Introduction
Countries around the world are now entering their second post-COVID-19 phase.
- Many people affected by this disorder may be at risk for long-term impairment and disability. [1]
- The extent of this impairment and disability varies, but it is clear from early research that these patients require rehabilitation at all stages of the disease—post-acute and long-term.
Rehabilitation is defined as a set of interventions aimed at reducing disability and optimizing function in interaction with the environment in individuals with health problems. [2]
- Rehabilitation is a key strategy for reducing the impact of COVID-19 on people’s health and function.
- Physiotherapists are vital in all phases of these rehabilitation efforts to facilitate early discharge, but more importantly support and empower patients.
Benefits of Rehabilitation for COVID-19 Patients
Rehabilitation has a positive impact on the health outcomes of severely ill COVID-19 patients. It achieves this by [3]:
- Optimizing Health and Functional Outcomes
- Rehabilitation can reduce ICU admission-related complications such as Post-Intensive Care Unit Syndrome (PICS) Intensive Care Unit Acquired Weakness (ICUAW)
- The purpose of rehabilitation is to improve recovery and reduce disability or the experience of disability
- Rehabilitation interventions address some of the consequences of severe COVID-19, such as:
- Physical impairments
- Cognitive impairments
- Swallow impairments
- Provision of psychosocial support
- Clearly, older adults and those with pre-existing medical conditions are at higher risk for more severe disease. Rehabilitation is beneficial for these populations to maintain their previous level of function and independence
- Early Discharge Facilitation
- Rehabilitation is critical to prepare patients for complex discharge coordination and continuity of care amid possible hospital bed shortages
- Reducing the risk of readmission
- Rehabilitation is a key strategy to ensure that patients do not deteriorate and require readmission after discharge.
- Rehabilitation professionals are frontline healthcare professionals and should be involved in the care of critically ill COVID-19 patients
- Patients with severe COVID-19 will go through multiple phases of care—acute to post-acute (subacute) and long-term care. In the acute phase, care is likely to be provided in an intensive care unit or intensive care unit. Later in the acute phase, most likely in a hospital ward or Step-down or rehabilitation facility. The long-term phase will be that the patient returns home and is still recovering and will receive rehabilitation at the community level.
Physiotherapy and post-acute COVID-19 rehabilitation phase
- Physiotherapists play an important role in the rehabilitation of patients from the acute phase to the post-acute phase. [4]
- The consequences of COVID-19 are specific to each individual and their recovery needs will be specific to those consequences, such as:
- Long term ventilation
- Immobilisation
- Deconditioning
- Associated Injury – Respiratory Neuromusculoskeletal
- Patients with COVID-19 often have pre-existing comorbidities, which must be considered in the patient’s recovery plan. Physiotherapists working across disciplines should work together and draw on each other’s expertise. [4]
The transition from acute to post-acute needs to be supported through service delivery pathways, and multidisciplinary teams will be key to making this happen.
Introduction of COVID-19 patients in rehabilitation department
Factors to consider when developing a recovery plan for a COVID-19 survivor include [5]:
- Comorbidities
- Direct lung trauma
- COVID-19 Injuries to Other Organs and Systems
Comorbidities
There is clear evidence from around the world that major comorbidities in patients with COVID-19 include [6][7]:
- Hypertension
- Coronary artery disease
- Stroke
- Diabetes
- Chronic kidney disease
- Lung and liver diseases
- Obesity
- Immunodeficiency
- Certain disabilities
- Mental health conditions
Given that these conditions are often associated with aging, survivors of COVID-19 are likely to be older adults with pre-existing conditions. [7] This will have implications for rehabilitation needs and rehabilitation outcomes. [5]
Severe COVID-19 Complications
Early complications of COVID-19 include [6][8]:
- Acute Respiratory Distress Syndrome (ARDS)
- Sepsis or septic shock
- Multi-organ failure
- Acute kidney injury
- Cardiac injury
These complications often result in the patient being admitted to the intensive care unit (ICU). Table 1 lists conditions that may result from a prolonged ICU stay.
Table 1. Symptoms that may be caused by long-term ICU stay [9] Critical illness polyneuropathy (CIP), critical illness myopathy (CIM), post-intensive care syndrome (PICS) critical illness polyneuropathy is a mixed sensorimotor neuropathy that may cause axonal degeneration and studies have shown ARDS patients admitted to the ICU may develop CIP. Critical illness polyneuropathy (CIP) can lead to difficulties such as [10]: Difficulty weaning from mechanical ventilation Generalized and symmetrical weakness (distal is greater than proximal but also includes diaphragm Weaknesses) Distal sensory loss Atrophy Deep tendon reflexes Diminished or absent Critical illness Polyneuropathy Associated with [10]: Pain Loss of range of motion Fatigue Incontinence Dysphagia Anxiety depression Post-traumatic stress disorder (PTSD) Cognitive loss Critical illness Polyneuropathy is diagnosis Passed [11]: Muscle biopsy electromyographic testing This condition is present in 48-96% of patients with ARDS in the intensive care unit. [10] It is a nonnecrotizing diffuse myopathy with steatotic fibroatrophy and fibrosis [11]. CIM and: Exposure to corticosteroids, paralysis and sepsis. It has similar clinical presentation to CIP but with more proximal weakness and preserved sensation [12]. Patients recover more completely from myopathy than from polyneuropathy, but for both conditions, long-term consequences need to be considered, such as: debilitating loss of function Poor quality of life Endurance Read more: Pathophysiology and management of critically ill polyneuropathy and myopathy [11] A striking feature of COVID-19 is that acute and ICU Nursing and ventilator dependence. aftershock as The results of such a long ICU period will last for months and years. [12] Features of PICS include[12]: Cognitive Impairment Memory Concentration Visual Spatial Psychomotor Impulsivity Psychiatric Illness Anxiety Depression PTSD Physical Disability Dyspnea/Impaired Lung Function Reduced Inspiratory Muscle Strength Pain Sexual Dysfunction Impaired Exercise Tolerance Neuropathy Muscle Weakness/Paresis Poor Arm and Grip Strength Poor Knee Extension Severe Fatigue Low Functional Capacity Neuromuscular complications of PICS often result in reduced mobility Falls or even quadriplegia. risk Factors of Post-Intensive Care Syndrome [12]: Delirium ICU Admission Duration Sedation Duration Mechanical Ventilation Age Hypoxia and Hypotension Sepsis Glucose Imbalance Premorbid Psychological and Physical ComorbiditiesRead more about Critical Care in Survivors of Critical Illness post syndrome Illness including COVID-19 patients: a narrative review [13]
The world’s healthcare systems will be overwhelmed by the cohort of post-ICU patients caused by the COVID-19 pandemic. Therefore, it is important to coordinate the rehabilitation response. [12]
Sequelae after COVID-19 Infection
Sequelae of Covid-19 Infection Cardiac Sequelae Studies have shown that hospitalized COVID-19 patients also have associated cardiac damage. Patients with this associated cardiac injury present [14] [15]: increased resting heart rate tachycardia palpitations hypotension or syncope intermittent Flushing newly diagnosed hypertensive heart disease angina pectoris heart attack arrhythmia cardiac insufficiency decreased ejection fraction elevated troponin I severe myocarditis with decreased systolic dysfunction cardiac injury and other comorbidities to consider Patients entering acute rehabilitation. [5] Neurologic sequelae Numerous neurologic sequelae have been reported in patients with COVID-19[16][17] Symptoms include[16][18]: headache disturbance of consciousness seizures sensory and olfactory paresthesia posterior reversible encephalopathy Syndromic encephalopathy Encephalitis Increased risk of acute cerebrovascular events Ischemic stroke Hemorrhagic stroke Reports of Guillain-Barré syndrome associated with COVID-19 Myoclonus Brain fog/long-term COVID depression Anxiety and sleep disturbance These neurological factors need to consider when Patient is entering acute recovery after COVID-19. Musculoskeletal sequelae Musculoskeletal sequelae include[1][19][20] Physical deindication Severe muscle weakness Joint range of motion Reduced neck and shoulder pain (due to prone position) Verticalization Difficulty with balance and Gait Intensive Care Unit Acquired Weakness (ICUAW) CIPCIM Arthralgia and Myalgia Read more: Impact of Covid-19 on the Musculoskeletal System: A Guide for Clinicians [20] Pulmonary Sequelae Impaired Lung Function Pulmonary Fibrosis as Sequelae of Pneumonia – Patient exhibits respiratory insufficiency Respiratory rehabilitation Requires specific physical therapy techniques or techniques to remove persistent discharge [21] Shortness of breath [15] Dyspnea after exertion [15] Dyspnea [15] Painful breathing [15] Chest tightness [15] Cough [15] Cognitive sequelae chronic confusion State and psychological problems Delirium and other cognitive impairments [21] Other sequelae of ADLD Difficulty swallowing Swallowing and communication disorders Skin disease sequelae [15] Digestive sequelae [15] Patients with severe COVID-19 infections appear to be hospitalized longer than usual ICU and many complications due to prolonged immobilization and prone position. It is important to gradually transition from the weaning phase to rehabilitation services – patients need to be monitored closely and accurately as they remain unstable over several years A few days after extubation.
Post Acute Covid-19 Recovery Procedures
Patients recovering from the acute respiratory effects of COVID-19 still require further recovery.
Read more about guidance for rehabilitation professionals on recovery of Covid -19 patients here [22]
Guidelines for Acute Recovery After COVID-19
All relevant healthcare professionals should evaluate each patient in the post-acute recovery unit. An appropriate and manageable treatment plan should be developed with input from the healthcare team and the patient. Immediate Respiratory and Other Effects of COVID-19 Sequelae of systemic COVID-19 (such as prolonged ICU stay on mechanical ventilation) and the comorbidities involved will guide and inform the rehabilitation plan. Other factors that affect rehabilitation planning are discharge destination and expected discharge date. [5]
- The World Health Organization and the Pan American Health Organization have produced a document on recovery considerations during the COVID-19 outbreak [3]:
- Pan American Health Organization. Rehabilitation considerations during the 2020 COVID-19 outbreak.
- The World Federation of Physiotherapy (WCPT) has also produced a fact sheet on COVID-19:
- WCPT Response to COVID-19 Briefing 2. The important role of rehabilitation and physical therapy.
- WHO Scientific Brief: Rehabilitation needs of people who have recovered from Covid -19 [23]
- This editorial provides some good insights: Two years on Covid-19: Trends in recovery[24]
- WHO: Guidelines for living with the clinical management of Covid-19 (see recovery section)
- Post-acute and subacute Covid-19 care
General Rehabilitation Considerations in the Post-Acute Period
- Patients recovering from an acute COVID-19 event may experience disability or impairment of function (respiratory function CIP CIM PICS), reduced participation and decreased quality of life (short-term and long-term post discharge)
- Variable recovery time – depends on degree of physical dysfunction (weak muscle weakness) emotional disturbance associated with normocapnic respiratory failure; presence of other comorbidities
- Daily Indicative Clinical Parameter Assessment Protocol – Body Temperature SaO2 Sp02/Fi02 Cough Dyspnea Respiration Rate Thoracic Abdominal Kinetics
- A simple and reproducible deoxygenation protocol should be used
- Rehabilitation interventions are indicated for weaned patients and patients who have been weaned off mechanical ventilation for extended periods of time to improve physical condition and the effects of prolonged immobilization
- Manual muscle testing with the MRC scale Isokinetic muscle testing to assess peripheral muscle strength; measurement of joint range of motion
- Gradually increasing the load of exercise according to subjective symptoms to help restore and maintain normal function
- Consider a telehealth system for patients who need to recover but are in isolation
- Balance function needs to be evaluated as soon as possible (especially in patients who are bedridden for a long time)
- Exercise capacity and oxygenation response during effort should be assessed
- Assessment of rehabilitation needs can be based on a basic set of measures [25]:
- Respiratory function (respiratory rate and SpO2)
- Mobility (ICU Mobility Scale)
- Muscle Strength (Medical Research Council Sumscore)
- Balance (Berg balance scale)
- Dysphagia (fluid and food trials)
- Activities of Daily Living (Barthel Index)
- Psychiatric and cognitive impairment (Montreal Cognitive Assessment Hospital Anxiety and Depression Scale PTSD Checklist 5)
Respiratory rehabilitation
It is advised not to start respiratory rehabilitation too early to avoid exacerbating respiratory distress or spreading the virus unnecessarily. Techniques such as diaphragmatic breathing Pout breathing Bronchial hygiene Lung expansion techniques (positive expiratory pressure) Manual mobilization of thoracic respiratory muscles and aerobic exercise with incentive spirometer are not recommended in the acute phase. In case of comorbidities such as bronchiectasis secondary to pneumonia or aspiration of increased secretions positional drainage and standing (gradual increasing time) may help with secretion management. [26]
Respiratory assessment for post-acute rehabilitation should include [1][26]:
- Dyspnea
- Thoracic activity
- Diaphragmatic activity and amplitude
- Respiratory muscle strength (maximum inspiratory and expiratory pressures)
- Respiratory pattern and frequency
Also includes an assessment of their heart condition
In the post-acute phase, respiratory rehabilitation may include the following:
- Inspiratory muscle training if inspiratory muscle weakness
- Diaphragmatic breathing
- Chest expansion (shoulder elevation)
- Mobilisation of respiratory muscles
- Airway clearance techniques (as needed)
- A positive exhalation device can be added if desired
Be careful not to overload the respiratory system and cause respiratory distress!
A randomized controlled trial from China implemented a respiratory rehabilitation program consisting of 10-minute sessions twice weekly for 6 weeks after discharge from emergency care. Results of the study showed significant improvements in respiratory function, endurance, quality of life and depression. Respiratory rehabilitation programs include respiratory muscle training and positive expiratory pressure devices cough exercises diaphragm training chest stretches and pout breathing [27]
Aspects of close patient monitoring include [26]:
- Shortness of breath
- Decreased SaO2 (<95%)
- Blood pressure (< 90/60 or > 140/90)
- Heart rate (>100 beats per minute)
- Temperature (> 37.2 C)
- Excessive fatigue
- Chest pain
- Severe cough
- Blurred vision
- Dizziness
- Heart palpitations
- Sweating
- Loss of balance
- Headache
Patients recovering from the acute phase can begin a multidisciplinary team rehabilitation program. Concepts of pulmonary rehabilitation can be applied, but keep in mind that formal pre-rehabilitation assessments such as lung function and exercise testing may not be feasible initially and cannot in infectious patients. Athletic training may have to begin with relatively simple graded functional and strength training with no or minimal equipment. [28]
Read more: Pulmonary rehabilitation for post-COVID-19 patients [29]
Functional rehabilitation
The European Respiratory Society recommendations for functional rehabilitation include:
- Assess motor and functional capacity
- Monitoring of pre-existing conditions
- Athletic training and/or physical activity instruction
Aspects of functional rehabilitation to be assessed [1]:
- Muscle and joint range of motion
- Strength testing
- Balance
- Exercise capacity – assessed by 6-minute walk test (includes continuous oxygen saturation monitoring)
- Cardiopulmonary exercise testing
- Activities of Daily Living (ADL)
Clinical outcome measures
Easy-to-apply tests are recommended, as advanced equipment to assess a patient’s functional capacity may not be available or safe during the pandemic. Clinical outcome measures that can be used [1][30]:
- Patient-specific functional scales to determine perceived limitations in activities of daily living
- Monitor patient oxygen saturation and heart rate frequency before and after physical activity and exercise
- Treat Shortness of Breath and Fatigue with the Borg Scale CR10
- International Physical Activity Questionnaire for Measuring Functioning and Disability
- Physical Activity Scale for the Elderly to Measure Functioning and Disability
- Berg Balance Scale[31]
- 6-minute walk test – assesses exercise capacity [31]
- Barthel Index to measure ADL
- Short Physical Performance Battery
- 30 seconds sit to stand test
- Handgrip dynamometer test
- Manual muscle strength test
The goal of a multidisciplinary team should be to use the same clinical results for the same structure to facilitate communication among team members without unnecessarily burdening the patient.
Read more: Functional outcomes in an inpatient rehabilitation setting after severe COVID-19 infection [31]
Specific Physiotherapy Interventions
- Ways of early mobilisation include[32]:
- Frequent posture changes
- Bed mobility
- Sit to stand
- Simple bed exercises
- ADL’s
It is important to monitor the patient’s respiratory and hemodynamic status during recovery!
- Active physical exercise should be followed by progressive muscle strengthening (suggested program 8-12 RM load, 8-12 repetitions, 1 to 3 sets, 2 minutes rest between sets, 3 times per week for 6 weeks)[1]
- Neuromuscular electrical stimulation can be used to help build strength.
- Aerobic exercise can be achieved with a walking cycle or an arm ergometer NuStep cross trainer
- Initially keep aerobic exercise to less than 3 metabolic equivalent tasks (METs)
- Progressive aerobic exercise can be increased to 20-30 minutes later
- Energy Conservation and Behavior Correction Education [5]
Advice on exercise as medicine
- Activities of daily living and physical function gradually increase
- Provide patients with exercises that help restore daily function
- All activities should be well monitored, especially in PICS patients
- Exercise at low to moderate intensity and of limited duration. Keep in mind that patients admitted to the ICU with symptoms of PICS have very low capacity for mobility and exercise.
- The patient’s activity level prior to infection with COVID-19, the patient’s needs, and the patient’s current physical ability will determine the specific parameters of the exercise prescription
- Because patients have decreased lung function after COVID-19 infection and cardiac function may be affected after COVID-19 infection, a maximum Borg scale CR10 score of 4/10 is recommended for shortness of breath and fatigue in the post-acute recovery phase.
- Maximal exercise testing not performed after active COVID-19 infection – limited due to pandemic. Therefore, there is not always enough clinical information to determine the specific parameters of a patient’s exercise prescription, nor is it possible to estimate the risks involved in physical activity Moderate/High Intensity Training.
- Exercises that prescribe training parameters regarding frequency, intensity, time/duration and type [30]
Multidisciplinary team involvement
Multiple members of the multidisciplinary team will be involved in the post-acute recovery phase of a severely ill COVID-19 survivor. Some of these team members include [22]:
- Occupational therapists
- Focus ADL and instrumental ADL guidance
- Interventions to Promote Functional Independence
- Helping patients prepare for discharge
- Can address cognitive changes
- Speech and Language Pathologist/Therapist
- Evaluation and treatment of intubation-induced dysphagia
- Evaluation and treatment of voice impairment due to prolonged intubation
- Address communication issues
- Patients should be educated about a healthy lifestyle and the importance of family and social participation.
- Occupational therapists social workers or rehabilitation psychologists should provide psychological interventions according to the needs of patients.
- The Chinese came up with TCM techniques (Tai Chi Qigong guided breathing)
Actions by rehabilitation service providers
These are actions that rehabilitation facilities, private clinics, and hospitals can take during the COVID-19 pandemic to improve and ensure quality care. [3]
- Stay informed about the status of the COVID-19 outbreak and regional and national guidance
- Connect with all relevant COVID-19 coordinating bodies and networks
- Source dissemination and enforcement of COVID-19 guidelines and protocols
- Ensure frequent communication with patients and distribute important information
- Rehabilitation should incorporate infection prevention and control (IPC) measures and healthcare workers should use personal protective equipment (PPE) appropriate to their risk exposure
- Protocols have been set for IPC (for whom, when and how)
- Rehabilitation professionals such as physiotherapists may be involved in the delivery of Aerosol Generating Procedures (AGP), for which basic PPE is required
- Recovered individuals (and family members) should be prioritized for COVID-19 testing
- IPC training is critical for all rehabilitation professionals
- Increasing the rehabilitation workforce in the post-acute recovery and long-term recovery phases of post-COVID-19
- Address workforce shortages
- Find rehabilitation professionals from fields such as retirement, workforce, interns, academics, private practice, and more.
- Competency-based training and supervision for professionals rejoining the rehabilitation workforce or changing roles to provide support
- Ensure productivity of existing workforce by implementing measures such as deferring leave, modifying shift structure, increasing part-time contracts to full-time
References
- ↑ Jump up to:1.0 1.1 1.2 1.3 1.4 1.5 Vitacca M, Lazzeri M, Guffanti E, Frigerio P, D’Abrosca F, Gianola S, Carone M, Paneroni M, Ceriana P, Pasqua F, Banfi P, Gigliotti F, Simonelli C, Cirio S, Rossi V, Beccaluva CG, Retucci M, Santambrogio M, Lanza A, Gallo F, Fumagalli A, Mantero M, Castellini G, Calabrese M, Castellana G, Volpato E, Ciriello M, Garofano M, Clini E, Ambrosino N, ARIR (Associazione Riabilitatori dell’Insufficienza Respiratoria), SIP (Società Italiana di Pneumologia) AIFI (Associazione Italiana Fisioterapisti) and SIFIR (Società Italiana di Fisioterapia e Riabilitazione) on behalf of A (Associazione IPO. Italian suggestions for pulmonary rehabilitation in COVID-19 patients recovering from acute respiratory failure: results of a Delphi process. Monaldi Arch Chest Dis [Internet]. 2020 Jun.23;90(2). Available from: https://www.monaldi-archives.org/index.php/macd/article/view/1444
- ↑ World Health Organization. Rehabilitation 2030: A Call for Action. Meeting report. 2017. Feb 6-7. Available from https://www.who.int/rehabilitation/rehab-2030-call-for-action/en/ (last accessed 24 June 2020)
- ↑ Jump up to:3.0 3.1 3.2 Pan American Health Organisation. Rehabilitation considerations during the COVID-19 outbreak.2020. 26 Apr. (last accessed 24 June 2020)
- ↑ Jump up to:4.0 4.1 World Confederation for Physical Therapy (WCPT). WCPT response to COVID-19 Briefing paper 2. Rehabilitation and the vital role of Physiotherapy. May 2020. (last accessed 24 June 2020)
- ↑ Jump up to:5.0 5.1 5.2 5.3 5.4 Sheehy LM. Considerations for postacute rehabilitation for survivors of COVID-19. JMIR public health and surveillance. 2020;6(2):e19462.
- ↑ Jump up to:6.0 6.1 Kakodkar P, Kaka N, Baig MN. A comprehensive literature review on the clinical presentation, and management of the pandemic coronavirus disease 2019 (COVID-19). Cureus. 2020 Apr;12(4).
- ↑ Jump up to:7.0 7.1 Adab P, Haroon S, O’Hara ME, Jordan RE. Comorbidities and Covid-19. BMJ. 2022 Jun 15;377.
- ↑ Rabaan AA, Bakhrebah MA, Mutair AA, Alhumaid S, Al-Jishi JM, AlSihati J, Albayat H, Alsheheri A, Aljeldah M, Garout M, Alfouzan WA. Systematic review on pathophysiological complications in severe COVID-19 among the non-vaccinated and vaccinated population. Vaccines. 2022 Jun 21;10(7):985.
- ↑ Connolly B, O’neill B, Salisbury L, Blackwood B. Physical rehabilitation interventions for adult patients during critical illness: an overview of systematic reviews. Thorax. 2016 Oct 1;71(10):881-90.
- ↑ Jump up to:10.0 10.1 10.2 Shepherd S, Batra A, Lerner DP. Review of critical illness myopathy and neuropathy. The Neurohospitalist. 2017 Jan;7(1):41-8.
- ↑ Jump up to:11.0 11.1 11.2 Cheung K, Rathbone A, Melanson M, Trier J, Ritsma BR, Allen MD. Pathophysiology and management of critical illness polyneuropathy and myopathy. Journal of Applied Physiology. 2021 May 1;130(5):1479-89.
- ↑ Jump up to:12.0 12.1 12.2 12.3 12.4 Stam H, Stucki G, Bickenbach J. Covid-19 and post intensive care syndrome: A call for action. Journal of Rehabilitation Medicine. 2020 Apr 14.
- ↑ Vrettou CS, Mantziou V, Vassiliou AG, Orfanos SE, Kotanidou A, Dimopoulou I. Post-Intensive Care Syndrome in Survivors from Critical Illness including COVID-19 Patients: A Narrative Review. Life. 2022 Jan 12;12(1):107.
- ↑ Shi S, Qin M, Shen B, Cai Y, Liu T, Yang F, Gong W, Liu X, Liang J, Zhao Q, Huang H. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA cardiology. 2020 Mar 25.
- ↑ Jump up to:15.0 15.1 15.2 15.3 15.4 15.5 15.6 15.7 15.8 Yang T, Yan MZ, Li X, Lau EH. Sequelae of COVID-19 among previously hospitalized patients up to 1 year after discharge: a systematic review and meta-analysis. Infection. 2022 Jun 24:1-43.
- ↑ Jump up to:16.0 16.1 Chang MC, Park D. How should rehabilitative departments of hospitals prepare for coronavirus disease 2019?. American journal of physical medicine & rehabilitation. 2020 Jun;99(6):475.
- ↑ Herman C, Mayer K, Sarwal A. Scoping review of prevalence of neurologic comorbidities in patients hospitalized for COVID-19. Neurology. 2020 Apr 24.
- ↑ Ahmad SJ, Feigen CM, Vazquez JP, Kobets AJ, Altschul DJ. Neurological Sequelae of COVID-19. Journal of Integrative Neuroscience. 2022 Apr 6;21(3):77.
- ↑ Simonelli C, Paneroni M, Fokom AG, Saleri M, Speltoni I, Favero I, Garofali F, Scalvini S, Vitacca M. How the COVID-19 infection tsunami revolutionized the work of respiratory physiotherapists: an experience from Northern Italy. Monaldi Archives for Chest Disease. 2020 May 19;90(2).
- ↑ Jump up to:20.0 20.1 Hasan LK, Deadwiler B, Haratian A, Bolia IK, Weber AE, Petrigliano FA. Effects of COVID-19 on the musculoskeletal system: clinician’s guide. Orthopedic Research and Reviews. 2021;13:141.
- ↑ Jump up to:21.0 21.1 Kiekens C, Boldrini P, Andreoli A, Avesani R, Gamna F, Grandi M, Lombardi F, Lusuardi M, Molteni F, Perboni A, Negrini S. Rehabilitation and respiratory management in the acute and early post-acute phase.“Instant paper from the field” on rehabilitation answers to the Covid-19 emergency. Eur J Phys Rehabil Med. 2020 Apr 15:06305-4.
- ↑ Jump up to:22.0 22.1 Kho, M.E., Brooks, D., Namasivayam-MacDonald, A., Sangrar, R. and Vrkljan, B.Rehabilitation for Patients with COVID-19. Guidance for Occupational Therapists, Physical Therapists, Speech-Language Pathologists and Assistants. School of Rehabilitation Science, McMaster University. 2020. May 6 Available from https://srs-mcmaster.ca/covid-19/ (last accessed 24 June 2020)
- ↑ World Health Organization. Rehabilitation needs of people recovering from COVID-19: scientific brief, 29 November 2021. World Health Organization; 2021.
- ↑ Polastri M, Ciasca A, Nava S, Andreoli E. Two years of COVID-19: trends in rehabilitation. Pulmonology. 2022 Feb 3.
- ↑ World Health Organization. Clinical management of COVID-19: living guideline, 15 September 2022. World Health Organization; 2022.
- ↑ Jump up to:26.0 26.1 26.2 Zhao HM, Xie YX, Wang C. Recommendations for respiratory rehabilitation in adults with COVID-19. Chinese medical journal. 2020 Apr 3.
- ↑ Liu K, Zhang W, Yang Y, Zhang J, Li Y, Chen Y. Respiratory rehabilitation in elderly patients with COVID-19: A randomized controlled study. Complementary therapies in clinical practice. 2020 Apr 1:101166.
- ↑ Spruit M, Holland A, Singh S, Troosters T. Report of an AD hoc international Task force to develop an expert-based opinion on early and short-term rehabilitative interventions (after the acute hospital setting) in COVID 19 survivors, 2020.
- ↑ Soril LJ, Stickland MK. Pulmonary Rehabilitation for Post-COVID-19 Patients.
- ↑ Jump up to:30.0 30.1 Royal Dutch Society for Physiotherapy 2020. KNGF position statement: Physiotherapy recommendations in patients with COVID-19. Amersfoort, Netherlands: KNGF. https://www.kngf.nl/kennisplatform/guidelines
- ↑ Jump up to:31.0 31.1 31.2 Olezene CS, Hansen E, Steere HK, Giacino JT, Polich GR, Borg-Stein J, Zafonte RD, Schneider JC. Functional outcomes in the inpatient rehabilitation setting following severe COVID-19 infection. PLoS One. 2021 Mar 31;16(3):e0248824.
- ↑ Felten-Barentsz KM, van Oorsouw R, Klooster E, Koenders N, Driehuis F, Hulzebos EH, van der Schaaf M, Hoogeboom TJ, van der Wees PJ. Recommendations for Hospital-Based Physical Therapists Managing Patients With COVID-19. Physical Therapy. 2020 Jun 18.