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 Rehabilitation after COVID 19 Disease
Chairs: Thierry Troosters (Leuven, Belgium) , Anne Holland (Fitzroy North,
Joint Webinar Australia)

Programme:
1- Introduction from the Chairs - 2 minutes
Thierry Troosters (Leuven, Belgium) - ERS past president ; Anne Holland (Fitzroy North, Australia) - Chair of ATS pulmonary rehabilitation assembly
2- The post COVID19 patient : who are we dealing with (questions around screening in ERS-ATS document ; systemic consequences and PICS) - 15 minutes
Martijn A Spruit (Maastricht, Netherland)
3- The ‘ideal’ program for restauration in all lines of health care (including relevant elements from the document and focuss of the rehab program - 15 minutes
Sally Singh (Leicester, United kingdom)
4- Organizational aspects (including knowledge on shedding and logistical aspects of (re-) opening rehabilitation programs including patients with COVID19) - 15
Minutes
Linda Nici (Providence, USA)
5- Q&A with panellists: 15 minutes
• Win Janssens (Leuven, Belgium)
• Michele Vittacca (Gussago, Italy)
• Johnathan Raskin (New York, USA)
• Stefano Belli (Somma Lombardo, Italy)
• Daisy Janssen (Horn, Netherlands)
• Martijn Spruit (Amsterdam, Netherlands)
• Sally Singh (Leicester, United kingdom)
• Linda Nici (Providence, USA)
The post-COVID-19 patient: who are we dealing with?
Prof. dr. Martijn A. Spruit

CIRO & Maastricht University

 Conflict of interest disclosure

I have the following perceived conflicts of interest, all outside of this presentation:

Grants/research support: Netherlands Lung Foundation, Stichting Astma Bestrijding,

AstraZeneca, Boehringer Ingelheim

Consultation fees: AstraZeneca, Boehringer Ingelheim

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a
conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but
rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence
the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device
advertisement is forbidden.
 REHABILITATION AFTER COVID 19 DISEASE-
The ideal programme for the restoration of all aspects of the patient
recovery

Sally Singh
Department of Respiratory Sciences, University of Leicester, Leicester, U.K
Centre for Exercise and Rehabilitation Science, University Hospitals of Leicester NHS trust, Leicester
 Conflict of interest disclosure
 X I have no real or perceived conflicts of interest that relate to this presentation.

 I have the following real or perceived conflicts of interest that relate to this presentation:

Affiliation / Financial interest Commercial Company

Grants/research support:

Honoraria or consultation fees:

Participation in a company sponsored bureau:

Stock shareholder:

Spouse / partner:

Other support / potential conflict of interest:

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker
with a conflict of interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a
presentation, but rather to provide listeners with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or
relationships may influence the presentation. The ERS does not view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s
presentation. Drug or device advertisement is forbidden.
 INTRODUCTION
AIMS
• Summarise the symptom burden of COVID-19
• Consider PR for COVID-19
• Consider modifications of current PR programmes
 PERSISTENT SYMPTOMS post COVID-19

Yvonne M.J. Goërtz et al. ERJ Open Res 2020;6:00542-2020

 THE NEED FOR REHABILITATION
The international Task Force suggests that COVID-19 survivors (with pre-existing/ongoing
lung function impairment) at 6-8 weeks following hospital discharge should receive a
comprehensive pulmonary rehabilitation program consistent with established
international standards, compared to no pulmonary rehabilitation program

80 80

60 60

% experts
% experts

40 40

20 20

0 0
++ + +/- - -- ++ + +/- - --

Pre- existing lung

COVID-19 impairment
 THE CAT SCORE & COVID-19

In the whole population, 52% had CAT total scores ≥10. (no pre-existing lung disease 42% had score ≥10, pre-existing lung disease 75%.)

Mean (SD) FACIT Score was 27.7 (13.9) with n=58 (54%) ‘severe fatigue’, no statistically significant differences in those with/without severe
fatigue in length of stay, number of days ventilated, CAT total or item scores, or HADS.

Daynes E et al Thorax 2020

 ATS/ERS DEFINITION & PR post COVID-19
“a comprehensive intervention based on a thorough
patient assessment followed by patient tailored
therapies that include, but are not limited to, exercise
training, education, and behavior change, designed to
improve the physical and psychological condition of
people with chronic respiratory disease and to
promote the long-term adherence to health-
enhancing behaviors.”

Aims of post COVID rehabilitation (TBC)

• To support a full recovery
• To support symptom management
• To support a return to economic productivity

Trisha Greenhalgh et al. BMJ 2020;370:bmj.m3026

 THE ESSENTIAL COMPONENTS OF AN ASSESSMENT AT 6-8
WEEKS POST HOSPITAL DISCHARGE

95%

85%

75%
Percentage of respondents

65%

55%

45%

35%

25%

15%

5%

-5% Strongly disagree Disagree Neutral Agree Strongly agree Unable to

comment

Consensus of components
An initial face to face (centre-based) assessment (N=1023)
Conduct of an exercise test (6MWT/ISWT) at the time of the assessment (N=1023)
Assessment of muscle strength (quadriceps) (N=1023)
Assessment of quality of life (N=1023)
Assessment of cough (N=1023)
Assessment of fatigue (N=1021)
Assessment of dyspnoea (N=1023)
Assessment of mood (e.g. anxiety and depression) (N=1023)
Screening for Post Traumatic Stress Disorder (N=1023)
Medication review (N=1023)

(Singh S J et al BMJ Open 2020)

Question: When should we deliver a recovery progamme?

a) Immediately post discharge (ITU and/or hospital)

b) 6-12 weeks post discharge (ITU and/or hospital)

c) 6-12 weeks post community managed infection

COMMON TARGETS OF PR (treatable traits)

?
 SYMPTOM MANAGEMENT
F2F review at 6/12 weeks for structured assessment & review

Fatigue (no • Cardiac non-ischaemic cognitive depression Pain –

desaturation): (pericarditis / costo- symptoms and anxiety: MSK
Support & chondritis) if focal acute Support & teams
advice • ischaemic features medical advice (if
-cardiology referral services or severe MH
• Ongoing & symptomatic Psychologist teams)
palpitations - cardiology
referral

Comprehensive (enhanced pulmonary) rehabilitation

 FATIGUE
• Although some people who have had COVID-19 may experience post-viral fatigue, there does
not appear to be an association with post-viral fatigue and diagnosis of chronic fatigue
syndrome (CFS) or myalgia encephalomyelitis (ME).
• For those who do experience chronic fatigue, there is conflicting evidence regarding benefits or
harm of graded exercise therapy .
• Draft guideline says that any programme based on fixed incremental increases in physical
activity or exercise, for example graded exercise therapy (GET) should not be offered for the
treatment of ME/CFS (NICE 10/10/2020).

Approach includes
• Activity diaries

• Pacing/prioritizing/planning
 RETURN TO WORK
Employee
• Barriers to RTW (physical fitness/fatigue/anxiety)
• Phased return to work (flexible work plan)
• Negotiation with employer

Employer
• Understanding of COVID-19 (infection mechanisms etc.)
• Accommodate phased return to work

Recovery team – link with occupational therapy/ occupational health

teams
WHAT - Altered duties/Changed responsibilities/ Amended targets
WHERE/WHEN - Changing start  finish times/Altered working hours/Changed location
HOW - Getting to & from work/ Assessing your workstation/ Taking breaks
 PSYCHOLOGICAL & COGNITIVE DISTURBANCES

• The high prevalence of post-traumatic

stress disorder and cognitive Mood & emotions
impairment in survivors of critical
illness.
Fear & anxiety Integration with
  additional specialist
Sleep services
• The COVID-19 pandemic. gives rise to
new psychosocial and emotional
stressors for recovering patients, Memory & thinking
including social isolation, physical
distancing, loss of employment and
uncertainties about the future.
 CONCLUSION
• Pulmonary rehabilitation provides a
comprehensive platform to deliver a
recovery programme to the post COVID
population.

• However, we do need to adapt and enhance

the service with further integration of the
wider multi-disciplinary team.

• Potential to deliver alternative formats of

rehabilitation to meet the demand.
 ORGANIZATIONAL ASPECTS
RE-OPENING REHABILITATION PROGRAMS INCLUDING
PATIENTS WITH COVID-19

Linda Nici, M.D.

Professor of Medicine
The Warren Alpert Medical School of Brown University
Chief, Pulmonary and Critical Care Section
Providence Veterans Affairs Medical Center
Providence, Rhode Island
USA
 Conflict of interest disclosure

I have no real or perceived conflicts of interest that relate to this presentation

This event is accredited for CME credits by EBAP and EACCME and speakers are required to disclose their potential conflict of interest. The intent of this disclosure is not to prevent a speaker with a conflict of
interest (any significant financial relationship a speaker has with manufacturers or providers of any commercial products or services relevant to the talk) from making a presentation, but rather to provide listeners
with information on which they can make their own judgments. It remains for audience members to determine whether the speaker’s interests, or relationships may influence the presentation. The ERS does not
view the existence of these interests or commitments as necessarily implying bias or decreasing the value of the speaker’s presentation. Drug or device advertisement is forbidden.
 OUTLINE
• When is a facility safe for resuming PR?
– Community prevalence rates
• When are patients safe to come into a PR program?
– Infectiousness of patient
• Special considerations when providing rehabilitation within the pulmonary
rehabilitation setting for people recovering from COVID-19
– Referral and triage
– Infection control
– Environment for rehabilitation
 BACKGROUND

• Transmission of SARS-CoV-2 is a dynamic process

• It is likely that the prevalence of COVID-19 in the community will
wax and wane
• This will impact an institution’s mitigation needs
• Operating procedures should be frequently reassessed and
modified as needed
 BACKGROUND
• Guiding principles
– As community physical distancing practices are loosened, there is a risk
of virus reintroduction
– Ambulatory clinics must make significant efforts to mitigate the risk of
viral exposure to patients and to staff
• Goals
– protect patients and staff from exposure to the virus
– account for limitations in staff, equipment, and space that are essential
for the care of COVID-19 patients
– provide access to care for patients with acute and chronic conditions
 WHEN TO RESUME
• CDC gating criteria for reopening
– Downward trajectory of COVID-like cases and influenza-like illnesses
over a 14-day period
– Downward trajectory of confirmed cases over a 14-day period or a
downward trajectory of positive tests as a percent of total tests over a
14-day period
– Hospitals are capable of treating all patients without crisis care
– A robust testing program is in place for at-risk healthcare workers

https://www.cms.gov/files/document/covid-recommendations-reopeningfacilities-provide-non-emergent-care.pdf
https://www/whitehouse.gov/openingamerica/
 INSTITUTIONAL CAPACITY FOR IMPLEMENTATION

• Operational strategies must be in place

– Patient prioritization
– Screening
– Diagnostic testing
– Physical distancing
– Infection control
– Follow-up surveillance
Question: Screening for COVID should occur:

a) within 72 hours of the scheduled appointment, and no more than seven

days before the scheduled appointment

b) upon arrival for the scheduled appointment

c) both a & b
 SCREENING AND TESTING
• All patients scheduled for outpatient services should undergo screening for
high-risk exposures, fever, and symptoms suggestive of COVID-19 (i.e.,
cough, dyspnea, myalgias, anosmia, dysgeusia)
• Two phases
– The first phase of screening should occur within 72 hours of the
scheduled appointment, and no more than seven days before the
scheduled appointment
– The second phase of screening should occur upon arrival for their
appointment
 WHEN ARE PATIENTS WITH COVID-19 SAFE TO
COME IN?

• Accumulating evidence supports ending isolation and precautions for

persons with COVID-19 using a symptom-based strategy
• People with mild to moderate COVID-19 remain infectious no longer than
10 days after their symptoms began
• People with more severe illness or those who are severely
immunocompromised remain infectious no longer than 20 days after their
symptoms began
 WHEN ARE PATIENTS WITH COVID-19 SAFE TO
COME IN?
• Persons with COVID-19 who have symptoms and were directed to care for
themselves at home may discontinue isolation under the following
conditions
– At least 10 days have passed since symptom onset and
– At least 24 hours have passed since resolution of fever without the use of fever-reducing
medications and
– Other symptoms have improved
• Persons infected with SARS-CoV-2 who never develop COVID-19
symptoms may discontinue isolation and other precautions 10 days after
the date of their first positive RT-PCR test for SARS-CoV-2 RNA.

https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-in-home-patients.html
 DURATION OF ISOLATION AND PRECAUTIONS FOR ADULTS
WITH COVID-19
• Data to date show that a person who has had and recovered from COVID-19 may have low
levels of virus in their bodies for up to 3 months after diagnosis. This means that if the person
who has recovered from COVID-19 is retested within 3 months of initial infection, they may
continue to have a positive test result, even though they are not spreading COVID-19
• There are no confirmed reports to date of a person being re-infected with COVID-19 within 3
months of initial infection. However, additional research is ongoing
• If a person who has recovered from COVID-19 has new symptoms of COVID-19, the person
may need an evaluation for reinfection, especially if the person has had close contact with
someone infected with COVID-19. The person should isolate and contact a healthcare provider
for testing

https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
 OCTOBER 20, 2020
CDC EXPANDS DEFINITION OF WHO IS A ‘CLOSE CONTACT’ OF AN INDIVIDUAL WITH COVID-19

• Someone who was within 6 feet of an infected person for a cumulative total
of 15 minutes or more over a 24-hour period starting from 2 days before
illness onset (or, for asymptomatic patients, 2 days prior to test specimen
collection) until the time the patient is isolated
• Likely to have its biggest impact in schools, workplaces and other group
settings where people are in contact with others for long periods of time 

https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/contact-tracing-plan/appendix.html#contact
 PULMONARY REHABILITATION PROGRAM
OPERATIONAL ASPECTS
• Throughout each session, healthcare workers and patients should maintain
social distancing
• A surgical mask should be worn during the educational and behavioral
change portions of the session
• Healthcare workers should change to an N95 mask, face shield, gloves, and
gown during the exercise training portion due to the risk of aerosolization
during exercise
• Only necessary equipment with adequate spacing should be kept in the
training area, which should be thoroughly decontaminated following each
session
 CHECKLIST FOR REOPENING PR SERVICES
• Preparation
– Determine the maximum number of people permitted in the room (including staff)
according to 4m2 per person recommendation
– Ensure adequate supply of hand hygiene products, cleaning products for surfaces
and equipment, surgical masks
– Re-organize seating in waiting area, gym and education room to ensure 1.5m social
distancing space
– Re-organize exercise equipment to ensure 1.5m social distancing space
– Provide a storage area for personal belongings (e.g. bags and jackets) – wall hooks
minimize the amount of surfaces being touched

https://pulmonaryrehab.com.au/wp-content/uploads/2020/06/ACI-COVID-19-Resp-CoP-reopening-of-cardiopulmonary-rehabilitation-services.pdf
 PRE- SCREENING & PROVISION OF INFORMATION
FOR PATIENTS
• 24 hours prior to attendance, contact patients to review COVID-19
screening questions
• Provide written instructions for new procedures in place with advice to not
attend if any new acute viral illness symptoms
– Inform patient of new hospital entrance screening procedures (e.g. temperature
check and COVID-19 screening questions)
• Patient should bring their own pen, water bottle and minimize other personal
items
 BEFORE AND DURING SESSION

• Hand hygiene before entering, before moving between or touching equipment

• Observe 1.5m social distancing space between patients at all times, and between
staff and patients when able
• Consider staff to patient ratio and minimize numbers when possible- for example, can
another staff member, located within the line of sight or hearing, respond in an
emergency?
• Sanitize exercise equipment after each use
• Consider providing patients with their own resistance bands, hand weights, oximeters
– sanitized after each session
 AFTER SESSION
• Sanitize all surfaces which have been touched including chairs,
tables, light switch, door handles, staff desk, drawers, cabinets,
music players
 RATIONALE FOR PR IN PATIENTS WITH COVID-19

• COVID-19 patients have impaired physical functioning when

discharged home, even after early mobilization/bedside physiotherapy
• COVID-19 patients, especially those that have required mechanical
ventilation, are likely to have cardiopulmonary impairment for a
prolonged period
• Early referral to rehabilitative intervention options in the post-
hospitalization phase should be considered
– The PR model can serve as a framework, particularly in a subset of patients with
long term respiratory consequences
 POST-COVID REHABILITATION
• Post-hospitalization recovery may vary considerably between
patients
– This justifies a formal assessment (including physical, emotional and cognitive
functioning, and return to work) to customize post-COVID rehabilitation
• A core outcome set for survivors of acute respiratory failure due to
COVID should be determined
– This will likely require multiple re-assessments at different time points (e.g., 3,6
and 12 months after hospital discharge)
 OTHER CONSIDERATIONS
• Hypoxemia is common in hospitalized COVID-19 patients, with hypoxic
respiratory failure a prominent feature of severe cases
– It is likely that some patients will have ongoing oxygen needs at hospital
discharge
– Hospitalized COVID-19 patients should have an assessment of oxygen
requirements at rest and during exertion prior to hospital discharge
• Exertional desaturation may also persist, even in those without the
requirement for supplemental oxygen at rest. While moderate intensity
exercise training is safe and feasible in survivors of critical illness, the
safety of high intensity exercise in patients recovering from COVID-19 is
unknown
 SUMMARY
• Operating procedures must be frequently reassessed and modified as
needed given the waxing and waning nature of COVID community
• Ambulatory clinics must make significant efforts to mitigate the risk of viral
exposure to patients and to staff
• It is unlikely that a unidimensional program of physical training will meet
the needs of the Covid-19 survivors as they will exhibit multiple treatable
traits that a comprehensive rehabilitation program can address
• PR in COVID-19 patients will likely be wider in scope than current
programs in order to meet the needs of these individuals