COVID–19 spread rapidly around the world and in its wake, has left many people still struggling with symptoms such as breathlessness and fatigue, which may be physical or mental effects, or a combination of both. Needless to say, the post–COVID era will involve many research approaches that will focus on finding the most effective methods in rehabilitating members of the population back to good health. In their study, Cheng et al (2021) considered what an effective rehabilitation programme would look like. Although they acknowledged other protocols being established, they recommended a comprehensive programme that encompasses a promotion of functional recovery, as they note that this has been ignored by much of the guidance. They gathered together specialists for an expert panel review over an online meeting, including members of the Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation. The expert panel sought to agree upon recommendations for rehab protocols for the five stages of the virus. These were written in relation to the following groups:
- Those who are outpatients with mild disease and no underlying risk factors
- Those with mild disease who are outpatients, but do have epidemiological risk factors
- Those who are hospitalised with moderate-to-severe disease
- Patients supported on a ventilator, but who have clear well-functioning cognition
- Those who are supported on ventilators but who have shown impaired cognitive function (Cheng et al, 2021).
The authors note there are medications to support care, but that rehabilitation is key in adjunct to this, with clear guidance made available to those caring for someone at any stage.
Those with known comorbidities such as cardiovascular disease, hypertension, diabetes and respiratory disease are at risk of a more severe development of the condition's symptoms. Therefore, Cheng et al (2021) recommend that outpatient programmes are home-based (as attending in person may result in increased transmission of the disease) but with the use of clear video instructions and telerehabilitation. The most important factor of rehabilitation is exercise, but that which is safe for the patient. The disease process is complex as it can differ in severity and is often accompanied by comorbidities that also limit the patient's ability to exercise. Cheng et al (2021) recommend that there is a comprehensive exercise programme that includes aerobic and resistance training for patients with comorbidities, but with special considerations.
Alongside the efforts made to support patients at all stages through effective and personalized rehabilitation, an online breathing and wellbeing tool has also shown promising results as an adjunct to aid recovery following COVID-19 infection. English National Opera (ENO) Breathe is a programme for people who have persistent symptoms following COVID-19 (Philip et al, 2022). The researchers stated that there are very few evidence-based interventions for ‘long COVID’. Despite the available medical protocols, holistic approaches are supported by specialists within the field. This is largely owed to their ability to manage mental health and in turn aid physical symptoms such as fatigue and breathlessness.
The team found promising results when comparing ENO Breathe results with usual care and concluded that health-related quality of life (HRQoL) was improved in this patient group with regards to mental wellbeing and symptoms of breathlessness. Therefore, in relation to adding an adjunct to usual care and medical treatment, it may be worthwhile to review protocols and guidance following further research, to include mind-body or music-based approaches as these add an enjoyable technique that a patient can develop in managing their symptoms and in taking control of their recovery. However, other methods to aid relaxation and reduce symptom severity such as Tai Chi can be examined more thoroughly in relation to their potential role in post-COVID recovery (Cheng et al, 2022).
Another adjunct to usual care and treatment could be to recommend that the patient is able to access, or be assisted with reviewing the guidance freely available on the NHS' dedicated website for the recovery campaign, ‘Your Covid Recovery’ (2022). There is a section for breathlessness and other sections for mental/physical health components.
The recommendations remind the patient of simple facts that health professionals may also use during their discussion with patients recovering from COVID-19. For example, it is simple and effective to remind someone that it is normal to occasionally get breathless, no matter who you are or what condition you have/have not had. A section on the site also covers ‘Getting moving again’ (2022)-a guide for patients to help themselves, and to remember that not only is exercise crucial, but that medication does not solve everything. Physical activity is an essential adjunct, when done safely. The site can advise on this and is a useful reference point. The patient should be reminded that despite their breathlessness, they should not stop doing the activity. Their tolerance will build over time and, in fact, aiming to do the activity is what will help cure the breathlessness. However, resilience needs to be built and as comorbidities often apply to this patient group, it is important that specialist consideration from a physiotherapist is sought regarding carrying out exercise and tasks without ‘overdoing it’.
Some of the recommended techniques for patients experiencing breathlessness include: using a cool wet flannel on the nose and upper cheeks to reduce the feeling of being out of breath, and using a breathing control exercise which can be highly effective. Your Covid Recovery (2022) explains that the breathing exercise involves deep and slow breathing while the patient places a hand on their tummy and another hand on their chest. The technique helps with the physical and mental aspects of mild breathlessness. With reference to medications, the British Medical Journal (2022) contains a ‘living journal’, providing open access to the latest advice regarding all medications known to be in use or newly ready for use for all stages of COVID-19.
The complex nature of COVID-19 will require an equally complex approach. This will involve medical and holistic methods to recovery from the virus, as well as its long-term effects. There has been an upsurge in mental health issues since the intensity of press–reporting in relation to the disease and measures to close schools, shops, gyms and other places that people relied on to maintain good health. While it is understandable that many people are now defining themselves as having ‘long COVID’ (as well as being described this way by GPs)—some of the long–term symptoms may be brought about by other pandemic measures. The mental health and physical aspects of breathlessness can be addressed through exercise where safe, and holistic therapies where suitable, as adjuncts to usual treatment. However, more focus will have to be placed on addressing several other physical and psychological effects of the virus and its legacy.