Over a year after the novel coronavirus cemented its grip on the world, much of the conversation surrounding the disease remains simple: how many people died and how many survived?

But researchers at Michigan Medicine say a devastating side effect lurks, underreported, between those extremes - the loss of ability caused by the virus.

In a study published in the journal PM&R, investigators found that 45% of patients hospitalized for COVID-19 experienced significant functional decline after being discharged.

"Rehabilitation needs were really, really common for these patients," says lead author Alecia K. Daunter, M.D., a pediatric physiatrist at Michigan Medicine. "They survived, but these people left the hospital in worse physical condition than they started. If they needed outpatient therapy or are now walking with a cane, something happened that impacted their discharge plan."

The team of researchers reviewed charts of nearly 300 adult patients hospitalized for COVID-19 at Michigan Medicine during the pandemic's first wave between March and April 2020. They analyzed patients' discharge locations, therapy needs at the time of release and if they needed durable medical equipment or other services.

Of survivors who experienced functional decline, 80% were referred for additional therapy after being discharged. Nearly 20% of all patients lost so much ability, they were not able to live independently after their release.

"These patients may have needed to move to a subacute facility, or they might have needed to move in with a family member, but they were not able to go home," Daunter says. "This has a massive impact on patients and their families - emotionally and physically."

The study period occurred in the pandemic's infancy, as health care providers sought best practices to minimize exposures and manage patient overflow. As a result, 40% of patients never had a rehabilitation evaluation while hospitalized. That likely means, Daunter explains, that the number of patients losing ability is underreported.

"Physicians and others in the health care system were working appropriately to discharge patients," she says. "They needed to keep patients safe while maximizing available beds and minimizing exposure to staff. I think that contributed to many people not being assessed by a therapist or PM&R physician. So, the things we do to in the hospital to maximize functioning, like mobility interventions and assessing activities of daily living were, not happening as often."

COVID-19 can systematically damage various organ systems, causing neurological and musculoskeletal impairments. Michigan Medicine recently opened two clinics to address the growing population of "long COVID" patients.

However, the virus' effect on daily functioning is not frequently described, which, given the magnitude of the current public health crisis, can't be ignored any longer, says Edward Claflin, M.D., a Michigan Medicine physiatrist and co-author of the paper.

"These results help to highlight the true impact of the COVID-19 disease on our patients," Claflin says. "They fill in that gap in knowledge about how patients with COVID recover and what kind of rehabilitation needs they have."

The "first wave" study is a snapshot look at acute therapy needs during a time when knowledge of the unique virus was even more limited. The team hopes for additional research examining the long-term effects COVID has on functionality. However, health systems can use the current data to optimize rehabilitation evaluations and prepare resources for this underserved population, Daunter says.

"These problems are frequent, and the stakes are pretty high if we miss them, or allow them to progress during hospitalization," she says. "Some of these people were working and many were living independently. To lose that level of function is meaningful. We want to make sure we're addressing those needs, not just looking at the black and white, survival or death."

Daunter AK, Bowman A, Danko J, Claflin ES, Kratz AL.
Functional Decline in Hospitalized Patients with COVID-19 in the Early Months of the Pandemic.
PM&R: The Journal of Injury, Function and Rehabilitation. 2021. doi: 10.1002/pmrj.12624