key: cord-0953659-j94bc4j9
authors: Daynes, E.; Gerlis, C.; Chaplin, E.; Gardiner, N.; Singh, S. J.
title: Early experiences of rehabilitation for patients post-COVID to improve fatigue, breathlessness exercise capacity and cognition.
date: 2021-03-28
journal: nan
DOI: 10.1101/2021.03.25.21254293
sha: 4d89d50f2cc860308b14a748078f9d7fdba4f07b
doc_id: 953659
cord_uid: j94bc4j9

Patients with lasting symptoms of COVID-19 should be offered a comprehensive recovery programme. Patients that completed a six week, twice supervised adapted pulmonary rehabilitation programme demonstrated statistically significant improvements in exercise capacity, respiratory symptoms, fatigue and cognition. Participants improved by 112m on the Incremental Shuttle Walking Test and 544 seconds on the Endurance Shuttle Walking Test. There were no serious adverse events recorded, and there were no dropouts related to symptom worsening. COVID-19 rehabilitation appears feasible and significantly improves clinical outcomes.

COVID-19 can lead to a number of lasting symptoms such as breathlessness, fatigue and reduced ability to engage in activities of daily living 1 . It became apparent that a recovery or rehabilitation programme would be necessary to support those to return to normal following infection. The European Respiratory Society taskforce identified a need for a formal assessment to understand physical and emotional functioning to determine rehabilitation needs following COVID-19 infection 2 . This statement identifies the need for a rehabilitative intervention following hospital discharge and includes a comprehensive programme. It has been acknowledged that a unidimensional programme will not meet the needs of COVID-19 survivors who will present with a variety of different symptoms 3 . However, there is invariably some overlap between the needs of COVID-19 survivors and a Pulmonary Rehabilitation (PR) population. PR is a highly evidenced based intervention and addresses many symptoms reported in the post COVID population, but it will likely need modifications. Therefore this model was adapted when developing COVID-19 rehabilitation to meet the complex needs of these patients 2 . This study presents the results of the initial COVID-19 rehabilitation programme using a modified PR programme.

This study reports the experiences of the first 32 patients that completed rehabilitation following COVID-19 infection. This observational study was approved by the National Health Service Research Ethics Committee (reference 17/EM/0156) and registered through the ISRCTN (ISRCTN45695543). Patients were referred through a discharge follow up pathway; at COVID-19 medical follow up or; a All rights reserved. No reuse allowed without permission. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted March 28, 2021. ; referral from their GP. Patients were included if they self-identified rehabilitation needs, and were excluded if they demonstrated acute symptoms or were not medically stable. Patients that had COVID-19 but managed in the community were eligible for the programme and were referred by their GP. All patients were screened for unexplained symptoms and unstable cardiovascular disease.

The rehabilitation programme was six weeks in duration, with two supervised sessions per week. The programme comprised of aerobic exercise (walking/treadmill based), strength training of upper and lower limbs and educational discussions with handouts from the www.yourcovidrecovery.nhs.uk website. The Borg breathlessness scale and rate of perceived exertion were used alongside selfreported symptoms to determine progression of the exercises. The outcomes were: the incremental and endurance shuttle walking test (ISWT/ESWT), COPD Assessment Test (CAT) 4 Data was analysed using SPSS v25. Patients were considered completers if they attended eight out of 12 scheduled sessions. A paired t-test was used to compare changes before and after rehabilitation. [4] respectively which was not statistically significant, however the baseline scores were low (table 1). Figure 1 demonstrates the changes in FACIT and ISWT. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in

The copyright holder for this this version posted March 28, 2021. ; 

This adapted rehabilitation programme for patients following COVID-19 has demonstrated feasibility and promising improvements in clinical outcomes. There was a high completion rate of COVID rehabilitation in the first 32 patients as demonstrated by this study, with no dropouts attributed to a worsening of symptoms, indicating acceptability to the participants of the intervention. There were significant improvements in clinical outcomes of walking capacity and symptoms of fatigue, cognition and respiratory symptoms (measured by the CAT). Whilst there are no known minimal important differences for these outcomes in patients with COVID-19; the ISWT, ESWT, CAT, FACIT and, MoCA all exceed the known minimal important differences in patients undergoing conventional pulmonary rehabilitation, or with a chronic respiratory condition. It is possible that there is some natural recovery in this cohort of patients, however, as the mean length of time between infection and enrolment onto the programme was 125 days it is likely that natural recovery had slowed down.

There has been concern that rehabilitation may worsen or trigger symptoms of post-viral fatigue and that exercise therapy may exacerbate fatigue. The exercise element of this programme is progressed (by staff experienced in delivering pulmonary and cardiac rehabilitation programmes) in line with patient's symptoms throughout the programme and provides a holistic and pragmatic approach to exercise therapy. The educational component of the programme supports management techniques useful for these symptoms (such as pacing and prioritising). There were no serious adverse events during the course of the programme supporting the safety of this intervention. The majority of patients improved both the symptom of fatigue and exercise capacity. One patient did not improve either fatigue or exercise capacity (due to a previous stroke). The remainder (n= 4) who reported an increase in fatigue recorded meaningful improvements in their exercise capacity.COVID-19

Rehabilitation programmes should aim to provide a holistic and multi-faceted approach to managing post-COVID symptoms. Clinicians should aim to individualise programmes and to monitor adverse events and symptoms, given the limited evidence in the field.

To conclude, an adapted pulmonary rehabilitation programme to support patients with lasting symptoms of COVID-19 is safe and demonstrates improvements in exercise capacity and symptoms of breathlessness, fatigue and cognition. perpetuity. preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in The copyright holder for this this version posted March 28, 2021. ; https://doi.org/10.1101/2021.03.25.21254293 doi: medRxiv preprint

Long-term follow-up of recovered patients with COVID-19 The Lancet

COVID-19: Interim Guidance on Rehabilitation in the Hospital and Post-Hospital Phase from a

Delivering rehabilitation to patients surviving COVID-19 using an adapted pulmonary rehabilitation approach -BTS guidance

COPD assessment test for the evaluation of COVID-19 symptoms

An Official European Respiratory Society/American Thoracic Society technical standard: field walking tests in chronic respiratory disease