Rehabilitation Plan for Discharged Covid-19 Patients (Provisional)

Document Number: [2020] No. 189
Issuing Body:  National Health Commission
Release Date 2020-03-04

This Plan is specially formulated to improve the operational techniques and processes for the rehabilitation of respiratory functions, physical functions and psychological dysfunctions of Covid-19 patients.

I. Goals

Improve discharged Covid-19 patients' breathing difficulties and dysfunctions, reduce complications, relieve anxiety and depression, reduce disability rate, restore capacity for routine activities as much as possible and improve quality of life.

II. Applicable populations and venues

(1) Populations. Discharged Covid-19 patients.

(2) Venues. Rehabilitation treatment bodies, isolated venues, old age homes, communities, and households designated for rehabilitative treatment of discharged Covid-19 patients.

III. Primary Content

(1) Dysfunctions requiring rehabilitative treatment.

Respiratory dysfunction. Manifestations include coughing, expectoration, dyspnea, and shortness of breath after exercise, and may be accompanied by respiratory muscle weakness and damaged lung function.

Impairment of Physical Functions. Manifests as full-body general fatigue, being easily fatigued, muscle soreness, and some may be accompanied by muscle atrophy or decline in muscle strength, and so forth.

Psychological dysfunction. Have emotional problems such as fear, anger, anxiety, and depression.

Impairments of capacity for routine activities and social participation. Unable to independently dress and undress, use the toilet, bathe, and so forth. Unable to carry out normal interpersonal communication and unable to return to work.

(2) Assessment of rehabilitation function.

Assessment of respiratory function. Conduct assessments using the mMRC (Modified Medical Research Council) Dyspnea Scale, and areas or institutions with the capacity are recommended to conduct lung function examinations.

Physical functions assessment. Conduct assessment using the Borg Rating Scale of Perceived Exertion and unassisted muscle strength tests.

Psychological dysfunction assessment. Conduct assessments using the Self-rating Depression Scale (SDS), Self-rating Anxiety Scale (SAS) and Pittsburgh Sleep Questionnaire.

Assessment of ability for daily activities. Use the Modified Barthel ADL index to assess.

Six-minute walk test. Patients are required to walk as fast as possible in a straight corridor, measuring the distance walked in 6 minutes with the minimum round trup distance ≥30 meters.

(3) Rehabilitation Treatment Methods.

1. Respiratory function training

Active Cycle of Breathing Technique （ACBT）: One cycle consists of three parts: breath control, thoracic dilation and forced exhalation In the breath control phase, guide patients in relaxation methods to breathe in a natural rythym, encouraging them to keep their shoulders and chests relaxed, actively contracting the lower chest and abdomen and completing the breath with the diaphragm. The duration of this stage should be adapted to the patients' need for rest. In the thoracic expansion stage emphasize inhalation, guiding patients to inhale deeply into the inhalation reserve, hold their breath for 1-2 seconds, and then exhale passively and easily. In the forced exhalation phase, intersperse breath control and huffing. Huffing is a rapid exhale that does not use much effort, the glottis should be kept open during the procedure. Using the huffing technique to clear mucus, to reduce respiratory muscle effort. Pay attention to using masks as a shield during the huffing process.

Breathing style training: including adjusting the pace of breathing (inhale:exhale ratio = 1:2), abdominal breathing training, pursed-lip breathing training, etc.

Respiratory rehabilitation exercises: Based on patients' physical condition, perform a series of exercises such as neck flexion and extension, chest enlargement, twists, waist rotation, lateral stretches, squats, leg lifts, leg abduction and adduction, ankle pumps, and so forth in reclining, seated, and standing positions.

2. Physical function training

Aerobic exercise: Formulate aerobic exercise prescriptions for patients with underlying diseases and residual dysfunction. Including stepping in place, walking slowly, walking fast, jogging, swimming, Tai-Chi, Baduanjin Qigong, and other forms of exercise. The day after exercising, it is advisable to exercise at an intensity that does not cause fatigue, starting from a low intensity and gradually increasing for 20-30 minute sessions, 3-5 times a week. Intermittent exercise can be used for patients who are prone to fatigue. Begin 1 hour after eating.

Strength training: Use sandbags, dumbbells, elastic bands or bottled water for progressive resistance training, with 15-20 movements per set with 1-2 sets per day for 3-5 days per week.

3. Psychological rehabilitation interventions:

Design therapeutic assignments that can produce a pleasant effect and divert attention, for the purpose of handling mood sand relieving stress. Nurses and rehabilitation therapists that have had professional psychological training can also carry out specialized psychological counseling, including mindfulness relaxation therapy and cognitive behavioral therapy. Attention should be paid to cautiously using the method of allowing patients to relive their traumatic experiences so as not to cause repeated injuries. If mental disorders occur, intervention by psychiatric specials is recommended.

4. Routine activities ability training.

Provide guidance on routine activities for patients. Mainly guidance on energy-saving techniques, breaking down routine activities such as dressing and undressing, going to the toilet, bathing and so forth into small sections and stages, and gradually returning to normal as physical strength recovers returns to normal.

IV. Relevant Considerations

(1) Contraindications. If patients have any of the following conditions, it is not recommended that the rehabilitative treatments above be implemented:

1. Resting heart rate > 100 beats/min.

2. Blood pressure <90/60mmHG, >140/90mmHg or blood pressure fluctuation exceeding baseline by 20mmHg, and accompanied by noticeable dizziness, headaches, and another discomfort.

3. Blood oxygen saturation ≤95%.

4. Discomfort in motion when combined with other symptoms.

(2) When patients present the following circumstances in the course of treatment, immediately stop the above rehabilitative therapy, conduct a new assessment, and adjust the treatment plan.

1. Significant fatigue that is not be relieved by rest.

2. Shows tightness in the chest, chest pain, dyspnea, severe cough, dizziness, headache, blurred vision, heart palpitations, sweating, unstable standing, and so forth.

(3) When patients have complications such as pulmonary hypertension, congestive heart failure, deep vein thrombosis, or unstable fractures, the respiratory rehabilitative treatment should be started after consulting with a specialist on relevant matters needing attention.

(4) Elderly patients often have a poor physique and poor tolerance to rehabilitative training from various preexisting illnesses, and a comprehensive assessment should be carried out before rehabilitation therapy. Rehabilitation training should start from a small and be gradually increased to avoid training injuries and other serious complications.

(5) After severe or critical patients are discharged, in light of the local rehabilitation and treatment conditions, a rehabilitative therapy establishment or basic level health establishments may be designated to carry out post-discharge rehabilitation. After mild or regular patients are discharged, they should take appropriate rest and exercise in the community and at home to recover physical fitness, physique, and immunity as much as possible.