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.

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

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 being admitted to an Intensive Care Unit. Conditions that may arise from lengthy ICU-stays include:

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. 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

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.
• 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. 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.

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 event
• 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.

Musculoskeletal sequelae

Perspectives from physiotherapists in Northern Italy indicate specific problems encountered in the post-acute phase. These include:

• Physical deconditioning
• Severe muscle weakness
• Reduced joint mobility
• Neck and shoulder pain (due to proning)
• Difficulty in verticalization
• Impaired balance and gait
• CIP
• CIM

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 (Kiekens et al, 2020)

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

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.

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