COVID-19: Community Rehabilitation: Difference between revisions
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== The Role of the Community-Based Physiotherapist == | == The Role of the Community-Based Physiotherapist == | ||
Once the surge in acute cases of COVID-19 patients has subsided, there will be an increase in rehabilitation needs of these patients following discharge from hospital. Community based physiotherapists will be essential in the provision of these rehabilitation services.<ref name=":0">Falvey JR, Krafft C, Kornetti D. The essential role of home-and community-based physical therapists during the COVID-19 pandemic. Physical Therapy. 2020 Apr 17.</ref> | Once the surge in acute cases of [[Coronavirus Disease (COVID-19)|COVID-19]] patients has subsided, there will be an increase in rehabilitation needs of these patients following discharge from hospital. Community based physiotherapists will be essential in the provision of these rehabilitation services.<ref name=":0">Falvey JR, Krafft C, Kornetti D. The essential role of home-and community-based physical therapists during the COVID-19 pandemic. Physical Therapy. 2020 Apr 17.</ref> | ||
Community based physiotherapists will actively contribute in the rehabilitation of patients recovering from COVID-19 and help reduce the risk of readmission to hospital for these patients. Two risk factors for hospital readmission are impaired physical function and unmet need for Activities of Daily Living assistance. These are two areas where physiotherapists are essential in delivering care.<ref name=":0" /> | Community based physiotherapists will actively contribute in the rehabilitation of patients recovering from COVID-19 and help reduce the risk of readmission to hospital for these patients. Two risk factors for hospital readmission are impaired physical function and unmet need for Activities of Daily Living assistance. These are two areas where physiotherapists are essential in delivering care.<ref name=":0" /> | ||
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== Rehabilitation Strategies in COVID-19 Patients Following Hospital Discharge == | == Rehabilitation Strategies in COVID-19 Patients Following Hospital Discharge == | ||
Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include: | * Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include<ref name=":1">Pan American Health Organisation. [https://iris.paho.org/bitstream/handle/10665.2/52035/NMHMHCOVID19200010_eng.pdf?sequence=6&isAllowed=y Rehabilitation considerations during the COVID-19 outbreak]. 2020. 26 Apr. (last accessed 28 June 2020)</ref>: | ||
** Graded exercise | |||
Graded exercise | ** Education on energy conservation and behaviour modification | ||
** Home modification | |||
Education on energy conservation and behaviour modification | ** Assistive products | ||
* Patients may also benefit form [[Pulmonary Rehabilitation|pulmonary rehabilitation]] interventions – this targets physical and respiratory impairments and include a combination of graded exercise, education, activity of daily living and psychosocial support. | |||
Home modification | * Pandemic related constraints (such as [[Social Distancing|social distancing]], limited human resources and limited public transport) and infection risks following discharge might mean physiotherapists need to think out of the box and find innovative ways to provide rehabilitation services. | ||
** This could include telehealth | |||
Assistive products | ** Remote exercise - such as “virtual group” education and exercise | ||
** Peer to peer support from COVID-19 patients who have received the appropriate training | |||
Patients may also benefit form pulmonary rehabilitation interventions – this targets physical and respiratory impairments and include a combination of graded exercise, education, activity of daily living and psychosocial support. | * Rehabilitation services in people’s communities are often the best-placed to provide long-term care<ref name=":1" /> | ||
Pandemic related constraints (such as social distancing, limited human resources and limited public transport) and infection risks following discharge might mean physiotherapists need to think out of the box and find innovative ways to provide rehabilitation services. | |||
This could include telehealth | |||
Remote exercise - such as “virtual group” education and exercise | |||
Peer to peer support from COVID-19 patients who have received the appropriate training | |||
Rehabilitation services in people’s communities are often the best-placed to provide long-term care | |||
< | |||
== Healthcare Needs of COVID-19 Patients Following Discharge == | |||
Patients may present with various issues on discharge from hospital or inpatient rehabilitation centres. Rehabilitation specialists such as physiotherapists in the community will be needed to provide the relevant care of these patients.The issues still prevalent in a patient recovering from COVID-19 following discharge will guide and inform the patient’s care and support plan. This can include considerations such as if the patients will be able to care for themselves and manage their needs and what wider support will be necessary.<ref name=":2">NHS England. [https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/06/C0388-after-care-needs-of-inpatients-recovering-from-covid-19-5-june-2020-1.pdf After-care needs of inpatients recovering from COVID-19].Version 1. June 5, 2020. (last accessed 28 June 2020)</ref> These issues may include: | |||
* Physical issues | |||
** Such as weakness | |||
** Fatigue | |||
** Balance | |||
** Gait issues | |||
** Loss of function | |||
** Respiratory problems such as: | |||
*** breathlessness | |||
*** oxygen desaturation | |||
* Psychological and neuro-psychological issues | |||
** Patients may present with anxiety, [[depression]] or [[Post-traumatic Stress Disorder|Post Traumatic Stress Disorder]] and other psychological difficulties as a result of their experience of the illness and the treatment they received | |||
* Social issues | |||
** A patient’s circumstances may be affected by the pandemic and changes during periods of lockdown | |||
It is critical that the needs of the patient and the symptom management should always be considered and addressed in a holistic way. The patients’ needs will also change as rehabilitation progresses and the treatment goals should be adjusted accordingly. | It is critical that the needs of the patient and the symptom management should always be considered and addressed in a holistic way. The patients’ needs will also change as rehabilitation progresses and the treatment goals should be adjusted accordingly. | ||
Physical Issues | === Physical Issues === | ||
==== Respiratory<ref name=":2" /> ==== | |||
* Patients may require supplemental oxygen following discharge, either temporary or long-term | |||
* Pulmonary rehabilitation - the need for this will depend on the severity of the COVID-19 infection, existing comorbidities and the patients’ functional status | |||
* Pulmonary vascular disease – evidence shows that patients with COVID-19 experience a high prevalence of thromboembolic disease and patients that were treated in ICU with severe COVID-19 may develop pulmonary artery hypertension | |||
* Chronic cough - this is defined in adults as having a cough lasting over eight weeks. Cough is one of the most common clinical features in patients with COVID-19, but research is still lacking on chronic cough post- COVID-19 infection. | |||
* Lung fibrosis – about 30% of SARS and MERS survivors experienced physiological impairment and abnormal radiology that is consistent with fibrotic lung disease. Pulmonary fibrosis may be a consequence of COVID-19. | |||
* Pulmonary physiology interventions to determine effect on lung function | |||
** Pulmonary function tests such as spirometry, lung volumes, gas transfer and exercise capacity may need to be done to determine the physiological impact of the effect of COVID-19. These tests are necessary to manage potential pulmonary scarring and resulting fibrosis, but the timing and nature of the tests to be done still needs to be determined. | |||
* Possible risk of bronchiectasis after COVID-19 infection needs to be considered | |||
==== Cardiac<ref name=":2" /> ==== | |||
* Acute myocardial injury is the most common described cardiovascular complication in patients with COVID-19 ( occurring in 8-12% of discharged patients, heart failure is reported in 12% of recovered and discharged patients) | |||
==== Neuromuscular<ref name=":2" /> ==== | |||
* Hospital acquired weakness | |||
** The impact of COVID-19 on the incidence of hospital acquired weakness, deconditioning in hospital and the long-term physical weakness is still not known. There seems to be anecdotal evidence from the UK and Europe that there might be a higher than usual incidence of [[ICU Acquired Weakness|ICU-AW]] compared to the usual critical care cohort. Early physical rehabilitation following hospital discharge is beneficial and may improve quality of life. An eight week pulmonary rehabilitation program in survivors of [[Acute Respiratory Distress Syndrome (ARDS)|ARDS]] significantly improved quality of life and exercise capacity. Physiotherapy is critical in addressing these issues of deconditioning and weakness. | |||
* Neuropathy | |||
** Patients may have neuropathies following discharge. One of the treatment methods for patients with respiratory failure is prone positioning for up to 16 hours per day. This may put patients at risk for compression neuropathies and neural damage. Other issues may be pressure damage to heels and other areas due to prolonged bed rest, lack of sensation, lack of proprioception and an increased risk for falls. Physiotherapists are key role players in the assessment and treatment of neuropathies. | |||
==== General function and well-being<ref name=":2" /> ==== | |||
* Fatigue | |||
** People who have had COVID-19 report extreme fatigue beyond the usual reported levels. This will influence the recovery rate, the need for support and the need for supportive equipment, as well as a person’s return to their normal activities and work. A gradual increase and return to activities and exercise is advised and patients need to be taught pacing strategies. Physiotherapists are in the unique position to early identify fatigue in patients and can implement fatigue management strategies. This can include sleep hygiene, energy conservation techniques, pacing, gradual increase in activity and graded exercise. The early implementation of these fatigue management strategies could limit the impact of fatigue and the possibility of fatigue developing into a chronic condition. | |||
New challenges to treatment of discharged COVID-19 patients | New challenges to treatment of discharged COVID-19 patients | ||
Revision as of 16:56, 28 June 2020
This article or area is currently under construction and may only be partially complete. Please come back soon to see the finished work! (28/06/2020)
Original Editor - User Name
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Introduction[edit | edit source]
The rehabilitation of patients recovering from COVID-19 is essential to ensure an improvement in long-term physical and mental health. Community-based physiotherapists will play a key role in the rehabilitation of COVID-19 survivors following hospital discharge.
The Role of the Community-Based Physiotherapist[edit | edit source]
Once the surge in acute cases of COVID-19 patients has subsided, there will be an increase in rehabilitation needs of these patients following discharge from hospital. Community based physiotherapists will be essential in the provision of these rehabilitation services.[1]
Community based physiotherapists will actively contribute in the rehabilitation of patients recovering from COVID-19 and help reduce the risk of readmission to hospital for these patients. Two risk factors for hospital readmission are impaired physical function and unmet need for Activities of Daily Living assistance. These are two areas where physiotherapists are essential in delivering care.[1]
For patients with poor health care outcomes the provision and participation in rehabilitation may increase their functional reserve and make a difference between surviving or succumbing to an acquired COVID-19 infection.[2] Community based physiotherapists also perform other tasks such as home safety assessments, acquisition of relevant medical equipment as well as caregiver training once patients have been discharged from hospital.[1]
Community based physiotherapists will be key in the ongoing rehabilitation of survivors of COVID-19 to optimise recovery of these patients.
Furthermore, community based physiotherapists can provide interventions to non-COVID-19 patients and possibly reduce the volume of new hospital admissions for this population, which in term will reduce the burden on already stretched hospitals.
Rehabilitation Strategies in COVID-19 Patients Following Hospital Discharge[edit | edit source]
- Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include[3]:
- Graded exercise
- Education on energy conservation and behaviour modification
- Home modification
- Assistive products
- Patients may also benefit form pulmonary rehabilitation interventions – this targets physical and respiratory impairments and include a combination of graded exercise, education, activity of daily living and psychosocial support.
- Pandemic related constraints (such as social distancing, limited human resources and limited public transport) and infection risks following discharge might mean physiotherapists need to think out of the box and find innovative ways to provide rehabilitation services.
- This could include telehealth
- Remote exercise - such as “virtual group” education and exercise
- Peer to peer support from COVID-19 patients who have received the appropriate training
- Rehabilitation services in people’s communities are often the best-placed to provide long-term care[3]
Healthcare Needs of COVID-19 Patients Following Discharge[edit | edit source]
Patients may present with various issues on discharge from hospital or inpatient rehabilitation centres. Rehabilitation specialists such as physiotherapists in the community will be needed to provide the relevant care of these patients.The issues still prevalent in a patient recovering from COVID-19 following discharge will guide and inform the patient’s care and support plan. This can include considerations such as if the patients will be able to care for themselves and manage their needs and what wider support will be necessary.[4] These issues may include:
- Physical issues
- Such as weakness
- Fatigue
- Balance
- Gait issues
- Loss of function
- Respiratory problems such as:
- breathlessness
- oxygen desaturation
- Psychological and neuro-psychological issues
- Patients may present with anxiety, depression or Post Traumatic Stress Disorder and other psychological difficulties as a result of their experience of the illness and the treatment they received
- Social issues
- A patient’s circumstances may be affected by the pandemic and changes during periods of lockdown
It is critical that the needs of the patient and the symptom management should always be considered and addressed in a holistic way. The patients’ needs will also change as rehabilitation progresses and the treatment goals should be adjusted accordingly.
Physical Issues[edit | edit source]
Respiratory[4][edit | edit source]
- Patients may require supplemental oxygen following discharge, either temporary or long-term
- Pulmonary rehabilitation - the need for this will depend on the severity of the COVID-19 infection, existing comorbidities and the patients’ functional status
- Pulmonary vascular disease – evidence shows that patients with COVID-19 experience a high prevalence of thromboembolic disease and patients that were treated in ICU with severe COVID-19 may develop pulmonary artery hypertension
- Chronic cough - this is defined in adults as having a cough lasting over eight weeks. Cough is one of the most common clinical features in patients with COVID-19, but research is still lacking on chronic cough post- COVID-19 infection.
- Lung fibrosis – about 30% of SARS and MERS survivors experienced physiological impairment and abnormal radiology that is consistent with fibrotic lung disease. Pulmonary fibrosis may be a consequence of COVID-19.
- Pulmonary physiology interventions to determine effect on lung function
- Pulmonary function tests such as spirometry, lung volumes, gas transfer and exercise capacity may need to be done to determine the physiological impact of the effect of COVID-19. These tests are necessary to manage potential pulmonary scarring and resulting fibrosis, but the timing and nature of the tests to be done still needs to be determined.
- Possible risk of bronchiectasis after COVID-19 infection needs to be considered
Cardiac[4][edit | edit source]
- Acute myocardial injury is the most common described cardiovascular complication in patients with COVID-19 ( occurring in 8-12% of discharged patients, heart failure is reported in 12% of recovered and discharged patients)
Neuromuscular[4][edit | edit source]
- Hospital acquired weakness
- The impact of COVID-19 on the incidence of hospital acquired weakness, deconditioning in hospital and the long-term physical weakness is still not known. There seems to be anecdotal evidence from the UK and Europe that there might be a higher than usual incidence of ICU-AW compared to the usual critical care cohort. Early physical rehabilitation following hospital discharge is beneficial and may improve quality of life. An eight week pulmonary rehabilitation program in survivors of ARDS significantly improved quality of life and exercise capacity. Physiotherapy is critical in addressing these issues of deconditioning and weakness.
- Neuropathy
- Patients may have neuropathies following discharge. One of the treatment methods for patients with respiratory failure is prone positioning for up to 16 hours per day. This may put patients at risk for compression neuropathies and neural damage. Other issues may be pressure damage to heels and other areas due to prolonged bed rest, lack of sensation, lack of proprioception and an increased risk for falls. Physiotherapists are key role players in the assessment and treatment of neuropathies.
General function and well-being[4][edit | edit source]
- Fatigue
- People who have had COVID-19 report extreme fatigue beyond the usual reported levels. This will influence the recovery rate, the need for support and the need for supportive equipment, as well as a person’s return to their normal activities and work. A gradual increase and return to activities and exercise is advised and patients need to be taught pacing strategies. Physiotherapists are in the unique position to early identify fatigue in patients and can implement fatigue management strategies. This can include sleep hygiene, energy conservation techniques, pacing, gradual increase in activity and graded exercise. The early implementation of these fatigue management strategies could limit the impact of fatigue and the possibility of fatigue developing into a chronic condition.
New challenges to treatment of discharged COVID-19 patients
Increased number of patients with Post Intensive Care Syndrome (PICS)
Maintaining infection control
Increased pressure on equipment provision – such as oxygen cannisters, personal protective equipment
Increased pressure on staffing
Increased number of patients with persisting psychological difficulties following hospital discharge
Emerging clinical perspectives that affects rehabilitation of COVID-19 patients
Post Intensive Care Syndrome (PICS) https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf
The aftershock of the pandemic will include ongoing rehabilitation needs of patients with PICS. Coordinated rehabilitation approaches should be considered and developed for this specific cohort of patients.
Post-viral fatigue syndrome https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf
There is the potential that people recovering from COVID-19 may develop post-viral fatigue syndrome. It is critical that physiotherapists are aware of the signs and symptoms of PVFS and be aware and know the management strategies. These management strategies should focus on rest, hydration and nutrition.
If the symptoms of post viral fatigue syndrome do not resolve within 4-5 months after viral infection it could then be diagnosed as Myalgic Encephalomyelitis (Chronic Fatigue Syndrome).
The main symptom of ME is post-exertional malaise and it is important that physiotherapists know this and also know the appropriate treatment. A key factor to keep in mind is that progressive physiotherapy can be harmful to people with ME. People with ME have an abnormal response to exercise. This abnormal response include:
Lower anaerobic threshold
Lower oxygen capacity
Increased acidosis
Abnormal cardiovascular responses
Suitable management approaches in:
Symptom contingent pacing
Heart rate monitoring
Following discharge, the support of the patient should be kept under review as the person’s situation changes and the personalised support and care plan also adapts. Some principles to consider once a person is home after a COVID-19 infection include:
Existing services: Patients should be supported through adapting and strengthening the local existing services in a community, as far as possible. These systems will differ between countries.
Infection risk: Infection prevention control measures should adhere to the local and national guidelines as set out the specific region or country.
Minimise steps: The number of steps in a treatment or management pathway of a patient being discharged from hospital should be minimised as well as the number of healthcare professionals involved in the management of the patient. This will help to further reduce the risk of infection.
Volunteers and carers: If available in a region or country make use of volunteers and carers to support patients
Education and training: The education and training needs of rehabilitation professionals involved in the care of COVID-19 patients need to be reviewed
Support for rehabilitation professionals: Psychological and practical support for rehabilitation professionals during the pandemic should be provided.
Video to add: https://www.youtube.com/watch?v=3sURTAaxmc8
Post Covid-19 effects could include: https://covidpatientsupport.lthtr.nhs.uk/#/
Muscle weakness and joint stiffness
Extreme tiredness and fatigue and lack of energy
Loss of apetite and weight loss
Sleep problems
Mental problems
Mood changes
Nightmares
PSTD
Ways to address breathlessness
Breathing control techniques
Positions of ease to help in assisting breath control such as:
Leaning forward while sitting
Leaning forward in standing while supported
Standing up, leaning backwards while supported (for example – lean back against a wall)
Sidelying with shoulders and head raised
Secretion management
Deep breathing techniques
Breath stacking technique
Postural drainage
Staying mobile as allowed by energy levels
Stay hydrated
Energy conservation methods
Things to remind patients:
Energy needs may fluctuate
Exercise is good – but be wise about it
Do activities they are comfortable doing, learn to stop and modify when tasks are difficult and modify
Set small goals
Aim to do a little more every day, but avoid overdoing it
Take breaks between tasks
Graded exercises
Bed exercises:
Neck movements
Neck rotations
Shoulder rolls
Arm raises
Biceps curls – no weight
Quadriceps setting
Leg raises
Ankle rolls
Exercises while sitting
Assisted shoulder exercises
Biceps curls with light weight
Above shoulder exercises with weights
Side shoulder exercises
Heel toe raises
Knee raises
Leg raises
Exercises while standing
Leg to the side
Leg backwards
Sitting squads
Knee raises
Toe raises
Core stability exercises
Pelvic tilts
Bridging
Hip rolls
Rehabilitation strategies from various countries
This is just a short summary of some rehabilitation strategies and interventions from different countries. Evidence is still emerging and the clinical guidance may change as more is learnt about the natural history of the disease.
Pulmonary Rehabilitation in COVID-19 patients recovering from ARDS – Suggestions from Italy
https://www.monaldi-archives.org/index.php/macd/article/view/1444/1048
This is the result of and Italian consensus through a Delphi process that was published in June 2020. The full article can be accessed here. Some of the suggestions that may influence the rehabilitation of patients discharged from hospital will be highlighted here:
Personal Protection Equipment
Suggestions for personal protection needs:
Appropriate PPE should be used by healthcare professionals and they should be trained in the proper donning and doffing procedures of PPEIn the first 3 months after infection, also if patient has negative nasal/throat swabs, use eye and respiratory protections, gloves and if possible disposable gown when using AGP’s
All patients should wear a medical mask during treatment
Measures to minimise droplet and aerosol dispersion should be implemented during AGP’s
Outpatient consultation: aerate the examination room after each consultation
Sanitize surfaces
Ensure spatial distance between patients in waiting rooms
Diagnosis of COVID-19 phenotype patients
Phenotypes
The following is still unknown:
Days of contagious risk
Need for pulmonary rehabilitation
Timing to commence pulmonary rehabilitation
Predictors of recovery
Pulmonary rehabilitation is proposed for:
Dyspnoeic, older patients with comorbidities with:
long length of hospital stay
history of ICU
needing weaning from mechanical ventilation
Reduced strength and exercise capacity
In need of oxygen at rest and during effort
Individualised pulmonary rehabilitation programs should be proposed
Frailty measures
Patients with frailty could be affected more seriously and may have a poor prognosis
Recognition of frailty is important before setting up a PR program, to reduce the risk of poor outcomes
Multidimensional assessment should be incorporated in frailty measurements such as:
Global exercise capacity
Strength
Balance
Coordination
Nutritional
Psychosocial status
Timing of Pulmonary Rehabilitation commencement
No clear scientific evidence for the timing as yet
PR is recommend from early stage in hospital
Interestingly, A suggestion that was not approved by the consensus panel was that outpatient rehabilitation programmes and telemedicine should be considered for patients discharged from hospital. Reasons for this included inconclusive literature evidence on telerehabilitation, the belief that telerehabilitation could only be used for stable patients and obstacles of telerehabilitation such as usable technology for largest possible number of patients, safety of patients at home; medico-legal liability and the issues around economic reimbursement.
Assessments
Discharge outcomes following COVID-19 is still unknown
Assessments should include: symptoms scales, cardiorespiratory function, pulmonary function tests, respiratory muscle strength, comorbidities, neurological and pshychological disorders and frailty
Outcome measures shoulde include: exercise tolerance, functional status and physical performance, presence of Critical Illness neuromyopathy and ICU-AW, ADL, baseline functional impairment due to dyspnea and how breathlessness affects patient’s mobility
Gas exchanges and best informative indexes
Pulse oximetry and SaO2/FiO2 values are critical to monitor clinical situation at rest and during effort
Pulse oximetry device at home is recommended
Lung function tests
When safe to perform by operators and patients
Not to be used as outcome measures of pulmonary rehabilitation programs
Severe impairment should not be considered a contra-indication for PR
Functional Evaluation
At discharge and before start of PR following discharge an assessment of physical performance and ADL autonomy is necessary.
Standard maximal cardiopulmonary exercise test is not recommended in the first 6-8 weeks following acute hospital discharge due to unknown cardiorespiratory and muscle involvement and infectious risk
Exercise induced oxygen desaturation assessment is critical during exercise tolerance tests
With exercise and exercise testing – fatigue and breathlessness should be evaluated through psychometric scales such as BORG scale or VAS
Follow-up assessments should routinely include monitoring of physical performance
Respiratory muscle assessment
Unknown factors: prevalence, severity and recovery of respiratory muscle weakness due to COVID
Standard maximal inspiratory and expiratory pressures (MIP/MEP) are not recommended in the first phase (6-8 week) due to infection risk
Quality of life assessment
Test for presence of disorders such as anxiety, depression, sleep disturbances, PTSD
Assess patients level of autonomy
Assess the quality of patient’s support network
Obtain a global measurement of the patient’s perceived QoL level
Emotional aspects to identify
Neuropsychological assessment at baseline and post PR
Measures of psychosocial effects such as depression, anxiety, PTSD
Do not ignore the long term psychological and psychosocial implications of infectious diseases
Consider caregiver and family of patient affecte by COVID
Interventions
Oxygen therapy
Oxygen need at rest, during effort and sleep should be assessed
Use standardised tests such as 6MWT (if patient is able to) to assess oxygen need during effort
Precautions about air dispersion distance should be considered during oxygen administration
Exercise programs
PR in post COVID Patients could improve symptoms, functional capacity and quality of life, but best exercise program intervention is still unknown
Exercise training principles in patients with chronic lung disease could be considered in post-COVID patients
In patients with mild or no disability (SPPB >10; Barthel Index > 70) – Aerobic exercise <3.0 METs with progressive increase of intensity based on symptoms (BORG fatigue and/or dyspnea below the score of 3) is advised to restore normal physical function
In patients with moderate to severe disability (SPPB<10; Barthel index <70) – a comprehensive rehabilitation programme is recommended to improve autonomy, peripheral and respiratory muscle strength, balance, walking ability, symptoms and Quality of life
Aerobic exercise (cycling, treadmill, free walking) and resistance strength training should be included in the exercise program
SpO2 Measurement is mandatory during exercise, subsequent oxygen supplementation may be prescribed if Sp02 < 93%
Lung recruitment exercises
Chest expansion breathing control exercises associated with posture positioning should be considered
Respiratory muscle training
Not routinely recommended, but could be used if respiratory muscle weakness is present
The type, efficacy and duration of muscle training in COVID-19, post-acute or longterm still needs to be investigated
Inspiratory muscle training should start at low intensity guided by dyspnea/fatigue and vital signs
Telerehabilitation
May be an appropriate response following discharge
May increase the accessibility to PR
The Royal Dutch Society for Physical Therapy (Koninklijk Nederlands Genootschap voor Fysiotherapie) compiled a position statement on Physiotherapy recommendations in patients with COVID-19. In this statement recommendations are included for physiotherapy interventions in patients following discharge from hospital. The English version of this position statement is available here: The recommendations are mainly aimed at physical rehabilitation aspects.
In summary the following recommendations are provided:
General recommendations:
The exact period of contagiousness of COVID-19 is still unknown. Physiotherapists should therefor consider the safety risks involved for both themselves and the patients.
There is uncertainty about the recovery path, the physical capacity and limitations of patients after an active COVID-19 infection. Caution is required with assessments and treatments of this cohort of patients
Social distancing principles should be respected and therefore physiotherapists should consider measures such as telehealth or e-health
Always consider and follow national and regional guidelines on safety, infection control and the prevention of transmitting the disease.
Initial 6 weeks following hospital discharge
Contact patient by telephone, telehealth, e-consult or e-health within the first two weeks following discharge to assess and determine if patient is experiencing any difficulties or limitations in daily physical functioning and if there is an indication for further rehabilitation
Be aware of existing and/or newly acquired comorbidities
Consider that patients that were in ICU and who shows signs of PICS may have very low and limited exercise tolerance
Recommend gradual resumption of ADL and physical function. Ensure appropriate monitor of the patient’s daily physical function.
ADL and exercise therapy are recommended to be performed at low to moderate intensity and with short interval durations.
The following clinical outcome measures are recommended:
Patient Specific Function Scale
Oxygen saturation before, during and after rehabilitation/exercise
Use Sp02 of 90% at rest as lower limit and 85% SpO2 during exercise as lower limit. Stop physical activities or exercise when desaturation( SpO2 < 85% during exercise) occurs
Heart rate frequency before, during and after rehabilitation/exercise
Borg Scale CR10 for Shortness of breath and fatigue before, during and after rehabilitation/exercise
Max score of 4/10 is recommended as threshold for exercise intensity on the Borg Scale CR10 for shortness of breath and fatigue
Reasons for this include:
The severe impact on lung function from COVID-19 – such as oxygen desaturation during exercise due to virus-induced lung disease)
Cardiac function may be compromised due to COVID-19
Adequate clinicial information is not always avaialalbe as no maximal exercise testing is done and it is impossible to estimate the risk of physical training/exercise at moderate to high intsnsity.
Patients should only perform exercises in the home situation if they are able to understand and apply proper exercise load management (frequency, intensity, time/duration and type)
Physical functioning of ADL should be the focus
After 6 weeks following hospital discharge
Reassess the patients’ needs to determine how rehabilitation should be adapted and progressed
Reassess the patients’ actual level of physical functioning (compare with previous tests such as hospital-based exercise tests, lung/heart function tests, etc)
Design future treatment goals relating to physical activity and/or exercise capacity based on exercise tests and measurements of physical activity
The aim of these treatment goals should be to further improve performance of ADL, increased physical activities and increased capacity to exercise
Clinical outcome measures that can be used during this phase:
Patient Specific Function Scale
Short Physical Performance Battery – this includes:
Standing balance test
Walking speed test over 4 meters
5 times chair stand test
Hand-held Dynamometer for grip strength
6 minute walk test
Pedometer/accelometer to assess and evaluate daily physical function
Oxygen saturation
Heart rate frequency
Borg Scale CR10 for shortness of breath and fatigue before, during and after physical exercise
When physical function tests (lung/heart function) and (sub)maximal exercise tests indicates no severe restrictions or risks, start with gradual increase in training
Implement a gradual increase in training frequency, intensity, time/duration as well as type of exericses - this should be based on the needs of the patient, the set treatment goals and the patient’s physical abilities
During exercise a score of 4 -6/10 on the Borg Scale CR 10 for shortness of breath and fatigue and/or an intensity of 60-80% of the tested maximum exercise performance (bicycle test, 6mwt and/or 1RM) is recommended.
Sub Heading 2[edit | edit source]
Sub Heading 3[edit | edit source]
Resources[edit | edit source]
- bulleted list
- x
or
- numbered list
- x
References[edit | edit source]
- ↑ 1.0 1.1 1.2 Falvey JR, Krafft C, Kornetti D. The essential role of home-and community-based physical therapists during the COVID-19 pandemic. Physical Therapy. 2020 Apr 17.
- ↑ Silver JK. Prehabilitation could save lives in a pandemic. bmj. 2020 Apr 6;369.
- ↑ 3.0 3.1 Pan American Health Organisation. Rehabilitation considerations during the COVID-19 outbreak. 2020. 26 Apr. (last accessed 28 June 2020)
- ↑ 4.0 4.1 4.2 4.3 4.4 NHS England. After-care needs of inpatients recovering from COVID-19.Version 1. June 5, 2020. (last accessed 28 June 2020)