Despite the onslaught of news about the Covid-19 pandemic, I hear nothing, anywhere about the painful and difficult rehabilitation process awaiting the survivors. This is similar to a war in many ways, where enormous sums are spent sending soldiers out but, historically, only a fraction of that is earmarked for the arduous return. We are not prepared.
Viruses such as the corona or influenza types have evolved with the main objective of making the most copies of themselves. To do so, they penetrate the cells in the body and hijack the protein making machinery to make exact copies of the virus. It's like a car factory modified to produce paperclips.
The virus has to be careful not to produce too many copies of itself, or risk killing the host which stops that infected individual from spreading it further. If the virus is too aggressive and kills too often and too quickly, it becomes less successful in spreading a disease.
Asymptomatic carriers, people who got infected but don't know it, are capable of transmitting the virus and are very effective in disseminating the disease. In the case of Covid-19 some estimates suggest the about fifty percent of people belong to that category. The other fifty percent will have varying degrees of illness and many will require hospitalization, sometimes with severe respiratory problems and a cascade of events that can lead to circulatory collapse and death. Predisposing conditions such as diabetes and cardiopulmonary disease greatly increase the chances for a poor outcome. The ones who survive moderately severe and severe illness will need medical and rehabilitation care perhaps for years.
Based on previous respiratory viral epidemics, we can assume that many survivors will recover only part of their lung function. That means varying degrees of reduced vitality, shortness of breath, decreased capacity for taking care of themselves, lung infections, falls, and decreased mental capacity among many other related sequela.
The damage to the musculoskeletal system can be severe due to prolonged inactivity in the hospital bed, poor nutrition, multiple harsh medications and invasive treatments. We can expect loss of muscle mass, stiffness and freezing of the joints, loss of bone calcium with increased chances for fractures.
The brain function and the psychological well being of survivors are expected to suffer. Episodes of hypoxia, or decreased blood oxygen, can lead to confusion, hallucinations and other neurological dysfunction. Less dramatic but no less important, is the development of chronic mental conditions such as depression, anxiety, and panic attacks. Just being in the hospital, sick and scared, is enough to shake one's mental strength. Add to this the banning of one's family from the hospital room, kept away by the risk of infections to themselves, and a gravely ill patient loses the support and hope provided by their loved ones.
Chronic pain will become an important issue during recovery. We expect that many of the survivors will develop generalized pain, a mixture of muscle and joint damage, weakness, decrease oxygen to the muscles and alterations of brain chemicals that regulate pain sensation. Painful peripheral neuropathies, a damage that affects the nerves in the feet and legs, are know to occur after prolonged ICU and hospital treatments.
Pain can be a consequence of the treatment itself. For example, the intense compromise of the lungs caused by the viral infection often require multiple interventions to the thorax, including chest tubes inserted between the ribs. Nerve pain can develop as a known complication from chest operations and it may become a substantial impediment to the recovery for these patients.
The rehabilitation process will require therefore a multidisciplinary approach involving different medical specialties, physical and occupational therapy, nutritionists, psychological support, social workers and others.
As we speak, many rehabilitation facilities have furloughed their employees and reduced their staff to a minimum. It will take time to ramp up to what could be hundreds of thousands of patients in need of a physical and mental recovery program. Assuming that just one out of a hundred Americans require rehabilitation, that number would be in the millions. We are not prepared.
A new methodology for treating these patients is needed. The number of inpatient and outpatient facilities is inadequate. We don't know to which extent the health insurance will cover the treatment of these individuals, and the loss of income suffered by patients and their families during this economic downturn will only magnify the problem. Family members entrusted with the care of weakened patients may not be able to hold a job either.
An intense, daily, exercise program geared towards the respiratory and musculoskeletal systems will likely form the basis of any rehab program. Whether to provide it in a hospital or outpatient setting will depend on the seriousness of each case. A combination of a brief, intensive rehabilitation program, followed by an at home exercise routine supervised by the health care professional through telemedicine may be our best option.
Solid pain management techniques will enable patients to participate in an accelerated rehabilitation program. Analgesics, anti neuralgic medications, nerve blocks, pharmacological neuropsychiatric support etc may provide the patients with the stepping stone required to begin the long journey.
Moacir Schnapp, MD
Mays & Schnapp Pain Clinic