Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia significantly impairs the quality of life and functional status of patients. Even few months after onset of the SARS-CoV-2 infection, many patients are still affected with chronic, clinically relevant sequelae. The most frequently reported health issues are fatigue (53–87%), breathlessness (43–71%) and neuropsychological impairments (47%), with a high prevalence of psychological disorders such as increased levels of stress, anxiety and depression (1,2,3,4). The place and role of rehabilitation treatment is important not only in improving respiratory status but also in improving the quality of life and functionality after treatment of SARS-CoV-2 pneumonia (5).
The goal of respiratory rehabilitation in hospitalized Covid-19 patients is to improve dyspnea, relieve anxiety and depression, prevent complications, reduce morbidity, preserve functionality and improve quality of life. Early respiratory rehabilitation is not recommended for severe and critically ill patients if their condition remains unstable or progressively worsens, but for all other patients it is crucial. Individual approach to each patient is mandatory especially for elderly patients, obese patients and patients with multiple comorbidities. Evaluation and monitoring of the patient is carried out all the time during the rehabilitation (5).
It is well known that respiratory rehabilitation leads to reduction of symptoms, strengthens extremity musculature and improves emotional state and management of daily activities in patients with respiratory diseases (6). Aim of our study was to determine impact of Covid-19 infection on patient’s quality of life and functionality and to investigate the efficacy of respiratory rehabilitation in improving them.
The research was conducted as prospective study at Department of physical medicine and rehabilitation, Clinical Center of Kragujevac, Serbia in June and July 2020. Participants included in study were patients in the post-acute phase of mild, moderate, severe or critical COVID-19 as defined by the World Health Organization (7) and treated in Clinical Center of Kragujevac. Inclusion criteria for participants were age 18 and above. Patient with heart failure (New York Heart Association classes III and IV), patient with cognitive and conscious impairment (Mini–Mental State Examination score below 21, Glasgow Coma Score below 13), patient with serious sight and hearing impairment and febrile patients were excluded from study. All patients give written consent and study was approved by the ethics committee of the Clinical Center of Kragujevac (no. 01/20/485 from 24/04/2020).
Respiratory rehabilitation was conducted once a day and involves patient positioning, postural drainage, and breathing exercises. Oxygen saturation (SpO2) and heart rate via a pulse oximeter were measured before and after treatment.
Breathing exercises were performed in the supine position with the legs bent at the knees, in a semi-sitting or sitting position according to patient’s respiratory status. After positioning, a physical treatment with breathing exercises was applied - training in diaphragmatic breathing to establish breathing control, reducing the consumption of energy needed for breathing, and improving lung ventilation. The patient was instructed to inhale the air through the nose and exhale lightly through the mouth in the position of pronouncing the letter “O” so that the expiration would be prolonged, two to three times longer than the inspiration. This way of breathing leads to a control and reduction of dyspnea and reduction of respiratory rate. During the implementation of the exercise program, accessory muscles of the shoulders and neck are relaxed. Attention is paid to the expansion of the lower part of the chest and the mobilization of the upper extremities. These exercises help eliminate secretions from the airways and increase vital capacity.
After breathing exercises postural drainage was then performed with manual chest percussion and followed with another course of exercises. The rehabilitation program lasted between 20 and 45 minutes and was performed once a day. Respiratory rehabilitation was ended if patients complained on dyspnea (modified Borg dyspnea scale (MBS)> of 3), chest tightness, shortness of breath, blurred vision, palpitations, increased sweating and dizziness and other serious symptoms that physician estimate as contraindication for further exercises.
Respiratory rehabilitation was performed during patients’ hospitalization and was continued at home by patients themselves.
Oxygen saturation and heart rate were measured via a pulse oximeter before and 15–30 minutes after respiratory exercise program, by nurse.
Measurement of dyspnea is performed using a modified ten-degree Borg scale for the assessment of dyspnea. It consists of ten verbal descriptors to which numerical values have been added, ranging from 0 to 10 (0 - no breathlessness, 10 - maximum breathlessness).
Quality of life was measured using the EuroQol 5-Dimension 5-Level (EQ-5D-5L) (8). The EQ-5D-5L essentially consists of 2 pages: the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS). The descriptive system consists of five dimensions. The question regarding mobility asks about problems in walking. Regarding self-care, the question asks about problems in walking or dressing oneself. Regarding usual activities, the question asks about problems in performing one’s usual activities such as study, work, familial duties, housework, or leisure activities. Regarding pain/discomfort, the question asks about having pain or discomfort in one’s usual life. Finally, the question regarding anxiety/depression asks about any feelings of anxiety/depression. Each dimension has 5 levels: no problems (1), slight problems (2), moderate problems (3), severe problems (4) and extreme problems (5). The digits for the five dimensions can be combined into a 5-digit number that describes the patient’s health state.EQ-5D-5L Crosswalk Index Value Calculator was used to calculate index values for the EQ-5D-5L dimension scores.
The EQ VAS records the patient’s self-rated health on a vertical visual analogue scale from o which stands for “The worst health you can imagine” to 100 which means “The best health you can imagine”.
In our study we performed first EQ-5D-5L measurement at patients’ admission and second three months later using telephone.
The Functional Independence Measure (FIM) is an 18-item instrument measuring a person's level of disability in terms of burden of care. FIM consist of 18 items, first 13 are forming motor subtotal score assessing independent performance in self-care, sphincter control, transfers, locomotion and last 5 are forming cognitive subtotal score assessing communication and social cognition. Each item is rated from 1 (requiring total assistance) to 7 (completely independent). After all items have been assessed, a total FIM score is calculated. Motor subtotal score can ranges between 13 and 91, while the cognitive component can range between 5 and 35, together forming total score from 18 to 126 (9).
In our study we performed first FIM score measurement at patients’ admission and second three months later using telephone.
Statistical analyses were performed using SPSS 26 (IBM, USA). Participant characteristics were reported as mean ± standard deviation (SD), or frequencies and percentages for categorical variables. The Chi-square goodness of fit test was used to determine the differences in the distribution of categorical variables. Continuous variables were compared between groups by the Mann-Whitney-U test. The Chi-square test of independence was used to examine the relationship between participant characteristics and domains. For comparing pre- to post-respiratory rehabilitation quality of life and patient functionality (EQ-5D-5L and FIM score), a two-tailed Wilcoxon rank-sum test was applied. A p-value less than 0.05 was considered to be a measure of statistical significance for all statistical tests used.
Our study included 62 patients, 38 males (61.3%) and 24 females (38.7%). Most of the patients were older than 60 years (n = 35; 56.45%) and most of the patients had hypertension, other comorbidities were less presented. The basic characteristics of the patients are given in Table 1.
Baseline demographic characteristics of the study population.
| Characteristics | Results (%) | p-value | |
|---|---|---|---|
| Gender | Male | 38 (61.3 %) | p=0.075 |
| Female | 24 (38.7%) | ||
| Age | 30–39 | 4 (6.45%) | p <0.001 |
| 40–49 | 9 (14.52%) | ||
| 50–59 | 13 (20.97%) | ||
| 60+ | 35 (56.45%) | ||
| Hypertension | Yes | 31 (50%) | p=0.799 |
| No | 31 (50%) | ||
| Diabetes mellitus | Yes | 16 (25.8%) | p <0.001 |
| No | 46 (74.2%) | ||
| COPD | Yes | 6 (9.7%) | p <0.001 |
| No | 56 (90.3%) | ||
| Heart failure | Yes | 5 (8.1%) | p <0.001 |
| No | 57 (91.9%) | ||
| Malignancy | Yes | 10 (16.1%) | p <0.001 |
| No | 52 (83.9%) | ||
| Endocrine disorder | Yes | 5 (8.1%) | p <0.001 |
| No | 57 (91.9%) | ||
The patient’s a mean EQ-5D index score and VAS score before respiratory rehabilitation were 0.8516±0.202 and 53.31±17.129, respectively (Table 2).
Average value of all five dimensions of EQ-D before and after respiratory rehabilitation.
| Results (mean ± SD) | p-value | |
|---|---|---|
| EQ-5D1 before | 1.177±0.425 | 0.010 |
| EQ-5D1 after | 1.370±0.773 | |
| EQ-5D2 before | 1.145±0.437 | 0.002 |
| EQ5-5D2 after | 1.320±0.672 | |
| EQ-5D3 before | 1.193±0.437 | 0.05 |
| EQ-5D3 after | 1.310±0.781 | |
| EQ-5D4 before | 1.790±0.447 | 0.009 |
| EQ-5D4 after | 2.00±0.747 | |
| EQ-5D5 before | 1.709±0.662 | 0.000 |
| EQ-5D5 after | 2.020±0.689 | |
| EQ-5D VAS | 53.31±17.129 | 0.000 |
| EQ-5D VAS | 64.53±8.368 | |
| EQ-5D Index before | 0.8516±0.202 | 0.000 |
| EQ-5DIndex after | 0.9147±0.074 |
The most frequently reported problem was anxiety/depression (80.6%) followed by pain/discomfort (79.1%). Selfcare (21%) and usual activities were (21%) were the least frequently reported problems. Patients with previously diagnosed malignant diseases were more likely to report problem in mobility and self-care while patients with endocrinology diseases like Cushing disease, hipo- or hyperthyroidism diseases were more likely to report problem in self-care and usual activities. Sex, age, length of hospitalization and chronic diseases like hypertension, diabetes mellitus and hearth failure had no influence on five dimensions of EQ-5D before respiratory rehabilitation (Table 3).
Percentage of reported any problem in 5 dimensions of EQ-5D before respiratory rehabilitation.
| Characteristics | Mobility | Self-care | Usual Activities | Pain/discomfort | Anxiety/depression | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No | Yes | p | No | Yes | p | No | Yes | p | No | Yes | p | No | Yes | p | ||
| Total | 77.5 | 22.5 | 79 | 21 | 79 | 21 | 20.9 | 79.1 | 19.4 | 80.6 | ||||||
| Gender | Male | 45.2 | 16.1 | 0.566 | 48.4 | 12.9 | 0.984 | 51.6 | 9.7 | 0.347 | 16.1 | 45.2 | 0.326 | 11.3 | 50.0 | 0.815 |
| Female | 32.3 | 6.4 | 30.6 | 8.1 | 27.4 | 11.3 | 4.8 | 33.9 | 8.1 | 30.6 | ||||||
| Age | 5.2 | 0.0 | 0.749 | 5.2 | 0.0 | 0.236 | 5.2 | 0.0 | 0.231 | 0.0 | 5.2 | 0.628 | 3.4 | 1.7 | 0.633 | 5.2 |
| 10.3 | 3.4 | 5.2 | 13.8 | 0.0 | 1.7 | 13.8 | 0.0 | 1.7 | 5.2 | 8.6 | 8.6 | 6.9 | 6.9 | 13.8 | 10.3 | |
| 19.0 | 1.7 | 1.7 | 20.7 | 0.0 | 0.0 | 19.0 | 1.7 | 1.7 | 3.4 | 17.2 | 17.2 | 6.9 | 13.8 | 17.2 | 19.0 | |
| 50.0 | 10.3 | 15.5 | 48.3 | 12.1 | 20.7 | 43.1 | 17.2 | 19.0 | 13.8 | 46.6 | 48.3 | 20.7 | 39.7 | 44.8 | 50.0 | |
| Length of hospitalization | 13.94±2.409 | 14.21±1.805 | 0.868 | 14.00±2.372 | 14.00±1.958 | 0.761 | 14.04±2.327 | 13.85±2.154 | 0.584 | 13.85±2.154 | 14.04±2.327 | 0.667 | 13.25±2.989 | 14.18±2.68 | 0.494 | |
| Hypertension | Yes | 35.5 | 14.5 | 0.224 | 38.7 | 11.3 | 0.755 | 37.1 | 12.9 | 0.349 | 9.7 | 40.3 | 0.755 | 8.1 | 41.9 | 0.520 |
| No | 41.9 | 8.1 | 40.3 | 9.7 | 41.9 | 8.1 | 11.3 | 38.7 | 11.3 | 38.7 | ||||||
| Diabetes mellitus | Yes | 17.7 | 8.1 | 0.538 | 21.0 | 4.8 | 0.800 | 19.4 | 6.5 | 0.646 | 8.1 | 17.7 | 0.241 | 4.8 | 21.0 | 0.943 |
| No | 59.7 | 15.5 | 58.1 | 16.1 | 59.7 | 14.5 | 12.9 | 61.3 | 14.5 | 59.7 | ||||||
| COPD | Yes | 6.5 | 3.2 | 0.610 | 6.5 | 3.2 | 0.597 | 0.0 | 9.7 | 0.328 | 1.6 | 8.1 | 0.861 | 6.5 | 1.6 | 0.884 |
| No | 71.0 | 19.4 | 72.6 | 17.7 | 21.0 | 69.4 | 17.7 | 72.6 | 71.0 | 21.0 | ||||||
| Heart failure | Yes | 6.5 | 1.6 | 0.886 | 8.1 | 0.0 | 0.352 | 8.1 | 0.0 | 0.352 | 3.2 | 4.8 | 0.280 | 1.6 | 6.5 | 0.970 |
| No | 71.0 | 21.0 | 71.0 | 21.0 | 71.0 | 21.0 | 17.7 | 74.2 | 17.7 | 74.2 | ||||||
| Malignancy | Yes | 8.1 | 8.1 | 0.024 | 8.1 | 8.1 | 0.041 | 9.7 | 6.5 | 0.196 | 3.2 | 12.9 | 0.934 | 3.2 | 12.9 | 0.955 |
| No | 69.4 | 14.5 | 71.0 | 12.9 | 69.4 | 14.5 | 17.7 | 66.1 | 16.1 | 67.7 | ||||||
| Endocrine disorder | Yes | 4.8 | 3.2 | 0.314 | 3.2 | 4.8 | 0.050 | 3.2 | 4.8 | 0.050 | 1.6 | 6.5 | 0.956 | 1.6 | 6.5 | 0.970 |
| No | 72.6 | 19.4 | 75.8 | 16.1 | 75.8 | 16.1 | 19.4 | 72.6 | 17.7 | 74.2 | ||||||
After respiratory rehabilitation, both scores were higher, EQ-5D index score 0.9147±0.074 and VAS score 64.53±8.368 (Table 1). Still, most frequently reported problems were anxiety/depression (61.3%) and pain/discomfort (77.5%), but overall less percentage of patients reported those problems. Also patients reported fewer problems in mobility, self-care and usual activities (Table 4).
Percentage of reported any problem in 5 dimensions of EQ-5D before respiratory rehabilitation.
| Characteristics | Mobility | Self-care | Usual Activities | Pain/discomfort | Anxiety/depression | |||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| No | Yes | p | No | Yes | p | No | Yes | p | No | Yes | p | No | Yes | p | ||
| Total | 83.9 | 16.1 | 88.7 | 11.3 | 82.2 | 17.8 | 22.5 | 77.5 | 38.7 | 61.3 | ||||||
| Gender | Male | 50.0 | 11.3 | 0.727 | 53.2 | 8.1 | 0.696 | 53.2 | 8.1 | 0.311 | 17.7 | 43.6 | 0.212 | 24.2 | 37.1 | 0.876 |
| Female | 33.9 | 4.8 | 35.5 | 3.2 | 29.0 | 9.7 | 4.8 | 33.9 | 14.5 | 24.2 | ||||||
| Age | 30–39 | 5.2 | 0.0 | 0.426 | 5.2 | 0.0 | 0.050 | 5.2 | 0.0 | 0.341 | 0.0 | 5.2 | 0.630 | 0.0 | 5.2 | 0.443 |
| 40–49 | 8.6 | 5.2 | 12.1 | 1.7 | 12.1 | 1.7 | 5.2 | 8.6 | 0.0 | 13.8 | ||||||
| 50–59 | 19.0 | 1.7 | 20.7 | 0.0 | 19.0 | 1.7 | 3.4 | 17.2 | 3.4 | 17.2 | ||||||
| 60+ | 44.8 | 15.5 | 39.7 | 20.7 | 41.4 | 19.0 | 12.1 | 48.3 | 15.5 | 44.8 | ||||||
| Length of hospitalization | 14.00±2.376 | 14.00±1.764 | 0.789 | 13.98±2.286 | 14.14±2.340 | 0.965 | 14.00±2.324 | 14.00±2.145 | 0.782 | 13.93±2.093 | 14.02±2.347 | 0.739 | 13.83±2.353 | 14.11±2.252 | 0.922 | |
| Hypertension | Yes | 40.3 | 9.7 | 0.731 | 43.5 | 6.5 | 0.688 | 40.3 | 9.7 | 0.739 | 11.3 | 28.7 | 0.999 | 14.5 | 35.5 | 0.118 |
| No | 43.5 | 6.5 | 45.2 | 4.8 | 41.9 | 8.1 | 11.3 | 38.7 | 24.2 | 25.8 | ||||||
| Diabetes mellitus | Yes | 19.4 | 6.5 | 0.266 | 24.2 | 1.6 | 0.666 | 21.0 | 4.8 | 0.903 | 8.1 | 17.7 | 0.336 | 8.1 | 17.7 | 0.561 |
| No | 64.5 | 9.7 | 64.5 | 9.7 | 61.3 | 12.9 | 14.5 | 59.7 | 30.6 | 43.5 | ||||||
| COPD | Yes | 8.1 | 1.6 | 0.970 | 8.1 | 1.6 | 0.528 | 8.1 | 1.6 | 0.942 | 0.0 | 9.7 | 0.322 | 3.2 | 6.5 | 0.776 |
| No | 75.8 | 14.5 | 80.6 | 9.7 | 74.2 | 16.1 | 22.6 | 67.7 | 35.5 | 54.8 | ||||||
| Heart failure | Yes | 6.5 | 1.6 | 0.811 | 8.1 | 0.0 | 0.405 | 8.1 | 0.0 | 0.575 | 3.2 | 4.8 | 0.314 | 1.6 | 6.5 | 0.640 |
| No | 77.4 | 14.5 | 80.6 | 11.3 | 74.2 | 17.7 | 19.4 | 72.6 | 37.1 | 54.8 | ||||||
| Malignancy | Yes | 9.7 | 6.5 | 0.046 | 9.7 | 6.5 | 0.010 | 9.7 | 6.5 | 0.067 | 3.2 | 12.9 | 0.831 | 4.8 | 11.3 | 0.727 |
| No | 74.2 | 9.7 | 79.0 | 4.8 | 72.6 | 11.3 | 19.4 | 64.5 | 33.9 | 50.0 | ||||||
| Endocrine disorder | Yes | 6.5 | 1.6 | 0.806 | 3.2 | 4.8 | 0.008 | 3.2 | 4.8 | 0.035 | 1.6 | 6.5 | 0.886 | 1.6 | 6.5 | 0.640 |
| No | 77.4 | 14.5 | 85.5 | 6.5 | 79.0 | 12.9 | 21.0 | 71.0 | 37.1 | 54.8 | ||||||
Comparing each dimension of EQ-5D, patients after respiratory rehabilitation showed significantly improvement in all five dimensions, mobility, self-care, usual activities, pain/discomfort and anxiety/depression (Table 2, Figure 1).
Five dimensions of EQ-5D before and after respiratory rehabilitation.
Respiratory rehabilitation showed improvement not only in quality of life but also in patient’s functionality. FIM motor subtotal score showed significantly improvement from 70.90±13.365 before to 74.97±10.078 after respiratory rehabilitation. Similar findings were obtained in FIM cognitive subtotal score, respiratory rehabilitation improved score from 33.58±2.551 to 34.06±1.114. Finally we calculated FIMI total score before (104.48±12.880) and after (106.21±9.791) respiratory rehabilitation and we found that respiratory rehabilitation significantly improved overall patient’s functionality, motor and cognitive (Table 5).
FIMI subtotal scores and total score before and after respiratory rehabilitation.
| Mean ± SD | p-value | |
|---|---|---|
| FIM motor subtotal score before | 70.90±13.365 | 0.000 |
| FIM motor subtotal score after | 74.97±10.078 | |
| FIM cognitive subtotal score before | 33.58±2.551 | 0.027 |
| FIM2 subtotal score after | 34.06±1.114 | |
| FIM total score before | 104.48±12.880 | 0.000 |
| FIM total score after | 106.21±9.791 |
Aim of present study was assessing EQ-5D score and FIM index before and after respiratory rehabilitation in patients with COVID 19 infection. The mean score for EQ-5D score and EQ-VAS scale before rehabilitation were 0.8516±0.202 and 53.31±17.129, respectively. When compared to EQ-5D values in patients with asthma (mean EQ-5D index: 0.77–0.88 and mean EQ-VAS: 57–67) (10,11), the current study demonstrate that quality of life is similarly effected in COVID-19 patients, even EQ-VAS values were better in asthma patients. The fact that majority of our patients had no pre-existing comorbidities, especially respiratory diseases, emphasizes the substantial persistent burden of COVID-19.
There are little data about long-term recovery from COVID 19 and quality of life of these patients. Previously studies showed that both non-hospitalized and hospitalized COVID 19 patients had lower quality of life (measured with EQ-5D) compared to general population three months after symptoms onset (12,13). These results clearly showed that COVID 19 patients had long-term problems that affected their everyday life. Our study demonstrated that respiratory rehabilitation could improve quality of life. EQ-5D index score and EQ-VAS score were higher after respiratory rehabilitation, 0.9147±0.074 and 64.53±8.368, respectively. These results are supported with previously studies that showed significantly improvement in respiratory parameters such as oxygen saturation, respiratory rate and need for oxygen therapy in COVID 19 patients after respiratory rehabilitation (14,15). Comparing each dimension of EQ-5D, patients after respiratory rehabilitation showed significantly improvement in all five, mobility, self-care, usual activities, pain/discomfort and anxiety/depression. The most common problems our patients reported were anxiety and pain. Generally, mental health complications of anxiety, depression and poor sleep are often in acute phase of COVID 19 and in recovery phase due to biological and psychosocial factor (16). Another very often post-COVID 19 symptom are pain, including musculoskeletal pain, chest pain, headache, testicular pain (17,18,19). Our patients showed significant improvement regarding both, anxiety and pain after respiratory rehabilitation.
Patient’s impairments in body functions and structure such as weakness, dyspnea, fatigue, chronic pain limit the ability to perform both, basic activities of daily living (ADL) and instrumental ADL. Basic ADL are related to personal care and mobility, whereas instrumental ADL are associated with the person’s ability to interact with his environment (20). Functional Independence Measure score which was used in our research is commonly used scale to assess functional status regarding both ADL in critically ill patients (21).
Previously studies clearly showed that respiratory rehabilitation improved ADL in COVID 19 patients (22,23,24). Our research accordingly demonstrated that respiratory rehabilitation started in the hospital and continued at home significantly improved overall patient’s functionality, motor and cognitive and improved patient’s ability to perform ADL.