REHABILITATION SETTINGS DURING AND AFTER COVID-19: AN OVERVIEW OF RECOMMENDATIONS

ObjectiveThe aim of this review is to identify the best evidence to define rehabilitative approaches to acute and post-acute phases of coronavirus 2019 (COVID-19) disease.MethodsA literature search (of PubMed, Google Scholar, PEDro and Cochrane databases) was performed for relevant publications from January to April 2020.ResultsA total of 2,835 articles were retrieved, and the search resulted in a final total 31 published articles. A narrative synthesis of the selected articles was then performed. Some studies examine the effect of the pandemic on rehabilitation services and provide suggestions for a new reorganization of these services. Other studies focus on COVID-19 sequelae, formulating recommendations for rehabilitative interventions.ConclusionFor COVID-19 patients, an integrated rehabilitative process is recommended, involving a multidisciplinary and multi-professional team providing neuromuscular, cardiac, respiratory, and swallowing interventions, and psychological support, in order to improve patients’ quality of life. The intervention of a physician expert in rehabilitation should assess the patient, and a dedicated intervention set up after thorough assessment of the patient’s clinical condition, in collaboration with all rehabilitation team professionals.LAY ABSTRACTRehabilitation, in a multidisciplinary and multi-professional setting, plays a pivotal role in the management of Covid-19 patients, focusing on respiratory and motor functions and it is therefore crucial to establish treatment strategies to guarantee an optimal recovery of these patients. We performed a review of the scientific literature. All the studies concerning respiratory rehabilitation treatments for Covid-19 patients were included. Respiratory rehabilitation has the goal of improve respiratory symptoms, preserve function and reduce complications and disability; it also has positive effects on the psychological sphere, reducing anxiety and depression that can frequently develop in this context.Key words: rehabilitation, COVID-19, recommendation

In late December 2019, coronavirus 2019 (COVID-19) emerged in Wuhan, the capital city of Hubei province, China, and spread rapidly throughout the world, causing a large global outbreak and becoming a major health concern (1). In March 2020, the World Health Organization (WHO) declared COVID-19 a global pandemic and public health emergency (2).The causative agent is the newly identified severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), initially named 2019 novel coronavirus (2019-nCoV) (3). It is a non-segmented, enveloped, positive-sense single-strand RNA β-coronavirus (4), which may have been transmitted to humans from a potential reservoir in bats, through as-yet unknown intermediate hosts (5). Human-to-human transmission of COVID-19 occurs mainly through the respiratory tract, by inhalation of infected droplets (from symptomatic, but also asymptomatic people) and through direct contact (6, 7). The estimated incubation period is 1–14 days, mainly in the range 3–7 days (8).COVID-19 infection displays a prevalence of respiratory involvement, being responsible for interstitial pneumonia, the major manifestation of the disease, which first led to identification of the pathogen (3, 9). It causes various degrees of illness, with a clinical picture ranging from asymptomatic cases to acute respiratory distress syndrome (ARDS) and multi-organ failure (10).Symptoms include fever and dry cough (dominant manifestations), anosmia, sore throat, upper airway congestion, fatigue, headache, muscle ache, shortness of breath, and other signs of upper respiratory tract infection. Progression to pneumonia (mainly occurring in the second or third week of a symptomatic infection) (10, 11) is associated with a reduction in oxygen saturation, reduction in arterial blood gas exchange, extreme increase in inflammatory markers, and lymphopaenia (10). The clinical picture also correlates with bilateral ground glass opacities and patchy consolidations, seen on chest computed tomography (CT) (12, 13).Diagnosis of COVID-19 infection can be made only through nucleic acid detection by real-time polymerase chain reaction (RT-PCR) in respiratory tract samples.Since there is currently no approved treatment for COVID-19, management of the disease is based on symptomatic and supportive treatments, mainly targeted at preserving hydration and nutrition and controlling fever and respiratory symptoms. Oxygen or non-invasive ventilation are necessary for hypoxic patients. In most severe cases mechanical ventilation is required, and even extra-corporeal membrane oxygen (ECMO), which is recommended by the WHO for patients with refractory hypoxaemia (14). Elderly people and patients with underlying comorbidities are more susceptible to developing complications, including ARDS, acute kidney injury, arrhythmias, cardiac injury, and liver dysfunction (15, 16).Patients may undergo prolonged bed rest, leading to immobilization syndrome (17) associated with respiratory dysfunction, both of which might require rehabilitation interventions. Prolonged immobilization leads to muscle weakness, motor deconditioning, balance and postural impairment, and joint stiffness, pain and limitation, which have a strong impact on patients’ general condition (17, 18).Post-intensive care syndrome (PICS) refers to a new or worsening impairment of patient’s physical, cognitive, or mental health status arising during stay in the intensive care unit (ICU) and persisting beyond ICU discharge or hospital discharge. These patients undergo various degrees of respiratory, physical and psychological distress (19, 20). It is essential that any rehabilitative intervention is customized to the specific condition of each patient, and that this should take into account, as already observed in SARS-CoV and MERS-CoV, that SARS-CoV-2 may also have a neurotropic effect, leading to neurological involvement, which may be partially responsible for acute respiratory failure in COVID-19 patients (21).Indeed, it has recently been observed that SARSCoV-2 is involved in neurological manifestations (22) in COVID-19 patients, including in the central nervous system (CNS) (e.g. dizziness, headache, impaired consciousness, acute cerebrovascular disease, ataxia, and seizure), peripheral nervous system (PNS) (e.g. impairments of taste, smell and vision, and nerve pain), and skeletal muscle injury (23). Cases of viral encephalitis and infectious toxic encephalopathy have been reported (24). Patients who had cerebrovascular disease were older, developed severe COVID-19 and underlying disorders, an increased inflammatory response, and a hypercoagulable state (25, 26). Neurological manifestations, apart from cerebrovascular disease and impairment of consciousness, have been reported early in the illness prior to the onset of COVID-19-related symptoms (23). Hence it is important to evaluate patients who present with neurological symptoms, to assess risk factors (25) and underlying disorders that indicate an early diagnosis of COVID-19 (23), enabling the recognition and management of complications and improving the prognosis (24).The ongoing COVID-19 pandemic is placing great stress on healthcare systems, especially acute care departments, and is already having an impact on the rehabilitation community (17, 18, 27). In a multidisciplinary and multi-professional setting, rehabilitation plays a pivotal role in the management of patients with COVID-19, focusing on respiratory and motor functions. It is therefore crucial to establish rehabilitation treatment strategies that enable optimal recovery of these patients.The aim of this study was to review the literature on COVID-19, in order to identify best evidence to define rehabilitative approaches to acute and post-acute phases of the disease.