Impact of Social Isolation due to the COVID-19 Pandemic in Patients With Pediatric Disorders: Rehabilitation Perspectives From a Developing Country

The novel coronavirus (COVID-19) appeared in Wuhan, China, in December 2019. It quickly spread across the globe and was declared a worldwide pandemic by the World Health Organization (WHO) 3 months later. COVID-19 can lead to acute respiratory distress syndrome, pneumonia, and other important complications, including death, especially in high risk groups.1 Among pediatric patients, according to the literature, COVID-19 appears to be less severe than in adults and the elderly, and approximately 90% of pediatric patients are diagnosed with asymptomatic, mild, or moderate disease.2,3 Even so, 6.7% of cases may be severe in children with serious underlying conditions such as neurologic and neurodevelopmental disorders.4 Respiratory complications are a major cause of death in the chronic neuropediatric population.5 Moreover, COVID-19 treatment may be more challenging in these children. For instance, prone ventilation, which is often practiced in patients with COVID-19,6 is difficult to perform in individuals with cerebral palsy and advanced neuromuscular conditions. Hydroxychloroquine and azithromycin are being indicated in treatment protocols of countries such as Brazil; however, a case report on an adult patient taking chloroquine for presumable reticular erythematous mucinosis indicated that the drug induced myasthenic syndrome, suggesting that the drug might affect neuromuscular junction transmission and might adversely affect children with myasthenia.7 Considering the absence of vaccines and effective antiviral therapies, the only strategies that have been shown to be effective in the reduction of cases and deaths in most countries are rigid public health measures such as social distancing.8,9 Despite its importance in the control of the pandemic and in the protection of groups who are at risk, social distancing seems to impact the lives of patients with neuropediatric conditions in a biopsychosocial manner. Analyzing this issue from a social perspective, children with disabilities in social isolation, especially in developing countries, may have problems in accessing the necessary therapies. Panda and Sharawat10 mentioned that due to strict isolation measures in some countries, children with epilepsy and neuromuscular disease may be deprived of their drug treatment.10 In addition, economic damage caused by pandemic has a negative impact on household income, which is already limited in these families due to the high costs of medication, support technologies, and physical therapies. Unfortunately, this vulnerable population has not received any special economic or sociopolitical support in most developing and underdeveloped countries. Other important negative effects of social isolation in children and adolescents during a pandemic are in the area of mental health.11,12 School closures and lack of access to day care centers and parks may exacerbate children’s feelings of loneliness, depression, and anxiety.13 Most schools have adopted the recommendation of United Nations Educational, Scientific, and Cultural Organization (UNESCO) and are using distance learning programs and open educational opportunities that can connect teachers and students remotely and limit the disruption of education; however, in most cases, this is not a reality for children with disabilities. Physical health is also negatively impacted by social isolation. Evidence shows the importance of physical rehabilitation for pediatric patients with chronic neurological conditions14,15; however, these activities must be interrupted during a pandemic. Rehabilitation staff, such as speech-language pathologists and physical therapists, are at increased risk of self-contamination and may contaminate others, because they are exposed directly to respiratory droplets from patients with neurological conditions. The absence of rehabilitation may lead to soft tissue contractures, bone deformities, regression in motor milestones, dysphagia, and respiratory difficulties in addition to other complications. Pediatric patients with neurological conditions also may experience declines in motor function. One modality of rehabilitation assistance that has been discussed and adopted in this period of social isolation is telerehabilitation, wherein rehabilitation professionals’ interactions with patients take place at a distance, through telecommunications devices, to provide rehabilitation assistance.16 In contrast to countries such as the United States, United Kingdom, Japan, and Canada, the use of telerehabilitation in Brazil was prohibited by the National Council of Physiotherapy and Occupational Therapy (COFFITO) and National Council of Speech Therapy (CFFA); however, in March 2020, due to the pandemic, both institutions published resolutions authorizing professionals to assist the population via telerehabilitation. For Brazilian rehabilitation therapists, and for many of the world’s physical therapists, the possibility of telerehabilitation was something extremely new and challenging. Telerehabilitation particularities, such as data privacy, prior programming of the session environment and material, internet quality, specific applications for telerehabilitation, and legal aspects of this type of service are being discussed strongly among regional councils and associations representing different specialties in Brazil. The treatments and interventions for rehabilitation of children and adolescents with neuromuscular disabilities comprise techniques that involve touch, handling, performing of specific tasks, correction of activities during execution, and use of machines or apparatuses, such as treadmills, suit therapy protocols, and virtual reality.14,17 Thus, the adoption and performance of attendance by telerehabilitation in neuropediatric patients may be a complex process. In addition, we still need to know more about the effects of telerehabilitation effects in the neuropediatric population. In a systematic review, Dos Santos et al18 discuss 9 studies about telerehabilitation in children and teenagers; 6 of the studies looked at asthma management, but none examined rehabilitation for pediatric neurological disorders.18 A recent systematic review with similar scope reported 17 studies, 4 of which explored telerehabilitation use in children and adolescents with neurological conditions (unilateral cerebral palsy and acquired brain injury).19 Even though this systematic review showed some benefits in rehabilitation for children with physical disabilities, the clinical outcomes evaluated were not clearly relevant for clinical practice, and the diseases and outcomes evaluated did not reflect the complexity of neuropediatric rehabilitation. We live in a unique time, and its real impact will be perceived only after the pandemic resolves. Until then, rehabilitation professionals, policy makers, and families of children with neuromotor disabilities should discuss and direct their attention to some key points: Public policies to support families of children with disabilities are needed. In developing countries, the majority of this population is socially vulnerable as a result of the COVID-19 pandemic. Accessibility to public health and information about prevention of COVID-19, financial compensation for families and caregivers of people with disabilities, monthly donations of basic food supplies, endowments of smartphones, and high-quality internet support in remote areas (eg, slums) for transmitting specialized information and educational assistance to children with disabilities are examples of public policies that could better support these families.20 As we do not have optimistic estimates for the duration of the pandemic, studies investigating telerehabilitation in neuropediatric areas are critical to identify this modality’s real efficacy and to better understand the practice, perceptions, and difficulties of rehabilitation staff and parents. To provide psychological and social support to families and help them to deal with this hard time of pandemic and social isolation. In this context, some measures may be adopted, such as maintaining regular routines and programs as much as possible or creating new ones (eg, regular exercising, daily chores, singing, painting, keeping in regular contact with friends and colleagues via telephone, e-mail, social media, or video calls). These strategies might reduce boredom and also help family members integrate themselves. Additionally, low-cost specific psychological support can be provided via teleconsultation from psychology faculty at local universities or nongovernmental organizations or even supported by the local public health system. Although we will probably will not be able to see the real impact of social isolation on health of children with disabilities until after COVID-19 is gone, pediatric physical therapists must adapt in order to provide the best possible care during this complex social moment that our patients and families are enduring. Concept/idea/research design: A.L.F. Meireles, L.C.F. de Meireles. Writing: A.L.F. Meireles, L.C.F. de Meireles. Data collection: A.L.F. Meireles, L.C.F. de Meireles. Data analysis: A.L.F. Meireles, L.C.F. de Meireles. Project management: A.L.F. Meireles, L.C.F. de Meireles. Consultation (including review of manuscript before submitting): A.L.F. Meireles, L.C.F. de Meireles. There is no funding to report. The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.

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