For patients who recover from COVID-19, surviving is just the first step

Among the enduring images from our days of COVID-19 is this: A patient, having survived the disease on a respirator and now free of symptoms, is wheeled from the hospital through a phalanx of exuberant staff.

Michel Landry, a professor of orthopaedic surgery and global health, acknowledges that such an occasion is cause for celebration. But his enthusiasm is tempered by the knowledge that for so many of those patients, the journey to recovery has just begun.

In a recent paper for the journal Physiotherapy, Landry and his co-authors share their conviction that “survival from an infectious disease is only the first step,” and that countering the potential for long-term impairment requires multidisciplinary rehabilitation in the days and years ahead.

Landry and his colleagues urge healthcare professionals and health systems to “expand our collective ‘peripheral vision’ and consider the magnitude and long-term impact of physical, mental and emotional decline post survival.”

A Deeper Commitment

Throughout the past three decades, Landry has joined emergency and disaster responses across the globe, including after the war in Bosnia and Herzegovina and earthquakes in Nepal and Haiti. He helped the World Health Organization craft guidelines for incorporating rehabilitation capacity into such efforts.

The rationale, Landry argues, is compelling: “If you’re prepared to spend considerable resources up front to preserve life, you should be equally enthusiastic about providing a continuum of care for the quality of life among those you just saved.”

He cites the parable of the Good Samaritan, who comes upon a man who’s been beaten and left for dead along the side of the road. The Samaritan not only stops and cares for the man, but takes him to an inn, gives the proprietor money and promises to return with more assistance as needed.

In the world of humanitarian aid, Landry says healthcare providers do phase one—the initial care—extremely well. “The long term is where we often fall short, and we fail in tremendous ways,” he says.

What’s required, he asserts, is a deeper commitment to the lives saved, and, he and his colleagues write in Physiotherapy, COVID-19 presents such a challenge.

Cameron Wolfe, an associate professor of medicine at Duke and infectious disease specialist, is among those who are concerned about potential long-term consequences for patients recovering from COVID-19. At Duke, he has treated patients who range in age from mid-20s to 94, many of whom have been “quite slow to recover.”

“The more severe the respiratory infection has been, the more likely people are going to be left with some underlying pulmonary scarring,” he says. “I do worry that the degree of inflammation that some of them have will lead to longer-term drop-offs in pulmonary function.”

Blood clotting is another risk.

There are concerns as well for mental health repercussions. Research indicates that a third of those who spend more than five days in an ICU experience some form of psychotic reaction.

Many who contract the virus and remain in their homes will also experience long-term consequences. Landry cites data from the 2003 SARS outbreak in Toronto indicating that roughly 30 percent of those who were quarantined with the virus have suffered post-traumatic stress disorder.

Landry’s concerns aren’t limited to those who become infected with the virus. Stress over being pent up, the threat of illness, lost income and dwindling resources—anxiety over the unknown—take a toll on the otherwise healthy and can be devastating for those with preexisting behavioral-health issues.

He advocates for the use of big data to gain a better understanding of the level of care an individual may need depending on their age, general health, living situation, socioeconomic status, access to resources and more. A multidisciplinary continuum of care would then be prescribed as appropriate, he says.

Janet Prvu Bettger, director of the Duke Roybal Center on Aging and a DGHI affiliate, also advocates for a more data-driven approach to the rehabilitative process. She co-authored a paper that calls for a core set of measures to monitor the health and functional outcomes of COVID-19 and to assess the quality, availability and accessibility of services today and ahead.

What’s needed, Bettger says, is adoption of both a COVID-19-specific measure of disease burden and a patient-reported outcome to assess quality of life.

“The people downstream—the psychologists, psychiatrists and rehab professionals—we’re the frontline after the attention is turned away to somebody else,” Landry says. “We need to think in terms of personalized medicine, personalized intervention.”

An Interdisciplinary Approach to Recovery

When Wolfe’s patients leave the hospital, he advises them that while the slow pace of deterioration with COVID-19 is mirrored by slow recovery, they should try to immediately re-engage in whatever activities they can.

Alice Aiken is vice president for research and innovation at Dalhousie University in Halifax, Canada. She contracted COVID-19 in mid-March after returning from a vacation in the Caribbean. She felt light-headed, terribly fatigued, and completely lost her senses of smell and taste. It took several weeks for the fatigue to subside. She now feels well.

“What brought me out of my fatigue and being generally worn down was yoga,” Aiken says. “Online yoga instructed by a physical therapist. An interdisciplinary approach to recovery is key.”

“I’ve now joined two serology studies so I can help be part of the solution,” she adds.

In another recent paper, Landry and colleagues write that facilitating physical, emotional and mental recovery after exposure to COVID-19 is “well within the scope of physiotherapists and other rehabilitation providers, and it is an area in which providers have a moral imperative to act.”

Providers “must be willing to advocate both at the time of an outbreak such as the current COVID-19 but also in less media-attractive moments such as emergency preparedness planning,” the authors write.

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