Citation: Sheehy, L. M. (2020). Considerations for Postacute Rehabilitation for Survivors of COVID-19. JMIR Public Health and Surveillance, 6(2), e19462. https://doi.org/10.2196/19462
Background:
The knowledge and impact of Coronavirus disease (COVID-19), an infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), is rapidly changing as new rehabilitation research emerges. The physical presentation of patients affected with SARS and MERS (Middle East Respiratory Syndrome) are different than that of COVID-19. While the SARS primarily causes respiratory symptoms along with diarrhea, MERS causes more gastrointestinal and kidney symptoms along with respiratory symptoms, COVID-19 presents with a wide variety of symptoms including cardiorespiratory, kidney, neurological etc. Due to the novel nature of COVID-19, the rehabilitation considerations of affected individuals are unknown, particularly regarding its sequelae and long-term outcomes.
Purpose:
The overall purpose of this viewpoint was to discuss “What rehabilitation services do survivors of COVID-19 require?” Specifically, the author discussed the following:
1. Physical, cognitive, and psychosocial presentation of COVID-19 survivors
2. Organizational procedures to treat or manage patients with COVID-19
3. Rehabilitation treatment & procedures for patients with COVID-19
Methods: Expert review summarizing available literature.
Results:
1. Physical, cognitive, and psychosocial presentation of COVID-19 survivors
| Comorbidities | Hypertension (55%) Coronary artery disease & stroke (32%) Diabetes (31%) |
| Complications from severe COVID-19 | Acute respiratory distress syndrome (ARDS) Sepsis/septic shock Multi-organ failure Critical illness polyneuropathy (CIP) and myopathy (CIM) Post–intensive care syndrome (PICS) |
| Persistence of COVID-19 | Virus may persist in oropharyngeal cavity and stools for up to 15 days after they are declared cured of COVID-19 (no fever, no respiratory symptoms, 2 negative swab tests). Additional 14 days in quarantine or discharge to a dedicated COVID-19 step-down unit has been recommended |
| Cardiac sequelae | Arrhythmia, cardiac insufficiency, ejection fraction decline, troponin I elevation, and severe myocarditis with reduced systolic function |
| Neurologic sequelae | headaches, disturbed consciousness, seizures, absence of smell and taste, and paresthesia Posterior reversible encephalopathy syndrome. Viral encephalitis. Increased risk for cerebrovascular events |
| Other body systems | acute kidney injury as well as secondary infection |
| Cognitive sequelae | Decreased attention, visual-spatial abilities, memory, executive function, and working memory |
| Potential psychological sequelae | Post-traumatic stress disorder, depression, anxiety |
2. Organizational procedures to treat or manage patients with COVID-19
For the rehabilitation unit:
- Create a separate unit or area for rehabilitation of patients post–COVID-19
- Dedicated facilities should be used to treat patients post–COVID-19
- Patients should stay in their rooms
- Group therapy and therapy in rehabilitation gyms should be prohibited
- Patients may be discharged to home sooner than usual (as soon as the family is able to take care of the patient) to free space
- Shared equipment must be decontaminated between patients; single-use equipment should be used where possible (eg, TheraBands rather than hand weights). Particular attention should be paid to electrode sponges, hydrocollator heat packs, gels, topical lotions, items for training manual dexterity, etc
- Plan therapeutic activities to minimize the number of personnel involved when possible
- Minimize the number of personnel entering a patient’s room
- Walking practice should be done in parts of the hospital that are not commonly used
- Surgical masks should be worn by the patients and the therapists
- Patients should be kept at least 2 meters apart and avoid talking or eating while facing each other
For the personnel:
- Health checks for personnel should be done frequently
- Be prepared for personnel shortages due to staff illness, staff in isolation, or redeployment.
- Continuous staff training will be required
- Train and retrain personnel in the use of personal protective equipment (PPE)
- Physiotherapists and speech-language pathologists should wear higher levels of PPE if they may be exposed to aerosols from post–COVID-19 patients (eg, chest physiotherapy and swallowing assessments)
- It is important to seek ongoing input from front line staff to inform others.
- All nonrequired therapies and services should be cancelled, or telecommunication should be used to deliver them.
- Allied health professionals should wear scrubs and a T-shirt at work and shower and change into street clothes before going home
- Rehabilitation staff may be divided into two teams who work independently of each other. If several members of one team become ill, the other team can take over
- Meetings should be held virtually when possible
Home-based rehabilitation:
- Isolation is easier at home, and the burden on inpatient services is lessened
- Telephone via telerehabilitation is preferred
3. Rehabilitation treatment & procedures for patients with COVID-19
A. Acute phase:
- Secretion management: Postural drainage and standing (for gradually increasing periods of time) are suggested
- NOT RECOMMENDED (to avoid respiratory distress and viral shedding):
- Diaphragmatic breathing
- Pursed lip breathing
- Bronchial hygiene
- Lung expansion techniques (positive expiratory pressure)
- Incentive spirometry
- Manual mobilization of the ribcage
- Respiratory muscle training
- Aerobic exercise
B. Inpatient rehabilitation:
- Assess respiration: dyspnea, thoracic activity, diaphragmatic activity and amplitude, respiratory muscle strength with maximal inspiratory and expiratory pressures, respiratory pattern, and frequency
- Assess cardiac status
- Respiratory treatment strategies:
- Inspiratory muscle training (strengthen different inspiratory muscles using manual or verbal or visual cues for example a spirometer
- Deep, slow breathing,
- Thoracic expansion (with shoulder elevation): Inhale big raising your arms
- Diaphragmatic breathing (breathe into your tummy)
- Mobilization of respiratory muscles
- Airway clearance techniques (as needed)
- Positive expiratory pressure devices
- Close vital monitoring is suggested, note for shortness of breath, decreased SaO2 (<95%), blood pressure <90/60 or >140/90, heart rate >100 bpm, temperature >37.2 ºC, excessive fatigue, chest pain, severe cough, blurred vision, dizziness, heart palpitations, sweating, loss of balance, and headache
- Mobility treatment strategies:
- Assess range of motion, strength, balance, exercise capacity, cardiopulmonary exercise status and functional status
- Early mobilization should include frequent posture changes, bed mobility, sit-to-stand, simple bed exercises, and ADLs
- Active limb exercises, progressive muscle strengthening
- Aerobic reconditioning (<3 METs initially)
- Balance exercises
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