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COVID-19 Outbreak During Inpatient Rehabilitation

Impact on Settings and Clinical Course of Neuromusculoskeletal Rehabilitation Patients

Spielmanns, Marc MD; Pekacka-Egli, Anna-Maria; Cecon, Mikis; Witassek, Fabienne MSc; Schoendorf, Sabine; Lutz, Dietmar MD; Hermann, Matthias MD

Author Information
American Journal of Physical Medicine & Rehabilitation: March 2021 - Volume 100 - Issue 3 - p 203-208
doi: 10.1097/PHM.0000000000001686
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What Is Known

  • COVID-19 is a dangerous and highly contagious infection. Nosocomial infections have a negative impact on the activities of daily living.

What Is New

  • In this article, we describe a COVID-19 outbreak at our neuromusculoskeletal rehabilitation (NMSR) center and its impact on rehabilitation process and patients. Continuation of the NMSR was feasible, but COVID-19 itself leads to decreased improvements of the participants.

Nosocomial infections or colonization with different pathogens is frequently described for rehabilitation clinics and has a negative impact on improvement in functional status of patients and clinic personnel.1–3 Rapid identification of outbreaks in hospitals is vital for the immediate implementation of infection control measures and isolation of infected individuals.4 Several potential risk factors for COVID-19 outbreaks in hospitals such as the lack of effective isolation measures are known.5 Few publications present data about the impact of COVID-19 on patient management during inpatient rehabilitation.6,7

Specific aspects of the rehabilitation setting can lead to difficulties in harmonizing the therapeutic needs with the required measures to protect professionals and prevent the spread of the infection. This includes, for example, the frequent need of a prolonged and/or close interaction between patients and professionals during treatment sessions. The frequent occurrence of difficulties in the communication with the patient (because of cognitive difficulties, disorders of consciousness) and the possible need of involving family members or other persons in the delivery of care are additional risk factors for spread of infections.

Some experiences with post–COVID-19 rehabilitation and recommendations mainly of respiratory societies emphasizing the importance of rehabilitation in the context of severe SARS-CoV-2 infections are already published.8–10 However, as far as we know, there are no data available about a COVID-19 outbreak among patients participating in a rehabilitation program. Therefore, we aimed to characterize patients with nosocomial infection by SARS-CoV-2 during inpatient neuromusculoskeletal rehabilitation (NMSR) and to describe the implementation of a strict hygiene concept and its impact on rehabilitation therapies and outcome of rehabilitation.


Participants and Procedures

The cohort describes 27 patients with nosocomial COVID-19 infection during NMSR between March and May 2020. Patient data were retrospectively analyzed to describe potential differences, performance, and outcome during rehabilitation due to COVID-19 and the subsequent necessary hygiene interventions. We used the German version of the program RehaTIS by Softsolution (International AG, Lahti, Finland) to record and control the individual rehabilitation process of each participant, including all therapies and procedures. To estimate the impact of the COVID-19 restrictions and hygiene regiment on the rehabilitation program and its results, we analyzed the time in rehabilitation before COVID-19, during the isolation intervention and for the postisolation period for each infected participant. Functional assessments and the amount of therapy quantity of COVID-19 cohort were compared with the results of all NMSR inpatients of the year 2019 (comparison group), representing a normal year in inpatient NMSR. The patient data and results of the assessments were stored and taken for evaluation out of the clinic information system Phoenix (CompuGroup Medical AG, Bern, Switzerland). All patients gave written informed consent, and local ethics committee approved the study protocol (BASEC-No 2020-01061).

Functional Independence Measure

The Functional Independence Measure (FIM) is an 18-item measurement tool that explores an individual’s physical, psychological, and social function.11 We used this tool to assess a patient’s level of disability at admission and discharge. It was assessed to measure the change in patient status in response to rehabilitation.

Cumulative Illness Rating Scale

Cumulative Illness Rating Scale (CIRS) was used at admission as an indicator of general health status and predicted 18-mo mortality and rehospitalization especially in hospitalized elderly patients.12

Description of a Normal NMSR

The duration of a usual multimodal inpatient program was 2–6 wks and was carried out according to a protocol adapted to diagnosis and the severity of the diseases based on the current guidelines.13,14 This program normally included an average of 20 therapy sessions per week, distributed over 5–6 days excluding Sundays. It consisted of 4–6 units of individual physical therapy per week with focus on gait rehabilitation. Depending on functional deficits, additional individual occupational and speech therapy and neuropsychology were offered. In addition, patients participated in group therapies taking place at the gym to improve their endurance capacity, strength, coordination, and ability to perform activities of daily living. Strength and coordination training were performed 3 × 10–15 repetitions with the maximum tolerated load if possible as a circuit training. The intensity of the endurance training units was continuously adjusted to achieve the maximum tolerated training load during each training unit. On average, the therapy sessions lasted for 30–45 mins. The average therapy minutes per week were calculated with 810 mins.

The COVID-19 Outbreak

Infections took place before a strict hygiene concept was fully established and could be traced to an asymptomatic healthcare professional who was already infected. A nurse on duty was assigned to take blood samples on two different wards on a weekend. At this time, wearing of hygiene masks was not established. On the following Monday, the employee developed symptoms (fever and cough) and contacted the staff doctor. COVID-19 was diagnosed within 24 hrs, and the employee went home to take up isolation. As a result, cumulative 27 patients of these two wards fell ill consecutively the following 10 days with confirmed COVID-19. Subsequently, no further in-house infections occurred because of a consequent implementation of the hygiene concept.

Definition of the COVID-19 Illness Severity

According to the National Institute of Health COVID-19 treatment guideline (, the COVID-19 illness severity is defined as follows:

  • Mild: if individuals had any of the various signs and symptoms of COVID-19 (eg, fever, cough, sore throat, malaise, headache, muscle pain, nausea, vomiting, diarrhea, loss of taste and smell) but who did not have shortness of breath, dyspnea, or abnormal chest imaging.
  • Moderate: if individuals showed evidence of lower respiratory disease during clinical assessment or imaging and who had saturation of oxygen (Spo2) ≥94% on room air at sea level.
  • Severe: if individuals had Spo2 < 94% on room air at sea level.

Hygiene Concept During COVID-19 Outbreak

In symptomatic patients and their contact persons, swabs were taken as soon as possible. Until the results were available, airborne precautions were carried out. If COVID-19 was confirmed, the patient was transferred to the newly established isolation ward with single bedrooms. Further treatment was then carried out there. For the treatment and management of COVID-19 patients, the recommendations of the Swiss Noso (Swiss National Institute of Infection Prevention) and the Health Department of Zurich were applied. The staff in close contact with these patients (especially nursing staff, speech and language therapists, and physiotherapists) had to wear FFP-2 masks, long-sleeved disposable fluid repellent gowns or disposable fluid repellent coveralls, eye protection, and gloves. The fiberoptic endoscopic evaluation of swallowing assessment in case of neurological patients with swallow disorders was suspended because of COVID-19 in-house regulations. Temporary isolation was stopped after negative COVID-19 swab, and patients were retransferred to a normal nonisolation ward. In some cases, the viral RNA was still detected in the polymerase chain reaction (PCR) although being asymptomatic leading to the continued isolation until at least one test was negative.

Symptomatic personnel were instructed to stay at home and should not come to the clinic for work. If they developed symptoms at home, they were asked not to return to work again until further investigations by their general practitioner (GP) were negative. If symptoms developed while working, the supervisor had to be informed immediately, work had to be stopped, and a staff physician had to be contacted for further diagnostics.

Description of the NMSR During Isolation Intervention

Therapies were provided with limited frequency because of the hygiene concept and necessary isolation. In isolated patients, individual therapies were carried out 1–2 times a day for 15–45 mins. Depending on the level of performance and according to the severity of the illness (assessed by the FIM), therapy intensity was adjusted in the course of time. Therapies took place in the patients’ room mainly and instructions for self-training were given as well as smaller therapy devices, such as elastic resistance bands and/or breathing training devices such as RC-Cornet or Flutter VRP1 in patients with respiratory tract symptoms. Some training devices were stored in a central location at the isolation ward and were disinfected after each therapy, such as motorized cycle ergometer, stepper, ergometer, etc. Dysphagia bedside assessments, respiratory therapies, psychological support, massages, nutrition and diabetes counseling, social services, etc. were provided if necessary sometimes by phone or telecommunication. The frequency of these treatments was adapted to the individual, and diagnosed limitations and needs of the patients were included in the overall therapy hours per week.


Binary variables were presented as frequencies and the Fisher’s exact test was used for group comparison. Normally distributed continuous variables were presented as mean with standard deviation, and the t test was used for comparison between groups. Linear regression was used to assess the impact of COVID-19 on FIM at discharge after correction for FIM at admission, age, sex, and morbidity index at admission. A P value of less than 0.05 was considered as statistically significant.


COVID-19 patients had a mean age of 71.5 ± 12.3 yrs, and 66.7% were male with a high CIRS of 17.2 ± 6.6 points and several cardiovascular comorbidities, strokes, and hypertension in particular (Table 1).

TABLE 1 - Baseline characteristics and assessments of COVID-19 and non–COVID-19 patients
COVID-19 (n = 27) No COVID-19 (n = 786)
Age, mean (SD) 71.5 (12.3) 71.5 (13.12)
Sex, male 18/27 (66.7) 387/786 (49.2)
BMI, mean (SD) 25.3 (5.5) 25.9 (5.8)
Comorbidities, n (%)
 Coronary artery disease 6/27 (22.0) 159/786 (20.2)
 Stroke 19/27 (70.4) 541/786 (68.8)
 Hypertension 18/27 (66.7) 512/786 (65.1)
 Type 2 diabetes 9/27 (33.3) 212/786 (26.9)
 Dyslipidemia 10/27 (37.0) 259/786 (32.9)
 Peripheral artery disease 0/27 (0.0) 89/786 (11.3)
 Chronic renal failure (eGFR <60 mL/min) 11/27 (40.7) 301/786 (38.2)
 Previous smoker 6/24 (25.0) 289/786 (36.7)
 Current smoker 2/24 (8.3) 58/786 (7.4)
 COPD (all stages) 6/27 (22.2) 159/786 (20.2)
 CIRS points, mean (SD) 17.2 (6.6) 16.9 (5.8)
6-MWT, 6-min walk test; BMI, body mass index; COPD, chronic obstructive pulmonary disease; eGFR, estimated glomerula filtration rate.

Ten COVID-19 patients (37%) required oxygen therapy, and no patient needed ventilation therapy during rehabilitation representing a mild or moderate course of the disease. Two patients (7.4%) had a severe COVID-19 illness and had to be referred to acute hospital because of respiratory failure, and one of these patients died in the acute hospital.

Compared with the 2019 group, no significant differences were observed for age, sex, and CIRS (Table 2).

TABLE 2 - Comparison between rehabilitation patients with and without COVID-19
No COVID-19* (n = 786) COVID-19 (n = 27) P
Age, mean (SD) 71.46 (13.12) 71.48 (12.31) 0.992
Sex, male 387/786 (49.2) 18/27 (66.7) 0.081
Rehabilitation duration (SD), d 32.05 (17.74) 54.22 (23.62) <0.001
CIRS, points (SD) 16.91 (5.79) 17.24 (6.61) 0.778
FIM admission, points (SD) 82.98 (22.73) 91.93 (25.64) 0.046
FIM discharge, points (SD) 103.28 (21.88) 98.89 (24.40) 0.307
FIM change, points (SD) 20.30 (15.98) 6.96 (8.96) <0.001
*No-COVID group (n = 758).

Impact of COVID-19 on Rehabilitation Therapies

Therapy intensity as measured by number of therapies and therapy duration decreased significantly during COVID-19 from 132.3 ± 44 min/d (6-day week) to 81.9 ± 27.3 min/d (P < 0.001) during isolation (Table 3). After the isolation intervention, the therapy amount did not increase significantly (P < 0.05; Fig. 1).

TABLE 3 - Impact of COVID-19 on applied rehabilitation therapies per patient
Before COVID-19 During COVID-19 P, Before vs. During After COVID-19 (n = 18) P, Before vs. After
Therapy in minutes per day (SD) 132.3 (44.0) 81.9 (27.3) <0.001 99.3 (70.2) 0.002
Duration in minutes per therapy (SD) 37.9 (4.1) 32.7 (3.1) <0.001 36.1 (4.7) 0.010
No. therapies per day (SD) 3.5 (1.0) 2.5 (0.8) <0.001 2.7 (1.9) 0.009
Therapy includes physiotherapy, logopedics, occupational therapy, and nutritional and diabetes counseling.

Mean therapy minutes per week before, during, and after isolation due to COVID-19.

Functional Independence Measure Changes

The FIM score at baseline was higher in the COVID-19 group (91.93 ± 25.64 points vs. 82.98 ± 22.73 points, P = 0.047). The FIM improvements during rehabilitation were attenuated in the COVID-19 group (20.3 ± 15.98 points vs. 6.96 ± 8.96 points, P < 0.0001; Table 2).

Regression analysis revealed that COVID-19 significantly reduced FIM at discharge by 8.9 points after correction for FIM at admission, age, sex, and CIRS (Table 4).

TABLE 4 - Linear regression: Impact of COVID-19 on FIM at discharge after correction for FIM at admission, age, sex, and morbidity index
Coefficient, B P 95% Confidence Interval
COVID-19 −8.911 0.003 −14.725 to −3.097
FIM at admission 0.700 <0.001 0.653 to 0.748
Age −0.032 0.437 −0.112 to 0.049
Sex, female −0.066 0.950 −2.100 to 1.969
CIRS −0.159 0.102 −0.349 to 0.031
Constant 50.208 <0.001 41.972 to 58.444


We describe a cohort, which had been nosocomial infected during an inpatient NMSR. Immediate isolation of COVID-19 patients resulted in a significantly decreased therapy amount during isolation measures and during the following period because of the increased general hygiene standards. Compared with all patients of 2019, COVID-19 patients did not achieve the expected clinical improvements although the rehabilitation duration was significantly longer. Because COVID-19 patients had a higher FIM score at baseline, we cannot exclude that a ceiling effect of FIM scores might also play a role here. Linear regression identified COVID-19 as a strong negative predictor. This finding is in line with previous reports on the negative impact of nosocomial infections, such as urinary tract infections and Clostridium difficile diarrhea, on rehabilitation outcome.1 This group reported a longer length of stay or diminished improvement in functional status among patients admitted for the first time to an acute rehabilitation unit with nosocomial infection. In addition, Colorado et al.15 showed that length of stay was 39% longer in inpatient rehabilitation patients with contact isolation. In our analysis, we observed an even longer length of stay, which suggests that COVID-19 isolation measures could be like responsible for increased length of stay compared with non–COVID-19 isolation measures

The implemented isolation procedures in patients with COVID-19 lead to a significant reduction in the amount of therapies in rehabilitation. However, even after the infection was overcome, the therapy intensity could not be fully re-established because certain therapies such as group-based therapies, exercising with other patients in the therapy gym, or circuit training could no longer be offered or just to a limited extent because of the hygiene concept in the COVID-19 pandemic. Although inpatient group therapy task training after stroke is known to be safe and equally effective as a dose-matched individual task training therapy,16 our COVID-19 patients did show lower improvements during rehabilitation. There is strong evidence that a higher dose of therapeutic training in stroke patients is better, as reported for motor function of the paretic arm or muscle strength of the paretic leg.17,18 It is therefore not surprising that the rehabilitation of COVID-19 patients was not as effective as expected. However, other aspects in addition to reduced therapies, such as COVID-19 specific limitations, nonspecific contact variables, or reduced therapeutic alliance, might negatively impact on rehabilitation success.

Most of our COVID-19 patients were patients who had had a stroke. Especially in stroke patients, nosocomial infections are associated with an increased risk of mortality and disability.19,20 Fortunately, in our cohort, the mortality rate was low despite the high stroke frequency. Most patients had a mild course of COVID-19, despite belonging to a high-risk group with several severe comorbidities and an average age of older than 70 yrs.21 We would have expected a higher number of patients to develop severe symptoms with subsequent hospital treatment, but only two patients had to be retransferred of which one patient died later on, which is in the expected range.22

Almost all patients in our inpatient rehabilitation clinic were referred from an acute hospital with preceding multiple medical interventions, insertion of monitoring devices, and several courses of antimicrobial agents, thus prone to and susceptible for new infections Specific skills and profound infectious knowledge among the medical staff of a rehabilitation clinics help reduce the risk of nosocomial infections. However, despite all the protective precautions, nosocomial infections cannot be completely avoided, especially for a highly contagious virus like SARS-CoV-2. Because of the structure of rehabilitation, for example, with group therapies and face-to-face physiotherapy, many contacts between patients and between staff and patients are inevitable. Unfortunately, the outbreak in our clinic occurred very early in the COVID-19 pandemic at a time when consistent hygiene practices such social distancing or wearing of hygiene masks had not been implemented.

However, the outbreak situation was a professional challenge for the clinic staff and, in addition, a mentally stressful situation. Health professionals are often exposed to specific stressors and risks for physical and mental health. The special COVID-19 situation is difficult for health workers in the acute clinical setting, but the staff of a rehabilitation clinic also complains stressful conditions because of the COVID-19 pandemic. These factors can result in different levels of psychological pressure, such as stress, irritability, physical and mental fatigue, and despair.3 The work overload and the symptoms related to stress make healthcare teams vulnerable to psychological distress and can lead to physical fatigue and mental weariness. Therefore, regular clinical screening for anxiety, depression, and suicidality by mental health workers should be implemented in healthcare systems working with COVID-19 patients.23 We observed this phenomenon partly in our staff as well. Indeed, dissatisfied patients were not able to cope with their infection, leading to several complains such as prolonged length of the stay. In addition, lack of contact with their relatives was a big problem because the official health department had addressed a visit ban for clinics in the meantime. We noticed this stress, for example, in the high amount of questions to the newly implemented COVID-19 task force, which had to meet on a weekly base to work up all the queries. Recognizing risks and planning of interventions aimed at reducing psychological damage of healthcare professionals involved in the care of rehabilitation patients experiencing COVID-19 are important. An analysis of mental health of medical and nursing staff in Wuhan showed the importance of being prepared to support frontline workers through mental health interventions at times of widespread crisis.24


Like all retrospective analyses, the validity of the data is already limited by the study design itself. Further limitations are the relatively low number of nosocomial COVID-19 infections and the single-center approach.


A COVID-19 outbreak during comprehensive NMSR leads to a significant negative impact on the rehabilitation settings and patients’ functional improvements as measured by FIM change. After implementation of a strict hygiene concept, no further COVID-19 infections were detected. Despite restrictions due to contact isolation, NMSR could be continued.


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Nosocomial Infection; COVID-19; Rehabilitation; Outcome; Therapy Reduction; FIM

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