For COVID-19 survivors, rehab plays vital role on the long road to recovery
Ashley Comrie just wanted to go home.
It was late May, and the 37-year-old had just spent three terrifying weeks at Toronto General Hospital, fighting a COVID-19 infection that landed her in the intensive care unit, where she narrowly avoided intubation. Lying on her stomach, hooked up to oxygen, she had felt as if she were underwater, breathing through a straw. Death seemed a distinct possibility.
Now, with the worst of the disease finally behind her, Comrie’s doctors wanted to transfer her to an in-patient rehabilitation program created for people like her, who had survived COVID-19 but faced a long road to recovery.
Comrie was still on oxygen. She couldn’t bathe herself or walk unassisted. She was also having trouble concentrating and carrying on conversations.
But she missed her husband, who had suffered through his own coronavirus infection at home, alone. She was desperate to return to ordinary life.
It wasn’t until she was admitted to rehab at Bridgepoint hospital that she realized her healing had only begun.
Three weeks later, she is doing puzzles on an iPad, and starting to tackle stairs.
She is amazed at her progress — and how much work lies ahead.
“I had no idea how much this part would be integral to my recovery,” Comrie said in a phone interview from her room at Bridgepoint. “As important as being in acute care and the ICU has been, this has been key.”
In the initial, frantic months of the COVID-19 pandemic, modern society was upended in the interest of saving lives. The economy was halted in a desperate bid to stop the spread, as hospitals scrambled to keep some of the sickest patients alive. So far, the disease has infected more than 100,000 people across Canada; roughly 8,400 have died.
The next phase carries its own set of challenges.
As lockdowns ease and governments tentatively roll out their COVID-19 recovery plans, there are now thousands of survivors of the disease in Canada who are also in recovery.
Shortness of breath can linger for weeks, even after relatively mild bouts of COVID-19. Those hit with more serious infections, like Comrie, who is immunocompromised, have spent weeks in hospital, immobilized in bed, isolated from friends and family. Some have been hooked up to ventilators, and need support from a speech therapist to learn how to swallow, or sound like themselves again. The therapies are complex, and in some cases may be limited by the realities of the pandemic.
“I would hope that we could dispel the notion that if you survive COVID, you’re better right away,” said Dr. Larry Robinson, the chief of Sunnybrook hospital’s St. John’s Rehab Program, which also has a dedicated unit for COVID-19 patients.
“The way the public thinks about (COVID) is you get a cold. If you get a bad cold you go to the hospital, but then you’re OK,” said Robinson. “For many, it’s going to be a slow, slow recovery — in the months kind of range — before you get back to normal.”
There are still a lot of unknowns about the effects of COVID-19 on the body. But in Toronto, where several hospitals have hived off separate units for in-patient rehabilitation after serious bouts of COVID-19, those treating these patients say their needs can be complex.
Dr. Ashley Verduyn, chief and director of medical affairs at Providence Healthcare, a rehab hospital in Scarborough that has also set aside space for COVID-19 patients, said these patients “really benefit from a multidisciplinary program.”
Long stints in bed can rob people of the strength needed to perform even basic tasks, such as dressing and feeding themselves. And in some cases, these patients are also suffering from post-traumatic stress disorder from being in the ICU, or are mourning a loss.
“We’ve had patients who have lost their partner to COVID,” she said. “So not only are there physical challenges — like muscle weakness and deconditioning … They need a lot of psychological support as well.”
Verduyn said some patients also struggle with loss of memory and cognition.
“It is a very complicated rehab,” she said. “It’s not just doctors. It’s not just physio. It’s not just (occupational therapy) … Patients recovering from COVID really need everybody.”
When Joe Kotelniski, 83, arrived at Providence in late May, he was weak and delirious after several weeks in hospital, battling COVID-19. He wasn’t intubated, but still couldn’t get anything down besides purées.
“It was this place here that pulled me out of the quagmire and brought me back to my senses,” he said in an interview last week, the day before he went home. “My appetite is back. I could eat a horse if they put one up here.”
Laura Conway, the speech therapist at Providence who treated Kotelniski, said the muscles in the throat can become deconditioned, making it difficult to co-ordinate swallowing and breathing. To rebuild that strength, she said she asks patients to pretend they’re swallowing a ping pong ball.
“The best practice for swallowing is swallowing,” she said.
In some cases, patients who were intubated in hospital complain that their voices sound different — the result, perhaps, of damage to the larynx, caused when the tube is removed. Ordinarily, Conway said she would refer these patients to a specialist to assess the damage, but these consultations are on hold during the pandemic because voice problems are “not considered urgent.”
Where possible, health professionals providing rehab after COVID-19 are taking their cues from what they know about recovering from other illnesses. For instance, Robinson said that acute respiratory distress syndrome — which, like COVID-19, can affect other organs such as the heart and brain, and lead to intubation — is proving to be “not a bad model.”
“You have lost muscle mass,” he said. “You have lost some of your peripheral nerve function. You have lost some of your cognitive function.”
However, the big difference with COVID-19 is that because of strict and necessary social distancing measures in hospitals and rehab facilities, patients are battling illness and recovery alone.
“Patients get a little bit disoriented or delirious when they’re sick for that long,” Robinson said. “That’s usually offset by family visits and connecting with those who they know so well — their loved ones.
“A big part of rehabilitation is family teaching. So how do you take care of your loved one after they get home? But we can’t really do that.”
Predicting the size of the wave of patients requiring intensive rehab after COVID is difficult, in part, because it will depend largely on our adherence to physical distancing guidelines and other public health measures, and how long it takes to find an effective treatment or vaccine.
But estimates suggest the numbers will be substantial. In Greater Toronto, for instance, Dr. Mark Bayley, who is vicechair of the GTA Rehab Network, projected that over the next year, 300 to 800 patients would need rehab services after COVID-19, based on the number of infections and the rate of ICU admissions as of last month.
Although Bayley, the program medical director at the Toronto Rehabilitation Institute, is “worried about a second wave” of new infections in the fall, the drop in new cases in recent weeks suggests “our lower estimates are probably more reflective of the needs.”
Unlike in some COVID-19 hot spots in the U.S., where there are reportedly significant wait lists to access in-patient rehab, the doctors interviewed for this story said there is currently enough capacity in the GTA to provide in-patient rehab to those who need it.
However, some doctors expressed concerns about the availability of outpatient rehab during the pandemic, both for COVID-19 patients and for others living with disabilities. And there are still a lot of unknowns.
“We don’t know what it’s going to look like in the future,” said Dr. Chris Fortin, the head of the physical medicine and rehabilitation division at Mount Sinai Health System, which includes Bridgepoint.
“We’re going to have all these patients who’ve had serious illness, whose lives have changed because of COVID, and we don’t know what kind of services they’re going to need in the future, or how we’re going to coordinate their services to meet their needs.”
Trevor Annon, 59, is trying to remain optimistic. Like Comrie, Annon initially pushed back against the idea of in-patient rehab after his battle with COVID-19.
“But (I realized) I can’t move like this,” he said. “So I thought it was an opportunity to change my whole perspective.”
Annon, a musician, was sick before COVID-19, with a heart condition and another virus that left him with a cough he couldn’t shake.
Since arriving at St. John’s, he has sworn off meat, and has dedicated himself to a rigorous exercise program that includes squats, leg lifts and bicep curls. He said rehab has given him “a chance to reflect” and “make necessary changes.”
“I’m not saying I’ll never get sick,” he said, “but I’ll never have the baggage that I have right now.”