COVID-19: Community Rehabilitation

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Introduction

Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include:

Graded exercise

Education on energy conservation and behaviour modification

Home modification

Assistive products

Patients may also benefit form pulmonary rehabilitation interventions – this targets physical and respiratory impairments and include a combination of graded exercise, education, activity of daily living and psychosocial support.

Pandemic related constraints (such as social distancing, limited human resources and limited public transport) and infection risks following discharge might mean physiotherapists need to think out of the box and find innovative ways to provide rehabilitation services.

This could include telehealth

Remote exercise  - such as “virtual group” education and exercise

Peer to peer support from COVID-19 patients who have received the appropriate training

Rehabilitation services in people’s communities are often the best-placed to provide long-term care

https://iris.paho.org/bitstream/handle/10665.2/52035/NMHMHCOVID19200010_eng.pdf?sequence=6&isAllowed=y

Healthcare needs of COVID-19 patients following discharge https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0388-after-care-needs-of-inpatients-recovering-from-covid-19-5-june-2020-1.pdf

Patients may present with various issues on discharge from hospital. Rehabilitation specialists such as physiotherapists in the community will be needed to provide the relevant care of these patients.

The issues still prevalent in a patient recovering from COVID-19 following discharge will guide and inform the patient’s care and support plan. This can include considerations such as if the patients will be able to care for themselves and manage their needs and what wider support will be necessary.

These issues may include:

Physical issues

Such as weakness

Fatigue

Balance

Gait issues

Loss of function

Respiratory problems –

such as breathlessness, oxygen desaturation

Psychological and neuro-psychological issues

Patients may present with anxiety, depression  or PTSD and other psychological difficulties as a result of their experience of the illness and the treatment they received

Social issues

A patient’s circumstances may be affected by the pandemic and changes during periods of lockdown

It is critical that the needs of the patient and the symptom management should always be considered and addressed in a holistic way. The patients’ needs will also change as rehabilitation progresses and the treatment goals should be adjusted accordingly.

Physical Issues

Respiratory

Patients may require supplemental oxygen following discharge, either temporary or long-term

Pulmonary rehabilitation - the need for this will depend on the severity of the COVID-19 infection, existing comorbidities and the patients’ functional status

Pulmonary vascular disease – evidence shows that patients with COVID-19 experience a high prevalence of thromboembolic disease and patients that were treated in ICU with severe COVID-19 may develop pulmonary artery hypertension

Chronic cough  - this is defined in adults, as having a cough lasting over eight weeks. Cough is one of the most common clinical features in patients with COVID-19, but research is still lacking on chronic cough post- COVID-19 infection

Lung fibrosis – about 30% of SARS and MERS survivors experienced physiological impairment and abnormal radiology that is consistent with fibrotic lung disease. Pulmonary fibrosis may be a consequence of COVID-19.

Pulmonary physiology interventions to determine effect on lung function

Pulmonary function tests such as spirometry, lung volumes, gas transfer and exercise capacity may need to be done to determine the physiological impact of the effect of COVID-19. These tests are necessary to manage potential pulmonary scarring and resulting fibrosis, but the timing and nature of the tests to be done still needs to be determined.

Possible risk of bronchiectasis after COVID- 19 infection need to be considered

Cardiac

Acute myocardial injury is the most common described cardiovascular complication in patients with COVID-19 ( occurring in 8-12% of discharged patients, heart failure is reported in 12% of recovered and discharged patients)

Neuromuscular

Hospital acquired weakness

The impact of COVID-19 on the incidence of Hospital Acquired Weakness, deconditioning in hospital and the long-term physical weakness is still not known. There seems to be anecdotal evidence from the UK and Europe that there might be a higher than usual incidence ICU-AW compared to the usual critical care cohort. Early physical rehabilitation following hospital discharge is beneficial and may improve quality of life. An eight week pulmonary rehabilitation programme in survivors of ARDS significantly improved quality of life and exercise capacity. Physiotherapy is critical in addressing these issues of deconditioning and weakness.

Neuropathy

Patients may have neuropathies following discharge. One of the treatment methods for patients with respiratory failure is prone positioning for up to 16 hours per day. This may put patients at risk for compression neuropathies and neural damage. Other issues may be pressure damage to heels and other areas due to prolonged bed rest, lack of sensation, lack of proprioception and an increased risk for falls. Physiotherapist are key role players in the assessment and treatment on neuropathies.

General function and well-being

Fatigue

People who have had COVID-19 report extreme fatigue beyond the usual reported levels. This will influence the recovery rate, the need for support and the need for supportive equipment, as well as a person’s return to their normal activities and work. A gradual increase and return to activities and exercise is advised and patients need to be taught pacing strategies. Physiotherapists are in the unique position to early identify fatigue in patients and can implement fatigue management strategies. This can include sleep hygiene, energy conservation techniques, pacing, gradual increase in activity and graded exercise. The early implementation of these fatigue management strategies could limit the impact of fatigue and the possibility of fatigue developing into a chronic condition.

New challenges to treatment of discharged COVID-19 patients

Increased number of patients with Post Intensive Care Syndrome (PICS)

Maintaining infection control

Increased pressure on equipment provision – such as oxygen cannisters, personal protective equipment

Increased pressure on staffing

Increased number of patients with persisting psychological difficulties following hospital discharge

Emerging clinical perspectives that affects rehabilitation of COVID-19 patients

Post Intensive Care Syndrome (PICS) https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf

The aftershock of the pandemic will include ongoing rehabilitation needs of patients with PICS. Coordinated rehabilitation approaches should be considered and developed for this specific cohort of patients.

Post-viral fatigue syndrome https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf

There is the potential that people recovering from COVID-19 may develop post-viral fatigue syndrome. It is critical that physiotherapists are aware of the signs and symptoms of PVFS and be aware and know the management strategies. These management strategies should focus on rest, hydration and nutrition.

If the symptoms of post viral fatigue syndrome do not resolve within 4-5 months after viral infection it could then be diagnosed as Myalgic Encephalomyelitis (Chronic Fatigue Syndrome).

The main symptom of ME is post-exertional malaise and it is important that physiotherapists know this and also know the appropriate treatment. A key factor to keep in mind is that progressive physiotherapy can be harmful to people with ME. People with ME have an abnormal response to exercise. This abnormal response include:

Lower anaerobic threshold

Lower oxygen capacity

Increased acidosis

Abnormal cardiovascular responses

Suitable management approaches in:

Symptom contingent pacing

Heart rate monitoring

Following discharge, the support of the patient should be kept under review as the person’s situation changes and the personalised support and care plan also adapts. Some principles to consider once a person is home after a COVID-19 infection include:

Existing services: Patients should be supported through adapting and strengthening the local existing services in a community, as far as possible. These systems will differ between countries.

Infection risk: Infection prevention control measures should adhere to the local and national guidelines as set out the specific region or country.

Minimise steps: The number of steps in a treatment or management pathway of a patient being discharged from hospital should be minimised as well as the number of healthcare professionals involved in the management of the patient. This will help to further reduce the risk of infection.

Volunteers and carers: If available in a region or country make use of volunteers and carers to support patients

Education and training: The education and training needs of rehabilitation professionals involved in the care of COVID-19 patients need to be reviewed

Support for rehabilitation professionals: Psychological and practical support for rehabilitation professionals during the pandemic should be provided.

Video to add: https://www.youtube.com/watch?v=3sURTAaxmc8

Post Covid-19 effects could include: https://covidpatientsupport.lthtr.nhs.uk/#/

Muscle weakness and joint stiffness

Extreme tiredness and fatigue and lack of energy

Loss of apetite and weight loss

Sleep problems

Mental problems

Mood changes

Nightmares

PSTD

Ways to address breathlessness

Breathing control techniques

Positions of ease to help in assisting breath control such as:

Leaning forward while sitting

Leaning forward in standing while supported

Standing up, leaning backwards while supported (for example – lean back against a wall)

Sidelying with shoulders and head raised

Secretion management

Deep breathing techniques

Breath stacking technique

Postural drainage

Staying mobile as allowed by energy levels

Stay hydrated

Energy conservation methods

Things to remind patients:

Energy needs may fluctuate

Exercise is good – but be wise about it

Do activities they are comfortable doing, learn to stop and modify when tasks are difficult and modify

Set small goals

Aim to do a little more every day, but avoid overdoing it

Take breaks between tasks

Graded exercises

Bed exercises:

Neck movements

Neck rotations

Shoulder rolls

Arm raises

Biceps curls – no weight

Quadriceps setting

Leg raises

Ankle rolls

Exercises while sitting

Assisted shoulder exercises

Biceps curls with light weight

Above shoulder exercises with weights

Side shoulder exercises

Heel toe raises

Knee raises

Leg raises

Exercises while standing

Leg to the side

Leg backwards

Sitting squads

Knee raises

Toe raises

Core stability exercises

Pelvic tilts

Bridging

Hip rolls

Rehabilitation strategies from various countries

This is just a short summary of some rehabilitation strategies and interventions from different countries. Evidence is still emerging and the clinical guidance may change as more is learnt about the natural history of the disease.

Pulmonary Rehabilitation in COVID-19 patients recovering from ARDS – Suggestions from Italy

https://www.monaldi-archives.org/index.php/macd/article/view/1444/1048

This is the result of and Italian consensus through a Delphi process that was published in June 2020. The full article can be accessed here. Some of the suggestions that may influence the rehabilitation of patients discharged from hospital will be highlighted here:

Personal Protection Equipment

Suggestions for personal protection needs:

Appropriate PPE should be used by healthcare professionals and they should be trained in the proper donning and doffing procedures of PPEIn the first 3 months after infection, also if patient has negative nasal/throat swabs, use eye and respiratory protections, gloves and if possible disposable gown when using AGP’s

All patients should wear a medical mask during treatment

Measures to minimise droplet and aerosol dispersion should be implemented during AGP’s

Outpatient consultation: aerate the examination room after each consultation

Sanitize surfaces

Ensure spatial distance between patients in waiting rooms

Diagnosis of COVID-19 phenotype patients

Phenotypes

The following is still unknown:

Days of contagious risk

Need for pulmonary rehabilitation

Timing to commence pulmonary rehabilitation

Predictors of recovery

Pulmonary rehabilitation is proposed for:

Dyspnoeic, older patients with comorbidities with:

long length of hospital stay

history of ICU

needing weaning from mechanical ventilation

Reduced strength and exercise capacity

In need of oxygen at rest and during effort

Individualised pulmonary rehabilitation programs should be proposed

Frailty measures

Patients with frailty could be affected more seriously and may have a poor prognosis

Recognition of frailty is important before setting up a PR program, to reduce the risk of poor outcomes

Multidimensional assessment should be incorporated in frailty measurements such as:

Global exercise capacity

Strength

Balance

Coordination

Nutritional

Psychosocial status

Timing of Pulmonary Rehabilitation commencement

No clear scientific evidence for the timing as yet

PR is recommend from early stage in hospital

Interestingly, A suggestion that was not approved by the consensus panel was that outpatient rehabilitation programmes and telemedicine should be considered for patients discharged from hospital. Reasons for this included inconclusive literature evidence on telerehabilitation, the belief that telerehabilitation could only be used for stable patients and obstacles of telerehabilitation such as usable technology for largest possible number of patients, safety of patients at home; medico-legal liability and the issues around economic reimbursement.

Assessments

Discharge outcomes following COVID-19 is still unknown

Assessments should include: symptoms scales, cardiorespiratory function, pulmonary function tests, respiratory muscle strength, comorbidities, neurological and pshychological disorders and frailty

Outcome measures shoulde include: exercise tolerance, functional status and physical performance, presence of Critical Illness neuromyopathy and ICU-AW, ADL, baseline functional impairment due to dyspnea and how breathlessness affects patient’s mobility

Gas exchanges and best informative indexes

Pulse oximetry and SaO2/FiO2 values are critical to monitor clinical situation at rest and during effort

Pulse oximetry device at home is recommended

Lung function tests

When safe to perform by operators and patients

Not to be used as outcome measures of pulmonary rehabilitation programs

Severe impairment should not be considered a contra-indication for PR

Functional Evaluation

At discharge and before start of PR following discharge an assessment of physical performance and ADL autonomy is necessary.

Standard maximal cardiopulmonary exercise test is not recommended in the first 6-8 weeks following acute hospital discharge due to unknown cardiorespiratory and muscle involvement and infectious risk

Exercise induced oxygen desaturation assessment is critical during exercise tolerance tests

With exercise and exercise testing – fatigue and breathlessness should be evaluated through psychometric scales such as BORG scale or VAS

Follow-up assessments should routinely include monitoring of physical performance

Respiratory muscle assessment

Unknown factors: prevalence, severity and recovery of respiratory muscle weakness due to COVID

Standard maximal inspiratory and expiratory pressures (MIP/MEP) are not recommended in the first phase (6-8 week) due to infection risk

Quality of life assessment

Test for presence of disorders such as anxiety, depression, sleep disturbances, PTSD

Assess patients level of autonomy

Assess the quality of patient’s support network

Obtain a global measurement of the patient’s perceived QoL level

Emotional aspects to identify

Neuropsychological assessment at baseline and post PR

Measures of psychosocial effects such as depression, anxiety, PTSD

Do not ignore the long term psychological and psychosocial implications of infectious diseases

Consider caregiver and family of patient affecte by COVID

Interventions

Oxygen therapy

Oxygen need at rest, during effort and sleep should be assessed

Use standardised tests such as 6MWT (if patient is able to) to assess oxygen need during effort

Precautions about air dispersion distance should be considered during oxygen administration

Exercise programs

PR in post COVID Patients could improve symptoms, functional capacity and quality of life, but best exercise program intervention is still unknown

Exercise training principles in patients with chronic lung disease could be considered in post-COVID patients

In patients with mild or no disability (SPPB >10; Barthel Index > 70) – Aerobic exercise <3.0 METs with progressive increase of intensity based on symptoms (BORG fatigue and/or dyspnea below the score of 3) is advised to restore normal physical function

In patients with moderate to severe disability (SPPB<10; Barthel index <70) – a comprehensive rehabilitation programme is recommended to improve autonomy, peripheral and respiratory muscle strength, balance, walking ability, symptoms and Quality of life

Aerobic exercise (cycling, treadmill, free walking) and resistance strength training should be included in the exercise program

SpO2 Measurement is mandatory during exercise, subsequent oxygen supplementation may be prescribed if Sp02 < 93%

Lung recruitment exercises

Chest expansion breathing control exercises associated with posture positioning should be considered

Respiratory muscle training

Not routinely recommended, but could be used if respiratory muscle weakness is present

The type, efficacy and duration of muscle training in COVID-19, post-acute or longterm still needs to be investigated

Inspiratory muscle training should start at low intensity guided by dyspnea/fatigue and vital signs

Telerehabilitation

May be an appropriate response following discharge

May increase the accessibility to PR

The Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie) compiled a position statement on Physiotherapy recommendations in patients with COVID-19. In this statement recommendations are included for physiotherapy interventions in patients following discharge from hospital. The English version of this position statement is available here: The recommendations are mainly aimed at physical rehabilitation aspects.

In summary the following recommendations are provided:

General recommendations:

The exact period of contagiousness of COVID-19 is still unknown. Physiotherapists should therefor consider the safety risks involved for both themselves and the patients.

There is uncertainty about the recovery path, the physical capacity and limitations of patients after an active COVID-19 infection. Caution is required with assessments and treatments of this cohort of patients

Social distancing principles should be respected and therefore physiotherapists should consider measures such as telehealth or e-health

Always consider and follow national and regional guidelines on safety, infection control and the prevention of transmitting the disease.

Initial 6 weeks following hospital discharge

Contact patient by telephone, telehealth, e-consult or e-health within the first two weeks following discharge to assess and determine if patient is experiencing any difficulties or limitations in daily physical functioning and if there is an indication for further rehabilitation

Be aware of existing and/or newly acquired comorbidities

Consider that patients that were in ICU and who shows signs of PICS may have very low and limited exercise tolerance

Recommend gradual resumption of ADL and physical function. Ensure appropriate monitor of the patient’s daily physical function.

ADL and exercise therapy are recommended to be performed at low to moderate intensity and with short interval durations.

The following clinical outcome measures are recommended:

Patient Specific Function Scale

Oxygen saturation before, during and after rehabilitation/exercise

Use Sp02 of 90% at rest as lower limit and 85% SpO2 during exercise as lower limit. Stop physical activities or exercise when  desaturation( SpO2 < 85% during exercise) occurs

Heart rate frequency before, during and after rehabilitation/exercise

Borg Scale CR10 for Shortness of breath and fatigue before, during and after rehabilitation/exercise

Max score of 4/10 is recommended as threshold for exercise intensity on the Borg Scale CR10 for shortness of breath and fatigue

Reasons for this include:

The severe impact on lung function from COVID-19 – such as oxygen desaturation during exercise due to virus-induced lung disease)

Cardiac function may be compromised due to COVID-19

Adequate clinicial information is not always avaialalbe as no maximal exercise testing is done and it is impossible to estimate the risk of physical training/exercise at moderate to high intsnsity.

Patients should only perform exercises in the home situation if they are able to understand and apply proper exercise load management (frequency, intensity, time/duration and type)

Physical functioning of ADL should be the focus

After 6 weeks following hospital discharge

Reassess the patients’ needs to determine how rehabilitation should be adapted and progressed

Reassess the patients’ actual level of physical functioning (compare with previous tests such as hospital-based exercise tests, lung/heart function tests, etc)

Design future treatment goals relating to physical activity and/or exercise capacity based on exercise tests and measurements of physical activity

The aim of these treatment goals should be to further improve performance of ADL, increased physical activities and increased capacity to exercise

Clinical outcome measures that can be used during this phase:

Patient Specific Function Scale

Short Physical Performance Battery – this includes:

Standing balance test

Walking speed test over 4 meters

5 times chair stand test

Hand-held Dynamometer for grip strength

6 minute walk test

Pedometer/accelometer to assess and evaluate daily physical function

Oxygen saturation

Heart rate frequency

Borg Scale CR10 for shortness of breath and fatigue before, during and after physical exercise

When physical function tests (lung/heart function) and (sub)maximal exercise tests indicates no severe restrictions or risks, start with gradual increase in training

Implement a gradual increase in training frequency, intensity, time/duration  as well as type of exericses -  this should be based on the needs of the patient, the set treatment goals and the patient’s physical abilities

During exercise a score of 4 -6/10 on the Borg Scale CR 10 for shortness of breath and fatigue and/or an intensity of 60-80% of the tested maximum exercise performance (bicycle test, 6mwt and/or 1RM) is recommended.

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