Supplementary Table I. Description of the articles on rehabilitation needs due to COVID-19 included in the rapid review updated to 31st May 2020. Note that the main content of the listed articles is available at https://rehabilitation.cochrane.org/sites/rehabilitation.cochrane.org/files/public/uploads/covid/evidmap_table.html  

 

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 of emerging disability after COVID-19

1

Heman-Ackah SM et al., et al., Neurosurgery 2020. DOI:10.1093/neuros/nyaa198.

To report two cases of devastating intracranial hemorrhage as a complication of veno-venous extracorporal membrane oxygenation.

COVID-19 patients

Case series

Not rehabilitation setting: ICU

USA

·  2 patients who required ECMO for refractory hypoxia secondary to COVID-19 developed devastating intraparenchymal hemorrhage despite lacking the classical risk factors.

·  It is suggested that the microvascular thrombosis observed as a precipitator of COVID-19 respiratory pathology may underlie ischemia and subsequent hemorrhage in these patients. Moreover, the COVID-19 might cause cytokine storm resulting in platelet dysfunction.

·  The authors propose the use of head CT to identify neurological complications as early as possible, aiding in the resource allocation of ECMO machines to the most appropriately selected patients.

2

Zanin L, et al. Acta Neurochir (Wien). 2020.

DOI: 10.1007/s00701-020-04374-x

To describe the case of COVID-19 patient that developed demyelinating lesions.

COVID-19 patient

Case Report

Not rehabilitation setting: ICU

Italy

·  The authors describe the case of a 54-year-old female, who complained of anosmia and ageusia for several days before severe  COVID-19 onset.

·  She needed mechanical ventilation and during intubation presented two episodes of seizures.

·  While head CT scan was negative, MRI showed demyelinating lesions of the periventricular white matter, at the bulbo-medullary junction and at the cervical and dorsal spinal cord.

·  The authors conclude that neurological impairment during COVID-19 acute phase and seizures could be attributed to demyelinating lesions.

3

Su XW, et al. Muscle Nerve. 2020. DOI: 10.1002/mus.26988

To present the case of a quadriplegic Guillain-Barré syndrome after a mild case of COVID-19.

COVID-19 patient

Case Report

Not rehabilitation setting: acute care

USA

·  The patient was a 72-year-old male that suffered from mild COVID-19-induced diarrhea.

·  He rapidly evolved in quadriplegic Guillain-Barré syndrome with dysautonomia and syndrome of inappropriate antidiuretic hormone secretion.

·  Patient with Guillain-Barré syndrome should be tested for COVID-19.

4

Ahmad  I, Rathore  FA, J Clin Neurosci 2020. DOI: 10.1016/j.jocn.2020.05.017

To collect data on neurological manifestations and complications of

COVID-19

COVID-19 patients

Narrative review

Not rehabilitation setting: acute care

Worldwide (China, Europe, Pakistan)

·  Papers analyzed: a Retrospective Chart review of 214  Chinese patients, an observational cohort study of 58 French patients and a few case reports/studies

·  Neurological involvement reported in 60.2% cases  (36.4% and 84% respectively), with some manifestations preceding respiratory symptoms and higher occurrence in severely ill patients (45.5% Vs.30.2%)

·  Dizziness (16.8%), headache (13.3%) followed by encephalopathy and delirium are most common symptoms; peripheral nervous system is involved in 19% of cases with hypogeusia present in 5.6% and hyposmia in 5.1%.

·  Skeletal muscle injury occurs in 10.7%

·  Other manifestations include cerebrovascular lesions, Guillain Barré syndrome, acute transverse myelitis and acute encephalitis.

5

Li H et al., Neurotox Res 2020. DOI: 10.1007/s12640-020-00219-8

To discuss the symptoms and the evidence of nervous system involvement caused by COVID-19 infection

COVID-19

patients

Narrative review

 

Not rehabilitation setting: ICU

China

·  Number of analysed studies not reported, number of total cases not known

·  Central and peripheral nervous system symptoms present at COVID-19 illness onset: headache (6.5% to 34% cases), nausea and vomiting (1% to 10.1%), dizziness, insanity, neck stiffness, hypogeusia, hyposmia, psychiatric and psychological involvement  (mild  in 35%, moderate to severe in 13% cases)

·  Encephalitis, cerebrovascular diseases, consciousness impairment, anxiety, and depression are frequent in COVID-19 patients.

·  CNS involvement is associated with poor prognosis, worsened clinical condition, and sudden death.

6

Cipollaro et al., J Orthop Surg Res 2020. DOI: 10.1186/s13018-020-01702-w

To report the prevalence of muscu- loskeletal symptoms reported worldwide in COVID-19 patients

COVID-19

patients

Expert opinion

 

 

Not rehabilitation setting: ICU, acute care

Worldwide (China, Singapore, Europe, USA, Bolivia)

·  One prospective and 53 retrospective studies (mostly from China) analysed, on 12,046 total patients (54% male and 46% females; mean age 52.13years).

·  Musculoskeletal symptoms like myalgia, arthralgia, and fatigue, were present at onset of COVID-19 illness up to the most severe stages.

·  Fatigue occurred in 25.6%, arthralgia and/or myalgia in 15.5%

Rehabilitation approaches dedicated to COVID-19 patients

1

Feng F, et al. Am J Geriatr Psychiatry. 2020. DOI: 10.1016/j.jagp.2020.05.012

To review literature about the application of Qigong for prevention and treatment of infectious disease

COVID-19 patients

SystematicReview

Outpatient rehabilitation, and rehabilitation services at home

China

·  Qigong is a mind-body training targeting body, breath and mind.

·  Qigong is easy to perform and the elderly can especially benefit from it during COVID-19 pandemic, due to its reported capacity of preventing respiratory infectious diseases and improve respiratory function

2

Brugliera L et al., Eur J Clin Nutr 2020.

DOI: 10.1038/s41430-020-0664-x

To discuss the efficacy of an interdisciplinary management of nutrition for COVID-19 patients.

COVID-19 patients

Prospective uncontrolled observational study

General post-acute rehabilitation

Italy

·  Cohort study assessing the efficacy of a three-step nutritional protocol:

1.        Nutritional assessment and malnutrition screening in all patients:

2.        Nutritional treatment plan:

3.        Continuous monitoring of body weight, nutrition intake, blood tests, and clinical condition with variable frequency.

·  In 32 out of 50 hospitalized patients (FIM 76.6; 90% with dysphagia; 45% at high risk and 26% at moderate risk of malnutrition), malnutrition improved in 15.3%, BMI improved in 43.7%.

3

Simonelli C et al., Monaldi Archives for Chest Disease 2020. DOI: 10.4081/monaldi.2020.1085

To describe and report the clinical outcome after the re-organization of a Cardio-Pulmonary Rehabilitation service during the COVID-19 emergency in a Northern Italian rehabilitation hospital, focusing on the RPTs role

 

COVID-19 patients

Retrospective uncontrolled observational study

Specialized postacute rehabilitation

Italy

·  COVID-19 care team developed based on a multidisciplinary panel of physicians, nurses, and RPTs to manage 90 beds for post acute patients with COVID-19

·  RPTs tasks are: oxygen therapy daily monitoring, non invasive ventilation  and CPAP delivery, pronation and postural changes, reconditioning exercises, functional assessments.

·  Three “what-to-do” algorithms guide: i) oxygen de-escalation by reducing inhaled fraction of oxygen (FiO2); ii) oxygenation improvement through the use of Venturi mask; iii) reconditioning and physical activity.

·  170 patients treated in 1 month, with RPTs managing oxygen therapy (in a third of cases), reconditioning (60% of the cases), and initial and final functional motor capacity assessment in all subjects.

4

Zheng Z, et al. J Med Virol. 2020. DOI: 10.1002/jmv.26040

To report effects of ozone therapy MAH in recovery of two severe cases with COVID-19.

COVID-19 patients

Case series

Rehabilitation in acute care

China

Two COVID-19 patients undergone ozone therapy MAH for seven days showed fast recovery of symptoms and normal range of laboratory indicators.

5

McGrath BA et al., Anaesthesia 2020.

DOI: 10.1111/anae.15120

To provide consensus recommendations about caring for COVID-19 patients with tracheostomy

COVID-19 patients

Consensus paper

Rehabilitation in acute care

 

UK

·  The role of the respiratory physiotherapist as part of the multidisciplinary team is critical for patients with tracheostomy, to ensure chest clearance and early weaning from mechanical ventilation.

The early involvement of speech and language therapists is needed, to provide creative methods of augmentative and alternative communication to reduce patient anxiety and facilitate communication and participation in care.

6

Falvey JR, Ferrante LE, Hear Lung 2020. DOI: 10.1016/j.hrtlng.2020.05.001

To advice how to improve outcomes in COVID-19 survivors in the current healthcare environment

COVID-19 patients

Expert opinion

Rehabilitation in acute care,

General postacute rehabilitation, Rehabilitation services at home

USA

·  Increase staffing and PPE availability within hospital and post-acute care settings

·  Increase use of telerehabilitation during the hospital stay both within the ICU and following ICU discharge.

Develop rehabilitation at home models for COVID-19 survivors after discharge

7

Klok FA, et al. Eur Respir J. 2020. DOI: 10.1183/13993003.01494-2020

To develop an outcome measure to detect the several consequences of  COVID-19.

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Netherlands

·  The “Post-COVID-19 Functional Status (PCFS) Scale” is an ordinal, not yet validated measure, targeting consequences of COVID-19.

·  The author propose its use at discharge from rehabilitation setting, 4 to 8 weeks after discharge, and 6 months after discharge to follow up the functional status of the patient over time.

8

Liu WH, et al. World J Acupunct Moxibustion. 2020. DOI: 10.1016/j.wjam.2020.03.005

To present the second edition of “Guidance for acupuncture and moxibustion intervention on COVID-19” issued by the China Association of Acupuncture–Moxibustion

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

China

·  The authors present a practical clinical guidance for the use of moxibustion and acupuncture on COVID-19 patients.

9

Ronconi G et al., Minerva Med 2020. DOI:10.23736/S0026-4806.20.06629-X

To provide advice on pathways and rehabilitation programs for patients with COVID-19, in the acute and subacute phases

COVID-19 patients

Expert opinion

 

Rehabilitation in acute care, General postacute rehabilitation

Italy

Acute phase:

·  Include the physiatrists in the interdisciplinary COVID 19 teams

·  Critical and very severe patients (ARDS): provide a thorough functional assessment of respiratory, cardiovascular, musculoskeletal and neurological system is needed; ensure ventilator support and disability prevention (passive movements, posturing, prone positioning 12 hours per day, switching head and arm postures every 4-6 hours); early respiratory rehabilitation not recommended;

·  Mild to severe patients: provide ventilator support, disability prevention (active exercise, strength, weaning from lodging), thoracic physiotherapy (cough sedation, airways clearance). Postural nursing with passive mobilization, changing the inclination of the bed, semi-sitting position at 45-60°.

·  Rehabilitation to be started:

o For respiratory system: if FiO2 ≤ 0.6, SpO2 ≥ 90%, Respiratory Rate ≤ 30 bpm and PEEP ≤ 10 cmH2O, even with endotracheal or tracheostomy tube.

o For cardiovascular system: if systolic BP ≥ 90mmHg or ≤ 180 mmHg, MAP  65mmHG or ≤ 110mmHg, HR ≥ 40bpm or ≤ 120 bpm; exclude arrythmia, myocardial ischemia, deep vein thrombosis and pulmonary embolism.

o For nervous system: Richmond Agitation- Sedation Scale score –2 to +2, intracranial pressure < 20 cmH2O.

·  Critical Illness Myopathy and Neuropathy (CRIMYNE): provide passive and active exercise, bed exercise, transfer training

·  Transfer patients to Rehabilitation Units if they have multiparametric stability for at least 36-48 hours and MEWS ≤2

Subacute phase: ensure:

·  Clinical monitoring, mechanical ventilation weaning, management of post tracheostomy complications. thoracic physiotherapy

·  Muscular training and reconditioning

·  Psychologic support

·  Physical activity planning at discharge

·  Follow up planning

10

Valenzuela PL, et al. Ann Phys Rehabil Med. 2020. DOI:10.1016/j.rehab.2020.04.005

To highlight the importance of early mobilization in hospitalized patients with COVID-19

COVID-19 patients

Expert opinion

Rehabilitation in acute care

Spain and USA

·  Early rehabilitation (stretching, resistance and walking exercises) might improve physical functioning, in hospitalized COVID-19 patients.

11

Yang LL & Yang T, Chronic Dis Transl Med. 2020. DOI:10.1016/j.cdtm.2020.05.002.

To establish a pulmonary rehabilitation model for COVID-19 patients

COVID-19 patients

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

China

·  Pulmonary rehabilitation should be provided to all patients in any setting (either in hospital and at home), tailored to the individual needs.

·  Pulmonary rehabilitation should be integrated in daily life routine in order to maximize the effects in the long run.

12

Yu HP-M, et al. Physiotherapy Theory and Practice. 2020. DOI: 10.1080/09593985.2020.1757264

To investigate current evidence on ultra-shortwave diathermy to minimise pulmonary inflammation in COVID-19 patients

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

China

·  To date there is no evidence to support the use of ultra-shortwave diathermy in COVID-19 patients.

·  Investigation of the effect of ultra-shortwave diathermy should start with carefully constructed and conducted case series to understand also safety and tolerability.

Organization of rehabilitation services after COVID-19

1

Sheehy LM. JMIR Public Health Surveill. 2020. DOI: 10.2196/19462

To report rehabilitation needs due to COVID-19, based on a scientific literature search

COVID-19 patients

Systematic

review

Rehabilitation in acute care, specialized postacute rehabilitation, and specialized outpatient rehabilitation

Canada

·  COVID-19 patients present several rehabilitation needs due to comorbidities and complications from ICU stay and/or intubation and negative effects of SARS-CoV-2 on multiple body systems (cardiac, neurological, cognition, and mental health).

·  Inpatient rehabilitation units for COVID-19 survivors should be properly designed, specifying staffing issues and considerations for outpatient rehabilitation

·  Physiotherapy, occupational therapy, speech-language therapy should be delivered in line with existing guidelines developed to treat COVID-19 patients, with respect to recovery of the respiratory system as well as mobility and function.

2

Tenforde AS et al., PM R 2020. DOI:10.1002/pmrj.12422.

To describe a quality improvement initiative during the rapid adoptive phase of telemedicine in outpatient sports medicine practices in the COVID-19 era

Patients with acute and chronic musculoskeletal conditions during the pandemic

Descriptive : cross-sectional

Specialized outpatient rehabilitation, Rehabilitation services at home

USA

·  119 patients and 13 physicians completed an online survey at the end of a telemedicine experience.

·  70.6% were follow-up visits of 15-29 minute duration, on average.

·  Patients rated the visit as “excellent” or “very good” across measures including addressing concerns, communication, developing a treatment plan, convenience, satisfaction and value in having a future telehealth visit.

·  62% of physicians had no prior experience with telemedicine visits, and 69% were comfortable performing these visits after completing 1-4 sessions. 92% of physicians rated their experience as very good or excellent. All physicians reported plans to perform telemedicine visits if reimbursement continues.

The main issue were technical barriers.

3

Middleton A, et al. Phys Ther. 2020. DOI:10.1093/ptj/pzaa089.

To describe the process of delivering physical therapist–guided telerehabilitation in older adults with functional limitations

Patients in need of rehabilitation

Descriptive: qualitative

Specialized outpatient rehabilitation and rehabilitation services at home

USA

·  There is a need of developing strategies for preventing functional decline among at-risk individuals during periods of social distancing and quarantine

·  A telerehabilitation program including 36 sessions delivered under the supervision of a physical therapist to a 67-year-old man is reported

o   The authors provide insight into the process and cost of developing telehealth exercise programs for older adults with functional impairments.

4

Prada V, et al. Int J Rehabil Res. 2020. DOI:10.1097/MRR.0000000000000418.

To report the case of a patient with Charcot-Marie-Tooth that was infected by SARS-CoV-2

COVID-19 patient

Case Report

Rehabilitation in acute care

Italy

·  A 28-year old male with Charcot-Marie-Tooth underwent a tendon transfer surgery in the left hand.

·  He developed COVID-19 during the rehabilitation period, 3 months after surgery.

·  To accomplish rehabilitation goals, the patient underwent 8 telerehabilitation sessions in the following month.

·  Thanks to telerehabilitation, the recovery process did not cause any appreciable setback.

5

Bikson M ET AL., Brain Stimul 2020 DOI: 10.1016/j.brs.2020.05.010.

To provide guidance on good practices for delivering NIBS through the immediate and ongoing stages of COVID-19.

Patients with clinical indications for NIBS

Consensus paper

Specialized outpatient rehabilitation

Worldwide

·  A 3-phase model (early COVID-19 impact, current practices, and future preparation) with an 11-step checklist (spanning removing or streamlining in-person protocols, incorporating telemedicine, and addressing COVID-19-associated adverse events) is proposed.

·  Recommendations: social distancing and sterilization of NIBS related equipment, specific provisions for COVID-19 positive populations, for regulatory and human resource in the era of COVID-19, and for specific clinical groups (stroke, chronic neurological conditions, drug, alcohol or behavioral addiction, children and older adults).

6

Bartolo M, et al. Front Neurol. 2020. DOI:10.3389/fneur.2020.00423.

To describe the measures adopted by rehabilitation structures, involved early in the COVID-19 pandemic.

Patients with neurological disability

Expert Opinion

Specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Italy

·  The authors advice about the need of a balance between two fundamental needs: prevent contagion spreading and consent the delivery of rehabilitation to neurological patients.

7

Bokan V, Obradovic M. Eur J Phys Rehabil Med 2020. DOI:10.23736/S1973-9087.20.06352-2.

To describe the impact of COVID - 19 epidemic on rehabilitation services in Montenegro

Patients in need of rehabilitation

Expert opinion

 

General outpatient rehabilitation

Montenegro

·  Rehabilitation services were reorganized as follows:

o   Outpatient service delivery was restricted to urgent conditions (in most cases, musculoskeletal trauma and peripheral nerve lesions).

o   The daily number of treated patients was reduced by 90%. 

o   A Call Centre was dedicated to help patients consult a PRM specialist

·  COVID- 19 epidemic pointed to the necessity of:

o   Organizing rehabilitation within the community (home rehabilitation poorly developed)

o   Opening PRM services at the territory of the capital city

·  Strengthening connections among associations and individuals to share information and knowledge.

8

Carda S, et al. Eur J Phys Rehabil Med. 2020. DOI:10.23736/S1973-9087.20.06317-0.

To share the clinical experience and perspective of different International Rehabilitation Units in the management of COVID-19 patients

COVID-19 patients

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Worldwide

·   Several rehabilitation needs are expected after COVID-19, due to respiratory failure, neurological and cognitive impairment, 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 hours with no fever and no fever-reducing medication

3) stable respiratory rate and oxygen saturation

·  4) clinical and/or radiological evidence of stability

9

Chang MC & Boudier-Revéret M. Am J Phys Med Rehabil. 2020. DOI: 10.1097/PHM.0000000000001468.

To underline the importance of tele-rehabilitation for stroke patients during COVID-19 pandemic.

Stroke patients

Expert Opinion

Outpatient rehabilitation, and rehabilitation services at home

Republic of Korea

·  Telerehabilitation is useful for stroke patients during COVID-19 pandemic as:

o   Previous studies have found it as effective as in-clinic rehabilitation

o   Patients can receive psychological counselling without the need to access the hospital

o   Clinicians can check the need for COVID-19 testing, and monitor symptom worsening while maintaining the patient at home.

10

Dantas LO, et al. Braz J Phys Ther. 2020. DOI:10.1016/j.bjpt.2020.04.006.

To define digital physical therapy in the COVID-19 pandemic and  describe its effects

COVID-19 patients and patients in need of rehabilitation

Expert opinion

Specialized outpatient rehabilitation, and rehabilitation services at home

Brazil

·  Digital practice includes “health care services, support, and information provided remotely via digital communication and devices”.

·  Digital physical therapy is an exponentially growing field, widely adopted within the COVID-19 pandemic, with the potential to reduce costs and increase quality of modern health care systems.

11

De la Corte-Rodriguez H, et al., Haemophilia. 2020. DOI:10.1111/hae.14070.

To provide guidance on measures to be taken to care for patients with haemophilia requiring intra-articular injection

Patients with haemophilia requiring intra-articular injection

Expert opinion

 

Specialized outpatient rehabilitation

Spain

·  Prepare specific internal protocols and organize appropriate training for the staff and patients involved.

·  Before the procedure, minimise face-to-face contact by previously reviewing the electronic history and through a remote consultation.

·  Ask the patient to sign an informed consent form adapted to the current epidemiological scenario.

·  Minimize the time of exposure and the number of people in the room

·  Consider to replace professionals who have a higher risk of complications from COVID-19 with others who are at lower risk.

·  Request health care personnel to use complete PPE.

·  Provide the necessary protection for patients, considering their epidemiological situation.

·  Postpone consultation for known COVID-19-positive patients whenever it is not essential, until the infection is recovered.

·  Ensure that the circuit of entry, stay, and exit of the patient are separated from the contact with other patients and non-healthcare personnel.

·  Ensure that all centers have adequate cleaning, disinfection and waste management protocols, following official recommendations and in accordance with their Occupational Health and Preventive Medicine departments.

o  Discourage the use of steroids if possible.

12

Feeley I et al., Ann Med Surg 2020. DOI: 10.1016/j.amsu.2020.04.023

To discuss the advances made by the foot and ankle department in the COVID-19 era

Patients with foot and ankle injuries

Expert opinion

 

Rehabilitation services at home

Ireland

A website (www.orthotac.ie) was created to provide educational material (videos of exercises performed by qualified physiotherapists and information leaflets explaining the management of common injuries).

13

Gopaul U, et al., Physiother Res Int 2020. DOI: 10.1002/pri.1847

To report on the preparedness and the role of physiotherapy in the clinical management of COVID-19 in Africa

COVID-19 patients

Expert opinion

 

Rehabilitation in acute care

Africa

·  The number of physiotherapists per 100,000 population range from 1 in Cameroon to 5 in Mauritius to 13 in South Africa. It is unclear how many physiotherapists are part of the team for COVID-19 patients.

·  The physiotherapists should play a proactive role by increasing preparedness for respiratory physiotherapy in intensive care for COVID-19 patients and for early rehabilitation in the post-acute phase to minimize the impact of COVID-19 in Africa.

14

Gupta R et al., NEJM CAT 2020. DOI:10.1056/CAT.20.0238.

To report a multi-disciplinary, comprehensive treatment model for those recovering from Covid-19 critical illness

COVID-19 patients

Expert opinion

 

Specialized postacute rehabilitation

USA

·  The NewYork-Presbyterian/Weill Cornell Medical Center created a Covid-19 Recovery Unit: a 30-bed unit to deliver a multi-disciplinary and comprehensive treatment including early rehabilitative therapy and extra support for psychosocial complications.

·  The Eligibility Criteria for the admission are: Medically stable, with ongoing medical and rehabilitative needs; Able to tolerate >30+ min  PT/OT each daily;Anticipation of final discharge to acute or sub-acute rehabilitation;Anticipation of at least one additional week of inpatient-level of care; Able to interact well with staff & other patients; Need for peritoneal dialysis is not an exclusion

·  Structured group and individual therapy include:

o   Five-times-weekly screening and sessions of PT and OT, and speech-language pathology as appropriate

o   Group therapy sessions three times weekly

o   Mindfulness and meditation classes three times weekly

o   Chair yoga classes five times weekly

·  Goal-setting with a therapist weekly

15

Haines KJ & Berney S. J Physiother. 2020. DOI: 10.1016/j.jphys.2020.03.012

To describe the role of physical therapists during COVID-19 pandemic

COVID-19 patients

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Australia

·  Physical therapists need to switch to a telerehabilitation delivery model of care, also to decrease the concerns of becoming infected during their work

·  Teamwork and collaboration are now more important than ever within own profession and inter-professionally

16

Karri J et al., Am J Phys Med Rehabil 2020. DOI: 10.1097/PHM.0000000000001463

To update the existing national recommendations and outline considerations about common rehabilitation procedures and their infectious risk profile

Patients in need of rehabilitation

Expert opinion

 

General outpatient rehabilitation

USA

·  Procedures were categorized as follows:

o  Elective procedures: injections of joint, peripheral nerve and trigger point; NCS and EMG, axial procedures including epidural steroid injections, medial branch blocks, facet injections, radiofrequency ablation

o  Functionally driven procedures: chemodenervation or neurolysis, axial or peripheral joint, nerve, and trigger point injections

o  Time-sensitive procedures: intrathecal pump catheter aspiration or intrathecal pump medication refill, NCS and EMG

·  Prophylactic considerations based on procedure specific risks:

o  Droplet or aerosolized contagion exposure: consider using a respirator (i.e. N95 mask) in patients with possible illness; consider adding a face shield in case of droplet exposure

o  Steroid administration: consider steroid dose reduction or other alternative medications for vulnerable and/or immunosuppressed populations

·  Reusable equipment: following Center for Disease Control and Prevention recommended cleaning and disinfection protocols is vital in maintaining sanitary equipment and surfaces

17

Leocani L, et al. Eur J Neurol. 2020. DOI: 10.1111/ene.14320.

To report the rehabilitation needs of COVID-19 patients and people with physical inactivity during the lockdown

 

COVID-19 patients and home-restricted subjects

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Italy

·  Rehabilitation needs are triggered by prolonged immobilization and acute neurological complications due to COVID-19, but also by the restriction of physical activity due to government decrees

·  Rehabilitation for COVID-19 patients should begin in the ICU, to foster functional recovery and ventilator weaning

·  Telerehabilitation should be offered for physical, language and cognitive training, considering that exergaming could allow remote supervision and collection of patient-reported outcomes

18

Lew HL, et al. Am J Phys Med Rehabil. 2020. DOI: 10.1097/PHM.0000000000001460

To highlight the role of rehabilitation during the current pandemic.

COVID-19 patients

Expert Opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

USA

·  Interdisciplinary rehabilitation is needed to care for all the impairment developed by COVID-19 patients.

·  Education of patients and care-givers is fundamental to permit a safe discharge to home.

·  Ensuring a continuity of care even after discharge, through face to face consultation or by telerehabilitation could be beneficial on long-term outcomes.

19

Meythaler JM, Arch Phys Med Rehabil. 2020. DOI: 10.1016/j.apmr.2020.05.001

To comment on the proposed changes to the inpatient rehabilitation facilities in the US.

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation

USA

·  The Centers for Medicare and Medicaid Services (CMS) proposed a change in regulations and guidance for inpatient rehabilitation facilities in the USA. The author argument that the timing for the proposal is poor and it should be revised after more careful consideration.

20

Pinto TF & Carvalho CRF, Braz J Phys Ther. 2020. DOI: 10.1016/j.bjpt.2020.04.004

To describe the lessons learnt from the experience of Brazilian Physical Therapists with COVID-19

COVID-19 patients

Expert Opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Brazil

·  Four lessons should be learnt from the Brazilian physical therapists experience:

o  Every professional should be trained in infection control strategies, such as washing hands or using PPE.

o  Primary care during a pandemic is of the utmost importance for reducing mortality rate by correctly treating comorbidities.

o  Cardiorespiratory and Intensive care Physical Therapists are at the center of the rehabilitation programs during the pandemic.

·  Physical therapists should remain scientifically updated.

21

Prvu Bettger J, et al. BMJ Glob Health. 2020. DOI: 10.1136/bmjgh-2020-002670

To describe adjustments to the continuum of International Rehabilitation Services

in the context of national COVID-19 preparedness responses

Patients in need of rehabilitation

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Worldwide

·  Rehabilitation service providers mobilised quickly to provide the best and safest care possible to those in greatest need, to optimize physical and cognitive functioning.

·  A core set of outcome measures should be adopted to monitor functioning for COVID-19 and other patients at risk for functional decline.

·  Safe and effective home-based rehabilitation strategies should be provided to mitigate the consequences of COVID-19 and reduced service capacity.

22

Smith et al. PM R. 2020. DOI:10.1002/pmrj.12405.

To present a model for field rehabilitation.

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation

USA

·  Given the intense stress on the health care systems due to COVID-19, rehabilitation services should be optimized to cope with it. The authors stress the need to identify patients with most severe disability and barriers to discharge in order to prioritize them during postacute inpatient rehabilitation. 

23

Stein J, et al. Am J Phys Med Rehabil. 2020. DOI:10.1097/PHM.0000000000001470.

To report the experience of a New York City academic medical center preparing for the pandemic, confronting it and the plans for post-peak recovery

COVID-19 patients

Expert Opinion

Specialized postacute rehabilitation

USA

·  Rehabilitation is a crucial aspect of our health care, but is particularly vulnerable during a pandemic.

·  The experience reported could provide guidelines for similar cases in the future.

·  Preparing for future pandemics is a critical long-term response.

24

Thornton J. BMJ. 2020. DOI: 10.1136/bmj.m1787

To describe the UK National Health Service plan for rehabilitation of COVID-19 patients on ICU discharge

COVID-19 patients

Expert opinion

Specialized postacute rehabilitation

UK

·  The “tsunami of rehabilitation needs” after ICU makes necessary to develop soon-to-be-released COVID-19 rehabilitation plans in UK

·  The UK government predicts that 45% of patients will need low level medical or social input for recovery and that 4% will require focused intensive rehabilitation.

·  COVID-19 patients will need an adequate psychological support after ICU discharge, because of higher levels of “survivors’ guilt” and post-traumatic stress

disorder.

25

·        Wainwright TW & Low M. J Rehabil Med. 2020. DOI: 10.2340/16501977-2685

To propose the inclusion of collaborative self-management

in the new models of post-acute care for COVID-19 to optimise outcomes

COVID-19 patients

Expert opinion

Specialized postacute rehabilitation

UK

·  Self-management is a complex intervention, consisting of encouraging and coaching patients to manage medical or emotional elements of their condition.

·  Rehabilitation services should include collaborative self-management in the new models of post-acute care for COVID-19 to optimise patient outcomes.

·  COVID-19 patients need specific advice on activity pacing, to cope with fatigue in the recovery phase from acute viral illness, and the potential associated complications.

Impact of COVID-19 on diseases of rehabilitative interest

1

NICE guideline www.nice.org.uk/guidance/ng167

 

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

People with rheumatologica l autoimmune, inflammatory and metabolic bone disorders

Rapid guideline

Specialized outpatient rehabilitation

UK

·  On 21 May 2020, the authors highlighted factors to take into account when considering temporarily stopping some drugs for children and young people

·  The authors aligned recommendation 1.4 (Communicating with patients and minimising risk) with current government advice on social distancing.

2

NICE guideline

www.nice.org.uk/guidance/ng177

To provide recommendations for the management of people with interstitial lung disease, including idiopathic pulmonary fibrosis and pulmonary sarcoidosis in the COVID-19 era, to protect staff from infection and enable services to make the best use of NHS resources.

People with interstitial lung disease

Rapid guideline

Specialized outpatient rehabilitation, rehabilitation services at home

UK

·  This guideline provides 50 different recommendations for the management of people with interstitial lung disease.

·  A small section concerns pulmonary rehabilitation, as indicated here:

o  Continue to offer pulmonary rehabilitation services to patients if available, including local services offering remote individualised education and exercise advice.

o  If remote pulmonary rehabilitation services are not available locally, use online pulmonary rehabilitation resources

·  When face-to-face pulmonary rehabilitation services become available, discuss the risks and benefits of attending with the patient, taking into account the current prevalence of COVID-19.

3

Negrini S, et al. Eur J Phys Rehabil Med. 2020. DOI: 10.23736/S1973-9087.20.06361-3.

To describe the impact of COVID-19 on people experiencing disability.

Patients in need of rehabilitation

Descriptive : cross-sectional

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation.

Italy

·  A survey about rehabilitation services in Europe in the COVID-19 era has been answered by 109 delegates of ESPRM from 35 countries.

·  Up to 2 million patients, in Europe, do not have access to rehabilitation services, due to stop of admissions to rehabilitation, early discharge and reduction of activities, during the pandemic.

·  Future increase of rehabilitation demand is expected, after the emergency, due to the return wave of these not well treated patients, and of post-Covid-19 patients' needs

4

Goodman-Casanova JM, et al. J Med Internet Res. 2020. DOI: 10.2196/19434.

To study the impact of quarantine in older patients with mild cognitive impairment.

Older people with mild cognitive impairment.

Descriptive : cross-sectional

Rehabilitation services at home

Spain

·  A telephone-base survey was administered to 93 patients participating in a study involving a television-based assistive integrated technology

·  Psychological well-being was optimal for the majority of the studied population.

·  Those living alone at home had the worst psychological outcomes.

·  Television was the preferred device to access to COVID-19 information.

5

Korupolu R, et al. Spinal Cord Ser Cases. 2020. DOI:10.1038/s41394-020-0284-7

To outline important differences in presentation along with COVID-19 cases co-morbid with SCI.

People with SCI

Case series

 

Rehabilitation in assistive service for specific disabled population groups

USA

·  SCI patients could not present with typical symptoms of COVID-19 due to altered physiology, posing challenges with their surveillance and management

·  A paradigmatic case with traumatic SCI (C5 motor level) presented fever, attributed to an UTI and treated with antibiotics, developed loose stools, attributed to neurogenic bowel; a few days later fever relapsed with intermittent cough. The patient underwent chest CT scan and was tested positive for SARS-CoV-2 only at 2 weeks from the initial onset of fever

6

Boldrini P et al., Eur J Phys Rehabil Med 2020. DOI: 10.23736/S1973-9087.20.06373-X.

To report the contents of the 6th SIMFER Covinar on the impact of the pandemic on people living with disability.

Persons with disability

Descriptive: qualitative

Rehabilitation services

Italy

·  7 representatives of Italian Patient Associations described the difficulties they are facing during the pandemic, the initiatives undertaken and their future perspectives and expectations.

·  The huge impact of the COVID-19 pandemic on rehabilitation services was confirmed

·  Associations made great efforts to assist their members offering information, advice and individual support (e.g. providing online videos with exercises)

·  Associations unanimously expressed a plea for rapid reactivation of rehabilitation services, the need for some changes in their organization and delivery, and the request to maintain tele-rehabilitation services.

7

Manto M et al., Cerebellum 2020. DOI: 10.1007/s12311-020-01139-1.

To provide guidance about how to care for patients with cerebellar ataxia  in the COVID-19 era

CA patients

Consensus paper

Rehabilitation services at home

Worldwide

·  CA patients are at higher risk of developing complications due to COVID-19:

o  they are mostly older patients;

o  ataxic respiration, maintenance of airway protection, and the presence of aspiration pneumonia are a constant threat;

o  immune ataxia subjects are treated with immune-modulating agents

o  many genetic ataxias are complicated by cardiac disorders and other comorbidities as diabetes.

·  Discontinuation of rehabilitation services including speech therapy may exacerbate symptoms and worsen functional impairment (increasing balance loss, muscle spasms, speech and swallow disorders)

·  Novel practice patterns need to emerge, including the use of telerehabilitation for balance and speech training and for psychological support

8

De Marchi F, et al. Neurol Sci. 2020. DOI: 10.1007/s10072-020-04457-8

To describe a novel approach using telemedicine for patients suffering from ALS

Patients with ALS

Expert opinion

Rehabilitation services at home

Italy

·  Quarantine due to COVID-19 pandemic creates huge difficulties in the care of patients with ALS, with the risk of speeding up functional decline.

·  The authors describe an integrated system for telemedicine, telehealth, tele-coaching and telecare supported by an internet-based app and education material that they will be testing in the near future.

9

Longo E et al., Phys Occup Ther Pediatr. 2020. DOI: 10.1080/01942638.2020.1759947

To describe the implementation of home-based rehabilitation for children in low- and middle-income countries

Children with disabilities

Expert opinion

Rehabilitation services at home

Brazil

·  Home-based rehabilitation programs could be effective in improving motor function of children with cerebral palsy.

·  A collaborative partnership with parents is warranted, to know the child’s needs and the home environment features.

·  Home-based rehabilitation programs should match the child and family goals.

·  Regular support and coaching to the family should be ensured to identify the child’s improvements and adjust the complexity of the program as needed.

·  It is crucial to promote telehealth for follow-up and continuity of care in children with disabilities during COVID-19 pandemic.

10

Sell NM et al., Ann Surg 2020. DOI: 10.1097/SLA.0000000000004002.

To report an adaptive response to pandemic-related prehabilitation barriers using a virtual platform.

 

Oncology patients who are receiving neo-adjuvant therapy prior to anticipated surgery

Expert opinion

Rehabilitation services at home

USA, CANADA

·  The authors suggest a multimodal, home-based, virtual prehabilitation program that include: standardized fitness program, nutrition supplementation, smoking cessation, and mindfulness practice.

·  Before commencing exercise sessions, instruct the patients to be mindful of any significant changes in symptoms or the presence of new symptoms. Common side-effects: muscular fatigue and soreness, transient increases in treatment-related symptoms. Rare risks: the possibility of injury due to unknown bone metastases or acute cardiac events in conjunction with cytotoxic therapy. Intensity and acute changes in symptoms should be closely monitored and reported.

11

Sylaja PN, et al. Ann N Y .Acad Sci. 2020. DOI: 10.1111/nyas.14379

To report the issues in stroke care due to COVID-19 pandemic in India.

Stroke patients

Expert Opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

India

·  In India, COVID-19 pandemic caused a significant reduction in stroke cases reported and treated.

·  Stroke rehabilitation facilities were hugely affected because of lower availability of personnel, fear of contagion between patients and staff and poor access to rehabilitation.

·  The authors propose possible solutions for handling stroke patients from acute phase to home-based rehabilitation, guaranteeing continuity of care.

·  Telemedicine could be an opportunity for stroke patients during the current pandemic.

12

Turolla A et al., Phys Ther 2020. DOI: 10.1093/ptj/pzaa093

To report clinical evidence on telerehabilitation (1), describe its feasibility and acceptability (2), explain opportunities and challenges for MSK physical therapists (3), and suggest clinical implications, calling to action the community of physical therapists (4).

Patients with MSK dysfunction

Expert opinion

 

Rehabilitation services at home

Italy

· Telerehabilitation unveils itself as a promising and timely model of care for patients who have MSK dysfunction during COVID-19

· Consultation for MSK pain is feasible and has a good acceptability

· There are benefits for patients (eg the reduction of hospitalization rates and the prevention of readmissions, improvements in health outcomes, quality of life and an early return to work), for physical therapists (eg maintaining continuity of care, monitoring patients’ progress), for health care services (eg increase care efficiency while containing costs, reduce waiting lists, guarantee adequate and continued services to both acute and chronic condition)

· Telerehabilitation should be enriched with contextual factors (eg elements of verbal communication and nonverbal communication)

· Establish in time the needed tools for exercise so that they can be rented and delivered to the patient’s home.

· Time for consultation and reimbursements for telerehabilitation services differ widely across countries.

·  Medicolegal aspects need to be considered while using the telerehabilitation (Protection of health care data and patient privacy)

13

Yarimkaia E & Esentürk OK. International Journal of Developmental Disabilities. 2020. DOI:10.1080/20473869.2020.1756115.

To describe the benefit of physical activity for children suffering from Autism Spectrum Disorders during COVID-19 quarantine.

Children suffering from Autism Spectrum Disorders

Expert Opinion

Rehabilitation services at home

Turkey

·  Quarantine can be an acute form of stress for children suffering from Autism Spectrum Disorders, and lead to mental health issues.

o  Parents should engage in physical activity with their children during the quarantine to increase well-being and calm at home, increasing quality of life of both children and care givers.

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

1

Wang X, et al. QJM. 2020. DOI:10.1093/qjmed/hcaa178.

To study the evolution of clinical outcomes after discharge from hospital in COVID-19 patients.

COVID-19 patient

Prospective uncontrolled observational study

Rehabilitation in acute care

China

·  Out of 131 patients, 40.05% cases still had symptomatology at discharge, with the most represented symptom being cough (29.01%), followed by fatigue (7.63%), expectoration (6.11%), chest tightness (6.11%), dyspnea (3.82%), chest pain (3.05%), and palpitation (1.53%).

·  In the third and fourth weeks only 18 patients had one or more symptoms.

·  8 patients still tested positive for SARS-CoV-2 after discharge.

Considerate self-quarantine and close follow-up of patients are required after discharge.

2

Candan SA, et al. Physiother Theory Pract. 2020. DOI: 10.1080/09593985.2020.1766181

To outline potential long-term secondary effects of

COVID-19 infection

on the musculoskeletal

system

 

COVID-19 patients

Expert opinion

Rehabilitation in acute care, specialized postacute rehabilitation, specialized outpatient rehabilitation, and rehabilitation services at home

Turkey and Nigeria

·  ICU stay might be the most important determinant of disability in the long term, considering the physical domains of PICS.

·  Rehabilitation program for the post-hospital period should involve strengthening, flexibility exercises, aerobic exercises, and balance and gait exercises.

·  Rehabilitation should be focused on reducing contributors to impaired long-term function to prevent or treat ICU-acquired weakness, deconditioning, and myopathies and neuropathies, in conjunction with respiratory care.

 

Abbreviations: ALS= Amyotrophic lateral sclerosis; ARDS= acute respiratory distress syndrome; BMI= Body Max Index; BP= Blood pressure; bpm= beats per minute; CA= Cerebellar ataxia; COVID-19= COronaVIrus Disease 19; Covinar= COVID-19 webinar; CNS= Central nervous system; CPAP= continuous positive airways pressure; CT= computed tomography; ECMO= extracorporal membrane oxygenation; EMG= electromyography; FIM= Functional Independence Measure; HR= heart rate; ICU= intensive care unit; MAH= major autohemotherapy; MAP= mean arterial pressure; MSK= musculoskeletal; MEWS= Modified Early Warning Scale; MRI= Magnetic Resonance Imaging; NCS= nerve conduction study; NIBS= non-invasive brain stimulation; OT= Occupational Therapy; PEEP= Positive end-expiratory pressure; PICS= post-intensive care syndrome; PPE= Personal Protective Equipment; PRM= Physical and Rehabilitation Medicine; PT= Physical Therapy; RPTs= Respiratory Physiotherapists; SARS-CoV-2= Severe Acute Respiratory Syndrome - Coronavirus–2; SCI= spinal cord injury;  SIMFER= Italian Society of Physical Medicine and Rehabilitation; UK= United Kingdom; USA = United States of America; UTI= urinary tract infection.


Reference:
Andrenelli E, Negrini F, De Sire A, Arienti C, Patrini M, Negrini S, et al; International Multiprofessional Steering Committee of Cochrane Rehabilitation RECOVER action. Systematic rapid living review on rehabilitation needs due to Covid-19: update to May 31st 2020. Eur J Phys Rehabil Med 2020 Jun 16. DOI: 10.23736/S1973-9087.20.06435-7

Link to Journal website: https://www.minervamedica.it/en/journals/europa-medicophysica/article.php?cod=R33Y9999N00A20061602
Link to PubMED: https://pubmed.ncbi.nlm.nih.gov/32539312/

This living rapid systematic review is one of the products of the Cochrane Rehabilitation REH-COVER (Rehabilitation - Covid-19 Evidence-based Response)

The other REH-COVER products include: