FUNCTIONALITY BEFORE AND AFTER PHYSIOTHERAPY IN POST-COVID-19 PATIENTS

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INTRODUCTION
Post-acute COVID-19 syndrome presents with persistence of symptoms and late complications over a period of more than four weeks from the onset of symptoms; it is estimated that more than one third of patients develop this syndrome post-infection.The main symptoms include fatigue (35-63%), pain (5-27%), (7) dyspnea (11-43%) and chest pain (5-22%) .According to the World Health Organization (WHO), from July 31 to August 27, 2023, more than 1.4 million COVID-19 cases were reported worldwide, with 1800 deaths.This represents 38% more cases and 50% fewer deaths than (8) the previous 28 days .As of August 2023, 7 649 199 cases have been con rmed in Mexico, 334 472 deaths, with a cumulative case incidence of 5 828.8 per 100 000 population, with 53.7% women and a median age of 38 (9) years .
The global pandemic of COVID-19 in 2020 originated by the SARS-CoV virus affected considerably the different health and medical care systems, it is estimated that this respiratory disease until August 2023 has affected a total number of 770 085 713 patients, including 6 956 173 reported deaths and an incidence of new cases per (1) week of 9 787 worldwide .COVID-19 infection represents a multisystemic disease, with a broad spectrum of acute, subacute, and long- (2) term manifestations .Symptoms of acute infection with this pathogen include cough, fever, fatigue, dysfunction .These long-term complications signi cantly diminish the patient's quality of life, with outstanding repercussions on general and emotional (6) health .
The management of this pathology requires the multidisciplinary participation of the entire health care team, especially rehabilitation and post-acute care (10) .The aim was to reduce symptoms, improve exercise (11) tolerance and quality of life .

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However, in hospitals there is low implementation and ( 1 2 , 1 3 ) little speci c dedication .So far, studies documenting the results of comprehensive physical and occupational respiratory rehabilitation in patients with post-COVID-19 sequelae in the Latin American (14,15) population are scarce .This paper proposes a physical, pulmonary, cognitive and functional performance reconditioning program to reincorporate these patients to their daily and occupational life.
The objective of this study was to demonstrate the physical, respiratory and functional effects of a post COVID-19 physical and occupational therapy program in patients at a 3rd level hospital.

METHODS
2. Barthel Index (Barthel).It rates neuromuscular and musculoskeletal processes for dependent or independent performance of activities.

Design and study area
Patients with physical, respiratory or functional independence sequelae were included.

Variables and instruments
A comparative, quasi-experimental, prospective study was conducted in outpatients discharged from hospitalization for COVID-19 treated at a 3rd level hospital of the Mexican Social Security Institute in Puebla, Mexico, during 2020-2021.
1. Medical Research Council (MRC) scale.It evaluates the strength of three muscle groups in the 4 extremities.Each muscle group scores between 0 (no visible contraction) and 5 (active movement against total resistance).The total sum records values between 0 (total paralysis) and 60 (normal muscle strength).A value below 48 is considered acquired weakness.The functions evaluated are: wrist extension, elbow exion and shoulder abduction (in thoracic limbs), and hip exion, knee extension and ankle dorsi exion (in pelvic limbs).Three attempts can be performed for each (13,14) muscle group .

Population and sample
Age and gender were recorded, and the following scales were applied before and after the rehabilitation program: Pág. 75

The Lowenstein Occupational Therapy Cognitive
Assessment Battery 1st edition (LOTCA).It is an instrument for cognitive assessment in patients with neurological disorders.It consists of ve domains: orientation, perception, visual-motor organization, rational operations, categorization, and attention and concentration.It is scored from 1 to 4 according to the (18) patient's capacity and maintenance of attention .

RESULTS
A total of 133 patients were recruited, of whom 116 successfully completed treatment and 17 did not (  In the modi ed Borg scale we obtained an initial median of 5.00 (strong effort) and a nal median of 1.00 (little effort) Table 2.The 6-minute walk test (6WT) considers it ideal for patients to walk over 350 meters.During this test, an initial mean of 334.50 meters was obtained and a nal mean after treatment of 433.5 meters (Table 2).In the LOTCA battery all patients scored 84 points before and after treatment (Table 2).
Manual strength was measured with a dynamometer in the right and left hand at the beginning and end of the treatment.

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Fatigue and dyspnea remained persistent in post COVID-19 patients affecting mobility and activities of (18) daily living , in addition severe acute respiratory (19) syndrome (SARS) was frequently observed .pulmonary ventilation .The 6-minute walk assesses functional exercise capacity in the management of (24) post-critically ill patients .In this study a before and after assessment was made, where before patients walked approximately 334.5 meters in 6 minutes, upon receiving therapy, patients increased to 433.5 meters.
The six-minute walk showed a better outcome in those who had a signi cant range related to the distance

CONCLUSION
The results of the study suggest that post COVID-19 patients show signi cant improvement with physical and occupational respiratory therapy.
dyspnea .Severe symptoms can lead to acute respiratory distress syndrome (ARDS) with (4) urgent need for invasive ventilation .These patients are susceptible to a wide variety of post-infectious complications such as post-intubation dysphagia, muscle weakness, general physical un tness, myo p at hy, n e u ro p at hy a n d m u s c u l o s k e l e t a l ( 5 )
Physical and Occupational Rehabilitation Program, which consists of a series of exercises: 1) From resting position, 2) Speci c respirator y exercises, 3) Occupational therapy routine, 4) Exercises from seated position, 5) From kneeling posture, 6) From dorsal Statistical analysis The different exercises applied in this physical and occupational rehabilitation protocol are described in detail in the annex to this document.Analytical statistics were performed.The Kolmogorov-Smirnov test was used to verify the normality of the data distribution.For comparison of parametric quantitative variables, Student's t test for related samples was used.For related nonparametric and ordinal qualitative variables, the Wilcoxon test was used.A p≤0.05 was considered signi cant.decubitus posture, 7) From standing posture, 8) Warmup and mobility, 9) From bipedal posture, 10) Stretching exercises, 11) Strengthening with rubber bands, 12) Strengthening with medicine ball, 13) Strengthening with dumbbells, 14) Strengthening with leggings, 15) Physical conditioning, 16) Exercises with balloon and hoop, 17) Tandem walk, 18) Static and dynamic balance.Ethical aspects The present study was approved by the Local Health Research Committee No. 2101 of the Mexican Social Security Institute.All patients signed a letter of informed consent.All information was handled with strict con dentiality and was used exclusively for research purposes.No con icts of interest were reported.
small sample size and the absence of a control group to evaluate the effect of therapeutic intervention are areas of opportunity in the present study.Although the natural history of the disease is to improvement, Physical Medicine and Rehabilitation intervention can shorten the evolution and improve the symptomatology of patients.

Table 2 .
In the MCR scale, an initial median of 48 points was obtained, indicating weakness acquired in intensive care, and a nal median of 57, indicating progress in terms of upper and lower limb mobility and strength.The Barthel index showed an initial mean of 95 with mild dependence and a nal mean of 98 (Table2).

Table 2 .
Analysis of the initial and nal statistics of the scales applied in patients with post-COVID-19.