Preface
The strategic preparedness and response plan outlines the World Health Organization’s (WHO) strategic objectives to end the COVID-19 pandemic and help national stakeholders develop a structured approach to their response. WHO’s main goals for COVID-19 are: 1) suppress transmission; 2) provide optimized care for all patients and save lives; 3) minimize the impact of the epidemic on health systems, social services and economic activity.
This guidance is based on the above strategic priorities, and is intended for clinicians involved in the care of patients with suspected or confirmed COVID-19. This guideline is not intended to replace clinical judgment or specialist consultation, but rather to strengthen frontline clinical management and public health response. Considerations for special and vulnerable populations, such as pediatric patients, older adults, and pregnant women, are highlighted throughout the text. This guide is the product of contributions from several members of the WHO team and independent experts from around the world. WHO is deeply grateful to each of the collaborators for their time and expertise.
Target audiences:
The target audience is anyone widely involved directly or indirectly in the care of COVID-19 and post-COVID-19 patients, i.e. doctors, healthcare workers, facility managers and hospital administrators.
Current practice:
The evidence base for the clinical management of COVID-19 is increasing rapidly. Numerous randomized and observational trials are being conducted to inform practice.
Post-COVID-19 rehabilitation
New recommendations : In this update, the Guidelines Development Group (GDG) makes 16 new recommendations for the rehabilitation of adults with post-COVID-19 condition:
- To support the provision of rehabilitation services for the post-COVID-19 condition, we suggest the following core components: 1. Multidisciplinary rehabilitation teams; 2. Continuity and coordination of care; and 3. People-centered care and shared decision making. To support the operationalization of core components, planners could implement core functions, including: 1. Standardized symptom assessment and outcome measurement; 2. Tracking system; and 3. Reference system.
- In adults with post-COVID-19 condition, exertional desaturation and heart failure after COVID-19 should be ruled out and monitored before considering exercise training. Although orthostatic intolerance and post-exertional symptom exacerbation (PESE) are amenable to rehabilitation, their presence will require that interventions be modified in light of these diagnoses for rehabilitation to be safe.
- Early referral of adults with a post-COVID-19 condition to appropriate rehabilitation services is suggested when they experience symptoms and impairments that can be managed effectively and impact daily functioning, where red flags have been considered. for safe rehabilitation.
- For the delivery of rehabilitation services for the post-COVID-19 condition, we suggest using a hybrid approach of in-person and remote models that are integrated into all levels of healthcare. It is suggested that the duration of a rehabilitation program be based on the patient’s needs, allowing for recommitment if further functional decline occurs.
- A rehabilitation workforce for adults with a post-COVID-19 condition may include, but is not limited to, physical therapists, occupational therapists, nurses, psychologists, speech and language therapists, physicians, and social workers. Community healthcare workers may be required based on local needs.
- For clinical rehabilitation management in adults with post-COVID-19 condition, we suggest using education and training in energy conservation techniques, such as stimulation approaches. Provision and training in the use of assistive products and environmental modifications may be helpful for people experiencing moderate to severe SEPE.
- For the clinical rehabilitation management of arthralgia in adults with post-COVID-19 condition, we suggest using a combination of pain education, skills training in self-management strategies, prescription of short-term anti-inflammatory medications and, in the absence of PESE , physical exercise.
- For clinical rehabilitation management of shortness of breath in adults with a post-COVID-19 condition, we suggest using a combination of education and skills training on self-management strategies, such as nasal breathing and pacing approaches, and in the absence of post-exertional symptom exacerbation ( PESE), physical exercise training. Breathing control techniques could be offered to those with a suboptimal breathing pattern and psychological support may be useful to address contributing factors such as anxiety.
- For clinical rehabilitation management of cognitive impairment in adults with post-COVID-19 condition, we suggest using a combination of education, skills training in self-management strategies, and cognitive exercises. Provision and training in the use of assistive products and environmental modifications may be useful in addressing cognitive dysfunctions as they apply to daily functioning.
- For clinical rehabilitation management of fatigue in adults with a post-COVID-19 condition, we suggest using a combination of education, skills training in energy conservation techniques such as stimulation approaches and, in the absence of PESE, a cautious return to physical exercise training adjusted to symptoms. . Provision and training in the use of supportive products and environmental modifications may be considered for people experiencing levels of fatigue that limit instrumental activities of daily living. Psychological support can be offered to help cope with the symptom.
- For the management of clinical rehabilitation of anxiety and depression in adults with a post-COVID-19 condition, we suggest using psychological support and, in the absence of PESE, physical training. Additionally, mindfulness-based approaches and peer support groups may be helpful in reducing distress in some people with a post-COVID-19 condition when managing long-term symptoms.
- For clinical rehabilitation management of olfactory impairment in adults with a post-COVID-19 condition, we suggest using education and skills training for olfactory training.
- For clinical rehabilitation management of orthostatic intolerance in adults with post-COVID-19 condition, we suggest using a combination of education and training in self-management strategies and, in the absence of PESE, physical exercise training. Environmental modifications may be useful in supporting activities of daily living for people who experience difficulties with upright or standing positions.
- For clinical rehabilitation management of swallowing impairment in adults with a post-COVID-19 condition, we suggest using a combination of education and training in positioning skills, dietary maneuvers and modifications, and swallowing exercises.
- For clinical rehabilitation management of voice impairment in adults with a post-COVID-19 condition, we suggest using education and skills training on voice rest and vocal behaviors. Additionally, any combination of breathing exercises and vocal training can be considered.
- Rehabilitation interventions for return to daily activities under post-COVID-19 conditions could include education and training in energy conservation techniques, and the provision and training in the use of assistive products for those who need further assistance with activity management and mobility. For a return to work, we suggest using a return to work action plan with a long and flexible phased return. Work environmental modifications may be needed based on an individualized workplace risk assessment of personal capabilities that match job requirements.
Justification of the new recommendations:
Member States, patient advocacy groups and doctors requested clinical guidance from WHO for post-COVID-19 condition rehabilitation. Many COVID-19 survivors experience one or more persistent or new symptoms that affect daily activities and functioning. Rehabilitation is a key health strategy to maintain and optimize people’s functioning and to improve family, recreational, educational and professional participation. The development of the recommendations was prompted by the need for guidance for rehabilitation program planning and the possibility of rehabilitation in other conditions for the most common symptoms and impairments in the post-COVID-19 condition.
How this guideline was created: A GDG of content experts, clinicians, patients, and methodologists produced recommendations following standards for developing reliable guidelines using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. No conflict of interest was identified for any panel member or other contributors to the guideline development process. This living guideline represents an innovation from WHO, driven by the urgent need for global collaboration to provide reliable and evolving guidance on COVID-19 that informs policies and practices around the world.
Latest evidence: Recommendations for post-COVID-19 rehabilitation program planning were based on the results of a systematic scoping review. Recommendations for clinical rehabilitation management of selected impairments were based on a summary of the evidence from the Cochrane Rehabilitation Rapid Living Systematic Reviews on Rehabilitation and COVID-19 (PICO Direct) and a summary of the evidence in other rehabilitation conditions. chronic health reports based on an overview of the results of the Cochrane systematic review (PICO indirect).
