This retrospective chart review was approved by the Institutional Review Board at HSS. Data were retrospectively collected from electronic medical records of all inpatients with COVID-19 who received telerehabilitation services between April 8 and May 12, 2020. We further focused our data gathering on inpatients who had telerehabilitation PT only.
COVID-19 Rehabilitation Response Algorithm
All patients admitted to HSS with COVID-19 were screened for PT consults through interdisciplinary rounds via a conference call. The interdisciplinary team consisted of an attending physician or a physician assistant, a case manager, a nurse manager, and a physical therapist. To determine which type of PT services the patients required, a COVID-19 rehabilitation response algorithm (Fig. 1) was created based on international expert consensus guidelines [23]. The guidelines recommend varying levels of PT intervention, depending on disease severity and symptomatology. Six therapists were trained and independent with the technology after a 60-min training session. Most patients (10 of 12) required only one telerehabilitation session to demonstrate independence with their individualized HEP and did not require any in-person PT. Using the algorithm, three groups were identified: (1) patients who required in-person PT only, (2) patients who required telerehabilitation PT only, and (3) patients who required a combination of in-person and telerehabilitation PT.
The primary factor in determining whether a patient required in-person PT was functional mobility status. In-person PT was provided to patients with functional mobility impairments who were not limited by shortness of breath. Telerehabilitation PT only was provided to patients who were mobilizing independently, either on or off supplemental oxygen, or to patients whose mobility was limited by shortness of breath but who did not have any barriers to discharge. The combination of in-person PT and telerehabilitation was provided when functional mobility limitations due to shortness of breath and barriers to discharge home were present. In these instances, telerehabilitation was performed first for education, therapeutic exercises, and assessment of barriers to discharge. Once the patient was weaned from supplemental oxygen, in-person PT addressed the barriers to discharge and assessed any residual functional limitations.
In order to qualify for telerehabilitation PT only, COVID-19 inpatients had to be able to ambulate independently in their rooms with a nurse and needed PT education, therapeutic exercises, and/or breathing techniques. They also had to demonstrate the ability to use technology, have stable vital signs (heart rate, blood pressure, oxygen saturation), require minimal supplemental oxygen (2 L/min or less), and be cognitively intact. The presence of functional deficits, a discharge destination of acute or subacute rehabilitation, and/or known physical barriers to discharge excluded patients from the telerehabilitation only program.
Staff Training
Physical therapists volunteered to treat patients with COVID-19 and were assigned to specific teams (critical care/intensive care unit, general medical COVID floors, and telerehabilitation) based upon clinical experience and staffing needs. The therapists assigned to inpatient telerehabilitation PT were trained to use Zoom for video communications (Zoom Video Communications, San Jose, CA, USA). Training was performed by the informatics team and took approximately 1 h (Table 1). Administration of this program required identification of appropriate patients, logistical coordination, delivery of telerehabilitation, and discharge of patients from the program (Fig. 2). In an effort to minimize staff exposure to COVID-19, physical therapists scheduled telerehabilitation sessions and delivery of iPads and written material in conjunction with nursing care. Once schedules were determined, physical therapists contacted Language Services for coordination of interpreters as needed.
Table 1 Telerehabilitation resources The telerehabilitation physical therapists were stationed near the external telemetry and oxygen saturation (SpO2) monitors for immediate vital sign feedback during sessions. Treatment was adjusted based on peripheral oxygen saturation, heart rate, respiratory rate, and blood pressure during sessions. The following interventions were performed via telerehabilitation, and supplemental written material was provided (Online Resource 1).
Patient Education
Physical therapists educated patients on the COVID-19 disease process and on energy conservation techniques such as activity pacing [10, 12]. Due to the cardiopulmonary limitations in the COVID-19 population, the modified Borg scale (MBS) was used to monitor patient response to therapy [4, 14, 15, 17]. If the activity was rated higher than 4 on the MBS, the patient was instructed to modify the activity. Additionally, traditional discharge education on fall prevention and modifications to the home environment for safety was performed.
Therapeutic Exercise
Patients assessed via telerehabilitation were provided individualized therapeutic exercises based on early anecdotal reports of high fatigability in patients with COVID-19 and clinical knowledge of therapeutic interventions for similar disease processes such as acute respiratory distress syndrome [3, 14, 15, 23]. Based on muscles important to maintain functional mobility such as ambulation and sit-to-stand transfers, lower extremity muscle groups including gluteals and quadriceps were targeted during supine, seated, and standing exercises [2, 24, 25]. Upper extremity exercises were provided to aid in respiratory function, posture, and functional mobility [18].
Typically, patients performed one set of five to ten repetitions of each exercise based on rate of perceived exertion (RPE) with physical therapist supervision via telerehabilitation. Patients were encouraged to complete the same set of exercises an additional two times, without supervision throughout the day, for a total of three sets per day. Patients were taught to progress based on RPE through the use of antigravity motions, resistance bands, and repetitions of exercise (Online Resource 1).
Breathing Techniques
At our institution, respiratory therapy traditionally performs respiratory inventions. Due to limited availability of respiratory therapists at our institution during COVID-19, physical therapists assumed responsibility for performing select, noninvasive respiratory interventions. The breathing techniques and exercises used in the telerehabilitation program were based on the PT guidelines adapted from expert consensus [23, 26, 27]. Patients with a productive cough were taken through the active cycle of breathing technique (ACBT) and cough etiquette [23], the latter important in this population due to the risk of SARS-CoV-2 transmission by aerosol generation. Pursed-lip breathing was taught to patients who were short of breath as a form of breathing control. Straw breathing was taught as a form of positive expiratory pressure to improve ventilation in select patients [23] (Online Resource 1).
Discharge Criteria
Patients were discharged from telerehabilitation when they could monitor exertion through the use of the MBS, verbalize contraindications to activity progression, and demonstrate independence with HEP and when physical barriers to return home safely were addressed. Oxygenation parameters for medical clearance were determined by the medical team. The standard parameters at HSS for discharge required patients to maintain SpO2 over 94% on room air (RA) at rest and over 90% with ambulation for 24 h prior to discharge. This was monitored by nursing staff.
Based on guidelines for COVID-19 functional mobility progression, patients were educated to maintain a metabolic equivalent for task (MET) level of 3 or lower for the first 6 weeks of recovery at home [14, 15]. Therefore, patients who had a flight of stairs or more to access their home were recommended ambulance transport home.