Rehabilitation services are essential: They need to continue during a pandemic and
after as they are an essential component of high-value care offered for individuals
across the lifespan to optimise physical and cognitive functioning to reduce disability.
Rehabilitation care is affected: Globally, the response to COVID-19 is shifting rehabilitation
services provided in all settings, introducing new burden on patients, families and
Measurement needed: A core set of measures needs to be adopted to monitor the health
and functional outcomes for COVID-19 and other patients at risk for functional decline
and to assess the quality, availability and accessibility of services today and as
our nations recover.
Telerehabilitation is necessary: Remote delivery of care and the necessary rapid scale-up
of telehealth could be optimised if financial, infrastructure, resource, training
and cybersecurity barriers were addressed.
Collaboration can support needs in the home: Novel partnerships that include the rehabilitation
community could enhance communication and delivery of safe and effective home-based
rehabilitative strategies to mitigate the consequences of COVID-19 and reduced service
Direct care providers need personal protective equipment: Rehabilitation providers
in all settings should be ensured personal protective equipment and training to use
COVID-19 is overwhelming healthcare services and healthcare workers globally. The
response, appropriately, is on the ability to care for people who become critically
ill, protect their carers and keep people physically distanced. However, this response
has shifted what is considered and how to provide essential healthcare services. Rehabilitation
services, which optimise physical and cognitive functioning to reduce disability,
are a core component of high-value care.1 The decisions to shift, transform, delay
or discontinue rehabilitation care are complex. These decisions have societal implications
for today and the future. This commentary describes adjustments to the continuum of
rehabilitation services across 12 low-income, middle-income and high-income countries
in the context of national COVID-19 preparedness responses (table 1) and provides
recommendations for decision makers on the provision and payment of these essential
Continuum of rehabilitation services across 12 low-income, middle-income and high-income
countries in the context of national COVID-19 preparedness recommendations
National government mandated COVID-19 response
Rehabilitation services during COVID-19*(inpatient, redeployment/bed shift, outpatient/home
Stay-at-home order 2020
Guidance for ‘non-essential’ healthcare services
National lockdown:essential trips for cleaning supplies, medicines and food.
Inpatient rehabilitation still offered in reduced capacity.Other inpatient bed types
converted to increase acute hospital bed capacity.Patients are not attending day rehabilitation
programmes despite programmes being open.All outpatients clinics in all public and
private hospitals closed.Physicians and therapists cannot get reimbursed for video
telehealth visits (neither video nor telephone).
Containment and mitigation: school and retail closures, ban on all gatherings, movement
only for essential needs and ban on non-essential international travel.
Non-essential services suspended.
Inpatient rehabilitation operational but discharging more quickly to prevent spread;
all activities in patients’ room.Rehabilitation personnel but not beds have shifted
to support acute care.All outpatient rehabilitation services discontinued.Government-approved
renumeration for telerehabilitation for all provider types (expanded for COVID-19).
Containment and mitigation: national guidance defined essential services and recommendations
for social distancing and foreign entry restricted.
Non-essential services suspended.
Reduced operations for inpatient rehabilitation.Shift in rehabilitation personnel
and outpatient services, encouraged to use telemedicine.Federal Council of Medicine
acknowledges use of telemedicine for teleorientation (distance guidance, training
and patient referral), telemonitoring under medical supervision or guidance and teleinterconsultation
(between physicians for diagnostic or therapeutic assistance).
Lockdowns across country: suspension of travel, banned public gatherings, early detection
and isolation, mobility restrictions and quarantine for returning migrant workers.
Non-essential services suspended.
Inpatient rehabilitation for all non-urgent patients suspended.Shift in rehabilitation
hospital beds or rehabilitation personnel to help with COVID-19 response.Outpatient
rehabilitation suspended.All home care discontinued.Teleconsultation/virtual rehabilitation
provided mostly free of charge.
Containment and mitigation: travel restrictions, school closure, closing non-essential
businesses and banned public gatherings.
All elective surgeries and non-essential services postponed.
Acute hospitals continued early acute rehabilitation.Rehabilitation hospitals discontinued
care for chronic, non-acute problems; acute patients (eg, surgery and stroke) stay
as long as needed.Some rehabilitation hospitals could be designated as overflow hospitals.
Rehabilitatation personnel supporting acute hospitals.Outpatient rehabilitation is
reduced but available for high need patients/essential care.Telerehabilitation for
physicians and health professionals in the acute COVID-19 phase possible and reimbursed.
Encouraging social distancing and hygienic practices.Established health emergency
operations centre.Curfew and stay-at-home policy implemented and all non-essential
business ordered closed.
All elective surgeries and non-essential services postponed.
Inpatient rehabilitation continued in acute hospitals.Outpatient rehabilitation therapists
reassigned to acute hospitals.All community-based rehabilitation suspended in hinterland
regions.Phased approach to cancelling/closing all outpatient rehabilitation services;
patients receive self-led home-based programme.Telerehabilitation via telephone, Zoom,
WhatsApp and emailing exercise programs. Also using MedBridge.
National lockdown: exceptions medical and pharma services, groceries, banks, telecom,
gas stations as essential services, school closures and restriction of international
and most domestic travel.
Non-essential elective surgeries postponed
Hospitals discharging stable patients at earliest possible.Inpatient rehabilitation
continued for patients who cannot return or travel home.Rehabilitation personnel considered
part of human resource mobilisation for training and possible role assignments.Outpatient
and home-based rehabilitation suspended.Telerehabilitation via phone, Whatsapp and
Zoom carried out by certain tertiary care and independent rehabilitation clinics especially
for the neurologically ill patients.
National lockdown: temp. screening, hospital and home quarantines, extensive tracing,
social distancing, bans on large gatherings, schools closed and travel restricted.
Non-essential appointments, including elective procedures and outpatient rehabilitation,
Inpatient rehabilitation continued but location shifted outside of acute hospitals
into stand-alone rehabilitation (community) hospitals. Focus on intensive care, cardiopulmonary
and severe, new onset disability.A significant proportion of outpatient providers
shifted to inpatient.Limited outpatient rehabilitation personnel focused on postacute
and shifted to small teams for physical distancing.All group and community-based rehabilitation
activities suspended including day rehabilitation and senior activity centres.Home
rehabilitation requests subject to review by health authorities, restricted to patients
with significant new-disability and limited caregiver support.In-hospital rehabilitation
consults and multidisciplinary team meetings through teleconference.Providers trained
to deliver teleconsultations with national regulatory guidance for quality and cybersecurity.
National lockdown: exceptions medical and pharmacy services, groceries and banks.
School closures and restriction of international travel.
Non-essential services suspended, non-urgent surgeries postponed and outpatient clinics
Inpatient rehabilitation offered in reduced capacity.Rehabilitation beds shifted to
extend capacity of acute care.Outpatient rehabilitation programmes suspended. All
outpatient clinics in all public and private hospitals closed.The majority of home-based
rehabilitation (but not completely) suspended.Physicians and therapists cannot get
reimbursed specifically for telehealth visits (neither video nor telephone as of 23
April). In some contexts (eg, Catalonia) the Board of Physical Therapists organised
a task force of volunteer physical therapists who can deliver some telephone-based
rehabilitation. (Provision of healthcare is regulated and reimbursed regionally.)
Containment and mitigation: public gatherings ban, 30-day closure of schools, universities,
training institutions, health screening at points of entry, 14-day quarantine for
travellers from high-risk countries.
Local KCMC. Example: care for older adults suspended unless an emergency, outpatient
block appointments, reduced elective surgeries and prioritised emergency surgeries.
Inpatient rehabilitation offered but length of stay and visitors reduced to prevent
hospital acquired infection (affecting amount of time therapists have to evaluate
and treat patients+train family for home-based rehabilitation).Shift in rehabilitation
personnel with those age >55 years exempt from patient contact.Outpatient rehabilitation
appointments scheduled in blocks to avoid overcrowding and congestion especially in
waiting areas.Telehealth not a standard of practice for rehabilitation (and not covered
by insurance); patients discharged early and appointments delayed/cancelled have limited
access to care.
By state or city
Stay at home orders, school closures, bans of mass gatherings and non-essential business
Recommendations to postpone all elective surgeries and non-urgent procedures and visits.
Fewer rehabilitation beds; beds converted for acute care.Shift in rehabilitation personnel
to acute inpatient and telemedicine follow-up.Outpatient rehabilitation available
only for high need patients following. CDC recommendations for essential care.Rehabilitation
teleconsultations. Slow scale to virtual visits. Physicians reimbursed. Therapists
reimbursed by some private insurers but not reimbursed by government insurance until
National lockdown: only leave home for food, health reasons, work and other travel
restrictions.Social distancing and personal hygiene guidelines.
Non-urgent surgeries postponed.
Hospital inpatients medically fit discharged early; inpatient rehabilitation offered
in reduced capacity.Shift in rehabilitation hospital beds to maximise inpatient capacity;
shift in rehabilitation personnel to provide greater acute hospital and community
service support.Outpatient rehabilitation at reduced capacity.Telephone and digital/video-based
*Authors provided reports of rehabilitation practice in the absence of national policies.
CDC, Centers for Disease Control and Prevention; KCMC, Kilimanjaro Christian Medical
Changes to rehabilitation care across settings
Rehabilitation addresses health and functioning for individuals across the lifespan.
The immediacy of care needs varies by condition.2 Services are provided in every setting—acute
hospitals, rehabilitation hospitals, outpatient clinics, in the community and in people’s
homes—and resources vary by region. Guidance for the delivery of rehabilitation during
COVID-19 is available for physiotherapy but not yet all rehabilitation professions.3
Several regions reported fewer non-urgent rehabilitation patient admissions in order
to expand acute care bed capacity. Lengths of inpatient stays for patients who receive
rehabilitation are now shorter in several countries including Belgium, India, Tanzania
and the UK. Shorter inpatient stays reduce the time available to assess and treat
patients and train family. Any need for continued home-based care has implications
for caregivers particularly while social distancing.
In addition to shorter lengths of inpatient stays, all 12 countries report outpatient
and home-based rehabilitation care suspended or operating at reduced service capacity.
These inevitable decisions for protection of both healthcare workers and the general
public may result in increases in disability and morbidity from a lack of necessary
rehabilitation care to those with continued care needs. Patients at home with limited
ability to move independently or facilitate their own self-care activities, and patients
with prolonged hospitalisation for COVID-19 who have returned home, are at high risk
of several adverse health effects. Skin breakdown, muscle weakness, joint stiffness,
reduced range of motion, changes to bowel and bladder functioning, venous stasis,
oedema, decreased rate of metabolism and respiratory movement, lowered mood and depression
are measurable in the first week of limited mobility. It is critical that public health
communication continue to address the significance of daily activity and movement
while uniquely considering limitations of individuals with significant physical or
cognitive disability. Guidance needs to also ensure the safety of caregivers involved
and be provided for households without available caregivers.
Protecting providers of direct care
While there is concern for people with unmet rehabilitation needs, it is important
to protect all direct care providers, paid and unpaid, during a pandemic response.
Many components of rehabilitation care require patient contact, for example, treating
patients weaning from mechanical ventilation, developing patients’ balance techniques
after stroke and fitting a new limb after amputation. Furthermore, rehabilitation
personnel from Guyana to Singapore are being redeployed to meet needs in care settings
different than their usual work environment. In Spain, health workers represent 15%
of all COVID cases and, in response, the country has mobilised retirees, medical residents
or other health personnel. In Singapore, private sector and retired rehabilitation
staff may join frontline healthcare. In planning for adequate personal protective
equipment and training for its use, governments need to include all direct care providers
in their calculations to adequately protect people in homes and community-based settings
when direct-patient contact is still necessary.
Telephone consultation for care is an option in some regions but is dependent predominantly
on the availability of personnel. Use of video visits and other forms of virtual care,
although preferred for rehabilitation over telephone consultation alone, requires
widespread and stable internet connectivity, availability of technology for both the
rehabilitation provider and the patient, ‘tech literacy’ or the ability to use a device,
the availability of ‘tech support’ to troubleshoot or first get connected and payment
for provider time. Although rehabilitation in some countries such as Guyana, Germany
and the UK is a component of universal healthcare coverage (UHC), governments and
health insurers of other non-UHC countries need to pay therapists, in addition to
physicians, to equitably provide care via telehealth.
Use of telehealth under usual circumstances in all forms—text, telephone and video—requires
planning, training and iterative improvement. It is imperative that experienced telehealth
providers share protocols and become champions to support their peers with rapid scale-up
in this challenging environment. Publications are emerging, and some professional
societies are sharing guides for remote consultations.4 5 China and the USA have live
webcast sessions with national experts to train rehabilitation providers and online
communities to empower caregivers. Creative solutions to use free and commercially
available communication tools like WeChat and WhatsApp are being used in Brazil, China
and Guyana. These approaches are limited in Tanzania and likely other low-income countries
due to costs for data plans and limited in-home internet access. With the majority
of rehabilitation care provided remotely during a pandemic response, telehealth strategies
need the infrastructure and to be resourced and financed appropriately.
Measuring the impact of COVID-19
Enhanced measurement and monitoring are desperately needed at the individual, health
system and national levels. With the release of the WHO Rehabilitation Guide for Action
only this past year,6 few countries had fully completed a systematic assessment of
the rehabilitation situation and developed a strategic plan to adequately meet rehabilitative
needs prior to this pandemic or to activate during pandemics. Yet, today, we need
alignment on a measurement strategy. Longitudinal assessments of health and functional
outcomes are needed to monitor individual and population health and support clinical
decision making for allocation of scarce resources in all settings.
The global significance of measurement on practice and policy was evident in the release
of COVID-19 outcomes assessments of intensive care unit patients7; similar data are
needed on the functional recovery of patients with COVID-19. Service-level records
need to be monitored to ensure adequate quality and equity with constrained resources.
In the longer term, greater attention to national census and cohort surveys will be
needed to detect changes in population health that can inform policy decisions on
rehabilitation service needs and geographic disparities. The rehabilitation community
needs to unite to consider a core set of measures to monitor recovery of patients
with COVID-19, health of persons with disability and chronic conditions, and the quality,
availability and accessibility of services today and as our nations recover.
Rehabilitation care is at a unique turning point. In 2017, the WHO had already noted
‘substantial and ever-increasing unmet need for rehabilitation services worldwide’.8
Today, we are faced with a new population of patients at risk of functional decline
in addition to the disability pandemic already present among one billion people globally.
We are providing care in new ways and standards of care are changing. The following
recommendations are provided to mitigate the consequences of COVID-19’s impact on
rehabilitation care and support continued health with reduced risk of disability.
Governments need to include rehabilitation and other direct care providers in home-based
and community-based settings in their plans for personal protective equipment acquisition
Global collaboration across rehabilitation professionals needs to accelerate the sharing
of resources, instructional tools, education and training packets for how patients
and families can continue rehabilitation at home during a pandemic response.
Public health messaging on mental and physical health while social distancing needs
to expand with input from rehabilitation professionals to provide guidance for persons
living with physical and cognitive limitations, with and without caregivers.
Public–private partnerships are needed to better support rapid scale of telehealth
today and in the future to ensure effective use, financing, cybersecurity, access
and increased reliability of broadband networks to reach people in low-resourced areas.
The rehabilitation community needs to unite on measurement of care and outcomes because
the evidence established in real world practice today could transform care and lives
The WHO called on nations to ensure continuity of essential services in parallel to
scaling public health preparedness and response measures.9 Our shared experience is
that national agencies did not issue specific guidance for the provision of rehabilitation.
Considerations for service delivery balanced risk of transmission with both the availability
of resources to provide care and the patient’s acuity, level of urgency and potential
for harm if services were postponed or altered. Rehabilitation service providers mobilised
quickly to provide the best, safest care possible to those in greatest need; decisions
were in many cases made locally. Looking beyond the pandemic, rehabilitation needs
to remain at the forefront of discussions for UHC; barriers to infrastructure, implementation
and financing care via telehealth and alternative approaches need to be eliminated.
Strong leadership for inclusion of rehabilitation in public health and healthcare
policymaking is acutely needed to ensure high-value care and reduce the global burden