COVID-19: Medium-to-Longer Term Health Considerations
Physical Impairment and Dysfunction Following COVID-19
Sequelae of Severe Acute Respiratory Syndrome (SARS)
Sequelae of and rehabilitation from SARS may serve as a useful starting point for planning for optimal recovery from COVID-19. At about one month post-discharge, one-third of patients with SARS had dyspnoea on exertion, general malaise and moderate to severe impairment of work or household tasks. Pulmonary fibrosis was found in 62% of post-acute patients but was generally patchy and not extensive thus it was not expected to have a significant impact on lung function. Patients with this fibrosis tended to be older and had a more severe acute phase. Respiratory muscle weakness (rather than parenchymal damage) was the major factor for the restrictive lung function defect. In addition, 50% of discharged patients demonstrated decreased handgrip strength. The authors stated that respiratory and skeletal muscle weakness could be due to various factors including prolonged bed rest and physical deconditioning.
Intensive Care Unit Acquired Weakness
Because mechanical ventilation is required with patients experiencing the severe phase of COVID-19, HCPs must be prepared to address Intensive Care Unit Acquired Weakness (ICUAW). ICUAW is a symmetrical and flaccid weakness of limbs (proximal > distal muscles) which can be evoked by either critical illness polyneuropathy, critical illness myopathy or both. Respiratory muscles are often affected and can contribute to delayed weaning from mechanical ventilation. In a review by Hermans and Van den Berghe (2015), weakness was found on wakening in 26-65% of patients who were mechanically ventilated for 5-7 days, respectively. Twenty-five percent of these patients remained weak for at least another seven days. ICUAW was diagnosed in up to 67% of patients mechanically ventilated for ≥ 10 days. In patients with ARDS, weakness on wakening has been reported in 60% with 36% of these patients still weak at discharge from hospital.
Factors other than ICUAW may also be relevant since the majority of ARDS survivors have a marked reduction in their physical function even though only a small number of them have a measurable persistent weakness. Other factors may include proprioception, gait balance, spatial attention, cognitive function, mental health, CNS dysfunction, pain and entrapment neuropathy.
ICUAW is associated with prolonged stays in the ICU and hospital at large and may have consequences lasting longer than the hospitalization phase of a critical illness. Recovery is typically within weeks or months but some patients may not recover. Persistence and higher severity of weakness at ICU discharge have been found to increase the risk of death within the first year. Attempts to prevent the occurrence of ICUAW are therefore important and may require multiple strategies including aggressive treatment of sepsis, insulin treatment to normalize glycemia, a reduction in the duration of immobilization (e.g. decreasing levels of sedation, early physiotherapy if medically safe, electrical muscle stimulation if unable to mobilise early) and correction of malnutrition.
Landry et al (2020) state that “physiotherapy can mediate the deleterious pulmonary, respiratory and immobility complications” of infectious diseases and that “rehabilitation can offer a cost-effective upstream strategy that can restore the mental and emotional quality of life during and after medical intervention.” The authors note that for a clearer idea of the range of interventions physiotherapists could offer in the management of infectious disease, the International Classification of Functioning, Disability and Health should be considered in the post-acute stage of the disease. This facilitates the identification of impairments, activity limitations and participation restrictions that could occur for a given patient and thus what interventions would be appropriate.
Again, the SARS crisis in 2003 provides some guidance for a starting point for post-acute physiotherapy intervention. Lau et al (2005) evaluated the impact of a six-week exercise program on post-SARS patients and found significant improvements in the six-minute walk distance (13.1% vs 3.4% in the control group), VO2max (10.% vs 0.3%), handgrip strength, curl-up and push-up performance compared to controls. The majority of both groups had returned to work during this six-week period (85.% of the control group and 88.5% of the exercise group). They did not find that physical training during the six-week intervention period had any impact on health-related quality of life. The exercise program consisted of four to five 1-1.5 hour sessions per week, two of which were supervised by physiotherapists. One session included cardiorespiratory training for 30-45 minutes (limb ergometer, step machine or treadmill, starting at a minimum of 60-75% of predicted HRmax) and resistance training (3x10-15 reps for large muscle groups of the upper ad lower limbs).
Mental Health Considerations
Mental health should be considered for the patient, family, and health care workers. Read more here.
- Chan K, Zheng J, Mok Y, Li Y, Liu Y, Chu C, Ip M. SARS: prognosis, outcome and sequelae. Respirology. 2003; 8(1): S36-S40.
- Hermans G, Van den Berghe G. Clinical review: intensive care unit acquired weakness. Crit Care. 2015;19(1):274. Published 2015 Aug 5. doi:10.1186/s13054-015-0993-7
- Landry MD, Tupetz A, Jalovcic , Sheppard P, Jesus TS, Raman SR. The novel coronavirus (COVID-19): making a connection between infectious disease outbreaks and rehabilitation. Physiother Can. 2020; e20200019; advance online article; doi: 10.3138/ptc-2020-0019
- Lau MC, Ng YF, Jones YM, Lee WC, Siu HK and Hui SC. A randomised controlled trial of the effectiveness of an exercise training program in patients recovering from severe acute respiratory syndrome. Australian Journal of Physiotherapy. 2005; 51: 213–219.