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Johns Hopkins doctor talks creative approach used to assist patients in COVID-19 recovery

28th May 2020

WASHINGTON (ABC7) — Johns Hopkins uses a unique approach when it comes to helping patients recovering from COVID-19.


ABC7 News spoke with Dr. Pablo Celnik, the director of the Department of Physical Medicine and Rehabilitation at Johns Hopkins University School of Medicine, about this method.

Questions

Dr. Celnik, when a critically ill COVID-19 patient turns the corner and improves, what does it take to get them ready for discharge?

Celnik’s response: “Many of the patients hospitalized with COVID-19 require rehabilitation. Out of all patients admitted around 40 to 50% are admitted to the ICU. Of those who are in the ICU ~70% are vented. Because of the disease severity leading to many patients being admitted to the ICU, the impairment complications become very prevalent leading to a significant need of more rehabilitation professionals to be involved in these patients’ care.”

“Here at Johns Hopkins, the physical medicine and rehabilitation (PM&R) team have been following approximately 70% of all hospitalized patients.”

“Here at Johns Hopkins, the physical medicine and rehabilitation (PM&R) team have been following approximately 70% of all hospitalized patients. Most patients need, depending on their specific problems, speech and swallowing rehabilitation, occupational, physical therapy, and physiatry (aka rehab medicine) care. Early on patients might be ventilated and sedated so heavily in an intensive care setting that are unable to move.”

“This can lead to the development of weakness, shortness of breath while walking, reduce endurance, trouble swallowing, hoarse voice, and cognitive abnormalities. Also, many patients suffer psychological side effects such as anxiety and depression or PTSD. Those patients that tend to be more severely affected by COVID 19 and stay in the ICU longer will likely have the most rehabilitation needs. While those more moderately affected are able to recover more quickly towards their baseline.”

What is unique about doctors what doctors are doing at Johns Hopkins?

Celnik’s response: “COVID-19 is a disease of Pulmonary and Rehabilitation. Indeed, while many people have compared this pandemic to the Spanish flu due to the death rate, I like to compare it to the polio pandemic of the early and mid-1900s where those who survived needed significant rehabilitation. In fact, the field of rehabilitation medicine was first created to address polio survivors. Rehab post-COVID involves many disciplines and is delivered by a large team, which includes physiatrist (or rehab medicine), physical and occupational therapists, speech-language pathologies, and rehabilitation psychologists.”

“In fact, the field of rehabilitation medicine was first created to address polio survivors.”

“A physiatrist is a special type of doctor that underwent training in Physical Medicine and Rehabilitation and treat patients of all ages focusing on the person’s overall function (rather than one single organ). In this manner, physiatrists lead and organize the treatment/prevention rehabilitation plan to treat the person as a whole not just one specific area. The COVID virus affects mostly the lungs, but this leads to many bodily function’s failure.”

“Thus, the physical and occupational therapist will focus on preventing and treating weakness and its complications (like joint contractures), the speech pathologist will focus on swallowing and communication abnormalities, the rehab psychologist will tackle anxiety, depression and cognitive abnormalities, and rehab physician will look at the entire picture providing coordination and continuity of care as patients progress from the ICU to the medical unit and the return to the community. Here at Hopkins we have adjusted the dose and intensity of rehabilitation activities based on the severity, needs of the patient, and setting.”

“The rehab team starts from the very beginning when patients are admitted to the ICU or medical units. We evaluate the patient’s charts daily to see when rehab therapists can start to see the patients in the ICU. Here we provide basic mobilization to prevent weakness and complications of immobility, we help with swallowing and communication issues and provide psychological support to reduce anxiety and depression. We then follow the patients when discharged to the medical unit to continue titrating the rehabilitation needs. If the patients become medically stable and improve in their function we help them to be discharged home.”

“If the patients are medically stable, but they persist with significant problems such as weakness, reduced endurance, cognitive difficulties, swallowing disorders then we admit them into a high-intensity rehabilitation unit. Once discharged and in the ambulatory setting we monitor them via telehealth to ensure they have a safe transition to home.”

Are patients with certain pre-existing conditions in need of more rehab after COVID-19?

Celnik’s response: “We know people with co-morbidities or older have more severe COVID19 which will lead for likely more rehabilitation needs. If patients have pre-conditions, such as stroke, COPD, heart failure, then they will be even more affected or more debilitated. The most common problems from COVID19 related problems that are triggering rehab needs are weakness, deconditioning or general debility, reduce physical endurance (shortness of breath with minimal strenuous activities), swallowing problems (due to intubations/vents), and emotional trauma in the ICU.”

Given the risk of exposure to rehab providers and the need to preserve personal protective equipment (PPE), is there a way to provide rehabilitation while addressing these concerns?

Celnik’s response: “Yes. Here are at Hopkins we have developed a very innovative approach to help minimize unnecessary exposure and use of PPEs. We have been using telerehabilitation equipment that is delivered to the patients’ rooms, or their homes once discharged, or even to the Baltimore field hospital created to treat CPVID19 patients. In this manner, patients engage in rehabilitation exercises that can be done while a therapist monitors from the distance, synchronously, or the patient can do the exercises on their own and the therapist can review what they’ve done at a different time, asynchronously.”

“The exercises are like video games, making them fun to do while the patient is doing the training. This approach has been highly successful; while patients love it, the rehabilitation team is very happy because they can monitor exactly what the patient is or was doing, without the need for exposure to COVID19 or the need to use excessive PPEs. We think that while tele-rehab has been developed to treat this patient population, this approach will become part of the standard of rehabilitation care in the near future. You can consider this innovation a positive side effect of this pandemic.”

Finally, what is so special about this rehabilitation approach?

Celnik’s response: “Historically and traditionally rehabilitation happens after patients are medically recovered and can be moved to an inpatient rehabilitation facility. Here at Hopkins we have taken a different approach. We do not wait to start rehabilitation until the patient comes to the rehab unit; we bring the rehabilitation professionals to the patient as soon as they arrived to the hospital. In this manner, we partner with the department of medicine and pulmonary team to care for these patients and prevent many of the complications that can arise from the severity of the disease as well as the prolonged hospitalization and ventilation in the ICU.”

“If the patient reaches a good state we follow them home with tele rehab approach. If patients require a longer time to recover we have two-unit for inpatient rehabilitation, one for patients who remain Covid19 + and for those who are not shedding virus any longer (Covid19 recovered). We have also created a vent rehabilitation unit for patients who remain on ventilators. Finally, PMR and pulmonary doctors continue to follow these patients longitudinally once they go home in what we called the Post-Acute COVID team (PACT), where we monitor the patients’ safe return home with pulmonary, PT, OT, SLP, Psychology to have a smooth return to the community.”

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