The aftermath of COVID-19 has left many people still struggling with symptoms such as breathlessness and fatigue. Therefore, the post-COVID era will surely involve much consideration and research into the most effective ways to rehabilitate individuals with long COVID back to good health.
Rehabilitation
In exploring what effective rehabilitation would look like, Cheng et al (2021) recommend a comprehensive programme encompassing the promotion of functional recovery, as they note that this has been ignored by much of the guidance. They gathered together specialists for an online expert panel review, including members of the Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation. The panel sought to agree on recommendations for rehabilitation protocols for the five stages. These were written in relation to the following groups (Cheng et al, 2021):
- Those who are outpatients with mild disease and no underlying risk factors
- Those with mild disease who are outpatients but do have epidemiological risk factors
- Those who are hospitalised with moderate-to-severe disease
- Patients supported on a ventilator but who have clear well-functioning cognition
- Those who are supported on ventilators but who have shown impaired cognitive function.
- While acknowledging existing medications to support care, the authors highlight rehabilitation as being a key adjunct to this, with the need for clear guidance to be made available to any individual who is caring for someone at any of the above stages.
Cheng et al (2021) highlighted those who are living with known comorbidities such as cardiovascular disease, hypertension, diabetes and respiratory disease, to be at risk of a more severe development of symptoms of COVID-19. Therefore, they recommend that outpatient programmes are home-based but use clear video instructions and telerehabilitation. The authors specify that as attending in-person may result in increased transmission of the disease, programmes would be home-based.
Exercise and breathing
One of the most important aspects of rehabilitation is exercise, but it is essential to ensure that the chosen exercise is safe for the patient. The disease process is complex as it can differ in severity and often is joined by comorbidities that also limit the patient's ability to exercise. Cheng et al (2021) recommend a comprehensive exercise programme consisting of aerobic and resistance training for all patients, with special considerations for those with comorbidities.
Alongside the efforts made to support patients at all stages through effective and personalised rehabilitation, an online breathing and wellbeing tool has also shown promising results as an adjunct to aid recovery following COVID-19 infection. The English National Opera breathe is a programme for people who have persistent symptoms following COVID-19 (Philip et al, 2022). The researchers noted that there are very few evidence-based interventions for long COVID. Despite the available medical protocols, holistic approaches are supported by specialists within the field, largely owing to the benefit the approaches can have on managing mental health, in turn aiding physical symptoms such as fatigue and breathlessness. The team sought to find outcomes on health-related quality of life (HRQoL) from patients using an online breathing and wellbeing programme, who have had breathlessness persistently since contracting the disease.
Read more: Living with long COVID
The trial enrolled patients who had been referred from any of 51 UK-based collaborating long COVID clinics. The patients had to be over 18 years of age, recovering from the disease with continuing breathlessness problems and had participated in at least 4 weeks of the problem since symptom onset. Participants had experienced anxiety or none at all and were deemed clinically suitable by the centre themselves. The participants were randomised one-to-one to either start immediate participation in the ENO breathe programme, or to receive usual care. A critique of this is that regardless of the effect on this patient group within this study, it may not produce generalisable results as not everyone would want or be able to participate in a programme involving singing. However, the authors note that other methods to aid relaxation and reduce symptoms severity such as Tai Chi can be examined more thoroughly as to their helpfulness in post-COVID recovery.
The researcher responsible for randomisation was masked in responses to reduce bias. Those who were assigned to the ENO Breathe group participated in a 6-week online breathing and wellbeing programme, which focused on retraining breathing through the use of singing techniques. The main outcome was to assess for changes in HRQoL, which was assessed using a RAND 36-item short-form survey instrument mental health composite (MHC) and physical health composite (PHC) scores. The team also evaluated for secondary outcomes through assessment using the chronic obstructive pulmonary disease assessment test score, visual analogue scales (VAS) for breathlessness, scores on the dyspnoea-12, the generalised anxiety disorder 7-item scale, and the short form-6D (Philp et al, 2022). They looked at the qualitative data gained through survey responses and conducted a thematic analysis to pick out the main themes of patient experience in the trial. 150 patients were able to participate and were deemed suitable for the trial, which was carried out in 2021. In total, 74 of these were assigned to the ENO Breathe programme.
The team found promising results when comparing ENO Breathe results with usual care. ENO Breathe was observed to be linked to an improvement in MHC score. However, it was not found to increase the PHC score. Three key themes were uncovered during thematic analysis, which the participants participating in the ENO Breathe programme noted as follows:
- Symptom improvement
- Feeling that the programme was complementary to standard care
- Suitability of singing and music in addressing their needs (Philip et al, 2022).
It was concluded that HRQoL was improved in this patient group with regards to mental wellbeing and symptoms of breathlessness. Therefore, in relation to adding an adjunct to the usual care and medical treatment, it may be worthwhile to review protocols and guidance following further research, to include mind-body or music-based approaches as these add an enjoyable technique a patient can develop in managing their symptoms and taking control of their recovery.
Another adjunct to usual care and treatment could be to recommend the patient is able to or can be assisted with reviewing the guidance freely available on the NHS' dedicated website for the recovery campaign, ‘Your COVID Recovery’ (2022). There is a section for breathlessness and other sections for mental health/physical health components.
Techniques recommend a patient experiencing breathlessness use include using a cool wet flannel on the nose and upper cheeks to reduce the feeling of being out of breath, and using a breathing control exercise can be highly effective. Your COVID Recovery (2022) explains that the breathing exercise involves deep and slow breathing while the patient places a hand on their tummy and another hand on their chest. The chest should hardly move but the tummy will if the breathing is done correctly. The patient can be encouraged to visualise tension leaving them as they feel the tummy fall as the breath leaves the body. The breathing should become slower as the patient follows the technique, as they focus on a calmer state of mind. Often breathlessness can be caused by anxiety, so alleviating the anxious symptoms using techniques such as this may help without always thinking of the medication or hospital route first – a patient will feel greater self-esteem if they know they can manage, without panicking, when they notice slight breathlessness. The technique helps the physical and mental aspects of mild breathlessness.
Conclusion
Overall, the complex nature of COVID-19 will require a approach involving, medical and holistic approaches to recovery from the virus and its long-term effects. There has been an upsurge in mental health issues since the intensity of press reporting in relation to the disease and measures to close schools, shops, gyms and other places that people relied on to maintain good health. Understandably, many people are now defining themselves as having ‘long COVID’ when in fact some of the longer-term symptoms may very well be brought on by other pandemic (or pandemic measure)-related factors. The mental health aspects of breathlessness and the physical functioning of the body as a whole can be addressed through exercise where safe, and holistic therapies where suitable, as adjuncts to usual treatment, to address the medical, physical and psychological effects of the virus and its legacy. With reference to medications, the British Medical Journal contains a ‘living journal’ with open access to the latest advice regarding all medications known to be in use or newly ready for use, for all stages of COVID-19 (Rochwerg et al, 2020).
Read more: Long-term effects of COVID-19: impact on prescribing practice