Key words rehabilitation - Physical and rehabilitation medicine - COVID-19 - SARS-CoV2 - physiotherapy
Preliminary remarks
Due to the early phase of the pandemic (beginning of April 2020), scientific evidence
of physical and rehabilitative medicine in patients with Covid-19 is sparse. These
recommendations should therefore be seen as best practice based on the experience of
early rehabilitation after pulmonary infectious diseases, especially acute
respiratory distress syndrome (ARDS).
However, there are a number of recommendations for the early functional treatment of
patients with COVID-19 up to now, including publications from the WHO, different
scientific societies, and Chinese sources [1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ]
[7 ]
[8 ]
[9 ].
With increasing expertise and scientific evidence, continuous updates of this paper
are necessary.
Background
During the pandemic, hospitals and rehabilitation facilities are facing completely
new challenges with regard to physical medicine, physiotherapeutic and early
rehabilitation care.
German legislation has also denominated rehabilitation facilities to serve as standby
hospitals (in accordance with §22 Krankenhausgesetz) for the treatment of
COVID-19.
Additionally, nursing homes will need safe protection strategies, with the
consequence that only proven negative cases will be transferred there from
hospitals. In some places there is even a complete admission ban. This can lead to a
prolonged length of stay of COVID-19 patients in hospitals.
In the treatment of hospitalized COVID-19 patients, early mobilization and early
rehabilitation are expected to be necessary. This poses new challenges if there are
no adequate pre-existing structures for such treatments.
Rehabilitation clinics will most likely play a role in the early rehabilitation of
patients with COVID-19 and in some cases also in the late acute phase of COVID-19
disease.
Departments for physical and rehabilitative medicine and for physiotherapy in
hospitals are already required during acute treatment, especially in
inter-professional cooperation in the intensive care sector, and must also develop
ad hoc concepts for effective early mobilisation and rehabilitation of patients.
Consecutively, the importance of early rehabilitation is not limited to the
individual case, but contributes to increasing hospital capacities by reducing the
length of stay in hospital. In the rehabilitation sector, mainly neurological
rehabilitation clinics with phase-B early rehabilitation have the necessary
expertise in early rehabilitation.
In Germany, there is no experience in the field of early post-treatment of COVID-19
until this date, but there is experience in the interdisciplinary early
rehabilitation of patients, e. g. after complicated influenza pneumonia, who
had a similar risk constellation of multimorbidity and acute respiratory distress
syndrome and who had an indication for early rehabilitation after intensive care
therapy, ventilation and often sepsis (in the context of bacterial superinfections)
[10 ]
[11 ]
[12 ]
[13 ].
In the practice, rehabilitation will be necessary for patients with isolated COVID-19
disease, but also for patients with underlying multimorbidity. In this case, it may
be necessary to react to different rehabilitation needs concerning their underlying
conditions on the one hand and the Covid-19 rehabilitation on the other. First
experiences of COVID-19 patients from the USA (Seattle) after ICU treatment show
inpatient treatment courses of more than 14 days after transfer from intensive care
[14 ].
Aim
To derive therapeutic concepts for the treatment of patients with COVID-19, based on
the experience gained from the early rehabilitation in the treatment of patients
with respiratory diseases in connection with currently available sources and
experiences.
The following situations are not to be displayed here:
the acute medical treatment of COVID-19
physical therapy measures in the intensive care unit (prone positioning,
respiratory therapy, early mobilization)
the phase of post-acute rehabilitation (follow-up treatment, medical
rehabilitation after hospital treatment)
Aftercare and long-term rehabilitation
community-based self-exercises for mild courses or after discharge from
hospital or rehabilitation
Palliative therapy
Rehabilitation needs after COVID-19
Functioning impairments result from
Organ damage: primarily the pulmonary affection, also cardiac, central
nervous, etc.
Pre-existing conditions and a high age of the patients
Consequences of immobilization, Post Intensive Care Syndrome (PICS): ulcers,
contractures (especially foot drop), neuromuscular transition disorders with
atrophy/CIP/CIM (critical illness
polyneuropathy/myopathy), delirium etc., sequelae of prone
positioning
Increased incidence of complications due to lack of time and capacity for
positioning and mobilization on ITS (in case of staff shortage)
Psychosocial consequences
Recommendations
Logistical preparation (staff training)
In-house training regarding prone positioning (factors to be considered:
team structure, management by anaesthesiologists or intensivists,
knowledge of the positioning materials as well as training of compromise
solutions regarding the materials in case of emergency)
All available physiotherapists should be trained
Face-to-face hygiene training, including use of personal protective
equipment (PPE) in an interdisciplinary team
Create an open and critical working atmosphere for this, encourage mutual
correction
Returnees to the workplace must be continuously retrained, CAVE: shift
work
All trainings are confirmed with signature
Obligatory daily information via the clinic's intranet, if
necessary training in the use of this information, especially for
non-native speakers
Detection of risk groups within the staff
For patients requiring oxygen: Staff needs to be trained in the use of
portable oxygen bottles (hazardous material)
Infectivity and personal protective equipment
Infectivity
Knowledge of the infectivity of the individual patient is important for
the therapy team to adapt the necessary PPE
If the indication for physical therapies is unclear, the PRM (physical
and rehabilitation medicine) specialist should always be involved
Aids (e. g. respiratory therapy devices) should be avoided during
infectious phase of disease (surface persistence of the pathogens,
presumably long aerosol persistence in ambient air)
Please refer to the regularly updated CDC and RKI infectivity guidelines
[15 ]
[16 ].
Personal protective equipment (PPE)
Therapists should wear adequate personal protective equipment (for
potentially aerosol generating activities, adequate FFP masks,
protective goggles, virus-proof gown; according to CDC or RKI
recommendations)
Surgical masks should also be worn by the (potentially) infectious
patients during therapy, if tolerated.
Contact minimization and distancing rules
Contact minimization is indicated within the rehabilitation team (where
there is usually a high contact frequency among the staff), this
requires good daily therapy planning
Implement distancing regulations between patients, also supply surgical
masks for patients in therapy
Positioning during therapy measures in the area of the coughing impulse
should be avoided
Avoid unnecessary team meetings and conduct comprehensive team meetings
with distance control and adequate protective measures or as video
conferences
Form stable teams, avoid fluctuations
Introduce digital PRM (physical and rehabilitative medicine) where
possible
if necessary, also integrate smartphones, tablets of the patients
in therapies (media-based self-exercise program, also video
therapy instructions)
to reduce the consequences of restricted rehabilitative
treatment, i. e. the stop of group treatments (applies
to rehabilitation clinics)
Adapting the patients’ environment
Provide aids in the patient’s room, a chair or wheelchair by the
bed
If necessary a toilet chair in the room
Therapy resources for self-exercise programme
Nutritional aspects (protein-rich nutrition for
training/deconditioning)
Personal protective equipment
Oxygen
Means of telecommunication and telerehabilitation
If possible, ensure good ventilation of the rooms
Interprofessional work and co-therapy
Activating care and ADL training through nursing staff and occupational
therapy, if necessary mutual interprofessional training
Immobile patients usually require more than one therapist for transfer
and mobilisation, co-therapy as distance regulations between staff
cannot be fulfilled has to be documented
Early rehabilitation assessments and goals
Perform a functioning-oriented assessment at admission to the early
rehabilitation unit to be able to work out goal-oriented therapies
Identify the premorbid functional status
Identify risk constellations for relevant functional deficits, in
particular
monitor COVID-19 symptoms (cough, fever, dyspnoea, loss of consciousness,
loss of smell and taste, stuffy nose, sore throat, headache, abdominal
pain, vomiting, nausea, loss of appetite, diarrhoea, conjunctivitis,
skin changes, anxiety, general deconditioning)
assessment of independent mobility (e.g. Charité Mobility Index,
freely available, [Fig. 1 ]) [17 ]
[18 ]
[19 ].
assessment of ADL (e.g. Barthel Index)
Indication-related application of basic psychological scores: emotion,
stress, depression (e. g. PHQ-9, or PHQ-4 for screening)
Standardized monitoring of pain as well as CNS and cardiac status
Training intensity: Borg Dyspnoea Scale
Define realistic main goals together with the patients (early
communication of expected limited functions is important for coping
strategies)
The admission assessment is the very beginning of the discharge planning:
foreseeable home care and support needs should be identified at an early
stage and the social services should be involved
The transfer or dismissal planning may have to be adjusted to the
infection status. It is necessary to demand that “COVID-19
rehabilitation clinics” be defined in order to achieve a
cohorting of the still infectious patients and to avert transfer
delays.
Fig. 1 The Charité Mobility Index assesses independent
mobility functions based on ICF items: Mini manual and grid.
Fig. 2 shows an exemplary course of mobilization with stepwise
rehabilitation goals
Respiratory therapy
Consider the indications and contraindications of respiratory therapy
[20 ]
[21 ]
[22 ]
[23 ]
[24 ].
In the acute phase of COVID-19 in severe or critical cases, respiratory
therapy measures that increase the total respiratory work should be
avoided.
In mild cases or pneumonia with a dry cough, no respiratory secretion
management is indicated. Instruct patients for self-exercise
Measures designed to increase the respiratory volume are not indicated in
the acute phase due to the risk of cardiac decompensation and cough
provocation
Respiratory therapy may be indicated e. g. in exudative coughing,
in hypersecretion or limited secretion clearance, in weakened
respiratory muscles, morphological imaging correlates for secretion
retention, or general weakness.
Teach self-exercise programmes as soon as possible
Combine respiratory therapy and mobilisation/transfer training;
mobilisation and “verticalisation” are fundamental for
lung function
if sitting at the edge of the bed have the patient use floor contact to
train proprioception
in immobility: passive breathing training and therapeutic
positioning:
Manual therapy (detonization techniques) of the diaphragma thoracis to
optimize breathing
CAVE aerosol-generating techniques. Respiratory therapy should be carried
out without aids when possible (aerosol formation and virus persistence
on surfaces), as long as the patient is infectious
Mobilization
The main goal in all mobilization phases is the “verticalization”
of the upper body
Mobilisation with graded therapy goals ([Fig. 2 ])
Assisted transfers
Seat at the edge of the bed/wheelchair
Assisted standing, Active participation in transfers
Independent steps with support or aids
Walking with support
Coordination and balance training
Submax isometrics and trunk muscle stabilization exercises
Active movement and resistance exercises
Activating care and ADL
Training intensity
Supply of aids (incl. long-term oxygen therapy)
The supply of aids should be initiated at an early stage within the
framework of discharge management (walking aids, home oxygen
therapy)
Most frequently prescribed aids in ARDS patients [own data]: Walking
frame, rollator, wheelchair, home oxygen (LTOT), shower stool, bathtub
board, toilet chair, hospital bed/care bed
Check indication for long-term oxygen therapy (LTOT) in persisting
hypoxemia or exertional hypoxemia with improvement under O2 application
[25 ]
[26 ].
Psychosocial Management
The treatment of Covid-19 patients is a considerable burden for staff, patients
and relatives. Uncertainty and fears exist regarding health, consequences for
the relatives/family, problems with isolation. An increased need for
co-treatment of these psychosocial factors has to be expected.
Psychological and social service staff must be trained to meet the
requirements of Covid-19
Create of psychosocial treatment concept for affected patients and staff
according to the required treatment level
Contact persons and areas of responsibility must be defined
Relatives should be involved at an early stage
Check whether pastoral care in hospitals should be included
Establish contacts for need of emergency psychosocial care
Mandatory coaching or supervision for staff should be established
