A Prospective Study of Patients with Persistent Symptoms after SARS-CoV-2 Infection Referred to Physical Medicine and Rehabilitation
Keywords:Activities of Daily Living, Physical and Rehabilitation Medicine, Portugal, Post-Acute COVID-19 Syndrome, Quality of Life
Introduction: New evidence and extrapolated data from other coronaviruses suggest that symptoms and consequences of COVID-19 may persist beyond the cure. The aims of this study were to evaluate persistent symptoms after SARS-CoV-2 infection and its impact on physical condition, activities of daily living, and quality-of-life; establish whether symptom persistence is associated with higher disability; and document the evolution of the multiple domains after a home exercise program.
Methods: Prospective study with patients referred to a Physical and Rehabilitation Medicine clinic, after SARS-CoV-2 infection. Patient evaluations, including a symptom questionnaire, the 1-Min Sit-to-stand test (1-MSTS), the EQ-5D questionnaire and the London Chest Activity Daily Living (LCA-DL) questionnaire, were performed before and after a home exercise program.
Results: Seventy-four patients were included. The majority (n = 71) had been hospitalized (mean stay 19.66 ± 13.35 days), 51% required intensive care. At first evaluation, 54 days after symptom onset, a mean of 18.6 repetitions in the 1-MSTS were performed. The percentage of LCA-DL was above 28% in 23% of the patients. Impairments on EQ-5D were present in 44% for mobility and 44% for anxiety/depression. Mean EQ-5D VAS was 66.5 out of 100. Fifty-one (70%) had at least one persistent symptom (Symptomatic Group), while 22 (30%) were asymptomatic (Asymptomatic Group). The Symptomatic Group had statistically significantly worse mean results on 1-MSTS (16.8 vs 22.9; p < 0.001), % LCA-DL score, EQ-D5 (7.8 vs 5.7; p < 0.001) and EQ-D5-VAS. No patient characteristic, clinical background, comorbidity, or hospitalization characteristics was significantly different between groups. Every patient was given a home exercise program; 47 patients joined an additional rehabilitation program or were clinically discharged and were therefore excluded from the second evaluation. Twenty-seven patients participated in a second evaluation. In the matched analysis, mean 1-MSTS improved by 3.4 repetitions. Mean LCA-DL, mean EQ-5D score (7.1 to 6.6) and EQ-VAS score changed favourably and significantly.
Conclusion: Two months after infection by SARS-CoV-2, persistent symptoms were frequent in patients referred to a Physical Medicine and Rehabilitation clinic. Additionally, the SARS-CoV-2 infection, as well as the persistence of symptoms, had a negative impact in the physical condition and functionality in ADL and quality-of-life. With a home exercise program in place, a statistically significant improvement was observed. Referral of patients with persistent symptoms to Physical and Rehabilitation Medicine may be warranted.
World Heath Organization. Update on clinical long-term effects of COVID-19. 2021. [cited 2022 Apr 10]. Available from: https://www.who.int/docs/default-source/coronaviruse/risk-comms-updates/update54_clinical_long_term_effects.pdf?sfvrsn=3e63eee5_8.
Tenforde MW, Billig Rose E, Lindsell CJ, Shapiro NI, Files DC, Gibbs KW, et al. Characteristics of adult outpatients and inpatients with covid-19 - 11 academic medical centers, United States, march-may 2020. MMWR Morb Mortal Wkly Rep. 2020;69:841-6. DOI: https://doi.org/10.15585/mmwr.mm6926e3
Carfì A, Bernabei R, Landi F. Persistent symptoms in patients after acute COVID-19. Jama. 2020;324:603-5. DOI: https://doi.org/10.1001/jama.2020.12603
Centers for Disease Control and Prevention. Post-COVID conditions: information for healthcare providers centers for disease control and prevention. 2022. [cited 2022 Apr 10]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html.
Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-COVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022;22:e102-e7. DOI: https://doi.org/10.1016/S1473-3099(21)00703-9
Mandal S, Barnett J, Brill SE, Brown JS, Denneny EK, Hare SS, et al. ‘Long-COVID’: a cross-sectional study of persisting symptoms, biomarker and imaging abnormalities following hospitalisation for COVID-19. Thorax. 2021;76:396-8. DOI: https://doi.org/10.1136/thoraxjnl-2020-215818
Garrigues E, Janvier P, Kherabi Y, Le Bot A, Hamon A, Gouze H, et al. Post-discharge persistent symptoms and health-related quality of life after hospitalization for COVID-19. J Infect. 2020;81:e4-6. DOI: https://doi.org/10.1016/j.jinf.2020.08.029
Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L, et al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: a cross-sectional evaluation. J Med Virol. 2021;93:1013-22. DOI: https://doi.org/10.1002/jmv.26368
Bellan M, Soddu D, Balbo PE, Baricich A, Zeppegno P, Avanzi GC, et al. Respiratory and psychophysical sequelae among patients with covid-19 four months after hospital discharge. JAMA Netw Open. 2021;4:e2036142. DOI: https://doi.org/10.1001/jamanetworkopen.2020.36142
Huang L, Yao Q, Gu X, Wang Q, Ren L, Wang Y, et al. 1-year outcomes in hospital survivors with COVID-19: a longitudinal cohort study. Lancet. 2021;398:747-58. DOI: https://doi.org/10.1016/S0140-6736(21)01755-4
Tenforde MW, Kim SS, Lindsell CJ, Billig Rose E, Shapiro NI, Files DC, et al. Symptom duration and risk factors for delayed return to usual health among outpatients with COVID-19 in a multistate health care systems network - United States, march-june 2020. MMWR Morb Mortal Wkly Rep. 2020;69:993-8. DOI: https://doi.org/10.15585/mmwr.mm6930e1
Chopra V, Flanders SA, O’Malley M, Malani AN, Prescott HC. Sixty-day outcomes among patients hospitalized with COVID-19. Ann Intern Med. 2021;174:576-8. DOI: https://doi.org/10.7326/M20-5661
Xiong Q, Xu M, Li J, Liu Y, Zhang J, Xu Y, et al. Clinical sequelae of COVID-19 survivors in Wuhan, China: a single-centre longitudinal study. Clin Microbiol Infect. 2021;27:89-95. DOI: https://doi.org/10.1016/j.cmi.2020.09.023
Goërtz YM, Van Herck M, Delbressine JM, Vaes AW, Meys R, Machado FV, et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the post-COVID-19 syndrome? ERJ Open Res. 2020;6:542-2020. DOI: https://doi.org/10.1183/23120541.00542-2020
Dennis A, Wamil M, Kapur S, Alberts J, Badley AD, Decker GA, et al. Multi-organ impairment in low-risk individuals with long COVID. medRxiv. 2020:2020.10.14.20212555. DOI: https://doi.org/10.1101/2020.10.14.20212555
Leung TY, Chan AY, Chan EW, Chan VK, Chui CS, Cowling BJ, et al. Short- and potential long-term adverse health outcomes of COVID-19: a rapid review. Emerg Microbes Infect. 2020;9:2190-9. DOI: https://doi.org/10.1080/22221751.2020.1825914
Strassmann A, Steurer-Stey C, Lana KD, Zoller M, Turk AJ, Suter P, et al. Population-based reference values for the 1-min sit-to-stand test. Int J Public Health. 2013;58:949-53. DOI: https://doi.org/10.1007/s00038-013-0504-z
Vaidya T, de Bisschop C, Beaumont M, Ouksel H, Jean V, Dessables F, et al. Is the 1-minute sit-to-stand test a good tool for the evaluation of the impact of pulmonary rehabilitation? Determination of the minimal important difference in COPD. Int J Chron Obstruct Pulmon Dis. 2016;11:2609-16. DOI: https://doi.org/10.2147/COPD.S115439
Gulart AA, Munari AB, Klein SR, Venâncio RS, Alexandre HF, Mayer AF. The London Chest Activity of Daily Living scale cut-off point to discriminate functional status in patients with chronic obstructive pulmonary disease. Braz J Phys Ther. 2020;24:264-72. DOI: https://doi.org/10.1016/j.bjpt.2019.03.002
Pitta F, Probst VS, Kovelis D, Segretti NO, Leoni AM, Garrod R, et al. Validação da versão em português da escala London Chest Activity of Daily Living (LCADL) em doentes com doença pulmonar obstrutiva crónica. Pulmonology. 2008;14:27-47. DOI: https://doi.org/10.1016/S0873-2159(15)30217-8
Ferreira PL, Ferreira LN, Pereira LN. Contribution for the validation of the portuguese version of EQ-5D. Acta Med Port. 2013;26:664-75. DOI: https://doi.org/10.20344/amp.1317
Fernandes J, Fontes L, Coimbra I, Paiva JA. Health-related quality of life in survivors of severe COVID-19 of a university hospital in Northern Portugal. Acta Med Port. 2021;34:601–7. DOI: https://doi.org/10.20344/amp.16277
Munblit D, Bobkova P, Spiridonova E, Shikhaleva A, Gamirova A, Blyuss O, et al. Risk factors for long-term consequences of COVID-19 in hospitalised adults in Moscow using the ISARIC Global follow-up protocol: StopCOVID cohort study. medRxiv. 2021:2021.02.17.21251895. DOI: https://doi.org/10.1101/2021.02.17.21251895
Thompson EJ, Williams DM, Walker AJ, Mitchell RE, Niedzwiedz CL, Yang TC, et al. Risk factors for long COVID: analyses of 10 longitudinal studies and electronic health records in the UK. medRxiv. 2021:2021.06.24.21259277. DOI: https://doi.org/10.1101/2021.06.24.21259277
Bae E, Choi SE, Lee H, Shin G, Kang D. Validity of EQ-5D utility index and minimal clinically important difference estimation among patients with chronic obstructive pulmonary disease. BMC Pulmonary Medicine. 2020;20:73. DOI: https://doi.org/10.1186/s12890-020-1116-z
Simonelli C, Paneroni M, Vitacca M, Ambrosino N. Measures of physical performance in COVID-19 patients: a mapping review. Pulmonology. 2021;27:518-28. DOI: https://doi.org/10.1016/j.pulmoe.2021.06.005
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