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| Role of the Physiotherapist in COVID-19 |
Coronavirus
Each virus behaves like a parasite for the purpose of multiplying. A virus does that by invading a host cell and releasing genetic material into that cell. Then the virus can pick up proteins and multiply. Thousands of virus particles can be made into new cells and as a result the become badly damaged that the cells eventually die. The more cells that are damaged, the sicker a person becomes.Patients recovering from the COVID-19 virus are expected to experience one or more symptoms:
- Reduced lung function: pulmonary fibrosis / reduced lung capacity
- Reduced breathing power (inspiratory and expiratory)
- IC-acquired muscle weakness due to prolonged inactivity
- ICU-acquired polyneuropathy and myopathy
- Reduced aerobic and anaerobic endurance
- Joint pain and/or stiffness
- Overall fatigue
- Problems in ADL
- Malnutrition
- Cognitive: memory, concentration, dealing with stimuli and plans
- Fear and depression
- Post-traumatic stress syndrome (PTSD)
Long-term consequences of PICS
- 60% keeps physical complaints after 1 year (Sommer et al, 2012)
- 32% anxiety complaints after 6 months (on brain-ICU) (Bienvenue et al, Parker et al)
- 30% depression after 6 months (on brain-ICU) (Bienvenue et al, Parker et al)
- 20-23% develops PTSD (Bienvenue et al, Parker et al)
- 40% keeps cognitive complaints (Pandharipande et al).
Between 4-62%) reported long term cognitive complaints (Wolters et al), depending on follow-up duration and clinimetry.
Risk factor PICS (duration of ICU admission/breathing, co-morbidity, delirium, sepsis, ARDS, anxiety/depression history, ICU acquired weakness
Risk factor PICS (duration of ICU admission/breathing, co-morbidity, delirium, sepsis, ARDS, anxiety/depression history, ICU acquired weakness
Pulmonary problems in PICS
It is expected that pulmonary problems (COLD) will become an important limiting factor during rehabilitation after COVID-19 infection, where lung rehabilitation is indicated if this problem is at the forefront. Knowledge about this is concentrated in specialist lung rehabilitation departments. Pulmonary rehabilitation requires a very gradual build-up of activities, in which a distinction should be made between ‘overusers’ and ‘underperformers’, and treatment should always be tailored to the specific patient factors.Physiotherapy in the ICU
Physiotherapy is the paramedical discipline that deals with the prevention and treatment of the effects of bed rest and inactivity in critical illness on moving to function and therefore plays an important role in the multidisciplinary treatment process [Grill 2011, Eeuwes 2010]Therapeutic process
The overall aim of the treatment is to safely start early with the mobilization and activation of the ICU patient in order to reduce the effects of bed rest and inactivity in critical illness on moving to function. As a result of the diagnostic process, specific treatment goals can be set within the ICU.Treatment goals focused on anatomical properties:
- Reducing edema in the extremities
- Focusing of treatment objectives to specific functions
- Optimizing and maintaining the ROM
- Optimizing and maintaining muscle strength
- Preventing muscle atrophy
- Normalizing and developingmuscle tone
- Optimizing and maintaining muscle endurance
- Optimizing effort tolerance
Clinimetrics
On the basis of a Delphi study on rehabilitation after PICS and clinimetry usedIn the REACH project the Dutch Hoogstraat Rehabilitation Clinic has the following advice regarding clinimetry at PICS after COVID-19:
- Exercise capacity/intensity: 6-minute walking test (6MWT) and 10-meter walking test
- Functional capacity, and bicycle ergometry (submax capacity).
- Physical functioning: TUGT, FIM, SF36 (physical function) and Barthel Index
- Respiratory muscle function: MIP and MEP
- Muscle strength: MRC scale, HKK, handheld dynamometry, Motricity Index.
- Fatigue: multidimensional fatigue inventory (MFI) or the Borg scale.
- Psychological factors: HADS, GPS, IES, PLC-5 and TSQ
- Cognitive complaints: The Montreal Cognitive Assessment (MoCA
- Nutrition: SNAQ65+ for malnutrition screening
- Psychosocial complaints of partner/adjacent: Caregiver Strain Index (CSI) and HADS (8)
Treatment protocol COVID-19
A number of established rehabilitation protocols indicate which treatment program COVID-19 patients should follow after long-term/complicated ICU admission. (7,8) A basic treatment program can be drawn up and adapted to each patient.
Basic treatment program COVID-19
The basic treatment program COVID-19 post-IC of the Hoogstraat has a duration of 4-8 weeks, in which the length of the program is determined on the basis of the rehabilitation goals necessary for dismissal. After the intake phase (first 2 weeks) a clear picture forms of all factors that determine the level of functioning of the patient. Then, a team meeting is scheduled (no later than the 3rd week after admission) in which treatment goals are evaluated with the patient (and partner/next-door) and further follow-up (in first line or in MSR) is discussed. If earlier hospital discharge is possible, the program will be stopped earlier.The aim is to continue rehabilitation in outpatient programmes.
The aim is to continue the rehabilitation, if possible, in outpatient rehabilitation programmes (via ICU aftercare outpatient clinics), in the first line or from home. At the intake, the conditions for dismissal are already discussed, so that this can be targeted from the start of rehabilitation. Possible remote rehabilitation (via telemonitoring and instructions via video) with the involvement of first-line therapists is a logical continuation of the clinical rehabilitation phase.
During the intake by the rehabilitation doctor/AIOS, treatment goals are drawn up in consultation with the patient. Because of the wide variety of possible consequences of PICS and seriousness, this is not a cookbook recipe, rather it requires an individual approach (no different from other diagnostic groups).
The following treatment goals can be considered:
- Improving general fitness
- Increase mobility: independent transfers, independent walking, climbing stairs
- Prevent loss of function: contractures, pulmonary complications and decubitus
- Respiratory force and adequate coughing techniques
- ADL independence
- Improve arm/hand function
- Insight/coping due to reduced energy
- Understanding compensation strategies
- Stable mood (signaling / treating depression, anxiety and PTSD
- Healthy nutritional status
- Swallow safely
- Rehabilitant and partner have insight into the consequences of
Partner counselling; identifying any psychological complaints and overburdening in good time.
Basis of the programme
The overview below forms the basis of the PICS rehabilitation programme after COVID-19. It concerns physiotherapy, sports and needs to be adapted to a tailor-made programme at an individual level during the course of the programme.
3-5x/week physiotherapy:
Improve overall VO2max/fitness. In case of indication: if pulmonary problems are the main complaint. aimed at promoting ventilation, coughing techniques (sputum mobilisation) exercise, increasing inspiratory and expiratory breathing power.
1-2x/week physiotherapy:
Improve overall VO2max/fitness Intensity and frequency by means of possibilities, exertion possibilities of rehabilitant. Indication: if general deconditioning is in the foreground (without important pulmonary component) extra sport.
Patients recovering from COVID-19 can be seen after the recovery phase post-detubation or admission without Intensive Care in the first-line physiotherapy practice. The physiotherapist should be aware, competent and familiar with the clinical picture and the physiotherapeutic possibilities. It is important that the accompanying physical therapist is aware of which rehabilitation has taken place in the hospital and can continue this if necessary. The physical therapist must also be able to signal whether other disciplines (with knowledge of the consequences of COVID-19) such as psychologists and dietitians must be involved.
