Rehabilitation During a Pandemic in People with Specific Rehabilitation Needs

Original Editor - Wanda van Niekerk

Top Contributors - Wanda van Niekerk and Tarina van der Stockt  

Introduction

The rehabilitation needs of people do not stop just because a pandemic has been declared. People in need of essential rehabilitation will still need this care amidst the pandemic. A lack of access to rehabilitation has complications in terms of[1]:

  • health outcomes of people
  • inpatient hospital stay duration
  • hospital admissions

Healthcare professionals will need to make decisions with regards to[1]:

  • the continuation of rehabilitation services
  • the implications it will have on different patient groups in need of rehabilitation
  • the infection risk involved to patients and healthcare professionals

Changes in rehabilitation services due to pandemic constraints will have implications for today and the future.[2]

Rehabilitation is Essential

"Rehabilitation is an essential part of health care and is integral to achieving universal health coverage. Rehabilitation needs are increasing globally, along with the rising prevalence of non-communicable diseases and ageing populations. National efforts must strengthen health systems to provide rehabilitation, making it available to everyone at all levels of health care, whenever needed."[3]

Rehabilitation must aim to be[4]:

  • Available
  • Accessible
  • Affordable, for many people.

This will allow people to[4]:

  • Remain as independent as possible
  • Participate in education
  • Be economically productive
  • Fulfil meaningful life roles
[5]

Aspects Influencing Decisions to Adapt Rehabilitation Services During a Pandemic

  • The immediacy of care needs
  • Services available
  • Setting
  • Resources available (staff, equipment, technology)
  • Risk for transmission
  • Risk of illness[2]

How has the COVID-19 Pandemic Affected Rehabilitation Services?

  • Rehabilitation beds and wards converted to increase acute care capacity
  • Inpatient admissions for rehabilitation delayed
  • Shorter lengths of inpatient stay for rehabilitation
  • Early discharge to expand bed capacity and/or to prevent transmission
  • Outpatient rehabilitation care suspended or reduced
  • Home-based rehabilitation suspended or reduced
  • Rehabilitation personnel redeployed[2]

Infection Risk Considerations in Rehabilitation

  • Increased risk of infection with face to face rehabilitation
  • Infection risk should be balanced against the risk to patient outcomes and health services if rehabilitation is interrupted, ceased or reduced.
  • Delivery of rehabilitation services during the COVID-19 outbreak should minimise the risk of exposure to patients and healthcare providers, especially those at high risk, such as older people and people with comorbidities.
  • The availability of personal protective equipment (PPE) will influence the degree of infection risk
  • Infection control measures may vary across service delivery settings and this will also influence the degree of infection risk
  • WHO and PAHO guidelines on infection prevention and control should be followed if rehabilitation services continue
  • Alternative ways of service delivery should be considered if feasible (e.g, telehealth in rehabilitation focused on patient education and advice)

Impact on Patient Outcomes if Rehabilitation is Suspended or Reduced

  • Essential rehabilitation services for non-COVID-19 patients should be identified and continued during the outbreak
  • Consider the effect of ceasing or reducing rehabilitation on certain patient groups (e.g, burns, spinal cord injuries, stroke)
  • Health and functioning outcomes can seriously be compromised if rehabilitation services are suspended or reduced
  • Risk of increased mortality if rehabilitation is not continued in certain patient groups[6]
  • It is critical to prioritize patients in settings where rehabilitation services are temporarily ceased, decreased or diverted. The risks associated with the sudden change in rehabilitation services should be well thought through.[1]

Rehabilitation Options During the Pandemic

Rehabilitation service providers should identify patients that are suitable for some of these service options[1]:

  • The patient can be discharged from rehabilitation with a comprehensive home rehabilitation programme. The patient has knowledge of potential complications that can arise or indications that will require a follow-up.
  • The patient continues with rehabilitation through either inpatient, outpatient, home-based or telehealth services or with modifications to their current rehabilitation setting
  • Temporary interruption or cessation of the patient’s rehabilitation programme (but the patient still receives interim education and a home programme). It is crucial to have an established, systematic method for follow-up after rehabilitation services are up and running again.
  • As the various stages of the pandemic progress, certain areas may be able to continue with some rehabilitation services again for patients with priority needs who have been cleared of COVID-19 or who have recovered.

Priority Patient Groups for Rehabilitation

The clinical risks associated with withdrawing rehabilitation should be considered. Patient groups who may be at an increased risk can include (but are not limited to)[1]:

  • Patients that have or have recently had significant injuries such as:
    • burns[7],
    • spinal cord injury[8],
    • traumatic brain injury[9]
    • fractures[10]
    • musculoskeletal injuries that may develop serious preventable complications[11]
  • Patients recovering from surgery
  • Patients with conditions such as stroke or myocardial infarction, that will benefit from early rehabilitation and are at risk of sub-optimal recovery if rehabilitation is delayed
  • Patients in need of long-term rehabilitation in hospitals, residential centres or community settings may develop complications and lose function if rehabilitation is ceased, delayed or interrupted
  • Patients who are not able to be discharged to a safe environment or who may have to be discharged to a setting that is a long way from the rehabilitation service and this will most likely limit their access to rehabilitation

Impact on Health Services Delivery if Rehabilitation is Affected

  • Rehabilitation services that contribute to safe and timely discharge from hospital should continue if possible – for both COVID-19 and non-COVID-19 patients
  • Safe and timely discharge from hospitals can aid in the surge capacity of hospitals (especially hospitals that need patients to move rapidly through acute care)
  • Restricted or no access to rehabilitation can lead to extended length hospital stays
  • Ineffective rehabilitation strategies and planning can lead to further complications and readmission of patients
  • There should be available rehabilitation follow-up following discharge from hospital
  • Patients in need of follow-up are those at risk of poor or compromised outcomes
  • During the pandemic, there will be a change in the profile of rehabilitation demands
    • For example, rehabilitation after elective surgery will be reduced as these surgeries will be postponed; whereas new rehabilitation needs will arise due to the exacerbation of underlying health conditions as a result of COVID-19 lockdown or containment measures.[12]
  • Also, the cessation and reduction of rehabilitation services will lead to a backlog of rehabilitation needs[12]
  • In the case of early supported discharge ensure the following[1]:
    • Proper patient and caregiver education
    • Proper self-management strategies and home exercise programmes if safe and suitable to do
    • Ensure that patients have access to the proper assistive products and adaptive equipment as well as proper guidance on how to use this equipment
    • Patients should be properly informed and advised on possible complications and clear instructions on where to call (telephone numbers, e-mails, etc) and when to call if there are any concerns
    • Telehealth services may be implemented if safe and appropriate to use. This may include remote assessments and treatments via telephone or video calls
    • Individual standard treatment plans may be provided to patients via e-mail, app, telehealth if it is safe and appropriate to do so
    • If rehabilitation is temporarily stopped, ensure that systematic methods such as databases for COVID-19 and non-COVID-19 patients, in need of follow-up, are compiled so that they can be tracked and relevant services organised as soon as normal health services resume.

Rehabilitation for People with a Disability and Frail Older People

An estimated 15% of the world’s population live with a disability.[13] Many of these people need rehabilitation. For many, this would mean rehabilitation in the acute phase of the disability or even on an ongoing basis when living with a chronic condition.

The WHO/Europe highlights the fact that there is an increasing demand for rehabilitation worldwide and the current pandemic has just exacerbated the unmet need for rehabilitation in vulnerable populations across the globe.[14]

It is also evident that people living with non-communicable diseases are at a higher risk of severe illness due to COVID-19. This implies that a large group of patients who are usually supported by long-term physiotherapy interventions and rehabilitation services will be at an increased risk for severe complications from COVID-19.[12]

The implementation of lockdown strategies in many countries around the world may lead to many people with disabilities and rehabilitation needs not being able to access rehabilitation services, or they may have an adaptive form of rehabilitation (e.g. telehealth). The reality is, however, that many people will be left behind with no access to rehabilitation services and this may compromise the health outcomes.

Older people with frailty may be at risk of the same issues as people living with a disability. Older people are more vulnerable to serious complications from COVID-19 and lockdown measures urge older people to stay at home and self-isolate. This may impact various short and long-term healthcare outcomes.[15] Older people may be at greater risk of[15]:

  • increased sedentary behaviour
  • deconditioning
  • balance deficits
  • increased falls risk
  • worsening and/or new mental health problems
[16]

Paediatric Rehabilitation during COVID-19

Children with disabilities often receive support from specialised professionals through schools. Families of children with disabilities may find childcare, education and rehabilitation challenging during Covid-19, as schools closures and social distancing are implemented. Children with disabilities are also at-risk populations during the pandemic and may experience negative outcomes due to reduced quality of care and rehabilitation.[17] It is key to remember that early rehabilitation in children, leads to a better outcome and this leads to a better quality of life.[18]

Prolonged interruption of rehabilitation may affect the functional prognosis of children with disabilities and could negatively influence behaviour and psychological aspects.[19] The use of telerehabilitation and other remote rehabilitation strategies should be considered during the pandemic, but the feasibility and efficacy of these methods still need more investigation.[20] Other strategies to consider include[18]:

  • Dance and movement therapy
  • Music therapy
  • Yoga therapy for children
  • Visual learning apps
  • Play therapy
  • Guided therapy

Ways to provide effective modified paediatric rehabilitation during the pandemic can include[18]:

  • home safety evaluations
  • post-discharge check-ups and safety screenings weekly or monthly got NICU and PICU children
  • provision of wellness and preventative services to avoid hospitalisation of children with respiratory disorders
  • Multidisciplinary team approach
  • Questionnaires for parents to complete to keep track of rehabilitation and free hours of the child at home - this is a good way to reinforce effective rehabilitation
  • Education of parents/caregivers on aspects such as important milestones that the child is supposed to reach, etc
  • Guided therapy where parent is instructed on how to provide rehabilitation via telehealth

The adoption of a biopsychosocial model in rehabilitation is recommended, especially during the pandemic, as a tool to strengthen the role of the immediate environment of the child. In this case, it will very well be the families. However, factors that may negatively influence the adoption of family-centred rehabilitation practices may play a role. Parents may feel unmotivated and unprepared to take on the responsibility and actively participate in the rehabilitation process with their children with disabilities.[21]

Children with cerebral palsy do benefit from home-based programmes and show an improvement in motor function with these home-based programmes.[22] The Covid-19 pandemic has caught everyone by surprise and rehabilitation professionals and parents are most likely unprepared for this situation and this can also lead to an increase in family stress. This pandemic, however, can offer an opportunity for therapists and families to implemented family-centred rehabilitation practices and find innovative ways to provide therapy to children with disabilities. With the implementation of home-based programmes rehabilitation professionals should understand the family circumstances during the pandemic. The rehabilitation programme should consider the family's general needs and priorities. One key strategy that can help with this is the use of information technologies. Another viable option could be the use of booklets as a resource, especially in low- and middle resource countries. It is vital though to have families feel that they are fundamental part of the care process of children with disabilities as this process can be the first step in the facilitation and implementation of home programmes.[21]

Short-term Rehabilitation Needs in Areas where Routine Care has been Suspended

Physiotherapists are key rehabilitation professionals over a vast range of specialities. These rehabilitation services is an essential part of healthcare to optimise cognitive and physical function and thus reduce disability. During the pandemic, many physiotherapy services will be suspended as countries have strict lockdown and social distancing regulations to reduce the spread of the virus. This will have an impact on patients and they are likely to experience a deterioration in conditions that is unrelated to COVID-19.[12]

Areas that may be affected where physiotherapy rehabilitation is provided

  • Elective surgeries cancelled – deconditioning can occur in patients waiting for orthopaedic and other surgeries
  • Acute musculoskeletal conditions - patients may not be able to access physiotherapy
  • Individuals may delay or ignore symptoms due to the concern around COVID-19
  • Many physiotherapy services in the community and out-patient settings will be suspended and classified as non-essential services to ensure social distancing
  • People who are confined to their homes as a result of lockdown or social distancing will be more sedentary and at risk of losing mobility and function. Once lockdown restrictions ease these patients will be in need of physiotherapy services and this will put an even greater burden on rehabilitation professionals.

Public Health Restrictions and Rehabilitation

Telerehabilitation may work for certain groups of patients, but for others, it may not be advised. The rehabilitation environment will change with restrictions being lifted with strict infection prevention and control measures and the requirements of physical distancing as far as possible.

Physiotherapists will need to consider[12]:

  • How rehabilitation services will be provided in the various stages of restrictions being lifted
  • How will inclusive rehabilitation fit in to limit the effect of public health restriction
  • The risk of some patients being missed or overlooked that was previously in the system
  • Rehabilitation professionals will need to review priorities, they may need to implement triage strategies as well as outreach strategies to commence rehabilitation services again.

Implications on Physiotherapy Rehabilitation Service Delivery and Workforce

Since the start of this pandemic, there has been a monumental change in the physiotherapy workforce. This will be ongoing for the foreseeable future and will keep on changing as the environment and rehabilitation needs change worldwide. Physiotherapists are key to delivering high-quality rehabilitation and working in multidisciplinary teams. Initially, there was and still is a rapid response in the acute phase of the pandemic, but this will change and as the rehabilitation needs of COVID-19 patients become clearer. The non-COVID-19 patients’ existing and new rehabilitation needs will also become more evident as the stages in the pandemic progress. The emotional, mental and physical wellbeing of physiotherapists need to be considered and appropriate services need to be made available to ensure their wellbeing.[12]

[23]

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 Pan-American Health Organisation and World Health Organisation. Rehabilitation considerations during the COVID-19 outbreak. Published 26 April 2020. (last accessed 2 July 2020)
  2. 2.0 2.1 2.2 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
  3. World Health Organisation. Rehabilitation 2030: REHABILITATION IN HEALTH SYSTEMS: GUIDE FOR ACTION INFORMATION SHEET. Published 16 June 2020 Available from  https://www.who.int/publications/i/item/rehabilitation-in-health-systems-guide-for-action---information-sheet (last accessed 2 July 2020)
  4. 4.0 4.1 World Health Organisation. Rehabilitation. Published on 4 July 2019. (last accessed 3 July 2020)
  5. World Health Organisation.Rehabilitation is about health and functioning in everyday life. Published on 5 July 2019. Avaialable from https://www.youtube.com/watch?v=uG_VdZe9VNU. (last accessed 2 July 2020)
  6. Silow-Carroll S, Edwards JN, Lashbrook A. Reducing hospital readmissions: lessons from top-performing hospitals. CareManagement. 2011 Apr;17(5):14.
  7. de Figueiredo TB, Utsunomiya KF, de Oliveira AM, Pires-Neto RC, Tanaka C. Mobilization practices for patients with burn injury in critical care. Burns. 2020 Mar 1;46(2):314-21.
  8. Nas K, Yazmalar L, Şah V, Aydın A, Öneş K. Rehabilitation of spinal cord injuries. World journal of orthopedics. 2015 Jan 18;6(1):8.
  9. Eghbali M, Khankeh H, Ebadi A. The importance of early rehabilitation in traumatic brain injury. Nursing Practice Today. 2020 Apr 22.
  10. Azhari A, Parsa A. Covid-19 Outbreak highlights: Importance of home-based rehabilitation in orthopedic surgery. The Archives of Bone and Joint Surgery. 2020 Apr 1;8(Covid-19 Special Issue):317-8.
  11. Robinson LJ, Stephens NM, Wilson S, Graham L, Hackett KL. Conceptualizing the key components of rehabilitation following major musculoskeletal trauma: A mixed methods service evaluation. Journal of Evaluation in Clinical Practice. 2019 Dec 9.
  12. 12.0 12.1 12.2 12.3 12.4 12.5 World Confederation for Physical Therapy (WCPT). WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy. May 2020. (last accessed 2 July 2020)
  13. Handicap International and Humanity and Inclusion. COVID-19 in humanitarian contexts: no excuses to leave persons with disabilities behind! 2020. Available from https://www.coordinationsud.org/wp-content/uploads/Study2020-EN-Disability-in-HA-COVID-final.pdf
  14. World Health Organization Regional Office for Europe. COVID-19 exposes the critical importance of patient rehabilitation. WHO Europe.2020. Available: http://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid19/news/news/2020/4/covid-19-exposes-the-critical-importance-of-patient-rehabilitation
  15. 15.0 15.1 De Biase S, Cook L, Skelton DA, Witham M, Ten Hove R. The COVID-19 rehabilitation pandemic. Age and Ageing. 2020 May 21.
  16. WKRG. Why older patients are continuing physical therapy amid the pandemic. Published on 9 April 2020. Available from https://www.youtube.com/watch?v=KCPQs9zvdHs (last accessed 2 July 2020)
  17. Phoenix, M. Children with disabilities face health risks, disruption and marginalisation under coronavirus. The Conversation. May 11, 2020.
  18. 18.0 18.1 18.2 Vriksha Healthcare. Effective Paediatric Rehabilitation during Covid-19 and its various aspects webinar. Published on June 27, 2020. Available from https://www.youtube.com/watch?v=vN2HlaOEk-s&t=492s (last accessed 10 July 2020)
  19. Lee H, Kim EK, Son DB, Hwang Y, Kim JS, Lim SH, Sul B, Hong BY. The Role of Regular Physical Therapy on Spasticity in Children With Cerebral Palsy. Annals of rehabilitation medicine. 2019 Jun;43(3):289.
  20. Corti C, Poggi G, Romaniello R, Strazzer S, Urgesi C, Borgatti R, Bardoni A. Feasibility of a home-based computerized cognitive training for pediatric patients with congenital or acquired brain damage: An explorative study. PloS one. 2018 Jun 20;13(6):e0199001.
  21. 21.0 21.1 Longo E, de Campos AC, Schiariti V. COVID-19 Pandemic: Is This a Good Time for Implementation of Home Programs for Children’s Rehabilitation in Low-and Middle-Income Countries?. Physical & Occupational Therapy In Pediatrics. 2020 May 14:1-4.
  22. Novak I, Morgan C, Fahey M, Finch-Edmondson M, Galea C, Hines A, Langdon K, Mc Namara M, Paton MC, Popat H, Shore B. State of the evidence traffic lights 2019: systematic review of interventions for preventing and treating children with cerebral palsy. Current neurology and neuroscience reports. 2020 Feb;20(2):1-21.
  23. Steps Rehabilitation. Rehabilitation during COVID-19 pandemic. Published on 15 April 2020. Available from https://www.youtube.com/watch?v=Tz1CI590xKY. (last accessed 2 July 2020)