Rehabilitation during the pandemic - FAQs 

Access to high quality community rehabilitation for those worst affected by Covid19 will be critical. On the horizon is a significant increase in demand.  These services already face major disruption from the  pandemic due to the redeployment of the workforce and social distancing and shielding requirements.  We answer some of your frequently asked questions about what all this means for rehabilitation during the Covid19 pandemic.

What sorts of rehabilitation needs are Covid19 patients typically having? 

People coming out of acute hospitals will most likely have the most severe rehabilitation needs. 

Up to 25% of hospitalised Covid19 patients will need to be in intensive care, often for prolonged periods.  Most of them (67%) will have acute respiratory distress syndrome. 

For patients with ARDS, a prolonged stay in the ICU, mostly including prolonged mechanical ventilation, has significant impact on lung function, physical functioning and emotional well-being. 

What we know about peoples rehabilitation needs based on what is known about acute respiratory distress syndrome (ARDS), post ITU and severe influenza.  

Patients will present with a range of COVID-related rehabilitation needs – primarily fatigue, dyspnoea (breathlessness) and extreme deconditioning.  

Emerging evidence from CSP members is that rehabilitation needs are extremely complex. 

People with pre-existing long term conditions will be more severely affected, and their rehab needs will be more complex and specific to the individual.

The longer term impact of Covid19 is not yet known and the global physiotherapy community is playing an important role to play in developing the evidence based. 

CSP members have an important part to play in reporting in real time on the symptoms their Covid19 patients are presenting with. 

(Last updated: 17 Apr 2020)


How does rehabilitation of Covid19 patients save lives? 

People with Covid19 will need rehabilitation as part of their care in ITU, acute wards, step down wards and after discharge. 

All stages of rehabilitation are a critical part of the urgent care response including community based rehabilitation. 

This is because it is essential to keeping the flow of patients moving, freeing up beds and capacity to treat more critically ill patients.

If rehabilitation isn’t provided at all steps of the pathway then there will be bottlenecks or people being readmitted.

(Last updated: 17 Apr 2020)


What forms of rehabilitation are likely to be needed by people recovering from Covid19 look like? 

The basic principles of patient centred, evidence-based rehab are no different for Covid19 patients. 

At discharge from the hospital, and to avoid readmission, an individual assessment of rehabilitation needs is essential. 

This should include: 

  • safe mobility
  • symptom control (dyspnoea, fatigue, and pain)
  • need for supplemental oxygen, adequate nutrition, sufficient psychological/social support and 
  • short and medium term needs to support improved physical and emotional functioning and a return to work. 

All decisions about care for Covid19 patients, including their rehabilitation, must be based on clinical need and presenting signs and symptoms, and local risk assessments, and not based on age. 

Rehabilitation for acutely ill Covid19 patients will focus on enabling people to clear their airways and manage their breathing, and being remobilised as soon as it is safe to do so. 

People will have significant complex rehabilitation needs after discharge – whether this is after returning home, to a care home or to a rehabilitation unit. 

Covid19 rehabilitation need to focus on supporting people build up strength to reverse the decline from deconditioning, reduce breathlessness and reduce fatigue, manage pain and psychological support.

Empowering people to recover and build up resilience at their own pace, with specific support to self-manage, will be an important part of any rehabilitation and recovery plan. 

Many covid19 patients will need paced rehabilitation: short in duration, several times every day. The intensity and frequency of rehab must be determined by the patient’s individual tolerance, taking into account that symptoms of fatigue will be common. 

Many covid19 patients, including the most severely ill, will have one or more underlying conditions in addition to Covid19. What is important is that rehab teams respond to the symptoms and it’s impact on the individual. 

As evidence on rehabilitation needs of Covid19 patients emerges we will be adding to this guidance. 

(Last updated: 17 Apr 2020)


What PPE should I be using? 

What PPE is appropriate will depend on where you work, who you are working with and what you are doing. 

The CSP recommends following the Public Health England guidance on this. 

Please also see our FAQs on PPE.

(Last updated: 17 Apr 2020)


Should rehabilitation for non covid19 patients continue in the period of the pandemic? 

Yes. Rehabilitation for non-covid patients will need to continue throughout the pandemic, based on need. 

These services are essential to maintaining independence, keeping people out of hospital and reducing pressures on all parts of the health and care system 

If rehabilitation for non-Covid19 patients does not continue then people’s needs will become more urgent, placing greater demands on the system. 

Physiotherapy is also a necessary part of looking after the health and wellbeing of healthcare workers, unpaid workers and volunteers, and other key workers, so that they are fit enough to work and care. 

Some will need to continue to be face to face in peoples homes, in rehabilitation facilities or care homes. 
Local risk assessments should be made in order that careful consideration is given as to whether this is through face to face contact or other means. Our current guidance on face to face consultations applies regardless of sector or setting.  During the COVID-19 emergency the physiotherapy workforce, regardless of sector or setting should be compliant with UK government advice and follow NHS guidance for healthcare professionals. 

Patients should only be offered face-to-face consultations if: 

  • They are in hospital and require physiotherapy. 
  • You have a high suspicion of risk of serious deterioration from underlying pathology and you are unable to determine this remotely. 
  • They have urgent rehabilitation needs, which if not met, will require care from General Practice, secondary care or social care agencies. This is particularly important if they are themselves a carer for someone who is vulnerable. 
  • They require rehabilitation to support their rapid discharge from secondary care. 

Our face-to-face consultation flow chart can support you in your decision making. 
To support social distancing and shielding of groups in the population who are very vulnerable to Covid19, many services will need to be provided remotely where possible. See our guidance on delivering physiotherapy services remotely

Further guidance to support your decision making for particular cohorts of patients or on a case by case basis use the resources below from NHS England and NHS Improvement.

Where you make decisions to either support a patient face to face or not you should follow usual good record keeping practices and ensure your clinical reasoning is documented in the patient’s clinical record.
Wherever you are working face to face with patients you must ensure that you use the appropriate PPE. See our PPE FAQs and guidance.

(Last updated: 17 Apr 2020)


Where should rehabilitation after discharge from acute hospitals happen? 

Where rehabilitation happens after discharge from acute hospitals will vary depending on the local set up and patient need. 

The CSP supports the guidance produced by NHS England which estimates that 45% of patients being discharged from hospital need some form of on-going health and care services, which includes rehabilitation. 

This guidance also estimates that 4% of patients discharged from hospital will require bedded rehabilitation. 

In some cities where there are temporary Nightingale Hospitals, large rehab bedded units are being developed to cope with the additional need for step down rehabilitation. 

The CSP has said that in all areas community rehabilitation teams need to be resourced and staffed sufficiently to meet the additional needs for people recovering from Covid19 returning home or to a care home.

Wherever it is delivered, rehabilitation must be consistently available at all stages of the patient’s journey, regardless of age, as people move from one part of the system to another.

(Last updated: 17 Apr 2020)


What should we do if we find patients recovering from Covid19 are not being offered suitable rehabilitation locally? 

Rehabilitation for Covid19 patients at all stages – including in the community - is critical to keeping the flow of patients moving, freeing up beds and capacity to treat more critically ill patients and preventing readmission to hospital. 

Physiotherapy managers should be trying to ensure that their expertise is being fully used by local health system leaders so that rehabilitation needs for covid19 and non covid 19 are met and maintained as much as possible. 

If too many physiotherapists and support workers are redeployed away from rehabilitation for covid19 patients as part of the urgent covid response effort, or for too long, then there will be bottlenecks in hospitals. This will cost lives and must be prevented. 

Community rehabilitation for patients who are not recovering from Covid19 will still be needed throughout the pandemic, with face to face and /or remote consultations and support options, based on need and risk. 

If you have gaps in your team or if you need to increase staffing to meet demand, the temporary NHS workforce, including physiotherapy staff from private practice, returning to practice and students may be very well suited to providing physiotherapy in the community.

If you are concerned about patients rehabilitation needs not being met, including Covid19 patients, you should work with your management locally and propose solutions. 
 
You should also do this if you believe this is because of how the physiotherapy workforce is being redeployed in your area. 

This is also a priority area for the CSP and we are seeking to influence at every level. To be able to do this we need to know from members what is happening on the ground. 

If you are not happy you should speak to your CSP rep or contact the CSP Enquiries Team on enquiries@csp.org.uk or 020 7306 6666.

For further guidance on this see our Redeployment and upskilling section and our Policy statement on rehabilitation during and after the pandemic.

(Last updated: 17 Apr 2020)


How are we going to meet people’s rehab needs after the pandemic is over? 

It is clear that there will be a substantial increase in rehabilitation needs in the population. 

This will be from people recovering from Covid19 or managing the long term damage caused by the virus. 

It will also be from a build up of needs among many people with other conditions whose rehabilitation needs have been exacerbated because they delayed seeking help due to the pandemic, their services were disrupted or they have been badly impacted by the requirements of social distancing and shielding. 

Community rehabilitation was already patchy and inconsistent, thanks to decades of lack of development and investment. This is why in 2019 the CSP brought together a Community Rehabilitation Alliance of professional bodies and charities with a shared concern in this area to work together. 

This is why now, along with our alliance partners, we are calling for the Government and the NHS to be preparing to meet peoples rehabilitation needs by radically overhauling and expanding community rehabilitation services. 

See Community rehabilitation and covid19 policy statement and our Community rehabilitation content for more details.
 
(Last updated: 17 Apr 2020)


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