Original article

Rehabilitation and physiotherapy protocols in patients affected by COVID-19

0000-0003-2328-8206Julio César Rodríguez-Díaz^{1  *}  , 0000-0003-3978-1046Yasmany González-Garcés¹  , 0000-0002-8849-4927Rigoberto González Piña²  , 0000-0003-3193-7683Roberto Rodríguez-Labrada¹  , 0000-0002-4763-4284Armando Sentmanat-Belisón^4. 

¹Centro para la Investigación y Rehabilitación de las Ataxias Hereditarias. Holguín. Cuba.

²Laboratorio de Biología del Envejecimiento, Instituto Nacional de Geriatría. CDMX, México

³Centro de Neurociencias de Cuba. La Habana, Cuba

⁴Universidad de Ciencias de la Cultura Física y el Deporte "Manuel Fajardo". Departamento de Cultura Física Terapéutica y Profiláctica. La Habana. Cuba

ABSTRACT

The COVID-19 represents an international emergency due to the increasing numbers of infected and deceased people worldwide. Recovered patients may suffer respiratory, cardiac and neurological effects and sequelae, which affects their quality of life. The objective of this article was to reconstruct the respiratory, cardiovascular, neurological and neuromuscular rehabilitation and physiotherapy protocols for patients affected by COVID-19, based on reported scientific evidence. For it, a bibliographic review was carried out in the main international databases (PubMed, sciELO, Google Scholar, among others). The key words were used for the search: COVID-19, acute respiratory distress syndrome, physiotherapy, respiratory rehabilitation, cardiovascular rehabilitation, neuromuscular and neurological rehabilitation, in English and Spanish. These protocols attribute significant improvements in sequelae and in the quality of life of patients. Respiratory physiotherapy exercises in the prone position, inspiratory muscle training, aerobic exercises and moderate muscle strength training are recommended. The results of the application of these protocols are satisfactory in the recovery of patients.

Key words: COVID-19; physiotherapy; respiratory rehabilitation; cardiovascular rehabilitation; neurological rehabilitation; neuromuscular rehabilitation.

INTRODUCTION

At the end of 2019, an outbreak of acute respiratory syndrome caused by a new coronavirus called SARS-CoV2 was reported in China. The disease, called COVID-19 from its English acronym, spread rapidly throughout the world to such an extent that the World Health Organization (WHO) declared it a pandemic ^{(Zhu et. al, 2020}; ^{Rodríguez-Labrada et., al, 2020)}. At the beginning of 2022, more than 400 million infections and nearly six million deaths from this disease were already reported worldwide, due to the appearance of more contagious and lethal viral strains ^{(Olivo et. al, 2022)}. As a result of this international emergency, doctors, scientists, researchers, psychologists and other professionals have joined forces to minimize the damage caused by this pandemic. For their part, the teams of rehabilitators and physiotherapists have not been left behind in the fight against COVID-19, since they play an important role in improving the quality of life of patients who suffered from this disease, even those who manifested more severe symptoms.

COVID-19 presents a characteristic set of symptoms and signs ^{(Castellón et. al, 2020)}, and patients may also have complications and even respiratory, cardiac, and neurological sequelae ^{(Grácio & Koçer, 2020}; ^{Ahmad, & Rathore, 2020)} . Given the intensive medical treatment for some COVID-19 patients, including prolonged protective lung ventilation, sedation, and the use of neuromuscular blocking agents, those admitted to the intensive care unit may be at high risk of developing acquired weakness. Therefore, it is essential to initiate early rehabilitation after the acute phase to limit the severity of the weakness suffered and promote rapid functional recovery. Physiotherapy and rehabilitation have an important role in providing exercise, mobilization and rehabilitation interventions to survivors of critical manifestations associated with COVID-19 in order to allow an improvement in their quality of life ^{(Condezo, 2020)}.

The above confirms that rehabilitation is an important factor for improving the quality of life of patients who suffered severe manifestations and sequelae of this disease. For their treatment, physiotherapy and rehabilitation protocols reported in the literature were generated (Table 1). Taking this into account, the objective of this article is to reconstruct the main respiratory, cardiovascular, neurological and neuromuscular rehabilitation and physiotherapy protocols for the care of patients who suffered from COVID-19, based on their effective results.

Table 1.  - Synthesis of the protocols for respiratory, cardiovascular, neurological and neuromuscular rehabilitation of the sequelae caused by COVID-19 

Damage caused by COVID-19	Recommended physiotherapy and rehabilitation protocols
Respiratory damage	Secretion drainage techniques Strengthening respiratory muscles Breathing training in the prone position Tai Chi, Qigong, and other traditional Chinese medicine Conventional oxygen therapy and high-flow nasal oxygen
Cardiovascular damage	Aerobic walking and cycling exercises Moderate muscle strength exercises Fitness Exercises in biohealthy gyms Sport games
Neurological and neuromuscular damage	Muscle strength exercises Endurance Coordination Balance Tai Chi and Qigong Telerehabilitation

DEVELOPMENT

Bibliographic review of articles published in the main bibliographic databases (Web of Sciences, SCOPUS, SciELO, Google Scholar, PubMed) was carried out. A total of 32 articles from the last 5 years were reviewed, related to rehabilitation and physiotherapy in pathologies similar to respiratory, cardiovascular, neurological and neuromuscular damage caused by infection with the SARS-CoV2 virus, as well as protocols applied in patients with COVID-19. The key words were used for the search: COVID-19, Acute respiratory distress syndrome, Physiotherapy, Respiratory rehabilitation, Cardiovascular rehabilitation, Neuromuscular and neurological rehabilitation, in English and Spanish.

Respiratory rehabilitation

The objective of respiratory rehabilitation in patients hospitalized with COVID-19 is improve symptoms of dyspnea, relieve anxiety and depression, reduce complications, prevent and improve dysfunction, reduce disability, preserve maximum function and improve quality of life. Given the high percentage of hospitalized patients requiring intensive care, it is likely that in the weeks and months following an increase in the number of patients admitted to hospitals and intensive care units, there will likely be a considerable number of COVID-19 survivors, which requires rehabilitation services. For this reason, a rehabilitation program must be developed that adapts to the specific needs of each patient ^{(Demeco et. al, 2020)}.

Physiotherapy may be beneficial in the respiratory treatment and physical rehabilitation of patients with COVID-19. Although productive cough is a less common symptom (34 %), physical therapy may be indicated if COVID-19 patients have copious airway secretions that they cannot clear independently. This must be evaluated on a case-by-case basis and the interventions applied must be established based on clinical indicators.

Physical therapists practicing in the intensive care unit setting may also perform secretion drainage techniques for ventilated patients who show signs of inadequate airway drainage, and may assist in the postural management of patients with severe respiratory failure associated with COVID-19, including the use of prone positioning to optimize oxygenation ^{(Thomas et. al, 2020)}.

It is important to carry out early respiratory rehabilitation in the acute phase, to improve the chances of recovery. Early active mobilization is essential to improve muscle strength, ensuring better mobility when the patient is discharged from the hospital and improving quality of life ^{(Simpson & Robinson, 2020)}. Despite this, other studies ensure that it is not advisable to carry out early rehabilitation, mainly in severe and critical states, because it is not well tolerated by patients ^{(Kiekens et. al, 2020}; ^{Martínez-Pizarro, 2020)}. The time to start respiratory rehabilitation should be determined after ruling out contraindications, and it is necessary to pay attention to all precautions to prevent the spread of infection ^{(Demeco et. al., 2020)}. In the acute phase, diaphragmatic breathing, pursed-lip breathing, bronchial hygiene, lung expansion techniques, incentive spirometry, manual mobilization of the rib cage, respiratory muscle training, and exercise are not recommended. aerobic, because they cause an additional load on the work of breathing, exposing the patient to a greater risk of respiratory distress ^{(Lazzeri et. al, 2020)}.

During the acute phase, it is proposed that the prone position for two minutes can help with lung ventilation. This position considerably increases transpulmonary pressure at the end of expiration and expiratory reserve volume, promotes more homogeneous lung inflation from dorsal to ventral and improves oxygenation. The prone position has also been used in intensive care units to improve gas exchange and reduce cardiovascular comorbidities. The patient may also engage in modified segmental breathing, whereby pressure is applied to his or her own rib cage, to resist respiratory excursion in one area of the thoracic cavity and facilitate expansion of adjacent regions of the thoracic cavity that may have decreased ventilation and mobility ^{(Wang et. al, 2020)}.

In the post-acute phase, training of the inspiratory muscles should be included if they are weakened. Slow deep breathing, chest expansion (with shoulder elevation), diaphragmatic breathing, respiratory muscle mobilization, airway clearance techniques if necessary, and positive expiratory pressure devices may be added as assessed needs. Care should be taken to avoid overloading the respiratory system and causing discomfort ^{(Zhao et. al., 2020)}.

Respiratory rehabilitation improves the lung function of patients with COVID-19 due to the strengthening of respiratory muscles, such as the intercostals, abdominal wall muscles, diaphragmatic muscles, among others ^{(Gu et al., 2020)}. These muscles play an important role in maintaining respiratory function. A respiratory muscle strengthening protocol is reported in elderly patients, a group at higher risk of suffering from severe forms of the disease. This protocol includes two sessions per week for six weeks, once a day with a duration of ten minutes of respiratory muscle training; cough exercises; diaphragmatic and stretching exercises. This series of exercises significantly improved lung function after six weeks of respiratory rehabilitation training, reducing chest wall movement, slowing respiratory rate to reduce energy consumption, increasing lung ventilation and oxygen content in blood. In addition, these exercises improved the performance of activities of daily living ^{(Liu et. al., 2020)}.

The practice of leisurely activities based on traditional Chinese medicine, such as Tai Chi, Baduanjin and Qigong, is also recommended. It is proposed that Qigong can improve immune function, reduce the risk of infection, improve prognosis, improve sports endurance, quality of life and rationality in carrying out activities of daily living. On the other hand, the practice of Qigong can strengthen the muscles of the chest and abdomen, increase the depth of breathing, relieve dyspnea, and improve lung function in patients who suffered from COVID-19. It can also relieve psychological stress, depression and anxiety, and improve sleep quality ^{(Peng et. al, 2020)}.

Other specialists recommend respiratory physiotherapy, conventional oxygen therapy, high-flow nasal oxygen, continuous positive airway pressure, and postural changes for the treatment of patients who did not undergo invasive ventilation. On the other hand, airway clearance techniques, lung recruitment maneuvers and endotracheal suction are recommended for those who did undergo invasive ventilation ^{(Lazzeri et. al, 2020)}. Relevant aspects of physiotherapy are multidisciplinary management of non-invasive ventilation, frequent changes in posture, passive mobilization, positional therapy and recovery of motor function once the acute phase has resolved.

Regarding postural management, it is important to gradually increase the antigravity position depending on the patient's clinical condition, until the patient can maintain an upright position. It can also be useful to keep patients in a semi-sitting position, with the back of the bed at 45 or 60 degrees ^{(Brugliera et. al., 2020)}.

Cardiovascular rehabilitation

In addition to the respiratory conditions caused by COVID-19, there is evidence of cardiovascular system damage caused by SARS-CoV2. It is proposed that 20% of patients hospitalized in China with COVID-19 had an associated cardiac injury. These patients were more likely to have comorbidities, require mechanical ventilation, and suffer other complications ^{(Sheehy, 2020)}. Presentations may include arrhythmia, heart failure, decreased ejection fraction, elevated troponin I, and severe myocarditis with reduced systolic function. One brief report described a woman with acute myopericarditis/heart failure post-COVID-19. Persistent tachycardia is common after respiratory syndrome ^{(Sheehy, 2020)}. Acute coagulopathies, malignant ventricular arrhythmias such as tachycardia and ventricular fibrillation, among other cardiovascular effects, are also reported ^{(García et. al, 2020)}.

Related to cardiovascular rehabilitation, individualized exercise training is proposed that includes aerobic exercises and muscle strength training. The aerobic exercise program focuses on six-minute walks and stationary bike exercises. Strength training is performed in three sets of 20 repetitions with the maximum tolerated load. The authors report that functional capacity and subjective health status improved significantly upon completion of this protocol. Interestingly, patients with prior mechanical ventilation showed identical improvements as patients without ventilation and without significant differences in baseline patient characteristics, including risk factors, respiratory parameters, and functional measures ^{(Hermann et al., 2020)}.

Currently, there are few reported cardiovascular rehabilitation protocols for patients recovered from COVID-19 with cardiac sequelae. Some exercise protocols for respiratory rehabilitation described above can be used, mainly those based on aerobic exercises, fitness, and moderate intensity muscle strength training. The authors of this article propose the following protocol for the rehabilitation of patients recovered from COVID-19 with cardiovascular sequelae, taking into account the damage caused by the SARS-CoV2 virus, taking into account the care of patients with high risks of suffering from diseases. cardiovascular ^{(Khera et. al, 2020)}.

The physical exercise program has an appropriate progression rate, depending on the patient's functional capacity, age, state of health, and needs. The exercise program is divided into three phases for its development:

• An initial phase: It covers the first to the sixth week. Starting with sessions of 12 to 20 minutes twice a week, excluding warm-up, with an equivalent number of days of rest between each session and with an intensity depending on the initial fitness level, one could set 10% below the minimum intensity level that would correspond to the prescription in more advanced phases. The end of this phase must be achieved by carrying out three weekly sessions, equidistant in time, at the minimum level of intensity prescription and lasting 20 minutes.

• Improvement phase: It is considered from the seventh to the 27th week. It will increase progressively; the duration above 20 minutes, the frequency of 4 to 5 times a week and the intensity of 60 to 70 %.

• Maintenance phase: Reached approximately after 6 months. At this time the patient will exercise with an intensity within the limits of the prescription, for 60 to 90 minutes and four or five times a week. And it should stay that way.

Warm-up exercises include stretching exercises and replacing joint mobility exercises. Patients must perform between 10 and 20 repetitions of each of the joint mobility and respiratory exercises, and must maintain the position for between 10 and 15 seconds during the stretching exercises. Subsequently, strengthening exercises without implements such as semi-squats and abdominal exercises will be incorporated, as well as with weights tolerable to the patients' capacity, between 8 and 10 repetitions. In this case, exercises are performed to strengthen the biceps, triceps, pectorals, shoulders and legs, mainly. Aerobic walking and jogging exercises are also recommended, as well as treadmill exercises. Sports games with balls, and finally, muscle relaxation are complementary exercises for complete cardiovascular rehabilitation ^{(Núñez-Hernández & Sentmanat-Belisón, 2020)}. In the maintenance phase, it is possible to perform exercises in biohealthy gyms with appropriate technical advice ^{(Núñez-Hernández & Sentmanat-Belisón, 2018)}.

In addition to the basic components of cardiac rehabilitation, nutritional behaviors and habits, smoking cessation, and stress control must be taken into account. It has been shown that these behaviors complement cardiac rehabilitation and improve physiological reserve to face SARS-CoV2 infection. Additionally, the intensity, type, and duration of exercise generally recommended in cardiac rehabilitation improve immune system regulation. This may have positive repercussions on the immunosenescence of elderly patients with cardiovascular disease, who in theory may have increased protection against the consequences of COVID-19 ^{(Ribeiro & Santos, 2020)}.

Neurological and neuromuscular rehabilitation

Isolation is effective in reducing the spread of SARS-CoV-2, but it also represents a severe limitation of the patient's movement and its corresponding disuse, which increases the possibility of immobilization syndrome, especially in case of fever, fatigue and muscle pain. All of these problems can lead to decreased muscle strength, increased risk of deep vein thrombosis, as well as neuropsychological problems, such as anxiety, depression, and demotivation ^{(Brugliera et. al., 2020)}. Additionally, weakness and neuromuscular disturbances occur in up to 50 % of all people who have prolonged intensive care unit stays due to critical illness polyneuropathy, which can result in dysfunction for more than five years in 85 % of the individuals. Considering the clinical conditions caused by prolonged immobilization and musculoskeletal deterioration, these patients also need rehabilitation treatments. On the other hand, neurological manifestations are reported in patients who have been infected with the SARS-CoV2 virus, such as encephalitis, transverse myelitis, ataxia, Guillain-Barré syndrome, among others, many of these with neurological sequelae, so the Neuromuscular rehabilitation plays an important role in the recovery of these patients ^{(Ahmad, & Rathore, 2020}; ^{Fiani et. al, 2020)}.

Strengthening exercises will help improve muscles that have become weak such as result of the disease. It is recommended to do three sessions of muscle strengthening exercises each week. It is recommended to try to complete up to three sets of ten repetitions of each exercise, taking a short rest between each set. It is advised to do the exercises and exhale as the effort is made. For this, biceps curl exercises with moderate weights, wall pushes from the bipedal position, lateral arm raises to strengthen the shoulders, heel raises, squats, among others, are recommended. Aerobic, endurance, balance, coordination and mobility training exercises are also recommended for the rehabilitation of patients recovered from COVID-19. Furthermore, it has been suggested to integrate the concept of cognitive training during the physical training session. Frequencies of five days a week are recommended, with sessions of at least 150 to 300 minutes per week of aerobic exercise and two endurance training sessions per week. Mobility training exercises should be performed every training day and balance and coordination should be distributed between different training days at least twice ^{(Jiménez-Pavón et. al, 2020)}.

Physical therapy should begin in the acute hospital setting and continue after transfer to inpatient rehabilitation. Early mobilization should include frequent postural changes, mobility in bed, sitting or standing, simple exercises in bed and activities of daily living, respecting the patient's respiratory and hemodynamic states. Active limb exercises should be accompanied by progressive muscle strengthening.

Neuromuscular electrical stimulation can be used to help with strengthening. Studies on the effectiveness of exercise interventions after severe acute respiratory syndrome showed benefits for endurance, maximal oxygen consumption, and strength. Speech and language specialists should evaluate and treat dysphagia and voice disturbances resulting from prolonged intubation and may also address respiratory strength and coordination. Other authors also report the benefits of traditional Chinese medicine for the treatment of neuromuscular ailments caused by COVID-19, such as Tai Chi and Qigong, with favorable results for patients ^{(Sheehy, 2020)}.

In the context of the COVID-19 pandemic, telerehabilitation may be more preferable than physical interactions. A tele-rehabilitation system, with a physiotherapist following patients performing rehabilitation exercises for 20 minutes, can be easily developed using a combination of technologies. Tele-rehabilitation could prove to be a very useful tool, regardless of whether it is used in hospitals or in the community, to address the social difficulties associated with the ongoing pandemic ^{(Mukaino et. al, 2020)}.

Through social platforms such as Skype and WhatsApp, several online exercise sessions are carried out for these patients, thus contributing to social isolation to prevent COVID-19 infection. This modality can bring beneficial effects for the recovery of muscle strength in patients who survive COVID-19 ^{(Turolla et. al, 2020}; ^{López et. al, 2020)}.

In relation to the different neurological diseases that could be associated with COVID-19, this group of authors is of the opinion that the different neurological rehabilitation protocols and programs traditionally established at the international level can be used, as long as special attention is paid to respiratory rehabilitation as a basic starting element, to gradually introduce protocolized or programmed activities for each type of neurological disease and the treatment of the sequelae that occur ^{(Bergado & Rodríguez, 2017)}.

CONCLUSIONS

Rehabilitation and physiotherapy are important pillars for the complete recovery of people infected by the new coronavirus. Although there are currently few protocols reported in the literature, these demonstrate their effectiveness in improving the quality of life of patients. This article updates effective protocols based on demonstrated results for their application in these individuals, improving their respiratory, cardiovascular and neuromuscular capacities, damaged by COVID-19. It is evident that from the recovery of respiratory capacity, decreased by COVID-19, the quantity and complexity of the exercises can be increased, and the exercise loads can be progressively increased, depending on the type of rehabilitation that is being carried out. is going to be applied.

Acknowledgments

We express our gratitude to the collaborators PhDs Darvin Manuel Ramírez Guerra, Lic. Carlos Proenza Domínguez and Lic. Arianna Santos Anta for their contribution to the preparation of this article.

REFERENCIAS BIBLIOGRÁFICAS

Ahmad, I., & Rathore, F. A. (2020). Neurological manifestations and complications of COVID-19: A literature review. Journal of Clinical Neuroscience: Official Journal of the Neurosurgical Society of Australasia, 77, pp. 8-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200361/ , https://doi.org/10.1016/j.jocn.2020.05.017

Bergado Rosado, J. A., & Rodríguez Cordero, M. L. (2017). El CIREN y la nueva neurología. Revista Cubana de Neurología y Neurocirugía, 7(1), pp. 66-80. https://dialnet.unirioja.es/descarga/articulo/6234191.pdf

Brugliera, L., Spina, A., Castellazzi, P., Cimino, P., Tettamanti, A., Houdayer, E., Arcuri, P., Alemanno, F., Mortini, P., & Iannaccone, S. (2020). Rehabilitation of COVID-19 patients. Journal of Rehabilitation Medicine, 52(4). https://doi.org/10.2340/16501977-2678

Condezo Casasola, G. (2020). Fisioterapia en tiempos de COVID-19. Revista Herediana de Rehabilitación, 3(1). https://revistas.upch.edu.pe/index.php/RHR/article/view/3719

Demeco, A., Marotta, N., Barletta, M., Pino, I., Marinaro, C., Petraroli, A., Moggio, L., & Ammendolia, A. (2020). Rehabilitation of patients post-COVID-19 infection: A literature review. The Journal of International Medical Research, 48(8). https://doi.org/10.1177/0300060520948382

Fiani, B., Covarrubias, C., Desai, A., Sekhon, M., & Jarrah, R. (2020). A Contemporary Review of Neurological Sequelae of COVID-19. Frontiers in Neurology, 11. https://doi.org/10.3389/fneur.2020.00640

García Hernández, R. A., Rivero Seriel, L., Aroche Aportela, R., Aldama Pérez, L. I., & Hernández Navas, M. (2020). COVID-19: En torno al sistema cardiovascular. Anales de la Academia de Ciencias de Cuba, 10(2), pp. 782. https://revistaccuba.sld.cu/index.php/revacc/article/view/782/821

Grácio, S., & Kocer, S. (2020). Rehabilitation is crucial for severe COVID-19 survivors. Revue Medicale Suisse, 16(696), pp. 1170-1173. https://pubmed.ncbi.nlm.nih.gov/32496707/

Gu, R., Xu, S., Li, Z., Gu, Y., & Sun, Z. (2020). The safety and effectiveness of rehabilitation exercises on COVID-19 patients. Medicine, 99(31). https://doi.org/10.1097/MD.0000000000021373

Hermann, M., Pekacka-Egli, A.-M., Witassek, F., Baumgaertner, R., Schoendorf, S., & Spielmanns, M. (2020). Feasibility and Efficacy of Cardiopulmonary Rehabilitation After COVID-19. American Journal of Physical Medicine & Rehabilitation, 99(10), pp. 865-869. https://doi.org/10.1097/PHM.0000000000001549

Jiménez Pavón, D., Carbonell Baeza, A., & Lavie, C. J. (2020). Physical exercise as therapy to fight against the mental and physical consequences of COVID-19 quarantine: Special focus in older people. Progress in Cardiovascular Diseases, 63(3), pp. 386-388. https://doi.org/10.1016/j.pcad.2020.03.009

Khera, A., Baum, S. J., Gluckman, T. J., Gulati, M., Martin, S. S., Michos, E. D., Navar, A. M., Taub, P. R., Toth, P. P., Virani, S. S., Wong, N. D., & Shapiro, M. D. (2020). Continuity of care and outpatient management for patients with and at high risk for cardiovascular disease during the COVID-19 pandemic: A scientific statement from the American Society for Preventive Cardiology. American journal of preventive cardiology, 1, 100009. https://doi.org/10.1016/j.ajpc.2020.100009

Kiekens, C., Boldrini, P., Andreoli, A., Avesani, R., Gamna, F., Grandi, M., Lombardi, F., Lusuardi, M., Molteni, F., Perboni, A., & Negrini, S. (2020). Rehabilitation and respiratory management in the acute and early post-acute phase. «Instant paper from the field» on rehabilitation answers to the COVID-19 emergency. European Journal of Physical and RehabilitationMedicine , 56(3), pp. 323-326. https://doi.org/10.23736/S1973-9087.20.06305-4

Lazzeri, M., Lanza, A., Bellini, R., Bellofiore, A., Cecchetto, S., Colombo, A., D'Abrosca, F., Del Monaco, C., Gaudiello, G., Paneroni, M., Privitera, E., Retucci, M., Rossi, V., Santambrogio, M., Sommariva, M., & Frigerio, P. (2020). Respiratory physiotherapy in patients with COVID-19 infection in acute setting: A Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Archives for Chest Disease = Archivio Monaldi Per Le Malattie Del Torace, 90(1). https://doi.org/10.4081/monaldi.2020.1285

León Castellón, R., Bender del Busto, J. E., & Velázquez Pérez, L. C. (2020). Afectación del sistema nervioso por la COVID-19. Anales de la Academia de Ciencias de Cuba , 10(2), 760. https://revistaccuba.sld.cu/index.php/revacc/article/view/760/790

Liu, K., Zhang, W., Yang, Y., Zhang, J., Li, Y., & Chen, Y. (2020). Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complementary Therapies in Clinical Practice, 39, pp. 101-166. https://doi.org/10.1016/j.ctcp.2020.101166

López, C., Closa, C., & Lucas, E. (2020). Telemedicina en rehabilitación: Necesidad y oportunidad post-COVID. Rehabilitacion, 54(4), pp. 225-227. https://doi.org/10.1016/j.rh.2020.06.003

Martínez Pizarro, S. (2020). Rehabilitación respiratoria en pacientes con COVID-19. Rehabilitación, 54(4), pp. 296-297. https://doi.org/10.1016/j.rh.2020.04.002

Mukaino, M., Tatemoto, T., Kumazawa, N., Tanabe, S., Katoh, M., Saitoh, E., & Otaka, Y. (2020). Staying active in Isolation: Telerehabilitation for individuals with the severe acute respiratory syndrome Coronavirus 2 infection. American Journal of Physical Medicine & Rehabilitation, 99(6), pp. 478-479. https://doi.org/10.1097/PHM.0000000000001441

Núñez Hernández, I., & Sentmanat-Belisón, A. (2018). Valoración de un programa de rehabilitación cardiovascular en la fase de mantenimiento para pacientes cardiópatas de bajo riesgo empleando como medio los gimnasios biosaludables. Revista Científica Olimpia, 15(52). https://redib.org/Record/oai_articulo1820323-valoraci%C3%B3n-de-un-programa-de-rehabilitaci%C3%B3n-cardiovascular-en-la-fase-de-mantenimiento-para-pacientes-cardi%C3%B3patas-de-bajo-riesgo-empleando-como-medio-los-gimnasios-biosaludables-original.

Núñez Hernández, I., & Sentmanat-Belisón, A. (2020). Consideraciones acerca de la condición física relacionada con pacientes cardiópatas. Revista Acción., 16. http://accion.uccfd.cu/index.php/accion/article/view/105

Olivo, RE., García, M.A., Arias, V.A., & Viteri, J.A. (2022) Epidemiología del Covid-19 en pacientes pediátricos del Ecuador. Archivos Venezolanos de Farmacología y Terapéutica, 41(1). http://doi.org/10.5281/zenodo.6370060

Peng, J., Wu, Z., Zhong, H., Zhou, Y., Wang, L., Wang, Y., Luo, W., Liu, Y., & Zhang, L. (2020). The effect of qigong for pulmonary function and quality of life in patients with covid-19. Medicine , 99(38). https://doi.org/10.1097/MD.0000000000022041

Ribeiro, F., & Santos, M. (2020). Exercise-based cardiac rehabilitation in COVID-19 times: One small step for health care systems, one giant leap for patients. Revista Española de Cardiología, 73(11), pp. 969-970. https://doi.org/10.1016/j.recesp.2020.06.040

Rodríguez Labrada, R., Vazquez Mojena, Y., & Velázquez Pérez, L. C. (2020). Transmisión asintomática y presintomática del SARS-CoV-2: La cara oculta de la COVID-19. Anales de la Academia de Ciencias de Cuba , 10(2), Article 2. http://www.revistaccuba.cu/index.php/revacc/article/view/770

Sheehy, L. M. (2020). Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health and Surveillance, 6(2), e19462. https://doi.org/10.2196/19462

Simpson, R., & Robinson, L. (2020). Rehabilitation After Critical Illness in People With COVID-19 Infection. American Journal of Physical Medicine & Rehabilitation, 99(6), pp. 470-474. https://doi.org/10.1097/PHM.0000000000001443

Thomas, P., Baldwin, C., Bissett, B., Boden, I., Gosselink, R., Granger, C. L., Hodgson, C., Jones, A. Y., Kho, M. E., Moses, R., Ntoumenopoulos, G., Parry, S. M., Patman, S., & van der Lee, L. (2020). Physiotherapy management for COVID-19 in the acute hospital setting: Clinical practice recommendations. Journal of Physiotherapy, 66(2), pp. 73-82. https://doi.org/10.1016/j.jphys.2020.03.011

Turolla, A., Rossettini, G., Viceconti, A., Palese, A., & Geri, T. (2020). Musculoskeletal Physical Therapy During the COVID-19 Pandemic: Is Telerehabilitation the Answer? Physical Therapy, 100(8), pp. 1260-1264. https://doi.org/10.1093/ptj/pzaa093

Wang, T. J., Chau, B., Lui, M., Lam, G.-T., Lin, N., & Humbert, S. (2020). Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19. American Journal of Physical Medicine & Rehabilitation, 99(9), pp. 769-774. https://doi.org/10.1097/PHM.0000000000001505

Zhao, H.-M., Xie, Y.-X., & Wang, C. (2020). Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chinese Medical Journal, 133(13), pp. 1595-1602. https://doi.org/10.1097/CM9.0000000000000848

Zhu, N., et al. (2020). A Novel Coronavirus from Patients with Pneumonia in China, 2019. The New England Journal ofMedicine , 382(8), pp. 727-733. https://doi.org/10.1056/NEJMoa2001017

Received: March 18, 2023; Accepted: July 05, 2023

^*Autor para la correspondencia: [e-mail]

Los autores no declaran conflictos de intereses

Julio César Rodríguez-Díaz, Yasmany González Garcés: conceptualización.

Julio César Rodríguez Díaz, Yasmany González Garcés, Roberto Rodríguez Labrada: Metodología

Julio César Rodríguez-Díaz, Yasmany González Garcés, Roberto Rodríguez Labrada, Rigoberto González Piña, Armando Sentmanat-Belisón: investigación.

Yasmany González Garcés: visualización.

Julio César Rodríguez Díaz, Roberto Rodríguez Labrada, Yasmany González Garcés: redacción borrador original.

Julio César Rodríguez Díaz, Roberto Rodríguez Labrada, Yasmany González Garcés, Rigoberto González Piña, Armando Sentmanat-Belisón: redacción revisión y edición.