This resource is intended to support rehabilitation and allied health providers across the care continuum who are working with patients of all ages recovering from symptoms of COVID-19. The recommendations in this document are intended to represent a biopsychosocial approach to care given the complex biological, physical, psychological, social, economic, and spiritual needs of patients. The purpose of this document is not to outline all treatment approaches, rather it is intended to highlight new practice considerations when working with patient's post-COVID. The recommendations in this document are based on current evidence and were established through consultation with practice directors, physicians, rehabilitation, and allied health staff. It is recognized that some patients may not have a confirmed diagnosis of COVID-19 but the treatment considerations outlined can be applied to anyone experiencing ongoing symptoms of COVID-19. This document is meant to guide clinicians in their practice, but treatment approaches should be adapted to meet the unique needs of each individual. Treatment approaches may also vary depending on the local context and services available in each zone.# Introduction
The majority of COVID-19 patients with mild symptoms will improve functionally in the 6-8 weeks following their illness. However, there may be some patients, including those experiencing long-term symptoms of COVID-19, who will benefit from rehabilitation and allied health services to aid in their recovery.
A variety of terms to describe symptoms after COVID-19 have emerged, including Long COVID, Post COVID Condition, Persistent Post COVID and more. It is important to clarify the terminology for the purposes of rehabilitation and recovery. Vu and McGill (2021) used the term post-COVID-19 condition to incorporate symptoms beyond the acute infection phase. The NICE rapid guideline (2022) in the UK describes two conditions: ongoing symptomatic COVID-19 with symptoms between 4-12 weeks after infection, and Post COVID-19 syndrome with symptoms present 12 weeks after illness and lasting at least 2 months. The World Health Organization (October 2021) developed a clinical case definition of Post COVID-19 through a Delphi consensus, this definition reflects the long term symptoms typically associated with what has been termed Long COVID.
"Post COVID-19 condition occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection, usually 3 months from the onset of COVID-19 with symptoms that last for at least 2 months and cannot be explained by an alternative diagnosis. Common symptoms include fatigue, shortness of breath, cognitive dysfunction but also others (see Table 3 and Annex 2) which generally have an impact on everyday functioning. Symptoms may be new onset, following initial recovery from an acute COVID19 episode, or persist from the initial illness. Symptoms may also fluctuate or relapse over time. A separate definition may be applicable for children." (Page 1 World Health Organization, 2021) Recognizing that definitions and terminology continue to evolve, for the purpose of this document, the term "Post-COVID" is used to capture patients in the sub-acute phase of recovery including patients who required an acute care or intensive care admission and patients experiencing Long COVID or Post COVID-19 conditions.
Rehabilitation and allied health professionals provide a variety of roles across the continuum of care. One important role is to help patients improve their activity tolerance and function while providing education and resources to support self-management over the longer term. Another key role is to address other long-term impacts including psychological needs, social needs, spiritual well-being, and community re-engagement.
At present, there is limited evidence to guide rehabilitation best practices for patients recovering from COVID-19. As a result, caution may be required, particularly when prescribing exercise to patients who present with any of the following physical sequelae: 1) Post-exertional symptom exacerbation 2) Cardiac symptoms 3) History of Multisystem Inflammatory Syndrome in Children (MIS-C) 4) Significant dyspnea 5) Exertional oxygen desaturation 6) Dysautonomia and orthostatic intolerance 7) Coagulation dysfunction
The guidelines in this document address the physical sequelae mentioned above as well as treatment recommendations for other post-COVID sequelae including cognitive changes, speech & language impairments, social, psychological, and spiritual impacts. Clinicians are encouraged to use validated, psychosocial screening tools that are organizationally approved such as the social determinants of health module in Connect Care.
The recommendations are based on current evidence (as of June 2022), published expert opinions and consensus statements. More detailed information and references are available at the end of the document. Every effort will be made to update the recommendations in this document as new evidence becomes available.
- Task 1: "Normalize the uncertainty in prognosis". It is important to acknowledge the limitations to medical knowledge and diagnostic investigations. Although we would like to be able to provide more certainty on what may cause a given symptom or provide more certainty that a treatment will result in the desired outcome -in almost all cases total certainty is not possible. Normalizing that having uncertainty is a normal part of illness, while also acknowledging that there is more uncertainty about Long Covid than other conditions (because it is new, less researched, does not have a diagnostic test to confirm the diagnosis, etc.) may be helpful when paired with the other two tasks of this framework. Take care to not dismiss the importance and emotional impact of this uncertainty with patients.
- Task 2: "Address  patients'  emotions about uncertainty, acknowledging how difficult it may be for them not to know." Some patients and family may become focused upon seeking answers to the uncertainty. To a degree, this seeking knowledge to alleviate uncertainty is a normal and helpful behaviour. However, if the distress, emotional intensity, or focus on seeking answers becomes barriers to engaging in treatment, the patient or family may need to revisit their physician to discuss (A) the steps that were taken to arrive at the diagnosis; and/or (B) to explore their current mental health and coping. o Be cautious in the use of statements of reassurance, such was "the doctors have ruled out everything bad" because in the face of uncertainty, many such statements may be perceived as dismissive of their experiences and the impact Long Covid may be having on their lives and functioning. Instead, focus on statements of validation: "It makes sense to me how you could be feeling ____ given ____ happening" and helping the patient to identify actions within their control (such as engaging in treatment) which may help achieve what they want for the future. This is where practices such collaborative goal setting may be helpful.
- Task 3: "Help patients and families manage the effect of uncertainty on their ability to live in the here and now." An effective way to manage uncertainty regarding what the future (in relation to one's health and quality of life), is to focus on the current moment. Allied staff have a critical role to play in this, as many of the therapies or symptom treatment options outlined in this document help to address the symptoms which may be causing the greatest disturbance in the patient's usual functioning. Again, this is where the use of goal setting, pacing and encouraging selfmanagement strategies may be helpful.

# Tips for Supporting Self-Management:
Begin any program with the clinician explaining their role and allow time for the patient and family to introduce themselves and state what they are hoping to gain from the service or program.