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Introduction

Coronavirus disease is an infectious disease that is caused by SARS-CoV2. It originated from Wuhan, China. Symptoms of the disease can range from asymptomatic, mild, moderate or severe. Viral invasion may be attained by several routes, such as blood-brain barrier spread, trans-synaptic spread, infection of the vascular epithelium, or entry via the olfactory nerve. [1] As reported by the National Institute for Health and Care Excellence (NICE), the symptoms may last for more than eight or twelve weeks. It can have devastating effects on people’s lives, and can make them fatigued even after a short walk. [2] Recent studies have indicated that even after recovering from the disease, the affected people have difficulty in returning back to their previous lives, have persistent symptoms of the disease, commonly fatigue and shortness of breath, which compromises their overall quality of life. This condition of long-term effects of the disease is referred to as Long COVID, Chronic COVID Syndrome or Long Haul COVID. Treatment of persons affected with long COVID requires a multi-disciplinary approach encompassing assessment, treatment on the basis of symptoms, occupational therapy, psychological support and physiotherapy. [3]Activity restrictions, difficulty in returning to work or socializing or reduced participation in general suggest the need for rehabilitation for those affected. The World Health Organization has urged nations over the globe to prioritize rehabilitation for the complications resulting from COVID. [4] Several studies have asserted that it is imperative to begin rehabilitation for a person as soon as the health is stabilized. The aim of rehabilitation is to reduce fatigue, dyspnea, and anxiety, prevent complications and improve function and quality of life. Prolonged stay in the intensive care unit (ICU) and prolonged use of ventilators can put the person at risk of developing post-ICU syndrome, the effects of which can remain even after years of discharge. Considering the cognitive, pulmonary, neuromuscular, neurological and debility complications, early rehabilitation in the ICU is crucial to prevent the development of Long COVID. The objective of the survey was to understand the long term sequelae of COVID-19 in COVID recovered people in different parts of India, and hence to assess the need of rehabilitation in them.

Materials and Methods

It was a cross-sectional survey design. A semi-structured questionnaire was constructed after analyzing and understanding the existing research on long COVID. The survey was conducted via Google Forms and circulated to the participants in India via social media platforms viz WhatsApp and Instagram, through convenient sampling. People who had recovered from coronavirus disease at least 2 months prior had been included for the study, while those who had active disease or re-infections were excluded. There was no restriction on age range.

Statistical analysis

Descriptive statistics was used and data were analyzed in terms of means, percentages and frequencies. The data was analyzed using SPSS version 16.

Result

The responses received were analyzed using descriptive statistics.

Demographic Data –            

The survey included 50 participants who had recovered from the disease. The participants’ age ranged from 8 to 66 years. 60% of the participants were females (n=30), and 40% were males (n=20). The participants were all Indians and belonged to the regions Delhi,Chennai and Pune. The participants had the following pre-existing comorbidities: Hypertension (10%), Asthma (4%), heart disease (2%), Obesity (6%), Hypothyroidism (6%), Post-Polio Residual Paralysis (2%), Migraine (2%), Cold and cough (2%), and Anxiety (2%).The reported range of symptoms during the course of COVID has been summarized in Table 1. 2% of the participants were asymptomatic

Symptom

Percentage distribution

Symptom

Percentage distribution

Cough

66%

Diarrhea

36%

Sore Throat

58%

Fatigue

20%

Fever

52%

Rashes

16%

Difficulty in Breathing

50%

Anxiety

16%

Loss of Taste

48%

Abdominal Pain

14%

Loss of Smell

42%

Nausea and Vomiting

8%

Myalgia

40%

Headache

6%

Difficulty in Sleeping

40%

Conjunctivitis

6%

Loss of Appetite

4%

Loss of hearing

2%                           

Inability to wake up or difficulty in staying awake

4%

Weakness

2%

Repeated shaking with chills

2%

Leg pain

2%

Table 1. Distribution of symptoms reported during COVID19

When asked about additional complications, the following were the responses received along with the percentage of participants mentioned in parenthesis:

  • Generalized weakness (8%)
  • Tiredness and Difficulty in Breathing (2%)
  • Eye weakness (2%)
  • Continuous burnt smell feeling (2%)
  • Poor immunity (2%)
  • High fever (2%)

Most of the participants were treated under home quarantine (72%), and 2% were admitted in ICU while the rest were either quarantined in designated institutions (6%) or treated in stable areas of hospital (20%), (Graph 1).

Graph1: Distribution of the location where the participants were treated

Around 26% of the participants took 1-10 days to recover, 46% recovered in 10-20 days, 24% took less than a month and 4% took ≥ 2 months to recover from COVID. 

The participants reported a range of symptoms that persisted even after 2 months of recovery; as summarized in Table 2.

The following were the relieving factors of their symptoms, as reported by the participants.

  • Rest (12%)
  • Medication (22%)
  • Yoga (4%)
  • Hot water gargles (8%)
  • Consuming healthy food (6%)
  • Vitamin C (2%)
  • Relaxation – Breathing exercises (14%)
  • Homeopathy medicines and Ayurveda medicines (4%)
  • Avoiding activities which can aggravate the symptoms (2%)
  • Being occupied (4%)
  • Sleep (6%)
  • Nebulization with the help of oxygen mask (2%)
  • Maintaining a daily routine (2%)
  • Honey and ginger (2%)
  • Home remedies – kadha (4%).

On being asked whether they felt tired or out of breath after walking or climbing stairs, 33% of the participants gave a negative response while 62% of reported walking for a short distance or climbing stairs made them tired (Graph 2).

Symptoms

Percentage distribution

symptoms

Percentage distribution

Difficulty in breathing

44%

Headache

8%

Cough

18%

Fever

8%

Difficulty in Sleeping

14%

Tachycardia

6%

Fatigue

12%

Skin Rashes

6%

Myalgia

12%

Short Term Memory Issues

6%

Loss of Smell

12%

Low mood

4%

Difficulty with Thinking and Concentration

10%

Anxiety

4%

Chest Pain

8%

Changes in Mood

4%

Runny or Congested Nose

2%

Hair loss

2%

Complete or partial loss of sense of taste

2%

Diarrhea

2%

Abdominal pain

2%

Blurred Vision

2%

                   Table No 2 Symptoms persisting after recovery from COVID19

 

33% No tiredness or out of , 62% Tired or out of breath

Graph 2: Percentage of participants reporting tiredness or out of breath while walking or climbing stairs 58% of the people felt that COVID has impacted their ability to be efficient at work, while 42% of them reported no such issues.  48% found it difficult to do daily tasks due to tiredness while 52% reported no such difficulty.

Majority of the participants (48% of them) said that the symptoms had not hindered their ability to socialize, while 16% of them said that it did. 36% of the participants reported confusion regarding this response.  Most of the participants reported being satisfied with their health, while a small portion (24%) responded that they were not at all satisfied with their health. When asked to rate their tiredness on a scale of 1 to 10, 52% of the participants gave a rating between 1 to 5 and 48% of the participants gave a rating between 6 to 10. When the participants were asked to rate their difficulty in breathing on a scale of 1 to 10, 86% gave a rating between 1 to 5, while 14% gave a rating between 6 to 10. When the participants were asked to rate their quality of life after COVID, 34% gave a rating between 1 to 5, while 64% gave a rating between 6 to 10, which indicates little to no disruption in the overall quality of life. The higher the score, the better the quality of life.

Discussion

This survey examined the long-term consequences of coronavirus disease and how it had impacted the lives of recovered persons. A total of fifty participants from Delhi, Chennai and Pune, who had recovered from COVID19, completed the survey. Though not a true representation, the survey from multiple regions helped us to understand how COVID has affected different regions. To the best of our knowledge, it is the first attempt to study the long term sequelae of COVID in the persons residing in India. The majority of the participants (72%) studied were home quarantined during their acute illness. One of the asymptomatic subjects during acute illness reported a late onset difficulty in breathing with activity after 2 months of recovery. [5]

The present study reported that shortness of breath, cough, insomnia, fatigue and anosmia are the most commonly reported symptoms that persists in an individual 2 months post recovery. This observation is consistent with a review conducted by Malkova et al [6]. Lemhofer et al. found that 84.1% participants had participation restrictions and activity restrictions and 61.9% of the participants had long-COVID symptoms more than 3 months post infection. However, they reported that those symptoms were not severe and did not lead to a reduced quality of life; which is consistent with our findings. [7]Majority of our participants also reported a better QOL. Chen (2020) had reported a poor health related QOL amongst COVID persons. That was understandable as during the COVID infection, the person suffers from multiple ailments and emotional stresses. Hence the status of health related QOL would be expected to be poorer as compared to our participants where the status of QOL was being understood after a recovery period of minimum 2 months. [8] 44% of the participants reported to have dyspnea and tiredness while walking or after climbing stairs. This was in line with the findings of the survey conducted by Orru, G et al (2021), where shortness of breath was reported by 40% of the participants, two months after recovery. They also found that the long COVID symptoms recede over time, which could explain the better quality of life. [9]

Lemhofer, C et al (2021) in their study found that 61.9% of the participants reported at least one symptom persisting more than 3 months of recovery and 49% of the participants had participation limitations and activity restrictions. However, the impacts on quality of life were rather low which is consistent with our findings. [10] While there were several studies that assessed the persistence of long-covid symptoms, very little investigated the impact of long COVID on return to work. In our study, we found that long COVID had a significant impact on the said area. 58% of the participants had difficulties in being as efficient at work as before and 48% of the participants faced difficulties in socializing. Additionally, 48% of the participants reported activities related to restrictions.

Among the reported long term sequelae, a structured, tailor-made rehabilitation has shown promising results in overcoming fatigue, difficulty in breathing, mood disorders, difficulty to concentrate, reduced functional capacity and generalized myalgia. Rehabilitation should focus on graded aerobic exercises, stress management techniques, facilitating safe return to work, energy conservation techniques and strategies to prevent ICU or hospital related complications.  Several rehabilitation protocols have also been laid down to address the complications resulting from this syndrome. [11 -14]

Lemhofer, C et al (2021) developed a comprehensive screening tool to evaluate the need of rehabilitation during and after the end of active phase of disease. [15] The results of the study may be generalized in view of certain limitations. The sample size was small and diverse in terms of geographical location and age. It was limited to people who could understand English and had access to social media. The responses were limited to the self-understanding of the participants. Yet our study managed to capture the main long- term effects of COVID 19 recovered persons in a diversified population.

Conclusion

The long-term complications prevail in people who have recovered from COVID-19 which can potentially be addressed with a structured rehabilitation program.

Conflict of interest

The authors declare no conflict of interest 

Acknowledgement

The authors gratefully acknowledge and would like to thank all persons who had participated in this research

References

1. Zubair, et al, “Neuropathogenesis and neurologic manifestations of the coronaviruses in the age of Coronavirus disease 2019: A review. JAMA Neurology. 2020; 77(8):1018–27.

2 .Halpin S, et al , “COVID and chronic COVID syndromes”. Journal of Medical Virology. 2021;93(3):1242–3.

3 .Raveendran, et al. “Long COVID: An overview”. Diabetes Metab Syndr. 2021;15(3):869–75.

4 .Wise J. “Long covid: WHO calls on countries to offer patients more rehabilitation”. BMJ. 2021; 372: 405

5. Zu ,et al, “Coronavirus disease 2019 (COVID-19): A perspective from China”. Radiology. 2020;296(2): E15–25.

6 .Malkova et al. Post COVID-19 syndrome in patients with asymptomatic/mild form. Pathogens. 2021;10(11):1408.

7. Lemhöfer et al. The impact of Post-COVID-Syndrome on functioning - results from a community survey in patients after mild and moderate SARS-CoV-2-   infections in Germany. J Occup Med Toxicol. 2021;16(1):45.

8.Chen K-Y,et al, “Predictors of health-related quality of life and influencing factors for COVID-19 patients, a follow-up at one month”. Front Psychiatry. 2020; 11:668.

9. Orrù G ,et al, Long-COVID Syndrome? A Study on the Persistence of Neurological, Psychological and Physiological Symptoms. Healthcare. MDPI AG; 2021 May 13;9(5):575.

10. Lemhöfer C ,et al, “The impact of Post-COVID-Syndrome on functioning - results from a community survey in patients after mild and moderate SARS-CoV-2-infections in Germany”. J Occup Med Toxicol. 2021;16(1):45.

11.Lew, et al, “The war on COVID-19 pandemic: Role of rehabilitation professionals and hospitals: Role of rehabilitation professionals and hospitals”. J Physical Medical Rehabilitation. 2020;99(7):571–2.

12.Dasgupta ,et al,  “Long term complications and rehabilitation of COVID-19 patients’. J Pak Med Assoc. 2020;(70):131–135.

13.Korupolu, et al, “Rehabilitation of critically Ill COVID-19 survivors”. J Int Soc Phys Rehabilitation Med. 2020;3(2):45.

14.Sivan, et al, University of Leeds, Airedale NHS Foundation Trust. Assessing long-term rehabilitation needs in COVID-19 survivors using a telephone screening tool (C19-YRS tool). Advances in Clinical Neuroscience Rehabilitation.2020 19(4):14–17.

15.Lemhöfer C, et al, “Assessment  of rehabilitation needs in patients after COVID-19: Development of the COVID-19-rehabilitation needs survey”. J Rehab Med. 2021;53(4)183.

The Journal publishes original papers, current concepts, reviews and other articles relevant to physiotherapy with the aim to promote advances in research in the field of Physiotherapy. It also provides an opportunity for the expression of individual opinions on healthcare." with "The journal aims to promote research advances in the field of physiotherapy by publishing original papers, current concepts, reviews, and other relevant articles. In addition, it provides a platform for individuals to express their opinions on healthcare.

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