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Telerehabilitation for COVID-19 Patients in India: Problem to Solution

By Pranjal Garg, Saidharshini Muthiah, and Chirag Singla

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Garg P, Muthiah S, Singla C. Telerehabilitation for COVID-19 patients in India: Problem to Solution. Harvard Public Health Review. 2021; 29.

Telerehabilitation for COVID-19 Patients in India: Problem to Solution

Introduction

COVID-19 has taken a massive toll on the planet, claiming over 3 million lives and infecting nearly 150 million people. (1) This highly contagious multisystem disease is caused by the novel SARS-CoV-2 strain. Originating in Wuhan, China, in December 2019, the infection rapidly pervaded the globe, being declared a public health emergency by the WHO on January 30, 2020, and a pandemic on March 11, 2020. (2)

 

Despite closely resembling the SARS-CoV-1 and MERS-CoV, the causative agents of two global pandemics in 2003, the SARS-CoV-2 varies widely in the presentation instead of the predicted trajectory. (3) Significant progress has been made in understanding the virus, the infection, and developing treatment protocols. Nevertheless, the long-term effects of COVID remain unknown.

 

In post-recovery, several heterogeneous manifestations are observed in COVID patients from the acute phase of illness. They vary widely in presentation and are often observed to involve multiple organ systems with consistent, transient, multiple, or fluctuating symptoms. (4) Several terms have been used to denote the long-term effects of COVID 19, including Long COVID, Post-acute sequelae, Post-COVID syndrome, and Post-acute COVID 19. (5) Up to now, a standard clinical definition or the pathogenesis of the Long COVID does not exist. Nor is there a standardized treatment protocol for managing the long-term sequelae of SARS COVID, despite the proactive measures taken by various nations towards preventing and managing the Long COVID, such as the Stanford Hall consensus,(6) the NICE, SIGN, and RCGP guidelines. (7)

 

Despite being fully treated, COVID-19 patients are still prone to develop persistent dysfunction of almost any organ system and, therefore, develop Long COVID. (8) Thus, rehabilitation, starting at the earliest stage, is needed to help the patients convalesce, especially in developing countries like India.

 

In early 2021, after what seemed to be a near-complete containment of the transmission, against the backdrop of the biggest vaccination drive, India witnessed a massive rise in the incidence of COVID. It crossed over 800,000 cases in a mere week. India has since seen more than 18 million cases with over 200,000 reported deaths. (9,10) This second wave of COVID in India took the world by surprise, and entertaining the possibility of an impending surge in Long COVID makes the need for proper rehabilitative guidelines all the more critical. Given the circumstances, telerehabilitation will ensure equitable access to rehabilitative care resources for the patients of long COVID.

Long Term Sequelae of COVID-19

Recorded symptoms of the Long COVID include and do not limit to breathlessness, fatigue, anxiety, depression, cognitive dysfunction, arrhythmias, and myocardial injuries. (11-14) The incidence is seen in all demographic groups. The pediatric population usually has a mild presentation of the acute symptoms of COVID 19. However, the post-acute manifestation showed an increased incidence in the multisystem inflammatory syndrome. (15,16) The incidence of post-intensive care syndrome is also on the rise due to the pandemic. Box 1 lists all the system-wise effects of Long COVID.

 

Many countries are working toward establishing a protocol for rehabilitating COVID 19 patients and managing the Long COVID. (17-20) Rehabilitation for COVID 19 is being done meticulously, starting right from discharging the patients. (21,22)

 

With the unprecedented hike in incidence, India has become the global epicenter of the pandemic. (23) Socioeconomic inequities, in addition to the steady demand, hinder equitable access to healthcare resources. While the financially sophisticated manage to procure the resources needed, people of lower socioeconomic status struggle to access essential care and life support. Psychosocial impacts of the pandemic and lockdown aside, the prevalence of stigma among society delay diagnosis and impede disease control. The discrimination is seen directed primarily at lower socioeconomic groups, people who have recovered from COVID-19, and healthcare workers. (24)

 

With the second wave witnessing the pandemic’s peak, the incidence of Long COVID is also expected to surge. There exists a severe deficit of research into the long-term effects and rehabilitation after the acute infective phase. In the absence of active rehabilitative measures, the country could face another wave soon.

Edition 29 – The United States Healthcare System Today: The COVID-19 Era
Box 1: Effects of long COVID (4,5,29,30,8,13,15,19,25–28)

Role of Telerehabilitation for COVID-19

Rehabilitation, at its core, encompasses assessment, monitoring, prevention, intervention, supervision, education, consultation, and counseling. (31) Telerehabilitation refers to the use of distance communication technologies to satisfy the components of rehabilitation. Evidence suggests that telerehabilitation is a feasible alternative for physical rehabilitation in stroke patients, physiotherapy, and neurorehabilitation as studied before the pandemic. (32-34) Studies have also shown comparable clinical outcomes and patient satisfaction with cost-effectiveness in telerehabilitation compared to conventional methods. (35-37) With physical access being restricted in light of the pandemic, telerehabilitation becomes essential for the rehabilitative care continuum.

 

The global rehabilitation alliance has suggested that rehabilitative care be given to COVID-19 patients as early as the acute phase. It is to be continued in early, late post-acute, and long-term phases. (38) Remote assessment of the long COVID patients, followed by intervention and long-term monitoring while providing psychological support, constitute the foundation of telerehabilitation for COVID-19. Telerehabilitation has also been found viable for inpatients suffering from COVID-19 by a study conducted in the European population. (39)

 

Many teleconsultation services already exist in India, like the one by the Ministry of Health and Family Welfare, esanjeevni platform. (40) However, telerehabilitation services have not been conscientiously implemented. The formidable disease load in India makes emphasizing telerehabilitation dubious. However, an epidemic of long COVID would be imminent if adequate measures are not taken on time. An exemplary setup of telerehabilitation for visually challenged individuals during the pandemic at All India Institute of Medical Sciences, Delhi, India, provides an optimistic outlook of the future of telerehabilitation in India. (41)

 

Due to the unforeseen COVID surge in India, dealing with the staggering load of active cases and resource distribution is given paramount importance. With the healthcare system being overwhelmed and understaffed, the handling of rehabilitation becomes nearly improbable. With society in survival mode, people’s perception of rehabilitation also needs significant improvement. There is a dire need for establishing, implementing, and centralizing a Telerehabilitation system in India.

 

A Proposed Strategy to Introduce Telerehabilitation in India for COVID-19

The authors suggest developing a web portal that serves as a repository for Long COVID and a centralized Telerehabilitation tool. Building a centralized repository helps enhance record-keeping and tracking symptoms of long COVID. Two pathways are proposed for the data compilation-the first, passive, and the second, active data collection. In the passive pathway, a reporting system shall be developed through which the survivors and physicians will report symptoms of long COVID. The inputs can undergo thorough screening before being submitted to the repository. Self-reporting of symptoms is observed to make significant revelations about the disease and, therefore, predict the rehabilitation needs of the patients. (42) The second active pathway involves post-hospitalization follow-up of COVID-19 survivors by a follow-up team. With the physicians engaged in acute care, medical students can be a potential alternative. The team could include medical (MBBS) and nursing students who have been trained in medical history taking and COVID-19 specific follow-up.

 

The patients will be contacted by the team via telecommunication and enquired about their symptoms if any. The database will then be updated. The information thus collected could help establish rehabilitation guidelines as well as in pursuing clinical training of medical students. Figure 1 demonstrates the algorithm of the telerehabilitation portal.

Edition 29 – The United States Healthcare System Today: The COVID-19 Era
Figure 1: Proposed Algorithm

Tele rehabilitation not only integrates safety (social distancing) in providing healthcare interventions but also helps lessen the burden on the physicians. The patients/survivors, through the portal, can access the rehabilitation specialist they require in the nearest rehabilitation center. Once the patient/survivor enters the details, their symptoms are assessed, profiled, and redirected to a nearby rehabilitation center with required resources. 

Potential Hurdles

Several challenges could arise in the proper implementation of the suggestion. At the outset, medical and nursing students can only be employed after adequate training to handle the follow-up of COVID-19 patients. Secondly, lack of awareness regarding rehabilitation in India might pose an initial barrier; however, with active campaigning both by the private and government sector, this can be solved. Given the technical readiness of the target demographic, the average time of implementation can be longer than expected.

Conclusion

Due to the impact of the ongoing coronavirus pandemic and its unpredictable course, it is anticipated that many patients will have some residual symptoms that need some rehabilitation support. Physicians should be well informed about the latest developments and guidelines to provide this support. The proposed protocol includes a repository that helps centralize the data on long COVID, thereby helping the physicians stay up to date. The telerehabilitation portal ensures providing rehabilitative care without actively burdening the healthcare system. It also helps raise awareness on the necessity and importance of rehabilitation in COVID-19 care. As the pandemic grows in leaps and bounds, the healthcare agencies across the world and India should begin taking care of the rehabilitative needs of the COVID-19 survivors with residual symptoms with adequate data collection systems and, as a result, practice cost-efficient and proper evidence-based medicine. 

References

  1.  WHO Coronavirus (COVID-19) Dashboard | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data. (n.d.). Retrieved April 28, 2021, from https://COVID19.who.int/
  2. Cucinotta, D., & Vanelli, M. (2020). WHO declares COVID-19 a pandemic. In Acta Biomedica (Vol. 91, Issue 1, pp. 157–160). Mattioli 1885. https://doi.org/10.23750/abm.v91i1.9397
  3. Zhu, Z., Lian, X., Su, X., Wu, W., Marraro, G. A., & Zeng, Y. (2020). From SARS and MERS to COVID-19: A brief summary and comparison of severe acute respiratory infections caused by three highly pathogenic human coronaviruses. In Respiratory Research (Vol. 21, Issue 1, p. 224). BioMed Central Ltd. https://doi.org/10.1186/s12931-020-01479-w
  4. Shah, W., Hillman, T., Playford, E. D., & Hishmeh, L. (2021). Managing the long term effects of COVID-19: Summary of NICE, SIGN, and RCGP rapid guideline. The BMJ, 372. https://doi.org/10.1136/bmj.n136
  5. Lerner, A. M., Robinson, D. A., Yang, L., Williams, C. F., Newman, L. M., Breen, J. J., Eisinger, R. W., Schneider, J. S., Adimora, A. A., & Erbelding, E. J. (2021). Toward Understanding COVID-19 Recovery: National Institutes of Health Workshop on Postacute COVID-19. Annals of Internal Medicine. https://doi.org/10.7326/m21-1043
  6. Barker-Davies, R. M., O’Sullivan, O., Senaratne, K. P. P., Baker, P., Cranley, M., Dharm-Datta, S., Ellis, H., Goodall, D., Gough, M., Lewis, S., Norman, J., Papadopoulou, T., Roscoe, D., Sherwood, D., Turner, P., Walker, T., Mistlin, A., Phillip, R., Nicol, A. M., … Bahadur, S. (2020). The Stanford Hall consensus statement for post-COVID-19 rehabilitation. British Journal of Sports Medicine, 54(16), 949–959. https://doi.org/10.1136/bjsports-2020-102596
  7. COVID-19 rapid guideline: managing the long-term effects of COVID-19 . (2021). http://www.nice.org.uk/guidance/ng188
  8. Iyengar, K. P., Jain, V. K., & Vaishya, R. (2021). PRACA ORYGINALNA Long COVID-19: An emerging pandemic in itself. Advances in Respiratory Medicine, 89(2), 234–236. https://doi.org/10.5603/ARM.a2021.0040
  9. Mallapaty, S. (2021). India’s massive COVID surge puzzles scientists. Nature. https://doi.org/10.1038/d41586-021-01059-y
  10. Thiagarajan, K. (2021). Why is India having a COVID-19 surge? BMJ (Clinical Research Ed.), 373, n1124. https://doi.org/10.1136/bmj.n1124
  11. Halpin, S., O’Connor, R., & Sivan, M. (2021). Long COVID and chronic COVID syndromes. Journal of Medical Virology, 93(3), 1242–1243. https://doi.org/10.1002/jmv.26587
  12. Davis, H. E., Assaf, G. S., McCorkell, L., Wei, H., Low, R. J., Re’em, Y., Redfield, S., Austin, J. P., & Akrami, A. (2020). Characterizing long COVID in an international cohort: 7 months of symptoms and their impact. In medRxiv (p. 2020.12.24.20248802). medRxiv. https://doi.org/10.1101/2020.12.24.20248802
  13. Huang, C., Huang, L., Wang, Y., Li, X., Ren, L., Gu, X., Kang, L., Guo, L., Liu, M., Zhou, X., Luo, J., Huang, Z., Tu, S., Zhao, Y., Chen, L., Xu, D., Li, Y., Li, C., Peng, L., … Cao, B. (2021). 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study. The Lancet, 397(10270), 220–232. https://doi.org/10.1016/S0140-6736(20)32656-8
  14. Carfì, A., Bernabei, R., & Landi, F. (2020). Persistent symptoms in patients after acute COVID-19. In JAMA – Journal of the American Medical Association (Vol. 324, Issue 6, pp. 603–605). American Medical Association. https://doi.org/10.1001/jama.2020.12603
  15. Jiang, L., Tang, K., Levin, M., Irfan, O., Morris, S. K., Wilson, K., Klein, J. D., & Bhutta, Z. A. (2020). COVID-19 and multisystem inflammatory syndrome in children and adolescents. In The Lancet Infectious Diseases (Vol. 20, Issue 11, pp. e276–e288). Lancet Publishing Group. https://doi.org/10.1016/S1473-3099(20)30651-4
  16. Whittaker, E., Bamford, A., Kenny, J., Kaforou, M., Jones, C. E., Shah, P., Ramnarayan, P., Fraisse, A., Miller, O., Davies, P., Kucera, F., Brierley, J., McDougall, M., Carter, M., Tremoulet, A., Shimizu, C., Herberg, J., Burns, J. C., Lyall, H., & Levin, M. (2020). Clinical Characteristics of 58 Children with a Pediatric Inflammatory Multisystem Syndrome Temporally Associated with SARS-CoV-2. JAMA – Journal of the American Medical Association, 324(3), 259–269. https://doi.org/10.1001/jama.2020.10369
  17. Curci, C., Pisano, F., Bonacci, E., Camozzi, D. M., Ceravolo, C., Bergonzi, R., De Franceschi, S., Moro, P., Guarnieri, R., Ferrillo, M., Negrini, F., & De Sire, A. (2020). Early rehabilitation in post-acute COVID-19 patients: Data from an Italian COVID-19 Rehabilitation Unit and proposal of a treatment protocol. European Journal of Physical and Rehabilitation Medicine, 56(5), 633–641. https://doi.org/10.23736/S1973-9087.20.06339-X
  18. Cheng, Y. Y., Chen, C. M., Huang, W. C., Chiang, S. L., Hsieh, P. C., Lin, K. L., Chen, Y. J., Fu, T. C., Huang, S. C., Chen, S. Y., Chen, C. H., Chen, S. M., Chen, H. S., Chou, L. W., Chou, C. L., Li, M. H., Tsai, S. W., Wang, L. Y., Wang, Y. L., & Chou, W. (2021). Rehabilitation programs for patients with COronaVIrus Disease 2019: consensus statements of Taiwan Academy of Cardiovascular and Pulmonary Rehabilitation. In Journal of the Formosan Medical Association (Vol. 120, Issue 1, pp. 83–92). Elsevier B.V. https://doi.org/10.1016/j.jfma.2020.08.015
  19. Salawu, A., Green, A., Crooks, M. G., Brixey, N., Ross, D. H., & Sivan, M. (2020). A proposal for multidisciplinary tele-rehabilitation in the assessment and rehabilitation of COVID-19 survivors. International Journal of Environmental Research and Public Health, 17(13), 1–13. https://doi.org/10.3390/ijerph17134890
  20. Sivan, M., Halpin, S., Hollingworth, L., Snook, N., Hickman, K., & Clifton, I. J. (2020). Development of an integrated rehabilitation pathway for individuals recovering from COVID-19 in the community. Journal of Rehabilitation Medicine, 52(8).
  21. Dou, P., Zhang, S., Wang, C., Cai, L., Liu, Z., Xu, Q., Li, X., Meng, Y., Rong, Y., Li, S., Hu, C., & Xu, K. (2020). Serial CT features in discharged COVID-19 patients with positive RT-PCR re-test. In European Journal of Radiology (Vol. 127). Elsevier Ireland Ltd. https://doi.org/10.1016/j.ejrad.2020.109010
  22. Zheng, Z., Yao, Z., Wu, K., & Zheng, J. (2020). Patient follow‐up after discharge after COVID‐19 pneumonia: Considerations for infectious control. Journal of Medical Virology, 92(11), 2412–2419. https://doi.org/10.1002/jmv.25994
  23. India: WHO Coronavirus Disease (COVID-19) Dashboard With Vaccination Data | WHO Coronavirus (COVID-19) Dashboard With Vaccination Data. (n.d.). Retrieved April 29, 2021, from https://COVID19.who.int/region/searo/country/in
  24. Chopra, K. K., & Arora, V. K. (2020). COVID-19 and social stigma: Role of scientific community. In Indian Journal of Tuberculosis (Vol. 67, Issue 3, pp. 284–285). Tuberculosis Association of India. https://doi.org/10.1016/j.ijtb.2020.07.012
  25. Nalbandian, A., Sehgal, K., Gupta, A., Madhavan, M. V., McGroder, C., Stevens, J. S., Cook, J. R., Nordvig, A. S., Shalev, D., Sehrawat, T. S., Ahluwalia, N., Bikdeli, B., Dietz, D., Der-Nigoghossian, C., Liyanage-Don, N., Rosner, G. F., Bernstein, E. J., Mohan, S., Beckley, A. A., … Wan, E. Y. (2021). Post-acute COVID-19 syndrome. In Nature Medicine. Nature Research. https://doi.org/10.1038/s41591-021-01283-z
  26. Alarming Life-threatening Mucormycosis Rises In This COVID-19 Pandemic In India | Pediatric News | Pediatric Oncall. (n.d.). Retrieved April 30, 2021, from https://www.pediatriconcall.com/pediatric-news/alarming-life-threatening-mucormycosis-rises-in-this-COVID-19-pandemic-in-india/37
  27. The Chronic Effects of COVID-19 or “Long COVID” | The Indian Practitioner. (n.d.). Retrieved May 4, 2021, from http://articles.theindianpractitioner.com/index.php/tip/article/view/1151
  28. Sudre, C. H., Murray, B., Varsavsky, T., Graham, M. S., Penfold, R. S., Bowyer, R. C., Pujol, J. C., Klaser, K., Antonelli, M., Canas, L. S., Molteni, E., Modat, M., Jorge Cardoso, M., May, A., Ganesh, S., Davies, R., Nguyen, L. H., Drew, D. A., Astley, C. M., … Steves, C. J. (2021). Attributes and predictors of long COVID. Nature Medicine, 27(4), 626–631. https://doi.org/10.1038/s41591-021-01292-y
  29. Biehl, M., & Sese, D. (2020). Post-intensive care syndrome and COVID-19 — Implications post pandemic. Cleveland Clinic Journal of Medicine. https://doi.org/10.3949/ccjm.87a.ccc055
  30. Stam, H. J., Stucki, G., & Bickenbach, J. (2020). COVID-19 and post intensive care syndrome: A call for action. In Journal of Rehabilitation Medicine (Vol. 52, Issue 4). Foundation for Rehabilitation Information. https://doi.org/10.2340/16501977-2677
  31. Brennan, D., Tindall, L., Theodoros, D., Brown, J., Campbell, M., Christiana, D., Smith, D., Cason, J., & Lee, A. (2010). A Blueprint for Telerehabilitation Guidelines. International Journal of Telerehabilitation, 2(2), 31–34. https://doi.org/10.5195/ijt.2010.6063
  32. van Egmond, M. A., van der Schaaf, M., Vredeveld, T., Vollenbroek-Hutten, M. M. R., van Berge Henegouwen, M. I., Klinkenbijl, J. H. G., & Engelbert, R. H. H. (2018). Effectiveness of physiotherapy with telerehabilitation in surgical patients: a systematic review and meta-analysis. In Physiotherapy (United Kingdom) (Vol. 104, Issue 3, pp. 277–298). Elsevier Ltd. https://doi.org/10.1016/j.physio.2018.04.004
  33. Tchero, H., Teguo, M. T., Lannuzel, A., & Rusch, E. (2018). Telerehabilitation for stroke survivors: Systematic review and meta-analysis. In Journal of Medical Internet Research (Vol. 20, Issue 10). JMIR Publications Inc. https://doi.org/10.2196/10867
  34. Calabrò, R. S., Bramanti, A., Garzon, M., Celesti, A., Russo, M., Portaro, S., Naro, A., Manuli, A., Tonin, P., & Bramanti, P. (2018). Telerehabilitation in individuals with severe acquired brain injury. Medicine, 97(50), e13292. https://doi.org/10.1097/MD.0000000000013292
  35. Fatoye, F., Gebrye, T., Fatoye, C., Mbada, C. E., Olaoye, M. I., Odole, A. C., & Dada, O. (2020). The clinical and cost-effectiveness of telerehabilitation for people with nonspecific chronic low back pain: Randomized controlled trial. JMIR MHealth and UHealth, 8(6). https://doi.org/10.2196/15375
  36. Harkey, L. C., Jung, S. M., Newton, E. R., & Patterson, A. (2020). Patient satisfaction with telehealth in rural settings: A systematic review. In International Journal of Telerehabilitation (Vol. 12, Issue 2, pp. 53–64). University Library System, University of Pittsburgh. https://doi.org/10.5195/ijt.2020.6303
  37. Bini, S. A., & Mahajan, J. (2017). Clinical outcomes of remote asynchronous telerehabilitation are equivalent to traditional therapy following total knee arthroplasty: A randomized control study. Journal of Telemedicine and Telecare, 23(2), 239–247. https://doi.org/10.1177/1357633X16634518
  38. Gutenbrunner, C., Stokes, E. K., Dreinhöfer, K., Monsbakken, J., Clarke, S., Côté, P., Urseau, I., Constantine, D., Tardif, C., Balakrishna, V., & Nugraha, B. (2020). Why rehabilitation must have priority during and after the COVID-19-pandemic: A position statement of the global rehabilitation alliance. Journal of Rehabilitation Medicine, 52(7). https://doi.org/10.2340/16501977-2713
  39. Rosen, K., Patel, M., Lawrence, C., & Mooney, B. (2020). Delivering Telerehabilitation to COVID-19 Inpatients:A Retrospective Chart Review Suggests It Is a Viable Option. HSS Journal, 16(Suppl 1), 64–70. https://doi.org/10.1007/s11420-020-09774-4
  40. eSanjeevaniOPD -SAFE HOME OPD National Teleconsultation Service-MoHFW. (n.d.). Retrieved May 3, 2021, from https://esanjeevaniopd.in/About
  41. Senjam, S. S., Manna, S., Vashist, P., Gupta, V., Varughese, S., & Tandon, R. (2021). Tele-rehabilitation for visually challenged students during COVID-19 pandemic: Lesson learned. Indian Journal of Ophthalmology, 69(3), 722–728.  https://doi.org/10.4103/ijo.IJO_2527_20
  42. Menni, C., Valdes, A. M., Freidin, M. B., Sudre, C. H., Nguyen, L. H., Drew, D. A., Ganesh, S., Varsavsky, T., Cardoso, M. J., El-Sayed Moustafa, J. S., Visconti, A., Hysi, P., Bowyer, R. C. E., Mangino, M., Falchi, M., Wolf, J., Ourselin, S., Chan, A. T., Steves, C. J., & Spector, T. D. (2020). Real-time tracking of self-reported symptoms to predict potential COVID-19. Nature Medicine, 26(7), 1037–1040. https://doi.org/10.1038/s41591-020-0916-2

About the Authors

Pranjal Garg

    

Saidharshini Muthiah

     

Chirag Singla