Rehabilitation During a Pandemic in People with Specific Rehabilitation Needs

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Introduction

The rehabilitation needs of people do not stop just because a pandemic has been declared. People in need of essential rehabilitation will still need this care amidst the pandemic. A lack of access to rehabilitation has complications in terms of:

• health outcomes of people
• inpatient hospital stay duration
• hospital admissions

Healthcare professionals will need to make decisions with regards to:

• the continuation of rehabilitation services
• the implications it will have on different patient groups in need of rehabilitation
• the infection risk involved to patients and healthcare professionals

Changes in rehabilitation services due pandemic constraints will have implications for today and the future.

Rehabilitation is Essential

"Rehabilitation is an essential part of health care and is integral to achieving universal health coverage. Rehabilitation needs are increasing globally, along with rising prevalence of non-communicable diseases and ageing populations. National efforts must strengthen health systems to provide rehabilitation, making it available to everyone at all levels of health care, whenever needed."

Rehabilitation must aim to be:

• Available
• Accessible
• Affordable, for many people.

This will allow people to:

• Remain as independent as possible
• Participate in education
• Be economically productive
• Fulfill meaningful life roles

Aspects Influencing Decisions to Adapt Rehabilitation Services During a Pandemic

• Immediacy of care needs
• Services available
• Setting
• Resources available (staff, equipment, technology)
• Risk for transmission
• Risk of illness

How has the Pandemic Affected Rehabilitation Services?

• Rehabilitation beds and wards converted to increase acute care capacity
• Inpatient admissions for rehabilitation delayed
• Shorter lengths of inpatient stays for rehabilitation
• Early discharge to expand bed capacity and/or to prevent transmission
• Outpatient rehabilitation care suspended or reduced
• Home-based rehabilitation suspended or reduced
• Rehabilitation personnel redeployed

Infection risk considerations with rehabilitation services during a pandemic

• Increased risk of infection with face to face rehabilitation

• Infection risk should be balanced against the risk to patient outcomes and health services if rehabilitation is interrupted, ceased or reduced.

• Delivery of rehabilitation services during the COVID-19 outbreak should minimise the risk of exposure to patients and healthcare providers, especially those at high risk, such as older people and people with comorbidities

• The availability of personal protective equipment (PPE) will influence the degree of infection risk

• Infection control measures may vary across service delivery settings and this will also influence the degree of infection risk

• WHO and PAHO guidelines should be followed if rehabilitation services continue

• Alternative ways of service delivery should be considered if feasible (eg, telehealth in rehabilitation focused on patient education and advice)

• Various factors should be considered when considering telehealth (availability of data, telecommunications infrastructure, etc)

The impact on patient outcomes if rehabilitation is suspended or reduced

• Essential rehabilitation services for non-COVID-19 patients should be identified and continued during the outbreak

• Consider the effect of ceasing or reducing rehabilitation on certain patient groups (eg, burns, spinal cord injuries, stroke)

• Health and functioning outcomes can seriously be compromised if rehabilitation services are suspended or reduced

• Risk of increased mortality if rehabilitation is not continued in certain patient groups

• It is critical to prioritize patients in settings where rehabilitation services are temporarily ceased, decreased or diverted. The risks associated with the sudden change in rehabilitation services should be well thought through.

Rehabilitation service options during the pandemic

Rehabilitation service providers should identify patients that are suitable for some of these service options:

• Patient can be discharged from rehabilitation with comprehensive home rehabilitation programme. The patient has knowledge of potential complications that can arise or indications that will require a follow-up

• Patient continues with rehabilitation through either inpatient, outpatient, home-based or telehealth services or with modifications to their current rehabilitation setting

• Temporary interruption or cessation of patient’s rehabilitation programme ( but patient still receives interim education and a home programme). It is crucial to have an established, systematic method for follow-up after rehabilitation services are up and running again.

• As the various stages of the pandemic progresses certain areas may be able to continue with some rehabilitation services again for patients with priority needs who have been cleared  of COVID-19 or who have recovered.

Patient groups that should continue to have access to rehabilitation during the pandemic:

• Patients that have or have recently had significant injuries such as

• burns,

• spinal cord injury,

• traumatic brain injury, and fractures

• musculoskeletal injuries that may develop serious preventable complication

• Patients recovering from surgery

• Patients with conditions such as stroke or myocardial infarctions, that will benefit from early rehabilitation and are at risk of suboptimal recovery if rehabilitation is delayed

• Patients in need of long-term rehabilitation in hospitals, residential centres or community settings may develop complications and lose function if rehabilitation is ceased, delayed or interrupted

• Patients who are not able to be discharged to a safe environment or who may have to be discharged to a setting that is a long way from the rehabilitation service and this will most likely limit their access to rehabilitation

The impact on health services delivery if rehabilitation is ceased or reduced

• Rehabilitation services that contributes to safe and timely discharge from hospital should continue if possible – for both COVID-19 and non-COVID-19 patients

• Safe and timely discharge from hospitals can aid in the surge capacity of hospitals (especially hospitals that need patients to move rapidly through acute care)

• Restricted or no access to rehabilitation can lead to extended length hospital stays

• Ineffective rehabilitation strategies and planning can lead to further complications and readmission of patients

• There should be available rehabilitation follow-up following discharge from hospital

• Patients in need of follow-up are those at risk of poor or compromised outcomes

• During the pandemic there will be a change in the profile of rehabiltaion demands

• E.g. Rehabilitation after elective surgery will be reduced as these surgeries will be postponed; whereas ne rehabilitation needs will arise due to the exacerbations of underlying health conditions as a result of COVID-19 lockdown or containment measures.

• Also, the cessation and reduction of rehabilitation services will lead to a backlog of rehabilitation needs

• In the case of early supported discharge ensure the following:

• Proper patient and caregiver education

• Proper self-management strategies and home exercise programmes if safe and suitable to do

• Ensure that patients have access to the proper assistive products and adaptive equipment as well as proper guidance on how to use this equipment

• Patients should be properly informed and advised on possible complications and clear instructions on where to call (telephone numbers, e-mails, etc) and when to call if there are any concerns

• Telehealth services may be implemented if safe and appropriate to use. This may include remote assessments and treatments via telephone or video calls

• Individual standard treatment plans may be provided to patients via e-mail, app, telehealth if it is safe and appropriate to do so

• If rehabilitation is temporarily stopped, ensure that systematic methods such as databases for COVID-19 and non-COVID-19 patients, in need of follow-up, are compiled so that they can be tracked and relevant services organised as soon as normal health services resume.

Rehabilitation for people with a disability and frail older people

An estimated 15% of the world’s population live with a disability. Many of these people need rehabilitation. For many this would mean rehabilitation in the acute phase of the disability or even on an ongoing basis when living with a chronic condition.

The WHO/Europe highlights the fact that there is an increasing demand for rehabilitation worldwide and the current pandemic has just exacerbated the unmet need for rehabilitation in vulnerable populations across the globe.

It is also evident that people living with non-communicable diseases are at a higher risk of severe illness due to COVID-19. This implies that a large group of patients who are usually supported by long-term physiotherapy interventions and rehabilitation services will be at an increased risk for severe complications from COVID-19.

The implementation of lockdown strategies in many countries around the world may lead to many people with disabilities and rehabilitation needs not being able to access rehabilitation services, or they may have an adaptive form of rehabilitation (e.g. telehealth). The reality is however, that many people will be left behind with no access to rehabilitation services and this may compromise the health outcomes.

Older people with frailty may be at risk of the same issues as people living with a disability. Older people are more vulnerable to serious complications from COVID-19 and lockdown measures urge older people to stay at home and self-isolate. This may impact various short and long-term healthcare outcomes. wcpt

Short-term rehabilitation needs in areas where routine care has been suspended

Physiotherapists are key rehabilitation professionals over a vast range of specialities. These rehabilitation services is an essential part of healthcare to optimise cognitive and physical function and thus reduce disability. During the pandemic, many physiotherapy services will be suspended as countries have strict lockdown and social distancing regulations to reduce the spread of the virus. This will have an impact on patients and they are likely to experience a deterioration in conditions that is unrelated to COVID-19.

Areas that may be affected where physiotherapy rehabilitation is provided

Elective surgeries cancelled – deconditioning can occur in patients waiting for orthopaedic and other surgeries

Acute musculoskeletal conditions- patients may not be able to access physiotherapy

Individuals may delay or ignore symptoms due to the concern around COVID-19

Many physiotherapy services in community and out-patient settings will be suspended and classified as non-essential services to ensure social distancing

People who are confined to their homes as a result of lockdown or social distancing will be more sedentary and at risk of losing mobility and function. Once lockdown restrictions eases these patients will be in need of physiotherapy services and this will put an even greater burden on rehabilitation professionals. wcpt

Public health restrictions and Rehabilitation

Telerehabilitation may work for certain groups of patients, but for others it may not be advised. The rehabilitation environment will change with restrictions being lifted with strict infection prevention and control measures and the requirements of physical distancing as far as possible.

Physiotherapists will need to consider:

how rehabilitation services will be provided in the various stages of restrictions being lifted.

How will inclusive rehabilitation fit in to limit the effect of public health restriction

The risk of some patients being missed or overlooked that was previously in the system

Rehabilitaion professionals will need to review priorities, they may need to implement triage strateiges as well as outreach strategies to commence rehabilitation services again.

Occupational rehabilitation

Following the easing of lockdown restrictions, certain people will have difficulties returning to work and may need physiotherapy related rehabilitation

Physiotherapists are critical  to ensure fitness to return to work as well as advising on adaptive requirments

Physiotherapists will also need occupational support through the provision of adequate PPE

Occupational rehabilitation response should focus on physical and mental wellbeing

Implications on  physiotherapy rehabilitation service delivery and workforce

Since the start of this pandemic there has been a monumental change in the physiotherapy workforce. This will be ongoing for the foreseeable future and will keep on changing as the environment and rehabilitation needs change worldwide. Physiotherapist are key to delivering high quality rehabilitation and working in multidisciplinary teams. Initially there was and still is a rapid response in the acute phase of the pandemic, but this will change and as the rehabilitation needs of COVID-19 patients become clearer. The non-COVID19 patients’ existing and new rehabilitation needs will also become more evident as the stages in the pandemic progress. The emotional, mental and physical wellbeing of physiotherapists need to be considered and appropriate services need to be made available to ensure their wellbeing. wcpt

Resources:

Living with a disability during the pandemic

https://www.minervamedica.it/en/getfreepdf/L2p4Vm91N2w2WkNGVkJLYkhMOGhBVWZCM3NrcVJ4WGNyaTc1WGtlbWVlZkxnTjBTT3dUMjVQQnBINS8vWUxZcg%253D%253D/R33Y9999N00A20051403.pdf

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