COVID-19: Post-Acute Rehabilitation

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Rehabilitation

Rehabilitation is defined as "a set of interventions designed to reduce disability and optimize functioning in individuals with health conditions in interaction with their environment." (World Health Organisation, 2017).

Benefits of Rehabilitation in COVID-19 Patients

Rehabilitation has a positive effect on health outcomes of patients with severe COVID-19. It achieves this through:

• Optimizing health and functioning outcomes
  • Rehabilitation can reduce Intensive Care Unit -admission related complications, such as Post Intensive Care Syndrome (PICS), Intensive care unit acquired weakness (ICUAW)
  • The aim of rehabilitation is to improve recovery and reduce disability or the experience thereof
  • Rehabilitation interventions address several consequences of severe COVID-19 such as:
    • Physical impairments
    • Cognitive impairments
    • Swallow impairments
    • Provision of psychosocial support (PAHO paper)
  • It is evident that older people and people with pre-existing comorbidities are at higher risk for more severe illness. Rehabilitation can be beneficial in these populations to maintain their prior levels of functionality and independence.

• Early Discharge Facilitation
  • During the pandemic there is a high demand for hospital beds in countries worldwide, especially during the times when the pandemic reaches its peak in a country or area. This leads to patients being discharged sooner than would normally be the case. Rehabilitation is crucial in this scenario to prepare a patient for discharge, coordinating complex discharges and also to safeguard continuity of care.

• Reducing the risk of readmission
  • Rehabilitation is a key strategy to ensure that patients do not deteriorate after discharge and require readmission. During the COVID-19 pandemic this is critical in the context of shortages of hospital beds.

• Physiotherapists as rehabilitation professionals are frontline healthcare professionals and should be engaged in the care of patients suffering from severe cases of COVID-19
  • A patient who has severe COVID-19 will go through multiple phases of care – acute, post-acute and long term care. In the acute phase care will most likely be provided in the ICU or critical care units. In the post-acute phase care will most likely be provided in a hospital ward, or a step-down or rehabilitation facility. The long-term phase will be when patients return home and are still recovering and will receive rehabilitation at community level.

Physiotherapy and the Post-Acute COVID-19 Rehabilitation Phase

• Physiotherapists are instrumental in the rehabilitation of patients as they transition from the acute phase to the post-acute phase.(WCPT)
• The consequences of COVID-19 will be specific in each individual and their rehabilitation needs will be specific to these consequences such as:
  • Long term ventilation
  • Immobilisation
  • Deconditioning
  • Related impairments – respiratory, neurological, musculoskeletal
• COVID-19 patients will often present with pre-existing comorbidities and this must be taken into consideration in the rehabilitation plan for the patient. Physiotherapists working across various disciplines should work together and draw on the expertise of each other

• The transition from the acute to the post-acute phase needs to be supported through service delivery pathways and the multidisciplinary team will be key to this.

Patient presentation for COVID-19 survivors in the rehabilitation unit

Factors to consider in creating a rehabilitation plan for survivors of COVID-19 include:

Comorbidities

Direct lung trauma

Injuries to other organs and systems due to COVID 19

Comorbidities

There is clear evidence from across the world that the leading comorbid conditions of people with COVID-19 include:

Hypertension

Coronary artery disease

Stroke

Diabetes

Considering that these conditions are often associated with ageing, it is most likely that survivors of COVID-19 are older people with pre-existing conditions such as cardiovascular and cerebrovascular disease. This will have an influence on rehabilitation needs as well as rehabilitation outcomes.

Severe COVID-19 Complications

Early complications of COVID-19 include:

Acute respiratory distress syndrome (ARDS)

Sepsis or septic shock

Multi-organ failure

Acute kidney injury

Cardiac injury

These complications often lead to the person’s being admitted to an Intensive Care Unit.

Conditions that may arise from lengthy ICU-stays include:

Critical illness polyneuropathy (CIP)(https://physio-pedia.com/Critical_Illness_Polyneuropathy_(CIP)

This is a mixed sensorimotor neuropathy that may lead to axonal degeneration and studies have shown that patients hospitalised in ICU with ARDS may present with CIP.

CIP causes several difficulties such as: (Connolly B, O'Neill B, Salisbury L, Blackwood B, Enhanced Recovery After Critical Illness Programme Group Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax. 2016 Oct;71(10):881–90. doi: 10.1136/thoraxjnl-2015-

Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med. 2016 May;42(5):725–738. doi: 10.1007/s00134-016-4321-8.208273. http://thorax.bmj.com/cgi/pmidlookup?view=long&pmid=27220357)

Shepherd S, Batra A, Lerner DP. Review of critical illness myopathy and neuropathy. Neurohospitalist. 2017 Jan;7(1):41–48. doi: 10.1177/1941874416663279. http://europepmc.org/abstract/MED/28042370.

Difficulty weaning from mechanical ventilation

Generalised and Symmetrical weakness (distal greater than proximal, but does also include diaphragmatic weakness)

Distal sensory loss

Atrophy

Decreased or absent deep tendon reflexes

CIP is associated with: ( Herridge MS, Moss M, Hough CL, Hopkins RO, Rice TW, Bienvenu OJ, Azoulay E. Recovery and outcomes after the acute respiratory distress syndrome (ARDS) in patients and their family caregivers. Intensive Care Med. 2016 May;42(5):725–738. doi: 10.1007/s00134-016-4321-8.)

Pain

Loss of range of motion

Fatigue

Incontinence

Dysphagia

Anxiety

Depression

Post-traumatic Stress Disorder (PTSD)

Cognitive loss

CIP is diagnosed through

Muscle biopsies

Electromyographic testing

Critical Illness Myopathy (CIM)

This condition is present in 48 – 96% of patients in ICU with ARDS. It is a non-necrotising diffuse myopathy with fatty degeneration, fibre atrophy and fibrosis. (ref)CIP is associated with exposure to corticosteroids, paralytics and sepsis. It has a similar clinical presentation to CIP but with more proximal weakness and sensory preservation. Stam et al 2020

Patients recover more completely from myopathies than polyneuropathies, but with both conditions there are long term consequences to consider such as:

Weakness

Loss of function

Loss of quality of life

Poor endurance

Post Intensive Care Syndrome (PICS)

A distinct feature of COVID-19 is that, when necessary, acute and ICU care as well as ventilator reliance is often required for considerably longer periods. The aftershock as a result of this long ICU period will be felt for many months and years.

Characteristics of PICS include:

Cognitive impairments

Memory

Attention

Visuo-spatial

Psychomotor

Impulsivity

Psychiatric Illness

Anxiety

Depression

PTSD

Physical Impairments

Dyspnea/ Impaired pulmonary function

Reduced inspiratory muscle strength

Pain

Sexual dysfunction

Impaired exercise tolerance

Neuropathies

Muscle weakness/Paresis

Poor upper extremity and grip strength

Poor knee extension

Severe fatigue

Low functional capacity

The neuromuscular complications from PICS often result in poor mobility, falls and even quadriparesis.

Risk factors for Post Intensive Care syndrome:

Delirium

Duration of ICU admission

Duration of sedation

Duration of mechanical ventilation

Age

Hypoxia and hypotension

Sepsis

Glucose dysregulation

Premorbid mental and physical comorbidity

Throughout the world, healthcare systems will be inundated with a cohort of post-ICU patients created by the COVID-19 pandemic. It is therefor important to have a coordinated rehabilitation response.

Specific problems post-acute phase (perspectives from Northern Italy)

Lengthy, longer than usual stay in ICU – average of 3 weeks

It is important to have a gradual progression from the weaning phase to transfer to a rehabilitation service – patients need to be monitored closely and accurately as they remain unstable for several days after extubation. Complications seen with patients in ICU (due to long period of immobilisation and prone positioning) include:

Physical deconditioning

Severe muscle weakness

CIP

CIM

Reduced joint mobility

Neck and shoulder pain (due to proning)

Difficulty in verticalization

Impaired balance and gait

Limitations of ADL

Dysphagia

Impaired swallow and communication

Difficult awakening with long lasting confusional state and psychological problems

Impaired lung function

Lung fibrosis as sequlae of pneumonia – patients showing respiratory insufficiency needing respiratory rehabilitation

Tough secretions requiring specific physiotherapy techniques or technical removal (Kiekens et al, 2020)

Delirium and other cognitive impairments

Persistence of SARS-CoV-2 Virus

Patients who have physically recovered and who have two negative tests after infection are considered to be cured and non-infectious. There are however reports of patients testing positive again at a later stage. Studies have also shown that the virus may persist in a persons’ oropharyngeal cavity and stools for up to 15 days after they have been declared cured. This needs to be considered when patients are being discharged to the ward or rehabilitation facilities as they still might be able to transmit the disease.

Sequelae after COVID-19 Infection

Cardiac sequelae

Studies have shown that hospitalised patients with COVID-19 also had associated cardiac injury. The mechanism of cardiac injury is uncertain, however. Patients with this associated cardiac injury presented with:

Arrythmia

Cardiac insufficiency

Ejection fraction decline

Troponin I elevation

Severe myocarditis with reduced systolic dysfunction

The presence of cardiac injury as well as other comorbidities need to be considered for patients entering post-acute rehabilitation.

Neurological sequelae

Numerous neurological symptoms have been reported in patients with COVID-19. These include:

Headaches

Disturbed consciousness

Seizures

Absence of sense and smell

Parasthesia

Posterior reversible Encephalopathy syndrome

Viral encephalitis

Increased risk for acute cerebrovascular even

Reports of Gullaine Barre Syndrome associated with COVID-19

Again, these  neurological factors need to be considered when a patient is entering post-acute rehabilitation after COVID-19.

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