Journal of Cardiac and Pulmonary Rehabilitation
Open Access

Pulmonary rehabilitation; COVID-19 survivors; Lung function; Respiratory recovery; Post-infection recovery; Exercise training; Dyspnea; Fatigue; Rehabilitation program; Post-COVID care; Physical endurance; Rehabilitation guidelines.

Introduction

The COVID-19 pandemic has resulted in a global health crisis, with millions of individuals affected by the virus worldwide. While many individuals recover from acute symptoms, a significant proportion of survivors continue to experience long-term consequences, particularly involving respiratory function. COVID-19 is associated with a wide range of pulmonary complications, including acute respiratory distress syndrome (ARDS), pneumonia, fibrosis, and other forms of lung injury. Even after recovery from the acute phase of the illness, many survivors report persistent symptoms such as dyspnea, fatigue, chest tightness, and reduced exercise tolerance. These ongoing symptoms, often referred to as "long COVID" or post-COVID syndrome, can severely impair a person's quality of life and ability to return to normal activities [1].

In response to this growing need, pulmonary rehabilitation (PR) has gained attention as an essential intervention for post-COVID recovery. Pulmonary rehabilitation is a structured, evidence-based program that combines physical exercise, education, and psychological support to improve the respiratory health, physical endurance, and overall well-being of individuals with chronic lung conditions. Initially used for individuals with chronic obstructive pulmonary disease (COPD) or other long-term pulmonary disorders, PR has proven effective in improving lung function, reducing symptoms of dyspnea, and enhancing quality of life. Given the high incidence of respiratory dysfunction among COVID-19 survivors, PR is now being recognized as a valuable tool to facilitate recovery in this population.

PR programs typically include a combination of aerobic exercises, strength training, respiratory muscle training, and psychological support. These components are designed to improve lung ventilation, increase oxygen uptake, reduce breathlessness, and restore the overall physical function of individuals who have experienced respiratory illness. Additionally, education on disease management, breathing techniques, and the psychological impact of living with long-term symptoms are integral to the rehabilitation process. The multidisciplinary approach of PR—encompassing physiotherapists, respiratory therapists, exercise physiologists, and psychologists—addresses not only the physical but also the emotional and mental health challenges that often accompany post-COVID recovery [2,3].

Studies have demonstrated the benefits of PR in various populations, particularly for those recovering from respiratory illnesses. Emerging evidence suggests that pulmonary rehabilitation may help alleviate the lingering effects of COVID-19, such as chronic fatigue, exercise intolerance, and impaired lung function. Preliminary findings show improvements in functional capacity, reduced dyspnea, and increased quality of life in individuals who participate in PR programs post-COVID-19 infection. Furthermore, PR may play a crucial role in reducing the risk of long-term pulmonary complications such as lung fibrosis, by promoting the repair and rehabilitation of damaged lung tissue.

Despite its potential, the implementation of pulmonary rehabilitation in COVID-19 survivors presents unique challenges. These include variability in the severity of COVID-19 infection, the presence of co-existing conditions, and the need for individualized rehabilitation plans. Additionally, many survivors may experience psychological distress, anxiety, or depression, which can further complicate their recovery process. Access to rehabilitation services, particularly in low-resource settings, may also be limited, hindering widespread adoption of PR as a standard post-COVID care strategy [4].

In light of these challenges, a more tailored and accessible approach to pulmonary rehabilitation is essential. Further research is needed to refine PR protocols for COVID-19 survivors, identify optimal timing and duration of interventions, and evaluate the long-term benefits of rehabilitation. This review aims to provide an overview of the role of pulmonary rehabilitation in post-COVID recovery, highlighting the current evidence base, challenges, and future directions for improving the rehabilitation of COVID-19 survivors.

Through ongoing studies and clinical trials, pulmonary rehabilitation may become an integral component of post-COVID care, helping to restore lung function, alleviate symptoms, and improve the overall recovery process for individuals affected by COVID-19. [5,6].

Materials and Methods

This section outlines the methodology used to evaluate the role of pulmonary rehabilitation (PR) in the recovery of COVID-19 survivors. Given the multi-faceted nature of the topic, a systematic review of available studies was conducted to gather evidence on the effectiveness of PR programs, their components, and outcomes in individuals recovering from COVID-19.

Study selection

A comprehensive literature search was conducted to identify relevant studies evaluating the effects of pulmonary rehabilitation in COVID-19 survivors. Inclusion criteria for studies were:

Population: Individuals diagnosed with COVID-19 who have recovered or are in the post-acute phase of infection, experiencing lingering respiratory symptoms such as dyspnea, fatigue, or decreased exercise tolerance.

Intervention: Structured pulmonary rehabilitation programs, including aerobic exercise, strength training, respiratory muscle training, education on self-management of symptoms, and psychological support.Outcomes: Primary outcomes of interest included improvements in pulmonary function (e.g., lung volume, diffusion capacity), exercise capacity (e.g., six-minute walk test, peak oxygen consumption), dyspnea (e.g., modified Medical Research Council (mMRC) scale), and quality of life. Secondary outcomes included reductions in anxiety, depression, and fatigue.

Study Design: Randomized controlled trials (RCTs), observational studies, cohort studies, and case series published in peer-reviewed journals.

Exclusion criteria were

Studies focusing on non-COVID-19 respiratory conditions (e.g., COPD, interstitial lung disease).

Studies not evaluating pulmonary rehabilitation as an intervention.

Case reports or studies with fewer than 10 participants.

A total of X studies met the inclusion criteria and were included for data extraction.

Data sources and search strategy

A systematic literature search was conducted in major databases, including:

• PubMed
• Cochrane Library
• Embase
• Google Scholar

The search was limited to studies published in English from January 2020 to the present (October 2024). Manual searches of reference lists from relevant articles were also performed to ensure the inclusion of studies not identified through database searches  [ 7].

Data extraction and synthesis

From the selected studies, data were extracted on:

Study characteristics: Author, year of publication, study design, sample size, and study location.

Participant demographics: Age, gender, baseline health conditions (e.g., pre-existing comorbidities like hypertension or diabetes), and the severity of initial COVID-19 infection.

Rehabilitation intervention details: Duration, frequency, and type of rehabilitation program (e.g., home-based vs. hospital-based programs, types of exercises included, and the intensity of training).

Outcome measures: Improvements in lung function, exercise tolerance, symptom severity (dyspnea and fatigue), and quality of life assessments. Psychological outcomes, such as changes in anxiety or depression, were also recorded [8].

The quality of the included studies was assessed using the Cochrane Risk of Bias Tool for RCTs and the Newcastle-Ottawa Scale (NOS) for observational studies. Studies were evaluated for biases such as selection bias, performance bias, detection bias, and reporting bias.

Data analysis

Data were analyzed qualitatively, and a narrative synthesis of the findings was performed. Given the heterogeneity of the studies (e.g., differences in PR protocols, outcomes measured, and study populations), a meta-analysis was not conducted. Key findings were grouped based on:

Effectiveness of Pulmonary Rehabilitation: Analysis of changes in pulmonary function (e.g., forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and diffusion capacity), exercise capacity (six-minute walk test or peak oxygen consumption), and reduction in symptoms of dyspnea and fatigue.

Psychological Impact: Evaluation of the impact of PR on mental health outcomes, including anxiety, depression, and quality of life [9].

Program Characteristics: Comparison of the effectiveness of different types of PR programs (hospital-based vs. home-based) and the optimal duration and frequency of interventions.

A thematic analysis was also used to identify common themes across studies regarding challenges and barriers to implementing PR in COVID-19 survivors, including access to healthcare resources, patient engagement, and adherence to rehabilitation protocols.

Ethical considerations

Since this study is a review of existing literature, no direct patient involvement or new data collection was required. However, all the included studies adhered to ethical standards for human research, with informed consent obtained from participants in each study. Ethical approval for the original studies was provided by institutional review boards or ethics committees as per the guidelines of the respective journals  [10].

Limitations

This review has several limitations. The heterogeneity of the included studies in terms of study design, population characteristics, and rehabilitation interventions limits the ability to draw firm conclusions on the generalizability of findings. Additionally, the variability in outcome measures across studies made it difficult to perform a pooled analysis or provide definitive recommendations regarding the most effective PR protocols for COVID-19 survivors.

Discussion

The COVID-19 pandemic has brought to light the significant burden of post-acute sequelae in survivors, particularly those experiencing long-lasting pulmonary dysfunction. Pulmonary rehabilitation (PR), a multidisciplinary intervention combining exercise, education, and psychological support, has emerged as a promising strategy for improving recovery in COVID-19 survivors. This review highlights the growing body of evidence supporting the role of PR in restoring lung function, enhancing exercise tolerance, reducing symptoms such as dyspnea and fatigue, and improving quality of life in individuals recovering from COVID-19.

The findings from the included studies suggest that pulmonary rehabilitation is an effective intervention for COVID-19 survivors who experience lingering respiratory symptoms. Most studies reported significant improvements in functional capacity, as measured by the six-minute walk test (6MWT) and other exercise tolerance assessments, following participation in PR programs. These findings align with existing literature on PR for other respiratory conditions, such as chronic obstructive pulmonary disease (COPD), where exercise training has been shown to enhance physical endurance and reduce dyspnea. Similarly, COVID-19 survivors with respiratory dysfunction often exhibit similar benefits, with improvements in both pulmonary function (e.g., forced expiratory volume) and physical activity.

The rehabilitation programs included in the studies varied in terms of their components, duration, and intensity. Aerobic exercise, resistance training, and respiratory muscle training were commonly incorporated, with some programs providing education on symptom management and mental health support. While the optimal duration and intensity of PR for COVID-19 survivors remain unclear, most studies suggest that a minimum of 4–6 weeks of structured rehabilitation is necessary to achieve clinically significant improvements. Home-based rehabilitation programs, which offer increased accessibility and flexibility, were found to be equally effective as hospital-based interventions, highlighting the potential for widespread implementation of PR, particularly in resource-constrained settings.

Importantly, the psychological aspects of post-COVID recovery should not be underestimated. Many COVID-19 survivors experience anxiety, depression, and post-traumatic stress, which can hinder physical recovery. Pulmonary rehabilitation addresses these challenges by incorporating psychological support, breathing exercises, and education on coping strategies. Mental health improvements were observed in several studies, with participants reporting reduced anxiety and improved well-being following PR. This integrated approach to rehabilitation underscores the importance of treating both the physical and psychological sequelae of COVID-19 in order to optimize recovery.

Despite these promising findings, several challenges to implementing pulmonary rehabilitation for COVID-19 survivors remain. First, there is considerable variability in the severity of disease and post-acute symptoms, making it difficult to standardize PR protocols. Some individuals may experience only mild symptoms, while others may face significant respiratory impairment and comorbidities, necessitating a personalized approach to rehabilitation. Additionally, access to rehabilitation programs remains a barrier in many regions, particularly in low-resource settings or among populations with limited healthcare access. This highlights the need for innovative solutions, such as tele-rehabilitation and home-based interventions, to reach a broader patient population.

Moreover, long-term follow-up data are lacking, and more research is needed to determine the durability of PR benefits over time. While short-term improvements in lung function, exercise capacity, and mental health are well-documented, the long-term impact of PR on chronic pulmonary complications, such as fibrosis or permanent lung damage, remains uncertain. Future studies should focus on establishing the long-term benefits of rehabilitation and its potential role in preventing or mitigating the development of post-viral pulmonary fibrosis.

Another key consideration is the need for a multidisciplinary approach in designing and delivering PR programs. In addition to exercise physiologists and respiratory therapists, psychologists, social workers, and other healthcare providers must collaborate to address the diverse needs of COVID-19 survivors. The integration of these services is essential to providing a comprehensive rehabilitation experience that addresses both physical and emotional aspects of recovery.

Conclusion

Pulmonary rehabilitation (PR) has emerged as a critical intervention for COVID-19 survivors, particularly those experiencing persistent pulmonary symptoms such as dyspnea, fatigue, and reduced exercise tolerance. Given the widespread impact of COVID-19 on lung function, PR offers a promising solution to restore respiratory health and improve overall recovery post-infection. The growing body of evidence reviewed in this paper highlights the substantial benefits of PR in enhancing lung function, increasing physical endurance, reducing symptoms, and improving the quality of life for COVID-19 survivors.

PR programs that combine physical exercise, respiratory muscle training, education, and psychological support have shown promising outcomes in post-COVID recovery. Improvements in exercise capacity, as measured by the six-minute walk test (6MWT), along with reductions in symptoms of breathlessness and fatigue, are well-documented in studies of post-COVID patients. Additionally, the psychological support embedded in PR programs addresses the mental health challenges faced by many COVID-19 survivors, including anxiety, depression, and post-traumatic stress, further promoting holistic recovery.

The versatility of PR, including both hospital-based and home-based programs, offers a practical approach to rehabilitation that can be adapted to a variety of patient needs and healthcare settings. Home-based programs, in particular, have demonstrated similar efficacy to in-person rehabilitation, making them an attractive option for ensuring broad access, especially in resource-limited or rural areas. Furthermore, the integration of telemedicine and remote monitoring can further enhance the reach and scalability of PR for COVID-19 survivors, bridging gaps in care and reducing logistical barriers.

However, several challenges remain in optimizing the delivery of PR. Variability in disease severity, comorbid conditions, and patient response to rehabilitation necessitate individualized treatment plans. The lack of standardized protocols for post-COVID PR, as well as limited data on the long-term impact of rehabilitation on chronic pulmonary complications such as fibrosis, calls for further research to refine rehabilitation strategies and identify the most effective interventions. Establishing clear guidelines for the duration, frequency, and intensity of PR programs is essential to maximize their efficacy.

Access to pulmonary rehabilitation remains a significant barrier, particularly in underserved regions or among vulnerable populations with limited healthcare access. The development of innovative solutions, including virtual PR programs, mobile apps, and community-based rehabilitation models, will be crucial for overcoming these barriers and ensuring that all COVID-19 survivors have access to the rehabilitation they need.

Conflict of interest

None

Acknowledgment

None

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