Physical functioning and perceived health status after surviving the rst COVID-19 wave. A long-term observational perspective

After the COVID-19 infection, individuals can experience impairment, activity limitation and participation restriction. Little information is available on range and frequency of individual problems arising after COVID-19 and its sequelae and long-term outcomes. In June and July 2020, nineteen individuals previously hospitalized with COVID-19 were referred to our outpatient physiotherapy unit. We monitored their level of independence in activities of daily living, mobility, and perceived health status for 7.4–9.5 months (median, 8.6) after healing. At baseline, our cohort showed substantial independence in activities of daily living, some mobility limitations, and below average perceived health status. Measures improved over time. Limitations of physical functioning were mostly moderate to slight and tending to improve; if present, severe limitations were probably related to pre- COVID-19 conditions. However, individuals in some cases may not have fully recovered their premorbid functioning seven to nine months after healing.


Introduction
The World Health Organization has declared the COVID-19 pandemic an international health emergency. COVID-19 could cause severe interstitial pneumonia and shows variability in symptoms and disease severity levels [1]. The occurrence of frailty and underlying illnesses may affect clinical presentation and course characteristics of the disease [1,2]. Health measures adopted to limit the diffusion of the disease (e.g., isolation, quarantine, social distancing, community containment), may contribute to negative health outcomes and disabilities [3].
After the COVID-19 infection, individuals can experience impairment, activity limitation and participation restriction. Impaired physical functioning has been observed at discharge, even after early mobilisation/bedside physiotherapy [4]. Physiotherapists are important across the COVID-19 care continuum [5] and it would be appropriate to offer to this population speci c physiotherapy services [6].
Little information is currently available on range and frequency of individual problems arising after COVID-19 and its sequelae and long-term outcomes [7]. Knowledge on functioning of individuals after COVID-19 may help to understand their potential impact on physiotherapy practice and service provision.
The purpose of this brief communication is to describe the long-term progression of independence in the basic activities of daily living, mobility, and perceived health status in a cohort of individuals referred to an outpatient functional rehabilitation clinic, after surviving the rst COVID-19 wave.

Methods
A cohort of individuals previously affected by COVID-19 was monitored up to six months after the end of physiotherapy. All the individuals recovering from the rst infection wave referred to the local health authority outpatient functional rehabilitation clinic were invited to participate in the study. Data were collected at baseline (T0), at the end of the intervention (T1), and two (T2) and six (T3) months after the end of treatment. Telephone follow-up was eventually proposed if transportation/traveling or other di culties arose. Individuals were referred in May and July 2020; we performed the last follow-up on March 22, 2021. The local Ethics Committee approved the study, participants given informed consent.
Relevant data were extracted using a standard data recording spreadsheet, including characteristics of the participants (age, number of falls in the last 12 months, comorbidities) and COVID-19-related issues (infection duration, locations of the course of the disease). The Pfeiffer Short Portable Mental Status Questionnaire [8] was used to measure intellectual functioning.
The physical functioning assessment comprised the modi ed Barthel index (BI) [9], the Timed Up and Go test (TUG) [10], and the Short Physical Performance Battery test (SPPB) [11]. The Patient Speci c Functioning Scale (PSFS) [12] was used to measure changes in physical function; individuals were invited to de ne the most important physical activity with which they were having di culty, and rate the di culty using as a reference the level of performance before the COVID-19 infection. The minimal detectable change (MDC) has been estimated in community dwelling adults for the SPPB and PSFS scales [11,12]. The EuroQOL 5D-3L (index and Visual Analogue Scale-VAS) [13], was adopted as measure of perceived health status.
We used descriptive statistics to depict the characteristics of the participants and COVID-19-related issues. The Friedman test was utilized to assess variations across the assessments; in case of signi cant results, post-hoc analysis was conducted by the Dunn test, with Bonferroni correction. The signi cant level was set at p ≤ 0.05. Analysis was intention-to-treat, missing data were dealt with carrying the last observation forward. We further analysed data on SPPB and PSFS by plotting change scores and the range of random measurement error (i.e., the interval spanning between the ± MDC values) and computing the proportions (95% Con dence Interval-CI) of individuals showing an improvement in performance equal to or greater than the absolute MDC value. Analyses were performed with IBM SPSS Statistics software for Windows (version 20.0; IBM Corp, Armonk, NY).

Results
Nineteen individuals surviving the rst COVID-19 wave accessed our clinic and consented to participate. The participants (male, 8) were 35-94 years old (median, 76 year). Time between hospitalization and healing/end of the isolation ranged from 16 to 129 days (median, 44 days). Frequent comorbidities were hypertension, hypercholesterolemia, heart and circulation disorders, and others (e.g., COPD, disorders of the prostate or thyroid glands). When the infection occurred, two individuals were admitted to the hospital for mild or severe stroke, and one for a femur fracture. All had been hospitalized in acute inpatient wards (intensive care unit, 4). Fifteen of them were transferred to low care wards, and four were discharged and isolated in non-hospital facilities (COVID-19 hotel, 2; home, 2). The individuals mostly accessed the baseline assessment session walking independently (alone, 9; accompanied, 8); two of them attended the clinic in a wheelchair.
According to the Pfeiffer short portable mental status questionnaire, three individuals had severe impairment, intellectual functioning was otherwise intact. The informed consent was given by the daughters in cases suffering from severe aphasia or intellectual impairment.
Individuals attended 1-15 sessions (median, 10) in 1-63 days (median. 42), and were monitored for 180-252 days (median, 223). The TUG test was not administered to individuals unable to walk independently and to the 94-year-old lady who reported high perceived exertion at rest (Borg Scale CR10, 7). The EuroQOL was not administered to the individual with severe aphasia. All but one individual were evaluated at T1; a participant felt recovered and withdrew from the intervention after the 3rd session. Two other individuals refused to participate in the T2 and T3 follow-up (did not like to evoke the illness or worsening of health condition). Telephone follow-up (i.e., assessing BI, PSFS, and EuroQOL) was administered to three individuals at T2, and four at T3.

Discussion
This brief communication describes the physical functioning and perceived health status of individuals after COVID-19. We prospectively observed our cohort for 7.4-9.5 months after the end of the infection. Our cohort showed substantial independence in activities of daily living. Some mobility limitations were present. Compared to normative data for community dwelling adults, the TUG and SPPB scores were slightly worse [14,15]. At baseline, many individuals showed disability [11], and, as outlined by the PSFS, walking was an important activity with which they were having di culty. The EuroQOL-VAS baseline values showed a perceived health status below the average [13]. According to repeated measures statistics, all outcomes increased (Table 1). Post hoc tests did not show differences between assessments of BI and EuroQOL-index; it is likely due to the prevalence of high scores at baseline, with little chance for subsequent improvement. Mobility measures have improved and the proportion of individuals at fall risk and with mobility disability decreased over time; unlike the TUG values, SPPB scores at T3 did not differ from the T0 ones (Table 1). The PSFS follow-up scores were greater than the baseline ones, as well as the EuroQOL-VAS T2 and T3 values. The analysis of individual data based on MDC displayed low to medium proportions of individuals (26-53%) showing improvements in SPPB and PSFS; two participants experienced worsening beyond the MDC negative value in SPPB and PSFS, respectively. Severe limitations in physical functioning were probably related to pre-COVID-19 conditions, (e.g., a stroke event).
Compared to individuals surviving the rst COVID-19 wave at discharge from acute inpatient ward [4] or at admission for inpatient rehabilitation [16] our cohort showed better independence in activities of daily living and mobility performances (i.e., BI and SPPB scores). Data on perceived health status are quite like those reported from others [17,18]. High percentages of individuals feeling not fully recovered seven months after the infection have been reported [19].
Our report is limited to a small sample observed in a single-centred study; however, to date, there is not much data available on range and frequency of sequelae and long-term outcomes after COVID-19. It should be considered that participants received attention from physiotherapists; moreover, assessors were not blinded, and some data were missed. We acknowledge that the generalizability of the ndings is limited.

Conclusions
Despite good independence in activities of daily living and perceived health status, individuals hospitalized with rst wave COVID-19 in some cases may not have fully recovered their premorbid functioning status seven to nine months after healing. Physiotherapists can play an important role in the knowledge of the functioning of individuals after COVID-19. Observational studies should be designed to eventually con rm our ndings, and to research which prognostic factors may impact long-term physical functioning and perceived health status after COVID-19. Score distributions / Abbreviations as in Table 1. Raw scores are depicted; TUG values are in seconds (B) Figure 2 Individual SPPB and PSFS change scores / A dot represents a case, the horizontal lines indicate a difference of 0 and the ±MDC values.