The Use of Modern Technologies in Post-COVID-19 Cardiopulmonary Rehabilitation

Round 1

Reviewer 1 Report

Dear authors,

The article seems to be a bibliographic or systematic review about telemedicine and cardiopulmonary rehabilitation after Covid-19. I have some suggestions for you.

 - The first lines of the introduction are confusing by the information inside the brackets, please rewrite them.

- CovidCOVID-19 is correct? If it is not there is a mistake in line 61, 231, 234...

- There is no structure along the study. At the beginning you mention that two reviewers analyze data independently, but there is any information about search strategy or study selection…

- Only two researchers conduct the review? If there is disagreement, how has it been resolved?

-What were the criteria for inclusion and exclusion from the review?

- There is no methodology section, only the discussion of the main articles selected.

- References does not follow the mdpi criteria

Author Response

• Dear reviewer, thank you very much for your interest and time in our manuscript. We tried to correct the article to meet your comments.
• The first lines of the introduction are confusing by the information inside the brackets, please rewrite them. - We have rewrite the first line in introduction section.
• CovidCOVID-19 is correct? If it is not there is a mistake in line 61, 231, 234...- there was a mistake on typing.
• There is no structure along the study. At the beginning you mention that two reviewers analyze data independently, but there is any information about search strategy or study selection- we added supplementary information about search strategy on Featured application section.
• Only two researchers conduct the review? If there is disagreement, how has it been resolved?- only two researchers selected studies that met the inclusion criteria.
• What were the criteria for inclusion and exclusion from the review?- we have added information about the inclusion criteria.
• there is no methodology section, only the discussion of the main articles selected. - we have added information about the methodology.
• References does not follow the mdpi criteria - we have modified the references to met the MDPI criteria.
• At the suggestion of the reviewers, we reorganized the text into subsections to make it easier to understand. Please see the attachment file where you will find the highlight modifications.

Author Response File: Author Response.pdf

Reviewer 2 Report

I read with great interest the manuscript from Andritoi et al. The topic is actual and interesting, but presentation of data is difficult to the reader and sometimes misleading.

First of all it is not clear if the intention of the authors is to provide a narrative or a systematic review, as reported in the "featured application" section. In this case the presentation of a flowchart of the papers revised is crucial.

The introduction is too long and not well focused on the topic of the review.

The following parts are confused and not well presented. It would be helpful to divide the section in different paragraphs that refer to the different types of device used.

Conclusions should highlight, if any, the benefits of medical technologies and remote monitoring of home based rehabilitation programs.

Author Response

• Dear reviewer, thank you very much for your interest and time in our manuscript. We tried to correct the article to meet your comments.

• I read with great interest the manuscript from Andritoi et al. The topic is actual and interesting, but presentation of data is difficult to the reader and sometimes misleading. - We have reorganized the text in to sections and subsections to make it more easier to understand.

  First of all it is not clear if the intention of the authors is to provide a narrative or a systematic review, as reported in the "featured application" section. In this case the presentation of a flowchart of the papers revised is crucial. - We have added information about the type of review in Featured Application section. It is a literature review.

  The introduction is too long and not well focused on the topic of the review. - we have rewrite the introduction section to be more easier to understand.

  The following parts are confused and not well presented. It would be helpful to divide the section in different paragraphs that refer to the different types of device used. - We have reorganized the text in to sections and subsections to make it more easier to understand.

  Conclusions should highlight, if any, the benefits of medical technologies and remote monitoring of home based rehabilitation programs. - we modified the conclusions trying to make a general conclusion about remote monitoring systems.

• Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Andritoi et al. offer a “narrative review” on the use of digital tools in the rehabilitation of post-COVID individuals. The authors discussed advances in tele-medicine and telemedicine-based rehabilitation, remote patient monitoring, and emerging technologies used in traditional cardiopulmonary rehabilitation that could be used for post-COVID rehabilitation.

Despite the interest of the scientific community in the field of rehabilitation and tele-rehabilitation, I have a few major points:

The themes of rehabilitation and tele-medicine are topical in the management of post-COVID patients. There are already articles on these topics. The subject is interesting. But I wonder in the current review, where the novelty is. The first two parts are too 'general'. I think that many of clinicians and scientists know (even if they are nor using it) that telemedicine can bring a lot in the remote monitoring of post-COVID patients. And that tele-rehabilitation used in cardiopulmonary diseases can also be useful for post-COVID patients. What is new in this review / what more does it bring ?

I have some questions about the methodology: the authors do not explain how they carried out their literature review. How did they select the articles, the data, etc.?

Throughout part 1 and 2, we do not know if the authors are talking about post-COVID rehab or cardiac rehab (e.g. line 118, or 125).

The “Introduction” part and the part 2 are too general and does not address the complexity of the sequelae of COVID-19, and the specificity of rehabilitation for post-COVID19 individuals. Long COVID syndrome is not defined. According to the scientific literature, a lot of patients are suffering from post-exertional malaise after cognitive or physical task. The analogy with other syndromes such as fibromyalgia or chronic fatigue syndrome / myalgic encephalomyelitis could be addressed. Physical rehabilitation described by the authors may not be suitable for these patients (50-80% of people with long COVID syndrome according to literature). From my point of view, post COVID rehab is much more complex than pulmonary or cardiac rehab based on physical activity. There are many post-COVID patients who can't cycle/walk...without feeling an exacerbation of symptoms a few days later. Should another type of rehabilitation be considered? Which and how digital tools can help concretely for these patients? Rehabilitation based on physical activity may only concern a small part of people who have had COVID-19? (It's a question). The authors should go into more details from the second part of the introduction. And in Part II.

Rehabilitation based on physical activity has already been the subject of published studies or published protocols and they must be named (e.g. PMID 35409815, PMID: 33284353…etc…).

Another major point is that throughout the text the reader has the impression that there is a lot of repetition in the ideas of one paragraph to another. Specifically, line 131 and 192 are the same for example.

Studies have already been published such as the one of Pinto et al. PMID: 33327384 which brings a concrete proposal. Or the one of Salawu et al. PMID: 32645876. Why did the authors not select them?

Minors comments:

The parts are too long. To aid reading they should be better organized with specific subsections.

“CRRCR”, “RCRC”, “RCR” … please standardize

“CovidCOVID-19”. lignes 231 and 234

Author Response

Dear reviewer, thank you for your interest and time in reviewing our article.

The themes of rehabilitation and tele-medicine are topical in the management of post-COVID patients. There are already articles on these topics. The subject is interesting. But I wonder in the current review, where the novelty is. The first two parts are too 'general'. I think that many of clinicians and scientists know (even if they are nor using it) that telemedicine can bring a lot in the remote monitoring of post-COVID patients. And that tele-rehabilitation used in cardiopulmonary diseases can also be useful for post-COVID patients. What is new in this review / what more does it bring ? - This article seeks to determine the main methods of cardiopulmonary rehabilitation that were applied in the COVID 19 era, including the applicability or feasibility to be applied on post-COVID cardiopulmonary sequelae.

I have some questions about the methodology: the authors do not explain how they carried out their literature review. How did they select the articles, the data, etc.? - we have added information about the study methodology in Featured Applications and we have added  a new subsection Material and methods in which we explain the selection and inclusion methodology.

Throughout part 1 and 2, we do not know if the authors are talking about post-COVID rehab or cardiac rehab (e.g. line 118, or 125). - we have reformulated for a better understanding.

The “Introduction” part and the part 2 are too general and does not address the complexity of the sequelae of COVID-19, and the specificity of rehabilitation for post-COVID19 individuals. Long COVID syndrome is not defined. According to the scientific literature, a lot of patients are suffering from post-exertional malaise after cognitive or physical task. The analogy with other syndromes such as fibromyalgia or chronic fatigue syndrome / myalgic encephalomyelitis could be addressed. Physical rehabilitation described by the authors may not be suitable for these patients (50-80% of people with long COVID syndrome according to literature). From my point of view, post COVID rehab is much more complex than pulmonary or cardiac rehab based on physical activity. There are many post-COVID patients who can't cycle/walk...without feeling an exacerbation of symptoms a few days later. Should another type of rehabilitation be considered? Which and how digital tools can help concretely for these patients? Rehabilitation based on physical activity may only concern a small part of people who have had COVID-19? (It's a question). The authors should go into more details from the second part of the introduction. And in Part II. - we have reformulated for a better understanding and we have divided the information in to subsection on type of devices used in rehabilitation.

Rehabilitation based on physical activity has already been the subject of published studies or published protocols and they must be named (e.g. PMID 35409815, PMID: 33284353…etc…). - The protocol applied in physical rehabilitation was not the interest for this study.

Another major point is that throughout the text the reader has the impression that there is a lot of repetition in the ideas of one paragraph to another. Specifically, line 131 and 192 are the same for example. - We have reformulated and revised the paragraphs so that the information would not be repeated.

Studies have already been published such as the one of Pinto et al. PMID: 33327384 which brings a concrete proposal. Or the one of Salawu et al. PMID: 32645876. Why did the authors not select them? - we have added the two studies - source 26 and 41.

Minors comments:

The parts are too long. To aid reading they should be better organized with specific subsections. - we have reorganized the study in to sections and subsections for a better understanding.

“CRRCR”, “RCRC”, “RCR” … please standardize - we eliminate this formulas.

“CovidCOVID-19”. lignes 231 and 234 - this was a typing mistake. Was removed.

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Many thanks to the authors for making the suggested changes. 

Please consider some modifications: 

Line 168, correct "et all" and line 174 "post-covid 19 disabilities".

Same comment on line 257 "et all" should be changed to "et al".

Revise writing.

Good job.

Author Response

Thank you for taking the time to review our article. We attach the improved version after the second round of review. We have taken into account all the indications received and we have modified the article to satisfy the imposed norms.

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

The authors improved the overall manuscript after first revision, but the message they want to convey is still not entirely clear. As already noted, the paper is interesting and authors really have to provide an extra-effort to make it appealing.

The introduction section is still too long. Lines 46-57 as well as lines 58-79 should be more focused and concentrated on the background of their hypothesis. I would suggest to revise also the conclusions accordingly.

Moreover: could you suggest an algorithm of rehabilitation for COVID-19 patients according to their severity and risk of post-infection complications?

Please verify english language and style.

Author Response

Thank you for taking the time to review our article. We attach the improved version after the second round of review. We have taken into account all the indications received and we have modified the article to satisfy the imposed norms.

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Thanks to the authors for making some changes. However, the majors issues pointed previously have not been addressed.

Introduction

The title of the manuscript is « …in post COVID cardiopulmonary rehab ». But Post-COVID syndrome is not define in the introduction part. There is a Delphi consensus about post-COVID. Please precise in your manuscript.

Who is concerned by the cardiopulmonary rehab stated by authors, all of the individuals infected by COVID-19? The authors should precise with details in the introduction part, which patients are they referring to? The complexity of post-COVID-19 syndromes is overshadowed. Post-COVID is an umbrella terminology and the authors don’t define precisely who cardiopulmonary rehabilitation is for and how technology / rehab and telerehab can help manage patients.

The introduction is too general with sentences that lack precision. There is no definition of the important keyword about the main topic of the manuscript:

e.g: post COVID; rehabilitation;...etc...  

e.g. but not only …  line 72 “Studies show that in addition to ongoing monitoring, additional investigations are needed to screen and treat patients at risk for cardiovascular complications and to elucidate the mechanisms by which SARS-CoV-2 complicates the cardiovascular system”. Avoid overly general formulations that bring nothing to the reader. Please be more specific, what monitoring are you talking about? what new investigations are you talking about? what are CV complications? what do you mean by “elucidate the mechanisms” ? Many sentences in your manuscript are general. You have to be much more specific and go deep into detailed explanations.

The objectives of the review and the novelty of the manuscript are still not presented in the intro

As already explained previously, the authors do not clearly show the novelty of their work. There are already reviews on telerehabilitation in CV and pulmonary diseases and now in COVID19. The word “COVID” does not make the manuscript something new. The novelty should appear in the text.

Main text

The text has been reorganized and that's a good point. It's a little clearer on the form. But it remains superficial. There are no details on the rehabilitation / telerehab programs / tools proposed in the studies. How can the non-specialist reader understand the interest of rehabilitation/tele-rehabilitation and what rehab program must include precisely? What are the results of the studies mentioned ? there are no details. Sentences remain vague (e.g. but not only: “Abayomi S. et all propose that supervised multidisciplinary tele-rehabilitation programs be included in the application of recovery programs for patients with COVID-19 after discharge from hospital. The implementation of these programs can lead to an effective assessment of the residual deficit”.) Moreover, when reading, we always have the confusion between cardiac rehabilitation and the rehabilitation of post-COVID patients. Section 4 discusses post-COVID rehab. But too often the content and the references deal with cardiac rehab. It's confusing.

After several readings, I am still confused: is this a literature review concerning cardiopulmonary telerehab and modern technologies in a post-COVID crisis context? Or is it a literature review that deals with patients who have had COVID and who need cardiopulmonary rehabilitation? May it is clear for the authors but not for readers. The manuscript should be strongly revised to be clear.

As I explained previously, many articles talked already about post-COVID rehabilitation. Among all post-COVID patients, more than 80% suffer from post-effort malaise (Davis et al. Eclinical Medicine 2021). In this online survey of 3762 people living with long COVID, “89.1% of respondents experienced worsening or relapse of symptoms after physical or mental activity during COVID-19 recovery. Post-exertional malaise was most often triggered by physical activities and exercise”. That is not a detail that can be ignored. Cardiopulmonary rehabilitation proposed by the authors is based on exercise therapy / exercise training. Post-COVID cardiopulmonary rehabilitation have to care this patients too. The authors are specialized in rehabilitation but do not speak at all of this. How can modern technologies used in rehab or telerehab could help? In 2022, there are enough articles about rehabilitation and post-exertional malaise in post-COVID syndrome. Authors have to address this point. (Cattadori et al. J Clin Med 2022 ; Twomey et al. Phys Ther 2022; Corman et al. J Med Internet Res 2022; Davis et al. Eclinical Medicine 2021, …etc…). A quote about “…Physical therapists working with people with long COVID should measure and validate the patient's experience. Postexertional symptom exacerbation must be considered, and rehabilitation needs to be carefully designed based on individual presentation…”

Author Response

Thank you for taking the time to review our article.

We attach the improved version after the second round of review. We have taken into account all the indications received and we have modified the article to satisfy the imposed norms.

We defined Post-COVID syndrome, we have modified the introduction, we added details on the rehabilitation / telerehabilitation programs / tools proposed in the studies.

Please see the attachment.

Author Response File: Author Response.pdf

Round 3

Reviewer 3 Report

Dear authors, It should be emphasized that an effort has been made on the organization of the text and on the explanations of the studies cited.

It is clearer.

However all my remarks were not answered.

-          Why don't the authors copy/paste the entire review report into a Word file and then respond point by point?

-          The introduction is now only 20 lines long (why entire lines have been deleted when on the contrary I asked for clarification).

-          As already mentioned several times, the manuscript should explain briefly (perhaps in a 'limit' or in the 'discussion' section) that cardiopulmonary rehabilitation with exercise training may not be suitable for all post-COVID patients (see my 2 previous review report). I already gave a full explanation with references. The authors should also consider the second version of the recommendations for the clinical management of people with COVID from the WHO (guidance on rehabilitation*) : “returning to activities of daily living is therefore a priority but must be done at an appropriate, safe and individualised pace within the limits of the symptoms. Exercise intensity should not be pushed because of the risk of post-exercise fatigue. A gradual increase in exercise should be based on symptoms”. Some cautions have to be taken and worsening of symptoms after exercise need to be carefully monitored. I still don't understand why the authors don't want to talk about these patients when the main subject is rehabilitation in post-COVID. Please, see my previous report with the references.

*WHO. COVID-19 Clinical Management: Living Guidance; WHO: Geneva, Switzerland, 2021.

Author Response

Thank you for your patience in reviewing this study.

Our intention is to conduct a study on the types of medical technologies that have been included in the recovery program of patients with post COVID -19 syndrome, focusing on cardiopulmonary rehabilitation. Also, our goal is to study the possibility of introducing modern technologies in post-COVID cardiopulmonary rehabilitation.

The intent of this review is not to establish types of beneficial exercise in post-COVID-19 cardiopulmonary rehabilitation. We will probably address this topic in further studies.

Obs:

-          The introduction is now only 20 lines long (why entire lines have been deleted when on the contrary I asked for clarification).

The introduction was shortened to the suggestions of the other two reviewers and the main editor. We were suggested a short introduction to summarize the main ideas. Following the changes made, we did not receive any other comments from the other reviewers.

As a change, in the Introduction you will also find added a paragraph that refers to a study indicated by the main editor. [reference 11] “Some studies have suggested that exercise should be applied in the acute phase for early and effective rehabilitation of COVID-19 patients with respiratory failure, while other studies propose the application of a 3-stage exercise protocol, beginning in the inpatient phase, continues in the post-acute and continuous phase and at home after discharge for the good physical condition of the patients [11].”

-          As already mentioned several times, the manuscript should explain briefly (perhaps in a 'limit' or in the 'discussion' section) that cardiopulmonary rehabilitation with exercise training may not be suitable for all post-COVID patients (see my 2 previous review report). I already gave a full explanation with references. The authors should also consider the second version of the recommendations for the clinical management of people with COVID from the WHO (guidance on rehabilitation*) : “returning to activities of daily living is therefore a priority but must be done at an appropriate, safe and individualised pace within the limits of the symptoms. Exercise intensity should not be pushed because of the risk of post-exercise fatigue. A gradual increase in exercise should be based on symptoms”. Some cautions have to be taken and worsening of symptoms after exercise need to be carefully monitored. I still don't understand why the authors don't want to talk about these patients when the main subject is rehabilitation in post-COVID. Please, see my previous report with the references.
*WHO. COVID-19 Clinical Management: Living Guidance; WHO: Geneva, Switzerland, 2021.

Because our intention is not necessarily to study the benefits of exercise in cardiopulmonary rehabilitation, we did not consider it necessary to introduce these aspects. But reading the studies indicated by you, I added in the Introduction part a warning paragraph of the reader in which we took into account the patients to whom physical exercise can harm them, which we hope will be suggestive and sufficient to meet your requirements [reference 19]. “Readers should exercise caution in applying rehabilitation with exercise training because of the risk of post-exercise fatigue reported to some patients [19].”

We also added the references that you suggested [20-21].  “Physiotherapists working with people with post-COVID-19 syndrome should determine the patient's level of exercise tolerance to avoid exacerbation of symptoms after exertion [20, 21].”

Author Response File: Author Response.docx