Respiratory sequelae of COVID-19: pulmonary and extrapulmonary origins, and approaches to clinical care and rehabilitation.

Although the exact prevalence of post-COVID-19 condition (also known as long COVID) is unknown, more than a third of patients with COVID-19 develop symptoms that persist for more than 3 months after SARS-CoV-2 infection. These sequelae are highly heterogeneous in nature and adversely affect multiple biological systems, although breathlessness is a frequently cited symptom. Specific pulmonary sequelae, including pulmonary fibrosis and thromboembolic disease, need careful assessment and might require particular investigations and treatments. COVID-19 outcomes in people with pre-existing respiratory conditions vary according to the nature and severity of the respiratory disease and how well it is controlled. Extrapulmonary complications such as reduced exercise tolerance and frailty might contribute to breathlessness in post-COVID-19 condition. Non-pharmacological therapeutic options, including adapted pulmonary rehabilitation programmes and physiotherapy techniques for breathing management, might help to attenuate breathlessness in people with post-COVID-19 condition. Further research is needed to understand the origins and course of respiratory symptoms and to develop effective therapeutic and rehabilitative strategies.

Symptoms burden and rehabilitation preference after an episode of COVID-19: A patients survey.

BACKGROUND: After COVID-19 infection, individuals can experience a variety of symptoms that might require further treatment. Early data showed the value of adapted pulmonary rehabilitation programmes and technology-based interventions. To develop appropriate services, it is important to understand the symptom burden and the preferred mode of rehabilitation delivery. METHODS: Post-hospital discharge (H) and post-community-managed (C) individuals received a follow-up call. A survey was completed to assess the most burdensome symptoms for which the patients would require support and their preference for the mode of rehabilitation delivery. RESULTS: Overall, 160 individuals who received a follow-up call completed the survey (51.2% male, mean [SD] age 54 [15] years) and 126 (78.8%) were post-hospital, while 34 (21.3%) had community-managed infections. A total of 101 (63.1%) reported that COVID-19-related symptoms were affecting their daily activities, and 106 (66.3%) reported their desire to be more active. The most common symptoms identified as needing support were fatigue and shortness of breath. Both groups expressed a preference for a face-to-face group programme (C: 54.8%; H: 46.8%), while (38.7%) of post-community-managed individuals and (40.3%) post-hospital patients preferred a supported digital rehabilitation programme. Few opted a non-digital home-based programme (C: 3.2%; H:12.9%, respectively). CONCLUSION: The survey responses indicated a significant symptom burden that may benefit from an intervention such as rehabilitation. Preferences for rehabilitation indicated that a face-to-face intervention was preferred by the majority, with a large proportion preferring digital intervention.

Review of the British Thoracic Society Winter Meeting 23 November 2022 23-25 November 2022.

The British Thoracic Society Winter Meeting at the QEII Centre in London provided the first opportunity for the respiratory community to meet and disseminate research findings face to face since the start of the COVID-19 pandemic. World-leading researchers from the UK and abroad presented their latest findings across a range of respiratory diseases. This article aims to represent the range of the conference and as such is written from the perspective of a basic scientist, a physiotherapist and two doctors. The authors reviewed showcase sessions plus a selection of symposia based on their personal highlights. Content ranged from exciting new developments in basic science to new and unpublished results from clinical trials, delivered by leading scientists from their fields including former deputy chief medical officer Professor Sir Jonathan Van-Tam and former WHO chief scientist Dr Soumya Swaminathan.

The effect of COVID rehabilitation for ongoing symptoms Post HOSPitalisation with COVID-19 (PHOSP-R): protocol for a randomised parallel group controlled trial on behalf of the PHOSP consortium.

INTRODUCTION: Many adults hospitalised with COVID-19 have persistent symptoms such as fatigue, breathlessness and brain fog that limit day-to-day activities. These symptoms can last over 2 years. Whilst there is limited controlled studies on interventions that can support those with ongoing symptoms, there has been some promise in rehabilitation interventions in improving function and symptoms either using face-to-face or digital methods, but evidence remains limited and these studies often lack a control group. METHODS AND ANALYSIS: This is a nested single-blind, parallel group, randomised control trial with embedded qualitative evaluation comparing rehabilitation (face-to-face or digital) to usual care and conducted within the PHOSP-COVID study. The aim of this study is to determine the effectiveness of rehabilitation interventions on exercise capacity, quality of life and symptoms such as breathlessness and fatigue. The primary outcome is the Incremental Shuttle Walking Test following the eight week intervention phase. Secondary outcomes include measures of function, strength and subjective assessment of symptoms. Blood inflammatory markers and muscle biopsies are an exploratory outcome. The interventions last eight weeks and combine symptom-titrated exercise therapy, symptom management and education delivered either in a face-to-face setting or through a digital platform ( www.yourcovidrecovery.nhs.uk ). The proposed sample size is 159 participants, and data will be intention-to-treat analyses comparing rehabilitation (face-to-face or digital) to usual care. ETHICS AND DISSEMINATION: Ethical approval was gained as part of the PHOSP-COVID study by Yorkshire and the Humber Leeds West Research NHS Ethics Committee, and the study was prospectively registered on the ISRCTN trial registry (ISRCTN13293865). Results will be disseminated to stakeholders, including patients and members of the public, and published in appropriate journals. Strengths and limitations of this study • This protocol utilises two interventions to support those with ongoing symptoms of COVID-19 • This is a two-centre parallel-group randomised controlled trial • The protocol has been supported by patient and public involvement groups who identified treatments of symptoms and activity limitation as a top priority.

Public Use of the "Your COVID Recovery" Website Designed to Help Individuals Manage Their COVID-19 Recovery: Observational Study.

BACKGROUND: At the start of the COVID-19 pandemic, unprecedented pressure was placed on health care services globally. An opportunity to alleviate this pressure was to introduce a digital health platform that provided COVID-19-related advice and helped individuals understand and manage their COVID-19 symptoms. Therefore, in July 2020, the Your COVID Recovery website was launched by the National Health Service of England with the aim of creating a practical tool that provides advice and support to individuals recovering from COVID-19. The website includes information on many of the key COVID-19 symptoms. To date, public use of the Your COVID Recovery website and user behavior remain unknown. However, this information is likely to afford insight into the impact of the website and most commonly experienced COVID-19 symptoms. OBJECTIVE: This study aimed to evaluate public use of the Your COVID Recovery website, a digital health platform that provides support to individuals recovering from COVID-19, and determine user behavior during its first year of operation. METHODS: Google Analytics software that was integrated into the Your COVID Recovery website was used to assess website use and user behavior between July 31, 2020, and July 31, 2021. Variables that were tracked included the number of users, user country of residence, traffic source, number of page views, number of session views, and mean session duration. User data were compared to COVID-19 case data downloaded from the UK government's website. RESULTS: During the study period, 2,062,394 users accessed the Your COVID Recovery website. The majority of users were located in the United Kingdom (1,265,061/2,062,394, 61.30%) and accessed the website via a search engine (1,443,057/2,062,394, 69.97%). The number of daily website users (n=15,298) peaked on January 18, 2021, during the second wave of COVID-19 in the United Kingdom. The most frequently visited pages after the home page were for the following COVID-19 symptoms: Cough (n=550,190, 12.17%), Fatigue (n=432,421, 9.56%), Musculoskeletal pain (n=406,859, 9.00%), Taste and smell (n=270,599, 5.98%), and Breathlessness (n=203,136, 4.49%). The average session duration was 1 minute 13 seconds. CONCLUSIONS: A large cohort of individuals actively sought help with their COVID-19 recovery from the website, championing the potential of this tool to target an unmet health care need. User behavior demonstrated that individuals were primarily seeking advice on how to relieve and manage COVID-19 symptoms, especially symptoms of cough, fatigue, and musculoskeletal pain. COVID-19 rehabilitation programs should use the results of this study to ensure that the program content meets the needs of the post-COVID-19 population.

Early experiences of the Your COVID Recovery® digital programme for individuals with long COVID.

OBJECTIVES: To describe the early data from the Your COVID Recovery® digital programme and to explore the data collected from two embedded outcome measures. DESIGN: Observational. SETTING: Primary and secondary care (England-Online). PARTICIPANTS: 110 individuals completed the programme (68.1% female, 88.1% White British, age: 46.3 (10.8) years, weight: 86.5 (21.1) kg, height: 169.3 (10.0) cm). 47.2% of patients reported comorbidities. INTERVENTION: Following an assessment by a healthcare professional, individuals with long COVID were offered access to the Your COVID Recovery® digital programme. The programme comprises of four stages for the participants to progress through. Participants are encouraged to record severity of their symptoms and amount of activity they are doing on a symptom and an activity tracker. Resources and interactive material on managing symptoms of long COVID are available throughout each stage. PRIMARY OUTCOME MEASURES: Questionnaire (EuroQ0l 5-Dimension 5-Level (EQ-5D-5L) and the chronic obstructive pulmonary disease assessment test (CAT)) data were extracted from the site from 11 March 2021 until 9 November 2021. RESULTS: Participants were on the programme for 8.6 (4.3) weeks. There was a statistically significant increase in EQ-5D-5L visual analogue scale (VAS) score (pre=48.8 (19.5); post=59.9 (22.1); p<0.01). The EQ-5D-5L Index Value preintervention to postintervention did improve but not significantly (pre=0.5 (0.3); post=0.6 (0.3); p=0.09). CAT total score improved significantly preintervention to postintervention (pre=19.8 (7.2); post=15.6 (7.6); p<0.01). All CAT item scores significantly improved preintervention to postintervention (p<0.005), except the phlegm item score (p=0.168). DISCUSSION: This early data describes the impact of the Your COVID Recovery® digital programme on the first cohort of patients to complete the digital recovery programme. The outcome data are promising and should encourage uptake.

Effects of combining electrical stimulation of the calf and thigh muscles in patients with osteoarthritis of the knee: protocol for a double-blind, randomised, sham-controlled trial.

INTRODUCTION: Knee osteoarthritis (KOA) is a leading cause of disability and is characterised by degenerative changes causing pain and loss of function. Neuromuscular electrical stimulation (NMES) has been shown to influence muscle size and strength in healthy subjects. A novel self-administered NMES device has been developed to help manage the symptoms of KOA. This study aims to investigate the effects of combining NMES of the calf and quadriceps on individuals with KOA. METHODS AND ANALYSIS: 193 individuals with KOA will be recruited to a single-centre, double-blind, randomised, sham-controlled trial at the Respiratory Biomedical Research Centre, Leicester, UK. Participants will be randomised (1:1) to follow an 8-week home-based intervention using a NMES device or sham device. The NMES device consists of footplate electrodes and two quadriceps electrodes. Footplate stimulation will be completed daily for 30 min and quadriceps stimulation for 20 min, five times a week (compliance is recorded in a self-reported participant diary). The primary outcome is the Western Ontario and McMaster Universities Arthritis Index pain domain, taken at 8 weeks follow-up. Secondary outcomes will explore quadriceps muscle strength, swelling, health-related quality of life, exercise capacity, anxiety and depression, sleep, physical activity and self-reported compliance. A powered subgroup analysis for compliance to the active device will be complete for the primary outcome. Participant focus groups will be completed following recruitment of half of the participants and after all participants have been recruited. ETHICS AND DISSEMINATION: Ethical approval has been obtained from the North-West Preston ethics committee (17/NW/0081). Participants are required to provide informed consent following review of the participant information sheet and discussion regarding study procedures with a member of the research team. The study results will be disseminated to the appropriate stakeholders through presentations, conferences and peer-reviewed journals. Results will be presented to participants following study completion at the Biomedical Research Centre-Respiratory, Glenfield Hospital, Leicester. TRIAL REGISTRATION NUMBER: ISRCTN registry, ISRCTN12112819 (date registered 1 May 2019). IRAS registry 219 693. University Hospitals of Leicester registry 91 017. Protocol Version 8.

Device-assessed sleep and physical activity in individuals recovering from a hospital admission for COVID-19: a multicentre study.

BACKGROUND: The number of individuals recovering from severe COVID-19 is increasing rapidly. However, little is known about physical behaviours that make up the 24-h cycle within these individuals. This study aimed to describe physical behaviours following hospital admission for COVID-19 at eight months post-discharge including associations with acute illness severity and ongoing symptoms. METHODS: One thousand seventy-seven patients with COVID-19 discharged from hospital between March and November 2020 were recruited. Using a 14-day wear protocol, wrist-worn accelerometers were sent to participants after a five-month follow-up assessment. Acute illness severity was assessed by the WHO clinical progression scale, and the severity of ongoing symptoms was assessed using four previously reported data-driven clinical recovery clusters. Two existing control populations of office workers and individuals with type 2 diabetes were comparators. RESULTS: Valid accelerometer data from 253 women and 462 men were included. Women engaged in a mean ± SD of 14.9 ± 14.7 min/day of moderate-to-vigorous physical activity (MVPA), with 12.1 ± 1.7 h/day spent inactive and 7.2 ± 1.1 h/day asleep. The values for men were 21.0 ± 22.3 and 12.6 ± 1.7 h /day and 6.9 ± 1.1 h/day, respectively. Over 60% of women and men did not have any days containing a 30-min bout of MVPA. Variability in sleep timing was approximately 2 h in men and women. More severe acute illness was associated with lower total activity and MVPA in recovery. The very severe recovery cluster was associated with fewer days/week containing continuous bouts of MVPA, longer total sleep time, and higher variability in sleep timing. Patients post-hospitalisation with COVID-19 had lower levels of physical activity, greater sleep variability, and lower sleep efficiency than a similarly aged cohort of office workers or those with type 2 diabetes. CONCLUSIONS: Those recovering from a hospital admission for COVID-19 have low levels of physical activity and disrupted patterns of sleep several months after discharge. Our comparative cohorts indicate that the long-term impact of COVID-19 on physical behaviours is significant.

The Recovery Journey and the Rehabilitation Boat - A qualitative study to explore experiences of COVID-19 rehabilitation.

INTRODUCTION: There are early data to suggest that a rehabilitation programme can help with on-going symptoms of COVID-19, including breathlessness, exercise limitation and fatigue. As yet, there are no published data to understand patients' perceived acceptability of a rehabilitation programme for COVID-19. METHODS: 2 focus groups (n = 9) and 4 one to one interviews were conducted with participants who attended a rehabilitation program following COVID-19. Interviews were analysed using reflexive thematic analysis with an inductive approach. RESULTS: Two overarching themes were generated from the data. The first, The Recovery Journey is sub-divided into five sub-themes of Expectations, Individual and Varied Journeys, Mental and Physical Improvements, Self-values and The Journey Continues. The second overarching theme, The Rehabilitation boat contains five subthemes: Programme Delivery, Safe and Supportive, Validation and Assurance, Shared Reflections and Education. CONCLUSION: A rehabilitation programme for post COVID-19 symptoms was considered to be acceptable and viewed positively in terms of improving physical and mental symptoms. The opportunity to share the experience with others in the same boat was highly valued in the context of an unexpected and potentially lonely COVID-19 recovery.

Early experiences of rehabilitation for individuals post-COVID to improve fatigue, breathlessness exercise capacity and cognition - A cohort study.

Individuals with lasting symptoms of COVID-19 should be offered a comprehensive recovery programme. 30 individuals (mean[SD] age 58[16]) that completed a 6 week, twice supervised rehabilitation programme demonstrated statistically significant improvements in exercise capacity, respiratory symptoms, fatigue and cognition. Participants improved by 112 m 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.

Which functional outcome measures can we use as a surrogate for exercise capacity during remote cardiopulmonary rehabilitation assessments? A rapid narrative review.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic has seen many cardiopulmonary rehabilitation services delivering programmes remotely. One area of concern is how to assess exercise capacity when a supervised exercise test is not possible. The aim of this review was to examine the relationship between functional exercise tests and recommended exercise tests for cardiopulmonary rehabilitation. METHODS: A rapid narrative review was carried out. Searches were conducted by two of the study authors. The study had the following features. Participants: adults, all with long-term conditions; intervention: any/none; outcome: Duke activity status index (DASI), sit to stand (STS, 30 s, 1 min and 5 repetitions), short physical performance battery (SPPB), 4-metre gait speed (4MGS) or step test (Chester/others) AND directly compared to one of the recommended exercise tests for cardiopulmonary rehabilitation: 6-min walk test (6MWT), incremental shuttle walk test (ISWT) or cardiopulmonary exercise test (CPET) in terms of reporting agreement/correlation; Study design: primary research only, controlled trials or observational studies. RESULTS: Sixteen articles out of 249 screened were included (n=2271 patients). Overall, there were weak-strong correlations for the included tests with a recommended exercise test (r=0.38-0.85). There were few reported issues with feasibility or safety of the tests. However, all tests were supervised in a clinical setting. The test that had the highest correlation with the field walking test was the 4MGS with the ISWT (r=0.78) and with the 6MWT (r=0.85). DISCUSSION: The 4MGS has the highest correlation with routine measures of exercise tolerance. However, it may be difficult to standardise in a remote assessment or to prescribe exercise from. Clinicians should strive for face-to-face standardised exercise tests where possible to be able to guide exercise prescription.

COPD assessment test for the evaluation of COVID-19 symptoms.

There is evidence to demonstrate the ongoing symptoms of COVID-19; however, there are currently no agreed outcomes to assess these symptoms. This study examined the use of the chronic obstructive pulmonary disease (COPD) assessment test (CAT) for patients recovering from COVID-19. 131 patients who were admitted with COVID-19 were followed up over the phone to assess symptoms. The median (IQR) CAT score was 10 (5-16). Cough, phlegm and chest tightness domains were within range for healthy people, but there was evidence of significant breathlessness, loss of energy, and activity and sleep disturbance. The CAT is a useful tool to assess symptoms of COVID-19 recovery.