Low-intensity rehabilitation in persistent post COVID-19 dyspnoea: the value of Spa health resort as appropriate setting
Keywords:
Post COVID-19 syndrome; dyspnoea; fatigue; exercise intolerance; low-intensivity rehabilitation setting; Spa rehabilitation settingAbstract
Background. Post COVID-19 syndrome is a frequent disabling outcome, leading to a delay in social reintegration and return to working life.
Study design. This was a prospective observational cohort study. The main objective was to explore the effectiveness of a Spa rehabilitation treatment on the improvement of post COVID-19 dyspnoea and fatigue, also analyzing the relationship between such symptoms. Additionally, it was assessed if different clinical characteristics could predispose patients in experiencing post COVID-19 symptoms or could influence the effectiveness of a Spa intervention.
Methods. From July to November 2021, 187 post COVID-19 patients were enrolled in the study. All the patients complained persisting dyspnoea, whose impact on daily activities was assessed using the modified Medical Research Council dyspnoea scale. 144 patients (77.0%) reported also fatigue. The Spa treatment was started at least 3 months after COVID-19 acute phase. At the end of the treatment, patients were asked to rate the improvement in the dyspnoea and fatigue sensation. 118 patients also underwent the modified Borg Dyspnoea Scale for severity estimation of Exertion Dyspnoea and the Barthel index for severity estimation of Physical Limitation.
Results. 165 out of 187 patients (88.2%) reported an improvement in dyspnoea, while 116 out 144 patients (80.6%) reported an improvement in both dyspnoea and fatigue. On a total of 118 subjects, a clinically significant improvement in the modified Borg Dyspnoea Scale (i.e. Delta Borg equal or more than -2.0 points) was reached by the 50.8% of patients, while a clinically significant improvement in the Barthel index (i.e. Delta Barthel equal or more than +10.0 points) was reached by the 51.7% of them. The 31.4% of patients reached a minimal clinically important improvement in both the modified Borg Dyspnoea Scale and the Barthel index. No risk factors were associated to a clinically impacting dyspnoea at entry, while a BMI>30 Kg/m2 was the main risk factor for chronic fatigue. Presence of respiratory comorbidities, obesity and severe acute COVID-19 (phenotype 4) configured risk factors for the lack of improvement of dyspnoea after the treatment, while no risk factors were associated to a lack of improvement for fatigue. Older age, obesity and comorbidities seemed to make more difficult to reach a clinically meaningful improvement in the modified Borg Dyspnoea Scale and the Barthel index after treatment. Female gender may imply more physical limitation at entry, while male patients seem to show less improvement in the Barthel index after treatment.
Conclusions. Dyspnoea and fatigue were confirmed to be important post COVID-19 symptoms even in younger subjects of working age and subjects with absent or modest pulmonary alterations at distance from acute COVID-19. A Spa health resort seems to be an effective “low-intensity” setting for a rehabilitation program of such patients. There is a strong relationship in terms of improvement between dyspnoea and fatigue, even if risk factors for their occurrence appear to be different. The improvement in exertion dyspnoea and physical limitation seemed to be less mutually related, probably due to a greater complexity in the assessment questionnaires. Some risk factors may predict a lack of improvement in symptoms after treatment.
References
1. Alwan NA, Johnson L. Defining long COVID: Going back to the start. Med. 2021 May; 2(5):501-4. doi:10.1016/j.medj.2021.03.003. Epub 2021 Mar 25.
2. Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, et al. Post-acute COVID-19 syndrome. Nat Med. 2021 Apr; 27(4): 601-15. doi:10.1038/S41591-021-01283-Z. Epub 2021 Mar 22.
3. World Health Organization (WHO). A clinical case definition of post COVID-19 condition by a Delphi consensus. Last updated October 6, 2021. Available from: https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-Clinical_case_definition-2021.1 [Last accessed: 2024 Feb 21].
4. Jacobs LG, Paleoudis EG, Lesky-Di Bari D, Nyirenda T, Friedman T, Gupta A, et al. Persistence of symptoms and quality of life at 35 days after hospitalization for COVID-19 infection. PLoS One. 2020 Dec 11; 15(12): e0243882. doi:10.1371/JOURNAL.PONE.0243882.
5. Fernández-De-las-Peñas C, Palacios-Ceña D, Gómez-Mayordomo V, Palacios-Ceña M, Rodríguez-Jiménez J, de-la-Llave-Rincón AI, et al. Fatigue and Dyspnoea as Main Persistent Post-COVID-19 Symptoms in Previously Hospitalized Patients: Related Functional Limitations and Disability. Respiration. 2022; 101(2): 132-41. doi:10.1159/000518854. Epub 2021 Sep 21.
6. Goërtz YMJ, Herck M Van, Delbressine JM, Vaes AW, Meys R, Machado FVC, et al. Persistent symptoms 3 months after a SARS-CoV-2 infection: the post-COVID-19 syndrome? ERJ Open Res. 2020 Oct 26; 6(4): 00542-02020. doi:10.1183/23120541.00542-2020.
7. Carfì A, Bernabei R, Landi F; Gemelli Against COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19. JAMA. 2020 Aug 11; 324(6): 603-5. doi:10.1001/JAMA.2020.12603.
8. 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 Nov; 9(11): 1328-41. doi:10.1016/S2213-2600(21)00385-4. Epub 2021 Oct 19.
9. Office for National Statistics. Updated estimates of the prevalence of long COVID symptoms: Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/adhocs/12788updatedestimatesoftheprevalenceoflongcovidsymptoms [Last accessed: 2024 Feb 21].
10. Pavli A, Theodoridou M, Maltezou HC. Post-COVID Syndrome: Incidence, Clinical Spectrum, and Challenges for Primary Healthcare Professionals. Arch Med Res. 2021 Aug; 52(6): 575-81. doi:10.1016/J.ARCMED.2021.03.010. Epub 2021 May 4.
11. Froidure A, Mahsouli A, Liistro G, De Greef J, Belkhir L, Gérard L, et al. Integrative respiratory follow-up of severe COVID-19 reveals common functional and lung imaging sequelae. Respir Med. 2021 May; 181: 106383. doi:10.1016/j.rmed.2021.106383. Epub 2021 Apr 4.
12. Lerum TV, Aaløkken TM, Brønstad E, Aarli B, Ikdahl E, Lund KMA, et al. Dyspnoea, lung function and CT findings 3 months after hospital admission for COVID-19. Eur Respir J. 2021 Apr 29; 57(4): 2003448. doi:10.1183/13993003.03448-2020.
13. Wu X, Liu X, Zhou Y, Yu H, Li R, Zhan Q, et al. 3-month, 6-month, 9-month, and 12-month respiratory outcomes in patients following COVID-19-related hospitalisation: a prospective study. Lancet Respir Med. 2021 Jul; 9(7): 747-54. doi:10.1016/S2213-2600(21)00174-0. Epub 2021 May 5.
14. Lam GY, Befus AD, Damant RW, Ferrara G, Fuhr DP, Stickland MK, et al. Exertional intolerance and dyspnea with preserved lung function: an emerging long COVID phenotype? Respir Res. 2021 Aug 6; 22(1): 222. doi:10.1186/S12931-021-01814-9.
15. Spruit MA, Holland AE, Singh SJ, Tonia T, Wilson KC, Troosters T. COVID-19: interim guidance on rehabilitation in the hospital and post-hospital phase from a European Respiratory Society- and American Thoracic Society-coordinated international task force. Eur Respir J. 2020 Aug 13; 56(6): 2002197. doi:10.1183/13993003.02197-2020.
16. Maley JH, Alba GA, Barry JT, Bartels MN, Fleming TK, Oleson CV, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of breathing discomfort and respiratory sequelae in patients with post-acute sequelae of SARS-CoV-2 infection (PASC). PM R. 2022 Jan; 14(1): 77-95. doi:10.1002/PMRJ.12744.
17. Herrera JE, Niehaus WN, Whiteson J, Azola A, Baratta JM, Fleming TK, et al. Multidisciplinary collaborative consensus guidance statement on the assessment and treatment of fatigue in postacute sequelae of SARS-CoV-2 infection (PASC) patients. PM R. 2021 Sep; 13(9): 1027. doi:10.1002/PMRJ.12684. Epub 2021 Aug 24.
18. Chen H, Shi H, Liu X, Sun T, Wu J, Liu Z. Effect of Pulmonary Rehabilitation for Patients With Post-COVID-19: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2022 Feb 21; 9: 837420. doi:10.3389/FMED.2022.837420.
19. Fugazzaro S, Contri A, Esseroukh O, Kaleci S, Croci S, Massari M, et al. Rehabilitation Interventions for Post-Acute COVID-19 Syndrome: A Systematic Review. Int J Environ Res Public Health. 2022 Apr 24; 19(9): 5185. doi:10.3390/IJERPH19095185/S1.
20. Soril LJJ, Damant RW, Lam GY, Smith MP, Weatherald J, Bourbeau J, et al. The effectiveness of pulmonary rehabilitation for Post-COVID symptoms: A rapid review of the literature. Respir Med. 2022 Mar 2; 195: 106782. doi:10.1016/j.rmed.2022.106782. Epub ahead of print.
21. Li J, Xia W, Zhan C, Liu S, Yin Z, Wang J, et al. A telerehabilitation programme in post-discharge COVID-19 patients (TERECO): a randomised controlled trial Rehabilitation. Thorax. 2022 Jul; 77(7): 697-706. doi: 10.1136/thoraxjnl-2021-217382. Epub 2021 Jul 26.
22. De Souza Y, MacEdo J, Nascimento R, Alves AA, Medeiros S, Leal L, et al. Low-Intensity Pulmonary Rehabilitation Through Videoconference for Post-Acute COVID-19 Patients. Am J Respir Crit Care Med. 2021; 203: A4124. https://doi.org/10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A4124.
23. Paneroni M, Vitacca M, Bernocchi P, Bertacchini L, Scalvini S. Feasibility of tele-rehabilitation in survivors of COVID-19 pneumonia. Pulmonology. 2022 Mar-Apr; 28(2): 152-4. doi: 10.1016/J.PULMOE.2021.03.009. Epub 2021 Apr 14.
24. Maccarone MC, Masiero S. Spa therapy interventions for post respiratory rehabilitation in COVID-19 subjects: does the review of recent evidence suggest a role? Environ Sci Pollut Res. 2021 Sep; 28(33): 46063-6. doi: 10.1007/S11356-021-15443-8. Epub 2021 Jul 17.
25. Vu K, Mitsunobu F. Spa Therapy for Chronic Obstructive Pulmonary Disease: Studies at the Misasa Medical Center. Altern Complement Ther. 2005 Apr 20; 11(2): 89-93. http://doi.org/10.1089/act.2005.11.89.
26. Martín-Valero R, Cuesta-Vargas AI, Labajos-Manzanares MT. Evidence-Based Review of Hydrotherapy Studies on Chronic Obstructive Pulmonary Disease Patients. Int J Aquat Res Educ. 2012; 6(3): 8. doi: https://doi.org/10.25035/ijare.06.03.08.
27. Khaltaev N, Solimene U, Vitale F, Zanasi A. Balneotherapy and hydrotherapy in chronic respiratory disease. J Thorac Dis. 2020 Aug; 12(8): 4459-68. doi: 10.21037/jtd-gard-2019-009.
28. Zajac D. Inhalations with thermal waters in respiratory diseases. J Ethnopharmacol. 2021 Dec 5; 281: 114505. doi: 10.1016/J.JEP.2021.114505. Epub 2021 Aug 8.
29. Antonelli M, Donelli D. Respiratory rehabilitation for post-COVID19 patients in spa centers: first steps from theory to practice. Int J Biometeorol. 2020 Oct; 64(10): 1811-3. doi: 10.1007/S00484-020-01962-5. Epub 2020 Jul 24.
30. Hajiro T, Nishimura K, Tsukino M, Ikeda A, Koyama H, Izumi T. Analysis of Clinical Methods Used to Evaluate Dyspnea in Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 1998 Oct; 158(4): 1185-9. doi: 10.1164/AJRCCM.158.4.9802091.
31. Saracino A. Review of dyspnoea quantification in the emergency department: Is a rating scale for breathlessness suitable for use as an admission prediction tool? Emerg Med Australas. 2007 Oct; 19(5): 394-404. doi: 10.1111/J.1742-6723.2007.00999.X.
32. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989; 42(8): 703-9. doi: 10.1016/0895-4356(89)90065-6.
33. Mendelow A, Grotta J, Albers G. Stroke: Patophysiology, Diagnosis and Management. (Grotta J, ed.). Elsevier; 2015.
34. Resta E, Cuscianna E, Pierucci P, Custodero C, Solfrizzi V, Sabbà C et al. Significant burden of post-COVID exertional dyspnoea in a South-Italy region: knowledge of risk factors might prevent further critical overload on the healthcare system. Front Public Health. 2023;11:1273853. doi:10.3389/FPUBH.2023.1273853.
35. Italian Republic. Law 323/2000; art. 5, para. 1 [Reordering of the spa sector]. Available from: https://www.parlamento.it/parlam/leggi/00323l.htm [Last accessed: 2024 Feb 21].
36. Italian Republic. Law 208/2015, para. 301-302. Available from: https://www.gazzettaufficiale.it/eli/id/2015/12/30/15G00222/sg [Last accessed: 2024 Feb 21].
37. Chen H, Shi H, Liu X, Sun T, Wu J, Liu Z. Effect of Pulmonary Rehabilitation for Patients With Post-COVID-19: A Systematic Review and Meta-Analysis. Front Med (Lausanne). 2022 Feb 21; 9: 837420. doi: 10.3389/FMED.2022.837420.
38. Berentschot JC, Heijenbrok-Kal MH, Bek LM, Huijts SM, van Bommel J, van Genderen ME, et al. Physical recovery across care pathways up to 12 months after hospitalization for COVID-19: A multicenter prospective cohort study (CO-FLOW). Lancet Reg Health Eur. 2022 Aug 24; 22: 100485. doi: 10.1016/J.LANEPE.2022.100485.
39. Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. 2020 May; 39: 101166. doi: 10.1016/J.CTCP.2020.101166. Epub 2020 Apr 1.
40. Spielmanns M, Pekacka-Egli AM, Schoendorf S, Windisch W, Hermann M. Effects of a Comprehensive Pulmonary Rehabilitation in Severe Post-COVID-19 Patients. Int J Environ Res Public Health. 2021 Mar 7; 18(5): 2695. doi: 10.3390/IJERPH18052695.
41. Nguyen NN, Hoang VT, Dao TL, Meddeb L, Lagier JC, Million M, et al. Long-term persistence of symptoms of dyspnoea in COVID-19 patients. Int J Infect Dis. 2022 Feb; 115: 17-23. doi: 10.1016/J.IJID.2021.11.035. Epub 2021 Nov 27.
42. Yong SJ. Long COVID or post-COVID-19 syndrome: putative pathophysiology, risk factors, and treatments. Infect Dis (Lond). 2021 Oct; 53(10): 737-54. doi: 10.1080/23744235.2021.1924397. Epub 2021 May 22.
43. Nittas V, Gao M, West EA, Ballouz T, Menges D, Wulf Hanson S, et al. Long COVID Through a Public Health Lens: An Umbrella Review. Public Health Rev. 2022 Mar 15; 43: 1604501. doi: 10.3389/PHRS.2022.1604501.
44. Fumagalli C, Zocchi C, Tassetti L, Silverii MV, Amato C, Livi L, et al. Factors associated with persistence of symptoms 1 year after COVID-19: A longitudinal, prospective phone-based interview follow-up cohort study. Eur J Intern Med. 2022 Mar; 97: 36-41. doi: 10.1016/J.EJIM.2021.11.018. Epub 2021 Dec 7.
45. Loosen SH, Jensen BEO, Tanislav C, Luedde T, Roderburg C, Kostev K. Obesity and lipid metabolism disorders determine the risk for development of long COVID syndrome: a cross-sectional study from 50,402 COVID-19 patients. Infection. 2022 Oct; 50(5): 1165-70. doi: 10.1007/S15010-022-01784-0. Epub 2022 Mar 30.
46. Vimercati L, De Maria L, Quarato M, Caputi A, Gesualdo L, Migliore G, et al. Association between Long COVID and Overweight/Obesity. J Clin Med. 2021 Sep 14; 10(18): 4143. doi: 10.3390/JCM10184143.
47. Chan Sui Ko A, Candellier A, Mercier M, Joseph C, Schmit JL, Lanoix JP, et al. Number of initial symptoms is more related to long COVID-19 than acute severity of infection: a prospective cohort of hospitalized patients. Int J Infect Dis. 2022 May; 118: 220-3. doi: 10.1016/J.IJID.2022.03.006. Epub 2022 Mar 5.
48. Crankson S, Pokhrel S, Anokye NK. Determinants of COVID-19-Related Length of Hospital Stays and Long COVID in Ghana: A Cross-Sectional Analysis. Int J Environ Res Public Health. 2022 Jan 4; 19(1): 527. doi: 10.3390/IJERPH19010527.
49. von Leupoldt A, Dahme B. Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases. Respir Med. 2007 Mar; 101(3): 411-22. doi: 10.1016/J.RMED.2006.06.011. Epub 2006 Aug 8.
50. Townsend L, Dyer AH, Jones K, Dunne J, Mooney A, Gaffney F, et al. Persistent fatigue following SARS-CoV-2 infection is common and independent of severity of initial infection. PLoS One. 2020 Nov 9; 15(11): e0240784. doi: 10.1371/JOURNAL.PONE.0240784.
51. Maltezou HC, Pavli A, Tsakris A. Post-COVID Syndrome: An Insight on Its Pathogenesis. Vaccines (Basel). 2021 May 12; 9(5): 497. doi: 10.3390/VACCINES9050497.
52. So M, Kabata H, Fukunaga K, Takagi H, Kuno T. Radiological and functional lung sequelae of COVID-19: a systematic review and meta-analysis. BMC Pulm Med. 2021 Mar 22; 21(1): 97. doi: 10.1186/S12890-021-01463-0.
53. Singh I, Joseph P, Heerdt PM, Cullinan M, Lutchmansingh DD, Gulati M, et al. Persistent Exertional Intolerance After COVID-19: Insights From Invasive Cardiopulmonary Exercise Testing. Chest. 2022 Jan; 161(1): 54-63. doi: 10.1016/J.CHEST.2021.08.010. Epub 2021 Aug 11.
54. Afrin LB, Weinstock LB, Molderings GJ. Covid-19 hyperinflammation and post-Covid-19 illness may be rooted in mast cell activation syndrome. Int J Infect Dis. 2020 Nov; 100: 327-32. doi: 10.1016/j.ijid.2020.09.016. Epub 2020 Sep 10.
55. Proal AD, VanElzakker MB. Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms. Front Microbiol. 2021 Jun 23; 12: 698169. doi: 10.3389/FMICB.2021.698169.
56. Nunn AVW, Guy GW, Brysch W, Bell JD. Understanding Long COVID; Mitochondrial Health and Adaptation—Old Pathways, New Problems. Biomedicines. 2022 Dec 2; 10(12): 3113. doi: 10.3390/BIOMEDICINES10123113.
57. Scurati R, Papini N, Giussani P, Alberti G, Tringali C. The Challenge of Long COVID-19 Management: From Disease Molecular Hallmarks to the Proposal of Exercise as Therapy. Int J Mol Sci. 2022 Oct 14; 23(20): 12311. doi: 10.3390/IJMS232012311.
58. Masiero S, Maccarone MC, Agostini F. Health resort medicine can be a suitable setting to recover disabilities in patients tested negative for COVID-19 discharged from hospital? A challenge for the future. Int J Biometeorol. 2020 Oct; 64(10): 1807-1809. doi: 10.1007/s00484-020-01947-4. Epub 2020 Jun 5. PMID: 32504142; PMCID: PMC7272594.
59. Khaltaev N, Solimene U, Vitale F, Zanasi A. Balneotherapy and hydrotherapy in chronic respiratory disease. J Thorac Dis. 2020 Aug; 12(8): 4459-68. doi: 10.21037/JTD-GARD-2019-009.
60. Pellegrini M, Fanin D, Nowicki Y, Guarnieri G, Bordin A, Faggian D et al. Effect of inhalation of thermal water on airway inflammation in chronic obstructive pulmonary disease. Respir Med. 2005 Jun; 99(6): 748-54. doi: 10.1016/j.rmed.2004.11.001. Epub 2004 Dec 13.
61. Festinger L, Carlsmith JM. Cognitive consequences of forced compliance. J Abnorm Soc Psychol. 1959 Mar; 58(2): 203-10. doi: 10.1037/H0041593.
62. Huang Y, Tan C, Wu J, Chen M, Wang Z, Luo L, et al. Impact of coronavirus disease 2019 on pulmonary function in early convalescence phase. Respir Res. 2020 Jun 29; 21(1): 163. doi: 10.1186/S12931-020-01429-6.
Downloads
Published
Issue
Section
License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Transfer of Copyright and Permission to Reproduce Parts of Published Papers.
Authors retain the copyright for their published work. No formal permission will be required to reproduce parts (tables or illustrations) of published papers, provided the source is quoted appropriately and reproduction has no commercial intent. Reproductions with commercial intent will require written permission and payment of royalties.