COVID forces rehab leaders to rethink approach

Many coronavirus sufferers face a long road to recovery. Here's how Toronto's KITE Research Institute is trying to help

It's been more than nine months since the first cases of COVID-19 showed up in Wuhan, China. Doctors had thought it was a respiratory illness that only deeply affected the elderly, with mostly everyone else able to recover fairly quickly. Now, though – with more than 30 million cases reported worldwide – it's clear that the novel coronavirus is a lot more dangerous than first thought.

Many survivors have experienced strokes, kidney failure, breathing issues, swallowing problems and a host of other ailments. While most people will feel fine after a few weeks, others face a potentially long recovery, explains Professor Catriona Steele, Director of the Swallowing Rehabilitation Research Laboratory at Toronto's KITE Research Institute.

“Many survivors are going to need a lot of help,” she says.

Fortunately, researchers at KITE, the research arm of the Toronto Rehabilitation Institute, are searching for new treatments to assist those in need. While much of the world's medical community is focused on developing a vaccine or finding pharmaceuticals to treat the disease, KITE's staff are examining the after-effects of the virus and redeploying rehab resources to help.

“There are still a lot of unknowns and that's a challenge,” explains fellow KITE scientist Dr. Azadeh Yadollahi. “We know patients are going to need a lot more rehab. We know some things based on what we see in the ICU, but there's a lot we don't know. We have to design programs and run them at the same time now.”

Here are four areas where KITE scientists and Toronto Rehab clinicians are helping COVID-19 patients recover from the virus:

1) Swallowing issues – Prof. Catriona Steele

Ventilators impact muscles, says Prof. Steele, as every muscle associated with breathing becomes weak. That includes the throat right down to the diaphragm. A breathing tube can also damage the throat and esophagus.

“The sensory nerves and receptors may become bruised or may not work,” says Prof. Steele. Some patients may no longer cough when liquid or food goes down the wrong way, and coughing is an important protection mechanism for keeping the airways clear of foreign material.

Swallowing issues, specifically, are showing up in many COVID-19 patients. That's caused partly by weakness of the muscles of the throat – about 50 pairs of muscles are involved in swallowing. Steele explains that people who have been through serious respiratory problems can't hold their breath to swallow like most people, which then causes their swallowing function to erode even more.

Patients who have become too weak after intensive care may not meet this standard. Steele says, “They often end up in long-term care, and there's effectively no rehab for swallowing or other conditions there.”

To help these patients get the support they need, and hopefully have them return home, Prof. Steele has applied for funding to conduct a study that will provide swallowing assessments for patients a month after their release from hospital. If persistent swallowing problems are found, then these patients could be offered rehabilitative treatment through the research study. The not-yet-funded research would look at COVID-19 patients, but ultimately, similar programs could be developed for those with head and neck cancers, stroke and other conditions that impact swallowing.

45: Estimated percentage of COVID-19 patients who need ongoing medical care after hospitalization.

Source: UK National Health Service

45: Estimated percentage of COVID-19 patients who need ongoing medical care after hospitalization.

Source: UK National Health Service

2. Geriatric Isolation – Dr. Andrea Iaboni

KITE is also helping those in long-term care homes, which have been the epicentre of numerous outbreaks. Geriatric psychiatrist Dr. Andrea Iaboni has been working closely with several long-term care facilities since March and has discovered that some of the COVID-19 safety protocols that were put in place led to mental and physical decline among residents.

She's now working on a research project where an isolation-care planning toolkit is used to help prevent the fear, isolation and the lack of activities that occurred in long-term care facilities.

“If we're going to isolate someone, we're doing so with a plan in place,” says Dr. Iaboni. The toolkit provides suggestions for how to keep seniors supported if they must be isolated, and teaches them to use tech tools, like FaceTime and Zoom, to communicate with others. “We have to prevent the virus from spreading, but also mitigate the negative effects of those preventative measures,” she explains.

There are still a lot of unknowns (with COVID-19) and that's a challenge. We know patients are going to need a lot more rehab. We know some things based on what we see in the ICU, but there's a lot we don't know. We have to design programs and run them at the same time now. – Dr. Azadeh Yadollahi

3. Cardiac Care – Dr. Paul Oh

Dr. Paul Oh, Medical Director of the Cardiovascular Prevention and Rehabilitation Program and a senior scientist at Toronto Rehab and the Peter Munk Cardiac Centre, says COVID-19 forced the cardiac rehab team to limit in-person visits with cardiac patients. The team had to act quickly to provide remote rehab to 750 people in their care.

His team began leveraging its patient education platform (Cardiac College), which has extensive content, including nutrition and fitness information, videos and webinars, to help with this task. They also measured everything they were doing. “We had a chance to do a number of observational evaluations as well as structured surveys,” says Dr. Oh.

The team discovered that patients, with support, were able to get active on their own, and adopted a routine of walking or doing light exercises from home, plus they appreciated getting one-on-one support via phone calls from staff. However, issues with the internet and using technology were a barrier for some patients, and many missed out on making friends and getting peer support, which is a key element of cardiac care at Toronto Rehab.

Dr. Oh's team is now using this data as they design and implement hybrid rehab care – a combination of virtual and in-person rehab – making sure that those limited face-to-face interactions have an impact.

4. Wearable Tech – Dr. Azadeh Yadollahi

There are a number of other innovations being developed at KITE related to COVID-19. Many services and research projects have been modified to help those with the virus. That includes an internet-based cognitive therapy project that's been adapted for survivors – indeed, this virus impacts the brain too, and many people experience cognitive decline after being bedridden and on painkillers for long periods.

Dr. Yadollahi develops wearable medical devices that can measure respiration and heart rate, among other indicators. She's adapting these tools to help diagnose COVID-19 and track recovery, and will possibly use them in high-risk groups, such as people experiencing homelessness, to help manage outbreaks in at-risk communities.

While there's still a lot of work to be done, researchers are excited about new opportunities that COVID-19 is presenting for rehab research and services.

“We're going to be able to deliver rehab to as many patients as possible in new ways. Not only those with COVID-19,” says Dr. Yadollahi. “If we can deliver great rehab remotely and effectively, we can take a lot of pressure off the health care system and caregivers.”