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.

Procedures for Post-Covid-19 Rehabilitation

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

Considerations for rehab physiotherapists

Determine risk

Consider the risk involved of a patient not receiving immediate rehabilitation on outcomes such as – risk of hospitalisation, extended hospital stay)

If the therapist continues with a rehabilitation assessment or treatment – point of care risk assessments should be done prior to each patient interaction

Try and do as much as possible without patient contact – Find other innovative ways to gather information without direct contact with patients in isolation. Consider telehealth methods to conduct a subjective assessment or do  a pre-treatment screening or discharge planning; observe patient mobility, etc)

Determine the type of PPE needed for patient contact

Aerosol Generating Procedures (AGP’s)

The type of oxygen therapy the patient is receiving and the type of procedure conducted will determine if a procedure is aerosol generating>

Therapies that require airborne precautions:

High flow nasal oxygen

Non-invasive ventilation

Nebuliser treatment

Tracheostomy tubes with/without mechanical ventilation requiring open suctioning

Sputum inducing procedures require airborne precautions

Respiratory physiotherapy

Activities resulting in expectoration of sputum – moving from lying to sitting, walking, bedside ADL’;s prone positioning

Other considerations before starting direct contact treatment

It is critical to have a step-by-step process for donning and doffing PPE to avoid contamination

Use the minimum amount of people required to safely administer a treatment session

Careful consideration is needed with regards to equipment use. Be sure that it is line with infection control measures and that any equipment can be properly decontaminated. Avoid moving equipment between COVID-19 and non-COVID-19 areas. Opt for using single patient use, disposable equipment  (i.e, theraband instead of hand weights)

Suggestions for the design and procedures for an inpatient rehabilitation unit

These suggestions will need to be assessed based on the unique setting of each rehabilitation unit and the specific needs of the individual patient. Many of these suggestions are extrapolated from the experiences in China and Italy as well as from the SARS epidemic.

A separate area or unit is necessary for the rehabilitation of post COVID-19 patients

Patients might be transferred from acute care earlier than is generally done, in order to clear beds for more patients in need of acute care

Patients should stay in their rooms

Therapy should be provided one on one

group therapy and therapy in rehabilitation gyms should not be allowed

Earlier discharge of patients (as soon as the family can take care of the patient) to free up space for incoming patients

There might be difficulty in discharging patients to long-term care facilities and retirement homes as these facilities might not be taking in new residents during the pandemic

Shared equipment should be decontaminated between patients

Best to utilise single-use equipment where possible (Therabands instead of free weights)

Special care and attention should be paid to the use of electrode sponges, heat packs, gels, topical lotions, etc)

Therapeutic activities should be planned as to minimise the number of personnel needed (i.e. therapist with a gait/walking aid instead of therapist and an assistant)

Minimise the number of personnel in contact with a patient. Have single staff member perform most of the care and duties for a patient

Walking practice should be done in areas that are not commonly used

Surgical masks should be worn by patients and therapists should be using the necessary PPE

Patients should always practice social distancing among each other

Personnel Considerations in a Rehabilitation Unit

Frequent health checks for rehabilitation personnel

Staff shortages may arise either due to illness, isolation or redeployment

Changes in staff/patient ratio – more one on one sessions

Guidelines and protocols will be changing as new evidence becomes available. Continuous staff training will be paramount

Personnel should be trained and re-trained in the use of PPE

Physiotherapists should use higher levels of PPE if they are at risk of exposure to aerosols from post COVID-19 patients.

Ongoing input from frontline staff is important to inform other healthcare professionals

Other ways of providing non-required therapies and services should be considered such as telerehabilitation

Work efficiency might be affected by the use of PPE and the time it takes to don PPE, as well as infection control measures

Virtual staff meetings should be held if possible

Post-acute Rehabilitation guidelines after COVID-19

The WHO and the PAHO have compiled a document on the rehabilitation considerations during the COVID-19 outbreak, and the WCPT have also compiled briefing papers in response to COVID-19. The second briefing paper specifically addresses rehabilitation and the vital role of physiotherapy.

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 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.

Currently there is limited evidence of the impact of rehabilitation after COVID-19. The information provided is based on evidence from countries such as China, Italy and other areas. This evidence is based on the experience and expert opinions of rehabilitation healthcare professionals from these regions.

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 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 in inpatient 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 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 Postive 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 rehabilitation centre can start MDT program, use pulmonary rehabilitation concepts. Pre-rehabilitation assessment such ans formal lung function and exercise testing is probably not feasible and the start and can not be done in infectious patients. Exercise training may have to start with relatively simple graded functional and strengthening exercises, using no or minimal equipemt (Spruit et al)

Functional Rehabilitation

Kho, M.E., Brooks, D., Namasivayam-MacDonald, A., Sangrar, R. and Vrkljan, B. (2020) Rehabilitation for Patients with COVID-19. Guidance for Occupational Therapists, Physical Therapists, Speech-Language Pathologists and Assistants. School of Rehabilitation Science, McMaster University. https://srs-mcmaster.ca/covid-19/

Recommendations from ERS

Assessment of exercise and functional capacity

Monitoring of pre-existing conditions

Exercise training and/or physical activity coaching

Aspects to assess:

Muscle and joint range of motion

Strength testing

Balance   - make use of the Berg Balance Scale

Exercise capacity – assess with 6 minute walking test (continuous oxygen saturation monitoring included)

Cardiopulmonary exercise testing

Clinical outcome measures:

Patient Specific Functioning Scale to identify perceived limitations in activities of daily living

Monitor patient’s oxygen saturation and heart rate frequency before, during and after physical acitivty and exercises

Use Borg Scale CR10 for shortness of breath and fatigue

Function and disability ( use International Physical Activity Questionnaire; Physical Activity Scale for the Elderly)

MDT should aim to use the same clinical outcomes for the same constructs to facilitate idt communication and not burden the patient unneccesary

Activities of Daily Living (ADL) – use the Barthel index to measure this

In the acute care setting, physiotherapy can begin and should be continued after transfer to inpatient rehabilitation or rehabilitation centres.

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

Progressive muscle strengnthening (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 – 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 behaviour modification

Easily applicable tests as advanced equipment to assess functional capacity of pateints may not be available such as Short Physical Performance Battery, 30 seconds sit to stand test, handgrip dynamometer test and manual muscle strength test

Advice on exercise

Gradual increase of daily living activites 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 maximum score of 4/10 on Borg Scale CR10 for shortness of breath and fatigue

Why?

Reduced lung function after COVID-19

Cardiac function possibly affected after COVID-19

No maximal exercise testing is done after active COVID-19 infection- limitations due to pandemic. So no adequate clinical information to determine patient specific parameters for exercise prescription and also not possible to estimate risk of physical training at moderate/high intensity

Prescribe exercises with training parameters regarding frequency, intensity, time/duration and type (kngf)

Multidisciplinary team involvement

Occupational therapists

ADL and instrumental ADL guidance

Interventions to facilitate functional independence

Help to prepare 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

Chinese medicine techniques (tai chi, Qigong, guided breathing)

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.

Considerations in the Post -Acute phase

Patients recovering from acute COVID-19 event may present with disability or functional damage (respiratory function, CIP, CIM, PICS) reduced participation and deterioration in quality of life (short term as well as long term post discharge)

Variable recovery time – dependent on degree of normocapnic respiratory failure, associated physical dysfunction (asthenia, muscle weakness), emotional dysfunction; presence of other comorboidities

Clinical parameter evaluating protocols 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 (6 min walk test 6MWT)

Actions for rehabilitation service providers  (rehabilitation facilities, private practices, hospital)

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 Preventions and Control (IPC) measures and healthcare workers should use 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 AGP 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 workfroce or shifting their roles to provide support

Ensure productivity of existing workforce implementing measures such as leave postponement, modifying shift structures, increase 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 respiraroty/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 COVIV-19 patients who experience ongoing respiratory and physical deconditioning should be available. These may include:

Exercise programmes with graded exercises

Pacing strategies

Behaviour modification

Advice on positioning

Recognition of red flags such as signs of medical deteriotation

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 – time involved, heat and the impact it will have on patient rapport

Plan for working in different teams to reduce therapist patient exposure

Amendments to scope of practice and more interdisciplinary practice to mimise patient’s contact with multiple professionals

Multidisplicinaty teamwork will be more virtual meetins than face to face interactions

Address barriers to telehealth such as technology, devices, network  and costs

Group patients beds and adjust spacing to reduce the risk of infection

Rehabilitation sessions should rather be done within a patient’s bed space in order to restrict movement of patients within a rehabilitation facility

Avoid use of shared therapy spaces such as gyms

Develop protocols for patient discharge to maximise bed availability and minimize patient time in rehabilitation facility

Encourage and ensure access to psychosocial support for patients

Increased levels of anxiety and depression is seen in COVID-19 patients. Ensure that patient 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

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