|Year : 2021 | Volume
| Issue : 3 | Page : 260-265
|Post-COVID-19 functional status: Relation to age, smoking, hospitalization, and previous comorbidities
Aliae A R Mohamed Hussein1, Mahmoud Saad2, Hossam Eldeen Zayan3, Mustafa Abdelsayed4, Mohamed Moustafa1, Abdel Rahman Ezzat5, Radwa Helmy6, Howaida Abd-Elaal7, Karim Aly8, Shaimaa Abdelrheem9, Islam Sayed10
1 Department of Chest, Assiut University Hospitals, Assiut, Egypt
2 Department of Faculty of Medicine, Assiut Faculty of Medicine, Assiut University, Assiut, Egypt
3 Department of Gastroenterology and Infectious Disease, Assiut University Hospitals, Assiut, Egypt
4 Faculty of Medicine, Assiut University Hospitals, Aswan, Egypt
5 Department of Medical Pharmacy, Asswan University, Aswan, Egypt
6 Faculty of Pharmacy, Asswan University, Aswan, Egypt
7 Faculty of Medicine, Faculty of Nursing, Assiut University, Assiut, Egypt
8 Department of Cardiology, Assiut University Hospitals, Assiut, Egypt
9 Faculty of Medicine, Aswan University, Aswan, Egypt
10 Faculty of Medicine, Aswan Faculty of Medicine, Aswan University, Aswan, Egypt
|Date of Submission||03-Oct-2020|
|Date of Acceptance||08-Apr-2021|
|Date of Web Publication||20-Jul-2021|
Prof. Aliae A R Mohamed Hussein
Faculty of Medicine, Assiut University
| Abstract|| |
RATIONAL: Recently, a new “Post-COVID-19 Functional Status (PCFS) scale” is recommended in the current COVID-19 pandemic. It is proposed that it could be used to display direct retrieval and the functional sequelae of COVID-19.
AIM OF THE STUDY: The aim of the study was to assess the PCFS and to evaluate if age, gender, smoking, hospitalization, and comorbidities have any effect on functional limitations in recovered COVID-19 patients.
METHODS: A total of 444 registered confirmed COVID-19 patients were included. They were interviewed in our follow-up clinics and filled an Arabic translated PCFS scale as well as their demographic and clinical data.
RESULTS: Eighty percent of COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible (63.1%), slight (14.4%), moderate (2%), to severe (0.5%) based on PCFS. Furthermore, there was a substantial variance between the score of PCFS with age (P = 0.003), gender (P = 0.014), the duration since the onset of the symptoms of COVID-19 (P < 0.001), need for oxygen supplementation (P < 0.001), need for intensive care unit (ICU) admittance (P = 0.003), previous periodic influenza vaccination (P < 0.001), smoking status (P < 0.001), and finally, the presence of any comorbid disorder (P < 0.001).
CONCLUSIONS: Most of the COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible to severe based on PCFS. These restrictions were affected by age, gender, periodic influenza vaccination, smoking, duration since symptoms onset, need for oxygen or ICU admittance, and finally the presence of coexisting comorbidity.
Keywords: COVID-19, post-COVID-19, post-COVID-19 functional scale, post-COVID-19 functional status, severe acute respiratory syndrome caused by coronavirus 2
|How to cite this article:|
Mohamed Hussein AA, Saad M, Zayan HE, Abdelsayed M, Moustafa M, Ezzat AR, Helmy R, Abd-Elaal H, Aly K, Abdelrheem S, Sayed I. Post-COVID-19 functional status: Relation to age, smoking, hospitalization, and previous comorbidities. Ann Thorac Med 2021;16:260-5
|How to cite this URL:|
Mohamed Hussein AA, Saad M, Zayan HE, Abdelsayed M, Moustafa M, Ezzat AR, Helmy R, Abd-Elaal H, Aly K, Abdelrheem S, Sayed I. Post-COVID-19 functional status: Relation to age, smoking, hospitalization, and previous comorbidities. Ann Thorac Med [serial online] 2021 [cited 2021 Dec 5];16:260-5. Available from: https://www.thoracicmedicine.org/text.asp?2021/16/3/260/321904
Throughout history, there have been plenty of pandemics; however, the social response to COVID-19 is unparalleled. The world will certainly not be identical for a second time. It is assessed that almost 4 billion individuals are living in social segregation during this mother of all pandemics.
Initially described in China in December 2019, a severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has spread all over the world. Most countries are still grappling and some are struggling with the problem, nowadays there was proved, 20.6 million confirmed cases of COVID-19, as well as 749 K deaths worldwide. Egypt reported slightly over 282,082 confirmed COVID-19 cases with 5085 deaths. The new pandemic is injuring not only health organizations of several countries but also the financial prudence universal.
In the coming days, great stress will progressively comprise postacute carefulness of those recovered cases from COVID-19. It is expected that COVID-19 may have a principal effect on the physical, mental, cognitive, and public health state, similarly in cases with minor disease exhibitions. Preceding outbreaks of coronaviruses have been concomitant with persistent impairment in pulmonary function, muscle weakness, pain, lethargy, depressed mode, anxiety, vocational disorders, and impaired quality of life to various grades.,,
It is fundamental to have a simple measure to monitor the progression of symptoms and the effect of these symptoms on the functional state of the affected patients. Because of the enormous number of COVID-19 recovered cases that necessitate strong follow-up, a simple and reproducible measure to categorize those patients complaining from sluggish or partial recovery would aid in guiding the deliberate use of medical funds and will also standardize research efforts. Recently, a group of investigators recommended an ordinal scale for the evaluation of patient-relevant functional restrictions following an event of venous thromboembolism (VTE): the post-VTE functional status scale., It covers the full spectrum of functional consequences and focuses on both restrictions in usual activities and alterations in lifestyle in 6-scale scores. It is already known that there is a great frequency of pulmonary embolism, myocardial injury/myocarditis, and neurological dysfunctions, in severely ill cases with COVID-19., That's why Klok et al. designed their novel “Post-COVID-19 Functional Status (PCFS) scale” (after slight adaptation) to be valuable in the existing COVID-19 pandemic. The recommended new scale could be used upon hospital discharge, at 4–8 weeks after-discharge to display direct rescue, and at 6 months to evaluate functional residue.
The aim of this work is to assess the PCFS in Egypt by the PCFS scale and to evaluate if age, gender, and comorbidities have any effect on functional limitations.
| Methods|| |
During the period from July 15 to August 13, 2020, patients were included if they had confirmed COVID-19 in the registry of Ministry of Health and Population in Egypt (positive or indeterminate COVID-19 polymerase chain reaction test, or presumed presence of COVID-19 based on clinical and radiological criteria) from different governorates. Patients were selected by consecutive sampling technique from home, hospital, or intensive care unit (ICU) treated registered cases. They were interviewed and asked to fill the survey forms. All responses were collected and revised for missing data. The original language of the questionnaire was English; it was translated to Arabic by Experts followed by back translation to English by other independent experts. Survey completion takes approximately 10 min. We recruited patients by consecutive sampling technique till the needed number of participant was achieved.
The study design was a cross-sectional study.
Sample size was calculated using Epi info statistical package version 7 Centers for Disease Control and Prevention (CDC, USA. Based on the following parameters for cross-sectional study, expected post-COVID-19 cases 0.50, with acceptable margin of error 0.05, design effect 1, and 95% confidence level. The required sample size will be 384 patients. It will be raised to 425 after considering 10% as a dropout (number of cases in Egypt on 18th July 26, 2020 = 86474).
The following data were collected:
- The patient demographics and clinical data including age, gender, smoking status, residence, seasonal influenza vaccination, the presence of coexisting comorbidity quarantine status, oxygen supplementation, and history of ICU admittance history were recorded
- PCFS scale proposed by Klok et al., 2020: A questionnaire covering the entire range of functional limitations, including changes in lifestyle, sports, and social activities. If there was no limitation of activity, it was graded as Grade 0, if there was a negligible effect on activities for patients was considered Grade 1, whereas a lower intensity of the activities was considered as Grade 2. Grade 3 accounted for the inability to perform certain accomplishments, forcing patients to structurally modify these. Finally, Grade 4 was reserved for those patients with unembellished functional restrictions [Supplement 1]
- The study was approved by the ethical committee of Aswan Faculty of Medicine, Egypt and registered in Clinicaltrial.gov: NCT04479293.
Data were coded and analyzed using the Statistical Package for the Social Sciences software program, version 26 (IBM SPSS 26 Statistics for windows, Armonk, NY: IBM Corp). Data was presented as range, mean, standard deviation, for quantitative variables and frequency and percentage for qualitative variables. Comparison for qualitative variables was performed using Chi-square, while for quantitative variables, the comparison was conducted using. One-way ANOVA test, P ≤ 0.05 was considered substantially significant.
| Results|| |
Demographic and clinical features of the study sample
The study involved 444 participants. They were 192 males and 252 females, the mean age was 33.09 ± 12.09 years, and the range was 18–86 years. Most cases (71.2%) resided in the urban areas versus (28.2%) lived in rural areas. Nearly 77.9% of participants were nonsmokers, 13.1% were active smokers, while 9% were former smokers. Around 25% of cases had comorbid disorders. The mean duration since the onset of their symptoms was 35.31 ± 18.75 days, 75.7% were admitted in hospitals, 20.7% required oxygen therapy, while 13.5% needed ICU as shown in [Table 1].
|Table 1: Demographic and clinical characteristics of COVID-19 recovered cases included in the study (n=444)|
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Post-COVID-19 functional status scale
Most of participants (63.1%) had a trivial limitation in activities after recovery from COVID-19 (Grade 1), 14.1% had slight (Grade 2), 2.5% had moderate (Grade 3), and only 0.5% had severe functional limitation (Grade 4). Only 20% had no functional limitations (Grade 0) as shown in [Table 2].
|Table 2: Post-COVID-19 Functional Status Scale in the studied recovered COVID -19 cases (n=444)|
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Regarding the association between both demographic and clinical features of study group and their PCFS, there was a substantial variance between the grade of functional activity limitation (based on PCFS score) with age (P = 0.003), gender (P = 0.014), the duration since COVID-19 symptoms onset (P < 0.001), need for oxygen supplementation (P < 0.001), ICU admission (P = 0.003), seasonal influenza vaccination (P < 0.001), smoking status (P < 0.001), and finally the presence of any comorbid disorders (P < 0.001) [Table 3].
|Table 3: Association between demographic and clinical characteristics and post COVID-19 Functional Status Scale in the studied recovered COVID-19 cases (n=444)|
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| Discussion|| |
During the pandemic of COVID-19, we have been encountered with an enormous proportion of cases with diverse clinical features such as cough, fever, shortness of breath, musculoskeletal (lethargy and joint ache), gastrointestinal, and sleep disorders.,, However, evidence is missing on the functional state after recovery. As far as we know, this is the first report to assess the persistent restrictions of functional activity among convalescent COVID-19 cases using the recommended PCFS. We found that 80% of COVID-19 recovered cases have diverse degrees of functional restrictions ranging from negligible (63.1%), slight (14.4%), moderate (2%), to severe (0.5%) based on PCFS. Furthermore, there was a substantial variance between the score of PCFS with age (P = 0.003), gender (P = 0.014), the duration since the onset of the symptoms of COVID-19 (P < 0.001), need for oxygen supplementation (P < 0.001), ICU admission (P = 0.003), previous periodic influenza vaccination (P < 0.001), smoking status (P < 0.001), and finally the presence of any comorbid disorders (P < 0.001).
These results are not surprising as, in addition to the impairment in physical activities, the long duration of confinement and the extreme doubt during the COVID-19 disease had generated remarkable mental and attitude disorders.
In accordance with current results, several patients in the convalescence phase of SARS suffered from restrictions in physical activity causing fluctuating grades of restrictions in their work-related, public, and vacation activities or circadian living activities., It was found that the exercise capability and physical status of SARS recovered cases were considerably worse than that of normal publics after 6-month follow-up. The functional frailty seemed disproportionate to the degree of functional lung injury and may be associated with additional aspects such as muscle weakness. It was concluded that recovered cases of SARS had outstanding defects identified with pulmonary function testing, with Diffuse Lung Capacity for carbon monoxide (DLCO) aberrations up to 2 years after retrieval, along with the health-related quality of life deficit. Finally, the long-standing hazardous properties of common enduring pain, lethargy, emotional stress, and troubled sleep after severe SARS led to the inability to return to dynamic effort for a minimum of 1 year after their acute disease.
Similarly, the MERS convalescent cases also reported the ominously lower quality physical health for at least 14 months after infection start, also survivors who anticipated ICU admittance described the ominously minor inclusive quality of life than those with noncritical disease.
In the present study, only 3% of cases necessitating ICU did not record any functional restriction and 93.3% had negligible to slight functional restriction (compared to 22.7% no restrictions and 75% negligible-slight functional restriction, in patients not admitted in ICU, P = 0.003). It was recorded that patients who require intensive care admittance or even invasive mechanical ventilation are at great hazard for emerging postintensive care syndrome. It is a usually detected phenomenon inside ICU recovered cases among the different age groups and often is described as protracted incapacity consequential to muscle dysfunction, lethargy, pain, and shortness of breath.
It is recommended that the functional state could have predictive value for COVID-19 patients, as compromised physical activity was independently concomitant with worst consequences in hospitalized cases with community-acquired pneumonia, according to a recent prospective study. The performance status may forecast 1-month death rates as well as the frequently used CRB-65 score (confusion, respiratory rate, blood pressure, and age ≥65) in patients with any bacteriological or viral pneumonia. Hence, the incorporation of patients' functional status measurement into patient assessment may improve the prognostic ability of current risk classification systems to predict mortality from COVID-19 pneumonia. The use of simple scales as suggested by Klok et al. may be very important in the assessment and follow-up of functional status in this novel post-COVID-19 syndrome and may reduce its related morbidities.
Since March, 2020 reports indicated that the severity and outcome of COVID-19 pneumonia (SARS-CoV-2) is affected by patients age, gender, smoking, ICU admission, and previous comorbidities.,,,, To the best of our knowledge, this is the first report of persistent effect of these factors on the functional status of COVID-19 after recovery. The exact mechanism is not yet explained.
Limitations of the study
First, the lack of data of functional status before COVID-19 infection; second, the history of the symptoms both at the onset of COVID-19 and after recovery is not included; third, the pharmacologic therapy given to the patients was not mentioned (however, all patients received the standard protocol of Ministry of health and population in Egypt, but it was changed several times according to international recommendations), finally, random selection bias may be present and an inability for personal face-to-face interview in some cases.
| Conclusions|| |
Most of COVID-19 recovered cases have different degrees of functional limitations ranging from negligible to severe based on PCFS. These limitations were affected by age, gender, periodic influenza vaccination, smoking status, duration since symptoms onset, need for oxygen therapy or ICU admittance, and finally the presence of coexisting comorbidity.
It is recommended that post-COVID-19 monitoring programs should be implemented in specific clinical settings or as an outpatient program to follow the functional status of patients in 1, 3, and 6 months visits to support the complete care for cases recovered from COVID-19. Furthermore, extended monitoring using simple scales as PCFS is necessary to determine whether these functional deficits after COVID-19 recovery persist or not. Further studies are required to explain the underlying cause of post-COVID-19 functional limitation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| Supplement File|| |
Supplement 1: Ordinal scale for functional status manual to the post-COVID-19 functional status scale v2 20200710
| References|| |
Simpson R, Robinson L. Rehabilitation after critical illness in people with COVID-19 Infection. Am J Phys Med Rehabil 2020;99:470-4.
Tansey CM, Louie M, Loeb M, Gold WL, Muller MP, de Jager J, et al
. One-year outcomes and health care utilization in survivors of severe acute respiratory syndrome. Arch Intern Med 2007;167:1312-20.
Ngai JC, Ko FW, Ng SS, To KW, Tong M, Hui DS. The long-term impact of severe acute respiratory syndrome on pulmonary function, exercise capacity and health status. Respirology 2010;15:543-50.
Neufeld KJ, Leoutsakos JS, Yan H, Lin S, Zabinski JS, Dinglas VD, et al.
Fatigue symptoms during the first year following ARDS. Chest 2020;158:999-1007.
Klok FA, Barco S, Siegerink B. Measuring functional limitations after venous thromboembolism: A call to action. Thromb Res 2019;178:59-62.
Boon GJ, Barco S, Bertoletti L, Ghanima W, Huisman MV, Kahn SR, et al
. Measuring functional limitations after venous thromboembolism: Optimization of the Post-VTE Functional Status (PVFS) Scale. Thromb Res 2020;190:45-51.
Lodigiani C, Iapichino G, Carenzo L, Cecconi M, Ferrazzi P, Sebastian T, et al
. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res 2020;191:9-14.
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al
. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.
Klok FA, Boon GJ, Barco S, Endres M, Geelhoed JJ, Knauss S, et al
. The post-COVID-19 functional status scale: A tool to measure functional status over time after COVID-19. Eur Respir J 2020;56:2001494.
Docherty AB, Harrison EM, Green CA, Hardwick HE, Pius R, Norman L, et al
. Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: Prospective observational cohort study. BMJ 2020;369:m1985.
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al
. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus-infected pneumonia in Wuhan, China. JAMA 2020;323:1061-9.
Landi F, Barillaro C, Bellieni A, Brandi V, Carfì A, D'Angelo M, et al
. The new challenge of geriatrics: Saving frail older people from the SARS-COV-2 pandemic infection. J Nutr Health Aging 2020;24:466-70.
WHO reference number: WHO/2019-nCoV/MentalHealth/2020.1 March 2020 18. WHO Briefing Note – Mental Health and Psychosocial Considerations during COVID-19 Outbreak. COVID-19: Risk communication and community engagement; 2020.
Chan KS, Zheng JP, Mok YW, Li YM, Liu YN, Chu CM, et al
. SARS: Prognosis, outcome and sequelae. Respirology 2003;8 Suppl: S36-40.
Lam SP, So HP, Tang I, Chong S, Tang E. Evaluation of physical consequences of SARS pulmonary rehabilitation screening (SPRS). Proceedings in New Challenges in Healthcare Hong Kong. Acad Med 2003:94.
Hui DS, Joynt GM, Wong KT, Gomersall CD, Li TS, Antonio G, et al
. Impact of severe acute respiratory syndrome (SARS) on pulmonary function, functional capacity and quality of life in a cohort of survivors. Thorax 2005;60:401-9.
Moldofsky H, Patcai J. Chronic widespread musculoskeletal pain, fatigue, depression and disordered sleep in chronic post-SARS syndrome; a case-controlled study. BMC Neurol 2011;11:37.
Batawi S, Tarazan N, Al-Raddadi R, Al Qasim E, Sindi A, Al Johni S, et al
. Quality of life reported by survivors after hospitalization for Middle East respiratory syndrome (MERS). Health Qual Life Outcomes 2019;17:1-7.
Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, et al
. Home and community-based physical therapist management of adults with post-intensive care syndrome. Phys Ther 2020;100:1062-73.
Ohtake PJ, Lee AC, Scott JC, Hinman RS, Ali NA, Hinkson CR, et al
. Physical impairments associated with post-intensive care syndrome: Systematic review based on the world health organization's international classification of functioning, disability and health framework. Phys Ther 2018;98:631-45.
Jeon K, Yoo H, Jeong BH, Park HY, Koh WJ, Suh GY, et al
. Functional status and mortality prediction in community-acquired pneumonia. Respirology 2017;22:1400-6.
Sanz F, Morales-Suárez-Varela M, Fernández E, Force L, Pérez-Lozano MJ, Martín V, et al
. A composite of functional status and pneumonia severity index improves the prediction of pneumonia mortality in older patients. J Gen Intern Med 2018;33:437-44.
Recinella G, Marasco G, Di Battista A, Bianchi G, Zoli M. Prognostic role of nutritional status in elderly patients hospitalized for COVID-19. Med Hypotheses 2020;144:110016.
Mohamed Hussein AA, Galal I, Mohammed MA, Ibrahim ME, Ahmed SB, et al
. Survival and 30-days hospital outcome in hospitalized COVID-19 patients in Upper Egypt: Multi-center study. 10.1101/2020.08.26.20180992.
[Table 1], [Table 2], [Table 3]