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ORIGINAL RESEARCH
Persistent Symptoms and Disability After COVID-
19 Hospitalization: Data From a Comprehensive
Telerehabilitation Program
Victor Figueiredo Leite, MD, Danielle Bianchini Rampim, MD, Valeria Concei¸c~
ao Jorge, PT,
Maria do Carmo Correia de Lima, PT, DPT, Leandro Gon¸calves Cezarino, PT,
Cleber Nunes da Rocha, MD, Rodrigo Barbosa Esper, MD, PhD on behalf of Prevent Senior
COVID-19 Rehabilitation Study
From the Prevent Senior Institute, S~
ao Paulo, Brazil.
Abstract
Objective: To report symptoms, disability, and rehabilitation referral rates after coronavirus disease 2019 (COVID-19) hospitalization in a large,
predominantly older population.
Design: Cross-sectional study, with postdischarge telemonitoring of individuals hospitalized with confirmed COVID-19 at the first month after
hospital discharge, as part of a comprehensive telerehabilitation program.
Setting: Private verticalized health care network specialized in the older population.
Participants: Individuals hospitalized because of COVID-19. We included 1696 consecutive patients, aged 71.8§13.0 years old and 56.1%
female. Comorbidities were present in 82.3% of the cases (N=1696).
Interventions: Not applicable.
Main Outcome Measures: Dependence for basic activities of daily living (ADL) and instrumental activities of daily living (IADL) using the Barthel
Index and Lawton’s Scale. We compared the outcomes between participants admitted to the intensive care unit (ICU) vs those admitted to the ward.
Results: Participant were followed up for 21.8§11.7 days after discharge. During postdischarge assessment, independence for ADL was found to
be lower in the group admitted to the ICU than the ward group (61.1% [95% confidence interval (CI), 55.8%-66.2%] vs 72.7% [95% CI, 70.3%-
75.1%], P<.001). Dependence for IADL was also more frequent in the ICU group (84.6% [95% CI, 80.4%-88.2%] vs 74.5%, [95% CI, 72.0%-
76.8%], P<.001). Individuals admitted to ICU required more oxygen therapy (25.5% vs 12.6%, P<.001), presented more shortness of breath dur-
ing routine (45.2% vs 34.5%, P<.001) and nonroutine activities (66.3% vs 48.2%, P<.001), and had more difficulty standing up for 10 minutes
(49.3% vs 37.9% P<.001). The rehabilitation treatment plan consisted mostly of exercise booklets, which were offered to 65.5% of participants.
The most referred rehabilitation professionals were psychologists (11.8%), physical therapists (8.0%), dietitians (6.8%), and speech-language
pathologists (4.6%).
Conclusions: Individuals hospitalized because of COVID-19 present high levels of disability, dyspnea, dysphagia, and dependence for both ADL
and IADL. Those admitted to the ICU presented more advanced disability parameters.
Archives of Physical Medicine and Rehabilitation 2021;000:1−9
Ó2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
Postacute symptoms and persistent disability after COVID-19 dis-
charge are still unclear.
1
Currently available data suggest that at
the time of discharge, individuals present high levels of physical
and mental health disability, as well as fatigue, respiratory, car-
diac, renal, neuropsychological, speech and swallow, nutritional,
and vocational impairments that persist for at least 6 months.
2-9
Those impairments seem to be more pronounced in those with
more severe disease.
2,6,9,10
In a cohort from China, individuals
that required high-flow nasal cannula, noninvasive ventilation, or
invasive ventilation presented more frequent mobility impairment,
pain, anxiety, and depression 6 months after discharge than those
hospitalized without oxygen therapy.
2
Data from the United
Disclosures: none
0003-9993/$36 - see front matter Ó2021 The American Congress of Rehabilitation Medicine. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.apmr.2021.03.001
ARTICLE IN PRESS
Archives of Physical Medicine and Rehabilitation
journal homepage: www.archives-pmr.org
Archives of Physical Medicine and Rehabilitation 2021;000: 1−9
Kingdom show that individuals admitted to the intensive care unit
(ICU), when compared with those admitted to the ward, presented
higher rates of fatigue (72% vs 60%), breathlessness (66% vs
43%), and neuropsychological impairments (47% vs 24%) in the
first 2 months after discharge.
6
However, data on different popula-
tions and demographics are needed to better understand disability
after COVID-19, as well as the potential effect of ICU admission.
Given the increasing number of cases and its potential disabil-
ity rates, COVID-19 is placing an enormous strain on rehabilita-
tion services worldwide.
11-14
To muster the appropriate resources
to respond to this disability epidemic, rehabilitation services
require data about frequency of persistent symptoms, disability
rates, and rehabilitation referral needs in this population, which
are currently scarce.
1
Identifying risk factors for disability is also
important for an appropriate response plan. ICU admission corre-
lates to more severe disease and prevalent disability rates in those
hospitalized because of COVID-19.
10
Our goal was to provide
data from a comprehensive telerehabilitation program on postdi-
scharge symptoms and disability, as well as rehabilitation referral
needs, comparing those admitted to the ICU and ward. We hypoth-
esized that individuals admitted to the ICU had higher prevalence
of symptoms, disability, and rehabilitation referral needs.
Methods
This retrospective cross-sectional study was performed at Prevent
Senior, a verticalized Brazilian private health care network spe-
cialized in the older population,
15
currently caring for over
500,000 lives. Reporting of this article was performed following
Strengthening the Reporting of Observational Studies in Epidemi-
ology guidelines.
16
The present study was approved by the ethics
committee.
Participants
Eligibility criteria
From March 15-August 27, 2020, all individuals hospitalized
because of COVID-19 at Prevent Senior in the city of S~
ao Paulo
were screened for eligibility. Participants were included if
COVID-19 was the cause of admission, confirmed by positive
molecular diagnosis (real-time polymerase chain reaction) for
SARS-CoV-2 infection, and if they were discharged alive. Partici-
pants hospitalized with asymptomatic COVID-19 and those who
presented symptoms only after hospitalization were excluded
from the present study (n=9). We did not exclude individuals that
were readmitted to the hospital.
Outcomes
Data were obtained from a comprehensive telerehabilitation pro-
gram implemented for individuals who were discharged after
COVID-19 hospitalization (fig 1). Our telerehabilitation team had
access to a central list containing all individuals hospitalized
because of COVID-19 in our verticalized health care network.
Each patient was individually and manually monitored using our
electronic health record. Once we identified that the patient had
been discharged, telephone contact was made by a physical thera-
pist. We elected the physical therapist for this role based on 2
main reasons: (1) we expected the highest impairments to be in
the motor and respiratory functions and (2) because of the number
of available professionals at that time owing to the suspension of
outpatient sessions. The objective of the first telephone contact
was to identify symptoms and disability and provide early referral
to telerehabilitation services.
Demographics, comorbidities, and hospitalization data were
retrieved using electronic health records. Radiological severity
was assessed by the Tomographic score for COVID-19 (RAD-
COVID score) at admission, which uses chest computerized
tomography scans to stratify overall pulmonary parenchyma
involvement in <25%, 25%-50%, and >50%, resulting in scores
1-3, respectively.
17
During the initial telephone contact, data were gathered using a
structured form specifically designed for identifying disability and
rehabilitation needs in individuals discharged after COVID-19 in
our institution (supplemental appendix S1, available online only at
http://www.archives-pmr.org/). This was the only time point at
which data were gathered from the individuals in this study. The
structured form used in the telerehabilitation program assessed
individuals’ physical and respiratory symptoms, mobility impair-
ments, measures of independence and affect, nutritional, and swal-
lowing symptoms. Individuals were also asked to report any other
symptoms not addressed by the form. The structured form
assessed the following self-reported variables:
Respiratory symptoms
Shortness of breath was assessed as a binomial variable (yes/no).
We assessed current shortness of breath in 3 different situations:
at rest, during routine activities, and during nonroutine activities.
Routine activities included ADL that were part of that individual’s
routine prior to COVID-19 infection, such as bathing, dressing,
walking inside home, or climbing stairs (for those individuals with
stairs at home). Nonroutine activities included any other activities,
such as exercising, climbing stairs (in case there were no stairs at
home), and walking outside the home.
Current use of oxygen therapy was assessed as a binomial vari-
able (yes/no). Thus, participants who were currently using oxygen
therapy for a few hours or for any specific activities were consid-
ered as users of oxygen therapy.
Physical symptoms
We assessed current energy levels using a 0-10 numeric rating
scale (0=no energy whatsoever, 10=best energy possible). Current
overall pain level (on any location) was rated using a 0-10 numeric
rating scale (0=no pain, 10=worst imaginable pain). We also asked
if there was any current numbness or tingling sensation present
(yes/no).
Mobility impairment
We asked if the individuals were having any difficulty standing up
for over 10 minutes unassisted (yes/no), if they had difficulty mov-
ing any limb (yes/no), and if they had any falls since hospital dis-
charge (yes/no). We also assessed if they required any gait
assistance devices, such as a cane, walker, or wheelchair (yes/no).
List of abbreviations:
ADL activities of daily living
CI confidence interval
COVID-19 coronavirus disease 2019
IADL instrumental activities of daily living
ICU intensive care unit
IQR interquartile range
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2 V.F. Leite et al
www.archives-pmr.org
Measures of independence
Independence for ADL (feeding, bathing, grooming, dressing,
bowel/bladder management, toilet use, transfers, mobility, use of
stairs) was assessed using the Barthel Index. Barthel Index was
scored from 0-100, with individual items scoring 0-10, where 0
meant dependent, 5 partially dependent, and 10 independent.
Transfers and mobility were scored 0-15 each, where 0 meant
dependent, 5 and 10 referred to different degrees of partial depen-
dence, and 15 mean independent.
18,19
Independence for IADL (telephone use, shopping, food prepa-
ration, housekeeping, mode of transportation, responsibility for
medication, ability to hand finances) was assessed using Lawton’s
Scale scored from 7-21, with individual items scoring 1-3
(1=unable, 2=needs assistance, 3=independent).
20
Dependence
was defined when scoring <21.
Measures of affect
We assessed for perception of anxious and or depressive symp-
toms by asking, “Have you been feeling anxious or depressed
lately?” (yes/no).
Nutrition/eating
We asked if the individuals presented weight loss with inappe-
tence (yes/no). We also assessed for dysphagia to liquids or solids
by asking, “Do you have any trouble swallowing food or liquids?”
(yes/no).
Follow-up and telerehabilitation protocol
During the initial telephone contact, individuals were stratified
based on their current Barthel Index score
18
: level 1 (0-39, depen-
dent), level 2 (40-79, partially dependent) and level 3 (80-100,
independent) as shown in table 1. All participants were provided
Fig 1 Telerehabilitation protocol for COVID-19.
Table 1 Follow-up protocol recommendations for telerehabilita-
tion following hospitalization for COVID-19 using the dependence
score on the Barthel Index
Barthel
Index Subgroup Follow-up
0-40 Level 1 Referral to a level 1 online physical therapy
group or
home exercises+weekly telemonitoring
(total of 4)
41-80 Level 2 Referral to a level 2 online physical therapy
group or
home exercises+biweekly telemonitoring
(total of 2)
81-100 Level 3 Referral to a level 3 online physical therapy
group or
home exercises+monthly telemonitoring
(total of 1)
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Persistent symptoms and disability after COVID-19 3
www.archives-pmr.org
with a physical exercise guide in booklet and/or video format,
based in a previous publication.
21
The physical therapist then
decided if the patient would perform unsupervised home exercises
onl or if a referral to an online physical therapy group was neces-
sary. Those performing unsupervised home exercises were fol-
lowed up by telemonitoring (telephone contact) for a month,
either weekly, biweekly, or monthly, for level 1, 2, or 3, respec-
tively. The objective was to assess and promote adherence to exer-
cises, correct any doubts regarding exercises, and assess any other
rehabilitation needs (data from telemonitoring follow-ups were
not recorded).
Criteria for referral to other rehabilitation professionals were
the following:
Dysphagia: referral to a speech-language pathologist.
Issues regarding oxygen therapy (eg, dosage, how to wean
down), worsened dyspnea, or impaired blood pressure or heart
rate: referral to a cardiologist specialized in cardiac rehabilita-
tion.
Complaints regarding fine motor control or cognition: referral
to occupational therapy.
Pain rated as >5 (0-10 numeric scale) or any numbness/tingling
or difficulty moving their limbs: referral to a physiatrist.
Weight loss or inappetence: referral to a dietitian.
Anxious or depressive symptoms: referral to a psychologist.
Statistical analysis
Categorical data were reported as frequency, percentage, and 95%
confidence intervals (CIs) estimated by the exact method. Contin-
uous variables were reported as mean, SD, median, and interquar-
tile range (IQR). Shapiro-Wilk test showed that all continuous
variables did not present normal distribution. Continuous variables
were compared among groups using a Mann-Whitney Utest. Cate-
gorical variables were compared using Pearson chi-square test,
with statistical power of 80% and ɑ=5%. No data imputation
method was used. We used Stata 13.0
a
for the analyses.
This is a descriptive and exploratory study, and sample size
calculation was not performed. We used all available data from
the telerehabilitation program at the time of protocol writing.
Results
A total of 1733 individuals were screened, and 1696 were included
(fig 2). A total of 357 individuals (21.0%) were admitted to the
ICU at any point during their hospitalization. Individuals admitted
to the ICU and the ward had similar characteristics (table 2),
although those admitted to the ICU were slightly younger (median
age, 71y [IQR, 63-78y] vs 73y [IQR, 64-82y] P=.006). Individuals
were institutionalized after discharge in 4.5% and 7.8% of the
cases admitted to the ICU and ward, respectively. As expected,
those admitted to the ICU presented longer length of hospital stay
(median, 16d [IQR, 11-2d] vs 6d [IQR, 4-9d] P<.0001) and higher
radiological severity (RAD-COVID 3 in 39.2% [95% CI, 34.1%-
44.4%] vs 10.5% [95% CI, 8.9%-12.3%]) (table 3). After dis-
charge, telephone contact was made with all individuals. Those
admitted to the ICU presented worse postdischarge outcomes than
those in the ward: higher incidence of shortness of breath during
routine (45.1% [95% CI, 39.9%-50.4%] vs 34.5% [95% CI,
32.0%-37.1%]) and nonroutine activities (46.8% [95% CI, 41.5%-
52.1%] vs 38.2% [95% CI, 35.6%-40.8%]); higher prevalence of
pain (33.9% [95% CI, 29.0%-39.1%] vs 27.1% [95% CI, 24.7%-
29.6%]); numbness/tingling (20.2% [95% CI, 16.1%-24.7%] vs
11.3% [95% CI, 9.6%-13.1%]); and need for gait assistance devi-
ces (39.8% [95% CI, 34.7%-45.1%] vs 28.8% [95% CI, 26.3%-
31.3%]) (table 4). Independence for ADL was lower in the ICU
group (61.1% [95% CI, 55.8%-66.2%] vs 72.7% [95% CI, 70.3%-
75.1%]). Dependence for IADL was also more frequent in the
ICU group (84.6%, [95% CI, 80.4%-88.2%] vs 74.5% [95% CI,
72.0%-76.8%]). Postdischarge telerehabilitation treatment plan
consisted mostly of exercise booklets (table 5), which were
offered to 65.5% of the individuals after discharge, whereas the
remaining individuals received those booklets during hospital
stay. Patients were most frequently referred to psychologists
(11.8%), physical therapists (8.0%), and dietitians (6.8%). Our
rehabilitation treatment plan was declined by patients and/or fami-
lies in 2.5% of the cases at time of referral (see table 5) for differ-
ent reasons: “she needs to rest,” “online rehabilitation will not
strengthen him,” “we are afraid she will be infected again,” and
“we are afraid that our family will be infected.” We have not
assessed if the remaining 97.5% of those referred to telerehabilita-
tion followed our recommendations and scheduled their therapy
sessions.
Discussion
We have showed high prevalence of symptoms and disability rates
after COVID-19. As anticipated, individuals admitted to the ICU
had higher disability levels than those admitted to the ward. Persis-
tent symptoms and disability after COVID-19 have been previously
reported,
2,4-8,10
and other authors have observed worse outcomes in
those admitted to the ICU (table 6). According to data from the
United Kingdom, breathlessness at rest in the first 2 months after
discharge was higher in those admitted to the ICU (28.1% vs 19.3%
in our sample) than the ward group (19.1% vs 15.8% in our sam-
ple).
6
That study also showed more prevalent fatigue, posttraumatic
stress disorder symptoms, and decrement in quality of life in the
ICU group compared with the ward group. Differences between
ICU and ward groups are likely multifactorial and could be partially
explained by disease severity.
2,9,10
SARS-CoV-2 infection can
cause pulmonary abnormalities; thrombocytopathy; endotheliop-
athy; hepatic, renal, and nervous system injuries, some due to viral
infection and others likely due to excessive immune response.
2,22,23
Recovery time of those injuries is still uncertain because a study
with matched controls found that the majority of survivors of
COVID-19 persisted with magnetic resonance imaging abnormali-
ties in the lungs, brain, heart, liver, and/or kidneys 2 to 3 months
Fig 2 Flowchart of patient selection according to the eligibility criteria.
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4 V.F. Leite et al
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Table 2 Demographics, comorbidities, marital status, and living situation in the first month after hospitalization because of COVID-19
Variables Total (N=1696) ICU (n=357) Ward (n=1339) PValue
Female, n (%)
95% CI
951 (56.1)
53.7%-58.4%
183 (51.3)
45.9%-56.6%
768 (57.4)
54.7%-60.0%
.039*
Age (y), median (IQR) 73 (64-81) 71 (63-78) 73 (64-82) .006*
Mean §SD 71.8§13.0 70.3§11.9 72.2§13.2 -
Age strata, n (%)
95% CI
<.001*
<60 y 253 (14.9)
13.3%-16.7%
56 (15.7)
12.0%-19.9%
197 (14.7)
12.9%-16.7%
-
60-80 y 930 (54.8)
52.4%-57.2%
225 (63.0)
57.8%-68.0%
705 (52.7)
49.9%-55.4%
-
>80 y 513 (30.2)
28.1%-32.5%
76 (21.3)
17.1%-25.9%
437 (32.6)
30.1%-35.2%
-
Comorbidities, n (%)
95% CI
Hypertension 1082 (63.8)
61.5%-66.1%
224 (62.8)
57.5%-67.8%
858 (64.1)
61.4%-66.7%
.642
Coronary artery disease 321 (18.9)
17.1%-20.9%
75 (21.0)
16.9%-25.6%
246 (18.4)
16.3%-20.6%
.258
Pulmonary 262 (15.5)
13.8%-17.3%
57 (16.0)
12.3%-20.2%
205 (15.3)
13.4%-17.3%
.760
Neurologic 284 (16.7)
15.0%-18.6%
41 (11.5)
8.4%-15.3%
243 (18.2)
16.1%-20.3%
.003*
Immunosuppressed 49 (2.9)
2.1%-3.8%
13 (3.6)
2.0%-6.1%
36 (2.7)
1.9%-3.7%
.340
Cancer 83 (4.9)
3.9%-6.0%
15 (4.2)
2.4%-6.8%
68 (5.1)
4.0%-6.4%
.495
None 300 (17.7)
15.9%-19.6%
60 (16.8)
13.1%-21.1%
240 (17.9)
15.9%-20.1%
.623
Smoking status, n (%)
95% CI
.177
Never 1136 (67.0)
64.7%-69.2%
231 (64.7)
59.5%-69.7%
905 (67.5)
65.0%-70.1%
-
Current 26 (1.5)
1.0%-2.2%
9 (2.5)
1.2%-4.7%
17 (1.3)
0.7%-2.0%
-
Former 534 (31.5)
29.3%-33.8%
117 (32.8)
27.9%-37.9%
417 (31.1)
26.7%-33.7%
-
Alcohol use, n (%)
95% CI
.900
Never 1581 (93.2)
91.9%-94.3%
331 (92.7)
89.5%-95.2%
1250 (93.4)
91.9%-94.6%
-
Regular 47 (2.8)
2.0%-3.7%
11 (3.1)
1.5%-5.4%
36 (2.7)
1.9%-3.7%
-
Former 68 (4.0)
3.1%-5.1%
15 (4.2)
2.4%-6.8%
53 (4.0)
3.0%-5.1%
-
Marital status, n (%)
95% CI
.054
Single 141 (8.3)
7.0%-9.7%
31 (8.7)
6.0%-12.1%
110 (8.2)
6.8%-9.8%
-
Married 861 (50.8)
48.4%-53.2%
198 (55.5)
50.1%-60.7%
663 (49.5)
46.7%-52.2%
-
Divorced 145 (8.6)
7.3%-10.0%
34 (9.5)
6.7%-13.1%
111 (8.3)
6.9%-9.9%
-
Widowed 549 (32.4)
30.1%-34.7%
94 (26.3)
21.8%-31.2%
455 (34.0)
31.4%-36.6%
-
Living situation, n (%)
95% CI
.196
Alone 177 (10.4)
9.0%-12.0%
32 (9.0)
6.2%-12.4%
145 (10.9)
9.2%-12.6%
-
Spouse 422 (24.9)
22.8%-27.0%
94 (26.3)
21.8%-31.2%
328 (24.5)
22.2%-26.9%
-
Spouse and children 409 (24.1)
22.1%-26.2%
94 (26.3)
21.8%-31.2%
315 (23.5)
21.3%-25.9%
-
Children 396 (23.4)
21.4%-25.4%
81 (22.7)
18.4%-27.3%
315 (23.5)
21.3%-25.9%
-
SNF 121 (7.1)
6.0%-8.5%
16 (4.5)
2.6%-7.2%
105 (7.8)
6.5%-9.4%
-
Other 171 (10.1)
8.7%-11.6%
40 (11.2)
8.1%-14.9%
131 (9.8)
8.2%-11.5%
-
Abbreviation: SNF, skilled nursing facility.
*Statistical significance.
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Persistent symptoms and disability after COVID-19 5
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Table 3 Length of hospital stay, symptoms, and radiological severity at admission because of COVID-19
Variables Total (N=1696) ICU (n=357) Ward (n=1339) PValue
Length of hospital stay (d), median (IQR) 7 (4-12) 16 (11-25) 6 (4-9) <.001*
Mean §SD 9.7§8.6 19.3§12.1 7.2§5.0 -
Symptoms at admission, n (%)
95% CI
-
Coughing 1046 (61.7)
59.3%-64.0%
221 (61.9) 56.6%-70.0% 825 (61.6) 58.9%-64.2% .920
Fever 1029 (60.7) 58.3%-63.0% 217 (60.8) 55.5%-65.9% 812 (60.6) 58.0%-63.3% .961
Malaise 1106 (65.2) 62.9%-67.5% 232 (64.5) 59.8%-69.9% 874 (65.3) 62.7%-67.8% .920
Shortness of breath 948 (55.9) 53.5%-58.3% 226 (63.3) 58.1%-68.3% 722 (53.9) 51.2%-56.6% .002*
Hypo/anosmia 469 (27.7) 25.5%-29.8% 114 (31.9) 27.1%-37.0% 355 (26.5) 24.1%-28.9% .042*
Hypo/ageusia 619 (36.5) 34.2%-38.8% 135 (37.8) 32.8%-43.1% 484 (36.2) 33.6%-38.8% .561
Radiological severity at admission, n (%)
95% CI
<.001*
RAD-COVID 1 593 (35.0) 32.7%-37.2% 70 (19.6) 15.6%-24.1% 523 (39.1) 36.4%-41.7% -
RAD-COVID 2 884 (46.2) 49.7%-54.5% 136 (38.1) 33.0%-43.4% 648 (49.4) 45.7%-51.1% -
RAD-COVID 3 281 (16.9) 14.8%-18.4% 140 (39.2) 34.1%-44.4% 141 (10.5) 8.9%-12.3% -
*Statistical significance.
Table 4 Symptoms on different systems and measures of disability in the first month after hospitalization because of COVID-19
Variables Total (N=1696) ICU (n=357) Ward (n=1339) PValue
Time from discharge to follow-up (d), median (IQR) 21 (14-27) 20 (14-26) 21 (14-27) .022*
Mean §SD 21.8§11.7 20.7§11.6 22.1§11.8 -
Respiratory symptoms, n (%)
95% CI
-
Shortness of breath at rest 281 (16.6) 14.8%-18.4% 69 (19.3)
15.4%-23.8%
212 (15.8)
13.9%-17.9%
.112
Shortness of breath during routine activities 623 (36.7)
34.3%-39.1%
161 (45.1) 39.9%-50.4% 462 (34.5) 32.0%-37.1% <.001*
Shortness of breath during nonroutine activities 678 (51.7) 37.6%-42.4% 167 (46.8)
41.5%-52.1%
511 (38.2) 35.6%-40.8% <.001*
Oxygen therapy 260 (15.3)
13.6%-17.1%
91 (25.5)
21.0%-30.3%
169 (12.6)
10.9%-14.5%
<.001*
Physical symptoms -
Energy level, (0-10), median (IQR) 7 (5-9) 7 (5-8) 7 (6-9) <.0001*
Mean §SD 6.9§2.4 6.5§2.4 7.0§2.4
Pain prevalence, n (%)
95% CI
484 (28.5) 26.4%-30.8% 121 (33.9) 29.0%-39.1% 363 (27.1) 24.7%-29.6% .012*
Median (IQR) 5 (4-7) 6 (4-7) 5 (4-7) .0696
Mean §SD 5.5§2.2 5.8§2.2 5.4§2.3 -
Numbness/tingling sensation, n (%)
95% CI
223 (13.1) 11.6%-14.9% 72 (20.2) 16.1%-24.7% 151 (11.3) 9.6%-13.1% <.001*
Mobility impairment, n (%)
95% CI
-
Difficulty standing still for >10 min 683 (40.3) 37.9%-42.7% 176 (49.3)
44.0%-54.6%
507 (37.9)
35.3%-40.5%
<.001*
Difficulty moving any limb 407 (24.0) 22.0%-26.1% 114 (31.9)
27.1%-37.0%
293 (21.9)
19.7%-24.2%
.007*
Need for gait assistance devices 527 (31.1) 28.9%-33.3% 142 (39.8)
34.7%-45.1%
385 (28.8)
26.3%-31.3%
<.001*
Recent falls 107 (6.3)
5.2%-7.6%
20 (5.6)
3.5%-8.5%
87 (6.5)
5.2%-8.0%
.536
Measures of independence
ADL total score, median (IQR) 100 (70-100) 90 (55-100) 100 (75-100) <.0001
Mean §SD 80.4§29.7 75.6§29.7 81.6§29.5 -
(continued on next page)
ARTICLE IN PRESS
6 V.F. Leite et al
www.archives-pmr.org
after discharge.
9
Besides disease severity, consequences of ICU stay
could partially explain our findings because long-term effect of ICU
stay has been previously demonstrated for acute respiratory distress
syndrome due to SARS-CoV infection, as well as for other nonres-
piratory critical illnesses.
24-26
ICU-acquired weakness is a neuro-
muscular dysfunction that consists of polyneuropathy, myopathy,
and/or muscle atrophy that results of critical illness and can be mag-
nified by conditions during ICU stay.
26
Potential risk factors for
ICU-acquired weakness include use of corticosteroids and continu-
ous neuromuscular blockade, which were present in more than 40%
and 80%, respectively, of those admitted to the ICU because of
COVID-19.
26,27
Table 4 (Continued)
Variables Total (N=1696) ICU (n=357) Ward (n=1339) PValue
Total dependence (level 1), n (%)
95% CI
232 (13.7)
12.1%-15.4%
55 (15.4)
11.8%-19.6%
177 (13.2)
11.4%-15.2%
<.001*
Partial dependence (level 2), n (%)
95% CI
272 (16.0)
14.3%-17.9%
84 (23.5)
19.2%-28.3%
188 (14.0)
12.2%-16.0%
<.001*
Independence (level 3), n (%)
95% CI
1192 (70.3)
68.0%-72.5%
218 (61.1)
55.8%-66.2%
974 (72.7)
70.3%-75.1%
<.001*
IADL total score, median (IQR) 16 (10-20) 14 (10-18) 17 (10-21) <.0001*
Mean §SD 15.0 (5.2) 14.1 (4.7) 15.2 (5.3) -
Dependence, n (%)
95% CI
1299 (76.6)
74.5%-78.6%
302 (84.6) 80.4%-88.2% 997 (74.5) 72.0%-76.8% <.001*
Measures of affect, n (%)
95% CI
Anxious/depressive symptoms 632 (37.3) 35.0%-39.6% 139 (38.9) 33.8%-44.2% 493 (36.8) 34.2%-39.5% .462
Nutrition/eating, n (%)
95% CI
Weight loss with inappetence 566 (33.4) 31.1%-35.7% 143 (40.1) 34.9%-45.3% 423 (31.6) 29.1%-34.2% .003*
Dysphagia 215 (12.7) 11.1%-14.4% 45 (12.6)
9.3%-16.5%
170 (12.7) 11.0%-14.6% .963
*Statistical significance.
Table 5 Exercise orientation and telerehabilitation referral needs during telemonitoring after COVID-19 hospitalization
Variables, n (%)
95% CI Total (N=1696) ICU (n=357) Ward (n=1339) PValue
Orientation
Exercise booklet 1111 (65.5) 63.2%-67.7% 213 (59.7)
54.3%-64.8%
898 (67.1)
64.5%-69.6%
.009*
Exercise video 21 (1.2)
0.8%-1.9%
7 (2.0)
0.8%-4.0%
14 (1.0)
0.5%-1.7%
.165
Referrals -
Telehealth physical therapist 98 (5.8)
4.7%-7.0%
21 (5.9)
3.7%-8.9%
77 (5.8)
4.6%-7.1%
.006*
In-home physical therapist 37 (2.2)
1.5%-3.0%
15 (4.2)
2.4%-6.9%
22 (1.6)
1.0%-2.5%
.003*
Occupational therapist 17 (1.0)
0.6%-1.6%
4 (1.1)
0.3%-2.8%
13 (1.0)
0.5%-1.7%
.801
Speech-language pathologist 78 (4.6)
3.7%-5.7%
16 (4.5)
2.6%-7.2%
62 (4.6)
3.6%-5.9%
.905
Psychologist 200 (11.8)
10.3%-13.4%
48 (13.5)
10.1%-17.4%
152 (11.4)
9.7%-13.2%
.276
Dietitian 116 (6.8)
5.7%-8.1%
36 (10.1)
7.2%-13.7%
80 (6.0)
4.8%-7.4%
.006*
Physiatrist 12 (0.7)
0.3%-1.2%
6 (1.7)
0.6%-3.6%
6 (0.5)
0.2%-0.9%
.014*
Cardiologist 13 (0.8)
0.4%-1.3%
5 (1.4)
0.5%-3.2%
8 (0.6)
0.3%-1.1%
.122
Patient declined 43 (2.5)
1.8%-3.4%
5 (1.4)
0.5%-3.2%
38 (2.8)
2.0%-3.9%
.125
*Statistical significance.
ARTICLE IN PRESS
Persistent symptoms and disability after COVID-19 7
www.archives-pmr.org
To our knowledge, our study is the first to report disability for
ADL and IADL after COVID-19 infection in the Brazilian popula-
tion. Individuals in our study presented high rates of dependence
for both ADL and IADL, which cannot be completely attributed to
COVID-19 hospitalization. Because of the absence of baseline
values, we cannot ascertain if such symptoms and disability rates
were already present prior to COVID-19 hospitalization. Disabil-
ity in the general population could be estimated from a popula-
tion-based study with 1451 community-living older Brazilians,
which reported dependence for ADL and IADL of 36.0% and
34.0%,
28
respectively, compared with our rates of 38.9% and
84.6% for the ICU group and 27.3% and 74.5% for the ward
group. Despite that, we cannot ascertain whether the individuals
who were admitted because of COVID-19 in our network were
representative of the general population or if they represented a
subset with higher (or lower) disability. Obtaining disability rates
before and after COVID-19 hospitalization in the same population
would provide a clearer image of its effect. Additional factors
may have affected the generalizability of our findings: (1) 35% of
the participants were instructed to perform home exercises during
hospitalization, which may have reduced disability rates. (2) Out-
come assessment relied on self-reporting. Reliability of self-
reported Barthel Index on older adults has been reported to be
>80% for eating, toileting, and transferring and 63% for bathing
and dressing, with frequent underestimation of disability on self-
reporting. Therefore, it is possible that actual rates of ADL depen-
dence are higher.
29
(3) Physical distancing measures during the
pandemic may have overestimated dependency for IADL, particu-
larly for the categories “using transportation” and “shopping.”
Telemonitoring, as part of a comprehensive telerehabilitation
program, was feasible in our population. We managed to telemoni-
tor 100% of individuals after discharge, resulting in early identifi-
cation of persistent symptoms and disability, as well as early
referral to telerehabilitation with low refusal rates at the time of
referral. The rehabilitation treatment plan was affected by the pan-
demic and physical distancing measures, and, thus, we have
focused on providing exercise booklets and videos. Exercise book-
lets were provided to all participants, and 65.5% of them received
those exercises during telemonitoring. Those with more
rehabilitation needs were referred to telerehabilitation using a
device with camera (eg, smartphone, tablet). In-place therapy was
provided only for in-home physical therapy. Referral rates for
occupational therapy were low (1%), considering that disability
for ADL and IADL were 29.7% and 76.6%, respectively, and
referral rate to physical therapy was 8%. Possible causes for this
disparity include (1) overestimation of IADL disability because of
physical distancing measures, which created barriers unrelated to
body functions or structures that may have affected categories
such as shopping and (2) underdiagnosis of triggers for occupa-
tional therapy referral (cognitive and/or fine motor impairments)
because they were not screened in the telemonitoring protocol and
required active complaint by the individual.
Study limitations
We did not assess variables relevant to our study topic, such as
obesity, prevalence and duration of mechanical ventilation, and
use of continuous neuromuscular blockade.
26,30
We have not
assessed prevalence of fatigue, which has been previously reported
as a persistent symptom in this population (see table 6).
Obtaining data on individual categories for both ADL (Barthel
Index) and IADL (Lawton’s Index) would provide more compre-
hensive information than the aggregate score. That would improve
the understanding of which activities need to be rehabilitated in
this population. Dysphagia and anxious/depressive symptoms
were identified without using validated assessment tools and are
prone to measurement bias.
Our findings are limited by the absence of a control group
and baseline values for the outcomes. Therefore, we cannot
ascertain if the participants already presented those symptoms
and disabilities nor if individuals hospitalized for conditions
other than COVID-19 would present such findings. When
assessing difference between outcomes in individuals admitted
to the ICU vs ward, we did not take measures to avoid third
variable effects. Therefore, it is possible there are other factors
influencing the higher rates of disability in this subgroup.
Using statistical methods that take those effects into account
could minimize this issue.
Table 6 Current available literature on postdischarge symptoms after COVID-19
Variables Current Study Carfi et al
4
Chopra et al
5
Halpin et al
6
Huang et al
2
Mandal et al
8
Sample size 1696 143 488 100 1733 384
Country Brazil Italy USA United Kingdom China United Kingdom
Time after discharge (d) 21 (14-27) 36.1§12 60 48§10.3 153 (143-160) 54 (47-59)
Age (y) ICU=71 (63-78)
Ward=73 (64-82)
56.5§14.6 62 (50-72) ICU=58.5 (34-84)*
Ward=70.5 (20-93)*
57 (47-65) 59§16.1
ICU admission (%) 21.0 12.6 13.2 32 4 14.5
LOS (d) ICU=16 (11-25)
Ward=6 (4-9)
13.5§9.7 5 (3-8) ICU=12 (10-16)
Ward=6.5 (4-14)
14 (10-19) 6.5 (4-10.75)
Breathlessness (%) ICU=45.1
y
Ward=34.5
y
43.4 16.6 ICU=65.6 Ward=42.6 26 54.8-63.3
z
Oxygen therapy at follow-up (%) ICU=25.5
Ward=12.6
NR 6.6 NR NR NR
Fatigue (%) NR 53.1 NR ICU=72.0
Ward=60.3
63 67.3-76.9
z
NOTE. Data expressed as median (IQR) or mean §SD.
Abbreviations: LOS, length of stay; NR, not reported.
*Median and range.
y
Breathlessness during routine activities (eg, climbing stairs).
z
Data provided by subgroups only.
ARTICLE IN PRESS
8 V.F. Leite et al
www.archives-pmr.org
Conclusions
We have reported high rates of pain, shortness of breath, anxious
and depressive symptoms, dysphagia, need for oxygen therapy,
and dependence for both ADL and IADL in a predominantly older
population, with worse outcomes in the ICU group. We also pro-
vided data on rehabilitation referral needs to address disability in
this population. Our study corroborates and expands on the current
body of evidence regarding high rates of disability after COVID-
19 hospitalization. Future studies should explore individuals lon-
gitudinally, ideally with preadmission assessments as well as vali-
dated assessment tools for ADL and IADL disability, pulmonary
function, sarcopenia, cardiopulmonary fitness, cognition, dyspha-
gia, neuropsychiatric effects (eg, cognition, mood disorder, post-
traumatic stress disorder, substance abuse). Our team is currently
conducting a prospective study assessing pre- and post-COVID
functionality with patient-reported outcomes and objective assess-
ments with follow-ups until 12 months after discharge, which
could contribute to our understanding of this subject.
Supplier
a. Stata 13.0; StataCorp.
Keywords
Activities of daily living; COVID-19; Deglutition disorders; Dis-
abled persons; Dyspnea; Mental disorders; Rehabilitation;
Telerehabilitation
Corresponding author
Danielle Bianchini Rampim, MD, Prevent Senior, Rua Louren¸co
Marques 158, S~
ao Paulo, SP, Brazil. CEP 04547-10. E-mail
address: danielle.rampim@preventsenior.com.br.
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