July 6, 2020

Patients hospitalized with COVID-19 can experience debilitating physical changes — extreme fatigue, difficulty breathing and muscle weakness, says physiatrist April Pruski. To maximize their physical recovery while in the hospital, Pruski and her colleagues in the Johns Hopkins Department of Physical Medicine and Rehabilitation (PM&R) have implemented several new therapy approaches.

The approaches include using new metric-based criteria to determine the frequency of rehabilitation, allowing therapists to work virtually with patients via telemedicine, and securing negative pressure rooms for patients who are ready for inpatient rehabilitation but still require isolation.

The Right Rehabilitation Prescription for Patients with COVID-19

The PM&R team aims to begin rehabilitation as early as possible for patients hospitalized with COVID-19, whether they are being treated in an intensive care unit, receiving intermediate medical care or are in the medical ward. 

Each day, physiatrist Kenneth Silver, reviews patients’ medical charts to identify those who could immediately benefit from rehabilitation. Next, Pruski consults with colleagues in the Division of General Internal Medicine who oversee the medical care of patients hospitalized with COVID-19. Once approved for rehabilitation therapy, patients are visited by therapists from the appropriate discipline.

As part of a comprehensive evaluation, the rehabilitation therapists perform the Activity Measure for Post-Acute Care (AM-PAC) assessment to gauge a patient’s physical capabilities. Administered every day, this evaluation provides a score that, along with consideration of a patient’s physical capabilities before hospitalization, guides the path of rehabilitation.

Patients with low scores follow a plan that includes brief activities in the hospital room. “That’s really all they can do for the first few days — stand up from a chair and walk over to the bed — and it feels like a marathon because they are fatigued and debilitated,” says Pruski.

Patients with midlevel and higher scores receive daily therapy — potentially, multiple times per day.

Telemedicine Inside the Hospital for Patients Recovering from COVID-19

When inpatients are able to complete physical activities without assistance, therapists deliver virtual therapy in order to conserve personal protective equipment and limit potential spread of the virus.

At this stage, many recovering patients use an iPad, tablet stand and speakers — all provided by the hospital — to engage with their therapists. A typical session might demonstrate ways to conserve energy, says Annette Lavezza, an occupational therapist and manager of inpatient rehabilitation at The Johns Hopkins Hospital.

“Because these patients are easily fatigued, we give them techniques to make tasks easier,” says Lavezza.

The PM&R team has also incorporated a computer program to provide rehabilitation through a video-game-like experience. A motion-detecting camera captures movements, and the program provides real-time feedback to patients about their form. Therapists can monitor the sessions remotely.

Rehabilitation with Negative Pressure for Patients Who Test Positive for COVID-19

When patients recovering from COVID-19 no longer require immediate medical care but need continued rehabilitation and medical monitoring, they may have inpatient rehabilitation at The Johns Hopkins Hospital.

Because these patients do not always clear the infection by the time they move to inpatient rehabilitation, Pruski worked with the Division of General Internal Medicine to secure rooms in a negative air pressure area of the hospital. There they receive customary levels of inpatient rehabilitation in an environment that doesn’t spread contaminated air. 

“This puts them in a better position to continue their recovery at home,” Lavezza says. “We want patients to be as strong as possible when they leave.”