Vol 2, No 2 (2020)

Patients with the new coronavirus infection (COVID-19) may need rehabilitation. Approaches to rehabilitation of patients with other conditions also have to be revised under the conditions of the SARS-CoV-2 epidemic. There is a need in clinical recommendations for delivery of rehabilitation care to patients with COVID-19 and other diseases during the pandemic. A group of experts analyzed real life reports on rehabilitation in COVID-19, along with earlier studies on rehabilitation in Post-intensive care syndrome (PICS) and acute respiratory distress syndrome of non-coronavirus etiology, and used them to develop the main points for clinical recommendations. We discuss the major rehabilitation problems in COVID-19 patients determining their needs in care, in particular, the structural and functional impairments leading to limitations of self-care, mobility, everyday life, communication, interpersonal relations, and professional activities. We provide general recommendations on managing medical rehabilitation in the pandemic at all three phases, including patients routing and safeguarding medical personnel and patients against the infection. We identify essential components of individual rehabilitation program for COVID-19 patients at all phases of rehabilitation, including patient examination, correction of nutritional deficiencies, improvement of respiratory function, exercise tolerance, and muscle strength, self-monitoring and training in new movement conditions; recovery of psychoemotional state and cognitive functions, as well as independence in everyday life. Medical rehabilitation during the COVID-19 epidemic should include all components of rehabilitation care and help in optimizing vital functions, preventing complications and improving the patient’s life quality.

Background. Cardiovascular diseases and their complications are the top cause of death and disability; the newly developed rehabilitation methods for these conditions have to be evaluated in terms of tolerability.

Objective. To examine the factors affecting better exercise tolerance in cardiac patients at the third phase of rehabilitation.

Methods. The study performed at IvGMA clinic involved 34 patients undergoing the 3rd phase of rehabilitation with a diagnosis of coronary heart disease: 5 (14%) — with acute Q myocardial infarction with ST segment elevation, 3 (9%) — without ST segment elevation, 3 (9%) — non-Q wave myocardial infarction, 23 (68%) — unstable angina pectoris. The age of patients was 49–76 years (average 59.47 ± 6.08 years), of which 23 were men and 11 women. Each patient underwent a complete clinical and functional examination to assess the anthropometric data, functional indicators of the respiratory and cardiovascular systems, mental functions, and posturography. The rehab course lasted 15 days and included exercise therapy, gym machine training according to an individually designed program, and dosed walking.

Results. Based on the results of exercise tolerance tests, we formed two case groups: patients of group 1 (n = 14) showed an improvement in the functional class of chronic heart failure according to 6-minute walking test; patients of group 2 (n = 20) showed only insignificant dynamics. Comparison of clinical and functional indicators between the 2 groups revealed that patients of group 1 had more pronounced anxiety and depressive symptoms, and a better preserved function of the respiratory system. A correlation analysis of the total sample of patients detected a correlation relationship between exercise tolerance and functions of the respiratory and cardiovascular systems, anthropometric data, and stabilogram indicators.

Conclusions. A better exercise tolerance in patients with heart problems was associated with better baseline functions of the respiratory and cardiovascular systems, a lower body mass index, and the optimal dose of statins taken. The exercise tolerance increased in parallel with improvement of stabilogram indicators, which suggests a positive effect of targeted individual training of the equilibrium function to improve the functional result of the cardiac rehabilitation process.

It is known that coronaviruses can cause acute coronary syndrome, arrhythmias, and aggravation of heart failure, mainly due to a combination of a significant systemic inflammatory response and a local vascular inflammation at the level of arterial plaque. In the context of massive SARS-CoV-2infections and the announced pandemic, there is a need to update management of cardiovascular patients in order to reduce COVID-19-related complications. COVID-19 can cause viral pneumonia, as well as extrapulmonary symptoms and complications. A larger proportion of severe COVID-19 patients had a cardiovascular disease or a high cardiovascular risk. The presence of arterial hypertension and other cardiovascular and cerebrovascular diseases is considered as a factor aggravating the course of the disease and increasing the lethality. Severe cases of COVID-19 were accompanied by acute, often lethal, cardiovascular disorders, with an increase in the level of highly sensitive troponins. There is no reliable evidence that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers can increase the risk of infection or severe course of COVID-19, so there is no reason to cancel them. The role of inhibition of the renin-angiotensin system in the treatment of COVID-19 remains controversial. COVID-19 treatment boils down to supportive care and treatment for complications. Based on the results of the studies, a large number of cardiovascular complications of COVID-19 can be expected. Their therapy should be carried out strictly according to modern guidelines. Recommendations include antiplatelet agents, β-blockers, ACE inhibitors and statins.

The emergence of SARS-CoV-2 and its worldwide spread has become a challenge for healthcare professionals related to rapid diagnosis of infection caused by the new coronaviruses, provision of specialized medical care, rehabilitation and secondary prevention. Currently, there is limited information on primary, secondary prevention and medical rehabilitation of this disease. The most common clinical manifestation of the new variant of coronavirus infection is bilateral pneumonia, with 3–4% of patients developing acute respiratory distress syndrome (ARDS). Given the unusual pandemic situation and the peculiar COVID-19 pathogenesis, the stereotyped application of generally accepted methods may be unsafe or ineffective. The Union of Rehabilitologists of Russia has prepared Temporary guidelines that are based on the advice on medical rehabilitation of patients with COVID-19 at various stages of special medical care published by WHO specialists, analysis of reports from clinics currently involved in rehabilitation of COVID-19 patients, as well as on the results of clinical studies conducted earlier on the rehabilitation of patients with Post-intensive care syndrome and adult respiratory distress syndrome (ARDS) of non-coronavirus etiology, regulatory documents of the Russian Ministry of Health and Federal Service on Surveillance for Consumer rights protection and human well-being. A syndrome-based approach to the use of means and methods of physical and rehabilitation medicine is also considered. The guidelines are intended for heads of medical organizations and their structural divisions, general practitioners, physicians, infectious disease doctors, pediatricians, emergency physicians of intensive care units in infectious hospitals, physiotherapy and sports medicine doctors, physiotherapists, medical psychologists, physical therapy instructors, nurses and other specialists of multidisciplinary rehabilitation teams working in the field of medical care for patients with COVID-19 at various stages.