The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0–10. Substantial agreement (range 7.5–10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Background Individuals who contract coronavirus disease 2019 (COVID-19) can suffer with persistent and debilitating symptoms long after the initial acute illness. Heart rate (HR) profiles determined during cardiopulmonary exercise testing (CPET) and delivered as part of a post-COVID recovery service may provide an insight into presence and impact of dysautonomia on functional ability. Objective Using an active, working age, post-COVID-19 population, the aim was to: 1) understand and characterise any association between subjective symptoms and dysautonomia, and 2) identify objective exercise capacity differences between patients classified ‘with’ and ‘without’ dysautonomia. Methods Patients referred to a post-COVID-19 service underwent comprehensive clinical assessment, including self-reported symptoms, CPET and secondary care investigations when indicated. Resting HR >75 beats per minute (bpm), HR increase with exercise <89bpm, and HR recovery <25bpm one minute after exercise were used to define dysautonomia. Anonymised data were analysed and associations with symptoms and CPET outcomes determined. Results Fifty-one (25%) of the 205 patients reviewed as part of this service evaluation had dysautonomia. There were no associations between symptoms or perceived functional limitation and dysautonomia (p>0.05). Patients with dysautonomia demonstrated objective functional limitations with significantly reduced work rate (219±37 W vs. 253±52 W, p<0.001), peak oxygen consumption (V̇O 2 : 30.6±5.5 ml/kg/min vs. 35.8±7.6 ml/kg/min, p<0.001) and a steeper (less efficient) V̇E/V̇CO 2 slope (29.9±4.9 vs. 27.7±4.7, p=0.005). Conclusion Dysautonomia is associated with objective functional limitations but is not associated with subjective symptoms or limitation.

Propionibacterium acnes is found increasingly as a cause of delayed infection, usually involving implanted biomaterials. Despite susceptibility to common antibiotics, such infections are very difficult to treat and usually require surgical removal of the device. Three clinical isolates of P. acnes were assessed for ability to adhere to titanium, surgical steel and silicone, with and without a plasma conditioning film. After adherence, the biomaterials were then incubated for a further 6 days and examined for biofilm development. All three isolates adhered to all three biomaterials similarly. Importantly, we were able to demonstrate biofilm formation, including production of exopolymer similar in appearance to the polysaccharide intercellular adhesin of Staphylococcus epidermidis. A case summary also demonstrated failure to eradicate P. acnes infection in a hydrocephalus shunt after prolonged treatment. The removed shunt showed obvious biofilm formation, initially obscured by exopolymer when viewed by environmental scanning electron microscopy. Biofilm development by P. acnes explains the difficulties encountered in clinical management of such infections.

Background: A failure to fully recover following coronavirus disease 2019 (COVID-19) may have a profound impact on high functioning populations ranging from front-line emergency services to professional or amateur/recreational athletes. Aim: To describe the medium-term cardiopulmonary exercise profiles of individuals with 'persistent symptoms' and individuals who feel 'recovered' after hospitalization or mild-moderate community infection following COVID-19 to an age, sex and job-role matched control group. Methods: 113 participants underwent cardiopulmonary functional tests at a mean 159±7 days (~5 months) following acute illness; 27 hospitalized with persistent symptoms (hospitalized-symptomatic), 8 hospitalized and now recovered (hospitalized-recovered); 34 community managed with persistent symptoms (community-symptomatic); 18 community managed and now recovered (community-recovered), and 26 controls. Results: Hospitalized groups had the least favorable body composition (body mass, body mass index and waist circumference) compared to controls. Hospitalized-symptomatic and community-symptomatic individuals had a lower oxygen uptake (V̇O2) at peak exercise (hospitalized-symptomatic, 29.9±5.0ml/kg/min; community-symptomatic, 34.4±7.2ml/kg/min; vs. control 43.9±3.1ml/kg/min, both p<0.001). Hospitalized-symptomatic individuals had a steeper V̇E/V̇CO2 slope (lower ventilatory efficiency) (30.5±5.3 vs. 25.5±2.6, p=0.003) vs. controls. Hospitalized-recovered had a significantly lower oxygen uptake at peak (32.6±6.6ml/kg/min vs. 43.9 ±13.1ml/kg/min, p=0.015) compared to controls. No significant differences were reported between community-recovered individuals and controls in any cardiopulmonary parameter. Conclusion: Medium term findings suggest community-recovered individuals did not differ in cardiopulmonary fitness from physically active healthy controls. This suggests their readiness to return to higher levels of physical activity. However, the hospitalized-recovered group and both groups with persistent symptoms had enduring functional limitations, warranting further monitoring, rehabilitation and recovery.

IntroductionThe multisystem COVID-19 can cause prolonged symptoms requiring rehabilitation. This study describes the creation of a remote COVID-19 rehabilitation assessment tool to allow timely triage, assessment and management. It hypotheses those with post-COVID-19 syndrome, potentially without laboratory confirmation and irrespective of initial disease severity, will have significant rehabilitation needs.MethodsCross-sectional study of consecutive patients referred by general practitioners (April–November 2020). Primary outcomes were presence/absence of anticipated sequelae. Binary logistic regression was used to test association between acute presentation and post-COVID-19 symptomatology.Results155 patients (n=127 men, n=28 women, median age 39 years, median 13 weeks post-illness) were assessed using the tool. Acute symptoms were most commonly shortness of breath (SOB) (74.2%), fever (73.5%), fatigue (70.3%) and cough (64.5%); and post-acutely, SOB (76.7%), fatigue (70.3%), cough (57.4%) and anxiety/mood disturbance (39.4%). Individuals with a confirmed diagnosis of COVID-19 were 69% and 63% less likely to have anxiety/mood disturbance and pain, respectively, at 3 months.ConclusionsRehabilitation assessment should be offered to all patients suffering post-COVID-19 symptoms, not only those with laboratory confirmation and considered independently from acute illness severity. This tool offers a structure for a remote assessment. Post-COVID-19 programmes should include SOB, fatigue and mood disturbance management.