Post COVID-19 – effective treatment and rehabilitation

A systematic review and assessment of medical and economic aspects

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SBU Policy support

identifies and presents available scientific evidence to support policy and decision making, including the development of national guidelines, at other government agencies. In consultation with professional experts, SBU staff generates supporting documentation to address the various questions that have been posed.

Published: Revised: 8/15/2022 Report no: 328 Registration no: 2021/137 https://www.sbu.se/328e

Background

SBU was commissioned by the Swedish Government to evaluate the scientific evidence for care for patients with post COVID-19 (long-term symptoms or sequelae of the disease COVID-19).

Aim

The aim was to summarize published scientific articles addressing the following research question: Which treatments are effective for post COVID-19?

Method

A systematic review conducted in accordance with THE PRISMA statement. The protocol is registered in Prospero. The certainty of evidence was assessed with GRADE.

Inclusion criteria

PICO

Population – 1. Patients with post COVID-19 condition according to WHO´s definition (individuals with persistent or new symptoms after 3 months from the initial onset of COVID-19 that last for at least 2 months and cannot be explained by an alternative diagnosis). 2. Patients who did not meet the criteria according to WHO´s definition (but had early symptoms, treatment started after infection clearance and were followed up at least three months).

Interventions – Treatment or rehabilitation for long-term symptoms.

Comparison – No treatment or other treatment.

Outcomes – All outcomes related to post COVID-19 (long-term symptoms or sequelae of the disease COVID-19).

Study design – RCT and non-randomised controlled trials. Observational and qualitative studies, as well as case studies, were excluded.

Search period: From April 26 2021, then weekly. Final search June 1 2022.

Databases searched: Every week, an information specialist searched the database Medline (OvidSP) via Alerts. Every month, five additional databases were searched: Cinahl (Ebsco), PsycINFO (Ebsco), Cochrane Library (Wiley), Embase (embase.com) and WHO: Global literature on coronavirus disease. Reference lists and citations for relevant primary studies and reviews were also screened.

The project group also continuously tracked the following COVID-19 specific resources:

  • COVID-NMA
  • Cochrane Rehabilitation

Patient involvement: No

Results

Evidence map: Post COVID-19 – effective treatment and rehabilitation

The articles in the evidence map are presented based on included population and intervention. You can filter which articles are displayed by making selections in the menu above the table. Below the table are functions for exporting the selection as an Excel file or image.

 

Table 1 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated; 4 Moderate number of participants.

MWD = Minute walking distance; MWT = Minute walk test; RCT = Randomised controlled trial; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Telerehabilitation vs short teaching instructions 120
(1 RCT)
[12]
Walking distance 6 minutes (6MWD) Very low

Risk of bias −11
Precision −12
Transferability −13
Inspiratory muscle training vs usual care 281
(1 RCT)
[9]
Health-related quality of life (three domains: psychological, shortness of breath and activity, chest symptoms) Very low

Risk of bias −11
Precision −14
Transferability −13
Instructor-led respiratory exercises via telemedicine vs a brochure describing the same respiratory exercises 52
(1 RCT)
[10]
Spirometry, walking distance 6 minutes (6MWT) Very low

Risk of bias −11
Precision −22
Transferability −13
Guided breathing training using singing techniques (online) vs usual care 150
(1 RCT)
[11]
Health-related quality of life Very low

Risk of bias −11
Precision −1 2
Transferability −13

 

Table 2 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated.

Net = Narrative exposure therapy; RCT = Randomised controlled trial; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Narrative exposure therapy (net) & personalized psychological treatment vs personalized psychological treatment 111
(1 RCT)
[21]
Post traumatic stress Very low

Risk of bias −11
Precision −12
Transferability −13

 

Table 3 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated; 4 The results have only been repeated as pilot study on the same research group.

NRSI = Non-randomised studies of interventions; RCT = Randomised controlled trial; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies
and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Palmitoylethanolamide and Luteolin (orally) combined with smell training vs smell training 185 + 12 participants
(2 RCT)
[16] [17]
Smell function Very low

Risk of bias −11
Precision −12
Transferability −14
Corticosteroids (methylprednisolone) combined with smell training vs smell training 27 participants
(1 NRSI prospective)
[18]
Smell function Very low

Risk of bias −11
Precision −22
Transferability −13

 

Table 4 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated;

RCT = Randomised controlled trial; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies
and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Acetyl-L carnitine combined with rehabilitation training vs rehabilitation training 60
(1 RCT)
[22]
Experienced pain and shortness of breath Very low

Risk of bias −11
Precision −22
Transferability −13

 

Table 5 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated;

NRSI = Non-randomised studies of interventions; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies
and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Cognitive training vs no treatment 45
(1 NRSI)
[20]
Cognitive function Very low

Risk of bias −11
Precision −22
Transferability −13

 

Table 6 Summary of findings (SOF table).
1 Moderate risk of bias; 2 Few participants, few events; 3 The results have not been repeated, and the population other than from a Swedish context, mainly the diagnosis ’qi deficiency’.

MWD = Minute walking distance; RCT = Randomised controlled trial; SOF = Summary of findings; vs = Versus
Intervention vs control Number of participants
(Number of studies
and study design)
[Reference]
Outcome Certainty of results

Reason for reduced certainty
Chinese herbal medicine (Bufei Huoxue) vs placebo 131
(1 RCT)
[23]
Lung changes (CT scan), walking distance 6 min (6MWD) Very low

Risk of bias −11
Precision −12
Transferability −23

Discussion

All in all, the scientific basis has very low reliability. It is therefore not possible to assess whether any of the treatments studied are effective or not, on the basis of the evidence identified up to and including 1 June 2022. This does not mean that the treatments have no effect, but that more well-done studies are needed to assess the effect.

Conflicts of interest

In accordance with SBU’s requirements, the experts participating in this project have submitted statements about conflicts of interest. These documents are available at SBU’s secretariat. SBU has determined that the conditions described in the submissions are compatible with SBU’s requirements for objectivity and impartiality.

See all studies and tables

Flow diagram for article screening

Study flowchart 24 729 records identified through database searches. After screening, we have included 11 studies with low or moderate risk for bias and 8 studies with high risk of bias.

Evidence map

Evidence map: Post COVID-19 – effective treatment and rehabilitation

The articles in the evidence map are presented based on included population and intervention. You can filter which articles are displayed by making selections in the menu above the table. Below the table are functions for exporting the selection as an Excel file or image.

Project group

Experts

  • Alison Godbolt, Danderyd Hospital
  • Judith Bruchfeld, Karolinska University Hospital
  • Jörgen Månsson, University of Gothenburg
  • Kristina Hedman, Sundsvall Regional Hospital
  • Marcus Ståhlberg, Karolinska University Hospital
  • Michael Runold, Karolinska University Hospital
  • Olof Hertting, Astrid Lindgren Children's Hospital

From SBU

  • Elizabeth Åhsberg, Project Manager
  • Nathalie Peira, Assistant Project Manager
  • Idha Kurtsdotter, Assistant Project Manager (from April 2022)
  • Jessica Dagerhamn, Assistan Project Manager (from November 2021 to April 2022)
  • André Sjöberg, Assistant Project Manager (up to December 2022)
  • Maria Ahlberg, Project Administrator
  • Carl Gornitzki, Information Specialist (up to November 2021)
  • Hanna Olofsson, Information Specialist (from December 2021)
  • Pernilla Östlund, Head of Department
  • Susanne Eksell, Web Project Manager
  • Irene Edebert, acting Head of Department (from November 2021)

More on the subject

SBU and COVID-19

3D-bild av virus

SBU closely monitors what actions other countries are taking to meet the needs of decision- and policymakers to respond to the COVID-19 pandemic. Via the International organisation of HTA, INAHTA, SBU shares and exchanges information to support staff and decision-makers in health care and social services.

SBU is also in contact with the other Swedish agencies within the national health care sector who currently are working intensively to support both the health care services as well as care homes.

Ongoing work on COVID-19 at SBU

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