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COVID-19’da akut ve kronik dönemde rehabilitasyonun yeri

Yıl 2020, Cilt: 45 Sayı: 4, 1818 - 1828, 27.12.2020

Öz

COVID-19 pandemisi tüm dünyada sağlık sistemleri üzerinde büyük bir etki oluşturmuştur. Vakaların çoğu asemptomatik veya hafif olup, %15-20 kadarı şiddetli seyretmektedir. Şiddetli vakalarda ağır pnömoni ve akut solunum sıkıntısı sendromu yoğun bakım ünitesinde tedaviyi gerektirir. Yoğun bakımdan kurtulan hastalarda “Yoğun Bakım Sonrası Sendromu” olarak tanımlanan ve hastaların uzun süreli prognozunu belirleyen bazı fiziksel, bilişsel ve zihinsel bozukluklar görülmektedir. COVID-19 iyi bilinen pulmoner tutulumun yanısıra diğer birçok organ sistemlerini de etkilemektedir. Yoğun bakımla ilişkili komplikasyonlar, hastalığın pulmoner ve ekstrapulmoner tutulumları COVID-19 enfeksiyonu ile ilişkili sekel ve dizabiliteye sahip hasta sayısında artışa neden olacaktır. Bu nedenle COVID-19'dan sağ kurtulan hastalara yönelik etkili rehabilitasyon programlarının uygulanması gündeme gelmiştir. Pulmoner, nörolojik, kas-iskelet sistemi ve yoğun bakım ilişkili komplikasyonlar göz önüne alındığında, rehabilitasyon uzmanları COVID-19 hastalığı olan bireylerin iyileşme sürecinde önemli rol oynayacaktır. Bu derlemede COVID-19 enfeksiyonunun yoğun bakımla ilişkili komplikasyonları, pulmoner ve ekstrapulmoner tutulumlarından bahsedilecek ve mevcut erken kanıtlarla tedavisine ve genel rehabilitasyon yaklaşımlarına değinilecektir.

Kaynakça

  • World Health Organisation. Coronavirus disease (COVID-19) pandemic. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (accessed Aug 2020).
  • Simpson R, Robinson L. Rehabilitation following critical illness in people with COVID-19 infection. Am J Phys Med Rehabil. 2020;99:470-4.
  • Stein J, Visco CJ, Barbuto S. Rehabilitation Medicine Response to the COVID-19 Pandemic. Am J Phys Med Rehabil. 2020;99(7):573-9.
  • Carda S, Invernizzi M, Bianchi F, Deltombe T, Draulans N, Francisco GE, et al. COVID-19 pandemic. What should PRM specialists do? A clinician’s perspective. Eur J Phys Rehabil Med. 2020;doi:10.23736/S1973-9087.20.06317-0 (in press).
  • Lew HL, Oh-Park M, Cifu DX. The War on COVID-19 Pandemic Role of Rehabilitation Professionals and Hospitals. Am J Phys Med Rehabil. 2020;99:571-2.
  • Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Pena R, Holguin-Rivera Y, Escalera-Antezana JP, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020;34:101623.
  • Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T, et al. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg. 2019;6(3):233-46.
  • Rawal G, Yadav S, Kumar R. Post-intensive Care Syndrome: an Overview. J Transl Int Med. 2017;5(2):90-2.
  • Stam HJ, Stucki G, Bickenbach J. Covid-19 and Post Intensive Care Syndrome: A Call for Action. J Rehabil Med. 2020;52(4):jrm00044.
  • Hosey MM, Needham DM. Survivorship after COVID-19 ICU stay. Nat Rev Dis Primers. 2020;6(1):60.
  • Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, et al. Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome. Phys Ther. 2020;100(7):1062-73.
  • Grasselli G, Greco M, Zanella A, Albano G, Antonelli M, Bellani G,et al. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy. JAMA Intern Med. 2020;180(10):1-11.
  • Stevens RD, Marshall SA, Cornblath DR, Hoke A, Needham DM, de Jonghe B, et al. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med. 2009;37(Suppl 10):S299-308.
  • Waldauf P, Jiroutkova K, Krajcova A, Puthucheary Z, Duska F. Effects of Rehabilitation Interventions on Clinical Outcomes in Critically Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med. 2020;48(7):1055-65.
  • Sheehy LM. Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health Surveill. 2020;6(2):e19462.
  • Zang K, Chen B, Wang M, Chen D, Hui L, Guo S, et al. The effect of early mobilization in critically ill patients: A meta-analysis. Nurs Crit Care. 2019;doi: 10.1111/nicc.12455 (in press).
  • Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc. 2016;9:247-56.
  • Liu M, Luo J, Zhou J, Zhu X. Intervention effect of neuromuscular electrical stimulation on ICU acquired weakness: A meta-analysis. Int J Nurs Sci. 2020;7(2):228-37.
  • Porta R, Vitacca M, Gile LS, Clini E, Bianchi L, Zanotti E, et al. Supported arm training in patients recently weaned from mechanical ventilation. Chest. 2005;128(4):2511-20.
  • Doiron KA, Hoffmann TC, Beller EM. Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD010754.
  • Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, et al. Extrapulmonary manifestations of COVID-19. Nat Med. 2020;26(7):1017-32.
  • Lopez M, Bell K, Annaswamy T, Juengst S, Nneka I. COVID-19 Guide for the Rehabilitation Clinician: A Review of Non-Pulmonary Manifestations and Complications. Am J Phys Med Rehabil. 2020;99(8):669-73.
  • Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S. Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19. Am J Phys Med Rehabil. 2020;99(9):769-74.
  • Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, et al. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020;66(2):73-82.
  • Righetti RF, Onoue MA, Politi FVA, Teixeira DT, de Souza PN, Kondo CS, et al. Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience. Clinics (Sao Paulo). 2020;75:e2017.
  • Kurtaiş Aytür Y, Köseoğlu BF, Özyemişçi Taşkıran Ö, Ordu Gökkaya NK, Ünsal Delialioğlu S, Sonel Tur B, et al. Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation. Turk J Phys Med Rehabil. 2020;66(2):104-20.
  • Genç A, Kurtaiş Aytür Y. COVID-19 enfeksiyonunda akut ve postakut pulmoner rehabilitasyon. In: COVID-19 Pandemisi ve Fiziksel Tıp ve Rehabilitasyon (Eds Ayhan FF, Demirbağ Kabayel D): 7-12. Ankara, Türkiye Klinikleri, 2020.
  • Zhao HM, Xie YX, Wang C; Chinese Association of Rehabilitation Medicine; Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation Medicine; Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation. Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chin Med J (Engl). 2020;133(13):1595-602.
  • COVID-19: Clinical Best Practices in Physical Therapy Management. https://cdn.ymaws.com/www.aptahpa.org/resource/resmgr/webinars/3-28-20_Presentation_Handout.pdf (accessed: Sep 2020)
  • Battaglini D, Robba C, Caiffa S, Ball L, Brunetti I, Loconte M, et al. Chest physiotherapy: an important adjuvant in critically ill mechanically ventilated patients with COVID-19. Respir Physiol Neurobiol. 2020;282:103529.
  • Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, et al. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis. 2020;90(1).
  • Sarıkaya S, Okan S. COVID-19 sonrası kronik dönemde pulmoner rehabilitasyon. In: COVID-19 Pandemisi ve Fiziksel Tıp ve Rehabilitasyon (Eds Ayhan FF, Demirbağ Kabayel D): 13-9. Ankara, Türkiye Klinikleri, 2020.
  • Polastri M, Nava S, Clini E, Vitacca M, Gosselink R. COVID-19 and pulmonary rehabilitation: preparing for phase three. Eur Respir J. 2020;55(6):2001822.
  • Yang LL, Yang T. Pulmonary Rehabilitation for Patients with Coronavirus Disease 2019 (COVID-19). Chronic Dis Transl Med. 2020;6(2):79-86.
  • Barker-Davies RM, O'Sullivan O, Senaratne KPP, Baker P, Cranley M, Dharm-Datta S, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020;54(16):949-59.
  • Zeng B, Chen D, Qiu Z, Zhang M, Wang G, Wang J, et al. Expert consensus on protocol of rehabilitation for COVID-19 patients using framework and approaches of WHO International Family Classifications. Aging Med (Milton). 2020 Jul 6;3(2):82-94.
  • Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. 2020;39:101166.
  • Verstrepen K, Baisier L, De Cauwer H. Neurological manifestations of COVID-19, SARS and MERS. Acta Neurol Belg. 2020;120(5):1051-60.
  • Herman C, Mayer K, Sarwal A. Scoping review of prevalence of neurologic comorbidities in patients hospitalized for COVID-19. Neurology. 2020;95(2):77-84.
  • de Sire A, Andrenelli E, Negrini F, Negrini S, Ceravolo MG. Systematic rapid living review on rehabilitation needs due to COVID-19: update as of April 30th, 2020. Eur J Phys Rehabil Med. 2020;56(3):354-60.
  • Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China [published online ahead of print, 2020 Apr 10]. JAMA Neurol. 2020;77(6):1-9.
  • Toscano G, Palmerini F, Ravaglia S, Ruiz L, Invernizzi P, Cuzzoni MG, et al. Guillain-Barre Syndrome Associated with SARS-CoV-2. N Engl J Med. 2020;382(26):2574-6.
  • D Leochico CF. Adoption of telerehabilitation in a developing country before and during the COVID-19 pandemic. Ann Phys Rehabil Med. 2020;S1877-0657(20)30123-8. doi:10.1016/j.rehab.2020.06.001 (in press).
  • Falvey JR, Ferrante LE. Flattening the disability curve: Rehabilitation and recovery after COVID-19 infection. Heart Lung. 2020;49(5):440-1.

The role of rehabilitation in acute and chronic period of COVID-19

Yıl 2020, Cilt: 45 Sayı: 4, 1818 - 1828, 27.12.2020

Öz

COVID-19 pandemic have enormous impact on healthcare systems around the world. The majority of cases are asymptomatic or mild, with a severe course in 15-20% of patients. In severe cases, treatment in the intensive care unit (ICU) is required for severe pneumonia and acute respiratory distress syndrome. A number of physical, cognitive and mental disorders defined as “Post-Intensive Care Syndrome” are seen in ICU survivors and determine the long-term prognosis of patients. COVID-19 affects other organ systems besides its well-known pulmonary involvement. ICU associated complications, pulmonary and extrapulmonary involvement of the disease will cause a growing proportion of patients with COVID-19 infection related sequelae and disability. Therefore, the implementation of effective rehabilitation programs for COVID-19 survivors has come to the fore. Considering the pulmonary, neurological, musculoskeletal and ICU related complications, rehabilitation professionals can play an important role in the recovery process of individuals with COVID-19 disease. In this review, intensive care associated complications of COVID-19 infection, pulmonary and extrapulmonary involvements will be discussed and treatment with available early evidence and general rehabilitation approaches will be mentioned.

Kaynakça

  • World Health Organisation. Coronavirus disease (COVID-19) pandemic. https://www.who.int/emergencies/diseases/novel-coronavirus-2019 (accessed Aug 2020).
  • Simpson R, Robinson L. Rehabilitation following critical illness in people with COVID-19 infection. Am J Phys Med Rehabil. 2020;99:470-4.
  • Stein J, Visco CJ, Barbuto S. Rehabilitation Medicine Response to the COVID-19 Pandemic. Am J Phys Med Rehabil. 2020;99(7):573-9.
  • Carda S, Invernizzi M, Bianchi F, Deltombe T, Draulans N, Francisco GE, et al. COVID-19 pandemic. What should PRM specialists do? A clinician’s perspective. Eur J Phys Rehabil Med. 2020;doi:10.23736/S1973-9087.20.06317-0 (in press).
  • Lew HL, Oh-Park M, Cifu DX. The War on COVID-19 Pandemic Role of Rehabilitation Professionals and Hospitals. Am J Phys Med Rehabil. 2020;99:571-2.
  • Rodriguez-Morales AJ, Cardona-Ospina JA, Gutiérrez-Ocampo E, Villamizar-Pena R, Holguin-Rivera Y, Escalera-Antezana JP, et al. Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis. Travel Med Infect Dis. 2020;34:101623.
  • Inoue S, Hatakeyama J, Kondo Y, Hifumi T, Sakuramoto H, Kawasaki T, et al. Post-intensive care syndrome: its pathophysiology, prevention, and future directions. Acute Med Surg. 2019;6(3):233-46.
  • Rawal G, Yadav S, Kumar R. Post-intensive Care Syndrome: an Overview. J Transl Int Med. 2017;5(2):90-2.
  • Stam HJ, Stucki G, Bickenbach J. Covid-19 and Post Intensive Care Syndrome: A Call for Action. J Rehabil Med. 2020;52(4):jrm00044.
  • Hosey MM, Needham DM. Survivorship after COVID-19 ICU stay. Nat Rev Dis Primers. 2020;6(1):60.
  • Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, et al. Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome. Phys Ther. 2020;100(7):1062-73.
  • Grasselli G, Greco M, Zanella A, Albano G, Antonelli M, Bellani G,et al. Risk Factors Associated With Mortality Among Patients With COVID-19 in Intensive Care Units in Lombardy, Italy. JAMA Intern Med. 2020;180(10):1-11.
  • Stevens RD, Marshall SA, Cornblath DR, Hoke A, Needham DM, de Jonghe B, et al. A framework for diagnosing and classifying intensive care unit-acquired weakness. Crit Care Med. 2009;37(Suppl 10):S299-308.
  • Waldauf P, Jiroutkova K, Krajcova A, Puthucheary Z, Duska F. Effects of Rehabilitation Interventions on Clinical Outcomes in Critically Ill Patients: Systematic Review and Meta-Analysis of Randomized Controlled Trials. Crit Care Med. 2020;48(7):1055-65.
  • Sheehy LM. Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health Surveill. 2020;6(2):e19462.
  • Zang K, Chen B, Wang M, Chen D, Hui L, Guo S, et al. The effect of early mobilization in critically ill patients: A meta-analysis. Nurs Crit Care. 2019;doi: 10.1111/nicc.12455 (in press).
  • Green M, Marzano V, Leditschke IA, Mitchell I, Bissett B. Mobilization of intensive care patients: a multidisciplinary practical guide for clinicians. J Multidiscip Healthc. 2016;9:247-56.
  • Liu M, Luo J, Zhou J, Zhu X. Intervention effect of neuromuscular electrical stimulation on ICU acquired weakness: A meta-analysis. Int J Nurs Sci. 2020;7(2):228-37.
  • Porta R, Vitacca M, Gile LS, Clini E, Bianchi L, Zanotti E, et al. Supported arm training in patients recently weaned from mechanical ventilation. Chest. 2005;128(4):2511-20.
  • Doiron KA, Hoffmann TC, Beller EM. Early intervention (mobilization or active exercise) for critically ill adults in the intensive care unit. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD010754.
  • Gupta A, Madhavan MV, Sehgal K, Nair N, Mahajan S, Sehrawat TS, et al. Extrapulmonary manifestations of COVID-19. Nat Med. 2020;26(7):1017-32.
  • Lopez M, Bell K, Annaswamy T, Juengst S, Nneka I. COVID-19 Guide for the Rehabilitation Clinician: A Review of Non-Pulmonary Manifestations and Complications. Am J Phys Med Rehabil. 2020;99(8):669-73.
  • Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S. Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19. Am J Phys Med Rehabil. 2020;99(9):769-74.
  • Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, et al. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020;66(2):73-82.
  • Righetti RF, Onoue MA, Politi FVA, Teixeira DT, de Souza PN, Kondo CS, et al. Physiotherapy Care of Patients with Coronavirus Disease 2019 (COVID-19) - A Brazilian Experience. Clinics (Sao Paulo). 2020;75:e2017.
  • Kurtaiş Aytür Y, Köseoğlu BF, Özyemişçi Taşkıran Ö, Ordu Gökkaya NK, Ünsal Delialioğlu S, Sonel Tur B, et al. Pulmonary rehabilitation principles in SARS-COV-2 infection (COVID-19): A guideline for the acute and subacute rehabilitation. Turk J Phys Med Rehabil. 2020;66(2):104-20.
  • Genç A, Kurtaiş Aytür Y. COVID-19 enfeksiyonunda akut ve postakut pulmoner rehabilitasyon. In: COVID-19 Pandemisi ve Fiziksel Tıp ve Rehabilitasyon (Eds Ayhan FF, Demirbağ Kabayel D): 7-12. Ankara, Türkiye Klinikleri, 2020.
  • Zhao HM, Xie YX, Wang C; Chinese Association of Rehabilitation Medicine; Respiratory Rehabilitation Committee of Chinese Association of Rehabilitation Medicine; Cardiopulmonary Rehabilitation Group of Chinese Society of Physical Medicine and Rehabilitation. Recommendations for respiratory rehabilitation in adults with coronavirus disease 2019. Chin Med J (Engl). 2020;133(13):1595-602.
  • COVID-19: Clinical Best Practices in Physical Therapy Management. https://cdn.ymaws.com/www.aptahpa.org/resource/resmgr/webinars/3-28-20_Presentation_Handout.pdf (accessed: Sep 2020)
  • Battaglini D, Robba C, Caiffa S, Ball L, Brunetti I, Loconte M, et al. Chest physiotherapy: an important adjuvant in critically ill mechanically ventilated patients with COVID-19. Respir Physiol Neurobiol. 2020;282:103529.
  • Lazzeri M, Lanza A, Bellini R, Bellofiore A, Cecchetto S, Colombo A, et al. Respiratory physiotherapy in patients with COVID-19 infection in acute setting: a Position Paper of the Italian Association of Respiratory Physiotherapists (ARIR). Monaldi Arch Chest Dis. 2020;90(1).
  • Sarıkaya S, Okan S. COVID-19 sonrası kronik dönemde pulmoner rehabilitasyon. In: COVID-19 Pandemisi ve Fiziksel Tıp ve Rehabilitasyon (Eds Ayhan FF, Demirbağ Kabayel D): 13-9. Ankara, Türkiye Klinikleri, 2020.
  • Polastri M, Nava S, Clini E, Vitacca M, Gosselink R. COVID-19 and pulmonary rehabilitation: preparing for phase three. Eur Respir J. 2020;55(6):2001822.
  • Yang LL, Yang T. Pulmonary Rehabilitation for Patients with Coronavirus Disease 2019 (COVID-19). Chronic Dis Transl Med. 2020;6(2):79-86.
  • Barker-Davies RM, O'Sullivan O, Senaratne KPP, Baker P, Cranley M, Dharm-Datta S, et al. The Stanford Hall consensus statement for post-COVID-19 rehabilitation. Br J Sports Med. 2020;54(16):949-59.
  • Zeng B, Chen D, Qiu Z, Zhang M, Wang G, Wang J, et al. Expert consensus on protocol of rehabilitation for COVID-19 patients using framework and approaches of WHO International Family Classifications. Aging Med (Milton). 2020 Jul 6;3(2):82-94.
  • Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complement Ther Clin Pract. 2020;39:101166.
  • Verstrepen K, Baisier L, De Cauwer H. Neurological manifestations of COVID-19, SARS and MERS. Acta Neurol Belg. 2020;120(5):1051-60.
  • Herman C, Mayer K, Sarwal A. Scoping review of prevalence of neurologic comorbidities in patients hospitalized for COVID-19. Neurology. 2020;95(2):77-84.
  • de Sire A, Andrenelli E, Negrini F, Negrini S, Ceravolo MG. Systematic rapid living review on rehabilitation needs due to COVID-19: update as of April 30th, 2020. Eur J Phys Rehabil Med. 2020;56(3):354-60.
  • Mao L, Jin H, Wang M, Hu Y, Chen S, He Q, et al. Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China [published online ahead of print, 2020 Apr 10]. JAMA Neurol. 2020;77(6):1-9.
  • Toscano G, Palmerini F, Ravaglia S, Ruiz L, Invernizzi P, Cuzzoni MG, et al. Guillain-Barre Syndrome Associated with SARS-CoV-2. N Engl J Med. 2020;382(26):2574-6.
  • D Leochico CF. Adoption of telerehabilitation in a developing country before and during the COVID-19 pandemic. Ann Phys Rehabil Med. 2020;S1877-0657(20)30123-8. doi:10.1016/j.rehab.2020.06.001 (in press).
  • Falvey JR, Ferrante LE. Flattening the disability curve: Rehabilitation and recovery after COVID-19 infection. Heart Lung. 2020;49(5):440-1.
Toplam 44 adet kaynakça vardır.

Ayrıntılar

Birincil Dil Türkçe
Konular Rehabilitasyon
Bölüm Derleme
Yazarlar

Sibel Başaran 0000-0003-3228-3909

Rengin Güzel 0000-0002-3064-5868

Yayımlanma Tarihi 27 Aralık 2020
Kabul Tarihi 15 Ekim 2020
Yayımlandığı Sayı Yıl 2020 Cilt: 45 Sayı: 4

Kaynak Göster

MLA Başaran, Sibel ve Rengin Güzel. “COVID-19’da Akut Ve Kronik dönemde Rehabilitasyonun Yeri”. Cukurova Medical Journal, c. 45, sy. 4, 2020, ss. 1818-2, doi:10.17826/cumj.793835.