 Marla Boscham, who is a physical therapist and assistant professor, soon to be associated, starting July 1. In the School of Rehabilitation Science and Department of Medicine at McMaster University, she holds a Tier 2 Canada Research Chair and an early researcher award from the Ontario Ministry of Colleges and Universities in Technology and Aging. Dr. Boscham's research program is focused on developing evidence-based strategies to improve mobility among older adults and those with chronic diseases. Her ongoing research includes a multi-side longitudinal cohort study on long-term outcomes after COVID-19. So it's great to be here today and especially to be here with Jonathan, who was, yes, my postdoc mentor, and I think a lot of my grad students are laughing because they're seeing a lot of similarities in how we conceptualize things. So Jonathan started by talking about the importance of mobility and rehab and, you know, physical function as a vital sign, and so now I'll talk to you about how that kind of applies when we look at COVID-19. So I'll talk to you about mobility after hospitalization for COVID-19, what mobility looks like in the community, in regard of where the majority of patients were not hospitalized, and then some implications for rehabilitation. So this was a meta-analysis that's probably been updated, has been updated since 2021, but I like it because it shows you all the different body systems that have been impacted by COVID-19. This, in this study, this was a meta-analysis and they found about 80% of patients had one or more long-term symptoms after their COVID-19, and the documented 55 different effects of COVID. The most common in this meta-analysis, which did include sort of a mix of patients were fatigue, headache, attention disorder, hair loss, and dyspnea. So what did we mean by post-COVID condition? And this has kind of been an area that is really a moving target. So the term post-COVID condition is sort of an umbrella term. It's been adopted by many major organizations, and it's meant to sort of encompass the wide range of different health effects that can be caused after COVID. So it includes things like new and persisting symptoms, the most common being fatigue, dyspnea, and brain fog, multi-organ effects of COVID-19, which have been documented in most, if not all, body systems. And then, of course, the effects of COVID-19 treatment or hospitalization itself. So patients with post-intensive care syndrome and post-traumatic stress disorder is also included here. So the World Health Organization, because of lack of consensus on what the definition of post-COVID was, and I should say post-COVID also called long COVID, long haulers, or PASC, post-cute sequelae of SARS-CoV-2 infection, lots of different names. But they've basically released this case definition, and I kind of like it because it's the most comprehensive one that's out there. It says that post-COVID conditions occur in individuals with probable or confirmed SARS-CoV-2 infection, usually three months from the onset of COVID-19, with symptoms that last for at least two months and cannot be explained by an alternative diagnosis. They say the most common symptoms include fatigue, shortness of breath, and cognitive dysfunction, but also others, and that these symptoms have an impact on everyday functioning. They also acknowledge that symptoms can be nuanced, they can persist, or they can fluctuate and relapse over time. So I think that definition really does a good job at reflecting the complexity of post-COVID and long COVID. So a lot of research has been done on symptoms and how long do symptoms persist, but a lot less research has been paid to looking at functional recovery and functional status. And as Jonathan pointed out in his talk, we know that functional status is an incredibly powerful predictor of health outcomes and is incredibly important to patients. So what does it look like after hospitalization for COVID-19? So early on in the pandemic, we started a longitudinal cohort study with five hospitals in Hamilton and Kitchener Waterloo, and it was based on a registry project called Courage. And it's a registry that we started. I don't know if Andrew cost us here, but he was the lead on this. And we started this registry very early in the pandemic in order to capture detailed medical information on all lab-confirmed COVID-19 cases. And we did this in collaboration with the WHO ICERIC platform. And it became clear to us really early on that besides capturing information on the acute phase of illness, that we needed to start looking at long-term effects. So we added this prospective cohort study extension to Courage. And so we recruited patients essentially on admission to the hospital ward. And they did a telephone interview, a telephone interview on discharge. And then we had three, six, nine, and 12 months of follow-up. And we did that using a combination of phone interviews and home visits. We also, because we started in July 2020, we had missed some patients that had already been discharged. And so we could still go back and recruit those patients. And they entered the study at their closest possible follow-up. So this is just a list of all the different study measures and time points. And you can see we get information from a variety of sources, from the Courage registry, from the phone interviews, and from the home visits. Today, given our focus on mobility, I'm going to focus on the AMPAC mobility scale, which was our primary outcome measure. And it's a measure I really like. It's called the Activity Measure for Post-Acute Care. And it measures patient-reported difficulty in doing 18 different tasks. And the really nice thing about it is it's designed specifically to look at mobility across transitions in care. So you can start looking in acute care, and it's completely relevant. Scores are then obtained when patients are back at home and can be compared. And then the physical performance test that we had, Jonathan already talked about short physical performance batteries. So I'll just go through those results today. So the study's done recruiting. So these are the 282 people that are in the study. We had a mean age of 60 years, minimum 19, max 93. Majority of patients had, well, no, not majority, sorry, 40 percent of patients had more than three comorbidities. And in terms of in-hospital characteristics, length of hospital stay was around 14 days. And with a lot of variability around that, admission to the ICU was about 34 percent. So these are the symptoms that we collected on admission discharge, on admission three months, six months, nine months, and 12 months. And you can see on admission, which is that sort of first column, fatigue, dyspnea, and walking long distances were the most commonly endorsed symptoms. And so quite high, right? 78 percent, 73 percent, 70 percent. Then as we go to 12 months, I can't read it, when we go to 12 months, the same issues are also, the same symptoms are also endorsed with fatigue reported by 48 percent of patients, dyspnea by 32 percent and walking long distances by 38 percent. And so that's still quite a high load of deficits that we're seeing even at 12 months after a resolution of COVID. So are these deficits, you know, what's the impact on functional mobility? So focusing just on the first panel, because we'll just focus on mobility, you can see here, this is results of repeated measures of NOVA. And what you can see is that if we compare different time points for mobility, we can see that if we compare to premorbid status, so where patients were before they got sick, and we compare them to where they were at three months, six months, nine months, and 12 months, they're significantly worse at all those time points. And then when we look at the data between three and 12 months follow up, we're not seeing it a whole lot of change. And then if we take this concept of clinically meaningful difference, so now we think how many people have a deficit compared to their baseline that exceeds what we know to be the minimal clinically important difference on this scale, we actually see that about at 12 months, you know, 57 percent of patients still have mobility deficits that are clinically important. The same applied for cognition and then daily activities as well with slightly different numbers. So now if we go to physical performance, and we look at results from the short physical performance battery, here we can see, remember that magic number of 10, you want to be, so scores of less than 10 indicate higher risk of mobility disability. And across the board, you know, even by 12 months, you still have 54 percent, or no, sorry, 65 percent of the sample reporting, having physical function deficits that put them at high risk of a number of different adverse outcomes. So we also looked at factors that predict mobility recovery. And so just as a busy slide, I know, so if we just focus on the bottom regression model, we can see first that pre-morbid mobility, so how, what your functional status was before you got sick, that predicted most of your functional recovery at 12 months. And that's not surprising, but what's the unique thing that we actually have this data in the study, a lot of studies don't have that data. So 65 percent of the variation in function at 12 months is explained by functional status before patients got sick. But also being male, being younger, having fewer comorbidities, and being hospitalized during the second wave of the pandemic also contributed to this model. And so this gives us a really good sense, a preliminary sense. This is data based on just waves one and two of what some risk factors might be for development of these long-term outcomes. So what about non-hospitalized people that get COVID-19? So we did this, we had the opportunity to do this analysis in the Canadian longitudinal study on aging because they completed a COVID survey, it was launched in the first wave of the pandemic. And we had data on over 24,000 people. And the really amazing thing about this is that because it was part of this population-based cohort study, we have this, we have a built-in comparison group, which a lot of studies don't have. So we had some physical function items from the first wave of follow-up in the CLSA where patients are asked about difficulty standing up from a chair, walking two to three blocks and climbing stairs. And we had that from the first follow-up of the CLSA, so that was conducted a couple years before COVID hit. And then we have global rating of change and mobility question, and anyone that knows me knows I love these questions, but it just asks participants to rate their ability to move around in the home, their ability to engage in housework, ability to engage in physical activity, and they rate their difficulty level, their change in those things from much worse to much better on a five-point scale. And what we found is that in individuals that had probable or confirmed COVID-19, and we did this based on definitions consistent with PEAC and the CDC at the time of data collection, these individuals had a two-fold higher odds of worsening housework activity and physical activity. They also reported new difficulty standing up after sitting in a chair. And these results held, even if we looked at the suspected COVID-19 cases. So these are people that would have been exposed to someone with COVID-19, had symptoms of COVID-19, but didn't necessarily receive a diagnosis. So these suspected COVID-19 participants had deficits in almost all of the mobility domains. And like I said, this is above and beyond background levels because our comparator group are people living in the community during the same time and subject to all the same public health restrictions. So what can we do about it? Well, good news is there's lots that we can do to help these patients. And the Canadian Therastic Society released a statement on best practices for rehabilitation for COVID-19 and some of the implications for pulmonary rehab. And most major health organizations now really endorse rehab as a strategy for these patients. And in all of the guidelines, an assessment at six to eight weeks after the resolution of acute COVID is recommended. And in our guideline, we stated that all patients with COVID-19 should be assessed for persistent or new symptoms and functional limitations six to eight weeks after their acute infection. And this includes people whose initial disease was mild. And then because there was a big call for pulmonary rehab for these patients, because of some of their symptoms of dyspnea, exercise intolerance and cough, there we had to have specific criteria around who would most benefit. And so people that should be referred to pulmonary rehab, they should really have respiratory symptoms, a need for supplemental oxygen and some evidence of pulmonary impairment. And just some general considerations for rehab for these patients. The big thing is conservative progression and symptom monitoring. Because these patients do experience what's called post-exertional malaise, which is physical and mental activity induced, activity induced physical and mental fatigue. And so it's really important, especially we want to get them to buy in and to stay the course with our rehabilitation programs that we don't push too hard and that we manage this as we go. The other thing is having education really specific to the challenges faced by people with COVID-19. So issues around fatigue, sleep and mood, cognitive problems and return to work. And obviously a huge need for a multidisciplinary team. In terms of evidence, evidence for rehabilitation in these patients is emerging, but it's still limited and there are issues with quality. But more is coming. So just to conclude, I hope I've shown you that I think COVID-19 has had a detrimental effect on mobility across the spectrum of illness. We need more investment in rehab to support our existing patients and patients that are dealing with post-COVID conditions. For example, pulmonary rehabilitation for people with chronic lung disease access to pulmonary rehabilitation is only 2%. So if you think about then referring all your post-COVID patients to pulmonary rehabilitation, then your regular patients have nowhere to go. So we do need to ramp up these services. And then we also need to look into virtual programs and post-infectious disease care pathways, not just for COVID, but for other types of infectious diseases that impact older people and figure out how we can also reach some of the vulnerable groups, the people that have been affected by COVID, because they may not be able to access rehabilitation in the usual way. So I just wanted to quickly acknowledge the teams that do this incredible work like Andrew Costa, Mylin, Zhuang, Rebecca Kesselbrink, Terence Hill, Parment Arena, who were co-PIs on our functional recovery study, and all of our funders, patient partners, and the other expert panel members on the CTS guidance statement. Thank you very much.