How does the Covid-19 crisis affect physical rehabilitation in medical centers?

    The topic of paramount importance nowadays is the Coronavirus Pandemic. Various fields have been affected by it and the adjacent measures including those linked to health-care. In order to get an insight of this I had an interview with Dr. Daiana-Mihaela Popa MD-Phd , delegate of UEMS (European Union of Medical Specialists), ISPRM (International Society of Physical and Rehabilitation Medicine) and former executive of the Băile Felix Rehabilitation Hospital. During the interview she provided materials she has been working on and the main content of the discussions held by the above mentioned societies.

    In the battle against COVID-19 worldwide, not only the medical emergency system but also the medical rehabilitation was significantly enlightened. Rehabilitation emphasizes on the treatment with appropriate methods at the right time, including bed positioning, respiratory training, exercises and mobilization, physical modalities, occupational therapy, speech, and swallowing therapy. The recent outbreak of Covid-19 pandemic  has challenged the provision of healthcare worldwide highlighting the needs of one of the frailest subjects in society such as people with disabilities. Both the direct effects of Covid-19 infection on our health and the indirect consequences of health policies restricting daily life, severely affected some of the population subgroups with the greatest health needs, such as people with disabilities, aging population, or people affected by chronic conditions. Several international bodies have already claimed health policies focusing not only on the acute management of the Covid-19 disease, but also on the care of the chronically ill patients staying at home or in healthcare facilities, as well as for  patients suffering from recent functional limitations requiring rehabilitation, for instance stroke or trauma.

    One of the most important lessons came from China, where medical rescue teams for major natural disasters have included rehabilitation experts, since 2008. But for COVID-19, rehabilitation experts were not included at the beginning as in the acute stage;  there is a great pressure to save lives, therefore the rescue teams include mainly professionals in respiratory medicine, critical care, nursing, and infection control. But in recent years, rehabilitation medical professionals in China have generally entered the early rehabilitation in ICU and the majority of clinical disciplines. The National Health Commission of China has repeatedly proposed documents emphasizing early intervention on rehabilitation, including shortening the length of hospital stay, preventing and managing complications, reducing dysfunction and improving function, and clinical efficacy. Rehabilitation ought to be beneficial as a team member. 

    Similar to  clinical disciplines, rehabilitation should be guided based on scientific evidence. In the face of COVID-19, a completely unfamiliar disease, many new methods of ‘rehabilitation’ have been included. There is a diversity of respiratory exercises, training programs, and even expert consensus and guidelines for the functional recovery after the COVID disease.

    Nowadays, when the pandemic starts to cool down, our main concern and challenge as rehabilitation specialists is the need to reorganize hospital and outpatient activities to face the following challenges: 

    – to ensure early rehabilitation to people hospitalized for Covid-19 infection, in the recovery phase after severe respiratory failure or due to the prolonged immobilization; 

    – to provide rehabilitation services to people experiencing functional decline after Covid-19 infection due to neurological sequelae; 

    – to provide safe rehabilitation services for people with emerging disability due to any other injury or illness 

    – to ensure appropriate long-term care to people with chronic disability restricted at home; 

    facing mobility restriction rules imposed on older people which eventually will affect functional independence.

    – to provide rehabilitation professionals with protective tools and a safe work environment. 

    To achieve these goals, policymakers and the rehabilitation community need to combine their efforts in developing evidence-based preventive and rehabilitative strategies for people quarantined at home or with restricted mobility due to lockdown

    • ensuring the provision of proper exercise programs to reduce the risk of frailty, sarcopenia, dementia, and to prevent the psychological effects of quarantine. A complex physical training program, including aerobic, resistance, balance, coordination, and mobility training exercises, for 5-7 days/week, at moderate intensity, is advised to maintain an adequate health status in older people. 
    • COVID-19 has greatly promoted the widespread application of remote rehabilitation medicine. Due to the need for quarantine, many patients need to perform necessary rehabilitation training at home. As a result, various remote rehabilitation approaches are greatly accelerated, which includes wearable devices, mobile phone APPs, virtual reality. It is hoped that work in this direction will lead to a new era of smart rehabilitation.
    • job activities should be re-organized both in inpatient and outpatient facilities to ensure patient and staff safety and limit the infection spread as routine cleaning and disinfection procedures, early detection of suspect cases, social distancing, suspension of unnecessary interventions (group rehabilitation).

    One of the greatest challenges for Medical Rehabilitation is represented by the minority hardly neglected nowadays of disabled children. Following the lockdown, pediatric rehabilitation services had to close to lessen the movement of people. Schools and special education facilities have been closed abruptly breaking the relationship of children and adolescents with a disability with support teachers. One of the most difficult questions for the medical community remains which rehabilitation activities are essential and which can be postponed instead? This is not an easy decision to take, particularly in the case of children with neurodevelopmental disorders (Autism Spectrum Disorder, Attention Deficit Hyperactivity Disorder), neuromuscular disorders, children with rare diseases, and other vulnerable children. In this instance, mandatory lockdown might become an aggravating factor for greater isolation and abrupt cessation of therapeutic pathways which, in turn, cause greater stress and puts even higher pressure on parental resources. 

    These considerations will certainly need to contribute to new planning. One thing is certain she said: “we must protect everybody. We are specifically thinking of children and adolescents with a disability and their families.  We must not let them alone. We need to ensure the continuity of care for them. Approaches such as Home-based rehabilitation (HBR) and telerehabilitation (TR) could help in coaching or training to support parents, as parents know their children best and can promptly recognize any critical issue. In order to do this, healthcare systems should streamline financing to cover for HBR or TR costs. These services are not largely diffuse yet, despite their potential benefits for people with disabilities who cannot go to a rehabilitation service during the COVID-19 pandemic.” 

    The COVID-19 pandemic is a sudden, unexpected, and anxiogenic event. In case of an emergency, some members of our community are more traumatically affected than others, including people with disabilities. 

    Source: Personal archive 

    “We should start thinking today on how we can transform our healthcare and social policy planning in the future.  On the “whom to protect” issue, we have no doubts: everybody needs to be safe. On the “how to protect” issue, safeguarding the most vulnerable among us is a provocation launched by this pandemic to us to rethink our work in the future” she concluded.