key: cord-0048705-x7kwfn1r authors: Liebl, Max Emanuel; Gutenbrunner, Christoph; Glaesener, Jean Jacques; Schwarzkopf, Susanne; Best, Norman; Lichti, Gabriele; Kraft, Eduard; Krischak, Gert; Reißhauer, Anett title: Early Rehabilitation in COVID-19 – Best Practice Recommendations for the Early Rehabilitation of COVID-19 Patients date: 2020-05-05 journal: nan DOI: 10.1055/a-1162-4919 sha: 7e8cbd9dcb21949866e24b711b1df090b15ab8e5 doc_id: 48705 cord_uid: x7kwfn1r The COVID-19 pandemic poses new challenges to physical medicine, physiotherapy, and acute care rehabilitation in rehabilitation clinics as well as in hospitals. We have to assume that COVID-19 patients may need early mobilization and acute care rehabilitation, despite of a possible scarcity of suitable facilities or services. It is the aim of this article to provide conceptual suggestions for the early rehabilitation of COVID-19, combining the existing experience in the acute care rehabilitation of patients with respiratory infections with the currently available sources and experience. These recommendations comprise a checklist of logistical and organisational preparations, aspects of infectivity and personal protective equipment, adjustment of the patients’ surroundings, interprofessional team work and co-therapy, respiratory therapy, mobilisation, activating care, ADL training, training intensity, and psychosocial management. und frührehabilitativer Behandlung auszugehen, auch wenn vorhandene Strukturen bislang nicht fl ächendeckend solche Komplexbehandlungen vorsahen. Aus den Erfahrungen aus der fachübergreifenden Frührehabilitation in der Behandlung von Patienten mit möglicherweise vergleichbaren Atemwegs erkrankungen in Verbindung mit aktuell verfügbaren Quellen und Erfahrungen sollen therapeutisch-konzeptuelle Hinweise für die Behandlung von Patient/innen mit COVID-19 abgeleitet werden. Die Empfehlungen betreff en: Logistische Vorbereitung (Mitarbeiterumgang und -schulungen), Infektiosität und persönliche Schutzausrüstung, Umgebungsanpassung, inter professionelles Arbeiten und Co-Therapie, Atemtherapie, Mo bilisierung, aktivierende Pflege und ADL, Trainingsintensität, psychosoziales Management. Due to the early phase of the pandemic (beginning of April 2020), scientific evidence of physical and rehabilitative medicine in pa tients with Covid-19 is sparse. These recommendations should therefore be seen as best practice based on the experience of early rehabilitation after pulmonary infectious diseases, especially acute respiratory distress syndrome (ARDS). However, there are a number of recommendations for the early functional treatment of patients with COVID-19 up to now, includ ing publications from the WHO, different scientific societies, and Chinese sources [1] [2] [3] [4] [5] [6] [7] [8] [9] . With increasing expertise and scientific evidence, continuous updates of this paper are necessary. ▪ Normal wards of hospitals treating COVID-19 ▪ Early (sub-acute) rehabilitation and physiotherapy depart ments in hospitals ▪ Rehabilitation facilities treating COVID-19 patients During the pandemic, hospitals and rehabilitation facilities are facing completely new challenges with regard to physical medicine, physiotherapeutic and early rehabilitation care. German legislation has also denominated rehabilitation facili ties to serve as standby hospitals (in accordance with §22 Kranken hausgesetz) for the treatment of COVID-19. Additionally, nursing homes will need safe protection strategies, with the consequence that only proven negative cases will be trans ferred there from hospitals. In some places there is even a complete admission ban. This can lead to a prolonged length of stay of COVID-19 patients in hospitals. In the treatment of hospitalized COVID-19 patients, early mo bilization and early rehabilitation are expected to be necessary. This poses new challenges if there are no adequate pre-existing struc tures for such treatments. Rehabilitation clinics will most likely play a role in the early re habilitation of patients with COVID-19 and in some cases also in the late acute phase of COVID-19 disease. Departments for physical and rehabilitative medicine and for physiotherapy in hospitals are already required during acute treat ment, especially in inter-professional cooperation in the intensive care sector, and must also develop ad hoc concepts for effective early mobilisation and rehabilitation of patients. Consecutively, the importance of early rehabilitation is not limited to the individual case, but contributes to increasing hospital capacities by reducing the length of stay in hospital. In the rehabilitation sector, mainly neurological rehabilitation clinics with phase-B early rehabilitation have the necessary expertise in early rehabilitation. In Germany, there is no experience in the field of early post-treat ment of COVID-19 until this date, but there is experience in the in terdisciplinary early rehabilitation of patients, e. g. after complicated influenza pneumonia, who had a similar risk constellation of multimorbidity and acute respiratory distress syndrome and who had an indication for early rehabilitation after intensive care ther apy, ventilation and often sepsis (in the context of bacterial super infections) [10] [11] [12] [13] . In the practice, rehabilitation will be necessary for patients with isolated COVID-19 disease, but also for patients with underlying multimorbidity. In this case, it may be necessary to react to differ ent rehabilitation needs concerning their underlying conditions on the one hand and the Covid-19 rehabilitation on the other. First ex periences of COVID-19 patients from the USA (Seattle) after ICU treatment show inpatient treatment courses of more than 14 days after transfer from intensive care [14] . To derive therapeutic concepts for the treatment of patients with COVID-19, based on the experience gained from the early rehabil itation in the treatment of patients with respiratory diseases in con nection with currently available sources and experiences. The following situations are not to be displayed here: ▪ the acute medical treatment of COVID-19 ▪ physical therapy measures in the intensive care unit (prone positioning, respiratory therapy, early mobilization) ▪ the phase of post-acute rehabilitation (follow-up treatment, medical rehabilitation after hospital treatment) ▪ Aftercare and longterm rehabilitation ▪ communitybased selfexercises for mild courses or after discharge from hospital or rehabilitation ▪ Palliative therapy Functioning impairments result from ▪ Organ damage: primarily the pulmonary affection, also cardiac, central nervous, etc. ▪ Pre-existing conditions and a high age of the patients This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Contact minimization and distancing rules ▪ Contact minimization is indicated within the rehabilitation team (where there is usually a high contact frequency among the staff), this requires good daily therapy planning ▪ Implement distancing regulations between patients, also supply surgical masks for patients in therapy ▪ Positioning during therapy measures in the area of the coughing impulse should be avoided ▪ Avoid unnecessary team meetings and conduct comprehen sive team meetings with distance control and adequate protective measures or as video conferences ▪ Form stable teams, avoid fluctuations ▪ Introduce digital PRM (physical and rehabilitative medicine) where possible -if necessary, also integrate smartphones, tablets of the patients in therapies (media-based self-exercise program, also video therapy instructions) -to reduce the consequences of restricted rehabilitative treatment, i. e. the stop of group treatments (applies to rehabilitation clinics) ▪ Provide aids in the patient's room, a chair or wheelchair by the bed ▪ If necessary a toilet chair in the room ▪ Therapy resources for self-exercise programme ▪ Nutritional aspects (protein-rich nutrition for training/ deconditioning) ▪ Personal protective equipment ▪ Oxygen ▪ Means of telecommunication and telerehabilitation ▪ If possible, ensure good ventilation of the rooms Interprofessional work and co-therapy ▪ Activating care and ADL training through nursing staff and occupational therapy, if necessary mutual interprofessional training ▪ Immobile patients usually require more than one therapist for transfer and mobilisation, co-therapy as distance regulations between staff cannot be fulfilled has to be documented ▪ Perform a functioningoriented assessment at admission to the early rehabilitation unit to be able to work out goalorient ed therapies ▪ Identify the premorbid functional status ▪ Identify risk constellations for relevant functional deficits, in particular -Frailty -Multimorbidity -Deconditioning due to prolonged immobility (e. g. ICU-acquired weakness, post intensive care syndrome PICS) ▪ Use patient-centered assessments that can be performed quickly and easily -if necessary, also post hoc or without additional patient contact -monitor COVID-19 symptoms (cough, fever, dyspnoea, loss of consciousness, loss of smell and taste, stuffy nose, sore throat, headache, abdominal pain, vomiting, nausea, loss of appetite, diarrhoea, conjunctivitis, skin changes, anxiety, general deconditioning) -assessment of independent mobility (e.g. Charité Mobility Index, freely available, ▶ fig. 1 ) [17] [18] [19] . -assessment of ADL (e. Sitting on edge of bed 3 Transfer to edge of bed 4 Transfer from bed to chair 5 Standing up 6 Walking < 10 m 7 Walking 10 -50 m 8 Walking > 50 m 9 Climbing stairs 10 Full mobility W Wheelchair mobility ▶fig. 1 The Charité Mobility Index assesses independent mobility functions based on ICF items: Mini manual and grid. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. -The admission assessment is the very beginning of the discharge planning: foreseeable home care and support needs should be identified at an early stage and the social services should be involved -The transfer or dismissal planning may have to be adjusted to the infection status. It is necessary to demand that "COVID-19 rehabilitation clinics" be defined in order to achieve a cohorting of the still infectious patients and to avert transfer delays. ▪ Consider the indications and contraindications of respiratory therapy [20] [21] [22] [23] [24] . ▪ In the acute phase of COVID-19 in severe or critical cases, respiratory therapy measures that increase the total respirato ry work should be avoided. ▪ In mild cases or pneumonia with a dry cough, no respiratory secretion management is indicated. Instruct patients for selfexercise ▪ Measures designed to increase the respiratory volume are not indicated in the acute phase due to the risk of cardiac decompensation and cough provocation ▪ Respiratory therapy may be indicated e. g. in exudative coughing, in hypersecretion or limited secretion clearance, in weakened respiratory muscles, morphological imaging correlates for secretion retention, or general weakness. ▪ Teach self-exercise programmes as soon as possible ▪ Combine respiratory therapy and mobilisation/transfer training; mobilisation and "verticalisation" are fundamental for lung function ▪ if sitting at the edge of the bed have the patient use floor contact to train proprioception ▪ in immobility: passive breathing training and therapeutic positioning: -Stretching position -Drainage position -Prone position -130 ° position -mucus mobilization -Distal breathing stimuli -Passive breathing stimuli -Thermal stimuli ▪ Manual therapy (detonization techniques) of the diaphragma thoracis to optimize breathing ▪ CAVE aerosol-generating techniques. Respiratory therapy should be carried out without aids when possible (aerosol formation and virus persistence on surfaces), as long as the patient is infectious The main goal in all mobilization phases is the "verticalization" of the upper body ▪ Mobilisation with graded therapy goals (▶ fig. 2 [20] . ▪ Supply of aids (incl. long-term oxygen therapy) ▪ The supply of aids should be initiated at an early stage within the framework of discharge management (walking aids, home oxygen therapy) ▪ Most frequently prescribed aids in ARDS patients [own data]: Walking frame, rollator, wheelchair, home oxygen (LTOT), shower stool, bathtub board, toilet chair, hospital bed/care bed ▪ Check indication for long-term oxygen therapy (LTOT) in persisting hypoxemia or exertional hypoxemia with improve ment under O2 application [25, 26] . The treatment of Covid-19 patients is a considerable burden for staff, patients and relatives. Uncertainty and fears exist regarding health, consequences for the relatives/family, problems with iso lation. An increased need for co-treatment of these psychosocial factors has to be expected. ▪ Psychological and social service staff must be trained to meet the requirements of Covid-19 ▪ Create of psychosocial treatment concept for affected patients and staff according to the required treatment level ▪ Contact persons and areas of responsibility must be defined ▪ Relatives should be involved at an early stage ▪ Check whether pastoral care in hospitals should be included ▪ Establish contacts for need of emergency psychosocial care ▪ Mandatory coaching or supervision for staff should be established Physiotherapy management for COVID-19 in the acute hospital setting. Recommendations to guide clinical practice Clinical Management of severe acute respiratory infection when novel coronavirus (2019-nCoV) infection is suspected Interim Guidance V1.2 Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM): Alhazzani, et al (2020) Surviving sepsis campaign: Guidelines of the Management of Critically Ill Adults with Coronavirus Disease 2019 (COVID-19) Navigating Coronavirus Disease 2019 (Covid-19) in Physiatry: A CAN report for Inpatient Rehabilitation Facilities Prone Positioning of Patients With Acute Respira tory Distress Syndrome Postacute care preparedness for COVID-19 Facing in real time the challenges of the Covid-19 epidemic for rehabilitation Handbook of COVID-19 Prevention and Treatment -Compiled According to Clinical Experience. 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Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin e Langzeitsauerstoffthera pie. Gegenwärtige Datenlage und alltagsrelevante, praktische Aspekte Klinische psychosoziale Notfallversorgung im Rahmen von COVID19 -Handlungsempfehlun gen The authors declare that they have no conflict of interest.This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.