Providing rehabilitation to patients recovering from COVID‐19: A scoping review

Abstract

Objective

To synthesize the nature and extent of research on rehabilitation care provision to patients with COVID‐19. Specifically, we aimed to (1) describe the impact of COVID on patients and associated rehabilitation needs, (2) outline the adaptations and preparations required to enable the provision of COVID rehabilitation, (3) describe the types of rehabilitation services and treatments provided to COVID patients, and (4) identify barriers and facilitators to delivering COVID rehabilitation.

Literature Survey

We searched Medline, PsychINFO, Embase, and CINAHL on June 26, 2020 using key words such as “rehabilitation,” “physical medicine,” “allied health professionals,” and variations of “COVID.” The search was updated on October 13, 2020. We included articles published in English and that focused on some aspect of COVID rehabilitation for adults. We excluded articles focused on pediatric populations and those not focused (or minimally focused) on rehabilitation for COVID patients.

Methodology

Data were charted based on article type (ie, primary data, secondary data, guidelines). Key information extracted included (1) COVID sequelae; (2) rehabilitation adaptations; (3) structure, function, and content of rehabilitation services/programs; (4) facilitators and/or barriers to providing COVID rehabilitation; and (5) recommendations for COVID rehabilitation programming. Data were synthesized narratively.

Synthesis

In total, 128 articles were included in the review that reported primary data (n = 33), secondary data (n = 82), and clinical practice/patient self‐management guidelines (n = 13). Evidence begins to suggest that rehabilitation is necessary and valuable for addressing COVID‐related declines in health, function, and well‐being. Most articles recommended that an individualized rehabilitation program be provided across the continuum of care by an interdisciplinary team of professionals and that the nature and extent of rehabilitation be informed by the care setting and COVID severity. Most issues that challenged COVID rehabilitation delivery were directly addressed by the facilitators and adaptations identified.

Conclusions

Future recommendations include a greater emphasis on the psychosocial aspects of COVID rehabilitation, inclusion of families in rehabilitation planning, and the use of qualitative approaches to complement clinical data.

BACKGROUND

The COVID‐19 pandemic has required a rapid and drastic response by health care systems worldwide, including major changes in how organizations and staff function and deliver patient care. ¹ Growing evidence indicates that many survivors are experiencing “long COVID” (ie, lasting and debilitating symptoms that impede both physical and emotional recovery). ² In turn, rehabilitation is being recognized as a pivotal aspect of the postacute COVID ³ , ⁴ response. Critically ill patients with COVID are typically ventilated for longer than other patients requiring care in the intensive care unit (ICU), which can lead to higher levels of physical deconditioning. ⁵ They also experience neurological and respiratory impairments, increasing the likelihood of a more complex and prolonged recovery. ⁵ Existing evidence on sepsis (which has an inpatient mortality rate similar to that of COVID) indicates that 30% of hospitalized patients require posacute care. ⁶ In the United Kingdom, it is estimated that 45% of COVID patients will need some form of rehabilitation and that 4% will require more specialized and long‐term rehabilitation in an inpatient setting. ⁵

Unfortunately, rehabilitation is often underemphasized in global disaster planning and responses, and the need for rehabilitation is often not recognized until many months after a disaster. ⁷ Yet rehabilitation is a key component of standard care delivery pathways and in other populations improves independence, facilitates community reintegration, and mitigates long‐term disability. ⁸ For patients with COVID, rehabilitation can improve functional capacity, address the effects of deconditioning after prolonged ICU stays, and alleviate stress by providing patients with needed support throughout recovery. ⁹ Collectively, this can potentially facilitate patients' return to home and vocational activities. Rehabilitation has been described as a necessity and right in the context of the COVID pandemic, and it is recommended that it be routinely incorporated into pandemic response plans early on before widespread disability. ⁵

The COVID care pathway is complicated by several issues including (1) a lack of clarity around the patients' eligibility for rehabilitation,¹⁰ (2) the ability of rehabilitation facilities/units to adapt and prepare for COVID patients, and (3) the impact of physical distancing on the provision of rehabilitation treatments and community discharge support. In light of the mounting recognition that rehabilitation will play a key role in COVID patients' recovery, many studies and practice guidelines have begun to address these issues. By synthesizing information across these data sources, our scoping review aims to provide rehabilitation practitioners with a comprehensive review of the evidence to support the ongoing rehabilitation response to the pandemic.

STUDY GOAL AND OBJECTIVES

Our goal was to synthesize the nature and extent of research on rehabilitation care provision to COVID patients. Specifically, we aimed to:

1. Describe the impact of COVID on patients and associated rehabilitation needs;

2. Outline the adaptations and preparations required to enable the provision of COVID rehabilitation;

3. Describe the types of rehabilitation services and treatments provided to patients with COVID; and

4. Identify barriers and facilitators to delivering COVID rehabilitation.

METHODS

We followed Arksey and O'Malley's methodological framework for conducting scoping reviews. ¹¹ The framework entails five stages: (1) identifying the research questions; (2) identifying relevant studies; (3) study selection; (4) charting the data; and (5) collating, summarizing, and reporting the results. We searched Medline, PsychINFO, Embase, and CINAHL on June 26, 2020. For stage 2, the search strategy was tailored to each database using key terms that included “rehabilitation,” “physical medicine,” “allied health professionals,” and variations of “COVID‐19” (see Appendix A for Medline search strategy). For stage 3, articles were included if they were in English and focused on some aspect of rehabilitation care specifically for COVID patients. Research articles reporting both primary and secondary data were included. Articles were excluded if they were (1) not focused on the COVID pandemic, (2) not focused on the field of rehabilitation, (3) not focused on rehabilitation for COVID patients (ie, focused on some aspect of rehabilitation in the context of the pandemic but not on care for COVID patients themselves), and (4) focused on a pediatric population.

The database searches produced 1399 studies for consideration. After duplicates were eliminated, 1167 articles remained. A two‐phase screening process was undertaken. For phase 1, M.B.W. reviewed the title and abstracts to determine if they were eligible for full‐text review. This resulted in the identification of 252 articles for full‐text review. For phase 2, M.B.W. and S.R.C. first screened 10% of the articles to establish interrater reliability (k = 0.746, 88% agreement). Discrepancies were resolved by discussing the abstract(s) in question and coming to a consensus. M.B.W. and S.R.C. then proceeded to screen the remainder of the articles, where 57 met the inclusion/exclusion criteria and were included in the review. Our hand search identified an additional 11 articles for inclusion in the review. In total, 68 studies were included. We conducted an updated search on October 13, 2020. After screening and full‐text review (conducted by S.R.C. and K.M.K.), we identified an additional 60 articles for inclusion. In total, we included 128 articles in our review. See Figure 1 for a Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) Flow Diagram of article selection.

FIGURE 1.

Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) flow diagram

For stage 4, we used a data abstraction chart to extract relevant information from studies (eg, sample details, rehabilitation program details). For stage 5, we employed a narrative synthesis of the included studies to answer the research questions. ¹² Analysis was an iterative process of combining, categorizing, summarizing, and comparing information across studies.

RESULTS

Study demographics

The initial search on June 26, 2020 produced 1167 articles after deduplication, of which 68 met the inclusion/exclusion criteria. Our updated search on October 13, 2020 produced 2501 articles after deduplication, of which 60 met the inclusion/exclusion criteria. In total, we included 128 articles in our review (see Figure 1 for PRISMA diagram). ³ , ⁴ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²² , ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³² , ³³ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴¹ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵⁰ , ⁵¹ , ⁵² , ⁵³ , ⁵⁴ , ⁵⁵ , ⁵⁶ , ⁵⁷ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶¹ , ⁶² , ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁶⁹ , ⁷⁰ , ⁷¹ , ⁷² , ⁷³ , ⁷⁴ , ⁷⁵ , ⁷⁶ , ⁷⁷ , ⁷⁸ , ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸² , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁷ , ⁸⁸ , ⁸⁹ , ⁹⁰ , ⁹¹ , ⁹² , ⁹³ , ⁹⁴ , ⁹⁵ , ⁹⁶ , ⁹⁷ , ⁹⁸ , ⁹⁹ , ¹⁰⁰ , ¹⁰¹ , ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ , ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁸ , ¹⁰⁹ , ¹¹⁰ , ¹¹¹ , ¹¹² , ¹¹³ , ¹¹⁴ , ¹¹⁵ , ¹¹⁶ , ¹¹⁷ , ¹¹⁸ , ¹¹⁹ , ¹²⁰ , ¹²¹ , ¹²² , ¹²³ , ¹²⁴ , ¹²⁵ , ¹²⁶ , ¹²⁷ , ¹²⁸ , ¹²⁹ , ¹³⁰ , ¹³¹ , ¹³² , ¹³³ , ¹³⁴ , ¹³⁵ , ¹³⁶ , ¹³⁷ , ¹³⁸ With respect to article type, 33 were primary data articles (ie, observational studies, case reports), ²² , ²⁴ , ³³ , ⁴¹ , ⁵¹ , ⁵⁵ , ⁵⁷ , ⁶³ , ⁶⁹ , ⁷⁸ , ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸² , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁷ , ⁸⁸ , ⁸⁹ , ¹¹⁵ , ¹¹⁷ , ¹¹⁹ , ¹²⁷ , ¹²⁸ , ¹²⁹ , ¹³¹ , ¹³² , ¹³⁴ , ¹³⁶ , ¹³⁷ , ¹³⁸ 82 were secondary articles (ie, reviews, letters to the editor that did not report results of an original research project, commentaries) ³ , ⁴ , ¹⁴ , ¹⁷ , ¹⁸ , ¹⁹ , ²⁰ , ²¹ , ²⁵ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³¹ , ³⁴ , ³⁵ , ³⁶ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ , ⁴² , ⁴³ , ⁴⁴ , ⁴⁵ , ⁴⁶ , ⁴⁷ , ⁴⁸ , ⁴⁹ , ⁵³ , ⁵⁴ , ⁵⁶ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶² , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷ , ⁶⁸ , ⁷⁰ , ⁷¹ , ⁷³ , ⁷⁴ , ⁷⁵ , ⁹⁰ , ⁹² , ⁹³ , ⁹⁴ , ⁹⁵ , ⁹⁶ , ⁹⁷ , ⁹⁸ , ⁹⁹ , ¹⁰⁰ , ¹⁰¹ , ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ , ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁸ , ¹⁰⁹ , ¹¹⁰ , ¹¹¹ , ¹¹² , ¹¹³ , ¹¹⁴ , ¹¹⁶ , ¹¹⁸ , ¹²⁰ , ¹²¹ , ¹²² , ¹²³ , ¹²⁴ , ¹²⁵ , ¹²⁶ , ¹³⁰ , ¹³³ , ¹³⁵ and 13 were articles reporting guidelines for rehabilitation in COVID patients. ¹³ , ¹⁵ , ¹⁶ , ²³ , ²⁶ , ³² , ⁵⁰ , ⁵² , ⁶¹ , ⁷² , ⁷⁶ , ⁷⁷ , ⁹¹ Details pertaining to the geographic distribution of research can be found in Table 1.

TABLE 1.

Geographic distribution of COVID rehabilitation research

Continent	Country	Articles (N)	Citations
Europe (n = 54)	Italy	24	3, 14, 18, 19, 24, 29, 36, 43, 44, 48, 51, 54, 60, 63, 68, 69, 94, 110, 111, 114, 117, 119, 121, 122
	United Kingdom	17	16, 23, 25, 30, 34, 52, 57, 61, 70, 71, 72, 80, 95, 97, 104, 108, 109
	Turkey	4	15 , 20 , 67 , 118
	Spain	2	90 , 100
	France	2	38, 55
	Denmark	1	26
	Greece	1	33
	Switzerland	1	84
	Netherlands	1	17
	Multi‐country	1	21
Asia (n = 33)	China	14	22, 40, 41, 56, 74, 75, 77, 78, 89, 96, 98, 128, 134, 135
	Japan	6	47, 49, 85, 103, 136, 137
	India	4	31, 99, 126, 127
	Singapore	3	87, 132, 138
	Korea	1	115
	Taiwan	1	120
	Iran	1	58
	Nepal	1	107
	Philippines	1	37
	Israel	1	133
The Americas (n = 31)	United States	21	27, 28, 39, 42, 45, 46, 64, 65, 73, 79, 81, 82, 83, 86, 92, 102, 112, 123, 129, 130, 131
	Canada	4	4 , 32 , 62 , 93
	Brazil	4	53 , 59 , 101 , 125
	Multicountry	2	50 , 91
Australia (n = 5)	Australia	4	13, 35, 66, 88
	New Zealand	1	76
Africa (n = 3)	Nigeria	2	105 , 106
	Morocco	1	113
Multi‐content (n = 2)	—	2	116 , 124

Note: Citations bolded correspond to articles reporting primary data. The remaining references correspond to secondary data articles and guidelines.

Primary study details

Of the 33 articles that reported primary data, most were cross‐sectional in nature and aimed to describe the development and delivery of a rehabilitation program for patients with COVID (n = 13). ²² , ²⁴ , ³³ , ⁴¹ , ⁵¹ , ⁶³ , ⁶⁹ , ⁷⁸ , ⁸¹ , ⁸⁸ , ¹²⁷ , ¹²⁹ , ¹³⁶ Additionally, one article described a physician's experience with being treated for COVID, ⁵⁷ a second outlined the organizational changes made to accommodate COVID patients, ⁶³ and a third estimated the postacute rehabilitation needs of COVID patients. ⁵⁵ Three studies aimed to describe the demographics, clinical characteristics, and level of rehabilitation of patients with COVID at their institutions. ⁷⁹ , ⁸⁰ , ⁸⁵ One additional study investigated the rehabilitation needs of COVID patients at their institution. ¹³⁴ Only one study implemented a randomized control trial (RCT) design to investigate the outcomes of a pulmonary rehabilitation program for COVID patients. ⁴¹

Study sample characteristics

In total, 30 studies reported sample sizes. Seventeen case report studies reported on 1 to 9 patients, ³³ , ⁵¹ , ⁷⁸ , ⁷⁹ , ⁸¹ , ⁸³ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁸ , ¹¹⁵ , ¹¹⁷ , ¹¹⁹ , ¹²⁸ , ¹³¹ , ¹³² , ¹³⁷ , ¹³⁸ and the remaining 16 studies reported sample sizes ranging from 9 to 312, with a mean of 101. The mean age of patients in the case reports was 53 years old (range: 41‐69). Five of the cross‐sectional studies ²² , ²⁴ , ⁶³ , ¹²⁷ , ¹²⁹ reported the mean age of patients in the sample (50‐73 years old; mean = 63) and one study ⁵⁵ reported the median (66 years old; interquartile range: 45; 85). A third cross‐sectional study reported age groups for their participants (ie, ≤35, 36‐50, 51‐65, ≥76). ¹³⁴ The RCT reported a mean of 69.4 years old for the intervention group and 68.9 for the control group. Twenty‐seven studies reported participants' gender. All but five of the case reports ⁸³ , ¹¹⁵ , ¹²⁸ , ¹³¹ , ¹³² reported on male patients ³³ , ⁵¹ , ⁷⁸ , ⁷⁹ , ⁸¹ , ⁸⁴ , ⁸⁵ , ⁸⁶ , ⁸⁸ , ¹¹⁷ , ¹¹⁹ , ¹³⁷ , ¹³⁸ and the RCT study included only men in both the intervention (n = 24) and control groups (n = 25). The remaining six cross‐sectional studies ²² , ²⁴ , ⁵⁵ , ¹²⁷ , ¹²⁹ , ¹³⁴ reported a mean of 61 women and 101 men. Ten studies reported information pertaining to patients' ICU length of stay (LOS). The manner of reporting varied, with two studies reporting a mean of 5 ²² and 16.4 days ²⁴ and one reporting a median of 15 days (interquartile range: 2;30), ⁵⁵ whereas two studies were similar at 14 days. ⁸³ , ¹³⁶ Another study mean reported a mean of 19 days (± 10 days). ⁸⁰ The mean ICU LOS across the case report studies was 18.8 days. ³³ , ⁵¹ , ⁷⁸ , ¹¹⁵ , ¹¹⁹ , ¹³¹ Only one study reported a 25‐day postacute rehabilitation LOS. ⁵¹ Other studies reported an overall rehabilitation LOS of 10 days to 14 weeks. ⁸¹ , ⁸⁴ , ⁸⁷ , ⁸⁸ , ¹¹⁹ , ¹²⁷ , ¹³⁶

COVID sequelae

In total, 19 of the 33 articles reporting primary data discussed COVID sequelae that would warrant the need for rehabilitation for this population. ²² , ³³ , ⁵¹ , ⁵⁵ , ⁵⁷ , ⁶³ , ⁶⁹ , ⁷⁹ , ⁸⁰ , ⁸¹ , ⁸⁷ , ¹¹⁵ , ¹¹⁷ , ¹¹⁹ , ¹²⁷ , ¹²⁸ , ¹²⁹ , ¹³¹ , ¹³⁶ , ¹³⁷ Table 2 outlines the specific sequelae reported.

TABLE 2.

COVID sequelae details from primary data articles (n = 22)

COVID sequelae	Manifestation
Respiratory (n = 15)	Obstructive respiratory dysfunction, pneumonia, deterioration and/or failure of respiratory function, dyspnea, cough, and intensive care unit‐acquired weakness. 22 , 33 , 51 , 55 , 57 , 82 , 87 , 119 , 127 , 128 , 129 , 131 , 136 , 137 , 138
Physical (n = 11)	Muscle weakness and fever. 22 , 51 , 57 , 63 , 83 , 87 , 129 , 137 COVID‐related fatigue and pain were discussed and included overall fatigue, nausea, vomiting, and myalgia. 57 , 82 , 119 One case study described lower‐limb amputation as the result of COVID related coagulopathy. 117
Psychosocial (n = 7)	Anxiety, depression, sense of abandonment, isolation, fear, posttraumatic stress syndrome. 69 , 83 , 87 , 115 , 119 , 128 , 138
Cognitive (n = 3)	Delirium. 80 , 84 , 86
Cardiovascular (n = 2)	Coagulopathy, stroke, and myocarditis. 117 , 127
Organ system(s) failure (n = 2)	Renal failure was mentioned by one article, 55 and another mentioned multiorgan failure. 127
Communication/swallowing (n = 1)	One study reported dysphagia. 84

Comorbidities

Eleven articles mentioned common comorbidities that COVID patients presented with, including cardiovascular comorbidities (eg, hypertension, arrhythmias, heart disease), ²⁴ , ⁴¹ , ⁶⁹ , ⁸⁰ , ⁸³ , ⁸⁵ , ⁸⁶ , ¹¹⁵ , ¹¹⁷ , ¹³¹ , ¹³⁴ overweight/obesity, ⁸³ , ⁸⁶ , ¹¹⁹ , ¹²⁸ , ¹³¹ mental health diagnosis (eg, depression), ⁸⁶ , ¹¹⁵ , ¹¹⁹ preexisting respiratory disease (eg, chronic obstructive pulmonary disease [COPD]), ¹¹⁷ , ¹³² , ¹³⁴ type 2 diabetes, ²⁴ , ⁴¹ , ⁸⁰ , ⁸³ , ⁸⁵ , ¹¹⁷ , ¹³¹ , ¹³⁴ and other chronic diseases (eg, liver disease, hyperthyroidism, polyneuropathy). ¹¹⁷ , ¹²⁹ , ¹³⁴

Rehabilitation admission criteria

Six articles discussed potential criteria and associated assessments that could be used to identify COVID patients for postacute rehab. The most commonly discussed criteria were as follows:

1. Age (>65 years) ⁴¹

2. Respiratory presentation ¹³⁸ :

   • Forced expiratory volume (FEV1): ≥70% ⁴¹
   • Oxygen needs: (1) patients wearing nonrebreather mask, Venturi mask, or oxygen mask (FiO2 ≥ 40 and < 60%); (2) patients without oxygen support devices or wearing nasal cannula (FiO2 ≥ 21 and < 40%) ²⁴

3. Mechanical ventilation and tracheostomy status (ie, those who were ventilated are expected to need rehab) ⁸⁰

4. Functional status ⁵¹ , ⁵⁵ , ¹³⁸ (eg, high level of dependency as determined by an activities of daily living [ADL] score < 4)

5. Dyspnea ⁵¹ , ¹³⁸ (eg, using Medical Research Council Dyspnoea Scale ²⁴ )

Other considerations for identifying eligible COVID patients included body composition, muscle function, and quality of life. ⁵¹ , ¹³⁸ Two articles suggested that patients might potentially be excluded from rehab because of other comorbidities (eg, stroke, neurodegenerative diseases, additional respiratory complications). ²⁴ , ⁴¹

Adaptations to rehabilitation

Six studies discussed the adaptations made to provide rehabilitation to COVID patients. ⁶³ , ⁸⁰ , ⁸² , ⁸⁴ , ¹³⁷ , ¹³⁸ These adaptations included (1) modifying tasks, roles, and scheduling of the rehabilitation teams; (2) creating multidisciplinary COVID teams including the physicians, nurses, respiratory physiotherapists (RPTs), and physiotherapists (PTs); (3) scheduling changes, including scaling back staff numbers to address personal protective equipment (PPE) shortages; (4) delegating tasks based on expertise (eg, RPTs trained in management of chronic respiratory failure and noninvasive ventilation); (5) organizing an online communication system to facilitate email and printing of documents (so as to minimize contact between care team members); and (6) mandating PPE for patients undergoing rehabilitation. Some studies described moving from in‐person rehabilitation to telerehabilitation. ⁸⁴ , ⁸⁸ , ¹³⁶

Nature of rehabilitation programs

All of the articles provided information on what a rehabilitation program for COVID patients could entail (Table 3).

TABLE 3.

Nature of rehabilitation program (primary data articles)

Program element	Details
Timing	No consensus on timing of rehabilitation initiation. Individual studies indicated that: Pulmonary rehabilitation was initiated on day 16 of 25 for patient in ICU. 78 General rehabilitation initiated on day 30 post‐COVID diagnosis. 115 Physiotherapy began within 24 hours of admission to ICU. 80 Rehabilitation therapy was started immediately, based on the patient's general condition. 136
Duration and frequency of rehabilitation activities	Most studies reported on exercise‐based rehabilitation performed by a physical therapist, with individual exercise sessions lasting 10‐45 minutes. 22 , 24 , 41 , 51 , 63 Exercise sessions took place 1‐2 times a day. 22 , 24 , 51 , 63 , 115 There was less consistency in the overall duration of activities needed to help patients resume a relatively normal level of daily function: One study suggested 2‐3 weeks. 24 , 80 One study suggested at least 6‐8 weeks. 22 , 55 , 81 , 82
Modality	ICU‐based rehabilitation predominantly taking place at the bedside. 24 , 33 , 57 , 80 , 127 , 131 , 137 Modality of post‐acute rehabilitation not clear in many articles but seems most took place in the patient's room, 22 , 41 , 51 , 83 , 115 , 119 later shifting to telerehab after discharge. 22 , 86 , 136
Disciplines involved	Physiotherapists and respiratory therapists most common. 22 , 41 , 51 , 57 , 63 , 80 , 81 , 86 , 87 , 88 , 127 , 129 , 131 Other disciplines involved included: Occupational therapy. 81 , 82 , 83 , 87 , 131 , 136 , 137 , 138 Psychiatry and/or psychology. 86 , 131 Speech‐language pathology. 84 , 138 Physiatry. 115 , 131
Rehabilitation treatments/services provided	Respiratory Therapy Interventions : Mostly respiratory muscle training through various exercises including cough exercise, diaphragmatic training and stretching. 22 , 51 , 119 , 127 , 128 , 131 Exercises included sit‐to‐stand training, walking, balance and aerobic training. 51 Interval training for those who could not tolerate sustained aerobic exercise. 131 Equipment used included commercial hand‐held resistance devices, 51 neuromuscular electrical stimulation via squared electrodes, 51 cycle ergometer, with elastic bands or free weights, 51 and an inspiratory volumetric exerciser. 78
	Pulmonary Therapy Interventions : Mostly posturing and prone positioning strategies. 24 , 33 , 69 , 78 , 87 , 127 , 131 , 137 Pulmonary therapy strategies to be provided according to patients' oxygen support needs: Those requiring oxygen support: breathing control and chest clearance techniques. 24 Those not requiring oxygen support: thoracic expansion training and forced inspiration/expiration. 24
	Musculoskeletal Therapy Interventions : Mostly passive and active‐assisted range of motion, stretching and pumping exercises for limbs. 22 These included exercises like balance training, walking, and limb strengthening exercises. 63 , 78 , 115 , 128 , 131
	Psychosocial Therapy Interventions : Psychological counseling and sleep‐promotion activities such as providing patients with earplugs, eyeshades, and sleep medications. 78 , 117 , 128 , 131
	Speech‐Language Therapy Interventions : Swallowing rehabilitation and nutritional support. 117 , 119 , 131

Abbreviation: ICU, intensive care unit.

Secondary data article details

Of the 82 secondary articles, 57 articles specified the place of rehabilitation (ie, acute care/ICU (n = 39), ³ , ⁴ , ¹⁷ , ¹⁹ , ²⁰ , ²¹ , ²⁷ , ²⁸ , ²⁹ , ³⁰ , ³⁶ , ³⁹ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁶ , ⁴⁹ , ⁵³ , ⁵⁹ , ⁶⁰ , ⁶² , ⁶⁴ , ⁶⁶ , ⁶⁸ , ⁷³ , ⁷⁵ , ⁹⁶ , ⁹⁹ , ¹⁰⁵ , ¹⁰⁷ , ¹¹⁰ , ¹¹⁴ , ¹¹⁸ , ¹²⁰ , ¹²² , ¹²³ , ¹²⁴ , ¹²⁶ , ¹³⁰ postacute/ICU discharge (n = 10), ³ , ²⁸ , ²⁹ , ⁴⁴ , ⁶⁴ , ⁶⁸ , ⁹⁵ , ¹¹⁰ , ¹¹⁸ , ¹²² inpatient rehabilitation (n = 15), ¹⁸ , ¹⁹ , ²¹ , ²⁹ , ³⁸ , ³⁹ , ⁴⁸ , ⁶² , ⁷⁴ , ¹¹⁰ , ¹¹² , ¹²⁴ , ¹³⁰ , ¹³³ and community‐based setting (n = 20). ¹⁷ , ²⁵ , ²⁷ , ³⁰ , ³⁹ , ⁴⁰ , ⁴⁷ , ⁵³ , ⁵⁴ , ⁵⁶ , ⁶⁵ , ⁶⁷ , ⁷³ , ⁷⁴ , ¹⁰⁵ , ¹⁰⁷ , ¹⁰⁹ , ¹¹¹ , ¹²⁰ , ¹³⁰ ) The most common rehabilitation profession to be involved in care for COVID patients was physiotherapy (n = 29), ⁴ , ¹⁹ , ²⁰ , ²⁷ , ⁴⁷ , ⁴⁹ , ⁵⁸ , ⁵⁹ , ⁶⁰ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁸ , ⁷³ , ⁹⁶ , ¹⁰² , ¹⁰³ , ¹⁰⁴ , ¹⁰⁵ , ¹⁰⁶ , ¹⁰⁷ , ¹⁰⁹ , ¹¹¹ , ¹¹³ , ¹¹⁴ , ¹²² , ¹²⁵ , ¹²⁶ , ¹³⁰ with three studies highlighting the inclusion of RPTs. ³⁰ , ³⁶ , ⁵³ Other rehabilitation professionals included physiatrists/physical medicine and rehabilitation (PMR) specialists (n = 11), ⁴ , ²¹ , ⁵⁸ , ⁶⁰ , ⁶⁴ , ⁶⁵ , ⁶⁷ , ⁹² , ⁹⁹ , ¹¹³ , ¹³⁰ occupational therapists (OTs) (n = 11), ⁴ , ²⁷ , ⁶² , ⁶⁴ , ⁶⁵ , ⁷³ , ⁹⁵ , ¹⁰² , ¹⁰⁴ , ¹¹³ , ¹²² , ¹³⁰ speech language pathologists (SLPs) (n = 7), ⁴ , ¹⁹ , ⁴⁶ , ⁶² , ⁶⁵ , ⁹⁵ , ¹⁰⁴ , ¹³⁰ psychologists (n = 2), ¹¹² , ¹¹³ dieticians (n = 1), ⁹⁵ respiratory therapists (n = 1), ¹¹³ and social workers (n = 1). ⁶²

COVID sequelae

In total, 60 articles discussed COVID sequelae (see Table 4).

TABLE 4.

COVID sequelae details from secondary data articles (n = 60)

COVID Sequelae	Manifestation
Respiratory (n = 41)	Breathing difficulties, acute respiratory distress syndrome, lung damage, pneumonia, and hypoxia. 4 , 14 , 17 , 21 , 28 , 29 , 31 , 34 , 35 , 38 , 39 , 40 , 44 , 45 , 49 , 53 , 54 , 56 , 59 , 60 , 62 , 66 , 67 , 70 , 74 , 90 , 93 , 94 , 95 , 96 , 98 , 99 , 100 , 102 , 103 , 104 , 105 , 107 , 113 , 114 , 121 , 122 , 123 , 125 , 126
Psychosocial (n = 30)	Depression, anxiety, posttraumatic stress disorder, and quality of life. 4 , 14 , 17 , 21 , 31 , 34 , 39 , 40 , 48 , 53 , 56 , 60 , 62 , 67 , 68 , 71 , 74 , 93 , 95 , 98 , 102 , 103 , 104 , 105 , 110 , 112 , 113 , 122 , 123 , 130
Neurological (n = 35)	Dizziness, impaired consciousness and polyneuropathy. 3 , 14 , 21 , 34 , 35 , 39 , 42 , 60 , 62 , 67 , 68 , 70 , 75 , 90 , 93 , 94 , 97 , 102 , 107 , 110 , 112 , 122 , 130 Impacts on cognition (eg, impaired memory, attention, and higher order executive function; delirium). 4 , 17 , 21 , 28 , 29 , 39 , 48 , 93 , 112 , 113 , 123 , 130
Motor (n = 23)	Deconditioning and muscle weakness. 17 , 20 , 21 , 29 , 30 , 34 , 35 , 39 , 42 , 53 , 56 , 59 , 60 , 67 , 68 , 74 , 97 , 105 , 107 , 110 , 113 , 122 , 130
Cardiovascular (n = 13)	Myopericarditis, thrombosis, and myocardial injury. 42 , 56 , 59 , 62 , 70 , 74 , 90 , 93 , 95 , 96 , 99 , 102 , 126
Physical/movement (n = 10)	Problems with fatigue or pain 34 , 59 , 95 , 96 , 98 , 107 , 110 , 122 and fever. 101 , 102
Organ system(s) failure (n = 9)	Renal and multiorgan failure. 56 , 62 , 70 , 74 , 95 , 96 , 102 , 104 , 126
Communication/swallowing (n = 5)	Communication and swallowing issues. 21 , 46 , 114 , 122 , 123
Other (n = 4)	Gastrointestinal issues 95 and malnutrition. 18 , 102 , 130

Comorbidities

Only 11 secondary articles identified comorbidities observed in individuals with COVID. ³⁴ , ³⁸ , ⁴⁰ , ⁵³ , ⁶² , ⁶⁵ , ⁷⁴ , ¹²⁰ The most commonly discussed comorbidities were cardiovascular diseases ⁴⁰ , ⁵³ , ⁹⁷ , ¹²⁰ , ¹²³ including coronary artery disease, ⁶² hypertension, ³⁸ , ⁵³ , ⁶² , ¹²⁰ and stroke. ⁶² , ⁶⁵ Other conditions included diabetes, ⁴⁰ , ⁵³ , ⁹⁰ , ⁹⁷ , ¹²⁰ pressure injuries, ⁴⁰ bladder dysfunction, ⁴⁰ chronic pulmonary diseases, ⁷⁴ , ¹²⁰ , ¹²³ , ¹²⁶ cancer, ¹²³ autoimmune diseases, ¹²³ and neurological conditions. ⁶⁵ , ¹²⁶

Rehabilitation admission criteria

Only 12 of the secondary articles explicitly outlined criteria that could be used to determine COVID patients' eligibility for rehabilitation: (1) negative COVID status of the patient (eg, two consecutive negative nasal swabs within 24 hours or 7+ since diagnosis) ⁴ , ²¹ , ²⁹ , ⁴² , ⁴⁸ , ¹¹¹ , ¹²⁴ , ¹³⁰ ; (2) stable cardiovascular function, respiratory function (eg, stable oxygen saturation with no need for respiratory assistance), nervous system function and general parameters (eg, no fever) ⁴ , ²¹ , ²⁹ , ³⁸ , ⁴⁴ , ¹⁰⁵ , ¹³⁰ ; and (3) functional status of the patient should reflect some independence (as determined by the Functional Independence Measure). However, patients should receive rehabilitation to address any functional deficits they may be experiencing (eg, unable to complete some activities/instrumental activities of daily living, residual functional deficits owing to hospital‐acquired weakness). ²⁹ , ⁷⁰ , ⁷³ Only two studies addressed ventilation status, with one suggesting that ventilator‐dependent patients to be tracheotomized at least 24 hours before admission ³⁸ and the other recommending that rehabilitation not begin unless there is absence of ventilator resistance. ¹⁰⁵

Adaptations to rehabilitation

Eighteen articles described adaptations to rehabilitation services that facilitated the provision of rehabilitation to COVID patients. These adaptations included (1) modifying the physical space of the rehabilitation unit/center (eg, to enable isolation of infectious COVID patients or to create additional space for ICU patients—many who could receive early rehabilitation as a result) or modifying tasks, roles, and schedules of the rehabilitation teams ⁴ , ¹⁹ , ²⁹ , ³⁸ , ³⁹ , ⁴³ , ⁴⁹ , ⁶² , ⁶⁵ , ⁶⁶ , ¹⁰⁷ , ¹²³ ; (2) creating multidisciplinary COVID teams including physicians, nurses, RPTs, and PTs ²⁹ , ³⁵ , ³⁸ , ⁴⁹ , ¹⁰⁷ ; (3) scheduling changes to address PPE shortages ⁴ ; (4) delegating tasks based on expertise (eg, matching approaches to the right profession, using best mix of skills) ²⁵ , ⁶⁸ , ¹⁰⁷ ; and (5) using technology to facilitate communication between providers and to deliver rehabilitation at a distance. ²⁵ , ⁶² , ⁷³ , ¹²³

Nature of rehabilitation programs across the continuum

All of the included articles discussed the nature of rehabilitation. Fourteen articles touched on what rehabilitation may look like in a broader context rather than within a specific area (ie, acute care). ³ , ¹⁴ , ³¹ , ³⁷ , ⁴² , ⁴⁵ , ⁵⁸ , ⁷⁰ , ⁷¹ , ⁹⁶ , ⁹⁹ , ¹¹³ , ¹²¹ , ¹²⁵ The articles highlighted how rehabilitation is a vital component of care and recovery for persons with COVID. ¹⁴ , ³¹ Articles suggested that the COVID rehabilitation program include pulmonary, ³¹ , ⁵⁸ , ¹²⁵ cardiac, ³¹ respiratory, ⁴⁵ , ¹¹³ physical, ⁴⁵ , ⁵⁸ , ⁷⁰ , ¹¹³ , ¹²¹ psychosocial, ⁷⁰ , ¹¹³ and swallowing ¹¹³ aspects. Postural positioning was discussed as an important technique to help mitigate the impacts of prolonged bedrest. ⁴⁰ , ⁵⁸ , ⁷⁰ Only two studies described specific techniques that could be used in this population (eg, Zheng's recumbent exercises, airway clearance, bed mobility, sit to stand, walking, etc) but did not describe specific prescription information. ⁵⁸ , ¹¹³ Articles also suggested that severity of the illness be considered when developing a therapy regimen. ⁴⁵ , ⁵⁸ , ⁷¹ Lopez and colleagues suggested that a registry be created to document symptoms and recovery trajectories over time of COVID patients to help inform rehabilitation practices going forward. ⁴² Finally, one study recommend the use of telehealth but did not describe a protocol. ³⁷ An additional 12 articles provided specific suggestions for frequency, duration, and modality of COVID rehabilitation (see Table 5). Most of the suggestions were adapted from respiratory rehabilitation guidelines for COVID patients specifically ⁵⁶ , ⁶² , ⁷³ , ¹⁰⁶ or for similar populations (eg, COPD, acute respiratory distress syndrome). ⁵⁸ , ⁵⁹ , ⁷³ , ¹⁰⁹ One article made recommendations based on front‐line expert consensus and references ⁷⁴ and another adapted general exercise principles from the American College of Sports Medicine. ¹²⁰ Three articles did not specify what they based their recommendations on. ⁴⁷ , ⁶⁰ , ¹²²

TABLE 5.

Suggested modality, frequency, intensity and timing of rehabilitation protocols from secondary articles

Article	Modality	Program components	Frequency	Intensity	Duration	Timing
Mukaino et al. 47	Telehealth	Exercise program	Once	NR	20 min	Community rehabilitation
Qu et al. 56	Telehealth	Exercise program	Daily	1.0 MET ‐ <3.0 METS	15‐45 min	Community rehabilitation
Rayegani et al. 58	NR	Physical activity	2x per day, 1 h after eating	NR	15–45 min	NR
Righetti et al. 59	In person	Prone ventilation	Once per day	NR	12‐16 h	Acute care
Ronconi et al. 60	In person	Prone positioning	Once per day	NR	12 h	Acute care
		Head and arm mobilization		NR	Every 4–6 h
Sheehy 62	In person	Strength training	3× per week, for 6 weeks	8–12 RM, 1–3 sets	NR	Across continuum
		Aerobic exercise	Increased to 3–5× per week over time	Start with <3 METs and increase over time	Increased to 20‐30 min over time
Wang et al., 73	In‐person	Prone positioning	NR	NR	2 min	Acute care
		Stretching	3× per day	NR	NR
Yang and Yang 74	Telehealth	Aerobic exercises	Increase to 3–5× per week	Progressive increase from low intensity	Increase up to 20–30 min	Community rehabilitation
		Strength training	2–3× per week	8–12 RM, 1–3 groups each time; increase load 5%–10% every week	2 min per group
		Traditional Chinese Medicine	Once per day	NR	30–50 min
Abdullahi 105 , 106	In person	Postural management	Once per day	NR	12–16 h	Within 72 h of endotracheal intubation
Ahmed and Haji 109	Telehealth	Aerobic exercises	3–5× per week	Build toward 12–14/20 RPE	Baseline tolerance build to 60 min	At home
		Resistance training	2+ days per week	40%–50% 1 RM, 1–4 sets, 10–15 reps	NR
		Flexibility	2 days per week	2–4 reps per muscle group	10–30 s per stretch
Cheng et al. 120 , a	Telehealth	Aerobic exercises	5×+/week	40%–59% HRR	30–60 min	At home
		Resistance training	2–3 days/week, 48 h intervals	Strength—60% 1 RM, 2‐4 sets, 8‐12 reps
				Endurance—50% 1 RM, ≤2 sets, 15‐25 reps
Demeco et al. 122	Telehealth	Aerobic exercises	3–5× per week	Low intensity with steady increase	20–30 min	At home
		Strength training	2–3× per week for 6 weeks	Weekly intensity increases by 5%–10%	NR

^a Recommended for mild COVID with no preexisting risk factors.

Abbreviations: HRR, heart rate reserve; METS, metabolic equivalents; NR, not reported; RM, repetition maximum; RPE, rate of perceived exertion.

Acute care

Thirty‐one articles provided information on what rehabilitation in the acute phase may look like. ⁴ , ¹⁷ , ¹⁹ , ²⁰ , ²¹ , ²⁷ , ²⁹ , ³⁰ , ³⁶ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁶ , ⁴⁹ , ⁵⁹ , ⁶⁰ , ⁶² , ⁶⁴ , ⁶⁶ , ⁶⁸ , ⁷³ , ¹⁰⁵ , ¹⁰⁷ , ¹¹⁰ , ¹¹⁸ , ¹²⁰ , ¹²² , ¹²³ , ¹²⁴ , ¹²⁶ , ¹³⁰ Four studies identified that rehabilitation in the acute phase would be helpful to mitigate sequelae of COVID but did not provide any additional information regarding the rehabilitation program itself. ³ , ³⁹ , ⁵³ , ⁷⁵ Nearly all the articles recommended in‐person rehabilitation at the bedside, with one specifying techniques that minimize handling of patients (eg, mechanical assisted limb exercisers, remote controlled mechanical tilting beds). ¹²⁴

Respiratory rehabilitation was most commonly discussed (n = 18). ¹⁹ , ²⁰ , ²⁸ , ²⁹ , ³⁰ , ³⁶ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁶ , ⁵⁹ , ⁶⁰ , ⁶² , ⁶⁶ , ⁶⁸ , ⁷³ , ¹¹⁴ , ¹²² In the acute stage, early mobilization (ie, postural management) was suggested by articles to improve respiratory function and maintain oxygen saturation levels. ⁴ , ¹⁹ , ²⁰ , ²⁸ , ³⁰ , ³⁶ , ⁴⁰ , ⁴³ , ⁴⁴ , ⁴⁶ , ⁶⁰ , ⁶⁶ , ⁶⁸ , ⁷³ , ¹⁰⁵ , ¹⁰⁷ , ¹¹⁰ , ¹¹⁸ , ¹²⁶ Articles proposed that for unconscious or sedated patients, passive range of motion mobilization exercises ¹⁹ , ²⁰ , ²⁷ , ³⁰ , ¹¹⁰ , ¹¹⁴ , ¹²⁰ , ¹²⁶ and electrical muscle stimulation (EMS) ³⁰ , ⁴⁹ , ⁵⁹ , ⁶⁸ , ¹¹⁰ , ¹¹⁴ , ¹¹⁸ could be used in an attempt to counteract deconditioning and immobilization deficits. Airway clearance techniques such as stimulated cough maneuvers and airway suctioning were also discussed in nine studies for those who were on invasive mechanical ventilation. ³⁰ , ³⁶ , ⁶⁶ , ⁶⁸ , ⁷³ , ¹⁰⁵ , ¹⁰⁷ , ¹¹⁴ , ¹²⁰ These techniques were not recommended for patients with significant bronchial obstruction. ³⁰ One study described exercise training, breathing exercises and chest care and airway secretion for those who were ventilated but had “clear cognitive status” (not defined in article). ¹²⁰ Further details about articles' recommendations for COVID rehabilitation in the acute care setting can be found in Table 6.

TABLE 6.

Nature and modality of acute‐based COVID rehabilitation

Nature of rehabilitation	Rehabilitation modality	Rehabilitation to avoid
For patients with mild COVID: Respiratory training, 40 , 44 , 59 , 68 , 73 , 118 exercise training, 4 , 27 , 30 , 40 , 43 , 44 , 59 , 66 , 73 , 123 , 130 and progressive recovery of standing and walking activation 43 , 66 , 68 , 73 , 118 to be adopted as early as possible to combat deconditioning. Exercise training (eg, resistance, balance and endurance). 29 , 30 , 44 , 68 For patients with moderate COVID: Chest physiotherapy (eg, airway clearance, positioning, chest percussion and controlled coughing). 120 For all patients regardless of COVID severity: Cognitive rehabilitation (eg, neuropsychological training, counseling sessions, and psychological support). 29 Address psychosocial issues (eg, anxiety management, family support, quality of life, nutritional support). 4 , 44 , 75 , 98 , 118 , 123 , 124 , 130 Introduce speech‐language therapy in the acute care setting. 123 , 130	For patients with mild or moderate COVID: Increased use of telerehab in intensive care unit setting to provide care to stable patients to facilitate mobility. 27 , 107 , 124 , 130 For ambulatory patients, walking and standing exercises can be prescribed via audio or videoconferences. 107	For patients with severe COVID: Breathing exercises, mobilization, and respiratory muscle training are not recommended during the acute phase when the patient is sedated or in a more critical condition. 36 , 62 , 105 , 118 Rehabilitation to begin after the patient is extubated and nonacute. 21

Postacute care (exact setting unspecified)

It was recommended by all articles that COVID patients receive rehabilitation after discharge from the acute care setting—though a subset did not specify the exact setting. ³ , ²⁸ , ²⁹ , ⁴⁴ , ⁶⁴ , ⁶⁸ , ¹⁰⁵ , ¹¹⁰ , ¹¹⁸ , ¹²² With respect to what a postacute program might look like, details were scarce. Articles suggested that post‐ICU discharge exercise therapy, ²⁸ multimodal physiotherapy treatment ⁴⁴ and respiratory therapy ³ be prescribed but did not provide further details. For individuals who have functional deficits and physical barriers to discharge (eg, inability to navigate steps to enter home, needing assistance with transfers), continued physical and occupational therapy as well as access to a physiatrist can help with discharge planning and symptom management. ⁶⁴ Few described a postacute care rehabilitation program in more detail. ²⁹ , ⁶⁸ , ¹⁰⁵ , ¹¹⁸ , ¹²² These articles focused on respiratory therapy, mobilization and postural management, ²⁹ , ⁶⁸ strength training, endurance training, balance training, EMS, and chest physiotherapy. ⁶⁸ , ¹⁰⁵ , ¹¹⁸ , ¹²² Articles recommended that prescribed exercise be of low intensity (<3.0 metabolic equivalents). ⁶⁸ , ¹¹⁸ Psychological support, nutritional support and ADL guidance was also suggested for this phase of recovery. ⁶⁸ , ¹⁰⁵ , ¹¹⁸ , ¹²² Finally, it was recommended that the rehabilitation program be tailored based on disease severity. ¹¹⁰

Inpatient rehabilitation

Three of the nine studies that suggested that persons with COVID undergo inpatient rehabilitation did not provide additional details. ³⁸ , ³⁹ , ⁶⁷ Overall, it was recommended that care be provided by a multidisciplinary team included OTs and PTs. ¹³⁰ Some articles proposed that rehabilitation programs in the inpatient setting include mobilization, ¹⁹ strength training, ¹⁹ , ²¹ , ²⁹ , ⁴⁸ , ¹²⁴ endurance training, ²¹ , ²⁹ , ⁴⁸ , ⁷⁴ , ¹²⁴ and balance exercises ⁴⁸ , ⁶² , ⁷⁴ to help with recovery from deconditioning and generalized weakness. The main goal of rehabilitation discussed for inpatient settings was for the patient to regain enough physical functioning to be independent. ¹⁷ , ¹³³ Three of the articles suggested that assessments be done to identify deficits in activities of daily living. ²⁹ , ⁴⁸ , ⁶² With respect to respiratory training, only three articles described the use of this type of therapy at this stage. ²¹ , ⁶² , ⁷⁴ One article proposed that oxygen therapy be provided to support COVID patients with chronic pulmonary diseases during exercises. ⁷⁴ Another suggested that respiratory functioning be assessed and if the muscles are found to be weak, respiratory training could be included. ⁶² Carda et al ²¹ recommended breathing training in line with published guidelines for primary lung fibrosis. Other areas of consideration for an inpatient rehabilitation program for COVID included cognitive rehabilitation, ¹¹² smoking cessation, ⁴⁸ , ⁷⁴ dietary and nutritional counseling, ¹⁸ , ²¹ , ⁴⁸ , ⁷⁴ , ¹²⁴ psychological support, ²¹ , ²⁹ , ⁴⁸ , ⁶² , ⁹⁸ , ¹¹² , ¹²⁴ , ¹³⁰ and supports to improve quality of life. ⁴⁸ , ⁷⁴ One article described the need to address voice or communication impairments. ⁶² Telerehab was recommended for consultations once approved by a consultant on the unit. ¹³⁰

Community‐based rehabilitation

A majority of the articles (n = 13) indicated the use of a telehealth‐based program for those requiring rehabilitation upon return to the community. ²⁵ , ²⁷ , ³⁰ , ³⁹ , ⁴⁰ , ⁴⁷ , ⁶⁵ , ⁶⁷ , ⁷³ , ⁷⁴ , ¹⁰⁴ , ¹⁰⁷ , ¹³⁰ It was recommended that the focus of the telehealth program be on physical functioning, quality of life, and support with returning to community participation. ¹⁰⁷ One article argues that telerehab is a better choice for patients at higher risk of COVID mortality, such as immunocompromised individuals and patients with diabetes. ⁹⁶ Another study recommended the use of apps that provided guidance on completing exercise regimens. ⁷⁴ With respect to in‐person settings, one article recommended the use of spa facilities to provide community rehabilitation. ¹¹¹

With respect to what these programs might entail, main areas included exercise training (ie, strength and endurance training), ³⁰ , ⁴⁰ , ⁵⁴ , ⁵⁶ , ⁷⁴ , ¹³⁰ diet guidance, ⁴⁰ , ⁵⁶ , ⁷⁴ pulmonary or respiratory rehabilitation, ³⁹ , ⁵⁴ , ⁷⁴ , ¹¹¹ , ¹³⁰ cognitive rehabilitation, ³⁹ , ⁵⁴ , ¹³⁰ and psychological support. ⁵⁶ , ⁷⁴ , ¹³⁰ Few studies (n = 6) discussed the assessment and rehabilitation of psychosocial issues such as quality of life, adjustment to family and social life, return to work, and ADL. ³⁰ , ³⁹ , ⁴⁰ , ⁵³ , ⁵⁴ , ⁵⁶ However, none of these studies described what may be included in this type of program.

Guideline details

A total of 13 guideline documents were included in the review. Each of these outlined an actionable set of recommendations that targeted patients with COVID, ²⁶ , ⁶¹ rehabilitation practitioners, ¹³ , ¹⁵ , ¹⁶ , ³² , ⁵⁰ , ⁷² , ⁷⁶ , ⁷⁷ , ¹³⁹ or policy makers. ⁵² The guidelines were published by organizations and researchers from the United Kingdom, ¹⁶ , ⁵² , ⁶¹ , ⁷² , ¹³⁹ Australia, ¹³ Turkey, ¹⁵ Denmark, ²⁶ Canada, ³² , ⁹¹ China, ⁷⁷ and New Zealand. ⁷⁶

Nature of rehabilitation programs across the continuum

Nearly all of the guidelines (n = 10) suggested that COVID rehabilitation programs be provided by an interdisciplinary team of practitioners including physiatrists, PTs, OTs, SLPs, and dietitians. ¹³ , ¹⁵ , ¹⁶ , ³² , ⁵⁰ , ⁵² , ⁶¹ , ⁷² , ⁷⁶ , ⁷⁷ Guidelines recommended that COVID rehabilitation begin early (ie, as soon as the patient has stable system(s) functioning) and be sustained throughout the patient's recovery and across the continuum of care. ¹³ , ¹⁵ , ¹⁶ , ⁵⁰ , ⁷⁶ , ⁷⁷ , ¹³⁹

Acute care

Guidelines suggested that rehabilitation in the acute care setting focus primarily on respiratory management, mobility, and nutrition. Respiratory management is likely provided by respiratory therapists and SLPs who can help COVID patients resume normal breathing patterns through oxygenation, airway secretion clearance, and ventilation weaning. ³² , ⁵⁰ , ⁵² , ⁷⁶ , ⁷⁷ PTs and OTs can support early mobility by mitigating the effects of deconditioning using both passive and active range of motion exercises, positioning, and strength training. ³² , ⁶¹ , ⁷⁶ , ⁷⁷ SLPs are well positioned to support patients' nutrition by screening for malnutrition, addressing swallowing difficulties, and providing appropriate diet and fluid modifications. ⁵⁰ , ⁷² , ⁷⁶

Inpatient rehabilitation

Guidelines suggested that postacute care focus on addressing ongoing impairments in mobility, respiratory function, nutrition, and communication with the goal of promoting independence with activities of daily living. ⁵⁰ Both mobility and respiratory function can be managed using aerobic exercises that are tailored to patients' abilities (eg, slow jogging, swimming, brisk walking), strength training, and breathing exercises. ⁷⁶ , ⁷⁷ Nutritional needs can be monitored in terms of oral intake and muscle function. Specifically, SLPs can help manage swallowing issues and promote communication ability. ⁷² , ⁷⁶

Community‐based rehabilitation

Most guidelines recognized that COVID recovery is a complex and ongoing process that will likely extend into the community. ²⁶ , ³² , ⁵⁰ , ⁵² , ⁷² , ⁷⁶ The suggested goal of community‐based rehabilitation is to optimize COVID patients' functional recovery and quality of life. This entails continuing to provide rehabilitation support to manage respiratory function, mobility, nutrition, and communication (eg, through tailored exercise programs, energy/fatigue management plans, SLP support for diet plans). ³² , ⁵⁰ , ⁷² , ⁷⁶ Importantly, it is recommended that patients be supported and empowered to manage their own health and reintegrate into the community. ⁷² This can be facilitated by rehabilitation practitioners providing patient education, ⁵⁰ virtual rehabilitation, ⁵⁰ home safety assessments. ³² , ⁵⁰ , ⁷⁶

Key recommendations (across article types)

Five primary articles, 12 guidelines, and 40 secondary data articles provided recommendations to inform the ongoing rehabilitation response to the COVID pandemic (Table 7).

TABLE 7.

Key recommendations from articles for COVID rehabilitation

Recommendation area	Details
Timing of rehabilitation	Early and sustained provision of rehabilitation by multidisciplinary team.13, 16, 19, 23, 28, 52, 65, 70, 74, 76, 77, 117, 129 Specific suggestions for inclusion of speech language pathologist interventions early on in intensive care unit 72 and overall management by physical therapists. 106
Rehabilitation assessment	Patient triage recommended (eg, discharge, referral and tracking systems via telehealth). 35 , 104 , 122 Use of triage tool and a functional capacity tool to identify patients' rehabilitation needs recommended. 64 , 121 Collect patient demographics and intervention outcomes data. 123
Rehabilitation provision	Provide adequate personal protective equipment to clinicians. 114 Use negative pressure rooms when possible and limit number of health care workers in the room at a time. 114
Prescribing rehabilitation	Rehabilitation prescription should be personalized to each individual patient according to their comorbidities, stage of recovery, severity of symptoms, and place of care.13, 15, 23, 27, 40, 48, 66, 68, 72, 75, 76, 77, 118, 120, 122, 132, 133 Monitor patients throughout the rehabilitation process and assess for additional sequalae.42, 68, 132 Use telerehab for those recovering in the hospital with mild cases 107 , 122 , 124 and for prehabilitation protocols. 109 Provide rehabilitation interventions such as: Postural management,27, 40, 127 Nutrition,18, 117 Strength training,19, 40, 58, 68, 124, 127, 132, 134 Aerobic exercise, 120 , 124 Respiratory rehabilitation,19, 30, 40, 58, 111, 124, 127, 134 Psychological support,19, 68, 111, 117, 134 Speech language pathology, 40 , 46 , 104 Electrical muscle stimulation, 49 Assessment of activities of daily living, 19 , 58 and Physical activity. 111 Should not provide early respiratory therapy (eg, diaphragmatic breathing, manual mobilization and active exercises). 60 , 73 , 122 , 127 Passive movement early on might be the best approach. 127 Engage in key psychological activities such as assessment of posttraumatic stress disorder, cognitive impairment, psychosocial impacts, and secondary adversities. 48 , 107
Discharge and community reintegration	Patients should receive educational and multidisciplinary support during discharge and ongoing rehabilitation to facilitate community reintegration.4, 13, 16, 19, 23, 27, 52, 61, 64, 67, 68, 72, 76, 127 Establish a link between community‐based rehabilitation programs and specialized rehabilitation centers. 110 Telerehab should be used for home‐based rehabilitation follow‐up.120, 124, 132 Rehabilitation pathways should consider those who are not admitted to the hospital. 108

Note: Citations bolded correspond to articles reporting primary data. The remaining references correspond to secondary data articles and guidelines.

Barriers and facilitators of COVID rehabilitation provision (across article types)

Factors that act as barriers (Table 8) or facilitators (Table 9) of COVID rehabilitation provision were discussed across primary data articles (n = 7), secondary data articles (n = 42), and guidelines (n = 6).

TABLE 8.

Barriers to providing COVID rehabilitation

Barriers	Details
COVID infectivity	Limited patients' access to rehabilitation because of isolation procedures 4 , 14 , 47 , 62 , 72 and rehabilitation facility closures. 27 , 64 , 122 Physical distancing difficult to implement. 13 Constrained therapists' ability to provide rehabilitation in common areas as they typically would. 24 Restricted use of usual therapies owing to potential aerosol transmission. 58 , 59 , 65 , 74 Prevented the involvement of families in the care of COVID patients. 127
Patients' health status	Variability in severity of COVID infection made prescribing and initiating rehabilitation challenging. 4 , 49 , 56 , 60 , 70 Severe disability heightens risk of fatigue and respiratory decompensation, which limits the range of therapies that can be provided.24, 34, 40 Lack of clarity about which patients are stable enough to receive rehabilitation using a virtual modality, thereby limiting the use of telerehab. 69
Lack of evidence/guidelines	Makes reorganizing care difficult since it is not clear which patients require rehabilitation and the type(s) of rehabilitation to be provided.21, 30, 34, 53, 63, 78, 110, 123 Absence of evidence pertaining to virtual care especially challenging for provision of telerehab.69, 74
Personal protective equipment	Insufficient personal protective equipment causes rationing of supplies and thereby challenges team assembly, shift schedules, and the overall ability to provide rehabilitation in an infectious environment.4, 13, 27, 35, 49, 63, 64, 65, 73, 76, 106, 107, 127 Use of personal protective equipment also affects communication between clinicians and patients. 127
Staff‐related issues	Declines in staff wellness, increased burnout, and staff shortages limit the extent and quality of rehabilitation provision to COVID patients.20, 34, 35, 104, 107, 127 Increased workloads. 80 Health care provider fear of infection and transmission to own families was challenging. 138
Health system issues	Lack of coordination across all levels of the health care system limits effective delivery of rehabilitation to patients across care settings (e.g., in hospital, at home). 27 , 56 , 70 , 71 Existing billing procedures are stringent and burdensome for physicians and take away from patient care time and quality. 4 , 65 Key challenge for developing nations is that they may not have an existing comprehensive rehabilitation system or disaster‐response systems that include rehabilitation. 13 , 106 Lack of funding to support telerehab and other infrastructure.86, 107

Note: Citations bolded correspond to articles reporting primary data. The remaining references correspond to secondary data articles and guidelines.

TABLE 9.

Facilitators of providing COVID rehabilitation

Facilitators	Details
Use of virtual care	Use of audiovisual and telehealth options helped overcome challenges of COVID infectivity to enable delivery of a range of rehabilitation services (eg, occupational therapy, physiotherapy [PT], speech language pathology, physiatry).21, 25, 27, 37, 39, 40, 62, 64, 65, 67, 68, 69, 74, 88, 105, 123 Telerehab viewed favorably by patients. 22
Multidisciplinary teams	Collaboration between rehabilitation disciplines enabled optimal patient recovery.57, 71, 74, 85, 87, 138 Key strategies included the coordination of professional skills and improvement of cross‐team communication.4, 38, 53, 63, 70, 72, 76, 78, 104
Self‐management	Empowering patients to take an active role in their recovery (eg, teaching them to perform exercises on their own) can help to ensure rehabilitation continuity.16, 61, 63, 76, 77, 105
Professional development	Professional recognition and proper delegation of responsibilities can motivate staff to endure stress. 63 Capitalizing on professional networks can facilitate collaborative skill development across disciplines and care teams.63, 72 Rehabilitation staff should receive pandemic preparedness training that includes training on infection control and the proper donning/doffing of personal protective equipment. 4 , 35 , 53 , 59 , 66 , 67 , 68 Important to support rehabilitation staff wellness. 4 , 65
Reorganization of unit and staffing	Units to be reorganized: In a way that promotes infection control. 21 , 35 , 65 , 66 Enables greater collaboration between health care providers and coordination of skills.63, 76 Facilitates the provision of care to large volumes of patients under stressful circumstances. 63 Capitalizing on health care providers' transferable skills can ensure broader delivery of care to COVID patients (eg, using respiratory PTs' skills with noninvasive ventilation and oxygen management during exercise).38, 63, 64

Note: Citations bolded correspond to articles reporting primary data. The remaining references correspond to secondary data articles and guidelines.

DISCUSSION

The goal of this scoping review was to provide a comprehensive and up‐to‐date synthesis of evidence pertaining to rehabilitation for COVID patients. We included 128 articles, with 26% reporting primary data (n = 33), 64% reporting secondary data (n = 82), and 10% outlining practice/self‐management guidelines (n = 13). A quarter of the included articles came from Italy and China, which were among the first countries to experience and begin responding to the impact of the COVID pandemic.

Rehabilitation programs to meet the needs of patients with COVID

The emerging body of literature on COVID rehabilitation has begun to elucidate the important role that rehabilitation can play in addressing COVID‐related declines in health, function, and well‐being. Most articles agreed that an individualized rehabilitation program be provided across the continuum of care by an interdisciplinary team of professionals and that the nature and extent of rehabilitation be informed by the care setting and COVID severity.

Only a small number of articles (29%) made mention of the psychosocial impacts of COVID (eg, anxiety, depression, posttraumatic stress disorder, reduced quality of life) and very few (5%) presented evidence pertaining to rehabilitation's role in addressing them. ²⁹ , ⁴⁸ , ⁶² , ⁶⁸ , ⁷⁴ , ¹⁰⁷ A number of psychosocial factors (eg, distress, mental health) have been found to be significantly associated with an elevated risk of COVID hospitalization. ¹⁴⁰ It is likely that these psychosocial vulnerabilities that predispose individuals to COVID hospitalization are the same vulnerabilities exacerbated post hospitalization. In turn, psychosocial rehabilitation programming warrants further attention. Our review begins to elucidate what psychosocial rehabilitation might entail, including psychological counseling/interventions to address issues such as depression, anxiety, and sleep deprivation ⁴⁸ , ⁶² , ⁶⁸ , ⁷⁸ ; collaboration between physical medicine and rehabilitation specialists and psychiatrists/psychologists ²¹ ; and education to promote patients’ participation in valued activities. ⁶² , ⁷⁴

None of the articles discussed what community‐based psychosocial rehabilitation should entail or how it should be delivered. Telehealth was widely discussed and endorsed by studies in our review but its potential for providing psychosocial rehabilitation was not considered. Telehealth and computer‐mediated consultations with other chronic illness populations have been shown to be beneficial and to foster closeness and communication amongst care providers, patients, and families. ¹⁴¹ Although telerehab interventions have been demonstrated to be comparable in effectiveness to in‐person therapy with other disease populations such as stroke, ¹⁴² , ¹⁴³ they disproportionately focus on physical recovery and have been underused to provide social support to patients and their family caregivers in the community setting. ¹⁴² To this end, we suggest that telehealth and other virtual care modalities have high potential for facilitating outpatient counseling and education to community‐residing COVID patients. Rehabilitation professionals can also leverage virtual modalities to facilitate peer‐led support and education for COVID patients. Despite peer support being recognized as an important aspect of psychosocial rehabilitation, ¹⁴⁴ it was not discussed by studies in our review. Peer support has been demonstrated to promote community reintegration in other patient populations ¹⁴⁵ and may be particularly beneficial for COVID patients who are already reporting that online groups are a valuable source of experiential knowledge and support—especially in the absence of other community/home care services. ¹⁴⁶

Adaptations to enable the provision of COVID rehabilitation

Several of the adaptations and facilitators we identified directly resolved issues that challenged the provision of COVID rehabilitation. For example, modifying physical spaces, schedules, and teams was done to limit the spread of COVID and to address PPE shortages. Providing professional development opportunities was considered one way of addressing staff wellness and burnout. These solution‐oriented adaptations should continue to be optimized so as to break down barriers to rehabilitation provision.

Notably, three aspects identified as challenging the provision of COVID care were not explicitly addressed by any of the adaptations or facilitators: (1) the paucity of evidence and guidelines for COVID rehabilitation, (2) patients' health status, and (3) health system issues. The first two issues are interconnected as the variability in COVID severity and impact has made it difficult to establish eligibility criteria and to generate a broad rehabilitation prescription. At a minimum, articles in our review recommend that eligibility criteria entail (1) negative COVID status (as determined by two negative nasal swabs or patient being 7+ days from diagnosis), (2) stability in respiratory and cardiovascular function as well as general health parameters (eg, stable oxygen saturation, no fever), and (3) functional need (one article suggested rehabilitation need be determined by a functional independence measure [FIM] score of <100). ²⁹ As mentioned earlier, the rehabilitation prescription itself is best tailored to each patient to ensure that it holistically meets individual needs.

The health system issues we identified centered on poor system coordination that limited the continuity of COVID rehabilitation across the care continuum. Challenges with rehabilitation continuity—especially as patients transition back to the community—are not new. ¹⁴⁷ However, several aspects of the COVID pandemic exacerbate these challenges (eg, physical distancing restrictions, closing outpatient services, and early discharge from inpatient rehabilitation), suggesting that a multipronged approach is needed. Many actionable strategies to promote COVID rehabilitation continuity can be leveraged from articles in our review and adapted from research that has focused on maintaining rehabilitation for non‐COVID patients in the wake of the pandemic. These include (1) capitalizing on telemedicine to provide remote rehabilitation ¹³⁰ , ¹⁴⁸ , ¹⁴⁹ —particularly using accessible tools such as Skype, FaceTime, and Zoom without penalty to health care providers for noncompliance with privacy regulations ¹⁴⁹ ; (2) creating strong partnerships with home care ¹³⁰ and ensuring that rehabilitation services are viewed as “essential” —particularly for those returning to congregate care settings where lockdowns may restrict nonessential care ¹⁴⁸ ; and (3) ensuring that health care providers can bill and/or be reimbursed for telehealth visits using appropriate billing codes and in a streamlined way that does not detract from their time with patients. ⁴ , ⁶⁵ , ¹⁴⁹ It is important to note that these suggestions will not universally apply to health systems and organizations across geographic boundaries. In turn, they should be adapted to countries' national and regional contexts and health system capacities.

Future directions

Many aspects of COVID rehabilitation were difficult to summarize across articles given the vast variability in reporting. Thus, there is a need for more consistent reporting to ensure that future studies can be meaningfully aggregated to inform COVID rehabilitation programming and evaluation. Based on our review, we suggest standardized reporting parameters for the following data elements: patient populations, rehabilitation admission, service adaptations, and rehabilitation programming. For patient populations, capturing demographic information such as age, gender, hospital/ICU/rehabilitation LOS, comorbidities, and COVID sequelae would provide important contextual information and enable detailed program evaluations. There was not a great deal of consistency in rehabilitation admission criteria reported but, at a minimum, our review elucidates that COVID status at admission, respiratory function (eg, oxygen saturation), and functional ability (eg, using the FIM) should be outlined. Some degree of consistency was observed in the reporting of adaptations to enable COVID rehabilitation according to the broad categories of modifications to physical space, staffing, scheduling, and communication modalities/procedures. Although information pertaining to rehabilitation programming was inconsistently reported across articles, we were able to extract data from at least one article for each of the following categories and thus suggest them as a good starting point for more streamlined reporting: (1) timing (ie, when program was initiated), (2) duration (ie, duration from start to end of program), (3) frequency, (4) modality (eg, bedside, virtual), (5) setting (ie, acute care, ICU, inpatient/outpatient/community rehabilitation), and (6) content (ie, rehabilitation disciplines involved, number of rehabilitation professionals involved, specific therapies provided).

The role of families in supporting COVID patients' rehabilitation and recovery was not a focus of any articles included in our review. This is potentially because of ongoing public health restrictions that limit the physical presence of families for hospitalized patients. ¹⁵⁰ However, it has been pointed out that physical restrictions on family presence should not undermine family‐centered care efforts. ¹⁵⁰ Distressing times like those experienced during the pandemic intensify patients' need to feel safe and connected to their loved ones, ¹⁵¹ making family‐centered rehabilitation more important now than ever. Like other complex illnesses, COVID leads to a large and diverse set of needs requiring active participation and support from families. ¹⁵² Family‐centered COVID rehabilitation ensures the involvement of both patients and families in treatment planning and can thus facilitate the individualized type of rehabilitation that COVID patients need. ¹⁵³ Several strategies for engaging families in the overall care of COVID patients can be adapted and implemented in the rehabilitation setting. These include (1) facilitating synchronous patient‐family communication (eg, using videoconferencing) as well as asynchronous engagement (eg, prerecorded videos, pictures, patient journaling), (2) ensuring environmental familiarity for patients (eg, arranging for family to bring in objects from home) and describing this environment to families, and (4) prioritizing family‐care provider communication (eg, establishing a family communication plan, daily videoconferencing). ¹⁵¹ Engaging families early on when COVID patients are in hospital can enable smoother transitions to home and greater continuity in care. ¹⁵³

Sociocultural factors were considered by only one article in our review, ¹¹⁶ highlighting the need for further investigation into their impact on COVID rehabilitation provision and outcomes. For example, those with lower socioeconomic status (SES) may have reduced access to telerehab, which may differentially affect their recovery and other outcomes). Future research should capture variations in age, race, gender, and SES as it is becoming increasingly apparent that COVID disproportionately affects older adults, people of color, women, and those with lower SES. ¹⁵⁴ , ¹⁵⁵ , ¹⁵⁶

Our review identified only one qualitative study pertaining to COVID rehabilitation. Qualitative approaches are an important complement to epidemiological and clinical research and can provide insight into behaviors and perceptions. ¹⁵⁷ In the context of COVID rehabilitation research, qualitative approaches can elucidate stakeholders' (eg, patients, families, care providers) lived experiences with rehabilitation care and recovery, thereby moving us beyond the “what” of COVID rehabilitation (eg, what aspects of rehabilitation to provide? what outcomes to measure?) to the “why” and “how” (eg, why are certain aspects of a rehabilitation program beneficial? How do the unique circumstances of COVID patients and families influence care needs and experiences?). ¹⁵⁷

STRENGTHS AND LIMITATIONS

To the best of our knowledge, this is the first scoping review to systematically identify and synthesize a diverse set of evidence sources (ie, primary data, secondary data, guidelines) pertaining to rehabilitation for COVID patients. Our comprehensive synthesis of 128 articles has the potential to provide rehabilitation practitioners with a range of evidence to support their ongoing response to the COVID pandemic. Although the authors have expertise in scoping review conduct, the present review may have been strengthened by an academic librarian designing and deploying the search strategy. The search strategy did not include any terms explicitly related to psychological rehabilitation, which may account to some extent for the lack of data on psychosocial rehabilitation programming for COVID patients. Given that this review was conducted during the early stages of the COVID pandemic, the large majority (74%) of articles we included reported only secondary data (eg, reviews, opinion papers). As such, we were limited in our ability to synthesize primary evidence and make recommendations based on real‐world data that capture COVID rehabilitation “in action.”

CONCLUSION

It is clear that rehabilitation will need to play an important role in the recovery of COVID patients, many of whom have long‐lasting symptoms that do not permit return to full community participation. Research to date has begun to elucidate the criteria that can be used to identify patients for rehabilitation as well as the nature, extent, timing, and mode of this rehabilitation. However, a large majority of articles reported secondary data, underscoring that we know little about actual COVID patients receiving rehabilitation, the rehabilitation program itself, and the effectiveness of COVID rehabilitation across the continuum of care. Organization‐ and system‐level adaptations have the potential to facilitate COVID rehabilitation delivery by mitigating barriers to rehabilitation provision. Additionally, engaging families in COVID rehabilitation may serve to optimize the continuity of care for patients. Future research should prioritize the reporting of primary data and subsequently the synthesis of studies reporting on the effectiveness of rehabilitation interventions as they are developed and delivered over time.

Supporting information

Appendix S1. Supporting Information

Wasilewski MB, Cimino SR, Kokorelias KM, Simpson R, Hitzig SL, Robinson L. Providing rehabilitation to patients recovering from COVID‐19: A scoping review. PM&R. 2022;14(2):239-258. 10.1002/pmrj.12669