The Importance of Rehabilitation for Functional Recovery and Long-Term Outcomes for Recovery From Critical COVID-19 Illness*

Abstract

I n this issue of Critical Care Medicine, Stripari Schujmann et al (1) described a prospective, multicenter study analyzing the trajectory of critically ill patients with COVID-19 during their critical care illness. It described the disease course of 328 survivors admitted between July 2020 and July 2021 across four ICUs in Sao Paulo, Brazil. The primary outcome was the Barthel Index (BI) measured at ICU and at hospital discharge. Secondary outcomes included duration of mechanical ventilation, ICU and hospital length of stay (LOS), muscle and hand grip strength, development of ICU-acquired weakness, and mobility milestones including time to out of bed and ambulation. Documented ICU exposures included mechanical ventilation, sedation, renal replacement therapy, proning, and receipt of physical therapy. The authors excluded patients who died in hospital, had a short ICU stay (i.e., < 4 d), those who had a functional decline due to other complications, and those who could not participate with their assessment.The cohort was functionally independent at baseline (i.e., BI = 100 points, described further below), relatively young (i.e., mean [sd] 55.3 (14.7) yr), and had ICU and hospital LOS of 13.9 (11.2) and 25.6 (23.0) days, respectively. Patients were quite sick with a Simplified Acute Physiology Score (SAPS)-3 score of 51.2 (16.5). Just over half of the cohort (i.e., 52.8%) received mechanical ventilation for 9.3 (8.2) days and accompanying sedation for 7.4 (6.0) days; 35.4% received neuromuscular blockade, and 33% of patients required proning during their ICU stay. The majority of the cohort (93.8%) received corticosteroids, and 11.2% required renal replacement therapy. Although no data were available on nutritional status, 56.3% of patients had reported hyperglycemia during this ICU stay. Mobility was recorded as the time to out-of-bed patient mobilization from ICU admission.The authors identified three outcome states at hospital discharge based on BI class. The BI was a marker of functionality that included an assessment of 10 activity and mobility activities, where each item's rating reflected the amount of assistance required to complete an activity. Scores vary from 0 to 100, where higher scores reflect better function (2). It is valid and reliable for use in ICU survivors, the smallest detectable change at ICU discharge is 20 points, and scores greater than 85 reflect mild to no impairment (2). In the study by Stripari Schujmann et al (1), the authors found that 44% of included patients were functionally independent (BI score > 85 at ICU and hospital discharge), 33% recovered functionality (BI score < 85 at ICU discharge and