|
 
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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 4
| Issue : 4 | Page : 174-183 |
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Developing clinfit COVID-19: An initiative to scale up rehabilitation for COVID-19 patients and survivors across the care continuum
Melissa Selb1, Gerold Stucki2, Jianan Li3, Masahiko Mukaino4, Leonard Li5, Francesca Gimigliano6, On behalf of the ISPRM ClinFIT Task Force‡7
1 ICF Research Branch; Swiss Paraplegic Research, Nottwil, Switzerland
2 ICF Research Branch; Swiss Paraplegic Research, Nottwil; Department of Health Sciences and Medicine, University of Lucerne, Lucerne, Switzerland
3 Department of Rehabilitation Medicine, First Affiliated Hospital of Nanjing Medical University; Jiangsu Geriatric Rehabilitation Hospital, Nanjing, People's Republic of China
4 Department of Rehabilitation Medicine I, School of Medicine, Fujita Health University, Toyoake, Aichi, Japan
5 Jiangsu Geriatric Rehabilitation Hospital, Nanjing, People's Republic of China; University of Hong Kong, Hong Kong, SAR, China
6 Department of Mental and Physical Health and Preventive Medicine, University of Campania “Luigi Vanvitelli”, Napoli, Italy
| Date of Submission | 04-Feb-2021 |
| Date of Decision | 31-May-2021 |
| Date of Acceptance | 02-Jun-2021 |
| Date of Web Publication | 06-Oct-2021 |
Correspondence Address:
Melissa Selb
ICF Research Branch Coordinator, Swiss Paraplegic Research, Guido-Zäch-Strasse 4, Nottwil
Switzerland
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/JISPRM-000128
Introduction: Health systems worldwide are challenged to address the health-care needs of persons with COVID-19. After the immediate need to mitigate the spread of COVID-19 and scale up relevant health-care capacities, one major challenge has emerged – scaling up rehabilitation to address the functioning limitations experienced by COVID-19 patients/survivors. To meet this challenge, the International Society of Physical and Rehabilitation Medicine (ISPRM) endeavors to develop a tool for the assessment and reporting of functioning of COVID-19 patients/survivors – “ClinFIT COVID- 19” to assist health professionals to optimally address patients' health-care needs. The first step in the development process is identifying the International Classification of Functioning, Disability, and Health (ICF) categories that ClinFIT COVID-19 should cover for acute, postacute, and long-term settings. Methods: The multistep process to develop the ClinFIT COVID-19 category list involved the development of a proposed list of ICF categories, a survey of ISPRM members worldwide about the proposed category list, and a postsurvey consultation with the ISPRM ClinFIT Task Force. Results: The final category list for the acute care context contains the seven categories provided to the survey participants (energy/drive functions, sleep, emotional functions, pain, exercise tolerance functions, carrying out daily routine, and walking) plus six categories related to respiration, mobility, and cognition. The postacute and long-term care versions also contain the seven categories plus additional categories relevant for the specific context. The postacute version contains 15 categories and the long-term 16 categories. Conclusions: To advance the next steps, the leaders of ISPRM and the Task Force call national and international societies of rehabilitation professionals to join this coordinated effort.
Keywords: COVID-19, functioning, International Classification of Functioning, Disability and Health, outcomes, rehabilitation
How to cite this article:
Selb M, Stucki G, Li J, Mukaino M, Li L, Gimigliano F, On behalf of the ISPRM ClinFIT Task Force‡. Developing clinfit COVID-19: An initiative to scale up rehabilitation for COVID-19 patients and survivors across the care continuum. J Int Soc Phys Rehabil Med 2021;4:174-83 |
How to cite this URL:
Selb M, Stucki G, Li J, Mukaino M, Li L, Gimigliano F, On behalf of the ISPRM ClinFIT Task Force‡. Developing clinfit COVID-19: An initiative to scale up rehabilitation for COVID-19 patients and survivors across the care continuum. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2023 May 28];4:174-83. Available from: https://www.jisprm.org/text.asp?2021/4/4/174/327573 |
| Introduction | |  |
Health systems worldwide are currently challenged to address the health-care needs of persons with COVID-19.[1],[2] After the immediate need to contain and slow the spread of COVID-19,[1],[2],[3] and increase acute health-care capacities, one major challenge that has emerged is the need to scale up rehabilitation to address the functioning limitations experienced by COVID-19 patients during the course of the disease[2],[4] and across rehabilitation services.[5],[6]
The ideal mode of increasing our understanding of functioning and rehabilitation needs over the course of COVID-19 is a learning health system approach with data collection “out of practice for practice.”[7] Moving toward this goal, the International Society of Physical and Rehabilitation Medicine (ISPRM) has recently launched the ClinFIT as a user-friendly clinical functioning information tool for health-care workers providing rehabilitation worldwide.[8] It uses the International Classification of Functioning, Disability, and Health (ICF)[9] as a reference system and allows the tailoring to specific health-care settings and populations. In the context of COVID-19 and the need for time-sensitive data collection of functioning across health systems worldwide, ISPRM has decided to develop a ClinFIT version for COVID-19 patients and survivors, referred to as “ClinFIT COVID-19.” To develop ClinFIT COVID-19, we need to know the ICF categories which best represent the aspects of functioning in which COVID-19 patients/survivors experience problems for health professionals to optimally address patients' health-care needs.
The objective of this paper is to report on the first steps in developing ClinFIT COVID-19 across the care continuum, specifically to identify the ICF categories that ClinFIT COVID-19 should cover for acute, postacute, and long-term settings.
| Methods | | |
Study design
The development of the ClinFIT COVID-19 category list was a multistep process: (1) development of a proposed list of ICF categories relevant for COVID-19 patients/survivors, (2) survey of ISPRM members worldwide about the proposed category list, and (3) postsurvey consultation with the ISPRM ClinFIT Task Force (henceforth “Task Force”).
Step 1: Development of a proposed list of International Classification of Functioning, Disability, and Health categories
The proposed list of ICF categories was developed in two substeps.
The first substep involved the development of an initial list of ICF categories relevant for COVID-19 patients/survivors (henceforth “initial list”). This involved selecting the most relevant categories from 1400+ categories in the ICF. The initial list was developed by an editorial team comprising the Co-chairs and Task Force members[8] from countries first hit by COVID-19 (FG Co-chair from Italy, JL from China, MM from Japan, GS Co-Chair, MS). The editorial team considered available ICF sets for specific health conditions and condition groups as well for generic use across the care continuum (acute, postacute, long-term)[10] as the starting point for the initial category list. Since the ClinFIT version for the general clinical population comprises the categories of the ICF Generic-30 Set,[11] considering this ICF set was warranted. The ICF Generic-30 Set also contains the ICF Generic-7 Set,[12] the minimum standard for assessing and reporting functioning, irrespective of health condition or health-care context. The editorial team also decided to examine the Brief ICF Core Set for cardiopulmonary conditions in acute care,[13] as COVID-19 is associated primarily with cardiopulmonary symptoms. Given that COVID-19 patients often experience neurological as well as musculoskeletal conditions, the Brief ICF Core Set for neurological conditions for acute care was also examined.[14] This ICF Core Set as well as the other aforementioned ICF sets contains musculoskeletal-related categories. Finally, as the WHO is partnering with the international rehabilitation community and is a driver of systematic data collection worldwide, it was essential to align with WHO's recommendation of functioning areas that are essential to include in obtaining a complete assessment: hearing, seeing, self- care, and cognition.[1]
According to the first experiences of the clinicians on the editorial team, the selection of the categories for the initial list was based not only on their relevance to COVID-19 patients/survivors but also on the consideration of the feasibility of applying ClinFIT COVID-19 in routine rehabilitation practice, with focus on the acute phase. This led to the decision to keep an efficiently small list of 20 categories that would also help ensure adoption by rehabilitation clinicians.
The second substep involved a consultation with the remaining Task Force members to gather their input on the initial list and corresponding questions. The Task Force members also received a simple description for each initial list category.[15]
Subsequently, a survey of ISPRM members worldwide was conducted on the category list revised according to the feedback received from the Task Force members.
Step 2: Survey of International Society of Physical and Rehabilitation Medicine members worldwide
Survey Gizmo (https://www.alchemer.com/), an online survey tool, was used to get feedback about the proposed category list from all active ISPRM members with experience treating COVID-19 patients/survivors. The survey was conducted from 27 August 2020 to 30 September 2020. The ISPRM Office sent the survey weblink to all active ISPRM members. Those who responded to the first question, i.e., “Have you had direct contact treating COVID-19 patients?,” were considered “participants.” If a participant responded “no,” he/she was finished with the survey. For participants who responded with “yes;” they were asked to indicate:
- In which phase(s) of care (acute, postacute, long-term), irrespective of setting, they treated COVID-19 patients. More than one selection was possible
- Whether the proposed category list with simple descriptions was adequate (yes/no) for assessing the essential aspects of functioning of COVID-19 patients in the acute phase.
The participants were then provided a list of 61 additional categories derived from the ICF Generic-30 Set, Brief ICF Core Sets for cardiopulmonary, and for neurological conditions. They were asked to indicate which of these categories they would add to the proposed list for assessing the functioning of COVID-19 patients/survivors in the postacute as well as in the long-term phase.
Descriptive statistics were used to describe the participants and response distributions. A thematic analysis of participant comments was conducted.
Based on the survey results, a proposal for the categories to include in the ClinFIT COVID-19 version for each of the phases of care was prepared for consultation with the Task Force.
Step 3: Postsurvey consultation with International Society of Physical and Rehabilitation Medicine ClinFIT Task Force
The Task Force members received a summary of the survey results and the proposed categories to include in the acute, postacute, and long-term care ClinFIT COVID-19 versions, which they were asked to confirm.
| Results | | |
Step 1: Development of a proposed list of International Classification of Functioning, Disability, and Health categories
First substep – Development of an initial list
The first version of the initial list consisted of 18 categories comprising (a) selected categories from the aforementioned ICF sets and (b) categories that assess hearing, seeing, self-care, and cognition not included in the ICF sets. However, after further deliberation, the editorial team proposed a much smaller core list consisting of seven categories to ensure its feasible use in clinical practice and a larger list of optional categories for individualizing assessments and reporting of functioning. [Table 1] shows the seven core categories and corresponding simple descriptions. | Table 1: Core categories included in the initial and proposed list (used for the survey) and corresponding simple descriptions
Click here to view |
This comprised five of the seven Generic-7 Set categories, b134 and b455 from the Generic-30 Set (11) that were included based on the real-life experience of the editorial group members treating COVID-19 patients.
The larger list of optional categories [Table 2] comprised 61 categories derived from the ICF Generic-30 Set and the Brief ICF Core Sets for cardiopulmonary conditions and for neurological conditions in acute care which were not already included in the seven core categories. | Table 2: Larger list of 61 optional categories to potentially add used for consultation with the International Society of Physical and Rehabilitation Medicine ClinFIT Task Force (initial list) and for the survey (proposed list)
Click here to view |
Second substep – Consultation with the Task Force
The Task Force received the smaller initial list and the larger optional list for review. The feedback was supportive of the seven categories. However, one member suggested adding categories related to interpersonal relationships to capture potential negative consequences of social distancing and other COVID-19 mitigation measures that affect interpersonal interactions. Another member suggested adding b440 Respiration functions. Since the optional list contained b440 as well as three additional respiratory-related categories (b445 Respiratory muscle functions, b450 Additional respiratory functions, and b460 Sensations associated with cardiovascular and respiratory functions) and five categories related to interpersonal interactions/relationships (d710 Basic interpersonal interactions, d760 Family relationships, d770 Intimate relationships, e310 Immediate family and e315 Extended family), no additional categories were added to the initial list before employing it in the ISPRM survey. Although the categories are the same, the category list used in the survey will be referred to as “proposed category list,” henceforth to differentiate it from the initial list.
Step 2: Survey of International Society of Physical and Rehabilitation Medicine members worldwide
The link to the survey was sent to 4869 email addresses on the ISPRM distribution list, of which 243 recipients opened the link – a response rate of 5%. Among these 243 persons, 201 completed the survey (83%). The survey participants came from 54 different countries from all six WHO world regions. [Figure 1] displays the distribution of the participants across the world regions. | Figure 1: Distribution of 201 survey participants across the six WHO world regions. The country with the most participants from each world region is indicated
Click here to view |
Of those completing the survey, 59% confirmed direct contact treating COVID-19 patients/survivors. With consideration that individual clinicians had contact in more than one phase of care, 61 clinicians (51%) had direct contact with COVID-19 patients in the acute phase, 95 clinicians (79%) in the postacute phase, and 69 clinicians (58%) in the long-term phase.
Acute phase
Regarding the question of whether the seven proposed categories were adequate for assessing functioning in the acute phase, 75% felt it was appropriate, and 11 participants provided comments. Some comments underscored the importance of including b130 Energy and drive, b152 Emotional, and b455 Exercise tolerance functions, and some suggested adding categories related to respiration and eating – all of which are covered by the optional list. Of the participants who indicated that the proposed category list was inadequate for the acute phase, at least one participant supported the addition of muscle functions (e.g., muscle power), range of motion, respiratory functions, swallowing, unspecified cognitive functions, various cardiovascular functions, and hematological functions. From all the comments received, respiratory, cognitive, and muscle functions garnered the most attention (>four comments).
Postacute phase
[Table 3] displays the optional list categories, highlighting seven categories that over 60% of the participants suggested adding for the postacute phase to the proposed category list. In terms of comments, three of 11 participants wrote “peripheral nerves” or “peripheral nerve function” without explanation whether this is related to pain, neuropathy, loss of smell and taste, or another body function or structure related to the peripheral nervous system. The other comments were similar to those expressed for acute care. Unlike the comments for acute care, three body structures were mentioned as important for the postacute phase, i.e. s4301 Lungs, s730 Structure of upper extremity, and s750 Structure of lower extremity, and one participant named e355 Health professionals and e415 Attitudes of extended family members. | Table 3: Percentage of the 201 participants who would like to add individual categories from the 61 International Classification of Functioning, Disability, and Health categories of the larger optional list to the seven proposed categories for the postacute context and for the long-term care context, respectively
Click here to view |
Long-term phase
Regarding the additional categories for the long-term phase, the results revealed slightly weaker support for categories to add. Nevertheless, eight categories were deemed by more than 60% of the participants as most important [Table 3].
Participant comments highlighted body structures and environmental factors that were similar to the postacute context. Although sensory functions of smell and taste are known body functions affected by COVID-19,[1],[16],[17] smell and taste were explicitly mentioned only pertaining to functioning in the long-term context.
Step 3: Postsurvey consultation with International Society of Physical and Rehabilitation Medicine ClinFIT Task Force
Based on the survey results, a final proposal of the categories was developed for review and finalization by the Task Force. The proposal for acute care included the seven originally proposed categories [Table 1] plus b440 Respiratory functions, b445 Respiratory muscle functions, b730 Muscle power functions, b710 Mobility of joint functions, b140 Attention functions, and d240 Handling stress and other psychological demands. These six categories corresponded to the domains that received the most comments, i.e. b440 and b445 for respiratory functions, b730 and b710 for muscle functions, and b140 and d240 for cognitive functions. Another factor that led to the decision to add these categories was the harmonization with the categories receiving the most support for inclusion in the ClinFIT COVID-19 postacute and long-term care versions [Table 3]. Finally, it was essential to keep the acute care version as short as possible while also having as many categories as necessary to be useful for the assessment of COVID-19 patients and reporting in acute care.
These factors also weighed in on the decision about which categories to include in the ClinFIT COVID-19 postacute and long-term care versions. Supported by the survey results, b440, b445, b730, b710, b140, and d240 were added for the postacute version. Furthermore, d455 Moving around was added as 63% of the participants suggested adding it. Based on the comments, s430 Respiratory system structures was also added, a category lacking in the optional list.
The long-term version contained the same categories as the postacute version, except for b140 Attention functions. The participants placed 4% less importance on b140 for the long-term version. The survey also supported adding d850 Remunerative employment and d920 Recreation and leisure, two categories not included in the postacute version. Both the categories reflect the target of potential long-term impact of COVID-19, i.e., the patient's participation in major life activities and in the community. To keep the long-term care version as short as possible, b140 was excluded.
The Task Force approved the category lists as described above. [Table 4] provides an overview of the categories to be covered by the ClinFIT COVID-19 versions across the care continuum. | Table 4: ClinFIT COVID-19 categories with corresponding simple descriptions across the care continuum
Click here to view |
| Discussion | | |
In this paper, we report on the results of a multistep process to identify the ICF categories that ClinFIT COVID-19 should cover for acute, postacute, and long-term settings. In addition to informing the development of this COVID-19 tailored data collection tool, the results will inform the work of health professionals treating COVID-19 patients/survivors through a better understanding of patient functioning and needs across rehabilitation service types.[5]
Novelty by way of the International Classification of Functioning, Disability, and Health
Among the few scientific publications highlighting the potential use of the ICF in the care of COVID-19 patients/survivors,[18],[19],[20],[21] this is the first paper that reports on specific ICF categories that can be used to tailor the assessment and reporting of patient functioning in the three overarching care contexts (acute, postacute, and long-term). In monthly “Cochrane Rehabilitation 2020 rapid living systematic reviews” on rehabilitation and COVID-19 patients, Ceravolo et al. from the Cochrane Rehabilitation REH-COVER initiative[21] have reported on studies organized according to the ICF framework and to acute and postacute phases, and “permanent sequelae or late onset complications” (long-term). However, to date, the functioning outcomes addressed in the studies have not been linked to specific categories. Although the focus of work outlined in this paper is clinical, the output of this work can inform COVID-19-related rehabilitation research.
Considerations for further development of the clinical tool
The survey results show that, despite the editorial group's initial concern that ClinFIT COVID-19 would be too long, survey participants who have treated COVID-19 patients had little apprehension in adding categories to the initial category list. This factored into the decision to add categories to the originally proposed seven ICF categories to ensure that the tailored category lists were adequate for clinical use in the different care contexts. Moreover, since diverse categories not included in the final category lists still received support, although not significant, it points to the potential benefit of providing clinicians a list of optional categories for individualized reporting of functioning. This may be especially significant for specific patients, for example, to report interpersonal interaction/relationship issues resulting from COVID-19 mitigation measures. Notably, the originally proposed optional category list contains five relationship-related categories. This optional list does, however, miss some ICF categories that were mentioned in the survey comments and reported in scientific literature and by WHO, as functioning aspects relevant for COVID-19 patients/survivors. This includes b250 Taste and b255 Smell functions.[1],[16],[17] Should an optional category list accompany ClinFIT COVID-19, then a review and potential modification of the optional category list is warranted.
The final category list presented in this paper is a major step toward finalizing a robust clinical tool – ClinFIT COVID-19. The tool is expected to be robust not only because a systematic, consensus-oriented process was employed to develop the category list but also because the categories themselves are consistent with studies published on ICF and COVID-19. For example, in a review of studies assessing posthospital clinical outcomes in adult survivors of severe acute respiratory distress syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19, Patel et al.[19] identified six categories that are consistent with the long-term care ClinFIT COVID-19 categories b130, b134, b152, b455, d450, and d920. They also identified other categories of the long-term category list (b280, b440, b730, and d845 – another work-related category) but not in as many outcome measures as those covering the six categories. In another example, the final ClinFIT COVID-19 categories b130, b280, b440, b445, and s430 are consistent with categories listed in a protocol developed by Zeng et al. for the rehabilitation of COVID-19 patients.[20] Both the examples included e310 Immediate family, an environmental factor that was included in the optional list but excluded from the ClinFIT COVID-19 category lists. In fact, these examples and the other two scientific publications[18],[21] on ICF and COVID-19 listed some environmental factors, while the present category list does not.
Testing the version of ClinFIT COVID-19 without environmental factors in real-life rehabilitation practice would be necessary to evaluate the need to assess and report environmental factors for this particular patient population in the individual phases of care.
Next steps
There are two immediate steps to be taken to finalize the development of the acute, postacute, and long-term care versions of ClinFIT COVID-19 – operationalizing each category on the final ICF category list into items/questions and developing a scoring system for rating the patient's status in each item.
The first steps toward operationalizing the ICF categories have already been taken in developing the initial list of ICF categories for the first feedback round of the Task Force. Task Force members received a proposal of questions that operationalized each ICF category of the initial list based on questions from WHO's Model Disability Survey, a validated self-report general population survey.[22] In terms of scoring, the Task Force also received a proposal for a scoring system with three options: an 11-point numeric rating scale (0 = no problem to 10 = complete problem),[23] a 0–4 ICF qualifier type scale with specifications,[24],[25] and without.[9] The operationalizations and scoring options are not elaborated further as a separate publication is planned pending further examination.
Beyond the immediate next steps, subsequent steps involve testing and validating the acute, postacute and long-term care versions of ClinFIT COVID-19 in all six WHO world regions, including evaluating which of the three versions would be best to use for asymptomatic patients or patients with mild COVID-19 symptoms being treated at home. Tailoring a version for these subpopulations of patients may be warranted.
| Conclusions | | |
This paper reports on the first steps toward developing a functioning-based clinical tool tailored to support the work of health professionals addressing the needs of COVID-19 patients/survivors across the continuum of care. Being developed under the auspices of ISPRM, this tool, ClinFIT COVID-19, not only draws from the ICF,[9] an internationally accepted framework for assessing and reporting functioning, to build its items, it also recognizes that the functioning and health of COVID-19 patients/survivors differ across the care continuum. To advance the next steps, the leaders of ISPRM and the Task Force call national and international societies of rehabilitation professionals to join this coordinated effort.
Members of the ISPRM ClinFIT Task Force qualified as contributors
Rochelle Dy (Physical Medicine and Rehabilitation, Texas Children's Hospital, Houston, USA); Julia Engkasan (Department of Rehabilitation Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia); Mario Giraldo-Prieto (University of Antioquia, Medellin, Colombia); Abderrazak Hajjioui (Department of Physical and Rehabilitation Medicine, Laboratory of Clinical Neuroscience, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdallah University, Fès, Morocco); Carlotte Kiekens (Spinal Unit, Montecatone Rehabilitation Institute, Imola, Bologna, Italy); John Melvin (Department of Rehabilitation Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, USA); Aydan Oral (Department of Physical Medicine and Rehabilitation, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey); Manoj Poudel (The International Stress and Behavior Society and ZENEREI Research Center, Slidell, USA)
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2], [Table 3], [Table 4]
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