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REHABILITATION FOR POST-ACUTE CARE PATIENTS DIAGNOSED WITH COVID-19

The purpose of this document is to provide a list of current resources and literature related to the rehabilitation of

COVID-19 patients. Documents included were derived from:

KRS literature review: Rehabilitation needs of patients recovering from COVID-19 (includes grey literature from

reputable consortiums).

Google scholar search of terms: Rehabilitation of COVID-19 patients.

KRS literature review: Dysphagia and COVID-19.

Patients requiring multi-disciplinary rehabilitation intervention are the focus of the recommendations of this summary.

There are already well-documented processes for providing telerehabilitation. The number of patients who would

potentially benefit from tertiary level inpatient care is not clear, and may be a function of the necessity to free up acute

care beds.

Recently published peer reviewed literature and grey literature (where the authors are a consortium of experts) were

reviewed. Studies and grey literature specific to COVID-19, as well as articles which were more generally related to

patients with para and post ICU with complications (i.e., anosmia, myalgia, meningitis, encephalitis, stroke, Acute

Respiratory Distress Syndrome, encephalopathy, encephalomyelitis etc.) were included. Regulatory colleges and

professional associations of specific rehabilitation disciplines also provided guidance.

This summary includes general considerations for tertiary level rehabilitation for COVID-19 patients, as well as specifics

based on primary presenting issues. It does not include specifics related to safety of clinicians providing care as this is

already well documented by AHS.

Rehabilitation for COVID-19 patients: These considerations and recommendations are taken directly from the following

references (additional links to articles that were found within these references are included in the review below and not

in this list):

1. Ad-Hoc International Task Force to Develop and Expert-Based Opinion on Early and Short-Term Rehabilitative

Interventions (After Acute Hospital Setting). https://ers.app.box.com/s/npzkvigtl4w3pb0vbsth4y0fxe7ae9z9

2. Choon-Huat Koh G & Hoenig H. (2020) How Should the Rehabilitation Community Prepare for 2019-nCoV? Archives of Physical Medicine and Rehabilitation, doi:10.1016/j.apmr.2020.03.003. Retrieved from https://www.archives-pmr.org/article/S0003-9993(20)30153-2/pdf

3. Thomas P, Baldwin C, Bissett B, Boden I, Gosselink R, Granger CL, Hodgson C, Jones AY, Kho ME, Moses R,

Ntoumenopoulos G, Parry SM, Patman S, van der Lee L (2020). Physiotherapy Management for COVID-19 in

the Acute Hospital Setting: Clinical Practice Recommendations. Science Direct, Journal of Physiotherapy (in

press). https://www.sciencedirect.com/science/article/pii/S183695532030028X?via%3Dihub

4. Gardner Paula J, Moallef Parvaneh. Psychological Impact on SARS Survivors: Critical Review of the English Language Literature, American Psychological Association, APA PsycNet, Canadian Psychology/Psychologie Canadienne, 56(1), 123-135. http://dx.doi.org/10.1037/a0037973

5. Simpson R & Robinson L (2020). Rehabilitation Following Critical Illness in People with COVID-19 Infection.

American Journal of Physical Medicine & Rehabilitation, 20 April 2020. https://journals.lww.com/ajpmr/Abstract/publishahead/Rehabilitation_following_critical_illness_in.98021.aspx

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 2

6. Kho ME, Brooks D, Namasivayam-MacDonald A, Sangrar R and Vrkljan B. (2020) Rehabilitation for Patients with COVID-19 Guidance for Occupational Therapists, Physical Therapists, Speech-Language Pathologists, and Assistants. School of Rehabilitation Science, McMaster University. https://srs-mcmaster.ca/wp-content/uploads/2020/04/Rehabilitation-for-Patients-with-COVID-19-Apr-08-2020.pdf

7. Brugliera L, Spina A, Castellazzi P, Cimino P, Tettamanti A, Houdayer E, Arcuri P, Alemanno F, Mortini P, Iannaccone S. (2020). Rehabilitation of COVID-19 Patients. Journal of Rehabilitation Medicine, Vol 52, Issue 4. https://www.medicaljournals.se/jrm/content/abstract/10.2340/16501977-2678

8. McNeary L, Maltser S & Verduzco‐Gutierrez M. (2020). Navigating Coronavirus Disease 2019 (COVID19) in Physiatry: A Can Report for Inpatient Rehabilitation Facilities. American Academy of Physical Medicine & Rehabilitation, Retrieved from https://COVID19.cdc.gov.sa/wp-content/uploads/2020/03/Navigating-Coronavirus-Disease-2019-COVID%E2%80%9019-in-Physiatry-A-CAN-report-for-Inpatient-Rehabilitation-Facilities.pdf

9. Liu K, Zhang W, Yang Y, Zhang J, Li Y, & Chen Y. (2020). Respiratory Rehabilitation in Elderly Patients with COVID-19: A Randomized Controlled Study. Complementary Therapies in Clinical Practice, Vol 39, May 2020, 101166. https://www.sciencedirect.com/science/article/pii/S1744388120304278

10. Coraci D, Fusco A, Frizziero A, Giovannini S, Biscotti L, & Padua L. (2020). Global Approaches for Global Challenges: The Possible Support of Rehabilitation in the Management of COVID-19. Journal of Medical Virology, Apr 20. doi:10.1002/jmv.25829. Retrieved from https://onlinelibrary.wiley.com/doi/abs/10.1002/jmv.25829

11. Mukaino M, Tatemoto T, Kumazawa N, Tanabe S, Kato M, Saitoh E & Otaka Y. (2020). Staying Active in Isolation: Telerehabilitation for Individuals with the Sars-Cov-2 Infection. American Journal of Physical Medicine & Rehabilitation, doi:10.1097/PHM.0000000000001441 Retrieved from https://journals.lww.com/ajpmr/Citation/publishahead/Staying_active_in_isolation__Telerehabilitation.98028.aspx

12. Polastri M. (2020). Physiotherapy In Hospitalized Patients with COVID-19 Disease: What We Know So Far. International Journal of Therapy & Rehabilitation, March 2020; 27(3): 1-3. (3p)Mark Allen Holdings Limited. Retrieved from https://web-a-ebscohost-com.ahs.idm.oclc.org/ehost/detail/detail?vid=0&sid=30401e75-22d5-47fe-afe2-f2a6c2d134c8%40sdc-v-sessmgr01&bdata=JnNpdGU9ZWhvc3QtbGl2ZSZzY29wZT1zaXRl#AN=142668466&db=rzh

13. Barazzoni R, Bischoff S C, Breda J, Wickramasinghe K, Krznaric Z, Nitzan D, . . . Singer, P. (2020). ESPEN Expert Statements and Practical Guidance for Nutritional Management of Individuals with SARS-COV2 Infection. Science Direct, Clinical Nutrition, available online 31 March 2020. doi:10.1016/j.clnu.2020.03.022 Retrieved from https://www.sciencedirect.com/science/article/pii/S0261561420301400?via%3Dihub

14. Duncan S, Gaughey JM, Fallis R, McAuley DF, Walshe M, & Blackwood B. (2019). Interventions for Oropharyngeal Dysphagia in Acute and Critical Care: A Protocol for a Systematic Review and Meta-Analysis. Systematic Reviews, Vol 8(1), 283. doi:https://dx.doi.org/10.1186/s13643-019-1196-0. Retrieved from http://gc7pr5bx5e.search.serialssolutions.com/?url_ver=Z39.882004&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rfr_id=info:sid/Ovid:prem&rft.genre=article&rft%20_id=info:doi/10.1186%2Fs13643-019-1196-0&rft_id=info:pmid/31747971&rft.issn=2046

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 3

15. Alberta Health Services, Health Professions Strategy and Practice. Allied Health Dysphagia Intervention in the Context of COVID-19. https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-COVID-19-dysphagia-intervention-COVID.pdf

16. Grabowski DC & Joynt Maddox KE. (March 25, 2020). Post acute Preparedness for COVID-19 Thinking Ahead. JAMA Network https://jamanetwork.com/journals/jama/fullarticle/2763818

17. Mental Health and the COVID-19 Pandemic. Canadian Association of Mental Health. https://www.camh.ca/en/health-info/mental-health-and-covid-19 18. Carda S, Invernizzi M, Bavikatte G, Bensma¨ıl D, Bianchi F, Deltombe T, Draulans N, Esquenazi A, Francisco GE,

Gross R, Jacinto LJ, P´erez SM, O’Dell MW, Reebye R, Verduzco-Gutierrez M, Wissel J, Molteni F. The Role Of Physical And Rehabilitation Medicine In The COVID-19 Pandemic: The Clinician’s View, Annals of Physical and Rehabilitation Medicine (2020), doi:https://doi.org/10.1016/j.rehab.2020.04.001

19. Ceravolo MG, De Sire A, Andrenelli E, Negrini F, & Negrini S. (2020). Systematic Rapid" Living" Review on Rehabilitation Needs Due To COVID-19: Update to March 31st 2020. European Journal of Physical and Rehabilitation Medicine, Retrieved from https://www.minervamedica.it/en/journals/europamedicophysica/article.php?cod=R33Y9999N00A20042201

20. Chaler J, Gil-Fraguas L, Gómez-García A, Laxe S, Luna-Cabrera F, Llavona R, . . . SánchezTarifa . (2020). Impact of Coronavirus Disease 2019 (COVID-19) Outbreak on Rehabilitation Services and Physical Medicine and Rehabilitation (PM&R) Physicians' Activities: Perspectives from the Spanish Experience. European Journal of Physical and Rehabilitation Medicine, Retrieved from https://www.minervamedica.it/en/journals/europamedicophysica/article.php?cod=R33Y9999N00A20042404

21. Khan F, & Amatya B. (2020). Medical Rehabilitation in Pandemics: Towards A New Perspective. Journal of Rehabilitation Medicine, 52(4) doi:10.2340/16501977-2676 Retrieved from https://www.medicaljournals.se/jrm/content/html/10.2340/16501977-2676

22. Ebenezer Cudjoe & Alhassan Abdullah (2020). Drawing On Kinship Care Support For Older People During A Pandemic (COVID-19): Practice Considerations For Social Workers In Ghana, Journal of Gerontological Social Work, DOI: 10.1080/01634372.2020.1758271 https://doi.org/10.1080/01634372.2020.1758271

23. Landry MD, Geddes L, Moseman A P, Lefler JP, Raman S R, & van Wijchen J. (2020). Early Reflection on the Global Impact of COVID19, And Implications for Physiotherapy. Physiotherapy, Retrieved from https://www.physiotherapyjournal.com/article/S00319406(20)30025-0/fulltext

24. Levy J, Léotard A, Lawrence C, Paquereau J, Bensmail D, Annane D, . . . Prigent H. (2020). A Model for a Ventilator-Weaning and Early Rehabilitation Unit to Deal with Post-ICU Impairments with Severe COVID-19. Annals of Physical and Rehabilitation Medicine, doi:10.1016/j.rehab.2020.04.002 Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7165266/pdf/main.pdf

25. Li J. (2020). Effect and Enlightenment of Rehabilitation Medicine in COVID-19 Management. European Journal of Physical and Rehabilitation Medicine, Retrieved from https://www.minervamedica.it/en/journals/europamedicophysica/article.php?cod=R33Y9999N00A20042403

26. Mattei A, Amy de la Bretèque B, Crestani S, Crevier-Buchman L., Galant C, Hans S., . . . Giovanni A. (2020). European Annals of Otorhinolaryngology, Head and Neck Diseases, doi:10.1016/j.anorl.2020.04.011 Retrieved

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 4

from http://www.sciencedirect.com/science/article/pii/S1879729620301010

27. Mustafa M. (2020). Audiological Profile of Asymptomatic COVID-19 PCR-Positive Cases. American Journal of Otolaryngology, 102483. Retrieved from https://www.sciencedirect.com/science/article/pii/S0196070920301654

28. Singh R, Burn J, & Sivan M. (2020). The Impact of COVID-19 on Rehabilitation Services and Activities. Letter to the editor in response to official document of SIMFER. European Journal of Physical and Rehabilitation Medicine, https://www.ncbi.nlm.nih.gov/pubmed/32293816

29. Stam H J, Stucki G, & Bickenbach J. (2020). COVID-19 and Post Intensive Care Syndrome: A Call for Action. Journal of Rehabilitation Medicine, 52(4), jrm00044. doi:https://dx.doi.org/10.2340/16501977-2677 Retrieved from: https://web-a-ebscohostcom.ahs.idm.oclc.org/ehost/pdfviewer/pdfviewer?vid=1&sid=872aedc7-afa8-4562-a5c1f934414fcce8%40sdc-v-sessmgr02

30. Treger I, & Friedman A. (2020). Organization Of Acute Patients' Transfer To Rehabilitation Services During COVID-19 Crisis. European Journal of Physical and Rehabilitation Medicine, Retrieved from https://www.minervamedica.it/en/journals/europamedicophysica/article.php?cod=R33Y9999N00A20042406

31. Vigorito C, Faggiano P & Mureddu GF. (2020). COVID-19 Pandemic: What Consequences for Cardiac Rehabilitation? Monaldi Archives for Chest Disease, 90(1) doi:https://dx.doi.org/10.4081/monaldi.2020.1315 Retrieved from https://www.monaldiarchives.org/index.php/macd/article/view/1315/1012

32. Walter-McCabe HA. (2020). Coronavirus Pandemic Calls For an Immediate Social Work Response. Social Work in Public Health, 35(3), 69-72. doi:https://dx.doi.org/10.1080/19371918.2020.1751533 Retrieved from https://www.tandfonline.com/doi/full/10.1080/19371918.2020.1751533

33. Liu Y, Cao L, Li X, Jia Y & Xia H. (2020). Awareness Of Mental Health Problems In Patients With Coronavirus Disease 19 (COVID-19): A Lesson From An Adult Man Attempting Suicide. Asian Journal of Psychiatry, 51 (accessed online). doi:10.1016/j.ajp.2020.102106

34. Levin A. (2020). COVID-19: Psychiatrists in Battle Mode To Help Patients, Public During Crisis. American Psychiatric Association, Psychiatric News. Published online 25 March 2020; Accessed April 29, 2020: https://psychnews-psychiatryonline-org.ahs.idm.oclc.org/doi/10.1176/appi.pn.2020.4a22

35. Smith AP. (2020). The Psychology of the Common Cold and Influenza: Implications for COVID-19. International Journal of Clinical Virology, 27-31 (4). https://www.heighpubs.org/hjcv/ijcv-aid1011.php

36. Brodsky M, Huang M, Shanholtz C, Mendez-Tellez P, Palmer L, Colantuonin E, and Needham D. Recovery from Dysphagia Symptoms after Oral Endotracheal Intubation in Acute Respiratory Distress Syndrome Survivors: A 5-Year Longitudinal Study. American Thoracic Society, Vol 14, No 3, pp 376–383, Mar 2017 DOI: 10.1513/AnnalsATS.201606-455OC) https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201606-455OC

37. Leder SB, Cohn SM, Moller BA. Fiberoptic Endoscopic Documentation of the High Incidence of Aspiration Following Intubation in Critically Ill Trauma Patients. Dysphagia 1998; 13:208–212.) https://www.ncbi.nlm.nih.gov/pubmed/9716751)

38. Yamanaka H, Hayashi Y, Watanabe Y, Uematu H & Mashimo T. Prolonged Hoarseness and Arytenoid Cartilage Dislocation After Tracheal Intubation. BJA: British Journal of Anaesthesia, Volume 103, Issue 3, September

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 5

2009, Pages 452–455) https://doi.org/10.1093/bja/aep169)

39. Hyzy R. Complications of The Endotracheal Tube Following Initial Placement: Prevention and Management in Adult Intensive Care Unit Patients, UpToDate website, peer reviewed, 2020.) https://www.uptodate.com/contents/complications-of-the-endotracheal-tube-following-initial-placement-prevention-and-management-in-adult-intensive-care-unit-patients

40. Arviso L, Klein A & Johns M. The Management of Post-intubation Phonatory Insufficiency. Journal of Voice

Volume 26, Issue 4, July 2012, Pages 530-533.

https://www.sciencedirect.com/science/article/abs/pii/S0892199710002158

41. Kiran S, Tandon U, Dwivedi D & Kumar R. Prolonged Hoarseness Following Endotracheal Intubation - Not so

Uncommon? Indian J Anaesth. 2016 Aug; 60(8): 605–606. doi: 10.4103/0019-5049.187816

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4989817/

42. Goldsmith Tessa (SLP). Guidelines for Swallowing Assessment and Treatment Following Extubation.

https://journals.lww.com/anesthesiaclinics/Fulltext/2000/07000/Evaluation_and_Treatment_of_Swallowing_Di

sorders.13.aspx

Additional Grey Literature:

Coronavirus (COVID‐19) Resources for the Physical Therapy Profession. American Physical Therapy Association. http://www.apta.org/Coronavirus/

Rehab Specific Resources on COVID-19. Rehabilitative Care Alliance. April 2020. http://www.rehabcarealliance.ca/COVID-19-rehab-resources

COVID-19. Canadian Physiotherapy Association. https://physiotherapy.ca/COVID-19. (list of resources]

COVID‐19 and Tele‐Rehabilitation. College of Physical Therapists of British Columbia. https://cptbc.org/physical-therapists/practice-resources/advice-to-consider/COVID-19-and-tele-rehabilitation/

Report Of An Ad‐Hoc International Task Force to Develop An Expert‐Based Opinion On Early And Short‐Term Rehabilitative Interventions (After The Acute Hospital Setting) In COVID‐19 Survivors, European Respiratory Society. https://ers.app.box.com/s/825awayvkl7hh670yxbmzfvcw5medm1d

COVID‐19 Rehab Resources. GTA Rehab Network, April 2020. http://www.gtarehabnetwork.ca/rehabilitation--COVID-19; (various resources listed)

Clinical Guide for the Management of Patients Requiring Transfer for Special Rehabilitation During the Coronavirus Pandemic (Spinal Cord Focus). NHS, 03 April 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/04/C0199-Specialty-guide_specialist-rehabilitation-v1-03-April_.pdf

Clinical Guide for the Management of Respiratory Patients during the Coronavirus Pandemic, NHS, 26 March 2020. https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0063-Specialty-guide-_Respiratory-and-Coronavirus-_v1_26-March.pdf (respiratory therapy across the continuum of care)

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COVID-19 Pandemic. Physiotherapy Alberta College + Association. https://www.physiotherapyalberta.ca/COVID_19_pandemic/#direction_to_physiotherapists_working_in_long_term_and_continuing_care_environments. (various resources and directions for PTs working long-term care and continuing care)

“Psychology Works” Fact Sheet & Resources. https://cpa.ca/corona-virus/cpa-COVID-19-resources/ Canadian Psychological Association Alberta Health Services, Health Professions Strategy and Practice.

Alberta Health Services, Health Professions Strategy and Practice. Allied Health Dysphagia Intervention in the Context of COVID-19. https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-COVID-19-dysphagia-intervention-COVID.pdf

Allied Health Dysphagia Intervention in the Context of COVID-19. https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-COVID-19-dysphagia-intervention-COVID.pdf

https://www.escardio.org/static_file/Escardio/Education-General/Topic%20pages/COVID-19/ESC%20Guidance%20Document/ESC-Guidance-COVID-19-Pandemic.pdf

COTBC – COVID-19 Practical Guidance – Telehealth in Occupational Therapy Practice https://cotbc.org/wp-content/uploads/COVID-19-Practice-Guidance-Telehealth-in-Occupational-Therapy-Practice-March-31-2020-Update_FINAL.pdf

Physiopedia – Role of the Physiotherapist in COVID-19 https://www.physio-pedia.com/Role_of_the_Physiotherapist_in_COVID-19 (includes online courses)

World Confederation For Physical Therapy - COVID Physio Registry Of Project/Activities https://www.wcpt.org/COVIDPhysio

World Confederation For Physical Therapy – COVID-19 Practice Based Resources https://www.wcpt.org/COVID19/practice

Goals for Rehabilitation:

“The recovery of COVID-19 patients aims at improving the respiratory function, counteracting immobilization, reducing the rate of long-term complications and disability and to improve cognitive and emotional domains, in order to promote the quality of life and facilitate the discharge at home.” (https://www.ncbi.nlm.nih.gov/pubmed/23306398) (7)

“After the clinical stabilization and, hopefully, virus eradication by the use of proper drugs, functional restoration should be the main goal.” (https://www.sciencedirect.com/science/article/pii/S0012369215498186?via%3Dihub) This role is not only limited to the design of specific programs, mainly based on physical exercises for respiratory improvement, but should also consider a continuous and global control of functions. (10)

“Preserving/restoring the function of those anti-gravity muscles, enhancing trunk control and postural transfers. If we consider COVID-19 patients as similar to those with acute respiratory distress syndrome, then mobilization can be a viable intervention.” (12)

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Considerations for Triaging Patients for Inpatient Rehabilitation, Post-Acute Care COVID-19:

Physiological limitations (physiological limitations e.g., lung function, exercise and functional capacity, muscle

function, balance) and patient-reported outcomes (e.g., symptoms and health-related quality of life). (1)

Potential for rehabilitation (factors could include age (1), comorbidity (1), other relevant admission criteria already

developed for inpatient rehabilitation at the GRH).

Need for multidisciplinary approach based on areas of functional limitations.

“Ideally, patients being transferred from acute facility to rehabilitation setting should have no ongoing signs or

symptoms of COVID-19 infection including resolution of fever without antipyretics, documented evidence of two

consecutive negative virologic specimens (i.e. nasopharyngeal throat swabs) 24 hours apart 48, and a clear

written plan with regards to code status.” (https://www.ncbi.nlm.nih.gov/pubmed/32196983 ) (5)

Discharge: “Minimum criteria for safe discharge to a less specialist facility or home may need to be fast tracked

and implemented at scale” (https://www.ncbi.nlm.nih.gov/pubmed/32196983 ). “This will require multi-

stakeholder engagement, training and co-operation, potentially via virtual media and will likely challenge

habitual working patterns and levels comfort with decision making.” (5)

Outpatient Rehab: “Because the disabling effects resulting from ARDS are typically both complex and long

lasting, it is expected that outpatient multidisciplinary rehabilitation follow-up will need to continue for an

extended period after discharge from inpatient rehabilitation. A variety of ‘post-ICU clinic’ models have been

described, but the optimal model remains unclear; given the range and complexity of impairments described,

pooling expertise from multiple disciplines (intensivist, clinical psychologist, physiatrist and others) depending

on patient need is often required.” (https://www.ncbi.nlm.nih.gov/pubmed/22152275 ) and

(https://www.ncbi.nlm.nih.gov/pubmed/30653056 ). (5)

“Particularly, those cases still experiencing respiratory or motor problems have to continue their rehabilitation programs in Specialist Rehabilitation units to improve the chances of recovery, while those cases with few and minor sequelae of COVID-19 infection, may undergo home or outpatient rehabilitation therapy, mainly aimed to restore motor skills and to promote psychological recovery.” (7)

“For those who are capable of performing rehabilitation at home with guidance from telerehabilitation, this

should be their first option. For the rest who need center-based or inpatient rehabilitation, we recommend

fever and flu symptom monitoring to separate the well from the unwell, and strict infection control measures

including handwashing between patients to reduce virus transmission. Patients who are symptomatic should be

separated from the well, quarantined and tested for 2019-nCoV, and isolated and treated if positive. Hospital

management should designate and prepare isolation rooms with adequate PPE and trained staff.” (2)

“We suggest the following criteria for admission to PMR (Table): 1) ≥7 days from diagnosis of COVID-19; 2) at

least 72 hr with no fever and no fever-reducing medication, 3) stable RR and SatO2; and 4) clinical and/or

radiological evidence of stability (CT-scan or lung ultrasonography). During rehabilitation, RR and SatO2 in

COVID-19 patients should be monitored on a regular basis, to quickly identify clinical degradation.(18)

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 8

Telerehabilitation approach:

o “By the use of simple self‐administrable exams, like Borg scale for perceived exertion or 6‐minute‐walking test, the subject can check his/her status.”https://www.sciencedirect.com/science/article/abs/pii/S001236921630215X?via%3Dihub . “These evaluations can reveal impairments in apparently asymptomatic patients and indicate the necessity of further medical assessments for an early diagnosis. In addition, for convalescent patients at home, rehabilitation programs should be developed for a rapid functional restoration and for a continuous monitoring https://www.sciencedirect.com/science/article/pii/S0012369215498186?via%3Dihub)” (10)

o A physical therapist guided 20 minute exercise program was delivered while participants wore a pulse

oximeter. The program consisted of stretching, muscle strengthening, and balance exercises directed by a video program with real-time instructions provided by the PT. A movie file of the video exercise program was pre-installed.” (11)

Considerations for treating patients post-acute care:

https://jamanetwork.com/journals/jama/fullarticle/2763818 (16)

Impact of COVID-19 on Rehabilitation Services:

Choose patients who will be seen in rehabilitation: Need to continue rehabilitation treatment to prevent loss of

function, while also preventing exposure to the virus. We don’t yet know the consequences of the significant

decrease in intensity of intervention for patients usually seen for rehabilitation. Need to expand tele-

rehabilitation. (20)

Considerations for rehabilitation medicine programs. (28)

Cohort of post-intensive care survivors will impact rehabilitation services. (29)

General Considerations for Rehabilitation of COVID-19 Patients:

Risk of Neurological Para-Infectious complications:

o Anosmia (loss of smell) is common albeit transient, and could be associated with loss of taste,

https://www.nejm.org/doi/full/10.1056/NEJMoa2002032

https://www.biorxiv.org/content/10.1101/2020.03.25.009084v2, but could result in encephalitis

(inflammation of the brain) as was the case in mouse models via the olfactory bulbs,

https://www.ncbi.nlm.nih.gov/pubmed/29925652

o Meningitis, inflammation of the meninges, has been documented in a case of SARS- infected patient

https://www.ncbi.nlm.nih.gov/pubmed/14633896

o Encephalitis, typically a diffuse inflammation of the brain as well as increased chance of seizures has

been noted in a patient with COVID-19,

https://www.sciencedirect.com/science/article/pii/S1201971220301958

o Stroke has been shown to occur as well as myocarditis, or inflammation of heart muscle, in patients with

coronavirus which could produce anoxic brain injury conditions

https://www.ncbi.nlm.nih.gov/pubmed/16252612

Fatigue: Highly prevalent (40%). (https://www.ncbi.nlm.nih.gov/pubmed/32240670) (1)

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 9

Deconditioning related to ICU stay. https://www.who.int/publications-detail/clinical-management-of-severe-

acute-respiratory-infectionwhen-novel-coronavirus-(ncov)-infection-is-suspected) (1)

Age: “69% of cases, 55% of hospitalizations, 47% of ICU admissions, and 20% of deaths associated with COVID-

19 were among adults aged greater than 60.” (https://www.ncbi.nlm.nih.gov/pubmed/32214079) (1)

“Less common potential issues: Cardiorespiratory deconditioning, postural instability, venous

thromboembolism.” (1)

Diabetes (increased risk for severe COVID-19 infections). (2)

“They are likely to be older, may be immunosuppressed, multimorbid, and dependent on others for fulfillment

of basic personal activities of daily living, meaning they require regular daily physical contact with health care

providers trained to assist with personal care and safe mobilization.”

(https://www.ncbi.nlm.nih.gov/pubmed/32196983) (5)

Critical Illness myopathy and neuropathy often present. (8)

“Monitoring of pre-existing comorbid conditions in COVID-19 survivors, including mental health diagnoses,

during rehabilitation is warranted to guarantee safety of the rehabilitative interventions, and to optimize health

and safety of these patients.” (1)(18)(19)

“Equipment in rehabilitation: Staff-patient-environment interface, particularly regarding rehabilitation equipment. Environmental persistence of coronaviruses varies with ambient temperature and humidity, surface type, and viral inoculum load. The coronavirus can persist on inanimate surfaces at typical room temperatures and humidity for up to 9 days but inactivated efficiently by surface disinfection procedures with 62%-71% ethanol, 0.5% hydrogen peroxide, or 0.1% sodium hypochlorite within 1 minute.” (https://www.sciencedirect.com/science/article/pii/S0195670120300463). “Although evidence on infection control specific to rehabilitation settings is sparse, limited data have shown persistence of bacterial contaminants in rehabilitation equipment such as electrode sponges, water for hot pack units, topical lotions, and therapy ball pits.” (https://www.jstage.jst.go.jp/article/jpts/29/6/29_jpts-2017-056/_article); (https://www.sciencedirect.com/science/article/abs/pii/S0031940610001483); (https://www.sciencedirect.com/science/article/abs/pii/S0195670199906473 ); (https://www.tandfonline.com/doi/full/10.1080/09593985.2018.1441935 ); (https://www.sciencedirect.com/science/article/pii/S0196655318309854 ). “Hence, we should also pay attention to infection control for such surfaces, in consultation with local infection control experts and with consideration of available disinfectants.” (2)

“Business continuity plans: strategies like split teams and restricted movement are more relevant in rehabilitation. Split teams is complete physical division of a workforce into (usually 2) subteams with each containing the necessary skill sets to continue most of its functions if 1 subteam becomes unable to work. Restricted movement is another strategy whereby the principle is every member in a subteam does not come in physical contact with any staff from other subteam(s) to minimize risk of cross-infection. Hospital management should also review triage processes at entry points and workflows that separate high-risk from low-risk areas and subteams.” (2)

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 10

Multidisciplinary approach: “need for a multidisciplinary rehabilitative approach, especially for those patients

with serious COVID-19 illness, advanced age, obesity, multiple chronic diseases, and organ failure. Every patient

needs a neuromotor and respiratory rehabilitation program, tailored based upon the aforementioned

features.”(7)

Main message of literature up to March 31: “adopting the shared strategies performed by a multidisciplinary

team, monitoring patients’ clinical condition carefully after a postural change, as this event can affect suddenly

patients’’ ability to exchange gas, reducing unnecessary manoeuvers, and checking for side effects determined

by prolonged prone position during ventilation; moreover, passive mobilization should be performed as early as

possible to avoid immobilization sequelae….” (19)

Role of rehabilitation in pandemics (21); Model for development of a rehab unit (24)

Transfer of patient from acute to rehabilitation. (30)

Specific Consideration for Rehabilitation Related to Presenting Issues for COVID-19 Patients Post-Acute Care

(Note: best practice guidelines for the treatment of COVID-19 sequelae may be similar to ____, regardless of

etiology):

Rehabilitation in recovery period (includes continuum of care, focus, need for smart rehabilitation equipment,

etc.) (25)

Audiological profile

“COVID-19 infection could have deleterious effects on cochlear hair cell functions despite being

asymptomatic.” (27)

Dysphagia:

Swallowing function-the invasive mechanical ventilation needed in some COVID affects swallowing functions.

(https://www.ncbi.nlm.nih.gov/pubmed/30096101)

“Many patients may undergo nasogastric feeding and the progressive return to normal feeding requires

an assessment of dysphagia and eventually targeted treatments by specialized rehabilitation

professionals, such as the speech therapist and physiotherapist.” (7)

Post-extubation dysphagia (extubated ICU patients): reviewed literature on non-instrumental

techniques for assessment of oropharyngeal dysphagia, measures of which are critical for detection and

follow-up. (14)

Guidelines of clinical practice for management of swallowing disorders and recent dysphonia in the

context of COVID-19. (26)

See AHS Dysphagia and COVID-19 intervention.

https://www.albertahealthservices.ca/assets/info/ppih/if-ppih-COVID-19-dysphagia-intervention-

COVID.pdf

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 11

See Dysphagia Research Society for COVID-19 Information and Resources:

https://dysphagiaresearch.site-ym.com/page/COVID-19Resources and Royal College of Speech and

Language Therapists for COVID-19: Maximizing the contribution of the speech and language therapy

workforce https://www.rcslt.org/-/media/docs/COVID/Redeployment-of-

SLTs.pdf?la=en&hash=3C2813F34D7A8B3F44D4A72CCBAD9FECF28ADE3F

Brodsky et al. estimates that that close to 60% of patients who are intubated in intensive care units (ICUs) experience dysphagia after extubation, and approximately half of those with dysphagia aspirate. https://www.atsjournals.org/doi/pdf/10.1513/AnnalsATS.201606-455OC (36)

Silent aspiration is also a significant risk.(37) https://www.ncbi.nlm.nih.gov/pubmed/9716751)

Guidelines for swallowing assessment and treatment following endotracheal intubation or

tracheostomy:

https://journals.lww.com/anesthesiaclinics/Fulltext/2000/07000/Evaluation_and_Treatment_of_Swallo

wing_Disorders.13.aspx

Nutrition:

European Society for Clinical Nutrition and Metabolism provides 10 concise recommendations for

nutritional management of COVID-19 patients, with specifics on assessment and management. (13)

Muscle Weakness, Deconditioning, Balance, Positioning:

Physical therapy guidelines for PT of acute care COVID-19 patients.

https://www.sciencedirect.com/science/article/pii/S183695532030028X?via%3Dihub

“Recommendations for physiotherapy workforce planning and preparation; a screening tool for

determining requirement for physiotherapy; and recommendations for the selection of physiotherapy

treatments and personal protective equipment.”

Resistance training, pulmonary rehabilitation (evidence from acute exacerbations of chronic COPD).

https://www.ncbi.nlm.nih.gov/pubmed/20133927 ; https://www.ncbi.nlm.nih.gov/pubmed/27930803;

https://www.ncbi.nlm.nih.gov/pubmed/24127811

“Physiotherapy management principles: Passive, active assisted, active, or resisted joint range of motion

exercises to maintain or improve joint integrity and range of motion and muscle strength; Mobilization

and rehabilitation (e.g. bed mobility, sitting out of bed, sitting balance, sit to stand, walking, tilt table,

standing hoists, upper limb or lower limb ergometry, exercise programs).” (3)

Specific rehab: “Aerobic exercise: for those cases with respiratory/ motor problems and physical deconditioning, strength training for peripheral muscle weakness; Static and dynamic balance training for balance dysfunction.” (7)

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 12

Rehabilitation care for post-COVID -19 patients: “Physicians are reporting that patients are requiring prolonged prone positioning during mechanical ventilation. From a rehabilitation perspective, we can expect to see posterior reversible encephalopathy syndrome and critical illness myopathy/neuropathy following acute respiratory distress syndrome (ARDS) and extracorporeal membrane oxygenation (ECMO). Patients will exhibit typical sequelae of neuromuscular illness along with plantar flexion contractures and wounds. These patients may have severe respiratory impairment and may not be able to tolerate intensive therapies.” (8)

“Neuromotor rehabilitation is a key concept of recovery from immobilization syndrome. Passive/active

mobilization, muscle strength, and articular recovery, assisted training even if only primarily in sitting

position, are essential to create the basis for starting a complete rehabilitation program as soon as the

infectious phase is over. All these issues can lead to muscular strength decrease, insufficient sputum

drainage, increased risk of deep vein thrombosis and bedsore, as well as neuropsychological issues, such

as anxiety, depression and lack of motivation.” (7)

Need to consider long-term impact for physiotherapy. (23)

Neurological post infectious complications:

o Acute disseminated encephalomyelitis, https://www.ncbi.nlm.nih.gov/pubmed/14702500,

o necrotizing hemorrhagic encephalopathy, https://pubs.rsna.org/doi/10.1148/radiol.2020201187,

o transverse myelitis, https://www.medrxiv.org/content/10.1101/2020.03.16.20035105v2,

o possibility of a Guillain Barre Syndrome as was detected with Middle East Respiratory Syndrome, and

suspected in SARS-COV-2 infection

https://synapse.koreamed.org/search.php?where=aview&id=10.3988/jcn.2017.13.3.227&code=0145JC

N&vmode=FULL https://www.nejm.org/doi/full/10.1056/NEJMc2009191

o “cytokine storm syndrome” excessive elevations of pro inflammatory cytokines in the blood plasma

including IL-6, TNF-α, IL-8, IL-10, IL-2R, https://www.bmj.com/content/368/bmj.m1091, excessive

inflammatory processes are implicated in a number of CNS/PNS diseases

o Sepsis-the life threatening illness caused by one’s response to infection has been documented in viral

conditions, including coronavirus, https://www.ncbi.nlm.nih.gov/pubmed/32150970

Voice Production Issues:

Endotracheal intubation is commonly used for severe cases of COVID-19. Since the risk and severity of voice issues increases with longer intubation time, the demand for voice therapy and assessment will likely increase Post COVID-19. Weissman, D., de Perio, M & Radonovich Jr, L. COVID-19 and Risks Posed to Personnel During Endotracheal Intubation JAMA. Published online April 27, 2020. doi:10.1001/jama.2020.6627

Up to 50% of people have voice problems after a short endotracheal intubation for surgical procedures.

Only a few require therapy and most hoarseness resolves within a week of extubation. Endotracheal

intubation may cause vocal fold paralysis (1 in 1300), vocal cord bowing, laryngeal edema, laryngeal

stenosis, tracheal stenosis, mucosal ulceration, vocal cord bowing, injury (usually dislocation) to an

arytenoid cartilage (varies from 1 in 100 to 1 in 4000) and dysphagia.(38)

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 13

Prolonged intubation of 36 hours to 3 days carries a greater risk of voice problems and this risk increases

as intubation time is extended. (39)

Voice Treatment: Many different laryngeal problems result from intubation. For each type of laryngeal

injury follow best practice guidelines already established.

https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589942600&section=Treatment

Specific voice treatment related to post intubation:

o Post intubation phonatory insufficiency (PIPI). (40)

o Arytenoid dislocation: Delay in diagnosis and treatment of arytenoid dislocation can lead to

vocal fold immobility due to fibrosis of the injured joint. (41)

Respiratory Therapy:

“Patients who are sent from hospital to a (inpatient) rehabilitation centre can start a multidisciplinary

patient-centric program, using known pulmonary rehabilitation concepts.”

(https://www.ncbi.nlm.nih.gov/pubmed/24127811 ). (1)

“The regular exercise training principles that are normally used in patients with chronic lung diseases

(COPD, asthma, IPF, etc.) can be considered in non-infectious COVID-19 survivors, including

transcutaneous SpO2-monitoring, and, subsequent supplementary oxygen if needed.” (1)

“Do not do lung function testing and maximal/submaximal exercise testing in infectious COVID-19

survivors within the first 6-8 weeks after discharge.” (1)

“Bronchial clearance techniques: in hypersecretive patients, training in techniques favoring secretions

removal is recommended.” (7)

Respiratory rehab for older adults 2 times a week for 6 weeks program, which was shown to improve

respiratory function, quality of life, and anxiety in elderly patients with COVID-19:(9)

o Respiratory muscle training: commercial handheld resistance device e.g. Threshold PEP;

Philips Co., for 2 sets with 10 breaths each set; parameters were set at 60% of the individual’s

maximal expiratory mouth pressure, with a rest period of 1 min between the two sets.

o Cough exercise: Three sets of 10 active coughs were adopted for cough exercises.

o Diaphragmatic training: 30 maximal voluntary diaphragmatic contractions in the supine

position, placing a medium weight (1–3 kg) on the anterior abdominal wall to resist

diaphragmatic descent.

o Stretching exercises: the respiratory muscles are stretched under the guidance of a

rehabilitation therapist. The patient was placed in the supine or lateral decubitus position with

the knees bent to correct the lumbar curve. Patients were ordered to move their arms in

flexion, horizontal extension, abduction, and external rotation.

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 14

o Home exercises: subjects were instructed in pursed-lip breathing and coughing training, and

asked to undergo 30 sets per day.

Measurements used to evaluate the respiratory rehab program for older adults (2 times per week for 6

week): (9)

o “Respiratory function: automated computerized spirometer (Model ML3500S) of Micro Direct.

The following parameters related to respiratory function were measured: (1) forced expiratory

volume in 1 second (FEV1); (2) forced vital capacity (FVC); (3) DLCO (%) refers to the amount

of CO that passes through the alveolar capillary membrane into the capillary blood per unit

time, per unit pressure difference with a percentage of the measured value to the predicted

value > 80% as normal.

o Exercise endurance: 6min walk test. Percutaneous oxygen saturation (SpO2), heart rate,

systolic blood pressure, diastolic blood pressure, respiratory rate and perceived exertion (Borg

scale) were measured before and after a 6-min walk using a saturated pulse oximeter.

o Activities for Daily Living (ADL): The rehabilitation therapist assessed ADL with the Functional

Independence Measure (FIM) scale. Respiratory program was not found to significantly

improve ADL.

o Quality of Life Assessment: The QoL of patients in the two groups before and after nursing

intervention was assessed using the Short Form-36 (SF-36).

o Assessment of Anxiety, Depression: Self-rating depression scale (SDS) and self-rating anxiety

scale (SAS). Respiratory rehab program was only found to significantly reduce anxiety self-

rating scores.”

Cognitive impairments and rehabilitation of commonly affected domains, at this point, must be derived from the

literature on the conditions which COVID-19 can cause such as sepsis, acute respiratory distress syndrome,

stroke, anoxia, encephalitis, encephalopathy, amongst others.

In the chronic phase of sepsis, more than 50% of surviving patients suffer from severe and long-term

cognitive deficits compromising their daily quality of life and placing an immune burden on primary

caregivers. Due to a growing number of sepsis survivors, these long-lasting deficits are going to become

more common place.

Memory and executive functioning need to be considered as impairments are often present in Acute

Respiratory Distress Syndrome. (https://www.ncbi.nlm.nih.gov/pubmed/19144052); neuropsychological

impairments include memory, attention and higher order executive functions.

Cognitive Impairments following stroke are long-lasting, multi-dimensional and well-documented in the

literature. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1747-4949.2012.00972.x

In anoxia, there are diffuse cognitive impairments. https://www.ncbi.nlm.nih.gov/pubmed/17123930

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 15

In immune system-mediated encephalopathy, verbal and visual memory is affected in most patients

followed by executive function and attention and after treatment recovery rates are variable.

https://n.neurology.org/content/84/14_Supplement/P4.057

Impairment of cognitive function is common following acute respiratory distress syndrome.

https://www.ncbi.nlm.nih.gov/pubmed/23989098

Delirium can affect up to 80% of patients in general ICU settings.

https://www.ncbi.nlm.nih.gov/pubmed/2988258

Neuropsychological impairments are multidimensional, and include memory, attention and higher order

executive functions. https://www.ncbi.nlm.nih.gov/pubmed/23989098

Cognitive Rehabilitation: At this point, rehabilitation will focus on the neurological manifestation of COVID-19

(i.e., anoxia, stroke, amongst others), based upon areas of neuropsychological deficit and with use of evidenced

based approaches primarily: compensatory strategies for the damaged cognitive skill, restorative skill retraining,

use of external electronic and/or other technological aids, amongst others. The goal(s) are generally to

compensate for the deficits using an intact cognitive skill(s), practice the lost skill until it becomes habitual or

encourage use and strengthening of alternate neural networks as a result of cognitive functions being

represented at multiple levels in both a localized and distributed manner. Several seminal texts are available and

in use at the Glenrose. https://psycnet.apa.org/record/2004-17354-000,

https://books.google.ca/books/about/Neuropsychological_Rehabilitation.html?id=cAEJCR1UAXIC&redir_esc=y,

https://www.guilford.com/books/Essentials-of-Neuropsychological-Rehabilitation/Wilson-

Betteridge/9781462540730

In addition, there is an existing cognitive rehabilitation multi-disciplinary group at the Glenrose Rehabilitation

Hospital in existence since 2015 which meets twice per month and reviews the latest literature on treatment for

cognitive dysfunction.

Mental Health; Psychosocial Supports:

Long ICU period and anoxic damage can lead to anxiety, post-traumatic stress disorder, and depression

or in more serious and especially elderly cases, to cognitive functions decline. Neuropsychological

support represents a fundamental activity, which has to be included in the rehabilitation programs of

these patients. (7)

(Based on SARS survivors) Key concerns in early recovery: Psychotic symptoms, Fear for survival, Fear of

infecting others; Key concerns across all stages of recovery: Stigmatization, Post-traumatic stress

symptoms, reduced quality of life, Emotional distress. (4)

Persistent mental health impairment is commonly described following treatment in the ICU, with pooled

estimates reporting high prevalence rates of depression (29%)

(https://www.ncbi.nlm.nih.gov/pubmed/27153046 ), PTSD (22%)

(https://www.ncbi.nlm.nih.gov/pubmed/25654178 ) and anxiety (34%)

(https://www.ncbi.nlm.nih.gov/pubmed/27796253 ) affecting survivors at 1 year. On the individual

level, dyspnea is generally recognized as a distressing experience in its own right

Glenrose Rehabilitation Hospital Prepared: May 1, 2020 16

(https://www.ncbi.nlm.nih.gov/pubmed/25560861 ). (5)

For additional information on mental health and psychosocial supports, a literature summary is available

from the AHS Provincial Psychosocial Emergency Strategic Committee.

Functional Capacity:

“Re-assess and address any cognitive changes to facilitate functional independence - Preparation and

planning for discharge, including home safety and caregiver supports - Consider social determinants of

health when discharge planning (e.g., income) - Re-assessment and management of ADLs, including

adaptive strategies, such as assistive devices and energy conservation, that encourage functional

independence OT role” (6)

Support For Families of Patients With COVID-19: Mental Health And The COVID-19 Pandemic. (17)

Social worker’s role: “Social workers should be able to facilitate the development of supportive

relationships through kinship care support to ensure that older people are not at severe risk to the

COVID-19.” (22)

Social workers’ role (32)

Cardiovascular complications:

“In those patients who are referred and admitted to CR, the organization, provision and delivery of

rehabilitative programs must be remodulated in COVID-19 era, according to the recommendations

recently issued by the CR section of European Association of Preventive Cardiology (EAPC) [4]. The more

relevant of these recommendations are establishing priorities for referral to CR, increase patients

turnover, adopt appropriate precautions during training (masks, distancing, avoid group exercises),

shorten the programs, keep track of discharged patients and follow them with remote assessment”

https://doaj.org/article/795675d6ae6d4ba68c1ad282f41b5d74

Considerations for cardiac patients who have COVID-19. (31)

Sequelae specific to older adults:

Advice for physicians treating older adults with COVID-19.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136027/

Clinical guidance, tools, and links for health providers caring for older adults during the COVID-19

Pandemic. https://www.rgptoronto.ca/resources/COVID-19/ (not included in list above-this resource

addresses many areas of care)

Prepared by: Cyndie Koning, Ph.D., OT (C) Laura Mumme, MHL Reno Gandhi, Ph.D., R.Psych. Heather Dyck, Ph.D., R.Psych. Merrill Tanner, Ph.D., R.SLP