Rehabilitation and COVID-19: rapid living systematic review by Cochrane Rehabilitation Field - third edition. Update as of June 30th, 2021.

INTRODUCTION: This paper updates and summarizes the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences of the disease and its treatment. EVIDENCE ACQUISITION: Studies published from May 1st to June 30th, 2021 were selected, excluding descriptive studies and expert opinions. Papers were categorized according to study design, research question, COVID-19 phase, limitations of functioning of rehabilitation interest, and type of rehabilitation service involved. From this edition, we improved the quality assessment using the Joanna Briggs Institute checklists for observational studies and the Cochrane Risk of Bias Tool for randomized-controlled clinical trials (RCTs). EVIDENCE SYNTHESIS: Twenty-five, out of 3699 papers, were included. They were three RCTs, 13 cross-sectional studies and nine cohort studies. Twenty studies reported data on symptom prevalence (N.=13) or disease natural history (N.=7); and five studies reported intervention effectiveness at the individual level. All study participants were COVID survivors and 48% of studies collected information on participants 6 months or longer after COVID-19 onset. The most frequent risks of bias for RCTs concerned weaknesses in allocation concealment, blinding of therapists, and lack of intention-to-treat analysis. Most analytical studies failed to identify or deal with confounders, describe or deal with dropouts or eventually perform an appropriate statistical analysis. CONCLUSIONS: Most studies in this updated review targeted the prevalence of limitations of functioning of rehabilitation interest in COVID-19 survivors. This is similar to past review findings; however, data in the new studies was collected at longer follow-up periods (up to one year after symptom onset) and in larger samples of participants. More RCTs and analytical observational studies are available, but the methodological quality of recently published studies is low. There is a need for good quality intervention efficacy and effectiveness studies to complement the rapidly expanding evidence from observational studies.

Functional outcome after inpatient rehabilitation in postintensive care unit COVID-19 patients: findings and clinical implications from a real-practice retrospective study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic is quickly spreading worldwide, with survivors that suffer functional impairments with a consequent key role of rehabilitation in this context. To date, there is a lack of findings on the role of rehabilitation in postacute COVID-19 patients. AIM: Thus, we aimed at describing the role of a patient-tailored rehabilitation plan on functional outcome in hospitalized COVID-19 patients. DESIGN: Real-practice retrospective study. SETTING: Inpatients Rehabilitation Unit. POPULATION: Postacute COVID-19 patients. METHODS: Medical records of patients referred to an Italian COVID-19 Rehabilitation Unit from March 10th, 2020 to April 30th, 2020 were collected. All patients underwent a rehabilitative (30 minutes/set, 2 times/day), aimed to improve gas exchanges, reducing dyspnoea, and improving muscle function. At the admission (T0) and at the discharge (T1), we evaluated as outcome measures: Barthel Index (BI), modified Medical Research Council Dyspnea Scale, 6-Minute Walking Test (6-MWT) and Borg Rating of Perceived Exertion (RPE) scale. We also assessed: type of respiratory supports needed, pulmonary function, coagulation and inflammation markers and length of stay (LOS) in Rehabilitation Unit. RESULTS: We included 41 postacute COVID-19 patients (25 male and 19 female), mean aged 72.15±11.07 years. Their mean LOS in the Rehabilitation Unit was 31.97±9.06 days, as 39 successfully completed the rehabilitation treatment and 2 deceased. We found statistically significant improvement in BI (84.87±15.56 vs. 43.37±26.00; P<0.0001), 6-MWT (303.37±112.18 vs. 240.0±81.31 meters; P=0.028), Borg RPE scale (12.23±2.51 vs. 16.03±2.28; P<0.0001). CONCLUSIONS: These findings suggest that postacute COVID-19 patients might beneficiate of a motor and respiratory rehabilitation treatment. However, further studies are advised to better understand long-term sequelae of the disease. CLINICAL REHABILITATION IMPACT: This study provides evidence on the role of rehabilitation COVID-19 postacute inpatients through a patient-tailored treatment.

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of October 31st, 2020.

INTRODUCTION: This living systematic review presents the monthly update of the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER Action Steering Committee. The aim of this study was to update the monthly COVID-19 and rehabilitation literature research up to October 31st, 2020. EVIDENCE ACQUISITION: Methodology described in the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER action was applied. PubMed, Embase, CINAHL, Scopus, Web of Science, and PEDro databases were searched, and papers related to COVID-19 and rehabilitation were retrieved and summarized descriptively. EVIDENCE SYNTHESIS: The database search retrieved 2704 publications. Duplicates were removed, and 1185 unique records were screened for inclusion. After screening titles, abstracts and full-texts, 22 papers were included in the present review. According to OCEBM 2011 Levels of Evidence table, 17 studies (77%) fall within the level of evidence 4 category, while the remainder (23%) are categorized as level of evidence 3. Most studies (N.=19; 86%) provided epidemiological data about the disease natural history/determining factor or the clinical presentation of COVID-19 infection, while only two studies focused on health service organization and intervention efficacy. CONCLUSIONS: The most recent published COVID-19 research relevant to rehabilitation primarily provides data on the clinical course and the clinical presentation of the pathology, rather than on rehabilitation interventions or service delivery. Studies with high levels of evidence regarding the efficacy of interventions, long-term monitoring, or new health service organization models are lacking.

Rehabilitation and COVID-19: a rapid living systematic review by Cochrane Rehabilitation Field updated as of December 31st, 2020 and synthesis of the scientific literature of 2020.

INTRODUCTION: COVID-19 infection significantly increased mortality risk and the burden of disability in most survivors, regardless of symptom severity at onset. The rehabilitation needs of people infected are receiving growing attention, as evidenced by the increasing number of publications, including those addressing the chronic consequences of infection. This rapid living systematic review reports the evidence published in November and December 2020 and summarises the entire body of literature on rehabilitation in COVID-19 patients published in 2020. EVIDENCE ACQUISITION: This update was performed using the methodology reported by the second edition conducted by Cochrane Rehabilitation REH-COVER Action. We searched PubMed, Embase, CINAHL, Scopus, Web of Science, and Pedro databases. Papers related to COVID-19 and rehabilitation were retrieved and summarised descriptively. EVIDENCE SYNTHESIS: The search retrieved 4441 studies. After the removal of duplicates and the screening for title and abstract, we retained 105 studies. Of these, we included 54 in the qualitative synthesis of this update. According to OCEBM 2011 levels of evidence table, most studies (64.8%) fall within the category of level 4 evidence. Up to 40.7% of papers included COVID-19 patients in the postacute phase. In 2020, our rapid living systematic review included 230 studies; most of these (73.9%) were level 4 studies, 25.7% were level 3, and only one study was level 2. The evidence level improved over time. While most studies (44.8%) included patients with acute COVID-19, we observed a gradual increase in the number of reports about chronic symptoms and the long-term consequences of the infection. CONCLUSIONS: The update of the rapid living systematic review by Cochrane Rehabilitation Field demonstrates an increase in the level of evidence of studies addressing the rehabilitation needs associated with COVID-19 infection. Although most studies are still case reports/series, there is a trend towards conducting prospective investigations of the early natural history of the disease (first months post onset). High-quality-level studies on the efficacy of rehabilitation, and long-term monitoring of the disease and its sequelae are yet to emerge.

Rehabilitation and COVID-19: a rapid living systematic review 2020 by Cochrane Rehabilitation Field. Update as of September 30th, 2020.

INTRODUCTION: The COVID-19 outbreak response requires identifying and understanding the long-term consequences of this new pathology and how to manage these. This living systematic review presents the most current and seminal information coming from the scientific literature. It is the monthly update of the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER Action Steering Committee. The aim of this review was to update the monthly COVID-19 and rehabilitation literature research up to September 30, 2020. EVIDENCE ACQUISITION: Methodology described in the second edition of the rapid living systematic review 2020 conducted by Cochrane Rehabilitation REH-COVER action was applied. The most important medical databases were searched, and papers related to COVID-19 and rehabilitation were retrieved and summarized descriptively. EVIDENCE SYNTHESIS: The database search retrieved 2526 publications. Duplicates were removed, and 1150 unique records were screened for inclusion. After screening titles, abstracts and full-texts, 37 papers were included in the present review. According to OCEBM 2011 levels of evidence table, most studies (78.4%) fall within the level of evidence 4 category, while the remainder (22.6%) are categorized as level of evidence 3. Most studies described patients in acute (51.4%) or subacute (35.0%) phase, while no studies described the chronic consequences of COVID-19. Just one study dealt with rehabilitation interventions regarding COVID-19, and two discussed reorganization of rehabilitative services. CONCLUSIONS: The most recently published COVID-19 research focuses more on describing the clinical presentations and the natural history of the pathology, rather than rehabilitation interventions or service delivery. Studies with high levels of evidence regarding the efficacy of interventions, long-term monitoring, or new organization models remain lacking.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of August 31st, 2020.

INTRODUCTION: A monthly systematic review update is carried out to maintain the currency of scientific literature on rehabilitation of patients with COVID-19 and/or describing consequences due to the disease and its treatment, as they relate to limitations in functioning of rehabilitation interest. The aim of this study was to provide an updated summary of the available evidence published in August 2020. EVIDENCE ACQUISITION: An extensive search on the main medical literature databases from August 1st, 2020 to August 31st, 2020 was performed, according to the methodology described in the second edition of the Cochrane Rehabilitation 2020 rapid living systematic review. EVIDENCE SYNTHESIS: After removing duplicates, 1136 papers were identified, and 51 studies were finally included. According to OCEBM 2011 Levels of Evidence Table, they were Level 4 in most cases (76.5%) and Level 3 in the remaining (23.5%). Randomized controlled trials (RCTs) were not found. Thirty-two studies (62.7%) included COVID-19 patients who were assessed in the acute (20/32) or postacute phases (12/32). The other studies reported data on the impact of COVID-19 infection (7/19) or on the effect of lockdown restrictions (12/19) on subjects with pre-existing health conditions. CONCLUSIONS: The scientific literature of August 2020 mainly focused on limitations in functioning of nervous system structure and related functions. Albeit the increased availability of data from analytical studies (both cohort and cross-sectional), there is still a lack of well-conducted Level 2 studies, to improve the knowledge on the effects of rehabilitation in COVID-19 patients.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review. Update as of July 31st, 2020.

INTRODUCTION: This paper is the first update of the second edition of the rapid living systematic review on the latest scientific literature informing rehabilitation of patients with COVID-19 and/or describing consequences of the disease and its treatment, as they relate to limitations in functioning of rehabilitation interest. The aim of this study was to report data of a systematic search performed on papers published in July 2020. EVIDENCE ACQUISITION: The methodology described in the second edition of the rapid living systematic review was applied to search eligible papers included in the databases between July 1, 2020 and July 31, 2020. EVIDENCE SYNTHESIS: Eight-hundred-ninety-two papers were identified through database searching (after removal of duplicates); of these, only 23 studies were included. According to OCEBM 2011 Levels of Evidence Table, they were level 3 in 30.5% cases and level 4 in 69.5%. No RCT was found. Nineteen papers studied COVID-19 patients, assessed in the acute (10 studies), post-acute (8 studies) and chronic phase (one study). Four studies reported data on the impact of COVID-19 on subjects with pre-existing health conditions. CONCLUSIONS: The current literature production still focuses more on describing all the possible aspects and complications of the pathology than on interventions or new organization models to deal with it. Albeit evidence on handling COVID-19 from a rehabilitative point of view is improving each month, further studies are still mandatory to report the role of rehabilitation in this scenario.

Rehabilitation and COVID-19: the Cochrane Rehabilitation 2020 rapid living systematic review.

INTRODUCTION: This paper improves the methodology of the first edition of the rapid living systematic review started in April 2020, with the aim to gather and present the current evidence informing rehabilitation of patients with COVID-19 and/or describing the consequences due to the disease and its treatment. EVIDENCE ACQUISITION: The Cochrane methodology for a rapid living systematic review was applied. Primary research papers, published from 1 January to 30 June 2020, reporting patients' data, with no limits of study design were included. Studies were categorized for study design, research question, COVID-19 phase, limitations of functioning (disability) of rehabilitation interest and type of rehabilitation service involved. Methodological quality assessment was based on the Cochrane Risk of Bias tools, and the level of evidence table (OCEBM 2011) for all the other studies. EVIDENCE SYNTHESIS: Thirty-six, out of 3703 papers, were included. One paper was of level 2 (RCT), 7 were of level 3 (2 cohort studies, 2 cross-sectional studies and 3 case-control studies), and 28 papers of level 4 (descriptive studies); 61% of papers reported epidemiological data on clinical presentations, 5 investigated natural history/determining factors, 1 searched prevalence, 2 studies reported on intervention efficacy (though not on harms), and 5 studies looked at health service organization. CONCLUSIONS: Main issues emerging from the review: it is advised to test for COVID-19 people with neurological disorders presenting with symptom changes; dysphagia is a frequent complication after oro-tracheal intubation in COVID-19 patients admitted to the ICU; after discharge, COVID-19 survivors may report persistent restrictive ventilatory deficits regardless of disease severity; there is only sparse and low quality evidence concerning the efficacy of any rehabilitation intervention to promote functional recovery; a substantial increase in resource (staff and equipment) is needed for rehabilitation.

Early rehabilitation in post-acute COVID-19 patients: data from an Italian COVID-19 Rehabilitation Unit and proposal of a treatment protocol.

BACKGROUND: Coronavirus disease 2019 (COVID-19) pandemic is quickly spreading, putting under heavy stress health systems worldwide and especially Intensive Care Units (ICU). Rehabilitation Units have a crucial role in reducing disability in order to reintroduce patients in the community. AIM: The aim of this study is to characterize pulmonary function and disability status and to propose an early rehabilitation protocol in a cohort of post-acute COVID-19 patients admitted to an Italian Rehabilitation Unit. DESIGN: Cross-sectional observational study. SETTING: Inpatients Rehabilitation Unit. POPULATION: Post-acute COVID-19 patients. METHODS: Demographic, anamnestic and clinical characteristics, laboratory exams and medical imaging findings were collected for the entire cohort. Outcome measures evaluated at the admission in Rehabilitation Unit were: type of respiratory supports needed, fraction of inspired oxygen (FiO2), partial pressure of oxygen (PaO2), FiO2/PaO2, Barthel Index (BI), modified Medical Research Council (mMRC) Dyspnoea Scale, and 6-Minute Walking Test (6-MWT). Furthermore, we proposed an early rehabilitation protocol for COVID-19 patients based on baseline FiO2. RESULTS: We included 32 post-acute COVID-19 patients (22 male and 10 female), mean aged 72.6±10.9 years. BI was 45.2±27.6, with patients in need of higher FiO2 (≥40%) showing lower values: 39.6±25.7 vs. 53.3±29.3. All patients had grade 4 or 5 on the mMRC Dyspnea Scale. Only 14 COVID-19 patients were able to walk (43.7%). 6-MWT was feasible in 6 (18.8%) patients with a mean distance of 45.0±100.6 meters. CONCLUSIONS: Taken together, our findings suggest that post-acute COVID-19 patients suffered from dyspnea and shortness of breath even for minimal activities, with a resulting severe disability, and only a few of them were able to perform 6-MWT with poor results. An early rehabilitation protocol was proposed according to the baseline conditions of the patients. CLINICAL REHABILITATION IMPACT: This study could provide an accurate description of COVID-19 sub-acute patients admitted to a Rehabilitation Unit along with a proposal of treatment to help physicians to tailor the best possible rehabilitative treatment.

Neuropsychological Features of Severe Hospitalized Coronavirus Disease 2019 Patients at Clinical Stability and Clues for Postacute Rehabilitation.

OBJECTIVES: To report the cognitive features of patients with severe coronavirus disease 2019 (COVID-19) entering the postacute phase, to understand whether COVID-19 acute respiratory distress syndrome itself could result in long-term cognitive deficits, and to determine whether neuropsychological treatment after the acute stage might represent a specific rehabilitation need. DESIGN: Case series. SETTING: Rehabilitation hospital. PARTICIPANTS: We assessed the general cognitive functioning through tablet-supported video calls in 9 of 12 consecutive patients (N=9) admitted to the hospital at least 30 days earlier for acute respiratory distress syndrome due to COVID-19. Three patients were excluded based on the exclusion criteria. None of the patients presented cognitive symptoms before hospitalization. MAIN OUTCOME MEASURE: General cognitive functioning, measured using the Mini-Mental State Examination (MMSE) test. RESULTS: A general cognitive decay was observed in 3 patients (33.3%) who had a pathologic score on the MMSE, with a specific decline in attention, memory, language, and praxis abilities. The cognitive malfunctioning appears to be linearly associated with the length of stay (in d) in the intensive care unit (ICU). The longer the amount of time spent in the ICU, the lower the MMSE score, indicating a lower global cognitive functioning. CONCLUSIONS: Our results indicate that some patients with COVID-19 might also benefit from neuropsychological rehabilitation, given their possible global cognitive decay. The link between neuropsychological functioning and the length of stay in the ICU suggests that neurocognitive rehabilitative treatments should be directed explicitly toward patients who treated in the ICU, rather than toward every patient who experienced acute respiratory distress syndrome owing to COVID-19. However, given the limitation of a case series study, those hypotheses should be tested with future studies with larger samples and a longer follow-up period.

Is disruption of sleep quality a consequence of severe Covid-19 infection? A case-series examination.

The Covid-19 outbreak put enormous stress on the health system worldwide, and objective data to handle the emergency are still needed. We aimed to objectively assess the consequence of severe symptoms of Covid-19 infection on sleep quality through wrist actigraphy monitoring of four patients during the sub-acute recovery stage of the disease. The sleep of those patients who had experienced the most severe respiratory symptoms and who had needed prolonged intensive care unit (ICU) stay showed lower Sleep Efficiency and Immobility Time and higher Fragmentation Index compared to those patients who had experienced only mild respiratory symptoms and not requiring ICU stay. Wrist actigraphy assessment provided important clinical information about the sleep and activity levels of Covid-19 patients during the post-acute rehabilitation management.

Systematic rapid living review on rehabilitation needs due to COVID-19: update to May 31st, 2020.

INTRODUCTION: This paper adds to the series of systematic rapid living reviews, started in April 2020, to provide the rehabilitation community with updates on the latest scientific literature on rehabilitation needs due to the COVID-19 pandemic. The aim of this study was to present the results of a systematic search performed on papers published from May 1^st to May 31^st, 2020. EVIDENCE ACQUISITION: An extensive search on the main medical literature databases for articles published (including Epub), in English, from May 1^st to May 31^st, 2020 was performed, according to the methodology already described in the previous 2 rapid reviews, with 2 important improvements: first, we made the search string more comprehensive; second, we relied on accredited terminologies to describe the study designs and report the rehabilitation settings. EVIDENCE SYNTHESIS: Fifty-eight out of 618 articles were finally included for qualitative analysis. The number of primary studies has increased, with respect to the previous months, although still around 60% papers are just expert opinions. Six papers report on the prevalence and /or characteristics of emerging disability after COVID-19, 12 on rehabilitation approaches to COVID-19 patients, up to 25 on the organization of rehabilitation services after COVID-19, 13 papers on the impact of COVID-19 on health conditions of rehabilitative interest and only 2 on late complications due to COVID-19 that may be of rehabilitative interest. CONCLUSIONS: Nowadays, all patients with disability, regardless of COVID-19 infection, are suffering because of restrictions imposed to rehabilitation service delivery. Neurological involvement is often present during acute and postacute stage, conveying the risk of a long-lasting disability. Accordingly, careful neurological monitoring should be granted. Although new therapies are under development, the main gap in the available scientific literature is the lack of high-quality primary studies, so experimental studies on the effects of rehabilitation are still warranted.

Systematic rapid "living" review on rehabilitation needs due to COVID-19: update to March 31st, 2020.

INTRODUCTION: The outbreak of COVID-19 epidemics has challenged the provision of health care worldwide, highlighting the main flaws of some national health systems with respect to their capacity to cope with the needs of frail subjects. People experiencing disability due to COVID-19 express specific rehabilitation needs that deserve a systematic evidence-based approach. The aim of this article is to provide the rehabilitation community with updates on the latest scientific literature on rehabilitation needs due to COVID-19. The first rapid "living" review will present the results of a systematic search performed up to March 31st, 2020. EVIDENCE ACQUISITION: A systematic search in PubMed, Pedro, and Google Scholar was performed using the search terms: "COVID-19," "Coronavirus," "severe acute respiratory syndrome coronavirus 2," "rehabilitation," "physical therapy modalities," "exercise," "occupational therapy," and "late complications." Papers published up to March 31st, 2020, in English, were included. EVIDENCE SYNTHESIS: Out of the 2758 articles retrieved, nine were included in the present review. Four of them are "calls for action", three provide recommendations about rehabilitation interventions in the acute phase, two address the needs of people quarantined at home or with restricted mobility due to the lockdown, and one provides a Core Outcome Set to be used in clinical trials to test the efficacy of health strategies in managing COVID-19 patients. CONCLUSIONS: All selected papers were based on previous literature and not on the current COVID-19 pandemic. Main messages included: 1) early rehabilitation should be granted to inpatients with COVID-19; 2) people with restricted mobility due to quarantine or lockdown should receive exercise programs to reduce the risk of frailty, sarcopenia, cognitive decline and depression; 3) telerehabilitation may represent the first option for people at home. Further updates are warranted in order to characterize the emerging disability in COVID-19 survivors and the adverse effects on the health of chronically disabled people.