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The highly infectious and pathogenic novel coronavirus (CoV), severe acute respiratory syndrome (SARS)-CoV-2, has emerged causing a global pandemic. Although COVID-19 predominantly affects the respiratory system, evidence indicates a multisystem disease which is frequently severe and often results in death. Long-term sequelae of COVID-19 are unknown, but evidence from previous CoV outbreaks demonstrates impaired pulmonary and physical function, reduced quality of life and emotional distress. Many COVID-19 survivors who require critical care may develop psychological, physical and cognitive impairments. There is a clear need for guidance on the rehabilitation of COVID-19 survivors. This consensus statement was developed by an expert panel in the fields of rehabilitation, sport and exercise medicine (SEM), rheumatology, psychiatry, general practice, psychology and specialist pain, working at the Defence Medical Rehabilitation Centre, Stanford Hall, UK. Seven teams appraised evidence for the following domains relating to COVID-19 rehabilitation requirements: pulmonary, cardiac, SEM, psychological, musculoskeletal, neurorehabilitation and general medical. A chair combined recommendations generated within teams. A writing committee prepared the consensus statement in accordance with the appraisal of guidelines research and evaluation criteria, grading all recommendations with levels of evidence. Authors scored their level of agreement with each recommendation on a scale of 0–10. Substantial agreement (range 7.5–10) was reached for 36 recommendations following a chaired agreement meeting that was attended by all authors. This consensus statement provides an overarching framework assimilating evidence and likely requirements of multidisciplinary rehabilitation post COVID-19 illness, for a target population of active individuals, including military personnel and athletes.

Background: The COVID-19 pandemic has led to significant morbidity and mortality, with the former impacting and limiting individuals requiring high physical fitness, including sportspeople and emergency services. Methods: Observational cohort study of 4 groups: hospitalised, community illness with on-going symptoms (community-symptomatic), community illness now recovered (community-recovered) and comparison. A total of 113 participants (aged 39 ± 9, 86% male) were recruited: hospitalised (n= 35), community-symptomatic (n= 34), community-recovered (n= 18) and comparison (n= 26), approximately five months following acute illness. Participant outcome measures included cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests and questionnaires on mental health and function. Results: Hospitalised and community-symptomatic groups were older (43 ± 9 and 37 ± 10, P= 0.003), with a higher body mass index (31 ± 4 and 29 ± 4, P< 0.001), and had worse mental health (anxiety, depression and post-traumatic stress), fatigue and quality of life scores. Hospitalised and community-symptomatic participants performed less well on sub-maximal and maximal exercise testing. Hospitalised individuals had impaired ventilatory efficiency (higher VE/V̇CO2slope, 29.6 ± 5.1, P< 0.001), achieved less work at anaerobic threshold (70 ± 15, P< 0.001) and peak (231 ± 35, P< 0.001), and had a reduced forced vital capacity (4.7 ± 0.9, P= 0.004). Clinically significant abnormal cardiopulmonary imaging findings were present in 6% of hospitalised participants. Community-recovered individuals had no significant differences in outcomes to the comparison group. Conclusion: Symptomatically recovered individuals who suffered mild-moderate acute COVID-19 do not differ from an age-, sex- and job-role-matched comparison population five months post-illness. Individuals who were hospitalised or continue to suffer symptoms may require a specific comprehensive assessment prior to return to full physical activity.

BackgroundThe medium-long impact of coronavirus disease 2019 (COVID-19) on active populations is yet to be fully understood, with potential individual and operational impact on military service personnel (SP). The M-COVID study was established to investigate cardiopulmonary, functional, cognitive, and mental health post-COVID-19 SP outcomes, across the spectrum of acute COVID-19 severity.MethodObservational four-cohort study; hospitalised, community-based illness with on-going symptoms (communitysymptomatic), community-based illness now recovered (community-recovered) and age, sex, job-role matched control. Participants underwent extensive clinical assessment involving cardiopulmonary imaging, submaximal and maximal exercise testing, pulmonary function, cognitive assessment, blood tests, electrocardiogram and questionnaires on mental health and physical function.Results113 participants (aged 39±9, 86% male) were recruited; Hospitalised (n=35), community-symptomatic (n=34), community-recovered (n=18) and control (n=26), 159±72 days following acute illness. Hospitalised and community-symptomatic groups were older (p=0.003), with a higher body mass index (p<0.001), and worse mental health (anxiety,p=0.011;depression,p<0.001;post-traumatic stress, p<0.001), fatigue (p<0.001), and quality of life scores (p=0.001), with a mean of 2±2 and 2±1 symptoms, respectively. Hospitalised and community-symptomatic participants also performed less well on sub-maximal (p<0.001) and maximal exercise testing, with hospitalised individuals displaying impaired ventilatory efficiency (p<0.001), less work at the anaerobic threshold and at peak (both p<0.001), and significantly reduced forced vital capacity (p=0.004). Clinically significant abnormal cardiopulmonary imaging findings were present in 6% of hospitalised participants, lower than those seen in other studies. Those who recovered from communitybased, mild-moderate COVID-19 had no significant differences from controls on any parameter.ConclusionsRecovered SP who suffered mild-moderate COVID-19 do not differ from an age, sex and job-role matched controls. This is reassuring for the vast majority of individuals who have had acute COVID-19 not requiring hospital management. Individuals who were hospitalised or continue to suffer symptoms may require a specific, comprehensive clinical and occupational assessment prior to a full return to duty.

IntroductionTraumatic brain injury increases the risk of both early and late seizures. Antiepileptic prophylaxis reduces early seizures, but their use beyond 1 week does not prevent the development of post-traumatic epilepsy. Furthermore, prolonged prophylaxis exposes patients to side effects of the drugs and has occupational implications. The American Academy of Neurology recommends that antiepileptic prophylaxis should be started for patients with severe traumatic brain injury and discontinued after 1 week. An audit is presented here that investigates the use of prophylaxis in a cohort of military patients admitted to the UK Defence Medical Rehabilitation Centre (DMRC).MethodsData were collected and analysed retrospectively from electronic and paper records between February 2009 and August 2012. The timing and duration of antiepileptic drug use and the incidence of seizures were recorded.ResultsDuring the study period, 52 patients with severe traumatic brain injury were admitted to the rehabilitation centre: 25 patients (48%) were commenced on prophylaxis during the first week following injury while 27 (52%) did not receive prophylaxis. Only one patient (2%) received prophylaxis for the recommended period of 1 week, 22 patients (42%) received prophylaxis for longer than 1 week with a mean duration of 6.2 months. Two patients (4%) had post-traumatic epilepsy and started on treatment at DMRC.ConclusionsThe use of antiepileptic prophylaxis varies widely and is generally inconsistent with evidence-based guidance. This exposes some patients to a higher risk of early seizures and others to unnecessary use of antiepileptics. Better implementation of prophylaxis is required.

BackgroundPost-COVID-19 syndrome presents a challenge when determining the occupational grading of symptomatic military personnel, and their ability to deploy. In particular, the accurate assessment of patients with post COVID-19 syndrome is complicated by health anxiety and coincident symptomatic autonomic dysfunction. We therefore sought to determine whether either symptoms or objective cardiopulmonary exercise testing could predict clinically significant findings in the UK Armed Forces.Methods113 consecutive patients were assessed in a post COVID-19 military clinical assessment pathway. This included symptom reporting, history, examination, spirometry, echocardiography and cardiopulmonary exercise testing (CPET) in all, with chest CT, dual-energy CTPA and cardiac MRI where indicated. Symptoms, CPET findings and presence/absence of significant pathology were reviewed. Data were analysed to identify diagnostic strategies that may be used to exclude significant disease.Results7/113 (6%) patients had clinically significant disease adjudicated by cardiothoracic multi-disciplinary team. These patients had reduced fitness (&Vdot;O2 26.7(±5·1) vs. 34.6(±7·0) ml/kg/min; p = 0·002) and functional capacity (peak power 200 (±36) vs. 247 (±55) Watts; p = 0·026) compared to those without significant disease. Simple CPET criteria (&Vdot;O2 <100% predicted and VE/&Vdot;CO2 slope >30.0 or VE/&Vdot;CO2 slope >35.0 in isolation) excluded significant disease with sensitivity and specificity of 86% and 83% respectively (AUC 0.89). The addition of capillary blood gases to estimate A-a gradient improved diagnostic performance to 100% sensitivity and 78% specificity (AUC 0.92). Symptoms and spirometry did not discriminate significant disease.ConclusionUK Armed Forces personnel with persistent symptoms post SARS-CoV-2 infection demonstrate reassuringly little organ pathology. CPET and functional capacity testing, but not reported symptoms, allow the exclusion of clinically significant disease.