Obesity constitutes an important threat to national and global public health in terms of its prevalence and rising incidence, quality of life, life expectancy, and economic burden [1,2]. In severe obesity, bariatric surgery is the most effective therapeutic option to achieve long-term weight loss and improve the associated comorbidities [3]. This has made Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and adjustable gastric banding the most popular and commonly performed bariatric surgeries [4]. However, a small proportion of patients have also been reported to not reach their optimum goal for weight loss two years after the procedure and very few can fail or regain the weight. While anatomical factors can play a part, behavioural and psychosocial optimizations are regarded as equally important. This includes eating patterns, depression, nutritional factors, and exercise [5,6].

Virtual reality (VR) development and applications have gained wide recognition in medical services by providing solutions to improve patients’ outcomes. This is through patients’ education, improving mental health, and post-operative care, including pain management, physical therapy, and rehabilitation [7,8]. VR is a computer-generated simulation of a real or imagined environment. It can be immersive or non-immersive according to its ability to involve the users [9]. The former has been the focus of many medical applications due to its ability to give the user control of the reproduced environment. Immersive virtual reality (IVR) is usually delivered in a variety of ways and the most popular being head-mounted displays or simply a headset [8].

We aim to provide insight on some of these immersive applications and how they can be included to enhance the patient pathway to optimize outcomes both in the pre- and post-operative period for patients undergoing bariatric surgery.


A systematic search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) research criteria was conducted from January 2015 to December 2021. PubMed was searched using the following keywords: virtual reality, patient education, anxiety and pain, physical rehabilitation, behavioural support, obesity, eating disorders, body image, and substance cessation.

Thirty-four studies were identified and included in the final manuscript (Figure 1) supporting VR technology across applications that can be applied to bariatric patients’ surgical pathways. The applications were subcategorized into eight different areas of interest, which can help to shape the concept of the virtual ecosystem of bariatric patients (Figure 2).


VR applications have been described in the eight domains mentioned below, which can be applied in relation to patients undergoing bariatric surgery.

Virtual Reality Patient Education (VR PE)

VR education has been introduced to make the information more meaningful and patient-centred by enabling its users to be fully immersed in an interactive simulated and self-controllable visual and auditory experience [10]. In a study by Pandrangi et al. [11], VR was found to be a useful informative tool in educating patients about their aneurysmal disease through interactive reconstructed three-dimensional (3D) images of their aortic anatomy. The majority of the patients in this study agreed that VR 3D anatomy helped to improve their understanding and therefore felt more engaged in their healthcare decisions [11].

VR PE has also played a role in improving the stress levels of patients undergoing radiotherapy (RT) by improving clarity and levels of education about their treatment. A randomized study on 60 patients with chest malignancy showed that patients who received VR PE showed significant improvement in comprehension and reduction in stress and anxiety levels when compared to standard education [12]. Another study on 43 patients utilized VR PE by creating 3D images of patients in RT sessions and what to expect during the treatment. After the VR PE, 95% of patients agreed that they had a clear understanding of how they would feel when lying on the treatment table. Also, patients’ understanding of the location and the size of their cancer had significantly improved from around 50% to 95% with an increase in the orientation of side effects of the treatment by 30% post-VR PE [13].

In bariatric surgery, there is no currently reported data on the applications of VR education. However, the potential impact of VR PE can be numerous across the weight management pathway. Preoperatively, bariatric patients could potentially utilize VR to be virtually educated about different surgical options versus conservative treatment through enhanced 3D interactive images. This could be seen to help in better understanding of their options including surgery and thereby enhancing informed consent and overall education.

Post-operatively, VR-enhanced education could provide an option for daily or weekly updates on lifestyle changes, which could help in improving compliance. Importantly, this can be done from the comfort of the patient’s home with the added advantage of reducing costs and time for travelling to attend appointments.

Anxiety Related to Surgery

A significant amount of anxiety related to surgery is due to the fear and uncertainty of the outcomes. Its psychological and physical effects are associated with longer recovery, an increase in the need for analgesia, anaesthetic requirement, and unfavourable behavioural and emotional outcomes [14]. Conventional methods of mitigation of preoperative anxiety are pharmacological and non-pharmacological strategies [15].

Recently, with promising results in the management of anxiety and other psychiatric disorders, VR has been successfully applied to reduce anxiety related to surgery in different surgical settings [16]. Chan et al. [17] tested the effect of VR relaxing meditation and breathing exercises on 108 women undergoing hysteroscopy. This showed that anxiety scores were significantly reduced after the 10 minutes of VR content, which helped in reducing pain and stress related to surgery. Also, around 85% of patients reported the VR experience as good or excellent [17].

In minimally invasive abdominal surgery, Haisley et al. [18] used VR meditation as a perioperative tool with favourable results in reducing pain, anxiety, and nausea and around 75% of patients stated that they would use the VR again [18]. Similarly, VR meditation showed favourable results in reducing pain and anxiety in burns and complex pain [19,20].

The rationale for using VR to improve anxiety preoperatively is by immersing patients in a fully simulated relaxing environment with the objective of placing them in a more empowered state to deal with the triggers of their anxiety [21]. This could be applied to the bariatric population before surgery. It is to be seen from future studies whether these expected results can be validated in bariatric patients. There is therefore the potential for obtaining better evidence for patient satisfaction and reducing stress related to bariatric surgery.

Pain Management

Successful pain management is a key element of the post-operative course as it shortens recovery and reduces risks of cardiovascular and pulmonary complications. In bariatric surgery, pain management is essential to enhance recovery and prompt early mobilization, which helps to decrease venous thromboembolism, prevent other events, and reduce hospitalization [22]. Therefore, a multimodal approach through regional and systematic analgesia is considered the most effective method as it minimizes opiate use, which can induce obstructive sleep apnoea, which is more liable due to the co-morbidities of obesity [23].

Applications of VR in pain management in other surgical patients have been reported to have numerous benefits. This includes a reduction in pain scores after cardiac, knee, abdominal, and spinal surgery with overall patients reporting the use of VR as a pleasant experience and stating that they would use it again on further occasions [18,24,25]. VR pain management follows a similar concept to VR and anxiety meditation by immersing patients in a simulated relaxing environment, which can help to divert the patient's feelings from their pain. This could be playing a major role in bariatric patients' management of pain and anxiety related to surgery with proper application integration in their peri-operative pathway.

Optimizing Pulmonary Function for Surgery

Respiratory function in morbidly obese patients follows a restrictive pattern with up to 77% suffering from obstructive sleep apnoea [26]. This increases the risk of impaired post-operative oxygenation and other respiratory complications in the form of atelectasis. Optimization of pulmonary function for surgery includes smoking cessation, breathing exercises, including inspiratory muscle training, incentive spirometry, and optimization of chronic disease, for example, asthma and chronic obstructive pulmonary disease (CPOD) [27].

With the increase of applications of VR in different rehabilitation programmes, VR has been aiding in pulmonary exercises in both healthy individuals and COPD patients [28,29]. VR pulmonary rehabilitation is designed to enable home-based exercises in the form of a 3D avatar instructor in an immersive relaxing environment to guide patients through breathing exercises based on traditional rehabilitation programmes [30]. In COPD patients, VR-based respiratory rehabilitation has shown to have similar outcomes when compared to a conventional programme with the additional benefit of performing the exercises from home. Moreover, VR showed enrichment of experience by also decreasing the levels of anxiety during exercise and therefore optimizing cardiorespiratory function [31].

Physical Fitness Applications

Pre- and post-operative physical activity (PA) is regarded as an important element in enhancing recovery after surgery as it improves physical state, responses to stress from surgery, and improvement of cardiovascular function, thereby reducing complications [32].

In the bariatric population, a structured exercise regime is considered a feasible and effective adjunct therapy that benefits cardiometabolic parameters when compared to those with bariatric surgery alone [33]. Exercise before surgery has shown to be beneficial in reducing body weight, improving blood pressure, general fitness, quality of life satisfaction, and decreasing fasting plasma insulin and blood lipid. Exercise after bariatric surgery has been shown to preserve dynamic muscle strength and contribute to maintaining weight loss after calorie restriction [34].

Although PA promotion is recognized as an important component of weight loss programmes, there are no current evidence-based or standardized bariatric surgery-specific PA guidelines [35]. Reported exercise regimes ranged from walking, aquatic, resistance, and supervised exercises. Also, adherence to exercise before and after surgery plays a big role in physical rehabilitation. As in the bariatric population, many can face barriers in the form of low confidence levels in their abilities and not feeling comfortable going to the gym due to real and perceived discrimination. Therefore, many come up with the belief of not having time to participate in sports [36].

VR rehabilitation has gained much recognition from dedicated platforms like treadmills, diving, cycling simulators, and medically oriented VR rehabilitation. These studies have demonstrated increased participation of users utilizing VR exercise programmes [37]. VR rehabilitation and exercise have shown to be effective in healthy individuals and different medical rehabilitations. It was reported to be equivalent and sometimes more superior to standard physiotherapy in cerebral palsy, spinal injury, and stroke [38]. In healthy individuals, VR exercise was demonstrated to increase adherence and enjoyment with positive physiological effects during exercise [39]. It was also reported that obese children performed better on treadmills while using VR than traditional walking, as VR allowed more distraction and less discomfort [40].

VR exercises during rehabilitation can therefore potentially play a major role in pre- and post-operative PA improvement in bariatric patients. Given the feasibility and the safety of these home-based devices, it can decrease the load on healthcare services, as most of the standard pre-operative programmes are resource intensive.

Virtual Reality and Enhanced Cognitive Behavioural Therapy

Eating and depressive disorders significantly affect the bariatric population with a prevalence of 24% and 17%, respectively. Both can lead to less post-operative weight loss, weight regains, impaired general psychology, and quality of life [41]. Cognitive behavioural therapy (CBT) is recommended for patients undergoing weight loss surgery (WLS). It has been shown to improve self-monitoring and control eating behaviours with significant improvement in depression and anxiety and therefore better results [42].

Over the last decades, VR-enhanced cognitive therapy (VRCBT) has been embraced for being a novel way to deliver CBT. The technique creates an interactive 3D environment to simulate successful goal achievement. This helps patients to overcome memories of previous real-life experiences through emotionally guided virtual exposure [43]. VRCBT has shown favourable results in anxiety, phobias, social anxiety disorders, and depression [21]. Moreover, randomized trials have shown VRCBT to be superior to conventional CBT in managing eating disorders and binge eating [44,45]. This helped in weight reduction therapy and adding adherence to programmes [46].

There is a paucity of evidence of the use of VR in the overweight and morbidly obese population. Phelan et al. [47] tested the use of a VR environment on 15 overweight adults for four weeks with the main hypothesis to evaluate the effect of the simulated scenes on behavioural skills related to eating habits. Although they showed no difference in weight loss among participants, VR intervention was more preferred by patients over traditional weight loss programmes [47]. Manzoni et al. [45] tested the efficacy of an enhanced VRCBT module aimed to unlock the negative memory of the body and modify its behavioural and emotional behaviour. A total of 163 female morbidly obese inpatients were randomly assigned to three CBT-based treatments: a standard behavioural inpatient programme (SBP), SBP plus standard CBT, and SBP plus VR-enhanced CBT. The study showed that patients in the VR group had a greater probability of maintaining or improving weight loss at one-year follow-up than SBP patients and, to a lesser extent, CBT patients. On the contrary, participants who received only a behavioural programme regained on average most of the weight they had lost [45].

VRCBT can therefore be a valuable tool in managing behavioural disorders related to obesity in patients undergoing WLS. This can help in maintaining weight loss and improving well-being and quality of life.

Virtual Reality and Body Image (VRBI)

Body image disorders (BIDs) are linked to various psychological and physical sequelae of impaired functions, for instance, depression, anxiety, eating disorders, and poor quality of life [48]. Among the bariatric population, body image dissatisfaction is associated with binge eating, depression, and lower self-esteem, with one in five bariatric patients identifying appearance as their main motive for surgery [49]. Improvement in body image perception after successful surgery has been linked to a decrease in compulsive eating syndromes, reduction in body mass index (BMI), and improvement in self-esteem and intimate relationships [50].

A contrary aspect of body image after surgery includes the issue of excess skin with massive weight reduction. This has been linked to poor body satisfaction, dermatitis and skin fold irritations, and impairment in daily activities and exercise. In turn, this leads 85% of bariatric patients to seek body-contouring surgery (BCS) to elevate this problem [51].

The application of VR has been used to improve BID. This is by creating a 3D simulation of their bodies in the form of avatars through an immersive environment that reproduces situations related to their body image concerns. Through multisensory simulations, it produces an empowered feeling of ownership of one’s body, which consequently promotes a healthier body image and behaviour [52]. A recent systematic review of six studies utilizing avatars and VR in weight loss programmes showed that avatar-based interventions were effective in both short- and mid-term weight loss. Also, the technology helped to improve exercise adherence in the long term [53]. VR was also used to assess the BID of 78 women with different BMIs by exposing the participants to different versions of avatars: slimmer, same weight, and overweight. The study showed that women with higher BMI reported more BID on their replicated avatar and showed satisfaction with their slimmer version. This finding indicated that VR may serve as a novel tool for measuring BID [54].

Potentially, VR avatars can also play a role in body image perception in bariatric patients. It can be integrated to improve BIDs by recreating slimmer avatars, which could promote adherence to weight loss and exercise programmes.

Smoking and Alcohol

While the increase in BMI is a risk factor for adverse outcomes related to surgical procedures, smoking's hazardous effects range from increased risks of pulmonary complications, wound infection, venous thromboembolism, and slower recovery. Similarly, alcohol consumption before surgery can lead to increased unfavourable outcomes [55]. Smoking and other substance abuse are recommended to be stopped four to six weeks pre-operatively [56]. VR has been tested as a potential solution to stop smoking and alcohol usage by inducing an advanced cue exposure therapy (CET), which was superior to static images or videos used in conventical settings [57]. Also, VR exposure therapy (VRET) has been reported to be more effective if combined with conventional cognitive behaviour therapy in relation to stopping smoking [58].

Although its applications are still under development and validation, VRET in smoking and alcohol cessation could play an important role in optimizing patients undergoing bariatric surgery as a part of a virtual reality surgical care package (VRSCP).


Patients who are candidates for WLS usually undergo variable preparatory phase and post-operative optimization to improve both short- and long-term results. Standard care models usually involve education and follow-up through multidisciplinary teams with reflection on the patient's progress through educational sessions and follow-up plans.

While VR applications are being investigated in many surgical and medical specialities, their application to patients undergoing WLS is limited and not yet explored. The favourable applications of VR in patient education, anxiety and pain management, preoperative optimization, and behavioural and physiological treatment can be packaged as a surgical care bundle making bariatric patients' journey more satisfactory with the potential for improved outcomes.

Despite its promising applications, VR is still an emerging technology and has its own initial drawbacks to gaining traction in the healthcare system. There are several reasons for this. Firstly, the obvious cost of the systems and the absence of adequate clinical validation could play a major role in limiting widespread adoption. Further delays in adoption would likely be seen within the education of both healthcare providers and their patients, particularly on the application and utilization of the systems. The technology is still seen to be clumsy to wear and will need educational support to use [59].

With the increased investments and advancement in VR technology, education of healthcare professionals and further studies demonstrating evidence of improved outcomes, VR will play a major role in surgical patients and more specifically bariatric patients. This could be even refined as a personalized surgical care package. This will contribute to a fully virtual ecosystem in health care.

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Why rehabilitation post lung transplant is critical to ensure optimum success of procedure

Human lungs. Image courtesy Pearson Scott Foresman/Wikimedia Commons

Lung transplant is an established treatment for patients with end-stage lung disease. It is a surgical procedure to replace a diseased or failing lung with a healthy lung, usually from a deceased donor.

Several modifiable pre- and post-transplant factors contribute to a wide range of physiological and psychological changes which need to be addressed and effectively managed.

It is well established that rehabilitation plays a major role in the pre and post-operative management of patients. It involves working in partnership with the patient, their family and caregivers and a comprehensive multidimensional medical team- towards a common goal of maximising the potential and independence of the patient and to promote a holistic health. It is the process of helping an individual achieve the highest level of function, independence, and to enhance their overall quality of life.

Global review of literature depicts that with the involvement of a multidisciplinary team of experts contributes greatly to the well-being of the patient.

The rehabilitation team typically includes physical therapist, exercise physiologist, psychologist and nutritionist.

The transplant trajectory is complex and intensive, and patients usually experience this period as extremely stressful. Along with the functional impairment – the patients also undergo significant degree of emotional distress. With the prevalence rates of anxiety and depression being high in transplant candidates and recipients, there is a strong need for psychological rehabilitation along with physical rehabilitation for their overall holistic wellbeing. Pre- and Post-transplant psychological support is an important, but overlooked, element in optimising transplant outcomes, particularly in lung transplant recipients who have some of the highest rates of complications and distress following transplantation.

In order to evaluate exercise capacity and function in lung transplant candidates and recipients, a combination of aerobic testing, muscle function, mobility testing and assessment of physical activity is utilised. Along with this- a comprehensive psycho-social assessment is carried out where patient’s understanding regarding the medical illness, process of transplant, willingness/desire for treatment, compliance and care of lifestyle factors, along with the patient’s present emotional and mental state, past psychiatric history is elicited. Based on the test results, a comprehensive rehabilitation programme is planned.

Rehabilitation can be divided into two broad categories:

1. Pre-operative Rehabilitation or Prehabilitation
2. Post-operative rehabilitation


Participating in a supervised pulmonary rehabilitation programme is recommended to assist with prevention of further deterioration and improvement in symptoms, understanding of the condition and enhancing the quality of life. The goal is to promote a better functional recovery post-transplant. Most of the patients awaiting transplant are recommended to be subjected to prehabilitation as indicated.

The prehabilitation is feasible and improves the quality of life by:

• Effective chest clearance and lung expansion techniques
• Maintaining or improving physical activity levels
• Maintaining or improving cardiorespiratory fitness
• Preparing the patient for the transplant surgery
• Psychological interventions to enhance coping

Post-operative rehabilitation

Inpatient rehabilitation

Early post-operative rehabilitation

Post-operative rehabilitation starts immediately after surgery once the patients is stabilised, where the initial focus is on maintenance of bodily systems, as well as to assist the patient with the weaning of ventilator/supplemental oxygen and facilitate early mobility.

It typically begins in ICU and then continues in wards with the goal to improve:

• pulmonary hygiene and lung capacity
• General mobility
• Functional capacity
• Muscle strength and endurance
• Emotional coping
• Facilitate discharge from the hospital

Rehabilitation in wards can be further escalated to frequent walking, cycling, strengthening and stair climbing.

Outpatient rehabilitation

An outpatient rehabilitation programme may begin as soon as possible after hospital discharge. A tailor-made exercise programme is prescribed keeping in mind individual patient goals. The outpatient rehabilitation programme facilitates regaining the muscle mass and strength lost during prolonged illness and the disuse associated with prolonged illness along with adequate emotional coping to regain a sense of normalcy in their day to day lives.

The comprehensive programme typically includes:

• Aerobic exercises
• Resistance training
• Flexibility exercises
• Breathing retraining
• Psycho-social counselling
• Nutritional intervention which makes it an efficacious rehabilitation programme

Remotely monitored (tele-health) home based exercise, or pedometer based walking interventions might serve as alternatives to supervised outpatient rehabilitation interventions in the long-term post-transplant phase.
Both inpatient and outpatient rehabilitation have proven to be beneficial for patients before and after lung transplant by improving exercise capacity, promote adaptive coping and overall quality of life.

With recent research showing reduced risk of cumulative mortality in patients of lung transplant- which was attributable to Pre and Post-Transplant rehabilitation, and with other studies depicting greater survival rates among patients even after five years- Rehabilitation should be seen as an essential service offered across all levels of the health care system. We encourage patients to enrol in rehabilitation programme pre-operatively and continue the journey post operatively for an optimal gold standard of care.

The author is Consultant – Rehabilitation and Sports Medicine, Sir HN Reliance Foundation Hospital. Views are personal.

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Culiacan, Sen. – The Culiacan Civil Hospital Followed by long tablecloths under celebrations from him 90th AnniversaryThrough the use of the attending physicians Hilda Orta s Ulysses Gonzalez PulidoSports medicine signs.

more than 40 years of experience In sports medicine, first with the national teams from his home country, Cuba. And now resides in Mexicothey work for National Sports Committee and the Mexican Olympic Committee.

You may also like: The Civil Hospital of Culiacan announces a 5 km race to celebrate its 90th anniversary

At the event held this weekend, in the same civil hospital, before a large attendance, Dr. Orta presented the topic, “Pulmonary Rehabilitation for Covid Patients”. While Dr. Gonzalez Pulido spoke about the importance of physical activity and health.

The authorities of the civil hospital in Culiacan headed by its director, Dr Dr. Everardo Quevedo Director of the Physical Rehabilitation Department Dr. Juan Lauro Martinez Barredawhich organized this new event in the framework of the celebrations of the 90th anniversary of the Culiacan Civil Hospital.

“It is important to have this kind of Exhibitions. Because even though covid is true, it’s starting to decline statistically. But he left us After the catastrophe Prolonged COVID-19 disease, and its consequences illness. Even hospitals are strongholds of health in Sinaloalike the Civil Hospital in Culiacan, you must be prepared to have a response that is as adequate and as scientific as possible to know how to respond to the needs of the population.”announced in an interview Dr. Gonzalez Pulido.

He added that this is the reason Importance who is this medical talks; “I congratulate Civil Hospital for that, because here we talked about the importance of exercise and physical activity as a response Economic And so on productive To counter the effects of covidDr. Ulysses Gonzalez Pulido concluded with these words.

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The Smart Sleeve-Powered MSK Platform Expands Footprint in Healthcare and Welcomes Advisors from Meta and Banner Health

DENVER, Sept. 7, 2022 /PRNewswire/ -- Cipher Skin, the hardware-enabled monitoring platform that enables flexible, hybrid recovery for musculoskeletal care, today announces it has deepened its mission to improve physical rehabilitation. The company has expanded product development, launched platform partnerships, and received new funding from strategic investors. Signaling steadfast confidence in the company's technology and vision, Tribe Capital, Draper Capital, and a number of large family offices continued their investment along with new capital from Andreessen Horowitz. The company has also welcomed Caitlin Kalinowski (CK), head of AR hardware at Meta, and Dr. Ara Feinstein, M.D, trauma and critical care at Banner Health, as advisors.

"At Cipher Skin we are intensifying our focus on physical rehabilitation and strengthening the industry by connecting in-clinic therapy with at-home care," said Phillip Bogdanovich, founder and CEO of Cipher Skin. "We are empowered by the continued support of our investors and new advisors to put connected care within reach of every rehab therapy provider. Cipher Skin's hardware-enabled platform is extending therapy beyond the walls of the clinic, allowing providers to offer connected, hybrid care and leveraging the healing power of the therapist-patient relationship."

The addition of Dr. Ara Feinstein and Caitlin Kalinowski to the advisory board will help advance Cipher Skin's influence within the health tech industry, encouraging providers to embrace modern technologies to optimize treatment plans and deliver higher quality care.

"The digital revolution in healthcare is changing the way patients seek treatment and how rehab therapists heal patients," said Kalinowski. "Seeing first-hand how impactful smart devices can be, I am energized by the enormous potential that Cipher Skin's smart sensor and Biosleeve technology has to improve healthcare."

Cipher Skin's patented technology tracks motion and biometric data translating it into instant, actionable insights so providers can evaluate the patient's condition and track outcomes over time. The company has recently expanded the hardware-enabled platform to focus on efficient, patient-centered care.

"Healthcare's pivot towards value-based care necessitates solutions that drive down cost and improve quality," said Dr. Feinstein. "CipherSkin's technology can enable inexpensive collection and delivery of data to inform preoperative decision-making while adding flexibility to postoperative rehabilitation and monitoring."

Recent product innovations from Cipher Skin include:

  • The BioSleeve® Lower Extremity: Smart sleeves are now available for both lower extremities and upper extremities featuring a network of interconnected sensors that capture range of motion and biometrics in real-time translating it to the Recovery App.
  • The BioCore®: A chest motion sensor supported by a lightweight elastic strip that measures the tilt and rotation of the torso and works in concert with the BioSleeves to position the body in space, enabling dynamic motion.
  • Remote Therapeutic Monitoring: The Recovery App comprehensive software solution now includes the ability to monitor, track, and subsequently bill for remote therapeutic monitoring (RTM). RTM can increase profitability and patient loyalty for clinics.
  • Data Sharing with Kno2: Data and outcomes can be securely shared with Certified Electronic Health Record Technology (CEHRT) systems to bridge the gaps between referring physicians, patients, and physical therapists.

To learn more about Cipher Skin's motion and biometrics tracking technology visit cipherskin.com.

About Cipher Skin:

Cipher Skin is a hardware-enabled monitoring platform that enables flexible, hybrid recovery for musculoskeletal care. Founded in 2017, Cipher Skin's patented technology is a network of sensors that captures gapless biometric and motion data and translates it through proprietary software to provide instantaneous, visualized data and diagnostics. By connecting in-clinic rehab therapy with at-home care through continuous patient progress monitoring, practitioners can track exact outcomes, deliver patient-centered care, and maximize clinic revenue. To learn more visit cipherskin.com.

Cision View original content to download multimedia:www.prnewswire.com/news-releases/cipher-skin-announces-new-investors-and-product-innovations-for-physical-rehabilitation-301618856.html

SOURCE Cipher Skin

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Nowadays physiotherapists are an integral part of a multidisciplinary team in most of the intensive care units (ICU) in Bangladesh. Doctors and hospital management realising the importance of physiotherapy management in ICU.

According to WCPT (World Confederation for Physical Therapy), Physiotherapy in ICU helps to reduce patient morbidity and mortality and prevent increased length of ICU and hospital stay. The focus of physiotherapy treatment in ICU is respiratory physiotherapy and physical rehabilitation.

Respiratory physiotherapy:

Every day our lungs produce fluid called sputum. Sputum traps the dirt particles that we breathe in and to clean the lungs this is normally coughed and cleared. Patients in ICU may require mechanical ventilation that helps for breathing but it stops patients from coughing and clearing the daily sputum load that causes sputum retention, chest infection or other complications.

Importance of respiratory physiotherapy in ICU:

* Reduce sputum retention, atelectasis and pneumonia

* Maintain lung volume

* Reduce airway resistance and work of breathing

* Optimise oxygenation and ventilation

* Improve respiratory muscle strength

* Improve ventilation/perfusion mismatch

* Minimise postoperative complications

* Decrease patient's dependency on the ventilator.

Physical rehabilitation:

Prolonged immobility or inactivity is a contributing factor of muscle weakness in ICU patients. According to The Chartered Society of Physiotherapy (CSP)-UK, patients who are mechanically ventilated for more than 7 days, 25% display significant muscle weakness, and approximately 90% of long-term ICU survivors will have ongoing muscle weakness. They can also experience joint stiffness, muscle tightness and reduce overall fitness. Physiotherapy rehabilitation programme plays an integral role in the treatment and prevention of these complications.

Importance of physical rehabilitation in ICU:

* Maintain joint range of movement

* Maintain muscle strength

* Help to improve cardio respiratory fitness

* Reduce venous stasis and risk of deep-vein thrombosis

* Maintain and improve exercise tolerance

* Maintain bone density

* Provide positive psychological benefits

* Aid to return to function and daily life

Physiotherapy in the ICU improves patient's physical wellbeing, facilitating weaning and promoting safe and early discharge from the intensive care unit. Early mobilisation results in decreased length of stay in ICU as well as overall hospital stay. ICU related complications such as deconditioning, muscle weakness, respiratory infections and contractures, can be prevented by early physiotherapy intervention.


The writer is a Clinical Physio-therapist at BRB Hospitals Ltd.

Email: [email protected]

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COVID-19 is most known as a virus that causes respiratory disease. It has had varying effects on people infected by it, with symptoms as basic as a headache to the inability to breathe or extreme fatigue. Currently, there have been more than 3 million cases with 46,494 deaths directly due to complications resulting from contracting COVID-19 just within the Commonwealth of Pennsylvania.

It has been just over a year since I got COVID and had a double lung transplant to save my life. The recovery process has been anything but easy. It has also been a fast-paced crash course in pulmonology, the study of lung anatomy, physiology, and function. Not only did I have to learn how to breathe all over again, but I also had to learn how to do it better than ever before.

It all began with a stay at an inpatient physical rehabilitation hospital for 30 days. Breathing better meant increasing my endurance so I wouldn’t tire so quickly while being physically active. That was the first-time bicycling was introduced to me as a method of improving my lung function. Initially, I was lucky if I could peddle for three minutes before getting tired. By the time I was discharged, I was able to bicycle on a stationary bike for 10 to 15 minutes.

My pulmonary therapy continued on an outpatient basis in which I had sessions three times a week for roughly two hours. I still worked with a stationary bike, but not as often. I completed the outpatient program and was on my own to continue being physically active with some focus on exercises the therapists recommended I continue at home.

I would love to tell you I did everything they recommended, that I was surpassing every expectation and becoming stronger than I ever was before, but the truth is I struggled. I lacked motivation. I fell into a mental funk. It took me several months to begin seeing I needed to work on my attitude, that I needed to be physically active so my new lungs would become strong and support me through this second chance I was given.

Not long ago, I was reading a blog thread on Facebook about a man that had a double lung transplant a few years ago and took up bicycling. So far, the longest trip he’s made was about 100 miles, bicycling from his home to the hospital that performed his double lung transplant and back. He is about 15 years older than me. I thought to myself, “If this man in his mid-sixties can do that, why can’t I?” I wiped the dust off my mountain bike after speaking with my pulmonologist and getting some guidance.

I cycled 2.5 miles my first ride and began increasing my distance quickly. It wasn’t long before I was riding beyond ten miles each ride. I started noticing improvements. For the first time since getting COVID and having my double lung transplant, I was able to take a nice, slow, deep breathe without coughing. I was able to control my breathing better and was able to “catch my breath” and slow it to a normal rate after being physically active. Of course, I was getting stronger. It surprised me how I felt like I completed a full body workout after a long bicycle ride. I was also surprised by how much I enjoyed it.

Sometimes, I need a little push or a reason to keep going; something to keep me motivated. I decided to plan/participate in a 38-mile bicycling event. I continued to train and bicycled every week leading up to the day I rode 38 miles within one ride along with friends and support from my family. I was exhausted, but in a good way. I was proud of what I accomplished. The clear and obvious thing is, bicycling improves respiratory function. The increase in your breathing rate while cycling improves and strengthens the muscles around your lungs. The healthier and stronger the lung, the more oxygen-rich air it can absorb. Overtime, the lung capacity will increase, your abdominal muscles become stronger and more formed, and your respiratory muscles become more engaged and work efficiently.

I admit, I took a break after the 38-mile ride but will continue to bicycle as I am actively looking for my next event to participate in; that thing I need to hold me accountable. Do I plan on setting any records or finishing first place in a race? The answer is no, but I do plan on winning the marathon!

Rick Bressler is a husband, father, and Veteran of the United States Army, who wants to share his experiences as a COVID survivor to help promote getting vaccinated and wearing a mask.

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Pulmonary rehabilitation is an effective intervention for people with chronic obstructive pulmonary disease (COPD) that is recommended in clinical guidelines worldwide.1 Outpatient group programs commonly run twice a week for 7–8 weeks and encompass comprehensive assessment followed by patient-tailored therapies including exercise training, education and behavior change.2 Level 1 evidence shows improvements in exercise capacity and symptoms3 with a reduction in hospitalizations and length of stay in the 12 months following program completion.4,5

It is well documented that the initial beneficial effects diminish over time following pulmonary rehabilitation2,6 and that there is scant evidence for the efficacy of current models of maintenance programs.7 In clinical practice, it is not uncommon for people with COPD to be re-referred to pulmonary rehabilitation on more than one occasion and international guidelines/statements acknowledge that additional pulmonary rehabilitation programs at some time following the initial program may provide further benefits.2,6 The timing of a repeat course of pulmonary rehabilitation may be prompted by a gradual decline in function or a rapid deterioration, such as may occur following an acute exacerbation of COPD. There have been calls for more information regarding the clinical benefits of repeat courses of pulmonary rehabilitation8 and recommendations regarding frequency,9 but synthesis of the available evidence to inform this practice has not been undertaken.

The aim of this systematic review is to establish the effects of repeating pulmonary rehabilitation subsequent to an initial program in people with COPD.


This systematic review was prospectively registered on PROSPERO (19 October 2020, CRD42020215093) and is presented according to the PRISMA guidelines.10

Studies, Participants and Intervention

Studies where participants with COPD undertook a pulmonary rehabilitation program on more than one occasion were included, incorporating randomized controlled trials (RCTs) and non-randomized studies. A control group was not required for inclusion. Data for adults (18 years of age and over) with a diagnosis of COPD according to established criteria were included, regardless of disease severity.

All participants must have undertaken an initial pulmonary rehabilitation program of defined duration that included a component of physical rehabilitation incorporating whole-body exercise training (with or without resistance training) with or without any form of education and/or psychological support.9 The repeat pulmonary rehabilitation program was in accordance with the definition for the initial intervention and undertaken at any time point after completion of an initial pulmonary rehabilitation program. Studies involving maintenance programs were excluded, where exercise training was delivered at a lower dose than the initial program and/or was an indefinite/ongoing program.11 This was to ensure that any repeat program was delivered according to the same model and dose as the initial program. Studies not published in English were excluded.

Outcome Measures

The primary outcome was disease-specific health-related quality of life as measured with tools, eg, Chronic Respiratory Disease Questionnaire (CRQ, higher score = improvement), St George’s Respiratory Questionnaire (SGRQ, lower score = improvement). Secondary outcome measures were exercise capacity, hospitalization, mortality, adverse events and adherence. Measures of exercise capacity could reflect maximal capacity, peak capacity or functional exercise capacity measured by field walking tests including the 6-minute walk test (6MWT) or incremental shuttle walk test (ISWT). Where possible, the measure of effect was change from baseline value (post-program value – pre-program value). Post-program values were used if change values were not reported.

Search methods for Identification of Studies

Electronic searches of the following databases were undertaken: Cochrane Database of Systematic Reviews; MEDLINE; Embase; CINAHL (Cumulative Index to Nursing and Allied Health Literature); CENTRAL (Cochrane Central Register of Controlled Trials) and PEDro (Physiotherapy Evidence Database) (Supplemental Tables 1 and 2). Reference lists of included articles were reviewed. There were no limits on publication date prior to search execution on January 27, 2022 (English language only). Two co-authors (AB, MH) independently screened titles and abstracts, retrieved full-text publications and identified studies for inclusion. Discrepancies were resolved in consultation with a third co-author (AH).

Data Collection

Two co-authors (AB, CM) undertook independent data extraction including study characteristics (location and dates of data collection, design, inclusion and exclusion criteria, assessment timepoints), program features, participant characteristics and outcome data. Discrepancies were resolved in consultation with a third co-author (AH). Where necessary, data were extracted from published figures using automeris.io/WebPlotDigitizer/.

Assessment of Risk of Bias

Two co-authors (AB, CM) independently assessed risks of bias for each included RCT using the Cochrane Risk of Bias Tool.12 Discrepancies were resolved in consultation with a third co-author (AH). We assessed risks of bias according to the following domains: random sequence generation; allocation concealment; blinding of participants and personnel; blinding of outcome assessment; incomplete outcome data; selective outcome reporting; and other potential bias. Overall risk of bias was then determined for each study (low: all adequate; moderate: 1 inadequate or 2 unclear; high: >1 inadequate or >2 unclear).12

Risk of bias was assessed for non-randomized studies using the Standard Quality Assessment Criteria.13 These criteria incorporate study design, participant selection, allocation and blinding procedures, outcome measures, sample size, estimates of variance, confounding, reporting of results and evidence to support the conclusions. Each of 14 questions is scored according to criteria met (yes: 2 points; partial: 1 point; no: 0 points; N/A). The maximum score possible is 28, with scoring for each study calculated as a proportion of maximum possible accounting for the number of N/A items (28 minus [number of N/A × 2]). Two thresholds for study inclusion in systematic reviews have been proposed; 55% represents a liberal threshold and 75% represents a conservative threshold. We reported included studies against these thresholds, but due to the shortage of available data, thresholds were not used for study exclusion.

Where additional data were required to determine eligibility for inclusion or to facilitate analysis, the study authors were contacted.

Data Synthesis

If studies were clinical homogenous, then a pooled quantitative synthesis was to be undertaken. As the included studies were clinically heterogeneous, narrative synthesis was used. Data from RCTs and non-randomized studies were not combined for analysis. Data for the second program was analysed separately from that for subsequent programs. Where appropriate, the I2 statistic was to be used to measure heterogeneity (substantial statistical heterogeneity if I2 >50%).14

Subgroup Analysis

Pulmonary rehabilitation programs commenced following an exacerbation were to be analysed separately to those commenced in a stable clinical state.

Statistical Analysis

Where data were able to be combined for analysis, data were entered into Review Manager 5 (RevMan Version 5.4: Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) for calculation of mean differences (MD) and 95% confidence intervals (CI).


Search results

After removal of duplicates, 3036 records were screened, 14 records were reviewed in full text and 10 studies were included (11 reports). Two studies were excluded as data for the subset of participants with COPD were unavailable15,16 and one study had no evidence for repeated program17 (Figure 1). Meta-analysis was not possible due to study heterogeneity.

Figure 1 PRISMA flow diagram.

Abbreviation: COPD, chronic obstructive pulmonary disease.

Notes: Adapted from Page M, McKenzie J, Bossuyt P et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71. This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license creativecommons.org/licenses/by/4.0/.10

Study Characteristics

The 10 included studies collected data between 1996 and 2017. Three studies were undertaken in Australia,18–20 two studies were undertaken in Italy21,22 and one study each in Turkey,23 Canada,24 the United Kingdom,25 the United States26 and France.27 Three studies were prospective21,22,24 of which two were RCTs22,24 (Supplemental Table 3).

One RCT followed participants for 12 months after an initial (inpatient/outpatient) pulmonary rehabilitation program.24 Participants were monitored to identify development of an exacerbation and any who experienced such events were subsequently randomized to a repeat program or usual care. The remaining nine studies involved repeat programs during periods of clinical stability. Of these, another prospective RCT employed an inpatient pulmonary rehabilitation model delivered twice at 6- and 12-month intervals after the first program or once at 12 months following the first program.22 Seven studies involved outpatient programs,18–21,26 of which two were published as abstracts23,25 (Supplemental Table 4).

Of the eight observational studies, three studies reported outcomes for participants who had undertaken a first and second pulmonary rehabilitation program.20,23,25 Two studies reported outcomes for participants who did and did not repeat programs following the initial program, as well as outcomes for participants following the second18,26 and third programs.18 Three other studies reported outcomes for participants who undertook three19,27 and five programs21 (Supplemental Table 5). Time between the first and subsequent programs in retrospective studies varied from mean 17 (SD 6) months21 to 45 (24) months26 (Table 1).

Table 1 Overview of Time Frame and Reported Outcome Measures

Participant Characteristics

The included studies involved 907 participants with COPD of whom 653 had undertaken more than one pulmonary rehabilitation program (Table 1). The mean age of participants varied from 68 to 70 years, FEV1 ranged from 36% to 58% predicted, and proportion of participants who were female varied from 12% to 64% (RCT: Supplemental Table 5; non-randomized studies: Supplemental Table 6).

Reported Outcome Measures

The primary outcome measure of health-related quality of life was reported by seven studies, with four studies using the SGRQ19,21–23 and three studies using the CRQ18,24,25 (Table 1).

The secondary outcome measure of exercise capacity was reported by nine studies, with seven studies using the distance walked on the 6-minute walk test (6MWD),18–20,22,24,26,27 two studies using the distance walked on the incremental shuttle walk test (ISWD)23,25 and one study reporting peak workload.21 Hospitalization was reported by three studies21,22,24 and program adherence by two studies.18,26 No studies reported mortality or adverse events (Table 1). Additional data were sought and provided by corresponding authors for two studies19,23 and in two instances original data were available from previous co-author publications.18,20

Risk of Bias

Both of the RCTs were assessed as being at high risk of bias, due to the number of domains assessed as unclear (Supplemental Table 7).22,24

Of the remaining eight non-randomized studies, six studies met the liberal threshold of 55%18–21,26,27 reflecting a high risk of bias. Four studies that met the conservative threshold of 75%18,20,21,27 (Supplemental Table 8).

OUTCOME, Primary: Health-Related Quality of Life


In patients recovering from an exacerbation, no overall group × time effect in health-related quality of life was demonstrated comparing those who repeated a program (outpatient program n=7, inpatient n=9) to those who did not (n=17) (post-rehabilitation CRQ domain scores: dyspnea MD 0.4, 95% CI −0.5 to 3; fatigue MD −0.1, 95% CI −0.9 to 0.7; emotional function MD 0.2, 95% CI −0.6 to 1.0; mastery 0.6, 95% CI −0.2 to 1.4; follow-up scores: dyspnea MD 0.8, 95% CI −0.3 to 1.9; fatigue MD 0.5, 95% CI −0.4 to 1.4; emotional function MD 1.0, 95% CI 0.3 to 1.7; mastery MD 1.2, 95% CI 0.5 to 1.9) (Supplemental Figure 1).24

In stable patients, one RCT demonstrated significantly better health-related quality of life (SGRQ symptoms domain score MD −9, 95% CI −15 to −3) at 12 months in patients who had repeated pulmonary rehabilitation twice (n=14) compared to those who had repeated once (n=15); no between-group differences were demonstrated in SGRQ total (MD 1, 95% CI −4 to 6) or other domain scores (activity MD 0, 95% CI −7 to 7; impact MD −4 95% CI −10 to 2) (Supplemental Figure 2).22

Figure 2 Health-related quality of life in non-randomized studies: Change in St George’s Respiratory Questionnaire total score (3 studies). Data from [19,21,23].

Abbreviation: SGRQ, St George's Respiratory Questionnaire.

Notes: Data are mean difference ± 95% CI. *p < 0.05.

Non-Randomized Studies

One abstract (n=125) reported within-group improvements in CRQ total score following the first program (MD 16.4, 95% CI 19.9 to 12.9) and second program (MD 11.1, 95% CI 8.0 to 14.2). The observed improvement was greater following the first program (MD 5.3, 95% CI 0.92 to 9.6).25 One study demonstrated that first (n=46) and second (n=38) programs results in similar improvements in CRQ domain scores, with more variability demonstrated following the third program (n=6) (Supplemental Figure 3).18

Figure 3 Exercise capacity in non-randomized studies: Distance walked on the 6-minute walk test (5 studies). Data from [18–21,26].

Abbreviation: 6MWD, distance walked on the 6-minute walk test (meters).

Notes: Data are mean ± SD. * p < 0.05.

Three uncontrolled studies reported SGRQ before and after repeat programs (Figure 2).19,21,22 Clinically significant improvements were demonstrated for repeat programs, however two studies indicated larger gains following the first program when compared to subsequent programs.19,21 The proportion of patients attaining a clinically significant change in SGRQ score did not change across the study period: first program n=6 (12.5%); second program n=4 (8.3%); third program n=6 (12.5%); fourth program n=6 (12.5%); and fifth program n=7 (14.6%).21 Changes in SGRQ domain scores following each program are presented in Supplemental Table 9.

OUTCOME, Secondary: Exercise Capacity


In one RCT of patients recovering from an exacerbation, the difference in 6MWD was greater in those who repeated a program (outpatient program n=7, inpatient n=9) than those who did not (n=17) both immediately post program (MD 30m, 95% CI −36 to 96) and at follow-up (MD 56m (95% CI −21 to 133) (Supplemental Figure 4).24

In one RCT of stable patients, the difference in 6MWD between those who repeated pulmonary rehabilitation once (n=15) and those who had repeated twice (n=14) was MD 4m (95% CI −58 to 66) at 12 months (Supplemental Figure 5).22

Non-Randomized Studies

Six uncontrolled studies reported 6MWD for repeat programs.18–21,26,27 One study presented the within-program change in 6MWD for the initial program (mean 65m, SD 30, n=190), for the second program (mean 44m, SD 20, n=190) and for the third program (mean 55m, SD 58, n=62).27 Pre/post program 6MWD data are presented in Figure 3 for the remaining studies.18–21,26 All programs resulted in within-program improvements in 6MWD with smaller changes in 6MWD following repeat programs. Six studies reported differences in 6MWD outcomes between first and second programs ranging from no difference to 30 m less improvement on the second program.18–21,26,27 Four studies reported differences in 6MWD outcomes between the first and third programs ranging from 2 to 65 m less improvement on the third program.18,19,21,27 One longitudinal study also reported less improvement in fourth and fifth programs compared to the first program (Supplemental Table 10).21

Data for the proportion of participants who achieved the 6MWD MID following pulmonary rehabilitation programs were reported by five studies (Table 2).18,19,21,26,27 A range of threshold definitions were used. Results for studies using 25–35m thresholds demonstrated consistent results across second programs, with 61–67% of the participants achieving the MID.18,19,26,27 One study demonstrated that of the 41/190 non-responders to the initial program, 23 (56%) did respond to the second program and of the 149/190 responders to the initial program, 44 (30%) became non-responders in the second program.27 The study looking at five programs used a 54m threshold and demonstrated consistent results over the first three programs (31–33% achieving the MID) with a decrease evident in the final two programs (first vs fourth program 12.5%, p<0.01; first vs fifth program 14.6%, p=0.03).21

Table 2 Exercise Capacity in Non-Randomized Studies: Proportion of Participants Who Achieved the Minimal Important Difference in the Distance Walked on the 6-Minute Walk Test (5 Studies)

Two abstracts reported change in ISWD.23,25 Clinically significant improvements were demonstrated for repeat programs (MD 46m, 95% CI 9 to 83, n=14; MD 46m, 95% CI 36 to 56, n=125).23,25 Comparisons demonstrated no statistically significant difference between programs in one abstract (p=0.864)23 and a statistically significant decrease in change in ISWD following the second program in the other abstract (MD −18m, 95% CI −33 to −2)25; however, this is less than the MID.28

The study looking at five programs (n=48) demonstrated significant improvements in peak workload with each program with the exception of the fifth program (Supplemental Table 11).21 No significant decreases in post-program peak workload comparing the first program with the second program (MD-1 watts, 95% CI −8 to 6), third program (MD −1 watts, 95% CI −8 to 6), or fourth program (MD −5 watts, 95% CI −12 to 2). Comparing the first and fifth programs, a significant decrease in post-program peak workload was demonstrated (MD −13 watts, 95% CI −53 to −9).21

OUTCOME, Secondary: Hospitalizations and Non-Admitted Exacerbations


In the year following the initial program, there was no difference in the mean number of hospitalizations per participant for those who repeated pulmonary rehabilitation twice (at 6 and 12 months) compared to those who repeated once (at 12 months) (mean 1.0 (SD 0.8) vs 1.5 (1.1) hospitalizations, p=0.132).22 Results were similar for hospital length of stay (mean 14 (SD 9) vs 9 (8) days, p=0.122).22 Those who repeated once were significantly more likely to spend more than 10 days in hospital (n=12) than participants who repeated twice (n=5, p<0.001).22

Non-Randomized Studies

The study looking at five programs (n=48) demonstrated a significant reduction in the number of exacerbations and hospitalizations following repeat programs compared to the year before the first program, as well as a significant increase in the number of participants free from exacerbations and hospitalizations per participant per year (exacerbation: episodes not requiring hospitalization but requiring a change of usual medication and prescription of systemic steroids and/or antibiotics; Supplemental Table 12).21

OUTCOME, Secondary: Adherence


Nil data.

Non-Randomized Studies

Participants completed a similar number of sessions in the initial and subsequent programs. One study offering a 16-session program reported completion of median 12 (IQR 11 to 14) sessions in the initial program, median 13 (IQR 11 to 14) sessions in the first repeat program and median 14 (IQR 10 to 14) sessions in the second repeat program.18 One study offering a 24-session program reported completion of mean 21 (SD 6) sessions in the initial program and mean 22 (SD 6) sessions in the first repeat program.26


Current practice may incorporate repeating pulmonary rehabilitation according to clinical indication and personal factors20,29 but no systematic review of the effects of programs subsequent to an initial pulmonary rehabilitation program has previously been undertaken.

In patients following an exacerbation, a single RCT did not demonstrate any benefits of repeating pulmonary rehabilitation shortly after the exacerbation, in comparison to usual care.24 For stable patients, clinically meaningful benefits of repeating pulmonary rehabilitation were demonstrated, with one RCT suggesting that more frequent programs might have greater benefit (repeating twice in 12 months vs once in 12 months).22 Uncontrolled data suggest that the absolute magnitude of improvement in health-related quality of life may not be as large in repeat programs, as it is in the first, but benefits remain clinically meaningful. Important reductions in hospitalizations were also demonstrated with repeating pulmonary rehabilitation. Most studies were at high risk of bias which reduces certainty in these findings.

This review only identified one study that specifically assessed repeat programs following hospitalization.24 International guidelines recommend referral to pulmonary rehabilitation following an exacerbation2,30,31 with evidence for improvements in quality of life and exercise capacity as well as important reductions in hospital readmissions and mortality for patients who have had a hospitalization.4,32 Recent US data have further demonstrated that initiation of pulmonary rehabilitation within 3 months of hospital discharge was associated with significantly fewer hospital readmissions, shorter hospital stays and a lower mortality risk at 12 months.33,34 The well-documented benefits and the value placed on these benefits by people with COPD35 highlight the need for more evidence to inform this element of COPD management.

The aim of the other recommendation regarding timing for re-referral is to prevent decline in pulmonary rehabilitation outcomes.2 The data in this review reinforce that clinically important improvements can be achieved following repeat programs, even if the extent of improvement is less than that seen following the initial program. This review also identified important new preliminary evidence that people who were not identified as “responders” following the initial program were able to achieve clinically significant improvements following a second program.27 One study had previously demonstrated that gains in the CRQ mastery domain were greater following a repeat program relative to the initial program, and suggested that more time may be required to achieve gains, in mastery in this instance, relative to other outcomes.18 Therefore, patients who are not identified as “responders” following an initial program should be considered eligible for repeat programs.6

Participants do not respond uniformly to pulmonary rehabilitation,36 and the rate of decline in different outcomes following program completion varies.37 Current guidelines state that re-referral may be considered from 12 months following pulmonary rehabilitation1 but may be appropriate earlier in the case of clinical indication.6 Included studies that sought to repeat pulmonary rehabilitation at scheduled intervals following initial programs (6- and 12-months,22 12 months,27 12 to 18 months21) demonstrated benefits for health-related quality of life,22 consistent proportions of 6MWD responders across the first three programs21,27 and ongoing benefits in terms of reducing both exacerbations and hospitalizations over five programs.21 Whilst the amount and quality of data preclude firm conclusions, studies in this review do signal that there may be benefits to this approach.

A model of care to assist people with COPD to “maintain the gains” after they finish pulmonary rehabilitation remains elusive but important, particularly as people live for longer with COPD.38 This review excluded studies providing maintenance programs (ie, exercise training undertaken at a lower dose than the initial program and/or of an indefinite/ongoing nature). International statements and two systematic review have been unable to recommend any model of maintenance due to insufficient evidence of benefit.1,7,11,39 Despite this, significant clinical resources are devoted to maintenance programs and some patients may find them useful to maintain motivation for physical activity, and to access support from peers and health professionals.40 The data in this review illustrate the evolving body of evidence for an alternative approach of repeating pulmonary rehabilitation, and supports calls for access to repeat programs.8 However, resource reallocation would require more evidence not only for clinical measures but also incorporate the impact of repeat programs on outcomes such as healthcare utilization, for which hospitalization forms the bulk of direct medical costs.41 Reductions in total healthcare costs over 12 months have been associated with pulmonary rehabilitation completion,42 but there are challenges to designing sufficiently large and long prospective studies to capture the long-term data that are required to assess the costs and benefits of repeat programs over many years.

Limitations to this review include the small number of eligible studies; as a result, we elected to include two abstracts, and this represents a variation from our published protocol. The lack of data from prospective studies (total of 62 participants in two RCTs) and the high risk of bias seen in many of the included studies does limit the capacity to draw strong conclusions. Only participants with COPD were included, so the findings may not be extrapolated to other disease groups commonly referred to pulmonary rehabilitation. Included studies mirrored the real-world heterogeneity in pulmonary rehabilitation program format, staffing and resources,43 but this also precluded meaningful quantitative synthesis.


This systematic review provides limited evidence for benefits of repeating pulmonary rehabilitation in people with COPD, including improvements in health-related quality of life and exercise capacity, and reduced need for hospitalization. However, the majority of included studies were at high risk of bias. Future studies should investigate the optimal timing and frequency for repeat programs, and investigate the cost-effectiveness of this strategy.


CI, confidence intervals; COI, conflict of interest; COPD, chronic obstructive pulmonary disease; CRQ, Chronic Respiratory Disease Questionnaire; 6MWD, distance walked on the 6-minute walk test; 6MWT, 6-minute walk test; FER, forced expiratory ratio; FEV1, forced expiratory volume in one second; GOLD, Global Initiative for Chronic Obstructive Lung Disease; HRQoL, health-related quality of life; IQR, interquartile range; ISWD, distance walked on incremental shuttle walk test; ISWT, incremental shuttle walk test; MD, mean difference; MCID, minimal clinically important difference; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PROSPERO, Prospective Register of Systematic Reviews; RCTs, randomized controlled trials; SD, standard deviation; SGRQ, St George’s Respiratory Questionnaire.


The abstract of this paper was presented at the American Thoracic Society International Conference as a poster presentation with interim findings. The poster’s abstract was published in ‘Poster Abstracts’ in American Journal of Respiratory and Critical Care Medicine: www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2021.203.1_MeetingAbstracts.A4142

Author Contributions

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; Have drafted or written, or substantially revised or critically reviewed the article; Have agreed on the journal to which the article will be submitted; Reviewed and agreed on all versions of the article before submission, during revision, the final version accepted for publication, and any significant changes introduced at the proofing stage; Agree to take responsibility and be accountable for the contents of the article.


This work was supported by Institute for Breathing and Sleep Research Grant 2020. The funding body had no role in study design, study conduct or manuscript preparation.


The authors report no conflicts of interests in this work.


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33. Lindenauer P, Stefan M, Pekow P, et al. Association between initiation of pulmonary rehabilitation after hospitalization for COPD and 1-year survival among Medicare beneficiaries. JAMA. 2020;323(18):1813–1823. doi:10.1001/jama.2020.4437

34. Spitzer K, Stefan M, Priya A, et al. Participation in pulmonary rehabilitation after hospitalization for chronic obstructive pulmonary disease among Medicare beneficiaries. Ann Am Thorac Soc. 2019;16(1):99–106. doi:10.1513/AnnalsATS.201805-332OC

35. Zhang Y, Morgan R, Alonso-Coello P, et al. A systematic review of how patients value COPD outcomes. Eur Respir J. 2018;52(1):180222. doi:10.1183/13993003.00222-2018

36. Spruit M, Augustin I, Vanfleteren L, et al. Differential response to pulmonary rehabilitation in COPD: multidimensional profiling. Eur Respir J. 2015;46(6):1625–1635. doi:10.1183/13993003.00350-2015

37. Güell R, Casan P, Belda J, et al. Long-term effects of outpatient rehabilitation in COPD: a randomised trial. Chest. 2000;117(4):976–983. doi:10.1378/chest.117.4.976

38. James G, Donaldson G, Wedzicha J, Nazareth I. Trends in management and outcomes of COPD patients in primary care, 2000–2009; A retrospective cohort study. Prim Care Respir Med. 2014;24(1):14015. doi:10.1038/npjpcrm.2014.15

39. Jenkins A, Gowler H, Curtis F, Holden N, Bridle C, Jones A. Efficacy of supervised maintenance exercise following pulmonary rehabilitation on health care use: a systematic review and meta-analysis. Int J Chron Obstruct Pulmon Dis. 2018;13:257–273. doi:10.2147/COPD.S150650

40. Souto-Miranda S, Dias C, Jácome C, Melo E, Marques A. Long-term maintenance strategies after pulmonary rehabilitation: perspectives of people with chronic respiratory diseases, informal carers, and healthcare professionals. Healthcare. 2022;10(1):119. doi:10.3390/healthcare10010119

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Chronic pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage” [1]. The economic loss due to chronic pain in Japan is estimated to be 1,935 billion yen, and those with chronic pain reportedly experience high levels of psychological distress and a significantly low quality of life (QOL) [2]. Catastrophic thinking, anxiety, and depression have been reported as psychological factors that lead to chronic pain [3]. Therefore, the development of occupational therapy (OT) practices based on psychological factors in the area of chronic pain is urgently warranted.

Knee osteoarthritis (OA) is a disease that typically presents as joint pain, and total knee arthroplasty (TKA) has been shown to improve postoperative QOL [4]. However, it has been reported that approximately 20% of post-TKA patients develop chronic pain, which affects activities of daily living (ADL) and participation in social activities [5,6]. In the early postoperative period, pain mediates anxiety, and self-efficacy affects long-term postoperative life disorders. This suggests that interventions for pain, anxiety, and self-efficacy, within this time frame, are important [7]. Pain-catastrophizing, depression, and lower psychosocial QOL scores among patients who have undergone TKA are associated with the risk of severe pain [5]. Addressing catastrophic effects of pain on psychological aspects, ADL and QOL are therefore crucial.

In recent years, cognitive behavioral therapy (CBT) has been shown to be an effective intervention for pain and psychological disturbances, in patients with chronic pain [8]. Studies on postoperative patients with knee OA, including those who have undergone TKA, have reported improvement of pain and its psychological impact, by practicing OT using coping skills, which is one of the typical techniques of CBT [9]. In addition, there is a practical report that OT using coping skills was found to improve the Canadian Occupational Performance Measure (COPM), which is a measure of goal achievement [9]. Coping skills are described as “various efforts that individuals make to improve the unpleasant situation of pain” [9]. With respect to all of the above, it is evident that achieving appropriate pain management through effective coping skills, from the early postoperative period onward, can break the vicious circle of chronic pain, and lead to an improvement in QOL. However, in Japan, OT interventions that incorporate coping skills for post-TKA patients are not standardized. In addition, it is necessary to verify OT practices using coping skills in a case series format, first. Therefore, this study aimed to explore the effectiveness of incorporating coping skills in OT practices.

Materials and methods

Study Design

This study was a case series that assessed each evaluation index (COPM, pain, psychological factors; catastrophizing, anxiety, depression, self-efficacy, life disability, QOL), at the start and end of OT.

Ethical Considerations

All patients provided written informed consent to participate in the study. The study design was approved by the ethics review board of Fukuoka Rehabilitation Hospital (FRH-2020-R015).


Patients who underwent TKA from July 2020 to July 2021 at the institution were included in the study (Table 1).

Case Surgical side Sex Age Hospital stay Intervention period Discharge destination
A Right female 60 37 28 Home
B Left female 70 37 22 Home
C Right female 80 52 36 Home
D Right female 70 44 28 Home
E Left female 60 47 33 Home

Exclusion criteria included a diagnosis of dementia or mental illness (e.g., depression) that would interfere with the completion of the questionnaire, as well as refusal to participate in post-surgical rehabilitation. Additional exclusion criteria were postoperative complications (e.g., nerve injury or deep vein thrombosis), other significant medical diseases interfering with postoperative rehabilitation, previous TKA (e.g., TKA of the opposite limb or revision surgery), and TKA performed for causes other than degenerative diseases (e.g., rheumatoid arthritis or bone necrosis). The screening was performed by an orthopedic surgeon prior to surgery. The TKA surgeries were performed by four surgeons.

Postoperative Rehabilitation

Surgeries were performed under general anesthesia in all patients. All patients received nonsteroidal anti-inflammatory drugs (NSAIDs) (dose, 60 mg, three tablets per day) for two weeks, postoperatively. All patients followed the same physical therapy protocol after surgery. All patients began physical therapy on postoperative day 1, including knee range-of-motion exercises (flexion-extension) and stretching. Approximately 3 weeks post-operation, walking using a walker was started. Approximately 5 weeks postoperatively, walking with a cane or without assistance was possible, and the patient was discharged from the hospital. All physical therapy interventions lasted 40 min/day.


Overview of Occupational Therapy Practice

The American Occupational Therapy Association explained that, in OT for pain, one must “implement a self-management approach focusing on participating in daily life” (e.g., set goals for management), “set individual occupational therapy goals,” and start “activation of behavior,” and perform “home exercise” (e.g., management of pain at home) [10].

It has been shown that interventions for OT education, OT goal setting using COPM, and behavioral activation using an activity diary are also effective in Japan [11]. However, there are no reports on pain management at home, which is referred to as home exercise. Therefore, to promote participation in daily activities after discharge, we considered the importance of early pain management in the early TKA postoperative period and devised the following outline.

The treatment time was two sessions twenty minutes each (20 min × 2 units of 40 min). Movement practice was performed step by step, in consultation with the physical therapist, according to the movement form.

Interview Using COPM

The first interview was conducted using COPM, and emphasis was placed on creating an environment in which the interviewer could easily form sympathetic and supportive relationships with the patient while listening to them narrate details of their current pain and anxiety. Further, we listened to the background of the patient’s life before surgery (e.g., daily/weekly schedule, etc.) and determined the necessary activities they needed to fulfill after discharge. We proposed a coping list for the necessary activities needed upon discharge, for the achievement of goals (ADLs, instrumental ADLs, and return to work and applied movements), and for pain management. The coping list included those who had an agreement on introduction and research and those who had an intention to acquire coping skills. At the time of the first interview, measurements of numerical rating scale (NRS), Hospital Anxiety and Depression Scale (HADS), modified fall efficacy scale (MFES), Pain Disability Assessment Scale (PDAS), EuroQol-5-dimension-5-level (EQ-5D-5L), and EQ-5D visual analogue scale (VAS) were performed simultaneously.

Acquisition of Coping Skills

In the early stage of the OT practice, an interview using a coping list was conducted, in combination with OT centered on motion practice (mainly ADL practice, such as bathing motion and step practice), to promote an understanding of its use. We conducted a review to note additional coping skills for patients who could provide specific coping mechanisms. In addition, for patients who lacked specific coping skills, coping skills based on the patient’s hobbies and tastes, which stemmed from coping skills that had already been brought up (for example, coping skills such as “stretching the knees” “stretching the shoulders”), presenting a collection of coping tips, listening to the conditions of the previous day, and acquiring coping skills from pain-free movements and the activities performed during that time, were urged upon. After being given specific coping skills, the patients were recommended to increase the number of coping skills, themselves, for better self-management.

OT Self-management

After progressing to self-management, we reviewed the content that was tackled at the time of the intervention. During the intervention, in addition to ADL practice, instrumental ADLs (activities necessary for life after discharge; for example, cooking, cleaning, shopping, etc.), and outdoor walking practice were carried out, step by step, toward discharge. Finally, an interview using COPM was conducted at the time of the final intervention, an intervention in the form of coping skills was reviewed, and the OT was completed.

At this time, NRS, HADS, MFSE, PDAS, EQ-5D-5L, and EQ-5D VAS were also measured.


Canadian Occupational Performance Measure

OT sessions were performed using the COPM [12]. Using COPM, we recorded the top five patient goals and prioritized them according to their importance. Subsequently, for each goal, the degrees of performance and satisfaction were evaluated using the 10-case method, and the average value of each item was calculated. The patients also practiced movements involved in their ADLs and instrumental ADLs (including cooking, cleaning, shopping, etc.), which were important for achieving goals and enabling hospital discharge.

Coping Skills

Regarding coping skills, a coping list (Figure 1) was used [9]. A coping list is a tool that describes the kind of coping that should be used for pain and anxiety situations and the kind of results that were obtained. The total number of effective coping skills for the adopted coping was tallied.


An NRS was used to evaluate pain [13]. The 11-point scale ranged from a grade of 0, which corresponded to “no pain”, to 10, which corresponded to “unbearable pain”.

Anxiety and Depression

The HADS was used to evaluate anxiety and depression [14]. The HADS is a self-administered questionnaire and consists of 14 questions and two scales-one for anxiety and the other for depression. A score of 0 to 7 points is considered as “no anxiety/depression,” 8 to 10 points are considered “suspicious for anxiety/depression,” and 11 points or more is considered “confirmed anxiety/depression”.

Self-efficacy for Daily Life

The MFES was used to evaluate self-efficacy in daily life [15,16]. The MFES is a self-administered questionnaire that consists of 14 questions, including those on ADLs and instrumental ADLs. It was developed as a fall-evaluation tool for the elderly and is correlated with self-efficacy in daily life [15,16]. Each item can be given one of 11 ratings, ranging from 0 (“not confident”) to 10 (“completely confident”). Higher scores reflect a higher self-efficacy for daily life.

Disability for Pain

The PDAS was used to evaluate life disorders associated with pain [17]. The PDAS is a self-administered questionnaire used to measure life disorders associated with chronic pain. It is a four-case method consisting of 20 items, with each item graded from 0 to 3. Higher scores indicate stronger disabilities. The cut-off value was set at 10 points.


QOL was measured by the EQ-5D-5L questionnaire, which contains five questions with five responses for each question, and the total score is converted into the final EQ-5D value, ranging from 0.000 to 1.000; higher scores indicate a better QOL [18]. The EQ-5D questionnaire also includes a VAS, by which respondents can report their perceived health status with a grade ranging from 0 (the worst possible health status) to 100 (the best possible health status) [18].

Data analysis

Statistical analyses were performed using JMP software version 14.2.0 (SAS Institute Co.), Ltd, and descriptive statistics were used to describe the demographic data. Descriptive analyses were performed using mean, standard deviation, and frequencies. Pre-OT and post-OT data were compared in terms of outcomes (COPM, NRS, HADS, EQ-5D, EQ-5D VAS, MFES, PDAS) using the Mann-Whitney U test with JUMP 14.2.0 (SAS Institute Co., Ltd). The effect size (r) to describe the magnitude of the treatment effect was as follows: small, 0.10 to < 0.30; medium, 0.30 to < 0.50; and large, ≥ 0.50 [19].


The values of each evaluation index at the start and end of the OT are shown in Table 2. Significant improvements were observed in the COPM, NRS, HADS, PDAS, and EQ-5D-5L (P < 0.05) (Table 3). No significant improvement was found in the EQ-5D VAS and MFES scores. The effect size (r) of each evaluation was r ≥ 0.5, indicating a large effect size.

  Case A Case B Case C Case D Case E
  Pre-OT Post-OT Pre-OT Post-OT Pre-OT Post-OT Pre-OT Post-OT Pre-OT Post-OT
COPM-performance 1 8 5 7 3 10 2 10 1 8
COPM-satisfaction 1 8 5 7 3 10 1 10 1 8
NRS 5 0 4 1 6 1 7 1 10 4
HADS depression 5 2 5 3 9 1 12 0 11 2
HADS anxiety 5 4 4 3 4 1 9 4 9 3
EQ-5D 0.6 1 0.8 0.8 0.7 0.8 0.2 0.8 0.3 0.8
EQ-5D VAS 80 90 75 90 50 70 70 70 30 80
MFES 76 138 102 2 132 139 53 96 105 110
PDAS 28 6 34 28 16 4 13 5 40 13
Coping skill (number) 28 23 21 11 13
Job and role Farmer Housewife Housewife Housewife Housewife
Current anxiety Return to work Pain Pain Life after discharge Pain and gait
  Pre-OT Post-OT p-value Effect size (r)
COPM-performance 2.4±1.5 8.6±1.2 0.01** 1.2
COPM-satisfaction 2.2±1.6 8.6±1.3 0.01** 1.2
NRS 6.4±2.1 1.4±1.4 0.01** 1.1
HADS depression 8.4±2.9 1.6±1.0 0.01** 1.2
HADS anxiety 6.2±2.3 3±1.1 0.03* 1.0
EQ-5D 0.5±0.2 0.8±0.1 0.02* 1.1
EQ-5D VAS 61±18.5 80±8.9 0.14 0.7
MFES 93.6±27.0 118±17.4 0.12 0.7
PDAS 26.2±10.3 11.2±9.0 0.05* 0.9

In addition, the total number of coping skills that were effective for each patient increased (Table 4). All participants had positive feedback at the time of discharge.

Case A Case B Case C Case D Case E
Take a deep breath Taking medicine Icing Icing Icing
calm down Rehabilitation Be positive Taking medicine Talk about pain
Prepare Stretch Have a goal Hot pack l Contact with family
Disperse feelings Rest Rehabilitation TV set Medication management
Have room Icing Listen to music Eat sweets Be positive
Think good Looking out Relaxation Distract attention from pain Get sleep
Not think of anything Listen to music Walking Rehabilitation Blame someone
Distract attention Hot pack Medication management Stretch Talk to people
Relax Talk to the patient Talk to a nurse Take a break Eat what you like
Icing Phone with family Inhale the outside air Don’t think about pain Watch TV
Positioning Think about what you want to eat Strength training Encourage yourself Become defiant
Stretch Think about life after discharge To sew   Positioning
Strength training Schedule Take a bath   Ignore pain
Walking Talk to the therapist Stretch    
Sleep Write a diary Radio gymnastics    
Take medicine Look at the foliage plants Do yoga    
Gymnastics watch TV Phone with family    
Contact with family Drink coffee Talk    
Talk to other patients Fabric shaver Clean    
Write a diary Play a jigsaw puzzle Reading    
Tell a dream Walking Make accessories    
Talk to the therapist        
Looking out        
Relax your body        
Have a goal        
Exercise (stairs)        

Progress of OT among patients

The progress of patients in terms of coping skills is listed below.

Case A: Anxiety was noted for pain and climbing stairs. After acquiring coping skills, he was able to manage pain and climb stairs and was discharged from the hospital after acquiring a total of 28 effective coping skills and saying, “I have no particular anxiety.”

Case B: The patient was anxious about pain. After acquiring coping skills, pain management became possible. The patient said, “I’m glad that I felt like doing this in various situations,” and was discharged from the hospital after acquiring a total of 23 effective coping skills.

Case C: Anxiety about pain was noted. After the introduction, it was difficult to improve effective coping skills; therefore, in the first week of the intervention, we deepened our understanding of their use, mainly through interviews. Effective coping skills were mentioned on the 5th day. After that, the patient acquired a total of 21 effective coping skills, said, “I am looking forward to my future life,” and was discharged from the hospital.

Case D: Pain and anxiety in life after discharge were noted. After acquiring coping skills, the patient reported subsidence in pain, acquired 11 effective coping skills, and was discharged from the hospital.

Case E: The patient became inactive due to anxiety caused by pain and admitted that he wanted to be anesthetized to feel better, even for a day. Through the interviews, we encouraged the acquisition of coping skills through empathic and supportive relationships. After the introduction, he acquired 13 effective coping skills and said “I think I can live at home,” and was discharged from the hospital.

Occupational therapy practice using coping skills

In this case series, improvements in COPM, NRS, HADS, and EQ-5D-5L were observed in five post-TKA patients, by OT practice using a coping list. To the best of our knowledge, this is the first case series combining coping lists and OT practice, after TKA. In a study, Riddle et al. reported that the practice of incorporating coping skills was found to improve pain, living function, and catastrophic pain in post-TKA patients, after two months [20]. Furthermore, a significant improvement in physical function was observed, compared to patients in the control group [20]. Similarly, in this study, significant improvements in pain and living function were observed with OT practice incorporating coping skills.

In another cohort study, Riddle et al. presented a practical protocol based on previous studies, incorporating coping skills after TKA [20]. This study compared programs designed with a focus on general physical rehabilitation and pain coping, and the presented protocol included pain, physical function and activity, QOL, pain management, and psychological factors. From these studies, it may be considered that the practice of incorporating coping skills in OT can lead to improvements in pain, QOL, psychological factors, and so on. Additionally, in this study, pain, psychological factors, disability, and QOL were improved by acquiring coping strategies, using the coping list, and connecting them to self-management.

However, this intervention did not result in a significant improvement in MFES. It has been reported that higher levels of self-efficacy in acquiring coping skills result in a greater effect; thus, MFES plays an important role in coping with pain [8]. Our results can likely be explained by the fact that there were many cases in which the MFES score and self-efficacy were higher at the end than at the start of the intervention. It is probable that these results were obtained because they were practiced in cases where the intention to acquire one’s own coping skills was obtained at the introduction.

Clinical application

According to a survey conducted among elderly people with long-term pain, patients felt that they did not understand the pain, they were not interested in their own pain, and they gave up on the situation of pain [8]. Therefore, it is important to deepen relationships through goal setting and working together to solve problems [9]. It is expected that intervention using coping skills will lead to smooth goal achievement and improve pain management and QOL after discharge. However, since techniques involving self-management, such as coping skills, strongly reflect the will of the individual, it can be said that interventions for post-TKA patients who are not driven remain problematic.

Limitations and prospects of this research

Since this study was a case series (small sample size), the results cannot be generalized. In addition, the long-term effects are unknown because of the limitations of the OT practiced by the first author and the verification of short-term effects alone. Furthermore, because physical therapy and drug therapy are used in combination, the confounding effects of these cannot be completely eliminated.

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Physical illness has an emotional reaction such as anger, shock, denial or acceptance.

In most cases, the onset of a medical problem or condition has a range of underlying emotions. Illness imposes an impact on the person, moving from a place of freedom to a loss of control or to a type of confinement.

Rehabilitation is a course of therapy, a journey, to recover and return a person to her prior level of functioning, to the best of her abilities following an illness, surgery or injury. Unlike physical rehabilitation, where you are subjected to the manipulation of physical, occupational, respiratory or speech and language therapists; emotional rehabilitation is the strengthening of ones emotional ability to cope with a loss or change in their lives.

Working Through Loss

Emotional rehabilitation is a method of steps to work through the pain of loss and to return to a stable and healthy place.

A person must use the emotional muscles inside her heart and mind to help her get there and utilize resources to help move forward. As the individual builds her emotional core, she will also return to a stronger self– filled with determination, confidence and competence.

Emotional muscles are typically invisible. Other people have a spectrum of emotional use from poor to capable, with varying skills reflecting the different degrees of emotions, how they are processed and expressed.

In order to do emotional rehabilitation, one must be prepared and ready to process the pain and associated thoughts, typically ambivalent feelings. Some people have never had an opportunity to use these specific muscles because of their own past history and need to be taught how to identify their feelings and thoughts about themselves.

The 4 Ss in Muscle:

Stretch: Let yourself loosen up the feelings, give yourself permission to cry and get rid of the tension building up in your body. In essence your facial, neck, head, stomach and lung muscles get a work-out.

Slowly: One must not move too quickly or else will not really own the emotion, acknowledge and process the pain. One cant skip the process as the pain may return when one least expects.

Strengthen: Using various methods to improve ones emotional response to the loss is necessary in order to adjust ones thinking, feeling and insight. This approach takes practice, exercises and support to move forward.

Stronger: At the end of emotional rehabilitation, ones skills and abilities to cope will be improved. The outcome is improved positive self-regard and confidence. The emotions, attitude and behavior will be healthy and functional.

The process of rehabilitation takes into account the grief and mourning process. Grieving varies per person and stage per Kubler-Ross. The amount of time is dependent upon ones ability to process the intense uncomfortable feelings, bear them and then let go of the pain.

Mourning Well

Many people may be told to keep as busy as possible, yet that very action actually prolongs the grief process, as you will be repressing your feelings. In order to mourn well, one must consciously take the time to feel the pain and let it out in order to move forward.

Factors which impact the length of each Stage: 1. Age 2. Sex 3. The meaning of the relationship for the individual. How one defines the level of importance and significance for the one who is lost. 4. Length of time in the relationship. 5. The causes of the end in the relationship. 6. Past ability to cope with loss and change. 7. Resources and supports available. 8. Self-awareness or cognitive awareness of where one is the continuum of grief.

Stage 1: Acute Injury This period occurs when you made a decision to end a relationship or it was made for you. How you say goodbye depends upon your personal preference, maturity, intellectual and emotional strength.

Where one lives in relationship to the person you lost plays a factor in perception, attitude and actions.

Ending a relationship in person provides a greater sense of self-respect, acknowledgment and control.

Pain has multiple effects on people. Everyday actions may be altered, such as thinking and concentration, sleeping and eating. Emotions continue to change and can take on the following: numbness, intense pain, sorrow, grief, regret, disappointment, and anger.

The ability to tolerate the variety and ups and down of pain varies per person. This intense period of time can last from 24 hours and up to a few weeks or months; depending upon the extent of the relationship and meaning associated with the person.

Others may have thoughts to end the suffering by getting back together with the person because the pain is seen as intolerable, and if a persons internal resources are poor, think of suicide.

Stage 2: Active Grieving

The process of rehabilitation occurs when one is cognizant that he is purposefully working through each wave of grief. He recognizes that the intensity is not as intense, the crying bouts not as frequent and the black cloud is lifting. The emotional waves affect the muscles and one has to re-learn how to stabilize the ups and downs.

Memories attach themselves to ones emotional self. A different emotional work-out schedule is to be planned–rehabilitation. Re-strengthening your emotional muscles takes effort and determination and time. Reminding oneself that there are waves and it is normal to feel good and bad is vital to assist in coping.

However during this phase its important to recall the issues which led to this point. It is important to note that this stage is not time specific. It is necessary to focus ones personal needs to move forward by learning or continuing to nurture the self; this is not selfish.

Emotional Rehabilitation Methods:

A. Journal, with a specific identified task, for instance: Why the relationship ended, what are the changes I see in myself, today, yesterday, last week, etc? Writing a letter to the person (but not sending it) is therapeutic and may even hasten the process.

B. Talk with close trusted friends, family and if needed, a therapist.

C. Develop or return to an exercise program.

D. Work or return to work.

E. Return to or start a hobby, for instance, paint.

F. Connect with others spiritually, physically, intellectually, emotionally and socially.

Stage 3: Emotional Rehabilitation Maintenance: Emotional stability occurs when one notices that his thoughts are clear, positive, feel relief and contentment. Laughter, enjoyment, and fun return as a result of removing the weight or burden from the heart, thoughts and body.

People will feel they are themselves once again. At this point in emotional rehabilitation, there might be brief periods of time that regression occurs. We learn from our experiences and our self-awareness grows as we become more aware of ones needs, strengths and weaknesses.

  • Identify positive self-affirmations and practice writing and saying them to ones self.
  • Meditate or do yoga.
  • Identify stress reducing and relaxation activities.
  • Find opportunities for emotional, spiritual, vocational and physical growth and take steps toward doing these activities.

Emotionally you are not yet ready to let go and move forward until you have completed the rehabilitation process. The wave in adjusting to the loss will diminish as your muscles are used effectively. The end of a relationship, regardless of the type and length of time, has as its goal to disentangle and uncouple from the painful loss toward connection and stabilization.

Recognizing that you are moving forward is freeing and powerful. Once your emotional muscles are strengthened, you will feel more like your old self and think, Im back to myself. Emotional rehabilitation is complete when the heart muscles are calm and at peace.

Sad woman photo available from Shutterstock

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Coronavirus disease 2019 (COVID-19) high-risk survivors experience long-term COVID-19 symptoms. Hence, these individuals require early and ubiquitous respiratory rehabilitation to avoid malnutrition. We report the case of a 93-year-old woman who recovered from moderate II severity (pneumonia requiring oxygen). The patient, after prolonged hospitalization, demonstrated low severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infectivity and showed no COVID-19 respiratory symptoms for more than 72 hours. Subsequently, the patient became debilitated and lost her appetite without dysphagia, dysgeusia, and smell disorder, developed nosocomial pneumonia as a sequela of acute COVID-19 and died. We also report the second case of an 84-year-old man diagnosed with moderate II COVID-19 severity. After recovery, the patient was frail due to the previous onset of COVID-19 and worsened during his stay at home, losing appetite without dysphagia, dysgeusia, and smell disorder, and dying of senility as the official cause. Recovered COVID-19 appears to be a health risk by malnutrition without anorexia and depression, among other conditions. A proven rehabilitation program for each phase of the disease is required for better lung function and nutritional status.


Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has overwhelmed the world. The mortality rate of coronavirus disease 2019 (COVID-19) is lower than that of Severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome coronavirus (MERS-CoV). In contrast to the influenza virus, SARS-CoV-2 has infectivity before symptoms arise in addition to clinical presentation, and symptoms are more severe [1]. Asymptomatic infectious cases spread around public spaces. The effective prevention measures practiced thus far include social distancing, hand hygiene implementation, and vaccination. Several COVID-19 waves identified high-risk factors, such as high body mass index, advanced age, and immunocompromised history. These high-risk survivors experience long-term COVID-19 symptoms, including low activities of daily living (ADL), deteriorating lung function, and malnutrition. Moreover, diffuse alveolar-damaged COVID-19 lungs are not easily recovered; thus, early and ubiquitous respiratory rehabilitation is required because there are several COVID-19 cases with damaged lungs [2]. I investigated how researchers consider malnutrition as a COVID-19-related sequela.

Here, I describe two low ADL COVID-19-related deaths due to appetite loss without dysphagia, dysgeusia, ageusia, infectivity, and cytokine storm formation.

Case Presentation

First case

A 93-year-old woman was exposed to a nursing home COVID-19 cluster. She had a history of hypertension, heart failure, and aortic valve stenosis. Her body temperature (BT) increased to 38 °C on April 17, 2021. After the patient took acetaminophen several times, her BT decreased to 37 °C 3 days after COVID-19 onset. On April 19, 2021, the patient’s SARS-CoV-2 antigen test was positive. Her SARS-CoV-2 polymerase chain reaction (PCR) test was also positive the next day. Upon admission to our hospital, the patient’s clinical status was as follows: oxygen saturation (room air), 86%; lactate dehydrogenase (LDH), 504 U/L; C-reactive protein (CRP), 11.2 mg/dL; and procalcitonin, 0.34 ng/mL. Her chest computed tomography image was compatible with COVID-19 (Figure 1a), and she was diagnosed with moderate II COVID-19 severity (pneumonia requiring oxygen) as Japanese severity criteria [3]. Mechanical ventilation as a treatment option was discussed with her family because our hospital did not have mechanical ventilation support for COVID-19. The patient’s family agreed to oxygen administration using a non-rebreather mask preferring it over invasive therapy. The patient’s oxygen saturation increased to 92% (using a 4-L mask), and from the next day of admission, the patient received remdesivir for five days and dexamethasone (6.6 mg per day for 10 days), based on our hospital protocol for moderate II severity disease, to suppress diffused alveoli damage and cytokine storm caused by the virus. Atrial fibrillation was noted, and bisoprolol was started to control the patient’s heart rate. Some studies reported the incidence of venous thromboembolism by autopsy in patients receiving bisoprolol, but the patient, in this case, did not receive anticoagulants. There was no evidence that the benefits outweighed the risks at that time, and even low-molecular-weight heparin was considered off-label use [4]. Because the patient had no appetite, she was under fasting and received fluid therapy.

At the end of April, her BT returned to normal (37.0 °C), antibiotics were discontinued, and no pathogenic bacteria were detected in the sputum. Based on health center criteria, our hospital protocol considered the patient as not having infection anymore as no COVID-19 respiratory symptoms were registered for more than 72 hours; moreover, her Charlson comorbidity index was 2 (medium). The patient resumed eating and had no dysphagia, dysgeusia, or smell disorder, but gradually she had loss of appetite again; although she was bedridden, respiratory rehabilitation was not possible owing to budget issues. In May, attempts were made to transfer the patient to several supporting hospitals; however, the target hospitals declined the patient because they did not have a negative-pressure isolation room or already had full occupancy. On June 1, 2021, the patient’s BT increased again. Because more than 10 days had passed after the patient’s COVID-19 onset, it was assumed that her SARS-CoV-2 infection was diminished and that her increased BT was due to COVID-19 secondary pneumonia (Figure 1b). The potential diagnoses were aspiration pneumonia, organizing pneumonia, and drug-induced interstitial pneumonia. The possibility of aspiration pneumonia was low because her appetite was poor and a high-calorie infusion from the central vein was administered in a fasting state. Moreover, organizing pneumonia after COVID-19 is rare [5]. Finally, interstitial pneumonia could not be excluded even if she did not experience diffused alveolar damage [6]. Therefore, the patient was thought to have experienced lung dysfunction by SARS-CoV-2 infection. Because the patient had negative SARS-CoV-2 PCR results on June 10 and 11, her transfer to a supporting hospital was stopped and she was transferred to our general intensive care unit (ICU) instead. Two negative PCR results were convincing for the ICU staff. The patient’s blood and sputum cultures were negative. After ceftriaxone (1 g q12h) was administered, as our antibiotic stewardship team suggested, ceftriaxone was changed to meropenem (1 g q8h). Her general condition worsened despite providing intensive supportive care and antibiotics, and she experienced disseminated intravascular coagulation. She subsequently died on June 21, 2021. The cause of death was secondary pneumonia induced by lung dysfunction as a long-term COVID-19 symptom. The patient did not spread SARS-CoV-2 in the general ward or ICU and did not receive physical rehabilitation for breathing or swallowing training.

Second case

An 84-year-old man had a history of hypertension and atrial fibrillation, and he took only antihypertensive medications daily, and his Smoking Brinkman Index was 200. The patient experienced fatigue on August 14, 2021, and visited our hospital on August 16. Subsequently, SARS-CoV-2 antigen result was positive, but chest radiography did not reveal any sign of pneumonia. The patient did not complain of any dyspnea or other respiratory symptoms and had a strong appetite; therefore, the health center categorized him in the mild group (symptoms without pneumonia and hypoxia), and stayed at home for home isolation. On August 21, the patient revisited our hospital complaining of shortness of breath and appetite loss. Chest radiography revealed bilateral infiltration shadows compatible with COVID-19 (Figure 2a) but no evident limb edema. A cardiac ultrasound test was not performed because of the risk of infection. The patient’s parameters were as follows: BT, 36.5 °C; oxygen saturation, 81% (room air); LDH, 257 U/L; CRP, 13.77 mg/dL; D-dimer, 4.14 𝜇g/mL; and procalcitonin, 0.39 ng/mL. He was hospitalized as a moderate II COVID-19 severity patient and received mask oxygenation instead of noninvasive positive-pressure ventilation.

High flow nasal oxygen cannula therapy was not administered because of our limited COVID-19 care unit facility. On the hospitalization day, the patient received remdesivir for five days, dexamethasone (6.6 mg per day for 5 days), and tocilizumab (400 mg) once based on our hospital protocol for moderate II COVID-19 severity. The patient gradually recovered and was transferred to the general ward for more than 10 days after COVID-19 onset as he was not considered contagious anymore. The Charlson comorbidity index was 3 (high) and PCR results were not requested as there was no infection risk. Chest radiography revealed decreased bilateral infiltration shadows with peripheral reduced permeability (Figure 2b), the brain natriuretic peptide (BNP) level was 180 pg/mL, and the oxygenation level returned to normal. Due to long-term bed-bound impairment of ADL, bedside rehabilitation was started, but ADL gradually worsened. To recover from malnutrition, the patient’s appetite was restored; however, because of low consciousness, the food and water intakes were not sufficient, leading to fluid therapy (500 ml per day). The patient did not complain of dysphagia, dysgeusia, or ageusia, and a transfer attempt to a supporting hospital was unsuccessful. The patient died on September 17, and his death was considered due to senility; therefore, an autopsy was not performed.


This case report highlights complications regarding after-care recovery from acute COVID-19. The first issue is the fear of SARS-CoV-2 infection to others. Researchers reported that patients’ infectivity without symptoms is already diminished 10 days after COVID-19 onset, suggesting that patients who recover after 10 days from the disease onset can be transferred to support hospitals. Several supporting hospitals were consulted for rehabilitation; however, despite the fact that the patient recovered from superinfection by bacteria after other virus infections and two rounds of PCR gave negative results, the fear of nosocomial infection was sufficient to deny the transfer. Similar to other countries, COVID-19 isolation rooms were limited in Japan. Therefore, the patients were transferred to our general ward, where personal protective equipment (PPE) was not required. COVID-19 requires isolation in a single room and prohibits going out of the room. In this case, the lack of isolation led an ambulant elderly person to become bedridden and malnourished.

The second issue is that COVID-19 can induce long-term malnutrition and multiple organ damage. During COVID-19-related isolation, general rehabilitation is rare because physical therapists refuse to provide rehabilitation in our region due to various reasons. Multiple organ failure is a sequela of COVID-19 [7]. Moreover, COVID-19 can severely impair pulmonary diffusion capacity imaging manifestations even six months and one year later, has been reported as a future risk factor for pulmonary fibrosis, and can cause residual ground-glass opacities, consolidations, reticular and linear opacities, and parenchymal fibrotic bands in the long term [8]. The time course of COVID-19 lung imaging is currently under investigation; however, COVID-19 can also injure neurons connected to the peripheral respiratory receptors [9].

Some reports have shown better results of early rehabilitation with PPE [10]. However, not all institutions are using PPE because rehabilitation with PPE requires tremendous medical resources. Some hospitals, including ours, do not have sufficient physical therapists for both breathing and swallowing training. Therefore, our human medical resources were limited despite guideline recommendations. Patients with COVID-19 require long-term follow-up due to long-term damage to multiple organs, and rehabilitation after recovery from COVID-19 in the elderly is still effective and improves lung function. Specialized personalized rehabilitation for respiratory, physical, and psychological long-term dysfunction caused by COVID-19 is required [11].

In Japan, in April 2021, two consecutive negative PCR results without the occurrence of symptoms for at least 72 hours, at least 10 days from disease onset, were required for discharge. In April 2021, 8 of 17 beds in the COVID-19 ward of our hospital were occupied in a city housing 63,000 people. The first case was suitable for transfer in June 2021. The government-approved supporting hospitals in our city were already full because other elderly (non-COVID-19) patients needed to stay in hospitals because of low ADL, suggesting that they could not leave the hospital. This was considered one of the reasons for delayed rehabilitation. COVID-19 occurs in cycles, acutely increasing maintenance costs for every hospital. Earlier transfer to supporting hospitals may improve ADLs and lower mortality rates through conventional rehabilitation.

COVID-19 induces damage to multiple organs, suggesting a higher risk of death after recovering from COVID-19 [12]. Our second patient died of being senile resulting from frailness, which started during hospitalization. Several studies have reported the increased risk of frailness from similar aspects: 1) Loss of appetite and sarcopenia induced by frailty is defined as declined muscular function in the presence of muscle loss. The COVID-19 pandemic makes it mandatory for elderly people to “stay at home,” leading to frailty [13]. 2) Social distancing and staying home reduce physical activity and increase other unhealthy lifestyle habits such as loneliness or malnutrition [14]. 3) Poor health after COVID-19 is associated with mortality risk that is independent of respiratory function [15]. Moreover, a meta-analysis concluded that frailty was significantly associated with an increased risk of adverse clinical events (all-cause mortality) [16] The Clinical Frailty Scale (CFS) is a quick and reliable screening tool used to evaluate frailty, and regular home exercises are recommended to prevent frailty [17]. Unfortunately, the Charlson comorbidity index and CFS were not commonly used in our hospital.

We could not properly treat malnutrition in the cases described owing to a lack of rehabilitation and monetary resources. To the best of our knowledge, the effect of direct rehabilitation in improving the simple loss of appetite without dysphagia, dysgeusia, or ageusia in COVID-19 is unknown. It is worth considering whether rehabilitation helps restore appetite as sequelae precisely.


COVID-19-related death appears to include a health risk after recovery. Early active physical therapy is not common in some hospitals, but it should start from the hospitalization day and continue during the isolation period. Researchers still produce inconsistent results regarding the COVID-19 sequelae care study. Evaluation of simple appetite loss is not well investigated. Further studies by researchers should focus on evaluating each study for real-world applicability to improve ignored malnutrition.

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Physical Rehabilitation Network Acquires Gillette Physical Therapy

Carlsbad, Calif., June 08, 2022 (GLOBE NEWSWIRE) -- Physical Rehabilitation Network (“PRN”), a leading U.S.-based owner-operator of nearly 200 outpatient physical therapy clinics, today announced its entrance into Wyoming with its acquisition of Gillette Physical Therapy (“Gillette PT” or “GPT”), which operates one outpatient clinic in the Gillette community. “We are pleased to welcome the team at Gillette PT and broaden our footprint in the Mountain West region,” said Ajay Gupta, CEO, PRN. “Wit

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According to health experts, as high as 50% of people hospitalized due to COVID-19 have experienced its long haul effects.

Herbosa said there is no treatment available yet for the weakness for cases of long COVID. “So your performance level, if you’re an athlete, it will definitely affect your performance level in whatever sport you are performing.”

Rehabilitation — physical and pulmonary — may help patients improve their body functions. For those with pulmonary fibrosis, there are also medicines that work by preventing the regeneration of fibroblast in the lungs.

Health Undersecretary Leopoldo Vega, the country's treatment czar, also suggest patients with long COVID may benefit from doing simple exercises such as walking, and getting proper sleep and nutrition. He also suggested doing mental exercises such as playing chess. Listening to classical music and meditation could also help their minds relax.

This is why her doctor advised Bethel Guansing to take daily walks at least 30 minutes each morning, a practice she continues to this day.

With pride evident in her voice, Bethel shared that the 30-minute walks have increased to over an hour.

“The doctor said this was good news. Sometimes I try to run. I remained fine. I didn’t really have difficulty breathing.” Not a beat later, Bethel corrected herself, “I had trouble breathing, but it wasn’t that bad.”

Her pulmonologist Dr. Jubert Benedict advised her to do breathing exercises to help with this struggle. “I just talked to her and asked her to focus on what she can do. Celebrate the small victories,” he told GMA News Online.

Meanwhile, Año is still undergoing therapy for his left arm, which became “frozen” after being inserted by an intravenous (IV) to his heart for months.

He recalled not being able to dress up on his own and even had to have his polo shirts customized with a zipper on the sides just so he could wear them.

He said he has also been doing stretching exercises and undergoing physical rehabilitation twice a week.

Like the soldier that he was, Año is back on his feet, doing activities like trail walking and golfing, but with more caution now considering his long battle with COVID-19. He has also returned to his post as the DILG secretary, serving out his remaining months in office before the term of President Rodrigo Duterte ends on June 30.

In January 2022, he contracted the virus anew amid the more transmissible Omicron variant surge. But unlike his first two infections, Año was in much safer hands in his third bout with COVID-19 as he was already fully vaccinated.

Limpin believes this is best way to avoid getting long COVID. “The one big way or the big and effective, preventive, management of long COVID will be to get vaccinated. Because the vaccine will prevent severe COVID,” she said.

Herbosa echoed this, adding that it is indeed vital to get the anti-COVID jabs, especially among children and adolescents so as to prevent the long COVID’s “lifetime effect.”

Both doctors already warn that long COVID may have a longterm impact not just on individuals, but on the country’s productivity and workforce. The Philippines’ has tallied nearly 3.7 million COVID-19 infections at the end of May.

“Among these post-COVID cases, many are 65 years old, but we also saw many who are still young and yet continue to have persistent symptoms,” Limpin said.

“IIf you have a workforce that has a chronic illness, that has chronic COVID or long COVID, what will happen is they will be in and out of the hospital. Number two, they cannot function as an individual of that same age,” Herbosa added.

Based on the NTF’s latest report, at least 64 million Filipinos are now fully vaccinated against COVID-19, while 11 million individuals have received booster shots or additional doses.

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Orthopedic surgery is a field of surgery whose objective is to solve various disorders of the skeletal and locomotor system or lessen your symptoms. The problems it treats usually affect mainly the bones, cartilaginous structures or joints.

Thus, there are numerous injuries in which orthopedic surgery is used, which can be divided according to the parts of the body they affect. Thus, for example, in the feet, orthopedic surgery is performed on metatarsalgia, valgus of the big toe, pes cavus, flat feet and hammer toes.

In the case of people with hand injuries of the scaphoid rupture type, carpal tunnel injury, De Quervain’s syndrome, thumb osteoarthritis (rhizarthrosis), stenosing tenosynovitis (snapping finger), can also resort to this specialty to solve their problem.

if we talk knee, are the operations of the meniscus or ligaments and osteoarthritis of the knee the most common; While in the shoulder is the rotator cuff; and in the hiphip osteoarthritis.

Within orthopedic surgery, emergency surgery It is considered a subspecialty. In this case, it is a type of surgery that deals with the emergency treatment of patients with traumatic injuries.

Regarding the convenience of contacting an orthopedist in cases of the aforementioned pathologies, on many occasions it can be highly recommended for the patient, since it will be this professional who will assess the need or not for a surgical intervention.

The fact that this specialist is also a surgeon makes it possible for him to resort to the intervention directly when he deems it appropriate.

Sport practice

Many times, traumatology and orthopedic surgery are specialties that walk hand in hand.

They range from clinical assessment, diagnosis, prevention, treatment by surgical means and adequate rehabilitation to the care of patients with congenital and acquired diseases, deformities and traumatic and non-traumatic functional alterations of the musculoskeletal system and its associated structures. .

Based on this, the practice of sports and its relationship with medicine have attracted the attention of many professionals towards traumatology and orthopedic surgery.

While is true that many orthopedic surgeons are drawn to sportsit should be clear that these professionals deal with more than just sports injuries.

Specifically, yeswith specialists seeking to restore normal function to a deformed, diseased, or injured part of the musculoskeletal system, and methods of physical rehabilitation.

For his part, heSports medicine is the medical specialty that studies fitness to practice sport, working both on the prevention and treatment of pathologies derived from its practice.

Thus, this specialty is responsible for the care, advice, diagnosis and treatment necessary to play sports safely.

But, to understand sports medicine, it is best to know the disciplines on which it is based.

The first is the prevention and treatment of injuries related to the practice of any of the sports disciplines, as well as the cControl and monitoring of your performance and the treatment of diseases such as hypertension, diabetes, obesity, heart disease with the prescription of physical exercise.

Another of the key aspects after a sports medicine treatment is that which has to do with the rehabilitation of injuries or interventions.

In this recovery process, postoperative physiotherapy plays a fundamental role in the recovery of a patient after surgery.

Regarding its benefits, it should be noted that it accelerates recovery after surgical interventions, which is why there are many doctors and surgeons who prescribe rehabilitation after a postoperative period.

Between the Advantages of going to a physiotherapista, specialists point to a risk minimization and faster recovery.

In addition, postoperative physiotherapy works on mobility and flexibility. Although not all postoperative procedures are the same, in almost all of them you have to rest.

Thus, postoperative physiotherapy sessions are aimed at retraining the mobility of the intervened areawith exercises scheduled according to the patient and with the appropriate rhythm for an effective recovery.

Another advantage of going to a physiotherapist during a rehabilitation process is that the techniques applied can calm postoperative pain.

In fact, the General Council of Colleges of Physiotherapists of Spain (CFCFE) recalls that physiotherapy is an essential discipline in the physical and emotional recovery of patients with postoperative pain. Its application has a significant improvement in patients with minor surgeries and in patients with long-term operations.

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Thrive Spine & Sports Rehab is a sports rehabilitation center located in Jersey Shore, NJ. They offer multiple services to help their clients relieve any physical ailment they may have. Their services are aimed not only at athletes but at anyone who needs physical relief.

Thrive Spine and Sports Rehab Center in Jersey Shore, NJ is a sports recovery center that offers various services to relieve and rehab physical stress. It is located in New Jersey and provides services to state residents. The center uses a combination of chiropractic care, physical therapy, and acupuncture.

Thrive Spine & Sports Rehab can offer patients sports recovery services with lasting effects. They use a unique approach that combines many functional techniques for physical care. The highly trained staff at Thrive Spine is dedicated to providing each patient with individualized care to achieve the best possible outcome.

At Thrive Spine & Rehab, athletes can find services tailored to their different physical rehabilitation needs. Their acupuncture services are perfect for looking for a natural way to achieve pain relief. Our acupuncture services offer many benefits for breathing and stress relief.

For athletes who need more hands-on care, the chiropractic services at Thrive Spine & Rehab are perfect. The chiropractors use various techniques to help patients find relief from pain, tension, and stress.

The physical therapists at Thrive Spine & Sports Rehab are highly experienced in helping athletes recover from various injuries. They offer a wide range of services to help athletes get back to their sport as soon as possible.

At Thrive Spine & Sports Rehab, you can also find cryotherapy services. This is a new and innovative way to help the body recover from strenuous activity. Cryotherapy helps to reduce inflammation and pain, which can speed up the healing process.

Thrive Spine & Rehab uses the latest technology and most efficient technique to offer their patients the best possible care. Their experience guarantees all the treatments will protect your body and health. Thrive Spine & Sports Rehab is dedicated to helping its patients find relief and achieve their physical goals.

If you are looking for a sports recovery center that offers various services, Thrive Spine & Sports Rehab is the perfect place for you. Their unique approach to care can provide you with lasting relief from your pain and stress. Contact Thrive Spine & Sports Rehab today to learn more about their services or schedule an appointment. thrivespineandsportsrehab.com/

About Thrive Spine & Sports Rehab

Thrive Spine & Sports Rehab is a sports rehabilitation center located in Jersey Shore, NJ. They offer multiple services to help their clients relieve any physical ailment they may have. Their services are aimed not only to athletes, but to anyone who needs physical relief.

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Whether you're obviously deconditioned after a lengthy hospitalization or coping with more subtle effects of a seemingly 'mild' COVID case, it can be challenging. Experts weigh in on what COVID-19 recovery involves.

Recovery from COVID-19 can continue for many weeks or even months after the infection passes. Whether you’re obviously deconditioned after a lengthy hospitalization or coping with more subtle effects of a seemingly ‘mild’ case, it can be challenging.

Restoring muscle mass and strength, physical endurance, breathing capacity, mental clarity emotional well-being and daily energy levels are important for former hospital patients and COVID long-haulers alike. Below, experts weigh in on what COVID-19 recovery involves.

Comprehensive Recovery Plan

Individual recovery needs vary depending on the patient and their COVID-19 course. Major health areas that are frequently affected and must be addressed include:

Strength and mobility. Hospitalization and virus infection itself can erode muscle strength and mass. Immobility from bedrest in the hospital or at home can be gradually reversed.

Endurance. Fatigue is a huge problem with long COVID, requiring careful activity pacing.

Breathing. Lung effects from COVID pneumonia may persist. Medical treatments plus physical therapy can improve breathing.

Functional fitness. When activities of daily life like lifting household objects are no longer performed with ease, function can be restored.

Mental clarity/emotional equilibrium. So-called brain fog makes it hard to work or concentrate, and the effect is real, not imaginary. Going through a serious illness, prolonged hospitalization and persistent health problems is upsetting. Support from therapy helps.

General health. The pandemic too often overshadowed concerns such as cancer care, dental checkups or routine screenings, but overall health issues also require attention.

[See: Mind-Blowing Benefits of Exercise.]

Strength and Mobility

When the muscular-skeletal system takes a hit from COVID-19, it reverberates throughout the body. “Muscle plays a critical role,” says Suzette Pereira, a muscle health researcher with Abbott, a global health care company. “It accounts for roughly 40% of our body weight and is a metabolic organ that works other organs and tissues in the body. It provides nutrients to critical organs during times of illness, and losing too much can put your health at risk.”

Unfortunately, without intentional focus on muscle health, muscle strength and function can drastically deteriorate in COVID-19 patients. “It’s a Catch-22,” says Brianne Mooney, a physical therapist at the Hospital for Special Surgery in New York City. She explains that lack of movement significantly exacerbates muscle loss, while movement can feel impossible with the energy-draining disease. To make matters worse, muscle atrophy increases fatigue, making movement even less likely.

Patients can lose up to 30% of muscle mass in the first 10 days of intensive care unit admission, research shows. Patients hospitalized due to COVID-19 are usually in the hospital for at least two weeks, while those who go into the ICU spend about a month and a half there, says Dr. Sol M. Abreu-Sosa, a physical medicine and rehabilitation specialist who works with COVID-19 patients at Rush University Medical Center in Chicago.

[Read: Telemedicine Explodes to the Forefront Amid COVID-19.]

Maintaining Muscle Strength

Even in the best of conditions, for those experiencing strong COVID-19 symptoms, it’s likely that some muscle loss will occur. However, patients can greatly influence the degree of muscle loss and, in mild cases, may be able to maintain muscle health, says Mooney, a member of the team that created the Hospital for Special Surgery’s COVID-19 nutritional and physical rehabilitation guidelines.

These strategies can help protect muscle, strength and overall health during recovery:

— Move as you’re able.

— Add resistance.

— Prioritize nutrition.

Move as you’re able

“The sooner you move, the better,” Abreu-Sosa says, explaining that, in the hospital, the COVID-19 patients she works with have three hours of physical therapy five days per week. “Here in the hospital, we are starting exercise even on the day of admission if vitals are stable. Even in patients who are intubated, we work on passive raise of motion, raising their arms and legs and positioning muscles.”

Once home, Mooney recommends people get up and move every 45 minutes or so. Walking, performing acts of daily living like bathing and dressing as well as structured exercises such as cycling and squats are beneficial.

“Any physical activity should be based on symptoms and current levels of function,” she says, explaining that the goal is to engage the muscles of the body without exacerbating any symptoms. Fatigue, shortness of breath and dizziness are all cause to stop exercise.

Add resistance

When integrating movement into your recovery routine, prioritize resistance-based exercises that challenge your body’s largest muscle groups, Mooney recommends. She says that completing three 15-minute workouts per week is a great starting point, and patients can increase frequency and duration as recovery progresses.

Take special care to focus on the hips and thighs as well as back and shoulders, as these muscle groups tend to lose the most strength in COVID-19 patients and have wide-reaching effects on the ability to stand, walk and perform everyday tasks, Abreu-Sosa says.

To strengthen the lower body, try exercises such as squats, glute bridges and side steps. For the upper body, incorporate row and shoulder-press variations. Your body weight, light dumbbells and resistance bands all make great at-home resistance gear, Mooney says.

Prioritize nutrition

“Protein is needed to build, repair and maintain muscle, but also to support the production of antibodies and immune system cells,” Pereira says. Unfortunately, protein intake is often lower than it should be in COVID-19 patients. “Aim for 25 to 30 grams of protein at every meal if possible, by eating meats, eggs and beans or using an oral nutrition supplement,” she recommends.

Vitamin A, C, D and E and zinc are critical to immune function, but they also play a role in both muscle health and energy, Pereira says. She recommends incorporating milk, fatty fish, fruits and veggies and other plants like nuts, seeds and beans into your recovery diet. If you have trouble cooking for yourself at home, consider trying out healthy meal-delivery services to help you get a wide range of nutrients.

[READ: COVID-19 and Hearing Loss.]


Pushing through fatigue and weakness can be counterproductive when you have long COVID. Respecting post-COVID fatigue is part of the path to recovery.

Excessive Fatigue

Fatigue is among the top symptoms that brings patients seeking physical therapy to the Johns Hopkins Post-Acute COVID-19 Team, says Jennifer Zanni, a cardiovascular and pulmonary clinical specialist at Johns Hopkins Rehabilitation at Timonium, in Maryland. “It’s not the type of fatigue necessarily that you’d see with someone who’s just become deconditioned or who has lost all this muscle strength,” she says. “It’s just symptoms that limit their ability to do their normal daily activities — their school or work activities.”

Pacing Yourself

A little too much activity can bring on disproportionate tiredness for people with post-COVID malaise. “Our treatment has to be very individualized to the patient, for example, if a patient presents and has what we term ‘post-exertional malaise,'” Zanni says. That, she explains, is when someone does a physical activity like exercise or even just a mental task like reading or being on a computer, and it causes fatigue or other symptoms to become much worse in the next 24 or 48 hours.

“If a patient has those types of symptoms, we have to be very careful about how we prescribe exercise, because you can actually make someone worse,” Zanni says. “So we may just be working on pacing and making sure they get through daily activities, like breaking things up into smaller tasks.”

What felt like a short, easy jaunt before COVID-19 can become a major stressor, patients may say. “It could be something small, like they walked a mile and can’t get out of bed for the next two days — so, way out of proportion to the activity,” Zanni says. “But it’s just like their available energy is very limited and if they exceed that it takes a long time to recover.”

Just as you do with money, spend your valuable energy wisely. By learning to pace yourself, you may prevent utter exhaustion from setting in.


Respiratory complications like pneumonia can have long-term breathing effects. In addition, Abreu-Sosa notes that in the treatment of COVID-19, doctors sometimes use steroids with patients, as well as paralytic agents and nerve blocks in those requiring ventilators, all of which can speed muscle breakdown and weakness. In COVID-19 patients, this deterioration even includes the respiratory muscles that control inhalation and exhalation.

Breathing exercises are a standard part of recovery. A patient booklet created by Zanni and colleagues early in the pandemic outlines movement recovery phases. “Breathe deep” is the message in terms of breathing. Deep breathing restores lung function by using the diaphragm, the booklet notes, and encourages a restoration and relaxation mode in the nervous system.

Beginning phase. Practice deep breathing on your back and on your stomach. Humming or singing incorporate deep breathing, as well.

Building phase. While sitting and standing, consciously use deep breathing while placing your hands around the side of your stomach.

Being phase. Deep breathe while standing and throughout all activities.

Aerobic training, such as sessions on a treadmill or exercise bike, is part of a comprehensive approach to building breathing capacity, overall fitness and endurance.

As the pandemic wore on, it became clear that persistent lung problems can complicate long-term recovery plans. “I do have some patients with ongoing lung problems, just because having COVID has caused some damage in their lungs,” Zanni says. “That can be very slow to resolve or in some cases permanent. Some patients need oxygen for a period of time. It just sort of depends how severe their illness was and how well they recovered.”

Rehab for a patient whose lungs are compromised takes a multidisciplinary approach. “We’re working with the physicians from a medical standpoint to optimize their lung functions,” Zanni says. For instance, she says, that could mean patients are using inhaler medication to allow them to exercise. “We also exercise in ways that they can tolerate. So if someone is having more shortness of breath, we may begin exercise more with interval training, meaning short periods of exercise with little rest breaks.”

Functional Fitness

Performing everyday tasks you used to take for granted, like walking downstairs or lifting household objects, is part of functional fitness. So is having the energy and ability to do your job.

For many employees, traditional expectations of working intently for hours on end are no longer realistic as they continue to recover from COVID-19.

After the initial bout with COVID-19, returning to work can be surprisingly difficult. “For a lot of people, work is challenging,” Zanni says. “Even sitting at a computer may not be physically taxing, but it can be cognitively taxing, which can (cause) just as much fatigue sometimes.”

Functional training allows people to return to meaningful activities in their lives, not just by building strength but also by using their bodies more efficiently. Learning proper movement patterns and strengthening key muscle groups can help restore balance and agility, coordination, posture and power to participate in family gatherings, outdoor activities like hiking or work routines such as sitting and working on a computer.

However, it may be impossible for some employees to resume normal work duties as usual. “Some people aren’t able to work at all because of their symptoms,” she says. “Some people are having to adjust their work schedules or work from home. Some people don’t have the ability to not work — they’re working but almost every day they’re going through their available energy, which is a tougher scenario.” That can be a challenge for many people who don’t have the luxury of not working or at least taking a break when they need one, she notes.

Some long-COVID care providers may help educate patients’ employers, for instance sending letters to inform them about long COVID, so they can better understand potential health effects and be more accommodating when needed.

Mental/Emotional Equilibrium

A well-rounded team of health care providers will ensure that your recovery plan is individualized, comprehensive and holistic, incorporating physical and mental health. As part of that, Zanni notes that many patients who are seen at the Hopkins PACT clinic receive screening for psychological and cognitive issues.

In a rehab bonus, patients have the opportunity to realize they’re not alone. Otherwise, it can be discouraging when employers, friends or even family members question whether you’re really still weak, tired or mentally or emotionally struggling when you know that’s truly the case. Part of long COVID rehab is receiving support and belief.

“A lot of my patients would say just having someone validate what they’re experiencing is probably a big thing,” Zanni says. “Because a lot of symptoms are what people are telling you and not what a lab test is showing.”

Zanni and colleagues see patients both as outpatients at the clinic or through telehealth, which can make access easier. Increasingly, medical centers are offering post-COVID programs for those with lingering issues. Your primary care provider may be able to recommend a program in your area, or you can check with local medical centers.

General Health

It’s important to keep in mind that a new health problem or symptom may be caused by something other than COVID-19. Multidisciplinary communication is crucial when patients are evaluated for long-COVID rehab, Zanni says.

With physical or cognitive changes, functional issues or symptoms of fatigue, clinicians must rule out non-COVID possibilities. As always, cardiac, endocrine, oncology or other pulmonary conditions can cause a multitude of overlapping symptoms. All this speaks to having good access to medical care, Zanni says, and the need for a thorough evaluation rather than just saying: This is all long COVID.

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Update 04/29/22: This story was previously published at an earlier date and has been updated with new information.

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When a traumatic injury occurs to the spinal cord, a significant amount of risk is present. A person may experience a loss of function of their limbs. In other cases, they may have extensive pain and limited mobility. A spinal cord injury may be noted as the presence of a bruise. In other cases, a true tear of the cord can also occur. The location of this injury and the severity of it can lead to numerous changes in a person’s mobility.

What Are the Consequences of Traumatic Spinal Cord Injuries Like This?

In some situations, a person may lose partial or full loss of feeling. They may lose all control in their arms. Sometimes, it may affect both the arms and the legs. In some situations, a person may develop difficulty with blood pressure management. They may have intense breathing conditions. Other times, bowel and bladder control becomes difficult.

Why Do Spinal Cord Injuries Occur?

These types of spinal cord injuries can happen to anyone. However, they are particularly common in people between the ages of 16 and 30. They are also more common in males. This may be because of the activities those in this population of people engage in.

This type of trauma can occur from a variety of incidents, though it is typically the result of a major impact, such as in a car accident. It may also occur when there is a fall or some type of act of violence. Sports injuries can also cause it if it is hit at just the right level or position.

In all situations, when this type of accident or incident occurs, the first step is to protect a person’s life. The second step is to help encourage healing of the area through a recovery of system function. Initial treatment for any of these injuries may involve surgery to create spine stability. There may also be the need to use breathing controls.

Treating the Long-Term Effects

Because of how many types of injuries can occur with spinal cord trauma, the type of treatment needed can differ from one person to the next quite extensively. Dr. Sean Ataee MD provides some insight into how a rehabilitation program is created for those who have this condition. 

“In most cases, the physiatry team works to determine the best type of rehabilitation for a person with this condition. They collect information to determine how the injury occurred and the severity of it, and then create a program that aims to improve, whenever possible, the functions that the individual has lost.”

In many cases, the initial examination by the physical rehabilitation team provides good insight into what the person’s long-term recovery may be. However, there is no way to know fully what to expect from this process. Each person may heal in their own way.

What Is the Goal of Rehabilitation?

After an injury like this, especially one that leads to a significant limitation on movement, the goal of rehabilitation is always the same. It is to improve the quality of life of an individual. While full recovery may not always be an option, there may be other steps these providers can offer that may help improve the overall quality of life of that individual, such as giving them more control over the daily activities of living.

There are a few key things that rehabilitation specialists may use to help improve outcomes for patients.

  • Patient and family education: By providing families with a better understanding of the spinal cord injury and its severity, they are more prepared to handle the changes to daily life that may need to occur. Education about the injury can be complex since many of these injuries are quite difficult themselves.
  • Improve function: The next primary goal of rehabilitation is to improve the function of any limitations a person has to the best of their ability. There is always a focus on improvement whenever that improvement is possible and is the desire of the individual. Improving function may not mean healing the problem fully but getting a person to the best level possible.
  • Returning a person to the community: The goal is not to remain in rehab long-term. Rather, it is to get a person capable of returning to the community and their life as much as possible. This may include the use of assistive devices or significant changes within their home. It may mean learning new ways of accomplishing tasks.

Each person’s needs are different. However, patients and families receive the level of support they need. For example, they may need to learn prevention of further injury by utilizing safety methods and taking new precautions. Others may need to gain support for performing bowel and bladder changes and how to improve outcomes.

There is often the inclusion of physical and occupational therapy as well. 

Many people with spinal cord injuries need to have a wide range of tools and techniques used to help them reach the best possible outcome. Yet, recovery often depends on the severity of the injury. The improvement a person sees in the first six months is often very important in gauging patients’ long-term outcomes.

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Houston, TXApex Physical Rehabilitation & Wellness is offering professional, well-researched, and evidence-based approaches to physical therapy in Houston. Their services include physical therapy, aquatic therapy, and spinal decompression. The clinic’s physical therapy services consist of functional capacity testing, vestibular rehabilitation therapy, balance and proprioception testing and training, and fall risk assessment and prevention. Apex Physical Rehabilitation & Wellness treats various conditions that require physical therapy. Some examples include neck, shoulder, elbow, and wrist pain, hip, knee, foot, and ankle pain. They also provide therapy for orthopedic-related dysfunction and postoperative rehabilitation. Their evidence-based approach to physical therapy has integrated their services with the best available evidence, clinical expertise, and patient values. This approach is also inclusive of client management, practice management, and health policy decision-making.

Apex Physical Rehabilitation & Wellness has a team of trained and experienced licensed physical therapists who provide services to patients. They use modern methods, techniques, and technologies in the delivery of their Houston physical therapy services. The clinic’s representative had this to say about their services, “Our focus is the resolution of chronic and acute injuries through detailed physical therapy evaluation and various modes of evidence-based treatment in Houston, Katy, and Sugar Land. We provide exceptional care in a friendly and professional manner and maintain the highest standards with regard to the application of evidence-based information. We strive to acknowledge, understand, and respond to our patient’s distinctive needs; while providing clinically superior service at a fair price, measuring our success in the trust we build with our patients and referring physicians.”

The evidence-based approach used by Apex Physical Rehabilitation & Wellness incorporates the values and needs of patients to increase patient satisfaction. The clinic’s well-researched methods ensure that their patients get the most advanced treatment approved in the industry. They also use advanced techniques and technologies to improve patient outcomes. Apex Physical Rehabilitation & Wellness has a portfolio of diverse services which ensure that each client gets services well-suited for their health needs. Their staff is well experienced in the provision of all general and specialized services they offer, which is essential for patient safety, reliability, and accountability.

Apex Physical Rehabilitation & Wellness offers other services like constellations. The clinic provides patients with an assessment of their injury or condition and recommendations for the treatment that is best suited for them. They also provide work health services that offer solutions to injured workers through prevention, management, treatment, and case closure. Their work health services include functional capacity evaluation, work conditioning or hardening, injury prevention, and endurance training.

Apex Physical Rehabilitation & Wellness is located at 2323 S Voss Rd #600, Houston, TX, 77057, USA. For consultation and booking, contact their staff by calling 832-299-1947. Visit the company website for more information on their evidence-based physical therapy services.

Media Contact

Company Name
Apex Physical Rehabilitation & Wellness
Contact Name
Amir Kazemi
2323 S Voss Rd #600
Postal Code
United States

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