key: cord-0819678-d1jjaf8k
authors: Leite, Victor Figueiredo; Rampim, Danielle Bianchini; Jorge, Valeria Conceição; Correia de Lima, Maria do Carmo; Cezarino, Leandro Gonçalves; da Rocha, Cleber Nunes; Esper, Rodrigo Barbosa
title: Persistent symptoms and disability after COVID-19 hospitalization: data from a comprehensive telerehabilitation program
date: 2021-03-10
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2021.03.001
sha: d564e1fd0b0aa1086b05515a18f5e07e225e5762
doc_id: 819678
cord_uid: d1jjaf8k

Objective To report symptoms, disability and rehabilitation referral rates after COVID-19 hospitalization in a large, predominantly elderly population Design Cross-sectional study, with post-discharge telemonitoring of individuals hospitalized with confirmed COVID-19, at the first month after hospital discharge, as part of a comprehensive telerehabilitation program Setting Private verticalized healthcare network specialized in the elderly population Participants Individuals hospitalized due to COVID-19 Interventions Not applicable Main Outcome Measure(s) Dependence for basic and instrumental activities of daily living (ADLs and IADLs, respectively) using Barthel's Index and Lawton's Scale. We compared the outcomes between participants admitted to the intensive care unit (ICU) vs. those admitted to the ward. Results We included 1,696 consecutive patients, aging 71.8±13.0 years-old, with 56.1% of females. Comorbidities were present in 82.3% of the cases. Participant were followed up for 21.8±11.7 days after discharge. During post-discharge assessment, independence for ADLs was found to be lower in the group admitted to the intensive care unit (ICU) than the ward group (61.1% [95%CI 55.8-66.2%] vs. 72.7% [95%CI 70.3-75.1], p<0.001). Dependence for IADLs was also more frequent in the ICU group (84.6%, 95%CI [80.4-88.2%], vs. 74.5%, [95%CI 72.0-76.8%], p<0.001). Individuals admitted to ICU required more oxygen therapy (25.5% vs 12.6%, p<0.001), presented more shortness of breath during routine (45.2% vs 34.5%, p<0.001) and non-routine activities (66.3% vs 48.2%, p<0.001), had more difficulty standing up for 10 minutes (49.3% vs 37.9% p<0.001). The rehabilitation treatment plan consisted mostly of exercise booklets, which were offered to 65.5% of participants. The most referred rehabilitation professionals were psychologists (11.8%), physical therapists (8.0%), dietitians (6.8%), and speech-language pathologists (4.6%). Conclusions Individuals hospitalized due to COVID-19 present high levels of disability, dyspnea, dysphagia, and dependence for both ADLs and IADLs. Those admitted at the ICU presented more advanced disability parameters.

disease 2, 6, 9, 10 . In a cohort from China, individuals that required high-flow nasal cannula, noninvasive ventilation or invasive ventilation, when compared to those hospitalized without oxygen therapy, presented more frequent mobility impairment, pain, anxiety and depression six months after discharge. 2 Data from the United Kingdom show that individuals admitted to the ICU, when compared to those admitted to the ward, presented higher rates of fatigue (72% vs 60%), breathlessness (66% vs 43%) and neuropsychological impairments (47% vs 24%) in the first two months after discharge. 6 However, data on different populations and demographics are needed to better understand disability after COVID-19, as well as the potential impact of ICU admission.

Given the increasing number of cases and its potential disability rates, COVID-19 is placing an enormous strain on rehabilitation services worldwide. [11] [12] [13] [14] In order to muster the appropriate resources to respond to this disability epidemic, rehabilitation services require data about frequency of persistent symptoms, disability rates, and rehabilitation referral needs in this population, which are currently scarce. 1 Identifying risk factors for disability is also important for an appropriate response plan. ICU admission correlates to more severe disease and prevalent disability rates in those hospitalized due to COVID-19. 10 Our goal was to provide data from a comprehensive telerehabilitation program on post-discharge symptoms and disability, as well as rehabilitation referral needs, comparing those admitted to the ICU and ward. We hypothesized that individuals admitted to the ICU had higher prevalence of symptoms, disability and rehabilitation referral needs.

This retrospective cross-sectional study was performed at Prevent Senior, a verticalized Brazilian private healthcare network specialized in the elderly population, 15 currently caring for over 500,000 lives. Reporting of this manuscript was performed as per STROBE guidelines. 16 The present study was approved by the ethics committee.

Eligibility criteria: From March 15 th to August 27 th , 2020, all individuals hospitalized due to COVID-19 at Prevent Senior in the city of São Paulo were screened for eligibility. Participants were included if COVID-19 was the cause of admission, confirmed by positive molecular diagnosis (rt-PCR) for SARS-CoV-2 infection, and if they were discharged alive. Participants hospitalized with asymptomatic COVID-19, and those who presented symptoms only after hospitalization were excluded from the present study (n=9). We did not exclude individuals that were readmitted to the hospital.

Data was obtained from a comprehensive telerehabilitation program implemented for individuals that were discharged after COVID-19 hospitalization (Figure 1 ). Our telerehabilitation team had access to a central list containing all individuals hospitalized due to COVID-19 in our verticalized healthcare network. Each patient was individually and manually monitored using our electronic health record. Once we identified that the patient had been discharged, telephone contact was done by a physical therapist. We elected the physical therapist for this role based on two main reasons: 1-We expected that highest impairments to be in the motor and respiratory functions, and 2-Due to the number of available professionals at that time, since outpatient sessions had been suspended. The objective of the first telephone contact was to identify symptoms and disability, and provide early referral to telerehabilitation services.

Demographics, comorbidities, and hospitalization data were retrieved using electronic health records. Radiological severity was assessed by the RAD-Covid score at admission, which uses chest computerized tomography (CT) scans to stratify overall pulmonary parenchyma involvement in <25%, 25-50%, and >50%, resulting in scores 1 to 3, respectively. 17 During the initial telephone contact, data was gathered using a structured form specifically designed for identifying disability and rehabilitation needs in individuals discharged after COVID-19 in our institution (Online supplement). This was the only time point in which data was gathered from the individuals in this study. The structured form used in the telerehabilitation program assessed individuals' physical and respiratory symptoms, mobility impairments, measures of independence and affect, nutritional, and swallowing symptoms. Individuals were also asked to report any other symptoms not addressed by the form. The structured form assessed the following self-reported variables:

Shortness of breath was assessed as a binomial variable (yes/no). We assessed current shortness of breath in three different situations: at rest, during routine and non-routine activities.

Routine activities included ADLs that were part of that individual's routine prior to COVID-19 infection, such as bathing, dressing, walking inside home or climbing stairs (for those individuals with stairs at home). Non-routine activities included any other activities, such as exercising, climbing stairs (in case there were no stairs at home), walking outside home. Current use of oxygen therapy was assessed as a binomial variable (yes/no). Thus, participants that were currently utilizing oxygen therapy for a few hours, or for any specific activities were considered as users of oxygen therapy.

We assessed current energy levels using a 0-10 numeric rating scale (0=no energy whatsoever, and 10=best energy possible). Current overall pain level (on any location) was rated using a 0-10 numeric rating scale (0=no pain, 10= worst imaginable pain). We also asked if there was any current numbness or tingling sensation present (yes/no).

We asked if the individuals were having any difficulty standing up for over 10 minutes unassisted (yes/no), if they had difficulty moving any limb (yes/no), and if they had any falls since hospital discharge (yes/no). We also assessed if they required any gait assistance devices, such as a cane, walker or wheelchair (yes/no).

Independence for ADLs (feeding, bathing, grooming, dressing, bowel/bladder management, toilet use, transfers, mobility and use of stairs) was assessed using Barthel's Index (BI). BI was scored from 0-100, with individual items scoring 0-10, where 0 meant dependent, 5 partially dependent, and 10 independent. Transfers and mobility were scored 0-15 each, where 0 meant dependent, 5 and 10 referring to different degrees of partial dependence, and 15 independent. 18, 19 Independence for IADLs (telephone use, shopping, food preparation, housekeeping, mode of transportation, responsibility for medication, ability to hand finances), was assessed using Lawton's Scale scored from 7-21, with individual items scoring 1-3 (1 = unable, 2 = needs assistance, 3 = independent). 20 Dependence was defined when scoring <21.

We assessed for perception of anxious and or depressive symptoms, by asking "Have you been feeling anxious or depressed lately?" (yes/no).

We asked if the individuals presented weight loss with inappetence (yes/no). We also assessed for dysphagia to liquids or solids by asking "Do you have any trouble swallowing food or liquids?" (yes/no).

During the initial telephone contact, individuals were stratified based on their current Barthel's Index 18 : Level 1 (0-39, dependent), Level 2 (40-79, partially dependent) and Level 3 (80-100, independent) as shown in Table 1 . All participants were provided with a physical exercise guide in booklet and/or video format, based in a previous publication. 21 The physical therapist then decided if the patient would perform unsupervised home exercises only, or if a referral to an online physical therapy group was necessary. Those performing unsupervised home exercises were followed up by telemonitoring (telephone contact) for a month, either weekly, biweekly, or monthly, for Level 1, 2, or 3, respectively. The objective was to assess and promote adherence to exercises, correct any doubts regarding exercises, and assess any other rehabilitation needs (data from telemonitoring follow-ups were not recorded).

Criteria for referral to other rehabilitation professionals were:

 Dysphagia: referral to a speech-language pathologist.

 Issues regarding oxygen therapy (e.g.: dosage, how to wean down), worsened dyspnea or impaired blood pressure or heart rate: referral to a cardiologist specialized in cardiac rehabilitation.

 Complaints regarding fine motor control or cognition: referral to occupational therapy.

 Pain rated as >5 (0-10 numeric scale), or any numbness/tingling or difficulty moving their limbs: referral to a physiatrist.

 Weight loss or inappetence: referral to a dietitian.

 Anxious or depressive symptoms: referral to a psychologist.

Categorical data was reported as frequency, percentage, and 95% confidence intervals estimated by the exact method. Continuous variables were reported as mean, standard deviation (SD), median and interquartile ranges (IQR). Shapiro-Wilk test showed that all continuous variables did not present normal distribution. Continuous variables were compared among groups using a Mann-Whitney U test. Categorical variables were compared using Pearson's Chi-square test, with statistical power of 80% and ɑ=5%. No data imputation method was used. We used Stata 13.0 (StataCorp. College Station, TX, United States of America) for the analyses. This is a descriptive and exploratory study, and sample size calculation was not performed.

We used all available data from the telerehabilitation program at the time of protocol writing.

A total of 1,733 individuals were screened, and 1,696 were included ( Figure 2) . A total of 357 individuals (21.0%) were admitted to the ICU at any point during their hospitalization.

Individuals admitted to the ICU and the ward had similar characteristics ( (Table 5) , which were offered to 65.5% of the individuals after discharge, whereas the remaining individuals had received those booklets during hospital stay. Patients were most frequently referred to psychologists (11.8%), physical therapists (8.0%), and dietitians (6.8%). Our rehabilitation treatment plan was declined by patients and/or families in 2.5% of the cases at time of referral (Table 5 ), for different reasons: "she needs to rest", "online rehabilitation will not strengthen him", "we are afraid she will be infected again", and "we are afraid that our family will be infected". We have not assessed if the remaining 97.5% of those referred to telerehabilitation followed our recommendations and scheduled their therapy sessions.

We have showed high prevalence of symptoms and disability rates after COVID-19.

As anticipated, individuals admitted to the ICU had higher disability levels than those admitted to the ward. Persistent symptoms and disability after COVID-19 have been previously reported, 2, 4-8, 10 and other authors have observed worse outcomes in those admitted to the ICU (Table 6 ) .

According to data from the United Kingdom, breathlessness at rest in the first two months after discharge was higher in those admitted to the ICU (28.1% vs 19.3% in our sample), compared to the ward group (19.1% vs 15.8% in our sample). 6 That study also showed more prevalent fatigue, post-traumatic stress disorder symptoms, and decrement in quality of life in the ICU group when compared to the ward. Differences between ICU and ward groups are likely multifactorial and could be partially explained by disease severity. 2, 9, 10 SARS-CoV-2 infection can cause pulmonary abnormalities, thrombocytopathy, endotheliopathy, hepatic, renal and nervous system injuries, some due to viral infection, and others likely due to excessive immune response. 2, 22, 23 Recovery time of those injuries is still uncertain, since a study with matched controls found that the majority of COVID-19 survivors persisted with magnetic resonance imaging (MRI) abnormalities in the lungs, brain, heart, liver and/or kidneys two to three months after discharge. 9 Besides disease severity, consequences of ICU stay could partially explain our findings, since long-term impact of ICU stay has been previously demonstrated for acute respiratory distress syndrome (ARDS) due to SARS-CoV infection, as well as for other nonrespiratory critical illnesses. 24-26 ICU-acquired weakness is a neuromuscular dysfunction that consists of polyneuropathy, myopathy and/or muscle atrophy which results of critical illness and can be magnified by conditions during ICU stay. 26 Potential risk factors for ICU-acquired weakness include use of corticosteroids and continuous neuromuscular blockade, which were present in more than 40% and 80%, respectively, of those admitted to the ICU due to COVID-

To our knowledge, our study is the first to report disability for ADLs and IADLs after COVID-19 infection in the Brazilian population. Individuals in our study presented high rates of dependence for both ADLs and IADLs, which cannot be completely attributed to hospitalization. Due to the absence of baseline values, we cannot ascertain if such symptoms and disability rates were already present prior to COVID-19 hospitalization. Disability in the general population could be estimated from a population-based study with 1,451 communityliving elderly Brazilians, which reported dependence for ADL and IADLs of 36.0% and 34.0%, 28 respectively, compared to our rates of 38.9% and 84.6% for the ICU; 27.3% and 74.5% for the ward group. Despite that, we cannot ascertain whether the individuals that were admitted due to COVID-19 in our network were representative of the general population, or if they represented a subset with higher (or lower) disability. Obtaining disability rates before and after COVID-19 hospitalization, in the same population, would provide a clearer image of its impact. Additional factors may have impacted the generalizability of our findings: 1) 35% of the participants were instructed to perform home exercises during hospitalization, which may have reduced disability rates; 2) Outcome assessment relied on self-reporting. Reliability of self-reported Barthel's Index on older adults has been reported to be over 80% for eating, toileting and transferring, and 63% for bathing and dressing, with frequent underestimation of disability on self-reporting.

Therefore, it is possible that actual rates of ADL dependence are higher. 29 3) Physical distancing measures during pandemic may have overestimated dependency for IADLs, particularly for the categories "using transportation" and "shopping".

Telemonitoring, as part of a comprehensive telerehabilitation program, was feasible in our population. We managed to telemonitor 100% of individuals after discharge, resulting in early identification of persistent symptoms and disability, as well as early referral to telerehabilitation with low refusal rates at the time of referral. The rehabilitation treatment plan was affected by the pandemic and physical distancing measures, and, thus, we have focused on providing exercise booklets and videos. Exercise booklets were provided to all participants, and 65.5% of them received those exercises during telemonitoring. Those with more rehabilitation needs were referred to telerehabilitation using a device with camera (e.g.: smartphone, tablet). In-place therapy was provided only for in-home physical therapy. Referral rates for occupational therapy (OT) were low (1%), considering that disability for ADLs and IADLs were 29.7% and 76.6%, respectively, and referral rate to physical therapy was 8%. Possible causes for this disparity include: 1)

Overestimation of IADL disability due to physical distancing measures, which created barriers unrelated to body functions or structures that may have affected categories such as shopping; 2) Underdiagnosis of triggers for OT referral (cognitive and/or fine motor impairments), since they were not screened in the telemonitoring protocol, and required active complaint by the individual.

We did not assess variables relevant to our study topic, such as obesity, prevalence and duration of mechanical ventilation and use of continuous neuromuscular blockade. 26, 30 We have not assessed prevalence of fatigue, which has been previously reported as a persistent symptom in this population (Table 6) .

Obtaining data on individual categories for both ADLs (Barthel's Index) and IADL (Lawton's Index) would provide more comprehensive information than the aggregate score.

That would improve the understanding of which activities need to be rehabilitated in this population. Dysphagia and anxious/depressive symptoms were identified without using validated assessment tools, and are prone to measurement bias.

Our findings are limited by the absence of a control group and baseline values for the outcomes. Therefore, we cannot ascertain if the participants already presented those symptoms and disabilities, nor if individuals hospitalized for conditions other than COVID-19 would present such findings. When assessing difference between outcomes in individuals admitted to the ICU vs ward, we did not take measures to avoid third variable effects. Therefore, it is possible there are other factors influencing the higher rates of disability in this subgroup. Using statistical methods that take those effects into account could minimize this issue.

We have reported high rates of pain, shortness of breath, anxious and depressive symptoms, dysphagia, need for oxygen therapy, and dependence for both ADLs and IADLs in a predominantly elderly population, with worse outcomes in the ICU group. We also provided data on rehabilitation referral needs to address disability in this population. Our study corroborates and expands on the current body of evidence regarding high rates of disability after COVID-19

hospitalization. Future studies should explore individuals longitudinally, ideally with pre-admission assessments, as well as using validated assessment tools for ADL and IADL disability, pulmonary function, sarcopenia, cardiopulmonary fitness, cognition, dysphagia, neuropsychiatric impacts (e.g.:

cognition, mood disorder, post-traumatic stress disorder, substance abuse). Our team is currently conducting a prospective study assessing pre and post-COVID functionality with patient-reported outcomes and objective assessments with follow-ups until 12 months after discharge, which could contribute to our understanding of this subject. 

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Data expressed in frequency and 95%CI

-Data expressed in frequency and 95%CI, unless otherwise specified