A survey on the impact of the coronavirus disease 2019 pandemic in Portuguese physical and rehabilitation medicine departments

Introduction: The pandemic Coronavirus Disease 2019 (COVID-19) strongly affected the organization and functioning of Physical and Rehabilitation Medicine (PRM) departments in Europe, posing specifi c challenges in the management of diseases and their consequences. We aim to evaluate the changes suffered by Portuguese PRM departments in the scope of assistance, organization, training and research. Methods: A self-administered, cross-sectional online questionnaire was sent to 41 Portuguese PRM departments, regarding the assistance provided to patients with COVID-19, organizational changes and diffi culties experienced on team management, training and research. Results: The survey had a response rate of 82.9%. The majority of the PRM departments assisted patients with COVID-19, mainly in the context of inpatient general ward care and intensive care units. Changes in the assistance activity and accessibility were reported by almost all PRM departments, mainly affecting the outpatient consultation. There was a reduction on the number of healthcare professionals reported, especially by transfer to other areas, and almost all used remote procedures, especially for patient reassessment, counseling, and monitoring. The majority of PRM departments highlighted the pandemic’s impact on the training availability, as well as in the applied research and publications. Conclusions: The pandemic triggered a complete overhaul of rehabilitation departments with signifi cant changes in assistance activity, changing routines and programmed procedures, with a strong negative impact on scientifi c research and training. Outpatient consultations was the most affected area, while support for hospitalization and internal consultations remained mostly operational. The use of remote procedures was high, particularly in follow-up and counseling. Observational Study A survey on the impact of the coronavirus disease 2019 pandemic in Portuguese physical and rehabilitation medicine departments Catarina A Branco1,2*, João P Branco3,4, Lurdes R Branquinho3 and João Pinheiro4 1Portuguese Society of Physical and Rehabilitation Medicine, Portugal 2Department of Physical Medicine and Rehabilitation, Centro Hospitalar Entre Douro e Vouga, Feira, Portugal 3Physical and Rehabilitation Medicine Unit, University of Coimbra Hospitals, Coimbra Hospital and University Center, Coimbra, Portugal 4Faculty of Medicine, University of Coimbra, Coimbra, Portugal Received: 24 March, 2021 Accepted: 15 April, 2021 Published: 16 April, 2021 *Corresponding author: Catarina A Branco, Portuguese Society of Physical and Rehabilitation Medicine, Portugal, E-mail:


Introduction
This pandemic affects mainly elderly populations, individuals with multimorbidity individuals with disabilities, poor people and ethnic minorities [2,3].
Physical and Rehabilitation Medicine (PRM) departments are strongly affected in their organization and functioning, making medical care for outpatients and inpatients diffi cult, as well as training and research activities [4].
The objective of this study was to evaluate the changes suffered by Portuguese PRM departments due to the COVID-19 pandemic in the scope of assistance, organization, training and research.

Materials and Method
We describe a self-administered cross-sectional survey.
Data were collected from November 6 th to 16 th , 2020. The questionnaire contained 13 questions, referring to assistance, organization, training and research.
The questionnaire was built according to the knowledge and experience of the authors, considering the positions they represent in the Portuguese PRM community.
The questionnaire was done in Google Forms and was distributed by email on November 6 th , 2020. It was sent to 41 PRM departments operating in the most representative NHS hospitals, according to the existing registry in the Portuguese PRM Society.
An email reminder was sent on November 12 th to increase participation. All responses were anonymous, and no ethical approval was required for this survey, considering the content.
The questionnaire was composed of three sections: 1) questions 1 to 4, regarding the assistance provided to patients with SARS-CoV-2 infection by the PMR departments, 2) questions 5 to 9, regarding the organizational changes that were carried out in the PMR departments due to the COVID-19 pandemic, 3) questions 10 to 17, about the diffi culties and limitations experienced during the COVID-19 pandemic on the team management, training and research.
The fi rst questions of the fi rst and second sections defi ned whether the responder would have to answer the remaining questions of that section or not, depending on whether that answer was affi rmative or negative, respectively.
Given the nature of the data collected in this study, only descriptive statistics were used to summarize the data.

Results
Of the 41 PRM departments operating in NHS hospitals, 34 participated in the survey, which represents a response rate of 82.9%. The majority of the PRM departments (n=25, 73.5%) provided assistance to patients with SARS-CoV-2 infection; almost all of them provided assistance in general wards (n=19, 92.0%) and, also the majority of departments, on Intensive Care Units (n=19, 76.0%) and outpatient consultation (n=14, 56.0%); one department also provided assistance in home visit ( Table 1). The overwhelming majority of departments assisted patients with severe and moderate infection, but some also assisted patients with mild infection, and even asymptomatic infection. Regarding the healthcare professionals, almost all PMR departments provided medical assistance, mainly with PMR specialists (n=23, 92.0%), but also with PMR residents (n=13, 52.0%); most departments also provided assistance with physiotherapists (n=22, 88.0%) and speech therapists (n=14, 56.0%).
All the PMR departments reported organizational changes due to the COVID-19 pandemic. The length of the period when the COVID-19 pandemic had the most impact was variable between the departments (Figure 1), approximately half of them reporting a length of over 20 weeks (n=16, 47.1%), although many referred to a period of 5 to 9 weeks (n=13, 38.2%). The changes ( Table 2) were related to the assistance activity in almost all the departments (n=33, 97.1%), and the overwhelming majority also reported changes regarding to be a major threat to healthcare systems across Europe [6]. Regarding the team management, the overwhelming majority of PRM departments reported diffi culties on the application of the rehabilitation program (n=29, 85.3%) and on the reduced number of healthcare professionals (n=23, 67.6%). On the other hand, diffi culties on the monitoring of the rehabilitation program (n=16, 47.1%), the decision-making process (n=11, 32.4%) and the communication between professionals (n=9, 26.5%) were reported by fewer departments ( Table 2).
A total of 22 PRM departments suffered diffi culties in resource reallocation due to the COVID-19 pandemic. Most of those departments had their professionals (n=17, 77.3%) and/ or physical space (n=14, 63.6%) re-allocated to perform other tasks.
Almost all of the PRM departments reported the use of remote procedures during the pandemic, especially for patient reassessment (n=29, 90.6%), counseling (n=27, 84.4%) and monitoring of the rehabilitation program (n=21, 65.6%); fewer departments used remote procedures on the decision-making process (n=10, 31.3%).
The majority of PRM departments (n=28, 82.4%) highlighted the pandemic's impact on scientifi c research and training, especially on training availability (n=24, 85.7%). A reduction in training capacity was identifi ed by most PRM departments (n=24, 85.7%), and a substantial impact on applied research (n=13, 46.4%) and publications (n=10, 35.7%) was also identifi ed.

Discussion
The need for intervention guided by rehabilitation medicine has steadily increased [5]. The COVID-19 pandemic is proving  with SARS-CoV-2 and were forced to change their priorities and treatment criteria.
Patients infected with SARS-CoV-2 were assisted mostly in the context of inpatient general ward care or intensive care units and had mostly moderate to severe clinical condition, which refl ects the need for urgent rehabilitation intervention in their recovery program. Since this is a disease with neurologic and muscle-skeletal sequelae at several levels, there was also a need for a global and multiprofessional rehabilitation program, which involved all healthcare professional groups to different extents [1]. The role of these multiprofessional teams has been fundamental in patient's identifi cation, not only to provide adequate, tailored rehabilitation procedures, but also to prevent loss of functionality [6].  [1,4]. Overall, the changes that took place to address COVID-19 needs compromised not only the physical but also the emotional well-being of healthcare professionals exposed to this reality, which may have a long-term impact on the psychological well-being of healthcare professionals.
The use of remote procedures was high, almost unanimous in all PRM departments, particularly in follow-up and counseling.
Given the reduced experience of Portuguese telemedicine in rehabilitation, there are several aspects to investigate, namely the quality of the means available, the effectiveness of the intervention, the level of patient compliance and the validity of the decision-making process (diagnosis and prescription) [1].
Training activity was severely impaired, considering the restrictions on differentiated consultations, accessibility to departments and the change in the focus of activity.
The negative impact on scientifi c research and training was particularly strong, limiting the possibilities of publication particularly in clinical rehabilitation but also in basic science.
Research during the pandemic must be able to adapt to new requirements, always supported by the idea of promoting In the management of rehabilitation teams, it is important to understand multidisciplinary dynamics and to verify the assumptions for medical decision making supported by the best evidence.

Conclusion
The COVID-19 pandemic has changed our lives and puts dramatic pressure on healthcare systems. There was a high impact on the organization and current activity of PRM departments. Rehabilitation care was strongly affected, as well as medical training and research. What are the direct and indirect costs in the loss of functionality of our patients? How will weaknesses in medical training reduce the quality of our professionals? Increased research in rehabilitation medicine can facilitate a better understanding on the topic and promote strategies to mitigate this negative effect.