The purpose was to examine Dual Task (DT) performance in patients surviving severe and critical COVID-19 compared to patients with chronic lung disease (CLD). Secondarily, we aimed to determine the psychometric properties of the Timed Up and Go (TUG) test in patients surviving COVID-19.
Ninety-two patients including 36 survivors of critical COVID-19 that required mechanical ventilation (critical-COVID), 20 patients recovering from COVID-19 that required supplemental oxygen with hospitalization (severe-COVID), and 36 patients with CLD serving as a control group.
Measurements and Main Results
Patients completed the TUG, DT-TUG, Short Physical Performance Battery (SPPB), and Six Minute Walk Test (6MWT) 1-month after hospital discharge. A subset of patients returned at 3-months and repeated testing to determine the minimal detectable change (MDC). Critical-COVID group (16.8 ± 7.3) performed the DT-TUG in significantly slower than CLD group (13.9 ± 4.8 s; P = .024) and Severe-COVID group (13.1 ± 5.1 s; P = .025). Within-subject difference between TUG and DT-TUG was also significantly worse in critical-COVID group (−21%) compared to CLD (−10%; P = .012), even despite CLD patients having a higher comorbid burden (P < .003) and older age (P < .001). TUG and DT-TUG demonstrated strong to excellent construct validity to the chair rise test, gait speed, and 6MWT for both COVID-19 groups (r = −0.84to 0.73, P < .05). One- and 3-months after hospital discharge there was a floor effect of 14% (n = 5/36) and 5.2% (n = 1/19), respectively for patients in the critical-COVID group. Ceiling effects were noted in four (11%) critical-COVID, six (30%) severe-COVID patients for the TUG and DT-TUG at 1-month.
Conclusion
The ability to maintain mobility performance in the presence of a cognitive DT is grossly impaired in patients surviving critical COVID-19. DT performance may subserve the understanding of impairments related to Post-intensive care syndrome (PICS) for survivors of critical illness.
BienvenuOJFriedmanLAColantuoniE, et al.Psychiatric symptoms after acute respiratory distress syndrome: a 5-year longitudinal study. Intensive Care Med. 2018;44(1):38‐47.
2.
NelliotADinglasVDO’TooleJ, et al.Acute respiratory failure survivors’ physical, cognitive, and mental health outcomes: quantitative measures versus semistructured interviews. Ann Am Thorac Soc. 2019;16(6):731‐737.
3.
PfohERWozniakAWColantuoniE, et al.Physical declines occurring after hospital discharge in ARDS survivors: a 5-year longitudinal study. Intensive Care Med. 2016;42(10):1557‐1566.
4.
PandharipandePPGirardTDJacksonJC, et al.Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369(14):1306‐1316.
5.
NeedhamDMSepulvedaKADinglasVD, et al.Core outcome measures for clinical research in acute respiratory failure survivors. An international modified Delphi consensus study. Am J Respir Crit Care Med. 2017;196(9):1122‐1130.
6.
LiXMaX. Acute respiratory failure in COVID-19: is it “typical” ARDS?Crit Care. 2020;24(1):198.
7.
CarfìABernabeiRLandiF. Persistent symptoms in patients after acute COVID-19. Jama. 2020;324(6):603‐605.
8.
DavisHEAssafGSMcCorkellL, et al.Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. EClinicalMedicine. 38
9.
OhtakePJLeeACScottJC, et al.Physical impairments associated with post–intensive care syndrome: systematic review based on the world health organization’s international classification of functioning, disability and health framework. Phys Ther. 2018;98(8):631‐645.
10.
MarraAPandharipandePPGirardTD, et al.Co-occurrence of post-intensive care syndrome problems among 406 survivors of critical illness. Crit Care Med. 2018;46(9):1393‐1401.
11.
KamdarBBSuriRSuchytaMR, et al.Return to work after critical illness: a systematic review and meta-analysis. Thorax. 2020;75(1):17.
12.
HopkinsROJacksonJC. Neuroimaging after critical illness: implications for neurorehabilitation outcome. NeuroRehabilitation. 2012;31(3):311‐318.
13.
HopkinsROSuchytaMRBeeneKJacksonJC. Critical illness acquired brain injury: neuroimaging and implications for rehabilitation. Rehabil Psychol. 2016;61(2):151‐164.
14.
JacksonJCMorandiAGirardTD, et al.Functional brain imaging in survivors of critical illness: a prospective feasibility study and exploration of the association between delirium and brain activation patterns. J Crit Care. 2015;30(3):653. e651‐e657.
15.
SpiesCKrampeHPaulN, et al.Instruments to measure outcomes of post-intensive care syndrome in outpatient care settings—results of an expert consensus and feasibility field test. J Intensive Care Soc. 2020;22(2):159-174. doi:10.1177/1751143720923597
16.
YangLLiaoLRLamFMHHeCQPangMYC. Psychometric properties of dual-task balance assessments for older adults: a systematic review. Maturitas. 2015;80(4):359‐369.
17.
McFadyenBJGagnéM-ÈCossetteIOuelletM-C. Using dual task walking as an aid to assess executive dysfunction ecologically in neurological populations: a narrative review. Neuropsychol Rehabil. 2017;27(5):722‐743.
18.
Al-YahyaEDawesHSmithLDennisAHowellsKCockburnJ. Cognitive motor interference while walking: a systematic review and meta-analysis. Neurosci Biobehav Rev. 2011;35(3):715‐728.
19.
ComberLSosnoffJJGalvinRCooteS. Postural control deficits in people with multiple sclerosis: a systematic review and meta-analysis. Gait Posture. 2018;61:445‐452.
20.
FritzNECheekFMNichols-LarsenDS. Motor-cognitive dual-task training in persons with neurologic disorders: a systematic review. J Neurol Phys Ther. 2015;39(3):142‐153.
21.
HeYYangLZhouJYaoLPangMYC. Dual-task training effects on motor and cognitive functional abilities in individuals with stroke: a systematic review. Clin Rehabil. 2018;32(7):865‐877.
22.
KellyVEEusterbrockAJShumway-CookA. A review of dual-task walking deficits in people with Parkinson’s disease: motor and cognitive contributions, mechanisms, and clinical implications. Parkinsons Dis. 2012;2012:918719.
23.
De FreitasTBLeitePHWDonáFPompeuJESwarowskyATorriani-PasinC. The effects of dual task gait and balance training in Parkinson’s disease: a systematic review. Physiother Theory Pract. 2020;36(10):1088‐1096.
24.
LiKZHBhererLMirelmanAMaidanIHausdorffJM. Cognitive involvement in balance, gait and dual-tasking in aging: a focused review from a neuroscience of aging perspective. Front Neurol. 2018;9(913).
25.
MorelliNMorelliH. Dual task training effects on gait and balance outcomes in multiple sclerosis: a systematic review. Mult Scler Relat Disord. 2021;49:102794.
26.
HeraudNAlexandreFGueugnonM, et al.Impact of chronic obstructive pulmonary disease on cognitive and motor performances in dual-task walking. COPD. 2018;15(3):277‐282.
27.
MorlinoPBalbiBGuglielmettiS, et al.Gait abnormalities of COPD are not directly related to respiratory function. Gait Posture. 2017;58:352‐357.
28.
OzsoyIOzsoyGKarartiC, et al.Cognitive and motor performances in dual task in patients with chronic obstructive pulmonary disease: a comparative study. Ir J Med Sci. 2021;190(2):723‐730.
29.
DenehyLNordon-CraftAEdbrookeL, et al.Outcome measures report different aspects of patient function three months following critical care. Intensive Care Med. 2014;40(12):1862‐1869.
30.
OlezeneCSHansenESteereHK, et al.Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection. PLOS ONE. 2021;16(3):e0248824.
31.
HellmuthJBarnettTAAskenBM, et al.Persistent COVID-19-associated neurocognitive symptoms in non-hospitalized patients. J Neurovirol. 2021;27(1):191‐195.
32.
ElmEAltmanDGEggerMPocockSJGøtzschePCVandenbrouckeJP. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ (Clinical research ed.). 2007;335(7624):806.
33.
MokkinkLBTerweeCBKnolDL, et al.The COSMIN checklist for evaluating the methodological quality of studies on measurement properties: a clarification of its content. BMC Med Res Methodol. 2010;10(1):22.
MayerKPBoustanyHCassityEP, et al.ICU recovery clinic attendance, attrition, and patient outcomes: the impact of severity of illness, gender, and rurality. Crit Care Explor. 2020;2(10):e0206.
36.
MayerKPSteeleAKJoshiRR, et al. Optimizing outcomes with physical therapy treatment for individuALs surviving an intensive care units admission for COVID-19 (OPTImAL)—A protocol for a single center prospective study. Cardiopulm Phys Ther J. 2020;.32:S32–S39. doi:10.1097/CPT.0000000000000156
37.
MayerKPParrySMKalemaAG, et al.Safety and feasibility of an interdisciplinary treatment approach to optimize recovery from critical coronavirus disease 2019. Critical Care Explorations. 2021;3(8):e0516.
38.
MesquitaRJanssenDJWoutersEFScholsJMPittaFSpruitMA. Within-day test-retest reliability of the timed up & go test in patients with advanced chronic organ failure. Arch Phys Med Rehabil. 2013;94(11):2131‐2138.
39.
McLayRKirkwoodRNKuspinarA, et al. Validity of balance and mobility screening tests for assessing fall risk in COPD. Chron Respir Dis. 2020;17:1479973120922538.
40.
BarryEGalvinRKeoghCHorganFFaheyT. Is the timed up and go test a useful predictor of risk of falls in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14.
41.
DenehyLSkinnerEHEdbrookeL, et al.Exercise rehabilitation for patients with critical illness: a randomized controlled trial with 12 months of follow-up. Crit Care. 2013;17(4):R156.
42.
JacksonJCElyEWMoreyMC, et al.Cognitive and physical rehabilitation of intensive care unit survivors: results of the RETURN randomized controlled pilot investigation. Crit Care Med. 2012;40(4):1088‐1097.
43.
MorelliNHeebnerNBerginRQuintanaCHochM. The effect of cognitive dual-tasks on dynamic postural sway during gait using inertial measurement units. Physiol Meas. 2020;41(4):045002. doi:10.1088/1361-6579/ab8050
44.
MorelliNHeebnerNRDeFeoCJHochMC. The influence of cognitive tasks on sensory organization test performance. Braz J Otorhinolaryngol. 2020.
45.
VolpatoSCavalieriMSioulisF, et al.Predictive value of the short physical performance battery following hospitalization in older patients. J Gerontol A Biol Sci Med Sci. 2011;66(1):89‐96.
46.
VolpatoSCavalieriMGuerraG, et al.Performance-based functional assessment in older hospitalized patients: feasibility and clinical correlates. J Gerontol A Biol Sci Med Sci. 2008;63(12):1393‐1398.
47.
FilesDMorrisPShresthaS, et al.Randomized, controlled pilot study of early rehabilitation strategies in acute respiratory failure. Crit Care. 2013;17(2):P540.
48.
BakhruRNDavidsonJFBookstaverRE, et al.Physical function impairment in survivors of critical illness in an ICU recovery clinic. J Crit Care. 2018;45:163‐169. doi:10.1016/j.jcrc.2018.02.001
49.
ParrySMDenehyLBeachLJBerneySWilliamsonHCGrangerCL. Functional outcomes in ICU—what should we be using?—an observational study. Crit Care. 2015;19(1):127.
50.
ATS Statement. Am J Respir Crit Care Med. 2002;166(1):111–117.
51.
EnrightPLSherrillDL. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998;158(5 Pt 1):1384‐1387.
52.
MuscedereJWatersBVaramballyA, et al.The impact of frailty on intensive care unit outcomes: a systematic review and meta-analysis. Intensive Care Med. 2017;43(8):1105‐1122.
53.
ChurchSRogersERockwoodKTheouO. A scoping review of the clinical frailty scale. BMC Geriatr. 2020;20(1):393.
54.
FerreiraFLBotaDPBrossAMélotCVincentJL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286(14):1754‐1758.
55.
MehtaSPMorelliNPrevatteCWhiteDOliashiraziA. Validation of physical performance tests in individuals with advanced knee osteoarthritis. HSS J®. 2019;15(3):261‐268.
56.
NormanGRSloanJAWyrwichKW. Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation. Med Care. 2003;41(5)582-592.
57.
PortneyLGWatkinsMP. Foundations of clinical research : applications to practice. 2015.
58.
TerweeCBBotSDde BoerMR, et al.Quality criteria were proposed for measurement properties of health status questionnaires. J Clin Epidemiol. 2007;60(1):34‐42.
59.
SalbachNMMayoNEHigginsJAhmedSFinchLERichardsCL. Responsiveness and predictability of gait speed and other disability measures in acute stroke. Arch Phys Med Rehabil. 2001;82(9):1204‐1212.
60.
HofheinzMSchusterschitzC. Dual task interference in estimating the risk of falls and measuring change: a comparative, psychometric study of four measurements. Clin Rehabil. 2010;24(9):831‐842.
61.
NasreddineZSPhillipsNABédirianV, et al.The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695‐699.
62.
Shumway-CookABrauerSWoollacottM. Predicting the probability for falls in community-dwelling older adults using the timed up & go test. Phys Ther. 2000;80(9):896‐903.
63.
MkacherWTabkaZTrabelsiY. Minimal detectable change for balance measurements in patients with COPD. J Cardiopulm Rehabil Prev. 2017;37(3):223‐228.
64.
MajorMEKwakmanRKhoME, et al.Surviving critical illness: what is next? An expert consensus statement on physical rehabilitation after hospital discharge. Crit Care. 2016;20(1):354.
65.
FalveyJRMurphyTEGillTMStevens-LapsleyJEFerranteLE. Home health rehabilitation utilization among medicare beneficiaries following critical illness. J Am Geriatr Soc. 2020;68(7):1512‐1519.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
