COVID-19: Community Rehabilitation: Difference between revisions
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== Introduction == | == Introduction == | ||
Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include: | |||
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 | |||
<nowiki>https://iris.paho.org/bitstream/handle/10665.2/52035/NMHMHCOVID19200010_eng.pdf?sequence=6&isAllowed=y</nowiki> | |||
Healthcare needs of COVID-19 patients following discharge <nowiki>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</nowiki> | |||
Patients may present with various issues on discharge from hospital. 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. | |||
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 PTSD 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 | |||
Respiratory | |||
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 need to be considered | |||
Cardiac | |||
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 | |||
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 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 programme 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. Physiotherapist are key role players in the assessment and treatment on neuropathies. | |||
General function and well-being | |||
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) <nowiki>https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf</nowiki> | |||
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 <nowiki>https://www.wcpt.org/sites/wcpt.org/files/files/wcptnews/COVID19-Briefing-paper-2-Rehab-PT-May2020.pdf</nowiki> | |||
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: <nowiki>https://www.youtube.com/watch?v=3sURTAaxmc8</nowiki> | |||
Post Covid-19 effects could include: <nowiki>https://covidpatientsupport.lthtr.nhs.uk/#/</nowiki> | |||
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 | |||
<nowiki>https://www.monaldi-archives.org/index.php/macd/article/view/1444/1048</nowiki> | |||
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 | |||
== Sub Heading 2 == | == Sub Heading 2 == |
Revision as of 22:14, 27 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! (27/06/2020)
Original Editor - User Name
Top Contributors - Wanda van Niekerk, Kim Jackson, Laura Ritchie, Lucinda hampton, Tarina van der Stockt, Jess Bell, Admin, Olajumoke Ogunleye and Aminat Abolade
Introduction[edit | edit source]
Patients recovering from COVID-19 will still need rehabilitation following discharge from hospital or a rehabilitation centre. Rehabilitation strategies can include:
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
https://iris.paho.org/bitstream/handle/10665.2/52035/NMHMHCOVID19200010_eng.pdf?sequence=6&isAllowed=y
Healthcare needs of COVID-19 patients following discharge 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
Patients may present with various issues on discharge from hospital. 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.
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 PTSD 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
Respiratory
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 need to be considered
Cardiac
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
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 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 programme 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. Physiotherapist are key role players in the assessment and treatment on neuropathies.
General function and well-being
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
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