Table I. Description of the articles on rehabilitation needs due to COVID-19 included in the rapid review updated to 30^th April 2020.

N.

Authors, Journal, Year

Aim of the study

Study population or target population

Study design

Study setting or target setting

Nation or geographical Area involved

Main results and conclusions

Prevalence and /or the characteristics emerging disability after COVID-19

1

Herman C, et al. Neurology 2020

To assess the potential impact of pre-existing neurological comorbidities and new neurological events in patients hospitalized with COVID-19.

COVID-19 patients

Scoping review

ICU, acute wards

China

·  32 retrospective studies selected out of 643 retrieved

·  Prevalence of pre-existing neurological illness:  8.0 % (322 cases out of a total 4014 patients hospitalized for Covid-19)

·  Incidence and risk of secondary neurologic events ranges from 6%, to 67%. Most frequent complications in people admitted to the ICU are: corticospinal signs, followed by confusion, neuromuscular injury, hypoxic encephalopathy and stroke. In people discharged home, 33% showed a dysexecutive syndrome.

Rehabilitation approaches dedicated to COVID-19 patients

1

Brugliera L, et al. J Rehabil Med. 2020

To provide information on the rehabilitation needs of COVID-19 patients in different settings

COVID-19 patients

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

Italy

·  Acute phase: early respiratory rehabilitation highly recommended (non-invasive ventilation, changes of posture, and passive mobilization)

·  Post-acute phase: neuromotor rehabilitation for immobilization syndrome (passive/active mobilization, muscle strength exercises, and articular recovery)

·  Need of speech therapists and neuropsychologists to treat dysphagia and cognitive impairment

·  Few and minor sequelae might benefit from outpatient or home-based rehabilitation (aerobic exercises, strength training, static and dynamic balance training, bronchial clearance techniques, exercises for activities of daily living, and neuropsychological support)

2

Kiekens C, et al. Eur J Phys Rehabil Med. 2020

To share the early experiences from the clinical field in Northern Italy about respiratory management in the acute and immediate post-acute phases.

COVID-19 patients

Descriptive: qualitative

ICU, acute wards, rehabilitation wards

Italy

Rehabilitation services reorganization:

·  no visitors 

·  reduction or suspension of activities and admissions of “classical” patients

·  support of therapists to nurses in other tasks

·  restriction of contacts between personnel and Covid-19 patients

·  use of web based electronic patient records

Advice:

·  accurate monitoring in the weaning phase from ventilatory support

·  early rehabilitation in ICU patients with several complications seems not well tolerated (rapid desaturation)

·  in case of lung fibrosis as a sequel of pneumonia use respiratory rehabilitation or NIV

·  in case of tough secretions, provide specific physiotherapy techniques or technical removal

3

Li J. Eur J Phys Rehabil Med. 2020

To describe rehabilitation management of patients with COVID-19.

COVID-19 patients

Expert opinion

Home, ICU, rehabilitation hospitals

China

Acute phase management:

·  Mild patients:

o Respiratory training and mild aerobic training and Chinese traditional exercises (Tai-ji, Ba-duan-jin), as well as square dance, in mobile cabin hospitals.

·  Severe and critical patients:

o Breath training at prone and/or semi recumbent bed position, moderate head elevation, limb mobilization, bed and bedside sitting and standing, as well as bedside walking.

o Respiratory training (timing and program remain should be clarified).

o Patients with chronic diseases or complications require appropriate rehabilitation plans.

o Psychological rehabilitation

Post-acute phase management

·  Telerehabilitation (wearable devices, mobile phone APPs, virtual reality)

·  Inpatient rehabilitation for some severe cases

4

Liu K et al., Complementary Therapies in Clinical Practice. 2020

To investigate the effects of 6-week respiratory rehabilitation training on respiratory function, QoL, mobility and psychological function in elderly patients with COVID-19.

Elderly patients with COVID-19 at ≥6 months of onset.

RCT

Hospital

China

·  RCT of respiratory rehabilitation (36 cases) vs no treatment (36 cases)

·  Intervention:  (1) respiratory muscle training; (2) cough exercise; (3) diaphragmatic training; (4) stretching exercise; and (5) home exercise. Respiratory training included 2 sessions/week for 6 weeks, each session lasting 10 min.

·  Significant increase in pulmonary function tests, 6 MWT, SF36 score and anxiety score, in the intervention group compared to controls

5

Mattei A et al., Eur Ann Otorhinolaryngol Head Neck Dis. 2020

To provide recommendations for the management of swallowing disorders and the assessment of acute dysphonia in the context of the COVID-19

Patients with swallowing disorders or recent dysphonia following ORL surgery.

Practice guideline

Hospital

France

·  Assess patients suffering from swallowing disorders only in cases of emergencies and in a hospital environment.

·  Postpone voice rehabilitation and provide tele-rehabilitation whenever it is technically possible and allowed by the current regulations

·  Apply same precautions to all patients (even asymptomatic)

·  Advice for caregivers:

o be aware of the high risk of contamination from droplets emitted by the patient

o Procedures at very high risk of contamination: clinical and flexible endoscopic swallowing assessments, flexible endoscopies, insertions of nasogastric tubes and video fluoroscopic swallowing exams.

o Personal protective equipment (PPE) recommended: protective glasses, FFP2 (N95) mask, cap, gloves and gown.

o Learn the appropriate dressing and undressing technique.

6

Rahmati-Ahmadabad S et al, Obes Med. 2020

To review literature about the effect of exercise intensity on inflammation in obesity patients in the COVID-19 era

Patients suffering from obesity

Expert opinion

Outpatient, home-based settings

Iran

·  Light and moderate intensity exercise can reduce inflammation in obese patients, thus having an indirect protective effect against the virus.

·  On the other hand, high intensity exercise, especially in obese people, can cause the production of oxidants and transient suppression of immune system that could exacerbate COVID-19 symptoms.

7

Severin R et al, Am J Med. 2020

To investigate the potential role of respiratory muscle performance.

COVID-19 patients

Expert opinion

ICU, acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

U.S.A.

·  Respiratory muscle performance can be reduced because of several factors, such as aging, obesity, physical inactivity, smoking and chronic disease.

·  People with pre-existent reduced respiratory muscle performance have major difficulties in weaning from mechanical ventilation and is reported an elevated number of complications during the process, especially in obese patients.

·  The authors propose to screen respiratory muscle performance, annually, in patients at risk. If reduced performance is detected a home-based training approach would be prescribed, remotely monitored using telemedicine.

8

Silver JK et al, Am J Phys Med Rehabil. 2020

To propose prehabilitation for patients awaiting surgery.

Patients awaiting surgery

Expert opinion

Inpatient rehabilitation, outpatient rehabilitation, and home-based settings

U.S.A.

·  Prehabilitation should be considered to reduce surgical risk in post-pandemic elective surgery.

·  Clinical prehabilitation programmes should:

o  Focus on modalities that could prevent or reduce incidence of known surgical complications,

o  Measure the outcome by both surgical and rehabilitation metrics,

o  Be practically feasible in order to increase adherence,

o  Be discernible from general lifestyle recommendations.

9

Simpson R et al, Am J Phys Med Rehabil. 2020

To describe impairment patterns in critically ill patients with acute respiratory distress and related service organization in the  ICU.

COVID-19 patients

Expert opinion

ICU, acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

Canada

·  Physical and cognitive functions and psychosocial wellbeing can be severely impacted in COVID-19 patients admitted to the ICU.

·  Multimodal interventions for acute care and inpatient rehabilitation are warranted optimize outcome.

·  Innovative approaches are used, like tele- rehabilitation to avoid face-to-face interaction between the patient and the healthcare provider,  and prehabilitation to prevent possible complications of COVID-19.

10

Smith JM et al, Phys Ther. 2020

To describe characteristics and prevalence of PICS, discuss the possibilities for optimizing outcomes for PICS patients and suggest future directions for research and practice.

PICS patients

Expert opinion

ICU, Inpatient rehabilitation, outpatient rehabilitation, and home-based settings

U.S.A.

·  Critical illness often leads to PICS, defined as “new or worsening impairments in physical, cognitive, or mental health status arising after critical illness and persisting beyond acute care hospitalization”.

·  The syndrome impacts on functional capabilities and psychological and neuropsychological aspects of patients.

·   Given the increasing number of survivors to critical illness, a routine screening of people referred to physical therapists is advised, with ICU stay being considered a yellow flag.

·  A comprehensive evaluation for PICS patients and interventions applicable in ICU, inpatients, outpatients and home-based settings are reported.

11

Thomas P, et al J Physiother. 2020

To provide recommendations

for use by physiotherapists and other

relevant stakeholders in the acute care setting caring for adult patients with confirmed or suspected

COVID-19.

COVID-19 patients.

Practice guideline

Acute care inpatients

Australia

·  17 recommendations for physiotherapy workforce planning and preparation, including criteria for assigning staff to acute care of  COVID19 patients

·  7 criteria to determine the indication for physiotherapy intervention in the acute hospital setting and a screening tool to match patient’s clinical features with the need for physiotherapy referral

·  27 recommendations concerning the delivery of respiratory, mobilization, exercise and other rehabilitation interventions by physiotherapists

·  15 recommendations about the use of personal protective equipment during physiotherapy care

12

Wainwright TW,et al  J Rehabil Med. 2020

To assert the necessity for the development, co-ordination,

and delivery of inter-disciplinary rehabilitation to patients with COVID-19 and propose that collaborative self-management strategies be considered as a key component within the interdisciplinary rehabilitation pathways dedicated to these patients

COVID-19 patients

Expert opinion

Outpatient rehabilitation, and home-based settings in a long-term care perspective

UK

·  Challenges are expected to threaten the healthcare system over the longer term due to the current epidemics, like: handling the rehabilitation burden of COVID-19 patients post-acute care; managing emergency non-COVID conditions within restricted resources and managing the interrupted care of patients with long-term chronic conditions.

·  Rehabilitation services are not currently resourced to assist with the operational management of the cited challenges.

·  The new models of post-acute care for COVID-19 must include collaborative self-management to encourage and coach patients to actively manage medical, lifestyle, or emotional elements of their condition. This can be done through online-guidance, live streaming and video-consultations.

13

Zhu C, et al. Heart Lung. 2020.

To support the need for early pulmonary rehabilitation program in severe

SARS-CoV-2 pneumonia.

COVID-19 patients

Expert opinion

ICU

China

·  This is a case report of a 41-year-old man with severe SARS-CoV-2 pneumonia admitted to the ICU and treated with an individualized  rehabilitation program for 9 days, during weaning from mechanical ventilation in the ICU.

·  Treatment included: a) Postural change and prone position, b) Respiratory training to restore respiratory muscle strength and lung volume, c) Early mobilization and physical exercises and d) Psychological intervention and sleep promotion.

Organization of rehabilitation services after COVID-19

1

Alpalhão V & Alpalhão M. Phys Ther. 2020

To provide information on clinical practices to reduce the risk of infection for both physical therapists and patients in COVID-19 era

COVID-19 patients, patients in need of rehabilitation and physical therapists

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

Portugal

Recommendations for physical therapists to ensure that they can be delivered also in the COVID-19 era, adopting precautions to reduce the risk of infection spread:

·  Wear disposable PPE, changing it between patients

·  Reduce the number of patients and therapists in the same physical space

·  Propose digital physical therapist practice, making use of technology for communicating with and guiding patients

2

Babu AS, et al. Can J Cardiol. 2020

To present alternative CR delivery models, implementing the HBCR options

Patients needing CR

Expert opinion

Home-based setting

India and USA

·  HBCR prescription should be modified due to stay at home orders.

·  Other types of physical activity should be explored, as: calisthenics, chair-based exercises, resistance and balance exercises, and the use of yoga.

·  TDCR, a non-supervised delivery of CR with the assistance of technology might be useful in COVID-19 era

3

Boldrini P, et al. Eur J Phys Rehabil Med. 2020

To provide notes for the preparation of PRM services worldwide starting from the 1^st Covinar by SIMFER

COVID-19 patients, patients in need of rehabilitation

Descriptive: qualitative

Acute care, inpatient and outpatient rehabilitation,   home-based settings

Italy

·  The first “Covinar”, organized by SIMFER (March 18^th, 2020) involved the webinar had 230 live viewers (4.5%) out of 5,000 PRM specialists, and more than 8,900 individual visualizations of the recorded version

·  The participants report an overall difficulty in acting proactively and in defining a stable framework for organization and delivery of rehabilitation interventions

4

Carda S, et al. Ann Phys Rehabil Med. 2020

To report the main clinical manifestations due to COVID-19 and to propose criteria for admission of COVID-19 patients to Rehabilitation Units

COVID-19 patients

Expert opinion

Inpatient rehabilitation, outpatient rehabilitation, and home-based settings

World

·   Main repercussions due to COVID-19 are: respiratory, central nervous system and cognitive, deconditioning, critical-illness–related myopathy and neuropathy, dysphagia, joint stiffness and pain, and psychiatric problems.

·   Admission to a Rehabilitation Unit should be performed based on 4 criteria:

1) ≥7 days from diagnosis of COVID-19

2) at least 72 hr with no fever and no fever-reducing medication

3) stable respiratory rate and oxygen saturation

4) clinical and/or radiological evidence of stability

5

Chaler J, et al. Eur J Phys Rehabil Med. 2020

To provide the point of-view by the SERMEF on the impact of COVID-19 outbreak on Rehabilitation Services and PRM specialists activity

COVID-19 patients, patients in need of rehabilitation

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

Spain

The SERMEF proposes to:

1) reinforce the academic and training contents of PRM physicians in the area of Internal Medicine

2) to provide resources to launch research projects on the COVID-19 impact on rehabilitation

3) to strengthen the Rehabilitation Services during COVID-19 outbreak

6

Dalal H, et al. Eur J Prev Cardiol. 2020

To clarify that there is need of caution in introducing innovative CR techniques

Patients needing CR and respiratory rehabilitation

Expert opinion

Outpatient rehabilitation, and home-based settings

UK

·  Self-managed, home-based interventions are being encouraged

·  Research on the implementation of novel CR approaches is urgently needed

7

Escalon MX, et al. Am J Phys Med Rehabil. 2020

To share the experience on COVID-19 pandemic from the PRM Department of Mount Sinai Hospital, New York. U.S.A.

COVID-19 patients, patients in need of rehabilitation

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

U.S.A.

·  COVID-19 patients should be treated like people with ARDS

·  A home monitoring program started for persons with true or suspected COVID-19

·  Their PRM Department provided only essential consultations, as for people in need of intrathecal baclofen pump refill

8

Falvey JR, et al. Phys Ther. 2020

To outline how physical therapists can help offload emergency department volume and of meet post-discharge rehabilitation demand for COVID-19 survivors

COVID-19 patients, patients in need of rehabilitation

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

U.S.A.

·  Home- or community-based rehabilitation should be guaranteed to the subset of patients at highest risk for avoidable hospitalization

·  Physical therapists might bring added value to Emergency Department practice for musculoskeletal injuries

·  Physical therapists might have a key role in rehabilitation of post-acute patients

9

Khan F & Amatya B. J Rehabil Med. 2020

To underline the role of medical rehabilitation as an integral component of the comprehensive management of the COVID-19 emergency and provide recommendations for rehabilitation approach of the COVID-19 patient.

COVID-19 patients

Expert opinion

Acute care, inpatient rehabilitation

Australia

·  The rehabilitation needs for COVID-19 survivors vary in various settings and over time, yet rehabilitation is essential in all phases of pandemic management.

·  Early rehabilitation is fundamental to promote respiratory function recovery, reduce complications, improve function and, eventually, mitigate cognitive impairment and increase quality of life.

·  Residual disability is expected to affect up to one-third of COVID-19 patients, due to neurologic manifestations occurring in the acute phase, including stroke, impaired consciousness and skeletal muscle injury.

·  Recommendations are provided about organizational (n. 10) and operational issues (n.13) to be considered when planning rehabilitation services in the COVID-19 era.

10

Lee A. Phys Ther. 2020

To identify recommendations on digital physical therapist practice and offer future directions in advancing digital practice and telehealth in the physical therapy profession in the wake of COVID-19.

Expert opinion

Home

World

·  COVID-19 presents digital practice opportunities for improved access, high quality, and safety in physical therapy services for both service user and provider.

·  Possible limitations concern: specific federal and state payer guidelines, regulatory hurdles, patient privacy barriers, inadequate technology training, limited knowledge translation, regulatory barriers;  telerehabilitation may require more provider time for consultations, and it is unclear whether it improves access to beneficial services.

·  The guiding principles require strong provider-patient relationship, valid and reliable evidence, and the conduct of research to show whether telerehabilitation gives more benefits than risks for digital physical therapist practice

11

Levy J et al., Ann Phys Rehabil Med. 2020

To describe a model for a ventilator-weaning early rehabilitation unit to deal with post-ICU impairments

COVID-19 ventilator-dependent patients with stable disease and no other organ failure but respiratory or neurological features

Expert opinion

Tertiary care university hospital, post-ICU rehabilitation unit

France

The main features of an organization model representing a possible intermediary stage between ICU and either home discharge or inward rehabilitation are described:

·  Beds and rooms dedicated to post-ICU ventilator-dependent COVID-19 patients: each bed equipped with a ventilator and non-invasive continuous monitoring; each room equipped with a lift and harness for transfers.

·  Staff: senior and junior physicians with ICU or ventilator training and expertise. Paramedic staff including rotations of nurses and caregivers per 24 hr. Paramedic staff undergoing a full-day teaching program with the medical staff and a ventilation-specialized nurse before the opening of the unit. Physiotherapists dedicated to motor and cardiorespiratory rehabilitation of patients, and part-time occupational, speech therapists and psychologists.

·  Criteria for admission: Ventilator-dependent patients tracheotomized at least 24 hr before admittance, weaned from vasopressors for 48 hr and without any other organ failure needing invasive support. Before ICU discharge, patients are switched from an ICU ventilator to the weaning unit ventilator with clinical assessment and arterial blood gas analysis after 2 hr.

12

Mukaino M, Am J Phys Med Rehabil, 2020.

To present a preliminary attempt to use a telerehabilitation system to deliver exercise to isolated individuals.

Patients in need of rehabilitation

Case series

Inpatients acute setting

Japan

·  4 patients underwent telerehabilitation using a tablet while in communication with the physical therapy and being monitored with a pulse oximeter.

·  Patients were overall satisfied with the exercise program (NRS ranged from 8 to 10 with a median of 10), felt meaningful for their health to participate in the program (range 7 to 10, median 10), and  they would recommend this exercise to others (range 8 to 10, median 10).

13

Negrini S, Eur J Phys Rehabil Med., 2020.

To report the contents of the third SIMFER Covinar about the application of telemedicine in rehabilitation.

COVID-19 and rehabilitative outpatients.

Descriptive: qualitative

Outpatient setting

Italy

·  The experience with telemedicine applied on rehabilitative outpatients of 6 clinicians is presented.

·  All the clinicians interviewed underlined that it was feasible and cost-effective.

·  They also clarified that it is not a substitute of the human interaction between patients and doctor. Furthermore, the clinicians presented the many problems related to organization, such as privacy and payment issues.

·  Overall, the consensus was that telemedicine could and must be an integrative solution to common practice.

14

NICE guideline

www.nice.org.uk/guidance/ng159

To provide recommendations about critical care in adults in the COVID-19 era

Adults needing critical care in the COVID-19 era

Practice guideline

ICU

UK

·  An algorithm supporting decision making for the admission of COVID-19 patients to critical care is described, it links admission of individual adults to critical care on the likelihood of their recovery to an acceptable outcome

·  The following recommendations about how to provide functional prognosis are given:

·  assess all adults for frailty, irrespective of COVID-19 status, using an individualized assessment of frailty for any patient aged under 65, or patient of any age with stable long-term disabilities (for example, cerebral palsy), learning disabilities or autism.

·  adopt a standard assessment (the CFS score), as part of a holistic assessment, for people >65 without stable long-term disabilities.

·  involve relevant specialists if needed.

·  record the frailty assessment in the patient's medical record.

15

Pedersini P et al, Phys Ther. 2020

To share insights useful to optimize physical therapy reaction and organization in response to COVID-19

Physical therapists

Expert opinion

Acute care, inpatient, outpatient and home-based rehabilitation setting.

Italy

·  The Italian physical therapists respond to the emergency is reported.

·  Due to the measures of social distancing undertaken by the government, activity had to be re-organized. Every non-urgent physical therapy treatment had to be suspended and reorganized, eventually, using telemedicine. All urgent treatments had to be performed using appropriate protective equipment because of the impossibility to maintain a safe distance.

·  Many therapists provided care in acute care setting in response of the increasing demand due to COVID-19.

16

Stam HJ et al J Rehabil Med. 2020

To launch a call for action to acknowledge the need for a coordinated response to the cohort of post-ICU patients

.

COVID-19 patients

Expert opinion

Acute care and inpatient rehabilitation setting.

Netherlands and Switzerland

·  Several disabling consequences of severe respiratory illness and intensive care treatments are expected to affect COVID-19 survivors, in the frame of a PICS.

·  Major risk factors for PICS are cognitive impairments, acute brain dysfunction, hypoxia, hypotension, and glucose dysregulation.

·  Cognitive impairments may occur in 30% to 80% of post-ICU patients, depending on pre-existing cognitive deficits and age. 

·  Early rehabilitation combining mobilization with physiotherapy is reported to be an important strategy to facilitate and improve long-term recovery and functional independence of patients with PICS, also shortening the duration of ventilation and hospitalization.

·  Resources should be allocated to facilitate in– and outpatients’ rehabilitation interventions for ICU survivors, by promoting an early transfer of patients from ICU to rehabilitation facilities.

17

Thomas E et al.  Eur J Prev Cardiol. 2020

To provide evidence summary and advice on telehealth as an efficacious and safe solution for patients, family and staff in the domain of cardiac rehabilitation (CR)

People in need of cardiac rehabilitation

in countries hit by the COVID-19 outbreak

Expert opinion

Home-based setting.

Australia

·  Telehealth is both efficacious and safe. Considering more than 30 unique telehealth trials conducted internationally within CR settings, a metanalysis confirms that tele-CR is significantly associated with reduced Hospitalizations and cardiac events.

·  Practical advices concern the content of messages to be conveyed by tele-CR, the media to be used (email, text messages, Mobile health). Videoconferencing is especially valued as a means to develop a therapeutic rapport, supervise exercise remotely, provide feedback and support, share screens and files for educational and counseling purposes, enhancing efficiency and providing the opportunity for participants to share experience if groups are allowed. Web-based resources, like Cardiac College, can also help.

18

Torres-Castro R et al. Spinal Cord. 2020

To alert rehabilitation professionals against the risks of performing aerosol-generating procedures in SCI subjects in the COVID-19 era.

People with cervical SCI in need of rehabilitation

in countries hit by the COVID-19 outbreak

Expert opinion

Spine unit or rehabilitation setting for SCI patients 

Spain and Chile

·  People with cervical SCI frequently need aerosol-generating procedures, like NIV and mechanical cough assist.

·  To ensure staff safety in the COVID-19 era, physiotherapists should wear a waterproof long-sleeved gown, double non-sterile gloves, eye protection (with lateral protection), and a respirator that ensures a level of protection equal to or greater than N95/FFP2. 

·  Physiotherapists should also be aware that exhaled air-jet spreads through the mask’s holes up to 91.6 cm, in the case of NIV via a full-face mask in a bi-level setting with a single limb circuit.

19

Treger I et al. Eur J Phys Rehabil Med. 2020

To describe changes in the organization of rehabilitation services in a Israeli rehabilitation department

People in need of post-acute rehabilitation in countries hit by the COVID-19 outbreak

Expert opinion

Acute and rehabilitation settings

Israel

Changes to the organization of rehabilitation services have challenged the transfer of acute patients to the appropriate rehabilitation setting. In fact, day rehabilitation services are closed, people prefer to be discharged home than prolong hospitalization in inpatient rehab facilities, home rehabilitation is severely compromised by staff loss and lockdown policies.

20

Yeo TJ et al. Eur J Prev Cardiol. 2020

To provide a range of options for Cardiac rehabilitation delivery during the COVID-19 crisis and beyond.

People in need of cardiac rehabilitation

in countries hit by the COVID-19 outbreak

Expert opinion

Home-based setting.

Singapore

·  CR is currently underutilised in most countries in spite of its proven efficacy.

·  The ongoing outbreak has amplified traditional barriers to CR

·  In this scenario, the authors list a range of CR methods and related barriers to their successful delivery, concluding with a call for enhancing the role of technology to boost CR programs.

Impact of COVID-19 on diseases of rehabilitative interest

1

Helmich RC & Bloem BR. J Parkinsons Dis. 2020

To describe the impact of the COVID-19 pandemic on Parkinson’s Disease

People with Parkinson’ s Disease

Expert opinion

Home

Netherlands

·  Individuals with PD are at risk of experiencing the sequelae of both stress and reduced physical exercise, with a worsening of their motor and non-motor symptoms.   The following is recommended:

·  Apply self-management strategies to reduce stress  (e.g., mindfulness), increase coping (e.g., cognitive behavioural therapy) or enhance physical activity (e.g., home-based training programs, online singing, exercise or dancing classes).

2

Jalali M, et al. Disability & Society. 2020

To describe the different challenges people with disabilities are facing during the COVID emergency in Iran, and provide advice for the management

People with disabilities

Expert opinion

Community

Iran

Advices for the management of people with disabilities in the COVID-19 era

·  Use tele-rehabilitation for therapy, assessment and follow-up

·  Provide valid and usable informative materials for people with hearing and visual disability (sign language translator, Braille, audio, and electronic formats) regarding the disease and infection control

·  Provide educational materials for specific types of disabilities and their families/caregivers

·  In case of caregivers’ illness or quarantine: a substitute caregiver needs to be put in place. A written history of the person with medical and rehabilitation needs should be provided in case of emergency.

·  In addition to political attempts, humanitarian and charity donations may be necessary to face the poverty of disabled people and the weakness of the health care system to respond to normal daily demands let alone those arising through the COVID-19 emergencies.

3

Ku PK et al., Head Neck. 2020

To provide a strategic plan to facilitate safe practice in dysphagia management for health care personnel and patients with dysphagia, without jeopardizing the standard of care.

Patients with dysphagia following surgery for Head and Neck Cancer

Expert opinion

Home setting, hospital

Hong Kong

·  Defer any non-urgent instrumental swallowing

·  Screening of TOCC in last 14 days and/or fever, acute respiratory symptoms and/or smell and/or taste disturbances (anosmia, hyposmia, taste loss)

·  Use telehealth to:

o screen and assess swallowing function,

o implement swallowing training,

o monitor and review progress,

o engage home caregivers and plan future services.

·  Advice for clinical evaluation through telehealth:

o advanced preparation is necessary to ensure the patient has appropriate food and liquid boluses available,

o use clear feeding instruments to allow the clinician to best gauge the size of bolus presented,

o food coloring in boluses to increase visibility, and application of colored tape at the level of the thyroid cartilage to aid in visualization of laryngeal elevation during swallow

o use also quantitative swallowing measures.

·  If instrumental assessment is necessary, adopt conservative, high level PPE. VFSS is preferable to FEES.

4

López-Dolado E & Gil-Agudo A. Spinal Cord. 2020

To describe the experience of a monographic center for SCI

People with SCI

Expert opinion

National SCI monographic hospital

Spain

·  Isolate and treat adequately SCI patients with COVID-19

·  Design and apply the infrastructure to perform face–to–face and remote ongoing rehabilitation treatment using telemedicine support

·  Continue admission of new patients with acute SCI using enhanced hygiene protection conditions: quarantine them for 7 days in single-use rooms in a dedicated ward. RT-PCR in suspect of COVID-19 infection and, if confirmed, send the patient to the SCI COVID-19 inpatient area.

5

Mesa Vieira C, et al. Maturitas, 2020.

To analyse the impact of COVID-19 and its prevention measures on the wellbeing of vulnerable populations.

People experiencing disability. Homeless, indigenous, migrant and imprisoned populations.

Expert opinion

Outpatient and homebased settings.

Switzerland

·  The authors focused on the most vulnerable populations, including people experiencing disability. During a pandemic, the barriers that impair their access to health care could worsen, and this could put them to an increased sanitary risk.

·  The author formulated a call for action for policymakers to promote strategies to protect the well-being of the whole population, especially the most vulnerable communities.

6

Mobasheri A. Case Rep Womens Health. 2020.

To stress the need for exercise for women suffering from osteoarthritis.

Women suffering from osteoarthritis

Expert opinion

Homebased setting.

Finland.

·  Women with osteoarthritis should be advised about the risks of immobility during social distancing due to COVID-19 and the importance of exercising even during the current crisis,

·  They should evaluate which kind of exercise are feasible in their house and perform regular physical activity.

7

NICE guideline

www.nice.org.uk/guidance/ng168

To provide recommendations about the community-based care of patients with COPD in the COVID-19 era

People with COPD

Practice guideline

Home-based setting

UK

The guideline provides 43 different recommendations for the management of people with COPD. A few of them may be relevant for the rehabilitation care, as indicated here:

·  Use online pulmonary rehabilitation resources. This covers self-management, home exercise and educational materials

·  Advise patients currently using airway clearance techniques to continue to do so, adopting precautions to reduce the risk of nebulization when inducing sputum.or using non-invasive ventilation at home

8

NICE guideline

www.nice.org.uk/guidance/ng170

To provide recommendations about the management of people with cystic fibrosis in the COVID-19 era

People with cystic fibrosis

Practice guideline

Hospital and home care setting

UK

The guideline provides 36 different recommendations for the management of people with cystic fibrosis Many of them are relevant for rehabilitation care, as indicated here:

Patients without COVID-19 infection

·  Communicate with patients, their families and carers, and support their mental health and wellbeing to help alleviate any anxiety and fear they may have about COVID-19.

·  Minimise face-to-face contact to reduce the risk of infection by video-consultation or any other remote communication aid

·  Tell patients, their families and carers to continue with all their usual self-care arrangements including.

·  Monitor patients with cystic fibrosis closely, because they may be at greater risk of rapid deterioration if they contract COVID-19.

·  Specialist cystic fibrosis centres should maintain sufficient inpatient beds and facilities for those patients for whom a hospital admission is essential

Patients with suspect COVID-19

·  Ensure that relevant members of the cystic fibrosis team are involved in decisions about the care of patients with suspected COVID-19, including escalation of treatment

·  Alert patients and family members against the risks of infectious aerosol generating procedures

9

NICE guideline

www.nice.org.uk/guidance/ng167

To provide recommendations for the management of people with rheumatological autoimmune, inflammatory and metabolic bone disorders in the COVID-19 era

People with rheumatological autoimmune, inflammatory and metabolic bone disorders

Practice guideline

Hospital and home care setting

UK

The guideline provides 42 different recommendations for the management of people with rheumatological autoimmune, inflammatory and metabolic bone disorders. A few of them are relevant for rehabilitation care, as indicated here:

Patients without COVID-19 infection

·  Communicate with patients and support their mental wellbeing, to help alleviate any anxiety and fear they may have about COVID-19.

·  Minimise face-to-face contact

·  In musculoskeletal services, prioritise rehabilitation for patients who have had recent elective surgery or a fracture, and for those with acute or complex needs (including carers).

Patients with known or suspect COVID-19

·  Continue hydroxychloroquine and sulfasalazine

·  Do not suddenly stop prednisolone

·  Only give corticosteroid injections if the patient has significant disease activity and there are no alternatives

·  Temporarily stop other disease-modifying antirheumatic drugs, JAK inhibitors and biological therapies, and contact their specialists for advice on when to restart treatment.

10

Righi G, et al. Spinal Cord Ser Cases. 2020

To report the first case of COVID-19 in a tetraplegic person in Italy.

Tetraplegic COVID-19 patient

Case report

Outpatient, inpatient settings

Italy

·  Case report of a 56-year-old tetraplegic male developing COVID-19.

·  The patient never exhibited coughing, and did not develop severe symptomatology, in spite of its disability

11

Singh R, et al. Eur J Phys Rehabil Med. 2020

To share early experience with COVID-19 in the UK.

Patients in need of rehabilitation

Expert opinion

Inpatient rehabilitation, outpatient rehabilitation, and home-based settings

UK

·  The following measures taken in UK to limit the spread of COVID-19 infection are expected to impact on patients in need of rehabilitation:

·  Many inpatients wards, especially rehabilitative wards, have been cleared.

·  Most face-to-face appointments have been switched to telephone appointments with mixed review.

·  The pandemic has interfered even with medical learning, as it is impossible for students to get access to the patients.

·  Eventually, the number of disabled people is expected to increase as most COVID-19 survivors will exhibit functional impairment.

12

Solé G, et al. Revue Neurologique. 2020.

To provide a practice guideline

to homogenize the management

of NMD patients within the French territory, in the COVID-19 era

People with NMD in countries hit by the COVID-19 outbreak

Practice guideline

Hospital and home care setting

France

The FILNEMUS advises the following strategies for the management of NMD:

1) reserve hospitalization for emergencies, urgent diagnostic approaches (as in case of Guillain–Barre´ syndrome, or myasthenia gravis)

2) offer hospital care for treatments, check-ups and cardiorespiratory assessments for which the delay may result in a loss of survival chance;

3) ensure teleconsultations be conducted by a doctor, a resident, or a coordinator nurse, to verify that the cancelation of the hospitalization will not harm the patient.  4) make support systems available  (e.g., illustrated sheets with links to online videos) for self-rehabilitation and exercises, to cope with the cessation of regular in-house or office care by the rehabilitation team;

5) continue nusinersen intrathecal injections in patients with type 1 SMA and among young children with type 2 SMA.

6) do not stop immunosuppressants in patients with a dysimmune pathology in the absence of any manifestations suggestive of COVID-19;

7) clearly identify patients with a good prognosis, who may be eligible for resuscitation admission in ICU;

8) adopt measures to adapt the circuit and the use of NIV to limit nebulization and continue using NIV in ventilator-dependent patients.

13

Stillman MD, et al. Spinal Cord Ser Cases. 2020

To investigate COVID-19 screening practices and availability of screening kits among rehabilitation professionals caring for people living with SCI.

People with SCI in countries hit by the COVID-19 outbreak

Descriptive: qualitative

Spine units

World

·  This worldwide survey collected 783 responses, highlighting substantial variability in the rehabilitation medicine community in COVID-19 screening practices and availability of screening kits.

·  Only 5.8% respondents had tested their outpatients with SCI for COVID-19, and 4.4% reported having a patient with SCI with the virus. Screening of inpatients was performed only for symptomatic individuals in 53.3% cases or never in 29.9% cases.

·  Patients with SCI are worried for their vulnerability to infection (76.9%) and fragility of caretaker supply (42%).

14

Veerapandiyan A, et al. Muscle Nerve. 2020

To provide recommendations pertaining to care of patients with DBMD in the COVID-19 era.

People with DBMD in countries hit by the COVID-19 outbreak

Expert opinion

Hospital and home care setting

USA

The following main recommendations are provided, concerning the care of patients with DBMD:

·  Continue treatment with corticosteroids, Exon skipping medications, and Angiotensin converting enzyme inhibitors and/or angiotensin receptor blockers (for prophylaxis or treatment of cardiomyopathy).

·  Do not prescribe Hydroxychloroquine.

·  Treat patients with chronic respiratory insufficiency in collaboration with pulmonary and/or anaesthesiology specialists, avoiding the use of supplemental oxygen without ventilatory support.

·  Continue multidisciplinary care for these patients using telehealth.

15

Vigorito C, et al Monaldi Arch Chest Dis. 2020

To describe the barriers to Cardiac rehabilitation delivery and provide strategies to overcome them in the COVID-19 era and beyond

People in need of cardiac rehabilitation in countries hit by the COVID-19 outbreak

Expert opinion

Hospital and home care setting

Italy

·  The results of an Italian survey among CR units demonstrate that:

·  Referral to residential CR from the traditional source (cardiac surgery, PTCA, etc.)  is drastically reduced due to postponement of all elective activities. Conversely, the proportion of STEMI vs NSTEMI has increased, as only patients with worse symptoms are hospitalized, while those with mild symptoms or chronic conditions (see heart failure) prefer to stay at home. The CR section of EAPC recommends setting priorities for referral to CR, increase patients turnover, adopt precautions during training, shorten the programs, keep track of discharged patients and follow them with remote assessment. In the near future, CR units should be prepared to face the needs of patients with ACS or with worsening HF whose features could be similar to that of pre-PTCA era, with more frequent STEMI, left ventricular systolic dysfunction, poorer physical function for longer inactivity and poorer prognosis.

Late complications due to COVID-19 that may be of rehabilitative interest

1

Coraci D, et al. J Med Virol. 2020

To provide information on the support that rehabilitation might provide for COVID-19 patients, taking into account the possible relationship between respiratory failure and neuroinvasion of SARS‐CoV‐2.

COVID-19 patients, patients in need of rehabilitation

Expert opinion

Acute care, inpatient rehabilitation, outpatient rehabilitation, and home-based settings

Italy

·  Rehabilitation could play a relevant role for the management of post-acute COVID‐19 patients preventing secondary impairments, due to immobilization syndrome, and critical illness of neuropathy and myopathy