial hand-held device (Threshold PEP: Philips Co.) 3 × 10 repetitions at 60% maximal expiratory mouth pressure, 37 30 maximal voluntary diaphragmatic contractions in supine position with 1-3 kg on abdominal wall, 37 inspiration against breathing device with initial resistance of 40 mm H 2 O (20 breaths, 3×/d) 38 Respiratory muscle stretching/Thoracic expansion exercises 37, 67 Specific upper extremity/trunk stretching movements 37 Exercise 4, 6, 28, 32, 35, 39, 40, [43] [44] [45] 47, 48, [52] [53] [54] [55] [56] [57] 60, [63] [64] [65] [66] [67] [68] Aerobic exercise 4, 6, 32, 35, 39, 40, 42, 44, 45, 47, [52] [53] [54] 56, 57, [63] [64] [65] [66] [67] [68] Walking, jogging, swimming gradually increasing intensity and duration to 3-5×/wk for 20-30 min 32, 35, 45 ; walking 5-10 min for 4 d/wk progressing to 30 min

National Institutes of Health COVID-19 Treatment Guidelines Panel. Coronavirus Disease 2019 (COVID-19) Treatment Guidelines. COVID-19 Treatment Guidelines Panel

Clinical features and short-term outcomes of 221 patients with COVID-19 in Wuhan

Impacts of COVID-19 on the immune, neuromuscular, and musculoskeletal systems and rehabilitation. Rev Bras de Medicina do Esporte

Clinical update for physical therapists: coagulopathy and COVID-19

Beyond acute respiratory distress: multiple organ effects and early rehabilitation in COVID-19. CONNECT: The World of Critical Care Nursing

Underlying Medical Conditions Associated with High Risk for Severe COVID-19: Information for Healthcare Providers

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

Covid-19 and post intensive care syndrome: a call for action

Persistent symptoms in patients after acute COVID-19

Post-discharge persistent symptoms and healthrelated quality of life after hospitalization for COVID-19

Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation

COVID-19 rapid guideline: managing the long-term effects of COVID-19 (NG188). National Institute for Health and Care Excellence

Long COVID and chronic COVID syndromes

Scoping studies: towards a methodological framework

Scoping studies: advancing the methodology

PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation

A scoping review of rehabilitation recommendations for people post-acute COVID-19. Open Science Framework

AGREE II: advancing guideline development, reporting and evaluation in health care

Development of the AGREE II, part 1: performance, usefulness and areas for improvement

Development of the AGREE II, part 2: assessment of validity of items and tools to support application

The AGREE Reporting Checklist: a tool to improve reporting of clinical practice guidelines

Guidance on the conduct of narrative synthesis in systematic reviews: A product from the ESRC Methods Programme

Systematic rapid "living" review on rehabilitation needs due to COVID-19: update to March 31st, 2020

Systematic rapid living review on rehabilitation needs due to COVID-19: update as of April 30th, 2020

Systematic rapid living review on rehabilitation needs due to COVID-19: update to May 31st, 2020

Rehabilitation and Covid-19: the Cochrane Rehabilitation 2020 rapid living systematic review

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of August 31st, 2020

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of September 30th, 2020

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of October 31st, 2020

Rehabilitation of patients post-COVID-19 infection: a literature review

Applying the WHO ICF framework to the outcome measures used in the evaluation of long-term clinical outcomes in coronavirus outbreaks

Systematic review of changes and recovery in physical function and fitness after severe acute respiratory syndrome-related coronavirus infection: implications for COVID-19 rehabilitation

Pulmonary rehabilitation in COVID-19 patients: A scoping review of current practice and its application during the pandemic

COPD assessment test for the evaluation of COVID-19 symptoms

Respiratory rehabilitation in elderly patients with COVID-19: a randomized controlled study

Pulmonary rehabilitation of patients with coronavirus infection COVID-19, clinical examples

Rehabilitation of a post-intensive care unit patient after severe COVID-19 pneumonia

COVID-19 rehabilitation delivered via a telehealth pulmonary rehabilitation model: a case series

Modified rehabilitation exercises for mild cases of COVID-19

The Stanford Hall consensus statement for post-COVID-19 rehabilitation

COVID-19: Interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society and American Thoracic Society-coordinated International Task Force

Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process

Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019

Safety and efficacy of chest physiotherapy in patients with COVID-19: a critical review

Management of post-acute covid-19 in primary care

Scaling the need, benefits, and risks associated with COVID-19 acute and postacute care rehabilitation: a review

Rehabilitation of patients with COVID-19

Physical Medicine and Rehabilitation and pulmonary rehabilitation for COVID-19

Respiratory rehabilitation for post-COVID19 patients in spa centers: first steps from theory to practice

Rehabilitation of post-COVID-19 patients

Rehabilitation of COVID-19 patients

Consideration of prevention and management of long-term consequences of post-acute respiratory distress syndrome in patients with COVID-19

COVID-19 infections and pulmonary rehabilitation

Ten Hove R. The COVID-19 rehabilitation pandemic

HSS beyond: moving forward after COVID-19

Graduated return to play guidance following COVID-19 infection

Cardiopulmonary exercise testing in the COVID-19 endemic phase

Comprehensive physiotherapy management in COVID-19 -a narrative review

The Post-COVID-19 Functional Status scale: a tool to measure functional status over time after COVID-19

COVID-19 and pulmonary rehabilitation: preparing for phase three

Considerations for postacute rehabilitation for survivors of COVID-19

Home and community-based physical therapist management of adults with post-intensive care syndrome

NICE advises against using graded exercise therapy for patients recovering from covid-19

Rehabilitation after COVID-19: an evidence-based approach

Pulmonary rehabilitation for patients with coronavirus disease 2019 (COVID-19)

Expert consensus on protocol of rehabilitation for COVID-19 patients using framework and approaches of WHO International Family Classifications

From SARS and MERS to COVID-19: a brief summary and comparison of severe acute respiratory infections caused by three highly pathogenic human coronaviruses

Long-term clinical outcomes in survivors of severe acute respiratory syndrome and Middle East respiratory syndrome coronavirus outbreaks after hospitalisation or ICU admission: a systematic review and meta-analysis

COVID-19: from an acute to chronic disease? Potential long-term health consequences

Outcome measures in chronic obstructive pulmonary disease (COPD): strengths and limitations

Aerobic and breathing exercises improve dyspnea, exercise capacity and quality of life in idiopathic pulmonary fibrosis patients: systematic review and meta-analysis

Six month radiological and physiological outcomes in severe acute respiratory syndrome (SARS) survivors

Pulmonary fibrosis secondary to COVID-19: a call to arms?

64 cardiopulmonary exercise testing, 6,45,59,63 Borg Rating of Perceived Exertion, 35,57,58 1-min STS, 35,40 1-or 2-min walk test, 35,57 1-min step test 67 Respiratory function 6

Spirometry and pulmonary function tests

Medical Research Council dyspnea scale, 35,40 Borg Rating Perceived Dyspnea Scale, 44 respiratory muscle strength, 45 breath hold test 67

Muscle strength 6

57 manual muscle testing, 45,64 hand grip, 39 UK Medical Research Council test, 45 isokinetic testing, 45 bilateral thigh girth, 57 hand-held dynamometry

ADL's, functional capacity, functional independence 6

39 Barthel Index, 45,63 Duke Activity Status Index, 35 TUG, 57 Extra Short Musculoskeletal Function Assessment, 60 Katz index of Independence in ADL

64 WHO Disability Assessment Schedule

Brief Model Disability Survey, 68 Generic functioning domains (VB40)

64 single leg stance, 57 Activitiesspecific Balance Confidence Scale 64 Quality of life 33

Health-Related Quality of Life and Interventions 60

64 Self-Rating Anxiety Scale and Self-Rating Depression Scale 37

Fatigue Severity Scale, 40 Visual analog scale 44 Physical activity 45,57,59,63 International Physical Activity Questionnaire, 45,63 PASE, 45,63 pedometers/accelerometers

Joint range of motion 6

The authors thank Michael Ball, Kailey Evans, Sophie Lam, Eric Richter, and Irini Youssef for assisting in screening titles/abstracts/articles, data extraction, and critical

related to nutritional support, and 10 pertaining to rehabilitation 6-8 wk postdischarge: patients should (1) do regular daily activities, (2) do low/moderate intensity physical activities/exercise, (3) have a formal assessment of physical and emotional functioning to identify rehabilitation needs, (4) be evaluated using the core outcomes set for survivors of acute respiratory failure, (5) be assessed for measures of respiratory function and (6) measures of exercise capacity, (7) receive a comprehensive general rehabilitation program if indicated, (8) receive respiratory rehabilitation if preexisting/ongoing lung function impairment, (9) receive a muscle strengthening program if indicated, ( 4, 6, 32, 35, 39, 40, [43] [44] [45] 48, [52] [53] [54] 56, 57, 60, 63, 64, [66] [67] [68] Progressive resistance training, 2-3×/wk for 6 weeks, increase 5%-10%/wk 32 ; strength training for large muscle groups 2 × 10 reps 40 ; 8-12 RM, 1-3 sets, 2-3 sessions/wk, increase 5%-10%/wk 35, 45 ; specific exercises to target large muscles in lower extremities, upper extremities and core 57 ; neuromuscular electrical stimulation 6, 63 ; loads of 70%-80% 1 RM 64 ; resistance bands, loads 8-12 RM, increase 5%-10%/wk; 67 medium and high intensity load training 68 Balance training 32, 35, 45, 48, 53, 54, 56, 57, 63, 64, 67 Weight shift and single leg stance; 57 hands-free balance training under balance trainer 35 Flexibility exercises 4, 54, 57, 63, 64, 67, 68 Stretches into shoulderflexion, knee to chest, gastrocs, hamstrings 57 Range of motion exercises 39, 48, 52, 64 Education 32, 35, 39, 40, 42, 43, 45, 47, 51, 55, 56, 65, 66 Energy conservation 39, 40, 56, 65 Resumption of physical activity 40, 43, 51 Healthy lifestyle 32, 35, 45 Behaviour modification 47 Self-management 66 Psychological support 6, 28, 35, 42, [51] [52] [53] 55, 56, 63, 64, 66, 68 Psychological interventions 35, 42, 63, 68 Trauma focused cognitive behavioral therapy, cognitive processing therapy or eye movement desensitization and reprocessing for those with acute stress disorder 42 ADL/iADL and/or gait training 6, 32, 35, 39, 45, 53, 54, 63, 64, 66, 68 Targeted ADL/iADL practice 32, 35, 45, 53, 64, 66 Assistive devices for walking 39, 64 Gait training 54, 64 Traditional Chinese Medicine 41, 45, 49, 67, 68 Baduanjin qigong 45, 67, 68 Tai Chi 45, 67 Chinese Martial Arts Eight-section Brocade 41 Overhead chest and shoulder stretch with breath holds, standing heel raises and upper body acupressure, upper body thoracic rotation and patting lateral side of thorax, and hand acupressure massage. Exercise prescription: 6-8 repetitions for each exercise, 2×/d 41 Acupuncture 49 Cognitive rehabilitation 4, 6, 63 Vocational rehabilitation 56, 64