Innovative Approaches in Providing Rehabilitation during the COVID-19 Pandemic: Difference between revisions
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* Direct contact between patients with providers and the ability for constant feedback enhances trust/peace of mind<ref name=":3" /> | * Direct contact between patients with providers and the ability for constant feedback enhances trust/peace of mind<ref name=":3" /> | ||
There are certain challenges associated with telehealth, which has limited its uptake prior to COVID-19.<ref>Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53.</ref> These are discussed in more detail [[Ethical and Professional Considerations with Telehealth|here]] and [https://physio-pedia.com/Practical_Considerations_in_Telehealth here], but key difficulties include the need for both providers/patients having access to stable internet and the appropriate technology to engage in this mode of communication. Similarly, both the health provider and the patient must have the knowledge to be able to use the technology and be able to access support for any troubleshooting.<ref name=":2" /> | There are certain challenges associated with telehealth, which has limited its uptake prior to COVID-19.<ref>Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53.</ref> These are discussed in more detail [[Ethical and Professional Considerations with Telehealth|here]] and [https://physio-pedia.com/Practical_Considerations_in_Telehealth here], but key difficulties include the need for both providers/patients having access to stable internet and the appropriate technology to engage in this mode of communication. Similarly, both the health provider and the patient must have the knowledge to be able to use the technology and be able to access support for any troubleshooting.<ref name=":2" /> | ||
== Prehabilitation == | |||
Another innovation being explored in the context of COVID-19 is prehabilitation. Prehabilitation focuses on preparing individuals for upcoming physiological stressors<ref name=":4">Silver, JK. Prehabilitation may help mitigate an increase in COVID-19 peripandemic surgical morbidity and mortality. American Journal of Physical Medicine & Rehabilitation. 2020; 99(6): 459-63.</ref> - by providing strategies to enhance general health and fitness, patients are more likely to have better outcomes.<ref name=":0" /> Prehabilitation has been explored more widely in pre-surgical patients and has been shown to be an effective method of enhancing outcomes for patients undergoing various elective surgeries.<ref name=":4" /> | |||
It has been proposed that prehabilitation may be particularly useful during the COVID-19 pandemic for two key reasons: | |||
# To improve the general health of those who may be vulnerable to COVID-19 (ie those who are older and/or who have pre-existing health conditions)<ref name=":5">Silver J. Prehabilitation could save lives in a pandemic. BMJ. 2020; 369.</ref> | |||
# To enhance the health of patients who have experience delays in elective surgery due to the COVID-19 pandemic (irrespective of if they contract COVID-19 or not). As COVID-19 becomes less prevalent, there will be a push to re-schedule these surgeries. A patient’s risk profile during a long period of social distancing/stay home orders may have changed, particularly if a patient has become deconditioned. Prehabilitation could therefore be a way to reduce risk and enhance outcome for these patients.<ref name=":4" /> | |||
It is important to note that, at this stage, these are only proposed benefits as there is no specific research to support its use thus far, but essentially prehabilitation will be most beneficial for those who are most vulnerable.<ref name=":4" /> | |||
It has been found that single modalities (eg exercise or diet) can be beneficial prior to surgery/stressor, but there is a general shift towards implementing multimodal prehabilitation programmes.<ref name=":4" /> Some interventions that could be included in a prehabilitation plan include: | |||
* Advice about smoking cessation | |||
* Regular exercise - people should be encouraged to at least maintain their baseline activity level<ref name=":5" /> | |||
* Good nutrition (particularly supplementation with protein and advice around glycemic control in patients with diabetes) | |||
* Physiological stress reduction<ref name=":4" /><ref name=":5" /> | |||
Rehabilitation providers can also emphasise the importance of hand/respiratory hygiene and social distancing when undertaking prehabilitation interventions.<ref name=":0" /><ref name=":4" /> Importantly, these interventions can all be provided in the context of social distancing and be delivering by telehealth.<ref name=":5" /> | |||
However, when creating prehabilitation plans, it is important to be mindful of the amount of information included. If too much information is included, patients may become overwhelmed or confused and be less likely to engage in the programme. Thus, it may be better to focus on a smaller number of interventions that will have the greatest effect.<ref name=":4" /> | |||
== Maintaining Services for Non-COVID-19 Patients == | |||
One key feature of the COVID-19 response is that many more critical care beds are needed to accommodate patients who become severely unwell with the virus.<ref name=":6">UCL News. Covid-19: UCL pilots virtual rehabilitation for discharged stroke patients. Available from https://www.ucl.ac.uk/news/2020/apr/covid-19-ucl-pilots-virtual-rehabilitation-discharged-stroke-patients (accessed 10 July 2020). </ref> Thus, other patients, including stroke patients or patients with brain injury, are being discharged much earlier than usual. | |||
However, normal community rehabilitation programmes cannot be implemented due to social distancing requirements. Thus, various pilot programmes are being considered to ensure that these patients still have access to essential rehabilitation services.<ref name=":6" /> One such programme, created by the UCL Centre for Neurorehabilitation, intends to deliver all stroke rehabilitation, including emotional and physical rehabilitation, remotely.<ref name=":6" /> | |||
Using a repurposed web portal, the UCL are able to provide virtual group rehabilitation sessions (via laptops/tablets/phones) for up to twenty people. All rehabilitation sessions are scheduled and patients are invited to participate. Sessions include physiotherapy, occupational therapy, speech and language therapy, cognitive strategy, fatigue management and emotional support. There are also options for one-on-one consultations and the programme includes access to other apps, as well as exercise videos on YouTube.<ref name=":6" /> | |||
Similarly, other organisations are exploring methods to provide Pulmonary Rehabilitation via telehealth.<ref name=":7">Agency for Clinical Innovation. Delivering pulmonary rehabilitation via telehealth during COVID-19. Chatswood NSW. 2020. 25 p. Report No.: 1. </ref> It is important to try to keep individuals with chronic lung disease out of hospital during the COVID-19 pandemic for two reasons: | |||
# To reduce the burden on already stretched health systems | |||
# To reduce these patients’ risk of being exposed to COVID-19<ref name=":7" /> | |||
One such guideline for virtual Pulmonary Rehabilitation can be found [https://pulmonaryrehab.com.au/wp-content/uploads/2020/06/ACI-Guide-for-Virtual-Models-of-Pulmonary-Rehabilitation_final.pdf here]. | |||
It has also been suggested that Pulmonary Rehabilitation may be beneficial for post-COVID-19 patients as it could improve symptoms, functional capacity and quality of life. While the best exercise programme intervention remains unknown, programmes delivered by telehealth could be beneficial in preventing further transmission of the virus.<ref>Ambrosino N. An [https://www.monaldi-archives.org/index.php/macd/article/view/1444/1048 Italian consensus on pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process.] Monaldi Archives for Chest Disease. 2020;90(1444):1444.</ref> | |||
== Summary == | |||
* It is essential to maintain rehabilitation services while ensuring the safety of patients and health workers | |||
* Telehealth/virtual rehabilitation provides a means of ensuring that services continue for both COVID-19 and non-COVID-19 patients during the pandemic | |||
* Prehabilitation may be a useful method of optimising the health outcomes of individuals who become sick with COVID-19 and those who are experiencing delays in elective surgery due to COVID-19 | |||
== References == | |||
<references /> | |||
Revision as of 04:34, 10 July 2020
Introduction[edit | edit source]
COVID-19 is currently placing significant pressure on health services around the world. While the majority (81%) of individuals who get COVID-19 have mild illness, including fever, cough and dyspnoea (REF SIMPSON), a significant minority face serious complications, particularly those who have comorbidities or who are older than 65 years.[1] It has been reported that, thus far, of those requiring hospital level of care, 20.3% need ICU management, most commonly because of Acute Respiratory Distress Syndrome ARDS (32.8%).[1]
There is currently no treatment for COVID-19. The management provided in hospital settings is supportive and it is likely that there will be a large number of COVID-19 survivors who require significant rehabilitation support after they recover.[1] Common sequelae of critical illness are:
- Persistent changes in carbon monoxide diffusion capacity
- Intensive-care acquired weakness
- Critical illness polyneuropathy/critical illness myopathy
- Cardiorespiratory deconditioning
- Impairment of cognitive function (delirium)
- Mental health impairment[1]
Commonly recorded complications of COVID-19 are:
- Neurological complications such as stroke
- Critical care neuropathy
- Complications associated with prolonged bed rest (such as venous thromboembolism, disseminated intravascular coagulation, acute kidney injury, delirium anxiety, post‐traumatic stress disorder)[2]
In general, patients who experience critical illness and who are ventilated for more than seven days will usually require quite significant rehabilitation input - for instance, sixty percent of these patients will initially be unable to walk.[2] If patients experience stroke or cardiac complications following COVID-19, they will require rehabilitation for an extended period - in some cases, they will require lifelong support.[2]
Rehabilitation services are, therefore, essential if patients are to optimise their physical and cognitive functioning and reduce disability.[3] However, during a pandemic when social distancing is required, healthcare providers need to explore innovative approaches to rehabilitation to ensure that both COVID-19 and non-COVID-19 patients receive adequate care and support.[1]
Telehealth[edit | edit source]
Any reduction in rehabilitation services has a significant impact on patients, families and healthcare workers.[3] One way in which rehabilitation providers can prevent disruptions to services during the COVID-19 pandemic is to adopt telehealth or virtual rehabilitation.[4]
The practicalities of telehealth are discussed in detail here, but a key benefit of virtual rehabilitation is that it enables personalised consultations and treatments to continue via electronic media (phone and/or video) during the pandemic, thus eliminating the risk of transmission of the virus.[1][4] This is significant as it protects both patients and the healthcare team - during the last major viral outbreak prior to COVID-19 in 2002, a fifth of all cases were health workers.[4]
Other benefits of virtual rehabilitation include:
- Innovative technology is often appealing to users, which can increase adherence and decrease the potential for patients to give up on treatment
- Direct contact between patients with providers and the ability for constant feedback enhances trust/peace of mind[4]
There are certain challenges associated with telehealth, which has limited its uptake prior to COVID-19.[5] These are discussed in more detail here and here, but key difficulties include the need for both providers/patients having access to stable internet and the appropriate technology to engage in this mode of communication. Similarly, both the health provider and the patient must have the knowledge to be able to use the technology and be able to access support for any troubleshooting.[3]
Prehabilitation[edit | edit source]
Another innovation being explored in the context of COVID-19 is prehabilitation. Prehabilitation focuses on preparing individuals for upcoming physiological stressors[6] - by providing strategies to enhance general health and fitness, patients are more likely to have better outcomes.[1] Prehabilitation has been explored more widely in pre-surgical patients and has been shown to be an effective method of enhancing outcomes for patients undergoing various elective surgeries.[6]
It has been proposed that prehabilitation may be particularly useful during the COVID-19 pandemic for two key reasons:
- To improve the general health of those who may be vulnerable to COVID-19 (ie those who are older and/or who have pre-existing health conditions)[7]
- To enhance the health of patients who have experience delays in elective surgery due to the COVID-19 pandemic (irrespective of if they contract COVID-19 or not). As COVID-19 becomes less prevalent, there will be a push to re-schedule these surgeries. A patient’s risk profile during a long period of social distancing/stay home orders may have changed, particularly if a patient has become deconditioned. Prehabilitation could therefore be a way to reduce risk and enhance outcome for these patients.[6]
It is important to note that, at this stage, these are only proposed benefits as there is no specific research to support its use thus far, but essentially prehabilitation will be most beneficial for those who are most vulnerable.[6]
It has been found that single modalities (eg exercise or diet) can be beneficial prior to surgery/stressor, but there is a general shift towards implementing multimodal prehabilitation programmes.[6] Some interventions that could be included in a prehabilitation plan include:
- Advice about smoking cessation
- Regular exercise - people should be encouraged to at least maintain their baseline activity level[7]
- Good nutrition (particularly supplementation with protein and advice around glycemic control in patients with diabetes)
- Physiological stress reduction[6][7]
Rehabilitation providers can also emphasise the importance of hand/respiratory hygiene and social distancing when undertaking prehabilitation interventions.[1][6] Importantly, these interventions can all be provided in the context of social distancing and be delivering by telehealth.[7]
However, when creating prehabilitation plans, it is important to be mindful of the amount of information included. If too much information is included, patients may become overwhelmed or confused and be less likely to engage in the programme. Thus, it may be better to focus on a smaller number of interventions that will have the greatest effect.[6]
Maintaining Services for Non-COVID-19 Patients[edit | edit source]
One key feature of the COVID-19 response is that many more critical care beds are needed to accommodate patients who become severely unwell with the virus.[8] Thus, other patients, including stroke patients or patients with brain injury, are being discharged much earlier than usual.
However, normal community rehabilitation programmes cannot be implemented due to social distancing requirements. Thus, various pilot programmes are being considered to ensure that these patients still have access to essential rehabilitation services.[8] One such programme, created by the UCL Centre for Neurorehabilitation, intends to deliver all stroke rehabilitation, including emotional and physical rehabilitation, remotely.[8]
Using a repurposed web portal, the UCL are able to provide virtual group rehabilitation sessions (via laptops/tablets/phones) for up to twenty people. All rehabilitation sessions are scheduled and patients are invited to participate. Sessions include physiotherapy, occupational therapy, speech and language therapy, cognitive strategy, fatigue management and emotional support. There are also options for one-on-one consultations and the programme includes access to other apps, as well as exercise videos on YouTube.[8]
Similarly, other organisations are exploring methods to provide Pulmonary Rehabilitation via telehealth.[9] It is important to try to keep individuals with chronic lung disease out of hospital during the COVID-19 pandemic for two reasons:
- To reduce the burden on already stretched health systems
- To reduce these patients’ risk of being exposed to COVID-19[9]
One such guideline for virtual Pulmonary Rehabilitation can be found here.
It has also been suggested that Pulmonary Rehabilitation may be beneficial for post-COVID-19 patients as it could improve symptoms, functional capacity and quality of life. While the best exercise programme intervention remains unknown, programmes delivered by telehealth could be beneficial in preventing further transmission of the virus.[10]
Summary[edit | edit source]
- It is essential to maintain rehabilitation services while ensuring the safety of patients and health workers
- Telehealth/virtual rehabilitation provides a means of ensuring that services continue for both COVID-19 and non-COVID-19 patients during the pandemic
- Prehabilitation may be a useful method of optimising the health outcomes of individuals who become sick with COVID-19 and those who are experiencing delays in elective surgery due to COVID-19
References[edit | edit source]
- ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 Simpson R, Robinson L. Rehabilitation after critical illness in people with COVID-19 infection. Am J Phys Med Rehabil. 2020;99(6):470-474.
- ↑ 2.0 2.1 2.2 Faux SG, Eager K, Cameron ID, Poulos CJ. COVID ‐19: planning for the aftermath to manage the aftershocks. MJA. 2020 Jun 29.
- ↑ 3.0 3.1 3.2 Bettger JP, Thoumi A, Marquevich V, De Groote W, Battistella LR, Imamura M, Ramos VD, Wang N, Dreinhoefer KE, Mangar A, Ghandi DB. COVID-19: maintaining essential rehabilitation services across the care continuum. BMJ Global Health. 2020 May 1;5(5):e002670
- ↑ 4.0 4.1 4.2 4.3 Dy Care. Rehabilitation and physiotherapy in times of pandemic. Available from https://www.dycare.com/products/rehabilitation-and-physiotherapy-in-times-of-pandemic/ (accessed 10 July 2020).
- ↑ Dinesen B, Nonnecke B, Lindeman D, Toft E, Kidholm K, Jethwani K. Personalised telehealth in the future: a global research agenda. J Med Internet Res. 2016; 18(3): e53.
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Silver, JK. Prehabilitation may help mitigate an increase in COVID-19 peripandemic surgical morbidity and mortality. American Journal of Physical Medicine & Rehabilitation. 2020; 99(6): 459-63.
- ↑ 7.0 7.1 7.2 7.3 Silver J. Prehabilitation could save lives in a pandemic. BMJ. 2020; 369.
- ↑ 8.0 8.1 8.2 8.3 UCL News. Covid-19: UCL pilots virtual rehabilitation for discharged stroke patients. Available from https://www.ucl.ac.uk/news/2020/apr/covid-19-ucl-pilots-virtual-rehabilitation-discharged-stroke-patients (accessed 10 July 2020).
- ↑ 9.0 9.1 Agency for Clinical Innovation. Delivering pulmonary rehabilitation via telehealth during COVID-19. Chatswood NSW. 2020. 25 p. Report No.: 1.
- ↑ Ambrosino N. An Italian consensus on pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process. Monaldi Archives for Chest Disease. 2020;90(1444):1444.
