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Citation: Sánchez-García, J.C.;
Rentero Moreno, M.; Piqueras-Sola,
B.; Cortés-Martín, J.; Liñán-González,
A.; Mellado-García, E.;
Rodriguez-Blanque, R. Physical
Therapies in the Treatment of
Post-COVID Syndrome: A
Systematic Review. Biomedicines 2023,
11, 2253. https://doi.org/10.3390/
biomedicines11082253
Academic Editor: César Fernández
De Las Peñas
Received: 30 July 2023
Revised: 9 August 2023
Accepted: 10 August 2023
Published: 11 August 2023
Copyright: © 2023 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
biomedicines
Review
Physical Therapies in the Treatment of Post-COVID Syndrome:
A Systematic Review
Juan Carlos Sánchez-García1,2 , María Rentero Moreno 2, Beatriz Piqueras-Sola 1,3, Jonathan Cortés-Martín1, 2, * ,
Antonio Liñán-González 1,4 , Elena Mellado-García1,5 and Raquel Rodriguez-Blanque 1,2,6
1Research Group CTS1068, Andalusia Research Plan, Junta de Andalucía, School of Nursing,
Faculty of Health Sciences, University of Granada, 18016 Granada, Spain; jsangar@ugr.es (J.C.S.-G.);
bpiquerassola@gmail.com (B.P.-S.); antoniolg@ugr.es (A.L.-G.); emg2684@gmail.com (E.M.-G.);
rarobladoc@ugr.es (R.R.-B.)
2School of Nursing, Faculty of Health Sciences, University of Granada, 18071 Granada, Spain;
mariiaren.mr@gmail.com
3University Hospital Virgen de las Nieves, 18014 Granada, Spain
4School of Nursing, Faculty of Health Sciences, Melilla Campus, University of Granada, 52005 Melilla, Spain
5Costa del Sol Health District, 29640 Fuengirola, Spain
6University Hospital San Cecilio, 18071 Granada, Spain
*Correspondence: jcortesmartin@ugr.es
Abstract:
Introduction: Several days to months after diagnosis of SARS-CoV-2, 35% of patients have
persistent symptoms in high incidence. This is referred to as post-COVID-19 Syndrome. There is
a pressing need to find a way to help patients with the manifested symptoms. Objective: To show
the different therapies that exist for post-COVID Syndrome and their efficacy. Methodology: A
systematic review of the scientific literature was carried out. The data search was carried out in
Scopus, PubMed, Cinahl, and Web of Science. Of the 106 articles found, 12 articles were obtained after
applying the following eligibility criteria. Results: Interventions related to respiratory musculature
and moderate intensity exercise both in supervised face-to-face sessions and in supervised home
sessions led patients to a significant improvement in the symptoms presented. Conclusion: Physical
therapies significantly reduce fatigue and dyspnea as well as other symptoms related to quality of life.
Keywords: physical exercise; post-COVID-19; fatigue; dyspnea; respiratory exercise
1. Introduction
As is well known, in March 2020, due to the SARS-CoV-2 coronavirus, a pandemic
called COVID-19 was declared. It is known that almost 50% of SARS-CoV-2 patients
with COVID-19 pneumonia can recover spontaneously from a functional point of view
at 3 months [
1
]; however, it has been possible to observe the persistence of symptoms
(
11.5 ±5.7 days
), and sometimes up to 10–35% of patients have persistent symptoms after
several days or months. In the same way it can happen with people who have been mildly
ill, undiagnosed, or who may have late or persistent symptoms [2,3].
This syndrome, which is appearing, attracts attention because it refers to the sum of
very diverse symptoms that last until after the confirmation of SARS-CoV-2 infection. When
we speak of a syndrome in health, we refer to a “coexistence of several symptoms” [
4
–
6
].
Therefore, this syndrome will continue to exist even after the acute phase has ended and
several symptoms are still present.
Several names have been coined for this syndrome among patients, such as persistent
COVID or long COVID [
6
], but the one recommended by the WHO [
7
] for use is the term
post-COVID-19, since it does not allude to any kind of durability or causality [3].
The symptomatology of this syndrome can be very heterogeneous. The prevalent
post-COVID symptoms encompass fatigue, difficulty breathing, impaired sense of smell
Biomedicines 2023,11, 2253. https://doi.org/10.3390/biomedicines11082253 https://www.mdpi.com/journal/biomedicines
Biomedicines 2023,11, 2253 2 of 14
and taste, chest pain, muscle aches, as well as sleep and psychological disturbances [
5
].
This leads to a poor quality of life [2,3].
Studies, such as Simani et al. [
8
], have determined a prevalence rate of 5.8% to 43%.
The symptoms of this syndrome related to physical and respiratory deterioration can affect
the psychological health and, as a consequence, can condition the performance of physical
activity [
2
]. All this affects the ability of individuals to achieve a full recovery, affecting the
basic activities of daily living and even the return to work [9].
In order to find a correct approach to this syndrome, it is recommended to have a
first consultation 4 weeks after the acute phase [
10
]. The assessment of each patient can be
performed telematically or in person depending on the patient’s data. The use of scales
and/or questionnaires will also help us for the subsequent comparison of the state of
health and the follow-up of the evaluation, and will also allow us to unify criteria with the
health professionals.
There is a study, in particular, that talks about the symptoms associated with post-
COVID syndrome. It shows that there is a high incidence of the syndrome in question,
exposing the imperative need to find a way to effectively and efficiently help patients with
the aforementioned symptoms [11].
For this reason, a review of the literature is proposed to show the different therapies
that exist for patients with post-COVID syndrome and to evaluate their efficacy.
2. Materials and Methods
2.1. Review Protocol
The methodology used for this report was a systematic review of the scientific literature
published on physical therapies for the treatment of post-COVID syndrome, following
the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [
12
]
review protocol, which consists of a 27-point checklist of the most representative parts of
an original article, as well as the process of elaboration of these sections.
2.2. Eligibility Criteria
Articles with randomised clinical trial (RCT) methodology and articles with case
study methodology were selected. The articles should be written after the COVID-19
pandemic was declared, January 2020, and should provide information on the modalities
of therapies for the recovery of post-COVID syndrome in patients older than 18 years,
without restriction in reference to the language of publication.
2.3. Sources of Information
This search was performed in the Scopus, PubMed, Cinahl, and Web of Science
databases. In addition, a manual search was performed using reference lists of studies to
find other relevant studies.
The structured language used was obtained by means of MeSH terms and health
science descriptors (DeCS). The DeCs used were Post-Acute COVID-19 Syndrome and
Physical Therapy Modalities, and the Boolean operators used were “OR” and “AND”.
2.4. Search Strategy
The following table (Table 1) shows the search strategy used for this work, the source,
filters, and the date on which the search was performed.
Biomedicines 2023,11, 2253 3 of 14
Table 1. Search strategy details: source, filters, and search date.
Source Search String Filters Date of Search Items
WEB OF SCIENCE
(TS = (Post-Acute COVID-19 Syndrome)) OR TS = (“COVID-19 Syndrome,
Post-Acute” OR “Post-Acute COVID-19 Syndromes” OR “Long Haul COVID-19”
OR “COVID-19, Long Haul” OR “Long Haul COVID 19” OR “Long Haul
COVID-19s” OR “Post Acute COVID-19 Syndrome” OR “Post Acute COVID 19
Syndrome” OR “Long COVID” OR “Post-Acute Sequelae of SARS-CoV-2 Infection”
OR “Post Acute Sequelae of SARS-CoV-2 Infection” OR “Post-COVID Conditions”
OR “Post COVID Conditions” OR “Post-COVID Condition” OR “Long-Haul
COVID” OR “COVID, Long-Haul” OR “Long Haul COVID” OR “Long-Haul
COVIDs”) AND (TS = (Physical Therapy Modalities)) OR TS = (“Modalities,
Physical Therapy” OR “Modality, Physical Therapy” OR “Physical Therapy
Modality” OR “Physiotherapy (Techniques)” OR “Physiotherapies (Techniques)” OR
“Physical Therapy Techniques” OR “Physical Therapy Technique” OR “Techniques,
Physical Therapy” OR “Group Physiotherapy” OR “Group Physiotherapies” OR
“Physiotherapies, Group” OR “Physiotherapy, Group” OR “Physical Therapy” OR
“Physical Therapies” OR “Physical” OR “Physical” OR “Neurological
Physiotherapy” OR “Physiotherapy, Neurological” OR “Neurophysiotherapy”)
Articles and article reviews 6 March 23 12 results
PUBMED
((“Post-Acute COVID-19 Syndrome” [MeSH Terms]) AND (“COVID-19 Syndrome,
Post-Acute” OR “Post-Acute COVID-19 Syndromes” OR “Long Haul COVID-19”
OR “COVID-19, Long Haul” OR “Long Haul COVID 19” OR “Long Haul
COVID-19s” OR “Post Acute COVID-19 Syndrome” OR “Post Acute COVID 19
Syndrome” OR “Long COVID” OR “Post-Acute Sequelae of SARS-CoV-2 Infection”
OR “Post Acute Sequelae of SARS-CoV-2 Infection” OR “Post-COVID Conditions”
OR “Post COVID Conditions” OR “Post-COVID Condition” OR “Long-Haul
COVID” OR “COVID, Long-Haul” OR “Long Haul COVID” OR “Long-Haul
COVIDs” [Title/Abstract])) AND ((“Physical Therapy Modalities” [MeSH Terms])
OR (“Modalities, Physical Therapy” OR “Modality, Physical Therapy” OR “Physical
Therapy Modality” OR “Physiotherapy (Techniques)” OR “Physiotherapies
(Techniques)” OR “Physical Therapy Techniques” OR “Physical Therapy Technique”
OR “Techniques, Physical Therapy “OR” Group Physiotherapy” OR “Group
Physiotherapies” OR “Physiotherapies, Group” OR “Physiotherapy, Group” OR
“Physical Therapy” OR “Physical Therapies” OR “Therapy, Physical” OR
“Neurological Physiotherapy” OR “Physiotherapy, Neurological” OR
“Neurophysiotherapy” [Title/Abstract]))
Full text and in the last 5 years 6 March 23 65 results
Biomedicines 2023,11, 2253 4 of 14
Table 1. Cont.
Source Search String Filters Date of Search Items
SCOPUS
(((TITLE-ABS-KEY (“Post-Acute COVID-19 Syndrome”) OR TITLE-ABS-KEY
(“COVID-19 Syndrome, Post-Acute” OR “Post-Acute COVID-19 Syndromes” OR
“Long Haul COVID-19” OR “COVID-19, Long Haul” OR “Long Haul COVID 19”
OR “Long Haul COVID-19s” OR “Post Acute COVID-19 Syndrome” OR “Post Acute
COVID 19 Syndrome” OR “Long COVID” OR “Post-Acute Sequelae of SARS-CoV-2
Infection” OR “Post Acute Sequelae of SARS-CoV-2 Infection” OR “Post-COVID
Conditions” OR “Post COVID Conditions” OR “Post-COVID Condition” OR
“Long-Haul COVID” OR “COVID, Long-Haul” OR “Long Haul COVID” OR
“Long-Haul COVIDs”))) AND (((TITLE-ABS-KEY (“Physical Therapy Modalities”)
OR TITLE-ABS-KEY (“Modalities, Physical Therapy” OR “Modality, Physical
Therapy” OR “Physical Therapy Modality” OR “Physiotherapy (Techniques)” OR
“Physiotherapies (Techniques)” OR “Physical Therapy Techniques” OR “Physical
Therapy Technique” OR “Techniques, Physical Therapy” OR “Group Physiotherapy”
OR “Group Physiotherapies” OR “Physiotherapies, Group” OR “Physiotherapy,
Group” OR “Physical Therapy” OR “Physical Therapies” OR “Therapy, Physical”
OR “Neurological Physiotherapy” OR “Physiotherapy, Neurological” OR
“Neurophysiotherapy”).))
Articles 6 March 23 17 results
CINHAL (MH “Post-Acute COVID-19 Syndrome”) AND (MH “Physical Therapy+”)
Limiters: Refereed publications,
expanders: Apply equivalent
subjects and search modes:
Boolean/Phrase
6 March 23 12 results
Biomedicines 2023,11, 2253 5 of 14
2.5. Data Extraction Process
After carrying out the search strategy, the articles found were transferred to the Mende-
ley web application using the Mendeley web importer tool. They were then structured by
folders, according to the databases through which they had been obtained, and duplicates
were later eliminated.
The included studies were randomised clinical trials (RCTs) and cohort studies with
the objective of showing therapies in post-COVID syndrome patients and evaluating
their efficacy. The studies were published between 2020 and 2023. The title, abstract
and keywords of each study were examined, and the inclusion and exclusion criteria
were applied.
2.6. Data Collection Process and Data Collected
The following data were extracted from each article: men and women over 18 years of
age who have had the disease, number of participants, type of physical exercise performed,
duration of exercise, intensity, and whether it was supervised by professionals.
Section 3shows the selection process of the articles in more detail.
2.7. Risk of Bias in Individual Studies
To carry out the methodological evaluation of the articles selected for this study, we
proceeded to analyse the design, methodology and type of study of each article, with the
aim of selecting the most specific methodological evaluation scale for each case.
Of the 13 articles, 4 were case studies, 1 was a cohort study, 7 were RCTs, and 1 was a
quasi-experimental study.
The articles whose design was a case study were evaluated using the Single-Case
Experimental Design (SCED) [
13
]. The SCED was constructed including 11 items, of which
10 are used to evaluate methodological quality and one for the use of statistical analysis.
The following table (Table 2) shows the results obtained after the methodological
evaluation using the SCED scale [13].
Table 2. Methodological evaluation results using SCED scale.
Author Article Numerical Score
Santos, et al. [9]Musculoskeletal physiotherapy in physical sequelae of SARS-CoV-2 infection: A
case report. 7/11
Wagner, et al. [14]Successful application of pulsed electromagnetic fields in a patient with
post-COVID-19 fatigue: A case report 4/11
Rausch, et al. [15] The effects of Exercise Therapy Moderated by Sex in Rehabilitation of COVID-19 8/11
Daynes, et al. [16]Early Experiences of Rehabilitation for individual sport-COVID to improve
fatigue, breathlessness exercise capacity and cognition—A cohort Study 10/11
Zha, et al. [17]Trigger point injections and dry needling can be effective in treating long COVID
syndrome-related myalgia: a case report 6/11
For the articles whose methodology corresponded to a clinical trial, the scientific
quality was evaluated using the PEDro scale [
18
]. This scale provides information on the
clinical scientific evidence and scores it based on certain indicators, adding 1 point to each
one if they are present and 0 points if they are not, giving a total score of 10 points. If the
trial obtains a score between 9 and 10, it indicates that it is of very good quality; if it obtains
between 6 and 8, it indicates good quality; if it is between 4 and 5, it indicates fair quality;
and if it is less than 4, it indicates poor quality. In the case of the articles chosen for this
systematic review, the values range between 6 and 9, receiving an average score of 8.30,
which indicates that the average scientific quality is considered to be “good quality”.
The following table (Table 3) shows the results obtained after carrying out the method-
ological evaluation using the PEDro scale [18].
Biomedicines 2023,11, 2253 6 of 14
Table 3. Assessment of methodology using the PEDro scale.
Author Article Numerical Score
Estebanez-Pérez, et al. [19]
The Effectiveness of a Four-Week Digital Physiotherapy Intervention to
Improve Functional Capacity and Adherence to Intervention in Patients
with Long COVID-19
6/10
Sharma, et al. [20]Pulmonary Tele-Rehabilitation in Patients (Post COVID-19) With
Respiratory Complications: A Randomized Controlled Trial 8/10
Jimeno-Almazán, et al. [21]
Rehabilitation for post-COVID-19 condition through a supervised exercise
intervention: A randomized controlled trial 9/10
Sari, et al. [22] Effects of Inspiratory Muscle Training in Patients with post-COVID-19 9/10
Okan, et al. [23]Evaluating the Efficiency of Breathing Exercises via Telemedicine in
Post-COVID-19 Patients: Randomized Controlled Study 9/10
McNarry, et al. [24]Inspiratory muscle training enhances post-COVID-19 recovery: A
Randomised controlled trial 8/10
Palau, et al. [25]
Effect of a home-based inspiratory muscle training programme on
functional capacity in postdischarge patients with long COVID: The
InsCOVID trial
9/10
3. Results
After applying the search strategy for articles in the different databases and applying
the inclusion and exclusion criteria set out in the methodology, we identified 12 studies
that we included in our review. Figure 1shows the flow chart of the identified articles.
Biomedicines 2023, 11, x FOR PEER REVIEW 6 of 13
Table 3. Assessment of methodology using the PEDro scale.
Aut ho
r
Article Numerical Score
Estebanez-Pérez, et al. [19] The Effectiveness of a Four-Week Digital Physiotherapy Intervention to Improve
Functional Capacity and Adherence to Intervention in Patients with Long COVID-19 6/10
Sharma, et al. [20] Pulmonary Tele-Rehabilitation in Patients (Post COVID-19) With Respiratory Com-
plications: A Randomized Controlled Trial 8/10
J
imeno-Almazán, et al. [21] Rehabilitation for post-COVID-19 condition through a supervised exercise interven-
tion: A randomized controlled trial 9/10
Sari, et al. [22] Effects of Inspiratory Muscle Training in Patients with post-COVID-19 9/10
Okan, et al. [23] Evaluating the Efficiency of Breathing Exercises via Telemedicine in Post-COVID-19
Patients: Randomized Controlled Study 9/10
McNarry, et al. [24] Inspiratory muscle training enhances post-COVID-19 recovery: A Randomised con-
trolled trial 8/10
Palau, et al. [25] Effect of a home-based inspiratory muscle training programme on functional capac-
ity in postdischarge patients with long COVID: The InsCOVID trial 9/10
3. Results
After applying the search strategy for articles in the different databases and applying
the inclusion and exclusion criteria set out in the methodology, we identified 12 studies
that we included in our review. Figure 1 shows the flow chart of the identified articles.
Figure 1. Flow diagram.
Figure 1. Flow diagram.
Biomedicines 2023,11, 2253 7 of 14
Taken together, the studies obtained highlight the efficacy of various therapeutic
interventions to address the symptoms of prolonged COVID, encompassing physical and
psychological well-being.
Overall, there were notable increases in physical function, with improvements in
balance, muscle strength, and functional capacity, among others. Symptoms, such as
fatigue and dyspnoea, decreased substantially in the intervention group compared to
the control group. In addition, improvements in mental health and cardiovascular and
pulmonary capacity were recorded. These results support the efficacy of exercise and
rehabilitation strategies in the overall recovery of patients.
A summary of the results can be found in Table 4.
Biomedicines 2023,11, 2253 8 of 14
Table 4. Summary of the conclusions of the results obtained.
Author Sample Type of Therapy Results
Estebanez-Perez, et al. (2022) [19]n= 32 (23 women and 9 men)
Average age = 45.93 years
Digital physiotherapy for 4 weeks, with individual
evaluation. One daily session of 45–40 min, three to five
times per week.
Walking, jogging, or swimming (20–30 min) for 3 to
5 sessions/week. Increasing strength training,
exercising 1–3 muscle groups with a load of 8 to 12.
Recommendation of ventilatory techniques to improve
ventilation and mobility of the thorax.
After 4 weeks of intervention, a significant
improvement was shown (p< 0.05). In the SPPB test
(balance, gait speed, and chair support test) an
improvement of 1.21 points was found. In the 1-STS
test, an improvement of 3.50 points was obtained.
There was an improvement in functional capacity, with
high adherence rate and MCID values.
Santos, et al. [9]n= 1
Age = 60 years
Therapy consisted of the application of transcutaneous
electrical nerve stimulation, Cyriax deep transverse
massage, stretching exercises, balance, coordination,
and manual therapy, with Maitland passive
kinesitherapy. Three times per week for 5 weeks.
Muscle strength improved from 2/5 to 4/5 on the
Daniels muscle range test. Walking balance increased
along with more coordinated movements. Fatigue and
weakness disappeared. Patient can perform BADLs
and IADLs normally again.
Wagner, et al. (2022) [14]n= 1
Age = 55 years
Having noticed no improvement in previous therapies,
he decided to use an electromagnetic field therapy, an
ionic induction. Ten sessions of 30 min each, twice a
week for 5 weeks.
Patient placed in the supine position, 6 min are
administered on the abdominal area, 3 min on the
sternum, 6 min on the dorsal area, 6 min on the soles of
the feet, and 6 min on the pelvic floor. The frequency
used was 2.5 Hz for the dorsal area and 1 Hz for
the rest.
The patient improved markedly with increased energy
and complete disappearance of fatigue. There were
improvements in the dimensions of mood, work,
relationships, and enjoyment of life. There were no side
effects except for transient neck pain.
Sharma, et al. (2022) [20]n= 30
Average age = 18–55 years
Pulmonary telerehabilitation. The control group
received conventional care and the experimental group
received a therapeutic treatment protocol 4 days a week
for 6 weeks. Exercises to reduce fatigue and shortness
of breath.
Significant improvement in both groups, and there was
also a significant difference between CG and EG in
MBDS (p= 0.005 and p= 0.011) and VAS-F (p= 0.018
and p= 0.036). Therefore, it is concluded that the
experimental group recovered more quickly. Women
were more fatigued than men.
Biomedicines 2023,11, 2253 9 of 14
Table 4. Cont.
Author Sample Type of Therapy Results
Jimeno-Alamazán, et al. (2022) [21]
n= 39
CG = 20
EG = 19
Age = 45.2 years
Eight-week supervised, personalised multi-component
exercise program. Two days resistance training (3 sets,
8 repetitions of squat, bench press, dead weight, and
bench pull) combined with moderate intensity variable
training and one day of light intensity continuous
training (30–60 min) for the experimental group.
For the control group, aerobic exercise was
recommended for 20 to 30 min, 5 days a week, at a
tolerable intensity together with strength exercises in
3 sessions a week.
STS test, HSQ 50% 1 RM, estimated VO2max, and BP
50% 1 RM improved significantly in both groups. The
most pronounced changes were dyspnoea (control vs.
exercise: 83.3% vs. 5.4%, p= 0.003; V = 0.48) and fatigue
(61.1% vs. 34.6%, p= 0.072; V = 0.30).
In the exercise group, there was a progressive
improvement in symptoms (94.7% vs. 72.2%, p= 0.063;
V = 0.31), with patients being more likely to become
asymptomatic (42.1% vs. 16.7%, p= 0.091; V = 0.28)
than the control group. In cardiovascular parameters
there was a loss in the main determinant of fitness in
the control group (VO2max, 5.7% vs. −0.8%, p= 0.01)
and final HR (−50.0% vs. −13.3%, p= 0.01). Lower
limbs recovered in both groups when measuring the
STS test (−22.7% vs. −20.7%).
Rausch, et al. (2022) [15]
n= 233
Women = 94, mean age = 61.50
years
Men = 139, mean age = 61.69 years
Moderate therapy exercise, duration of 3 weeks. The
6MWT and a pulmonary function test were performed.
They followed a standardised program which consisted
of respiratory muscle training (3 sets of 10 breaths and
1 min rest), strength exercises, endurance training, and
relaxation exercises.
Men received more respiratory strength exercises than
women. No significant correlations were found
between the number of respiratory muscle training
sessions and lung function parameters (
p> 0.05
). In the
6MWT test, both men and women had statistically
significant results (T (232) =
−
16.67; p< 0.001; d = 0.48).
Men showed a shorter distance run compared to
women (T (231) = −3.04; p< 0.01; d = 0.41). The
improvement in ICmax was significantly higher in men
(F (1227.46) = 8.93; p> 0.01; ω2= 0.03). Men showed
higher FVC before and after. The same was true for
FEV1. Women showed a smaller difference with respect
to FEV1 improvement. Significant reduction in FVC.
Sari, et al. (2022) [22]
n= 24
TG = 13
CG = 11
Age = 18–65 years
Inspiratory muscle training. Diagrammatic respirations,
together with thoracic expansion and exercises to
increase thoracic distensibility. A total of 10 repetitions,
3 sets per day. Resistance training to strengthen the
quadriceps (squats and bridge exercises) for 6 weeks
every day with 10 repetitions and 3 sets per day.
The 6MWT distance and the 30 s standing test
increased significantly in TG (p< 0.001) and CG
(
p< 0.05
). mMCR dyspnea scale significantly decreased
in TG, from 10 to 2 patients with dyspnea in TG and
from 7 to 6 patients with dyspnea in CG. Muscular
strength of hand pressure increased significantly in TG.
Biomedicines 2023,11, 2253 10 of 14
Table 4. Cont.
Author Sample Type of Therapy Results
Okan, et al. (2022) [23]
n= 49
IG = 26
CG = 26
Age > 18 years
Breathing exercises. In IG, 10 breathing exercises for
3 sessions per day, every day for 5 weeks. Light
walking 20–30 min, 5 times a week.
The CG had the exercises explained through a handout
plus a recommendation for light walking.
The FEV1 and FVC values after the test in IG were
significantly higher (95% CI: 2.921–8.771, 95% CI:
2.619–7.381 p2< 0.001). Between IG and CG, the
differences were not significant. In the MVV value, the
IG had higher significance (97.54 ±10.23). mMRC
values were more significant in the CG. The 6MWT
parameters were significantly higher in the IG.
Daynes, et al. (2021) [16]n= 32
Rehabilitation for 6 weeks and 2 supervised days per
week. Aerobic exercise, strength training of upper
limbs and lower limbs. Educational meetings.
Thirty completed rehabilitations. All improved:ISWT
by 112 m (p< 0.01) and 544 s (p< 0.01), FACIT by
6 points (pz 0.01), the EQ5D by 8 and MoCA by 2
(p< 0.01), and CAT by a score of 3 (p< 0.05). Anxiety
and depression were not statistically significant.
McNarry, et al. (2022) [24]n= 281
Age > 18 years
Inspiratory muscle training in 8 weeks. Intervention
group and control group (standard care). Participants
were trained to know how to use PrO2. Three sessions
per week unsupervised. A total of 6 blocks of 6 breaths,
interspersed breaks decreasing from 40 to 10 s in a
maximum time of 20 min.
KBILD (dyspnoea and activities and psychological) had
a significant improvement in GI. The GI had a good
reduction in dyspnoea. It also significantly increased
inspiratory muscle strength in the IG. Physical fitness
and functional capacity increased significantly in the IG
with an increase in VO2max.
Palau et al. (2022) [25]
n= 26
IG = 13
CG = 13
Age > 18 years old
Twelve weeks. IG training 2×week for 20 min each
session with inspiratory muscle trainer applying a
resistance of 25–30% of maximal inspiratory pressure.
Diaphragmatic breathing will be instructed. The CG do
not receive physiotherapy.
The IG mean VO2max was higher than that of CG
(22.2 mL/kg/min, 95% CI: 21.3 to 23.2). For VE/VCO2
there was no significant difference between IG and CG
(∆−1.92; 95% CI: −4.69 to 0.85; p= 0.165). Significant
improvement in depression/anxiety in IG.
Non-significant improvement in mobility, self-care, and
pain in both groups. IG had a significant improvement
in MIP.
Biomedicines 2023,11, 2253 11 of 14
Table 4. Cont.
Author Sample Type of Therapy Results
Zha et al. (2022) [17]n= 1
Age = 59 years
Dry and wet puncture. At 6 months after presenting
pain, WN was performed with 1% lidocaine without
epinephrine with a 25-gauge needle and 1.5 inches,
with four in the neck and shoulders, and one on each
side of the triceps. Four sessions were performed. At
12 months, DN was tried with a 21-gauge 1-inch needle
at 10 sites (4 in the neck and upper back region, 1 in the
posterior triceps, and 2 in each calf). She carried out
two sessions.
After several punctures, the patient improved
markedly as he remained pain free 18 months later.
SPPB, Short Physical Performance Battery. 1-STS, 1-min sit-to-stand test. MCID, Minimal Clinically Important Difference. BADL, Basic Activities of Daily Living. IADL, Instrumental
Activities of Daily Living. CG, control group. EG, experimental group. MBDS, Minimum Basic Data Set. VAS-F, Visual Analog Scale—Fatigue. HSQ, half squat exercise. 1 RM, one
repetition maximum. VO
2
, volumen máximo de oxígeno. BP, bench press. HR, heat rate. 6MWT, 6 min walk test. ICmax, maximal inspiration capacity. FVC, forced vital capacity. FEV1,
forced expiratory volume in the first second. TG, treatment group. mMRC, Modified Medical Research Council Dyspnea Scale. IG, intervention group. MVV, maximum voluntary
ventilation. ISWT, Incremental Shuttle Walking Test. FACIT, Functional Assessment of Chronic Illness—Therapy Fatigue Scale. EQ5D, EuroQual 5 Domain. MoCA, Montreal Cognitive
Assessment. CAT. COPD Assessment Test. PrO
2
, PrO
2
Fit Health (Device). KBILD, King’s Brief Interstitial Lung Disease. MIP, maximal inspiratory pressure. WN, wet needling. DN,
dry needling.
Biomedicines 2023,11, 2253 12 of 14
4. Discussion
The objective of this systematic review was to show the therapies that exist in patients
with long-COVID and to evaluate their efficacy, and for this reason the study of the articles
has been carried out.
This topic is closely related to the assessment of the systemic consequences of
COVID-19
,
which is a broad field of research in which the assessment of respiratory function plays a
key role. This was presented in the report by Pini et al. [
26
], where respiratory function
was analysed 4–6 months after hospital discharge in these patients to study the negative
consequences of COVID-19 pneumonia.
The results of this systematic review demonstrated that the exercise and rehabilitation
strategies had a positive impact on multiple aspects of patients’ health, from physical func-
tion to mental health. These findings support the efficacy of the interventions implemented
and suggest a pathway to improved recovery and well-being in people facing similar
health challenges.
Most of the articles selected in the elaboration have been published in the year 2022,
since we are dealing with a recent disease, namely COVID-19, and, above all, our objective
concerns therapies against post-COVID syndrome. After analysing them, we can con-
clude that the selected articles have a generally good methodological level. We have been
able to answer the main objective, since we have found different therapies for persistent
COVID, such as exercises of moderate intensity [
19
,
21
], exercises for the respiratory muscu-
lature [
15
,
20
,
22
–
25
], electromagnetic field therapy [
15
,
20
,
22
–
25
], application of cutaneous
electromagnetic nerve stimulation [9], and trigger point injections [17].
In the clinical guideline for long-COVID care, they recommend for fatigue a type of
progressive exercise therapy tailored to the individual patient [
27
], information that we
have been finding offers good results after completion [
19
,
21
]. In relation to dyspnoea,
the guideline recommends respiratory exercise [
20
]. However, we cannot determine the
efficacy of all studies as these have been based on a single case [9,14,17].
Several studies mention the improvement in the 6MWT test. Thanks to the controlled
exercise, it was observed that men run a shorter distance when compared to women, with
a significant increase for both [15,22,23].
Another improvement observed with controlled exercise was dyspnoea, which was
shown to decrease significantly, with a decrease of approximately 80% in the control
groups [15,21,22,24].
Depression and anxiety are a more subjective issue, since some studies show that there
is a significant improvement in the control groups [
24
,
25
] but there is another that does
not show a significant difference [
16
]. Despite that, it is observed that controlled exercise
improves depression and anxiety.
Regarding articles that discuss electromagnetic field therapy [
14
], namely the appli-
cation of electromagnetic nerve stimulation [
11
], it is shown that both women improved
the sensation of fatigue, pain disappeared completely, and quality of life improved. On
the other hand, the patient who received the trigger injections only manifested a complete
disappearance of the pain [
17
]. It is necessary to qualify this aspect, as it is interesting to
relate dry and wet needling with evident improvements in pain control in patients with
post-COVID symptomatology. As shown in the case of Zha et al. [
17
]. It is true that this
relationship can only be seen in this specific patient, so it is proposed as a new line of
research derived from this study to substantiate this possible new treatment pathway.
One of the limitations that have been found is the poor adherence of study participants
to the interventions [15,19,21,22,24] and the very small samples used [9,14,17].
Although there are several studies that demonstrate the efficacy of physical therapies,
it remains to be determined whether other types of therapies or treatment would be effective
against physical and psychological symptoms. And, above all, it is necessary to provide
psychological and emotional help to these patients.
Biomedicines 2023,11, 2253 13 of 14
In terms of the limitations observed, more studies are needed, as the limitations are
evident and may compromise the validity and reliability of the results. These limitations
stem from sample sizes, the potential for bias, inadequate control of confounding variables
and even the cross-sectional approach. Therefore, it is crucial to take these limitations
into account when interpreting and applying the results of such studies to ensure accurate
interpretation and appropriate use of their results in relation to physical therapies and
prolonged COVID.
5. Conclusions
After searching the literature, we have found that moderate exercise and respiratory
muscle exercises are beneficial for recovery from the most common symptoms of persistent
COVID, namely fatigue and dyspnoea.
It can be concluded that, in cases where there was exercise control, patients have a
considerable improvement in fatigue, depression and dyspnoea, among others.
However, there are still too few studies to be able to speak of the efficacy of certain
therapies for the symptoms of long-COVID-19.
Author Contributions:
Conceptualisation, J.C.-M., R.R.-B. and J.C.S.-G.; data curation, M.R.M.,
E.M.-G.
, R.R.-B. and J.C.S.-G.; formal analysis, J.C.-M., M.R.M., B.P.-S., A.L.-G. and R.R.-B.; investiga-
tion, R.R.-B. and E.M.-G.; methodology, R.R.-B., J.C.S.-G. and J.C.-M.; project administration, R.R.-B.
and E.M.-G.; resources, R.R.-B. and A.L.-G.; supervision, J.C.S.-G.; validation, R.R.-B., J.C.-M., E.M.-G.
and B.P.-S.; visualisation, R.R.-B. and J.C.-M.; writing—original draft, M.R.M., E.M.-G., J.C.-M., R.R.-B.
and J.C.S.-G.; writing—review and editing, R.R.-B., M.R.M., B.P.-S., J.C.-M. and J.C.S.-G. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement:
This systematic review was carried out following a protocol,
available on the web: http://www.crd.york.ac.uk/PROSPERO/ (accessed on 16 January 2023) and
whose registration number is CRD42023391811.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments:
We are grateful to the Official College of Nursing of Granada (CODEGRA) for
their help in the research support programme, and to the Chair of Research in Nursing Care of the
University of Granada and the Official College of Nursing of Granada.
Conflicts of Interest: The authors declare no conflict of interest.
References
1.
Orzes, N.; Pini, L.; Levi, G.; Uccelli, S.; Cettolo, F.; Tantucci, C. A prospective evaluation of lung function at three and six months
in patients with previous SARS-COV-2 pneumonia. Respir. Med. 2021,186, 106541. [CrossRef] [PubMed]
2.
Gómez Conesa, A. ¿Cómo abordar desde la fisioterapia la salud mental en el COVID persistente? Fisioterapia
2022
,44, 1–5.
[CrossRef]
3.
López-Sampalo, A.; Bernal-López, M.R.; Gómez-Huelgas, R. Síndrome de COVID-19 persistente. Una revisión narrativa. Rev.
Clín. Esp. 2022,222, 241–250. [CrossRef] [PubMed]
4.
Timewar, R.R.; Sumar, A.I.; Nitin, B.; Kohale; Suraj, B.; Rathod; Guarav, G. Manwar Post Acute Corona Virus (COVID-19)
Syndrome. Int. J. Adv. Res. Sci. Commun. Technol. 2023,3, 385–391. [CrossRef]
5.
Maltezou, H.C.; Pavli, A.; Tsakris, A. Post-COVID Syndrome: An Insight on Its Pathogenesis. Vaccines
2021
,9, 497. [CrossRef]
[PubMed]
6.
Fernández-de-las-Peñas, C.; Palacios-Ceña, D.; Gómez-Mayordomo, V.; Cuadrado, M.L.; Florencio, L.L. Defining Post-COVID
Symptoms (Post-Acute COVID, Long COVID, Persistent Post-COVID): An Integrative Classification. Int. J. Environ. Res. Public
Health 2021,18, 2621. [CrossRef]
7.
World Health Organization. Post COVID-19 Condition (Long COVID). Available online: https://www.who.int/europe/news-
room/fact-sheets/item/post-covid-19-condition (accessed on 8 August 2023).
8.
Simani, L.; Ramezani, M.; Darazam, I.A.; Sagharichi, M.; Aalipour, M.A.; Ghorbani, F.; Pakdaman, H. Prevalence and correlates of
chronic fatigue syndrome and post-traumatic stress disorder after the outbreak of the COVID-19. J. Neurovirol.
2021
,27, 154–159.
[CrossRef] [PubMed]
Biomedicines 2023,11, 2253 14 of 14
9.
Santos, S.; Flores, J.A. Musculoskeletal physiotherapy in physical sequelae of SARS-CoV-2 infection: A case report. Physiother. Res.
Int. 2022,27, e1938. [CrossRef]
10.
Centre for Disease Control and Prevention. CDC Post-COVID Conditions: Information for Healthcare Providers. Available online:
https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-care/post-covid-conditions.html#print (accessed on 8 August 2023).
11.
Donnachie, E.; Hapfelmeier, A.; Linde, K.; Tauscher, M.; Gerlach, R.; Greissel, A.; Schneider, A. Incidence of post-COVID
syndrome and associated symptoms in outpatient care in Bavaria, Germany: A retrospective cohort study using routinely
collected claims data. BMJ Open 2022,12, e064979. [CrossRef]
12.
Welch, V.; Petticrew, M.; Tugwell, P.; Moher, D.; O’Neill, J.; Waters, E.; White, H. Extensión PRISMA-Equidad 2012: Guías para la
escritura y la publicación de revisiones sistemáticas enfocadas en la equidad en salud. Rev. Panam. Salud Publica/Pan Am. J. Public
Health 2013,34, 60–67. [CrossRef]
13. Psycbite SCED Scale. Available online: http://www.psycbite.com/docs/The_SCED_Scale.pdf (accessed on 27 March 2021).
14.
Wagner, B.; Steiner, M.; Markovic, L.; Crevenna, R. Successful application of pulsed electromagnetic fields in a patient with
post-COVID-19 fatigue: A case report. Wien. Med. Wochenschr. 2022,172, 227–232. [CrossRef]
15.
Rausch, L.; Puchner, B.; Fuchshuber, J.; Seebacher, B.; Löffler-Ragg, J.; Pramsohler, S.; Netzer, N.; Faulhaber, M. The Effects of
Exercise Therapy Moderated by Sex in Rehabilitation of COVID-19. Int. J. Sports Med. 2022,43, 1043–1051. [CrossRef]
16.
Daynes, E.; Gerlis, C.; Chaplin, E.; Gardiner, N.; Singh, S.J. Early experiences of rehabilitation for individuals post-COVID to
improve fatigue, breathlessness exercise capacity and cognition—A cohort study. Chron. Respir. Dis.
2021
,18, 147997312110156.
[CrossRef] [PubMed]
17.
Zha, M.; Chaffee, K.; Alsarraj, J. Trigger point injections and dry needling can be effective in treating long COVID syndrome-related
myalgia: A case report. J. Med. Case Rep. 2022,16, 31. [CrossRef] [PubMed]
18.
Gómez Conesa, A. Escala PEDro. Available online: https://pedro.org.au/spanish/resources/pedro-scale/ (accessed on 27
March 2021).
19.
Estebanez-Pérez, M.-J.; Pastora-Bernal, J.-M.; Martín-Valero, R. The Effectiveness of a Four-Week Digital Physiotherapy Interven-
tion to Improve Functional Capacity and Adherence to Intervention in Patients with Long COVID-19. Int. J. Environ. Res. Public
Health 2022,19, 9566. [CrossRef] [PubMed]
20.
Sharma, P.; Goswami, S.K. Pulmonary Tele-Rehabilitation in Patients (Post Covid-19) With Respiratory Complications: A
Randomized Controlled Trial. Indian J. Physiother. Occup. Ther. 2022,16, 182–189. [CrossRef]
21.
Jimeno-Almazán, A.; Franco-López, F.; Buendía-Romero, Á.; Martínez-Cava, A.; Sánchez-Agar, J.A.; Sánchez-Alcaraz Martínez,
B.J.; Courel-Ibáñez, J.; Pallarés, J.G. Rehabilitation for post-COVID-19 condition through a supervised exercise intervention: A
randomized controlled trial. Scand. J. Med. Sci. Sports 2022,32, 1791–1801. [CrossRef] [PubMed]
22.
Sari, F.; Bayram, S.; Pala, G.G.; Çömçe, F.; Küçük, H.; Oskay, D. Effects of Inspiratory Muscle Training in Patients with post-
COVID-19. Harran Üniversitesi. Tıp Fakültesi. Derg. 2022,19, 581–588. [CrossRef]
23.
Okan, F.; Okan, S.; Duran Yücesoy, F. Evaluating the Efficiency of Breathing Exercises via Telemedicine in Post-Covid-19 Patients:
Randomized Controlled Study. Clin. Nurs. Res. 2022,31, 771–781. [CrossRef]
24.
McNarry, M.A.; Berg, R.M.G.; Shelley, J.; Hudson, J.; Saynor, Z.L.; Duckers, J.; Lewis, K.; Davies, G.A.; Mackintosh, K.A.
Inspiratory muscle training enhances recovery post-COVID-19: A randomised controlled trial. Eur. Respir. J.
2022
,60, 2103101.
[CrossRef]
25.
Palau, P.; Domínguez, E.; Gonzalez, C.; Bondía, E.; Albiach, C.; Sastre, C.; Martínez, M.L.; Núñez, J.; López, L. Effect of a
home-based inspiratory muscle training programme on functional capacity in postdischarged patients with long COVID: The
InsCOVID trial. BMJ Open Respir. Res. 2022,9, e001439. [CrossRef] [PubMed]
26.
Pini, L.; Montori, R.; Giordani, J.; Guerini, M.; Orzes, N.; Ciarfaglia, M.; Arici, M.; Cappelli, C.; Piva, S.; Latronico, N.; et al.
Assessment of respiratory function and exercise tolerance at 4–6 months after COVID-19 infection in patients with pneumonia of
different severity. Intern. Med. J. 2023,53, 202–208. [CrossRef] [PubMed]
27.
Sociedad Española de Médicos Generales y de Familia. Guía Clínica Para la Atención al Paciente Long COVID/COVID Persistente;
ERGON: Madrid, Spain, 2021.
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