Effectiveness of a Community-based Cardiopulmonary Rehabilitation Program to the Elderly Recovered from Coronavirus Disease 2019 (COVID-19)

Coronavirus Disease 2019 (COVID-19) is an infectious disease that affects patients’ lung function and thus exercise tolerance. Elderly patients have shown to have more severe and long-term symptoms after contracting COVID-19. Limited evidence has been published on the effectiveness of cardiopulmonary rehabilitation programme for elderly patients recovered from COVID-19. Therefore, the aim of this study was to launch and evaluate the effectiveness of a communitybased cardiopulmonary rehabilitation programme.

Participants followed a 8-week cardiopulmonary rehabilitation programme which included cardiopulmonary and strength exercises. Prior and after the rehabilitation programme, chosen parameters of lung function, physical performance and functional outcomes were recorded.

Seven participants (4 males, 3 females) with mean age of 64.7±8.6 completed the rehabilitation program. No statistical significance was found between pre- and post-rehabilitation outcome measures. However, improving trends were found across all outcome parameters. There was no statistical significance in the self-administrated questionnaires before and after the rehabilitation programme. Nevertheless, there were improving trends in all three questionnaires reporting better health and functioning, less limitations and reduced impact of breathlessness on physical and mental health.

The study did not show any significant improvement on functional capacity, lung function or muscle strength in elderly recovered from COVID-19. However, improving trends have shown in all domains.

It is to confirm that a community-based rehabilitation programme is potentially beneficial to elderly recovered from COVID-19.

Keywords: Coronavirus Disease 2019; COVID-19; community-based; cardiopulmonary rehabilitation; elderly

Coronavirus Disease 2019 (COVID-19) is an infectious disease caused by a novel coronavirus leading to illness ranging from mild upper respiratory infections to severe pneumonia. The World Health Organization (WHO) declared the outbreak to be a Public Health Emergency of International Concern in January 2020 and recognized it as a pandemic in March 2020[1]. As of June 2022, more than 500 million cases have been reported, resulting in more than 6 million deaths across the globe [1].

Common symptoms of COVID-19 include fever, malaise, cough, and shortness of breath. Some cases were in serious condition [1]. It is recently reported that half of recovered patients in Hong Kong (HK) were still suffering from abnormal lung functions such as shortness of breath in daily activities and decreased exercise tolerance three months after being from the hospitals. Lung function of around 17 per cent of them remained poor nine months after recovery. Some patients might have a drop of about 20 to 30 percent in lung function. It is also found that significant changes were found in the functional respiratory capacity (FRV) and diffusion capacity of elderly patients diagnosed with COVID-19 for up to 6 months [23, 24].

Besides the impacts on physical and physiological functions, about 19 percent of the recovered COVID-19 patients expressed that they suffered depressive symptoms while 12 percent of them experienced anxiety. Medical doctors encouraged the recovered COVID-19 patients to participate in physiotherapy and perform regular exercise to strengthen their lungs [2, 3].

Current data showed that most people contracted COVID-19 recovered but the long-term effects of the illness such as declined bodily functions are not fully understood, particularly for patients who need more intensive care and the elderly. It is most likely that these ongoing complications will disproportionately affect the elderly especially in those with acute or chronic health conditions [4, 5].

Since the 5th wave of the pandemic, local figures revealed that the number of COVID-19 patients aged equal to or above 60 years old has reached over 300,000 [6]. On the other hand, a systematic review showed that the percentage of older adults meeting recommended physical activity ranged from 2.4 – 83.0% across the studies [22].

In view of the large number of older adults recovered from COVID-19 living in the community and varied physical activity level among them, a community based physical and cardiopulmonary rehabilitation programme should be rolled out and the effectiveness of the program should be investigated. It is hypothesized that the community based physical and cardiopulmonary rehabilitation programme is effective for older adults recovered from COVID-19 living in the community.

The study was conducted in a district non-governmental organization. Elderly recovered from COVID-19 fulfilling the inclusion and not the exclusion criteria were recruited to the study. Before the commencement of the study, ethical approval was sought from the Research and Ethics Committee of XXX (approval reference number HRE210125).

Participants were recruited if they fulfilled the following inclusion criteria: (1) recovered from COVID-19; (2) able to walk independently with or without walking aids; (3) does not undergo major operations in the past 3 months; and (5) able to obey and follow instructions. Participants were excluded if they did not fulfil the inclusion criteria, not cooperative or have unstable medical conditions or musculoskeletal diseases which affect mobility.

Participants performed a structured 8-week community based cardiopulmonary rehabilitation programme after recruitment. Duration of the whole training programme was 8 weeks. The workflow of the program is shown in Figure 1.

After recruitment, the participants were given a consultation session for baseline assessment and an educational talk about the importance of staying physically active during and after the pandemic. The participants were required to attend a face to face 1- hour exercise class once a week for a total of 8 weeks. The participants were also given a water dumbbell home cardiopulmonary exercise video, a pedometer watch and a resistance exercise band for continuing different types of exercise at home. They were strongly encouraged to perform all the provided exercise for 5-7 days per week. A logbook was given to record participants’ number of steps and the frequency of performing exercises every day. It was to self-empower the participants to develop the habit of exercise.

Prior to the training, participant characteristics e.g., gender, age, time post COVID-19, past medical history, functional status etc., were collected from the participants. The following outcome measures on the aspects of lung function, physical performance and functional outcomes were chosen and recorded:

1. Forced expiratory volume in one second (FEV1) and forced vital capacity (FVC): these are usually measured during a pulmonary function test.

2. Short Physical Performance Battery (SPPB): it is a test of lower extremity functioning which combines scores from usual gait speed, timed tests of balance and chair stands of the participants. Scores range from 0-12 with higher score indicating better functioning.

3. 6-min Walk Test (6MWT): it is widely used as an indicator of cardiorespiratory endurance and can be accessed as the most distance an individual can walk in 6 minutes.

4. Isometric deltoid and gluteal muscle strength: these muscle strengths were used to measure proximal muscle strengths of the participants.

5. Handgrip stren