Promulgation Date: 2020-5-13 Title: Announcement on the Issuance of Rehabilitation Plan for Major Dysfunctions in Discharged COVID-19 Patients Document Number: Fafa (2020) #38国卫医函〔2020〕207号 Expiration date: Promulgating Entities:National Health Commission, Ministry of Civil Affairs, National Medical Security Bureau, etc. Source of text: http://www.nhc.gov.cn/yzygj/s7653pd/202005/b15d59b5228341129cc8c5126f663b10.shtml
This Plan was formulated to improve the respiratory function, cardiac function, physical function and psychological functions in patients recovered from COVID-19, to standardize the operation techniques and procedures of rehabilitation, to minimize the burden on patients, and to promote comprehensive rehabilitation.
I. Respiratory dysfunction
(1) Primary manifestations. May manifest as dyspnea, shortness of breath following physical activities, wheezing, chest tightness, weakness in coughing and sputum production. Restrictive ventilatory defects, diffusing capacity reduction accompanied by hypoxemia or respiratory failure are the main manifestations.
(2) Functional evaluations. 1. Symptom assessment: assess with the Modified Medical Research Council (mMRC) Dyspnea Scale. 2. Endurance assessment: assess with the Six-Minute Walk Test (6MWT) and Cardiopulmonary Exercise Testing (CPET). 3. Resting pulmonary function assessment: pulmonary ventilatory function and diffusing capacity. 4. Arterial blood gas or non-invasive pulse oximetry assessment: use arterial oxygen tension and oxygen saturation to assess hypoxemia in patients
(3) Rehabilitation Care.
1. Breathing exercises: including breathing function exercises (Active Cycle of Breathing Techniques (ACBT), which includes breathing control, thoracic expansion exercise and forced expiratory technique), breathing method training (including coordinated breathing, diaphragmatic breathing training, pursed-lip breathing training), respiratory muscle training, pulmonary rehabilitation exercises (a series of exercises in the lying, sitting and standing positions. )
2. Aerobic exercise: including walking, jogging, cycling, swimming, and aerobics, including those conducted with fitness equipment, such as walking, spinning and rowing. It's recommended to start with low-intensity exercises for 20-60 minutes each time and 3-7 times per week, where the patient rates 13-16 on Borg Rating of Perceived Exertion Scale and less than 5-6 on the Modified Borg Dyspnoea Scale, and gradually increase the intensity and duration based on conditions of the disease and the patient's tolerance levels.
3. Oxygen therapy: (1) Oxygen therapy should be given if the arterial oxygen tension at rest is lower than 55mmHg, or when the SpO2 is lower than 88%. (2) For those with underlying conditions such as congestive heart failure or pulmonary hypertension, oxygen therapy should be given when arterial oxygen tension is lower than 60mmHm or when SpO2≤90%. (3) Supplemental oxygen therapy should be given if hypoxemia occurs or SpO2≤88% during exercise, to maintain an SpO2 level of 95%.
4. ADL training, rehabilitation education (such as lifestyle coaching).
II. Cardiac Dysfunction
(1) Primary manifestations. Palpitations, chest tightness, shortness of breath after physical activity, difficulty breathing due to exertion. Precordial discomfort and angina can also occur and are mostly related to physical activities. The heart rate may increase or decrease, and a variety of arrhythmias can occur. The cause of cardiac dysfunction is related to direct damage to the heart by the SARS-COV-2 virus, and may also be secondary to the pulmonary dysfunction induced by COVID-19, as well as the disuse syndrome caused by long-term bed rest and immobility in severe and critical patients. Additionally, it can also be associated with with underlying conditions such as hypertension, coronary heart disease, and diabetes.
(2) Functional evaluations. Base on the patient's condition and the hospital's capacity, CPET can be used to evaluate cardiac function. Otherwise, 6MWT, step test, or MET questionnaire can be used for evaluation. Also take into consideration medical conditions of the patient, such as primary diseases, underlying diseases, electrocardiogram, Doppler echocardiography, and myocardial enzyme levels for comprehensive evaluation.
(3) Rehabilitation Care. Formulate exercise plans based on cardiopulmonary function assessment.
1. Aerobic exercise: same as aerobic exercise for the rehabilitation from respiratory dysfunctions.
2. Muscle strength and muscle endurance training: methods include resistance exercise equipment, dumbbells, pull-ups, push-ups, elastic bands and elastic tubes. Base on the ability of the patient, use weights appropriate for 10-15 repetitions (10-15RM) where the patient scores between 13-14 on the Borg Scale and less than 5-6 on the Modified Borg Dyspnoea Scale. Base on the patient's condition and tolerance level, train 8-16 groups of muscle groups each time, 2-3 sets per muscle group, and 10-15 reps per set. It's recommended to train every other day, to a total of 2-3 times per week.
3. Flexibility training: after aerobic exercise or resistance training. Stretch for 15-60 seconds and 2-4 reps per muscle group, preferably to the point where stretch can be felt but not pain.
4. Balance and coordination training: conduct according to the situation.
Monitor ECG, blood pressure, and oxygen saturation during exercise. If necessary, exercise therapy should be performed in conjunction with oxygen therapy. Adjust the exercise plan appropriately if the patient has active viral myocarditis. During exercise therapy, do not neglect the medical treatment of the patient's underlying disease, as well as diet, sleep, psychological guidance, and etc.
III. Physical dysfunction
(1) Primary manifestations. 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. It's commonly seen in discharged patients who had been severely or critically ill, due to secondary physical dysfunction caused by long-term bed rest and immobility.
(2) Functional evaluations. Use the Borg Rating of Perceived Exertion Scale, manual muscle testing, manual balance evaluation and so on to assess.
(3) Rehabilitation Care. Patients with mild and moderate respiratory dysfunction can choose aerobic exercise, muscle strength and muscle endurance training. Patients with severe respiratory dysfunction and extreme physical decline need to start training from in-bed exercise, movement, balance function, walking function, and going up and down stairs.
1. Aerobic exercise: same as aerobic exercise for the rehabilitation from respiratory dysfunctions.
2. Muscle strength and muscle endurance training: same as muscle strength and muscle endurance training for the rehabilitation from cardiac dysfunction.
3. Balance and coordination training: conduct according to the situation.
4. Oxygen therapy: refer to oxygen therapy for the rehabilitation from respiratory dysfunction.
IV. Psychological Dysfunction
(1) Primary manifestations.
1. Emotional reactions: Anxiety, fear, emotional instability, depression, sadness, helplessness and anger.
2. Cognitive changes: Some patients experience dissociation, inability to concentrate, indecision and self-blame.
3. Behaviour disorders: insomnia, avoidance behaviours, overeating, excessive drinking, self-harm and even suicidal behaviours.
4. Physiological reactions: emotions may induce psychosomatic symptoms such as palpitation, headache, muscle aches, indigestion, bloating, nausea, and decreased appetite.
(2) Functional evaluations.
1. Patient Health Questionnaire-9 (PHQ-9): consists of 9 items scored on a 4-point scale ranging from 0 to 3 points. A total score of 0-4 is interpreted as no depression, 5-9 as mild depression, 10-14 as moderate depression, 15 and above as severe depression.
2. General Anxiety Disorder-7 (GAD-7): comprised of 7 items scored on a 4-point scale ranging from 0 to 3 points. A total score of 0-4 points is interpreted as no anxiety, 5-9 as mild anxiety, 10-14 as moderate anxiety, 15 and above as severe anxiety.
3. The Pittsburgh Sleep Quality Index (PSQI): It is a self-report questionnaire used to evaluate the quality of sleep in the past month. It is scored on a scale of 0-3, with a total score range from 0 to 21 points. Higher scores indicate worse sleep quality.
4. PTSD Checklist – Civilian Version (PCL-C): It is the version recommended in China's "Guide to the Prevention and Treatment of Post-traumatic Stress Disorder". It is a self-assessment scale, including 17 items scored on a scale of 1-5. Higher scores indicate a higher likelihood of developing PTSD.
(3) Rehabilitative Intervention.
1. Promote public science education. Conduct public science education for community residents. Announce information through official media in a timely manner. Carry out targeted public science education in the community by posting posters and leaflets, and distributing COVID-19 information manuals and mental health service manuals to community residents.
2. COVID-19 education. Educate the public on the science of COVID-19; guide the public to understand the characteristics of COVID-19, reduce discrimination and exclusion of recovered COVID-19 patients and their families, and ensure the rights of recovered patients to resume work.
3. Mental health education. Provide mental health service flyers for rehabilitation patients, including mental health knowledge, general knowledge on psychological self-adjustment, and support resources such as QR codes for mental health support sites and hotlines.
4. Conduct targeted psychological counselling and social work services. Based on the impact of the epidemic, specialized mental health experts shall be set up in community health service centers where conditions allow. Set up workstations with full-time and part-time social workers in neighbourhoods (townships). If conditions allow, communities may establish community psychological counselling and social work service teams composed of community workers, social workers, volunteers, psychological counsellors, psychotherapists, and psychiatrists. Establish mental health service records. Provide appropriate levels of mental health services according to the patients' needs, including individual counselling, couple counselling, family counselling and group counselling or online psychological counselling services. If the discharged patients or their families were found at risk for self-harm, suicide, or impulsive aggression, community workers, social workers, psychological professionals and other personnel should increase the frequency of their visits and provide an emergency contact number or psychological hotline. Psychological counsellors and mental health social workers should conduct crisis intervention, and refer the patient to mental health institutions if necessary.
5. Strengthen the humanistic care for discharged COVD-19 patients and their family members to help patients recover their normal lives. Encourage the public to help each other, and eliminate discrimination.
IV. Impairment of Activities in Daily Life
(1) Primary manifestations. Some patients with severe illness or underlying diseases may not be able to dress, undress, use the toilet, take a bath, and etc without aid.
(2) Assessment Methods. Use the Modified Barthel ADL index to assess.
(3) Rehabilitative 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. Conduct functional training and vocational rehabilitation for discharged patients who can no longer work.
VI. Rehabilitation through Chinese Medicine
(1) Primary manifestations. 表现为乏力、气短、咳嗽、胸闷、心悸、失眠、纳差、呕恶等。
(2) Rehabilitation treatment by traditional Chinese medicine.
2. Appropriate techniques for traditional Chinese medicine.
3. Syndrome differentiation.
（2）痰瘀阻络证：胸闷，胸痛，动则气短，乏力，咳嗽。 舌紫暗或有瘀斑、瘀点，苔薄白，脉涩弱。 适用于重型、危重型恢复期患者，肺功能损伤或肺部CT有纤维化表现。
VII. Organizational Safeguards
(1) Clarify the principles of rehabilitation treatment. With the severely and critically ill patients being the key rehabilitation population, individualize rehabilitation measures for patients with different conditions and dysfunctions. Before rehabilitation, conduct a comprehensive and scientific assessment of the patient's health status and their ability to tolerate rehabilitation. Monitor vital signs and patient tolerance during rehabilitation to ensure patient safety. Start rehabilitation treatment early. Ensure a good transition between the clinical treatment stage and rehabilitation after discharge. Attention should be paid to the comprehensive rehabilitation of patients' organs and multi-system function as well as psychological functions.
(2) Identify rehabilitation institutions. All regions should introduce specific rehabilitation management plans for discharged COVID-19 patients based on circumstances. Select the appropriate level of rehabilitation facility based on the patient's illness, type of dysfunction and the capacity of medical establishments, and carry out rehabilitation treatment for discharged COVID-19 patients.
(3) Strengthen the force of rehabilitation. All regions should carry out professional training for medical personnel (including doctors, nurses, rehabilitation therapists, medical social workers, etc.) at different levels to continuously improve rehabilitation awareness and enhance the ability of rehabilitation medical treatment. In particular, focus on improving the community rehabilitation capacity of primary-level medical institutions. Provide targetted training of basic knowledge and skills of rehabilitation medicine to improve the standard and capacity of community rehabilitation, and to provide convenient and accessible services for discharged COVID-19 patients.
(4) Strengthen rehabilitation medical coverage. All localities should manage medical insurance for the medical rehabilitation of discharged COVID-19 patients, and effectively integrate the coverage of the 29 rehabilitation items outlined in the "Notice on Incorporating Some Medical Rehabilitation Items into the Basic Medical Insurance (Weinongwei(2010) No.80)" and the "Notice of Incorporating Some Medical Rehabilitation Items into the Basic Medical Insurance Coverage" (Ministry of Human Resources and Social Security (2016) No. 23). Eligible psychological treatment may be covered by medical insurance if funds allow. At the same time, strengthen the supervision of rehabilitation activities. Outpatient rehabilitation medical expenses for discharged COVIDa-19 patients who meet the requirements are included in the management of outpatient chronic diseases. The medical insurance department should strengthen the guidance and supervision on the implementation of the price policy of rehabilitation medical services.
(5) Strengthen basic living assistance. Local civil affairs departments should promptly include discharged COVID-19 patients and their families who are in need of rehabilitation into the subsistence or social assistance program if they meet the requirements. For those in need but are not presently covered by the subsistence allowances or the social assistance program, temporary assistance should be provided to ensure that those who need help receive it. Strengthen the social assistance service hotline to ensure that the hotline is not jammed, and ensure that COVID-19 patients who are in need of rehabilitation treatment can get help.