COVID-19 Neurorehabilitation

Neurorehabilitation facing the COVID-19 pandemic

The SARS-CoV-2/COVID-19 pandemic is deeply affecting our health systems both directly and indirectly. In several countries, neurorehabilitation units have had to reduce their bed numbers in order to allow doctors and nurses to work in intensive care units or in dedicated wards to isolate and care of patients with SARS-CoV-2 pneumonia.

The SARS-CoV-2/COVID-19 pandemic is deeply affecting our health systems both directly and indirectly. In several countries, neurorehabilitation units have had to reduce their bed numbers in order to allow doctors and nurses to work in intensive care units or in dedicated wards to isolate and care of patients with SARS-CoV-2 pneumonia. Home and outpatient rehabilitation should be restricted to selected cases, both for patients and caregivers’ protection, we hope temporarily. Similarly, in-patient neurorehabilitation has been limited to patients with severe post-acute disabilities, and those suffering from chronic degenerative diseases such as movement disorders or multiple sclerosis have had to be postponed. These hard decisions are contingent on the interval of disruption not being too long, otherwise alternative strategies should be considered, such as telerehabilitation. The same applies for cognitive assessment and rehabilitation, and psychological support, including cognitive and behavioral interventions. The issue of technology for tracing people infected with SARS-CoV-2 to protect their contacts is now being discussed at political level. At the medical level, we should actively promote the use of technology to allow clinical monitoring of our patients, not only to perform tele-visits but also to provide objective measures of their performance (e.g. mobility measures) and to collect patient-reported outcomes. Even if remote monitoring of patients can be facilitated with the use of digital outcomes or telemedicine, this type of service is still not sufficiently advanced at present to fully substitute the regular neurological visit and a negative impact should be expected, particularly in management of chronic complex neurological diseases. A possible consequence is the increase of undetected negative events or disease progression, as well as adverse events related to treatment.

In regard to specific healthcare settings, such as management of coma, the first challenge is to achieve the right prognostication during the acute phase in order to bring the right patient to the right place at the right time. To date, the clinical tools of observation of motor behavior (Pincherle et al. Ann Neurol, 2019, and Jane, PloS One 2020) together with neurophysiological investigations (standard EEG and peri-personal space encoding (Noel JP et al Neuroimage 2019) contribute to avoid misdiagnosis and ensure the correct rehabilitation pathway for neurolesioned patients. Second, a strict weaning protocol applied  by an interdisciplinary team (Berney at al Neurorehabilitation 2014) allows more rapid transfer of patients with tracheostomy out of the university hospital creating more places for COVID patients.

It is important that all staff involved in direct patient management (doctors, nurses, technicians, physiotherapists, psychotherapists and porters) wear FFP2-3 masks, protective gowns and eye protection in order to avoid infection, particularly in staff managing patients with tracheostomy. It is also important to improve and develop our diagnostic tools and procedures aimed at identifying asymptomatic infected individuals, both in terms of healthcare professionals and patients to limit the spread of infection.

Finally, we are starting to face emerging COVID-19 related neurological complications, and will increasingly see more of a need for rehabilitation in patients with syndromes varying from stroke to Guillain-Barré and critical illness polyneuropathies or myopathies discharged from COVID-19 units, not to mention respiratory rehabilitation and motor rehabilitation to counteract the consequences of prolonged immobilization, with the need of implementing units not only dedicated to “neurocovid”, but also to neurorehabilitation for COVID-19 patients more generally.

The present COVID-19 tsunami has both immediate and long-term global consequences on our healthcare systems. Although the present effects are certainly very negative, we do hope that by learning from events worldwide, this will help us to reshape health organization models, to enable us to promptly react and prevent some of the complications of other similar nightmares that may come in the future.

Letizia Leocani, MD, PhD
Co-Chair – EAN SP Neurorehabilitation
Associate Professor of Neurology,
Chair, Neurorehabilitation Unit,
Group Leader, Experimental Neurophysiology Unit, INSPE-Institute of Experimental Neurology
San Raffaele University Hospital and San Raffaele Scientific Institute Milan, Italy

Karin Diserens, MD,
Co-Chair – EAN SP Neurorehabilitation
Director, Acute Neurorehabilitation Unit, Department of Clinical Neurosciences,
University Hospital of Lausanne, Lausanne, Switzerland

 

On behalf of the EAN SP Neurorehabilitation Management Group: Voelker Dietz, Sasa Filipovic, Voelker Hoemberg, Marcello Moccia, Dafin Muresanu