Expert consensus on protocol of rehabilitation for COVID‐19 patients using framework and approaches of WHO International Family Classifications

Abstract Coronavirus disease 2019 (COVID‐19) has widely spread all over the world and the numbers of patients and deaths are increasing. According to the epidemiology, virology, and clinical practice, there are varying degrees of changes in patients, involving the human body structure and function and the activity and participation. Based on the World Health Organization (WHO) International Classification of Functioning, Disability and Health (ICF) and its biopsychosocial model of functioning, we use the WHO Family of International Classifications (WHO‐FICs) framework to form an expert consensus on the COVID‐19 rehabilitation program, focusing on the diagnosis and evaluation of disease and functioning, and service delivery of rehabilitation, and to establish a standard rehabilitation framework, terminology system, and evaluation and intervention systems based the WHO‐FICs.

. The ICF has established a unified and standardized terminology system to classify the functioning and disability. It is the fundamental system of physical medicine and rehabilitation and is recommended in the fields of diagnosis and coding, evaluation, and interventions of functioning to maximize patients' functioning at three levels: (1) body function and structure; (2) activity and participation; and (3) environmental factors and personal factors. The ICHI provides a set of general classifications to report and analyze the evaluation and health interventions. It is applicable to all health system levels and uses the same structure and terminology as the ICF to describe health interventions. The ICD is used for disease diagnosis and coding; the ICF is used for description, evaluation, and coding of functioning; and the ICHI is used for intervention and coding of functioning. The ICHI is consistent with the ICD-11 and ICF in ontological structure and terminology. 14,15 [Consensus 1] This consensus adopts the framework and approach of WHO-FICs to build a rehabilitation protocol of COVID-19 disease diagnosis, description and evaluation, coding and intervention of functioning (see Table 1).

| Protocol of diagnosis, coding, evaluation, description and intervention of functioning of COVID-19 cases based on ICF
[Consensus 2] The WHO recommends three standardized functional assessment tools based on the ICF in ICD-11, namely the WHO Disability Assessment Schedule 2.0 (WHODAS 2.0), the Brief Model Disability Survey, and the Generic functioning domains (VB40). The functional evaluation based on the ICF, such as ICF-Core set, can be used for patients' overall functional assessment, rehabilitation-needs assessment, and rehabilitation-outcome assessment. This consensus recommends the use of these three standardized assessment tools in rehabilitation evaluation. The qualifiers of ICF can be used to standardize the results of functional assessment in the field of rehabilitation to achieve comparable international functional data.
According to the ICF, this consensus also recommends all evaluations mapped to ICF structure involve in four aspects: body function and structure, activity and participation, environmental factors and personal factors. [15][16][17][18][19][20] According to the framework and scope of rehabilitation developed by the International Society of Physical and Rehabilitation Medicine (ISPRM white paper), ICF and ICHI β-2, we develop a personalized intervention plan based on specific unmet needs of patients with COVID-19. 21

| Build COVID-19 rehabilitation service
delivery system based on ICF and WHO guideline: rehabilitation in health system. 6,[28][29][30][31] In light of the WHO rehabilitation guideine: Rehabilitation in health system, rehabilitation for COVID-19 survivors should be provided at tertiary-, secondary-, and primary-care levels and integrated into the continuum of prevention, treatment, rehabilitation, and health promotion.
[Consensus 4] According to the recommendations from WHO guidelines Rehabilitation in health system, considering the functioning caused by COVID-19, including mental health issues and environmental support factors, we should implement the people-oriented rehabilitation throughout lifespan and concerns social determinants, adopt multidisciplinary and cross-domain approaches, and with approaches of universal design to bulid barriers-free environments and to establish a comprehensive rehabilitation service system.

| Virological characteristics
The new coronavirus is a coronavirus of β genus, with a capsule, round or oval particles, often pleomorphic, with a diameter of 60-140 nm. [32][33][34]40 The virus is sensitive to UV; and heat of 56°C for 30 minutes, ether, 75% ethanol, chlorine containing disinfectant, peracetic acid, and chloroform can effectively inactivate the virus.
Chlorhexidine cannot effectively inactivate the virus.
The novel coronavirus is the main source of infection.
Asymptomatic infections can also be a source of infection. The main route of transmission is through respiratory droplets and close contact. It is possible to propagate through aerosols when exposed to high-concentration aerosols for a long time in a relatively closed TA B L E 1 Protocol of rehabilitation for COVID-19 cases using the WHO-FICs

| Pathological characteristics
The results of a lung biopsy and autopsy in a COVID-19 patient showed that the patient had pleural effusion, pleural thickening, and extensive and severe adhesion with the lung. The lung tissue showed dark red and gray white patchy changes in toughness, while a large amount of gray white viscous fluid overflowed in the lung tissue, and fiber cords were seen. White foam mucus was seen in the endotracheal tube, and mucus adhered in the lumen of the right pulmonary branch.

| Clinical manifestations
The main manifestations of patients are fever, dry cough, and fa- It is necessary to establish a multi-disciplinary rehabilitation team for patients with COVID-19. According to the functioning characteristics and the rehabilitation stage of patients, individualized rehabilitation intervention strategies and approached are recommended. 5,41 From the current situation of the cases, most patients have a good prognosis, and a few patients are in a critical condition. The prognosis of the elderly and those with chronic basic diseases is poor. The symptoms of children are relatively mild.

| Clinical classification
Mild: The clinical symptoms are mild, and no pneumonia is found in radiology.
Moderate: Fever, respiratory tract and other symptoms are present, and pneumonia is found in radiology.
Severity: Those complying with any of the following should be (4) radiology shows that the lesions progress more than 50% in

| Coding protocol of COVID-19 with ICD-10 recommended by China National Health and Health Commission and China National Health Insurance Bureau
A coding protocol of COVID-19 with ICD-10 had been issued by National Health and Health Commission and National Health Insurance Bureau.
The "U07.100" code is used for novel coronavirus as a statistical code for all confirmed COVID-19 cases. It is not used as a main diagnostic code for the front page of the medical record.

Code U07.100x001: Novel coronavirus pneumonia
The "U07.100x001: Novel coronavirus pneumonia" code is only applicable to the "confirmed inpatients with new coronavirus pneumonia" and must be used as the main diagnostic encode.
The code is defined as follows: (1)

| Description and coding of functioning of cases with COVID-19
[Consensus 5] COVID-19 cases have secondary functioning and disability. Using the rapid extended ICF core set, we can describe, evaluate, and code the functioning of cases with COVID-19. This rapid ICF core set developed from ICF core set for COPD. See Table 2 for description and coding demonstration case.

| THE PRINCIPLE S OF FUNC TIONAL E VALUATION AND DE SCRIP TION
[Consensus 6] According to the disease classification, functional status, and rehabilitation needs of patients with COVID-19, the following rehabilitation assessment and evaluation are recommended.
As novel coronavirus is highly infectious and highly pathogenic, The ICF core set is a widely used standardized tool. There is no ICF core set for COVID-19. We recommend a rapid and extended ICF core set from ICF core set for COPD for evaluation and description of functioning and disability for COVID-19 cases (Table 2).

| Assessments and evaluations in body structure and function
According to the COVID-19-cases-related body functions and structures and the assessments and evaluation tools commonly used in the fields rehabilitation, we recommend the following assessments and evaluations. Transferring oneself (d420) Moving from one surface to another, such as sliding along a bench or moving from a bed to a chair, without changing body position Caring for body parts (d520) Looking after those parts of the body, such as skin, face, teeth, scalp, nails and genitals, that require more than washing and drying Services, systems and policies for preventing and treating health problems, providing medical rehabilitation and promoting a healthy lifestyle

| Recommended subjective assessments and evaluations in body structure and function
(1) Evaluation of dyspnea: Modified Borg Scale for daily follow-up.
(3) Limb pain assessment: Visual Analog Scale and Oral Rating Scales.
(4) Evaluation of anxiety and depression: Zung's Anxiety/Depression Scales, Self-rating Depression Scale and Self-rating Anxiety Scale for regular follow-up evaluation.

| Recommended clinical examinations assessments and evaluations in body structure and function
(1) Vital signs evaluation: Record the body temperature, respiration, pulse, blood pressure, blood oxygen saturation, urine volume, and other indicators regularly every day, and make relevant records before and after the intervention treatment.
(2) Imaging evaluation: Chest X-ray; if necessary, CT and color Doppler echocardiography may be used to evaluate the morphology of heart and lung and provide an objective basis for making a treatment plan.
(3) Assessment of bone, joint and muscle: Bed rest or disease con-

| Evaluations in activity and participation
We recommend the WHODAS 2.0, activities of daily living (ADL) assessments, and the 36-item Short Form Health Survey (SF-36) to evaluate patients' activities of daily life and participation.

| WHODAS 2.0
The WHODAS 2.0 is a standardized activity and participation assessment tool recommended by the WHO.

| ADL
According to the severity of the patient's condition, ADLs should be evaluated regularly for mild, medium, severe, and discharged patients, including basic ADL evaluation and instrumental ADL evaluation for cases who return to the community after discharge.
The improved Barthel Index or other instrumental ADL scales are recommended. For severe cases, we recommend observational evaluation.

| Quality of life
As there are no assessment scales specific to COVID-19, we recommend using the Medical Outcomes Study SF-36 or the COPD Assessment Test in order to shorten the time of evaluation.

| Assessments and evaluations at different stages of rehabilitation
Considering that COVID-19 cases may have different health conditions and will be at different rehabilitation stages, we recommend not only collecting data of vital signs, laboratory tests, and other information on disease, but also evaluating pulmonary function, subjective fatigue, dyspnea, pain, joint and muscle function, activity level, and quality of life tailored to patients' health conditions. Those assessments should be carried out pre-and post-rehabilitation. Only comprehensive and systematic rehabilitation data will provide evidence for the effect of rehabilitation in the intervention of infectious diseases, such as COVID-19.

| PROTOCOL OF COVID -19 REHABILITATION INTERVENTION BA SED ON ICF
[Consensus 7] We developed a protocol of rehabilitation intervention based on the ICF tailored to COVID-19 diagnosis, functional status, and unmet needs of rehabilitation.

| Rehabilitation environment and setting, measures, and principles
Within the framework of the WHO-FICs, rehabilitation service de-

| Intensive rehabilitation training
The main clinical manifestations of COVID-19 are respiratory dysfunction, with pulmonary consolidation and airway secretion obstruction. 43

| Expectoration coach
According to the patient's condition, the therapist can use bodyposition drainage, vibration and clapping, active cycle of breathing techniques, and other techniques or equipment to clear the airway, and should pay attention to the local humidification of the whole body and airway to reduce the viscosity of the sputum. For mild, medium, and heavy patients, and patients after discharge, reducing the time spent in bed is helpful to reduce the risk of various bed complications, promote the improvement of cardiopulmonary function, and shorten recovery time.

| Breathing training
The threshold loading inspiratory muscle training device is the most commonly used method of respiratory resistance training at present.
Generally, the initial load is 30% of the personal maximum inspiratory Respiratory control can significantly improve the experience of breathing, reduce respiratory-related oxygen consumption, and relieve the tension of patients. Generally, deep and slow breathing is used to increase the compliance of the respiratory system, reduce the work of breathing, and relieve the dyspnea of patients.
Diaphragmatic breathing or abdominal breathing also have similar effects. If possible, physical therapy can be used for training, such as an electrical stimulation diaphragmatic trainer, electronic biofeedback, and so forth.

| Aerobic (endurance) training
In aerobic training, it is best to monitor blood pressure, heart rate, and blood oxygen saturation.
(1) Intensity: Patients in the acute stage mainly take low-intensity exercise without fatigue on the second day. In general, patients in better condition can try medium-intensity exercise. After discharge, patients can carry out medium-and high-intensity exercise training according to further evaluation results to obtain more benefits.
(2) Frequency: According to the patient's tolerance, they should carry out active and passive training once or twice a day. If the patient's condition is serious and the tolerance is poor, they should shorten the training duration and increase the frequency accordingly to ensure the training quantity.

| Joint active and passive motion
Long-term bed rest can lead to joint stiffness, contracture, and other changes. Patients should be guided to actively carry out active and passive motions of the spine and limb joints to maintain their normal range of motion, which can be arranged 1-2 times per day and can be completed by joint and position. Severe patients may not be able to complete the active whole joint motion effectively. At this time, they may need other people or special equipment to carry out the passive motion of joints, including the limbs, head, neck, and waist, to reduce the risk of deep vein thrombosis.

| Physical factor therapy
(1) Ultrashort wave therapy: Ultrashort wave therapy can promote the exudation and absorption of the lung and improve ventilation function. It can be used for patients with lung exudation and the specific prescription is mainly short-term with micro or without heat; however, fever is a contraindication. Small ultrashort waves can be used for bedside treatment to reduce the impact of high-frequency electromagnetic fields on monitoring equipment, but the ultrashort wave machine, its electrodes, and wires should be disinfected and protected according to the protection level.
(2) Ultraviolet therapy: Whole-body ultraviolet irradiation can increase immunity function, which may be applicable to mild and medium patients, but severe and critical patients may have immune disorders, so it is not recommended.
(3) Low-frequency neuromuscular electrical stimulation therapy: Neuromuscular electrical stimulation can improve the respiratory muscle and peripheral muscle function, so it can be used in bed patients for respiratory muscles or limb muscles, to delay muscle disuse atrophy, and to increase neuromuscular function.

| Psychological intervention
For some COVID-19 cases, there may be some negative stress responses, mainly emotional disorders, such as panic, anxiety, and somatization symptoms, which affect the mood, state, sleep and overall mental health level. 49,50 These psychological and behavioral disorders will affect the treatment effect of patients.
For hospitalized patients with emotional disorders, such as anxiety or depression, we recommend: the implementation of psychological intervention as early as possible (including cognitive therapy and behavior therapy); the elimination of stressors; the improvement of patients' anxiety or depression; establishing a positive and optimistic mood; and seeking support from families, medical staff, and psychologists. In addition to psychological and behavioral interventions, drug therapy and biofeedback therapy can also be used in the treatment of severe anxiety or depression.
For COVID-19 patients who receive rehabilitation in the community, we recommend: the establishment of a psychological support service system; the relief of panic about infectious diseases at the community level; the establishment of a psychological support and assistance system between community members, family members and patients; and the provision of special psychological services for those who suffer critical psychological events in the pandemic situation, such as the death of family members, to ensure that patients will not suffer from serious psychological obstacles that reduce their quality of life.
In view of the psychological problems caused by COVID-19, we recommend to provide mental health services for patients and their families, assist them to acquire and understand the correct information about the pandemic and the impact of COVID-19, prevent them from panic and long-term stress state, and help them to establish a positive lifestyle and behaviors.

| Health-promotion activities
Participating in taijiquan, wuqinxi, baduanjin, and other physical activities is helpful to regulate breath, dredge meridians, and improve stability of the core muscle group and balance ability. These activities are especially suitable for elderly or weak patients with low physical abilities and can be carried out by mild, medium, and discharged patients, using group mutual aid mode or at home through video exercises.

| Interruption criteria of rehabilitation intervention
We recommend the following criteria for interruption of interven-  to ensure that patients receive high-quality rehabilitation services from medical institutions, rehabilitation institutions, and community based service providers. We should build a patient-centered rehabilitation service system.

| REHABILITATION MANAG EMENT AND GOVERNANCE
It is necessary to establish a multidisciplinary rehabilitation team for patients with COVID-19. According to the functioning characteristics and the rehabilitation stage of patients, individualized rehabilitation intervention strategies and approaches are recommended. 5,41 We should establish a comprehensive rehabilitation service system in all professional fields, integrating all levels of health services, and providing comprehensive rehabilitation services for COVID-19 patients from clinical treatment to community rehabilitation services. In the community, we should especially emphasize the empowerment of patients, enhance their self-confidence, and improve their overall functions and their quality of life.

| Establish a comprehensive rehabilitation system
For patients in different rehabilitation stages, we should analyze their unmet needs of rehabilitation, main functioning disability and rehabilitation resources from medical institutions, rehabilitation institutions and communities levels, and establish different rehabilitation solutions to improve the quality and cost-effectiveness of rehabilitation. 5

| Using big data and remote rehabilitation and other new technology
We recommend: the establishment of a rehabilitation service platform; cooperation with experts in epidemiology and clinical medicine; and the integration of rehabilitation into the modern health-service system. For special patient groups, such as the elderly, people with disabilities, and children, we strongly recommend the consideration of their special needs and obstacles, as well as multiple functioning and its impact on COVID-19 rehabilitation.
In the community, we recommend the all members pay attrention to the negative influences and discrimination against COVID-19 cases. The proposed measures include the provision of correct information, the prevention of panic and bias, and the consideration of the psychological, social, and environmental factors in community rehabilitation services. 41

ACK N OWLED G MENTS
Thanks to members of the expert group for guidance and review of this paper.

CO N FLI C TS O F I NTER E S T
Nothing to disclose.