Letter to the Editor on "Rehabilitation Following Critical Illness in People With COVID-19 Infection".

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To the Editor: We read with interest the article entitled “Rehabilitation following critical illness in people with COVID-19 infection” by Simpson and Robinson.1 This article emphasizes the important role that physical medicine and rehabilitation may have in the COVID-19 pandemic. The authors highlight that rehabilitation professionals and facilities will be critical not only in helping speed recovery for survivors with residual impairments after critical care but also in providing an appropriate outlet for acute services. Furthermore, multidisciplinary rehabilitation should start early and involve patients and families. These two goals are not easily achievable in the context of the pandemic. The early start may be challenged by persisting signs, symptoms, and positive virology testing. Family involvement is limited by the visitation restrictions many rehabilitation centers have put in place. Furthermore, in hard-hit areas, physiatrists have been redeployed to acute care and other medical roles. These barriers are particularly worrisome, considering the multitude of disabling effects confronting patients with prolonged intensive care unit stays due to severe infections. In addition, rehabilitation will also be challenged by limited availability of outpatient rehabilitation and physician services. This impacts planning of rehabilitation after discharge from inpatient postacute care and puts additional pressures on inpatient rehabilitation to provide needed services that are scarce in the outpatient world. New information is rapidly accruing regarding the physical, cognitive, and emotional impairments and associated functional deficits. A recent report by Herman et al.2 entitled “Scoping review of prevalence of neurologic comorbidities in patients hospitalized for COVID-19” suggested secondary neurological complications of this novel disease, such as ischemic stroke, seizures, Guillain-Barre syndrome, meningoencephalitis, confusion, dysexecutive syndrome, and encephalopathies. These findings need to be taken into consideration when assessing the rehabilitation needs for this patient population. Importantly, this information is specific to the COVID-19 pandemic and sequelae caused by this novel viral infection. In addition, postintensive care unit sequelae is well documented.3 A recent article by Stam et al.3 of intensive care unit sequelae that is relevant to rehabilitation medicine includes many of the conditions that physiatrists will be treating in post–COVID-19 patients. For example, secondary disabilities that result from intensive care treatments include critical illness polyneuropathy and critical illness myopathy, as part of the postintensive care syndrome. Critical illness polyneuropathy and critical illness myopathy are seen in approximately 25%–45% of critically ill patients, and this patient population exhibits even more severe neurodegenerative complications, including flaccid and symmetric paralysis, limb and respiratory muscle weakness, systemic inflammatory response syndrome, or multiple organ failure. To improve short- and long-term outcomes, the early involvement of the multidisciplinary rehabilitation team in the care of these patients is paramount. Physiatrists can expect to encounter patients with many of the neurologic and musculoskeletal issues listed in Figure 1—during the pandemic and in ambulatory care long after it is over.FIGURE 1: Neurologic and musculoskeletal sequelae* in Patients hospitalized with COVID-19.4–6 Figure legend: listed are examples of neurologic and musculoskeletal sequelae that patients who have sustained COVID-19 infections may present with, particularly if they have been hospitalized with severe infections. *This is not intended to be a complete list.We applaud Drs Simpson and Robinson for their timely article, and we look forward to working collaboratively with colleagues to bring rehabilitation expertise to the forefront of this unfortunate pandemic. Razvan P. Turcu, MD, MBA Physical Medicine and Rehabilitation Residency Program Harvard Medical School Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, MassachusettsGinger R. Polich, MD Department of Physical Medicine and Rehabilitation Harvard Medical School Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, Massachusetts Brigham and Women’s Hospital Boston, MassachusettsHannah K. Steere, MD Department of Physical Medicine and Rehabilitation Harvard Medical School Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, Massachusetts Department of Physical Medicine and Rehabilitation Boston VA Healthcare System Boston, MassachusettsJeffrey C. Schneider, MD Department of Physical Medicine and Rehabilitation Harvard Medical School Boston, Massachusetts Massachusetts General Hospital Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, Massachusetts Spaulding Research Institute Boston, MassachusettsJoanne Borg-Stein, MD Department of Physical Medicine and Rehabilitation Harvard Medical School Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, Massachusetts Spaulding Wellesley Center Wellesley, Massachusetts Newton-Wellesley Hospital Newton, MassachusettsJulie K. Silver, MD Department of Physical Medicine and Rehabilitation Harvard Medical School Boston, Massachusetts Massachusetts General Hospital Boston, Massachusetts Brigham and Women’s Hospital Boston, Massachusetts Spaulding Rehabilitation Hospital Boston, Massachusetts