{"paper_id":"673935fe-7204-43ac-a303-690210370e3f","body_text":"Study Title: Effects of Six Weeks of Supervised Telerehabilitation on Pulmonary Function, \nFunctional Capacity, and Dyspnoea among individuals with Long COVID\nAuthors and Affiliations: Alya Al Mheiri 1¶\n , Srilatha Girish 1, # a *,¶ & Sampath Kumar \nAmaravadi 1,#b, ¶ \n1 Department of Physiotherapy, College of Health Sciences, Gulf Medical University, Ajman, \nUnited Arab Emirates.\n#a Current address: Department of Community Physiotherapy, MGM Institute of \nPhysiotherapy, Aurangabad, Maharashtra, India\n#b Current address: Department Physiotherapy, Institute of Sport, Nursing and Allied Health, \nUniversity of Chichester, West Sussex, PO196PE. United Kingdom.\nCorresponding author*: Srilatha Girish, Associate Professor, Department of Community \nPhysiotherapy, MGM Institute of Physiotherapy, Aurangabad, Maharashtra, India. E-mail: \nsrilathagirish@gmail.com.\nRunning Title: Telerehabilitation in Long COVID \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nABSTRACT\nBackground:  Long COVID, characterized by persistent symptoms post-COVID-19, presents \nchallenges like reduced functional capacity, pulmonary function, and dyspnea. \nTelerehabilitation, a remote healthcare approach, is gaining attention for its potential to address \nthese issues\nObjectives:  The study aims to determine the effect of telerehabilitation on functional capacity \nby six-minute walk test (MWT), pulmonary function by pulmonary function test (PFT), \ndyspnea by modified medical research council (mMRC) and level of physical activity by \nGlobal physical activity questionnaire (GPAQ) in individuals with long COVID.\nMaterials and Methods: At Al Ain Hospital, UAE, a 6-week telerehabilitation program for \nLong COVID patients aged 18-75 was studied using single-group pretest-posttest quasi-\nexperimental design . Pre  and post assessments included 6MWT, PFT, mMRC, and GPAQ. \nThe study also monitored technical issues and session adherence.\nResults:  Participants had an average age of 49.30 ± 15.46, height of 163.80 ± 9.76, and weight \nof 78.70 ± 15.58, with a gender ratio of 12 females to 8 males. After six weeks of \ntelerehabilitation, significant improvements were seen in the 6MWT (21% improvement) and \nPFT (4% FVC increase, 8% FEV1 increase, 1% FEV1/FVC increase, and 11% PEF increase). \nmMRC scale scores post-rehabilitation were significantly lower, indicating substantial \nimprovement in dyspnea levels with clinical significance.\nConclusion: This approach has shown tangible benefits in enhancing functional capacity, \npulmonary function, reducing dyspnea, and improving physical activity levels among \nindividuals with Long COVID. The results of the study demonstrate the feasibility and \neffectiveness of implementing a telerehabilitation program for individuals with Long \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nBACKGROUND\nCoronavirus 2019 (COVID-19), caused by the outbreak of the acute respiratory syndrome \ncoronavirus 2 (SARS-CoV-2) is a global pandemic and has led to an unprecedented public \nhealth crisis. [1] According to the World Health Organization (WHO), 1,038,228 cases of \nCOVID-19 have been observed in United Arab Emirates (UAE). [2] The clinical spectrum of \nCOVID-19 varies from asymptomatic infection to severe outcomes including respiratory \nillness, multiorgan failure, and fatal cases. [3,4] Clinical manifestations have been categorized \ninto three phases by the joint guidelines proposed by the National Institute for Health and Care \nExcellence (NICE), the Scottish Intercollegiate Guidelines Network (SIGN), and the Royal \nCollege of General Practitioners (RCGP): ‘Acute COVID-19ʹ (signs and symptoms of COVID-\n19 infection up to 4 weeks), ‘ongoing symptomatic COVID-19ʹ (from 4 weeks up to 12 weeks), \nand ‘post-COVID-19 syndrome’ (when signs and symptoms continue beyond 12 weeks).[5]\nThe majority (~ 80%) symptomatic individuals recover without hospitalization. \nApproximately15% become seriously ill and require oxygen, while the remaining 5% become \ncritically ill and need intensive care. [6] While most individuals recover from COVID-19, \nsurvivors have reported persistent symptoms that remain unresolved for months after being \ndischarged from the hospital. [7] Various terms, such as \"long haulers,\" \"Chronic COVID \nsyndrome,\" \"post-COVID-19 syndrome,\" \"post-acute COVID-19,\" or \"Long-COVID,\" have \nbeen used interchangeably to describe the lingering effects of COVID-19. Among these, \"Long \nCOVID\" is widely accepted globally. [8]\nWhile a specific definition is yet to be universally agreed upon, Long COVID is generally \ndescribed as a cluster of new symptoms that emerge around 12 weeks after a confirmed or \nsuspected case of COVID-19, in the absence of no other clinical diagnosis. [9] Individuals \nexperiencing Long COVID commonly report impaired lung functions, post-exertional fatigue, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nand dyspnea. Additionally, other symptoms include neurocognitive impairment, autonomic \ndysfunction, and mental health issues like anxiety and depression, among others. [10]\nLong COVID can manifest regardless of the severity of the initial infection, \nhospitalization status, or age. [11] Long COVID can lead to decreased physical activity levels \nand have a significant impact on the overall quality of life. [12,13]. \nResearch has shown that dedicated efforts to curb the spread of COVID-19, including \nthe implementation of prevention methods, development of treatments, and distribution of \nvaccines, have been instrumental in reducing the initial stage of infections. [14]  Shifting the \nperspective on the pandemic and giving significant attention to Long COVID is crucial. \nVarious professional organizations have emphasized the importance of early detection and \nrehabilitation for individuals experiencing Long COVID symptoms. [10] Despite ongoing \nresearch, the mechanisms behind Long COVID remain incompletely understood, and there is \ncurrently limited evidence for effective pharmacological management. As a result, exercise \ntraining has emerged as a viable alternative for effectively controlling the symptoms associated \nwith Long COVID.\nA large body of research has established exercise training as the cornerstone for \naddressing dyspnea and fatigue in various respiratory conditions in hospital setup (in or patient \nrehabilitation [15,16] However, training in a hospital setup is challenged by  factors including \nbut not limited to low participant uptake, insufficient attendance by the individual, and high \ndropout rates, accessing hospital-based training are transportation issues, acute exacerbation of \nthe conditions, disruption of daily routine, and symptom severity. As an alternative approach \nthe American Thoracic Society (ATS)/European Respiratory Society (ERS) now recommends \ntelerehabilitation (TR) to extend the benefits of hospital set up. [16,17]\nTR is a method of providing rehabilitation services to individuals remotely, utilizing \ninformation and communication technologies. [18] Unlike hospital-based rehabilitation, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nexercising at home may enhance effectiveness, facilitate long-term integration of exercise \nroutines into daily life, and improve compliance. The beneficial impact of exercise training \nthrough TR on exertional tolerance and dyspnea in conditions such as COPD has been \nextensively documented.[18] Nevertheless, there is limited literature available regarding the \nimpact of telerehabilitation training on exertional tolerance and dyspnea in individuals with \nLong COVID. [19-26] Apart from the challenges faced in hospital-based training, the ongoing \npandemic necessitates clinical and public measures to minimize the risk of viral transmission.   \nTR programs present a practical alternative in such situations.  The objective of the study was \nto determine the effect of six weeks of telerehabilitation on pulmonary function, functional \ncapacity and dyspnea in individuals with Long COVID.\nMETHOD\nStudy design: The current study adopted one group pretest-posttest quasi-experimental design.\nSelection criteria: Participants of both the gender aged between 18 to 75 years discharged \nfrom the Physical Medicine and Rehabilitation Department in Al Ain hospital, with a history \nof molecular testing confirmed COVID-19 infection, having a score of 0-2 on the modified \nmedical research council (mMRC) and having the access and ability to use virtual conference \ncall application (google meet or micro-soft team) were considered for the current study. The \nparticipant with mMRC dyspnea score of 3–4, resting heart rate over 100 bpm, uncontrolled \nhypertension (resting BP > 160/100mmHg), uncontrolled diabetes (e.g., diabetes with random \nblood glucose >16.7 mmol/L, hemoglobin A1C >7.0%), cerebrovascular disease within six \nmonths,  intra-articular drug injection or surgical treatment of lower extremities within six \nmonths and those who are unable to walk independently without the assistive device were \nexcluded from the study as they require close supervision and not considered fit for \ntelerehabilitation program.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nSample size calculation: The minimal important difference (MID) for COVID-19 has not been \nestablished, a MID of 30 meters is recommended for a 6-minute walk test in chronic diseases. \nGiven the limited knowledge about the long-term course of COVID-19, a MID of 50 was \nassumed. With 80% power, 5 % alpha error, and an attrition rate of 20%, the required sample \nwas 26.\nOutcome measure:\n Lung Functions: Lung functions were measured from a pulmonary function test (PFT) \nusing a portable pulmonary function device (EasyOne Pro® LAB, USA) according to \nguidelines of the American Thoracic Society. Changes in baseline parameters of vital \ncapacity (FVC), forced expiratory volume in the first second (FEV1), the ratio of FEV1 \nand FVC (FEV1/FVC), and Peak Exploratory Flow (PEF) at six weeks were assessed. \n[27]\n Functional capacity: The functional capacity was evaluated by a six-minute walk test \n(6MWT) in accordance with guidelines from the American Thoracic Society. The \nchange in distance walked in the 30-meter corridor from baseline functional capacity at \nsix weeks was assessed. [28-29]\n Dyspnea perception: The individual’s perception of dyspnea was measured with the \nModified Medical Research Council Dyspnea Scale (mMRC). Change in baseline \nperception of dyspnea level at six weeks was assessed on a 5-point ordinal scale (0: no \ndyspnea; 4: Severe dyspnea). [30]\n Level of Physical Activity: The level of physical activity was measured using the \nGlobal physical activity questionnaire (GPAQ) at six weeks of exercise training. [31]\nProcedure:\nThe study was conducted in the physical medicine and rehabilitation department at Al \nAin hospital. Ethical approval was obtained Institutional Review Board (Ref. no. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\n(IRB/COHS/STD/04/Jan-2022) of Gulf Medical University and SEHA, Al Ain hospital (Ref \nno. ERC-19022-1-2022). Consent to recruit the participants from the present study was \nobtained from Al Ain hospital. To locate the potential participants, the discharge registry of the \nPhysical Medicine and Rehabilitation Department in Al Ain hospital was accessed.  \nParticipants were contacted over the phone and the study protocol was explained. Upon \nobtaining verbal consent, participants were provided with appointments in the hospital for \nfurther evaluation of eligibility criteria. On meeting the eligibility criteria, participants signed \ninformed consent form. \nThe virtual platform used in the current study was google meet. Google meet is a web-\nbased video conferencing application from Google. The user interface is extremely simple, \neasy to use, and intuitive. The researcher ensured that all the participants met the minimum \nrequirements for google meet (meet mobile application, Gmail mobile application, or a \nsupported web browser, a compatible device with minimum system requirements, a supported \noperating system, broadband connection to the internet, a built-in web camera or external USB \ncamera) video conference. All the participants were trained for using the google meet interface \nin terms of starting and joining video meetings; adjust meeting’s audio and video setup.\nBaseline assessment of all the selected participants were carried out for functional \ncapacity, pulmonary function and dyspnea using 6MWT, PFT and mMRC scale respectively. \nFollowing this all the participants received two sessions of face-to-face training on setting up \nthe virtual platform, individualized exercise training to be carried out at participants residence. \nIn addition, participants were trained to monitor heart rate and SPO2 through a portable \noximeter, and rate of perceived exertion (RPE) by modified Borg scale throughout the \nintervention. A schedule of home-based exercise training was provided for all the participants \nbased on their convenience.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nA home-based aerobic training was carried out for six weeks with three synchronous \nsessions per week remotely monitored by the physiotherapist through the google meet platform. \nEach session lasted for 40 minutes. Each session has a warm-up (10 minutes), conditioning (20 \nminutes), and cool-down phase (10 minutes). At the beginning of the session, the individual \nwears a portable oximeter and records HR and SPO2. \nThe warm-up and cool-down period included breathing exercises as well as stretching \nexercises of the upper and lower extremities (pectorals, triceps, biceps, deltoid, hamstrings, \nquadriceps, gastrocnemius muscles) with 30 secs hold of 3 repetitions with intensity to the \npoint of the feeling of slight discomfort).\nThe conditioning phase consisted of aerobic training. The aerobic training was \nperformed in the form of spot marching (2 minutes) with alternate chest trunk mobilization (1 \nminute) and dynamic exercises in large muscle groups 2-3 sets of 10 repetitions. The exercise \nintensity was based on the HRR determined by Karvonen’s formula and was scheduled to \nincrease from 30-40% HRR at the beginning of the session to 40-60% HRR in the final two \nweeks.\nParticipants were advised to perform physical activity (swimming, brisk walking, \njogging) for 30 minutes on the reminder days. And they were provided with a daily log sheet \nto monitor compliance with to exercise program. Following six weeks of exercises, \nappointments were scheduled, and a post-intervention assessment of the outcome measure was \ntaken for functional capacity, pulmonary function and dyspnea.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nRESULTS\nA total of 50 participants were contacted by phone after being identified through the \nPhysical Medicine and Rehabilitation Department's discharge register at Al Ain Hospital. \nTwenty-four of the 27 participants who consented to participate in current study, presented for \nfurther evaluation of eligibility requirements. All of the selection criteria were met by 20 \nparticipants and same completed six weeks aerobic training through telerehabilitation. (Figure \n1) The demographic characteristics of the participants are shown in Table 1. The mean age of \nall the participants was 49.30 ± 15.46 years. Average height and weight of the participants in \nthe study were 163.80 ± 9.76 cm and 78.70 ± 15.58 kg, respectively. The study participants \nwere predominantly female (n=12) and nine were with comorbidity of obesity\nTable 2 presents the outcomes of the 6MWT, PFT, and mMRC scale scores before and \nafter the telerehabilitation intervention. Overall, the telerehabilitation program demonstrated a \nstatistically significant improvement in the 6MWT and PFT results after a 6-week duration. \nThe 6MWT showed a noteworthy improvement of 21%, while the PFT values exhibited \nimprovements in forced vital capacity (FVC) by 4%, forced expiratory volume in one second \n(FEV1) by 8%, FEV1/FVC ratio by 1%, and peak expiratory flow (PEF) by 11 units. Moreover, \nthe post-rehabilitation scores of mMRC indicated a significant decrease when compared to the \npre-rehabilitation scores. \nTable 3 provides a comprehensive overview of the statistical significance of changes in \nthe 6MWT, PFT and mMRC scale of the study participants. These results help evaluate the \neffectiveness of the intervention and provide insights into the impact on functional capacity, \npulmonary function and dyspnea in participant The physical activity levels of the participants \nat baseline were determined using the Global Physical Activity Questionnaire. The findings \nrevealed that 35% (n=7) of the participants were identified as physically active (> 600 MET- \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nmin/week), while 65% (n=13) were classified as physically inactive (<600 MET- min/week) \nat baseline\nDISCUSSION\nTelerehabilitation has gained significant popularity and widely promoted during \nCOVID-19 pandemic to assure rehabilitation continuity. However, there is a paucity of \npublished reports in UAE to support the usefulness of telerehabilitation among Long COVID \nindividuals. The current study is the first study in the UAE, conducted with rigorous \nmethodology and ensure safety among UAE individuals with Long COVID.[32]\nThe findings from current study demonstrated that the telerehabilitation is effective in \nsignificantly improving functional capacity, pulmonary function and reducing dyspnea among \nlong COVID individuals.  The literature evidenced, exercise delivered via telerehabilitation \nhas led to increase in functional capacity as assessed by the 6 MWT [22–24,26] with low level \nof certainty.  However, its effects on dyspnea [22–24] and pulmonary functions [22,26] were \ninconclusive.\nThe current study demonstrated that aerobic training through remote monitoring \nappears to be same with no incidence of adverse events. One trial has reported adverse events \nsuch as chest tightness, weakness, dizziness, sputum discharge, dizziness, chest pain and back \npain.[22]\nDuring the pandemic telerehabilitation has been promoted across the globe for health \ncare delivery for various conditions. However, there is a lack of strong scientific evidence on \neffectiveness of aerobic training on main symptoms of Long COVID specifically with no \nevidence in UAE. Existing trails presented heterogeneity in terms of participant’s demography, \nstage of COVID-19 and method adopted in telerehabilitation [22–24,26]\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nFurthermore, telerehabilitation offers the advantage of delivering therapy wherever is \nmost convenient for the individual, while allowing therapists to prescribe various interventions \nand receive feedback through modern digital technology. Additionally, individuals can \nparticipate in telerehabilitation sessions from the comfort of their own homes or care centers, \nreducing the burden and involvement of healthcare providers compared to traditional face-to-\nface setups.\nThe study demonstrates notable strengths. Firstly, during the implementation of \nexercises through telerehabilitation, no adverse events were reported, indicating a high level of \nsafety. Secondly, the study observed an impressive adherence rate of over 90% among \nparticipants, indicating a strong commitment to attending the exercise sessions. These findings \nunderscore the study's robustness and highlight the safe implementation and high acceptance \nof telerehabilitation for delivering exercise interventions.\nThe current study has few drawbacks. Due to time constraints, participants recruitment \nwas confined to a single center. Furthermore, the lack control group, small sample size, \noverrepresentation of female and lack of participant’s knowledge on web and technology \nliteracy were also few factors. Hence while generalizing the results of the current study, one \nmust exercise caution. Additionally, these considerations also make determining the \nintervention’s effectiveness in compared to spontaneous recovery difficult.\nThe clinical implications of the study are promising. According to preliminary findings \nfrom the study, telerehabilitation appears to be a beneficial and convenient method in assisting \nthe recovery of individuals with long COVID. Increasing the number and duration of \nsupervised sessions may reduce the risk of complications associated with long COVID thereby \nfacilitating the improvement in the overall quality of life.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nFuture research endeavors should place emphasis on implementing a comprehensive \nmonitoring system that accurately tracks the dosage, adherence, and precision of each exercise \ncomponent. Additionally, it is crucial to consider the long-term effect of the telerehabilitation \non Long COVID, an aspect that was not addressed in the present study. \nCONCLUSION\nA six-week of aerobic exercise training delivered through telerehabilitation can effectively \nimprove functional capacity, pulmonary function and reduce dyspnea among long COVID \nindividuals. Telerehabilitation, with its high adherence rate and little side effects, makes \naerobic delivery possible and well tolerated by individuals with Long COVID. Large scale \nresearch is warranted to explore the long-term benefits and optimal implementation strategies \nof telerehabilitation among Long COVID individuals.\nREFERENCES\n1. Kingstone T, Taylor AK, O’Donnell CA, Atherton H, Blane DN, Chew-Graham CA. \nFinding the “right” GP: a qualitative study of the experiences of people with long-\nCOVID. BJGP Open. 2020 Dec;4(5):bjgpopen20X101143. \n2. COVID W. Dashboard. Geneva: world health organization, 2020. Available online:(last \ncited: 03–08-2021). 19. \n3. Garg P, Arora U, Kumar A, Wig N. The “post‐COVID” syndrome: How deep is the \ndamage? J Med Virol. 2021 Feb;93(2):673–4. \n4. Wiersinga WJ, Rhodes A, Cheng AC, Peacock SJ, Prescott HC. Pathophysiology, \nTransmission, Diagnosis, and Treatment of Coronavirus Disease 2019 (COVID-19): A \nReview. JAMA. 2020 Aug 25;324(8):782. \n5. Shah W, Hillman T, Playford ED, Hishmeh L. Managing the long-term effects of covid-\n19: summary of NICE, SIGN, and RCGP rapid guideline. BMJ. 2021 Jan 22;n136. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\n6. Mohamed NA, Solehan HM, Mohd Rani MD, Ithnin M, Che Isahak CI. Knowledge, \nacceptance and perception on COVID-19 vaccine among Malaysians: A web-based \nsurvey. Sobh E, editor. PLOS ONE. 2021 Aug 13;16(8):e0256110. \n7. Dennis A, Wamil M, Alberts J, Oben J, Cuthbertson DJ, Wootton D, et al. Multiorgan \nimpairment in low-risk individuals with post-COVID-19 syndrome: a prospective, \ncommunity-based study. BMJ Open. 2021 Mar;11(3):e048391. \n8. Baig AM. Chronic COVID syndrome: Need for an appropriate medical terminology for \nlong‐COVID and COVID long‐haulers. J Med Virol. 2021 May;93(5):2555–6. \n9. Thaweethai T, Jolley SE, Karlson EW, Levitan EB, Levy B, McComsey GA, et al. \nDevelopment of a Definition of Postacute Sequelae of SARS-CoV-2 Infection. JAMA \n[Internet]. 2023 May 25 [cited 2023 Jun 12]; Available from: \nhttps://jamanetwork.com/journals/jama/fullarticle/2805540\n10. Koc HC, Xiao J, Liu W, Li Y, Chen G. Long COVID and its Management. Int J Biol Sci. \n2022;18(12):4768–80. \n11. Soriano JB, Murthy S, Marshall JC, Relan P, Diaz JV. A clinical case definition of post-\nCOVID-19 condition by a Delphi consensus. Lancet Infect Dis. 2022 Apr;22(4):e102–7. \n12. Líška D, Liptaková E, Babičová A, Batalik L, Baňárová PS, Dobrodenková S. What is the \nquality of life in patients with long COVID compared to a healthy control group? Front \nPublic Health. 2022 Nov 2;10:975992. \n13. Wright J, Astill S, Sivan M. The Relationship between Physical Activity and Long COVID: \nA Cross-Sectional Study. Int J Environ Res Public Health. 2022 Apr 22;19(9):5093. \n14. Güner R, Hasanoğlu İ, Aktaş F. COVID-19: Prevention and control measures in \ncommunity. Turk J Med Sci. 2020 Apr 21;50(SI-1):571–7. \n15. Leemans G, Taeymans J, Van Royen P, Vissers D. Respiratory physiotherapy interventions \nfocused on exercise training and enhancing physical activity levels in people with chronic \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nobstructive pulmonary disease are likely to be cost-effective: a systematic review. J \nPhysiother. 2021 Oct;67(4):271–83. \n16. Rochester CL, Vogiatzis I, Holland AE, Lareau SC, Marciniuk DD, Puhan MA, et al. An \nOfficial American Thoracic Society/European Respiratory Society Policy Statement: \nEnhancing Implementation, Use, and Delivery of Pulmonary Rehabilitation. Am J Respir \nCrit Care Med. 2015 Dec 1;192(11):1373–86. \n17. Cox NS, McDonald CF, Hill CJ, O’Halloran P, Alison JA, Zanaboni P, et al. \nTelerehabilitation for chronic respiratory disease. Cochrane Airways Group, editor. \nCochrane Database Syst Rev [Internet]. 2018 Jun 5 [cited 2023 Jun 12]; Available from: \nhttps://doi.wiley.com/10.1002/14651858.CD013040\n18. Holland AE, Hill CJ, Rochford P, Fiore J, Berlowitz DJ, Mcdonald CF. Telerehabilitation \nfor People with Chronic Obstructive Pulmonary Disease: Feasibility of a Simple, Real Time \nModel of Supervised Exercise Training. J Telemed Telecare. 2013 Jun;19(4):222–6. \n19. Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly \npatients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. \n2020 May;39:101166. \n20. Jimeno‐Almazán A, Franco‐López F, Buendía‐Romero Á, Martínez‐Cava A, \nSánchez‐Agar JA, Sánchez‐Alcaraz Martínez BJ, et al. Rehabilitation for post-COVID-19 \ncondition through a supervised exercise intervention: A randomized controlled trial. Scand \nJ Med Sci Sports. 2022 Dec;32(12):1791–801. \n21. Compagno S, Palermi S, Pescatore V, Brugin E, Sarto M, Marin R, et al. Physical and \npsychological reconditioning in long COVID syndrome: Results of an out-of-hospital \nexercise and psychological - based rehabilitation program. IJC Heart Vasc. 2022 \nAug;41:101080. \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\n22. Li J, Xia W, Zhan C, Liu S, Yin Z, Wang J, et al. A telerehabilitation programme in post-\ndischarge COVID-19 patients (TERECO): a randomised controlled trial. Thorax. 2022 \nJul;77(7):697–706. \n23. Rodríguez-Blanco C, Bernal-Utrera C, Anarte-Lazo E, Saavedra-Hernandez M, De-La-\nBarrera-Aranda E, Serrera-Figallo MA, et al. Breathing exercises versus strength exercises \nthrough telerehabilitation in coronavirus disease 2019 patients in the acute phase: A \nrandomized controlled trial. Clin Rehabil. 2022 Apr;36(4):486–97. \n24. Rodriguez-Blanco C, Gonzalez-Gerez JJ, Bernal-Utrera C, Anarte-Lazo E, Perez-Ale M, \nSaavedra-Hernandez M. Short-Term Effects of a Conditioning Telerehabilitation Program \nin Confined Patients Affected by COVID-19 in the Acute Phase. A Pilot Randomized \nControlled Trial. Medicina (Mex). 2021 Jul 3;57(7):684. \n25. Lei J, Yang L, Wen G, Qumu S, Ren X, Yang T. Pulmonary telerehabilitation and efficacy \namong discharged COVID‐19 patients: Rational and design of a prospective real‐world \nstudy. Clin Respir J. 2021 Nov;15(11):1158–67. \n26. Teixeira Do Amaral V, Viana AA, Heubel AD, Linares SN, Martinelli B, Witzler PHC, et \nal. Cardiovascular, Respiratory, and Functional Effects of Home-Based Exercise Training \nafter COVID-19 Hospitalization. Med Sci Sports Exerc. 2022 Nov;54(11):1795–803. \n27. Zhu P, Wang Z, Guo X, Feng Z, Chen C, Zheng A, et al. Pulmonary Rehabilitation \nAccelerates the Recovery of Pulmonary Function in Patients With COVID-19. Front \nCardiovasc Med. 2021 Jul 20;8:691609. \n28. Fuglebjerg NJU, Jensen TO, Hoyer N, Ryrsø CK, Lindegaard B, Harboe ZB. Silent hypoxia \nin patients with SARS CoV-2 infection before hospital discharge. Int J Infect Dis. 2020 \nOct;99:100–1. \n29. Kamal Bandhu Klanidhi, Avinash Chakrawarty, Shailendra S. Bhadouria, Sudeep M. \nGeorge, Gaurav Sharma, Prasun Chatterjee, Vijay Kumar,, Saurabh Vig, Nishkarsh Gupta, \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nVishwajeet Singh, Aparajit Ballav Dey, Anant Mohan, Sushma Bhatnagar. Six-minute \nwalk test and its predictability in outcome of COVID-19 patients. J Educ Health Promot. \n11(58):1–5. \n30. Ribeiro S, Cardoso CS, Valério M, Machado J, Costa J, Rodrigues C, et al. Confirmatory \nEvaluation of the Modified Medical Research Council Questionnaire for Assessment of \nDyspnea in Patients with Chronic Obstructive Pulmonary Disease in Portugal. Acta Médica \nPort. 2022 Feb 1;35(2):89–93. \n31. Doyle C, Khan A, Burton N. Reliability and validity of a self-administered Arabic version \nof the Global Physical Activity Questionnaire (GPAQ-A). J Sports Med Phys Fitness \n[Internet]. 2019 Jul [cited 2023 Jun 12];59(7). Available from: \nhttps://www.minervamedica.it/index2.php?show=R40Y2019N07A1221\n32. Taito S, Yamauchi K, Kataoka Y. Telerehabilitation in Subjects With Respiratory Disease: \nA Scoping Review. Respir Care. 2021 Apr;66(4):686–98.\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nTables:\nTable 1: Demographic and clinical characteristics of the study participants\nSI No Variables n=\n20\n1. Age in years (Mean±SD) 49.30 ± 15.46\n2. Heights in cm (Mean±SD) 163.80 ± 9.76\n3. Weight in kg (Mean±SD) 78.70 ± 15.58\n4. Body mass index (kg/m2) \n(Mean±SD) 29.45 ± 6.08\n5. Male: Female (M: F) 8:\n12\nComorbidities\nObesity 09\nHypertension 03\nSmoking 03\nAlcoholism 02\nDiabetes Mellitus 02\n6.\nAnxiety 01\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nTable 2: Pre and post tele-rehabilitation changes of six-minute walk distance, pulmonary \nfunction & dyspnea levels of the study participants\nOutcome measures Mean\nMean\n%\nchange\nStd. \nDeviatio\nn\nStd. \nError\nMean\nCorrelatio\nn\nP\nvalue \nSig. \n(<0.05)\nPre 441.0\n0 89.78 20.07Six-MWD \n(meters) Post 534.0\n0\n21.08\n95.16 21.28\n0.88 <\n0.001\nPre_FVC 3.15 0.86 0.19\nPost_FVC 3.29\n4.44\n0.84 0.18\n0.99 <\n0.001\nPre_FEV1 2.50 0.91 0.20\nPost_FEV1 2.70\n8\n0.67 0.15\n0.84 <\n0.001\nPre_FEV1/\nFVC 83.05 5.74 1.28\nPost_FEV1/FV\nC 82.17\n1.05\n4.75 1.06\n0.95 <\n0.001\nPre_PEF 6.31 11.5 2.13 0.47\nPFT (%)\nPost_PEF 7.04 1.93 0.43\n0.97 <\n0.001\nPre 2.30 0.47 0.10\nmMRC\nPost 1.20\n-47.8\n0.41 0.09\n0.76 <\n0.001\nNote: MWD: Minute walk test(MWD), Forced vital capacity (FVC), forced expiratory volume in \nthe first second (FEV1), Peak Exploratory Flow (PEF) and Modified Medical Research Council \n(mMRC)\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint \n\nTable 3: Paired T test of six-minute walk distance, pulmonary function & dyspnea levels of the \nstudy participants.\nPaired Differences\n95%\nConfidence \nInterval of\nthe \nDifference\n95%\nConfidence \nInterval of\nthe \nDifference\nOutcome measures Mean Std. \nDeviation\nStd. \nError \nMean\nLower Upper\nt df\nSig. \n(2-\ntailed)\nSix-\nMWD\nPre - Post\n- \n93.00000\n45.54928 10.18513 -114.31772 -71.68228 -9.131 19 .000\nPre_FVC -\nPost_FVC\n-.13800 .11701 .02616 -.19276 -.08324 -5.275 19 .000\nPre_FEV1 -\nPost_FEV1\n-.19600 .49637 .11099 -.42831 .03631 -1.766 19 .093\nPre_FEV1/FVC \n-\nPost_FEV1/FVC\n.88000 1.86677 .41742 .00632 1.75368 2.108 19 .049\nPFT\nPre_PEF - \nPost_PEF\n-.72400 .49180 .10997 -.95417 -.49383 -6.584 19 .000\nmMRC\nscale\nPre -Post 1.10000 .30779 .06882 .95595 1.24405 15.983 19 .000\nNote: MWD: Minute walk test(MWD), PFT: Pulmonary Function Test, Forced vital capacity (FVC), \nforced expiratory volume in the first second (FEV1), Peak Exploratory Flow (PEF) and Modified Medical \nResearch Council (mMRC)\n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 29, 2023. ; https://doi.org/10.1101/2023.09.27.23296254doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}