Rehabilitation for COVID-19 Deconditioning
All COVID-19 patients experiencing deconditioning should undergo systematic screening for rehabilitation needs before hospital discharge or when persistent symptoms develop, followed by a structured exercise program that begins with recumbent activities and gradually progresses based on symptom tolerance. 1
Screening and Assessment
Screen all patients for rehabilitation needs addressing physical deconditioning, respiratory impairments, swallowing difficulties, cognitive deficits, and mental health disorders before discharge or when functional limitations persist post-discharge. 1 This screening should facilitate timely referral to appropriate rehabilitation services rather than delaying intervention. 1
Exercise Prescription Algorithm
Initial Phase: Recumbent Exercise
- Start with recumbent or semi-recumbent exercise (rowing, swimming, or cycling) rather than upright activities, as upright exercise can worsen fatigue and cause postexertional malaise. 1
- Begin with 5-10 minutes daily at submaximal intensity where patients can speak in full sentences. 1
- Gradually increase duration by 2 minutes per day each week as tolerance improves. 1
- This approach increases cardiac mass, blood volume, improves ventricular compliance, and shifts the Frank-Starling curve upward. 1
Respiratory Component
For patients with severe COVID-19 history, implement breathing control education including: 1
- High side lying positioning
- Forward lean sitting
- Pursed lip breathing
- Square box breathing
- Appropriate walking pace regulation to prevent oxygen desaturation
A specific 6-week respiratory rehabilitation program (10 minutes daily) should include: 1
- Respiratory muscle training
- Cough exercises
- Diaphragmatic training
- Stretching exercises
- Home exercise progression
Progression Strategy
- Transition to upright exercise only after orthostatic intolerance resolves. 1
- Increase exercise intensity naturally as functional capacity improves, maintaining submaximal sustained effort throughout. 1
- Resume daily activities conservatively at a safe, manageable pace with gradual symptom-based progression. 1
Supportive Interventions
Volume Expansion (for patients with tachycardia/orthostatic intolerance)
- Liberalized sodium intake: 5-10 grams (1-2 teaspoons) daily through diet, not salt tablets. 1
- Fluid intake: 3 liters daily of water or electrolyte-balanced fluids. 1
- Elevate head of bed with 4-6 inch (10-15 cm) blocks during sleep. 1
- Use waist-high support stockings to maintain central blood volume. 1
- Avoid dehydration triggers: alcohol, caffeine, large meals, excessive heat. 1
Setting-Specific Delivery
Inpatient rehabilitation is appropriate for post-ICU patients and those with severe functional impairments, showing significant improvements in Barthel Index, 6-minute walk test, and fatigue scores. 1
Outpatient options include: 1
- Virtual rehabilitation programs (demonstrated significant improvement in sit-to-stand and step tests)
- Home physical therapy with professional guidance
- Supervised independent exercise programs
Home health care for discharged patients improves pain, dyspnea, cognitive function, anxiety, and activities of daily living. 1
Critical Pitfalls to Avoid
Do not prescribe upright exercise initially for deconditioned patients, as this worsens fatigue and causes setbacks. 1 The UK NICE guidelines specifically caution against standard graded exercise therapy for COVID-19 recovery, particularly for those with ME/CFS features. 1
Do not use salt tablets for volume expansion due to gastrointestinal side effects; liberalize dietary sodium instead. 1
Do not delay rehabilitation until full recovery—early intervention during acute hospitalization through post-discharge is essential for optimal functional outcomes. 2, 3
Multidisciplinary Team Composition
Organized rehabilitation teams should include physical therapists, occupational therapists, speech-language pathologists, rehabilitation psychologists or neuropsychologists, and physiatrists collaborating with acute medical teams. 3 This interdisciplinary approach addresses the complex physical, cognitive, and mental health sequelae of COVID-19. 1, 4
Evidence Quality Note
While multiple cohort studies demonstrate significant functional improvements with rehabilitation interventions 1, systematic reviews note that overall evidence quality remains low to moderate, with most studies being noncomparative. 1 However, the consistent direction of benefit across all functional outcomes (pulmonary function, exercise capacity, quality of life, activities of daily living) supports aggressive rehabilitation implementation. 1