Post-COVID Stroke and Rehabilitation: A Rising Concern

Abstract

The study of the consequences following COVID infection to comprehend the long-term and after-effects of this lethal epidemic is an emerging area of interest. In the light of COVID’s many known and unknow manifestations, life after COVID seems to be so unpredictable. To the best of their ability, biopsychosocial models have described the scope of the epidemic. Acute ischemic stroke (AIS) is one of the biggest consequences following COVID, albeit the underlying mechanisms are yet unknown. Research on the connection between COVID-19 infection and stroke is ongoing. We can obtain a better knowledge of the efficacy of rehabilitation by looking at the functional improvement of such a susceptible population following active rehabilitation services and by comprehending the likely predictors. To deliver the right care, these variables influencing functional gain must be quickly addressed. The goal of rehabilitation, an evidence-based, problem-solving approach, is to promote positive outcomes and demonstrate success. This chapter offers a perspective on the problems following a COVID stroke as well as the consequences of rehabilitation and its efficacy in promoting optimal functioning and raising general quality of life.

1. Introduction

On January 30, 2020, the World Health Organization (WHO) deemed the COVID-19 outbreak a public health emergency of global significance. Since then, there has been a sharp increase in the pandemic’s transmission and spread. Different strategies have been used to halt the infection’s spread. Those impacted by the post-COVID-19 infection have had long-lasting effects of varying intensities. The post-pandemic severity levels appear to have had a negative impact on people’s general quality of life. The incidence of stroke is currently one of the most common post-COVID consequences observed and studied. Stroke is a crippling ailment that ranks as the second greatest cause of mortality and a significant contributor to disability globally. Along with premorbid health traits and lifestyle, its incidence rises with age. The rise of cerebrovascular events (CVE) linked to COVID-19 is a new finding. Following COVID-19 infection, acute ischemic stroke (AIS) is now a serious consequence. In order to treat such diseases, rehabilitation is essential.

Recovery from an infection or trauma requires a multi-disciplinary team approach known as rehabilitation. The main essential concepts of rehabilitation are to enable maximal function, enable return to employment, enable safe departure from the hospital to home, and facilitate reintegration into the community. In order to achieve the best results, rehabilitation goals in such a vulnerable population must be carefully evaluated and tailored. The necessity and demand for the right intervention are highest due to the rise in post-COVID stroke cases. This enables the fields of study and rehabilitation to examine the requirements and effects brought on by the illness. The consequences and repercussions of the illness have been the subject of numerous researches recently. However, the need for rehabilitation is brought on by the various clinical presentations. Investigating how the rehabilitation process might assist and permit enough functioning in such a vulnerable population becomes extremely important as a result.

2. Impact of COVID-19

The COVID-19 infection has already created enough havoc and commotion around the globe. Depending on the infection’s severity and the amount of its dissemination, the effect may differ. To treat the weak and limit the spread of disease, however, the entire world returned with a range of strategies. Isolation, quarantine, and lockdowns have impacted the lives of millions of people, which has had a negative impact on the economy and general well-being [1, 2]. Critically ill patients and COVID-19 survivors are more likely to have preexisting disorders that make them disabled, including functional, social, and mental or psychological side effects from severe illness. This includes a typically gradual recovery that lowers overall quality of life [3].

Cerebrovascular events (CVE) were one of the COVID-19 infection’s many post-infection consequences that were of major importance [4]. A significant COVID-19 disease consequence is still acute ischemic stroke. Even if there are more reports of these situations, it is still unclear what the underlying mechanisms are [5]. The incidence of acute ischemic stroke (AIS) linked to severe COVID-19 is rising quickly. Currently, research is being done on the underlying pathophysiological pathways linked to peripheral and central inflammation that cause ischemic strokes linked to COVID-19. The angiotensin-converting enzyme 2 (ACE2) receptors on epithelial and endothelial cells are known to bind to SARS-CoV2, and this binding results in hypercoagulability, clot formation, and ultimately AIS [6]. Systemic immunity-mediated hyperinflammation, endothelitis, deregulation of the renin-angiotensin-aldosterone system (RAAS) in the central nervous system, oxidative stress, and excessive platelet aggregation are some of the main mechanisms that have been proposed so far [7, 8, 9]. According to other research, the inflammatory reactions to COVID-19 may cause a previously identified atheroma to rupture, which could result in thrombosis and ischemic stroke [10]. However, the rising reports of ischemic strokes linked to COVID-19 infections may be a symptom of this disease’s hypercoagulable spectrum. One of the numerous post sequelae problems, post-COVID-19 stroke, has resulted from this and is now progressing.

According to a preliminary retrospective case series investigation from Wuhan, China, acute CVE was the cause in 5.7% of cases with neurological involvement [4]. Following the outbreak, many homes and facilities were quarantined and isolated. As a result, a lot of people spent a lot of time stuck at home or in facilities, which led to inactivity. One of the research projects [11, 12] suggested that this physical inactivity may have increased the risk of a subsequent stroke. 5.88% of patients with new onset CVE were discovered in another recent publication from the same center that examined 221 individuals [13]. Additionally, occurrences of ischemic stroke with no obvious risk factors as the presenting symptom have been described in COVID-19 patients who are not severely unwell [14]. This may bring attention to the variety of COVID-19 ischemic strokes. Additionally, there may have been additional risk factors for the stroke, such as diabetes and high blood pressure. It is unclear, nevertheless, if those traditional risk factors put people at an increased risk of having ischemic episodes after contracting COVID-19. The middle cerebral or posterior cerebral arteries had anterior circulation big artery infarctions in the majority of published cases [15]. Additionally, reports of multifocal strokes in severely unwell individuals are emerging [16]. Therefore, a thorough analysis and understanding of the elevated thrombotic risk in this sensitive population are crucial.

3. Post-COVID-19 stroke and management

To speed up recovery, extensive therapy and a wholistic strategy needed to be used. Rehabilitation is a procedure for solving problems, and it has a strong record of success [17]. It involves identifying the patient’s main issues and worries, as well as how they develop and can be resolved. A multidisciplinary team worked together to deliver the appropriate skills to treat and intervene [18] using the holistic biopsychosocial model of illness as a framework [19]. In order to prevent a secondary stroke and other problems, recent research has recommended rehabilitation techniques and treatment for stroke patients during the pandemic [12]. A stroke care model was developed in one study during the COVID-19 epidemic. Its overarching objective was to protect patient outcomes while lowering the risk of COVID-19 exposure for both patients and healthcare professionals [20]. The intensity and extent of their recovery affected the functional gain in terms of regaining independence after the condition. Age was one of the predictor variables that was identified as having a significant impact on functional gain. One such study found that a person’s chance of recovery is higher the younger they are. Additionally, the study noted that more limits were seen with longer stays. This was noted as a negative impact of the length of stay on effective ambulation [21]. Hence, to maximize recovery and achieve improved functional outcomes, it is necessary to carefully consider the management and rehabilitation of such a susceptible population.

Treatment and recovery for stroke victims who also have COVID-19 infection are very different from those who do not. According to recent studies, stroke patients with COVID-19 had worse clinical outcomes than stroke patients without COVID-19 [22]. This could be as a result of the various comorbidities that stroke survivors with COVID-19 may have. In addition to the typical clinical symptoms of a stroke patient, a person with COVID-19 infection may also exhibit dyspnea, extreme fatigue, a low endurance tolerance, musculoskeletal abnormalities, and diminished cardiovascular and respiratory functioning. In one study, 51.2% of COVID-19-infected stroke patients died, and the survivors were referred to rehabilitation centers for additional care [23]. In a different study, patients with COVID-19 had higher median National Institutes of Health Stroke Scale (NIHSS) scores than patients without COVID-19. Additionally, stroke patients who had COVID-19 had a greater probability of dying and suffering from severe impairment [24]. This might explain why stroke patients with COVID-19 receive different rehabilitation than stroke patients without COVID-19. Future research needs to be done to fully understand the long-term risks, manifestations, and the appropriate management for this emerging rehabilitation population.

4. Conclusion

Acute ischemic stroke caused by COVID-19 is regarded as a crippling condition to be worried about. To manage such a fragile population, there are many different treatment approaches and rehabilitation best practices. To assess a patient’s rehabilitation needs, a multidisciplinary team approach with a holistic point of view is advised and necessary. To manage such mixed diagnoses efficiently, a team must have goals and move quickly. To prevent and manage the infection that causes strokes, it is critical to have a thorough grasp of the underlying mechanisms. In order to develop a clearer picture of how COVID-19 infection predisposes to stroke and other problems, extreme caution must be used, and further study must be conducted. Future research would benefit from this review.

Acknowledgments

We would like to acknowledge the support of the administration of Qatar Rehabilitation Institute and the Medical Research Center (HMC, Qatar) in encouraging and enabling us to engage in this endeavor.

Conflict of interest

The authors declare no conflict of interest.

Notes/thanks/other declarations

Thanks: The authors wish to acknowledge and thank the entire therapy team and the hospital for supporting in this endeavor.

Acronyms and abbreviations

FIM	functional independence measure
CVE	cerebrovascular events
AIS	acute ischemic stroke