The Stress of a Pandemic and its Impact on Physiatry

by Ramza Malik, DO

Nearly every era has faced a pandemic of its own. Some were caused by pathogens we fear no longer, while others have left behind lingering threats. Irrefutably, microbes carry the power to alter the course of history. Today, we are dealing with the devastating impact of a new pathogen, SARS-CoV-2. What began as an outbreak in late 2019, developed into a pandemic by March 11, 2020 affecting over a hundred countries and 100,000 people. As this number now surpasses 2 million, the world as we knew it a few months ago has transformed entirely.

From the various historic plagues to the more recent viral epidemics, human populations have suffered tremendously. Though the cause and course of disease varies among the different pandemics, one similarity surely exists — the undeniable level of stress imposed by these events upon humanity. Pandemics are marked by death, fear, isolation, uncertainty, as well as destabilization of our social, civil, political and economic pillars. It is no surprise that in these times of catastrophe, stress is at an all-time high.

Biologically speaking, stress has been defined as a state of threatened homeostasis, during which the body responds with various measures to resist unfavorable change (7). Dr. Selye first described biological stress as the response of the body to demands placed upon it, giving rise to the ‘General Adaptation Syndrome’, which he distinguished from acute stress. Dr. Selye’s Syndrome characterized stress as having three stages: alarm, resistance and exhaustion. Over time however, our understanding of biological stress changed and the term itself evolved (11). The word “stress” has become mainstreamed into our daily lives to also indicate physical, mental, or emotional strain or tension.

As we can see, stress is complex in nature, formulated and influenced by a multitude of factors that ultimately contribute to change, either good (eustress) or bad (distress). There seems to be a notable parallel between the biological stress that is challenging our COVID-19 affected patients and the form of stress, we as a healthcare community, are facing during these times. Below, I draw a connection between these unique types of stress as they occurr in the different stages in our affected patients and in our community.

Alarm

The initial exposure to a stressor results in recruitment of specific and non-specific recruitment of the body’s defensive resources. As our patients are relying on their immune systems to recognize this foreign entity and build up an initial response, we, as a global community, have taken immediate measures in attempts to minimize the spread of this disease. Implementing lock-downs, closures and distancing protocols became our first guards of defense. In the realm of healthcare, our immediate focus is on patient stabilization and provider safety.

During this stage, rehabilitation services are essentially an afterthought and are not often considered in emergency planning. The Conditions, Actions, Needs (CAN) report for Inpatient Rehabilitation Facilities (IRFs) attempts to provide guidance for acute IRFs providers during this public health emergency.6 The report indicates that IRFs are filled with patients who have multiple comorbidities and are at risk of being affected. This promotes early discharge practices for patient safety but also to aid in hospital bed availability efforts. Acute rehab services offered to hospitalized patients (including ICU) and to those admitted to an IRF are being altered to follow current social distancing protocols which means less efficiency and frequency with which staff can work with patients. For example, due to reduced staffing and limited access to protective equipment, patients therapy needs are being sacrificed. Additionally, outpatient rehab facilities are mostly closed or have altered services in accordance with emergency healthcare protocols. Thus, patients will experience significant delays and postponements in their rehab program, resulting in significant burden on their physical health. Although appropriate for emergency situations, these actions affecting both inpatient and outpatient facilities can possibly prohibit their overall recovery.

Resistance

When the stressor is persistent, the body attempts to return some physiological functions back to normal levels while remaining on high alert. The alarm responses come to a plateau and the body resists further physiologic change. Non-severe COVID-19 patients in this state battling mild-moderate symptoms might begin their journey towards recovery. On the other hand, patients with more severe disease would likely demonstrate worsening respiratory function and possibly even progress towards Acute Respiratory Distress Syndrome (ARDS), requiring ICU admission. These critically ill patients are susceptible to developing further physical, cognitive and mental health problems, otherwise termed post-intensive syndrome. Typical sequelae include myopathy, muscular atrophy, neuropathy, and delirium (10).

Neurologic injury has been confirmed in the infection of other coronaviruses in the past such as in SARS-CoV and MERS-CoV. Furthermore, new evidence suggests that patients affected by COVID-19 are experiencing symptoms of neuromuscular disease such as acute stroke (6%), consciousness impairment (15%), and skeletal muscle injury (19%), especially since most of the affected patient have comorbid or underlying neurological conditions. The findings of elevated CPK and proinflammatory cytokines in serum provide supporting evidence for possible skeletal muscle damage (5). A recent case report describes Guillain-Barré Syndrome in association with SARS-CoV-2 infection (12). Undoubtedly, these conditions would create the necessity for physical rehabilitation.

Rehabilitation for patients recovering from a critical illness is a key component of the holistic healthcare approach, which aids in minimizing the risk of developing long-term disabilities. Numerous studies have shown the positive impact of rehabilitation in hospitalized patients, including ICU patients, by improving their mobility status and muscle strength (11). Specifically, there have been studies demonstrating the positive impact of rehab in patients affected by the prior coronavirus, SAR-CoV-1, which was demonstrated to improve cardiorespiratory and musculoskeletal fitness (3). These studies strongly support the anticipated need for physical rehabilitation while caring for patients affected by the novel virus.

Exhaustion

Unfortunately, in the case of patients with severe disease, their immune system eventually tires and the disease burden is too grueling to fend off. It is at this stage, where we have lost many of our COVID-19 patients. For those who have survived, the burden of this disease may have a lasting impact; even more for those plagued with severe symptoms. Severe cases require an ICU admission, with a hospital length of stay up to 6 weeks, leading to worse deconditioning. Furthermore, Dr. Selye demonstrated that persistent stress could possibly lead to the development of various other diseases such as stroke and joint disease.13 In fact, one year after the SARS-CoV-1 outbreak, affected patients still had elevated stress levels (4). These findings indicate the potential for development of new illnesses, both physical and psychological, as well as the potential for the aggravation of comorbid chronic conditions.

Similarly, the global and healthcare communities impacted by the stressor (this pandemic) are under an extended period of vulnerability. These times of uncertainty have been heightened by a tide of unemployment, workplace strain for essential workers, and death of millions of loved ones. Essentially, our world is experiencing a traumatic event, impacting some of us physically but many others emotionally and mentally. Surviving this life-threatening experience will likely reconstruct each of us individually and collectively (8). We should expect to see a significant increase in patients complaining of psycho-somatic pain caused by stress. Rehabilitation, whether physical or psychological, will be of vital component during this stage, not only for the affected patients but also for the general population. Overall, we will experience higher volumes of those requiring rehabilitation. Now more than ever, the connection between mind and body may be the key to holistic recovery.

So, what could we as physiatrists do about all of this? Certainly, our immediate goal during this time should be first-line response for unstable patients. However, addressing disability should not be forgotten. Multiple avenues exist in our modern society to help aid us with this goal. For admitted COVID-19 patients, for example, the International Rehabilitation Forum (IRF) provides guidance for identifying sources of potential patient disability, resource limitations in the hospital, and rehabilitation strategies to be incorporated into the admission process and discharge plan.1 Another great resource for all patients, especially those currently unaffected by COVID-19, is prehabilitation, which it a tool that emerged during World War II to prepare soldiers for battle. Prehabilitation involves interventions to improve patient health in anticipation of a stressor. It is a multimodal approach that includes addressing exercise, nutrition, home safety, mental health, reducing medical risks and pain management skills. This intervention could be essential for patients at high risk of contracting this virus, like the elderly. Lastly, telemedicine is a great asset for our community given the current physical contact limitations. Telemedicine is a medium through which not only prehabilitation could be delivered to our patients, but it can also be used to provide guidance and continuity of care to rehab patients. Studies have shown that tele-rehabilitation is not only feasible, but efficient (2). The resources mentioned above are but a few of the vast majority available to us during this time. Utilizing some of these resources can significantly impact patient recovery, quality of life and improve long-term outcomes.

References

1. International Rehabilitation Forum. http://www.rehabforum.org/tools.html.
2. Isernia, S, C Pagliari and J Jonsdottir. “Efficiency and Patient-Reported Outcome Measures from Clnic to Home: The Human Empowerment Aging and Disability Program for Digital-Health Rehabilitation .” Front Neurol (2019): 1206.
3. Lau, H M, et al. “A randomised controlled trial of the effectiveness of an exercise training program in patient recovering from severe acute respiratory syndrome.” Aust J Physiother (2005): 213–219.
4. Lee, A M and al. et. “Stress and psychological distress among SARS survivors 1 year after the outbreak.” Can J Psychiatry (2007): 233–240.
5. Mao, L, H Jin and M Wang. “Neurologic Manifestations of Hospitalized Patients With Coronavirus Disease 2019 in Wuhan, China.” JAMA Neurol (2020).
6. McNeary, L. “Navigating Coronavirus Disease 2019 (Covid-19) in Physiatry: A CAN report for.” 2020. https://amrpa.org/Portals/0/covid19-for-irf-for-pm-r_1.pdf.
7. Melzack, Ronald. “Pain and Stress: A new Perspective .” Gatchel, Robert J and Dennis C Turk. Psychosocial Factors in Pain: Critical Perspectives. Guilford Press, Feb 12, 1999 . 89.
8. Ogilvie, R, et al. “The experience of surviving life-threatening injury; a qualitative synthesis.” Int Nurs Rev (2012): 312–320.
9. Rawal, G, S Yadav and R Kumar. “Post-intensive care syndrome: an overview.” Journal of translational internal medicine (2017): 90–92.
10. Rosch, Paul J. “The Birth of Stress.” n.d. American Institue of Stress. https://www.stress.org/about/hans-selye-birth-of-stress. <https://www.stress.org/about/hans-selye-birth-of-stress>.
11. Tipping, C J, et al. “The effects of active mobilisation and rehabilitation in the ICU on mortality and function: a systemic review.” Intensive Care Med (2016).
12. Toascano, G. “Guillain-Barre Syndrome Associated with SARS-CoV-2.” New England Journal of Medicine (2020).
13. “What is Stress?” n.d. The American Institute of Stress. 15 April 2020. <https://www.stress.org/what-is-stress>.

Ramza Malik is a PGY-1 at SUNY Upstate Medical University where she will continue in PM&R in July 2020.