COVID-19 was declared a pandemic by the World Health Organization on 11 March 2020. Physiotherapy consensus guidelines were quickly developed to guide acute respiratory management for those with COVID-19. When managing a new disease like COVID-19, health professionals can utilise high-quality clinical research evaluating the management of similar patient groups (eg, those admitted to an intensive care unit with severe respiratory illness). This systematic review aimed to estimate the effects of rehabilitation interventions compared to usual care on functional ability and quality of life in people with severe respiratory illness and consider whether this evidence was generalisable to people with severe COVID-19. A secondary aim was to explore the views and experiences of those undergoing rehabilitation.
Guided by a prospectively registered protocol, Cochrane guidance for rapid reviews and the PRISMA guidelines, sensitive searches were performed in 7 databases (including Medline and PEDro) to 7 May 2020. Systematic reviews and randomised controlled trials that evaluated any rehabilitation intervention aimed at enhancing or restoring physical impairment or disability in adults with severe respiratory illness requiring intensive or critical care (eg, severe adult respiratory distress syndrome) were included. Interventions were classified as: fitness, balance or strengthening exercise; mobility training; early mobilisation; neuromuscular electrical stimulation; insufficient information to categorise. Interventions that used a combination of these were classified as multicomponent. The intervention could be applied in any setting, including in the intensive care unit, in a sub-acute hospital ward, as an outpatient, at home, or any combination of these settings. Qualitative studies were also included if they explored the patient experience of rehabilitation. The comparator was usual care. The primary outcomes were functional ability and quality of life. Two independent reviewers screened 25% of the search results. The remaining 75% were screened by a single reviewer and a second reviewer checked the excluded articles. Data were extracted by a single reviewer and checked by a second reviewer. A third reviewer was involved where necessary. Quality was assessed using the Critical Appraisal Skills tools. A narrative synthesis was undertaken, organised by age and intervention type and setting.
23 systematic reviews (61 unique randomised controlled trials), 11 additional trials (993 participants) and 8 qualitative studies (99 participants) were included in the narrative synthesis. The quality of the reviews was generally good, but the additional trials and qualitative studies were more variable. The most common intervention was early mobilisation (9 reviews, 3 qualitative) followed by multicomponent intervention (6 reviews, 2 trials), exercise and early mobilisation (3 reviews, 2 trials), neuromuscular electrical stimulation (3 reviews, 2 trials), and fitness, balance or strengthening exercise (4 trials, 1 qualitative). There was insufficient information provided to categorise the intervention for 2 reviews, 1 trial and 4 qualitative studies. The interventions were mostly implemented in the intensive care unit (17 reviews, 6 trials, 4 qualitative).
Early mobilisation in intensive care may decrease intensive care acquired weakness and improve functional ability. Within 72 to 96 hours of starting mechanical ventilation appears to be the optimal time to commence this intervention. More information about the effects of early mobilisation is available in a PEDro blog. Exercise combined with early mobilisation or as part of a multicomponent intervention in intensive care can improve strength and independent walking, while multicomponent intervention may improve activities of daily living when applied in a sub-acute hospital ward and improve respiratory function when home-based. Progressive fitness, balance and strength exercise delivered in intensive care can improve functional independence. Home-based exercise may increase functional capacity in younger patients, but the findings are inconclusive for older patients. The findings are inconclusive for neuromuscular electrical stimulation in the intensive care setting, but may improve strength in older patients in the sub-acute hospital ward setting. Findings regarding quality of life were inconclusive.
The qualitative studies revealed that people receiving rehabilitation valued it. A consistent theme was that individually tailored interventions encouraged hope and confidence.
Exercise, early mobilisation and multicomponent rehabilitation programs may improve recovery following admission to intensive care for severe respiratory illness. This evidence can be generalised to people with, or recovering from, COVID-19.
Goodwin VA, et al. Rehabilitation to enable recovery from COVID-19: a rapid systematic review. Physiotherapy 2021;111:4-22
Watch or listen to an interview with Vicki Goodwin about the review: