Role of the Physiotherapist in COVID-19

Introduction

Clinicians, especially physiotherapists, are most often in direct contact with patients, which make them susceptible to transmission of infectious diseases. Physiotherapists are also often first contact practitioners putting them in a position to take responsibility for early identification of Infectious disease. It is therefore very important for physiotherapists and other health professionals to be familiar with the condition of COVID-19 and how to prevent it.

Primary Care

To avoid transmission of COVID-19 the following are recommended practices for clinical staff:

1. Adhere to basic protective measures at all times
2. Promote of respiratory and hand hygiene
3. Provide of up to date information about the virus to staff and patients
4. Avoid unnecessary direct physical contact with individuals who may be infected
5. Liaise with local public health specialists
6. Initiate early identification strategies

Adhere to basic protective measures at all times

• Perform hand hygiene frequently with an alcohol-based hand rub if your hands are not visibly dirty or with soap and water if hands are dirty
• Avoid touching your eyes, nose and mouth.
• Practice respiratory hygiene by coughing or sneezing into a bent elbow or tissue and then immediately disposing of the tissue.
• Wear a medical mask if you have respiratory symptoms and performing hand hygiene after disposing of the mask.
• Maintain social distancing (a minimum of 1 m) from individuals with respiratory symptoms.
• If you have fever, cough and difficulty breathing seek medical care.

Promote of respiratory, hand and clinic hygiene

• Place additional signage in and around the clinic to encourage regular hand washing.
• Ensure that alcohol-based hand sanitisers and/or a hand washing stations are available.
• Ensure regular cleaning and disinfection of the clinic and equipment, especially after attendance by a COVID-19 patient.

Provide of up to date information about the virus to staff and patients

• Share educational messages with patients.
• Review and amend information on your clinic website, appointment reminders and appointment protocols.
• Posters, about hand and respiratory hygiene and other basic protective measures, should be displayed prominently at the first point of contact to the service such as reception areas, waiting rooms.

Avoid unnecessary direct physical contact with individuals who may be infected

• Don't perform physical assessments.
• Avoid exposures to respiratory secretions.
• Encourage patients with symptoms to stay at home.

Liaise with staff and local public health specialists

• Stay up to date with the latest information on the COVID-19 outbreak through WHO updates or your local and national public health authority.
• Liaise with local public health specialists to keep up to date with local guidelines.
• Hold regular team meetings with staff to review this information and provide any updates

Initiate early identification strategies

On booking an appointment

If an individual telephones to make an appointment or has concerns about COVID-19 in advance of attending for an appointment they should be asked if they have:

• recent travel to places with presumed ongoing community transmission to COVID-19.
• recent contact with anyone with confirmed COVID-19.
• recent work  or visits to a healthcare facility where patients with confirmed COVID-19 were being treated.

If the answer is NO to all of the above questions they can proceed to make/attend an appointment.

If the answer is YES to any of the above questions the individual should be asked if they have any of the following symptoms - fever, cough, shortness of breath or any other features or an upper respiratory tract infection such as nasal discharge or frequent sneezing.

• If the individual has any of the above symptoms then they should not make an appointment and should be advised with local authority guidelines.
• If the individual does not have any of the above symptoms it is ok for them to make an appointment BUT they should be advised to follow local guidelines for people who may be at risk of transmission.

On attending clinic

Patients with respiratory symptoms and a relevant travel history may also be identified when they book in at reception for example by direct questioning or incorporating a question on symptoms of cold or flu like illness and travel in registration paperwork. Ask the patient about:

1. 1. recent travel to places with presumed ongoing community transmission to COVID-19.
   2. recent contact with anyone with confirmed COVID-19.
   3. recent work  or visits to a healthcare facility where patients with confirmed COVID-19 were being treated.
   4. if they have any of the following symptoms - fever, cough, shortness of breath or any other features or an upper respiratory tract infection such as nasal discharge or frequent sneezing.

If concerns about possible COVID-19 are identified in the course of a consultation:

1. Isolate the patient away from other patients. Ideally this should be an unoccupied room with the door closed. If a room is not available the person should be asked to wait in their car or be seated in an area separated by at least 1m from other individuals.
2. Initiate basic protective procedures and use personal protective equipment (PPE) (gowns, gloves, medical mask and eye protection).
3. Provide the patient with tissues, a surgical face mask and alcohol hand rub.
4. Follow local authority guidelines to arrange COVID-19 assessment.
5. If the patient is to return home they should quarantine themselves while awaiting home assessment. Patients should not travel home by taxi, public transport or walking. Patient may travel home by car if the patient feels well enough to drive or can be driven by a person who has already had significant exposure, who is aware of the risks and who is willing to drive them.
6. Follow clinic cleaning and disinfection protocols once the patient has left the clinic.

Community (Home) Care

In the situation where a person has suspected COVID-19 with mild symptoms, care can be provided at home. It is suggested that a healthcare professional assesses whether the residential area is suitable for providing the necessary care. The WHO has provided advice for providing home care for a suspect case with mild symptoms.

Factors to consider:

• Will the patient and family be able to adhere to the recommended precautions as part of home care isolation (adhere to hand and respiratory hygiene principles, cleaning of the home environment, limitation of movement around the home).
• Will the patient and family be able to correctly handle safety concerns that arise while isolating at home (accidental ingestion or fire hazards that may be associated with the use of alcohol-based hand sanitisers).
• A communication link between the patient, the healthcare professional and the public health authority of specific area/country should be confirmed.
• Education of the patient and family members of basic hand and respiratory hygiene principles.
• Provision of ongoing support to the patient and family.

Recommendations for patients, families and carers:

• Patients should remain in a well-ventilated room (open windows and doors).
• Limit movement of patients around the home and limit shared spaces.
• Shared spaces should be well-ventilated at all times.
• Family or household members should stay in different rooms and keep a distance of at least 1m from the ill family/household member.
• Limit the number of caregivers and no visitors allowed until the patient has recovered and have no more signs and symptoms.
• Proper hand hygiene is essential after any contact with the patient or their immediate environment.
• Patient should wear a medical mask to contain respiratory secretions.
• Respiratory hygiene should be practiced - cover mouth or nose with disposable paper tissue when coughing or sneezing and discarded appropriately, when tissue isn't available sneeze or cough into the bend of the elbow and not into hands.
• Caregivers are advised to wear medical masks when providing care to the patient.
• Avoid direct contact with bodily fluids.
• Patient should use dedicated linen and eating utensils - these should be cleaned with soap and water after use.
• Surfaces in the patient’s room or areas where the patient is should be cleaned and disinfected. It is recommended to use regular household cleaning products first and then a household disinfectant afterwards.
• Bathroom and toilet surfaces should be cleaned at least once daily.
• The patients’ clothes and linen may be washed with regular laundry products and water. Machine wash at temperatures of 60 - 90 ℃.
• All gloves and masks used during home care isolation should be discarded as infectious waste.
• Avoid any exposure to contaminated items of patient (toothbrushes, towels, linen, wash clothes, eating utensils, etc).
• Healthcare professionals tending to patients under home care should be familiar with and be able to select, use, remove and dispose of the correct personal protective equipment (PPE) to be used.

Secondary Care

A minority group of people will present with more severe symptoms pf COVID-19 and will need to be hospitalised, most often with pneumonia, and in some instances the illness can includes severe pneumonia, ARDS, sepsis and septic shock[9][8]. In these cases the physiotherapist may find themselves involved in respiratory care of the patient.

Safety First

Specific advice for front line clinicians:

1. Ensure that there is enough supply and access to appropriate Personal Protective Equipment (PPE) for front line staff.
2. Ensure that staff have an opportunity to take adequate breaks during and between shifts.
3. Ensure access to appropriate support services for psychological health of staff.

Physiotherapy Interventions

As with any patient displaying respiratory symptoms it may be necessary to provide treatment to relieve symptoms and improve function.  As with any contagious respiratory condition care must be taken to protect yourself and those in the immediate environment by following strict protocols and ensuring the use of PPE as well as taking the following steps:

• Where possible treat the patient in a single room with the door closed.
• Limit the number of staff present.
• Minimise entry and exit from the room during treatment.

The main goal in respiratory physiotherapy is to clear secretions and ease the work of breathing.  This may include interventions such as:

• Autogenic Drainage, Active Cycle of Breathing and manual techniques (eg percussion, assisted cough) to aid sputum expectoration
• Deep breathing exercises and pursed lip breathing to ease the work of breathing.
• Nebulisation to administer medication into the lungs.  Note that the mist created does not contain patient derived viral particles but hand hygiene protocols should be followed when assisting the patient to remove the oxygen mask and nebuliser.
• Non-invasive ventilation (NIV) eg. Bi-level Positive Airway Pressure (BiPAP) and Continuous Positive Airway Pressure ventilation (CPAP).

Management of Contacts

The WHO describes a contact as a person who is involved in any of the following within 14 days after the onset of symptoms in the patient:

• Providing direct care for patients with COVID-19 disease without using proper personal protective equipment.
• Staying in the same close environment as a COVID-19 patient (including sharing a workplace, classroom or household or being at the same gathering).
• Travelling in close proximity with (that is, having less than 1 m separation from) a COVID-19 patient in any kind of conveyance.

Contacts should be advised to monitor their health for 14 days from the last possible day of contact.

The following counts as exposure to contacts:

• Healthcare related contact - providing direct care to patients with COVID-19.
• Working in close proximity or sharing a classroom with a person with COVID-19.
• Traveling with a persons with COVID-19 in any kind of vehicles.
• Living in the same household as a person with COVID-19 within 14 days after the onset of the person’s symptoms.

Healthcare professionals should monitor the contacts on a regular basis. Recommendations if a contact develops symptoms:

• Notify the relevant healthcare authorities as well as medical facility where symptomatic contact will be directed.
• Symptomatic contact should wear a medical mask while traveling to seek care.
• The symptomatic contact should avoid taking public transport if possible, an ambulance can be dispatched or if the person is being transported via private vehicle, all the windows should be opened (vehicle well-ventilated).
• The symptomatic contact should be advised on proper hand and respiratory hygiene as well as to keep a distance of at least 1 m from others.
• Clean and disinfect any surfaces that could have been contaminated with respiratory secretions during transport of the symptomatic contact with cleaning products and then with a disinfectant.

Telemedicine Consultations

To reduce transmission or in the case where our clinic is forced to close you may consider implementing digital strategies to continue the delivery of your service.  There are currently no established or recognised global standards or agreement for delivering physiotherapy care digitally. However, the overall emerging evidence appears to indicate that digital technologies are providing new opportunities for the physical therapy profession to deliver high-quality and acceptable care to users of their service in ways that can have benefits for all.  Some national physiotherapy organisations are welcoming the use of digital practices where it enhances the service to the patient.