Post-COVID-19 Cardiopulmonary Rehabilitation: Comparison
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Managing cardiopulmonary rehabilitation in patients with COVID-19 remains a global challenge due to the facets of this virus. The technologies used in the rehabilitation of post-COVID-19 patients fail to keep pace with the global epidemiological developments.

  • COVID-19
  • rehabilitation
  • emerging technologies
  • telemedicine

1. Introduction

Due to the COVID-19 pandemic and the extremely rapid increase in the number of infected people [1], the medical world has had to consider adapting medical services by adopting new strategies for patient care and monitoring [2,3][2][3].
The COVID-19 disease took the medical world by surprise because, although this disease mainly affects the respiratory tract, the sequels also affect the heart, the brain and the digestive tract [4]. At this point, wresearchers can say that COVID-19 is a disease of the whole body [5].
Post-COVID-19 syndrome is a condition that is marked by the presence of symptoms (such as fatigue, cough, shortness of breath, headache or brain fog) which persist for an extended period of time (such as weeks or months) following a person’s initial recovery from a COVID-19 infection [6].
The need for cardiopulmonary rehabilitation has increased with the COVID-19 pandemic due to the sequels developed as a result of this pathology [7,8,9,10][7][8][9][10]. Some studies have suggested that exercise should be applied in the acute phase for early and effective rehabilitation of COVID-19 patients with respiratory failure, while other studies propose the application of a three-stage exercise protocol, beginning in the inpatient phase, continues in the post-acute and continuous phase and at home after discharge for the good physical condition of the patients [11].
At discharge, some studies have shown that most subjects with COVID-19 have cardiopulmonary sequels with reduced functional capacity, exercise tolerance and muscle strength, regardless of previous health condition/level and other pre-existing disabilities [12,13][12][13]. Increasing the exercise tolerance, decreasing the intensity/control of symptoms and improving the level of daily activity are the most documented benefits of cardiopulmonary rehabilitation [14,15][14][15]. Cardiopulmonary rehabilitation in post-COVID-19 patients with cardiopulmonary sequels is necessary for them to have a normal life [16,17,18][16][17][18].

2. Cardiopulmonary Rehabilitation

Cardiopulmonary sequels for post-COVID-19 patients are significant. Recent studies report patient desaturation and dyspnea during exercise in this category of patients. In this case, the therapeutic approach of the rehabilitation program should be based on the principles of cardiovascular and pulmonary rehabilitation with an emphasis on restoring functional capacity and increasing the muscular strength of patients [23][19]. Prior to the pandemic, cardiopulmonary rehabilitation programs were available in two forms: center-based cardiac rehabilitation at the center and home-based cardiac rehabilitation at home, with an emphasis on rehabilitation in hospitals or specialized institutions for the proper supervision of patients [24][20]. Since the Centers for Disease Control and Prevention recommends that all high-risk individuals, including those with cardiovascular risk factors, stay home to limit potential COVID-19 exposure, it changes the way the patient approaches the rehabilitation process changes. Rehabilitation programs in hospitals have been closed, suspended or discontinued, as many other elective and outpatient care activities have been suspended. In this way, the patients’ access to high-performance medical equipment used in cardiopulmonary rehabilitation has become limited. Complex medical equipment is used to monitor controlled heart rate, patient training heart rate and continuous ECG recording, which is required for the monitoring of heart rate, arrhythmias, decreased oxygen and blood pressure. A database for complete documentation is no longer available for home use. At this time, attempts are being made to find solutions for remote cardiac rehabilitation to become a viable alternative. Current studies have demonstrated the efficacy of distance cardiopulmonary rehabilitation, improving patients’ short-term prognosis. At the moment, the solutions found are not necessarily related to e-health and telemedicine [24][20].

3. Medical Technologies Used in Post-COVID-19 Cardiopulmonary Rehabilitation

3.1. Video Guides

There are few studies that specify the results of following a cardiopulmonary rehabilitation program at home through a video, although there are a large number of free videos on different platforms that offer cardiopulmonary rehabilitation programs. Old studies show uresearchers the benefit of cardiovascular rehabilitation at home following a program set by the attending physician [25,26][21][22]. Rosen K. et al. mentions that some patients who have participated in remote cardiopulmonary rehabilitation have been offered digital video disc (DVD) guides for rehabilitation at home. After discharge, patients were provided with a telephone consultation service by cardiologists and nurses, every 2 weeks for 5 months. The video addressed to patients explains at a basic level what heart failure is, presents some warm-up exercises, followed by aerobic exercises that can be applied both indoors and outdoors. Possible symptoms requiring emergency visits to the attending physician or the emergency department are also presented [27][23].

3.2. Hybrid Approach

In order to facilitate the transition to telemedicine, there are studies currently testing the application of a post-COVID-19 cardiopulmonary rehabilitation program with a hybrid approach at the patient level. In this case, the patients are initially offered cardiac rehabilitation in a recovery center and then the long-term maintenance exercises are performed at the patient’s home, using various medical technologies. The complicated part of these studies is the demonstration of the effectiveness of these hybrid systems. This involves active and ongoing contact between patients and professionals through traditional methods, such as home visits and telephone consultations, or the use of technology-based solutions, which include web-based video calling and social networking platforms [28][24]. There are studies that aim to investigate the effectiveness and safety of the application of cardiopulmonary recovery programs at home, by the patient, without supervision. In this sense, issued application protocols include two parts: an aerobic training using an ergometer, which will be installed at the patients’ homes, and patient education using an e-learning system. Cardiovascular parameters will be monitored remotely during exercise through video chats. An e-learning system that will promote a better understanding of cardiovascular disease is used. The necessary devices for cardiopulmonary recovery such as calibrated ergometers and tablets will be made available free of charge to the patients enrolled in the program. The patients will perform anaerobic exercises at home using the ergometer for 30–40 min at least 3 times a week. During the exercise, an instructor will monitor the patient in real time (using interactive video tools and monitoring tools for various vital data) [29][25]. It is necessary to use monitoring systems of some important parameters in order to ensure the safety of the patient at home during the implementation of the rehabilitation program.

3.3. Telemedicine-Based Cardiopulmonary Rehabilitation

The Internet and mobile applications are currently the most widely used technologies in cardiopulmonary rehabilitation, especially in the COVID-19 era, offering patients a wide range of programs. In this sense, it is expected that all groups of cardiac or cardiopulmonary patients will benefit from this type of treatment [31][26]. In this case, more and more studies show that telemedicine has been applied as a screening option to provide treatment to patients. Telemedicine can be considered as personal protective equipment that reduces the risk of exposure and contamination for both patients and practitioners [32][27]. The COVID-19 pandemic has highlighted the importance and usefulness of telemedicine in providing a way to connect patients and healthcare professionals when a personal consultation is not possible [33][28]. Tele-consultations are a safe and effective way to assess suspected cases of COVID-19 and to guide the patient’s diagnosis and treatment, minimizing the risk of disease transmission. Telemedicine also allows many of the key clinical services to continue to operate regularly and without interruption during a public health emergency [34][29]. Telemedicine legislation varies across countries, but any healthcare institution interested in implementing telemedicine services must assess its technological level before doing so [35][30]. Digital health technologies use computing platforms, connectivity, software and sensors for health care and related uses [36][31]. Post-COVID-19 cardiopulmonary tele-rehabilitation has been shown to be effective in several recent studies [37][32]. Marcelo Dalbosco-Salas et al. developed a tele-rehabilitation program with a duration of 24 session [38][33]. At the beginning and the end of the rehabilitation program, all patients were evaluated in a primary care center. The tele-rehabilitation sessions were done at the home of the patient. The program included a warm-up (5 min), breathing exercises (3 min), aerobic and/or strength exercises (20–30 min) and stretching (5 min). The protocol was based on the recommendations of the Colegio Profesional de Fisioterapeutas de la Comunidad de Madrid [39][34] and on the recommendations of the American College of Sports Medicine [40][35]. The recovery program included weekly phone calls to assess the patients. Physiotherapists performed exercises at the same time as the patients using the online environment and using household objects, constantly assessing the patient’s condition using the Borg scale [41][36]. A. Gabriela da Silva Vieira et al. showed that breathing exercise programs offered by tele-rehabilitation may improve functional capacity and reduce dyspnea in both patients with COVID-19 in the acute phase and in post-COVID-19 disorders. Tele-rehabilitation seems to be a safe environment for the patient, considering that adverse events occurred were generally mild or moderate. Tele-rehabilitation has also been shown not to increase hospital readmissions in patients infected with COVID-19. Breathing exercises delivered by tele-rehabilitation improved the results of the 6-min walking test, the score on the dyspnea questionnaire and the effort perceived by the patient from 0 to 10 on the Borg Scale [42][37]. Li J suggests scheduling home visits for patients included in a tele-rehabilitation program at the time of inclusion in the program, at 6 weeks (post-treatment) and at 24 weeks (follow-up). Additional assessments were used for dyspnea performed by consultation by mobile phone or WeChat voice call at 2 and 4 weeks. They also used the 6-min walk test and devices for the monitoring of blood pressure, heart rate, oxygen saturation and lung function [43][38].

3.4. Virtual Reality in Cardiopulmonary Rehabilitation

Virtual reality (VR) could help patients in need of medical recovery. In the future, they could successfully perform the exercises at home, because the researchers will have been able to combine VR technology with 3D motion capture technology. VR offers high protocol customization capabilities, fully automatic reporting and tele-recovery functionality. It is designed as a “central hub” to which wresearchers connect a wide range of specialized peripheral devices, fully synchronized and integrated with this system, and being used as a clinical routine for recovery of a wide range of pathologies through numerous modules containing multiple clinically validated exercises [46][39]. The application of virtual reality and video games has proven to be an adjunct tool in the conventional cardiopulmonary rehabilitation program. The results show that there was an increase in resistance to fatigue for the patient, an increased quality of life and a cessation of depression reported by patients [47][40]. It has been observed that the application of virtual reality therapy on cardiac patients has significantly reduced the severity of depressive symptoms, anxiety and stress levels [48][41]. Resources such as remote patient monitoring devices, artificial intelligence (AI), machine learning and block-chain systems must be combined to achieve complex lower cost cardiopulmonary rehabilitation programs [49][42].

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