A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID

Md. Feroz Kabir; Khin Nyein Yin; Mohammad Saffree Jeffree; Fatimah Ahmedy; Muhamad Faizal Zainudin; K M Amran Hossain; Sharmila Jahan; Md. Waliul Islam; Md. Abu Khayer Hasnat; Abdullah Ibn Abul Fazal

doi:10.12688/f1000research.132098.2

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Systematic Review

Revised

A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID

[version 2; peer review: 1 approved, 1 not approved]

Md. Feroz Kabir^1,2, Khin Nyein Yin ², Mohammad Saffree Jeffree², [...] Fatimah Ahmedy², Muhamad Faizal Zainudin³, K M Amran Hossain¹, Sharmila Jahan¹, Md. Waliul Islam⁴, Md. Abu Khayer Hasnat⁴, Abdullah Ibn Abul Fazal⁴

Md. Feroz Kabir^1,2, Khin Nyein Yin ², [...] Mohammad Saffree Jeffree², Fatimah Ahmedy², Muhamad Faizal Zainudin³, K M Amran Hossain¹, Sharmila Jahan¹, Md. Waliul Islam⁴, Md. Abu Khayer Hasnat⁴, Abdullah Ibn Abul Fazal⁴

PUBLISHED 24 May 2023

Author details Author details

¹ Department of Physiotherapy & Rehabilitation, Jashore University of Science & Technology, Jashore, Bangladesh
² Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
³ Faculty of Medicine, Universiti Teknologi MARA, Sungai Buloh, Malaysia
⁴ Department of Physiotherapy, Centre for the Rehabilitation of the Paralysed (CRP), Dhaka, Bangladesh

Md. Feroz Kabir
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Validation, Writing – Original Draft Preparation, Writing – Review & Editing

Khin Nyein Yin
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Writing – Original Draft Preparation, Writing – Review & Editing

Mohammad Saffree Jeffree
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing

Fatimah Ahmedy
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Software, Supervision, Validation, Visualization, Writing – Review & Editing

Muhamad Faizal Zainudin
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

K M Amran Hossain
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Sharmila Jahan
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Md. Waliul Islam
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Md. Abu Khayer Hasnat
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

Abdullah Ibn Abul Fazal
Roles: Conceptualization, Data Curation, Formal Analysis, Funding Acquisition, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing

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REVIEWER STATUS

This article is included in the Emerging Diseases and Outbreaks gateway.

Abstract

Background: A diverse spectrum of long COVID symptoms (LCS) have the scope of physical rehabilitation. Due to limited resources, very little is known about the physiotherapy and rehabilitation interventions for LCS and their clinical application. This study aims to explore the role of physiotherapy and rehabilitation interventions in the management of musculoskeletal, neurological, cognitive, cardiorespiratory, mental health, and functional impairments of LCS.
Methods: The study was a systematic scoping review of the literature published between April 2020 and July 2022.
Results: 87 articles were extracted followed by a standard process of The Preferred Reporting Items for Systematic reviews and meta-analysis (PRISMA) extension for Scoping reviews (PRISMA-ScR). The included studies had a 3223 LCS population. All types of primary and secondary articles were retrieved except for qualitative studies. The evidence was evaluated by an appraisal scoring tool followed by the guidelines of the “Enhancing the Quality and Transparency of Health Research ( EQUATOR) network”. The included papers had a mean appraisal score of 0.7807 on a 0 to 1 scale (SD 0.08), the minimum score was for study protocols (0.5870), and the maximum score was for Cohort studies (.8977). Sixty seven (67) evidence-based interventions were documented from 17 clinical categories. The most weighted interventions were treating underlying symptoms of long COVID (Adjusted score 1/1), management of fatigue (Adjusted score 0.963/1), aerobic exercise and balance training (Adjusted score 0.951/1), multidisciplinary rehabilitation (Adjusted score 0.926/1), and low resistance training and aerobic exercise (Adjusted score 0.889/1).
Conclusion: We recommend Long COVID rehabilitation in a multidisciplinary approach by treating the individual symptoms, especially fatigue. Physiotherapy interventions play a significant role as most of the recommended interventions were exercise, modalities, patient education, respiratory rehabilitation, and telerehabilitation
Scoping reviews do not require protocol registration from PROSPERO.

Keywords

Long COVID, Physiotherapy, Rehabilitation, Scoping review

Corresponding author: Khin Nyein Yin

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Kabir MF et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Kabir MF, Nyein Yin K, Jeffree MS et al. A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID [version 2; peer review: 1 approved, 1 not approved]. F1000Research 2023, 12:368 (https://doi.org/10.12688/f1000research.132098.2) First published: 05 Apr 2023, 12:368 (https://doi.org/10.12688/f1000research.132098.1) Latest published: 24 May 2023, 12:368 (https://doi.org/10.12688/f1000research.132098.2)

Revised Amendments from Version 1

The revised manuscript added further analysis on weighting of interventions by evaluating articles through adjusted scoring system and synchronizing the recommended interventions according to the evidence pyramid. In the abstract, the weighted interventions with highest score (0-1) were added and summarized in the conclusion. In the result section, the detailed intervention recommendation were placed according to the nature of evidence (Systematic review, RCTs) in a descending order (strong evidence first). A table is added in the result section. In the discussion section, the most recommended interventions or approaches were compared and contrasted with the NICE guideline for long COVID rehabilitation, also a hyperlink added to the guideline. The conclusion was précised to the summery of recommendation from this scoping review.

See the authors' detailed response to the review by Romy Parker and Jacqui Koep

Introduction

WHO working group defines Long COVID (LC) as symptoms experienced for more than 12 weeks after the provable or confirmed diagnosis of COVID-19 that can’t be explained with any other diagnosis. With the progression of time, the global prevalence of long COVID symptoms (LCS) is increasing from 10 to 36 percent.¹ Between 16.2% and 25.2% of Bangladeshi people are experiencing LCS.²^,³ The respondents reported a broad spectrum of LCS, those were reported as fatigue, musculoskeletal pain, headache, loss of concentration, anxiety, depression, and post-exertion dyspnea. The presentation of LCS was noted as a relapsing remittent nature, which might not be described as related to a single biological system or organ involvement in the human body. With each relapsing episode, LCS had new symptoms, and symptoms were reported to be lasting more than a year.⁴ The management of LCS is multidisciplinary, as it has impacts on multiple organs in humans.⁵ WHO living guideline reports, rehabilitation is the key to managing the persistent illness that interferes with body function, daily activities, and overall quality of life. This guideline also states rehabilitation is an integral part of universal health and well-being and the global scope of rehabilitation stands for 2.4 billion people; 50% of the people living in lower-middle-income countries are out of reach of the scope. In the household LCS survey, Bangladeshi people had significant impairments in the musculoskeletal, neurological, and cognitive domains,⁴ and there is an emerging scope of physiotherapy and rehabilitation. Moreover, managing this significant scope will be another challenge because the COVID-19 pandemic changed the paradigm of rehabilitation service by adding a set of new impairments within the spectrum of rehabilitation.⁶

In a lower middle-income country like Bangladesh, it is important to study symptom responses and impairments to determine the scope of rehabilitation and generate clinical trials and shreds of evidence. From recent studies in Bangladesh,²^,³ we understand the symptom responses, disease spectrum, and scope of rehabilitation but there are inconclusive answers on the rehabilitation interventions for LCS. From the fact sheets of WHO, we know rehabilitation interventions play an important for the clinical management of LCS. To elicit the outcome of rehabilitation, clinical trials are necessary. And to design the trial interventions and achieve the greater clinical benefit, a review of the literature and consensus is important. There is a research gap in studies focusing on physiotherapy and rehabilitation interventions for LCS, and this comprehensive systematic scoping can address the research gap.

This study aims to determine the physiotherapy and rehabilitation interventions in the management of (1) musculoskeletal symptoms, (2) neurological and cognitive symptoms, (3) cardiorespiratory symptoms, (4) mental health issues, and (5) Functional limitations for Long COVID.

Methods

We conducted a systematic scoping review of the literature published between April 2020 and July 2022. To maintain the rigor of the paper we followed Preferred Reporting Items for Systematic reviews and meta-analysis (PRISMA) extension for Scoping reviews (PRISMA-ScR) (Extended data 1¹⁰⁰).

Review question

To generate the review question, we have used the “PICO” format (Table 1). The short review question was “What is the physiotherapy and rehabilitation management for Long COVID?”. The detailed question was “What is known from literature about physiotherapy, exercise, or rehabilitation for the management of musculoskeletal symptoms, neurological and cognitive symptoms, cardiorespiratory symptoms, mental health issues, and functional limitations for Long COVID?

Table 1. Generating questions in PICO.

Population	Intervention	Comparison	Outcome
Long COVID or Long haul COVID or Post COVID 19 or LCS	Physiotherapy Physical therapy or Exercise or Rehabilitation	None	Symptom sequel or symptom intensity or function or daily living activities or participation or physical impairments or psychological issues or mental health

Inclusion criteria

• Articles fall within the LCS population and Physiotherapy and Rehabilitation criteria.
• All types of primary and secondary literature (cohort, RCT, case-control, case report, case series), reviews and editorials, viewpoints, guidelines, letters to editors, and commentaries.
• Articles published or accepted for publication between April 2020 and July 2022.
• Grey literature that was published between April 2020 and July 2022.

Exclusion criteria

• Qualitative study design because it falls into different steps of evaluation, data curation, and extraction.
• Literature in another language except for English
• Unavailable full texts
• Journals or publishers included in Beall’s List – of Potential Predatory Journals and Publishers

Search strategy

We have adopted a search strategy following the Boolean method and conducted the study in four phases. We have searched in Cochrane Library, PsycINFO, PubMed, Embase, Scopus, PEDro, Hinari Summon 2.0, CINHAL, and the Web of Sciences. Searching keywords are stated in Table 2. The result was reviewed and categorized using Endnote 20 and Microsoft Excel 2016. We removed the duplicate publications and downloaded all the papers. Two authors conducted a comprehensive study of the paper and matched it with the eligibility criteria. Another two authors followed the reference list of the primarily selected studies and included other relevant studies. In phase II, after finalizing the papers, two authors categorized the papers according to major keywords and checked for the comprehensiveness of the scope of physiotherapy & Rehabilitation. In phase III, we looked at google scholar for articles’ citing and current publications, maximizing our efforts to collect all relevant studies. In phase IV, 87 papers were finalized and distributed to four authors. The authors checked the quality of evidence with an “author-generated appraisal system” and documented the appraisal score. Also, they made a synopsis of every article and filled up the quantitative questionnaire form for review. Finally, we analyzed the information from the quantitative questionnaire form and the appraisal scores in the Statistical Package of Social Sciences (SPSS) V.20 for data analysis and formulating results.

Table 2. Searching keywords.

Database	Keywords	Search strategy
PubMed	“long COVID” OR “long haulers,” OR “post-acute COVID” OR “chronic COVID syndrome” OR “late sequela COVID” OR “persistent COVID” AND “Physiotherapy” OR “Physical therapy” OR “exercise” OR “rehabilitation” OR “management” AND Symptom sequel OR symptom intensity OR function OR daily living activities OR participation OR physical impairments OR psychological issues OR mental health	Boolean Grid 1, Grid 2, and Grid 3 with Title, abstract, and keyword in MeSH term
Embase, Web of sciences, Scopus, PsycInfo, Cochrane Library, HINARI Summon 2.0, CINHAL	“long COVID” OR “long haulers,” OR “post-acute COVID” OR “chronic COVID syndrome” OR “late sequela COVID” OR “persistent COVID” AND “Physiotherapy” OR “Physical therapy” OR “exercise” OR “rehabilitation” OR “management” AND Symptom sequel OR symptom intensity OR function OR daily living activities OR participation OR physical impairments OR psychological issues OR mental health	Boolean Grid 1, Grid 2, and Grid 3 with Title, abstract, and keywords in general, or in MeSH term
PEDro	COVID 19, Post COVID or Post COVID Rehabilitation or Long COVID	Simple search

Tools for determining the quality of evidence

We prepared a scoring system to determine the quality of the evidence. We have followed the appropriate guidelines of the “Enhancing the Quality and Transparency of health Research (EQUATOR) network” as indicators of the scoring system. For systematic reviews, we have made a 27-score checklist (Extended data 2¹⁰⁰) followed by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. For randomized control trials, we made a 25-score checklist (Extended data 3¹⁰⁰) followed by the Consolidated Standards of Reporting Trials (CONSORT) guideline. The observational studies were reported with a 22-score checklist (Extended data 4¹⁰⁰) followed by The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement, case reports by a 13-score checklist (Extended data 5¹⁰⁰) Consensus-based Clinical Case Reporting (CARE) Guideline, Clinical practice guidelines by 23-score checklist (Extended data 6¹⁰⁰) The Appraisal of Guidelines for Research and Evaluation (AGREE) guideline, and the study protocols by 33-score checklist (Extended data 7¹⁰⁰) Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guideline (Extended data 7¹⁰⁰). The scoring was prepared and converted to a uniform range between 0 and 1 to analyze and visualize the data. Viewpoints, Editorials, Communication, and Letter to the editor were not evaluated as there is no guideline to evaluate this evidence.

The scoring checklist has been prepared from the guidelines of EQUATOR NETWORK, and the copyright states, “No material may be modified, edited or taken out of context such that its use creates a false or misleading statement or impression as to the positions, statements or actions of the EQUATOR Network.” We didn’t make any modifications to the original guidelines, we made a score out of the guideline checklist.

Data extraction, synthesis, and analysis

Data were extracted by a quantitative questionnaire consisting of information on the first author, date of publication, type of study, keywords, the population of the study, score in applicable checklist designed according to EQUATOR guidelines, category of papers according to the scope of physiotherapy and rehabilitation, and key interventions explained. Four authors extracted the data in Microsoft Excel for analyzing the scores. From the raw scores, the scores were further converted between 0 and 1 and calculated the mean, median, and 95% Confidence interval (CI). The presentation of all studies with their relative strength with 95% CI was presented in Figure 5. Figure 6 represents the strength of the papers by mean and median of the converted score. In the discussion, the interventions were presented in chronological order of scope of practice according to study objectives.

Results

Description of the selection process

The study followed the guideline of PRISMA extension for scoping reviews (PRISMA-ScR).⁶ From the Boolean searching strategy (Table 2) we found 142 publications. After that, we removed the duplicates (14), and then 128 publications were screened for the relevance of the title and abstract and categorized according to the main keywords. 96 publications were checked for the accessibility of full text, among those 24 articles were not within the objectives of the paper, and 8 publications couldn’t be accessed, hence 32 articles were excluded. Then, we had gone through the reference list of the included papers and found 23 relevant additional papers, and finally, 87 papers⁷^–⁹³ were selected for this review study. Figure 1 shows the process of literature searching, data extraction, and finalization of review papers according to the PRISMA extension for scoping reviews (PRISMA-ScR).

Figure 1. PRISMA extension for scoping reviews (PRISMA-ScR).

Types of included papers

Eighty seven papers were included in the study. Reviews and case study or series was the majority at 23% and 21.8% respectively (Table 3). About 6.9% papers were practice guidelines, 5.7% were Randomized control trials (RCT), 2.3% were quasi-experimental studies, 4.6% were cohort studies, 2.3% were Case-control study designs, 11.5% were cross-sectional studies, 2.3% Delphi consensus study, 3.4% study protocols and 16.1% were viewpoints, editorials, communication, or letter to editors.

Table 3. Distribution of Included studies and screening tools.

Included papers	n (%)	Screening tool	Evaluation score
Viewpoint, Editorials, Communication, Letter to the editor	14 (16.1)	Not evaluated	Not applicable
Study Protocol	3 (3.4)	SPIRIT	0-33
Delphi Consensus	2 (2.3)	CREDES	0-9
Case study, Case series	19 (21.8)	CARE	0-13
Cross-sectional	10 (11.5)	STROBE CS	0-22
Case-Control	2 (2.3)	STROBE CC	0-22
Cohort	4 (4.6)	STROBE Co	0-22
Quasi-experimental	2 (2.3)	TREND	0-22
Randomized Control Trail	5 (5.7)	CONSORT	0-25
Systematic reviews, Narrative reviews, Scoping reviews, Reviews	20 (23)	PRISMA	0-27
Practice Guideline	6 (6.9)	AGREE	0-23

Duration of publications

Figure 2 shows, the publications were published between 2020 and 2022. Most of the publications retrieved were published in 2021. From the studies of 2021, case studies and reviews were retrieved most. The 2020 studies were editorials and guidelines. In the studies of 2022, every area of primary and secondary sources of evidence was available.

Figure 2. Included studies according to the year of publication.

^*Viewpoints, editorials, communication, or letter to editors; ^**Systematic reviews, Narrative reviews, Scoping reviews, Reviews.

Categories of papers

The papers were from different categories according to their main keywords, titles and abstracts, and subject context. Figure 3 shows the categories of included papers according to subspecialty. Forty two papers (48.3%) were primary literature, and 45 papers were secondary literature (48.3%). Twenty three percent (23%) of the literature was about pulmonary rehabilitation, 18.4% on overall rehabilitation, 11.5% on exercise therapy, 9.2% on physiotherapy alone, 4.6% on telerehabilitation, 4.6% on neuro-rehabilitation, 6.9% on functional rehabilitation, 4.6% on long COVID symptom responses, and 6.9% on post-acute rehabilitation. Other papers were on early mobilization, pain rehabilitation, cardiovascular rehabilitation, geriatric rehabilitation, pediatric rehabilitation, community-based rehabilitation, and psychological rehabilitation.

Figure 3. Category of papers.

Study population

The study included a reviewed paper with a total of 3223 COVID-19 cases. The minimum study had 1 sample and the maximum was 782 samples. The median sample number was 26, and the interquartile range was 99. The studies in 2020 had 309 samples, and studies in 2021 had 2344 samples, and the studies in 2022 had 570 samples. Figure 4 shows, Cohort had the highest median of population 260, followed by case-control 101, Randomized control trial 99, cross-sectional 68, and quasi-experimental 42 samples.

Figure 4. Median study population according to the study types.

Error bar, 95% Confidence interval (95% CI).

Strength of evidence

Figures 5 and 6 show the strength of included evidence. The evidence scores were calculated according to the reporting guideline checklist of the EQUATOR network. For the study protocols, SPIRIT converted score (0-1) was between .363 and .742, with a mean of .601 ± .206 (95% CI .08, 1). The Delphi-based consensus CREDES converted score was between .776 and .778, mean of .777 ± .001 (95% CI .77765, .7779). For case studies and case, series CARE converted score ranged from .57 to .92, mean of .79 ± .094 (95% CI .74, .83). For the Cross-sectional study STROBE checklist converted score was a minimum of .52 and a maximum of 1, a mean was .75 ± .156 (95% CI .64, .86). Case-control study converted score of STROBE ranges from .72 to .90, mean .81 ± .206 (95% CI .03, 1). The cohort study converted score mean was .88 ± .13 (95% CI .06, 1), with a minimum of.72 and a maximum of 1. The Quasi-experimental study was evaluated by TREND and the converted score mean was .81 ± .206 (95% CI .009, 1). Randomized control trial converted CONSORT score ranges between .70 and .98, mean .86 ± .12 (95% CI .6, 1). Reviews were evaluated by PRISMA and the converted score mean was .73 ± .23 (95% CI .6, .8), the score varied from .2 to 1. However, the practice guidelines were evaluated by the converted score of AGREE checklist, the mean was .63 ± .23 (95% CI.38, .88) and the minimum to the maximum range was between .3 and .9. Figure 5 shows the median of the converted score (0-1) of the studies with 95% error bar. The studies marked as non-evaluative scored 0 for the studies with no reporting checklist. Figure 6, the radar plot indicates almost all the studies had 60% to 80% adherence to the EQUATOR network guideline checklist.

Figure 5. Strength of Evidence by the converted score of reporting guidelines checklist.

SPIRIT, Standard Protocol Items; Recommendations for Interventional Trials; CREDES, Conducting and Reporting Delphi Studies; CARE, Case Reports; STROBE CS, Strengthening the Reporting of Observational Studies in Epidemiology for Cross-sectional study; STROBE CC, Strengthening the Reporting of Observational Studies in Epidemiology for Case-Control study; STROBE Co, Strengthening the Reporting of Observational Studies in Epidemiology for Cohort study; TREND, Transparent Reporting of Evaluations with Nonrandomized Designs; CONSORT, Consolidated Standards of Reporting Trials; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; AGREE, Appraisal of Guidelines for Research and Evaluation; Non-evaluative, scored as 0 for the studies with no reporting checklist from the EQUATOR network as Viewpoint, Editorials, Communication, and Letter to the editor; Scores ranged as continuous variables, scoring sheets supplied to Extended dataset. Scores are calculated by the converted unit in the 0-1 range, and then displayed with the median of the converted scores with an Error bar representing a 95% Confidence interval (95% CI).

Figure 6. Strength of Evidence in radar plot.

The converted Score range between 0 to 1, 0 indicates the absence of the standard of the criteria in the EQUATOR network and 1 indicates absolute strength as complete fulfillment of standard criteria.

Weighting of interventions

We evaluated the interventions according to the position of the study in the evidence pyramid and presented in a descending manner of converted mean score between 0 and 1. There was limited evidence on any specific intervention items. Table 4 describes the weighting of recommended interventions in long COVID Rehabilitation. The most weighted interventions were treating underlying symptoms of long COVID (Adjusted score 1/1), management of fatigue (Adjusted score 0.963/1), aerobic exercise and balance training (Adjusted score 0.951/1), multidisciplinary rehabilitation (Adjusted score 0.926/1), and low resistance training and aerobic exercise (Adjusted score 0.889/1). Detailed recommended interventions were presented in Table 4 with the adjusted scores for reviews and RCTs.

Table 4. Weighting of recommended interventions in long COVID Rehabilitation.

Recommended interventions	Article	Method	Adjusted score of evaluation (0-1)
Weighting of Interventions for systematic review or reviews (PRISMA)
Treatment of underlying symptoms	Fugazzaro et al. (2022)¹⁶	Review	1
Interventions for fatigue management	Fowler-Davis et al. (2021)⁸⁰	Systematic Review	0.963
Aerobic exercise and Balance training	Demeco et al. (2020)¹⁷	Review	0.951
Multidisciplinary rehabilitation	Harry Crook et al. (2021)⁸¹	Systematic Review	0.926
Low resistance training and aerobic exercise	Hekmatikar et al. (2022)⁴⁴	Review	0.889
Pulmonary Rehabilitation	Munteanu et al. (2020)⁸⁴	Systematic Review	0.888
Pulmonary Rehabilitation	Soril et al. (2022)¹⁸	Review	0.871
Tele-rehabilitation	Vieira et al. (2022)⁴⁷	Systematic Review	0.870
Neuro-rehabilitation (sequel’s treatment)	Camargo-Martínez et al. (2021)²¹	Review	0.781
Exercise therapy	Patricio-Rafael et al. (2021)⁵²	Systematic Review	0.778
Breathing exercises, aerobic training, Exercise therapy	Wittmer et al. (2021)¹³	Review	0.768
Whole-Body Vibration Exercise	Sá-Caputo et al. (2021)⁵⁰	Review	0.741
Pursed lip breathing	Rahman et al. (2021)⁷⁹	Review	0.704
Phase-Adapted Rehabilitation	Gutenbrunner et al. (2021)²⁴	Review	0.482
Tele-rehabilitation	Tsutsui et al. (2021)³³	Review	0.407
Exercise therapy considering the multifactorial condition	Cattadori et al. (2021)⁷⁰	Review	0.333
Pulmonary Rehabilitation	Boutou et al. (2021)⁶²	Review	0.296
Weighting of Interventions for Randomized Control/clinical trials (CONSORT)
Cognitive-behavioral therapy	Mark Vink et al. (2020)⁸²	RCT	0.980
Pulmonary Rehabilitation and endurance exercise	Spielmanns et al. (2021)⁹	RCT	0.970
Physical efficiency training on a cycle ergometer	Szczegielniak et al. (2021)⁵⁴	Pilot RCT	0.840
Respiratory muscle strength and fitness exercise	McNarry et al. (2022)⁷¹	RCT	0.801
Pursed lip breathing exercise with bhastrika pranayama	Srinivasan et al. (2021)⁷⁸	RCT	0.702

Discussion

The discussion section is narrated into 5 categories where we present perspectives around (1) the management of musculoskeletal symptoms, (2) the management of neurological and cognitive symptoms, (3) the management of cardiorespiratory symptoms, (4) the management of mental health issues, and (5) Functional rehabilitation. Detailed interventions are provided in the extended data 8.

Management of Musculoskeletal impairments is focused on pain, fatigue, muscle loss, muscle weakness, and fatigue. Self-directed exercise and lifestyle advice prescribed through telemedicine or in-person consultation was recommended for managing chronic pain in LCS.²² To battle chronic pain along with physical limitations and low exercise tolerance, strengthening exercises, multi-component training, and guided walking practice were recommended.²⁸^,⁵⁰ Pain associated with myalgia and arthralgia was advised to be treated by neuromuscular exercises, however, functional electrical stimulation (FES) can be promising to restore function and muscle performance.³⁶ For musculoskeletal pain, studies suggest⁴²^,⁴⁶ aerobic exercise and respiratory re-education, and pacing exercises as an initial bout, progressing to strengthening, pelvic bridging, and core stability exercises. These interventions are also effective in managing generalized pain associated with lower back pain and sudden weight gain.⁴²^,⁴⁶ Fatigue, muscle pain, and muscle weakness were the commonly reported symptoms, and a wide range of manual therapy, manipulative therapy, exercise therapy, and electrotherapy was suggested.²⁴^,²⁵^,⁴¹^,⁵⁰^,⁵⁸^,⁶² Manual and manipulative therapy approaches included soft tissue techniques, relaxation techniques, release techniques, and trigger point therapy. Exercise therapy included aerobic training, range of motion exercise, and dynamic muscle training. Respiratory exercises were suggested as pacing, deep breathing exercise, thoracic expansion exercise, and aerobic exercise. Swimming and hydrotherapy were also suggested for LCS cases with myalgia and fatigue. Neuromuscular electrical stimulation (NEMS) was found to be effective in managing fatigue-related weakness, fatigue associated with neuromuscular weakness. Fall is a consequence of neuromuscular weakness and fall prevention strategies included passive range of motion exercises progressing to active range of motion exercises and strengthening exercises.³⁶ To prevent muscle loss rated to long-term physical inactivity and frailty²⁷ early mobilization and positioning in ICU were found to be effective. To manage sarcopenia,⁴⁸ aerobic exercise, resistance training, a multidisciplinary approach of physiotherapy, nutrition, and cognitive behavioral therapy were recommended.

Major neurological symptoms and consequences were anosmia, ageusia, headache, cerebrovascular accidents, Guillain-Barré syndrome, seizures, and encephalopathy,¹⁴^,¹⁵^,²¹^,²³ and recommended exercises were neuro-physiotherapy interventions, motor training exercises, balance, and coordination practice, walking training, music therapy and robotic rehabilitation through the in-person or telerehabilitation approach. For these conditions, cognitive behavioral therapy was also recommended. Headache was another prominent symptom,²⁸^,³⁵ the study recommended relaxation through breathing exercises, diaphragmatic breathing, and exercise therapy as aerobic exercise, and strengthening or vigorous physical exercise was effective. However, mindfulness training and resistance training improves memory loss.³⁵^,⁶⁴

A variety of interventions were recommended for cardio-respiratory impairments. To manage primary dyspnea¹⁶^,¹⁸^,²⁰^,²⁴^,²⁹^,³⁰^,⁶³ breathing exercises such as pursed lip breathing, yoga, and pranayama (ancient Indian technique), and a low-intensity pulmonary rehabilitation program were recommended. Managing dyspnea as LCS needs to cover a comprehensive approach³⁵^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴⁷^,⁵⁷^,⁶⁰^,⁷⁰ on aerobic training, strengthening exercises, diaphragmatic breathing techniques, and mindfulness training. Moreover, stretching exercises, warm-up, breathing exercises, resistance training, respiratory rehabilitation, respiratory muscle training exercises, coughing exercises, slow, deep, and sustained inhalations, patient Education, functional activity training, and behavioral changes were found to be significant. In case of chest pain associated with fatigue or breathlessness²³^,²⁴^,²⁶^,³¹^,³⁸^,⁴⁶ intervention starts with primary healthcare management with medical screening, meditation, and gradual pacing of stretching exercises, strengthening exercises, stretching exercises, resistant training, coping and ADL strategies (including management of energy and drive functions), ES, FES cycling was recommended. If there are productive cough with dyspnea²⁵^,³¹^,³⁸^,⁵³ recommended treatments were bronchial hygiene techniques such as assisted cough, postural drainage, and percussion, breathing exercises and mobilization, active-assisted or active ROM exercises, achieving mobilization, whole body muscle strengthening exercises, incentive spirometry for patients having sputum and productive cough. The utilization of devices for individual use such as Tri-flow, flutter breathing device, acapella, cornet, positive expiratory pressure (PEP), aerobic exercises, strength exercises, and resistance training were effective. In case of shortness of breath,²⁶^,⁶² goal-directed therapy should be applied. Dyspnea associated with fatigue and tachycardia can be managed by oxygen therapy, noninvasive ventilation, spontaneous prone positioning, and early mobilization. Oxygen therapy and pacing are recommended for low saturation levels and hypoxia.⁵⁶

Anxiety and depression¹⁷^,¹⁸^,²⁶^,⁴¹^,⁴²^,⁵⁴ were the most prominent issues in LCS cases. The issues can be managed by respiratory rehabilitation, aerobic training, hydrotherapy, and thermotherapy coping and ADL strategies (including management of energy and drive functions), strength exercises, resistance training, postural gymnastics, and respiratory re-education. Mood disturbances and sleep disturbances²⁴^,³⁶^,⁴¹^,⁵⁰ can be managed by cycle ergometer exercises and muscular strengthening, aerobic exercises, strength exercises, resistance training, and vibration exercises. Impairments in the functional status due to sleep issues,²⁴ and functional capacity issues²⁷ can be managed through proper primary care management, along with aerobic training, hydrotherapy and thermotherapy, coping, and ADL strategies (including management of energy and drive functions).

The review found a multi-directional and multi-professional role in LCS. But we focused on the treatment regimen of physiotherapy, related therapy, and rehabilitation perspectives. Our study met the research gap on the large-scale rehabilitation intervention-focused review that was insufficient and with a small scale in the previous reviews.⁹⁴^–⁹⁶ To our best knowledge, this is the larger scale review of LCS focused on rehabilitation interventions concerning the number of included papers and study population. We did not measure the sources of bias in the included study separately, instead, we evaluated the papers with a comprehensive appraisal by our appraisal tools for each type of included study following EQUATOR guidelines (Extended data 2-7). Scoping reviews do not require a complete appraisal and evaluation of the strength of included articles,⁹⁷ we have included additional analysis to present the reader with a comprehensive scenario of the intervention recommendations and the strength of information sources. The appraisal tool was an innovative concept. There are a few appraisal tools, mostly for randomized control trials or reviews,⁹⁸^,⁹⁹ our appraisal scoring was for cross-sectional, case-control, cohort, randomized control trials, study protocols, and Delphi-consensus. The scoring tools had no psychometric validation yet, but the system has a significant rigor as they are designed and adhered to the established EQUATOR guideline. A different type of study was evaluated with different scoring parameters, to present a uniform approach, the score was converted between 0 and 1. In that appraisal scoring evaluation, the minimum score of included studies was 0.6 out of 1. That means the lowest quality articles included in this study had 60% adherence to the EQUATOR standard for reporting research. According to the adjusted score, there was not any single specific intervention was recommended for long COVID rehabilitation, management of underlying symptoms especially fatigue through multidisciplinary rehabilitation was the most weighted recommendation. However, aerobic exercise, balance training, and low-resistance exercise were mostly recommended. NICE guidelines strongly recommended not to use resistance exercise or graded exercise for long COVID patients having chronic fatigue syndrome, as it can provoke post-exertion symptom exacerbation.

The primary limitation of the study was the insufficiency of randomized control trials, and level I studies. Long COVID is a relatively new term and clinical evidence is yet to be explored, hence we had a few pieces of evidence due to our focus on physiotherapy and rehabilitation. The future study recommendations will be systematic reviews and meta-analyses on RCTs or cohorts of LCS. Our most weighted recommended interventions do not completely adhere to NICE guidelines in the means of resistance training, but low resistance training can’t be entitled as graded exercise, as it can be prescribed as a part of pacing with careful observation. Moreover, the paradigm of long covid rehabilitation needs more clinic-based and community-based trials.

Conclusion

Long COVID is recommended to be managed by a multidisciplinary approach by treating the individual symptoms, especially fatigue. There is significant scope for physiotherapy in long COVID, as most of the recommended interventions were exercise, electro-physical agents, respiratory physiotherapy and telerehabilitation. Physiotherapy and rehabilitation interventions can be provided at home or in clinical setups such as primary care settings, specialized rehabilitation services, community care, and telerehabilitation by physiotherapists only or as a part of the multidisciplinary team. Current understanding is limited to the appropriate doses of rehabilitation interventions and the long-term outcome of rehabilitation.

Data availability

Underlying data

Mendeley Data: LCS ScR, www.doi.org/10.17632/w7m3bhnvcr.1.¹⁰⁰

This project contains the following underlying data:

- Scoping final dataset.xlsx
- Scoping SPSS.sav

Extended data

Mendeley Data: LCS ScR, www.doi.org/10.17632/w7m3bhnvcr.1.¹⁰⁰

This project contains the following extended data:

- Extended data 2: 27-score PRISMA checklist
- Extended data 3: 25-score CONSORT Checklist
- Extended data 4: 22-score STROBE checklist
- Extended data 5: 13-score CARE checklist
- Extended data 6: 23-score AGREE checklist
- Extended data 7: 33-score SPIRIT checklist
- Extended data 8: Recommended Physiotherapy and rehabilitation strategies summary

Reporting guidelines

Mendeley Data: PRISMA-ScR checklist for “A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID”, www.doi.org/10.17632/w7m3bhnvcr.1.¹⁰⁰

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

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96. Prabawa IM, Silakarma D, Prabawa IP, et al.: Physical rehabilitation therapy for long covid-19 patient with respiratory sequelae: A systematic review. Open Access Macedonian. J. Med. Sci. 2022 Jun 6; 10(F): 468–474. Publisher Full Text
97. Pham MT, Rajić A, Greig JD, et al.: A scoping review of scoping reviews: advancing the approach and enhancing the consistency. Res. Synth. Methods. 2014 Dec; 5(4): 371–385. PubMed Abstract | Publisher Full Text | Free Full Text
98. Moseley AM, Rahman P, Wells GA, et al.: Agreement between the Cochrane risk of bias tool and Physiotherapy Evidence Database (PEDro) scale: a meta-epidemiological study of randomized controlled trials of physical therapy interventions. PLoS One. 2019 Sep 19; 14(9): e0222770. PubMed Abstract | Publisher Full Text | Free Full Text
99. Fenton L, Lauckner H, Gilbert R: The QATSDD critical appraisal tool: comments and critiques. J. Eval. Clin. Pract. 2015 Dec; 21(6): 1125–1128. PubMed Abstract | Publisher Full Text
100. Hossain KMA, Kabir MF: LCS ScR. [Dataset]. Mendeley Data. 2022; V1. Publisher Full Text

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Author details Author details

Mohammad Saffree Jeffree
Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Supervision, Validation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (2)

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https://doi.org/10.12688/f1000research.132098.2

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Kabir MF, Nyein Yin K, Jeffree MS et al. A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID [version 2; peer review: 1 approved, 1 not approved]. F1000Research 2023, 12:368 (https://doi.org/10.12688/f1000research.132098.2)

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Reviewer Report 20 Feb 2024

Romy Parker, Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa

Jacqui Koep, Train Pain Academy, Cape Town, South Africa

Approved

https://doi.org/10.5256/f1000research.148341.r175047

I am very happy with the way the authors addressed our comments and amended the paper which is ... Continue reading

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Author Response 13 Apr 2024

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

13 Apr 2024

Author Response

Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Competing Interests: There were no competing interests.
Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Competing Interests: There were no competing interests. Close
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Author Response 04 Apr 2024

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

04 Apr 2024

Author Response

Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Competing Interests: No Competing Interests
Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Competing Interests: No Competing Interests Close
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COMMENTS ON THIS REPORT

Author Response 13 Apr 2024

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

13 Apr 2024

Author Response

Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Competing Interests: There were no competing interests.
Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Respected Reviewers,
Thanks a lot for your expertise and appreciation. Your appreciation encourages us to study further. Hope for the best. Wishing you sound health and long life.
Thanks
Competing Interests: There were no competing interests. Close
Report a concern
Author Response 04 Apr 2024

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

04 Apr 2024

Author Response

Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Competing Interests: No Competing Interests
Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Dear Reviewers,
Thanks a lot for your kind appreciation and scientific review. Your appreciation will encourage us to do further research work. Thank you very much.
Competing Interests: No Competing Interests Close
Report a concern

Views

Reviewer Report 07 Feb 2024

Kay Cooper, School of Health Sciences, Robert Gordon University, Aberdeen, UK; The Scottish Centre for Evidence-based, Multi-professional Practice, A JBI Centre of Excellence, Robert Gordon University, Aberdeen, UK

Not Approved

https://doi.org/10.5256/f1000research.148341.r233210

A scoping review on physiotherapy interventions for long COVID is timely and the authors have attempted a comprehensive search of the contemporary evidence-base, which should be commended. There are however, a number of limitation in conduct/reporting when comparing to methodological and reporting guidance for scoping reviews. I would suggest that the manuscript is revised in keeping with such guidance to enhance its rigor (see citations below).
TITLE
Use of the terms comprehensive, systematic and scoping are unnecessary - simply describing the review as a Scoping review would be appropriate
INTRODUCTION
The sentence ‘the respondents’ needs some context – which respondents? Is a particular study being referred to?
Reconsider the repeated use of the term ‘scope’. It is not clear what is means by ‘50% of the people living in LMIC are out of reach of the scope’ and the section that follows.
What does ‘shreds of evidence’ mean?
The justification for conducting a scoping review is not clearly presented – if there is a research gap in studies focussing on physiotherapy, how can a scoping review be conducted – when a scoping review requires literature to be available to be included in the review?
Moreover, the aims of the scoping review are not clear – is it to map what interventions have been reported? The authors might find this guidance useful: Scoping reviews: reinforcing and advancing the methodology and application | Systematic Reviews | Full Text (biomedcentral.com)
METHODS
Was there an a priori protocol published or registered that guided this scoping review – as is accepted good practice?
Suggest that the PICO is re-considered in light of the review aims – if the aim is to map physiotherapy interventions that have been reported for managing Long COVID symptoms then it is not clear why an ‘outcome’ is required – this would of course be relevant in a systematic review of effectiveness, but a scoping review cannot draw conclusions on the effectiveness of interventions.
It is interesting that qualitative studies were excluded – these might be qualitative studies where patients or staff describe their experiences of physiotherapy interventions.
Search strategy is not presented in a wat that it could be replicated – not clear what grid 1,2,3 mean and which terms are subject headings, keywords etc.
Did 2 reviewers independently conduct all stages of the review (title/abstract screening, full-text screening, data extraction, critical appraisal)? This is not clear from the manuscript.
RESULTS
Please use standard terminology to refer to literature included in the review – the PRISMA flow diagram uses records (results of searching), reports (i.e., articles) and studies – with studies referring to research. You introduce the terms ‘papers’ in the results section, which is not consistent with the flow diagram. You also have other types of reports (i.e., editorials, communication, letters to the editor) – this needs to be considered throughout the reporting.
Assessing quality is not common on a scoping review. I remain unclear as to what the quality assessments add to the review – if its purpose is to map what interventions have been reported. I am also not clear on the weighting of interventions section – how it has been calculated and what the difference between ‘review’ and ‘systematic review’ are in the table.
Rather than the quality & weighting, what would be far more useful is a table of included studies detailing the interventions that have been reported – this seems to be entirely missing from the review.
DISCUSSION
The discussion seems to discuss the type of information that I would expect – but without there being a table of included studies it is difficult as a reader to pass comment on its appropriateness.
I would suggest that if the comments above are addressed, then the discussion will likely need to be revised accordingly. The same will apply to the abstract.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

No
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

No

References

1. Peters MDJ, Marnie C, Colquhoun H, Garritty CM, et al.: Scoping reviews: reinforcing and advancing the methodology and application.Syst Rev. 2021; 10 (1): 263 PubMed Abstract | Publisher Full Text
2. Peters MDJ, Marnie C, Tricco AC, Pollock D, et al.: Updated methodological guidance for the conduct of scoping reviews.JBI Evid Synth. 2020; 18 (10): 2119-2126 PubMed Abstract | Publisher Full Text

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Physiotherapy; Rehabilitation; Long COVID; Evidence synthesis methodology

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Reviewer Report 04 May 2023

Romy Parker, Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa

Jacqui Koep, Train Pain Academy, Cape Town, South Africa

Approved with Reservations

https://doi.org/10.5256/f1000research.144998.r169253

This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.

The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.
The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.

This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.

The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Editing of the grammar would be helpful to facilitate understanding.

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Yes
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

No

Competing Interests: No competing interests were disclosed.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.

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Author Response 20 Jul 2023

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

20 Jul 2023

Author Response

Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms ... Continue reading Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.
The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.

Author’s response: Thank you for your scholarly review. We hope your recommendations improved the clarity and strength of the paper.

The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

Author’s response: An RCT (cited as Reference 82) found CBT as an effective intervention, but no study found CBT combined with strengthening exercises. We recommended CBT as the strongest evidence among RCTs, hence due to arranging evidence according to the evidence pyramid, RCTs were aligned after the review or systematic reviews. In the discussion, we discussed the most weighted interventions.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.
This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.
The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Author’s response: We have added Table 4 as the weighting of the evidence. We have revised the result section adding a table and key results from the weighting of evidence.
In the discussion, we have added the recommended intervention according to the strength of evidence and their adherence to NICE guidelines on Long COVID rehabilitation.
In conclusion, we concluded with recommended interventions.
We had an extensive revision of the abstract also.

Editing of the grammar would be helpful to facilitate understanding.
Author’s response: Our author's experienced with English proofreading revised the manuscript for grammar editing.
Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Is the statistical analysis and its interpretation appropriate?

Not applicable

Are the conclusions drawn adequately supported by the results presented in the review?

No

Author’s response: We have revised the conclusion as per the reviewer’s recommendations.

Competing Interests
No competing interests were disclosed.
Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.
The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.

Author’s response: Thank you for your scholarly review. We hope your recommendations improved the clarity and strength of the paper.

The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

Author’s response: An RCT (cited as Reference 82) found CBT as an effective intervention, but no study found CBT combined with strengthening exercises. We recommended CBT as the strongest evidence among RCTs, hence due to arranging evidence according to the evidence pyramid, RCTs were aligned after the review or systematic reviews. In the discussion, we discussed the most weighted interventions.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.
This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.
The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Author’s response: We have added Table 4 as the weighting of the evidence. We have revised the result section adding a table and key results from the weighting of evidence.
In the discussion, we have added the recommended intervention according to the strength of evidence and their adherence to NICE guidelines on Long COVID rehabilitation.
In conclusion, we concluded with recommended interventions.
We had an extensive revision of the abstract also.

Editing of the grammar would be helpful to facilitate understanding.
Author’s response: Our author's experienced with English proofreading revised the manuscript for grammar editing.
Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Is the statistical analysis and its interpretation appropriate?

Not applicable

Are the conclusions drawn adequately supported by the results presented in the review?

No

Author’s response: We have revised the conclusion as per the reviewer’s recommendations.

Competing Interests
No competing interests were disclosed.
Competing Interests: Authors declares no competing interest Close
Report a concern
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COMMENTS ON THIS REPORT

Author Response 20 Jul 2023

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

20 Jul 2023

Author Response

Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms ... Continue reading Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.
The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.

Author’s response: Thank you for your scholarly review. We hope your recommendations improved the clarity and strength of the paper.

The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

Author’s response: An RCT (cited as Reference 82) found CBT as an effective intervention, but no study found CBT combined with strengthening exercises. We recommended CBT as the strongest evidence among RCTs, hence due to arranging evidence according to the evidence pyramid, RCTs were aligned after the review or systematic reviews. In the discussion, we discussed the most weighted interventions.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.
This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.
The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Author’s response: We have added Table 4 as the weighting of the evidence. We have revised the result section adding a table and key results from the weighting of evidence.
In the discussion, we have added the recommended intervention according to the strength of evidence and their adherence to NICE guidelines on Long COVID rehabilitation.
In conclusion, we concluded with recommended interventions.
We had an extensive revision of the abstract also.

Editing of the grammar would be helpful to facilitate understanding.
Author’s response: Our author's experienced with English proofreading revised the manuscript for grammar editing.
Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Is the statistical analysis and its interpretation appropriate?

Not applicable

Are the conclusions drawn adequately supported by the results presented in the review?

No

Author’s response: We have revised the conclusion as per the reviewer’s recommendations.

Competing Interests
No competing interests were disclosed.
Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.
The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.

Author’s response: Thank you for your scholarly review. We hope your recommendations improved the clarity and strength of the paper.

The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

Author’s response: An RCT (cited as Reference 82) found CBT as an effective intervention, but no study found CBT combined with strengthening exercises. We recommended CBT as the strongest evidence among RCTs, hence due to arranging evidence according to the evidence pyramid, RCTs were aligned after the review or systematic reviews. In the discussion, we discussed the most weighted interventions.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.
This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.
The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Author’s response: We have added Table 4 as the weighting of the evidence. We have revised the result section adding a table and key results from the weighting of evidence.
In the discussion, we have added the recommended intervention according to the strength of evidence and their adherence to NICE guidelines on Long COVID rehabilitation.
In conclusion, we concluded with recommended interventions.
We had an extensive revision of the abstract also.

Editing of the grammar would be helpful to facilitate understanding.
Author’s response: Our author's experienced with English proofreading revised the manuscript for grammar editing.
Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Is the statistical analysis and its interpretation appropriate?

Not applicable

Are the conclusions drawn adequately supported by the results presented in the review?

No

Author’s response: We have revised the conclusion as per the reviewer’s recommendations.

Competing Interests
No competing interests were disclosed.
Competing Interests: Authors declares no competing interest Close
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Version 2 (revision) 24 May 23	read	read
Version 1 05 Apr 23	read

Romy Parker, University of Cape Town, Cape Town, South Africa

Jacqui Koep, Train Pain Academy, Cape Town, South Africa
Kay Cooper, Robert Gordon University, Aberdeen, UK; Robert Gordon University, Aberdeen, UK

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20 Feb 2024 | for Version 2

Romy Parker, Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa

Jacqui Koep, Train Pain Academy, Cape Town, South Africa

11 Views Cite this report Responses(2)

Approved

I am very happy with the way the authors addressed our comments and amended the paper which is now methodologically robust and also clinically relevant.

We recommend accepting the paper for indexing with no further amendments.

Competing Interests

No competing interests were disclosed.

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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27 Views

07 Feb 2024 | for Version 2

27 Views Cite this report Responses(0)

Not Approved

Are the rationale for, and objectives of, the Systematic Review clearly stated?

No
Are sufficient details of the methods and analysis provided to allow replication by others?

No
Is the statistical analysis and its interpretation appropriate?

Partly
Are the conclusions drawn adequately supported by the results presented in the review?

No

References

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Physiotherapy; Rehabilitation; Long COVID; Evidence synthesis methodology

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Reviewer Report

51 Views

04 May 2023 | for Version 1

Romy Parker, Pain Management Unit, Department of Anaesthesia and Perioperative Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, 7925, South Africa

Jacqui Koep, Train Pain Academy, Cape Town, South Africa

51 Views Cite this report Responses(1)

Approved With Reservations

Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes
Are sufficient details of the methods and analysis provided to allow replication by others?

Yes
Is the statistical analysis and its interpretation appropriate?

Not applicable
Are the conclusions drawn adequately supported by the results presented in the review?

No

Competing Interests

No competing interests were disclosed.

Respond to this report

Responses (1)

Author Response

20 Jul 2023

Khin Nyein Yin, Faculty of Medicine and Health Sciences, Universiti Malaysia Sabah, Kota Kinabalu, Malaysia

Response to reviewer 1

APPROVED WITH RESERVATIONS
This is a timely and well conducted scoping review which clearly identifies the need for a better understanding of Long COVID Symptoms (LCS) and their response to the range of rehabilitation strategies used by physiotherapists. The introduction provides an insightful overview into the multisystem nature of LCS with a comprehensive list useful for the clinical context.
The methods are well described, and the authors are to be commended for their rigorous approach to screening and selecting data. A novel method has been used to normalise analysis of the quality of evidence from studies using different methods e.g. case reports vs observation studies.

Author’s response: Thank you for your scholarly review. We hope your recommendations improved the clarity and strength of the paper.

The study provides a broad overview of the different rehabilitation interventions currently used in the field of physiotherapy for LCS. Helpfully, some discussion such as combining CBT and strength training are of clinical interest.

Author’s response: An RCT (cited as Reference 82) found CBT as an effective intervention, but no study found CBT combined with strengthening exercises. We recommended CBT as the strongest evidence among RCTs, hence due to arranging evidence according to the evidence pyramid, RCTs were aligned after the review or systematic reviews. In the discussion, we discussed the most weighted interventions.

The main limitation of this work is the lack of weighting of the evidence itself in the results. The quality of the data are summarised by methodology, however there is no analysis or weighting of the evidence for each rehabilitation modality. We strongly recommend that the authors consider generating a table for each of the rehabilitation strategies e.g. guided walking; FES with the relevant scoring of the quality of the studies; and appropriate effect sizes, NNT or other measure for interpretation of the clinical effectiveness of the modality.
This limitation results in the discussion being no more than a listing of what rehabilitation modalities are described in the literature with no discussion of the proposed mechanism of action of these modalities nor discussion which would enable the reader to consider one rehabilitation modality as preferential to another. For the researcher, the discussion is also limited as it does not highlight the strength of the evidence for each modality, thus providing no clarity about which of these modalities is worth exploring further.
The limited engagement with the strength of the evidence for each of the rehabilitation strategies, means that the conclusion lacks direction giving a generic recommendation for more research into physiotherapy for LCS. An engagement with the strength of the evidence and proposed mechanism of action for the specific rehabilitation strategies would provide more specific direction for future research and guidance for clinical application.

Author’s response: We have added Table 4 as the weighting of the evidence. We have revised the result section adding a table and key results from the weighting of evidence.
In the discussion, we have added the recommended intervention according to the strength of evidence and their adherence to NICE guidelines on Long COVID rehabilitation.
In conclusion, we concluded with recommended interventions.
We had an extensive revision of the abstract also.

Editing of the grammar would be helpful to facilitate understanding.
Author’s response: Our author's experienced with English proofreading revised the manuscript for grammar editing.
Are the rationale for, and objectives of, the Systematic Review clearly stated?

Yes

Are sufficient details of the methods and analysis provided to allow replication by others?

Yes

Is the statistical analysis and its interpretation appropriate?

Not applicable

Are the conclusions drawn adequately supported by the results presented in the review?

No

Author’s response: We have revised the conclusion as per the reviewer’s recommendations.

Competing Interests
No competing interests were disclosed.

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Competing Interests

Authors declares no competing interest

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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A comprehensive systematic scoping review for physiotherapy interventions for people living with long COVID

Abstract

Keywords

Revised Amendments from Version 1

Introduction

Methods

Review question

Table 1. Generating questions in PICO.

Inclusion criteria

Exclusion criteria

Search strategy

Table 2. Searching keywords.

Tools for determining the quality of evidence

Data extraction, synthesis, and analysis

Results

Description of the selection process

Figure 1. PRISMA extension for scoping reviews (PRISMA-ScR).

Types of included papers

Table 3. Distribution of Included studies and screening tools.

Duration of publications

Figure 2. Included studies according to the year of publication.

Categories of papers

Figure 3. Category of papers.

Study population

Figure 4. Median study population according to the study types.

Strength of evidence

Figure 5. Strength of Evidence by the converted score of reporting guidelines checklist.

Figure 6. Strength of Evidence in radar plot.

Weighting of interventions

Table 4. Weighting of recommended interventions in long COVID Rehabilitation.

Discussion

Conclusion

Data availability

Underlying data

Extended data

Reporting guidelines

References

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