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Research Article
Revised

Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf

[version 4; peer review: 1 approved, 1 approved with reservations]
Previously titled: Long-term effect of non-severe COVID-19 on pulmonary function, functional capacities and physical activities: a cross-section study in Sakaka Aljouf
PUBLISHED 09 Jan 2024
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Abstract

Background

COVID-19 has serious consequences on different body systems particularly the respiratory system with its impact on pulmonary function, exercise capacities, and physical activities. This study aimed to investigate the long-term effect of COVID-19 on pulmonary function, exercise capacities, and physical activities in patients with non-severe COVID-19.

Methods

160 individuals were selected to participate in a cross-section study. Group-I: 80 male and female patients with non-severe COVID-19 at least 3 months after the recovery time. Group-II: 80 male and female matched (non-infected with COVID-19) participants. The spirometer, six-minute walk test (6MWT), and International Physical Activity Questionnaire (IPAQ) were used to assess pulmonary function, exercise capacities, and physical activities respectively. The Kolmogorov-Smirnov test was used to test normality of data. The Mann–Whitney and independent t-tests were used to compare the significant differences between both groups.

Results

The results show significant differences in FVC & FEV1 of the pulmonary function, exercise capacities, and physical activities of the work & transportations between both COVID-19 and matched groups p-value = (0.001 & 0.001, 0.001 and 0.005 & 0.012) respectively.

Conclusion

Pulmonary function, exercise capacities, and physical activities are negatively influenced by COVID-19 as long-term consequences indicating the need for extended health care, and prescription of proper rehabilitative training programs for non- severe COVID-19 patients whatever their severity degree of infection or history of hospitalization. Outcome reflections of the current results raise awareness of physical therapists to the importance of the proper rehabilitative training programs for non-severe COVID-19 patients.

Keywords

COVID-19, Pulmonary Function, Physical Activities, Exercise capacities

Revised Amendments from Version 3

The amendment in version 3 of our manuscript included the functional capacity was measured by using the 6MWT: "without oxygen inhalation" is changed to without oxygen support, figure -1 was updated, and the word of drop was removed, the mean & SD was replaced with median and IQR in all tables as the variables are non-normal distributed. The writing style of confidence intervals was corrected in table 3, also table 4 was cancelled as it is a repeat of data.

See the authors' detailed response to the review by Asir John Samuel and Vencita Priyanka Aranha
See the authors' detailed response to the review by Ashraf Abdelaal Mohamed Abdelaal

Introduction

Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which began spreading on 31 December 2019 and had spread globally in the first months of 2020.1 Although many patients with COVID-19 do not suffer from any symptoms and recover spontaneously without medical interventions, one in every six patients develops breathing difficulties and becomes seriously ill.1 Until 29 September 2022, there had been 613,942,561 confirmed cases, including 6,520,263 deaths worldwide due to COVID-19.2 Public health was forced to take specific protocols to prevent rapid spread of pandemic, and its associated economic crisis.3 Tens of millions lost their jobs and increased poverty levels.4 Consumption, investments,5 work absenteeism, productivity, and hospitality sectors all impacted negatively on income and supply.5,6 COVID-19 affects people of all ages and seriously impacts different body systems.7

Post-COVID-19 syndrome means the sequelae that develop during or after a SARS-CoV-2 infection and persist for more than 12 weeks.8 It encompasses multi-organ sequelae beyond the acute phase which ranges from physical and cognitive abnormalities to functional limitations, exercise impairments and deterioration of quality of life.9,10 A massive number of humans suffered from multi-organ impairments in extra-pulmonary tissues.11,12 The pulmonary and cardiovascular systems are the most important impacted organs with their reflections on patient’s physical activities, and quality of life. Similar coronavirus infection (SARS-CoV) caused its impairments for two years which are expected to occur for the survivors of COVID-19.13 COVID-19 causes marked impairments in the diffusing lung capacity for carbon monoxide (DLCO), total lung capacity, forced expiratory volume in one second and forced vital capacity ratio (FEV1/FVC), restrictions in small airways,14 16 restrictive and obstructive patterns of the pulmonary function,15 low quality of life15,16 consolidation patterns,17 restrictions in both the two minute walking test (2MWT) and FVC,17 respiratory muscles dysfunction and lung fibrosis,18,19 in addition to formation of pneumocytes.20 Middle East respiratory syndrome (MERS) and SARS are the two previous viral infection outbreaks like the current COVID-19.20 Abnormalities of the lung function are classified to obstructive pattern, restrictive pattern, and small airway disease.21 COVID-19 patients with cardiovascular and pulmonary comorbidities are more vulnerable to hospitalization,22,23 and for developing neurological events, e.g., acute cerebrovascular disease, conscious disturbance, and skeletal muscle injury.19 Even though vaccination against COVID-19 can prevent hospitalization and severe infection. It has been adequate protection only against some long-COVID-19 symptoms, including cognitive dysfunction, sleeping disorders, and kidney diseases.24 Even after recovery of survivors of COVID-19, almost 10-20% may suffer long-term consequences including fatigue, dyspnea, and impairments in both cognitive and daily functions.7 Also, COVID-19 patients may be complicated with bladder dysfunction, severe urinary symptoms,2527 higher liver enzymes,28 gastrointestinal symptoms,29 psychotic disorders30 and poly-neuromyopathy.31

However, there were restrictions in the physical performance, activities, and the detected impairments in sleep quality at 12 weeks post-COVID-19 infection.32 Although time of walk improved significantly at the sixth month of recovery it still reduced on comparison with that spent before COVID-19 for the same patients,33 also, the physical activities and the one-minute standing test were impaired at discharge of patients with COVID-19.34 Evidence of persistent physiological and radiographic changes is available in most patients who recovered from severe COVID-19.35 Patients with persistent dyspnea had several abnormalities during the 6MWT e.g., greater restriction on spirometry, reduced exercise capacity and increased exertional symptoms.36 As a result of wide variations in epidemiology and treatment for long-term sequels of COVID-19, it is considered a new area of research.7,37,38 There is need for more studies to investigate effects of COVID-19, particularly its long-term impact on the pulmonary function, physical activities, and exercise capacities. The authors mainly concentrated in previous studies on investigating critical hospitalized survivors and who experienced severe infection,19,3941 whereas Non-severe COVID-19 survivors might be ignored during the pandemic so; further research is recommended particularly for those patients with mild and moderate degree of COVID-19.32,33 Therefore, the current study aimed to investigate long-term effect of COVID-19 on pulmonary function, exercise capacities and physical activities in patients with non-severe degree after three months from recovery time.

Methods

Design of the study

A cross-section study.

Sample size

The sample size was calculated by using an online tool ( http://www.stat.ubc.ca/~rollin/stats/ssize/n2a.html). It was based on the FEV1% (μ1 = 94.2, μ2 = 100.3, sigma/SD = 13.1, in the previous study.42 The significant value is 0.05 with a power of .80.

Ethical approval

All procedures of the study were approved by the Ethics Research Committee of the Institutional Review Board of Imam Abdualrahman bin Faisal University (IRB-PGS-2021-03-427). Also, by the Research Ethics Committee in Qurayyat Health Affairs, Ministry of Health, Project no: 083, Saudi Arabia. This study was conducted in accordance with the Declaration of Helsinki at the out-patient clinic of the Physical Therapy Department of King Abdulaziz Specialist Hospital in Sakaka Aljouf, Ministry of Health- Saudi Arabia between September 2021 to June 2022. Prior to participation, all participants signed a consent form, and they were informed that the collected data would be submitted for publication.

Subjects

600 participants were screened from the department of pulmonology and out-patient clinic of the Physical Therapy Department, King Abdulaziz Specialist Hospital in Sakaka Aljouf. They were assigned to, COVID-19 group: 80 male and female patients (After physical examination, inspection and analysis and reports of analysis checking by pulmonologist) with confirmed non-severe COVID-19 at least 3 months from recovery time. Recovery is being free from fever and respiratory symptoms for at least 3 days followed by two negative polymerase chain reaction (PCR) tests 24 hours apart, or if PCR was not available, resolution of the clinical manifestations for 3 days and at least 10 days have passed from the appearance of the first symptom.43 Matched Group: 80 male and female matched participants (non-infected with COVID-19, their PCR was negative for COVID-19, no signs, or symptoms of infection) who were invited to participate as control group.

Inclusion criteria

Male and female patients who diagnosed with mild & moderate COVID-19 after three months from recovery time and matched non-infected with COVID-19 participants, their age ranges from 25 to 55 years.

Exclusion criteria

Patients with severe COVID-19, and who have acute infections, recent surgeries, unstable cardiovascular conditions, chronic respiratory diseases, neurological disease, mental illness, critically ill patients with intubation any other medical condition that contradict with the conduction of this research, who cannot walk, and smokers, critically ill patients with intubation in addition any other medical condition that contradict with the conduction of this research were excluded.4446

Procedure of the study

Demographic data were recorded including weight, body mass index (BMI), oxygen saturation, heart rate, blood pressure, comorbidities, admission to the intensive care unit or hospitalization, severity degree of infection was determined with pulmonologist according to the classification of WHO progression scale.47 This scale classifies severity of COVID-19 infection into five categories: 1-Uninfected with a 0 score, 2-Mild disease with a score ranging from 1-3, patient is asymptomatic with detected viral RNA or symptomatic with assistant needed, 3-Moderate disease with a score ranging from 4-5, patient is hospitalized and not need for oxygen therapy or hospitalized and need for oxygen therapy or non-invasive ventilation, 4-Severe disease with a score ranging from 6-9, patient is hospitalized and need for oxygen therapy by non-invasive ventilation or high flow, 5-Dead with score 10.

All participants underwent these outcome measures:

  • a) Pulmonary function was measured by using the Spirobank II spirometer (Medical International Research, USA, Inc., www.spirometry.com). It is a validated device used for diagnosing and evaluating pulmonary diseases.48 The lung function are classified according to the American Thoracic Society as: normal, if both FVC and the FEV1/FVC ratio are in the normal range; obstructive pattern, if FEV1/FVC ratio is <70% of the normal predicted value and FEV1 <80% of the predicted; restrictive pattern, if FEV1/FVC ratio is ≥70% of the normal predicted value, and the total lung capacity <80% of the predicted value. If total lung capacity is not available, a reduction in the FVC <80% of predicted is considered as a restrictive pattern, small airway disease, if forced expiratory flow between 25% and 75% of FVC (FEF25-75%) is <65% of predicted value.21 All participants underwent the test according to guidelines of the American Thoracic Society and European Respiratory Society (ATS/ERS).46 The obtained parameters are FVC, FEV1, FEV1/FVC ratio, FEF25-75%, and peak expiratory flow (PEF). All measurements of pulmonary function testing (PFT) were expressed as absolute and percentage of predicted normal values (% predicted), the percentage of predicted normal values was calculated automatically based on age, sex, height, and ethnicity.49 Each participant completed three accepted maneuvers and the highest value was recorded and used in the statistical analysis.

  • b) Physical activity was measured by using the International Physical Activity Questionnaire (IPAQ-Arabic version) which is valid and reliable.50 It assesses physical activity during the last seven days throughout four domains: work-related physical activity, transportation-related physical activity, domestic and yard, and leisure time physical activity. Every participant was asked to answer each question in all domains. The scores are calculated for each domain and expressed as metabolic equivalent minutes per week (MET-minutes/week). The total physical activity score is calculated by summating the total scores for all domains, the physical activity score is classified into high, moderate, and low as 3000,600 and <300 MET minutes/week respectively.51

  • c) Exercise capacity was measured by using the 6MWT: It is valid and reliable, and it has been approved to estimate sub-maximal exercise performance, daily physical activities,52 and endurance in older adults5355 and post-COVID-19 patients over 18 years.39 Each participant was asked to walk independently with his or her comfortable footwear on a flat, well illuminated, non-slippery ground surface in corridor 30-meters space for 6 minutes as fast as possible without oxygen support, the results were expressed in meters.52

  • d) Pulse oximeter is a valid and reliable device; a wearable wrist oxygen pulse oximeter was well fastened in the index and wrist of the non-dominant hand to detect oxygen saturation and heart rate for every participant during 6MWT.56

  • e) Modified Borg Scale of Dyspnea is a scale rated from 0 to 10. It was used to monitor severity of self-reported breathlessness during the 6MWT.57

Statistical analysis

The collected data were analyzed using SPSS statistical software (version 25) and were tested for normality using the Kolmogorov-Smirnov test. Group comparisons were done using independent t-test and Mann–Whitney test for normal and not normal data distribution respectively. The Chi-squared test was used to compare the categorical variables. The COVID-19 group was divided into pre-6 months and post-6 months sub-groups to determine time effect on the associated consequences, these two sub-groups were compared descriptively with the matched group by using the confidence intervals. Statistical significance was set at P-value <0.05 with a confidence interval of 95%.

Results

80 male and female patients with confirmed diagnosis of mild and moderate COVID-19 (COVID group), and another 80 matched participants non-infected with COVID-19 (Matched group) were recruited in this study (Figure 1). Demographic and clinical characteristics of both groups including age, gender, BMI, and comorbidities were matched (P-value > 0.05) (Table 1). There were significant differences in oxygen saturation between both groups (P-value = 0.003), 30 patients (37.5%) had comorbidities. The most common co-morbidities were obesity (31.25%), hypertension (2.5%) & diabetes (3.75%). Severity degree of infection was 32 patients (40%) with mild, and 48 patients (60%) with moderate, 25 patients (31%) had restrictive pattern, and 13 participants (16%) in matched group, (P-value = 0.026), 17 patients (21%) with dyspnea & 48 patients (60%) were hospitalized (Table 1).

792dd83f-32d5-4161-94d2-fdc0e381b6fc_figure1.gif

Figure 1. Flow chart of the participants’ recruitment.

Table 1. Demographic and clinical characteristics data of recruited participants.

VariablesCOVID-19 group
(Median ± IQR)
Matched group
(Median ± IQR)
P-value
Gender male & female N (%)M 25 (31.3%)
F 55 (68.8%)
M 23 (28.7%)
F 57 (71.3%)
0.730a
Age (in years)45.0 ± 14.544.0 ± 20.00.333b
Weight in kg75.0 ± 18.075.0 ± 20.250.177b
BMI (in kg/m 2)26.15 ± 7.5727.55 ± 10.650.765b
Comorbidities: N %30 (37.5%)31 (38.75%)0.965a
SpO298.0 ± 1.098.0 ± 1.00.003*b
Restrictive pattern N (%)25 (31%)13 (16%)0.026*a
Overweight N (%)20 (25%)17 (21.25%)
Obese N (%)25 (31.25%)27 (33.75%)
HTN N (%)2 (2.5%)2 (2.5%)
DM N (%)3 (3.75%)2 (2.5%)
Time after recovery in months8.0 ± 5.0
Severity degree of infection N (%)Mild32 (40%)
Moderate48 (60%)
In-patients in ICU N (%)12 (15%)
Hospitalization N (%)48 (60%)
Dyspnea N (%)17 (21%)
Affected smell and taste N (%)8 (10%)

a Chi-squared.

b Mann–Whitney test.

† Non-significantly differences (P-value > 0.05).

* Significantly differences (P-value < 0.05).

After 3 months from time of recovery the results of pulmonary function test show significant reductions in mean values of the FVC%, FEV1%, FEV1/FVC Ratio%, FEF 25-75%, and PEF% in COVID-19 group on comparison with matched group (P-value <0.05) (Table 2). Also, the mean values of distance of the 6MWT and four domains of physical activity including work, transportation, domestic & yard, and leisure & free time reduced significantly in COVID-19 group on comparison with matched group (P-value <0.05) (Table 2).

Table 2. Mean values of PFT, 6MWT and IPAQ of COVID-19 and control matched groups.

VariablesCOVID-19 group
(Median ± IQR)
Matched group
(Median ± IQR)
P-value
FVC (Liters)3.18 ± 0.543.51 ± 1.32<0.001*b
FVC % pred (%)85.0 ± 1190.0 ± 18.75<0.001*b
FEV1 (Liters)2.81 ± 0.613.11 ± 0.810.001*c
FEV1 % pred (%)87.50 ± 1293.0 ± 19.50.001*b
FEV1/FVC ratio (Liters)83.55 ± 7.2885.25 ± 8.780.007*b
FEV1/FVC ratio % pred (%)99.0 ± 11103.0 ± 17.00.001*b
FEF25-75% (Liters)3. 41 ± 1.113.54 ± 1.320.038*b
FEF25-75% % pred (%)91.5 ± 19.0103.0 ± 35.250.001*b
PEF (Liters)6.0 ± 1.756.45 ± 1.630.009*b
PEF % pred (%)99.0 ± 25.75103.5 ± 28.750.011*b
6MWT D366.0 ± 81.5410.0 ± 54.5<0.001*c
PA of work693 ± 16501116 ± 31550.005*b
PA of transportations0 ± 19849.5 ± 3460.012*b
PA of domestic and yard630.0 ± 11701260.0 ± 11970.011*b
PA of leisure and free time346.5 ± 720756 ± 14900.002*b

b Mann Whitney test was used to determine significant differences between two groups for not normal distributed variables.

c Independent t-test was used to determine significant differences between two groups for normal distributed variables.

* Significantly difference P-value < 0.05. FEF 25-75% of pred: forced expiratory flows at 25-75% of FVC percentage of predicted, FEV1% of pred: Forced expiratory volume in the first second percentage of predicted, FEV1/FVC% of pred: forced expiratory volume in the first second and forced vital capacity ratio percentage of predicted, FVC% of pred: forced vital capacity percentage of predicted, PEF% of pred: peak expiratory flow percentage of predicted, 6MWT: Six minute walking test. IPAQ: international physical activities questionnaire, PA: physical activity.

The COVID-19 group was divided into pre-6 months and post-6 months sub-groups to investigate the time effect on post-COVID-19 consequences. The results of pulmonary function, four domains of the IPAQ and 6MWT of COVID-19, pre-6 months and post-6 months groups were descriptively compared by using the confidence intervals at 95% (Table 3).

Table 3. Confidence intervals values of PFT, 6MWT and IPAQ for pre-6 months, post-6 months and matched groups.

VariablesPre-6-months
(lower ; upper)
CI at 95%
Post-6 months
(lower ; upper)
CI at 95%
Matched group
(lower ; upper)
CI at 95%
FVC % pred(−0. 34 ; 0.1)(−0.35 ; 0.02)(−10.38 ; −3.75)
FEV1 % pred(−0.78 ; 0.14)(−0.78 ; −0.15)(−12.53 ; −4.19)
FEV1/FVC ratio % pred(−0.76 ; 5.26)(−0.57 ; 5.08)(−9.43 ; −3.32)
FEF25-75% pred(−0.7 ; 0.21)(−0.73 ; 0.24)(−16.84 ; −3.73)
PEF % pred (%)(0.32 ; 1.15)( 0.32 ; 1.15)(−12.26 ; −2.1)
6MWT D(−37.91 ; 5.81)(−39.18 ; 7.08)(−53.35 ; −17.54)
PA of work(−1368.8 ; 373.9)(−1319.3 ; 324.4)(−1395.1 ; −108.75)
PA transportations(−72.44 ; 71.94)(−74.7 ; 74.2)(−185.69 ; −43.56)
PA domestic & yard(−201.34 ; 426.1)(−194.3 ; 419.04)(−775.71 ; −179.04)
PA leisure & free time(−258.5 ; 171.9)(−265.4 ; 178.84)(−864.46 ; 305.49)

The results of pulmonary function, domains of the IPAQ and the 6MWT distance showed non-significant differences on comparison of pre 6 months with the post 6 months groups (except the predicted FVC P-value <0.05).

The spearman’s correlations with the severity of infection showed positive correlations between 6 MWT, physical activity transportation, and physical activity domestic & yard (r = 0.005, 0.01 & 0.03) respectively and positive correlation between FEFa & FEF25-75 (r = 0.042), While the results show negative correlations between BMI, physical activity transportation and leisure & free time (r = 0.015, 0.003 & 0.012) respectively whereas presence of positive correlation between 6MWT distance & FEV1 (r = 0.014). In addition to time factor the results show negative correlations between BMI & both physical activity of work and transportation (r = 0.015 & 0.027 and 0.001 & 0.046) in pre 6 months and post 6 months subgroup respectively.

Discussion

COVID-19 is a new rapidly spreading epidemic, its initial symptoms may progress to long-term consequences. Results of the current study indicate that post-COVID-19 patients may experience chest abnormalities including reductions in pulmonary function, decreases in exercise capacity, and physical activities within the average time 7.9 months after recovery time. Sights of researchers were attracted to investigate them all over the world. Our findings agree with the results of Abdallah et al, Lorent et al & Salem et al they found significant reductions in mean values of FVC, FVC% predicted, FEV1, PEF, PEF% predicted at the third month of recovery on comparison with matched participants.40,58,59 Restrictive pattern of impairments was observed in 50% of COVID-19 patients’ sample of Salem et al.40 while it was 31% in the current study. A greater percent of restrictive pattern in findings of Salem et al.40 may be due to their patients’ sample was COVID-19 patients with pneumonia or hospitalized (more complicated), whereas the current patients’ sample was selected with mild and moderate degree of infection. The current findings of pulmonary function are consistent with the findings of previous studies. Salem et al found significant reductions in pulmonary function of the survivors of COVID-19 after three months of discharge on comparison with matched controls.40 Also, Abdallah et al. found reductions in the measured FVC, total lung capacity (TLC), and DLCO at the third month in hospitalized patients with severe COVID-19.58 In contrast to our results the findings of Lerum et al. show normal pulmonary outcomes including lung function, 6MWT distance, oxygen saturation, dyspnea prevalence measured at the third month after hospital discharge.60 Also, Eksombatchai et al. found non-significant differences in the pulmonary function of mild and moderate survivors COVID-19 with pneumonia.61 The authors highlighted the absence of PFT data for their patients’ samples prior to occurrence of COVID-19.40,62

The underlying mechanisms for COVID-19 multiple findings may be due to acute lung injury with diffuse alveolar damage which is associated with fibrotic changes and microthrombi in the pulmonary vasculature.63 The restrictive impairment of the lung function may be caused by fibrotic changes in the lung and increase proinflammatory cytokines which recruit fibroblasts resulting in lung fibrosis.64 The decline in pulmonary function results from the respiratory muscles fatigue as a significant improvement of PFT after pulmonary rehabilitation for COVID-19 survivors,65 the results of PFT are also influenced by several factors e.g., sex and body type.66

Our findings show significant reductions in measured parameters of pulmonary function, 6MWT distance and domains of physical activities in patients with COVID-19 after 3 months, on comparison with the matched group. There are progressive improvements on comparison of pre with post 6 months sub-groups as a time effect and being non-significant may be due to patients’ sample of pre 6 months was not the same patients’ sample of post 6 months. The current results are consistent with findings of Magdy et al. determined lower limits in lung function (<80%) and non-statistically significant differences in the pulmonary function at 3 and 6 months post-infection.67 Whereas existing significant improvements at one year follow-up.59 This finding does not contradict with our results as they compared the same patients at 3 months, 6 months and after one year not the case in the current study where the patients’ sample was descriptively compared at pre 6 months and after 6 months to matched control. Also, Zhang et al. found 20% of the survivors of COVID-19 had FEV1/FVC below 70% of predicted values at the eighth month.62

The current results contradict the findings of Wu et al. as they found significant increases in pulmonary function at 3, 6, 9 and 12-month interval measures post-infection (time effect)35 this may be also due to the authors did the interval assessments for the same COVID-19 patients. They found high rate of dyspneic patients (81%) measured at the third month whereas it was 21% in the current study. This may be their sample included only severe COVID-19 patients whereas the sample in the current study included both mild and moderate degree of COVID-19. Also, Madrid-Mejía et al. determined improvements in PFTs at the sixth month of infection compared to the results of the same participants at the third month after infection.68 The variations in the time of evaluation in different studies may explain the differences in the results.15,40,69

In our study, despite the result of the exercise capacities (6MWT distance) show significant reductions in the COVID-19 group after 3 months, from recovery on comparison with the matched control, there are non-significant increases at both pre and post 6 months. This finding is consistent with the results of Magdy et al. who determined significant reductions in the 6MWT results of the survivors of COVID-19 on comparison with the normative data,40 whereas a significant improvement was determined in the 6MWT at the sixth month in regarding the third-month follow-up.40 They referred their findings to the extended period of hospital stay and extra usage of corticosteroids which could influence the muscles resulting in muscle wasting and myopathy.40,70,71 Also, Calabrese et al. demonstrated significant reductions in the FVC %, DLCO, low oxygen saturation (SpO2) (>90%) during the 6MWT with higher dyspnea.41 In addition, Raman et al. found significant reductions in the distance of the 6MWT for COVID-19 patients on comparison with controls.72 They referred this limited exercise capacity to muscle wasting that caused by the catabolic state resulting from severe illness, and potentially inflammation.72 74 While Abdallah et al. reflected the persistence of breathlessness and limitation in exercise capacity at the third month to the residual defects in TLC.58 In addition, the recovery of the physical function within the first 6 months of patients after SARS-COV was incomplete as it lasts for one to two years.13 In addition, Magdy et al. found significant increases in the 6MWT distance at the 6-month follow-up.67 Accordingly, the lower results of the 6MWT distance may be attributed to the higher BMI, and high number of female participants in the current study. The distance of the 6MWT is negatively influenced by sex and body type.52 On contrary to the current findings Wu et al determined significant improvements in the 6MWT at 3, 6, 9, and 12-month interval measures post-infection.35

Our results agree with the findings of Belli et al. they found patients with COVID-19 suffer from impairments in physical functions and fitness, as 33.3% of patients had impaired physical fitness, and 17.5% with moderate scores in activities of daily livings performance.75 Cao et al. also stated that performance in the 6MWT was significantly lower in post COVID-19 patients than in health controls.76 Lower performance in the 6MWT was reported in patients with severe/critical COVID-19 compared to patients with mild/moderate disease at baseline.77 On contrary to the results of the current study the findings of Lerum et al. they concluded non-significant differences in the results of the 6MWT between ICU and non-ICU groups and Eksombatchai et al. they found statistically typical results for the 6MWT among three groups, while the severe infection group showed lower results when compared with the mild and moderate infection groups but not statistically significant.60,61 The results of oxygen saturation show non- significant differences (p = 0.201) among groups for both pre and post 6MWT. They referred the reductions in their results to the higher BMI and older age in the severe group.60,61

In the current study, the results of the IPAQ significantly reduced in all domains in the COVID-19 survivors’ group on comparison with the matched group after 3 months. The current findings are supported with the results of Tanriverdi et al. found poor physical activities and impaired hand grip power at least three months of survivors of COVID-19.32 Paneroni et al. who determined impaired physical activities at the discharge time.34 As a result of improvements in physical activities with time effects on comparing survivors of COVID-19 of pre and post 6 months with the matched controls, descriptive differences were determined in some IPAQ domains. Also, the current findings supported the findings of Delbressine et al. who found significant improvements in physical activities in the survivors of COVID-19 at the sixth month compared with results at the third month post-infection.33 In the current study, the IPAQ questionnaire was used to assess the physical activities during the last seven days only, which may not give an accurate perception of the physical activities as it could be affected by other factors e.g., the work domain could be lower for some participants because they were on vacation for the last seven days. The transportation domain may be lower for some patients because they must use vehicles due to the hot weather. Some participants did not have gardens or backyards, which reduces their domestic and yard scores. Other participants may have lower leisure time domain scores because they did not feel well to walk or did exercise during the last seven days in convalescent stage. Although the current results of outcome measures show significant reductions in pulmonary function, physical activities, and exercise capacity after 3 months, on comparison to matched participants there are general progressive improvements as time effects but still patients with COVID-19 need to extend their health care and to prescribed proper rehabilitative training programs whatever their severity degree of infection or history of hospitalization.

Limitations

There was a lack of data on health conditions of patients prior to contracting COVID-19 so the authors tried to overcome this limitation by including a matched control group, small sample size, usage of simple spirometry approach, lack of DLCO and plethysmography. Despite these limitations, the authors believe that the results of this study contribute to filling a significant knowledge gap about consequences of COVID-19 after 3 months of recovery time.

Recommendations

Further studies to investigate effectiveness of COVID-19 long-term complications and follow-up for patients with different severity of infections and effectiveness of individualized comprehensive rehabilitative programs for such patients.

Conclusion

Pulmonary function, exercise capacities, and physical activities are negatively influenced by COVID-19 as long-term consequences indicating the need for extended health care, and prescription of proper rehabilitative training programs for those patients whatever their severity degree of infection or history of hospitalization. Gaining the deepest knowledge and awareness that enables physical therapists how to tailor the appropriate rehabilitative training programs for non-severe COVID-19 patients.

Data availability

Underlying data

Figshare: Sensory perception, https://doi.org/10.6084/m9.figshare.23153540.v1.78

This project contains the following underlying data:

  • BASE DE DATOS EVALUACIÓN SENSORIAL 24 05 2023.xls (Data for tastings carried out with students. The samples were 4 cereal bars made with cereal grains and with different percentages of ant flour.)

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

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Alshammari M, SHANB A, Alsubaiei M and youssef E. Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.12688/f1000research.133516.4)
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ApprovedThe 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 approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 4
VERSION 4
PUBLISHED 09 Jan 2024
Revised
Views
13
Cite
Reviewer Report 28 Feb 2024
Asir John Samuel, Yenepoya Physiotheapy College, Mangalore, Karnataka, India 
Vencita Priyanka Aranha, Aikya Physiotherapy and Rehabilitation Centre, Karkala, Karnataka, India;  Physiotherapy, Aikya Physiotherapy and Rehabilitation, Karkala, Karnataka, India 
Approved with Reservations
VIEWS 13
Reply to the response of the first comment:
"maximizing the sample size is healthy" is unjustifiable. Increasing sample size may result in considering small differences to be statistically significant differences, even though they are clinically insignificant.

Reply to the response of ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Samuel AJ and Aranha VP. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.161031.r236426)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 13 Apr 2024
    ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
    13 Apr 2024
    Author Response
    1-Reply to the response of the first comment:
    "maximizing the sample size is healthy" is unjustifiable. Increasing sample size may result in considering small differences to be statistically significant differences, even though they are clinically ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 13 Apr 2024
    ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
    13 Apr 2024
    Author Response
    1-Reply to the response of the first comment:
    "maximizing the sample size is healthy" is unjustifiable. Increasing sample size may result in considering small differences to be statistically significant differences, even though they are clinically ... Continue reading
Views
6
Cite
Reviewer Report 29 Jan 2024
Ashraf Abdelaal Mohamed Abdelaal, Department of Physiotherapy, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia 
Approved
VIEWS 6
Authors justified ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Abdelaal AAM. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.161031.r236427)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 3
VERSION 3
PUBLISHED 30 Nov 2023
Revised
Views
17
Cite
Reviewer Report 19 Dec 2023
Asir John Samuel, Yenepoya Physiotheapy College, Mangalore, Karnataka, India 
Vencita Priyanka Aranha, Aikya Physiotherapy and Rehabilitation Centre, Karkala, Karnataka, India;  Physiotherapy, Aikya Physiotherapy and Rehabilitation, Karkala, Karnataka, India 
Approved with Reservations
VIEWS 17
Methods:

Sample size:
  • By calculation, it was estimated to be n=73 in each group. Then, why n=7 samples were added to each group? It is unethical to utilize 14 human valuable times when
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Samuel AJ and Aranha VP. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.159022.r227200)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 11 Jan 2024
    ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
    11 Jan 2024
    Author Response
    Dear respected reviewer  Thanks for your valuable and important comments.

    First comment  
    Sample size: By calculation, it was estimated to be n=73 in each group. Then, why n=7 samples ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 11 Jan 2024
    ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
    11 Jan 2024
    Author Response
    Dear respected reviewer  Thanks for your valuable and important comments.

    First comment  
    Sample size: By calculation, it was estimated to be n=73 in each group. Then, why n=7 samples ... Continue reading
Version 2
VERSION 2
PUBLISHED 04 Sep 2023
Revised
Views
21
Cite
Reviewer Report 31 Oct 2023
Asir John Samuel, Yenepoya Physiotheapy College, Mangalore, Karnataka, India 
Vencita Priyanka Aranha, Aikya Physiotherapy and Rehabilitation Centre, Karkala, Karnataka, India;  Physiotherapy, Aikya Physiotherapy and Rehabilitation, Karkala, Karnataka, India 
Approved with Reservations
VIEWS 21
Abstract:
Background:
  • Retain either, "physical activities" or "physical performance".
  • Avoid duplicating similar words, "pulmonary function, functional capacities, physical activities" in the same paragraph.

Methods:
    ... Continue reading
    CITE
    CITE
    HOW TO CITE THIS REPORT
    Samuel AJ and Aranha VP. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.155029.r210129)
    NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
    • Author Response 30 Nov 2023
      ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
      30 Nov 2023
      Author Response
      The comments of the second reviewer and responses of the authors.
      My grateful thanks for the your valuable and important scientific comments, all of theses comments are considered.

      ... Continue reading
    COMMENTS ON THIS REPORT
    • Author Response 30 Nov 2023
      ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
      30 Nov 2023
      Author Response
      The comments of the second reviewer and responses of the authors.
      My grateful thanks for the your valuable and important scientific comments, all of theses comments are considered.

      ... Continue reading
    Views
    4
    Cite
    Reviewer Report 15 Sep 2023
    Ashraf Abdelaal Mohamed Abdelaal, Department of Physiotherapy, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia 
    Approved
    VIEWS 4
    Authors justified ... Continue reading
    CITE
    CITE
    HOW TO CITE THIS REPORT
    Abdelaal AAM. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.155029.r203744)
    NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
    Version 1
    VERSION 1
    PUBLISHED 11 Jul 2023
    Views
    29
    Cite
    Reviewer Report 16 Aug 2023
    Ashraf Abdelaal Mohamed Abdelaal, Department of Physiotherapy, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia 
    Approved with Reservations
    VIEWS 29
    This cross-sectional study investigated the long-term effect of mild-moderate COVID-19 infection on the pulmonary, functional capacity and physical activities variables in patients living in Sakaka Aljouf Saudi Arabia. 160 participants of both genders were allocated to either: group-I that included ... Continue reading
    CITE
    CITE
    HOW TO CITE THIS REPORT
    Abdelaal AAM. Reviewer Report For: Long-term effect of non-severe COVID-19 on pulmonary function, exercise capacities and physical activities: a cross-section study in Sakaka Aljouf [version 4; peer review: 1 approved, 1 approved with reservations]. F1000Research 2024, 12:809 (https://doi.org/10.5256/f1000research.146511.r186229)
    NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
    • Author Response 28 Mar 2024
      ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
      28 Mar 2024
      Author Response
      Comments of reviewer one: 

      Abstract 
      Background:

      “Personal performance”: better to change it to “physical performance”.
      Author Response:
      Personal performance was changed to physical performance.

      Results:
      “The results show ... Continue reading
    COMMENTS ON THIS REPORT
    • Author Response 28 Mar 2024
      ALSAYED SHANB, Physical Therapy Department, College of Applied Medical Sciences, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
      28 Mar 2024
      Author Response
      Comments of reviewer one: 

      Abstract 
      Background:

      “Personal performance”: better to change it to “physical performance”.
      Author Response:
      Personal performance was changed to physical performance.

      Results:
      “The results show ... Continue reading

    Comments on this article Comments (0)

    Version 5
    VERSION 5 PUBLISHED 11 Jul 2023
    Comment
    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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