COVID 19 Rehabilitation Programme

COVID-19
Rehabilitation
P HYSIO - P EDI A.COM
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2
PH YS I O - PEDI A.CO M
CONTENTS
05 Post-Acute
Rehabilitation
Benefits of Rehabilitation Conditions That May Arise
in COVID-19 Patients 6 From Lengthy ICU-Stays Include [7] 8
Physiotherapy and the Post-Acute Persistence of SARS-CoV-2 Virus 9
COVID-19 Rehabilitation Phase 7
Sequelae after COVID-19 Infection 9
COVID-19 Patient Presentation
Procedures for Post-Acute
in the Rehabilitation Unit 7
Covid-19 Rehabilitation 10
18 Medium to Longer Term

Health Considerations
Physical Impairment and
Dysfunction Following COVID-19 18
Physical Rehabilitation 19
Mental Health Considerations 19
20 COVID-19 Community
Rehabilitation
The Role of the Community-Based Rehabilitation Strategies for
Physiotherapist 20 COVID-19 Patients Following
Discharge from Hospital 24
General Rehabilitation Strategies
in COVID-19 Patients Following Interventions 26
Hospital Discharge 20
KNGF position statement:
Healthcare Needs of COVID-19 Physiotherapy recommendations
Patients Following Discharge 21 in patients with COVID-19 27
New Challenges to Treatment of Rehabilitation Following
Discharged COVID-19 Patients 22 Critical Care in Adults 29
Emerging Clinical Perspectives Advice and Examples of Exercises for
that Affect Rehabilitation of COVID-19 Patients Post-Discharge 29
COVID-19 Patients 23
Clinical Bottom Line 30
People Living with Disabilities 32
31 COVID-19 Rehabilitation
in Vulnerable Populations
People with Existing Conditions 33 Impact of COVID-19 on
Refugees/Displaced People 34
Older People 33
Addressing Rehabilitation Needs 35
People Living in Low Resource Settings 33
Shielding 35
Refugees/Displaced People 34
Rehabilitation Planning 36
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38 Rehabilitation During a Pandemic
in People with Special Needs
Rehabilitation is Essential 39 Rehabilitation for People with a
Disability and Frail Older People 41
Aspects Influencing Decisions
to Adapt Rehabilitation Services Paediatric Rehabilitation
During a Pandemic 39 During COVID-19 42
How has the COVID-19 Pandemic Short-term Rehabilitation Needs
Affected Rehabilitation Services? 39 in Areas where Routine Care
has been Suspended 43
Infection Risk Considerations in
Rehabilitation 39 Areas that may be affected where
physiotherapy rehabilitation is provided 43
Impact on Patient Outcomes if
Rehabilitation is Suspended or Reduced 40 Public Health Restrictions and
Rehabilitation 43
Rehabilitation Options
During the Pandemic 40 Implications on Physiotherapy
Rehabilitation Service Delivery and
Priority Patient Groups Workforce 44
for Rehabilitation 40
Impact on Health Services Delivery
if Rehabilitation is Affected 40
45 Resources
Physiopedia Pages Used 45
COVID-19 Post Acute Rehabilitation 45
COVID-19 Physiopedia Resources 45
Physioplus Courses 46
COVID-19: Community Rehabilitation 45
47 References
PAGE
COVID-19 Rehabilitation/ Acknowledgements
4
Acknowledgements
Editors
Kim Jackson | Rachael Lowe
Contributors
This eBook has been produced with contributions from the following:
Vidya Acharya, Amanda Ager, Lucy Aird, Jess Bell, Richard Benes,
Nikhil Benhur Abburi, Scott Buxton, Shaimaa Eldib,
Rewan Elsayed Elkanafany, Candace Goh, Lucinda Hampton ,
Kim Jackson, Rachael Lowe, Tony Lowe, Rania Nasr, Naomi O’Reilly,
Laura Ritchie, Tarina van der Stockt, Wanda van Niekerk
Copyright 1st Edition

© Physiopedia | Terms December 2020
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COVID-19 Rehabilitation/ COVID-19 – Post Acute Rehabilitation
5
COVID-19 – Post Acute
Rehabilitation
Countries all across the

world are in various stages
of the pandemic with many
countries now entering the
“day after” COVID-19 phase.
1. Many people who have suffered from the 2. The extent of this impairment and disability
effects of this disease might now be at risk of is yet unknown, but it is clear from early
long-term impairment and disability.[1] research that these patients will be in need
of rehabilitation in all phases of the disease -
acute, post-acute and long-term.
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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.”[2]
» Rehabilitation might very well be a key risk for more severe illness. Rehabilitation
strategy to reduce the impact of COVID-19 on can be beneficial in these populations to
the health and function of people. maintain their prior levels of functionality
» Physiotherapists are essential to these and independence.
rehabilitation efforts in all phases to facilitate » Early Discharge Facilitation
early discharge, but even more to support and • During the pandemic, there is a high
empower patients. demand for hospital beds in countries
worldwide, especially during the times
when the pandemic reaches its peak in a
Benefits of Rehabilitation in country or area. This leads to patients being
COVID-19 Patients discharged sooner than would normally be
Rehabilitation has a positive effect on health the case. Rehabilitation is crucial in this
outcomes of patients with severe COVID-19. It scenario to prepare a patient for discharge,
achieves this through[3]: coordinating complex discharges and also
» Optimizing health and functioning outcomes to safeguard the continuity of care.
• Rehabilitation can reduce Intensive Care » Reducing the risk of readmission
Unit -admission related complications, • Rehabilitation is a key strategy to ensure
such as Post Intensive Care Syndrome that patients do not deteriorate after
(PICS), Intensive care unit acquired discharge and require readmission. During
weakness (ICUAW) the COVID-19 pandemic, this is critical in
• The aim of rehabilitation is to improve the context of shortages of hospital beds.
recovery and reduce disability or the » Physiotherapists as rehabilitation
experience thereof professionals are frontline healthcare
• Rehabilitation interventions address several professionals and should be engaged in the
consequences of severe COVID-19 such as: care of patients suffering from severe cases of
ʅ Physical impairments COVID-19
ʅ Cognitive impairments • A patient who has severe COVID-19 will go
ʅ Swallow impairments through multiple phases of care – acute,
ʅ Provision of psychosocial support post-acute and long term care. In the acute
phase, care will most likely be provided
• It is evident that older people and people
in the ICU or critical care units. In the
with pre-existing comorbidities are at higher
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post-acute phase, care will most likely be COVID-19 Patient
provided in a hospital ward, or a step-down Presentation in the
or rehabilitation facility. The long-term Rehabilitation Unit
phase will be when patients return home
Factors to consider in creating a rehabilitation
and are still recovering and will receive
plan for survivors of COVID-19 include[5]:
rehabilitation at community level.
» Comorbidities
» Direct lung trauma
Physiotherapy and the » Injuries to other organs and systems due to
Post-Acute COVID-19 COVID-19
Rehabilitation Phase
Physiotherapists are instrumental in the Comorbidities
rehabilitation of patients as they transition from
There is clear evidence from across the world
the acute phase to the post-acute phase.[4]
that the leading co-morbid conditions of people
The consequences of COVID-19 will be specific with COVID-19 include[6]:
in each individual and their rehabilitation needs 1. Hypertension
will be specific to these consequences such as: 2. Coronary artery disease
» Long term ventilation 3. Stroke
» Immobilisation 4. Diabetes
» Deconditioning
Considering that these conditions are often
» Related impairments – respiratory,
associated with ageing, it is most likely that
neurological, musculoskeletal
survivors of COVID-19 are older people with
COVID-19 patients will often present with pre- pre-existing conditions such as cardiovascular
existing comorbidities and this must be taken and cerebrovascular disease. This will have
into consideration in the rehabilitation plan for an influence on rehabilitation needs as well as
the patient. Physiotherapists working across rehabilitation outcomes.[5]
various disciplines should work together and
draw on the expertise of each other.[4]
Severe COVID-19 Complications
The transition from the acute to the post-acute
Early complications of COVID-19 include[6]:
phase needs to be supported through service
1. Acute respiratory distress syndrome (ARDS)
delivery pathways and the multidisciplinary
2. Sepsis or septic shock
team will be key to this.
3. Multi-organ failure
4. Acute kidney injury
5. Cardiac injury
These complications often lead to the person

being admitted to an Intensive Care Unit (ICU).
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Conditions That May Arise fatty degeneration, fibre atrophy and fibrosis.
From Lengthy ICU-Stays CIM is associated with:
Include [7] » exposure to corticosteroids, paralytics and
sepsis.
Critical Illness
It has a similar clinical presentation to CIP but
Polyneuropathy (CIP) with more proximal weakness and sensory
Critical Illness Polyneuropathy is a mixed preservation[9].
sensorimotor neuropathy that may lead to
Patients recover more completely from
axonal degeneration and studies have shown
myopathies than polyneuropathies, but
that patients hospitalised in ICU with ARDS may
with both conditions, there are long term
present with CIP. Critical illness polyneuropathy
consequences to consider such as:
(CIP) causes several difficulties such as[8]:
» Weakness
» Difficulty weaning from mechanical
» Loss of function
ventilation
» Loss of quality of life
» Generalized and symmetrical weakness
» Poor endurance
(distal greater than proximal, but does also
include diaphragmatic weakness)
» Distal sensory loss Post Intensive Care Syndrome (PICS)
» Atrophy
A distinct feature of COVID-19 is that, when
» Decreased or absent deep tendon reflexes
necessary, acute and ICU care, as well as
Critical Illness Polyneuropathy is associated ventilator reliance, is often required for
with[8]: considerably longer periods. The aftershock as
» Pain a result of this long ICU period will be felt for
» Loss of range of motion many months and years.[9]
» Fatigue
Characteristics of PICS include[9]:
» Incontinence
» Cognitive impairments
» Dysphagia
• Memory
» Anxiety
• Attention
» Depression
• Visuo-spatial
» Post-traumatic Stress Disorder (PTSD)
• Psychomotor
» Cognitive loss
• Impulsivity
Critical Illness Polyneuropathy is diagnosed » Psychiatric Illness
through: • Anxiety
» Muscle biopsies • Depression
» Electromyographic testing • PTSD
» Physical Impairments
• Dyspnea/ Impaired pulmonary function
Critical Illness Myopathy (CIM)
• Reduced inspiratory muscle strength
This condition is present in 48 – 96% of patients • Pain
in ICU with ARDS.[8] • Sexual dysfunction
• Impaired exercise tolerance
It is a non-necrotising diffuse myopathy with
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• Neuropathies Sequelae after COVID-19
• Muscle weakness/Paresis Infection
• Poor upper extremity and grip strength
• Poor knee extension 1. Cardiac sequelae
• Severe fatigue
Studies have shown that hospitalised patients
• Low functional capacity
with COVID-19 also had associated cardiac
The neuromuscular complications from PICS injury. The mechanism of cardiac injury is
often result in poor mobility, falls and even uncertain, however. Patients with this associated
quadriparesis. cardiac injury presented with[12]:
» Arrhythmia
Risk factors for Post Intensive Care syndrome[9]:
» Cardiac insufficiency
» Delirium
» Ejection fraction decline
» Duration of ICU admission
» Troponin I elevation
» Duration of sedation
» Severe myocarditis with reduced systolic
» Duration of mechanical ventilation
dysfunction
» Age
» Hypoxia and hypotension The presence of cardiac injury, as well as other
» Sepsis comorbidities, need to be considered for patients
» Glucose dysregulation entering post-acute rehabilitation.[5]
» Premorbid mental and physical comorbidity 2. Neurological sequelae
Throughout the world, healthcare systems will Numerous neurological symptoms have been
be inundated with a cohort of post-ICU patients reported in patients with COVID-19[13]. The
created by the COVID-19 pandemic. It is therefore scoping review of the available literature
important to have a coordinated rehabilitation on COVID-19 shows an increase in the risk
response.[9] of secondary neurological complications in
patients hospitalised with COVID-19[14].
Persistence of SARS-CoV-2 The symptoms include[13]:

Virus » Headaches
» Disturbed consciousness
Patients who have physically recovered and
» Seizures
who have two negative tests after infection are
» Absence of sense and smell
considered to be cured and non-infectious.[10]
» Parasthesia
There are however reports of patients testing » Posterior reversible Encephalopathy syndrome
positive again at a later stage. » Viral encephalitis
» Increased risk for acute cerebrovascular event
Studies have also shown that the virus may
» Reports of Guillain-Barre
persist in a persons’ oropharyngeal cavity and
Syndrome associated with COVID-19
stools for up to 15 days after they have been
declared cured.[10][11] Again, these neurological factors need to be
considered when a patient is entering post-acute
This needs to be considered when patients are
rehabilitation after COVID-19.
being discharged to the ward or rehabilitation
3. Musculoskeletal sequelae
facilities as they still might be able to transmit
the disease. Perspectives from physiotherapists in Northern
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Guidance for Rehabilitation
Italy indicate specific problems encountered in
the post-acute phase[1][15]. These include:
Physiotherapists
» Physical deconditioning 1. Determine risk
» Severe muscle weakness » Consider the risk involved of a patient not
» Reduced joint mobility receiving immediate rehabilitation on
» Neck and shoulder pain (due to prone lying) outcomes such as risk of hospitalization,
» Difficulty in verticalization extended hospital stay
» Impaired balance and gait » If the therapist continues with a rehabilitation
» CIP assessment or treatment – point of care risk
» CIM assessments should be done prior to each
patient interaction[17]
4. Pulmonary sequelae
2. Try and do as much as possible without patient
» Impaired lung function
contact
» Lung fibrosis as sequelae of pneumonia –
» Find other innovative ways to gather
patients showing respiratory insufficiency
information without direct contact with
needing respiratory rehabilitation
patients in isolation. Consider telehealth
» Tough secretions requiring specific
methods to conduct a subjective assessment
physiotherapy techniques or technical removal
or a pre-treatment screening or discharge
planning; to observe patient mobility, etc)[17]
5. Cognitive sequelae[16]
» Difficult awakening with long-lasting 3. Determine the type of Personal Protective
confusional state and psychological problems Equipment (PPE) needed for patient
» Delirium and other cognitive impairments[16] contact[17]
» Aerosol Generating Procedures (AGP’s)
6. Other sequelae » The type of oxygen therapy the patient
» Limitations of ADL is receiving and the type of procedure
» Dysphagia conducted will determine if a procedure is
» Impaired swallow and communication aerosol-generating
» Therapies that require airborne precautions:
Patients with severe COVID-19 infection seem to
• High flow nasal oxygen
have lengthy and longer than usual stays in ICU
• Non-invasive ventilation
and many complications due to the long period
• Nebuliser treatment
of immobilisation and prone positioning. It is
• Tracheostomy tubes with/without
important to have a gradual progression from
mechanical ventilation requiring open
the weaning phase to transfer to a rehabilitation
suctioning
service – patients need to be monitored closely
» Sputum inducing procedures require airborne
and accurately as they remain unstable for
precautions
several days after extubation.
• Respiratory physiotherapy
• Activities resulting in expectoration
Procedures for Post-Acute of sputum – moving from lying to
Covid-19 Rehabilitation sitting, walking, bedside ADL’s, prone
positioning[17]
Patients who have recovered from the acute
respiratory effects of COVID-19 will still need 4. Other considerations before starting direct
further rehabilitation. contact treatment[17]
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» It is critical to have a step-by-step process » Best to utilize single-use equipment where
for donning and doffing PPE to avoid possible (Therabands instead of free weights)
contamination » Special care and attention should be paid to
» Use the minimum amount of people required the use of electrode sponges, heat packs, gels,
to safely administer a treatment session topical lotions, etc
» Careful consideration is needed with regards » Therapeutic activities should be planned to
to equipment use. Be sure that it is line with minimize the number of personnel needed
infection control measures and that any (i.e. therapist with a gait/walking aid instead
equipment can be properly decontaminated. of a therapist and an assistant)
Avoid moving equipment between COVID-19 » Minimize the number of personnel in contact
and non-COVID-19 areas. Opt for using with a patient. Have a single staff member
single patient use, disposable equipment (i.e, perform most of the care and duties for a
Theraband instead of hand weights) patient
» Walking practice should be done in areas that
are not commonly used
Suggestions for the Design and
» Surgical masks should be worn by patients
Procedures for an Inpatient and therapists should be using the necessary
Rehabilitation Unit PPE
These suggestions will need to be assessed based » Patients should always practice social
on the unique setting of each rehabilitation unit distancing among each other
and the specific needs of the individual patient.
Many of these suggestions are extrapolated
Personnel Considerations in a
from the experiences in China and Italy as well
as from the SARS epidemic.[5] [13] [18] Rehabilitation Unit
» A separate area or unit is necessary for the » Frequent health checks for rehabilitation
rehabilitation of post-COVID-19 patients personnel
» Patients might be transferred from acute care » Staff shortages may arise either due to illness,
earlier than is generally done, in order to clear isolation or redeployment
beds for more patients in need of acute care » Changes in staff/patient ratio – more one on
» Patients should stay in their rooms one sessions
» Therapy should be provided one on one » Guidelines and protocols will be changing as
» group therapy and therapy in rehabilitation new evidence becomes available. Continuous
gyms should not be allowed staff training will be paramount
» Earlier discharge of patients (as soon as the » Personnel should be trained and re-trained in
family can take care of the patient) to free up the use of PPE
space for incoming patients » Physiotherapists should use higher levels of
» There might be difficulty in discharging PPE if they are at risk of exposure to aerosols
patients to long-term care facilities and from post-COVID-19 patients.
retirement homes as these facilities might » Ongoing input from frontline staff is
not be taking in new residents during the important to inform other healthcare
pandemic professionals
» Shared equipment should be decontaminated » Other ways of providing non-required
between patients therapies and services should be considered
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such as telerehabilitation event may present with a disability or
» Work efficiency might be affected by the use functional damage (respiratory function,
of PPE and the time it takes to don PPE, as well CIP, CIM, PICS), reduced participation and
as infection control measures deterioration in their quality of life (short
» Virtual staff meetings should be held if term as well as long term post-discharge)
possible[15][19] » Variable recovery time – dependent on the
degree of normocapnic respiratory failure,
associated physical dysfunction (asthenia,
Post-Acute Rehabilitation Guidelines
muscle weakness), emotional dysfunction;
After COVID-19 the presence of other comorbidities
The WHO and the PAHO have compiled a » Clinical parameter evaluating protocols are
document on the rehabilitation considerations indicated on a daily basis – temperature,
during the COVID-19 outbreak[3], and the SaO2, Sp02/Fi02, cough, dyspnea, respiratory
WCPT has also compiled briefing papers in rate, thoraco-abdominal dynamics
response to COVID-19[4]. The second briefing » Simple and repeatable protocols to wean
paper specifically addresses rehabilitation and oxygen therapy should be used
the vital role of physiotherapy.[4] » Reconditioning interventions are indicated
in weaned patients and those with prolonged
Each patient in the post-acute rehabilitation unit
weaning from mechanical ventilation
should be assessed by all the relevant healthcare
to improve physical status and effects of
professionals. A suitable and manageable
prolonged immobilisation
treatment plan should be created with input from
» Evaluate peripheral muscular strength with
the healthcare team and the patient. The direct
MRC scale, manual muscle testing, isokinetic
impact of COVID-19 on the respiratory system
muscle test; measurement of joint range of
and other systems, the sequelae of COVID-19
motion
(such as a long period of ICU stay, mechanical
» Exercise with gradual load increase and based
ventilation) as well as the comorbidities involved
on subjective symptoms can help to regain
will direct and inform the rehabilitation plan.
and maintain normal function
Other factors that will affect the rehabilitation
» Consider telehealth systems for patients that
plan is the discharge destination and estimated
need rehabilitation but who are in isolation
discharge date.[5]
» Balance function assessment is necessary as
Currently, there is limited evidence of the soon as possible (especially in patients who
impact of rehabilitation after COVID-19. The have been bedridden for a long period)
information provided is based on evidence from » Exercise capacity and oxygenation response
countries such as China, Italy and other areas. during effort should be assessed
This evidence is based on the experience and
expert opinions of rehabilitation healthcare
Respiratory Rehabilitation
professionals from these regions.
It is recommended to not begin with
respiratory rehabilitation too early to avoid
General Rehabilitation Conside-
aggravating respiratory distress or dispersing
rations in the Post-Acute Phase the virus unnecessarily. Techniques such as
» Patients recovering from an acute COVID-19 diaphragmatic breathing, pursed-lip breathing,
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bronchial hygiene, lung expansion techniques rehabilitation programme included respiratory
(positive expiratory pressure), incentive muscle training with positive expiratory
spirometry, manual mobilisation of the ribcage, pressure device, cough exercises, diaphragmatic
respiratory muscle training and aerobic exercise training, chest stretching and pursed-lip
are not recommended in the acute phase. In the breathing.[21]
event of comorbidities such as bronchiectasis,
Aspects to monitor closely in patients
secondary pneumonia or aspiration increasing
include[20]:
secretions, postural drainage and standing
» Shortness of breath
(gradual increase in time) may help with
» Decreased SaO2 (<95%)
secretion management.[20]
» Blood pressure (< 90/60 or > 140/90)
Respiratory assessment for post-acute » Heart rate (>100 beats per minute)
rehabilitation should include[1][20]: » Temperature (> 37.2 C)
» Dyspnea » Excessive fatigue
» Thoracic activity » Chest pain
» Diaphragmatic activity and amplitude » Severe cough
» Respiratory muscle strength (maximal » Blurred vision
inspiratory and expiratory pressures) » Dizziness
» Respiratory pattern and frequency » Heart palpitations
» Sweating
Also include an assessment of their cardiac
» Loss of balance
status
» Headache
In the post-acute phase, the following respiratory
Patients in post-acute rehabilitation can start a
rehabilitation may be included:
multidisciplinary team rehabilitation program.
» Inspiratory muscle training if inspiratory Concepts of pulmonary rehabilitation can be
muscles are weak applied, but keep in mind that pre-rehabilitation
» Diaphragmatic breathing assessments such as formal lung function
» Thoracic expansion (with shoulder and exercise testing is probably not feasible
elevation) at the start and cannot be done in infectious
» Mobilisation of respiratory muscles patients. Exercise training may have to start
» Airway clearance techniques (as needed) with relatively simple graded functional and
» Positive expiratory devices may be added if strengthening exercises, using no or minimal
needed equipment.[22]
Be careful to not overload the respiratory system

and causing respiratory distress! Functional Rehabilitation
A randomised controlled trial from China Recommendations on functional rehabilitation
implemented a respiratory rehabilitation from the European Respiratory Society include:
program consisting of 2 sessions of 10 minutes » Assessment of exercise and functional
per week for 6 weeks post-discharge from acute capacity
care. The study results showed a significant » Monitoring of pre-existing conditions
improvement in respiratory function, endurance, » Exercise training and/or physical activity
quality of life and depression. The respiratory coaching
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Functional Rehabilitation aspects to assess[1]: Specific Physiotherapy Interventions
» Muscle and joint range of motion Ways of early mobilisation include[24]:
» Strength testing » Frequent posture changes
» Balance » Bed mobility
» Exercise capacity – assess with the 6-minute » Sit to stand
walking test (continuous oxygen saturation » Simple bed exercises
monitoring included) » ADL’s
» Cardiopulmonary exercise testing
It is important to monitor the patient’s
» Activities of Daily Living (ADL)
respiratory and hemodynamic state during
rehabilitation!
Clinical Outcome Measures » Active limb exercises should be followed by
progressive muscle strengthening (suggested
It is recommended to use easily applicable tests,
programs 8-12 RM load for 8 -12 repetitions,
as advanced equipment to assess the functional
1 to 3 sets with 2 minutes rest between sets, 3
capacity of patients may not be available or safe
sessions a week for 6 weeks)[1]
to do during the pandemic. Clinical outcome
» Neuromuscular electrical stimulation can be
measures that can be used[1][23]:
used to help with strengthening.
» Patient Specific Functional Scale to identify
» Aerobic reconditioning can be achieved with
perceived limitations in activities of daily
walking, cycle or arm ergometry, NuStep
living
cross trainer
» Monitor patient’s oxygen saturation and
» Keep aerobic activity less than 3 metabolic
heart rate frequency before, during and after
equivalents of task (MET’s) initially
physical activity and exercises
» Progressive aerobic exercise can later be
» Use Borg Scale CR10 for shortness of breath
increased to 20 -30 minutes
and fatigue
» Education on energy conservation and
» International Physical Activity Questionnaire
behavior modification[5]
to measure function and disability
» Physical Activity Scale for the Elderly to Advice on Exercise as Medicine
measure function and disability 1. Gradual increase of daily living activities and
» Berg Balance Scale physical functioning
» 6 Minute Walking Test - to assess exercise 2. Provide patient with exercises that support
capacity recovery in daily function
» Barthel Index to measure ADL 3. All activities should be well monitored
» Short Physical Performance Battery especially in patients with PICS
» 30 seconds sit to stand test 4. Perform exercises at low to moderate
» Handgrip dynamometer test intensity and off limited duration. Keep in
» Manual muscle strength test mind that patients who have been admitted
to ICU and who show symptoms of PICS will
The multidisciplinary team should aim to
have a very low capacity to perform activities
use the same clinical outcomes for the same
and exercise.
constructs to facilitate communication between
5. The activity levels of the patient prior to
team members and not burden the patient
COVID-19 infection, the patient’s needs and
unnecessary.
the current physical abilities of the patient
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15
will determine the specific parameters for activities should be provided to the patient.
exercise prescription
Psychological interventions should be provided
6. Recommendation of a maximum score of
where required for patients by occupational
4/10 on Borg Scale CR10 for shortness of
therapists, social workers or rehabilitation
breath and fatigue during the post-acute
psychologists.
rehabilitation phase as patients have reduced
lung function after COVID-19 infection and Chinese medicine techniques (tai chi, Qigong,
cardiac function may possibly be affected guided breathing) have been suggested by the
after COVID-19 infection. Chinese
7. No maximal exercise testing is done after
active COVID-19 infection - limitations due
Actions for Rehabilitation Service
to pandemic. So there will not always be
adequate clinical information to determine Providers
a patient’s specific parameters for exercise These are actions that rehabilitation facilities,
prescription and also not possible to estimate private practices and hospitals can take during
the risk involved of physical training at a the COVID-19 pandemic to improve and ensure
moderate/high intensity. quality service delivery.[3]
8. Prescribe exercises with training parameters » Stay informed on the outbreak status
regarding frequency, intensity, time/duration and regional and national guidelines
and type[23] regarding COVID-19
• Set-up communication links with all
relevant COVID-19 coordination bodies and
Multidisciplinary Team Involvement
networks
Various members of the multidisciplinary team • Source, disseminate and enforce COVID-19
will be involved in the post-acute rehabilitation guidelines and protocols
phase of survivors of severe COVID-19. Some of • Ensure frequent communication with
these team members include[17]: patients and distribute important
» Occupational therapists information
• Focus ADL and instrumental ADL guidance » Rehabilitation should be integrated
• Interventions to facilitate functional into Infection Prevention and Control
independence (IPC) measures and healthcare workers
• Help to prepare the patient for discharge should use Personal Protective Equipment
• Can address cognitive changes (PPE) appropriate to their risk exposure
» Speech and language pathologists/ • Have set protocols for IPC (to whom, when,
therapists and how these apply)
• Assess and treat dysphagia as a result of • Rehabilitation professionals like
intubation physiotherapists may engage in the delivery
• Assess and treat voice impairments as a of Aerosol Generating Procedures (AGP’s)
result of prolonged intubation and the essential PPE is required for this
• Address communication issues • The rehabilitation workforce (and family
members) should have priority access to
Education on healthy lifestyle and the
COVID-19 testing
importance of participating in family and social
• IPC training is critical to all rehabilitation
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professionals respiratory and physical deconditioning
» Increase the rehabilitation workforce for should be available
the post-acute and long-term recovery phases • These may include:
after COVID-19 ʅ Exercise programs with graded
• Address workforce shortages exercises
• Source rehabilitation professionals from ʅ Pacing strategies
areas such as retired workforce, trainees, ʅ Behavior modification
academics, private practice ʅ Advice on positioning
• Develop competency-based training and
• Recognition of red flags such as signs of
supervision for professionals who are
medical deterioration
rejoining the rehabilitation workforce or
• Implement systems for tracking COVID-19
shifting their roles to provide support
patients and remote-follow-up
• Ensure productivity of the existing
• Implement referral pathways and develop
workforce by implementing measures such
contact lists for services required by
as leave postponement, modifying shift
COVID-19 patients
structures, increasing part-time contract to
» Rehabilitation practices modification for
full time
Infection control
• Identify high-risk rehabilitation healthcare
• Develop and implement protocols for the
professionals and define clear and strict
management of rehabilitation equipment
conditions for their practice
and assistive devices to reduce infection
• The wellbeing of rehabilitation professionals
risk
can be supported by monitoring for and
• Prepare rehabilitation professionals for the
taking steps to prevent burnout, and
impact of PPE such as the time involved
guarantee access to psychosocial support
donning and doffing PPE and the impact it
» Additional equipment
will have on patient rapport
• Attain additional equipment needed
• Plan for working in different teams to
for the surge in rehabilitation demand
reduce therapist-patient exposure
related to COVID-19 patients, such as
• Amendments to the scope of practice and
pulse oximeters, rehabilitation equipment
more interdisciplinary practice to minimize
such as hoists, walking aids, equipment
patient’s contact with multiple professionals
used during respiratory/pulmonary
• Multidisciplinary teamwork will be
rehabilitation such as stationary bikes
more virtual meetings than face to face
• Attain additional assistive devices that can
interactions
support early discharge, such as walking
• Address barriers to telehealth such
frames, commode chairs, mattresses and
as technology, devices, network and costs
transfer products
• Group patients beds and adjust the spacing
» Rehabilitation clinical management for
to reduce the risk of infection
COVID-19 patients
• Rehabilitation sessions should rather be
• Implement clinical management guidelines
done within a patient’s bed space in order to
and protocols of care related to COVID-19
restrict the movement of patients within a
patients based on best available evidence
rehabilitation facility
• Adaptable rehabilitation resources for
• Avoid the use of shared therapy spaces such
COVID-19 patients who experience ongoing
as gyms
PAGE
17
• Develop protocols for patient discharge to • Be aware of patients’ normal family or
maximize bed availability and minimize support structure being disrupted due to
the patient time in the rehabilitation facility the COVID-19 outbreak. Facilitate support
» Encourage and ensure access to psychosocial such as communication with family
support for patients members.
• Increased levels of anxiety and depression • Provide training and access to psychological
as seen in COVID-19 patients. Ensure that first aid skills for rehabilitation professionals
patients have access to the support that they • Implement peer support mechanisms
need during their rehabilitation process
PAGE
COVID-19 Rehabilitation/ COVID-19 – Medium to Longer Term Health Considerations
18
COVID-19 – Medium to Longer
Term Health Considerations
Physical Impairment and Because mechanical ventilation is required

Dysfunction Following with patients experiencing the severe
phase of COVID-19, HCPs must be prepared
COVID-19 to address Intensive Care Unit Acquired
Weakness (ICUAW).
Sequelae of Severe Acute Respiratory » ICUAW is a symmetrical and flaccid
Syndrome (SARS) weakness of limbs (proximal > distal muscles)
which can be evoked by either critical illness
Sequelae of and rehabilitation from SARS may
polyneuropathy, critical illness myopathy
serve as a useful starting point for planning for
or both.[26] Respiratory muscles are often
optimal recovery from COVID-19.
affected and can contribute to delayed
» At about one month post-discharge, one-
weaning from mechanical ventilation. In
third of patients with SARS had dyspnoea
a review by Hermans and Van den Berghe
on exertion, general malaise and moderate
(2015), weakness was found on wakening in
to severe impairment of work or household
26-65% of patients who were mechanically
tasks.[25]
ventilated for 5-7 days, respectively.
» Pulmonary fibrosis was found in 62% of post-
[2] Twenty-five percent of these patients
acute patients but was generally patchy and
remained weak for at least another seven
not extensive thus it was not expected to have
days. ICUAW was diagnosed in up to 67%
a significant impact on lung function. Patients
of patients mechanically ventilated for ≥ 10
with this fibrosis tended to be older and had a
days. In patients with ARDS, weakness on
more severe acute phase. Respiratory muscle
wakening has been reported in 60% with
weakness (rather than parenchymal damage)
36% of these patients still weak at discharge
was the major factor for the restrictive lung
from hospital.[26]
function defect.
» In addition, 50% of discharged patients Factors other than ICUAW may also be relevant
demonstrated decreased handgrip strength. since the majority of ARDS survivors have a
marked reduction in their physical function
The authors stated that respiratory and skeletal
even though only a small number of them have
muscle weakness could be due to various factors
a measurable persistent weakness.
including prolonged bed rest and physical
» Other factors may
deconditioning.[25]
include proprioception, gait, balance, spatial
attention, cognitive function, mental
Intensive Care Unit Acquired health, CNS dysfunction, pain and
Weakness entrapment neuropathy.[26]
PAGE
COVID-19 Rehabilitation/ COVID-19 – Medium to Longer Term Health Considerations
19
ICUAW is associated with prolonged stays evaluated the impact of a six-week exercise
in the ICU and hospital at large and may program on post-SARS patients and found
have consequences lasting longer than the significant improvements in the six-minute
hospitalization phase of a critical illness.[26] walk distance (13.1% vs 3.4% in the control
» Recovery is typically within weeks or group), VO2max (10.% vs 0.3%), handgrip
months but some patients may not recover. strength, curl-up and push-up performance
Persistence and higher severity of weakness compared to controls.[28] The majority of
at ICU discharge have been found to increase both groups had returned to work during this
the risk of death within the first year. six-week period (85.% of the control group
» Attempts to prevent the occurrence of ICUAW and 88.5% of the exercise group).[28] They
are therefore important and may require did not find that physical training during the
multiple strategies including aggressive six-week intervention period had any impact
treatment of sepsis, insulin treatment to on health-related quality of life. The exercise
normalize glycemia, a reduction in the program consisted of four to five 1-1.5 hour
duration of immobilization (e.g. decreasing sessions per week, two of which were supervised
levels of sedation, early physiotherapy if by physiotherapists. One session included
medically safe, electrical muscle stimulation cardiorespiratory training for 30-45 minutes
if unable to mobilise early) and correction of (limb ergometer, step machine or treadmill,
malnutrition. starting at a minimum of 60-75% of predicted
HRmax) and resistance training (3x10-15 reps
for large muscle groups of the upper and lower
Physical Rehabilitation limbs).[28]
Landry et al (2020) state that “physiotherapy can
mediate the deleterious pulmonary, respiratory
and immobility complications” of infectious
Mental Health
diseases and that “rehabilitation can offer a cost- Considerations
effective upstream strategy that can restore the Mental health should be considered for the
mental and emotional quality of life during and patient, family, and health care workers. Read
after medical intervention.”[27] more here.
The authors note that for a clearer idea of the

range of interventions physiotherapists could
offer in the management of infectious disease,
the International Classification of Functioning,
Disability and Health should be considered in the
post-acute stage of the disease.[3] This facilitates
the identification of impairments, activity
limitations and participation restrictions that
could occur for a given patient and thus what
interventions would be appropriate.
Again, the SARS crisis in 2003 provides some

guidance for a starting point for post-acute
physiotherapy intervention. Lau et al (2005)
PAGE
COVID-19 Rehabilitation/ COVID-19 - Community Rehabilitation
20
COVID-19 - Community
Rehabilitation
The rehabilitation of patients recovering from » Will be key in the ongoing rehabilitation of
COVID-19 is essential to ensure an improvement survivors of COVID-19 to optimise recovery of
in long-term physical and mental health. these patients.
Community-based physiotherapists will play » Will perform other tasks such as home safety
a key role in the rehabilitation of COVID-19 assessments, acquisition of relevant medical
survivors following hospital discharge. equipment as well as caregiver training once
patients have been discharged from hospital.
[29]
The Role of the Community- » Can provide interventions to non-COVID-19
Based Physiotherapist patients and possibly reduce the volume of
Once the surge in acute cases of COVID-19 patients new hospital admissions for this population,
has subsided, there will be an increase in which in turn will reduce the burden on
rehabilitation needs of these patients following already stretched hospitals.
discharge from hospital. Community-based
physiotherapists will be essential in the provision
of these rehabilitation services. [29]
General Rehabilitation
Strategies in COVID-19
Community-based physiotherapists will actively Patients Following Hospital
contribute to the rehabilitation of patients
Discharge
recovering from COVID-19 and help reduce the
risk of readmission to hospital for these patients. Patients recovering from COVID-19 will still
Two risk factors for hospital readmission are need rehabilitation following discharge from a
1. Impaired physical function hospital or a rehabilitation centre. Rehabilitation
2. Unmet needs for Activities of Daily strategies can include[3]:
Living assistance. » Graded exercise
» Education on energy conservation and
These are two areas in which physiotherapists
behaviour modification
are essential in delivering care.[29]
» Home modification
For patients with poor health care outcomes, » Assistive Devices
the provision and participation in rehabilitation » Patients may also benefit from pulmonary
may increase their functional reserve and make rehabilitation interventions – this targets
a difference between surviving or succumbing physical and respiratory impairments and
to an acquired COVID-19 infection.[30] include a combination of graded exercise,
education, activities of daily living and
Community-based physiotherapists:
psychosocial support.
PAGE
21
» Pandemic-related constraints (such as social » oxygen desaturation (decrease on O2 in the
distancing, limited human resources and blood resulting from any condition that
limited public transport) and infection affects the exchange of CO2 and O2)
risks following discharge might mean
Psychological and neuro-psychological
physiotherapists need to think out of the
issues
box and find innovative ways to provide
» Patients may present with
rehabilitation services.
anxiety, depression or Post Traumatic Stress
• This could include telehealth (conference
Disorder and other psychological difficulties
on telehealth, image at R)
as a result of their experience of the illness
• Remote exercise - such as “virtual group”
and the treatment they received
education and exercise
• Peer to peer support from COVID-19 patients Social issues
who have received the appropriate training » A patient’s circumstances may be affected by
» Rehabilitation services in people’s the pandemic and changes during periods of
communities are often the best-placed to lockdown
provide long-term care[3]
It is critical that the needs of the patient and
the symptom management should always be
Healthcare Needs of considered and addressed in a holistic way. The
COVID-19 Patients Following patients’ needs will also change as rehabilitation
Discharge progresses and the treatment goals should be
adjusted accordingly.
Patients may present with various issues
on discharge from hospital or inpatient
rehabilitation centres. Rehabilitation specialists Respiratory
such as physiotherapists in the community will
» Patients may require
be needed to provide the relevant care of these
supplemental oxygen following discharge,
patients. The issues still prevalent in a patient
either temporary or long-term [31]
recovering from COVID-19 following discharge
» Pulmonary rehabilitation - the need for this
will guide and inform the patient’s care and
will depend on the severity of the COVID-19
support plan. This can include considerations
infection, existing comorbidities and the
such as if the patients will be able to care for
patients’ functional status
themselves and manage their needs and what
» Pulmonary vascular disease – evidence shows
wider support will be necessary.[31] These issues
that patients with COVID-19 experience a
may include:
high prevalence of thromboembolic disease
Physical issues and patients that were treated in ICU with
» Such as weakness severe COVID-19 may develop pulmonary
» Fatigue artery hypertension
» Balance » Chronic cough - this is defined in adults as
» Gait issues having a cough lasting over eight weeks.
» Loss of function Cough is one of the most common clinical
features in patients with COVID-19, but
Respiratory problems such as:
research is still lacking on chronic cough
» breathlessness
post- COVID-19 infection.
PAGE
22
» Lung fibrosis – about 30% of SARS and improved quality of life and exercise capacity.
MERS survivors experienced physiological Physiotherapy is critical in addressing these
impairment and abnormal radiology issues of deconditioning and weakness. [31]
that is consistent with fibrotic lung
Neuropathy
disease. Pulmonary fibrosis may be a
consequence of COVID-19. Patients may have neuropathies following
» Pulmonary physiology interventions to discharge. One of the treatment methods for
determine the effect on lung function patients with respiratory failure is prone-
• Pulmonary function tests such positioning for up to 16 hours per day. This
as spirometry, lung volumes, gas transfer may put patients at risk for compression
and exercise capacity may need to be done neuropathies and neural damage. Other issues
to determine the physiological impact of the may be pressure damage to heels and other areas
effect of COVID-19. These tests are necessary due to prolonged bed rest, lack of sensation, lack
to manage potential pulmonary scarring of proprioception and an increased risk for falls.
and resulting fibrosis, but the timing and Physiotherapists are key role players in the
nature of the tests to be done still needs to assessment and treatment of neuropathies. [31]
be determined.
» Possible risk of bronchiectasis after COVID-19
General Function and Well-being
infection needs to be considered [31]
Fatigue
Cardiac People who have had COVID-19 report extreme

fatigue beyond the usual reported levels. This
» Acute myocardial injury is the most common
will influence the recovery rate, the need for
described cardiovascular complication
support and the need for supportive equipment,
in patients with COVID-19 ( occurring in
as well as a person’s return to their normal
8-12% of discharged patients, heart failure is
activities and work. A gradual increase and
reported in 12% of recovered and discharged
return to activities and exercise are advised and
patients) [31]
patients need to be taught pacing strategies.
Physiotherapists are in a unique position
Neuromuscular to early identify fatigue in patients and can
implement fatigue management strategies. This
Hospital-acquired weakness
can include sleep hygiene, energy conservation
The impact of COVID-19 on the incidence techniques, pacing, a gradual increase in activity
of hospital-acquired weakness, deconditioning and graded exercise. The early implementation
in hospital and the long-term physical weakness of these fatigue management strategies could
is still not known. There seems to be anecdotal limit the impact of fatigue and the possibility of
evidence from the UK and Europe that there fatigue developing into a chronic condition. [31]
might be a higher than usual incidence of ICU-
AW compared to the usual critical care cohort.
Early physical rehabilitation following hospital
New Challenges to
discharge is beneficial and may improve quality Treatment of Discharged
of life. An eight-week pulmonary rehabilitation COVID-19 Patients
program in survivors of ARDS significantly » Increased number of patients with Post
PAGE
23
Intensive Care Syndrome (PICS) malaise and it is important that physiotherapists
» Maintaining infection control know this and also know the appropriate
» Increased pressure on equipment provision – treatment. A key factor to keep in mind is that
such as oxygen canisters, personal protective progressive physiotherapy can be harmful
equipment to people with ME. People with ME have an
» Increased pressure on staffing abnormal response to exercise. This abnormal
» Increased number of patients with persisting response includes[32]:
psychological difficulties following hospital » Lower anaerobic threshold
discharge[31] » Lower oxygen capacity
» Increased acidosis
» Abnormal cardiovascular responses
Emerging Clinical » Suitable management approaches include:
Perspectives that Affect » Symptom contingent pacing
Rehabilitation of COVID-19 » Heart rate monitoring[4]
Patients
Steps to Consider Following
Post Intensive Care Syndrome (PICS) Discharge
The aftershock of the pandemic will include Following discharge, the support of the patient
ongoing rehabilitation needs of patients with should be kept under review as the person’s
PICS. Coordinated rehabilitation approaches situation changes and the personalised support
should be considered and developed for this and care plan also adapts. Some principles to
specific cohort of patients.[4] consider once a person returned home after a
COVID-19 infection include[31]:
More information on PICS is available on
» Existing services
this Physiopedia Page: COVID-19: Post-Acute
• Patients should be supported through
Rehabilitation
adapting and strengthening the local
existing services in a community, as far as
Post-Viral Fatigue Syndrome possible. These systems will differ between
countries.
There is the potential that people recovering
» Infection risk
from COVID-19 may develop post-viral
• Infection prevention control measures
fatigue syndrome (PVFS). It is critical that
should adhere to the local and national
physiotherapists are aware of the signs and
guidelines as set out the specific region or
symptoms of PVFS and be aware and know the
country.
management strategies. These management
» Minimise steps
strategies should focus on rest, hydration and
• The number of steps in a treatment or
nutrition.[4]
management pathway of a patient being
If the symptoms of post-viral fatigue syndrome discharged from the hospital should
do not resolve within 4-5 months of the viral be minimised as well as the number of
infection, it could then be diagnosed as Myalgic healthcare professionals involved in the
Encephalomyelitis (Chronic Fatigue Syndrome). management of the patient. This will help
to further reduce the risk of infection.
The main symptom of ME is post-exertional
PAGE
24
» Volunteers and carers if the patient has negative nasal/throat swabs,
• If available in a region or country, make use use eye and respiratory protection, gloves
of volunteers and carers to support patients and if possible disposable gowns when using
» Education and training Aerosol Generating Procedures (AGP’s)
• Rehabilitation professionals involved in » All patients should wear a medical mask
the care of COVID-19 patients may have during treatment
education and training needs » Measures to minimise droplet and aerosol
» Support for rehabilitation professionals dispersion should be implemented during
• Psychological and practical support for AGP’s
rehabilitation professionals during the » Outpatient consultation
pandemic should be provided. • Aerate the examination room after each
consultation
• Sanitise surfaces
Rehabilitation Strategies for • Ensure spatial distance between patients in
COVID-19 Patients Following waiting rooms
Discharge from Hospital
This is just a short summary of some
Diagnosis of COVID-19 Phenotype
rehabilitation strategies and interventions from
different countries. Evidence is still emerging Patients
and the clinical guidance may change as more
Phenotypes [33]
is learnt about the natural history of the disease.
The following is still unknown:
» Days of contagious risk
Pulmonary Rehabilitation in
» Need for pulmonary rehabilitation
COVID-19 Patients Recovering from » Timing to commence pulmonary
ARDS – Suggestions from Italy rehabilitation
These are the results of an Italian consensus » Predictors of recovery
through a Delphi process that was published
Pulmonary rehabilitation is proposed for
in June 2020[33]. The full article can be
dyspnoeic, older patients with comorbidities,
accessed here. Some of the suggestions that
with:
may influence the rehabilitation of patients
» Long length of hospital stay
discharged from hospital will be highlighted
» History of ICU admission
here.
» Weaning from mechanical ventilation was
required
Personal Protection Equipment » Reduced strength and exercise capacity
» In need of oxygen at rest and during effort
Suggestions for personal protection
needs[33] Individualised pulmonary rehabilitation
» Appropriate PPE should be used by healthcare programs should be proposed.
professionals. They should be trained in the
proper donning and doffing procedures of PPE. Frailty Measures[33]
In this Italian consensus, they recommend
Patients with frailty could be affected more
that in the first 3 months after infection and
seriously and may have a poor prognosis
PAGE
25
Recognition of frailty is important before • comorbidities
setting up a PR program, to reduce the risk of • neurological disorders
poor outcomes • psychological disorders
• frailty
Multidimensional assessment should be
» Outcome measures should include:[33]
incorporated in frailty measurements such as:
• exercise tolerance
» Global exercise capacity
• functional status and physical performance
» Strength
• presence of Critical Illness neuromyopathy
» Balance
and ICU-AW
» Coordination
ʅ ICU-AW can be measured with manual
» Nutritional
muscle testing to assess the strength
» Psychosocial status
of six muscle groups bilaterally to
determine the Medical Research
Timing of Pulmonary Rehabilitation
Council (MRC) Sum Score. MRC Sum
Commencement[33] Score of < 48 is an important criteria to
» No clear scientific evidence for the timing as define ICU-AW.[34]
yet
• Activities of Daily Living
» PR is recommended from an early stage in
• baseline functional impairment due to
hospital
dyspnea and how breathlessness affects the
» Interestingly, a suggestion that was not
patient’s mobility
approved by the consensus panel was that
» Gas exchanges and best informative
outpatient rehabilitation programs and
indices[33]
telemedicine should be considered for patients
• Pulse oximetry and SaO2/FiO2 values are
discharged from the hospital. Reasons for this
critical to monitor the clinical situation at
included;
rest and during effort
• inconclusive literature evidence on
• Pulse oximetry device at home is
telerehabilitation
recommended
• the belief that telerehabilitation could only
» Lung function tests[33]
be used for stable patients
• When safe to perform by operators and
• obstacles of telerehabilitation such as
patients
useable technology for the largest possible
• Not to be used as outcome measures of
number of patients and the safety of patients
pulmonary rehabilitation programs
at home
• Severe impairment should not be considered
• medico-legal liability
a contra-indication for Pulmonary
• issues around economic reimbursement.[33]
Rehabilitation
Assessments » Functional Evaluation[33]
» Discharge outcomes following COVID-19 are • At discharge and before the start of
still unknown[33] Pulmonary Rehabilitation
» Assessments should include:[33] • Following discharge an assessment of
• symptoms scales physical performance and ADL autonomy
• cardiorespiratory function is necessary.
• pulmonary function tests • The standard maximal cardiopulmonary
• respiratory muscle strength exercise test is not recommended in the
PAGE
26
first 6-8 weeks following acute hospital Interventions
discharge due to unknown cardiorespiratory
and muscle involvement and infectious risk
Oxygen Therapy[33]
• Exercise-induced oxygen desaturation
assessment is critical during exercise » Oxygen needs at rest, during effort and sleep,
tolerance tests should be assessed
• With exercise and exercise testing » Use standardised tests such as 6MWT (if
ʅ fatigue and breathlessness should be the patient is able to) to assess oxygen need
evaluated through psychometric scales during effort
such as BORG scale or VAS » Precautions about air dispersion distance
ʅ Follow-up assessments should should be considered during oxygen
routinely include monitoring of administration
physical performance
» Respiratory muscle assessment[33] Exercise Programs[33]

• Unknown factors
» Pulmonary Rehabilitation in post-COVID-19
ʅ prevalence
patients could improve symptoms, functional
ʅ severity and
capacity and quality of life. However, the
ʅ recovery of respiratory muscle
best exercise program intervention is still
weakness due to COVID-19
unknown
• Standard maximal inspiratory and » Exercise training principles in patients with
expiratory pressures (MIP/MEP) are not chronic lung disease could be considered in
recommended in the first phase (6-8 week) post-COVID-19 patients
due to infection risk » In patients with mild or no disability (SPPB* >
10; Barthel Index > 70) – Aerobic exercise <3.0
Quality of Life Assessment[33] MET›s with a progressive increase of intensity
» Test for the presence of disorders such as based on symptoms (BORG fatigue and/or
anxiety, depression, sleep disturbances, PTSD dyspnea below the score of 3) is advised to
» Assess patient’s level of autonomy restore normal physical function
» Assess the quality of the patient’s support » In patients with moderate to severe
network disability (SPPB < 10; Barthel index < 70)
» Obtain a global measurement of the patient’s – a comprehensive rehabilitation program
perceived Quality of Life level is recommended to improve autonomy,
peripheral and respiratory muscle strength,
Emotional Aspects to IdentifyI[33]
balance, walking ability, symptoms and
» Neuropsychological assessment at baseline
Quality of life
and post-Pulmonary Rehabilitation
» Aerobic exercise (cycling, treadmill, free
» Measures of psychosocial effects such as
walking) and resistance strength training
depression, anxiety, PTSD
should be included in the exercise program
» Do not ignore the long term psychological
» SpO2 measurement is mandatory during
and psychosocial implications of infectious
exercise, subsequent oxygen supplementation
diseases
may be prescribed if SpO2 < 93%
» Consider caregiver and family of patient
» *SPPB = Short Physical Performance Battery
affected by COVID
PAGE
27
Lung Recruitment Exercises[33] General Recommendations
» Chest expansion breathing control exercises » The exact period of contagiousness of
associated with posture positioning should COVID-19 is still unknown. Physiotherapists
be considered should therefore consider the safety risks
involved for both themselves and the patients.
» There is uncertainty about the recovery
Respiratory Muscle Training[33]
path, the physical capacity and limitations
» Not routinely recommended but could be used of patients after active COVID-19 infection.
if respiratory muscle weakness is present Caution is required with assessments and
» The type, efficacy and duration of muscle treatments of this cohort of patients
training in COVID-19, post-acute or long-term » Social distancing principles should be
still needs to be investigated respected and therefore physiotherapists
» Inspiratory muscle training should start at should consider measures such as telehealth
low intensity guided by dyspnea/fatigue and or e-health
vital signs » Always consider and follow national and
regional guidelines on safety, infection
control and the prevention of transmitting
Telerehabilitation[33]
the disease.
» May be an appropriate response following
discharge
Initial 6 Weeks Following Hospital
» May increase the accessibility to Pulmonary
Rehabilitation Discharge
» Contact patient by telephone, telehealth,
e-consult or e-health within the first two
KNGF position weeks following discharge to assess and
statement: Physiotherapy determine if the patient is experiencing any
recommendations in difficulties or limitations in daily physical
patients with COVID-19 functioning and if there is an indication for
further rehabilitation
The Royal Dutch Society for Physical
» Be aware of existing and/or newly acquired
Therapy (Koninklijk Nederlands Genootschap
comorbidities
voor Fysiotherapie) compiled a position
» Consider that patients that were in the ICU
statement on Physiotherapy recommendations
and who show signs of PICS may have very
in patients with COVID-19. In this statement,
low and limited exercise tolerance
recommendations are included for physiotherapy
» Recommend gradual resumption of Activities
interventions in patients following discharge
of Daily Living (ADLs) and physical function.
from hospital. The English version of this
Ensure appropriate monitoring of the patient
position statement is available here: The
daily physical function.
recommendations are mainly aimed at physical
» ADLs and exercise therapy are recommended
rehabilitation aspects[35].
to be performed at low to moderate intensity
In summary, the following and with short interval duration.
recommendations are provided[35]: » The following clinical outcome measures are
recommended:
PAGE
28
• Patient Specific Function Scale » Reassess the patients’ needs to determine
• Oxygen saturation before, during and after how rehabilitation should be adapted and
rehabilitation/exercise progressed
• Use SpO2 of 90% at rest as the lower limit » Reassess the patients’ actual level of physical
and 85% SpO2 during exercise as the lower functioning (compare with previous tests
limit. such as hospital-based exercise tests, lung/
ʅ Stop physical activities or exercise heart function tests, etc)
when desaturation (SpO2 < 85% » Design future treatment goals relating to
during exercise) occurs physical activity and/or exercise capacity
based on exercise tests and measurements of
• Heart rate frequency before, during and
physical activity
after rehabilitation/exercise
» The aim of these treatment goals should be
• Borg Scale CR10 for Shortness of breath
to further improve the performance of ADLs,
and fatigue before, during and after
increased physical activities and increased
rehabilitation/exercise
capacity to exercise
• Max score of 4/10 is recommended as a
» Clinical outcome measures that can be used
threshold for exercise intensity on the Borg
during this phase:
Scale CR10 for shortness of breath and
• Patient Specific Function Scale
fatigue
• Short Physical Performance Battery – this
• Reasons for this include:
includes:
ʅ The severe impact on lung function
ʅ Standing balance test
from COVID-19 – such as oxygen
ʅ Walking speed test over 4 meters
desaturation during exercise due to
ʅ 5 times chair stand test
virus-induced lung disease
ʅ Cardiac function may be compromised • Hand-held Dynamometer for grip strength
due to COVID-19 • 6-minute walk test (6MWT)
ʅ Adequate clinical information is • Pedometer/accelerometer to assess and
not always available as no maximal evaluate daily physical function
exercise testing is done and it is • Oxygen saturation
impossible to estimate the risk of • Heart rate frequency
physical training/exercise at moderate • Borg Scale CR10 for shortness of breath and
to high intensity. fatigue before, during and after physical
exercise
» Patients should only perform exercises in the
» When physical function tests (lung/heart
home situation if they are able to understand
function) and (sub)maximal exercise tests
and apply proper exercise load management
indicate no severe restrictions or risks, start
(frequency, intensity, time/duration and
with a gradual increase in training
type)
» Implement a gradual increase in training
» Physical functioning of ADLs should be the
frequency, intensity, time/duration as well
focus[35]
as type of exercises. This should be based on
the needs of the patient, the agreed treatment
After 6 Weeks Following Hospital goals and the patient’s physical abilities
Discharge • During exercise, a score of 4-6/10 on the
Borg Scale CR 10 for shortness of breath
PAGE
29
and fatigue and/or intensity of 60-80% of The Road to Recovery
the tested maximum exercise performance The Chartered Society of Physiotherapy released
(bicycle test, 6MWT and/or 1RM) is this short video on the road to recovery. It may
recommended.[35] be useful to show this to patients.
Rehabilitation Following Ways to Address Breathlessness

Critical Care in Adults » Breathing control techniques[36]
The NICE guidelines for rehabilitation following » Positions of ease to help in assisting breath
critical care also recommends a 2-3 month control such as:
follow-up after illness, above and beyond the • Leaning forward while sitting
community rehabilitation that patient received • Leaning forward in standing while
since being discharged from hospital. supported
• Standing up, leaning backwards while
Recommendations from these guidelines are:
supported (for example – lean back against
» Patients with rehabilitation needs should be
a wall)
reviewed 2- 3 months after discharge from
• Side-lying with shoulders and head raised
critical care.
» Secretion management[36]
» Functional reassessment should include the
• Deep breathing techniques
following:
• Breath stacking technique
• physical problems
• Postural drainage
• sensory problems
• Staying mobile as allowed by energy levels
• communication problems
• Stay hydrated
• social care or equipment needs
» Energy conservation methods[36]
• anxiety
• Things to remind patients:
• depression
ʅ Energy needs may fluctuate
• PTSD symptoms
ʅ Exercise is good – but be wise about it
• behavioural and cognitive problems
ʅ Do activities they are comfortable
• psychosocial problems
doing, learn to stop and modify when
» The impact of the outcomes from the
tasks are difficult and modify
functional assessment on Activities of Daily
ʅ Set small goals
Living and participation should be assessed.
ʅ Aim to do a little more every day, but
» The rehabilitation goals should be reviewed
avoid overdoing it
and updated based on the functional
ʅ Take breaks between tasks
assessment.
» Family or caregivers should be involved if
patient agrees to it. Graded exercises
The full NICE guideline is available
Bed Exercises[36]
here: Rehabilitation after critical illness in adults
» Neck movements
» Neck rotations
Advice and Examples of » Shoulder rolls
Exercises for COVID-19 » Arm raises
Patients Post-Discharge » Biceps curls – no weight
PAGE
30
» Quadriceps setting
» Leg raises
» Ankle rolls
Exercises While Sitting[36]

» Assisted shoulder exercises
» Biceps curls with lightweight
» Above shoulder exercises with weights
» Side shoulder exercises
» Heel-toe raises
» Knee raises
» Leg raises
Exercises While Standing[36]

» Hip abduction/adduction (Leg to the side)
» Hip extension (Leg backwards)
» Sitting squads
» Knee raises
» Toe raises
Core Stability Exercises[36]

» Pelvic tilts
» Bridging
» Hip rolls
Clinical Bottom Line

People recovering from COVID-19 will need
individual and personalised rehabilitation
goals and plans. Rehabilitation should be based
on appropriate assessment and treatment
strategies. Physiotherapists should always use
their clinical judgement in the rehabilitation of
patients recovering from COVID-19
PAGE
COVID-19 Rehabilitation/ COVID-19 Rehabilitation in Vulnerable Populations
31
COVID-19 Rehabilitation in
Vulnerable Populations
COVID-19 poses a severe threat

to all communities, but there are
several vulnerable communities
that are particularly affected and
face even greater challenges[37].
Prior to COVID-19 many people relied on environment’[38] For some access to services was
rehabilitation services to improve function and already limited by resources, socio-economic
quality of life. According to the World Health factors and location. For others rehabilitation
Organisation (WHO) rehabilitation is ‘a set of has been disrupted as rehabilitation is seen
interventions designed to reduce disability as a non-essential service by many healthcare
and optimize function in individuals with providers, although people who need access
health conditions in interaction with their would not agree as rehabilitation is essential
PAGE
32
to their daily health and well-being[39]. It has People Living with
been recommended by the WHO where there Disabilities
has been a reduction in rehabilitation services
People with disabilities will face higher health
it is necessary to identify patients who are a
risks as a result of COVID-19 - they may be more
priority for services. The needs of service users
susceptible to getting the virus and having
should, where possible, be addressed by other
significant sequelae.[41] They also face various
means, such as Telehealth Services, with policies
challenges due to changes in their environment,
in place to direct the reintegration of services as
including reductions in services, such as social
soon as possible.[2] Vulnerable groups affected
support, rehabilitation or protection service.
include:
These changes further exacerbate the impact
» People living with disabilities
of COVID-19 on these individuals, leading to
» People with existing conditions
poorer health outcomes, including permanent
» Older People
impairments and reduced function. Thus, it is
» People living in Low Resource settings
essential that both people with disabilities and
» Refugees/displaced people
their relevant support organisations are actively
Physiotherapy and rehabilitation is a vital involved in COVID-19 planning to ensure that
component of recovery post COVID-19 as their needs are considered.[5] People with
people transition from the acute to post-actue disability may be impacted both directly and
phase after infection[39]. This has resulted indirectly and have a higher risk of infection or
in a redistribution of the workforce, with severe illness COVID-19 because of[42]:
physiotherapist being redeployed to areas » Underlying medical conditions
such as acute and critical care to deal with the » Barriers to implementing hand hygiene.
immediate respiratory symptoms of COVID » Difficulty in enacting social distancing.
patients. Where possible some rehabilitation » The need to touch things to obtain information
services have managed to adapt service delivery from the environment or for physical support.
to limit face to face contact, this is not always » Barriers to accessing public health
possible for vulnerable people as their access information.
to technology may be limited by such factors » Barriers to accessing healthcare.
as:[39]
This WHO document, Disability considerations
» Availability of technology, including devices
during the COVID-19 outbreak, outlines actions
and the internet
for authorities, healthcare workers, disability
» Inability to use technology efficiently due to
service providers, the community, people with
disability and cognitive deficits
disability and their household.
» Unaware of how to use technology, especially
important to consider in the older population It is important to note that COVID-19 presents
» Location particularly relevant to refugees and even greater risks for refugees/displaced people
displaced persons living with disabilities. It is estimated that
15% of the world’s population have disabilities.
The other consideration when looking at
However, these figures may be higher in areas
vulnerable communities is the stigma that
where there is a conflict or humanitarian crises.
surrounds COVID-19. Many people do not want
For instance, it is estimated that 30% of the
to access services, especially those in LMICs for
population aged 12 and above in Syria are people
fear of reprisal and ostracisation.[40]
with disabilities.[41]
PAGE
33
People with Existing there will be less access, not only from health
Conditions professionals but friends and family, to support
and assist in maintaining their physical and
With advances in medical technology there
mental wellbeing.
are has been an increase in life expectancy of
people living with non-communicable diseases
(NCDs) such as COPD, Diabetes, cancer, HIV/ People Living in Low
AIDs[43]. The existence of an underlying Resource Settings
condition and weakened immune system has
Physiotherapy and rehabilitation services were
been shown to be a factor in determining
already poorly supported in Low Middle Income
the severity of complications and death from
Countries (LMIC) before COVID-19 leaving people
COVID-19. Because of this, people in this group
at an even greater disadvantage. Rehabilitation
have been classified as vulnerable and therefore
professionals are under-represented due to a
extra care and strict protocols have been put in
shortage of professional education and funding.
place. This has resulted in a reduction of regular
[39]
rehabilitation services which are needed to cope
with the daily demands of their condition.[44] It has been established that rehabilitation needs
The fear of exposure to COVID-19 has meant in LMICs are much higher in women but the
that people with underlying health issues are difficulties experienced in accessing services
[avoiding contact with others and also their impacts them negatively.[47] and this may
attendance at local clinics and hospitals which be even more of an issue during the COVID-19
may lead of functional decline and increased pandemic where services have been affected not
risk of complications only by COVID-19 but also by travel restrictions
and many volunteer organisations being told to
return home[39]. Another vulnerable group in
Older People LMICs are older people, who have to deal with
Evidence suggests that older people (those of 60 additional social and environmental factors
years and older), and in particular those living such as:
with NCDs, have an increased risk of developing » poverty
a severe form of the disease.[44][45] Individuals » poor transportation
over 60 who contract COVID-19 have been » difficult terrains
found to have increased functional decline and » poor sanitation
need rehabilitation on discharge from acute » shifting geo-political dynamics
care.[46] But it is not only the symptoms of
The link between mortality and health care
COVID-19 that can impact older people. The
resources in the COVID-19 pandemic may cause
protocols introduced to protect them such as
concerns for LMICs due to[48]:
social distancing and isolation may make them
» Inability to afford large-scale diagnostics.
feel excluded and also limit their social and
» ICU beds and personnel trained in critical
physical interactions. This may lead to inactivity
care may be limited.
and deconditioning which may influence
» Inability to fund the additional cost of critical
their quality of life and their return to normal
care units from limited health budgets.
every day activities. With rehabilitation being
» Disruption of supply chains and depletion of
redirected to other services and the lack of face
stock, such as medical supplies, equipment
to face interactions within this vulnerable group
and PPE.
PAGE
34
» High numbers of internally displaced professionals and poor access to health
people and displace refugees who often information.[50] For instance, in Greece,
have co-morbidities and reside in large-scale there is only one public physiotherapist
camps[49] available for every 12,852 people and many
people report that they queue for hours to
access medical services at both public and
Refugees/Displaced People NGO clinics, only to be turned away unseen
» The United Nations High Commission for at the end of the day.[53]
Refugees found that in 2018, over 70.8 million
Thus, basic prevention measures like social
people worldwide were forcibly displaced,
distancing, hand hygiene and self-isolation are
which is the highest figure of population
more difficult to implement in these settings.
displacement ever recorded.[50] 41.3 million
[52] These individuals may, therefore, be more
of these individuals were internally displaced
heavily impacted by COVID-19.[51]
people (ie they remain within their country’s
borders), 3.5 million were asylum seekers (ie It is important to note that while these
have crossed international borders but are groups are more vulnerable to COVID-19,
awaiting decisions to determine their refugee evidence suggests that they have a low risk of
status) and 25.9 million were refugees (ie have transmitting communicable diseases to host
fled their home, but been granted refugee countries[52] as they are effectively isolated
status in another country).[50] from the wider community.[54] Aid workers
» Because of their past experiences, these who visit the camps are the most likely vectors
individuals often present with various for transmission of COVID-19 into camps.[54]
complex health issues[50] and have a greater The World Health Organisation highlights the
prevalence of comorbidities, including both importance of communicating to communities
non-communicable and communicable that migrants and refugees do not pose an
diseases.[51] However, they generally face increased risk in comparison to other travellers,
administrative, financial, legal and language but they are more vulnerable and need additional
barriers which impact on their ability to support, particularly in relation to preventive
access health services.[52] For example, in and care services.[55]
Greece a recent study reports that around
62% of the 80,000 undocumented migrants
Impact of COVID-19 on Refugees/
living in over-crowded camps have unmet
health needs. 53% had major difficulty Displaced People
accessing health services due to barriers such There are three key reasons why COVID-19 will
as cost and long waiting lists.[53] likely have an even greater impact on refugees/
displaced people:[51]
Moreover, refugees/displaced people are often
1. There will likely be a higher transmission of
living in camps or camp-like settings where
COVID-19 in camps/camp-like settings due
living conditions are inadequate. They are:
to larger household sizes and overcrowding
» Often overcrowded
in camps, as well as certain cultural/religious
» Lack of basic amenities, including clean
practices such as mass prayer gatherings,
running water and soap
large weddings and funerals.
» Have insufficient access to healthcare
PAGE
35
2. There will be higher infection-to-case ratios As mentioned, COVID-19 appears to have a more
and progression to severe disease due to significant impact on individuals with certain
COVID-19’s interaction with comorbidities, comorbidities. Thus, one measure to reduce
including non-communicable diseases, the impact of this virus could be to maintain
under-nutrition, tuberculosis and HIV. existing health services that focus on non-
3. There is also a lack of intensive care capacity communicable disease, TB and HIV detection
in these settings, which will lead to higher and management. Non-essential services can
fatality rates. The extreme pressure on health also be postponed to free up health service
services can reduce access to other services, capacity.[37]
thus adversely affecting health outcomes
It is unlikely in low-income or camp-like settings
related to other conditions.[51][56]
that intensive care services can be increased to
the levels required if there is a large outbreak
Addressing Rehabilitation of COVID-19. Similarly, isolating patients with
Needs COVID-19 in general wards may not be clinically
beneficial or reduce transmission of the virus.
In an attempt to prevent COVID-19 from
Without adequate training and infection control
spreading, many measures including border
supplies, these sorts of facilities could generate
closures, social distancing and quarantine
increased risk for health workers - this is
measures have been introduced to protect these
significant as there is often a scarcity of workers
vulnerable populations. These measures are,
in low income and crisis settings.[51]
however, resource-intensive, and it is argued that
they are not easily replicated in lower-income/
crisis settings. This is because it is more difficult Shielding
to introduce adequate surveillance and testing
Because of these issues, a report by Favas[51]
in these areas. Thus, it is harder to determine
for the London School of Hygiene and Tropical
levels of community transmission of COVID-19.
Medicine/Health in Humanitarian Crisis Centre
[51]
have suggested that a more targeted approach
In order to reduce the transmission of COVID-19 focused on “shielding” high-risk individuals
in the community, it has been found that most may be an option in these settings[51] - it should
non-essential workers need to work from home. be noted that this is not the only approach and
However, this strategy is not well suited to many may not be adopted in all areas.
low-income settings. Moreover, it needs to be
Shielding in the context of COVID-19 is,
sustained long term until either vaccination or
essentially, a reversal of the approach taken in
treatment (or both) is available.[37]
Ebola epidemics where unwell individuals are
Measures such as travel restrictions can be isolated into contaminated ‘red zones’, so that
harmful to export-dependent economies. healthy individuals are protected. In COVID-19,
This quickly has an impact on individuals’ a green zone is created for at-risk individuals. In
livelihoods, which reduces the likelihood a this zone, these individuals can be shielded from
community will adhere to control measures. the transmission of COVID-19 and cared for if
Thus, these strategies may work for a limited they need to isolate.[51]
time and provide a window to prepare a response
While there is no one approach that will fit all
to COVID-19 but may fail long term.[1]
settings, shielding aims to protect those who are
PAGE
36
most vulnerable from infection by helping them Managing Symptomatic Residents of the
to live safely, but away from their families and Green Zone
neighbours for an extended period of time, until
It is essential that there is an alert system, so
treatment or vaccinations are available.[51]
that if/when an individual develops symptoms
Who Should Be Shielded? of COVID-19, s/he will be immediately isolated
(and tested where possible). Isolation measures
The risk from COVID-19 appears to increase
will vary depending on the context.[51]
with age, particularly those aged over 70 and/
or those who have non-communicable diseases Health Service Provision
and other immuno-suppressing conditions. It
Where possible, it is important that health
has been suggested that in low-income/crisis-
services are as close as possible to the green
affected settings, the high-risk definition should
zones. This will reduce the amount of movement
be extended to include:[37][51]
of individuals outside of the green zone. There
» Individuals aged 60 and above
are various options to provide these services,
» Individuals living with TB or HIV
including the use of mobile clinics.[37][51]
» Malnourished adults
Types of Shielding
Rehabilitation Planning
There are three main shielding options
Many people in the groups discussed above
1. Household-level shielding (where a room/
have limited access to digital services so such
area in a house is demarcated as a green zone).
as Telehealth and Social Media, which has been
2. Street or extended family level shielding (a
used to share information and promote health
specific shelter/group of shelters within a
and disease prevention, which puts them at a
small camp area - for a maximum of 5-10
huge disadvantage. The need to limit face to
households)
face contact and follow social distancing has
3. Neighbourhood or sector level isolation (eg
brought to the fore the importance of digital
in displaced persons’/refugee camps - ideally
services. The next barrier to overcome is making
located at the periphery of camps, comprising
this universally available and acceptable to all
of a specific group of shelters in a camp for
age groups regardless of location. This will also
up to 50 high-risk individuals, with infection
require a period of education so that equally
control/social distancing)[37][51]
opportunity and value is experienced by all.
Implementation of Shielding
Specific community rehabilitation for COVID-19
Ideally, the selection of shielding measures is discussed here. Shortages of PPE have been
should be community-led (although this may highlighted elsewhere in all settings,[48] so
not always be possible). Decisions to consider it is important to ensure that you are aware
include: of local requirements/standards for infection
» Deciding which household members meet the control. Standard infection control practices
inclusion criteria for shielding are discussed here. Read more about the mental
» Who should be moved to each green zone health challenges in COVID and f refugees here.
» Which shelters should be vacated/swapped However, there are some considerations, which
» What provisions (such as beds and supplies) are specific to working with refugees/displaced
need to be transferred[51] people.
PAGE
37
Healthcare for refugees and displaced people on the part of the health provider will also
often takes place in difficult social, political, contribute to poor outcomes.[57] Disparities
and economic contexts and no universal in health outcomes for patients from different
rehabilitation model exists to meet their needs. cultural/linguistic backgrounds have also
However, certain key points should be considered been documented.[58] Physiotherapists
when planning rehabilitation services:[57] must, therefore, have an understanding of the
» Each individual should be individually special needs of different groups to be able
evaluated and their rehabilitation needs to provide appropriate care based on their
should be considered. individual needs and, social and cultural
» Measures such as the International backgrounds.[60] This goes beyond the use
Classification of Functioning, Disability and of an interpreter; physiotherapists need to
Health (ICF) and adopting the biopsychosocial be familiar with the common beliefs and
method can be useful in this context.[57][58] practices held by the communities they
» Management should be holistic and consider work with. They must be able to recognise
physical, psychological, social and cultural that there is always intra- and inter-cultural
dimensions.[57] Some interventions, such as variation. Moreover, they must reflect on their
manual therapy, may not be appropriate for own personal/professional culture and any
all cultures.[58] Similarly, some communities associated biases.
may be more collectivist in nature, so group
interventions of those that engage family
members may be more beneficial for some
Summary
individuals.[58] However, it is important
to note that all management plans and Vulnerable people have differing needs but
modifications based on culture should be all will benefit from rehabilitation services
considered an individual basis to avoid
Lack of technology and digital skills lead to
cultural stereotyping.[58]
a disparity of care and service provision
» Barriers, including cultural differences,
language and limited information available Refugees/displaced people and those living
contribute to poor outcomes.[57] WHO in low-income areas will face significant
advises that refugees and migrants should be additional challenges during the COVID-19
involved in the creation of readiness/response pandemic.
plans/strategies, which may help to address
Individuals may require a different
some of these issues.[55]
community response to ensure it meets
» When assessing children, it is important
their needs.
to remember that they are at increased
risk of various physical, behavioural and Many people are living with significant
developmental health issues. Understanding long-term, pre-existing health conditions
each child’s immigration history will which may increase their vulnerability
enable the healthcare team to carry out to COVID-19 and the related alterations/
appropriate screening for infectious diseases reductions in existing healthcare services.
and determine any other exposure risks
It is important that rehabilitation services
(including trauma).[59]
are holistic and all domains are considered.
» A lack of understanding of the complexities
of health issues faced by vulnerable people
PAGE
COVID-19 Rehabilitation/ Rehabilitation During a Pandemic in People with Specific Rehabilitation Needs
38
Rehabilitation During a Pandemic in People
with Specific Rehabilitation Needs
The rehabilitation
needs of people
do not stop just
because a pandemic
has been declared.
People in need of essential rehabilitation will » the continuation of rehabilitation services

still need this care amidst the pandemic. A lack » the implications it will have on different
of access to rehabilitation has complications in patient groups in need of rehabilitation
terms of[3]: » the infection risk involved to patients and
» health outcomes of people healthcare professionals
» inpatient hospital stay duration
Changes in rehabilitation services due to
» hospital admissions
pandemic constraints will have implications for
Healthcare professionals will need to make today and the future.[61]
decisions with regards to[3]:
PAGE
39
Rehabilitation is Essential » Shorter lengths of inpatient stay for
rehabilitation
“Rehabilitation is an essential part of health care
» Early discharge to expand bed capacity and/
and is integral to achieving universal health
or to prevent transmission
coverage. Rehabilitation needs are increasing
» Outpatient rehabilitation care suspended or
globally, along with the rising prevalence of non-
reduced
communicable diseases and ageing populations.
» Home-based rehabilitation suspended or
National efforts must strengthen health systems
reduced
to provide rehabilitation, making it available to
» Rehabilitation personnel redeployed[61]
everyone at all levels of health care, whenever
needed.”[38]
Rehabilitation must aim to be[62]:

Infection Risk Considerations
» Available in Rehabilitation
» Accessible » Increased risk of infection with face to face
» Affordable, for many people. rehabilitation
» Infection risk should be balanced against the
This will allow people to[62]:
risk to patient outcomes and health services
» Remain as independent as possible
if rehabilitation is interrupted, ceased or
» Participate in education
reduced.
» Be economically productive
» Delivery of rehabilitation services during
» Fulfil meaningful life roles
the COVID-19 outbreak should minimise the
risk of exposure to patients and healthcare
Aspects Influencing providers, especially those at high risk, such
Decisions to Adapt as older people and people with comorbidities.
Rehabilitation Services » The availability of personal protective
equipment (PPE) will influence the degree of
During a Pandemic
infection risk
» The immediacy of care needs
» Infection control measures may vary across
» Services available
service delivery settings and this will also
» Setting
influence the degree of infection risk
» Resources available (staff, equipment,
» WHO and PAHO guidelines on infection
technology)
prevention and control should be followed if
» Risk for transmission
rehabilitation services continue
» Risk of illness[51]
» Alternative ways of service delivery should
be considered if feasible (e.g, telehealth in
How has the COVID-19 rehabilitation focused on patient education
Pandemic Affected and advice)
Rehabilitation Services? • Various factors should be considered when
considering telehealth such as:
» Rehabilitation beds and wards converted to
ʅ availability of data
increase acute care capacity
ʅ telecommunications infrastructure, etc.
» Inpatient admissions for rehabilitation
delayed
PAGE
40
Impact on Patient up after rehabilitation services are up and
Outcomes if Rehabilitation is running again.
Suspended or Reduced » As the various stages of the pandemic progress,
certain areas may be able to continue with
» Essential rehabilitation services for non-
some rehabilitation services again for patients
COVID-19 patients should be identified and
with priority needs who have been cleared of
continued during the outbreak
COVID-19 or who have recovered.
» Consider the effect of ceasing or reducing
rehabilitation on certain patient groups (e.g,
burns, spinal cord injuries, stroke) Priority Patient Groups for
» Health and functioning outcomes can Rehabilitation
seriously be compromised if rehabilitation
The clinical risks associated with withdrawing
services are suspended or reduced
rehabilitation should be considered. Patient
» Risk of increased mortality if rehabilitation is
groups who may be at an increased risk can
not continued in certain patient groups[63]
include (but are not limited to)[3]:
» It is critical to prioritize patients in settings
» Patients that have or have recently had
where rehabilitation services are temporarily
significant injuries such as:
ceased, decreased or diverted. The risks
• Burns[64],
associated with the sudden change in
• spinal cord injury[65],
rehabilitation services should be well thought
• traumatic brain injury[66]
through.[3]
• fractures[67]
• musculoskeletal injuries that may develop
Rehabilitation Options serious preventable complications[68]
During the Pandemic » Patients recovering from surgery
» Patients with conditions such as stroke or
Rehabilitation service providers should identify
myocardial infarction, that will benefit from
patients that are suitable for some of these
early rehabilitation and are at risk of sub-
service options[3]:
optimal recovery if rehabilitation is delayed
» The patient can be discharged from
» Patients in need of long-term rehabilitation in
rehabilitation with a comprehensive home
hospitals, residential centres or community
rehabilitation programme. The patient has
settings may develop complications and lose
knowledge of potential complications that
function if rehabilitation is ceased, delayed or
can arise or indications that will require a
interrupted
follow-up.
» Patients who are not able to be discharged to
» The patient continues with rehabilitation
a safe environment or who may have to be
through either inpatient, outpatient,
discharged to a setting that is a long way from
home-based or telehealth services or with
the rehabilitation service and this will most
modifications to their current rehabilitation
likely limit their access to rehabilitation
setting
» Temporary interruption or cessation of the
patient’s rehabilitation programme (but the Impact on Health Services
patient still receives interim education and Delivery if Rehabilitation is
a home programme). It is crucial to have an Affected
established, systematic method for follow-
PAGE
41
» Rehabilitation services that contribute to safe numbers, e-mails, etc) and when to call if
and timely discharge from hospital should there are any concerns
continue if possible – for both COVID-19 and • Telehealth services may be implemented
non-COVID-19 patients if safe and appropriate to use. This may
» Safe and timely discharge from hospitals include remote assessments and treatments
can aid in the surge capacity of hospitals via telephone or video calls
(especially hospitals that need patients to • Individual standard treatment plans may
move rapidly through acute care) be provided to patients via e-mail, app,
» Restricted or no access to rehabilitation can telehealth if it is safe and appropriate to do
lead to extended length hospital stays so
» Ineffective rehabilitation strategies and • If rehabilitation is temporarily stopped,
planning can lead to further complications ensure that systematic methods such as
and readmission of patients databases for COVID-19 and non-COVID-19
» There should be available rehabilitation patients, in need of follow-up, are compiled
follow-up following discharge from hospital so that they can be tracked and relevant
» Patients in need of follow-up are those at risk services organised as soon as normal health
of poor or compromised outcomes services resume.
» During the pandemic, there will be a change
in the profile of rehabilitation demands
• For example, rehabilitation after
Rehabilitation for People
elective surgery will be reduced as these with a Disability and Frail
surgeries will be postponed; whereas Older People
new rehabilitation needs will arise due An estimated 15% of the world’s population
to the exacerbation of underlying health live with a disability.[41] Many of these people
conditions as a result of COVID-19 lockdown need rehabilitation. For many, this would mean
or containment measures.[69] rehabilitation in the acute phase of the disability
» Also, the cessation and reduction of or even on an ongoing basis when living with a
rehabilitation services will lead to a backlog chronic condition.
of rehabilitation needs[69]
The WHO/Europe highlights the fact that there
» In the case of early supported discharge
is an increasing demand for rehabilitation
ensure the following[3]:
worldwide and the current pandemic has just
• Proper patient and caregiver education
exacerbated the unmet need for rehabilitation in
• Proper self-management strategies and
vulnerable populations across the globe.[70]
home exercise programmes if safe and
suitable to do It is also evident that people living with
• Ensure that patients have access to the non-communicable diseases are at a higher
proper assistive products and adaptive risk of severe illness due to COVID-19. This
equipment as well as proper guidance on implies that a large group of patients who are
how to use this equipment usually supported by long-term physiotherapy
• Patients should be properly informed and interventions and rehabilitation services will
advised on possible complications and clear be at an increased risk for severe complications
instructions on where to call (telephone from COVID-19.[60]
PAGE
42
The implementation of lockdown strategies in behaviour and psychological aspects.[74] The
many countries around the world may lead to use of telerehabilitation and other remote
many people with disabilities and rehabilitation rehabilitation strategies should be considered
needs not being able to access rehabilitation during the pandemic, but the feasibility and
services, or they may have an adaptive form of efficacy of these methods still need more
rehabilitation (e.g. telehealth). The reality is, investigation.[75] Other strategies to consider
however, that many people will be left behind include[73]:
with no access to rehabilitation services and this » Dance and movement therapy
may compromise the health outcomes. » Music therapy
» Yoga therapy for children
Older people with frailty may be at risk of the
» Visual learning apps
same issues as people living with a disability.
» Play therapy
Older people are more vulnerable to serious
» Guided therapy
complications from COVID-19 and lockdown
measures urge older people to stay at home Ways to provide effective modified paediatric
and self-isolate. This may impact various short rehabilitation during the pandemic can
and long-term healthcare outcomes.[63] Older include[65]:
people may be at greater risk of[71]: » home safety evaluations
» increased sedentary behaviour » post-discharge check-ups and safety
» deconditioning screenings weekly or monthly got NICU and
» balance deficits PICU children
» increased falls risk » provision of wellness and preventative
» worsening and/or new mental health services to avoid hospitalisation of children
problems with respiratory disorders
» Multidisciplinary team approach
» Questionnaires for parents to complete to
Paediatric Rehabilitation keep track of rehabilitation and free hours
During COVID-19 of the child at home - this is a good way to
Children with disabilities often receive support reinforce effective rehabilitation
from specialised professionals through schools. » Education of parents/caregivers on aspects
Families of children with disabilities may such as important milestones that the child is
find childcare, education and rehabilitation supposed to reach, etc
challenging during Covid-19, as schools closures » Guided therapy where parent is instructed on
and social distancing are implemented. Children how to provide rehabilitation via telehealth
with disabilities are also at-risk populations
The adoption of a biopsychosocial model in
during the pandemic and may experience
rehabilitation is recommended, especially
negative outcomes due to reduced quality of care
during the pandemic, as a tool to strengthen the
and rehabilitation.[72] It is key to remember that
role of the immediate environment of the child.
early rehabilitation in children, leads to a better
In this case, it will very well be the families.
outcome and this leads to a better quality of life.
However, factors that may negatively influence
[73]
the adoption of family-centred rehabilitation
Prolonged interruption of rehabilitation may practices may play a role. Parents may feel
affect the functional prognosis of children unmotivated and unprepared to take on the
with disabilities and could negatively influence responsibility and actively participate in the
PAGE
43
rehabilitation process with their children with function and thus reduce disability. During the
disabilities.[76] pandemic, many physiotherapy services will be
suspended as countries have strict lockdown
Children with cerebral palsy do benefit
and social distancing regulations to reduce the
from home-based programmes and show an
spread of the virus. This will have an impact
improvement in motor function with these
on patients and they are likely to experience a
home-based programmes.[77] The Covid-19
deterioration in conditions that is unrelated to
pandemic has caught everyone by surprise
COVID-19.[69]
and rehabilitation professionals and parents
are most likely unprepared for this situation
and this can also lead to an increase in family Areas that may be affected where
stress. This pandemic, however, can offer an physiotherapy rehabilitation is
opportunity for therapists and families to provided
implemented family-centred rehabilitation
» Elective surgeries cancelled – deconditioning
practices and find innovative ways to provide
can occur in patients waiting for orthopaedic
therapy to children with disabilities. With the
and other surgeries
implementation of home-based programmes
» Acute musculoskeletal conditions - patients
rehabilitation professionals should understand
may not be able to access physiotherapy
the family circumstances during the pandemic.
» Individuals may delay or ignore symptoms
The rehabilitation programme should consider
due to the concern around COVID-19
the family’s general needs and priorities. One
» Many physiotherapy services in the
key strategy that can help with this is the use
community and out-patient settings will be
of information technologies. Another viable
suspended and classified as non-essential
option could be the use of booklets as a resource,
services to ensure social distancing
especially in low- and middle resource countries.
» People who are confined to their homes as a
It is vital though to have families feel that they are
result of lockdown or social distancing will be
fundamental part of the care process of children
more sedentary and at risk of losing mobility
with disabilities as this process can be the first
and function. Once lockdown restrictions ease
step in the facilitation and implementation of
these patients will be in need of physiotherapy
home programmes.[76]
services and this will put an even greater
burden on rehabilitation professionals.
Short-term Rehabilitation
Needs in Areas where Public Health Restrictions
Routine Care has been and Rehabilitation
Suspended
Telerehabilitation may work for certain groups
Physiotherapists are key rehabilitation of patients, but for others, it may not be advised.
professionals over a vast range of specialities. The rehabilitation environment will change
These rehabilitation services is an essential part with restrictions being lifted with strict
of healthcare to optimise cognitive and physical infection prevention and control measures and
PAGE
44
the requirements of physical distancing as far as
possible.
Physiotherapists will need to consider[69]:

» 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 The emotional,
as the rehabilitation needs of COVID-19 patients mental and physical
become clearer. The non-COVID-19 patients’
existing and new rehabilitation needs will
wellbeing of
also become more evident as the stages in the physiotherapists
pandemic progress.
need to be
considered and
appropriate services
need to be made
available to ensure
their wellbeing.[69]
PAGE
COVID-19 Rehabilitation/ Resources
45
Resources
PHYSIOPEDIA PAGES USED
» Section 1: Post-Acute Rehabilitation

www.physio-pedia.com/COVID-19:_Post-Acute_Rehabilitation
» Section 2: Medium to Longer Term Health Considerations
www.physio-pedia.com/COVID-19:_Medium-to-Longer_Term_Health_Considerations
» Section 3: COVID-19 Community Rehabilitation
www.physio-pedia.com/COVID-19:_Community_Rehabilitation
» Section 4: COVID-19 Rehabilitation in Vulnerable Populations
www.physio-pedia.com/COVID-19_Rehabilitation_in_Vulnerable_Populations
» Section 5: Rehabilitation During a Pandemic in People with Special Needs
www.physio-pedia.com/Rehabilitation_During_a_Pandemic_in_People_with_Specific_
Rehabilitation_Needs
COVID-19 POST ACUTE REHABILITATION

Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute
respiratory failure: results of a Delphi process
Rehabilitation considerations during the COVID-19 outbreak
WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy.
Physiotherapy recommendations in patients with COVID-19
Post-COVID rehabilitation and management strategies
The Stanford Hall consensus statement for post COVID-19 rehabilitation
COVID-19: COMMUNITY REHABILITATION

Home and Community-Based Physical Therapist Management of Adults With Post–Intensive Care
Syndrome. Physical Therapist Management of Adults With PICS
Support for Rehabilitation: (Self-Management after COVID-19 Related Illness (2020)
COVID-19 PHYSIOPEDIA RESOURCES

COVID-19 Post-Acute Rehabilitation
COVID-19 Medium-to-Longer Term Health Considerations
PAGE
COVID-19 Rehabilitation/ Resources
46
Community Rehabilitation
COVID-19 Rehabilitation in Vulnerable Populations
Rehabilitation During a Pandemic in People with Specific Rehabilitation Needs
International Classification of Functioning, Disability and Health
PHYSIOPLUS COURSES
Coronavirus Disease Programme
COVID-19 Rehabilitation Programme
Telehealth for Physiotherapy Programme
COVID-19 and Nutrition
COVID-19 and Sleep
COVID-19 and the Multidisiplinary Team
Innovative Approaches in Providing Rehabilitation during the COVID-19 Pandemic
Mental Health during the COVID-19 Pandemic
Physical Activity and COVID-19
Return to Play During a Pandemic
PAGE
COVID-19 Rehabilitation/ References
47
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COVID-19

18 Medium to Longer Term

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Countries all across the

These complications often lead to the person

Persistence of SARS-CoV-2 The symptoms include[13]:

Be careful to not overload the respiratory system

Physical Impairment and Because mechanical ventilation is required

The authors note that for a clearer idea of the

Again, the SARS crisis in 2003 provides some

Cardiac People who have had COVID-19 report extreme

» Respiratory muscle assessment[33] Exercise Programs[33]

Rehabilitation Following Ways to Address Breathlessness

Exercises While Sitting[36]

Exercises While Standing[36]

Core Stability Exercises[36]

Clinical Bottom Line

COVID-19 poses a severe threat

People in need of essential rehabilitation will » the continuation of rehabilitation services

Rehabilitation must aim to be[62]:

Physiotherapists will need to consider[69]:

PHYSIOPEDIA PAGES USED

» Section 1: Post-Acute Rehabilitation

COVID-19 POST ACUTE REHABILITATION

COVID-19: COMMUNITY REHABILITATION

COVID-19 PHYSIOPEDIA RESOURCES

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