Rehabilitation of post-COVID-19 patients

Si bien la incidencia es incierta, algunos reportes de caso sugieren que la infección por COVID 19 se asocia con un aumento del riesgo de tromboembolismo venoso Sugerimos iniciar tromboprofilaxis a todos los pacientes hospitalizados por síntomas asociados con una infección por COVID-19, a menos que esté contraindicado, con enoxaparina 40 mg SC diariamente si el clearance de creatinina es mayor a 30 ml/min Although the incidence is uncertain, some case reports suggest that COVID 19 infection is associated with an increased risk of venous thromboembolism We suggest starting prophylactic anticoagulant therapy for all patients hospitalized with a symptomatic infection with COVID-19, unless contraindicated, with enoxaparin 40 mg SC daily if creatinine clearance is greater than 30 ml/min

Since the first case of coronavirus disease presented in Wuhan, China on December 31, 2019, the disease had rapidly spread to the rest of the World accounting for high morbidity and mortality. In Morocco, the first COVID-19 case was confirmed in Casablanca on 2 March 2020. Then, cases have increased alarmingly in the last month. On  Post COVID-19 ARDS can progress to restrictive respiratory failure due to respiratory muscle weakness, and secondary pulmonary fibrosis with impaired diffusion [4,5] associated with physical deconditioning. Both of ARDS and the prolonged hospital stay due to COVID-19, including time spent in an intensive care units lead respiratory, physical, and psychological dysfonction in patients. This puts them at greater risk for developing post-intensive care syndrome (PICS). PICS is defined as new or worsening impairment in physical, cognitive, or mental health status arising after critical illness and persisting beyond discharge from the acute care setting. [6,7]. The presentation of PICS can be varied. The common symptoms include: Physical impairment: neuromuscular weakness, fatigue, decreased mobility, recurrent falls, deconditioning; Psychological impairment: anxious or depressed mood, sexual dysfunction, sleep disturbances; Cognitive issues: memory disturbance, slow mental processing, poor concentration, Recognizing Delirium). The symptoms can last for a few months to many years post recovery. Family members of patients can be also affected similarly [8,9].
Pulmonary, musculoskeletal, neurological, cardiac, psychological sequelae in some COVID-19 survivors, can affect a person´s ability to perform activities of daily living and lead social restrictions. Rehabilitation care will serve as an important link in the continuum of care, especially for severe forms and dependent elderly with chronic diseases.
Rehabilitation interventions must be based on each patient´s individual needs. Therefore, after COVID-19 recovery, patients should be assessed for possible or occuring deficiencies to determine the modalities of rehabilitation (hospital or ambulatory care, intervenants, programs) and they should be managed by a multidisciplinary team which includes physical medicine and rehabilitation doctor, psychologist, physiotherapist, occupational therapist and respiratory therapist, with the use of pharmacological and non-pharmacological interventions. Depending on the deficiencies, Rehabilitation program includes [10]: Neuromotor rehabilitation with: Passive mobilization, active exercises and postures to recover or preserve of joint range of motion of lower limbs, shoulder girdle and cervical spine; Muscle strengthening begin with overall muscle strengthening, using cycloergometers. Progressive-intensity analytical and dynamic muscle strengthening strengthening can be combined with functional exercices (bed mobility, sitting out of bed, sitting balance, sit to stand, walking); Progressive verticalization to fight against orthostatism disadaptation, with appropriate venous compression and monitoring blood pressure and pulse.
Respiratory rehabilitation: Breathing exercises aimed to improve breathing control may potentially be proposed, under assessment and monitoring of exercise tolerance. They are effectiveness for increasing tidal volume and reducing psychological consequences (stress, anxiety and depression); Lung secretion clearance should implement, if necessary, using expiratory flow accelerator (EFA) technique; Neuropsychological rehabilitation: can be proposed after assessment to patients with cognitive disorders, related to hypoxic encephalopathy or to encephalic lesions due to coronavirus (stroke, etc.); Speech therapy is proposed in case of swallowing or voice disorders after prolonged intubation or focal brain damage; Occupational therapy: is indicated to elderly, who lost their autonomy and have limitations in carrying out their daily activities. It allows to encourage of independence and to accelerate for return home; Psychological care is offered to patients with psychological disorders: anxiety, depression, posttraumatic stress; Reconditioning for exercise, including cycloergometer exercises and muscular strengthening, will be helpful to prepare for a return to socio-professional activities. Depending on the case, this rehabilitation can be carried out in several organisational modalities: inpatient, outpatient or at home. In the context of the COVID-19 pandemic, the use of remote monitoring and mobile intelligence technologies with wearable devices can made possible to practice intelligent and digital remote rehabilitation. Remote virtual reality exercises can be offered to these patients, the effectiveness and safety of these tools have been proven to be non-inferior to traditional approaches.

Conclusion
We share the health situation in Morocco during the COVID-19 pandemic and we propose rehabilitation guidelines for patients recovered from COVID-19 and who are still experiencing disabilities.