Innovative Approaches in Providing Rehabilitation during the COVID-19 Pandemic

Original Editor - Jess Bell Top Contributors - Jess Bell, Tarina van der Stockt, Vidya Acharya and Kim Jackson

Introduction

COVID-19 is currently placing significant pressure on health services around the world. While the majority (81%) of individuals who get COVID-19 have a mild illness, including fever, cough and dyspnoea, 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)
  • Post-extubation dysphagia
  • Impaired mobility[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 a 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] They also need to consider ways of providing services to a larger number of patients than usual.[2]

Telehealth

Background

Any reduction in rehabilitation services has a significant impact on patients, families and healthcare workers.[3] One way in which rehabilitation providers can prevent disruption to services during the COVID-19 pandemic is to adopt telehealth or virtual rehabilitation.[4] Telehealth refers to the delivery of healthcare services via electronic communication (phone, internet, video calls).[5] Telehealth encompasses preventive, promotive and curative aspects of health and many different healthcare professions are involved in its delivery.[6]

Telehealth phone.jpg

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. This reduces the risk of transmission of the virus.[1][4] This is significant as it protects both patients and the healthcare team.[4]

Other benefits of virtual rehabilitation include:

  • Innovative technology is often appealing to users, which can increase adherence and decrease the likelihood that patients will stop treatment
  • Direct contact between patients with providers and the ability for constant feedback enhances trust, as well as peace of mind[4]

There are certain challenges associated with telehealth, which limited its uptake prior to COVID-19.[7] 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] It is also essential that providers explore if they are licensed/insured to practise telehealth and if they will be reimbursed for their work.[8] [9]

Telehealth for patients in the hospital

To conserve PPE and limit the spread of the virus, some hospitals make use of telehealth within the hospital to do virtual therapy sessions. An iPad, stand and speakers could be made available to the patient. Early on these sessions could include education on energy conservation. The therapist could observe the patient doing tasks like sitting up, reaching, and putting on socks and give them advice and techniques to decrease fatigue. Real-time feedback can also be provided when a computer program monitors the patient during movement through motion detection and gives feedback as they move. [10]

As one example the Hasharon hospital in Israel was converted to only receive corona patients. The physiotherapy department quickly adapted to provide services specifically tailored for patients with COVID-19. In preparation, they had regular multidisciplinary team meetings, training on PPE and infection control, prepared clinical guidelines for telehealth and hands-on treatments, decided on appropriate outcome measures and characterized risk factors, imaging results and pathology results that could affect the therapist's intervention. In addition, they prepared exercise sheets and videos in multiple languages. [11]

The multidisciplinary team worked on a strategy to reduce unnecessary exposure to physiotherapists by providing telehealth as a first option to the patients who met the following criteria:[11]

  • respiratory symptoms are mild to moderate
  • the patient can independently clear secretion
  • the patient's ability to comply with telehealth[11]

The physiotherapist can monitor the patient's saturation and for any signs indicating dyspnea. The physiotherapy telehealth intervention for COVID-19 patients consisted of the following: [11]

  • instructing the patient on airway clearance
  • increasing lung volume
  • breathing and breathing relaxation techniques
  • education on independent pulmonary and general exercises to prevent deconditioning
  • instructions on positioning and mobility
  • fall prevention education[11]

Read this article to learn more about this hospital's protocol for in-hospital telehealth and hands-on treatment

Remote monitoring of patients

  • The development of apps that monitor the whole rehabilitation process of a patient and provides data to improve interventions and provide research in that area. [12]

Prehabilitation

Another innovation being explored in the context of COVID-19 is prehabilitation. Prehabilitation focuses on preparing individuals for upcoming physiological stressors[13] - 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.[13] The following video explores rehabilitation generally for pre-surgical patients.

[14]

It has been proposed that prehabilitation may be particularly useful during the COVID-19 pandemic for two key reasons:

  1. 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)[15]
  2. To enhance the health of patients who have experienced 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/stays 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.[13]

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.[13]

It has been found that single modalities (eg exercise or diet) can be beneficial prior to surgery or a stressor, but there is a general shift towards implementing multimodal prehabilitation programmes.[13] 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[15]
  • Good nutrition (particularly supplementation with protein and advice around glycemic control in patients with diabetes)
  • Physiological stress reduction[13][15]

Rehabilitation providers can also emphasise the importance of hand/respiratory hygiene and social distancing when undertaking prehabilitation interventions.[1][13] Importantly, these interventions can all be provided in the context of social distancing and be delivered by telehealth.[15]

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.[13]

Early Rehabilitation for COVID-19 Patients

  • It is important to start the rehabilitation of COVID-19 patients as soon as possible. Learn more about Post-Acute Rehabilitation here.
  • Patients can be reviewed daily for appropriateness for therapy, and daily therapy based on the patient's needs and fatigue level can be incorporated. [10]
  • John's Hopkins also created rooms with negative pressure where they can move patients that require rehabilitation but no longer require immediate medical care. These rooms allow the patients to start with rehabilitation in an environment that limits the circulation of contaminated air. [10]

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.[16] Thus, other patients, including those with stroke or 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.[16] One such programme, created by the UCL Centre for Neurorehabilitation, intends to deliver all stroke rehabilitation, including emotional and physical rehabilitation, remotely.[16] Learn more about maintaining COVID-19 Rehabilitation in Vulnerable Populations here.

Recent study (June 2020) suggests implementing: virtual assessments and consultation, essential investigation, and fewer and shorter hospital admissions, clinical protocols for expedient discharge with virtual physical therapy, and cardiac rehabilitation options to minimize patient exposure to infection during the COVID-19 pandemic and manage patients with severe aortic stenosis (AS) optimally[17].

Virtual Group Rehabilitation

Using a web portal, the UCL is 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 strategies, the management of fatigue 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.[16]

Similarly, various organisations are exploring methods to provide Pulmonary Rehabilitation via telehealth.[18] Pulmonary rehabilitation programmes are designed to enhance a patient's physical and psychological health and help to improve quality of life.[19][20] It is important to try to keep individuals with chronic lung conditions out of hospital during the COVID-19 pandemic for two reasons:

  1. To reduce the burden on already stretched health systems
  2. To reduce these patients’ risk of being exposed to COVID-19[18]

Thus, the continuation of these programme via telehealth could be very beneficial. Guidelines 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.[21]

Mobile Rehabilitation Teams

In Australia, it has been proposed that the use of mobile rehabilitation teams may be beneficial in managing the increased numbers of patients in the hospital during the pandemic.[2] These teams have been operating in New South Wales since 2009 and are designed to provide both rehabilitation and discharge planning services to acute care patients. Thus far, they have been able to reduce hospital stay and facilitate early discharge/transfer to inpatient rehabilitation services. Almost 50% of patients managed by these teams have been discharged straight home. This reduces inpatient stays, freeing up beds for other patients.[2]

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
  • Using technology to monitor patients and to provide individual or group rehabilitation.

References

  1. 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. 2.0 2.1 2.2 2.3 2.4 2.5 Faux SG, Eager K, Cameron ID, Poulos CJ. COVID ‐19: planning for the aftermath to manage the aftershocks. MJA. 2020 Jun 29.
  3. 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. 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).
  5. Achenbach SJ. Telemedicine: Benefits, Challenges, and its Great Potential.  Health Law and Policy Brief. 2020; 14(1). Available at: https://digitalcommons.wcl.american.edu/hlp/vol14/iss1/2
  6. Cottrell, M. and Russel, T. Introduction to Telehealth Course. Physioplus. 2020
  7. 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.
  8. Digital Physical Therapy Task Force. Report of the WCPT/INPTRA digital physical therapy practice task force. World Confederation for Physical Therapy. 2019. 24 p. Report No. 7. Available from https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/REPORT%20OF%20THE%20WCPTINPTRA%20DIGITAL%20PHYSICAL%20THERAPY%20PRACTICE%20TASK%20FORCE.pdf
  9. 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.
  10. 10.0 10.1 10.2 Eddy, L. Innovative Approaches to Patient Rehabilitation Maximize COVID-19 Recovery at Johns Hopkins. Johns Hopkins Medicine. June 8, 2020
  11. 11.0 11.1 11.2 11.3 11.4 Yamin R, Bathish J, Berman Y, Isa A, Zeidman A, et al. (2020) In hospital physiotherapy treatment for Covid-19 patients – Management and clinical practice. Arch Pulmonol Respir Care 6(1): 017-020. DOI: 10.17352/aprc.000044
  12. COVID-19 Rehabilitation. Welcome to Covid-19 Rehab: the best Covid-19 rehabilitation by connection
  13. 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 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.
  14. University of California TV. Pre-Habilitation: Planning for the Best Outcomes from Surgery. Available from https://www.youtube.com/watch?v=dzFKOZ-_OZ8 [last accessed 10/07/2020]
  15. 15.0 15.1 15.2 15.3 Silver J. Prehabilitation could save lives in a pandemic. BMJ. 2020; 369.
  16. 16.0 16.1 16.2 16.3 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).
  17. Tanguturi VK, Lindman BR, Pibarot P, Passeri JJ, Kapadia S, Mack MJ, Inglessis I, Langer NB, Sundt TM, Hung J, Elmariah S. Managing Severe Aortic Stenosis in the COVID-19 Era. JACC: Cardiovascular Interventions. 2020 Jun 1.
  18. 18.0 18.1 Agency for Clinical Innovation. Delivering pulmonary rehabilitation via telehealth during COVID-19. Chatswood NSW. 2020. 25 p. Report No.: 1.
  19. Spruit MA, Singh SJ, Garvey C, ZuWallack R, Nici L, Rochester C, Hill K, Holland AE, Lareau SC, Man WD, et al.; ATS/ERS Task Force on Pulmonary Rehabilitation. An official American Thoracic Society/ European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013;188:e13–e64.
  20. McCarthy  B, Casey  D, Devane  D, Murphy  K, Murphy  E, Lacasse  Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD003793. DOI: 10.1002/14651858.CD003793.pub3. Accessed 28 November 2019.
  21. 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.