Rehabilitation after critical illness
BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n910 (Published 15 April 2021) Cite this as: BMJ 2021;373:n910Read our latest coverage of the coronavirus outbreak
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Dear Editor
White and associates[1] are to be commended for reminding us of the rehabilitation needs of Covid-19 patients after intensive care treatment and even more so for highlighting the general importance of rehabilitation after critical illness (by which the authors seem to refer to patients treated in critical care units).
We however find that the authors do not go far enough and on the contrary, probably unintentionally, reinforce common preconceptions about rehabilitation that need to be corrected in our opinion. Covid-19 serves as an example.
1. Rehabilitation is a health strategy relevant to patients beyond those with critical illness, e.g. the ageing population and those with non-communicable disease or multi-morbidity. Globally, about one third of the world population could benefit from rehabilitation services as a recent re-analysis of the global burden of disease data from 2019 demonstrates[2]. The same study shows a sharp increase of rehabilitation needs by 63 percent compared with figures from 1990. As regards Covid-19, Huang and colleagues from Wuhan[3], for example, report a high 6 months-prevalence of ongoing symptoms including fatigue and muscle weakness (with 63% prevalence), impaired lung function and exercise capacity, and reduced quality of life in 1,733 patients with Covid-19 discharged from hospital. These clinically relevant longer-term problems of Covid-19 survivors were elevated in but not confined to the population that had been treated at the ICU.
2. Rehabilitation is a health strategy that is relevant along the whole continuum of care from acute hospital-based treatment to the community and home setting. Lack of integration of rehabilitation into primary care and with other medical disciplines is an obstacle to the implementation of early rehabilitation strategies. As regards Covid-19, psychological[4] and pulmonary rehabilitation interventions delivered at the ICU as well as other acute settings[5-7] could for example be added to acute treatment regimens. On the other end of the care continuum, tele-rehabilitation[8,9] as well as remote monitoring and assessment[10] are strategies to be considered for improving patients’ function and health in the community, particularly in situations where options for hospital-based delivery of in- or outpatient rehabilitation are limited due to lack of resources or pandemic control measures.
3. The primary focus of rehabilitation is function not diagnosis and it aims to optimize functioning of people with health conditions[11]. The focus on names and syndromes such as post-Covid syndrome or post-acute care syndrome blurs this pivotal focus. People with the same diagnosis can largely diverge in extent and type of functional problems, that is disability, that they experience. With regard to Covid-19, we got the impression that scientists avoid the word “disability” and in fact White and colleagues do not mention disability or the related concept of functioning once. We would thus like to take this opportunity to recall the WHO’s International Classification of Functioning, Disability, and Health (ICF)[12] that was published about 20 years ago. The ICF emphasizes that disability is a universal phenomenon as well as a complex experience comprising impairment, activity limitation, and participation restrictions in interaction with environments that are ill suited to addressing the needs of people with health conditions. ICF Core Sets for obstructive pulmonary disease are available[13] and should be considered in the evaluation of rehabilitation needs of Covid-19 survivors.
4. While physical and psychological rehabilitation interventions delivered by experienced multi-disciplinary teams are suitable candidates to address experiences of disability of people with various diagnoses and along the continuum of care, we currently, however, lack solid evidence on the effectiveness of such interventions in many patient populations including Covid-19. The experience from SARS, unfortunately, shows that related research is not prioritized and not much attention is devoted to longer-term sequelae once infection rates in the general population are going down. Our ongoing systematic review (registered at PROSPERO under CRD42020184617; URL: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=184617) found just one randomized clinical trial evaluating a rehabilitation intervention in SARS survivors with baseline and post-treatment assessment but no longer-term follow up[14].
In summary, we advocate here for the recognition of rehabilitation as a general and universal health strategy that is, sooner or later, relevant to everybody.
Jan D. Reinhardt; Siyi Zhu; Chengqi He, Jian’an Li, (Authors contributed equally to this response).
The opinions and views expressed in this response are those of the authors and not necessarily of the institutions and organizations they are affiliated with.
References
1. White C, Connolly B, Rowland MJ. Rehabilitation after critical illness. BMJ. 2021;373:n910.
2. 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;396(10267):2006-2017.
3. Huang C, Huang L, Wang Y, et al. 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. Lancet. 2021;397(10270):220-232.
4. Giummarra MJ, Lennox A, Dali G, Costa B, Gabbe BJ. Early psychological interventions for posttraumatic stress, depression and anxiety after traumatic injury: A systematic review and meta-analysis. Clinical psychology review. 2018;62:11-36.
5. Ryrso CK, Godtfredsen NS, Kofod LM, et al. Lower mortality after early supervised pulmonary rehabilitation following COPD-exacerbations: a systematic review and meta-analysis. BMC pulmonary medicine. 2018;18(1):154.
6. Zhang L, Hu W, Cai Z, et al. Early mobilization of critically ill patients in the intensive care unit: A systematic review and meta-analysis. PLoS One. 2019;14(10):e0223185.
7. Vogiatzis I, Rochester CL, Spruit MA, Troosters T, Clini EM. Increasing implementation and delivery of pulmonary rehabilitation: key messages from the new ATS/ERS policy statement. The European respiratory journal. 2016;47(5):1336-1341.
8. Suso-Marti L, La Touche R, Herranz-Gomez A, Angulo-Diaz-Parreno S, Paris-Alemany A, Cuenca-Martinez F. Effectiveness of Telerehabilitation in Physical Therapist Practice: An Umbrella and Mapping Review with Meta-Meta-Analysis. Physical therapy. 2021.
9. Cox NS, Dal Corso S, Hansen H, et al. Telerehabilitation for chronic respiratory disease. The Cochrane database of systematic reviews. 2021;1:CD013040.
10. Holland AE, Malaguti C, Hoffman M, et al. Home-based or remote exercise testing in chronic respiratory disease, during the COVID-19 pandemic and beyond: A rapid review. Chronic respiratory disease. 2020;17:1479973120952418.
11. Cieza A. Rehabilitation the Health Strategy of the 21st Century, Really? Archives of physical medicine and rehabilitation. 2019;100(11):2212-2214.
12. WHO. International Classification of Functioning, Disability, and Health. Geneva: WHO Press; 2001.
13. Stucki A, Stoll T, Cieza A, et al. ICF Core Sets for obstructive pulmonary diseases. Journal of rehabilitation medicine. 2004(44 Suppl):114-120.
14. Lau HM, Ng GY, Jones AY, Lee EW, Siu EH, Hui DS. A randomised controlled trial of the effectiveness of an exercise training program in patients recovering from severe acute respiratory syndrome. The Australian journal of physiotherapy. 2005;51(4):213-219.
Competing interests: No competing interests
Dear Editor,
We support the call from White and colleagues for more expert, multidisciplinary, integrated and consistent follow-up for all patients admitted to Intensive Care Units (ICUs) in the UK. [1] We would like to highlight two additional factors that play significant roles in recovery after critical illness – technology and community.
Besides creating a ‘tsunami of need’ which threatens to overwhelm NHS rehabilitation services, [2] the COVID-19 pandemic has fundamentally changed the nature of ICU aftercare. Where services are available, strict lockdowns and social distancing have necessitated a switch to ‘virtual rehabilitation’. Even with widespread vaccination rollouts, it is likely that post-ICU follow-up will incorporate some form of virtual rehabilitation for years to come. Virtual consultations may benefit ICU survivors by reducing the frequency of expensive and inconvenient journeys to hospital appointments. However, remote consultations may obscure subtle clues suggesting unmet psychological and physical needs and depersonalise the professional-patient relationship. Virtual rehabilitation could also exacerbate health inequalities by excluding patients with unreliable internet access and those who speak English as a second language. Future research must compare long-term clinical outcomes and staff and patient experiences of face-to-face and virtual ICU aftercare.
Wider pandemic circumstances have also sidelined carers and relatives in the rehabilitation process and curtailed social factors that are integral to recovery after critical illness. An expert multidisciplinary team can identify and address complex and myriad physical, cognitive and psychological consequences of prolonged ICU admission, but this is only part of the puzzle of recovery. For many patients, rediscovering a sense of purpose and reconnecting with friends, family and the wider community are equally important. Patient-led post-ICU support groups provide space for reflection on the personal and collateral impact of critical illness, and access to a network of ICU survivors with lived experience and expertise in navigating local health services. Even with optimal ICU aftercare, the postponement of support group meetings and social isolation resulting from lockdown may have left patients feeling alone and rudderless. Although we face the daunting prospect of substantial unmet need in recent ICU survivors, hope springs from the end of lockdown and social reconnection.
References
1. White C, Connolly B, Rowland MJ. Rehabilitation after critical illness. BMJ 2021;373:n910
2. Thornton J. Covid-19: the challenge of patient rehabilitation after intensive care. BMJ 2020;369:m1787
Competing interests: No competing interests
Dear Editor
I welcome the recent articles on the need for rehabilitation after critical illness and the lack of appropriate resources to provide what is needed [1, 2]. The deficiencies in rehabilitation services have been long recognised [3]. In my personal experience, it is quite possible for a consultant in rehabilitation medicine to have beds to receive patients from intensive care, discharge them into the community and continue to support them from a community team that may be an extension of the hospital rehabilitation service, or may be from a community-based team. Regrettably such community-based rehabilitation teams are also in short supply [4].
White et al comment on the ability to return to work (RTW) after critical illness [1]. Delayed RTW or even job loss can be catastrophic for individuals and their families, but also costly for employers and the state [5]. Intensive care teams can influence this situation by ascertaining (through talking to the patient or their family) whether or not their patient was working prior to their illness. For those uncertain how to discuss work issues with patients or relatives, advice is now available [6]. For those who were working, the following advice should be given:
• It is important to remain in contact with your employer [7-9]
• That there are many ways of supporting individuals back into work after severe illness [10]. Such measures, singly or in combination, may include:
o A phased RTW which might start by working only a few hours per week initially
o Working from home
o Modifications to the tasks and/or responsibilities at work
o Allowing time off work for health-related activities e.g. appointments and rehabilitation
o Utilising the Access to Work Scheme or other advice from the Department for Work & Pensions
The technical aspects of how this is achieved by vocational rehabilitation professionals has been described elsewhere [11]. Thus critical care teams can, by these simple means, reduce unnecessary worry about future job prospects. Facilitating a successful RTW helps not only the disadvantaged individuals and their families but also their employers and the government.
These views are personal and do not necessarily reflect those of the Vocational Rehabilitation Association.
1. White C, Connolly B and Rowland MJ. Rehabilitation after critical illness. BMJ (Clinical research ed.) 2021; 373: p. n910.
2. Iacobucci G. All intensive care patients must have access to community rehabilitation, leaders urge. BMJ 2021; 373: n137
3. Royal College of Physicians of London. Physical Disability Services in 1986 and Beyond. J R Coll Phys (London). 1986; 20(3): 160-194.
4. Collective of 20 Charities. Manifesto for community rehabilitation. Manifesto for community rehabilitation | The Chartered Society of Physiotherapy (csp.org.uk), 2019.
5. Black, Dame Carol. Working for a healthier tomorrow. London: TSO. 2008
6. Council for Work and Health. Talking Work: A guide for Doctors discussing work and work modifications with patients. London (UK), Council for Work and health 2019: 1-20.
7. Society of Occupational Medicine. COVID-19 return to work guide for recovering workers. 2021 [cited 2021]; Available from: https://www.som.org.uk/COVID-19_return_to_work_guide_for_recovering_work....
8. NICE. Managing long-term sickness absence and capability to work overview. 2019 [cited 2020 18/06/20]; Available from: https://pathways.nice.org.uk/pathways/managing-long-term-sickness-absenc...
file:///C:/Users/andre/Downloads/workplace-health-longterm-sickness-absence-and-capability-to-work-pdf-66141783176389.pdf.
9. Mikkelsen M and Rosholm M. Systematic review and meta-analysis of interventions aimed at enhancing return to work for sick-listed workers with common mental disorders, stress-related disorders, somatoform disorders and personality disorders. Occupational and Environmental Medicine, 2018. 75(9): 675-686.
10. Frank A. Rehabilitation after COVID-19: supporting those in employment back to work (letter). Clin Med, 2020. 20(6 ): 2.
11. Frank A. Vocational rehabilitation: supporting ill or disabled individuals in(to) work: a UK perspective. Healthcare, 2016. 4(46).
Healthcare | Free Full-Text | Vocational Rehabilitation: Supporting Ill or Disabled Individuals in (to) Work: A UK Perspective | HTML (mdpi.com)
Competing interests: No competing interests
Dear Editor,
We, as a multidisciplinary clinical group of caring individuals, have witnessed the worst pandemic in a hundred years. The COVID-19 virus caused a terrible tragedy for humanity. Yet the multi-disciplinary teams worldwide responded by providing the best care we humanly could.
I don't speak for any other entity than myself. I have witnessed how teams provided healing and comfort to alleviate the suffering using every approved and available tool and modality. We stroked the faces of the dying and held video devices beside patients to facilitate families' interactions. We participated in the joy of our patients' recoveries, assisting with the first steps out of bed after long internments. We clapped and sang songs when patients were discharged, to give people (patients and providers alike) the hope and will to keep fighting.
My greatest personal fear was not succumbing to the virus, but rather the possibility of being a vector of viral transmission to my family. I was moved to tears of joy when I felt the vaccination needle pierce the epidermis of my arm.
The pandemic has internationally brought to light many systemic healthcare issues. Only when hidden issues are brought into the light can they be seen and resolved. We now have the PPE to fight. We now have the vaccines to prevent. We are starting to win this tremendous war against a 0.4 micron viral enemy.
Now that the waves of transmission are receding, it is time to use the same forces that mobilized with urgency and efficiency to produce the PPE, ventilators and vaccinations to stay unified in the continued post critical care recovery pathway for patients.
Prior to the current pandemic, the Society of Critical Care Medicine (SCCM) made recommendations that, in consideration of a cost-benefit analysis, there is validity to the argument for return on investments made to continue rehabilitation for post critical care patients (1). The SCCM recently evaluated the need to identify factors which would predispose patients to the sequelae of symptoms, ranging from muscle wasting to psychological trauma (often caused by dyspnea), which are associated with post intensive care syndrome. The SCCM consensus ultimately recommended that repeated evaluations be conducted on ICU inpatients in the weeks prior to discharge to identify patients at risk (2). Identifying and intervening with at risk patients both before and after discharge, and subsequently investing in post critical care rehabilitation, would benefit both patents and facilities by controlling expenditures associated with readmissions (1).
We have fought hard as teams worldwide to facilitate recoveries for so many patients. As clinicians of all disciplines, we stood fiercely together against ignorance and fear, let us continue to fiercely advocate for the rehabilitation of people we have helped recover from COVID, and other critical illnesses, as they continue to fight the lasting impacts of long intensive care hospitalizations.
Winston Churchill once said "We shall not fail or falter. We shall not weaken or tire. Neither the sudden shock of battle nor the long-drawn trials of vigilance and exertion will wear us down. Give us the tools and we will finish the job."
Focused and ongoing post critical care rehabilitation is the tool we need now more than ever before.
References:
1. Haines KJ, McPeake J, Hibbert E, et al. Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives. Critical care medicine. 2019;47(9):1194-1200. doi:10.1097/CCM.0000000000003818
2. Mikkelsen ME, Still M, Anderson BJ, et al. Society of Critical Care Medicine’s International
Consensus Conference on Prediction and Identification of Long-Term Impairments After Critical Illness. Critical care medicine. 2020;48(11):1670-1679. doi:10.1097/CCM.0000000000004586
Competing interests: No competing interests
Re: Rehabilitation after critical illness-why it isn't happening
Dear Editor
Rehabilitation after critical illness – why it isn’t happening
We echo the call by Catherine White of ICUsteps and colleagues (1) for better care after critical illness. The next stage of care is complicated by a move from biomedical treatments directed at saving life, to an increasingly personal focus incorporating many dimensions of need, and requiring a network of rehabilitation services. Rehabilitation entails not only treatment by therapists but also a process of biopsychosocial assessment and re-evaluation so that the individual and their family/carers are supported to achieve their maximum potential (2). Standards developed by the British Society of Rehabilitation Medicine in the context of major trauma are now applicable to any critical disabling illness, including COVID-19 (3). The quality of the assessment is crucial in ensuring that patients access the services they need when in hospital and when seen by a therapy professional and/or social worker who may still be faced with this responsibility as part of the current Discharge to Assess process.
The PICUPS post ICU presentation screen (4) referenced in this editorial is an effective way of improving assessment, uncovering hidden problems and challenging confirmation bias whereby referrals are only made to familiar services that are readily available. The initial evaluation of this instrument demonstrated, for instance, that only 42% of rehabilitation plans included a recommendation for Clinical Psychology despite this need being identified by the PICUPS instrument in 80% of patients - and in only 24% was Clinical Psychology actually delivered (5). A similarly marked discrepancy was seen in the identification of a need for Psychiatry and Rehabilitation Medicine. Rehabilitation Medicine can have a vital role in the management of more complex patients both in hospital and after discharge.
The aim of such a screen is to formulate a Rehabilitation Prescription that ensures that the individual and their family/carer access the further information, assessment and therapeutic treatment they require on both discharge from the ICU and discharge from hospital (5). This rehabilitation plan should be a core responsibility of the MDT and might be incorporated and updated within the therapy professionals’ electronic record. The PICUPS takes only about three minutes to complete and a software package with in-built functionality to support clinicians in the preparation of a personalised rehabilitation prescription is freely available as a software package from the UK Rehabilitation Outcomes Collaboration (UK ROC).
The rehabilitation pathway will vary according to the severity of the illness or injury with the most severely affected patients benefitting from the availability of a hyperacute rehabilitation unit when they no longer need to be under the acute specialties but need these specialties to be immediately available. Such patients will need then to move to a specialist rehabilitation facility. There are about 75 such facilities in the UK but they are unevenly spread. An audit of rehabilitation provision after major trauma indicated that only 40% of patients with specialist rehabilitation needs were admitted to a specialist rehabilitation facility despite the cost of such rehabilitation being offset within 17 months by reduction in care needs (6).
A key additional advantage of widespread national adoption of the PICUPS instrument and formal Rehabilitation Prescription will be to make explicit local lack of provision and to identify what is needed to mend the gap. In order to achieve this it is essential that data from this tool is centrally collated and linked with other datasets. Proof of principle for the usefulness of this approach exists within the major trauma networks (7).
1. White C, Connolly B and Rowland MJ. Rehabilitation after critical illness. BMJ (Clinical research ed.) 2021; 373: p. n910.
2. British Society of Rehabilitation Medicine. BSRM Core Standards for Specialist Rehabilitation following major trauma: https://www.bsrm.org.uk/downloads/bsrm-core-standards-for-major-trauma-1...
3. British Society of Rehabilitation Medicine. Rehabilitation in the wake of COVID-19. A Phoenix from the Ashes. 2020; Available from: https://www.bsrm.org.uk/downloads/covid-19bsrmissue2-11-5-2020-forweb11-...
4. Turner-Stokes L, Corner EJ, Siegert RJ, et al. The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part 1: development and clinimetric evaluation. J Intensive Care 2021;1751143720988715. Doi: 10.1177/1751143720988715
5. Puthucheary Z, Brown C, Corner E et al. The post-ICU presentation screen (PICUPS) and rehabilitation prescription (RP) for intensive care survivors part 2: clinical engagement and future directions for the national Post-Intensive Care Rehabilitation Collaborative. . J Intensive Care 2021;1751143720988708. doi: 10.1177/1751143720988708.
6. Turner-Stokes L, Bavikatte G, Williams H, et al. Cost-efficiency of specialist hyperacute in-patient rehabilitation services for medically unstable patients with complex rehabilitation needs: a prospective cohort analysis. BMJ open 2016 Sep 8;6:e012112.
7. Turner-Stokes L, Hoffman K, Bill A et al. National Clinical Audit for Specialist rehabilitation following major Injury (NCASRI): Final report. Healthcare Quality Improvement Partnership (HQIP). London April 2019. https://www.kcl.ac.uk/cicelysaunders/about/rehabilitation/national-clini...
Competing interests: No competing interests