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Year : 2023  |  Volume : 18  |  Issue : 1  |  Page : 10-14
General rehabilitation for the Post-COVID-19 condition: A narrative review

1 Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Universitas Padjadjaran, Bandung, West Java, Indonesia
2 Inpatient Care Department, Siloam Hospitals Semarang, Semarang, Central Java, Indonesia

Date of Submission03-Aug-2022
Date of Acceptance06-Oct-2022
Date of Web Publication25-Jan-2023

Correspondence Address:
Mrs. Dian Marta Sari
Eyckman 38, Bandung, West Java 40161
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/atm.atm_286_22

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COVID-19 significantly impacts the acute phase or the period after being infected by severe acute respiratory syndrome coronavirus-2. Studies have shown it has affected multiorgan and needs continuous care by a multidisciplinary team. Nowadays, guidance is required to assist the recovery process of survivors who reported at least one symptom as a residual effect. This study aims to describe the rehabilitation management of post-COVID-19 conditions. As the number of survivors seems to be increasing, it is expected that COVID-19 survivors will recover through a holistic approach by all physicians. Comprehensive rehabilitation for long COVID or COVID-19-related illnesses includes exercising, nutrition, education, managing voice, breathlessness, neurocognitive problems, mental health, feeding problems, and daily activities. Specific recommendations have already been published to support rehabilitation for survivors in every targeted organ. Supportive care, especially rehabilitation programs, is recently an urgent knowledge in this pandemic.

Keywords: COVID-19, long COVID, multidisciplinary team, rehabilitation, severe acute respiratory syndrome coronavirus-2

How to cite this article:
Sari DM, Wijaya LC. General rehabilitation for the Post-COVID-19 condition: A narrative review. Ann Thorac Med 2023;18:10-4

How to cite this URL:
Sari DM, Wijaya LC. General rehabilitation for the Post-COVID-19 condition: A narrative review. Ann Thorac Med [serial online] 2023 [cited 2023 Mar 20];18:10-4. Available from:

COVID-19 (Coronavirus-19) is a highly contagious respiratory disease that eventually becomes a pandemic and has significantly impacted the world.[1] The respiratory system, especially the lungs, is the most common site of the infection.[2]

Due to the advancing studies following the disease, the definition of long COVID kept developing, such as long-haul COVID or postacute sequelae of severe acute respiratory syndrome coronavirus-2 infection (PASC).[3],[4],[5],[6] Fatigue, shortness of breath, and cognitive dysfunction are common symptoms and impact daily functioning. Symptoms may be new-onset, following initial recovery from an acute COVID-19 episode, or persist from the initial illness. Symptoms may also fluctuate or relapse over time.[7]

Studies show that approximately 10% of people experience prolonged illness after being infected with COVID-19.[5] The disease is recently predicted with significant morbidity for 3–6 months (intermediate phase) and requires routine medical and rehabilitation services for 12 months or longer (chronic phase).[1],[8]

At 6 months after acute COVID-19, the most common pulmonary impairment is decreased lung diffusing capacity for carbon monoxide (about 33% of patients), followed by decreased total lung capacity (approximately 17%).[9]

There is a strong need for COVID-19 survivors to be given a rehabilitative program.[1] Their wellness can be achieved through multidisciplinary team rehabilitation and community-based rehabilitation services, including patient self-management and peer support.[1],[5],[10] Thus, this article aimed to describe recommendations and the most effective management of post-COVID-19 conditions.

   Rehabilitation for Post-COVID-19 Condition Top

Since the COVID-19 pandemic emerged, continuous rehabilitation and management have already been introduced in the critical care setting or soon after the acute phase. The National Institute for Health and Care Excellence recommends starting progressive rehabilitation programs within the first 30 days (postacute phase) to maximize recovery. The management for rehabilitation in COVID-19 is shown in [Table 1].[1],[2],[4],[5],[9],[11],[12]
Table 1: Management of post COVID syndrome conditions[2],[4],[5]

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World Health Organization also provides a supportive rehabilitation guideline for COVID-19 survivors. It is shown in [Figure 1] below. There are several main components in supportive care for them. [Table 1] also describes specifically each of the components.[11],[12]
Figure 1: Components of supportive care for COVID-19-related Illness.[11],[12] 3P: Pace, plan, prioritize

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Many COVID-19 survivors feel doubtful about returning to their daily activities since they still have some residual symptoms. Thus, physicians take a significant role in encouraging and educating the survivors to start their initial recovery. A staged strategy can be utilized to improve physical activity levels to baseline or beyond once a patient has been symptom-free for at least 7 days. Patients should be risk-stratified before the next phase of recovery management if there are still several symptoms, such as cardiac, psychological, or other enduring symptoms post-COVID-19. Further examinations are sometimes needed to complement the assessment, such as an electrocardiogram, laboratory blood panel, or cardiopulmonary exercise testing. A special precaution is made for myocarditis cases. If COVID-19 patients are confirmed to have myocarditis, they are restricted to exercise for 3 up to 6 months and need periodic assessment.[13]

After the acute phase of COVID-19, patients might experience worsening of fatigue and other symptoms (described as "crashing" or "relapse") after minimal exertion. Recently, it has been known in terms of postexertional malaise. Typically, the exacerbation occurs hours or days after the physical or mental activity. It takes 24 h or longer to recover. It can affect your energy levels, concentration, sleep, and memory and cause muscle/joint pains and flu-like symptoms. Thus, it is recommended to have gradual exercise before ultimately returning to normal activities. Five steps below, described in [Table 2], can be implemented to guide the preparation before the patients are entirely back to their previous activities.[12]
Table 2: Five steps before returning to the previous exercises and sports participation for COVID-19 survivors[12]

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Exercise for survivors also should be started with a warm-up and closed by cooling down exercise. Fitness and strengthening exercises are the main exercises for both arms and legs. For warm-up exercises, patients can do shoulder shrugs, shoulder circles, side bends, knee lifts, ankle taps, or ankle circles. To cool down the body, patients can walk at a slower pace, gently march on the spot for approximately 2 min, or repeat the warm-up exercises to move the joints while sitting or standing. The fitness exercise can march on the site, take step-ups, walk, jog, or cycling, while the strengthening exercise is mainly included in phase three.[11],[12]

Finally, physicians should provide a prudent approach for the survivors. The supportive care, especially the exercise program, should be gradual, individualized, and based on subjective activity tolerance.

   Interdisciplinary Management in COVID-19 Top

Several studies have promoted comprehensive care for post-COVID patients, including referral pathways, initial assessment after being referred, subsequent care, and disposition intervention. The primary goals of that comprehensive care are to (a) provide a comprehensive evaluation of post-COVID-19 complications, (b) characterize and mitigate pulmonary sequelae of COVID-19, and (c) address persistent symptoms experienced by post-COVID-19 survivors. A multidisciplinary care program should include coordination with primary care, access to rehabilitation services, social work and welfare support, pharmacy, subspecialty care through direct inclusion or targeted referrals, and structured peer support programs with trained moderators.[13],[14] Various assessments are needed to examine patient's condition either before or after discharge. Outpatient should be assessed after the referral to the rehabilitation. In the [Table 3] below, we summarize the assessment section.[4],[5],[13],[14],[15],[16]
Table 3: Assessments before discharging the patients and after the referral to rehabilitation[4],[5],[13],[14],[15],[16]

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Rehabilitation takes a leading role in the subsequent care in pulmonary rehabilitation and physical/occupational therapy of outpatient care.[5],[14] Physiatrist also needs to conduct programs during acute and postacute phases. Comprehensive management is urgently required to facilitate physical, cognitive, psychosocial, and vocational rehabilitation due to the complexity of PASC. They should examine neurological and musculoskeletal complications. Specifically, physical therapy needs to teach the survivors or caregivers compensatory strategies to adapt and improve functioning until tolerated and can be titrated to the optimum. Occupational therapy plays a role in evaluating and managing cognitive impairment, encouraging active engagement in meaningful activities, resumption of productive life, and returning to social participation.[6],[14]

   Conclusion Top

A rehabilitation program for long COVID aims to recover physical function optimally. Post-COVID-19 condition becomes increasingly common as the pandemic evolves. It has many symptoms and involves multi-organ. To handle COVID-19 survivors, a thorough and multidisciplinary strategy is required, incorporating primary care physicians for initial evaluation and appropriate referrals. Every supportive program is individualized, comprehensive, and should be safe for the survivors. Thus, we encourage health-care professionals to recognize the implications of long-term rehabilitation of post-COVID-19 conditions effectively.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Barker-Davies RM, O'Sullivan O, Senaratne KP, Baker P, Cranley M, Dharm-Datta S, et al. The stanford hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med 2020;54:949-59.  Back to cited text no. 1
Kordzadeh-Kermani E, Khalili H, Karimzadeh I. Pathogenesis, clinical manifestations and complications of coronavirus disease 2019 (COVID-19). Future Microbiol 2020;15:1287-305.  Back to cited text no. 2
Maxwell E, Poole R. A dynamic review of the evidence around ongoing Covid19. Living with COVID19 second review. Natl Inst Health Res 2021:1-34. [Doi 10.3310/themedreview_45225].  Back to cited text no. 3
Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med 2021;27:601-15.  Back to cited text no. 4
Greenhalgh T, Knight M, A'Court C, Buxton M, Husain L. Management of post-acute covid-19 in primary care. BMJ 2020;370:m3026.  Back to cited text no. 5
Parker AM, Brigham E, Connolly B, McPeake J, Agranovich AV, Kenes MT, et al. Addressing the post-acute sequelae of SARS-CoV-2 infection: A multidisciplinary model of care. Lancet Respir Med 2021;9:1328-41.  Back to cited text no. 6
WHO. A clinical case definition of post COVID condition by a Delphi consensus. Denmark: WHO; 2021.  Back to cited text no. 7
Gutenbrunner C, Nugraha B, Martin LT. Phase-adapted rehabilitation for acute coronavirus disease-19 patients and patient with long-term sequelae of coronavirus disease-19. Am J Phys Med Rehabil 2021;100:533-8.  Back to cited text no. 8
Menges D, Ballouz T, Anagnostopoulos A, Aschmann HE, Domenghino A, Fehr JS, et al. Burden of post-COVID-19 syndrome and implications for healthcare service planning: A population-based cohort study. PLoS One 2021;16:e0254523.  Back to cited text no. 9
Aiyegbusi OL, Hughes SE, Turner G, Rivera SC, McMullan C, Chandan JS, et al. Symptoms, complications and management of long COVID: A review. J R Soc Med 2021;114:428-42.  Back to cited text no. 10
WHO. Support for rehabilitation: Self-management after COVID-19-related illness. 1st ed. Denmark: WHO;2020.  Back to cited text no. 11
WHO. Support for rehabilitation: Self-management after COVID-19-related illness. 2nd ed. Denmark: WHO;2021.  Back to cited text no. 12
Salman D, Vishnubala D, Le Feuvre P, Beaney T, Korgaonkar J, Majeed A, et al. Returning to physical activity after covid-19. BMJ 2021;372:m4721.  Back to cited text no. 13
Lutchmansingh DD, Knauert MP, Antin-Ozerkis DE, Chupp G, Cohn L, Dela Cruz CS, et al. A clinic blueprint for post-coronavirus disease 2019 RECOVERY: Learning from the past, looking to the future. Chest 2021;159:949-58.  Back to cited text no. 14
Leochico CF, Mojica JA, Rey-Matias RR, Supnet IE, Ignacio SD. Role of telerehabilitation in the rehabilitation medicine training program of a COVID-19 referral center in a developing country. Am J Phys Med Rehabil 2021;100:526-32.  Back to cited text no. 15
Thornton J. Covid-19: The challenge of patient rehabilitation after intensive care. BMJ 2020;369:m1787.  Back to cited text no. 16


  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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