Renee Kinder

If you are an avid reader, or even if you are not, you have likely heard of “Hillbilly Elegy.”

The book was written by J.D. Vance and has subsequently been turned into a movie on Netflix ripe with creative attempts to mimic the sing-song nature of a Eastern Kentucky accent. 

That inflection that is deeply interwoven in culture with words you have likely never heard before simply cannot be trained. Ask a speech therapist. 

While the majority of folks who read this book give it rave reviews, I simply didn’t love it … The truth is I didn’t even like it. Just one woman’s opinion. Like most Kentuckians, I struggled with the ability of someone with close contacts in the area, however not truly “raised” in Kentucky, to give a full and adequate picture of life in the Bluegrass State.

The elegy provided seemed to be one of sorrow.

Your review of this book may be associated with how you view the word elegy. Do you view the story as one of nostalgia or melancholy? One of sorrow or song?

Elegy el·​e·​gy | \ ˈe-lə-jē  \

plural elegies

Definition of elegy

1: a poem in elegiac couplets

2 a: a song or poem expressing sorrow or lamentation especially for one who is dead

  b: something (such as a speech) resembling such a song or poem

3 a: a pensive or reflective poem that is usually nostalgic or melancholy

   b: a short pensive musical composition

So now I ask: 2021, what will our elegy be? 

Will it be one of song? Or one of melancholy?

Which definition will your community fall into when it comes to long-term recovery practices for those healing from COVID-19?

The answer lies in your approach to treatment of COVID-19 as a life-long condition, versus a transient or acute event. 

Furthermore, where can you turn for clinical guidance on best practice for managing the recovery of COVID-19, which has evolved into much more than an acute illness with anecdotal evidence showing long-standing physical and mental residual impairments.

One tool I have been turning to often (OK, daily) is the Dec. 1, 2020, publication provided by the American Congress of Rehab Medicine titled, “What Now for Rehabilitation Specialists? Coronavirus Disease 2019 Questions and Answers.”

The abstract is concise, clear, and best of all, outlines the practical nature of the manuscript.

For those who are working to stay abreast of the growing research, I know you appreciate the challenge and hope you will enjoy this article’s tone and ease of understanding. 

The abstract reads: Recognizing a need for more guidance on the coronavirus disease 2019 (COVID-19) pandemic, members of the Archives of Physical Medicine and Rehabilitation Editorial Board invited several clinicians with early experience managing the disease to collaborate on a document to help guide rehabilitation clinicians in the community. 

This consensus document is written in a question-and-answer format and contains information on the following items: common manifestations of the disease; rehabilitation recommendations in the acute hospital setting; recommendations for inpatient rehabilitation; and special considerations. These suggestions are intended for use by rehabilitation clinicians in the inpatient setting caring for patients with confirmed or suspected COVID-19. The text represents the authors’ best judgment at the time it was written.

Guidance is then provided to outline various systems which are noted to be significantly impacted secondary to COVID-19 recovery. 

These include:

  • Pulmonary
  • Neurologic
  • Hematologic
  • Renal
  • Skin
  • Liver
  • Mobility Considerations
  • Chronic Condition and Cognition

A synopsis of the systems impaired is below. I hope however you all will take the time to read the full text.


  • The lung damage of COVID-19 leads to an impairment of gas exchange, with the potential for impaired pulmonary function.
  • As a result, many patients report prolonged dyspnea and chest tightness, although the dyspnea may not be commensurate with the degree of hypoxia.
  • Pulmonary fibrosis is another factor that may impact long-term myocarditis.
  • Left ventricular dysfunction in the acute phase may be attributed to markedly increased cytokine levels.
  • Activation or enhanced release of inflammatory cytokines can lead to necrosis of myocardial cells and exacerbations of coronary atherosclerotic plaques making them prone to rupture.
  •  An intense inflammatory response superimposed on preexisting cardiovascular disease may precipitate cardiac injury.
  • Myocardial damage might result in long-term dysfunction and must be taken into consideration for patients entering rehabilitation.
  • Although most patients develop persistent tachycardia, it has been found to be relatively benign and self-limiting.


  • Acutely, 36% of patients with COVID-19 develop neurologic symptoms, including headaches, altered consciousness, seizures, absences of smell and taste, paresthesias and stroke.
  • Posterior reversible encephalopathy syndrome, which causes headache, confusion, seizures and visual loss can be a complication.
  • COVID-19 has been associated with viral encephalitis but has been rarely reported
  • Patients are found to have very high D-dimer levels and hypercoagulability, in turn potentially increasing the risk of acute cerebrovascular events.
  • As with many viral syndromes, Guillan-Barre’ syndrome, acute demyelinating encephalopathy, acute necrotizing hemorrhagic encephalopathy and acute transverse myelitis have also been rarely reported.
  • Myopathy with severe muscular symptoms is commonly observed among moderate and severe cases.


  • Patients severely affected by COVID-19 are at high risk for a hypercoagulable state, characterized by very high D-Dimer levels, thrombo-embolism and stroke.
  • In one review, thromboembolism was documented in as many as 1 in 5 patients and strokes occurred in 3%.
  • Thromboembolic events occur despite Prophylactic use of anticoagulants, and both venous and arterial thrombosis occurs.
  • In addition, severe COVID-19 infection appears to be associated with bleeding complications and increased risk for intracranial hemorrhage, and, in some instances disseminated intravascular coagulation.


  • Patients severely affected by COVID-19 are more likely to have acute kidney injury.
  • Studies have shown that among those with normal creatinine levels on admission, most will recover from an acute kidney injury. However, proteinuria and hematuria can be prolonged.
  • It is recommended that patients with acute kidney injury be regularly assessed for 3-6 months after discharge.


  • COVID-19 has been associated with skin lesions, including (from most common to least common) Maculopapular eruptions, urticarial, acral erythema with vesicles or pustules (pseudo-chilblains), Vesicular eruptions, and livedo reticularis.
  • Frank necrosis, secondary to vasculopathy, can also occur and may result in limb loss.
  • Because of prone positioning, facial wounds may occur among survivors and could be problematic because of secondary infections and necrosis.


  • COVID-19–related liver dysfunction with abnormal liver enzymes (mainly elevated serum aspartate aminotransferase levels) may occur.
  • This may be the result of secondary liver damage caused by hepatotoxic drugs, an inappropriate inflammatory response, hypoxia, hypotension and multiple organ failure.
  •  It is important to monitor liver laboratory tests and avoid hepatotoxic medications during the recovery phase.

Additional guidance is provided related to the need for interdisciplinary collaboration between the rehabilitation team, nursing and respiratory therapy, including:

Providing frequent pressure relief. Prone teams that include physical or occupational therapists and are available 24 hours a day, 7 days per week may be helpful in reinforcing proper technique to minimize injuries.

The importance of daily-of-bed mobility and participation in activities of daily living (ADL) helps to promote functional recovery and improve delirium.

And education about engaging patients in daily therapeutic exercises, ADLs and cognitive stimulation tasks is recommended for carry over from therapy sessions to amplify functional recover.

It is 2021, and our COVID-19 elegy is ours to create. 

We have a responsibility to our patients.

Let us aim to make the elegy reflective, one appropriately recognizing the history of COVID-19, and creating a path of song for the days ahead. 

Renee Kinder, MS, CCC-SLP, RAC-CT, is Executive Vice President of Clinical Services for Broad River Rehab and a 2019 APEX Award of Excellence winner in the Writing–Regular Departments & Columns category. Additionally, she serves as Gerontology Professional Development Manager for the American Speech Language Hearing Association’s (ASHA) gerontology special interest group, is a member of the University of Kentucky College of Medicine community faculty and is an advisor to the American Medical Association’s Relative Value Update Committee (RUC) Health Care Professionals Advisory Committee (HCPAC).