American Journal of Physical Medicine & Rehabilitation Articles Ahead of Print

DOI: 10.1097/PHM.0000000000001443

Rehabilitation following critical illness in people with COVID-19 infection

Dr Robert Simpson, PhD MBChB*

University of Toronto

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Sunnybrook Health Sciences Centre

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Larry Robinson, MD

University of Toronto
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Sunnybrook Health Sciences Centre

*Corresponding author: [email protected]

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Sunnybrook Health Sciences Centre H390

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2075 Bayview Ave

Toronto, ON
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Canada M4N 3M5

The authors do not have any disclosures.

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Abstract

The current COVID-19 pandemic will place enormous pressure on healthcare systems around the

world. Large numbers of people are predicted to become critically ill with acute respiratory

distress syndrome (ARDS) and will require management in intensive care units (ICUs). High

levels of physical, cognitive and psychosocial impairments can be anticipated. Rehabilitation

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providers will serve as an important link in the continuum of care, helping move patients on from

acute sites to eventual discharge to the community. Likely impairment patterns, considerations

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for healthcare practitioner resilience, and organization of services to meet demand are discussed.

Innovative approaches to care, such as virtual rehabilitation, are likely to become common in this

environment.
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Key Words:

COVID-19, coronavirus, acute respiratory distress syndrome, pandemic

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Introduction

On March 11th 2020 the World Health Organization (WHO) declared a pandemic in relation to

infection with Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV2), a novel

coronavirus, hereafter referred to as COVID-191. For the majority (81%)2 infection with

COVID-19 will confer a mild disease; fever (88.7%), cough (57.6%), and dyspnea (45.6%) being

the most commonly reported symptoms in a recent systematic review and meta-analysis3.

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However, for a significant minority, and particularly those aged>65 years and with co-

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morbidities such as hypertension and diabetes, the infection may have very serious

consequences4. In those patients requiring hospitalization, a relatively high proportion (20.3%)

have required management in an intensive care unit (ICU) environment, the most common

reason being the development of acute respiratory distress syndrome (ARDS) (32.8%)3. Less
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commonly, patients may develop acute liver injury, acute cardiac injury, acute kidney injury, and

viraemic septic shock1. In a meta-analysis, among hospitalized patients with COVID-19

infection, a case fatality rate of 13.9% has been reported3. The leading cause of death following
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COVID-19 infection is acute respiratory failure, and disseminated intravascular coagulopathy

has been reported in 71% of non-survivors1.

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Currently, there are no known effective treatments for COVID-19 infection specifically; general

measures recommended are supportive1. Given that COVID-19 is a novel coronavirus, where
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etiopathology remains incompletely understood1, it is important to note that current approaches

to care described in this manuscript are based on treatments extrapolated from diverse underlying

health conditions. However, this is a rapidly evolving literature. The WHO is coordinating the

five-treatment arm ‘Solidarity’ trial, testing remdesivir, lopinavir/ritonavir, lopinavir/ritonavir

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plus interferon beta, and chloroquine. For the critically ill with COVID-19 associated ARDS,

supportive management at present means5:

 Conservative intravenous (IV) fluids

 Empirical IV antibiotics for suspected bacterial coinfection

 Consideration for early, invasive endotracheal intubation and ventilation to maintain

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adequate oxygenation and carbon dioxide elimination

 Lung protective ventilation strategies, such as limiting tidal volumes and inspiratory

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pressures

 Periods of prone positioning whilst mechanically ventilated to decrease the risk of

mechanical lung injury


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Consideration of extracorporeal membrane oxygenation

As the spread of COVID-19 continues to accelerate despite extraordinary public health measures

to prevent transmission, and given the high proportion of hospitalized patients requiring ICU

level care, it is likely that in the weeks and months following the surge in patients being admitted
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to acute hospitals and critical care units there will be considerable number of critical illness

survivors requiring rehabilitation6. Indeed, the WHO Emergency Medical Team minimum
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standards recommend that rehabilitation is a core component of patient-centred care in

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responding to disasters, with minimum standards recommended with regards to staffing,

equipment and space7. It is thus important that rehabilitation providers develop plans to receive

large numbers of patients from acute care facilities, possibly directly from the ICU8.

Rehabilitation professionals and facilities will play an important role in helping speed the

recovery of those survivors with residual impairments post-ICU, but also a critical role in

providing an appropriate outlet for acute services, creating space for newly affected patients to

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receive the acute care they need9. Rehabilitation should be routinely incorporated into pandemic

response plans early on, rather than in retrospect, only after widespread disability becomes

apparent10.

COVID-19 infection, ARDS and disability

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Critical illness for any reason has major long term sequelae, prompting the characterization of

‘post-ICU syndrome’, defined as ‘new or worsening impairment in physical, cognitive, or mental

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health status arising after critical illness and persisting beyond discharge from the acute care

setting11. Following ARDS, patients can present with numerous functional impairments across

bio-psycho-social domains12.
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Physical function
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In a cohort study of 109 survivors, lung volume and spirometry were normal six months

following ARDS, however carbon monoxide diffusion capacity was persistently impaired, with a
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median value of 63-72% predicted value13. At 5 years, spirometry was reported as ‘normal to

near normal’, with computed tomography (CT) demonstrating ‘minor, non-dependent fibrotic
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changes consistent with ventilator induced lung injury’14. ICU-acquired weakness (ICUAW) is

very common following ARDS, estimates suggesting anywhere between 25-100%15; thought to

relate to immobility, suboptimal glycemic control and iatrogenic use of steroids and

neuromuscular blocking agents12. Critical illness polyneuropathy and critical illness myopathy

are also common, reported in almost 25-46% and 48-96% respectively16. ICUAW confers a

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major determinant of poor long term functional outcome and costly rehabilitation and care

needs12. Other, less common physical sequelae of prolonged immobility may also occur,

including cardiorespiratory deconditioning, postural instability, venous thromboembolism,

muscle shortening, contractures (myogenic, neurogenic, arthrogenic), and pressure injuries.

Some of these secondary complications can be anticipated in critically ill and immobilized

patients and are to some extent preventable.

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Cognitive function

Impairment of cognitive function is common following ARDS17. Delirium can affect up to 80%

in general ICU settings18. Delirium commonly occurs in acute illness and hospitalization, is more
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common in those with sepsis, the elderly and multimorbid, is associated with worse functional

outcomes and a higher mortality rate18. Cognitive impairment following ARDS has been noted to

affect the majority of survivors at hospital discharge and in around 10% impairments are

persistent at long term follow up17. Neuropsychological impairments are multidimensional, and
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include memory, attention and higher order executive functions17. Treatment of ICU acquired
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delirium is challenging and largely preventative19. The Society of Critical Care Medicine

recommend the ABCDEF bundle: Assess, prevent and manage pain; Both spontaneous
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awakening and breathing trials; Choice of sedation; Delirium monitoring and management; Early

mobility and exercise; Family engagement and empowerment20.

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Psychosocial wellbeing

Persistent mental health impairment is commonly described following treatment in the ICU21,

with pooled estimates reporting high prevalence rates of depression (29%)22, PTSD (22%)23 and

anxiety (34%)24 affecting survivors at 1 year. Beyond this, pandemics are associated with high

levels of emotional distress across society25. On the individual level, dyspnea is generally

recognized as a distressing experience in its own right26. For patients and families, admission to

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hospital with a COVID-19 diagnosis may raise fears for survival27. To compound matters, due to

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infection control requirements and public health imperatives, patients may be separated from

families for prolonged periods, particularly if critically ill. It seems likely that having the

infection will carry a social stigma28, including among healthcare providers29 who will

necessarily seek to limit case contact to bare essentials, further limiting social interaction for
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patients. ICU admission with critical illness affects patient’s families profoundly30, where

impairment of mental health is also common31. In the context of a pandemic, it is possible that

families may not see or speak to their loved one at all during admission; in fatal cases never
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again.
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Acute Care Rehabilitation:

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Rehabilitation following critical illness is a key component in the continuum of care.

Rehabilitation is a complex intervention32 and refers to a longitudinal process focused on

minimizing the disabling effect of an individual’s impairments, promoting and optimizing

functional independence in activities of daily living, and maximizing opportunities to participate

meaningfully in society on the basis of any new functional baseline32. Rehabilitation is best

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delivered by specialists in multidisciplinary teams (MDT) with a broad range of skills to support

bio-psycho-social functioning33-35. Existing evidence for effectiveness suggests that MDT

rehabilitation should start early in the course of hospital treatment36, involve patients and family

in goal planning as far as possible/practical37, and consider holistic bio-psycho-social needs,

taking into consideration likely short-, medium-, and longer- terms care trajectories38. MDT

meetings and interactions with patients, families and between professionals will likely be limited

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during the COVID-19 pandemic. Maintaining active, reciprocal lines communication between a

finite number of care providers will be important for effective co-ordination of care, avoidance

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of redundancy/unnecessary duplication of services. The same holds true when communicating

with patients and families.

Rehabilitation in the ICU may involve screening for delirium and use of general prevention
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strategies, medication review, planned regular sedation breaks, multimodal attempts at

orientation, passive and active mobilization, and, where possible, begin to build an empathic,

compassionate therapeutic alliance with the patient and family. Active mobilization in the ICU
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has been manualized. For example, Green et al. (2016) suggest that if a patient does not have

independent sitting balance and a Medical Research Council (MRC) power score of <3 in the
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lower limbs, ‘phase 1’ mobilization should start with sitting balance practice, use of a tilt table

and muscle strengthening exercises. Those with independent sitting balance and an MRC power
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score >/= 3 can progress to ‘phase 2’ mobilization with supported/active weight bearing with

exercises including ‘sit-to-stand’, marching on the spot +/- gait aid, eventually moving away

from the bed space +/- a gait aid39. Early active mobilization is associated with improved muscle

strength, better mobility status at hospital discharge, and more days alive out of hospital40. A

commonly described barrier to active mobilization in the ICU is fear that this may interfere with

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critical life support devices, such as endotracheal tubes, chest drains, arterial and central venous

access lines, and dialysis catheters41. However, various studies have confirmed that active

mobilization is feasible and safe in these circumstances and consensus recommendations, such as

the ‘traffic light’ system42, can be used to guide the ICU/rehabilitation team in this regard.

Rehabilitation providers working in the ICU must know how to identify confirmed cases of

COVID-19, as well as those actively under investigation. Rehabilitation providers may have to

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don personal protective equipment (PPE), a practice with which they may have limited

experience43, and it is important that they are aware of correct donning and doffing guidelines44,

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besides general conservation strategies. Extra planning may be necessary when coordinating

patient assessments, so as to avoid having to throw away masks and vizors between patients.

Step down from an ICU environment to ward level care will likely come with mixed feelings for
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patients and families. In one sense this juncture may represent a turning point in care and

recovery, where the greatest risk is perceived as having passed45. On the other hand, the patient

may still be considered infective, requiring ongoing isolation, and disease reactivation has been
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observed in COVID-19 patients discharged from hospital1. Patients are also likely to be

considerably impaired after prolonged sedation, immobilization, mechanical ventilation, and

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delirium12. The patient may remain highly dependent for personal care and activities of daily

living fulfilment46, and is likely to be emotionally distressed21. Acute disablement is distressing

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for patients and families and in qualitative synthesis is described as a disorienting experience47. It

is therefore important to provide simple, honest, accurate, factual information regarding

treatments thus far, likely next steps, and to make time to explore ideas, concerns and

expectations that patients and families may have. Baseline measures of function taken in the ICU

can be compared with current status and the patient may at this stage have a greater capacity for

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involvement with goal planning and engagement with therapy sessions. Emphasis on enabling

self-care may become increasingly important if staff resources are depleted, thus provision of

information to patients and families regarding how to carry on therapeutic interventions beyond

treatment sessions should feature strongly in the formulations and interventions provided.

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Inpatient Rehabilitation

Many of the patients who survive COVID-19 associated critical illness will require admission to

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an inpatient rehabilitation facility in order to optimize functional status prior to eventual

discharge and community re-integration. In the context of a pandemic, special considerations are

required with regards to when a patient is ‘ready’ for transfer to such a facility8. Ideally, patients
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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 apart48, and a clear written plan with regards to code status8. Inpatient
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rehabilitation populations typically comprise a particularly vulnerable patient group. They are
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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
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contact with health care providers trained to assist with personal care and safe mobilization8.

Isolation in such a setting is challenging.

Ultimately, however, it is possible that in some localities patients with active COVID-19 and

associated disability will need admission to inpatient rehabilitation facilities, particularly if acute

care hospitals become full during the pandemic. This will be challenging for several reasons.

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First, PPE for staff in general may not be available as worldwide shortages have been well

described and what supplies do exist are likely to be prioritized for acute care sites, where

aerosolizing procedures (i.e. intubation, cardiopulmonary resuscitation - CPR) carry the highest

risk49. In addition, access to resuscitative equipment and expertise will also be less readily

available than in the acute hospital, and transfer back to an acute facility may not be possible in

the context of mass, population-level infection and illness. For staff safety, wherever possible,

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appropriate PPE must be in place in the event of a patient requiring CPR.

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Whether patients with active infections come or not, inpatient rehabilitation units will still have

to plan for a surge in patient admissions, on top of established work streams, including those

requiring inpatient rehabilitation following stroke, trauma and exacerbations of pre-existing

conditions such as multiple sclerosis. Bed availability is likely to be constrained and difficult
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decisions will be required with regards to prioritizing which patients need inpatient rehabilitation

and could not otherwise be managed in another, less specialist facility, or at home. Rehabilitation

units will have to consider how to minimize risk of spread of COVID-19 among inpatients,
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which may mean designating a specific area for such individuals8, a healthy workplace policy

screening and preventing staff with symptoms from working8, guided by infection
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control/occupational health policies and procedures. Care episodes may have to preferentially

take place at the bedside and in a more rudimentary fashion than is custom. Congregations in
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gyms and common spaces are likely to be off limits8. Minimum criteria for safe discharge to a

less specialist facility or home may need to be fast tracked and implemented at scale8. 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.

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Rehabilitation physicians in several developed healthcare systems rely on billing schedules for

reimbursement. This is a time consuming endeavor, feeds in to physician burnout50, and in the

context of the COVID-19 pandemic may detract from precious patient care episodes. Pro-active

administrative support mechanisms may largely offset this challenge, whereby a centralized,

coordinated approach can be used by all specialists working in rehabilitation in a given area to

cut down on physician administrative time, freeing up clinical capacity. Flexible working hours

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may be required for some staff, as schools close and childcare needs emerge29. Equally important

is healthcare provider wellness in the context of an extraordinarily stressful social and work

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environment. In the USA, rehabilitation physicians are already among the most ‘burned out’50 51.

Wellness resources with existing evidence for effectiveness, such as virtual mindfulness-based

interventions52 and/or Schwartz rounds53 could be made available to support staff wellbeing,
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providing both self-care skills and an important source of social support.

Because the disabling effects resulting from ARDS are typically both complex and long lasting12,

it is expected that outpatient multidisciplinary rehabilitation follow-up will need to continue for
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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
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complexity of impairments described, pooling expertise from multiple disciplines (intensivist,

clinical psychologist, physiatrist and others) depending on patient need is often required54 55.
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However, it is also important to remember that many patients with existing disabling conditions

will have been waiting to see a rehabilitation specialist prior to the outbreak of COVID-19; it is

likely that their appointments will have been postponed, if not cancelled outright.

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Innovative approaches to providing rehabilitation during the COVID-19 pandemic

Virtual rehabilitation

In the context of the COVID-19 pandemic, virtual care outpatient episodes may be preferable to

face-to-face interactions for multiple reasons. Firstly, in order to take care of patients, healthcare

providers must first themselves be in good health56. The healthcare population, physicians in

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particular, is aging57. In the USA >20% of physicians are over 65 yrs57. Many older healthcare

practitioners will have their own long-term health conditions and may fear for their safety on

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exposure to COVID-19 patients. Secondly, from a patient, family and wider societal perspective,

delivering healthcare in settings where groups of people gather such as ‘waiting rooms’ is

actively discouraged for fear of further community spread1. In this context, it is also possible that
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a healthcare provider may be carrying COVID-19 asymptomatically; in such a case the

healthcare provider may then inadvertently become a ‘super spreader’1. Virtual care circumvents

these issues and allows personalized consultation and treatment via telephone or live internet

connections, or via pre-recorded sessions for more generic materials58. In some countries, well
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developed, secure virtual care platforms already exist; in others, media such as Zoom, Skype,

Facetime and others may be suitable alternatives. However, virtual care also has many
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limitations, such as ready availability of equipment, technical malfunctions, potential for

inadvertent personal data disclosure, limited scope for physical examination, and the process
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largely relies upon the patient being able to attend to sessions, communicate and interact

accordingly59. This may not be possible for many patients. Rehabilitation providers should start

to consider the scope and limitations of virtual physical examinations and make patients

expressly aware of this accordingly.

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Prehabilitation

A related construct to rehabilitation is pre-habilitation. Pre-habilitation operates on the premise

that those who take pre-emptive steps to optimize their general health and fitness have better

outcomes following the stress challenge of elective surgery60. A recent opinion article61 in the

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British Medical Journal makes the case for pre-habilitation in the context of the COVID-19

pandemic. In brief, the following pre-habilitative interventions are recommended: smoking

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cessation, regular exercise, good nutrition, and stress reduction61. Although there is no direct

evidence to support pre-habilitation in the context of COVID-19, it seems likely that good

general health measures such as those suggested will confer benefit to people generally,
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particularly those with pre-existing long term conditions62. In this view, rehabilitation specialists

could have an important public health role to play in educating patients and families through

provision of evidence based, personalized recommendations for home-based physical activity62,

nutrition63, managing stress64 and stopping smoking65. Finally, rehabilitation specialists, like all
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health professionals, through their extensive contact with patients, also have an opportunity to

reinforce the importance of current public health measures designed to stop the spread of
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COVID-19, namely effective handwashing, respiratory hygiene, and social distancing1.

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Summary

COVID-19 associated critical illness will have dramatic implications for patients, families and

healthcare workers around the world. Healthcare services will have to adapt rapidly to an

anticipated surge of cases and this will place enormous strain on acute services. Rehabilitation

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professionals will have a critical role in assisting people recover from COVID-19 associated

critical illness, make sense of their experiences, help optimize independent function, and

facilitate community re-integration. While COVID-19 is a novel disease, rehabilitation providers

already routinely treat patients who suffer disability as a result of critical illness generally, and

ARDS specifically. However, we need to take care of each other in the crisis we face and being

prepared is a major first step in this regard.

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