Millions of Americans of all ages suffer from post-COVID-19 condition, or long COVID. In fact, recent data show that the condition is affecting more than 16 million working-age Americans and is keeping between two and four million of them out of work completely.

According to the World Health Organization, long COVID occurs when an individual continues to suffer from prolonged symptoms of the virus at least 3 months after initial onset. Common symptoms include difficulty thinking or concentrating, sleep trouble, dizziness, headaches, fatigue, brain fog and more. In many cases, these symptoms prove to be debilitating and result in significant health and quality of life issues.

Health care professionals around the globe are working tirelessly to understand, diagnose. and treat long COVID. While there is no single treatment that has been approved to completely rid those with long COVID of their symptoms, a growing body of clinical research supports the potential of a specific hyperbaric oxygen therapy (HBOT) protocol to become part of the standard of care for the condition. A breakthrough randomized controlled trial on use of the protocol for symptom management was published in Scientific Reports in July.

The study was conducted by the Sagol Center for Hyperbaric Medicine and Research at Shamir Medical Center in Israel, known for its pioneering research on novel indications of hyperbaric medicine for cognitive and physical rehabilitation. The cohort was comprised of 73 participants with reported long COVID cognitive symptoms. To study the effectiveness of the HBOT protocol in treating these individuals, patients were randomly assigned to either a treatment or placebo (sham) group. The unique treatment protocol was comprised of 40 daily HBOT sessions, 5 sessions per week.

The randomized, double-blind, placebo-controlled clinical trial demonstrated that HBOT, when used in a specific protocol was effective at improving symptoms of long COVID. Participants showed significant improvement in global cognitive function, energy, sleep, psychiatric symptoms, and pain interference. Participants in the control group did not exhibit these same improvements.

The study revealed that HBOT can induce structural and functional repair of damaged regions of the brain and improve cognitive, behavioral, and emotional function of patients with long COVID conditions.

Further analysis of the brain network activity of those patients was published in the journal Neuroimage: Clinical and shed additionallight on how COVID can disrupt the normal functionality of the brain. Moreover, the study shows that in post-COVID-19 patients, HBOT improves disruptions observed in white matter tracts (neuronal fibers) and alters the functional connectivity organization of neural pathways attributed to cognitive and emotional recovery.

While HBOT has been used for centuries, this new study indicates that utilizing a specific protocol involving oxygen fluctuation in a multiplace chamber can induce neurogenesis, neuronal stem cell proliferation, increased blood flow, and neuroplasticity. HBOT involves breathing 100% pure oxygen while in a controlled hyperbaric chamber. The air pressure inside is elevated above normal to help the lungs collect more oxygen and more effectively deliver that oxygen to damaged tissues, thus expediting the healing process. Deliberate fluctuations of oxygen levels during each HBOT session work to induce the hypoxia inducible factor, increasing vascularization and promoting angiogenesis in damaged brain tissues.

The specific HBOT protocol studied here is in use for treatment of the symptoms of long COVID at Aviv Clinics through an exclusive partnership with the Sagol Center. The partnership allows Aviv clinics in Florida and Dubai to use the protocols, evaluation methods, and treatments used in the Scientific Reports study. Patient assessment includes high resolution brain imaging to identify damage in the brain caused by the SARS-CoV-2 virus. When combined with the results of intensive cognitive, physical, and nutritional assessments, these scans allow a multidisciplinary team of clinicians to develop a customized treatment program to help each patient.

Shai Efrati, MD, is founder and director of the Sagol Center for Hyperbaric Medicine and Research at Shamir Medical Center, Be'er Ya'akov, Israel, where he also serves as director of research and development and head of nephrology. Efrati’s research focuses on novel aspects of hyperbaric medicine and brain rehabilitation. He is a professor at the Sackler School of Medicine and the Sagol School of Neuroscience in Tel Aviv University. Since 2008, he has served as Chairman of the Israeli Society for Diving and Hyperbaric Medicine.

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Eden Private Hospital delivers comprehensive rehabilitation programs.

Eden Private Hospital is the Sunshine Coast’s longest operating private rehabilitation facility, with 48 dedicated medical, rehabilitation and mental health beds.

Eden Private Hospital delivers comprehensive rehabilitation programs to both inpatients and outpatients, that are tailored to the patient’s specific needs and goals, and managed by a multidisciplinary team of allied health professionals under the care of a rehabilitation consultant.

Their experienced staff work together to help patients regain strength and cardio fitness, balance and mobility as well as redevelop skills and ultimately function with the highest possible level of independence and confidence.

Each program includes an individual consultation followed by physical rehabilitation and education sessions that are structured around the health diagnosis and patient goals. The programs are typically run twice a week, over a six week period and the duration of the programs can vary.

The programs offered which patients can be referred into include:

– Orthopaedic.

– Neurological.

– Reconditioning.

– Pain.

– Cardiac rehabilitation.

– Cancer rehabilitation.

– Falls prevention.

– Pulmonary rehabilitation.

– Robotic assistive therapy.

How to be referred

Eden accepts referrals from general practitioners, specialists and surgeons, and public and private hospitals. You would simply need to see your GP or specialist and ask for a referral to be sent to Eden Private Hospital and the admissions and assessment team will be in contact with you once received.


Eden Private Hospital has agreements with most private health funds as well as tier one provider status with the Department of Veteran’s Affairs. The outpatient allied jealth team also conducts sessions under Medicare’s enhanced primary care program for physiotherapy, exercise physiology and occupational therapy.

For further support in navigating your care or to utilise this service as either an inpatient or outpatient, or to learn more about Eden Private Hospital, please contact the admissions and assessment team on 1800 333 674 or visit

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  • The physical rehabilitation market in India largely comprises of geriatric care, restorative care and pain relief.
  • An estimated 35-40% of the physical rehab spend in India is concentrated in the top 10 cities.
  • Restorative care comprises 28% of the physical rehabilitation market in India.

India’s physical rehabilitation market is expected to grow by 15.5% to become a $35 billion market by FY28, according to a report by Redseer Consultants.

Currently, it’s a $17 billion market and covers – restorative care that includes recovery after critical health conditions like a complex surgery; geriatric care that includes services and products for the elderly; and pain-relief via physiotherapy for arthritis, injury and more. Both at-home and at-centre care are included here.

“Rehab is rapidly evolving and today transition care centres and out-of-hospital care providers can address a wide range of patient requirements from basic to complex or critical care,” says Vivek Srivastava, CEO of HCAH India, an out-of-hospital patient care provider.

According to Redseer’s Rehab Tech report, lack of awareness, sparse availability and limited capabilities of rehab providers are currently restricting the usage of rehab, despite its strong need.

The report says that the potential for growth comes from the fact that an estimated 35-40% of the physical rehab spend in India is concentrated in the top 10 cities – Delhi NCR, Hyderabad, Bangalore, Mumbai, Kolkata, Chennai, Pune, Kochi, Coimbatore and Indore.

Physical rehabilitation care in India:

Segment Market value in India Description
Restorative care $5 billion Recovery from critical health conditions, post-surgical care
Geriatric care $5 billion Medical care to optimise functioning in elderly people
Pain relief $3-4 billion Physiotherapy-led care in non-critical conditions such as arthritis, injuries and lifestyle related pains
Others $3 billion

Source: Redseer Rehab Tech Report

Physical rehab market an attractive business opportunity

Not only is physical rehab a large opportunity, it is also an attractive business proposition. In the case of restorative care, which comprises 28% of the total market, the gross margins are at 50-55% for the service provider, as per the report.

Moreover, this is a high-value service. A consumer recovering from a critical surgery spends anywhere around $650-700 or ₹50,000 for 12 days of care.

It’s also a scattered and an unorganised market. While hospitals dominate the critical, restorative rehab segment, local providers lead the geriatric and pain-relief segments.

“Both of them aren’t able to aptly serve the consumer needs. Despite providing a standard service, consumers find rehab at hospitals to be expensive and lacking a recovery-focused environment. While local players are more affordable, they lack the basic quality and professionalism in service and have limited ability to address complex situations,” said the report.

Redseer also believes that there is a strong case for specialised players who employ technology to solve these pain points. Consumers also have a latent need related to the ease of availing rehab – booking, customisation, care plan management, remote monitoring etc.

"Elders are consuming more technology, are using tech devices, buying online, and want more safety, more healthcare, and more engagement than ever before", says Saumyajit Roy, CEO, Emoha, an eldercare facility in India.

Kushal Bhatnagar, engagement manager at Redseer, believes that players with a stronger tech enablement are better placed to thrive in the market. “Specialised rehab providers with wide segment coverage have access to a larger total addressable market (TAM) and potential to create a stronger brand in the rehab space among both consumers and doctors,” he added.

Redseer also believes that specialised rehab players with cross-segment coverage, both at-home and at-centre capabilities, and tech focus, are likely to prosper.

SEE ALSO: A startup that could ‘either be a hero or zero in 2 years’ get no funds on Shark Tank India S2
From selling puran poli on a bicycle to being offered seat at Shark Tank: Bhaskar’s Puranpoli Ghar’s story

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Patients with acute decompensated heart failure who were frail at baseline improved more with targeted, early physical rehabilitation than those who were prefrail, a new analysis of the REHAB-HF study suggests.

"The robust response to the intervention by frail patients exceeded our expectations," Gordon R. Reeves, MD, PT, of Novant Health Heart and Vascular Institute in Charlotte, North Carolina, told | Medscape Cardiology. "The effect size from improvement in physical function among frail patients was very large, with at least four times the minimal meaningful improvement, based on the Short Physical Performance Battery (SPPB)."

Furthermore, the interaction between baseline frailty status and treatment in REHAB-HF was such that a 2.6-fold larger improvement in SPPB was seen among frail vs prefrail patients.

However, Reeves noted, "We need to further evaluate safety and efficacy as it relates to adverse clinical events. Specifically, we observed a numerically higher number of deaths with the REHAB-HF intervention, which warrants further investigation before the intervention is implemented in clinical practice."

The study was published online January 4 in JAMA Cardiology.

Interpret With Caution

Reeves and colleagues conducted a prespecified secondary analysis of the previously published Therapy in Older Acute Heart Failure Patients (REHAB-HF) trial, a multicenter, randomized controlled trial that showed that a 3-month early, transitional, tailored, multidomain physical rehabilitation intervention improved physical function and quality of life (QoL) in comparison with usual care. The secondary analysis aimed to evaluate whether baseline frailty altered the benefits of the intervention or was associated with risk of adverse outcomes.

According to Reeves, REHAB-HF differs from more traditional cardiac rehab programs in several ways.

  • The intervention targets patients with acute HF, including HF with preserved ejection fraction (HFpEF). Medicare policy limits standard cardiac rehabilitation in HF to  long-term patients with HF with reduced ejection fraction (HFrEF) only who have been stabilized for 6 weeks or longer after a recent hospitalization.

  • It addresses multiple physical function domains, including balance, mobility, functional strength, and endurance. Standard cardiac rehab is primarily focused on endurance training, which can result in injuries and falls if deficits in balance, mobility, and strength are not addressed first.

  • It is delivered one to one rather than in a group setting and primarily by physical therapists who are experts in the rehabilitation of medically complex patients.

  • It is transitional, beginning in the hospital, then moving to the outpatient setting, then to home and includes a home assessment.

For the analysis, the Fried phenotype model was used to assess baseline frailty across five domains: unintentional weight loss during the past year; self-reported exhaustion; grip strength; slowness, as assessed by gait speed; and low physical activity, as assessed by the Short Form-12 Physical Composite Score.

At the baseline visit, patients were categorized as frail if they met three or more of these criteria. They were categorized as prefrail if they met one or two criteria and as nonfrail if they met none of the criteria. Because of the small number of nonfrail participants, the analysis included only frail and prefrail participants.

The analysis included 337 participants (mean age, 72; 54%, women; 50%, Black). At baseline, 57% were frail, and 43% were prefrail.

A significant interaction was seen between baseline frailty and the intervention for the primary trial endpoint of overall SPPB score, with a 2.6-fold larger improvement in SPPB among frail (2.1) vs prefrail (0.8) patients.

Trends favored a larger intervention effect size, with significant improvement among frail vs prefrail participants for 6-minute walk distance, QoL, and the geriatric depression score.

"However, we must interpret these findings with caution," the authors write. "The REHAB-HF trial was not adequately powered to determine the effect of the intervention on clinical events." This plus the number of deaths "underscore the need for additional research, including prospective clinical trials, investigating the effect of physical function interventions on clinical events among frail patients with HF."

To address this need, the researchers recently launched a larger clinical trial, called REHAB-HFpEF, which is powered to assess the impact of the intervention on clinical events, according to Reeves. "As the name implies," he said, "this trial is focused on older patients recently hospitalized with HFpEF, who (compared to HFrEF) also showed a more robust response to the intervention, with worse physical function and very high prevalence of frailty near the time of hospital discharge."

"Never Too Old or Sick to Benefit"

Commenting on the study for | Medscape Cardiology, Jonathan H. Whiteson, MD, vice chair of clinical operations and medical director of cardiac and pulmonary rehabilitation at NYU Langone Health's Rusk Rehabilitation in New York City, said, "We have seen in clinical practice and in other (non–heart failure) clinical areas that frail older patients do improve proportionally more than younger and less frail patients with rehabilitation programs. Encouragingly, this very much supports the practice that patients are never too old or too sick to benefit from an individualized multidisciplinary rehabilitation program."

However, he noted, "patients had to be independent with basic activities of daily living to be included in the study," so many frail, elderly patients with heart failure who are not independent were not included in the study. It also wasn't clear whether patients who received postacute care at a rehab facility before going home were included in the trial.

Furthermore, he said, outcomes over 1 to 5 years are needed to understand the long-term impact of the intervention.

On the other hand, he added, the fact that about half of participants were Black and were women is a "tremendous strength."

"Repeating this study in population groups at high risk for frailty with different diagnoses, such as chronic lung diseases, interstitial lung diseases, chronic kidney disease, and rheumatologic disorders will further support the value of rehabilitation in improving patient health, function, quality of life, and reducing rehospitalizations and healthcare costs," Whiteson concluded.

The study was supported by grants from the National Key R&D program. The authors have disclosed no relevant financial relationships.

JAMA Cardiol. Published online January 4, 2023. Abstract

Follow Marilynn Larkin on Twitter: @MarilynnL.

For more from the | Medscape Cardiology, follow us on Twitter and Facebook.

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Cambridge, UK: Michael Parr of Elementary Health has been trained and certified in The Schroth Best Practice Program. Thanks to his specialised training in Scoliosis, the smart and friendly osteopath has assisted many patients suffering from back pain, fatigue, difficulties optimising breathing patterns, and poor posture (among others). And considering each patient is unique, the consulting osteopath offers an individualised treatment plan.

The first step in the treatment is consultation and diagnosis. Michael Parr of Elementary Health checks the cause of Scoliosis from a wide range of issues, neurological abnormalities, structural abnormalities, asymmetry, and aberrant global movement patterns. He also checks whether the patient has signs of neuromuscular, idiopathic, or congenital Scoliosis. With the individualised diagnosis, the professional can make key decisions, such as whether to use spinal manipulation, massage, or providing the patient with a prescriptive exercise programme.

The first intervention may be focused in dealing with pain, nerve irritation, and back pain as this could be putting the patient into a further scoliotic curve. Then the application of clinically supervised Scoliosis Specific Exercises (SSE) becomes the primary focus. Besides being one of the primary interventions for many forms of scoliosis, Scoliosis Specific Exercise Therapy is deemed one of few treatments available for mild Scoliosis in adolescents and adults, as therapy by Physical Rehabilitation reduces the need for more invasive treatments. And while undergoing Scoliosis Specific Exercise Therapy, the patient is under the supervision of Michael Parr and his team.

Bracing is another Scoliosis treatment. With an orthotist’s guidance, the patient wears a special device to reduce the spinal curvature and ensures the condition does not worsen. The choice of suggesting a brace depends on the clinician’s assessment of the curvature’s severity and the patient’s age. For effective results, the bracing treatment is accompanied by SSE under the supervision of a trained team.

The clinician may also recommend combination therapy for Adolescent Idiopathic Scoliosis (AIS) patients. As the name suggests, the treatment combines two forms of therapy to ensure the progress achieved from the bracing is retained. Under Michael Parr, patients perform specific exercises based on their condition.

Another conservative method the clinician may recommend is Manual Therapy. It is ideal in cases where the patient needs assistance releasing undesirable tension around their soft tissue. The treatment may also be ideal for providing pain relief, especially if they have thorax pain, rib pain, and spinal pain.

When speaking about the treatment, one patient noted: “‘I developed scoliosis in several parts of my spine and this year a nerve in my spine became trapped causing pain and numbness.’ ‘My exercises now are designed to support my whole body and straighten my spine. In addition to pain, scoliosis caused a 2 inch height loss which I am now regaining at the age of 68! Michael’s knowledge of the body is phenomenal’.” Patients looking for a trusted clinic to help them with their condition can trust Elementary Health as the team provides conservative management of Scoliosis and other spinal deformities.

Elementary Health is located at 8c Romsey Terrace, Cambridge, Cambridgeshire, CB1 3NH, UK. Patients with Scoliosis can contact the Cambridge clinic at 01223 902 433 and schedule a consultation with Michael Parr of Elementary Health, who has been trained and certified in the Schroth Best Practice Program. Visit the website for more information.

Media Contact

Company Name
Elementary Health
Contact Name
Michael Parr
01223 902 433
8c Romsey Terrace
Postal Code
United Kingdom

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In December 2019, an outbreak of acute respiratory disease characterized by fever, dry cough, and shortness of breath began in Wuhan (People’s Republic of China). Weeks later, a novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causing coronavirus disease 2019 (COVID-19) was identified.1 The disease evolves similarly to the influenza virus, with general pain, sputum, weakness, and headache.2 However, in other cases, several risk factors are associated with COVID-19 complications and mortality, including chronic respiratory disease (8.0%), cardiovascular disease (13.2%), hypertension (8.4%), diabetes (9.2%), and cancer (7.6%).3–6 In addition to the aforementioned, some people experience psychological symptoms such as irritability, anxiety, depression, and sleep disorders, among others.7

The severity of the disease depends mainly on the immune system and age of the infected individual, where most (86.6%) of the patients with confirmed cases are between the ages of 30 and 79 years. Also, patients aged >65 years tend to present a worse prognosis and may need between 7 and 11 days of hospitalization, intensive care, or a ventilator to help them breathe.8,9 All the above make older adults’ infection forecasts even higher than the rest due to the comorbidity, geriatric syndromes, and frailty associated with aging.10

The confinement to contain the COVID– 19 outbreak increased sedentary time and altered life habits, mainly in older adults. Similarly, during and after the COVID-19 infection, patients of this age group decrease their physical activity (PA) levels, bringing with them a general physical condition in general, such as aerobic capacity, loss of muscle mass, and strength.11 This leads to a decrease in the autonomy and functionality of people, affecting their well-being and quality of life (QoL) even after illness.7,12

Because COVID-19 is a multisystem disease that, in some cases, can affect different organs and functions, its approach and treatment must be interdisciplinary. The early initiation of a structured and adapted PA program, in accordance with the patient’s age, fitness levels, previous comorbidities, and disease severity, contributes to improvement in cognitive, respiratory, neuromuscular, and osteoarticular function.13,14 It also reduces the clinical sequelae, restores functional capacity, and, above all, shortens the length of stay in the intensive care unit (ICU).13,14

It is necessary to investigate the favorable effects of PA and physical exercise (PE) on the recovery of these patients, considering that there is sufficient evidence that protective factors against noncommunicable diseases are established through these interventions. Additionally, PA and PE positively affect multiple pathologies that share similarities in terms of symptoms and their possible pathogenic mechanisms.15

Non-pharmacological interventions, such as PE and pulmonary rehabilitation, are effective in patients with chronic obstructive pulmonary disease and are currently used in patients with COVID-19.16 For example, respiratory muscle training is performed to decrease the incidence of COVID-19 symptoms and improve dyspnea, exercise capacity, and, thus, QoL.16 In addition, relaxation exercises are implemented to manage anxiety and sleep problems. Economic interventions are also used because they do not require any technology or special equipment.17–20 Moreover, PA and PE have a positive effect on both mental health and physical health.21

Therefore, this systematic review aimed to analyze the available scientific evidence regarding the effects of a PA program on adults and older adults during and after hospitalization for COVID-19.

Materials and Methods

This review was registered in the “International Prospective Register of Systematic Reviews” (PROSPERO; registration number, CRD42021267517).

The approach to reporting the systematic review was in line with the PRISMA.22 The study evidence quality for RCTs was evaluated using data derived from the Physiotherapy Evidence Database (PEDro) as it provides information resources to support evidence-based clinical practice.23 The methodological index for non-randomized studies (MINORS) scale was used for intervention studies.24

Below is the PICOS strategy used in the review:

  • Population: Patients aged >18 years who were hospitalized for COVID-19.
  • Intervention: Intervention studies that incorporated programs of PA, PE, physical therapy, or pulmonary rehabilitation in patients during or after hospitalization for COVID-19.
  • Comparison: Patients who followed the usual medical care.
  • Result: Physical effects (dyspnea, fatigue, the 6-minute walk test), functional effects (pulmonary function test forced expiratory), psychological effects (anxiety, sleep quality and depression), and social effects of a PA program in adults and older adults (activities of daily living and quality of life).
  • Study design: Randomized clinical trials and intervention studies.
  • Research question: What are the effects of a PA program on adults and older adults during and after hospitalization for COVID-19 for physical effects, psychological effects, and social effects?

Information Sources and Searches

The systematic review was performed from July to August 2021 in nine databases and electronic search engines: PubMed, Web of Science, Scopus, EBSCOhost, Science Direct, Cochrane Library, PEDro, SciELO, and Google Scholar. In addition, the exact keywords were combined with Boolean operators (ie, AND and OR) and Medical Subject Heading (MeSH) terms centered on the title and abstract. Updated literature in Spanish, English, and Portuguese was considered without specifying the publication date. We selected the studies that included patients aged >18 years who were hospitalized for COVID-19 and intervention studies that incorporated programs of PA, PE, physical therapy, or pulmonary rehabilitation in patients during or after hospitalization for COVID-19. The main reasons for exclusion in the systematic review were as follows: gray or unconventional literature and specific COVID-19 studies without PA programs or containing programs with passive gymnastics, management guidelines for COVID-19, or recommendations for PA during the COVID-19 pandemic.

The search strategy was adapted to the characteristics of each of the search engines. We used the following keywords: COVID, SARS, coronavirus, SARS-CoV-2, physical activity, physical exercise, aerobic capacity, resistance training, aerobic exercise, therapeutic exercise, physical therapy, physiotherapy, physical rehabilitation, respiratory rehabilitation, and pulmonary rehabilitation. For example, the Cochrane database used the following strategy: “(‘physical activity’ OR ‘physical exercise’ OR ‘aerobic capacity’ OR ‘resistance training’ OR ‘aerobic exercise’ OR ‘fitness’ OR ‘therapeutic exercise’ OR ‘physical therapy’ OR ‘physical rehabilitation’ OR ‘respiratory rehabilitation’ OR ‘pulmonary rehabilitation’ OR physiotherapy):ti AND (‘Covid’ OR ‘SARS’ OR ‘coronavirus’ OR ‘SARS-CoV-2’):ti.” The authors performed a reference review of the definitive studies, where a study was included for the analysis. The complete strategy of all search engines is shown in Supplementary Table 1.

Selection of Studies

Two authors independently exported the search engine results to an online reference manager (EndNote version Here, the duplicate studies were automatically deleted. Subsequently, the reviewers removed those duplicates not detected by the program through a detailed manual inspection. Discrepancies between evaluators were resolved by mutual agreement or by a third evaluator. The titles and abstracts were reviewed, verifying each article’s inclusion and exclusion criteria. Then, a complete reading of the remaining studies was performed, and by consensus, the final list of studies included in the review was selected.

Data Extraction and Quality Assessment

Two investigators independently extracted the following data using an Excel form: characteristics of the studies, characterization of the population, demographic data of the participants, methodology of the study, details of the intervention, outcomes of interest, and monitoring and analysis of the results (Table 1).

Table 1 Characteristics of the Included Studies

PEDro23 was used to determine the quality of RCTs, which helps users quickly assess whether studies have sufficient internal validity and the statistical information necessary for their results to be interpretable. Non-randomized intervention studies were evaluated with the MINORS scale,24 determining whether the studies had sufficient quality to be included in reviews. Any disagreement was resolved through discussion by the authors.

Data Analysis

Because of the limited number of studies, diversity of variables analyzed, and use of different scales for evaluating the same variable, the authors analyzed the data descriptively, using numbers, means, percentage distributions, standard deviations, and frequencies.


Characteristics of Intervention Studies

After a comprehensive search of the literature on our topic of interest, 302 titles were identified for inclusion. Of these, 274 titles were identified in seven databases and 28 titles through other search methods. For the selection of our studies, 74 automatically duplicated titles were discarded. The titles and abstracts were then reviewed, eliminating 191 studies that did not meet the eligibility criteria. Subsequently, six studies were evaluated through a full-text review, where four studies were included in the review. Using other search methods, an article was found to obtain five studies for the review. There were three RCTs25–27 and two intervention studies without a control group (CG)28,29 (Figure 1). The review of an institutional ethics board was not necessary for the research.

Figure 1 Flow diagram showing the number of studies identified and selected for inclusion in the systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020.

Note: PRISMA figure adapted from Page MJ, McKenzie JE, Bossuyt PM, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372:n71. doi:10.1136/bmj.n71. Creative Commons.22

Characteristics of Participants

The studies included 254 patients, all diagnosed with COVID-19. The distribution by sex was 58.7% for men, and the mean age of the whole sample was 51.7±10.4 years. At follow-up, 96.2% of the population completed the intervention. In RCTs, the exercise group and CG did not differ in the baseline characteristics of the participants. Only two studies reported clinical symptoms,25,28 the most relevant being fever, cough with sputum, fatigue, and dyspnea. Three studies reported a previous history of disease,26–28 such as hypertension, diabetes, osteoporosis, cancer; previous hospitalization; and engaging in regular exercise prior to infection. Neither of the participants of studies included reported clinical complications. The complete details of the features are shown in Table 1.

Description of the Intervention

Sessions were performed twice a day in the studies of,25,27,28 once a day in the study of,29 and twice a week in the study of,26 where an additional respiratory rehabilitation session was performed per day. The intervention time was 5 days in the studies of25,27 and 3–6 weeks in the studies of.26,28,29 The duration of each session ranged from 20 to 30 min for the studies, except for the study of,26 which did not specify. Several studies included respiratory muscle training,26,28,29 followed by relaxation techniques also used in three studies,25,27,28 two of which used accompaniment with music to obtain better results.27,28

Three studies26,28,29 evaluated the physical, lung function, psychological, and social components. However, one study28 did not include the lung function results. Two studies25,27 evaluated only the psychological component.

Primary Outcomes

The primary outcomes were anxiety and sleep quality, which were assessed in most results 80% and 60%, respectively.


Four studies25–27,29 evaluated anxiety using different scales: Spielberger State-Trait Anxiety Inventory used in two studies,25,27 Self-Rating Anxiety Scale (SAS) used in two studies,26,27 Trait Anxiety Scale used in one study,27 and Hamilton Anxiety Rating Scale used in one study.29 The results of all studies were statistically significant within the intervention group, and in the three RCTs,25–27 they were statistically significant compared with those in the CG (P < 0.05).

Sleep Quality

Sleep quality was investigated in three studies25,27,28 using different scales: Sleep State Self-Rating Scale used in one study;25 Richards–Campbell Sleep Questionnaire used in one study;27 and sleep quality used in one study,28 which was evaluated through three questions “sleep well”, “wake up two to three times at night”, and “do not sleep.” Two studies25,27 presented statistically significant results after the intervention (P < 0.05), and in one study28 in the items “good” and “wake up one to two times a night”, the results were also statistically significant after the intervention (P < 0.0001).

Secondary Outcomes

Two studies each evaluated the following variables, representing 40% of the total studies.

The 6-Minute Walk Test

Two studies26,29 evaluated the 6-min walk test (6MWT), which reported significant differences before and after the intervention (P = 0.020). One26 of these studies also showed statistically significant results compared with those in the CG.


Two prospective intervention studies28,29 evaluated dyspnea, showing highly significant results between before and after the exercise intervention (P < 0.0001 and P = 0.022, respectively).


Two studies evaluated depression. The study of26 used the Self-Rating Depression Scale, which did not report statistically significant results within and between groups. On the other hand, the study of29 used the Hamilton Depression Rating Scale, which showed statistically significant results in the intervention group (P = 0.0032).

Quality of Life

Two studies26,29 measured the QoL through the short form – 36 health survey (SF-36). In the study of,26 the scores in the eight dimensions were statistically significant between the intervention group and the two groups (P < 0.05). In the study of,29 only two dimensions presented significant results after the intervention: physical functioning (P = 0.014) and role-physical (P = 0.009).

Activities of Daily Living

Two studies26,28 analyzed the activities of daily living (ADLs) endpoint. In the study of,26 no significant improvement was noted either within the intervention group or between the intervention group and CG. On the other hand, in the study of,28 significant improvement was observed only in the intervention group (P< 0.0001).

Quality Assessment

The quality of three randomized studies25–27 was evaluated using PEDro.23 On the other hand, two studies28,29 were reviewed using the MINORS scale because these were intervention studies and, thus, could not be evaluated using the same criteria.24

The PEDro helps users quickly identify whether RCTs have sufficient internal validity (criteria 2–9) and statistical information necessary for their results to be interpretable (criteria 10–11). The studies not in the PEDro were reviewed through independent, rigorous reading by the reviewers. The results were recorded in a spreadsheet where “Yes” or “No” was written if the study met or did not meet the criteria established by the PEDro. Any disagreement was resolved through discussion. Table 2 presents the elements selected for methodological evaluation according to the PEDro criteria and all complete information of the quality assessment.

Table 2 Quality of the Studies Included in the Review Using the PEDro23

The studies of25–27 presented initial comparability, good follow-up, comparison between groups, and point estimates and variability. None of the studies had concealed allocation, blind subjects, blind therapists, blind assessors, and intention-to-treat analysis, which are common in the PEDro. Table 2 shows that the studies of25–27 met the same criteria of the PEDro, except for that of.26 Random allocation was met by approximately 97% of the studies in this database. The items concealed allocation, blind subjects, blind therapists, blind assessors, and intention-to-treat analysis that were not satisfied in any of the studies were reported in 27%, 6%, 1%, 36%, and 28% of the studies in the PEDro. The mean PEDro score was 5.1 ± 1.6, and the quality of the studies included in this review had a mean of 4.6 ± 0.57, classifying the studies as regular quality, which could hinder the development of the review.23 Finally, these studies performed intragroup and intergroup comparisons.

For non-randomized studies,28,29 the MINORS scale was used, which is a list containing eight essential points: at least one explicit research aim, information about the inclusion of consecutive patients, prospective data collection, appropriate assessment for the research goal, impartial evaluation of the endpoints, significant follow-up period, loss to follow-up not exceeding 5%, and prospective calculation of the sample size. The score of each section ranged from 0 to 2 depending on the quality (0, uninformed appearance; 1, inadequately informed appearance; and 2, adequately informed appearance). The overall assessed score was according to the following quality parameters, with 16 being the ideal score: 0–4, low quality; 5–10, medium quality; and 11–16, high quality.24 These data are presented in Table 3.

Table 3 Methodological Items for Non-Randomized Studies Using the MINORS Scale24

The studies of28,29 presented similar characteristics; did not report on the impartial evaluation of the results, rates of abandonment of the follow-up, and prospective sample size estimation; and adequately reported other points. The total score of the MINORS scale for each of these studies was 10, ranking studies with medium quality.24

Effect According to the Type of Intervention

Relaxation Exercises

Two studies25,27 included relaxation exercises in their intervention, which only evaluated anxiety and sleep problems. The study of25 used Jacobson’s technique, which consisted of muscle contraction–distension, that is, contracting a muscle or a group of muscles for a few seconds and then loosening the contraction progressively. As such, Jacobson argued that if muscle tension is accompanied by anxiety, the individual can reduce the anxiety by learning to relax that muscle tension, decreasing almost entirely the muscle contractions and experiencing a feeling of relaxation. Jacobson’s technique remains one of the most commonly used techniques to reduce anxiety and stress worldwide.30 This study evaluated anxiety and sleep problems; both variables obtained statistically significant post-intervention results (P< 0.05).

The study of27 performed an intervention of progressive relaxation exercises accompanied by music during the sessions. As in the previous study, progressive muscle relaxation is a deep relaxation technique based on the principle that muscle tension is a physiological response of the human body to disturbing thoughts. This technique leads to voluntary and regular relaxation of the main muscle groups and, thus, relieves the whole body.27 In addition, the music component facilitates the process and could affect the reduction of anxiety, improve the QoL, relieve stress, and even facilitate social integration.31 In this study, it effectively reduced and improved the anxiety and sleep problems in patients with COVID-19 (P<0.05).

Respiratory Muscle Training

Three studies26,28,29 included respiratory muscle training in their intervention. The first study26 included pulmonary resistance, cough, stretching, and home breathing exercises in its program. The following variables were analyzed: 6MWT, forced expiratory volume in 1s (FEV1), forced vital capacity (FVC), FEV1/FVC, diffusing capacity of the lungs for carbon monoxide (DLCO), SAS, and QoL, where statistically significant differences were found between and compare to CG before and after the intervention (P<0.05). On the other hand, no statistically significant differences were noted in the depression and ADL variables.

The study of,28 as in the previous one, included the combination of respiratory muscle training and psychological intervention, in which the patient listened to light music daily. The physical components fatigue, dyspnea, and oxygen saturation showed statistically significant post-intervention results (P=0.003, P<0.0001, and P=0.004, respectively). The psychological components sleep problems and ADLs also showed highly statistically significant results (P < 0.0001).

The study of29 used Liuzijue’s technique in their intervention, which consisted of the coordination and combination of movements and breathing patterns with specific sounds: Xu, He, Hu, Si, Chui, and Xi. In this study, different components were assessed and showed statistically significant post-intervention results: the physical components 6MWT (P=0.020) and dyspnea (P=0.022), pulmonary function components maximal inspiratory pressure and peak inspiratory flow (P<0.001), and psychological components anxiety (P<0.001) and depression (P=0.0032). No statistically significant results were noted in the social component QoL.


Here, we describe the results derived from the systematic review of the physical, functional, psychological, and social effects of PA in adults and older adults during or after hospitalization for COVID-19. This systematic review included five studies, three RCTs, and two non-randomized intervention studies according to eligibility criteria. We found that there were a limited number of studies registered in the seven databases and two search engines and the references cited at the time of systematic review. We considered that the small number of intervention studies was due to the novelty of COVID-19 and the limited knowledge regarding SARS-CoV-2, the disease and its effects, and, indeed, both physical and psychosocial treatments for patients. To organize this section, the results of the physical and functional variables are discussed first, followed by the results of the psychological and social variables.

The studies reviewed included relatively few physical variables, 6MWT and dyspnea, measured by two studies. Both variables showed significant results in the post-intervention groups. These variables are essential in rehabilitation after hospital discharge for COVID-19. In this regard, the study of32 was conducted in an Italian population that measured dyspnea and the 6MWT. Here, the patients presented with dyspnea and shortness of breath even when performing minimal activities. In addition, only a small percentage of patients could perform the 6MWT, resulting in low performance after discharge from the ICU.

For this reason, this study concluded that patients should be placed in a rehabilitation unit once they leave the ICU, for which an early rehabilitation protocol adapted to these patients would be proposed. Similarly, another study33 highlighted the need to follow-up patients with hospital discharge. This study evaluated the benefits of the 6MWT and concluded that this test is pertinent because it is correlated with COVID-19 severity and functional impairment and can be used to determine improvement in exercise capacity.

Regarding the variables of lung function, the COVID-19 particularly affects lung function, given that in moderate and severe cases, it causes acute respiratory syndrome. However, few studies evaluated variables such as FEV1, FVC, and DLCO.26 This finding is important considering that current scientific evidence shows that PA and PE are protective factors for multiple diseases and coronavirus-like symptoms.15

One study found improvement in dyspnea and respiratory muscle strength at the level of specific respiratory muscle training. The study estimated aerobic fitness, generating statistically significant changes for the intervention in maximal oxygen consumption (VO2 max).34

The systematic review of the literature on the psychological effects of PA in adults and older adults during or after hospitalization for COVID-19 is limited; however, there is evidence of a reduction in the levels of physical activity in these patients, leading to an increase in post-pandemic sedentary lifestyle.35 This result may be related to the limited knowledge of the disease study in the psychological, physical, functional, and social fields. However, the studies reviewed showed the actual results concerning the psychological effects in three variables: anxiety, sleep problems, and depression.36 Of these variables, the most frequently evaluated is anxiety, followed by sleep problems. Overall, the studies reviewed showed statistically significant results in the intervention group, especially for anxiety and sleep problems. On the other hand, the results for depression were heterogeneous.

Psychological conditions during and after COVID-19 have been identified, where patients report higher anxiety and depression levels than health professionals and the general population.37 Similarly, a literature review38 concludes that the COVID-19 pandemic has affected the population’s mental health, particularly hospitalized patients with notable symptoms of anxiety, depression, and sleep disorders. These can be associated with psychosocial components, including the isolation that patients with COVID-19 experience and the series of uncertain situations resulting from a novel virus, which are related to negative emotions such as the fear of death that, in some cases, can lead to anxiety before death.

Symptoms of anxiety and depression in patients with COVID-19 may be associated with the inflammatory process and release of cytokines due to the multisystem disease. Similarly, the effects of psychological and physical stresses experienced by patients may be related to the activation of the hypothalamic–pituitary–adrenal axis.39 One study40 found that in diseases with some characteristics similar to COVID-19, such as SARS and Middle East Respiratory Syndrome (MERS), patients had psychological deterioration even 6 months after discharge from hospitalization.

The effects of COVID-19 on mental health in patients hospitalized for this disease and in the general population reported in the aforementioned studies highlight the need for further research to investigate possible treatments for patients’ mental health during and after hospitalization for COVID-19. The studies discussed in this systematic review provide information on the positive effects of the different interventions on mental health, specifically in the reduction of anxiety and improvement of sleep problems: relaxation exercises such as Jacobson’s technique, progressive muscle relaxation, Liuzijue’s technique, and breathing muscle training. Additionally, it is essential to highlight the use of music as a form of psychological intervention in the patients who participated in the studies. Overall, these significant results can be associated with pre-COVID-19 pandemic scientific evidence confirming the positive effects of PE on mental health41 and more recent studies interested in investigating mental health and PA in the general population during the COVID-19 quarantine.42

In comparison with the psychological results, the social results of the studies included in this systematic review were more heterogeneous. In one study with a single group, significant improvement in the ADL variable was evident, whereas in another, no differences were noted between the control and experimental groups. These results suggest the need for further studies about the effects of PA on the social components, such as ADLs. A study found that there is improvement in mental health, quality of life, and function even with low volumes of exercise per day. However, the studies had heterogeneous aspects in the dosage of exercise, and it is recommended to continue with the intervention processes in this area.43

Some studies also had heterogeneous results regarding the effects of PA on QoL. One study26 presented significant results in all eight QoL dimensions, whereas another29 found that only two of them had significant results. Regarding this variable, the systematic review of40 found that 1 year after discharge, patients hospitalized for other viruses similar to COVID-19 had not resumed their working life level. These authors consider that one of the reasons why social life after the disease is affected could be related to symptoms such as fatigue that people who were infected continue to experience. Although it was not a direct objective of this review, it is estimated that between 10 and 20% of patients with SARS-CoV-2 present post-COVID-19 syndrome. These patients go through an acute symptomatic phase and experience the effects of the disease well beyond 12 weeks after diagnosis. Exercise is an adjuvant to stimulate the immune system by inducing mitochondrial adaptations, cell generation, and immune surveillance.15


This review of literature has some limitations. First, the scientific evidence available at the time of systematic review was limited. Second, the studies reviewed included a few physical and functional variables. Therefore, further research is needed on the effects of PA in the studied population and, in particular, RCTs.


This review of literature found that men had the highest incidence of COVID-19 (58.7%), which is consistent with the findings of previous studies that reported that women are less susceptible to viral infections.44,45 Moreover, the mean age (± standard deviation) of the whole sample was 51.7 ± 10.4 years, which is consistent with the data on the charts worldwide where the highest prevalence of confirmed cases is in the age range of 30 and 79 years.10

Considering that the lungs are the organs primarily affected, this review found that respiratory muscle training was the most commonly used intervention because the main symptoms of the disease showed positive results in the components: physical and pulmonary functions, psychological, and social. The relaxation exercises intervention showed positive effects with anxiety, sleep problems, and, therefore, the QoL of the affected individuals.


This research has been funded by Dirección General de Investigaciones of Universidad Santiago de Cali for allowing the development of this research.


This research was funded by the General Research Directorate of the Universidad Santiago de 314 Cali under call No. 01-2022.


The authors report no conflicts of interest in this work.


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There is a huge difference between music and noise not only in concept but experientially. Music can be defined as a group of sounds that have been deliberately produced to make a regular pattern, but noise is usually a group of sounds with no regular pattern. Music is enjoyable and very pleasant as it helps to fully relax the person but noise is disturbing and can actually make people very nervous. Music is capable of affecting a person’s thoughts, feelings and behavior and has been shown to assist with managing stress, expressing emotion, and improving communication. There is no doubt that listening to your favorite music can instantly put you in a good mood.  Music works on the autonomic nervous system which is the part of the nervous system responsible for controlling blood pressure, heartbeat and brain function and also the limbic system; the part of the brain that controls feelings and emotions.  When slow rhythms are played, our heartbeat slows down which helps us breathe more slowly thus reducing muscle and psychological tension. Music is an integral part of our well-being since we were fetuses in our mother’s wombs listening to her heartbeat and breathing rhythms. Music releases endorphins which are ‘feel-good hormones that give the motivation to carry on with life irrespective of our experiences. In profound memory loss, Music can actually help patients remember tunes that help them link up with their history since the part of the brain that processes music is located next to memory. Anyone who has ever wiped tears away from their eyes listening to their favorite song linked to a sad occurrence will know how powerful music could be.   Our reactions and preference for music vary from person to person. One individual may love heavy metal for example, while another is happiest listening to classical; the bottom line is that your music must make you feel good about yourself. Music helps the brain cortex to generate specific brain waves that can induce different states of alertness, depending on what we aim to do. Music is a very powerful tool in mental health either as a means of communication and self-expression or for its inherent restorative qualities. Someone who is experiencing some depressive feelings may find that appropriate music can act as an outlet for expressing things they are unable to put it into words. It can also act as a stimulus to awaken buried memories or evoke emotional responses that may take weeks to achieve with talking therapies. According to a 2011 survey from a mental health charity; nearly a third of people are plugged into their music players to give them a mood boost about work and almost one in four use music to handle stress.

Music therapy is an allied health profession and one of the expressive therapies, consisting of a process in which music and all of its facets-physical, emotional, social, and aesthetics, and even its spiritual value help clients improve their health. Music therapists help patients improve their health in several domains such as cognitive functioning, motor skills, emotional development, social skills and quality of life by using music experiences such as free improvisation, singing, listening to, discussing and responding to music to achieve treatment goals. The application of music therapy is wide and includes developmental issues involving communication and motor skills with individuals with special needs, songwriting and listening in reminiscence work with the elderly, processing and relaxation work and rhythmic entertainment for physical rehabilitation in stroke patients.  Music therapy can also find application in cancer centers, alcohol and drug recovery programs, and correctional facilities.

In children with autism; music helps their brains to respond in a more socially useful way through constructive repetitive stimuli from the lyrics. On average, adolescents listen to approximately 4.5 hours of music per day and are responsible for 70% of pop music sales. They obtain many benefits including emotional, and social as Music provides a sense of independence that contributes to their self-discovery and identity. Music education programs provide adolescents with a safe place to express themselves and learn life skills such as self-discipline, diligence, and patience. This is a serious challenge for parents who must creatively engage the world of their teenagers to ascertain that their brands of music will promote sound mental health rather than those that could inflame their sexual orgies and get them to experiment with drugs and indiscriminate sexual escapades with dire consequences. In our world here, music is often used inappropriately as noise resulting in noise pollution.  It can cause hypertension, high-stress levels, hearing loss, sleep disturbances, and heart disease. Nigerians need to learn how to use music intelligently to enhance physical and psychological health rather than make it an agent that endangers our personal and collective health.

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Involvement and lifestyle quality in terms of health are impacted by spinal cord injury. Spinal cord injury (SCI) patient sufferers deal with physical, social, and psychological repercussions. Annual spinal cord injuries are anticipated to range between 250,000 and 500,000. Clinical signs of SCI could include a partial or complete sensation loss and/or motor activity below the site of the damage. While quadriplegia could develop from injuries to the cervical region, paraplegia could result from injuries to the lower thorax. The most popular technique for predicting outcomes after the SCI is the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), which was created in partnership with the American Spinal Injury Association. A 28-year-old patient visited our hospital with complaints of reduced strength in both lower limbs and unable to walk. For those with whole or incomplete paraplegia, regaining independent mobility during the chronic phase is the most crucial goal. Bed mobility training, upper limb strengthening, trunk control, and intervention were started. SCI is an example of a low-incidence ailment that does not generate sufficient market demand to sustain the development of specialist services in distant places. The rehabilitation strategy should include weight-bearing mat exercises, home exercise programs, and ambulation orthoses. Early physiotherapy participation on the side of the patient allowed him to avoid major secondary issues including bed sores and joint contractures. One of the crucial components of the recovery process for those with spinal cord injuries is physical therapy.


Spinal cord injury (SCI) is a challenging and quickly developing condition. Participation and health-related quality of life (HR-QOL) are impacted by SCI. Spinal cord injury patients are affected physically, socially, and psychologically [1]. A strategic plan aids in determining a person's requirements, priorities, and expectations for restoration. Annual spinal cord injuries are anticipated to range between 250,000 and 500,000 [2]. More than 90% of SCI instances have traumatizing etiologies that include incidents like automobile accidents, assaults, sports, or falls. Clinical indications of SCI may include a partial or complete loss of perception and/or functional ability immediately below the level of injury, depending on the extent and location of the damage [3]. Injuries in the lower thorax can result in paraplegia, whereas those in the cervical region might result in quadriplegia [4].

There are two stages in SCI: the first one, which consists of two mechanical injuries, glial cells and neurons and their surroundings; and the second one, which includes vasculature, the environmental deterioration that is pervasive in spinal cord cells [4]. Fractures and vertebral dislocation are common outcomes of acute SCI, which frequently stems from rapid trauma to the spine [5]. The approach is most frequently used to predict outcomes after SCI. The American Spinal Injury Association (ASIA) and the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) together developed the disability scale [6]. Around 5% and 10% of polytrauma patients experience spinal fractures or dislocations, with the lumbar or dorsal spine accounting for 65%-80% of these injuries [7]. Paraplegia, or the paralysis of the entire trunk and both lower extremities, results from damage to the dorso-lumbar region of the spinal column. The lower limb and bowel and bladder may be compromised based on the extent of the impairment, whereas the arm may continue to function correctly [8].

Depending on the kind of injury, there may or may not be bowel and bladder involvement, in which case they have neurogenic bowel and bladder that are spastic or flaccid [6]. A patient's standard of living may suffer as a result of having restricted and altered mobility, the ability to care for oneself, and the ability to engage in beloved social activities if muscles below the level of injury are paralyzed. Patients with paraplegia can gain improvement if physical therapy interventions are started earlier as possible. Through target, practice, and repetition, initial activities training in rehabilitation can enhance performance [9]. In such patients, our main target is focusing on bed mobility training, transferring activities, and making the patient skillful to execute his activities of daily living (ADLs). A task is allotted to the patient, and we teach them how to perform it within a pain-free limit [8].

Case Presentation

Patient information

A 28-year-old male citizen of Gadchiroli had a road traffic accident one year ago. He was taken to a local hospital for treatment. He was diagnosed with wedge compression fracture of the D6 vertebra and was advised for operation. He was taken to Nagpur for an operation. Now he visited our hospital with the complaint of bilateral lower limb weakness, absence of bowel and bladder control, and unable to walk. He was advised for physiotherapy on September 7, 2022. The patient’s blood pressure was 130/80 mmHg, pulse rate was 82 b/min, and respiratory rate was 13 breaths/min on physical examination.

Clinical findings

The patient’s build was mesomorphic, with an attitude of limb: ankle in slight plantar flexion and hip externally rotated. During a neurological examination, sensations below the D6 level were absent. In both lower limbs, the tone was spastic grade 1 according to the Modified Ashworth Scale (MAS). All the deep tendon reflexes were present. Both upper limbs were neurologically normal. The patient underwent intermittent catheterization because the bowel and bladder were involved. Magnetic resonance imaging (MRI) finding reveals fixation of screw seen in D4-D8 vertebra and compression fracture of D6 with no retropulsion of vertebral body. An X-ray of the dorso-lumbar spine's anteroposterior (AP) and lateral views indicates spinal fixation at levels D4 and D8, as well as a compression fracture at level D6.


Magnetic resonance imaging (MRI) was done, displayed in Figure 1.

Physiotherapy interventions

Management for this patient was primarily focused on preventing secondary complications such as bed sores, deep vein thrombosis, and respiratory complications. Bed mobility training was started. Strengthening of both upper limbs was initiated with a weight cuff of 1 kg. For lower limb stretching exercises, positioning, bed mobility exercises, trunk stability exercises, exercises to improve static and dynamic balance, scooting, pelvic tilt, and weight shift exercises were given. Table 1 indicates the physiotherapy rehabilitation protocol (Figures 2A-2C, 3A-3C).

Problems faced by the patient Goals to improve problems Physiotherapy intervention
1. Secondary complications such as bed sores, deep vein thrombosis, etc. To prevent this secondary complication. Ankle-toe movement every two hours and changing the position.
2. Respiratory complications To prevent breathing difficulties. Techniques for breathing involve pursed lip breathing, diaphragmatic breathing, and thoracic expansion.
3. Tightness (tendon Achilles (TA), hamstring) To reduce the tightness. Stretching of TA, stretching of the hamstring (15-sec hold × 3 reps).
4. Mobility issue To improve mobility. Bed rolling, passive movements for bilateral lower limbs. Back extension exercise (Figure 3A).
5. Bowel and bladder To strengthen the pelvic muscles.  Kegel’s exercises, transverse abdominal contraction, hip abductor, and adductor roll.
6. Core muscle weakness To strengthen core musculature. Crunches both straight and diagonally (5 sec hold × 10 reps: 1 set) of each (Figure 3C). Push-ups on arms (10 reps × 1 set).
7. Trunk muscle weakness To strengthen the trunk muscles and improve stability.  In the quadruped position shifting of weight side to side, forward, and backward (Figure 3B) (10 reps × 1 set).
8. Balance To improve static and dynamic balance.  Scooting (Figure 2A-2C), weight shifts in sitting position side to side, forward, and backward (10 reps × 1 set), maintain static balance (20 sec hold with eyes closed and open × 3 reps).
9. Difficulty in maintaining a standing position To make the patient stand.  Supported standing.
10. Sensations were absent Sensory reeducation. Using different textures such as feathers, cotton cloth, Turkish cloth, rubbing sand, silk cloth, etc., from distal to proximal.
11. Disuse may lead to reduce in upper extremity strength Maintenance of upper extremity strength. Upper limb strengthening with 1 kg of weight cuff (10 reps × 2 sets).

Outcome measures

The American Spinal Injury Association (ASIA) scale was used to measure the outcome of rehabilitation. In the pre-treatment score for the right side, the sensory was 48 and the motor score was 30, and for the left side, the sensory was 48 and the motor was 30, and the overall neurological level was T5. In the post-treatment score for the right side, the sensory is 72 and the motor is 34, and for the left side, the sensory is 72 and the motor is 34, and the overall neurological level is T7. Spinal Cord Independence Measure (SCIM) and Manual Muscle Testing (MMT) were used as outcome measures. Figures 4-7 indicate the outcomes of the intervention.


This case study intends to demonstrate how effective surgical and physical therapy treatment can be provided to a patient who has suffered a serious spinal cord injury. During the chronic phase, achieving independent mobility is the most important objective for people with total and incomplete paraplegia [10]. Patients with chronic SCI require a long-term, intense rehabilitation program. Reducing the rate of death due to complications requires aggressive prevention and control of any problems that may arise [10].

Weight-bearing mat exercises, home exercise routines, and ambulation orthoses should all be part of the rehabilitation protocol [11]. Every exercise was performed three times daily. After the rehabilitation program, he was able to restart his ADL on his own [12]. The first coordinated effort is to determine critical markers of high-quality rehabilitation for people with SCI that may be integrated into routine clinical care. SCI is an example of a low-incidence ailment that does not generate enough of a market to sustain the establishment of specialist services in distant locations [13].

However, the designs and the functions must be enhanced so that they help users to achieve their goals more effectively with mechanical orthotic devices. To increase physical fitness and survival in these patients, adequate respiratory treatment for pulmonary function optimization may be essential. However, respiratory care is generally used in physical rehabilitation therapy [14].

In this case, when a patient came for physiotherapy on the first day, he was unable to move both lower limbs. As the patient came one year later to take the physiotherapy treatment, it was difficult to gain recovery as early as possible. But as we started giving the treatment, our main focus was on bed mobility activities, transferring activities, and making the patient perform his ADLs [8]. After two months of treatment, he was able to initiate the movement and he has achieved unsupported sitting. If early physiotherapy is not adequately implemented, there is a potential that recovery time will take longer. Sometimes it might result in the emergence of strange synergy patterns [9].


This case study's findings show the importance of effective physical therapy interventions and exercises in enabling patients to carry out activities of daily living. The patient's early participation in physical therapy helped him to prevent serious secondary problems such as pressure sores and joint contractures. One of the crucial aspects of spinal cord injury patients' recovery is early physical therapy intervention. This study also suggests that if intervention is followed five days per week three times a day, it will be helpful for patients to gain recovery earlier.

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Wilmington, Delaware, United States, Oct. 18, 2022 (GLOBE NEWSWIRE) -- Transparency Market Research Inc. – In 2020, the home rehabilitation products & services market size was clocked at ~US$ 130 Bn. The market analysis of home rehabilitation products & services market projects the market to register growth at ~7% CAGR during the forecast period, from 2021 to 2031. By 2031, The value of global home rehabilitation products & services market is estimated to touch US$ 265 Bn. In the global home rehabilitation products & services market, e-health and tele-rehabilitation are experiencing rapid growth. Since tele-rehab is becoming more and more popular as a practical and affordable way to enhance patients’ quality of life, success rates are climbing with its intervention.

The exoskeletons find utilization as a tool to supplement a physical rehabilitation program that offers automated readings of a patient's condition and permits independent mobility for those with disabilities safely. Market players are developing technologies and devices that can detect body posture and create a rehabilitation program with robotic algorithms under remote guidance of a physician. Such moves are expected to come up as home rehabilitation products & services market trends in the coming years.

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Home-based rehabilitation has a number of benefits, including lowered stress levels, confidentiality, as well as a lowered likelihood of hospital readmission. This is likely to raise worries concerning patient safety and shortage of required infrastructure, such as durable medical equipment that can maintain life quality and provide assistance. As a result, businesses in the home rehabilitation products & services market are expanding their R&D capacities to develop novel methods of lasting support equipment.

Key Findings of Market Report

  • Wearable sensors are being developed by med-tech firms and startups in the global market to help patients perform activities with biofeedback and gain a useful range of movement. Other gadgets like exoskeletons and smart gloves are gaining popularity, which is said to bode well for the global industry.
  • Tele-rehab is facilitating contact between distant patients and professionals and boosting subject involvement and is also estimated to emerge as key home rehabilitation products & services market strategies. For orthopaedic patients in particular, this trend can improve access to rehabilitation services. Tele-rehab has been shown to be a significant alternative to clinic-based therapy for typical musculoskeletal pain.
  • Chronic illnesses including high blood pressure, diabetes, and respiratory and cardiovascular disorders need be regularly and continuously monitored. Adoption of home healthcare products and services is growing as the number of individuals with chronic illnesses rises, and this is expected to have a positive influence the preference for rehabilitation equipment.

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Global Home Rehabilitation Products & Services Market: Growth Drivers

  • The usage of products and services offered by home rehabilitation service providers is driven by the rise in the number of individuals with disabilities. Sales of rehabilitation goods and services are closely correlated with the number of people with physical disabilities. Patients choose rehabilitation treatments at home since they are unable to visit hospitals. This factor is likely to raise the need for products and services for home rehabilitation.

Global Home Rehabilitation Products & Services Market: Key Competitors

  • Active Medical & Rehabilitation Services Pvt. Ltd.
  • Ekso Bionics Holdings, Inc.
  • Medline Industries, Inc.
  • Stryker Corporation
  • AliMed, Inc.
  • Hocoma AG

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Global Home Rehabilitation Products & Services Market: Segmentation

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Physiotherapy is one of the medical and health sciences branches that deal with the treatment of pain, physical impairments, and deformities in physically disabled people. It is the science of the mobility of various aspects of the body.

It does not include any surgical methods to heal but uses physical methods like massage, heat, and electrical equipment. It is a hands-on technique that helps in reviving the proper functionality of the body. It helps in relaxing muscular-skeletal pains, neurological ailments, and body malfunctioning.


Physiotherapy Information

Physiotherapy is a vast field. It offers treatment in many conditions. The different types of Physiotherapy are- Neurological, Cardiopulmonary, Pediatric, Orthopedic, Muscular-skeletal, Geriatric, and various women’s health-related concerns.

Who needs Physiotherapy?

  • Recovering from any injury
  • During and after pregnancy
  • After surgery
  • Regular muscular-skeletal pains
  • Chronic pain
  • Heart and lung-related diseases
  • Women’s health concerns


Physiotherapy is a young emerging branch of medical sciences in India. It has many great and promising job opportunities. There are many career options open for a qualified physiotherapist. Physiotherapists are in great demand due to the increase in the number of patients with constant muscular-skeletal pains. The increase in the number of such patients is because of the inactive and lazy lifestyle of a major segment of the population. With the advancement in urbanization and digitalization, people hardly move from their seats which has led to various problems in the mobility and functioning of the body.

Also Check: Medical Entrance Exams for National and University Level

Physiotherapy has a wide scope in the upcoming years. A career in this field helps in improving the lifestyle, health, and well-being of people.

Physiotherapy is not only limited to muscular pains or body deformities & disabilities but also treats several neurological disorders, heart diseases, strokes, and female reproductive system-related issues.

Current Situation

The current situation of physiotherapy in India is not so rosy. There is no such awareness about its importance and prospects among the people. Very few courses are available. There is no proper association for the community of physiotherapists. Once there is an efficient and effective spread of awareness about the role and duties of a physiotherapist, the future of this career field is immense and wide open for many aspirants.

Why choose Physiotherapy as a Career?

Top reasons to pursue Physiotherapy as a career option are-

  • Variety of employment opportunities: A physiotherapist has many employment areas, for example, he can have his own private clinic, associate himself with a sports team, any rehabilitation centre, or become a lecturer.
  • New Challenges: There can be a variety of patients with a variety of injuries or ailments. A physiotherapist is given a new challenge daily to showcase and enhance their abilities and skills.
  • Helping People: Choosing physiotherapy is a satisfying job. People appreciate you for your quality of treatment and how your lifestyle and health enhances.
  • Practical Knowledge: A physiotherapist needs practical knowledge of physics-related concepts and principles and the effect of their treatment on human tissues.
  • Rewardable Salary: A handsome amount of salaries is paid to well-educated and experienced physiotherapists in the country.

Courses Available

This branch of medical sciences is quite recent in India. Thus, there are not many course programmes available for Physiotherapy aspirants. The only existing courses at different levels are:

Diploma Diploma in Physiotherapy DPT
UG Bachelors in Physiotherapy BPT
PG Masters in Physiotherapy MPT

Course Duration

  • DPT – Two years
  • BPT – Four years (full-time) + 6 months (internship)
  • MPT – Two years (full-time)

Course Curriculum

DPT Clinical Pathology, Applied Pathology, Anatomy, Physical Exercise Therapy, Gynecology, Electrotherapy, Physical Rehabilitation, Orthopaedics, Medical Physiotherapy, Surgical Physiotherapy, Biomechanics and Kinesiology
BPT Anatomy, Clinical Pathology, Applied Pathology, First Aid and CPR, Microbiology, Physical Exercise Therapy, Neuro-Physiotherapy, Gynecology, Electrotherapy, Physical Rehabilitation, Orthopaedics, Medical Physiotherapy, Surgical Physiotherapy, Biomechanics & Kinesiology, Sports Physiotherapy, Cardio-Respiratory & General Physiotherapy, Biochemistry, Basic Nursing
MPT Electrophysiology & Electro-diagnosis, Physiotherapy Practice & Education Technology, Applied Biomechanics & Kinesiology, Advanced Electrotherapy, Didactic, Clinical Training & Clinical work

Eligibility and Admission

The eligibility criteria for admission in DPT, BPT and MPT are as follows:

DPT Passed 10+2 with PCB as a major subject from any recognized board with a minimum score of 50% marks.
BPT Passed 10+2 with PCB as a major subject from any recognized board with a minimum score of 50% marks + qualifying entrance examinations like NEET, or JIPMER, if required.
MPT Bachelor’s degree in Physiotherapy (BPT) from any recognized university with a minimum score of 50% marks.

Top Colleges for Physiotherapy Courses

  • Christian Medical College, Vellore
  • Sanskriti University, Mathura
  • Kasturba Medical College, Mangalore
  • Chandigarh University, Chandigarh
  • Madras Medical College, Chennai
  • GGS Indraprastha University, New Delhi
  • St. Johns Medical College, Bangalore

Skills Required

For becoming a highly rewarded and successful physiotherapist, one must possess the following attributes that will help to grow in his field.

  • Good Medical Knowledge: A physiotherapist must know the medical treatments for a specified injury or ailment.
  • Good Listener: A physiotherapist must be a good listener so that the patient can deliver his thoughts in more detail.
  • Sensitive and Patient: A physiotherapist must be sensitive and patient enough to listen to the patient’s problems.
  • Good Communication Skills: A good physiotherapist is one who delivers his instructions and treatment technique accurately and clearly. Clarity of speech is a must.
  • Organizational Skills
  • Time Management Skills
  • Technology-based Skills

Career and Jobs

A career in physiotherapy in India varies from place to place. In big cities like New Delhi, Mumbai, Chennai, Kolkata, etc. it is very flourishing whereas to talk about smaller cities and towns, it is still struggling. But in the coming years, it is a rewarding career and will be highly recognized.

Physiotherapists are recruited by many private and government hospitals and healthcare centres. Rehabilitation centres, Defence Medical organizations, and several Sports clubs also hire physiotherapists. The top job profiles of Physiotherapists in India are-

  • Chief Physiotherapist
  • Therapy Manager
  • Assistant Physiotherapist
  • Sports Physiotherapist
  • Home Care Physiotherapist
  • Lecturer
  • Physiotherapist (having own private clinic)


The pay scale of physiotherapists in India depends on their work experience and the organization they are working for.

Initially, the salary of a physiotherapist working for an organization could be INR 10,000 – 20,000 per month. After growing work experience, it can easily reach up to 50,000 or more per month.

A physiotherapist owning a private clinic in a city like New Delhi or Mumbai can earn INR 30,000 – 60,000 per month.

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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

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

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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

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

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:

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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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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