Narrative review documents COVID-19 rehabilitation workforce and care gaps

The COVID-19 pandemic exposed gaps in health-worker protection, vaccination confidence and the continuity of rehabilitation care, according to a testimony-informed narrative review that brought these issues together from the perspective of rehabilitation professionals. Drawing on evidence published or updated through December 2025, mostly concerning conditions during 2020 and 2021, the review reports that the World Health Organization’s estimated range of health and care worker deaths was far above the number captured by surveillance. It also finds that telerehabilitation produced outcomes comparable to centre-based pulmonary rehabilitation in selected populations, although remote physiotherapy accounted for only 6% of outpatient episodes in one large US database. The author proposes four heuristic concepts to guide future research, but none has undergone formal concept analysis or empirical validation.

Review author Ibrahim Npochinto Moumeni describes the work as a narrative review prepared with recommendations from SANRA, using purposive searches of PubMed, Scopus and Google Scholar. The initial search covered January 2019 to December 2022 and was updated to December 2025 to capture later publications reporting data collected during 2020 and 2021. Sources included systematic reviews, large multicentre studies, official agency reports and selected French research. The 49-source evidence base was selected thematically rather than through a systematic screening process, and individual studies did not receive formal quality appraisal. First-person observations from the author’s postgraduate training in two French university hospitals were kept separate from the literature and were not used to support quantitative claims.

Health-worker mortality was one of the review’s central subjects. WHO estimated that between January 2020 and May 2021, 80,000 to 180,000 health and care workers died from COVID-19, with a central estimate of 115,500. Over the same period, 6,643 health-worker deaths had been reported through surveillance, less than 6% of the central estimate. Early systematic-review data through 8 May 2020 identified 152,888 infections and 1,413 deaths among health workers. Infections were concentrated among women, who represented 71.6% of cases, and nurses, who accounted for 38.6%; deaths were concentrated among men, who represented 70.8% of fatalities, and physicians, who accounted for 51.4%. In the United Kingdom and United States, front-line workers had an adjusted 3.4-fold higher risk of a positive test than the general community, with risk increasing further where protective equipment was inadequate or reused.

Although the United States did not produce an official national count, an investigative journalism database documented more than 3,600 health-worker deaths during the first pandemic year and found that lower-paid staff, including nurses and support workers, were disproportionately represented. The review also reports psychological distress among health workers, citing a meta-analysis with pooled prevalences of 23.2% for anxiety, 22.8% for depression and 38.9% for insomnia. From the synthesis and the author’s clinical observations, the paper proposes Frontline Abandonment Syndrome as a possible description of temporary or prolonged withdrawal from high-risk duties and its consequences for continuity of care. This is a hypothesis rather than a diagnosis or validated syndrome; it differs from burnout, moral injury and compassion fatigue by focusing on observable withdrawal and organisational conditions such as protective-equipment availability and communication.

Vaccine hesitancy was another major focus. Defined in the review as delay in accepting or refusing vaccination despite its availability, hesitancy was reported in 37% of 4,630 health workers surveyed across 91 countries between February and April 2021. A separate review involving 76,471 workers estimated hesitancy at 22.5%, while a scoping review of 41,098 nurses in 36 countries found a pooled refusal prevalence of 20.7%. The nurse review found refusal prevalence was higher in 2020 than in 2021. Reported reasons included safety concerns, side effects, doubts about efficacy, misinformation and mistrust of authorities or pharmaceutical companies. The figures cannot be compared directly because the studies used different populations, periods and definitions, and the review notes this limitation explicitly.

French data showed an occupational gradient at the beginning of the vaccination campaign. In a February 2021 survey of 1,965 workers at a tertiary centre, 73.1% favoured vaccination, 23.1% were hesitant and 3.9% opposed it. Fewer than 60% of auxiliary nurses and technicians intended to be vaccinated, compared with 60% to 79% of nurses and support staff and more than 80% of medical personnel. Controversy surrounding AstraZeneca tolerability was independently associated with lower vaccination intention. The review also discusses the temporary European pause involving France in March 2021 and the legal requirement introduced in France on 5 August 2021. From these observations, the author proposes the Vaccination Refusal Cascade, a hypothesis in which a salient institutional or media event triggers successive refusals across professional networks. The French association is consistent with that idea but does not demonstrate that such a cascade occurred.

Physiotherapy guidance developed during the pandemic addressed respiratory management, patient positioning, early mobilisation and exercise prescription under strict infection-control conditions. A Stanford Hall consensus described post-discharge rehabilitation, including a graded return to activity, while a rapid living systematic review documented the emerging evidence on patients’ rehabilitation needs. A WHO pulse survey also recorded widespread disruption of essential health services, including rehabilitation, in 2020. The author’s clinical observations from home-based physiotherapy during the first French lockdown described programmes adapted to minimal equipment, greater family involvement and the integration of psychosocial support. These observations illustrate practical adaptations but do not constitute evaluated outcomes, and they come from a single practitioner in a high-resource setting.

For patients with persistent symptoms, the review distinguishes physiological recovery from functional recovery. WHO defines post-COVID-19 condition as symptoms that usually arise three months after probable or confirmed infection, continue for at least two months and cannot be explained by another diagnosis; fatigue, post-exertional symptom exacerbation, cognitive dysfunction and dysautonomia are frequent. The proposed Post-COVID Functional Decoupling describes a pattern in which measures such as oxygenation, imaging and inflammatory markers normalise while functional capacity lags by weeks or months. It is not presented as a diagnosis, but as a rehabilitation-oriented pattern within post-COVID-19 condition and post-intensive care syndrome. The stated practical implication is that functional measures may guide rehabilitation and discharge decisions, while exercise progression must be individualised because post-exertional symptom exacerbation can occur.

The shift to remote rehabilitation produced both promising evidence and limited routine uptake. A rapid overview found telerehabilitation generally comparable to in-person physical therapy for several conditions. A Cochrane review of 15 studies involving 1,904 participants, mostly patients with chronic obstructive pulmonary disease, found pulmonary telerehabilitation achieved outcomes similar to centre-based rehabilitation without reported safety issues, although certainty of evidence was limited. A retrospective study of 164 patients found telerehabilitation non-inferior to in-person rehabilitation 12 weeks after total knee arthroplasty, and a prospective observational study of 23 patients found mixed in-person and remote delivery feasible in cancer rehabilitation. Yet a US database containing 222,680 outpatient physiotherapy episodes recorded telerehabilitation in only 6% of cases, declining from 10% to 5% between the second and third quarters of 2020. The proposed Telerehabilitation Emergency Pivot describes the rapid, improvised system-level transition to remote care and the subsequent persistence of hybrid models.

The review’s four constructs collectively shift attention toward service-level processes: from psychological distress to observable workforce withdrawal, from generic hesitancy to possible network diffusion, from digital transition to rehabilitation-specific constraints, and from physiological normalisation to delayed functional recovery. Proposed tests include linking staffing and deployment data with protective-equipment availability and validated distress measures; interrupted time-series analyses around vaccine safety alerts; adoption and safety comparisons across in-person, remote and hybrid rehabilitation; and cohort studies comparing physiological recovery with functional measures such as the six-minute walk test and activities-of-daily-living scales. These ideas remain hypotheses. The evidence base is non-exhaustive and exposed to selection and publication bias, clinical observations are vulnerable to recall bias, rehabilitation data from sub-Saharan Africa are scarce, and the review focuses mainly on 2020 and 2021. Formal concept analysis and empirical testing are therefore required before the proposed terms should be used beyond research settings.

Subject of Research: Narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation during COVID-19

Article Title: Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation

Article References: Npochinto Moumeni, I. (2026). Rehabilitation professionals at the COVID-19 frontline: a testimony-informed narrative review of health-worker mortality, vaccine hesitancy, physiotherapy and telerehabilitation. Frontiers in Rehabilitation Sciences, 7, Article 1921614. https://doi.org/10.3389/fresc.2026.1921614

Image Credits: AI Generated

DOI: 10.3389/fresc.2026.1921614

Keywords: COVID-19, health workers, mortality, vaccine hesitancy, physiotherapy, telerehabilitation, post-COVID condition, rehabilitation services, narrative review, pandemic preparedness, Rehabilitation, professionals