Physical Therapy Management of Postacute Sequelae of COVID-19 in Outpatient Settings: A Scoping Review : Cardiopulmonary Physical Therapy Journal

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Physical Therapy Management of Postacute Sequelae of COVID-19 in Outpatient Settings: A Scoping Review

Scott, Kylie PT, DPT1; Ankrum, Summer SPT1; Lindsey, Elizabeth SPT1; Lopez, Oskar SPT1; Beitner, Jessica SPT1; Reck, Cyndi SPT1; Kargela, Mallory PT, DPT1,2

Author Information

1Physical Therapy Department, Midwestern University, Glendale, AZ

2Physical Therapy Department, Tufts University, Phoenix, AZ

Correspondence: Mallory Kargela, PT, DPT, Physical Therapy Program, Tufts University, 101 E. Washington St., Ste 950, Phoenix, Arizona 85004 ([email protected]).

The authors declare no conflicts of interest.

This study was deemed exempt by the Midwestern University, Institute Review Board, therefore written informed consent was not gathered.

Cardiopulmonary Physical Therapy Journal ():10.1097/CPT.0000000000000217, December 26, 2022. | DOI: 10.1097/CPT.0000000000000217
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Abstract

INTRODUCTION AND PURPOSE

The SARS-CoV-2 virus that provoked the coronavirus disease 2019 (COVID-19) pandemic has resulted in over 6 million deaths worldwide, and over 1 million confirmed deaths in the United States as of August 2022.1,2 Although research focused on acute COVID-19 continues to expand, the long-term effects of COVID-19 are still being discovered.3,4 The medical community is still working to define these effects, and they can be referred to collectively as Postacute Sequalae of SARS-CoV-2 (PASC) infection or post-COVID conditions (PCCs).5 For this review, we considered PASC to meet the criteria of ongoing symptomatic COVID-19 and post-COVID-19 syndrome based on the following definitions per a rapid clinical practice guideline:6

  1. Acute COVID-19: signs and symptoms of COVID-19 for up to 4 weeks.
  2. Ongoing symptomatic COVID-19: signs and symptoms of COVID-19 from 4 up to 12 weeks.
  3. Post-COVID-19 syndrome: Signs and symptoms that develop during or after an infection consistent with COVID-19, continue for more than 12 weeks and are not explained by an alternative diagnosis. It usually presents with clusters of symptoms, often overlapping, which can fluctuate and change over time and can affect any system in the body. In addition, the term “long COVID” is commonly used to describe signs and symptoms that continue or develop after acute COVID-19. It includes ongoing symptomatic COVID-19 (from 4 to 12 weeks) and post-COVID-19 syndrome (12 weeks or more).

Evidence shows that the effects of PASC can manifest across the spectrum of cardiovascular, pulmonary, neurologic, orthopedic, and cognitive body systems, and extend far beyond the postinfection period.3,4,7–12 This multisystem sequelae that ensue after COVID-19 infection results in a relatively heterogenous population entering requiring various levels of intervention.13 The state of the science currently promotes the necessity of outpatient physical therapy (PT) services to ensure safe and effective management of patients recovering from PASC.3,14–17 The Center for Disease Control (CDC) has identified that patients who previously had COVID-19 reported poorer general, mental, and physical health and overall function compared with patients without a previous diagnosis of COVID-19.7 They also reported that patients post-COVID-19 did not perform as well on a 6-minute walk test (6MWT) and used more rehabilitative services than control patients.7 In addition to a practice guideline recommending future research to explore the clinical effectiveness of exercise-based interventions for patients experiencing PASC in the outpatient settings,6 the American PT Association, National Institutes of Health, and CDC have issued statements proposing a call to action for further investigations into the evidence for those recovering from COVID-19 in outpatient PT settings.17,18

Although no specific recommendations for managing PASC in the outpatient PT settings have been established at the time of this publication, a few resources have been available for clinicians to reference. One such resource was a series of papers by World Physiotherapy19 providing brief suggestions for physical activity and exercise for patients with long-term effects from COVID-19. This publication drew conclusions from a variety of resources discussing exercise considerations for diagnoses similar to PASC; however, there remains limited evidence to support exercise recommendations specific to the PASC population.19 Another resource available to clinicians, known as the Postacute COVID-19 Exercise and Rehabilitation (PACER) project, set out to enhance the knowledge and proficiency in cardiopulmonary PT with the intent to provide educational resources to rehabilitation professionals as related to COVID-19.20 Although this resource has proven to be instrumental in the early guidance of PT interventions for patients with COVID-19 across practice areas and settings, it did not meet the criteria for inclusion in this review. Therefore, our study proves to be timely and relevant to the PT management of PASC in outpatient settings, so that we can build on these foundational resources and provide clinicians a summary of the evidence.

The objective of this review was to answer the following questions related to current evidence because it pertains to the management of PASC:

  1. What evidence exists for treatment approaches in an outpatient PT setting for patients with PASC?
  2. If there is an absence of evidence, can treatment approaches from other practice settings be applied in outpatient PT to manage patients with PASC?

METHODS

This review followed the guidance of the Preferred Reporting Items for Systematic Reviews and Meta-analysis Protocols Extension for Scoping Reviews (PRISMA-ScR).21 The protocol was registered with the Open Science Framework on September 16, 2021 (https://osf.io/8hnpz).

Eligibility Criteria

The participant, concept, context framework was used to develop eligibility criteria, according to the PRISMA-ScR.21

Participants

To be included in this review, papers needed to focus on PT interventions for adult patients with the diagnosis of PASC or other nomenclature for the same diagnosis (see Systematic Search for comprehensive list).

Concept

This review concentrated on publications that assessed or proposed different ways to implement PT interventions for patients diagnosed with PASC in the outpatient setting. Because of the novelty of the diagnosis and the nomenclature related to it, there was not an abundance of scientific literature available. So, we included studies in which information provided explained how PT interventions have been implemented in postacute settings for the same population of people. In addition, because the medical community is still developing a uniform definition of what we refer to as PASC in this review, we also included studies that used alternative nomenclature for PASC.

Context

This review focused to synthesize all the available information into a broad overview of how PT interventions can be used to assist in managing patients with PASC in the outpatient setting. We included publications in which PT was delivered in the context of postacute settings, such as inpatient rehabilitation facilities (IRFs) and home health, for patients recovering from COVID-19 infections.

Data Sources and Systematic Search

After an initial search of the available evidence, we identified 1 rapid guideline published in December of 2020.6 Because of limited publications specifically related to the management of patients with PASC in outpatient PT settings, we investigated the recommendations presented in guideline and developed searches in 5 databases: PubMed, Cumulative Index to Nursing and Allied Health Literature, Cochrane CENTRAL, Academic Search Complete, and MedLine. By means of these 5 databases, we used the following terms: “PT” OR “physiotherapy,” AND “postacute sequelae of SARS-CoV-2” OR (“PASC” AND [“COVID-19” OR “Sars-CoV-2”]) OR “postacute sequelae of COVID” OR “COVID-19 sequelae” OR “long haul covid” OR “covid long haul” OR “long covid” OR “long term covid” OR “chronic covid syndrome” OR “post covid syndrome” OR “post COVID-19 neurological syndrome” OR “post-acute COVID-19 syndrome” OR “COVID-19 post-intensive care syndrome” OR “PCCs.”

The last search was performed on August 12, 2022. Two independent reviewers (M.K. and K.S.) developed the search criteria and strategy. It was filtered by language (English), and all types of study design were considered. Once the search was complete, the reviewers discussed the results. If no agreement could be made, a third reviewer (E.L.) was consulted as a method to avoid bias.

Selection of Articles

Studies were selected if the methodology of the abstract described: (1) PT in postacute settings and (2) PT interventions to assist in the management of patients with PASC. We accepted a variety of types of publications: systematic reviews, scoping reviews, randomized control trials (RCTs), clinical guidelines, narrative studies, case reports; all pertaining to the scope of our review. Exclusion criteria were: (1) articles published before 2019; (2) non-English texts; (3) articles without full-text; (4) articles that discussed PT interventions in the outpatient or postacute setting for populations outside the diagnosis of PASC, such as non-COVID-19 pneumonia, non-COVID-19 cardiac diagnoses, etc.; and (5) articles that discussed PASC, but did not include PT-specific interventions. Duplicate and nonrelevant publications were removed.

Data Extraction

We extracted data on article characteristics, intervention studied, parameters used, general recommendations, and outcomes for each of the setting practice areas (outpatient and postacute). This information was synthesized in Table 1.

TABLE 1 - Study Characteristics and Quality Assessment
Source Study Design Study Setting Study Population Functional Outcome Measures Quality Tool and Score
Ceravolo et al 27 Systematic rapid “living” review Inpatient, home COVID-19 patients; no premorbidities reported NA PRISMA 24 score: 19/27
Siddiq et al 28 Scoping review Inpatient, post-acute, outpatient COVID-19 survivors receiving PR; no premorbidities reported Reported on the use of 6MWT, FIM, SF-36, Self-Rating Anxiety and Depression scales when assessing outcomes PRISMA-ScR 21 score: 20/22
Nambi et al 29 Randomized controlled trial Outpatient Men aged 60–80 years with post-COVID-19 sarcopenia; multiple premorbidities excluded Hand dynamometry, Tampa Scale of Kinesiophobia-11, SarQOL scales collected as baseline, 4 weeks, 8 weeks, and 6 months postintervention JBI-RCT 26 score: 12/13
Calabrese et al 30 Narrative review Outpatient NA NA SANRA 25 score: 12/12
Liska and Andreansky 31 Narrative review Postacute, outpatient NA Reported relevance for use of 6MWT, Chair Stand Test, Step Test, TUG, and PCFS when assessing outcomes SANRA 25 score: 8/12
Mayer et al 32 Case report Outpatient 37-year-old female with post-COVID syndrome; no premorbidities MRC-ss, hand dynamometry, TUG, TUG-cog, SPPB, 6MWT, MRC-dyspnea, MOCA, IES-R, HrQOL scales collected at baseline and 8 weeks post-intervention CEBM 23 score: 7/10
Shan et al 33 Case report Postacute Female in early 80's with premorbid DM2, HTN, obesity Chair Stand Test, TUG, and 6MWT collected on days 1, 5, and 10 during rehabilitation stay CEBM 23 score: 5/10
Thomas et al 34 Clinical guideline Inpatient, postacute, outpatient, home NA NA AGREE II 22 score: 6/7
6MWT, 6-minute walk test; AGREE II, Appraisal of Guidelines for Research & Evaluation II; CEBM, Center for Evidence-Based Management, COVID-19, coronavirus disease 2019; DM2, diabetes mellitus type II; FIM, functional independence measure; HrQOL, health-related quality of life; HTN, hypertension; IES-R, impact of events scale-revised; MOCA, Montreal cognitive assessment; MRC-dyspnea, Medical Research Council dyspnea; MRC-ss, Medical Research Council sum score; NA, not applicable; PCFS, post-COVID-19 functional status; PR, pulmonary rehabilitation; PRISMA-ScR, preferred reporting items for systematic reviews and meta-analysis protocols extension for scoping review; JBI, Joanne Briggs Institute; RCT, randomized control trial; SANRA, scale for the assessment of narrative review article; SarQOL, sarcopenia quality of life; SPBB, short physical performance battery; SF-36, short-form 36; TUG, timed up and go; TUG-cog, TUG-cognitive.

Critical Appraisal of Individual Sources of Evidence

This review cites a variety of publications across the scope, and appraisal of the evidence was conducted. We evaluated the quality of evidence through use of the Appraisal of Guidelines for Research and Evaluation II instrument, Center for Evidence-Based Management Critical Appraisal of a Case Report, the PRISMA-ScR checklist, the PRISMA-ScR checklist, Scale for the Assessment of Narrative Review Articles instrument, and the Joanne Briggs Institute (JBI) Checklist for Randomized Controlled Trials.21–26 All recommendations for use of the instruments were followed. This procedure was performed by 2 reviewers (M.K. and K.S.) independently and discussed later. If any disagreement occurred, a third reviewer (E.L.) was consulted for decision. Because of the nature of this review and the limited number of resources meeting the inclusion criteria, we did not exclude articles based on the quality of study; however quality of evidence for included articles can be observed in Table 1.

Synthesis of Results

A narrative review of the collected data was written. We set out to provide an overview of how PT interventions can be used to assist in managing patients with PASC in the outpatient setting. Because of limited publications within the scope of the review, we decided to divide the information into subsections based on practice setting to better identify present the available evidence.

RESULTS

Study Selection

We identified a total of 108 studies after reviewing the databases. After removing duplicates, 101 publications remained for eligibility screening. These publications were assessed against the above criteria by 2 reviewers (M.K. and K.S.). A total of 8 publications were selected and included in this review (Fig. 1).

F1
Fig. 1.:
PRISMA-ScR flow diagram.21 PRISMA-ScR, preferred reporting items for systematic reviews and meta-analysis protocols extension for scoping review

Relevant Data About Included Studies

This review was comprised of a diverse selection of publications. We identified 1 systematic review,27 1 scoping review,28 1 RCT,29 2 narrative reviews,30,31 2 case reports,32,33 and 1 clinical guideline.34 (Table 1).

Physical Therapy in Outpatient Settings

Physical therapists exist across many facets of the medical continuum including, but not limited to, hospitals, rehabilitation facilities, home health, and outpatient centers. It is important for all physical therapists to recognize the difference in medical support across these settings. Acute care based physical therapists work alongside other advanced medical providers (e.g., nurses, physicians, etc.) throughout a patient's hospitalization. Similarly, therapists who work in some postacute settings also have interdisciplinary support, including those in long-term acute care facilities, IRFs, skilled nursing facilities, and on-site hospice facilities. Conversely, physical therapists seeing patients in home health and outpatient settings lack on-site interdisciplinary support (Fig. 2). This is important to recognize as physical therapists in these more autonomous settings will need to recognize and manage the medical complexities of patients with PASC, including, but not limited to, autonomic dysfunction, postviral fatigue, and arrhythmias.13,35–37

F2
Fig. 2.:
Continuum of care for patients receiving PT. Adapted from the original source.48 PT, physical therapy

The interventions and recommendations detailed in this review have been divided into 2 categories that best represent the setting practice area: those publications that are specific to outpatient PT and those that are not specific to outpatient PT. Further subcategories have been identified based on the interventions provided within each setting practice area.

Summary of Publications Specific to Outpatient Setting of Physical Therapy

Physical therapy intervention is generally indicated for patients presenting with PASC in the outpatient setting.29,30,32 The interventions provided in the outpatient settings included routine vital monitoring before, during, and after the intervention and consisted of various forms of exercise-based interventions, resistance strength training, and pulmonary training exercises.29,30,32

Exercise-Based Interventions

All 3 of the outpatient specific articles included aerobic exercise training as a method of intervention. This included recumbent upper extremity bicycle ergometer, recumbent cross-training stepper, treadmill walking, jogging, and dancing, delivered at a range from low-intensity (40%–60% of maximum heart rate [HRmax]) to high-intensity (60%–80% of HRmax).29,30,32 Frequency for aerobic intervention varied across all studies with a range of 2 to 5 days/week. In 1 RCT by Nambi et al 29 low-intensity aerobic training improved the hand-grip strength, kinesiophobia status, and quality of life more than high-intensity aerobic training in older adults with sarcopenia symptoms. In addition, they reported that low and high-intensity aerobic training played a similar role in increasing the muscle cross-sectional area of arm, thigh, and calf region in older adults with sarcopenia symptoms.29 Calabrese et al30 stated that interval-based training delivered 2 to 3 times/week was preferable and tolerated better for patients with more complex symptoms with an additional recommendation that high-intensity exercises should only be administered after a careful initial evaluation and at a frequency of 2 to 3 times/week. One case report delivered biweekly aerobic training at an intensity of 60% to 80% of peak heart rate during the 6MWT with increases based on modified rate of perceived exertion (mRPE) at a goal of 4 to 6/10.32 At the end of 8 weeks of intervention the participant increased their distance on the 6MWT; however, still underperforming based on their age-predicted distance.32

Resistance Strength Training Interventions

Strength training was a method of intervention used to manage patients across the outpatient setting. One group made the recommendation that resistance strength training should be offered at moderate intensity equal to 8 to 12-repetition maximum at a frequency of 2 to 3 times a week, but no clinical outcomes were reported.30 Nambi et al29 opted for resistance at the intensity of 3 sets of 10 reptations at the 10-repetition max with 60 second rest period between sets for all major muscle groups. This group identified the major group muscles to be shoulder flexors, shoulder extensors, shoulder abductors, elbow flexors, elbow extensors, hip flexors, hip extensors, knee flexors, knee extensors, abdominals, and back muscles.29 Outcomes for this study cited resistance training coupled with low-intensity aerobic exercise demonstrated improvements in muscle strength and psychological effects and quality of life while also decreasing kinesiophobia.29

Finally, Mayer et al32 included strength training based on mRPE, with an initial rating of 5 to 6/10 performing 10 to 15 repetitions including the major muscle groups, including multijoint or compound exercises such as using a leg press. The authors reported that resistance exercises were progressed based on rating of mRPE increasing the load and/or repetitions when an exercise was rated <4/10 on mRPE. The participant began resistance training in sitting and standing with 3-pound dumbbells or ankle weights and progressed to include functional movements such as squats and lunges using 6-pound weights. Resistance exercise in-clinic was discontinued after the 12th visit and included as part of a home exercise program, with the participant showing improvements in muscle strength and power and physical function as discharge.32

Pulmonary Training Interventions

Two of the publications specific to PT in the outpatient setting used pulmonary training exercise as an intervention. Mayer et al32 specifically emphasized the use of breathing techniques focused on controlled diaphragmatic breathing with cues for relaxation and mindfulness. Diaphragmatic breathing and controlled breathing techniques were combined with general core and trunk exercises while sitting, quadruped, or standing. Although the authors reported improvements in function, the participant continued to show fatigue and dyspnea after 8 weeks of intervention.32 Another study made recommendations for including thoracic expansion exercises at 4 to 5 repetitions to avoid hyperventilation.30 In addition, they reported the practice of airway clearance techniques that use positive expiratory pressure is recommended for individuals in the postacute phase of COVID-19 infection, with an additional recommendation for cough assist and cough machines to assist in sputum expulsion. They concluded by strongly recommending the use of personal protective equipment when performing pulmonary-based interventions.30

Functional Outcome Measures Used in Outpatient Physical Therapy

Functional outcome tools were used across the publications specific to outpatient practice included in this review (Table 1). One such article reported the use of several different functional outcome measures to assess muscle strength and physical function: the Medical Research Council Sum Score, hand dynamometry, the 6MWT, the Short Physical Performance Battery, Medical Research Council Dyspnea scale, and the Timed Up and Go.32 The Montreal Cognitive Assessment and the TUG-cognitive component test were used to evaluate the cognitive component of PASC, whereas the Health-Related Quality of Life and Impact of Events Scale-revised scales assisted in evaluating perceived function.32 Nambi et al29 used hand dynamometry to determine grip strength, whereas the Tampa Scale of Kinesiophobia-11 and the Sarcopenia Quality of Life scales were used to assess patient perceived function across multiple body systems.

Summary of Publications Not Specific to Outpatient Setting of Physical Therapy

Publications included in this section explored settings other than ambulatory PT including 1 in an IRF, 2 that featured postacute and outpatient settings, and 2 that were generalized across multiple practice settings.27,28,31,33,34 The evidence within these practice settings largely agrees that PT interventions are supported for patients with PASC.27,28,31,33,34 Similar to those studies focused in the outpatient setting, the interventions featured consistent vital monitoring and were broadly categorized into exercise-based, resistance strength training, and pulmonary training interventions.27,28,31,33,34

Exercise-Based Interventions

A systematic review published by Ceravolo et al27 cites 1 article that offers parameters for exercise-based PT interventions for patients with PASC. This study suggested that a multicomponent rehabilitative program, including at least 150 to 300 min/week of aerobic exercise at moderate intensity (40%–60% heart rate reserve or 65%–75% of maximal heart rate) distributed among 5 to 7 days/week is effective for older individuals with PASC in the home setting.38 In addition, a scoping review by Siddiq et al28 provided a summary of recommendations for patients experiencing PASC in the postacute and ambulatory settings. Aerobic exercise interventions (walking, ergometry) should be at low intensity (between 1.0 and 3.0 metabolic equivalent of tasks for those who require oxygen therapy) in the postacute environment, whereas in the ambulatory setting, aerobic exercises (walking, slow jogging, swimming) should begin at low intensity, occurring 3 to 5 times/week, lasting between 20 and 30 minutes with intermittent rest.28 Another publication recommended aerobic exercise in the form of walking, swimming, cycling, or Nordic walking at an intensity that should not exceed 40% to 50% of patient's HRmax.31 In addition, the authors reported that physical activity should be performed at least 5 times/week for 30 minutes, with progression of intensity and duration if patient tolerates the load; however, the settings for these recommendations were not explicitly stated.31

Two publications included in this review supported the importance of exercise-based interventions for patients diagnosed with PASC, but offered little guidance to the implementation.33,34 Shan et al33 presented a case study of 1 patient who demonstrated improvements in functional outcomes and endurance over the course of 11 days of intervention in an IRF; however, specifics of the PT interventions were not provided. The authors report that the patient discharged home and required ongoing PT in the home health and outpatient settings.33 An updated clinical guideline published in 2022, stated the importance of a thorough assessment of exercise capacity and endurance in all practice settings for patients recovering from COVID-19, but did not provide specific recommendations for implementation.34

Resistance Strength Training Interventions

There was limited evidence available from the included studies that used resistance training as part of PT interventions. The scoping review provided recommendations for strength training in the ambulatory setting, but not in the postacute setting.28 The authors recommended starting with a reduced load within target muscle groups for 8 to 12 repetitions at 1 to 3 sets over the course of 6 weeks at 2 to 3 sessions per week.28 The updated clinical guideline again stated the importance of a comprehensive assessment of muscular strength and physical function in all practice settings for patients with PASC, but recommendations for achievement were not provided.34

Pulmonary Training Interventions

One group reported the use of active cycle of breathing, autogenic drainage, inspiratory muscle training, cough, and breathing techniques as methods to improve pulmonary function in patients post-COVID-19; however, the setting of practice was not identified.31 Another publication also included various breathing techniques as methods to improve pulmonary function, in the postacute and ambulatory setting.28 Breathing techniques were recommended at low intensity (between 1.0 and 3.0 METs) twice per day from 15 to 45 minutes. The authors also recommended positioning, bronchial hygiene techniques (cough assist, postural drainage, percussion), and chest maneuvers for postacute environments, whereas thoracic expansion, airway clearance, and forced expiratory techniques were to be used in the ambulatory environment.28 The clinical guideline published by Thomas et al34 supported the use of pulmonary training interventions across the postacute settings, and the importance of a thorough examination of oxygen requirements, oxygen saturations, and dyspnea at rest and exercise, the presence of cough with or without sputum, and indications for airway clearance techniques in the ambulatory settings.

Functional Outcome Measures Used in Postacute Settings of Physical Therapy

The use of functional outcome tools was reported across most of the publications in this section and can be reviewed in a condensed format in Table 1.

Shan et al33 reported the use of 3 measures to assess activity tolerance and endurance during 1 patient's IRF stay: the Chair Stand Test (30 seconds), TUG, and 6MWT. The updated clinical guideline provided only a brief mention of the 6MWT as an example assessment of exercise capacity or endurance.34 A third publication reported on the relevance of use of the 6MWT, Chair Stand Test, Step Test, TUG, and Post-COVID-19 functional Status (PCFS) scale when assessing outcomes for patients with PASC, although not specific to a setting.31 The scoping review published by Siddiq et al28 discussed the use of numerous outcome measures across different settings. The 6MWT, Functional Independence Measure, and Short-Form 36 Health Survey Questionnaire were used to capture the patient's physical function, whereas the Self-Rating Anxiety and Depression scales were used to assess mental health performance.28

DISCUSSION

The COVID-19 pandemic has led to an increase in patients with PASC across all PT settings. Although the goal of PT is to evaluate, diagnose, and manage health conditions, it is important to point out that a physical therapist's role may vary from setting to setting based on state practice acts and individual therapists' competencies. Moreover, we have observed a need for more evidence to guide PT interventions in the postacute and ambulatory settings. Increased public awareness and encouraged research in the area of the long-standing effects of COVID-19 can assist to fill knowledge gaps and improve the quality of life among COVID-19 survivors.39 More recently, attention has been called to this topic internationally when World Physiotherapy released a series of papers highlighting the significance of physical therapists' role in managing PASC, including brief suggestions for physical activity and exercise. These studies draw inferences from a variety of publications discussing exercise considerations for diagnoses similar to PASC; however, there remains limited evidence to support specific exercise recommendations for the PASC population.19 Thus, the goal of this scoping review was to determine the current evidence that exists for PT treatment approaches in an outpatient setting for patients with PASC.

Similarities and Differences of Interventions Across Settings

Of the 8 articles included in this review, only 3 publications were specific to the outpatient setting area, with 5 more studies that focused on outpatient practice as part of a multisetting study, or specifically the postacute setting. Although the limited number and quality of total publications creates challenges applying the interventions provided across a population, each of the studies were specific to PASC, which partially answers our first research question. Physical therapists who aim to use evidence-based practice must first recognize the importance of considering the risks and benefits of the decisions they make. Many of the articles referenced in this review acknowledge the importance of sound clinical decision-making and assessment skills before, during, and after the application of the interventions provided.28-29,34 In addition, some of the cited interventions were applied in the postacute settings that may not be appropriate for all patients.28,33 Therefore, implementation of these interventions without careful consideration of the risks could lead to more serious implications for patients in the outpatient setting. For patients with PASC in the outpatient setting, some guidelines that may warrant a possible deferral of the PT include:30

  1. Saturation <88% to 93%.
  2. Heart rate <40 beats/minute or >120 beats/minute.
  3. Systolic blood pressure <90 and >180 mm Hg.
  4. Body temperature fluctuations >37.2°C.
  5. Respiratory symptoms and fatigue that worsen during exercise and are not alleviated after rest.
  6. Symptoms such as chest tightness or pain, difficulty in breathing, severe cough, dizziness, headache, unclear vision, palpitations, sweating, and instability.

Careful recognition of the potential difficulties in vital monitoring is warranted for patients who experience PASC in outpatient settings. For example, in the case of pulse oximetry, several factors may limit the accuracy or effectiveness of monitoring such as the presence of nail polish, anemia, or low peripheral perfusion.40 Therefore, the use of any clinical guideline related to vital monitoring should be coupled with clinical reasoning and experience of the clinician to best serve the patient's unique needs.28,30,34

Although most often, patients in the postacute environment receive daily PT and near constant vital monitoring, patients being seen in ambulatory settings do not. A national survey of physical therapists revealed that only 14.8% of PTs perform routine monitoring of blood pressure and heart rate.41 The fact that very few PTs in outpatient therapy consistently monitor vitals41 is important to note when prescribing exercise for patients presenting with PASC. The biggest barriers that clinicians reported was time and perceived importance, so patients with PASC should be seen in an outpatient environment in which one-on-one care can be achieved and thorough evaluation with consistent vital monitoring is supported. Also of importance is the rate of recovery following exercise in an otherwise healthy population. Normally, heart rate should decrease by 12 beats within 1 minute of rest and 22 beats by the end of 2 minutes of recovery.42 Systolic blood pressure should recover to pre-exercise levels or less within 6 minutes of recovery.45 These distinctions are crucial and should not be overlooked when applying the interventions used in postacute settings and particularly with patients with PASC in an outpatient PT setting, because this population may not demonstrate a typical recovery response to exercise.13

Similarities in intervention type, intensity, duration, and delivery were found among all publications presented in this review and categorized into 3 main types: exercise-based, resistance strength training, and pulmonary training interventions. The interventional options and outcome measures found are consistent with current guidelines in place for outpatient cardiac and pulmonary rehabilitation (PR) programs adding to the importance of addressing all systems in patients with PASC.43,44 All studies prescribed a form of aerobic exercise, but it varied widely in intensity (40%–80% HRmax), frequency, duration, type, and description of intervention. An RCT reported better patient-related outcomes using low-intensity (40%–60% HRmax) versus high-intensity (60%–80% HRmax) aerobic exercise when combined with resistance strength training.29 Furthermore, some evidence has suggested that high-intensity training may be detrimental to patients' healing processes, exacerbating a postviral fatigue, similar to myalgic encephalomyelitis/chronic fatigue syndrome.15,29,30,45 This evidence is important because it may guide physical therapists away from interventions that may not be necessary to see improvements in strength, muscle size, and quality of life with patients presenting to outpatient therapy with PASC.29 Currently, entry-level physical therapists are educated to be adept at prescribing exercise-based interventions based on patient presentation and tolerance; thus this variation in interventions, although important to distinguish, may not present a disadvantage to clinicians skilled in exercise prescription. We feel that such variations in the limited available evidence create an opportunity to under-dose or overdose exercise-based interventions in a population that already has increased risk for cardiovascular and pulmonary compromise.

Resistance strength training was a consistent intervention in 5 of the studies; however, the intensity, frequency, and duration were different among each of them including a lack of any specific dosage in the postacute studies. If considering parallels across the intervention dosage for the available evidence, the consensus would be to prescribe resistance strength training at an intensity of 2 to 3 sets of 10 to 15 repetitions at the 10 to 12-repetition max (or 5–6/10 on the mRPE scale) with a 60-second rest period between sets. These should be performed at all major muscle groups, with a special focus on coupling it with low-intensity (40%–60% HRmax) aerobic exercise in the outpatient environment. We feel these parameters for prescription of resistance training are varied and may create challenges for novice clinicians to apply evidence-based practice if unfamiliar with the nuances of PASC.

There were 5 articles across PT setting practice areas that emphasized the value in pulmonary training interventions. The most frequent used interventions across all practice settings were breathing techniques that included diaphragmatic breathing and thoracic expansion techniques.30,32 Airway clearance techniques and cough assistance were more commonly observed in the postacute environments.28,31,34 In the clinical guideline, an emphasis was put on proper evaluation of oxygen levels and status, again, highlighting the importance of vital monitoring across all settings.34 A stronger emphasis was put on pulmonary-based interventions in the postacute settings,28,31,34 likely secondary to the acuity of disease in the patient population being treated. These recommendations should be closely evaluated by outpatient physical therapists to determine whether patients will require extensive pulmonary-based interventions as mentioned in postacute articles.

Finally, 1 additional commonality that spanned all PT practice settings was the performance of functional outcome measures. The 6MWT was the most used functional outcome measure for postacute and outpatient settings, appearing in half of the publications. Interestingly, only 1 study by Thomas et al34 recommended use of the PCFS Scale. This scale assists in determining the functional limitations of patients post-COVID-19 at varying points in the disease process.46 The limited use of this tool may be related to its lack of established validity in the population, however, may still present an opportunity to link patient functional status and improvement along the spectrum of care for those experiencing the long-term effects of COVID-19. Other outcome measures that were represented across practice settings were the TUG and Chair Stand Test.

Additional Considerations

Several other recommendations included in the publications within this review did not fit within the previously identified categories of intervention, but remain within the scope of PT and thus important to discuss. In addition to the need for thorough PT evaluation, Thomas et al34 included recommendations for areas of potential PT intervention related to pain, pelvic floor/continence, fatigue, sleep, delirium, cognitive function, social support, return to work/family/recreation, and additional health care referrals warranted. Another article went on to endorse interventional strategies aimed at patient education such as using booklets, videos, telehealth, advising on healthy lifestyle education, and encouraging family and social activities.28 They reinforced a multidisciplinary approach to managing patients with PASC in the outpatient setting, suggesting the use of PR and targeted occupational therapy involvement.28 Finally, the authors advocated for caregiver training, patient counseling, nutritional support, oxygen therapy, behavioral modification strategies, and vocation-specific support in the ambulatory settings.28

The condition of PASC is unique and should be managed on an individual basis using appropriate screening, evaluation, and interventions based on the available evidence and resources.15 Although some postacute management approaches of COVID-19 may be relevant for outpatient PT, not all techniques will be applicable because of the nuances of the setting and practice area. With the far-reaching nature of the pandemic and increasing survival rates, the management of PASC needs to be at the center of PT research. A recent publication suggests that up to 40% of nonhospitalized previously healthy patients will experience some degree of persistent symptoms with nearly half of them having concurrent comorbid conditions.47 This, again, demonstrates the need for skilled and guided outpatient PT management for patients recovering from COVID-19. Despite the growing support from domestic and international groups19,20,34 and the increasing need of our patients, the limited number and quality of studies aimed at PT interventions for managing PASC in the outpatient setting represented in this scoping review confirms the need for further resources and research in this area.

Limitations

The authors recognize that there were a few limitations to this study. Despite the amount of search entities used, there were a limited number of studies (n = 8) included in this review. We did not include studies that were written in languages other than English; thus, the potential of additional relevant studies being omitted was possible. Although our focus for this review was a patient population over the age of 18, we recognize that the included studies did not provide extensive demographic details or social determinants of health to represent the heterogeneity of the population. Similarly, despite an extensive list of nomenclature that has been linked to PASC, it is possible that relevant articles that did not use the terminology could have been excluded. However, we believe that this provides an opportunity for future researchers to enhance the evidence with high-quality projects specific to the patients with PASC in outpatient settings.

CONCLUSION

The COVID-19 pandemic is a global crisis that may pose long lasting health problems to some patients. This scoping review set out to identify the evidence that guides PT practice when managing PASC in the outpatient settings and was found lacking. Limited evidence has been published regarding the management of PASC in the ambulatory settings, despite a growing patient population. Although initiatives such as the PACER project, the World Physiotherapy papers, and an updated clinical guideline that have called to action, the need for more resources allocated to patients suffering from PASC, there remains a deficiency of evidence to provide direction in the outpatient PT settings. In addition, further studies that capture more detailed demographics and social determinants of health would provide clinicians useful resources to aid in the recognition of those patients that require longer and more intense bouts of PT in outpatient settings. Continued research into the development of a well-defined PT pathways of interventions is necessary to effectively determine the best strategies for patients experiencing the multitude of symptoms related to PASC. In addition, a call to action for consistent vital monitoring in postacute and outpatient settings is warranted to improve clinical and functional outcomes for our patients. Finally, in the absence of an abundance of high-quality evidence, clinicians may want to consider a thorough multisystem-based examination and clinical reasoning coupled with the interventions and outcome measures mentioned in this scoping review to assist in the management of patients with PASC symptoms in the outpatient setting.

ACKNOWLEDGMENTS

The authors would like to thank Linda Woodhouse, Debra Bierwas, Mariah Kahwaji, Marielle Jensen-Battaglia, and Catherine Yount for their support and advice on this project.

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    Keywords:

    long COVID; coronavirus; rehabilitation; post-COVID conditions; PASC

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