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Post-Acute Covid-19 Recovery and Rehabilitation April 28, 2020 DR. TCHAJKOVA Physiatry RIH DR. KAMBO Respirology RIH DR. CALDER Physiatry RIH
Post-Acute Covid-19 Recovery and Rehabilitation April 28, 2020
DR. TCHAJKOVA Physiatry RIH
DR. KAMBO Respirology RIH
DR. CALDER Physiatry RIH
Conflicts of interest
• None to declare
• References compiled >100 – available
Outline
• Part 1. medical sequelae
• Part 2. how does this apply to rehab?
• Part 3. review how this may apply to IH
~6.9% death rate world wide ~20-30% hospitalized~5-10% ICU admission
large burden of surviving group
The Best Rehabilitation…• NO NEED FOR REHAB
• Concept of “pre-habilitation” – WWII soldiers – Anesthesiology cardio-pulm in high risk
Julie K. Silver: Prehabilitation could save lives in a pandemic, March 19, 2020
Physical activity and health. Ann Epidemiol2009;19:253-256.
World Health Organization. (2016). Emergency medical teams: minimum technical standards and recommendations for rehabilitation. World Health
• Reduces disability
• Social reintegration
• Prevents congestion in medical and acute facilities
Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper (March 30, 2020)
• Rehab teams now integrated from early to discharge of COVID-19 flow
3 POINTS
• Not all people die from COVID-19 (majority don’t)
• Patients have sequelae
• Respiratory but also NON-respiratory burden
Sequelae “Our ignorance is profound” Dr.K–multiple body systems?
– Pulmonary – 3-67% ARDs*, milder resp symptoms majority– Neurological – 30-84% admitted
• CNS – strokes ischemic + hemorrhagic – 5%-23%• PNS - Loss of smell and taste - 40-70%• Neuromuscular – myalgia 40%
– Fatigue – 44%+– Neurocognitive – 36-80%– Hyper-coagulation – 30-80% – Cardio, vascular inflammation –MI, CHF, myocarditis – 8-33%– Psychiatric –depression anxiety, PTSD - 48%+ – Renal – catabolic, AKI, dialysis – unknown– Other – GI, dermatology, hepatology, endocrine - unknown
– ICU related – PICS, weakness – 70-80%+– prolonged admission (±21 days)
Into CONTEXT Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) -- United States, February 12-March 16, 2020.
CDC COVID-19 Response Team, MMWR 3/27/2020.
More co-morbidities, elderly, severe = worse outcomes (Wang et al.)
55% of hospitalized, 47% of ICU, and 20% of deaths = adults <65 yearsLOS shorter for dead 5 days VS 28 days survivors (Wang et al., Wuhan)
Sequelae – Theories Presently supportive treatment
- ACE2 receptors neurotropism? –direct invasion
- Increased inflammatory response?
- Cytokine storm?
- COVID-19 coincidental finding?
Baig et al., 2020.
Neurological - WuhanRetrospective 3 designated covid-19 hospitals in Wuhan
3 main symptoms: 36.4%
Mao et al, 2020
N Engl J Med. 2020 Apr 15. Neurologic Features in Severe SARS-CoV-2 Infection. Strasbourg, France. Julie Helms, M.D., Ph.D. St.phane Kremer, M.D., Ph.D.
58 consecutivepatients admitted to ICU
84% Neurological features
Neurological - France
• Dr. Pezzini (neurologist): "There is a dramatic increase in the number of vascular events, ischemic strokes, and thrombosis, which is likely due to the virus affecting coagulating mechanisms."
• "Many of the patients on the neuro-COVID-19 unit initially presented with stroke, delirium, or encephalitis, and then developed respiratory distress.”
Italy – Neuro COVID-19 Unit
- Dr Thomas Oxley, neurosurgeon at Mount Sinai
7 fold increase in sudden strokes in young patients during past two weeks (April 22, New Engl J pending)
– <age 50
– Mild symptoms or no symptoms of COVID-19
– Large arterial clots
– Significant rehab sequelae
Neurological other -
Poyiadji et al.Hua et al, 2020Moriguchi et al, 2020(April 22, New Engl J pending)
• Two studies of critically-ill patients 23% cardiac injury and 33% developed cardiomyopathy
• Troponin rise
• Cardiorespiratory rehab program up to 50% lower mortality long-term (Cardiac Rehab Series Canada: 2014)
Weiyi Tan ⁎, Jamil AboulhosnMadjid et al, 2020
Sherry L. et al, 2014
Cardiac Burden
• China - 48% of COVID-19 patients manifested psychological distress during early admission
• Social stigma, “labeled”
• Survivors of critical illness >30% depression, >32% anxiety, and 20% PTSD 1 year follow up
• Family, community distress + support
Dijkstra-Kerste SMA et al. 2019James M. Smith et al. 2020
Barrett and Brown 2008
COVID-19 Handbook, Zhejiang China
Psychiatric
PICS (post-intensive care syndrome)
• “new or worsening impairments in physical, cognitive, or mental health status after critical illness” – 70-80%
• Persistent Impairments at 1 + 5 year f/u
• 1/3+ don’t return to work
• 2 years - 80% required further inpatient admission
• Outpatient support
Marra et al., 2018Smith et al., 2020
ICUAW (ICU Acquired Weakness)
• Can exceed 10% loss of muscle mass 1 week of ICU
• CIM (myopathy) and CIN (neuropathy) complicate• Weakness impairments persist >2 years despite
recovery of pulmonary function long-term ARDs
• Diaphragmatic weakness• Post-intubation dysphagia 30%• Sores, contractures
Kress JP, Hall JB (2014) ICU-acquired weakness and recovery from critical illness. N Engl J Med 371(3):287–288Fan et al, 2014
• Longer duration hypoxemia association with worse cognitive impairment* (Kapfhammer et al, 2004)
– Full sequelae unknown, mild-moderate patients captured?
• “dysexecutive syndrome” 36%
• ARDs critical illness survivors @ 2 years = 56% deficiencies in short-term memory, 29% executive function
Bilotta et al., 2019
Neurocognitive
Herridge et al 2016
Strasbourg et al 2020
• Elective surgeries• Other vulnerable patients
OTHER rehab needs – unfortunate casualties , how to balance?
3 POINTS
• Not all people die from COVID-19 (majority don’t)
• Patients have sequelae
• Respiratory but also NON-respiratory burden
= degree of rehab need
= learning from others
British Society of Rehabilitation Medicine, 2020.
Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper (March 30, 2020)
• Acute Critical Phase (ICU)• Ventilation support/ weaning• Reduction of dyspnea, airway clearance*• Positional therapy• WHO advises early activation, fatigue level (Carda et al,
2020)
• OT – delirium, early ADLs, seating• SLP – dysphagia, communication
Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper (March 30, 2020)
• Acute Ward (out of ICU or not needing it)• Mobilize (get out of bed)• Therapeutic postures • Limb exercises• Neuromuscular electrical stim*• Respiratory muscle training• Bronchial clearance closed circuits
• OT – ADLS, cognitive, coping, mobilize• SLP – dysphagia, cognitive • RT – trach, respiratory• Discharge planning team
Joint statement on the role of respiratory rehabilitation in the COVID-19 crisis: the Italian position paper (March 30, 2020)
• Post-Acute (Intermediate rehab location)Depends on degree of pre- and post- comorbidities, recovery sequence- Trach weaning + phonation, secretions
- Mobilize muscle strength
- Specific mobility aides
- Respiratory muscle training
- PT, OT, SLP, RT, discharge team- Tele-follow ups
- Community* and home
program
What’s Next?...?
Not all people die from COVID-19 (majority don’t)
Patients have sequelae, *degree of post-acute rehab need
Respiratory but also NON-respiratory burden
= team effort= learning from others who
were less able to prep
CONNECTION ON INTERNATIONAL AND NATIONAL LEVELREGIONAL PLANNING
medical flow + our patients
Part 2Implementing Pulmonary Rehab as
part of a COVID Rehab strategy
Jas Kambo, MBBS FRCPC
Respirology and Sleep Medicine
Royal Inland Hospital
Overview
• What are the pulmonary sequelae of ARDS?
• What are the non-pulmonary sequelae ARDS?
• Can community-based longitudinal pulmonary rehab help?
• SPOILERS: NOT MUCH DATA
Clinical
• Similar symptoms to severe viral respiratory infections
– Fevers (poor response to anti-pyretics)
– Dry cough
– Malaise
– Dyspnea
• Severity
– “Usual” viral -> ARDS, septic shock, organ failure
Pulmonary complications of ARDS
• Objective– 80% have decreased DLCO– 20% have airways obstruction– 20% have restrictive lung disease– Some will recover over time– INCONSISTENT data about whether or not PFTs correlated
with HRQOL/functional
• Long term impairments in HRQOL, exercise tolerance, ability to return to work, mental health, social health– Includes date from recent viral pandemics– Younger patients (<40) tend to do better– Some conflicting data
HRQOL
• SF-36– Likert scale
• Physical function
• Social function• Role limitation
from emotional problems
• Role limitation from physical problems
• Mental health• Body pain• Vitality• General Health
Hui et al, 2005
What is Pulmonary Rehab?
• A multidisciplinary, long-term program based on targeted exercise and education for patients with chronic respiratory illnesses– COPD, ILD
• Improves HRQOL, mortality, exercise tolerance• Decreased exacerbations
– Aimed at improving physical, mental and emotional health
– 6 weeks, 2x/wk– Physical: Endurance, Resistance, Flexibility– Education: Diet, anxiety, disease-specific education,
social stigma and more
Is Pulmonary Rehab beneficial?
• Evidence is SPARSE
• Prior to COVID• One small observational study (Taiwan, n=9)
• H1N1 ARDS survivors
• PFT measures, 6MWT improved within 3 months
• HRQOL improved in 6 months
American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary
rehabilitation. (2013)
• Pulmonary rehab includes interval, strength, flexibility and respiratory training
• Initiated early reduces subsequent hospital admissions
• Function and QOL
Is Pulmonary Rehab beneficial?
• Recent RCT (China) assessed full 6 week PR program in COVID-19 patients– Inclusion criteria
• Age > 65
• No pre-existing moderate-severe lung disease
• MMSE > 21
– Exclusion criteria• No significant cardiovascular/neurodegenerative co-morbidity
– Primary outcome• Respiratory function
– Secondary outcome• QOL, ADL, 6MWT, Psychological status
Liu et al, 2020.
Is Pulmonary Rehab beneficial?
• Baseline characteristics similar
Is Pulmonary Rehab Beneficial?
So what do we do?
• Majority of evidence suggests that there are long term deficits in pulmonary function and HRQOL after ARDS
• PR is designed to address these, but data is sparse– One recent RCT supporting PR
• How to implement?– Timing?– In person vs. virtual sessions?
Post-Acute COVID SequelaeSupporting our Patients through
Recovery to Rehabilitation
Section 3 – Rehabilitation Services in this Pandemic
Dr. Jill Calder,
Phys Med & Rehab, RIH
Acute Medical
Subacute Medical “Pre-Rehab”
Acute phase Rehab “Rehab Ward” Activation/”Short Stay” Beds
Outpatient therapyCommunity-based Rehab
“Recovered”
Typical Rehabilitation Services access and flow:
FIM Scale Legend
7 – Complete independence (timely, safe)
6 – Modified Independence (extra time,
device)
5 – Supervision (cuing, coaxing, prompting)
4 – Minimal assist (performs 75% or more of
the task)
3 – Moderate assist (performs 50 – 74% of
task)
2 – Maximal assist (performs 25 – 49% of task)
1 – Total assist (performs less than 25% of
task)
N/A – Not achievable
FIM Item FIM
ScoreDate:
Self Care Items
1. Eating
2. Grooming
3. Bathing
4. Dressing upper body
5. Dressing lower body
6. Toileting
Sphincter Control
7. Bladder Management
8. Bowel Management
Mobility Items
9. Bed, chair, wheelchair
10. Toilet
11. Tub or shower
Triaging Rehab Services:
Functional Independence Measure (FIM)
Alpha-FIM (short form)
Locomotion
12. Walking/wheelchair (circle)
13. Stairs
Communication Items
14. Comprehension (circle)
Auditory / Visual
15. Expression (circle)
Verbal / Non-verbal
Psychosocial Adjustment
16. Social Interaction
Cognitive Function
17. Problem Solving
18. Memory
Total FIM Score
Medical phase
Projected Rehab levelTask-Time hours of care
projection
Duration of care
projection
Unrecognized,
symptomatic isolating at home
Rehab needs not assessed. Home based, not currently case managed.
Routine reactivation self-directed 1 hour / day. In home services.
1 month
New cases tested
Bad enough to seek testing, low rehab needs presumed. Home based likely. Not currently case managed.
1-2 hour / day, skilled rehab resource preferred, community-based.
1-2 mo
Hospital care required
Medium rehab needs projected.2 - 4 hours / day, skilled rehab resource required blend of inpatient to outpatient service, graduating to community-based.
2-3 mo
Critical care required
High rehab needs projected.
6 - 8 hours / day, skilled resource essential, starting with inpatient COVID Rehabilitation, phased to general activation unit, graduating to outpatient and finally community based services.
6 + mo
2 mo HIGH2 mo MED2 mo LOW
Where the numbers came from: BC CDC reports
TASK-TIME ESTIMATE: 509 minutes of care, or 8.5 hours of care needed for the HIGH NEEDS COVID case in the early nursing and rehab activation phase.
The echo incidence curve for this Mar 16 onward interval might be two to three weeks if the ventilation and acute care chapter lasts that long.
0
1
2
3
4
5
6
7
8
16 MR18 20 22 24 26 28 301 AP 3 5 7 9 11 13 15 17 19 21 23 25
CR
ITIC
AL
CA
RE
CA
SES
DATE
IHA 'CRITICAL CARE CASES' by 'DATE'
Current estimate for high care patient workload @ 8 hr X 14 d and 4 hr @ X 14d = 76 hours.
8 hours of need might be: RN, LPN – 4.5 hours of basic nursing and extension of activationPT, Rehab aide – 2 hoursOT, Rehab aide – 1.25 hoursSLP – 0.25
Total estimate converted to hours of workload:RN, LPN – 42.53 hours, 3.5 positionsPT, Rehab aide – 18.9 hours, 2.5 positionsOT, Rehab aide – 11.8 hours, 1.6 positionsSLP – 2.36 hours, 0.31 positions
0
10
20
30
40
50
60
70
80
0 10 20 30 40 50
DATE
'IHA - currently in critical care', 'Cumulative workload' by 'DATE'
IHA - currently in critical care Cumulative workload
COVID rehab care during “medium needs” category: Gross estimate - 200 min/day, 3.5 hours of direct rehab time.
0
5
10
15
20
25
30
16MR
18 20 22 24 26 28 30 1 AP 3 5 7 9 11 13 15 17 19 21 23 25 27
IHA
CA
SES
IN H
OSP
ITA
L
DATE
IHA HOSPITAL CASES ADMITTED BY DATE
0
10
20
30
40
50
60
70
0 10 20 30 40 50
DATE
'IHA Hospitalized', 'WORKLOAD' by 'DATE'
IHA Hospitalized (ever) WORKLOAD
Current estimate for medium severity patient workload 50% @ 2 hr or 56 hours.
Based on 4 hours rehab activation.RN, LPN – 2 hours of basic nursing and extension of activationPT, Rehab aide – 1.5 hoursOT, Rehab aide – 1 hoursSLP – 0.25 hours
Total estimate converted to hours of workload:RN, LPN – 28 hours, 2.3 positionsPT, Rehab aide – 21 hours, 2.8 positionsOT, Rehab aide – 14 hours, 1.9 positionsSLP – 3.5 hours, 0.4 positions
CASES BELOW THE WATER LINE:Those who sought testing are the “tip of the iceberg” of those who actually had a mild case.
Suspect incomplete recovery is likely without some support and re-activation curriculum available to them.
Further study needed on those who stayed home – may need augmentation to community based activation programs to recover fully.
Need for Telehealth outreach and online resources.
Source: Twitter, Dr. Victor Tseng 2020, modified by Dr. Brian McMichael 2020.
Acute Medical
Subacute Medical “Pre-Rehab”
Acute phase Rehab “Rehab Ward” Activation/”Short Stay” Beds
Outpatient therapyCommunity-based Rehab
“Recovered”
Rehabilitation Services-changes due to COVID:
Acute Medical
Outpatient therapy
“Recovered”
Rehab should be part of COVID-19 response teamIntegration, Coordination
Subacute Medical “Pre-Rehab”
Acute phase Rehab “Rehab Ward” Activation/”Short Stay” ward
Outpatient therapy
COVID “Ward”/cohort - specialized team suggested.PPE requirements during rehab activation.
Vulnerable highly co-morbid population needs separate stream, space, equipment, and staffing.
May not be able to fast track to usual program.When is a patient clear of COVID?
Multiple populations using space and equipment. Level of pre-cautions required. Not currently available.
Acute Medical
Community-based Rehab
“Recovered”
Big push to the community, but manpower not ramped up. Limitations to home visitation. Virtual Rehab: assessment, education, groups - all need development.
“Getting home” – poster, video, home exercises.“COVID Club” – online exercises and supports.
Should we be using a different term?“Sent to community phase”
Montefiore example of exercises:
We need to be readyReady to be flexible
Ready to re-tool equipment and spacesReady to cohort populations
Ready to re-allocate staffReady new innovations in care
Yet preserve existing care
Key points: • novel, un-precedented, unpredictable• majority of cases survive• not just a pulmonary disease• luxury of time and connections around the world• we are innovating on a fast track to beat the second wave
