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Fresh evidence of the scale and scope of long covid

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n853 (Published 01 April 2021) Cite this as: BMJ 2021;373:n853

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Post-covid syndrome in individuals admitted to hospital with covid-19

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There is a medical specialty for the multidisciplinary care of long covid patients: Physical and Rehabilitation Medicine

Dear Editor

We want to thank Sivan M et al. for their recent editorial in the BMJ (1). COVID-19 is challenging health systems worldwide and highlights some of their strengths and weaknesses, different from country to country. While the editorial focuses on the UK, the issues discussed impact the worldwide community. For this reason, we would like to contribute with a more global vision.

This editorial raises a series of important points. The iceberg of long-term illness is linked to acute care organisations that discharge to home patients who frequently end up either being readmitted to hospital or presenting with long covid. COVID-19 and long covid are now recognised as multi-organ diseases with a broad spectrum of acute and post-acute manifestations pertinent to multiple medical specialties (2). The single-specialty referral model fails to address this complexity, with the need for good generalist care by GPs and specialists to be identified. The authors discuss the UK “multispecialty long covid clinics”, where there is a lack of “specialist medical supervision” and “multidisciplinary teams”, and the “inappropriately lengthy or unidisciplinary pathways that lack the right skills to manage complexity”. Here “rehabilitation therapy teams” miss “appropriate medical support and leadership”. The conclusion is that the “most pressing need is for rapid learning to understand what represents good multidisciplinary care, informed by real-world outcome data and patient experience” (1).

The authors state that the hospital services predominantly focus on individual organ systems, with the only notable exceptions of elderly care, pain, and cancer services. From a worldwide perspective, the exceptions also include physical and rehabilitation medicine (PRM), called rehabilitation medicine in the UK, the medical specialty with a focus on functioning and disability (according to the World Health Organization [WHO] definitions) (3). The PRM approach goes beyond body structures and functions and considers the whole person and interactions with its environment (4). In 2019 the International Society of PRM published the Scope Book of PRM (5) following the 3rd edition of the White Book on PRM in Europe (6) published in 2018 by the European PRM Bodies Alliance. These reference books can contribute to broaden the opinions expressed in Sivan’s editorial to include a more global perspective.

Discharge home of patients “not-ill” any more responds to the single specialty perspective and current health systems’ mortality/morbidity indicators (and perspective). Physicians note recurrences because they impact health systems (7), while professionals hardly recognise patients reported long-term symptoms, and long covid is still not a well-defined diagnosis (8). Patients who are “not-ill” are frequently still not functioning well, according to the concept of functioning as the third health indicator (9) strongly supported by the WHO’s “Rehabilitation 2030: a call for action” initiative (10,11). Beyond COVID-19, for many diseases discharging “non-functioning” patients without a referral for rehabilitation can lead to further deterioration and other complications and illnesses (12). The quality of life of these survivors is further compromised, increasing the cost to societies (13). For years it has been known that rehabilitation reduces all these adverse outcomes (12).

By definition, rehabilitation is multiprofessional and requires an interdisciplinary approach based on coordinated teams. PRM specialists are the physicians trained in the multifaceted aspects of rehabilitation and on managing these multidisciplinary (medical “organ-based” specialties) and multiprofessional (different rehabilitation professionals) teams. PRM physicians focus on the needs of persons experiencing disability, with their multiple comorbidities (14), to reduce them as much as possible and improve their level of activity and participation (4). They are specifically trained to approach a broad spectrum of organ involvements like those of patients who have survived (or are suffering) COVID-19. Worldwide PRM physicians work in all the health systems settings: acute to prevent secondary dysfunctions, post-acute to improve functioning in the most effective “opportunity window” for enhancing spontaneous recovery, and chronic to maintain or optimise functioning over time (15). In most of the countries, there are no “multispecialty long covid clinics” but post-acute rehabilitation services with PRM physicians who provide the “specialist medical supervision” and manage the “multidisciplinary teams” for COVID-19 patients. The need to address ”inappropriately lengthy or unidisciplinary pathways” is directly related to the need to upscale rehabilitation in all health systems as recommended by the WHO (11,16).

The challenges created by COVID-19 will change health systems worldwide. They should lead to a better appreciation of the central role of rehabilitation and the medical specialty of PRM because its focus is on the person and associated functional capacity and not only on the structure and function of a specific organ. According to the European PRM bodies, in the UK, PRM physicians (called rehabilitation medicine specialists) represent 0.2% of all specialists and 0.1% of physicians versus 1.7% and 0.9% in the other 38 censed European countries, respectively (17). The UK ranks above Ireland and Ukraine only. The BMJ is leading a battle for patients and their needs in the UK NHS. We believe that part of this battle should be fought to promote rehabilitation and PRM (rehabilitation medicine) inside the NHS. We do not believe it is a coincidence that the primary author of this paper is a UK rehabilitation medicine specialist.

References
1. Sivan M, Rayner C, Delaney B. Fresh evidence of the scale and scope of long covid. BMJ. 2021 Apr 1;373:n853. doi: 10.1136/bmj.n853.
2. Nalbandian A, Sehgal K, Gupta A, Madhavan MV, McGroder C, Stevens JS, Cook JR, Nordvig AS, Shalev D, Sehrawat TS, Ahluwalia N, Bikdeli B, Dietz D, Der-Nigoghossian C, Liyanage-Don N, Rosner GF, Bernstein EJ, Mohan S, Beckley AA, Seres DS, Choueiri TK, Uriel N, Ausiello JC, Accili D, Freedberg DE, Baldwin M, Schwartz A, Brodie D, Garcia CK, Elkind MSV, Connors JM, Bilezikian JP, Landry DW, Wan EY. Post-acute COVID-19 syndrome. Nat Med. 2021 Mar 22. doi: 10.1038/s41591-021-01283-z. Epub ahead of print.
3. World Health Organization. International Classification of Functioning, Disability and Health. https://www.who.int/standards/classifications/international-classificati.... Accessed April 13th, 2021.
4. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine (PRM) in Europe. Chapter 3. A primary medical specialty: the fundamentals of PRM. Eur J Phys Rehabil Med. 2018 Apr;54(2):177-185. doi: 10.23736/S1973-9087.18.05146-8.
5. International Society of Physical and Rehabilitation Medicine. The Scope Book of Physical and Rehabilitation Medicine. Journal of the International Society of Physical and Rehabilitation Medicine 2019 June 11;2(5s):1-158.
6. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine in Europe. Introductions, Executive Summary, and Methodology. Eur J Phys Rehabil Med. 2018 Apr;54(2):125-155. doi: 10.23736/S1973-9087.18.05143-2.
7. Ayoubkhani D, Khunti K, Nafilyan V, Maddox T, Humberstone B, Diamond I, Banerjee A. Post-covid syndrome in individuals admitted to hospital with covid-19: retrospective cohort study. BMJ. 2021 Mar 31;372:n693. doi: 10.1136/bmj.n693.
8. National Institute for Health and Care Excellence (NICE). COVID-19 rapid guideline: managing the long-term effects of COVID-19. https://www.nice.org.uk/guidance/ng188. Accessed April 13th, 2021.
9. Stucki G, Bickenbach J. Functioning: the third health indicator in the health system and the key indicator for rehabilitation. Eur J Phys Rehabil Med. 2017 Feb;53(1):134-138. doi: 10.23736/S1973-9087.17.04565-8. Epub 2017 Jan 24.
10. Krug E, Cieza A. Strengthening health systems to provide rehabilitation services. Bull World Health Organ. 2017 Mar 1;95(3):167. doi: 10.2471/BLT.17.191809.
11. World Health Organization. Rehabilitation 2030. https://www.who.int/rehabilitation/rehab-2030/en/. Accessed April 13th, 2021.
12. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine in Europe. Chapter 2. Why rehabilitation is needed by individual and society. Eur J Phys Rehabil Med. 2018 Apr;54(2):166-176. doi: 10.23736/S1973-9087.18.05145-6.
13. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2021 Dec 19;396(10267):2006-2017. doi: 10.1016/S0140-6736(20)32340-0. Epub 2020 Dec 1. Erratum in: Lancet. 2020 Dec 4;.
14. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine (PRM) in Europe. Chapter 6. Knowledge and skills of PRM physicians. Eur J Phys Rehabil Med. 2018 Apr;54(2):214-229. doi: 10.23736/S1973-9087.18.05150-X.
15. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine (PRM) in Europe. Chapter 8. The PRM specialty in the healthcare system and society. Eur J Phys Rehabil Med. 2018 Apr;54(2):261-278. doi: 10.23736/S1973-9087.18.05152-3.
16. World Health Organization. Rehabilitation and COVID-19. https://www.who.int/teams/noncommunicable-diseases/covid-19/rehabilitation. Accessed April 13th, 2021
17. European Physical and Rehabilitation Medicine Bodies Alliance. White Book on Physical and Rehabilitation Medicine (PRM) in Europe. Chapter 5. The PRM organisations in Europe: structure and activities. Eur J Phys Rehabil Med. 2018 Apr;54(2):198-213. doi: 10.23736/S1973-9087.18.05149-3.

Competing interests: No competing interests

15 April 2021
Stefano Negrini
MD, PRM Specialist, Professor
Carlotte Kiekens (3), Allen W. Heinemann (4), Levent Özçakar (5), Walter R. Frontera (6) - 3) Montecatone Rehabilitation Hospital, Imola (Bologna), Italy; 4) Feinberg School of Medicine, Northwestern University, Chicago USA; 5) Hacettepe University Medical School, Ankara, Turkey; 6) University of Puerto Rico School of Medicine, San Juan, Puerto Rico
1) University “La Statale”, Milan, Italy; 2) IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
20121 Milan, Italy