Physical recovery across care pathways up to 12 months after hospitalization for COVID-19: A multicenter prospective cohort study (CO-FLOW)

Abstract

Backgroud: The sudden COVID-19 pandemic forced quick development of care pathways for patients with different needs. Trajectories of physical recovery in hospitalized patients for COVID-19 following different care pathways are unknown. We aimed to assess trajectories of physical recovery and levels of physical function reached within the different care pathways. Additionally, we assessed differences in physical function across care pathways at follow-up visits.

Methods: This multicenter prospective cohort study of adults who had been hospitalized for COVID-19 was performed in 10 centers, including 7 hospitals (1 academic and 6 regional hospitals) and 3 rehabilitation centers (1 medical rehabilitation center and 2 skilled nursing facilities), located in the Netherlands. Study visits were performed at 3, 6, and 12 months post-hospital discharge and included assessment of cardiorespiratory fitness (6 min walk test [6MWT], 1 min sit-to-stand test [1MSTST]), muscle strength (maximum handgrip strength [HGS]) and mobility (de Morton Mobility Index [DEMMI]).

Findings: We report findings for 582 patients who had been discharged from hospital between March 24, 2020 and June 17, 2021. Patients had a median age of 60·0 years, 68·9% (401/582) were male, 94·6% (561/582) had received oxygen therapy, and 35·2% (205/582) mechanical ventilation. We followed patients across four different rehabilitation settings: no rehabilitation (No-rehab, 19·6% [114/582]), community-based rehabilitation (Com-rehab, 54·1% [315/582]), medical rehabilitation (Med-rehab, 13·7% [80/582]), and rehabilitation in a skilled nursing facility (SNF-rehab, 12·5% [73/582]). Overall, outcomes in 6MWT (14·9 meters [95% CI 7·4 to 22·4]), 1MSTST (2·2 repetitions [1·5 to 2·8]), and HGS (3·5 kg [2·9 to 4·0]) improved significantly (p<0·001) from 3 to 6 months and only HGS from 6 to 12 months (2·5 kg [1·8 to 3·1]; p<0·001). DEMMI scores did not significantly improve over time. At 3 months, percentage of normative values reached in 1MSTST differed significantly (p<0.001) across care pathways, with largest impairments in Med- and SNF-rehab groups. At 12 months these differences were no longer significant, reaching, overall, 90·5% on 6MWD, 75·4% on 1MSTST, and 106·9% on HGS.

Interpretation: Overall, physical function improved after hospitalization for COVID-19, with largest improvement within 6 months post-discharge. Patients with rehabilitation after hospital discharge improved in more than one component of physical function, whereas patients without rehabilitation improved solely in muscle strength. Patients who received rehabilitation, and particularly patients with Med- and SNF-rehab, had more severe impairment in physical function at 3 months, but reached equal levels at 12 months compared to patients without follow-up treatment. Our findings indicate the importance of rehabilitation.

Funding: ZonMw, Rijndam Rehabilitation, Laurens (The Netherlands).

Keywords: COVID-19; Physical function; Physical recovery; Rehabilitation.

Figure 1

Dutch care pathways for hospitalized COVID-19 patients. MDT: multidisciplinary team. ¹Assessment of functional impairments (physical, cognitive, and/or psychological), medical status, care needs, comorbidity, and premorbid functional level.²Rehabilitation as defined by the World Health Organization aims to help a child, adult, or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation, and meaningful life roles such as taking care of family. Geriatric rehabilitation focuses primarily on frail elderly with co-morbidities. Medical rehabilitation is aimed at high-intensity treatment, mostly of a younger population.

Figure 2

Flowchart of CO-FLOW study participants included in the analysis. In total 582 patients attended at least one follow-up visit with physical tests and were included in this analysis. ≤3M refers to participants enrolled prior to or at 3 months after hospital discharge; >3M refers to participants enrolled after 3 months but within 6 months after hospital discharge.

Figure 3

Trajectories of outcomes in 6MWT, 1MSTST, HGS, and DEMMI over time within care pathways assessed at 3, 6, and 12 months after hospital discharge. Care pathways comprise patients with No-rehab: no rehabilitation, Com-rehab: community-based rehabilitation, Med-rehab: in- and outpatient medical rehabilitation, and SNF-rehab: inpatient rehabilitation in a skilled nursing facility after hospitalization for COVID-19. Trajectories of physical outcomes over time were assessed with generalized estimating equations analysis, adjusted for demographic and clinical characteristics during hospital admission including age, sex, having one or more comorbidities, obesity, employment status, delirium, thrombotic event, admission to intensive care unit, and the length of hospital stay. Data are presented as estimated mean with standard error. In 6MWT: significant improvement in Com-rehab (p=0·01) and Med-rehab (p=0·047) from 3 to 6 months but not thereafter; no significant improvement over time within other care pathways. In 1MSTST: significant improvement in Com-rehab (p<0·001), Med-rehab (p<0·001), and SNF-rehab (p=0·002) from 3 to 6 months but not thereafter; no significant improvement over time within No-rehab. In HGS: significant improvement within all care pathways from 3 to 6 months and from 6 to 12 months (all p<0·001 except for No-rehab from 6 to 12 months [p=0·002]). In DEMMI: significant improvement in Med-rehab (p=0·001) from 3 to 6 months but not thereafter; no significant improvement over time within other care pathways. 6MWT=6 min walk test; 6MWD=6 min walk distance; 1MSTST=1 min sit-to-stand test; STS=sit-to-stand; HGS=handgrip strength; DEMMI=de Morton Mobility Index.

Figure 4

Trajectories of the percentage of normative values reached in 6MWT, 1MSTST, and HGS over time within care pathways assessed at 3, 6, and 12 months after hospital discharge. Care pathways comprise patients with No-rehab: no rehabilitation, Com-rehab: community-based rehabilitation, Med-rehab: in- and outpatient medical rehabilitation, and SNF-rehab: inpatient rehabilitation in a skilled nursing facility after hospitalization for COVID-19. The percentages of normative values reached in physical tests were assessed with generalized estimating equations analysis, adjusted for demographic and clinical characteristics during hospital admission including having one or more comorbidities, obesity (excluded in 6MWT analysis), employment status, delirium, thrombotic event, admission to intensive care unit, and the length of hospital stay. Data are presented as estimated mean with standard error. In 6MWT: significant improvement in Com-rehab (p=0·03) from 3 to 6 months but not thereafter; no significant improvement within other care pathways. In 1MSTST: significant improvement in Com-rehab (p<0·001), Med-rehab (p<0·001), and SNF-rehab (p=0·001) from 3 to 6 months but not thereafter; no significant improvement over time within No-rehab. In HGS: significant improvement within all care pathways from 3 to 6 months and from 6 to 12 months (all p<0·001 except for No-rehab 6-12 months [p=0·002]). Normative values in 6MWT are calculated using reference equations described by Enright and Sherill, in 1MSTST using reference values described by Strassman and colleagues, and in HGS using reference values described by Dodds and colleagues. 6MWT=6 min walk test; 6MWD=6 min walk distance; 1MSTST=1 min sit-to-stand test; STS=sit-to-stand; HGS=handgrip strength.