Overview and Description
SARS COV2 virus and COVID19
COVID19 is a novel disease, caused by the SARS CoV-2 virus, an enveloped, singe stranded RNA virus, belonging to the Coronavirus family. The predominant molecular mechanism is the use of Spike glycoprotein for attachment at corresponding ACE-2 receptors with entry into the cell by fusion.1 While the predominant manifestations described are related to the respiratory system, we now recognize a whole host of multisystem manifestations in the cardiac, vascular, neurologic, psychologic, renal and dermatologic systems.
Given that the most severe cases can have significant impairments beyond the acute course, and medical management and monitoring is often required, the need for rehabilitation for COVID19 in the acute, post-acute and community settings to improve activity and participation cannot be overemphasized.
The rehabilitation team approach is vital to ensure that the focus is on the person with impairments and not on impairments only. The direct-care rehabilitation team includes physiatry, physical and occupational therapy, speech language pathology, respiratory therapy and rehabilitation psychology.
The role of physiatry is maintaining medical stability, incorporating evolving medical knowledge into clinical management, and setting rehabilitation goals / refining COVID19 rehabilitation protocols with the rehabilitation team.
Relevance to Clinical Practice
Diagnosis and monitoring
Screening test focus on detecting viral proteins or host antibodies, while confirmatory tests use RT-PCR for detecting viral RNA. Sensitivity and specificity of these tests continues to be debated. 2 Major lab abnormalities reflect hypoxia, hyperinflammation, hypercoagulability, and organ failure in the most severe case. Accordingly, CRP, ESR and LDH, D-dimer, prothrombin time, neutrophils, LFTs and creatinine may be increased, while fibrinogen and platelets may be decreased. These markers often indicate severity and may have prognostic implications.
Defining clinical severity
Understanding the severity and prognosis is helpful for providers to define management strategies for COVID19 and guide patients and caregivers to optimize outcomes from care provided. Clinical classifications proposed for COVID19 severity and prognosis 3 have evolved over time for special care settings including ED 4 and ICU 5 and for populations including pediatrics. 6 The commonly utilized latest CDC clinical classification currently includes five categories: Asymptomatic or presymptomatic, mild, moderate, severe, and critical. 7 (Table I)
Infection Prevention: Isolation and personal protective equipment (PPE)
Isolations and use of PPE is vital for maintaining patient and provider safety as well as continued care. Recommended PPE includes N95 respirators / face mask and shield to address aerosol and droplet modes of spread, while gown, gloves and shoe/hair covers offer additional contact precautions.8 Prolonged (more than 15 minutes) and close exposure (more than 15 minutes over 24 hours) contact without appropriate PPE is indication for isolation for 14 days from exposure, and testing per clinical suspicion. 9
The CDC classification serves as the basis for discontinuing transmission-based precautions in healthcare facilities. Isolation can be discontinued for the mild to moderate categories at least 10 days post-diagnosis, 24 hours fever free and improving symptoms. For severely immunocompromised and severe to critical categories, the duration of isolation is a minimum of 20 days. Additionally, CDC test based criteria for discontinuing isolation have limited utilization per latest recommendations. 10
Goals at presentation in the acute setting include early identification and management of hypoxia by measures such as intubation and ventilation. In the acute hospitalization phase, additional management goals include reducing viral load, with promising candidates such as post-COVID19 plasma and intravenous Remdesivir. Hyperinflammation monitoring and management with low dose dexamethasone has been described. Hypercoagulability management with low molecular weight heparin for 2-4 weeks required monitoring with markers such as d-Dimer. 11 As patients transition from the acute to post-acute setting, these principles become important for postacute providers to incorporate into their decision-making. The role of vitamin D and zinc has been explored, and vaccines are hopefully fast approaching fruition. 12
Impairments, activity and participation: Rationale and role of therapy
The need for early rehabilitation in the acute setting 13 continued rehabilitation in the postacute setting and follow-up in the community setting 14, 15 is vital.
Acute Care Rehabilitation
Acute phase impairments relate to severity. Among the most severe cases, respiratory failure is often accompanied by multisystem impairments and prolonged immobility. Patients with severe to critical COVID19 present with significant limitations in functional mobility and ability to complete ADLs. An initial course of prolonged ICU stay 16 may contribute to multiple impairments as part of a Post-ICU syndrome. 17 Post-stabilization presenting symptoms are reflective of impairments in cardiopulmonary endurance and neuromuscular. 18 The goals of occupational and physical therapy include building up endurance and maximizing mobility and ADLs tailored to patient tolerance. Prolonged intubation in the most severe subset 15 may results in post-extubation dysphagia 16 and changes in vocal quality. 19 Emerging evidence also suggests association with acute neuropsychiatric symptoms, including cerebrovascular complications, delirium, and encephalopathies. 20, 21 Goals of speech therapy include improving the safety of swallowing, improving communication, and improving cognition.
For the most severe presentations, increasing tolerance to out of bed activity by starting with sitting edge of bed prior to initiating standing activities or gait training is important in the acute care setting. 12 Cognitive support strategies include reorientation, controlled environment, virtual family support and psychological services.
Severe cardiopulmonary deconditioning and critical illness myoneuropathy is a common presentation for postacute rehabilitation, with ischemic stroke and limb loss from thrombotic complications been less common. Cognitive, speech and swallowing impairments accompanied by mobility and daily living activity limitations are a major focus for inpatient rehabilitation. 22
The initial physical and occupational therapy assessments set rehabilitation goals, incorporating increased monitoring of vital signs and patients’ self-reported effort to determine their individual therapeutic tolerance. 23 Standard functional outcome metrics include those reported to insurance such as Section GG mobility and self-care measures. COVID19 specific outcome metrics are being defined not only at the national levels such as by the APTA 24, but also at institutional levels based upon their experience, such as 5 time sit to stand, 10 meter walk test, activities specific balance confidence scale, and 6 minute walk test. Therapy sessions focus on gradual increase in activity tolerance with close attention to vital signs and observational analysis for decompensation throughout activities or adverse response to treatment. Discharge assessment for functional gain includes repeat measurement of parameters defined at admission.
Speech therapy protocols for cognitive assessment include instruments such as Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) and Montreal Cognitive Assessment. Cognitive treatment includes training in compensatory strategies and rehabilitation targeting cognitive-linguistic skills, including attention, memory, and executive functioning. Speech and swallow protocols require particular attention to aerosolization potential. Dysphagia assessment includes recent MBS or FEES reports and performance of bedside swallow evaluation and instruments such as the Mann Assessment of Swallowing (MASA). Dysphagia treatment includes training in compensatory strategies, completion of exercises, and trials of advanced consistencies. Impaired vocal quality is evaluated with Voice Handicap Index (VHI) with voice treatment focusing on vocal hygiene strategies, voice treatment regimens, and referral to ENT upon discharge if vocal quality as needed. All admission assessments are repeated at discharge to track progress.
The role of rehabilitation counseling is to assist patient and their families adjust to the mental health burden that has been created by having a novel disease that has limited treatment options and growing but non-definitive infectivity information. 25 Respiratory therapy is vital for tracking daily respiratory function, including during early occupational and physical therapy sessions and providing pulmonary rehabilitation. 26 Family training is an essential part of rehabilitation, especially since many individuals will require assistance at discharge. This can be accomplished by remote methods such as telemedicine as well as in-person toward the end of the stay with appropriate PPE as needed.
COVID survivors report persistent disabling symptoms from physical and mental health issues such as low endurance, delayed strength recovery, and memory issues. Physiatry clinics focus on these and other issues to maintain therapy services and to monitor and manage impairments. Outpatient therapy includes a mix of in-person and telehealth services, offered by occupational therapy 27, physical therapy 28, speech therapy and psychological services. Home health services are generally accessible once the patient is considered recovered and help continue rehabilitation across the continuum.
Cutting Edge/ Unique Concepts/ Emerging Issues
The role of health systems for facilitating COVID19 rehabilitation cannot be overemphasized. National policy facilitating care includes CMS waivers on telehealth, waiver of the 60% rule and 3-hour therapy rule for IRFs 29 and of the 3-day Prior Hospitalization rule for SNFs. 30 It is vital for physiatrists, as leaders of the postacute field, to work closely with administrative personnel to collaboratively ensure patient and provider safety while ensuring rehabilitation care for both COVID19 and non-COVID populations.
Gaps in Knowledge/ Evidence Base
There are several gaps in knowledge regarding COVID19 and rehabilitation. Long-term impairments are not well characterized since sufficient time to fully understand the clinical course has not elapsed. Rehabilitation protocols in the acute and postacute setting are still evolving as the knowledge around functional outcomes and infection prevention emerges.
Several systems are still struggling to manage the resource requirements COVID19 demands, such as PPE in all settings, periodic staff and patient testing in skilled nursing facilities, staffing shortages amidst uncertainty, and the threat of significant morbidity and mortality. It is with multidisciplinary planning, resource and knowledge sharing and collaborative action that rehabilitation professionals will continue to move forward in providing the best possible care for COVID19 and non-COVID populations.
- Duan L, Zheng Q, Zhang H, Niu Y, Lou Y, Wang H. The SARS-CoV-2 Spike Glycoprotein Biosynthesis, Structure, Function, and Antigenicity: Implications for the Design of Spike-Based Vaccine Immunogens. Front Immunol. 2020 Oct 7;11:576622. doi: 10.3389/fimmu.2020.576622. eCollection 2020.
- Ebrahimi M, Malehi AS, Rahim F. COVID-19 Patients: A Systematic Review and Meta-Analysis of Laboratory Findings, Comorbidities, and Clinical Outcomes Comparing Medical Staff versus the General Population. Osong Public Health Res Perspect. 2020 Oct;11(5):269-279. doi: 10.24171/j.phrp.2020.11.5.02.
- Yan X, Han X, Peng D, Fan Y, Fang Z, Long D, Xie Y, Zhu S, Chen F, Lin W, Zhu Y. Clinical Characteristics and Prognosis of 218 Patients With COVID-19: A Retrospective Study Based on Clinical Classification. Front Med (Lausanne). 2020 Aug 11;7:485. doi: 10.3389/fmed.2020.00485. eCollection 2020.
- ACEP , Emergency Department COVID-19 Severity Classification, retrieved from https://www.acep.org/globalassets/sites/acep/media/covid-19-main/acep_evidencecare_covid19severitytool.pdf
- Lu X, Wang Y, Chen T, Wang J, Yan F. Classification of COVID-19 in intensive care patients. Crit Care. 2020 Jul 9;24(1):399. doi: 10.1186/s13054-020-03127-7.
- Buonsenso D, Parri N, De Rose C, Valentini P; Gemelli-pediatric COVID-19 team. Toward a clinically based classification of disease severity for paediatric COVID-19. Lancet Infect Dis. 2020 May 15:S1473-3099(20)30396-0. doi: 10.1016/S1473-3099(20)30396-0. Online ahead of print.
- U.S. Department of Health & Human Services, Clinical Presentation of People with SARS-CoV-2 Infection, last Updated: October 9, 2020 , retrieved from https://www.covid19treatmentguidelines.nih.gov/overview/clinical-presentation/
- U.S. Department of Health & Human Services, Using Personal Protective Equipment (PPE), updated Aug. 19, 2020 , https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html
- U.S. Department of Health & Human Services, Duration of Isolation and Precautions for Adults with COVID-19, Updated Oct. 19, 2020, https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
- U.S. Department of Health & Human Services, Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance), Updated Aug. 10, 2020, Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html
- Stratton CW, Tang YW, Lu H. Pathogenesis-Directed Therapy of 2019 Novel Coronavirus Disease. J Med Virol. 2020 Oct 19. doi: 10.1002/jmv.26610. Online ahead of print.PMID: 33073355 Review.
- 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. Physiotherapy management for COVID-19 in the acute hospital setting: clinical practice recommendations. J Physiother. 2020 Apr;66(2):73-82. doi: 10.1016/j.jphys.2020.03.011. Epub 2020 Mar 30.
- Smith JM, Lee AC, Zeleznik H, Coffey Scott JP, Fatima A, Needham DM, Ohtake PJ. Home and Community-Based Physical Therapist Management of Adults With Post-Intensive Care Syndrome. Phys Ther. 2020 Jul 19;100(7):1062-1073. doi: 10.1093/ptj/pzaa059.
- Falvey JR, Krafft C, Kornetti D. The Essential Role of Home- and Community-Based Physical Therapists During the COVID-19 Pandemic. Phys Ther. 2020 Jul 19;100(7):1058-1061. doi: 10.1093/ptj/pzaa069.
- Richardson S., Hirsch J., Narasimhan M. Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York city area. The Journal of the American Medical Association, 2020, retrieved from https://doi.org/10.1001/jama.2020.6775
- Ohtake PJ, Lee AC, Scott JC, Hinman RS, Ali NA, Hinkson CR, Needham DM, Shutter L, Smith-Gabai H, Spires MC, Thiele A, Wiencek C, Smith JM. Physical Impairments Associated With Post-Intensive Care Syndrome: Systematic Review Based on the World Health Organization’s International Classification of Functioning, Disability and Health Framework. Phys Ther. 2018 Aug 1;98(8):631-645. doi: 10.1093/ptj/pzy059. PMID: 29961847.
- Halpin SJ, McIvor C, Whyatt G, Adams A, Harvey O, McLean L, wt al. Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. .J Med Virol. 2020 Jul 30. doi: 10.1002/jmv.26368. Online ahead of print.
- Kim MJ, Park YH, Park YS, Song YH. Associations Between Prolonged Intubation and Developing Post-extubation Dysphagia and Aspiration Pneumonia in Non-neurologic Critically Ill Patients. Ann Rehabil Med. 2015 Oct;39(5):763-71. doi: 10.5535/arm.2015.39.5.763. Epub 2015 Oct 26. PMID: 26605174; PMCID: PMC4654083.
- Brodsky MB, Levy MJ, Jedlanek E, Pandian V, Blackford B, Price C, et al. Laryngeal Injury and Upper Airway Symptoms After Oral Endotracheal Intubation With Mechanical Ventilation During Critical Care: A Systematic Review. Crit Care Med. 2018 Dec;46(12):2010-2017. doi: 10.1097/CCM.0000000000003368. PMID: 30096101; PMCID: PMC7219530.
- Troyer EA, Kohn JN, Hong S. Are we facing a crashing wave of neuropsychiatric sequelae of COVID-19? Neuropsychiatric symptoms and potential immunologic mechanisms. Brain Behav Immun. 2020 Jul;87:34-39. doi: 10.1016/j.bbi.2020.04.027. Epub 2020 Apr 13. PMID: 32298803; PMCID: PMC7152874.
- Wu Y, Xu X, Chen Z, Duan J, Hashimoto K, Yang L, Liu C, Yang C. Nervous system involvement after infection with COVID-19 and other coronaviruses. Brain Behav Immun. 2020 Jul;87:18-22. doi: 10.1016/j.bbi.2020.03.031. Epub 2020 Mar 30. PMID: 32240762; PMCID: PMC7146689.
- Yonter SJ, Alter K, Bartels MN, Bean JF, Brodsky MB, González-Fernández M, Henderson DK, Hoenig H, Russell H, Needham DM, Kumble S, Chan L. What Now for Rehabilitation Specialists? Coronavirus Disease 2019 Questions and Answers. Arch Phys Med Rehabil. 2020 Dec;101(12):2233-2242. doi: 10.1016/j.apmr.2020.09.368. Epub 2020 Sep 20. PMID: 32966809; PMCID: PMC7502167.
- Rahmati-Ahmadabad S, Hosseini F. Exercise against SARS-CoV-2 (COVID-19): Does workout intensity matter? (A mini review of some indirect evidence related to obesity). Obes Med. 2020 Sep;19:100245. doi: 10.1016/j.obmed.2020.100245. Epub 2020 Apr 27. PMID: 32342019; PMCID: PMC7184978.
- American Physical Therapy Association, COVID-19 Core Outcome Measures, APTA Academies and Sections Consensus Statement, https://www.apta.org/contentassets/1a6e0ee7cd25403888d2959c1c8476cd/covid-19-core-outcome-consensus-statement-june-2020.pdf
- Rehman S, Lela U. Psychological Aid to COVID-19 Pandemic: A Mental Health Response to Crises Management. Psychiatr Danub. 2020 Summer;32(2):262-265. doi: 10.24869/psyd.2020.262.
- Wang TJ, Chau B, Lui M, Lam GT, Lin N, Humbert S. Physical Medicine and Rehabilitation and Pulmonary Rehabilitation for COVID-19. Am J Phys Med Rehabil. 2020 Sep;99(9):769-774.
- Gross DP, Asante A, Pawluk J, Niemeläinen R. A Descriptive Study of the Implementation of Remote Occupational Rehabilitation Services Due to the COVID-19 Pandemic Within a Workers’ Compensation Context. J Occup Rehabil. 2020 Oct 28. doi: 10.1007/s10926-020-09934-7.
- Eannucci EF, Hazel K, Grundstein MJ, Nguyen JT, Gallegro J. In-Person Services During the COVID-19 Pandemic. HSS J. 2020 Oct 19:1-7. doi: 10.1007/s11420-020-09800-5.
- Inpatient rehabilitation facilities: CMS flexibilities to fight COVID-19. CMS. https://www.cms.gov/files/document/covid-inpatient-rehab-facilities.pdf. Published Apr 29, 2020. Accessed Jun 8, 2020.
- Long term care facilities (skilled nursing facilities and/or nursing facilities): CMS flexibilities to fight COVID-19. CMS. https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf. Published May 15, 2020. Accessed Jun 8, 2020.
Prateek Grover, MD, PhD, MHA
Nothing to Disclose
Natalie Lynch PT, DPT
Nothing to Disclose
Sarah Elkins MS, CCC-SLP, CBIS
Nothing to Disclose