COVID-19: Post-Acute Rehabilitation

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk, Naomi O'Reilly, Tarina van der Stockt, Kim Jackson, Lucinda hampton, Vidya Acharya, Admin and Olajumoke Ogunleye  

Introduction

Countries all across the world are now entering the "day after" COVID-19 phase.

• Many people who have suffered from the effects of this disease might be at risk of long-term impairment and disability.
• The extent of this impairment and disability varies, but it is clear from early research that these patients will be in need of rehabilitation in all phases of the disease - acute, post-acute and long-term.

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."

• Rehabilitation is a key strategy to reduce the impact of COVID-19 on the health and function of people.
• Physiotherapists are essential to these rehabilitation efforts in all phases to facilitate early discharge, but even more to support and empower patients.

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:

1. 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
   • 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
2. Early Discharge Facilitation
   • In situations where a shortage of hospital beds may arise rehabilitation is crucial to prepare a patient for discharge, coordinating complex discharges and also to safeguard the 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.
   • 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 (sub-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

1. Physiotherapists are instrumental in the rehabilitation of patients as they transition from the acute phase to the post-acute phase.
2. 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
3. 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.

COVID-19 Patient Presentation 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 co-morbid conditions of people with COVID-19 include:

• Hypertension
• Coronary artery disease
• Stroke
• Diabetes
• Chronic kidney disease
• Lung and liver diseases
• Obesity
• Immunodeficiency
• Certain disabilities
• Mental health conditions

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. 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 being admitted to an Intensive Care Unit (ICU). Conditions that may arise from lengthy ICU - stays are listed in Table 1.

Table 1. Conditions that may arise from lengthy ICU-stays

Critical Illness Polyneuropathy (CIP)	Critical Illness Myopathy (CIM)	Post Intensive Care Syndrome (PICS)
Critical Illness Polyneuropathy 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. Critical illness polyneuropathy (CIP) causes several difficulties such as: Difficulty weaning from mechanical ventilation Generalized and symmetrical weakness (distal greater than proximal, but does also include diaphragmatic weakness) Distal sensory loss Atrophy Decreased or absent deep tendon reflexes Critical Illness Polyneuropathy is associated with: Pain Loss of range of motion Fatigue Incontinence Dysphagia Anxiety Depression Post-traumatic Stress Disorder (PTSD) Cognitive loss Critical Illness Polyneuropathy is diagnosed through: Muscle Biopsies Electromyographic Testing	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. CIM 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. 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 Read more on: Pathophysiology and management of critical illness polyneuropathy and myopathy	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 Read more on Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A narrative review

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

Sequelae after COVID-19 Infection

Sequelae after Covid-19 infection

Cardiac Sequelae	Studies have shown that hospitalised patients with COVID-19 also had associated cardiac injury. Patients with this associated cardiac injury presented with: Resting heart rate increase Tachycardia Palpitations Hypotension or syncope Discontinous flushing Newly diagnosed hypertension Cardiac disease Angina pectoris Heart attack Arrhythmia 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 sequelae have been reported in patients with COVID-19The symptoms include: Headaches Disturbed consciousness Seizures Absence of sense and smell Parasthesia Posterior reversible Encephalopathy syndrome Encephalopathy, encephalitis Increased risk for acute cerebrovascular event Ischemic stroke Hemorrhagic stroke Reports of Guillain-Barre Syndrome associated with COVID-19 Myoclonus Brain fog/ Long COVID Depression, anxiety and sleep disorders These neurological factors need to be considered when a patient is entering post-acute rehabilitation after COVID-19.
Musculoskeletal Sequelae	Musculoskeletal sequelae include Physical deconditioning Severe muscle weakness Reduced joint mobility Neck and shoulder pain (due to prone lying) Difficulty in verticalization Impaired balance and gait Intensive care unit acquired weakness (ICUAW) CIP CIM Arthralgias and Myalgias Read more: Effects of Covid-19 on the Musculoskeletal System: Clinician's Guide
Pulmonary Sequelae	Impaired lung function Lung fibrosis as sequelae of pneumonia – patients showing respiratory insufficiency needing respiratory rehabilitation Tough secretions requiring specific physiotherapy techniques or technical removal Shortness of breath Post-activity polypnea Dyspnea Pain on breathing Chest distress Cough
Cognitive Sequelae	Difficult awakening with long-lasting confusional state and psychological problems Delirium and other cognitive impairments
Other Sequelae	Limitations of ADL Dysphagia Impaired swallow and communication Dermatological sequelae Digestive system sequelae Patients with severe COVID-19 infection seem to have lengthy and longer than usual stays in ICU and many complications due to the long period of immobilisation and prone positioning. 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.

Procedures for Post-Acute Covid-19 Rehabilitation

Patients who have recovered from the acute respiratory effects of COVID-19 will still need further rehabilitation.

Read more here about guidance for rehabilitation professionals on Rehabilitation for Patients with Covid -19

Post-acute Rehabilitation Guidelines after COVID-19

Each patient in the post-acute rehabilitation unit should be assessed by all the relevant healthcare professionals. A suitable and manageable treatment plan should be created with input from the healthcare team and the patient. The direct impact of COVID-19 on the respiratory system and other systems, the sequelae of COVID-19 (such as a long period of ICU stay, mechanical ventilation) as well as the comorbidities involved will direct and inform the rehabilitation plan. Other factors that will affect the rehabilitation plan is the discharge destination and estimated discharge date.

• The WHO and the PAHO have compiled a document on the rehabilitation considerations during the COVID-19 outbreak:
  • Pan American Health Organisation. Rehabilitation considerations during the COVID-19 outbreak.2020.
• The World Confederation for Physical Therapy (WCPT) has also compiled briefing papers in response to COVID-19:
  • WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy.

• WHO Scientific brief: Rehabilitation needs of people recovering from Covid -19
• This editorial provides some good insights: Two years of Covid-19: trends in rehabilitation
• WHO: Living guidance for clinical management of Covid-19 (see section on Rehabilitation)
• Post-acute and subacute Covid-19 care

General rehabilitation considerations in the post-acute phase

• Patients recovering from an acute COVID-19 event may present with a disability or functional damage (respiratory function, CIP, CIM, PICS), reduced participation and deterioration in their quality of life (short term as well as long term post-discharge)
• Variable recovery time – dependent on the degree of normocapnic respiratory failure, associated physical dysfunction (asthenia, muscle weakness), emotional dysfunction; the presence of other comorbidities
• Clinical parameter evaluating protocols are indicated on a daily basis – temperature, SaO2, Sp02/Fi02, cough, dyspnea, respiratory rate, thoraco-abdominal dynamics
• Simple and repeatable protocols to wean oxygen therapy should be used
• Reconditioning interventions are indicated in weaned patients and those with prolonged weaning from mechanical ventilation to improve physical status and effects of prolonged immobilisation
• Evaluate peripheral muscular strength with MRC scale, manual muscle testing, isokinetic muscle test; measurement of joint range of motion
• Exercise with gradual load increase and based on subjective symptoms can help to regain and maintain normal function
• Consider telehealth systems for patients that need rehabilitation but who are in isolation
• Balance function assessment is necessary as soon as possible (especially in patients who have been bedridden for a long period)
• Exercise capacity and oxygenation response during effort should be assessed
• Assessment of rehabilitation needs can be based on basic sets of measures:
  • Respiratory function (respiratory rate and SpO2)
  • Mobility (ICU Mobility Scale)
  • Muscle strength (Medical Research Council Sumscore)
  • Balance (Berg balance scale)
  • Dysphagia (fluid and food trials)
  • Activities of Daily Living (Barthel Index)
  • Mental and cognitive impairment (Montreal Cognitive Assessment, Hospital Anxiety and Depression Scale, PTSD checklist-5)

Respiratory rehabilitation

It is recommended to not begin with respiratory rehabilitation too early to avoid aggravating respiratory distress or dispersing the virus unnecessarily. Techniques such as diaphragmatic breathing, pursed-lip breathing, bronchial hygiene, lung expansion techniques (positive expiratory pressure), incentive spirometry, manual mobilisation of the ribcage, respiratory muscle training and aerobic exercise are not recommended in the acute phase. In the event of comorbidities such as bronchiectasis, secondary pneumonia or aspiration increasing secretions, postural drainage and standing (gradual increase in time) may help with secretion management.

Respiratory assessment for post-acute rehabilitation should include:

• Dyspnea
• Thoracic activity
• Diaphragmatic activity and amplitude
• Respiratory muscle strength (maximal inspiratory and expiratory pressures)
• Respiratory pattern and frequency

Also include an assessment of their cardiac status

In the post-acute phase, the following respiratory rehabilitation may be included:

• Inspiratory muscle training if inspiratory muscles are weak
• Diaphragmatic breathing
• Thoracic expansion (with shoulder elevation)
• Mobilisation of respiratory muscles
• Airway clearance techniques (as needed)
• Positive expiratory devices may be added if needed

Be careful to not overload the respiratory system and causing respiratory distress!

A randomised controlled trial from China implemented a respiratory rehabilitation program consisting of 2 sessions of 10 minutes per week for 6 weeks post-discharge from acute care. The study results showed a significant improvement in respiratory function, endurance, quality of life and depression. The respiratory rehabilitation programme included respiratory muscle training with positive expiratory pressure device, cough exercises, diaphragmatic training, chest stretching and pursed-lip breathing.

Aspects to monitor closely in patients include:

• Shortness of breath
• Decreased SaO2 (<95%)
• Blood pressure (< 90/60 or > 140/90)
• Heart rate (>100 beats per minute)
• Temperature (> 37.2 C)
• Excessive fatigue
• Chest pain
• Severe cough
• Blurred vision
• Dizziness
• Heart palpitations
• Sweating
• Loss of balance
• Headache

Patients in post-acute rehabilitation can start a multidisciplinary team rehabilitation program. Concepts of pulmonary rehabilitation can be applied, but keep in mind that pre-rehabilitation assessments such as formal lung function and exercise testing is probably not feasible at the start and cannot be done in infectious patients. Exercise training may have to start with relatively simple graded functional and strengthening exercises, using no or minimal equipment.

Read more: Pulmonary Rehabilitation for Post-COVID-19 Patients

Functional rehabilitation

Recommendations on functional rehabilitation from the European Respiratory Society include:

• Assessment of exercise and functional capacity
• Monitoring of pre-existing conditions
• Exercise training and/or physical activity coaching

Functional Rehabilitation aspects to assess:

• Muscle and joint range of motion
• Strength testing
• Balance   
• Exercise capacity – assess with the 6-minute walking test (continuous oxygen saturation monitoring included)
• Cardiopulmonary exercise testing
• Activities of Daily Living (ADL)

Clinical outcome measures

It is recommended to use easily applicable tests, as advanced equipment to assess the functional capacity of patients may not be available or safe to do during the pandemic. Clinical outcome measures that can be used:

• Patient Specific Functional Scale to identify perceived limitations in activities of daily living
• Monitor patient’s oxygen saturation and heart rate frequency before, during and after physical activity and exercises
• Use Borg Scale CR10 for shortness of breath and fatigue
• International Physical Activity Questionnaire to measure function and disability
• Physical Activity Scale for the Elderly to measure function and disability
• Berg Balance Scale
• 6 Minute Walking Test - to assess exercise capacity
• Barthel Index to measure ADL
• Short Physical Performance Battery
• 30 seconds sit to stand test
• Handgrip dynamometer test
• Manual muscle strength test

The multidisciplinary team should aim to use the same clinical outcomes for the same constructs to facilitate communication between team members and not burden the patient unnecessary.

Read more: Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection

Specific Physiotherapy Interventions

• Ways of early mobilisation include:
  • Frequent posture changes
  • Bed mobility
  • Sit to stand
  • Simple bed exercises
  • ADL’s

It is important to monitor the patient’s respiratory and hemodynamic state during rehabilitation!

• Active limb exercises should be followed by progressive muscle strengthening (suggested programs 8-12 RM load for 8 -12 repetitions, 1 to 3 sets with 2 minutes rest between sets, 3 sessions a week for 6 weeks)
• Neuromuscular electrical stimulation can be used to help with strengthening.
• Aerobic reconditioning can be achieved with walking, cycle or arm ergometry, NuStep cross trainer
• Keep aerobic activity less than 3 metabolic equivalents of task (MET’s) initially
• Progressive aerobic exercise can later be increased to 20 -30 minutes
• Education on energy conservation and behavior modification

Advice on exercise as medicine

• Gradual increase of daily living activities and physical functioning
• Provide patient with exercises that support recovery in daily function
• All activities should be well monitored especially in patients with PICS
• Perform exercises at low to moderate intensity and off limited duration. Keep in mind that patients who have been admitted to ICU and who show symptoms of PICS will have a very low capacity to perform activities and exercise.
• The activity levels of the patient prior to COVID-19 infection, the patient’s needs and the current physical abilities of the patient will determine the specific parameters for exercise prescription
• Recommendation of a maximum score of 4/10 on Borg Scale CR10 for shortness of breath and fatigue during the post-acute rehabilitation phase as patients have reduced lung function after COVID-19 infection and cardiac function may possibly be affected after COVID-19 infection.
• No maximal exercise testing is done after active COVID-19 infection - limitations due to pandemic. So there will not always be adequate clinical information to determine a patient's specific parameters for exercise prescription and also not possible to estimate the risk involved of physical training at a moderate/high intensity.
• Prescribe exercises with training parameters regarding frequency, intensity, time/duration and type

Multidisciplinary team involvement

Various members of the multidisciplinary team will be involved in the post-acute rehabilitation phase of survivors of severe COVID-19. Some of these team members include:

• Occupational therapists
  • Focus ADL and instrumental ADL guidance
  • Interventions to facilitate functional independence
  • Help to prepare the patient for discharge
  • Can address cognitive changes
• Speech and language pathologists/therapists
  • Assess and treat dysphagia as a result of intubation
  • Assess and treat voice impairments as a result of prolonged intubation
  • Address communication issues
• Education on healthy lifestyle and the importance of participating in family and social activities should be provided to the patient.
• Psychological interventions should be provided where required for patients by occupational therapists, social workers or rehabilitation psychologists.
• Chinese medicine techniques (tai chi, Qigong, guided breathing) have been suggested by the Chinese

Actions for Rehabilitation Service Providers

These are actions that rehabilitation facilities, private practices and hospitals can take during the COVID-19 pandemic to improve and ensure quality service delivery.

• Stay informed on the outbreak status and regional and national guidelines regarding COVID-19
  • Set-up communication links with all relevant COVID-19 coordination bodies and networks
  • Source, disseminate and enforce COVID-19 guidelines and protocols
  • Ensure frequent communication with patients and distribute important information
• Rehabilitation should be integrated into Infection Prevention and Control (IPC) measures and healthcare workers should use Personal Protective Equipment (PPE) appropriate to their risk exposure
  • Have set protocols for IPC (to whom, when, and how these apply)
  • Rehabilitation professionals like physiotherapists may engage in the delivery of Aerosol Generating Procedures (AGP's) and the essential PPE is required for this
  • The rehabilitation workforce (and family members) should have priority access to COVID-19 testing
  • IPC training is critical to all rehabilitation professionals
• Increase the rehabilitation workforce for the post-acute and long-term recovery phases after COVID-19
  • Address workforce shortages
  • Source rehabilitation professionals from areas such as retired workforce, trainees, academics, private practice
  • Develop competency-based training and supervision for professionals who are rejoining the rehabilitation workforce or shifting their roles to provide support
  • Ensure productivity of the existing workforce by implementing measures such as leave postponement, modifying shift structures, increasing part-time contract to full time
  • Identify high-risk rehabilitation healthcare professionals and define clear and strict conditions for their practice
  • The wellbeing of rehabilitation professionals can be supported by monitoring for and taking steps to prevent burnout, and guarantee access to psychosocial support
• Additional equipment
  • Attain additional equipment needed for the surge in rehabilitation demand related to COVID-19 patients, such as pulse oximeters, rehabilitation equipment such as hoists, walking aids, equipment used during respiratory/pulmonary rehabilitation such as stationary bikes
  • Attain additional assistive devices that can support early discharge, such as walking frames, commode chairs, mattresses and transfer products
• Rehabilitation clinical management for COVID-19 patients
  • Implement clinical management guidelines and protocols of care related to COVID-19 patients based on best available evidence
  • Adaptable rehabilitation resources for COVID-19 patients who experience ongoing respiratory and physical deconditioning should be available
  • These may include:
    • Exercise programs with graded exercises
    • Pacing strategies
    • Behavior modification
    • Advice on positioning
  • Recognition of red flags such as signs of medical deterioration
  • Implement systems for tracking COVID-19 patients and remote-follow-up
  • Implement referral pathways and develop contact lists for services required by COVID-19 patients
• Rehabilitation practices modification for Infection control
  • Develop and implement protocols for the management of rehabilitation equipment and assistive devices to reduce infection risk
  • Prepare rehabilitation professionals for the impact of PPE such as the time involved donning and doffing PPE and the impact it will have on patient rapport
  • Plan for working in different teams to reduce therapist-patient exposure
  • Amendments to the scope of practice and more interdisciplinary practice to minimize patient’s contact with multiple professionals
  • Multidisciplinary teamwork will be more virtual meetings than face to face interactions
  • Address barriers to telehealth such as technology, devices, network  and costs
  • Group patients beds and adjust the spacing to reduce the risk of infection
  • Rehabilitation sessions should rather be done within a patient’s bed space in order to restrict the movement of patients within a rehabilitation facility
  • Avoid the use of shared therapy spaces such as gyms
  • Develop protocols for patient discharge to maximize bed availability and minimize the patient time in the rehabilitation facility
• Encourage and ensure access to psychosocial support for patients
  • Increased levels of anxiety and depression as seen in COVID-19 patients. Ensure that patients have access to the support that they need during their rehabilitation process
  • Be aware of patients’ normal family or support structure being disrupted due to the COVID-19 outbreak. Facilitate support such as communication with family members.
  • Provide training and access to psychological first aid skills for rehabilitation professionals
  • Implement peer support mechanisms

Resources

• Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process
• Rehabilitation considerations during the COVID-19 outbreak
• WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy.
• Physiotherapy recommendations in patients with COVID-19
• Post-COVID rehabilitation and management strategies
• The Stanford Hall consensus statement for post COVID-19 rehabilitation