key: cord-0867161-2de6275f
authors: de Oliveira Almeida, Katna; Nogueira Alves, Iura Gonzalez; de Queiroz, Rodrigo Santos; de Castro, Marcela Rodrigues; Gomes, Vinicius Afonso; Santos Fontoura, Fabiane Costa; Brites, Carlos; Neto, Mansueto Gomes
title: A systematic review on physical function, activities of daily living and health-related quality of life in COVID-19 survivors
date: 2022-04-11
journal: Chronic Illn
DOI: 10.1177/17423953221089309
sha: 45724987aead72e7097bf6ab14617c10ff11a5b8
doc_id: 867161
cord_uid: 2de6275f

OBJECTIVE: To analyze the published studies that investigated the physical function, activities of daily living and health-related quality of life in COVID-19 survivors. DESIGN: Systematic review. METHODS: We searched MEDLINE/PubMed, Scopus, SciELO, and Cochrane Library for studies that evaluated the physical function, activities of daily living and health-related quality of life after COVID-19 from the earliest date available to July 2021. Two independent reviewers screened and selected the studies. The Newcastle Ottawa Scale was used to evaluate methodological quality. RESULTS: We included 35 studies in this systematic review. Of the 35 studies included, 28 were cohort, and 7 cross-sectional studies The studies demonstrated that COVID-19 survivors had reduced levels of physical function, activities of daily living, and health-related quality of life. Furthermore, incomplete recovery of physical function, and performance in activities of daily living were observed 1 to 6 months post-infection. DISCUSSION: Physical disability and reduction in health-related quality of life is a common condition in post-COVID-19 and impairments may persist up to 1 to 6 months. Researchers and clinicians can use these findings to understand the potential disabilities and rehabilitation needs of people recovering from the COVID-19.

daily living activities, reducing the patient's autonomy and independence and, negatively impacting their quality of life. 9,10 A better understand of functional repercussions of COVID-19 can be of help in designing and implementing strategies and interventions focused on the recovery of disability that can improve the quality of life of this population. 9, 10 Recently Pizarro-Pennarolli et al., 11 published a systematic review to understand the impact of COVID-19 on activities of daily living performance of adult patients and to describe the common scales used to assess performance of activities of daily living on patients post-COVID- 19 . In the nine studies included, all demonstrated reduced performance in activities of daily living revealing a vital worsening of functional ability in activities of daily living performance and consequently loss of independence in COVID-19 patients after the acute phase of infection. 11 Despite this, as far as we know, there is no published systematic review that analyzed the impact of COVID-19 on the physical function, and health-related quality of life of survivors. The aim of this systematic review is to analyze the published studies on physical function, activities of daily living and health-related quality of life in COVID-19 survivors.

We included published peer-reviewed studies that investigated the physical function, activities of daily living and health-related quality of life after COVID-19. Eligible studies should meet the following criteria: (a) included adult patients post-COVID-19 infection for the first time; (b) studies that assessed physical function, activities of daily living and/or health-related quality of life in COVID-19 survivors. Review studies, guidelines and case studies were excluded. In addition, studies in which patients were re-infected and diagnosed by covid-19 were excluded.

We searched for references on MEDLINE/ PubMed, SciELO, Scopus and the Cochrane Library without language restrictions. Additionally, we search for studies in google scholar. The electronic databases were searched from inception to July 21st, 2022. A standard protocol for this search was developed and whenever possible, controlled vocabulary (Mesh term for MEDLINE/PubMed) was used. Key words and their synonymous were used to sensitize the search.

The strategy developed by Higgins and Green 13 was used for the identification of studies in MEDLINE/PubMed. To identify studies in other database we adopted a search strategy using similar terms. Two groups of keywords were used for the preparation of the search strategy: participants and outcomes. The full search strategy can be found in Electronic Supplementary File 1 for independent replication.

We checked the references used in articles included in this systematic review to identify other potentially eligible studies. Authors were contacted by e-mail to obtain information for ongoing studies, confirmation about data and any additional information considered relevant for the analysis.

Potential studies for the systematic review were initially selected according to their titles and abstracts and the pre-defined search strategy. Selection of studies records from databases and other resources will be uploaded to a database created by EndNote X7.8 software (Clarivate, Philadelphia, PA). Two authors independently evaluated the abstracts of each study. If at least one of the authors considered the study eligible for the systematic review, the full text was obtained for complete assessment. Two reviewers independently assessed the full text of selected articles to verify if they met the inclusion criteria.

Two authors independently extracted data from the published reports using standard data extraction forms adapted from Higgins and Green. 13 Characteristics of study population, follow-up period, rates of missing data, outcome measures, and results were reviewed. In case of any disagreement, authors discussed the reasons for their decisions and a consensual decision was made. If necessary, further information was requested by e-mail to the corresponding authors of specific publications.

The quality of studies included in this systematic review was scored by two researchers using the Newcastle Ottawa Scale (NOS) (with a score ranging from 0 to 9 points). The NOS is a review tool for evaluating risk of bias in observational studies. The scale consists of four domains of risk of bias assessment; (i) selection bias; (ii) performance bias; (iii) detection bias and; (iv) information bias. 14 

The initial search led to the identification of 5195 abstracts, from which 95 studies were considered as potentially relevant and were retrieved for detailed analysis. Initially the de Oliveira Almeida et al.

5101 studies were excluded after reading the title and abstracts, for not meeting the eligibility criteria. After a complete reading of 94 articles, 59 were excluded (reasons presented in the flowchart), resulting in 35 studies that met the eligibility criteria. Figure 1 shows the flow diagram of studies in this review according to PRISMA guidelines.

Of the 35 studies included in this review, 28 were cohort, and 7 cross-sectional studies. Twelve studies evaluated only physical function, [15] [16] [17] [19] [20] [21] 33, 37, 43, 45, 47, 48 two studies evaluate only activities of daily living 24, 49 and eighth only the health-related quality of life. 23, 29, 30, 32, 39, 40, 42, 46 Five studies evaluated physical function and activities of daily living. 27, 28, 36, 38, 41 Five studies evaluated physical function and health-related quality of life 18, 22, 25, 26, 34 two studies evaluated physical function, activities of daily living and health-related quality of life, 31, 35 and one study evaluated daily living activities and health-related quality of life. 44 For each study, design, sample size, sex, outcomes measures and key findings were extracted (Table 1) .

COVID-19-related outcomes on physical function, activities of daily living, and health-related quality of life in included studies The NOS was applied to score and classify the quality of these studies, as displayed in Table 3 . According to NOS 13 (37.14%) of the 35 studies were classified as "Good studies", 19 (54.28%) as "Satisfactory Studies" and 3 (8.58%) as "Unsatisfactory Studies" quality ranking. The minimum and maximum scores were, respectively, 3 and 8 points. The items with lower proportion of compliance were adequacy of follow-up of cohorts, comparability of cohorts based on the design or analysis, and selection exposed cohort.

This systematic review indicate that COVID-19 survivors can have a reduction in physical function, individuals' ability to perform activities of daily living and their health-related quality of life 1 to 6 months postinfection. Our systematic review expands the knowledge about the impact of COVID-19 on the activity of daily living and additionally includes other important outcomes such as physical function and health-related quality of life. Thus, this systematic review is important because it analyzes the impact of COVID-19 on important outcomes for COVID-19 survivors. the eligibility of physical function, activities of daily living and health-related quality as outcomes in this systematic review is important because they are related to prognosis in patients with chronic diseases. [50] [51] [52] Post-acute COVID-19 is defined as persistent symptoms and/or delayed or long-term complications beyond 4 weeks from the onset of symptoms. There are increasing reports of persistent and prolonged effects after acute COVID-19. 10 Thus, this systematic review is important because it analyzes the impact of COVID--19 on pulmonary function tests, functional and exercise capacity, fatigue, and health-related quality. Nalbandian et al., 10 reinforces the need for systematic studies of sequelae after recovery from acute COVID-19 with a focus on developing new evidence-based multidisciplinary team approaches to care for these patients and to inform research priorities. Furthermore, decreased levels of physical function, physical performance and exercise capacity are associated with an increased risk of mortality in the general population and in people with chronic diseases. [50] [51] [52] [53] [54] Our results show that there is a reduction in physical and pulmonary function tests in COVID-19 survivors. Specifically, postinfection COVID-19 patients showed impaired lung function, muscle strength, exercise capacity and persistent fatigue. Patients also had reduced performance in functional tests such as Short Physical Performance Battery Test, 2-min walking test, and 1-min sit-to-stand test. Our findings are consistent with those of recent reviews, in which acute post-COVID-19 patients suffer from changes in respiratory function, fatigue, muscle weakness and disability. [55] [56] [57] [58] Welch et al. 59 point out that declines in function/quantity of muscle mass in six months can result in acute sarcopenia, which has affected patients with COVID-19. According to Iqbal et al., 60 persistent respiratory symptoms are consistent with findings from previous outbreaks of SARS-CoV that demonstrated a restrictive pattern of lung function metrics consistent with the resultant muscle weakness six to eight weeks following hospital discharge. They also reported that the persistence of functional symptoms could be exacerbated in the context of social distancing and isolation. 60 Our results also showed that there is a reduction in activities of daily living in COVID-19 survivors. In a recent systematic review, Pizarro-Pennarolli et al., 11 identified nine studies that assessed performance of activities of daily living using six different scales: Barthel Index, Activities of Daily Living Score, Functional Independence Measure, Composite Functional Score, Modified Rankin Scale, and EQ-5D-5L. In accordance with our results, they reported that in all included studies, the findings revealed a decline in activities of daily living performance after COVID-19 infection regardless of the scale applied. 11 For Belli et al., 38 this generates loss of autonomy and independence for the patient, which can negatively impact their quality of life. 38 Clemente-Suárez et al. 61 reported that the COVID-19 negatively influences motor behavior, levels of regular exercise, nutritional patterns, and psychological status. 61 In addition, immobilization during acute illness also can cause loss of physical functions with impact on activities of daily living. These factors may be associated with physical and functional decline and reduced performance in activities of daily living. Thus, further research is needed to determine the factors associated with reduced functioning and activities of daily living, as well as to identify the best rehabilitation strategy to improve functioning and activities of daily living after COVID-19.

Quality of life is a particularly important outcome in studies involving COVID-19 survivors. Our results also showed that there is a reduction in health-related quality of life in COVID-19 survivors. Valent et al., 46 reported that physical and psychological sequelae may be more frequent in COVID-19 patients because of restriction of visitation, and constraints on social as well as rehabilitation supports due to the risk of transmission. Iqbal et al., 23 describes that, after recovery, the COVID-19 survivors often experience discrimination and prejudice because of the community's irrational fear that they are still contagious. Thus, it is important to dispel any myths reinforcing the idea that a COVID-19 survivor is still contagious after recovery to help reduce the stigma and allow rapid reintegration of the individual into society. 23 Considering the global scale of this pandemic, it is expected that the healthcare needs for patients with sequelae of COVID-19 will continue to increase for the future. A comprehensive understanding of patient care needs beyond the acute phase is necessary and will help in the development of infrastructure and healthcare for improved quality of life and physical health of survivors of COVID-19 in the long term.

Prioritization of follow-up care may be considered for those at high risk of post-acute COVID-19, including those who had severe illness during acute COVID-19 and/or required care in an ICU, and those with the highest burden of persistent symptoms. 10 Nalbandian et al. 10 reported that it is clear that care for patients with COVID-19 does not complete at the time of hospital discharge, and interdisciplinary cooperation is needed for comprehensive care of these patients in the outpatient setting. 10 Rehabilitation programs after early hospitalization can minimize functional losses and improve quality of life. Sheehy et al., 9 suggest that a thorough assessment and an individualized, progressive treatment plan which focuses on functioning, and return to participation in society will help each patient to maximize their functioning and quality of life. Careful consideration on the rehabilitation environment will ensure that all patients recover as completely as possible. 9 Thus, the available findings in this systematic review can be used to understand the potential disabilities and rehabilitation needs of people recovering from the COVID-19.

Despite the important findings presented, the results of this systematic review are limited by the lack of high-quality, larger, multicentric and long-term studies. Results were limited by heterogeneity of studies, insufficient standardization, and absence of control for confounders in individual studies. A main limitation of the included studies is the small sample sizes. In addition, included studies reported a mixture of cohort sampling (hospitalized, community, and mixed), different follow-up timepoints, and data collection measures, which likely contributed to the detected heterogeneity.

Physical disability and reduction in health-related quality of life is common in COVID-19 survivors 1 to 6 months postinfection. These results highlight the need for a long-term follow-up of those patients and for rehabilitation programs. Rehabilitation studies are warranted, especially low-cost strategies, to prevent and treat functional declines.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Not applicable, because this article does not contain any studies with human or animal subjects.

Not applicable, because this article does not contain any studies with human or animal subjects.

Not applicable, because this article does not contain any clinical trials.

Katna de Oliveira Almeida https://orcid.org/ 0000-0002-6190-7189 Iura Gonzalez Nogueira Alves https://orcid.org/ 0000-0003-2455-3788 Mansueto Gomes Neto https://orcid.org/0000-0002-0717-9694

Supplemental material for this article is available online.

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