Pan American Health Organization · First edition, 2020
Guidance on integrating rehabilitation into COVID-19 care pathways and maintaining essential rehabilitation services during the pandemic.
- Issuer
- Pan American Health Organization
- Edition
- First edition, 2020
- Audience
- National and subnational governments, rehabilitation service providers (hospitals, rehabilitation centres, private practices), rehabilitation professionals (physiotherapists, occupational therapists, speech-language pathologists, physical and rehabilitation medicine doctors, respiratory therapists, psychologists), health emergency planners
- Evidence
- Expert consensus based on emerging COVID-19 evidence and established critical care rehabilitation literature; input from global respiratory rehabilitation experts
- Reviewed
- 19 Oct 2026 · GMJ
What this guideline says
GMJ summary
This PAHO guidance addresses the critical role of rehabilitation in managing severe COVID-19 cases and maintaining essential rehabilitation services during the pandemic. Approximately 14% of COVID-19 cases develop severe acute respiratory infection requiring hospitalization and oxygen support, while 5% require ICU admission with median lengths of stay of 8 days. These patients experience significant rehabilitation needs including impaired lung function, physical deconditioning, muscle weakness, delirium, cognitive impairments, swallowing difficulties, and psychosocial challenges.
The document emphasizes that rehabilitation professionals are frontline health workers who should be engaged across all phases of care: acute (ICU/critical care), sub-acute (hospital wards and stepdown facilities), and long-term (community and home-based). Rehabilitation optimizes health outcomes, facilitates early discharge in the context of bed shortages, and reduces readmission risk. The guidance stresses that certain rehabilitation services for non-COVID-19 patients (burns, spinal cord injuries, stroke, major surgery) must be designated essential and continue during the outbreak.
Key recommendations include embedding rehabilitation focal points in health emergency coordination structures, expanding stepdown facilities with embedded rehabilitation to enable early discharge from acute settings, increasing rehabilitation workforce capacity through upskilling and redeployment, implementing telehealth services where appropriate, and ensuring infection prevention measures with adequate PPE for rehabilitation professionals. The guidance provides specific actions for governments and service providers to maintain rehabilitation service continuity while managing infection risks.
Key points
For clinicians — doses and thresholds as stated in the guideline
- Approximately 14% of COVID-19 cases require hospitalization with severe acute respiratory infection and oxygen support; 5% require ICU admission with median stays of 8.0 days (IQR 4.0–12.0)
- Rehabilitation professionals should provide care across three phases: acute (ICU/critical care units), sub-acute (hospital wards, stepdown facilities), and long-term (community, home-based, telehealth)
- Essential non-COVID-19 rehabilitation services must continue for priority groups: burns, spinal cord injuries, traumatic brain injury, fractures, major surgery, stroke, myocardial infarction, and perinatal complications
- Stepdown facilities should be established with embedded rehabilitation to enable early discharge from acute settings where bed shortages occur, staffed with appropriate multidisciplinary teams
- Rehabilitation interventions for severe COVID-19 include airway secretion clearance, ventilation weaning support, graded exercise, respiratory function improvement, cognitive rehabilitation, swallow therapy, and psychosocial support
- Infection prevention and control protocols must define appropriate PPE for rehabilitation professionals, particularly for aerosol-generating procedures such as airway clearance
- Telehealth should be implemented for rehabilitation delivery where appropriate, with necessary administrative and financial adjustments including insurance coverage for remote services
- Patients requiring early discharge should receive maximum education, home exercise programmes, assistive products with usage guidance, clear advice on complications, and telehealth follow-up access
Rehabilitation interventions across phases of COVID-19 care
Table extracted from the guideline
| Phase of care | Rehabilitation interventions | Typical delivery setting |
|---|---|---|
| Acute | Support acute respiratory management; improve oxygenation, airway secretion clearance, ventilation weaning; promote nutrition and prevent aspiration pneumonia post-intubation and with tracheostomy | Intensive and/or critical care units, high dependency units (including in SARI centres) |
| Sub-acute | Address impairments in mobility, respiratory function, cognition, swallow and nutrition, communication; promote independence with activities of daily living; provide psychosocial support; discharge preparation and planning | Hospital wards, stepdown facilities (including in SARI centres) |
| Long-term | Graded exercise; education on energy conservation and behaviour modification; home modification; assistive products; pulmonary rehabilitation combining graded exercise, education, activities of daily living, psychosocial support; telehealth including remote exercise and peer support | Rehabilitation centres, outpatient programmes, in-home services, mobile services, telehealth |
Source: Pan American Health Organization, Rehabilitation considerations during the COVID-19 outbreak. Reproduced in summary form.
From the guideline
Verbatim
“Rehabilitation professionals are frontline health workers who should be engaged in the care of patients who experience severe cases of COVID-19.”
Editor’s perspective
Why this matters for Georgia and the region
Prof. Giorgi Pkhakadze, MD, MPH, PhD
Editor-in-Chief, Georgian Medical Journal · Chair, Public Health Institute of Georgia · WHO consultant, health and migration
As we review pandemic preparedness in the South Caucasus, this PAHO guidance highlights critical gaps in our regional rehabilitation infrastructure that COVID-19 exposed. The recommendation to embed rehabilitation focal points in health emergency coordination structures is particularly important for Georgia, where rehabilitation has historically been underdeveloped within our health system despite progress in UHC implementation. I would stress to Georgian clinicians the specific finding that 14% of COVID-19 cases require hospitalization with rehabilitation needs and 5% require ICU care with median 8-day stays—these are concrete planning figures for our national capacity assessments. The concept of stepdown facilities merits serious consideration; during our COVID surges, premature discharge from Tbilisi hospitals created readmission problems that rehabilitation-embedded stepdown care could have prevented. However, implementing comprehensive telehealth rehabilitation faces real obstacles in Georgia: rural internet connectivity remains inconsistent, many elderly patients lack digital literacy, and our current insurance reimbursement mechanisms do not adequately cover remote rehabilitation services. We need regulatory amendments and targeted infrastructure investment before telehealth can become a reliable rehabilitation delivery mode across our country.
ORCID 0000-0001-7609-4515 · Perspective written for the GMJ Guidelines Library, 19 Oct 2026
Applicability
Georgia and the South Caucasus
For Georgia and the South Caucasus, this guidance remains highly relevant for strengthening rehabilitation capacity in pandemic preparedness and recovery planning. The region’s health systems, like many in Eastern Europe, face challenges with rehabilitation workforce shortages and limited stepdown care infrastructure. National programmes should assess current rehabilitation capacity across acute, sub-acute, and community settings; develop telehealth infrastructure considering internet accessibility in rural areas; establish systematic referral pathways between hospital and community rehabilitation services; and ensure rehabilitation is embedded in emergency preparedness plans. The emphasis on maintaining essential rehabilitation for stroke, cardiovascular disease, and trauma patients is particularly pertinent given the high burden of noncommunicable diseases in the region. Georgia’s experience with UHC implementation since 2013 provides a foundation for ensuring rehabilitation service financing, but specific mechanisms for telehealth reimbursement and stepdown facility payment would need development.
Questions this guideline answers
Quick answers
What percentage of COVID-19 patients require rehabilitation services?
Approximately 14% of COVID-19 cases develop severe acute respiratory infection requiring hospitalization and oxygen support, and 5% require ICU admission. Patients in these categories will have rehabilitation needs related to ventilatory support, prolonged immobilization, and bed rest, including impaired lung function, physical deconditioning, muscle weakness, cognitive impairments, swallowing difficulties, and mental health challenges.
Which rehabilitation services should continue during the pandemic for non-COVID-19 patients?
Essential rehabilitation services must continue for patients with new acute injuries (burns, spinal cord injuries, musculoskeletal), those recovering from surgery, patients at risk of suboptimal recovery (stroke, myocardial infarction, perinatal complications), and long-term rehabilitation patients who may lose function or develop complications. Evidence shows that withdrawal of rehabilitation for these groups seriously compromises health outcomes and increases mortality.
What are stepdown facilities and why are they important for COVID-19 care?
Stepdown facilities are inpatient facilities established to increase hospital surge capacity by providing interim, sub-acute care for medically stable COVID-19 patients with rehabilitation strongly embedded. They enable early discharge from acute settings where bed shortages occur, while ensuring patients receive necessary rehabilitation before returning home. These facilities may be purpose-built alongside SARI centres or created by converting existing facilities such as community hospitals, rehabilitation centres, or nursing homes.
How should rehabilitation be delivered during the pandemic when face-to-face contact poses infection risks?
Multiple delivery modifications are recommended: telehealth for assessment, treatment, education and remote exercise where appropriate; home-based services for high-risk patients when other options unavailable; early supported discharge with comprehensive home programmes, assistive products, and clear follow-up instructions; cohorting patient beds to minimize infection risk; confining rehabilitation to bed spaces rather than shared gym areas; and ensuring rehabilitation professionals have appropriate PPE, especially for aerosol-generating procedures like airway clearance.
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- Issuer
- Pan American Health Organization
- Type
- Procedures, manuals, guidelines
- Edition
- First edition, 2020
- Status
- Current
- Published
- 2020-01-01
- Scope
- Global guidance applicable to all countries and territories in the Americas and beyond
- Audience
- National and subnational governments, rehabilitation service providers (hospitals, rehabilitation centres, private practices), rehabilitation professionals (physiotherapists, occupational therapists, speech-language pathologists, physical and rehabilitation medicine doctors, respiratory therapists, psychologists), health emergency planners
- Licence
- CC BY-NC-SA 3.0 IGO
- Evidence
- Expert consensus based on emerging COVID-19 evidence and established critical care rehabilitation literature; input from global respiratory rehabilitation experts
- Record history
- Created 19 Oct 2026 · updated 19 Oct 2026 · next check Apr 2027
Pan American Health Organization. Rehabilitation considerations during the COVID-19 outbreak. Washington, D.C.: PAHO; 2020. (NMH/MH/COVID-19/20-0010). Available from: https://iris.paho.org/handle/10665.2/52035GMJ Guidelines Library records are original summaries written by the GMJ editorial team from the issuer’s published document and reviewed by a physician. They do not replace the full guideline. The document is the copyright of its issuer and is linked, not hosted. Spotted an error or a newer edition? Tell the Guidelines Desk.
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